| Issue |
Patients' Bill of Rights of 1998 (Democratic Proposal) |
President's Quality Commission |
HIP/ Kaiser Permanente/AARP/Families USA |
AAHP's Putting Patients First |
Norwood H.R. 1415 |
| Entities Regulated |
Individual health insurance, group health insurance, group health
plans (including ERISA plans). |
Applies to all consumers and participants in the health system. |
Legally enforceable national standards would apply to all plans
including ERISA plans. |
Voluntary compliance for plans that are members of AAHP. AAHP member
plans will attest that their plan abides by PPF and will provide information to enable
AAHP to report on compliance. |
Individual health insurance, group health insurance, group health
plans (including ERISA plans). |
| Plan Choice - Enrollment Protections |
Plans must provide access to specialists outside of plan if the plan
has no appropriately qualified health professional available to treat enrollee. Such out
of plan referrals would be available at no extra cost to the enrollee. The plan and the
primary care doctor would establish the terms for out of network referrals.
If an individual is offered only one health plan by their employer and
that plan is a closed panel HMO, that HMO would have to offer beneficiaries (upon
enrollment) the option to enroll in a Point of Service (POS) plan instead. Plans would
have the option of using higher cost sharing and premiums. There are no requirements on
employers with regard to the POS option. |
If a plan has insufficient number or type of providers to provide a
covered benefit with appropriate degree of specialization, the plan should ensure the
consumer obtains the benefit outside the network at no extra cost.
Public and private group purchasers should, wherever feasible, offer
consumers a choice of high quality health insurance products. |
Health plans must provide out-of-network referrals at no cost to the
member when the health plan does not have a network physician with the appropriate
training or expertise or when the health plan does not have an affiliation with a
recognized specialty care center to meet a member's covered medical needs.
Individuals should be given a choice of health plans. |
No provision for out-of-network referrals.
No provision on choice of health plan. |
Does not specifically state that beneficiaries may go outside of plan
if there is no available specialist in plan.
Must offer POS option at time of enrollment if a health insurance
issuer (group health plan) is a closed panel HMO. Premiums for this option must be
established by the state in consultation with NAIC and must be fair and reasonable.
Reimbursement rates for non-participating providers may not be less than those offered to
participating providers, but only for covered services.
|
| Information Disclosure |
Up-front disclosure to include: covered benefits;
cost-sharing; procedures for resolving complaints; comparable measures of quality and
consumer satisfaction (including outcomes of grievance and appeals decisions); procedures
that govern access to specialists and emergency services; provider ability to accept new
patients; coverage of experimental treatment; use of prescription drug formulary; plan
loss ratios; and methods to assist non-English speaking enrollees. Information provided upon request: description of utilization review
process and requirements; provider financial incentives and payment methods;
confidentiality policies; provider credentials and current participation status; and
formulary restrictions. |
Disclosure should include: covered benefits; cost-sharing;
procedures for resolving complaints; comparable measures of quality and consumer
satisfaction; the procedures that govern access to specialists and emergency services;
care management information; health professional/facility education and/or board
(re)certification; licensure, certification and accreditation status; years of practice;
experience performing certain procedures; provider network composition; and community
benefits provided. |
Disclosure to include: covered and excluded benefits; how to
obtain services, select providers, and obtain referrals; cost-sharing requirements;
names/credentials of plan physicians; physician compensation mechanisms; utilization
management procedures; a description of drug formularies; procedures for receiving
emergency care and out-of-network services; procedures for determining coverage for
investigational or experimental treatments; how to appeal decisions, and file grievances;
plan loss ratios. Should also include information on contacting consumer organizations,
such as ombudsman programs or government agencies regulating the health plan. |
Disclosure to include: information on plan's structure and
provider network; covered and excluded benefits; out-of-area and emergency coverage;
cost-sharing requirements; and policies for referrals to specialists. Plans should allow
access to up-to-date information about physician availability to accept new members. Disclosure upon request: pre-certification and other utilization review
procedures; the plan's basis for specific utilization review decisions; whether a specific
prescription drug is included in a formulary; a summary of participating physician payment
methods, including financial incentives; and the procedures and medically-based criteria a
health plan uses to determine whether experimental treatments and technologies should
become covered services. |
Disclosure to include (does not specify if this is mandatory
disclosure or upon request): covered and excluded benefits; enrollee financial
obligations; list of health plan providers; description of prior authorization/utilization
review processes and requirements; outcomes of utilization determinations and percentage
reversed on appeal; quality indicators; grievance and appeals data; financial arrangements
and incentives that may limit services or treatment options; plan loss ratios; and ratio
of enrollees to providers in professional category. The Secretaries of Labor and HHS shall
issue regulations establishing the format of this information publication and the
placement and positioning of the information in health plan marketing materials. |
| Non-Discrimination |
For enrollees: prohibits discrimination in the delivery of
services based on health status, genetic information and variety of other factors.*
For providers: plans may not discriminate on the basis
standard civil rights protections (age, race, sex, etc), on the basis of having a high
risk patient base, or being located in area with residents of poorer health status.
