WASHINGTON, DC – The Bipartisan Consensus Managed Care Improvement Act
of 2000 was released today for consideration by House and Senate members
by U.S. Representative Charlie Norwood (R-GA).
The full text of the draft legislation, co-authored by U.S.
Representatives Charlie Norwood (R-GA), John Dingell (D-MI), and Greg
Ganske (R-IA), was formally released in order for House and Senate members
and the public to have adequate time to consider the compromise
legislation before Congress considers the matter later this month.
“Legislation that will so dramatically impact the health care of all
Americans should not be brought forward and voted on before members even
have a chance to see it, much less read or study it,” says Norwood.
“By this release today, members and the American people will have time to
carefully study this document before the House and Senate face this
important issue.”
Norwood and Dingell, co-authors of the House-passed HR 2723, have
worked with House and Senate members, leadership of both parties, and the
White House since late May to develop a compromise plan for use as a final
conference report. The new proposed legislation is supported by the
American Medical Association.
The full text of the legislation, along with a summary and legislative
comparisons chart are available through Norwood’s office or on the
Internet at http://www.house.gov/norwood.
Norwood-Dingell as passed v. the
Alternative
Issue |
Norwood- Dingell, HR2723 |
The Alternative |
Language Source for the Alternative |
Grievances and Appeals |
|
|
|
Utilization review and standards |
 |
 |
Norwood-Dingell |
Internal Review |
 |
 |
The Nickles Amendment |
External Review |
 |
 |
The Nickles Amendment |
Grievance Process |
 |
|
N/A |
Access to Care |
|
|
|
Consumer Choice Option |
 |
 |
Norwood-Dingell |
Choice of Health Professional |
 |
 |
Norwood-Dingell |
Access to Emergency Room Care |
 |
 |
Coburn-Shadegg |
Access to Ambulance Services |
|
 |
Coburn-Shadegg |
Access to Specialists |
 |
 |
The Nickles Amendment |
Access to Obstetricians and Gynecologists |
 |
 |
The Nickles Amendment |
Access to Pediatricians |
 |
 |
The Nickles Amendment |
Continuity of Care |
 |
 |
The Nickles Amendment |
Access to Non-formulary Drugs |
 |
 |
The Nickels Amendment |
Clinical trials for all life-threatening
conditions |
 |
 |
Norwood-Dingell |
Coverage for mastectomy length of stay and breast cancer
second opinions |
|
 |
The Nickles Amendment |
Access to Information |
|
|
|
Patient Access to Information |
 |
 |
The Nickles Amendment |
Protecting the Doctor-Patient Relationship |
|
|
|
Gag Rule |
 |
 |
Norwood-Dingell |
Nondiscrimination against providers |
 |
 |
The Nickles Amendment |
Restriction on Incentive Plans |
 |
 |
Norwood-Dingell |
Prompt payment on claims |
 |
 |
Norwood-Dingell |
Due Process for Health Professionals and
Providers |
 |
 |
Norwood-Dingell |
Whistleblower protections for health
professionals |
 |
 |
Norwood-Dingell |
New Language Pieces in the
Alternative
Issue |
Norwood-Dingell,
HR2723 |
The Alternative |
Scope |
|
|
Americans covered by the bill |
All Americans in private insurance are covered using the HIPAA
mechanism, Which requires all states to conform to the federal
law |
All Americans in private insurance are covered by the bill or a
state can seek to certify that an existing state law is
substantially equivalent to a provision |
Accountability for Decision Makers |
|
|
Federal Liability for Health Plans |
None |
Allows a plan to be held liable in federal court for decisions
that do not involve medical judgment |
State Liability for Health Plans |
Allows a plan to be held liable for their decisions that cause
injury or death to a patient in a state court of law |
Allows a plan to be held liable in state court for decisions of
medical judgment that injure of kill a patient |
Protection for the development of case law |
None specifically written into the bill |
Language written to ensure that recent Supreme Court decisions
are not overturned |
Protection for employers |
Protects employers frim being held liable unless they exercised
discretionary authority in making a decision |
Protects employers from being held liable unless they
directly partcipate in making a decision; language developed
from Coburn-Shadegg Substitute |
Limitations on damages |
Punitive damages are prohibited if a plan followed the
determination of the external review entity |
For the federal and state causes of action, punitive damages are
prohibited unless the plan acts willfully or
wantonly |
The Bipartisan Consensus Managed Care Improvement Act of
2000 September 20, 2000
A Plain Language Summary
1. Scope All new health plan standards apply to all plans,
an estimated 191 million Americans. The standards can be enforced by
the states or the federal government, at the discretion of the
states. The states are further empowered to waive specific federal
standards in favor of substantially similar state standards. The
Department of Health and Human Services can challenge the state position
if HHS feels the state standards are inadequate.
2. Liability Jurisdiction: Shared
Federal/State ·
State Remedy – Medically-reviewable decisions. If an independent benefit
review entity determines the patient and/or requested benefit is included
in the plan, legal remedy is in state court.
· Federal Remedy – If the
benefit review panel cannot determine that the requested patient and/or
benefit is included in the plan, suits for injury are federal court
jurisdiction.
· Damages - Economic,
pain-and-suffering, and punitive damages are available in both federal and
state court. Punitive damages are strictly limited to specific
conditions. If the plan met the timelines, and abided by the decisions of
the external appeals panel, punitive damages are prohibited.
