Access to Out-of-Network Providers

Consumer Choice Option – consumers would be permitted to see other, non-network providers as a premium not to exceed a rate established by the National Association of Insurance Commissioners. Also prohibits plans from reimbursing non-network providers for covered services less than network providers receive for similar services but may charge enrollee more for this option.

If the HMO does not include specialists qualified to treat a condition, it would have to allow the patient to see a qualified doctor outside its network at no extra cost.

Plans that offer network-only plans would be 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 plans that offer a choice of two or more health insurance option or two or more options with significantly different providers. Plans could charge higher premiums and cost sharing for the POS option.

Plans that offer network-only plans would be 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 plans that offer a choice of two or more health insurance option or two or more options with significantly different providers. Plans could charge higher premiums and cost sharing for the POS option.

Would provide a Point-of-Service option to empower patient with the right to choose their own providers, when they are enrolled in a restricted plan.

Subject to certain exceptions, closed panel HMOs would have to offer a point-of-service option to employers in conjunction with plans that limit choice. Employers will be able to accept or decline the expanded choice option at the time of enrollment. If employers decline, the insurance company will be required to offer a POS option as supplemental coverage to employees through the individual market.

(No Point of Service Provision)

However, if a plan or issuer refers an individual to a non-participating specialist, services provided pursuant to the approved treatment plan (if any) would be provided at no additional cost to the individual beyond what the individual would otherwise pay for services received by such a specialist that is a participating provider.

Would require that enrollees be offered the option to obtain care for covered benefits from non-participating health care providers. Would not require employers to pay the costs of such an option. Would allow group health plans and issuers to charge a higher premium or to increase a participant’s cost-sharing for selecting or using this option. Would require plans and issuers to pay at least as much to out-of-network providers as to in-network providers for the same service.

Access to In-Network Access Specialists

Would require access to specialists when "medically or clinically indicated in the professional judgment of the treating health professional, in consultation with the participant, beneficiary, or enrollee."

Specialists are defined in the bill as health professionals with expertise in special health care needs or chronic conditions.

Would ensure that patients who suffer from a chronic condition or a disease that requires care by a specialist will have access to a qualified specialist.

Would allow patients with serious ongoing conditions to choose a specialist as their primary doctor or to see that doctor without having to ask their HMO for permission before every visit.

Plans who terminate or non 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, is in the second (or late) trimester of pregnancy, or is terminally ill.

Plans who terminate or non 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, is in the second (or late) trimester of pregnancy, or is terminally ill.

Seeks to guarantee that patients and their primary care physicians who request referral to a medical specialist must receive an answer from the health plan within 72 hours. If a specialist request is initially denied, a patient still has recourse through the internal and external review process provided for in the bill.

Would provide access to specialists, pursuant to a treatment plan

To prevent difficult transitions when a provider leaves a network, the bill would allow pregnant women, the terminally ill, and certain other patients to continue to see their provider under certain circumstances even after the provider leaves the network.

For persons with a condition or disease of sufficent seriousness and complexity to require treatment by a specialist, the plan or issuer must make or provide for referral to an available and accessible specialist with adequate expertise.

Would require plans and issuers that use participating health care providers to have a "sufficient" number, distribution, and variety of qualified providers to ensure that all covered health benefits will be available and accessible in a timely manner to all participants.

Coverage of Emergency Services

If a plan provides emergency room services, plans would be forbidden to require prior authorization for such services whether the provider is in- or out-of-network, at a cost that is no more than that for in-network services. It also specifies that plans may not use inappropriate cost-sharing, exclusion, or coordination of benefits rules to obscure this requirement. Plans would also be required to reimburse providers for post stabilization and maintenance care consistent with relevant SSA regulations regarding timeliness and coordination.

Emergency Services are defined in the bill as those which are available at that facility to stabilize the patient.

Would allow patients to go to any emergency room during a medical emergency, without having to call a health plan for permission. Emergency room physicians would be able to stabilize their patients and plan for a cure after stabilization without fear that health plans would deny coverage.

Plans would be required to use the "prudent layperson" standard for providing initial emergency screening exams and "additional emergency services" determined necessary by a "prudent emergency medical professional."

Plans would be required to use the "prudent layperson" standard for providing initial emergency screening exams and "additional emergency services" determined necessary by a "prudent emergency medical professional."