Prohibits discrimination in participation or indemnification based solely on license but
does not require plans to contract with unneeded providers or cover benefits that are not
covered under the plan*. Does not override state licensure or scope of practice laws. |
For enrollees: prohibits discrimination in the delivery of
health care services or marketing and enrollment practices based on race, ethnicity,
national origin, religion, sex, age, mental or physical disability, sexual orientation,
genetic information, or source of payment. |
For enrollees: plans shouldn't discriminate in the provision
of health care based on age, gender, race, national origin, language, religion,
socio-economic status, sexual orientation, disability, genetic make-up, health status, or
source of payment. For providers: health plans should
not discriminate against providers who treat a disproportionate number of patients with
expensive or chronic medical conditions. Health insurance reform should address
discriminatory practices that discourage enrollment of high-risk, high-cost or vulnerable
populations in health plans. |
No provision. |
For enrollees: prohibits discrimination directly or through
contractual arrangements in any activity that has the effect of discriminating against
enrollees on the basis of race, national origin, gender, language, socio-economic status,
age, disability, health status, or anticipated need for health services.
For providers: health plans may not discriminate against
providers on the basis of race, national origin, gender, age or disability or the
professional's lack of affiliation with or admitting privileges at a hospital. In
addition, plans may not discriminate in participation, reimbursement, or indemnification
against a health professional that is acting within the scope of their license solely on
the basis of such license or certification |
| Consumer Ombudsman |
States that receive a grant from the federal government shall
establish an Ombudsman to assist enrollees in understanding health insurance options and
in filing grievances and appeals. Federally established when States default. Federal
appropriations are necessary for the establishment of these programs. |
Does not specifically call for an ombudsman but notes that consumer
assistance programs would be a benefit to consumers and other stake holders. Consumer
assistence programs should inspire confidence, act as a resource to help individuals
resolve problems and foster collaboration of resources to meet the needs of consumers, as
some consumers may need assistance in the health system. |
Consumers should have access to, and health plans should cooperate
with, an independent, external non-profit ombudsman program that helps consumers
understand plan marketing materials and coverage provisions, educates members about their
rights within health plans, investigates members' complaints, helps members file
grievances and appeals, and provides consumer education and information. |
No provision. |
No provision. |
| Access -- General |
Plans must have a sufficient number, distribution and variety of
qualified providers to ensure that all enrollees receive covered services, including
specialty services, on a timely basis (including rural areas).* Plans should consider
contracting with federally-qualified health centers (FQHCs) if necessary to meet access
standard. |
Plan networks should provide access to sufficient numbers and types of
providers to ensure that all covered services will be accessible without unreasonable
delay -- including emergency access 24 hours/day, 7 days/week. Plans should establish and
maintain adequate arrangements to ensure reasonable proximity of
providers to the business or personal residence of their members. Consumers should have a
choice of provider sufficient to ensure access to appropriate health care. |
Plans must have enough physician specialists and other providers to
provide timely, appropriate care 24 hours a day, seven days a week. Health plans should
develop culturally competent provider networks. Members should be allowed to choose their
own PCP and change PCP at any time. |
Plans should offer a choice among primary care physicians
participating in the network who are available to accept new patients. Members should be
allowed to switch among participating primary care physicians who are available to accept
new patients. |
Requires access to sufficient number, mix and distribution of
providers in a variety of service sites with reasonable promptness. Telemedicine and other
innovative means may be considered to meet these requirements in rural or medically
underserved areas. Enrollees must be allowed to choose a health professional from among
