The Patients' Bill of Rights Act is based on the 2001 bipartisan Senate-passed bill that was introduced in the House, with minor modifications, as the Ganske-Dingell bill, H.R. 2563, and brought to the House Floor in August 2001. It provides strong patient protections for every American with private health insurance, provides patients with the right to enforce those protections, and protects employers who do not directly participate in health plan decisions on coverage.

     Provides access to emergency care.

     Provides access to specialty care.

    Provides access to non-formulary drugs.

    Provides access to clinical trials.

    Provides direct access to pediatricians and obstetricians/gynecologists.

    Provides continuity of care for those with ongoing health care needs.

    Provides access to important health plan information.

    Ensures health professionals are free to provide information about a patient's medical treatment options.

    Provides grants to states to establish consumer healthcare assistance programs.

    Applies point-of-service provisions to pathology services.

    Establishes an independent, speedy external review process for patients dissatisfied with the results of the internal review, resolved by independent medical experts who evaluate the individual patient's medical situation, current scientific evidence, and plan documents to issue a recommendation on the right course of care which is binding on the plan (but reviewers cannot override plan contracts).

The protections in the bill apply to every American with private health insurance. States may develop their own patient protection laws, which are in effect if Governors certify they are comparable to Federal law. The Secretary of the Department of Health and Human Services has 90 days to approve or reject the certification request. The bill gives deference to state interpretations of their own patient protection laws and allows states to enter into agreements with the Secretary to enforce the requirements of the bill. The bill also explicitly directs Federal health insurance programs to comply with the standards in the bill and requires the General Accounting Office to report on where there are deficiencies.

As with medical negligence cases against other health care providers today, cases involving medical decisions against HMOs would be heard in state court and would be subject to any state law caps or restrictions on damages. In order to address employers' desire to preserve ERISA's uniformity surrounding plan administration, disputes in cases of injury or death stemming from administrative decisions over coverage, eligibility, or cost sharing would be heard in Federal court.

Patients are required to exhaust internal and external appeals before going to court unless the patient is seeking injunctive relief (or if the reviewer is delinquent in returning a decision). The external reviewer's decision must be considered by the court.

Employers are protected against any liability, unless they directly participate in making the decision on a claim for benefits that result in personal injury or death. The bill specifically lists a number of areas that are not to be considered "direct participation," including: selecting a health plan; choosing which benefits to cover under the plan; or advocating on behalf of a beneficiary for coverage.

Additionally, the bill includes the ability for employers to choose a "designated decision maker" who assumes all liability of the employer for both medical and non-medical decisions. The Patients' Bill of Rights Act also exempts self-insured, self-administered employer plans from any Federal liability and clarifies that individual board members of employer plans are protected from liability.

For cases of personal injury or death pertaining to medically reviewable decisions (those heard in State court), state law would apply, including any caps on damages or other restrictions. Additionally, punitive damages are specifically prohibited in State court if the plan complies with the internal and external appeals process, unless clear and convincing evidence shows the plan acted with willful or wanton disregard for the rights and safety of others. However, in this instance, any state law caps on punitive damages would still apply. For cases of injury or death involving non-medically reviewable decisions (those heard in Federal court), punitive damages are specifically prohibited. However, if a plan acts with bad faith and flagrant disregard to a patient's rights, a court may assess a civil monetary penalty. This penalty can not exceed five million dollars. The bill also limits attorneys' fees.

Finally, the bill clarifies that HMOs cannot require individuals to waive their rights under the Patients' Bill of Rights Act, for example, by requiring mandatory arbitration as a condition of enrollment.