"The Senate-Passed Patients' Bill of Rights" has six major
components that will provide consumer protections, enhance
health care quality and increase access. These are:
An equally important goal of "The Senate-Passed Patients'
Bill of Rights" 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.
- 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 b 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 don't
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 case of pregnancy through
post-partum care.
Access to Medication: Health plans that provide
prescriptions drugs through a formulary would be required to
ensure that 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 nonformulary 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.
- 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.
- 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.
Qualifications 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, and peer-reviewed
literature, and the plan's evidence-based and clinical
practice guidelines.
- 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
individuals' genetic tests, genetic tests of family members,
or information about family medical history.
- 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.
- 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.