all participating professionals and change selection as appropriate. |
| Access -- Emergency Care |
Allows a beneficiary to go to the nearest emergency room in an
emergency. Uses prudent layperson definition and conforms post-stabilization standards to
those proscribed by the Secretary for Medicare.* Protects enrollees against excess charges
by emergency facilities. Plans should inform members about proper use, etc of emergency
rooms. |
Allows beneficiary to go to the nearest emergency room in an emergency
based on prudent layperson standard without prior authorization and in-network
requirements. Non-network providers and facilities should not bill patients or plans for
any charges in excess of health plans' routine payment arrangements. ER department should
contact plan as quickly as possible to coordinate follow-up and post-stabilization care. |
Plans should cover emergency services, based on prudent layperson
definition. Emergency departments should inform the health plan within 30 minutes after
stabilization to obtain authorization for any post-stabilization services; plan should
respond to the request within 30 minutes and provide access to a participating physician
if it intends to deny the request for authorization. Plans should educate their members
about ER use availability, cost sharing, etc. Plans should cover unforseen emergency and
urgent care services for members traveling outside of the plan's service area. |
Health plans should cover emergency -room screening and stabilization
as needed for conditions that reasonably appear to constitute an emergency, based on the
patient's presenting symptoms. Emergency conditions are those that arise suddenly and
require immediate treatment to avoid jeopardy to a patient's life or health. To promote
continuity of care and optimal care by the treating physician, the emergency department
should contact the patient's primary care physician as soon as possible. |
Requires plans to provide access to emergency care 24 hours a day, 7
days a week, and cover and reimburse for and not require PA for emergency services,
ancillary services to diagnose, treat and stabilize a condition, and urgent care services.
Uses prudent layperson definition. Post-stabilization care is not addressed. |
| Access -- Specialty Care |
Plans must provide access to specialists or specialty centers
affiliated with the plan, pursuant to treatment plans, including standing referrals to
specialists, if appropriate. Plans may restrict choice to participating specialists unless
no appropriate specialist available. |
Consumers with complex or serious medical conditions who require
frequent specialty care should have direct access to a qualified specialist of their
choice within a plan's network. |
Health plans must provide access to specialists and specialty care
centers affiliated with the plan pursuant to treatment plans, including standing referrals
to specialists if appropriate. |
Health plans should have procedures to promote timely and appropriate
access to specialty care. Plans should periodically evaluate these procedures with
reference to selected medical conditions, focusing on appropriateness of care. Each health
plan should offer members a choice, in coordination with their primary care physician,
among specialty physicians who participate in the plan's network and are available to
accept new patients. |
Plans must demonstrate enrollees have access to specialized treatment
when deemed necessary by treating health professional in consultation with enrollee. |
| Access -- Women's Services |
Women must have direct access to routine and preventive women's health
services through a provider that specializes in obstetrics or gynecology. Women may
designate an OB/GYN as PCP. Also includes provisions on
mastectomy length of stay and breast reconstruction. |
Women should be able to choose a qualified provider (including a
ob/gyn, certified nurse midwife or other qualified provider) to provide routine and
preventive women's health care services. |
Health plans must provide women members with direct access to
obstetricians and gynecologists. |
Health plans should not require outpatient mastectomies and mastectomy
care decisions should be made by a physician, after consultation with the patient, based
on the best scientific information and unique characteristics of the patient. |
No provisions on direct access to or selection of OB/GYN as PCP. |
| Access -- Chronic Care |
Plans must have written process for issuing standing referrals and for
selection of specialists as PCP for enrollees requiring ongoing care, pursuant to a
treatment plan. |
Authorizations for specialty care should be for an adequate number of
