Senator Don Nickles: Press Releases; THE PATIENTS' BILL OF RIGHTS PLUS ACT

Summary of
THE PATIENTS' BILL OF RIGHTS PLUS ACT

"The Patients' Bill of Rights Plus Act" has six major components that will provide consumer protections, enhance health care quality and increase access. These are:

1. Consumer protection standards for the 48 million Americans covered by self-funded group health plans

2. Comparative information about health insurance coverage for the 124 million Americans covered by both self insured and fully insured group health plans

3. New standards for coverage determinations and internal/external appeal rights for 124 million Americans covered by both self insured and fully insured group health plans

4. A ban on the use of predictive genetic information for underwriting purposes for 140 million Americans covered by both self insured and fully insured group health plans and individual plans

5. New quality focus and expanded research activities for the Agency for Health Care Policy and Research

6. Provisions that increase health insurance coverage by allowing full deduction of health insurance for the self-employed, the full availability of medical savings accounts and the carryover of unused benefits from flexible spending accounts.

An equally important goal of "The Patients' Bill of Rights Plus Act" is to provide these new protections without significantly increasing the cost of health coverage and causing more Americans to become uninsured. The CBO estimates that the Act would raise average premiums by about 0.8 percent.

1. Consumer protection standards for self-funded plans:

Since States already regulate insured health plans, the bill provides that the following standards would apply to the 48 million Americans covered by self-funded group health plans governed exclusively by the Employee Retirement and Income Security Act (ERISA).

Emergency Care: Plans would be required to use the "prudent layperson" standard for providing in network and out of network emergency screening exams and stabilization.

Choice of Plans: Plans that offer network-only plans would be required to offer enrollees the option to purchase point-of-service coverage. Small employers with 50 or fewer workers would be exempt. Also exempt would be group health plans that offer two or more options with significantly different providers. Plans could charge higher premiums and cost sharing for the POS option.

OB-GYN/Pediatricians: Health plans would be required to allow direct access to obstetricians/gynecologists and pediatricians for routine care without referrals.

Continuity of Care:Plans who terminate or non renew providers from their networks would be required to notify enrollees and allow continued use of the provider (at the same payment and cost-sharing rates) for up to 90 days if the enrollee is receiving institutional care, or is terminally ill; and, in the case of a pregnancy through post-partum care.

Access to Medication: Health plans that provide prescription drugs through a formulary would be required to ensure the participation of physicians and pharmacists in developing and reviewing that formulary. Plans would also be required to provide for exceptions from the formulary limitation when a non-formulary alternative is medically necessary and appropriate.

Access to Specialists: Health plans would be required to ensure that patients have access to covered specialty care within the network, or, if necessary, through contractual arrangements with specialists outside the network. If the plan requires authorization by a primary care provider, it must provide for an adequate number of referrals to the specialist.

Gag Rules: Plans would be prohibited from including "gag rules" in providers' contracts or restricting providers from communicating with patients about treatment options.

Self-pay for Behavioral Health: Plans that offer behavioral health services would be prohibited from barring a participant from self-paying for behavioral health care services.

2. Comparative Information:

All group health plans would be required to provide a wide range of comparative information about health insurance coverage, such as descriptions of the networks and cost-sharing information to the 124 million Americans covered by both self insured and fully insured group health plans.

3. Grievance and Appeals:

All group health plans would be required to have written grievance procedures and have both an internal and external appeals procedure for the 124 million Americans covered by both self insured and fully insured group health plans.

Time frames: Routine requests would need to be completed within 30 days, and expedited requests for care that could jeopardize enrollee's health would have to be handled within 72 hours.

Qualification of reviewers for Internal/External Appeals: Appeals for coverage determinations based on lack of medical necessity or experimental treatment must be by a provider with appropriate expertise in field of medicine involved.

External Appeals: Enrollees and their authorized providers could appeal to independent external medical reviewers for amounts above a significant financial threshold or where the enrollees' health is in jeopardy for issues based on medical necessity. They may also appeal for services that involve an experimental treatment where the enrollees' health is in jeopardy. External reviewers would include those certified as meeting specific criteria established by the State or Federal government for this purpose. The determination of an independent external review is binding on plans and issuers.

The external reviewer would be required to have relevant expertise and must consider appropriate and available information, including evidence offered by the patient and the patient's physician, expert consensus, peer-reviewed literature, and the plan's evidence-based criteria and clinical practice guidelines.

4. Genetic Information:

All group health plans and health insurance issuers would be prohibited from denying coverage, or adjusting premiums or rates based on "predictive genetic information" for the 140 million Americans covered by both self-insured and fully insured group health plans and individual health insurance plans. The term "predictive genetic information" includes individual's genetic tests, genetic tests of family members, or information about family medical history.

5. Refocusing AHCPR on Quality Improvement:

The bill would refocus AHCPR (and rename it the Agency for Healthcare Research and Quality) to encourage overall improvement of quality in the nation's health care systems. The new agency will facilitate state-of-the-art information systems, support primary care research, conduct technology assessments, and coordinate the Federal Government's own quality improvement efforts.

6. Provisions that would increase access to health insurance

The bill would expand coverage by allowing full deduction of health insurance for the self-employed, provide for the full availability of medical savings accounts and permit the carryover of unused benefits from flexible spending accounts.