"....although as governor of Texas he has allowed similar legislation to
take effect." My question - is this legislation????????????????????????????
Clinton Plans to Issue Rules Expanding Patients' Rights http://www.nytimes.com/2000/10/09/politics/09HEAL.html
October 9, 2000
By ROBERT PEAR
WASHINGTON, Oct. 8 With legislation to define patients' rights
languishing in Congress, Clinton administration officials say they
will soon issue rules that establish many of the same protections
for most Americans with private health insurance.
The rules, to be issued in final form before Election Day, will
set new federal standards for the handling of claims under employee
health benefit plans, the officials said. The existing standards
have not been substantially revised since they were adopted in
1977, before the widespread use of managed health care.
White House officials said they saw the new rules as a way to get
around an impasse in Congress on patients' rights legislation.
Publication of the rules could also yield political dividends for
Vice President Al Gore, allowing him to boast that the
administration is moving to protect patients while the Republican-
controlled Congress fails to act.
Administration officials said the new standards, prepared by the
Labor Department over the last three years, would expand the rights
of more than 130 million Americans who received health insurance
through private employers, the largest source of coverage in the
United States. The stalled legislation would cover all of them,
plus 38 million people with other types of insurance now regulated
by the states.
The new rules specify what information must be given to patients,
set deadlines for decisions on claims and establish procedures to
help patients appeal the denial of benefits.
All private employee benefit plans will have to revise their
claims and appeal procedures to comply with the rules, officials
said.
Sara Rosenbaum, a professor of health law and policy at George
Washington University, said, "The rules will go a long way toward
defusing an issue at the heart of the national debate over managed
care: patients' perception that they have been unfairly denied care
and have no adequate recourse."
Administration officials said the rules included these
provisions:
A health plan would normally have 15 days to decide a claim for
benefits and would have 30 additional days to rule on an appeal. If
a patient had an urgent need for medical care, the health plan
would be expected to make decisions as soon as possible, with a
maximum of 72 hours allowed for initial rulings and another 72
hours for appeals.
If a claim for benefits is denied, the patient must be informed of
the "specific reasons" and must be told of any policies, guidelines
or criteria used in making the decision.
If a health plan refuses to authorize an operation or other medical
procedure, that action is tantamount to denying a claim, and the
patient may appeal.
A health plan may not reduce or terminate benefits without first
notifying the patient, and the patient is entitled to a hearing
before services are curtailed.
If a patient appeals the denial of a claim, the person who rules on
the appeal must consult an independent medical expert on any
question involving medical judgment for example, whether a
treatment is medically necessary or experimental.
The Labor Department said it had the authority to issue the rules
under a 1974 law, the Employee Retirement Income Security Act,
which regulates health and pension benefits.
Federal officials said the rules were needed to keep pace with
changes in the health care system. When the current standards were
adopted 23 years ago, a claims dispute typically meant a dispute
over who would pay for care already provided. But today, managed
care plans may withhold approval for expensive procedures or
hospital admissions, so patients do not receive care recommended by
their doctors.
Under the new rules, if patients believe they have been improperly
denied benefits, they are entitled to a prompt "full and fair
review" by independent medical experts.
The new standards did not go as far as bipartisan legislation
passed by the House last October. They did not give patients a
right to sue health maintenance organizations for damages resulting
from the improper denial of care, as President Clinton had
demanded. The Senate earlier passed a very different version of the
bill, without the right to sue. But the legislation has bogged down
in a conference committee, and lawmakers said a compromise was
unlikely.
Some provisions of the new rules would make it easier for patients
to sue for benefits under existing law. For example, the rules say,
a patient may go directly to court if a health plan fails to meet
deadlines for acting on claims or fails to follow "reasonable
claims procedures," as defined by the rules.
Diana C. Dennett, executive vice president of the American
Association of Health Plans, a trade group for H.M.O.'s, said, "The
rules put the claimant on a fast track to federal court and will
lead to an increase in litigation."
But the American Medical Association and patients' advocates like
AARP (formerly the American Association of Retired Persons) and the
National Senior Citizens Law Center support the rules.
Dr. Susan H. Adelman, a trustee of the A.M.A., said the rules
"would vastly improve the claims and appeal rights of a majority of
working Americans."
