Emergency Services. Individuals should be assured that if they have an emergency, those services will be covered by their plan. The Bipartisan Consensus Bill says that individuals must have access to emergency care, without prior authorization, in any situation that a "prudent lay person" would regard as an emergency.

Specialty Care. Patients with special conditions must have access to providers who have the requisite expertise to treat their problem. The Bipartisan Consensus Bill allows for referrals for enrollees to go out of the plan’s network for specialty care (at no extra cost to the enrollee) if there is no appropriate provider available in the network for covered services.

Chronic Care Referrals. For individuals who are seriously ill or require continued care by a specialist, plans must have a process for selecting a specialist as a gatekeeper for their condition to access necessary specialty care without impediments.

Women’s Protections. The Bipartisan Consensus Bill provides direct access to ob/gyn care and services.

Children’s Protections. The Bipartisan bill ensures that the special needs of children are met, including access to pediatric specialists and the ability for children to have a pediatrician as their primary care provider.

Continuity of Care. Patients should be protected against disruptions in care because of a change in plan or a change in a provider’s network status. The Bipartisan Consensus Bill lays out guidelines for the limited continuation of treatment in these instances. There are special protections for pregnancy, terminal illness, and individuals on a waiting list for surgery.

Clinical Trials. Access to clinical trials can be crucial for treatment of an illness, especially if it is the only known treatment available. Plans must have a process for allowing certain enrollees to participate in approved clinical trials, and the plan must pay for the routine patient costs associated with these trials.

Drug Formularies. Prescription medications should not be one-size-fits all. For plans that use a formulary, beneficiaries must be able to access medications that are not on the formulary when the prescribing physician dictates.

Choice of Plans. Choice is one of the key components of consumer satisfaction with the health system. The Bipartisan Consensus Bill would allow individuals to elect a point of service option when their health insurance plan did not offer access to non-network providers. Any additional costs of this option would be borne by the patient.

Health Plan Information. Informed decisions about health care options can only be made by consumers who have access to information about health plans. This bill requires managed care plans to provide important information so that consumers understand their health plan’s policies, procedures, benefits, and other requirements.

Utilization Review. When a plan is reviewing the medical decisions of its practitioners, it should do so in a fair and rational manner. The Bipartisan Consensus Bill lays out basic criteria for a good utilization review program: physician participation in development of review criteria, administration by appropriately qualified professionals, timely decisions (within 14 days for ordinary care, up to 28 days if the plan requests additional information within the first 5 days, or 72 hours for urgent situations), and the ability to appeal these decisions.

Internal Appeals. Patients must be able to appeal plan decisions to deny, delay, or otherwise overrule doctor-prescribed care and have those concerns addressed in a timely manner. Such an appeal system must be expedient, particularly in situations that threaten the life or health of the patient, and conducted by appropriately credentialed individuals.

External Appeals. Individuals must have access to an external, independent body with the capability and authority to resolve disputes for cases involving medical judgment. The plan must pay the costs of the process, and any decision is binding on the plan. If a plan refuses to comply with the external reviewer’s determination, the patient may go to federal court to enforce the decision. The court may award reasonable attorneys’ fees in addition to ordering the provision of the benefit and may assess a penalty against the plan of $1000 per day until the plan complies with the determination.

Anti-Gag and Provider Incentive Plans. Consumers have the right to know all of their treatment options. The Bipartisan Consensus Bill prohibits plans from gagging doctors and from retaliating against providers who advocate on behalf of their patients. It protects providers in these situations from retribution. It also prevents plans from providing inappropriate incentives to providers to limit medically necessary services.

Provider Selection. Providers should not be discriminated against based on the basis of license in selection for plan participation. The Bipartisan Consensus Bill forbids discrimination against providers based on license, location, or patient base. Plans would, however, be able to limit the number and mix of providers as needed to serve enrollees for covered benefits.

Payment of Claims. Health plans should operate efficiently and pay providers in a timely manner. This bill would require that claims be paid in accordance with Medicare guidelines for prompt payment.

Paperwork Simplification. In order to minimize the confusion and complicated paperwork that providers face, this bill would require that the industry develop a standard form for providers to use in submitting a claim.

Insurer Liability. Health plans are not currently held accountable for decisions about patient treatment that result in injury or death. Currently, the Employee Retirement Income Security Act preempts state laws and provides essentially no remedy for injured individuals whose health plans’ decisions to limit care ultimately cause harm. If the plan was at fault, the maximum remedy is the denied benefit itself. The Bipartisan Consensus Bill would remove ERISA’s preemption and allow patients to hold health plans accountable according to state law. However, plans that comply with an external reviewer’s decision may not be held liable for punitive damages. Additionally, any state law limits on damages or legal proceedings would apply.