"The Children’s Health Insurance Accountability Act of 1998," S.636 was introduced by Senator Jack Reed (D-RI) on March 16. It currently has two cosponsors. This legislation establishes a set of managed care standards that are specific and unique to children, including:

• Access to pediatricians;
• Access to pediatric specialty services;
• Continuity of care for a period of time if the physician is terminated from the plan or if the health plan is changed by the employer;
• Access to emergency care, using the "prudent layperson" standard for access to emergency services for children;
• Procedures for the provision of services to enrollee children with special health care needs;
• Internal and independent external appeals and grievance procedures that require review by appropriate pediatric experts;
• Disclosure of health information to consumers that includes measures of structures, processes and outcomes in a manner that is separate for both the adult and child enrollees using measures that are specific to each group;
• Ongoing internal quality assurance program that measures health outcomes that are unique to children;
• Utilization review criteria established with input from those with expertise in pediatrics.

This legislation is designed to serve as the children’s piece to any other larger managed care legislation moving through Congress.

Democrats and Republicans reintroduced the bills they had proposed last year, but the legislation will go through the regular committee process this year and could see changes along the way. Senate Majority Leader Trent Lott (R-MS) said that the Senate will have to pass some kind of managed care reform bill this year. House Speaker Dennis Hastert (R-IL) has said that any legislation must make sure health care is "affordable and available." Republicans and Democrats are still divided over the right to sue health plans for damages, the scope of the patient protections, and issues such as the Republican effort to expand the availability of medical savings accounts.

"The Patients’ Bill of Rights" (S. 6, H.R. 358) Introduced by Senator Thomas Daschle (D-SD) and Rep. John Dingle (D-MI): Similar to last year’s bill, this legislation includes the right to sue health plans for damages over delayed or denied benefits and a provision giving physicians, not health plans, the authority to determine whether medical care is medically necessary. The bill allows patients to recover damages when benefits are delayed or denied by eliminating the preemption in the Employee Retirement Income Security Act (ERISA) that prevents patients from suing under state malpractice laws. Under ERISA, patients who have had trouble getting coverage approved for needed medical care generally can recover only the value of the service or treatment they did not receive.

The legislation also gives all patients the right to an external review of a health plan’s benefit decision by independent medical reviewers. It would guarantee coverage of emergency services if a "prudent layperson" would consider the patient’s condition an emergency, give patients’ direct access to specialists, provide continuity of care for certain patients whose specialists have left the network, and ban financial incentives for providers to withhold care. Republicans say the liability provision would raise costs and force people to lose their coverage. They also say the medically necessary provision would eliminate virtually all of the savings managed care can produce. The Senate bill has 31 cosponsors and the House bill has 176 cosponsors.

"Patients’ Bill of Rights Plus Act" (S. 300) Introduced by Senator Trent Lott (R-MS):

This legislation, with 49 cosponsors, applies its protections only to the 48 million Americans in self-insured plans, the one group that is not covered by state protection laws because they are preempted by the federal Employee Retirement Income Security Act (ERISA). The protections include guaranteed coverage of emergency services, a mandatory point-of-service option to allow consumers to use non-network providers, direct access to obstetrician-gynecologists, comparative information on health insurance options, a ban on gag-clauses in managed care contracts, and continuity of care for some patients whose specialists have left the network.

The bill also gives patients and providers the right to an external appeal of health plans’ decisions if they turn down coverage as medically unnecessary or reject an experimental treatment when the patient’s life is in jeopardy. The appeals provision applies to the 75 million Americans in insured health plans as well as the 48 million in self-insured plans. Instead of last year’s $1,000 threshold for external review, this bill has new language that says that the cost involved must exceed "a significant financial threshold." (same as Democrats bill) The bill includes provisions to make medical savings accounts more available. Democrats have criticized this bill for not extending protections to all Americans and for not giving patients the right to sue, which they believe is needed to hold the managed care industry accountable.

"Promoting Responsible Managed Care Act of 1999" (S. 374) Introduced by Senator John Chafee (R-RI) and Senator Bob Graham (D-FL): This legislation represents an attempt at a bipartisan approach to the managed care issue. It allows patients to sue but recover only economic damages, not punitive or "pain and suffering" damages. The idea is to leave out the most objectionable proposals in the Republican and Democratic Leadership bills.

Senator William Roth (R-Del) and Senator Patrick Moynihan (D-NY) are considering a managed care reform proposal that focuses mainly on internal and external appeals.

"Patient Protection Act of 1999" (H.R. 448) Introduced by Rep. Michael Bilirakis (R-FL): This bill is basically the same as the one that passed the House last year. It will provide easier access to medical savings accounts, it will include medical liability reform along with "Health Marts" a kind of supermarket of health plans, and association health plans, which would allow small businesses to pool together and self-insure like larger companies. The bill will also include the right to internal and external appeals of health plan decisions, guaranteed coverage of emergency services if a "prudent layperson" would consider the condition an emergency, disclosure of health plan information, and a ban on "gag clauses" in managed care contracts.

"Managed Care Reform Act of 1999" (H.R. 719) Introduced by Rep. Greg Ganske (R-IA), this legislation allows patients to sue for damages under state laws but exempts health plans from punitive damages if they follow the recommendations of the external reviewers. Ganske’s bill would exempt employers and plan sponsors from the lawsuits unless they were involved in the benefit decision and it resulted in death or injury to the patient. His legislation, with 15 cosponsors, includes many of the pediatric provisions supported by the pediatric community.

"Access to Quality Care Act of 1999" (H.R. 216): Introduced by Rep. Charles Norwood (R-GA), this legislation does not include medical necessity language. Instead, it leaves the medical necessity decision in the hands of the external reviewers, meaning any question of medical necessity would be decided by doctors who do not have a vested interest in providing the treatment.

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Last Modified: March 14, 2001