Would be based upon the "prudent layperson" standard and, importantly, would include reimbursement for post-stabilization and maintenance care. Prior authorization of services would be prohibited.

Would require that emergency services be provided, without prior authorization and without regard to network limitations, if a prudent layperson could reasonably expect the absence of immediate medical attention to result in serious jeopardy to individual’s health.

Access to Obstetric and Gynecological Care

Would require direct access for enrollees to routine obstetric and gynecological care where their plan covers this type of care. No prior authorization or referral would be required or permitted. These providers may act as primary care providers in referring to other, related services.

Would allow a woman to have direct access to her OB/GYN without having to get a referral from her HMO. Women also would have the option to designate their OB/GYN as their primary care physician.

Health plans would be required to allow direct access to obstetricians and gynecologists without referrals.

Health plans would be required to allow direct access to obstetricians and gynecologists without referrals.

Would allow enrollees of plans that provide routine gynecological care or pregnancy-related services direct access to gynecological and obstetrical care, without authorization or referral by a primary care physician.

Would allow women to obtain obstetrical/gynecological services without a referral from a primary care provider.

If a plan requires or allows a beneficiary to designate a participating primary care provider, women would be allowed direct access to covered, routine ob-gyn services.

Ban on Financial Incentives to Deny Care

Plans would be prohibited from denying "medically necessary services" though inducements to providers to limit such care and requires plans to have sufficient stop-loss insurance to guard against financial losses. It would require plans to submit a plan to the Secretary detailing these actions.

Would limit insurance companies’ ability to use financial incentives to get doctors to deny care. HMOs and insurers also would have to disclose to all patients information about the incentives used.

Plans would be barred from using financial incentives as an inducement to physicians for reducing or limiting the provision of medically necessary services.

Would prohibit contract requirements that transfer plan or issuer liability—incurred through activities, actions or omissions—to the health care provider. Would apply Medicare rules for limiting the use of physician incentive plans that place providers at substantial financial risk for the cost of providing care.

Ban on Gag Clauses

Would include a prohibition on gag clauses that is very similar to the one included in the BBA of 1997. It would forbid plans from prohibiting providers from discussing any relevant care or treatment with their patients but would not require counseling or provision of services that the provider objects to on moral or religious grounds.

Would prevent HMOs from interfering with doctors’ communications with their patients. Doctors cannot be penalized for referring patients to specialists or discussing costly medical procedures.

Plans would be prohibited from including "gag rules" in providers’ contracts.

Plans would be prohibited from including "gag rules" in providers’ contracts.

Would prohibit health plans from restricting physicians from giving advice to a patient about his/her health status, or the medical care or treatment for the condition or disease of that patient. This is regardless of whether benefits for such care or treatment are provided under the terms of his or her health benefit plan. Lifting gag rules will allow free and open communications between patients and doctors in order to make fully informed decisions about the best course of treatment.

Plans would be prohibited from using "gag rules" to restrict physicians from discussing health status and legal treatment options with patients.

Following the blueprint enacted for Medicare and Medicaid in 1997, the bill would prevent health plans from restricting communications between patients and their health care providers about their health status and treatment options.

Health Plan Information Disclosure to Patients

Would require plans to publish at enrollment, provide annually, and upon written request send to enrollees and participating providers, the following information: plan benefits including covered items and ER services and plan rules on preventive services, drug formularies, COBRA rules, lifetime or annual caps on coverage, custodial care, experimental treatment, second or subsequent options, specialty care, continuity of care, restrictions on coverage of ER services, participant’s financial responsibilities, dispute resolution procedures, network characteristics, care management information such as disease management programs, preauthorization and utilization review, accreditation status of plan and details about its utilization review organization, measures of enrollee satisfaction, and quality performance measures. Upon written request, enrollees may request information on provider credentials including how they are compensated, facility licensing information, and advance notice of changes in drug formularies.

Plans would be required to provide a wide range of information about health insurance options, such as descriptions of the networks, premium and cost sharing information. Quality outcomes data and information is not mandated.

Plans, providers, schools, and others would be required to: permit enrollees to inspect and copy their own medical records, except when such information could endanger a person’s physical safety; and disclose their confidentiality practices and to establish appropriate safeguards for patient information. Civil money penalties would be imposed for violations.

