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Issue Briefs

ISSUE: Legislation to Ensure Patient Access to Responsible Care in Managed Care Plans Similar to Last Year's PARCA Bill (H.R. 1415/S.644)

The ACA is part of a broad coalition of health care groups and consumer organizations, known as the PARCA coalition, which have joined together to seek the passage of a comprehensive package of federal legislative reforms which would establish national standards to ensure patient choice of provider and improve quality in health plans, including managed health care plans.
STATUS: Many versions of managed care reform legislation have been introduced in Congress this year including:
  • The Access to Quality Care Act (H.R. 216) introduced by Representative Norwood (R-GA) with 14 cosponsors;
  • The Patients' Bill of Rights (S. 6/H.R.358) introduced by Senator Daschle (D-SD) and Representative Dingell (D-MI) with 31 cosponsors in the Senate and 173 in the House.
  • House and Senate Republican Leadership bills (S. 300/H.R. 448) introduced by Senator Majority Leader Trent Lott (R-MS) and Representative Michael Bilirakis (R-FL) with 49 cosponsors in the Senate and 12 in the House (including the Speaker and Majority Leader).
KEY
PRINCIPLES:
None of these bills have all the principles endorsed by the ACA and the PARCA coalition. Any final legislation should contain:
  • Pro-competition provisions, which prevent managed care plans from discriminating against health care providers based solely on licensure or certification and allow patients' access to appropriate care;
  • A meaningful point-of-service provision, which ensures patients' freedom to select providers of their choice, including the ability to access out-of-network providers;
  • Patient and provider rights to due process to appeal adverse coverage decisions.
POLICY
RATIONALE:
  • America's health care delivery system is now dominated by managed health care and self-insured health plans. All too often, these plans deny the patient choice of provider and through a system of positive and negative financial incentives, deny necessary health care to plan enrollees.
  • States, which have traditionally set standards to protect both consumers and providers in health and insurance plans, have little ability to ensure quality and choice of provider, because the vast majority of managed care plans escape state regulation through a loophole -- the federal Employee Retirement Income Security Act (ERISA) statute. ERISA not only preempts state authority but provides no comparable set of standards to protect patients and providers at the federal level. Legislation should provide a comprehensive set of legislative protections which would allow for state enforcement where possible, and for federal enforcement when state enforcement is not possible.

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