direct visits under an approved treatment plan. |
Access to specialists including standing referrals to specialists. |
No provisions. |
Coordination of care or cost controls must not create an undue burden
for enrollees with special health conditions or chronic conditions. Plan in conjunction
with enrollee and treating professional must determine in these cases whether specialist
or care coordinator appropriate to ensure continuity of care. |
| Transitional Care |
If an enrollee's provider leaves the plan or if the enrollee's plan is
terminated (except for quality or fraud violations), the enrollee must be permitted to
continue their course of treatment for up to 90 days, with additional protections for
institutional care, pregnancy, and terminal illness. The provider must accept the payment
rate prior to termination and may not charge the beneficiary cost-sharing beyond what the
plan allows. |
If an enrollee's provider leaves the plan or if the enrollee's plan is
terminated (except for quality or fraud violations) and the enrollee is receiving care for
a chronic or disabling condition (or is in the second or third trimester of pregnancy)
must be permitted to continue their course of treatment for up to 90 days (or through
completion of postpartum care). Providers must accept the plan's rates in full, provide
all necessary information to the plan for quality purposes, and promptly transfer all
medical records with patient authorization during the transition period. |
Members who are being treated for a serious illness or who are in the
second trimester of pregnancy should be allowed to receive treatment from their physician
specialists for up to 60 days or through post-partum if their doctor's contract is
terminated by a plan (for reasons other than quality of care), or if their former health
plan is replaced and the patient's previous physicians specialist is not in the new plan. |
Each health plan should have procedures to facilitate the transfer of
care from one practitioner to another when a practitioner treating a patient during an
episode of serious illness (or a patient in the second or third trimester of pregnancy)
leaves a network for reasons other than cause. Procedures may include, but are not limited
to, facilitating establishment of appointments with a qualified new practitioner, a period
of coverage of the previous practitioner (if the provider is in good standing), and/or
supporting the transfer of medical records (which depends on cooperation of patient's
previous practicioner). |
Plans must cover items and services provided by the health
professional or provider that was treating the enrollee before the change in provider.
This may be due to change in the membership of an issuer's health professional and
provider network, changes in the health coverage made available by an employer, or other
similar circumstances. Applies to enrolles with special health care needs and with chronic
conditions. Also applies to inpatients and persons dependent on high-tech home medical
equipment. |
| Clinical Trials and Experimental Treatment |
Plans must have an objective process for considering experimental
treatments. Clinical trials must be covered in defined circumstances. The plan may not
discriminate against the enrollee based on their participation in the trial. Plan not
responsible for costs reasonably expected to be covered by trial sponsors but plan must
provide for routine patient costs. |
No specific provision relating to clinical trials. However, health
plans should provide consumers with the procedures used to determine coverage for
investigational or experimental treatments. |
Plans should have an objective process for reviewing new drugs,
devices, procedures, and therapies. Plans should also have an external, independent review
process to examine the cases of seriously ill patients who are denied coverage for
experimental treatments. |
No provision. But in the event of a dispute of coverage over
experimental treatments and technologies, the plan should tell the beneficiary, if they
ask, the procedures and medically-based criteria used to make the coverage decision. |
No provisions, except that issuer must disclose
"information" about the benefits covered and excluded, including experimental
treatments. No coverage mandate. Clinical Trials not addressed. |
| Grievances -- Internal |
Requires plans to have a system of internal review with timely written
notice of decision to deny, reduce or terminate services, and reasons for the decision and
procedures for appeal. Appeals must be resolved in a timely manner (not longer than 15
business days) with expedited consideration for emergency/urgent care (within 72 hours).
