April 1998
Pending Health Legislation
Independent External
Review of Managed Care Disputes
The New York Assembly has passed legislation, A.6585-A
, introduced by Assemblyman Richard Gottfried, Chair of the Assembly Health Committee,
which would establish an independent system for resolving disputes between health plans
and consumers. The Senate is also considering legislation which would address this issue.
The purpose of this type of legislation is to give patients a prompt and easy way of
getting an independent medical review of claim denials. [Note: In June, 1998, the New York legislature passed Governor
Pataki's Program Bill, S7838,
which will establish an independent external review system starting in July, 1999.]
Similar legislation has been adopted in New Jersey, and Texas. The New Jersey law is
part of P.L.
1997 c. 192.
The Texas law is part of SB386. The
Texas Insurance Department rules implementing the Texas law are contained in
28 Texas
Administrative Code Chapter 12.
Experimental Treatments
for Seriously Ill Patients
The New York Assembly has passed legislation, A.1020,
introduced by Assemblyman Alexander "Pete" Grannis, which would require HMOs and
other insurers to cover experimental treatments provided to seriously ill patients, such
as cancer patients, participating in clinical trials. Governor Pataki has introduced
legislation, S.5489, which also addresses this issue but
takes a different approach under which patients would file appeals in order to get
coverage for experimental treatments. [Note:
In June, 1998, the New York legislature passed Governor Pataki's Program Bill, S7838, which will establish an independent
external review system to review denials of coverage of experimental treatments.]
Maryland has passed a law, SB 137, which
is similar to Assemblyman Grannis' bill. (To get the full text of the Maryland law,
download the enrolled version of SB137.)
In 1996, California adopted The
Friedman - Knowles Experimental Treatment Act which is similar to the bill
being proposed by Governor Pataki.
There are also bills pending in Congress which would provide insurance coverage for
patient care costs in clinical trials, for example: H.R.
1069, the Improved Patient Access to Clinical Studies Act of 1997, introduced
by Representative Nita Lowy ; and S.
381, the Medicare Cancer Clinical Trial Coverage Act of 1997, introduced by
Senator John D. Rockefeller, which would establish a demonstration project to study and
provide coverage of routine patient care costs for Medicare patients with cancer enrolled
in an approved clinical trial.
HMO Liability
Key members of the New York legislature have agreed on a bill A. 1816-A, S.2544-A which would hold HMOs and other insurers legally responsible
for the harm patients may suffer when an insurer refuses to provide treatment needed by
the patient. The bill is sponsored by Assemblymen Richard Gottfried and Alexander
"Pete" Grannis and State Senators Guy Velella and James Lack. The bill has
passed the Assembly and is awaiting action by the Senate.
Consumer Bill of Rights
and Responsibilities of the President's Advisory Commission on Consumer Protection and
Quality in the Health Care Industry
An individual patient's rights under a health plan can vary significantly from state to
state because each state regulates health plans differently. In his 1998
State of the Union Message, President Clinton urged Congress to adopt
legislation which would guarantee certain basic rights to patients regardless of the state
in which they live. These rights are set forth in the November, 1997 health care Consumer Bill of Rights and Responsibilities issued by the
President's Advisory Commission on Consumer
Protection and Quality in the Health Care Industry. The following are some of the protections which the Bill of Rights would give to
patients. Many are already provided under New York's Managed Care Reform Act.
- The right to receive information about the
benefits patients will get, including coverage of specific drugs, and the physicians who
will treat them under their health plan.
- The right to go to an emergency department
without prior plan approval when a patient is in a situation which a "prudent
layperson" would regard as an emergency.
- The right to an independent appeal of a claim
denial based on a decision that a proposed treatment is not "medically
necessary" or is "experimental".
- The right to see a specialist who is not part
of a plan's network of physicians if the plan does not have an appropriate specialist for
the patient within its network.
President Clinton has issued a Memorandum
directing that Medicare, Medicaid and federal employee health programs come into
substantial compliance with the Consumer Bill of
Rights and Responsibilities no later than December, 1999. The President has stated
that he would pursue legislation to apply it to everyone.
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