Managed Care Reform

 

 

 

Patients' Bill of Rights



Members of Congress on both sides of the aisle continue to express interest in advancing meaningful protections for patients in managed care settings. Multiple bills have been introduced.



The AMA believes that Congress should work in a bipartisan manner to implement:
bulletPATIENT PROTECTIONS AND PLAN DISCLOSURE REQUIREMENTS SUCH AS:

bulletENSURING THAT THE "MEDICAL NECESSITY" OF PATIENT CARE IS BASED ON "GENERALLY ACCEPTED STANDARDS OF MEDICAL PRACTICE," RATHER THAN HEALTH PLAN DEFINITIONS BASED SOLELY ON COST;

bulletMEDICALLY-BASED GRIEVANCE AND INDEPENDENT, THIRD-PARTY EXTERNAL APPEALS PROCEDURES FOR PHYSICIANS AND PATIENTS;

bulletCOMPARATIVE INFORMATION FOR PATIENTS AND PROSPECTIVE ENROLLEES ON COVERED BENEFITS, COST-SHARING, SERVICE AREAS, PHYSICIAN AND PROVIDER ACCESS (INCLUDING ACCESS TO SPECIALISTS), AND PHYSICIAN COMPOSITION; NON-DISCRIMINATION BASED ON HEALTH STATUS;

bulletBAN ON GAG CLAUSES AND GAG PRACTICES IN ALL PLANS;

bullet"PRUDENT LAYPERSON" STANDARD FOR EMERGENCY SERVICES;

bulletPROCEDURES TO ASSURE CONTINUITY OF CARE FOR PATIENTS AND ACCESS TO SPECIALTY CARE;

bulletPROHIBITION ON INCENTIVE ARRANGEMENTS TO LIMIT MEDICALLY NECESSARY CARE TO PATIENTS; AND


bulletHEALTH PLAN ACCOUNTABILITY SO THAT HEALTH PLANS WOULD BE LIABLE FOR NEGLIGENT MEDICAL DECISION-MAKING REGARDING DENIAL OF COVERED SERVICES.

bulletESTABLISHING A FLOOR, NOT A CEILING, AND NOT PREEMPT STRONGER STATE PATIENT PROTECTION STATUTES.




 

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