The review must be conduced by appropriately credentialed staff uninvolved with the
initial decision. Determinations may be communicated orally to expedite the process,
however denials must be in writing and include the process for appeal and reasons for
denial. Expedited appeal process (activated by physician request) available for emergency
situations. |
Requires plans to have a system of internal review with timely written
notice of decision to deny, reduce or terminate services, and reasons for the decision and
procedures available for appeal. Appeals must be resolved in a timely manner with
expedited considerations for emergency or urgent care (within 72 hours). The review must
be conducted by appropriately credentialed staff uninvolved in initial decision. Plans
must also have a reasonable process for resolving consumer complaints about issues such as
waiting times, operating hours, demeanor of personnel, and the adequacy of facilities. |
Does not establish a grievance and appeals process. Health plans
should provide information on appealing appeal decisions, filing grievances, and
contacting consumer organizations, such as ombudsman programs or government agencies
regulating the health plan. |
Plans must explain in a timely notice the basis for a determination
which a patient disagrees with along with a description of rights and time frames for
appeal. Appeals should be resolved as rapidly as warranted by the patient's situation. An
expedited appeals process should be available for situations in which the normal time
frame could jeopardize a patient's life or health. |
Internal grievance procedure by appropriate clinical peer required for
adverse utilization determinations and for other enrollee complaints of inadequate access.
Review in 1 hour for urgent services; 24 hours for other services. |
| Grievances -- External |
Requires enrollees to have access to an independent external appeal
body. To qualify for review, the case must involve a denial of care for experimental
treatment, a decision based on lack of medical necessity where cost exceed a significant
threshold, or a denial of care where the patient's life or health is jeopardized.
Individuals first must exhaust internal appeals process (unless time frames are not met).
Qualified entities must conduct review activities using appropriately credentialed
clinical peers. The cost of the appeal is borne by the plan and the determination is
binding on the plan. The state and the appropriate Secretary shall conduct reviews of the
certified organizations to ensure their integrity. Appeals must be resolved within 60
days, with expedited consideration for emergency/urgent care (72 hours). |
Requires enrollees to have access to an independent external appeals
body. To qualify for review, the case must involve a denial of care for experimental
treatment, a decision based on lack of medical necessity where cost exceed a significant
threshold, or a denial of care where the patient's life or health is jeopardized.
Individuals first must exhaust the internal appeals process. Appeals must be conducted by
professionals who are appropriately credentialed (w/o conflict of interest and
independent) and follow a standard of review that promotes evidence-based decision making
relying on objective evidence. Appeals must be resolved in a timely manner with expedited
consideration for emergency/urgent care consistent with time frames required by Medicare
(72 hours). |
Plans should have an external, independent review process to examine
the cases of seriously ill patients with less than two years to live who are denied
coverage for experimental treatments. |
No provision. |
A health insurance issuer (group health plan) must maintain an
accessible appeals process that reviews adverse prior authorization determinations for
urgent and other care services and an initial determination on payment for claims...by an
appropriate clinical peer professional...that is not involved in the operation of the plan
or in making the determination or policy being appealed (sect. 2776 (b)(4). No time frames
set forth. Does not specify if these decisions are binding. |
| Utilization Review |
Plans must have a utilization review process administered by
appropriately trained, qualified health professionals. Physician input required for
development of clinical review criteria. The utilization review program may not provide
financial incentives for denials of care. Beneficiaries may have medical director (or
other appropriate person with authority to reverse decision) review an adverse