· Exhaustion of
Administrative Remedies - Once a patient suffers physical injury,
they can sue regardless of their status in the appeals process.
However, if an external medical review is requested by either party, the
review must be completed.
· Patient’s Right To Sue
Without Injury - If the plan refuses to abide by the external appeals
ruling, but the patient is not injured, the patient can still sue in
federal court for $1000 a day for every day that care was denied with no
limit, plus attorney fees and court costs.
· Reinforcement of
Justifiable ERISA Liability Shields
· Approved Treatments: If a
plan or employer approves a patient’s request, they remain shielded from
liability.
· Direct Participation: If an
employer does not directly participate in a dispute, they are shielded
from all liability.
· Choice of Plan Or Benefits:
Employers cannot be sued for their choice of health plan, or benefits
package. Insurers cannot be sued for excluding specific benefits in their
plan. Employers remain shielded from all liability when offering
defined contribution plans.
· Class Actions: No
class action suits may be brought under these ERISA liability reform
provisions.
3. The Appeals Process
· Up-Front Medical Review:
Patients and their doctor must be able to talk to a health plan doctor,
not just an insurance clerk, when a plan denies coverage.
· Benefit and Medical
Necessity Review Panels: If the plan still denies coverage, the patient
can demand an independent review. The dispute must be initially referred
to an independent benefit review entity, which will determine whether the
requested benefit, and the patient, is a part of the plan. If the
panel finds for the patient, the dispute is referred to an independent
medical review panel, whose final decision is legally binding on the
plan. Medical and contract review panels must be certified as
independent by the Secretary of Labor.
· Filing Fee: A $25 filing
fee for external review. Fee is waived if the patient is
indigent. Further, the appeal must move forward regardless of
whether the patient pays.
· Timelines: Urgent Care: 72
hours. Non-urgent care a maximum 75 days from initial request to final
external appeal panel decision, unless the patient requires more
time.
4. The Freedom To Choose A Doctor
Every American should be able to choose their doctor and hospital, and
change their decision on a regular basis if they feel the
need. The responsibility for providing a choice option lies
with the insurance company, not the employer.
5. Specialists Every American should be able to see a
specialist if their doctor thinks they need one.
6. Obstetricians, Gynecologists, and Pediatricians Women
should be able to see obstetricians and gynecologists without any
referral. Children should be able to see pediatricians, without any
referral, as their primary physician.
7. Continued Care Patients should not be forced to change
doctors and hospitals while being treated for a problem.
8. Guaranteed Emergency Room Care Patients should be able to
go to the nearest emergency room when they think they have an emergency,
and should pay no more out-of-pocket than they would have at their health
plan’s designated hospital. If the problem reasonably appeared to be an
emergency, but turned out not to be, the insurance plan still has to
pay.
9. Clinical Trials Reform Patients should be able to
participate in clinical trials without undue interference from their
health plan. The health plan is not forced to pay more for
clinical trials than they would have paid for regular care.
10. Drug Formulary Reform Patients should have the right to
insist on their doctor’s prescribed drug, if their doctor determines that
the specific drug is necessary over the health plan’s designated
drug.
11. Incentives To Deny Care No health plan may provide
payment incentives for doctors or hospitals to deny care.
However, reasonable capitation plans are allowed, as defined under current
federal law.
12. Readable Contracts Every American should be able
to clearly understand what benefits are covered by their health plan,
before they agree to the coverage. Plans should provide specific
information in laymen’s terms, including information on the rights of
patients to challenge plan decisions.
13. Privacy No medical information on a patient should
be released without the patient’s approval.
14. Freedom Of Communication Every doctor should be free to
discuss anything relative to a patient’s health with the patient, even if
the information may be negative towards the health plan. Health
plans should not fire or discipline doctors for talking freely with their
patients, or discriminate against doctors for past cooperation in patient
advocacy.
15. Nondiscrimination Plans cannot discriminate against
providers in allowing participation based on nothing more than the type of
license held by the provider, as long as the provider is licensed to
provide the service in the particular state. However, varying
reimbursement rates for different levels of training are not affected by
this provision
16. 100% Tax Deductibility of Health Premiums for the
Self-Employed Self-employed Americans will be afforded the same
100% tax deductibility of health premiums as is currently enjoyed by
businesses, beginning in 2001.
17. Medical Savings Accounts The current sunset provision on
MSA’s for December 31 of this year is extended another four years.
The restriction of medical savings accounts to businesses with fewer than
50 employees is doubled, to include businesses with up to 100
workers. The overall cap of 750,000 policies is increased to
1,000,000 policies. The General Accounting Office would conduct
research to determine whether this expansion of MSA’s leads to adverse
selection or any skewing of the insurance risk pool.
18. Incentives for Small Businesses to Provide Health Care
Coverage The bill provides a tax credit for the purchase of health
insurance for small employers (2-50 employees) who have previously not
offered coverage. The basic credit would be equal to 20% of the
costs of providing insurance coverage, but would be 30% for coverage
purchased through a small business purchasing pool. The credit would
apply to individual coverage up to $2,000 and $5,000 for family
coverage. It would be available for the first 48 months that the
employer purchases insurance.
The bill provides for foundation grants to qualified health benefit
purchasing cooperatives would be treated as a grant or loan for charitable
purposes. Expenses covered would include all ordinary and necessary
expenses for the establishment of the cooperative within the first 24
months of its creation. Finally, the bill would provide $500 million
over 5 years in new federal grants for state health insurance coverage
expansions. |