Key Patient Protections |
House Bipartisan Consensus Bill (H.R.
2723)
|
Boehner Bill (H.R. 2926) |
Apply all protections to all people with employment-based
insurance (including state and local government workers) and people
who buy insurance on their own. |
ü |
NO . All of the
protections (except the point-of-service option) apply to all ERISA
plans. State and local government workers are not covered by the
review provisions at all, and their plan sponsors may elect to opt
out of the remaining protections. No protections
apply to people who buy insurance on their own.
|
Ensure that medical judgments are made by medical experts, not
insurance bureaucrats. |
ü |
NO, because
independent medical reviewers are only allowed to determine if the
plan followed its own rules, not whether the care was medically
necessary or appropriate by any object measure. |
Hold managed care plans accountable when their decisions to
withhold or limit care injures patients. |
YES , but
punitive damages are not available when plan follows
recommend- ation of external
reviewer. |
NO |
Ensure that patients in the middle of treatment for an ongoing
special condition can continue to see the same health care provider
if their provider leaves the plan or their employer changes
plans. |
ü |
NO . Continuity is only
ensured when the patient is pregnant, scheduled for surgery, or
terminally ill. |
Allow patients to see an outside specialist at no additional cost
whenever the specialists in their plan can’t meet their
needs. |
ü |
NO |
Require that HMOs and insurance companies pay for emergency
services if a reasonable person would consider the situation an
emergency. |
ü |
YES, but patients could
be left with bills for services rendered by emergency room personnel
if the plan concludes, after the fact, that those services were
rendered by non-participating health care professionals after the
patient had been adequately stabilized. |
Ensure that doctors and nurses can report quality problems
without retaliation from HMOs, insurance companies, hospitals, and
others. |
ü |
NO |
Prevent plans from financially rewarding health care
professionals for limiting a patient’s care. |
ü |
NO |
Give consumers access to an independent consumer assistance
program to help them choose plans and get the services they
need. |
NO |
NO |
Allow doctors to prescribe prescription drugs not on the HMO’s
predetermined list when needed. |
ü |
NO |
Prevent plans from denying access to clinical trials that may
save people’s lives. |
ü |
NO, except for cancer trials. |
Allow patients to appeal denials or limitations of care to an
external, independent reviewer who makes an independent judgment
about the patient’s medical needs and the appropriateness of any
proposed treatment. |
ü |
NO . The bill only
authorizes the reviewer to determine if the plan followed its own
rules. Thus, the reviewer must follow the plan’s own definition of
what care is "medically necessary or appropriate," no matter how
inconsistent with best medical practice that definition may be.
|
Give women direct access to ob-gyn services from any qualified
participating health care professional who provides such
care. |
ü |
YES , but the bill may
limit the ability of these health care professionals to refer
patients for other care. |