news release header
October 6, 2000
The Final Version Bipartisan Consensus Managed Care Improvement Act of 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, but must do so within a maximum 150 days.   

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 – 
State Court: Economic, pain-and-suffering, and punitive damages are available in  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.  
Federal Court: Economic and pain-and-suffering damages are available without limit.  Punitive damages are not allowed.  Statutory damages for “willful and wanton” misconduct are available up to $5 million. 
Exhaustion of Administrative Remedies -  Once a patient suffers “irrevocable” 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. 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. 

14. 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. 

15. 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.   

16. 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.  

17. 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.



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