Key Patient Protections

Apply all protections to all people with employment-based insurance (including state and local government workers) and people who buy insurance on their own.

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NO. Most provisions apply only to the 55 million people in private employment-based plans where the employer “self-insures.” This leaves out more than 100 million people.

Preserve state laws that provide better consumer protections.

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NO. The amendment generally preempts state consumer protection laws.

Ensure that medical judgments are made by medical experts.

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NO. It allows plans to adopt restrictive definitions of what care is “medically necessary” -- definitions that control the outcome of the external review process.

Hold managed care plans accountable when their decisions to withhold or limit care injure patients.

YES, although court cannot award punitive damages when the plan follows the recommendation of the external reviewer.

NO. It fails to provide genuine accountability, and it even takes away legal rights patients now have under current law.

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.

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NO. Continuity is not ensured when employers switch plans.

Allow patients to see an outside specialist at no additional cost whenever the specialists in their plan can’t meet their needs.

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Only when the plan itself determines that an in-network specialist is not “available” to provide care. The adequacy of the in-network specialist does not appear to be relevant to this determination.

Require that insurance companies pay for emergency services at the nearest emergency room if a reasonable person would consider the situation an emergency.

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Unclear. The amendment includes a good “prudent layperson” definition, but patients could be left with emergency room bills if the plan decides, after the fact, that post-stabilization care was not medically necessary or did not need to be rendered immediately.

Ensure that doctors, nurses and other health care professionals can report quality problems without retaliation from HMOs, insurance companies, hospitals and others.

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NO

Prevent plans from financially rewarding health care professionals for limiting a patient’s care.

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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.

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Prevent plans from denying access to clinical trials that may save people’s lives.

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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.

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NO. Reviews may not be sufficiently “independent” because plans select the reviewing entity. Existing state laws creating other selection mechanisms (better designed to ensure unbiased decision making) would be preempted.

Give women direct access to ob-gyn services from any qualified participating health care professional who provides such care.

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NO. The amendment does not ensure access to participating health care professionals who are not physicians.