Martin A. Corry, director of federal affairs at AARP, said the
rules were "a huge improvement over the current outdated
regulations."
Labor Department officials said they had been told by the White
House to be ready to issue the rules before Election Day, Nov. 7.
The department formally proposed the rules in September 1998 and
held three days of public hearings on them in February 1999.
If elected president, George W. Bush, could alter the regulations,
although as governor of Texas he has allowed similar legislation to
take effect.
James A. Klein, president of the American Benefits Council, a
trade group composed mainly of Fortune 500 companies, said: "The
final regulations appear to be imminent. They're waiting to be
released at any minute."
Chris Jennings, the health policy coordinator at the White House,
said, "We haven't given up hope that Congress will pass a
meaningful patients' bill of rights."
Opinion polls have found broad public support for efforts to rein
in H.M.O.'s. Mr. Gore and other Democrats have repeatedly denounced
Congress for failing to deliver legislation. Speaker J. Dennis
Hastert, Republican of Illinois, has avidly sought a compromise.
But Senate Republicans have stood firm in opposition to any bill
that significantly expands patients' right to sue. Such
legislation, they say, would lead to an increase in health
insurance costs, so that fewer people would have coverage.
When the Labor Department proposed the rules, it estimated that
businesses would have to spend $155 million on compliance in the
first year. That is an average of 19 cents for each of more than
800 million claims. Subsequent compliance costs will run $30
million a year, it said.
Insurers and employers say the costs could be two or three times
the official estimates. Under the rules, a patient cannot be
required to pay a fee as a condition of filing a claim or an
appeal. The government said it feared such fees would discourage
patients from exercising their rights.
In appealing an unfavorable decision, the rules say, a patient
shall have access to all relevant documents and records, regardless
of whether the health plan relied on them in making its decision.
When a health plan rejects a claim, it must tell patients that
they may sue to enforce their rights or to obtain promised
benefits, the rules say. In general, courts have held, a decision
on benefit claims may be overturned only if the patient shows that
the decision was unreasonable or arbitrary and capricious.
To help consumers "in the event of litigation," the Labor
Department said, it is considering a rule that would allow patients
to see how similar claims from other people were handled.
take effect." My question - is this legislation????????????????????????????
Clinton Plans to Issue Rules Expanding Patients' Rights http://www.nytimes.com/2000/10/09/politics/09HEAL.html
October 9, 2000
By ROBERT PEAR
WASHINGTON, Oct. 8 With legislation to define patients' rights
languishing in Congress, Clinton administration officials say they
will soon issue rules that establish many of the same protections
for most Americans with private health insurance.
The rules, to be issued in final form before Election Day, will
set new federal standards for the handling of claims under employee
health benefit plans, the officials said. The existing standards
have not been substantially revised since they were adopted in
1977, before the widespread use of managed health care.
White House officials said they saw the new rules as a way to get
around an impasse in Congress on patients' rights legislation.
Publication of the rules could also yield political dividends for
Vice President Al Gore, allowing him to boast that the
administration is moving to protect patients while the Republican-
controlled Congress fails to act.
Administration officials said the new standards, prepared by the
Labor Department over the last three years, would expand the rights
of more than 130 million Americans who received health insurance
through private employers, the largest source of coverage in the
United States. The stalled legislation would cover all of them,
plus 38 million people with other types of insurance now regulated
by the states.
The new rules specify what information must be given to patients,
set deadlines for decisions on claims and establish procedures to
help patients appeal the denial of benefits.
All private employee benefit plans will have to revise their
claims and appeal procedures to comply with the rules, officials
said.
Sara Rosenbaum, a professor of health law and policy at George
Washington University, said, "The rules will go a long way toward
defusing an issue at the heart of the national debate over managed
care: patients' perception that they have been unfairly denied care
and have no adequate recourse."
Administration officials said the rules included these
provisions:
A health plan would normally have 15 days to decide a claim for
benefits and would have 30 additional days to rule on an appeal. If
a patient had an urgent need for medical care, the health plan
would be expected to make decisions as soon as possible, with a
maximum of 72 hours allowed for initial rulings and another 72
hours for appeals.
If a claim for benefits is denied, the patient must be informed of
the "specific reasons" and must be told of any policies, guidelines
or criteria used in making the decision.
