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NOW Supports The Patients' Bill of Rights Act

H.R. 358/S. 6, the Patients' Bill of Rights Act, was introduced by Congressman John Dingell (D-MI) and Senator Tom Daschle (D-SD).

Key Provisions :

Access to Care

Emergency Services. The bill requires that patients have access to emergency care, without prior authorization, in any situation that a "prudent lay person" would regard as an emergency.

Specialty Care. Patients with special conditions are guaranteed access to providers who have the requisite expertise to treat their problem. The legislation allows for referrals for enrollees to go out of the plan's network for specialty care (at no extra cost to the enrollee) if there is no appropriate provider available in the network for covered services.

Chronic Care Referrals. For individuals who are seriously ill or require continued care by a specialist, plans must have a process for selecting a specialist as a primary care provider and accessing necessary specialty care without impediments.

Women's Protections. The bill provides patients direct access to ob/gyn care and services and the ability to designate an ob/gyn as a primary care provider. The bill also provides protection regarding mastectomy length-of-stay.

Children's Protections. The bill ensures that children have access to pediatric specialists and the ability for children to have a pediatrician as their primary care provider.

Continuity of Care. The bill sets guidelines for the limited continuation of treatment when there are disruptions in a patient's care due to a change in the plan or a change in a provider's network status. There are special protections for pregnancy, terminal illness, and institutionalization.

Clinical Trials. Health plans must have a process for allowing certain enrollees to participate in approved clinical trials, and plans must pay for the routine patient costs associated with these trials.

Drug Formularies. For plans that use a drug formulary, beneficiaries must be able to access medications that are not on the formulary when the prescribing physician dictates.

Non-discrimination. The bill prohibits plans from discriminating against their enrollees on a variety of factors such as age, religion, genetic information, and disability.

Choice of Plans. The bill would allow a limited point of service option (POS) for employees who are offered only a closed panel HMO as their choice of health plan.

Adequacy of Provider Network. Plans must have a sufficient number, distribution, and variety of providers to ensure that all enrollees receive covered services on a timely basis.


Health Plan Information. The bill requires that patients have access to information about health plans, including coverage policies and quality indicators.

Confidentiality. The bill requires that health plans establish procedures to safeguard the privacy of individually identifiable medical information and records, maintain this information in an accurate and timely manner, and assure enrollees, participants, and beneficiaries timely access to such information.

Ombudsman. The bill authorizes an ombudsman program in each state to assist consumers in understanding health insurance options, filing appeals and grievances, etc.

Quality Assurance and Improvement

Quality Assurance. The bill requires plans to have a quality assurance program to monitor care and improve care.

Data Collection. The bill requires the collection of standardized information, including information on utilization of services, health outcomes, satisfaction, and grievances, for reporting to the states, the federal government, and where appropriate, consumers and providers. The information will be used to monitor the quality of the health plan and compare success across plans.

Provider Selection. The bill requires health plans to have a written, objective process for provider selection and forbids discrimination against providers based on license, location, or patient base. Plans would, however, be able to limit the number and mix of providers as needed to serve enrollees for covered benefits.

Utilization Review. The bill sets basic criteria for utilization review programs: physician participation in development of review criteria, administration by appropriately qualified professionals, timely decisions, and the ability to appeal.

Grievance and Appeals

Internal Appeals. Patients will be guaranteed the ability to appeal plan decisions to deny, delay, or otherwise overrule doctor-prescribed care and have those concerns addressed in a timely manner. The appeals system will be expedient, particularly in situations that threaten the life or health of the patient, and be conducted by appropriately credentialed individuals. If plans fail to meet designated time frames for reviewing appeals, patients will be able to appeal directly to an independent entity.

External Appeals. Patients will be guaranteed access to an external, independent body with the capability and authority to resolve disputes for cases involving an experimental or investigational treatment, cases involving a denial of a service which was determined not to be medically necessary, or for cases where a patient's life or health is jeopardized. In the bill, States and the Department of Labor must establish an independent external appeals process for the plans under their respective jurisdictions. The plan must pay the costs of the process, and any decision is binding on the plan.

Protecting the Provider-Patient Relationship

Anti-Gag and Provider Incentive Plans. The bill prohibits health plans from restricting communications between doctors and their patients and from retaliating against providers who advocate on behalf of their patients. It protects providers in these situations from retribution, and protects providers who report quality problems to appropriate authorities from retribution. It also limits plans' ability to provide incentives to providers to limit medically necessary services.

Provider Due Process. Providers will receive reasonable notice of termination and be allowed to review any information behind the termination decision and appeal such adverse determinations within the plan.

Medical Necessity. Prohibits health plans from interfering with the decisions of treating physicians when those decisions are a covered benefit and medically necessary according to generally accepted principles. Treatment decisions must be made in accordance with generally accepted principles and standards of professional medical practice.

*Insurer Liability. The bill amends the Employee Retirement Income Security Act (ERISA) to allow patients to hold health plans legally accountable for their medical decisions that cause harm according to state law. The provision also protects employers and employees from liability when they were not involved in the treatment decision.
* Many legislators want to Weaken the Insurer Liability and other provisions - Don't Let Them Do It !