THE HOUSE BIPARTISAN PATIENT PROTECTION ACT

The Old Norwood-Dingell Bill: HR 2723

• Americans covered by the bill: All Americans in private insurance are covered using the HIPAA mechanism, which requires all states to conform to the federal law
• Accountability for Decision Makers-Federal Liability for Health Plans:None
• Accountability for Decision Makers-State Liability for Health Plans: Allows a plan to be held liable in federal court for decisions that do not involve medical judgment
• Protection for the development of case law:None specifically written into the bill
• Protection for employers:Protects employers from being held liable unless they exercised discretionary authority in making a decision
• Limitations on damages:Punitive damages are prohibited if a plan followed the determination of the external review entity

The New Ganske-Dingell Bill: HR 526

• Americans covered by the bill: All Americans in private insurance are covered by the bill or a state can seek to certify that an existing state law is substantially equivalent to a provision of the bill
• Accountability for Decision Makers-Federal Liability for Health Plans: Allows a plan to be held liable in federal court for decisions that do not involve medical judgment
• Accountability for Decision Makers-State Liability for Health Plans: Allows a plan to be held liable in state court for decisions of medical judgment that injure or kill a patient
• Protection for the development of case law: Language written to ensure that recent Supreme Court decisions are not overturned
• Protection for employers: Protects employers from being held liable unless they directly participate in making a decision; language developed from Coburn-Shadegg substitute
• Limitations on damages: For the federal cause of action, punitive damages are not available; for the state causes of action, punitive damages are prohibited unless the plan acts willfully or wantonly

Highlights of the Bill

• The bill applies its patient protection to ERISA plans, nonfederal governmental plans, and plans in the individual market.
• The bill clarifies the process for enforcement of patient protections in the state regulated insurance market.
• If a plan denies coverage a patient and doctor can appeal to health plan doctor. If the plan still denies coverage, the patient can appeal to an external review panel, whose decision is legally binding.
• Patients can hold HMOs accountable for bad decisions:
• If dispute is an administrative benefit decision, the patient can seek limited redress in federal court, under federal law
• If the HMO acted in bad faith manner against the patient, the bill sets a ceiling of $5million dollars on civil penalties.
• If the dispute involves medical judgment, the patient can seek redress in state court under state law
• Employers are protected from liability in either federal or state court unless they have directly participated in a denial that caused irreparable harm or death to the patient.