Comprehensive
Summary of the
Patients’ Bill of Rights Act of 2001
Specific Patient Protection Provisions
Emergency Care. The bill requires insurers and health plans to provide coverage, without prior authorization, for emergency care if a “prudent layperson” with an average knowledge of health and medicine would consider the situation an emergency.
Point-of-Service Option. The bill requires group health plans that only offer a closed panel of health care providers to make available an option allowing participants to choose their own doctors.
Access to OB/GYNs. The bill requires insurers and plans to provide direct access for female patients to a participating physician or health care professional who specializes in obstetrics and gynecology.
Access to Pediatricians. The bill requires insurers and plans to allow parents to designate as their child’s primary care provider a participating physician or health care professional who specializes in pediatrics.
Timely Access to Specialists. The bill requires insurers and plans to provide a referral to a specialist for patients with covered conditions that require specialty care. If there is not an appropriate specialist in the plan or issuer’s network, it must arrange for a referral to an out-of-network provider.
Continuity of Care. In the event that a plan and a provider terminate their contract, the bill ensures that certain patients may continue to see the provider for a period of time after the termination. In addition to patients receiving treatment for serious and complex conditions and those with scheduled surgeries, other eligible patients include pregnant women through post-partum care, and the terminally ill through the end of life.
Gag Rules. The bill lifts so-called “gag rules” to allow free and open communications between patients and doctors about all treatment options.
Prescription Drugs. The bill requires insurers and plans that use a drug formulary (i.e., a list of approved medicines) to (1) involve participating physicians and pharmacists in developing the formulary; (2) disclose the nature of formulary restrictions to providers and participants; and (3) establish exceptions when medically indicated (i.e., allow physicians to prescribe a non-formulary drug).
Clinical Trials. The bill requires insurers and plans to cover routine patient costs associated with participating in government-sponsored clinical trials for life threatening diseases.
Provider Non-discrimination. The bill prohibits plans and insurers from excluding from networks or reimbursement any provider solely based on that provider’s licensure. For example, chiropractors and optometrists could not be excluded based solely on their license status.
Plan Information. The bill requires insurers and plans to disclose up-front, concise information about their plan, including covered and excluded benefits, cost sharing requirements, participating providers and the patient’s rights to review denied benefit claims.
Study of Payment Methods. The bill requires the Secretary and the Institute of Medicine to conduct a study to examine the types of physician compensation and determine their impact, if any, on the quality of health care provided to patients.
Internal Review. The bill establishes three basic standards for internal review of health plan decisions:
(1) Expedited reviews must be completed within 72 hours. Concurrent reviews that could result in the discontinuation of inpatient care must be completed within 24 hours.
(2) Non-expedited, prior authorization reviews must occur within 14 days.
(3) Retrospective claim review requests (a review in which the care has already been provided) must be completed within 30 days.
External Review. The same review timelines apply for external review as for internal review outlined above. Any denial of a claim for benefits is eligible for review by the external review entity.
The external review entity will determine if an external medical review is required, and will provide for a medical review if the denial was:
(1) based on a determination of medical necessity or appropriateness,
(2) based on the fact that the procedure was experimental or investigative, or \(3) requires an evaluation of medical facts to make a final determination.
The denial is not eligible for medical review if the health plan does not cover the benefit in question. If a claim is not eligible for medical review, the external review entity shall notify the participant and treating physician of that decision.
The bill requires external medical review decisions to be made by practicing physicians and health care professionals, independent of the health plan, who practice in a similar specialty as the physician or professional who recommended the care. Determinations must be made without deference to the plan’s coverage decision, or the recommendation of the treating physician, and must take into account all valid, relevant, scientific and clinical evidence, as well as peer-reviewed literature, and expert consensus. Reviewers are not bound by the plan’s definitions of the terms medical necessity, experimental, or investigational. Independent medical reviewers’ decisions are binding on health plans; plans must provide coverage in accordance with the recommendations and timeframes established by the independent medical reviewer.
If an insurer or plan makes a medical decision by failing to comply with the decision of the independent external medical review panel and the patient is harmed, the bill removes the ERISA preemption for this decision, subjecting the plan or insurer to State court action. Damages would vary from State to State depending upon applicable recovery limitations.
If an insurer or plan makes a coverage decision that harms a patient, the bill holds the plan or insurer accountable in Federal court. Patients must complete the external medical review, and the panel must overturn the insurer or plan’s decision. Economic damages are unlimited, and non-economic damages are limited to $500,000. Patients may file suit only in Federal or State Court, not both.
The bill allows patients to file lawsuits in Federal and State courts against a “designated decision-maker” (1) that is authorized to make the final coverage decision; (2) that failed to exercise ordinary care in complying with the external review decision; and (3) when the failure is the proximate cause of personal injury or wrongful death. Appointment of a designated decision-maker protects the employer from liability.
Patients may proceed to court at any time to receive injunctive relief (in other words, the court can require the health plan to approve needed care) if they demonstrate that exhausting internal or external review would cause irreparable harm. The bill prohibits class action and RICO lawsuits as of the date of enactment.
Scope of Coverage
The protections in the bill apply to all Americans in employer-sponsored plans. The bill preserves the ERISA preemption for internal and external appeals. For patient protections, the governor may certify compliance with the federal standard on the basis that current state law is “substantially equivalent. The Secretary has 90 days to accept the certification. If it is not accepted, the state may file an appeal to the applicable Federal Circuit Court of Appeals.
Association Health Plans (AHPs). The measure allows small business to join together within bona-fide trade associations to purchase health insurance, thus enjoying the same uniform regulation, economies of scale, and administrative efficiencies that large companies currently enjoy.
Medical Savings Accounts. The bill expands access to Medical Savings Accounts.