If a health plan refuses to authorize an operation or other medical
procedure, that action is tantamount to denying a claim, and the
patient may appeal.
A health plan may not reduce or terminate benefits without first
notifying the patient, and the patient is entitled to a hearing
before services are curtailed.
If a patient appeals the denial of a claim, the person who rules on
the appeal must consult an independent medical expert on any
question involving medical judgment for example, whether a
treatment is medically necessary or experimental.
The Labor Department said it had the authority to issue the rules
under a 1974 law, the Employee Retirement Income Security Act,
which regulates health and pension benefits.
Federal officials said the rules were needed to keep pace with
changes in the health care system. When the current standards were
adopted 23 years ago, a claims dispute typically meant a dispute
over who would pay for care already provided. But today, managed
care plans may withhold approval for expensive procedures or
hospital admissions, so patients do not receive care recommended by
their doctors.
Under the new rules, if patients believe they have been improperly
denied benefits, they are entitled to a prompt "full and fair
review" by independent medical experts.
The new standards did not go as far as bipartisan legislation
passed by the House last October. They did not give patients a
right to sue health maintenance organizations for damages resulting
from the improper denial of care, as President Clinton had
demanded. The Senate earlier passed a very different version of the
bill, without the right to sue. But the legislation has bogged down
in a conference committee, and lawmakers said a compromise was
unlikely.
Some provisions of the new rules would make it easier for patients
to sue for benefits under existing law. For example, the rules say,
a patient may go directly to court if a health plan fails to meet
deadlines for acting on claims or fails to follow "reasonable
claims procedures," as defined by the rules.
Diana C. Dennett, executive vice president of the American
Association of Health Plans, a trade group for H.M.O.'s, said, "The
rules put the claimant on a fast track to federal court and will
lead to an increase in litigation."
But the American Medical Association and patients' advocates like
AARP (formerly the American Association of Retired Persons) and the
National Senior Citizens Law Center support the rules.
Dr. Susan H. Adelman, a trustee of the A.M.A., said the rules
"would vastly improve the claims and appeal rights of a majority of
working Americans."
Martin A. Corry, director of federal affairs at AARP, said the
rules were "a huge improvement over the current outdated
regulations."
Labor Department officials said they had been told by the White
House to be ready to issue the rules before Election Day, Nov. 7.
The department formally proposed the rules in September 1998 and
held three days of public hearings on them in February 1999.
If elected president, George W. Bush, could alter the regulations,
although as governor of Texas he has allowed similar legislation to
take effect.
James A. Klein, president of the American Benefits Council, a
trade group composed mainly of Fortune 500 companies, said: "The
final regulations appear to be imminent. They're waiting to be
released at any minute."
Chris Jennings, the health policy coordinator at the White House,
said, "We haven't given up hope that Congress will pass a
meaningful patients' bill of rights."
Opinion polls have found broad public support for efforts to rein
in H.M.O.'s. Mr. Gore and other Democrats have repeatedly denounced
Congress for failing to deliver legislation. Speaker J. Dennis
Hastert, Republican of Illinois, has avidly sought a compromise.
But Senate Republicans have stood firm in opposition to any bill
that significantly expands patients' right to sue. Such
legislation, they say, would lead to an increase in health
insurance costs, so that fewer people would have coverage.
When the Labor Department proposed the rules, it estimated that
businesses would have to spend $155 million on compliance in the
first year. That is an average of 19 cents for each of more than
800 million claims. Subsequent compliance costs will run $30
million a year, it said.
Insurers and employers say the costs could be two or three times
the official estimates. Under the rules, a patient cannot be
required to pay a fee as a condition of filing a claim or an
appeal. The government said it feared such fees would discourage
patients from exercising their rights.
In appealing an unfavorable decision, the rules say, a patient
shall have access to all relevant documents and records, regardless
of whether the health plan relied on them in making its decision.
When a health plan rejects a claim, it must tell patients that
they may sue to enforce their rights or to obtain promised
benefits, the rules say. In general, courts have held, a decision
on benefit claims may be overturned only if the patient shows that
the decision was unreasonable or arbitrary and capricious.
To help consumers "in the event of litigation," the Labor
Department said, it is considering a rule that would allow patients
to see how similar claims from other people were handled.
)