determination. Written notice to beneficiary for denial of care. |
No provision. |
Plans must have a utilization review process that uses appropriately
licensed providers to evaluate the clinical appropriateness of adverse decisions. Health
plans should make timely and, if necessary, expedited decisions, and give the principal
reasons for adverse determinations and instructions for initiating an appeal. Health plans
should be prohibited from providing incentives for making adverse utilization review
decisions. |
Plans must have a utilization review process that is based on
scientific and medical evidence; be directed by an experienced physician; and involve
participating physicians in reviewing utilization management criteria. An exceptions
process, directed by an experienced physician, should be available for cases in which a
participating physicians believes that a utilization management determination does not
adequately account for the unique characteristics of a particular patient, based on
relevant medical evidence offered by the participating physician for review. Utilization
management decisions should be based on clinical information about the patient and the
treating physician should have an opportunity to provide clinical information and a
rationale for recommending a specific course of treatment prior to a utilization review
decision. |
Plans must have a utilization review process whose fondation is a
uniform criteria based on sound medical evidence applied by appropriately licensed health
professionals and must not compensate individuals for denials. Must notify promptly of
determination and explain basis of determination and right to immediate appeal. The
utilization review program (1) must be developed with the involvement of participating
health professionals, (2) may not compensate individuals conducting UR for denials of
payment or coverage. |
| Quality Assurance Program |
Plans must have a quality assurance program guided by a written plan
which includes quality criteria directed at meeting needs of at-risk or chronically ill
populations (including gender, age and pediatric-specific criteria where appropriate).
Plans must have procedures for providers and enrollees to report quality concerns;
systematic review of type of health services provided and patient outcomes; and drug
utilization required to promote proper use of medicines. Standardized comparative
information will be collected and reported across all plans. The plan may be deemed to
meet the requirements of the bill if their quality assurance program is accredited by a
Secretary-certified program with standards at least as stringent as those in the bill.
Requires a Health Care Quality Council similar to that advocated by the President's
Quality Commission. |
Recommends an Advisory Council for Health Care Quality that would
identify national aims for improvement, specific objectives for improvement, and track the
nation's progress in meeting those objectives. Council would include representatives from
the public and private sectors and report annually to the President and Congress on
progress in improving health care quality. The private sector should work to establish
core sets of quality measures applicable to each sector of the industry. Special attention
should be paid to the health needs of vulnerable populations including children.
Information systems need to be upgraded to accomplish these goals. |
Health plans should meet national standards for measuring and
reporting performance in a number of areas. National standards for quality assurance
should be non-duplicative and should provide latitude in the specific methods and
activities employed to meet the standards to reflect differences in health plan
organization. Standards should provide for external review of the quality of care
conducted by qualified health professionals who are independent of the plan and
accountable to the appropriate regulatory agency.
There should be a collaborative effort to develop a national core data
set of outcome-oriented , scientifically-based measures. Health plans should disclose the
results of performance assessments subject to independent audit. |
Health plans should have quality assessment and improvement programs
to monitor targeted areas of a patient care to detect whether patterns of under-service or
over-service exist and act to assure the appropriate care is rendered. This program should
be physician-directed; participating physicians should be involved in its design and
implementation; and all participating physicians should be informed of the program.