Plans would be required to provide a wide range of information about health insurance options, such as descriptions of the networks, premium and cost sharing information. Quality outcomes data and information is not mandated.

Plans, providers, schools, and others would be required to: permit enrollees to inspect and copy their own medical records, except when such information could endanger a person’s physical safety; and disclose their confidentiality practices and to establish appropriate safeguards for patient information. Civil money penalties would be imposed for violations.

Would provide Americans full access to easy to understand information about their health plans before they determine which plan best suits their needs. This will empower patients to make more informed decisions and allow them more responsibility to pursue their rights under law. Such information includes: a complete description of covered benefits and which items and services are excluded, limited, or otherwise restricted; a procedure must be in place – for the first time ever- to notify participants in advance of changes to a drug formulary involving chronic diseases; an explanation of the participant’s financial responsibility as to premiums, coinsurance, copayments, deductibles and other provisions; and a complete description of the claims procedure and appeals process.

Would also ensure the availability of the following additional information: what doctors and providers participate in the health plan; what qualifications and experience plan physicians have, what qualifications and experience plan hospitals and healthcare facilities have; availability and criteria for use of special disease management programs; a full explanation of any coverage denial based on medical necessity or experimental treatment; patient satisfaction measures maintained by the plan; and quality performance measures about care delivery maintained by the plan. Upon request, the participant would have direct access to the complete plan description and any summary in a generally recognized electronic form. Plans may satisfy this requirement by posting the information on a company intranet or secure internet site.

Consumers would be given uniform comparative information on quality measures in order to make informed choices. Data would include: patient satisfaction, delivery of health care services such as immunizations, and resulting changes in beneficiary health.

Patients would be provided with information on benefits, cost-sharing, access to services, grievance and appeals, etc. A grant program would be authorized to provide enrollees with information about their coverage options, and with grievance and appeals processes.

Plans would be required to provide a written description of their physician and provider selection procedures.

Would require plans to disclose—at specified time periods or upon request—a variety of information to patients, including covered benefits, cost-sharing requirements, out-of-network coverage, grievance and appeals procedures, credentials of participating providers, and formulary restrictions.

Grievance and Appeals Process

Would establish a sound and independent external appeals process. Would ensure that patients who are denied care by an insurance company can appeal the decision to an independent reviewer with medical and legal expertise, and receive timely decisions that are binding on the HMO.

Plans would be required to have written grievance procedures and have both an internal and external appeals procedure. Grievances would not be appealable.

Appeals for coverage determinations based on lack of medical necessity or experimental treatment would be by a doctor "with appropriate expertise in field of medicine involved" who was not involved in the initial decision.

Enrollees and providers could appeal to independent medical reviewers for amounts above a significant financial threshold for issues based on medical necessity or for services that involve an experimental treatment where the enrollees’ life is in jeopardy. External reviewers could include those licensed by the State or under Federal contract for this purpose, a teaching hospital, or entities meeting specific criteria. External review would be binding on plans and issuers.

Plans would be required to have written grievance procedures and have both an internal and external appeals procedure. Grievances would not be appealable.

Appeals for coverage determinations based on lack of medical necessity or experimental treatment would be by a doctor "with appropriate expertise in field of medicine involved" who was not involved in the initial decision.

Enrollees and providers could appeal to independent medical reviewers for amounts above a significant financial threshold for issues based on medical necessity or for services that involve an experimental treatment where the enrollees’ life is in jeopardy. External reviewers could include those licensed by the State or under Federal contract for this purpose, a teaching hospital, or entities meeting specific criteria. External review would be binding on plans and issuers.

Would provide patients and their physicians the ability to find out quickly if something is covered especially in the case of emergency and urgent care situations.

Would give patients the ability to pursue an immediate and informed appeal for routine care (within 30 days) whenever they feel a denial of coverage is unwarranted. Expedited time frames would apply in emergency (within 72 hours) and urgent (within 10 days) cases.

Would ensure that the patient’s appeal is to a doctor, not involved in the initial denial, who will decide if a requested item or service is medically appropriate or experimental.

Seeks to guarantee patients the right to seek an additional review of coverage denials involving medical necessity or experimental treatment within 25 days of the review filing date (or within the expedited time frames for emergency or urgent care). This additional review would be conducted by an external medical expert, independent from the health plan and not affiliated with the related party.

Would provide patients the right to go immediately to court to protect the patient from the potential of irreparable harm to their health.

