|
Key Patient Protections |
House-passed Bipartisan Bill |
Senate-passed Bill |
| 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. Most provisions apply only to the 48 million people in private employment-based plans where the employer "self-insures." |
| Ensure that medical judgments are made by medical experts, not insurance bureaucrats. | ü |
NO, except in some situations for some breast cancer patients. |
| Hold managed care plans accountable when their decisions to withhold or limit care injure 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 not ensured when employers switch plans. When a provider leaves a plan, continuity is available only when the patient is pregnant, institutionalized, 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 insurance companies pay for emergency services if a reasonable person would consider the situation an emergency. | ü | Unclear. The bill includes a good "prudent layperson" definition, but limits required coverage to those services necessary to "stabilize" (or, in some cases, to maintain stability of) the patient. 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 after the patient had been adequately stabilized. |
| Ensure that doctors, nurses, and other health care professionals 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 |
ü |
| Prevent plans from denying access to clinical trials that may save people’s lives. | ü | NO, except for some 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 allows the plan’s own definition of what care is "medically necessary and appropriate" to dictate the outcome of the external review, 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 |
NO. The bill does not ensure access to participating health care professionals who are not physicians. |
10/13/99 For More Information contact: National Partnership for Women and Families (202) 986-2600.
National Partnership for Women & Families.
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