Practice guidelines should be based on current scientific and medical evidence; designed
with the input of participating physicians used to augment the physician patient
relationship. Guidelines should be regularly updated and available to participating
physicians as appropriate to their specialty. Health plans should have an internal
committee (including participating physicians and other appropriate professionals)
available to consider requests from participating physicians that guidelines be modified
based on relevant scientific medical evidence. |
Issuer must have a quality assurance program that assesses and
improves enrollee health status, patient outcomes, processes of care, and enrollee
satisfaction associated with health care provided by the issuer. Thia also applies to
administrative and funding capacity of issuer to fund preventive care, utilization, access
and availability, cost effectiveness, acceptable treatment modalities, specialist
referrals, peer review. Must report findings to purchasers, participating health
professionals, and administrative personnel. |
| Privacy -- Confidentiality |
Plans must establish procedures to safeguard the privacy of enrollee
information, maintain records in manner that is accurate and timely, and assure timely
access to enrollees to such records and information.* |
Individually- identifiable health care information should be protected
and should not be disclosed without written consent except for health purposes or where
there is a clear legal need. Consumers should be able to review, copy and request
amendments to their medical records. Non-identifiable health care information should be
used to the maximum extent feasible. |
Individual-level information should not be disclosed except: a) if
necessary for quality assurance, for purchasers of providers (e.g., to determine
eligibility for coverage or to administer payments) or to conduct research (but these data
should not contain patient identifiers which could lead to violation of individual privacy
and harm to patients); b) if the individual provides consent; or, c) if required by law or
court order. |
Consistent with applicable federal and state law, confidentiality
policies should include reasonable and appropriate administrative, technical and physical
safeguards to provide for appropriate training of plan staff; and delineate mechanisms,
including a clear disciplinary policy, to address improper use of patient-identifiable
health information. Patient-identifiable health information should not be disclosed
without the patient's consent except when necessary to provide care; perform essential
plan functions (e.g., quality assurance and plan administration); conduct bona fide
research; comply with law or court order; or comply with public health needs. |
Must establish procedures for compliance with Federal and State laws. |
| Provider Protections -- Anti-Gag Protections |
Provider contracts must not contain "gag-clauses" or other
contractual mechanisms that restrict health care providers' communication with patients
about medically necessary treatment options. |
Provider contracts must not contain "gag-clauses" or other
contractual mechanisms that restrict health care providers' communication with patients
about medically necessary treatment options. |
Plans should not limit the exchange between health care providers and
patients regarding the patient's condition and treatment options. |
Plan policies or contracts between health plans and physicians should
be interpreted as prohibiting physicians from discussing treatment options with patients. |
Plans must not limit medical communication including information on
patient's health status, utilization provisions that may affect treatment options,and
financial incentives that may affect treatment. |
| Provider Protections -- Physician Incentive Plans |
Prohibits physician incentive plans if used as inducement to restrict
medically necessary services. If plan puts provider at substantial financial risk, plan
must provide stop-loss protection and conduct periodic customer satisfaction/access
surveys.* |
No specific provision on provider incentive plans or stop-loss
requirements. Plans should disclose factors - such as compensation - that could influence
advice on treatment plans. |
Prohibits health plans or provider groups payment methodologies that
directly encourage provider to overtreat patients or to limit medically necessary care.
Full-risk capitation should not be used for an individual provider. Provider capitation
should only apply to services directly rendered by that provider. Reinsurance or stop-loss
coverage should be used when individual providers or small groups of providers are
capitated or when providers are placed at substantial financial risk. |
No provision. |
Prohibited if made as inducement to restrict medically necessary
services; if plan puts provider at substantial risk, plan must provide stop-loss
protection and conduct periodic customer satisfaction/access surveys; and plan must
provide State or Secretary with sufficient information to determine whether plan is
acceptable. |
| Provider Protections -- Due Process |
Reasonable notice to provider of adverse participation decision,
opportunity to review reasons/ information behind termination, and a process for appeal.*
Prohibits transfer of any liability to provider relating to acts or omissions of plan.