Would give patients new rights to recover costs, such as attorneys’ fees and other reasonable costs relating to court action. Courts may also assess penalties of up to $500 per day (or up to $1000 in the case of a bad faith violation), up to $250,000, if plans wrongfully deny coverage after an external review.

Plans would be required to make decisions as to whether to provide benefits, or payments for benefits, in a timely manner. The plan would be required to have a process for making expedited determinations in cases in which the standard deadlines could seriously jeopardize the patient’s life, health, ability to regain or maintain maximum function or (in the case of a child under the age of 6) development.

Patients would be assured the right to appeal the following: failure to cover emergency services, the denial, reduction, or termination of benefits, or any decision regarding the clinical necessity, appropriateness, efficacy, or efficiency of health care services, procedures or settings. The plan would be required to have a timely internal review system, using health care professionals independent of the case at hand, and procedures for expediting decisions in cases in which the standard timeline could seriously jeopardize the covered individual’s life, health, ability to regain or maintain maximum function, or (in the case of a child under the age of 6) development.

Individuals would be assured access to an external, independent appeals process for cases of sufficient seriousness or which exceed a certain monetary threshold that were not resolved to the patient’s satisfaction through the internal appeals process. The external appeal entity, not the plan, would have the authority to decide whether a particular plan decision is in fact externally appealable. In addition to the patient’s medical record and the treating physician’s proposed treatment, the range of evidence that is permissible in an external review would include valid and reliable research, studies and other evidence from impartial experts in the relevant field—the same types of evidence typically used by the courts in adjudicating health care quality cases. The external appeal process would require a fair, "de novo" determination, the plan would pay the costs of the process, and any decision would be binding on the plan.

Would require plans and issuers to establish and maintain a grievance system, which documents both grievances and appeals, and provides for timely processing and resolution of grievances, and follow-up procedures.

Would allow patients to appeal certain decisions concerning coverage and access to care in accordance with a specified internal appeals process. The bill specifies who may conduct the review, within explicitly stated time frames, and under what circumstances the timing of a review can be either expedited or extended.

Would allow a patient, plan or issuer to submit an interal review decision to an independent review panel if the amount involved exceeds $100 OR the patient’s life or health is in jeopardy as a consequence of the decision. The panel would be required to employ clinical peers and have sufficient medical, legal and other expertise as well as sufficient staffing. The process would be required to provide for a fair, de novo determination of medical necessity, without regard to the definition used by the plan or issuer. Would set minimal standards, including time frames, for the appeals process. Would make the determination of the external appeals entity binding on the plan. The panel would be immune from civil or criminal penalty except in cases of malice or gross misconduct.

Enforcement of Patient Protections/ Health Plan Liability

Would close the loophole from the Employee Retirement Income Security Act of 1974 (ERISA) and ensures that like any other industry, HMOs can be held accountable for their actions.

Health plans would be prohibited from arbitrarily interfering with the decision of the treating physician if the services are medically necessary and a covered benefit. Medically necessary services are defined in the bill to be those which are consistent with generally accepted principles of professional medical practice.

Would ensure that enforcement of federal law is not dependent upon individuals bringing court cases to enforce plan compliance by giving the Secretaries of Labor and Health & Human Services enhanced authorities to enjoin managed care plans from denying medically necessary care and to levy fines (up to $50,000 for individual cases and up to $250,000 for a pattern of wrongful conduct).

All privately insured individuals would have access to federal courts for economic loss resulting from injury caused by the improper denial of care by managed care plans. Economic loss would be defined as any pecuniary loss caused by the decision of the managed care plan, and would include lost earnings or other benefits related to employment, medical expenses, and business or employment opportunities. Awards of economic loss would be uncapped and attorneys’ fees could be awarded at the discretion of the court.

Would prohibit plans from retaliating against providers who alert regulators or inspectors to quality or safety concerns or who reasonably participates in an internal or external grievance process of the plan. Also would prohibit retaliation against providers and patients for use of, or participation in, utilization review or grievance processes.

Would amend ERISA to allow patients access to state laws which may allow for the recovery of damages for personal injury or wrongful death resulting from acts connected with or arising out of an arrangement for the "provision of insurance, administrative services, or medical services" by or for a group health plan. However, plans that promptly follow the binding recommendation of an external review panel would be protected from punitive damage awards.

