• Choice of Plans

  Choice is one of the key components of consumer satisfaction with the health system. The Democratic bill would allow a limited point of service option (POS) for employees who are offered only a closed panel HMO. The health plan, not the employer, would be required to make the POS available, and the employer would not be required to contribute to the point of service option.

• 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.

• Specialty Care

  Patients with special conditions must have access to providers who have the requisite expertise to treat their problem. The Democratic bill 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 for accessing necessary specialty care without impediments.

• Women's Protections

  The Democratic bill extends important protections for women in managed care, including direct access to ob/gyn care and services and the ability to designate their ob/gyn as a primary care provider. The proposal also includes bills regarding mastectomy length-of-stay and breast reconstruction.

• Children's Protections

  The Democratic bill ensures that the special needs of children are met, including access to pediatric specialists.

• Continuity of Care

  Patients should be protected against disruptions in care because of a change in plan or a change in a provider's network status. The Democratic bill lays out guidelines for the limited continuation of treatment in these instances. There are specific protections for pregnancy, terminal illness, and institutionalization.

• Emergency Services

  Individuals should be assured that if they have an emergency, those services will be covered by their plan. The Democratic bill says that individuals must have access to emergency care, without prior authorization in any situation that a "prudent lay person" would regard as an emergency.

• Clinical Trials

  Access to clinical trials can be the only hope left for individuals with serious and life-threatening diseases, especially when no standard treatment is effective. Plans must have a process for allowing certain enrollees to participate in a defined set of approved clinical trials and for covering the routine patient costs associated with these trials.

• Drug Formularies

  Prescription medications can not be one-size-fits all. For plans that use a formulary, the plan must have a process for beneficiaries to access medications that are not on the formulary when medically indicated. And, plan doctors and pharmacists must help in the formulary development.

• Non-discrimination

  Patients should not be discriminated against in their access to covered health care services. The Democratic bill prohibits plans from discriminating against their enrollees on a variety of factors including genetic information, sexual orientation, and disability. This provision does not affect issuance or pricing of policies.

INFORMATION

• Health Plan Information

  Informed decisions about health care options can only be made by consumers who have access to uniform, comparable information about health plans, plan policies, and providers. This bill requires managed care plans to provide that information.

• Confidentiality

  Patients need to know that their medical records are kept confidential. This bill says that health plans must have appropriate safeguards to ensure confidentiality, update records in a timely and accurate fashion, and allow patients access to their records. It does not address the broad issue of medical records confidentiality, which will require separate legislation.

• Ombudsman

  The health care marketplace can be confusing. The Democratic 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

  In order to constantly improve the quality of health care provided, plans should be monitoring care given to their enrollees, especially with regard to at-risk or chronically ill populations. The Democratic bill requires plans to have a quality assurance program to monitor care and improve care.

• Data Collection

  The Democratic bill requires plans to collect data in order to monitor the quality of care provided to enrollees. Data must be in a standard format so comparisons can be made across all plans.

• Advisory Board

  A private/public Advisory Board would be established to advise the Secretary on the standardized minimum data set and other activities to improve health care quality.

• Provider Selection

  Plans should not discriminate against providers when selecting them for the network. The Democratic bill requires 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

  When a plan is reviewing the medical decisions of its practitioners, it should do so in a fair and rational manner. The Democratic bill lays out basic criteria for a good utilization review program: physician participation in development of review criteria, administration by appropriately qualified professionals, timely decisions, and ability to appeal.

GRIEVANCE AND APPEALS

• Internal Grievances

  Patients need to be able to appeal denials of care and voice concerns about their plans. They also should have their concerns addressed in a timely manner. Plans must maintain an internal grievance process that is expedient and conducted by appropriately credentialed individuals. There also must be an expedited process for special circumstances.

• External Grievances

  For cases of sufficient seriousness or beyond a certain monetary threshold, individuals must have access to an external, independent body with the capability and authority to resolve these cases. In the Democratic 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. Plans may not retaliate against providers who advocate on behalf of their patients nor against patients who choose to access the appeals process.

PROTECTING THE PROVIDER-PATIENT RELATIONSHIP

• Anti-Gag and Provider Incentive Plans

  Consumers have the right to know all of their treatment options. The Democratic bill prohibits plans from gagging providers. It protects providers in these situations from retribution, and protects providers who report quality problems to appropriate authorities from retribution. It also prohibits plans from providing incentives to providers to limit medically necessary services.

• Provider Due Process

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

• Medical Necessity

  Health plans should not be allowed to place arbitrary limits on covered services. Treatment decisions should be made in accordance with generally accepted principles and standards of professional medical practice. The Democratic bill applies this standard for medically necessary care.

• Insurer Liability

  Although health plans are increasingly involved in health care decisions, the Employee Retirement Income Security Act (ERISA) preempts individuals in employer-sponsored plans from holding health plans legally accountable for decisions to limit care that ultimately cause harm. Presently, an injured person can only recover the dollar value of the benefit that was denied. The Democratic bill includes a provision that would allow State law to determine whether or not a health care beneficiary can bring a state cause of action against health plan administrators who cause harm through their actions. The provision also protects employers from liability when they were not involved in the decision.