AOTA Cheers House Action on HMO Patients' Rights

H.R. 2723, the "Bipartisan Consensus Managed Care Improvement Act" is the culmination of years of work by AOTA and others to protect patient's rights to necessary and effective care.

Bethesda, MD (October 8, 1999) The House passed bipartisan legislation on Thursday, October 6, 1999, that extends patient protections to all 161 million Americans who receive their healthcare through private insurance. HR 2723 combines the patient protections found in the major managed care reform bills introduced by the Democratic leadership in the House this year with Charlie Norwood's Access to Quality Care Act, and includes many patient protections that AOTA believes are critical.

The Norwood-Dingell bill:

Guarantees patient access to all medically necessary specialty care, employing appropriate utilization review standards;
Gives patients in a healthcare plan access to providers outside of the specified network;
Prohibits the restriction of important medical communication, and requires healthcare plans to abide by information disclosure standards;
Prohibits discriminatory practices against healthcare professionals;
Requires timely, independent due process procedures; and
Holds health plans accountable for their medical decisions.

The bill was introduced by Republican Rep. Charlie Norwood (GA) and Commerce Committee Ranking Democrat John Dingell (MI) in August just prior to the congressional recess and is considerably more comprehensive than legislation passed by the Senate in July. It applies to all patients covered by private insurance, unlike the Senate bill that applies only to people enrolled in plans regulated by federal law. The bill would force managed care organizations to allow providers to determine what is "medically necessary" for their patients. It also lifts the ban on lawsuits, permitting patients to file suit against their health plans for damages caused as a result of the plan's decision to withhold appropriate care.

AOTA began a grassroots effort in August designed to get members of the association to contact their representatives in support of the bill over the summer recess. Those efforts were not wasted.

The legislation passed the House by a vote of 275 to 151, despite a massive public relations campaign launched by the health insurance industry. Advertisements were designed to intimidate members of Congress and to mislead patients into believing that the protections included in H.R. 2723 would cost them their health insurance coverage.

Throughout the last several years AOTA's senior legislative counsel, Kathryn Pontzer, has worked with Norwood and others through the PARCA Alliance to draft legislation that would provide key patient protections and ensure that Americans have access to necessary services, including occupational therapy. The issues that AOTA has fought for include the following:

The right of patients to choose their health care providers and to have access to all medically necessary services including specialty care. AOTA believes patients should have access to an adequate mix and distribution of providers as well as a point-of- service (POS) option that allows participants to obtain care outside the plan's "network" without confronting prohibitive cost barriers. Particularly important for patients with chronic care conditions, legislation should allow access to specialists, including occupational therapy practitioners, on an ongoing basis, and the use of specialists as gatekeepers under certain circumstances.

H.R. 2723: Includes a POS requirement that all consumers must have the choice of at least two health care plans where one plan allows the consumer to go out-of-network for care. Access to specialists outside of the network is required when there is no appropriate provider available in the network for covered services. For individuals who are seriously ill or require continued care by a specialist, plans must have a process for selecting a specialist as a gatekeeper as well as a process for standing referrals to specialists for beneficiaries with ongoing care needs. Continuity of care requirements apply in situations where employers switch health plans and when providers are eliminated from the health plan's network.

The right of patients to all medically necessary services using appropriate utilization review standards. AOTA believes that health plan utilization review procedures should involve staff appropriately trained in the service area under consideration when making medical necessity determinations. These determinations should be based on recognized professional standards of care.

H.R. 2723:Requires health care plans to utilize written clinical review criteria developed with input from a range of appropriate actively practicing health professionals and based on valid clinical evidence. The review program must be administered by qualified health care professionals who oversee timely decisions, and the process for appealing these decisions.

Prohibition of restrictions of important medical communications and a requirement for information disclosure standards. Patients should have access to easily understandable information about their policies, particularly with respect to coverage details and history of patient satisfaction. No plan should restrict appropriate patient-provider communication about treatment options.

H.R. 2723: Prohibits health care plans from gagging health professionals, from retaliating against providers who advocate on behalf of their patients, and from providing inappropriate incentives to providers to limit medically necessary services. Health plans are required to provide a broad range of information to enrollees including the service area of the plan, information on covered benefits including benefit limits and coverage exclusions, cost sharing information, the extent to which beneficiaries can select form among providers, the number, mix and distribution of providers in the plan, the procedures for selecting and accessing specialty providers, and due process right.

Prohibition of discriminatory practices against health care professionals. Health plans should be prohibited from arbitrarily eliminating whole classes of providers from their networks, based solely on their license or certification.

H.R. 2723: Contains a provision prohibiting health plans from discriminating with respect to participation or indemnification against any provider who is acting within the scope of the provider's license or certification under applicable state law, solely on the basis of such license or certification.

Requirements for due process protections for patients and health care providers. Health plans should include a fair and reasonable process for patients to appeal adverse coverage decisions and for providers to appeal decisions concerning their inclusion in health plan networks.

H.R. 2723: Requires health care plans to provide written notice of benefit denials with an opportunity for a full and fair review by the plan. The patient, or a health professional acting on behalf of the patient, may request an internal review of an adverse coverage decision. The review must be conducted within 28 days from the time of request, and within 72 hours for expedited cases. Beneficiaries have access to an independent external review if the care in question involves covered benefits covered by the plan but deemed not medically necessary or appropriate or is investigational or experimental.

Accountability of health plans for their medical decisions. AOTA believes a health plan that denies or restricts treatment or referral to specialists should assume any liability that may ensue from such action.

H.R. 2723: All patients enrolled in private health insurance plans, including ERISA plans, will have the right to sue their plan according to state law. But, plans that comply with an external reviewer's decision may not be held liable for punitive damages. Additionally, any state law limits on damages or legal proceedings would apply. The legislation also explicitly protects employers from liability when they are not involved in treatment decisions.