Plans may not penalize providers who advocate on behalf of their patient in participation
in the utilization review or grievance process. |
Plans should be prohibited from penalizing or seeking retribution
against health care professionals or other health workers for advocating on behalf of
their patients. |
Plans should not penalize providers who in good faith advocate for
their patients, assist patients with claims appeals, or report quality concerns to
government authorities or health plan managers. |
Plans should use, where feasible, AAHP's standardized Physician
Application Form to help reduce repetitive and duplicative paperwork requirements. |
No termination of provider contracts without cause. Plan must provide
reasonable notice of decision to terminate provider for cause, opportunity to review
reasons/information behind termination, and opportunity to enter into corrective action
plan before determination becomes subject to appeal. Must allow all providers to apply
annually, provide reasonable notice of application period, provide for review of
applications by appropriately credentialed committee for each type and category of
provider, notify applicants of information indicating that they fail to meet the plan's
standard and allow them to submit supplemental or corrected information. These providers
are based on objective standards. When economic considerations are used in selection, they
must be objectively applied and adjusted for case mix and disclose results. |
| Provider Protections -- Credentialing |
Plans must have written standards for hiring and contracting with
health providers and facilities, including verification of provider's license and a
history of suspension and revocation. |
No provision. |
Health plans and provider groups should develop written standards
similar to those used by the National Committee for Quality Assurance for hiring and
contracting with physicians, other providers and health care facilities. |
Participating physicians should be credentialed and periodically
recredentialed. |
No provisions. |
| Drug Formularies |
Plan physicians must participate in the development of the drug
formulary. Plans must disclose the nature of formulary restrictions and make allowance for
exceptions to the formulary when medical necessity dictates that a non-formulary
alternative is needed. |
Requires disclosure of use of formulary, whether a specific drug is
included in the formulary, and procedures for considering requests for patient-specific
waivers. |
Plans should allow physicians to participate in the development of
drug formularies, provide a description of the formulary to consumers, and provide for an
exception process when non-formulary alternatives are medically necessary. |
Plans should involve participating physicians in developing and
reviewing formularies (based on current medical and pharmacoeconomical evidence).
Formularies should be regularly reviewed and updated, if necessary on an expedited basis,
to take into account new medical evidence and newly approved drugs. Selective formularies
should include an exceptions process (directed by a clinical with appropriate expertise)
through which a patient or participating physician may present science-based medical
evidence to support coverage for a prescription drug not routinely included in the
formulary. |
No provision. |
| Medical Necessity |
Prohibits health insurance issuers from arbitrarily limiting or
altering the manner or setting of service delivery of covered benefits when determined to
be medically necessary and appropriate. Medically necessary and appropriate services or
benefits are those provided consistent with generally accepted principles of professional
medical practice. Utilization review should be conducted consistent with this standard. |
No specific provision relating to medical necessity. Bill of Rights
states that health care should be evidence based, however. |
No provision. |
No provision. However, utilization management decisions should be
based on clinical information about the patient and the treating physician should have an
opportunity to provide clinical information and the rationale for recommending a specific
course of treatment prior to a utilization review determination. Plans physicians should
use plan practice guidelines to in determining what medical care to provide their patient.
|
A health issuer offering network coverage shall demonstrate that
enrollees have access to specialized treatment expertise when such treatment is medically
or clinically indicated in the professional judgement of the treating health professional
in consultation with the enrollee. Health plans must ensure direct access to relevant
specialists for the continued care of such enrollees when medically or clinically
indicated in the judgement of the treating health professional in consultation with the
enrollee. |
| ERISA Liability |
Removes ERISA preemption that currently prevents beneficiaries from
holding health plans liable when they make medical decisions that cause harm. Plans would
be subject to state law concerning liability for their actions. Protects employers from
liability when they were not involved in the decision. |
Calls for a national dialogue among policy makers and other
stakeholders on the state of existing remedies for individuals in public and private
health plans who are injured as a result of inappropriate health care decisions. |
No provisions. |
No provisions. |
Permits state liability laws to apply to ERISA plans in cases of
wrongful death or personal injury. Does not specifically exempt employers from being sued,
however, Norwood has introduced a bill, H.R. 2960, that would clarify that employers are
not to be sued in these instances unless they exercised discretionary authority that lead
to death or wrongful injury. They are also shielded from plan insurers and administrator's
claims for indemnification. |
| Enforcement |
The draft bill would apply to all plans, both ERISA and state
regulated, using the HIPAA mechanism of enforcement. Sets national floor of protections,
but states may do more. |
Federal programs have come into compliance for most of the Bill of
Rights, however, plans regulated by the Department of Labor or by States would need
legislative action to bring them into compliance. |
Asks for federally enforceable standards to be put in place. |
Voluntary compliance for plans that are members of AAHP. |
States may impose equivalent or more stringent requirements on plans. |