Other

Prescription Drug Coverage

Would ensure that patients with drug coverage are able to obtain needed medications, even if they are not on the HMO’s approved list.

Doctors’ Decisions on Patients’ Care

Would protect the doctor-patient relationship and ensure that doctors – not HMO accountants – drive medical decisions.

Would prevent HMO’s from inappropriately interfering with doctors’ judgments and cannot mandate drive-through procedures or set arbitrary limits on hospital lengths of stay. Doctors and nurses who advocate on behalf of their patients would be protected from retaliation by HMO’s.

Genetic Information

All plans—self-funded and insured group plans, as well as individual plans—would be prohibited from denying coverage, or adjusting premiums or contribution amounts based on "predictive genetic information." The term "predictive genetic information" includes individual’s genetic tests, genetic tests of family members, or information about family medical history.

Refocusing AHCPR on Quality Improvement

Would refocus AHCPR (and rename it the Agency for Healthcare Quality Research) to encourage overall improvement of quality in the nation’s health care systems. The new agency would facilitate support of state-of-the-art information systems, support of primary care research, technology assessment and coordination of the Federal Government’s own quality improvement efforts.

Access to Health Insurance

Includes three provisions seeking improved access:

1. Would allow full deduction of health insurance for self-employed individuals.
2. Would give individuals the ability to carry forward up to $500 in their flexible spending accounts from one year to the next or to be deposited into an IRA, and MSA, or a 401(K) plan.
3. Would lift the caps for MSAs and would allow all individuals, including Federal employees, the option to purchase these plans.

Access to Health Insurance

Includes three provisions seeking improved access:

1. Would allow full deduction of health insurance for self-employed individuals.
2. Would give individuals the ability to carry forward up to $500 in their flexible spending accounts from one year to the next or to be deposited into an IRA, and MSA, or a 401(K) plan.
3. Would lift the caps for MSAs and would allow all individuals, including Federal employees, the option to purchase these plans.

Creation of Association Health Plans

Would Create Association Health Plans (AHPs) to help provide healthcare options to the uninsured and employees of small businesses that can’t afford providing health care benefits.

Workers in small businesses and the self-employed would be able to join together to obtain the same economies of scale, purchasing clout and administrative efficiencies that employees of large employers benefit from.

AHP’s would have the freedom to design more affordable benefit options and offer workers access to the same, uniform benefit choices wherever they live.

Would promote increased competition and greater choice in the health insurance market

Create HealthMarts

Would be a new option within existing health care system for small business and their employees. HealthMarts would be private, voluntary, and competitive health insurance "supermarkets" that transfer choice within the current employer-based health insurance market from small employers to their employees and dependents.

HealthMarts would be established and governed by private sector partnerships comprised of equal representatives of providers, consumers, small employers, and insurers.

Medical Malpractice Reform Would limit "non-economic" damages to $250,000 but would give States authority to enact higher or lower limits if State so chooses.

Would allow juries to be informed about multiple recoveries paid to plaintiffs.

Payments of damages would be allowed to be made periodically, rather than immediately.

Lawsuits would have to be brought within two years from date of discovery of injury, but not later than five years from date of injury.

Plaintiffs would not be able to recover 100% of damages from one party where multiple parties are involved.

Would not allow for punitive damages unless "clear and convincing evidence" of reckless disregard for victim.

Continuity of Care

Would allow for the continuation of care in the case of a contract termination for a set period of time for chronic and terminal illnesses, pregnancies, and institutional care.

Continuity of Care

Would require continuation of coverage with a terminated provider for at least 90 days, if an enrollee is undergoing a course of treatment at the time of contract or benefit termination. Exceptions to allow for more than 90 days would be specified for institutional care, for enrollees who have entered into the second trimester of pregnancy at the time the contract termination, and terminal illness.

Access to Prescription Drugs

Would require plans and issuers that limit prescription drug benefits to those included in a formulary to provide exceptions from the formulary limitation when a non-formulary alternative is medically indicated. Also would require the plan or issuer to ensure participation of participating physicians and pharmacists in the development of the formulary. Would require plans that provide any coverage of drugs or devices to provide coverage of drugs and devices for certain investigational uses.

Effective Date

January 1, 2000

January 1, 2000

January, 2001

January, 2001

January 1, 2001

January 1, 2000

October 1, 2000