Under instructions from the House Republican leadership, GOP advocates for managed-care reform last week unveiled new legislation that merged provisions of various bills.
The Consensus Managed Care Improvement Act includes a controversial provision that would allow enrollees to sue their health plans for benefit denials that result in injury or death.
But the measure dilutes another contentious proposal barring health plans from dictating whether services are medically necessary.
The bill, which applies to group health plans covered by the Employee Retirement Income Security Act, was drafted by Rep. Charlie Norwood (R-Ga.), a dentist, and Reps. Greg Ganske (R-Iowa) and Tom Coburn (R-Okla.), both physicians.
All three are members of the House Commerce Committee, whose chairman, Tom Bliley (R-Va.), will formally sponsor the legislation.
Ganske called for quick action on the bill but said the leadership may not respond.
Like many of the bills that have been introduced, the GOP consensus legislation requires that plans:
* Guarantee direct access to specialists, including pediatricians and OB/GYNs, and emergency care.
* Provide internal and external appeals of denials of care.
* Provide a point-of-service option to closed-panel plans.
* Allow physicians to provide patients with full information about treatment options.
The bill also prohibits plans from providing financial incentives for physicians to withhold care.
Although the measure allows lawsuits against health plans, it insulates employers from liability unless they determined whether services related to the lawsuits should have been covered.
Although the bill does not bar plans from deciding whether services are medically necessary, it does grant broad discretion to external review panels to determine whether services denied by health plans were medically necessary.
Health insurers said they oppose the consensus bill. "Write up the list of usual suspects of mandates on health plans, and this one has it all," said Sharon Cohen, senior vice president for federal affairs at the Health Insurance Association of America.
Meanwhile, the Senate Health, Education, Labor and Pensions Committee has passed a patient-protection bill. Senate Majority Leader Trent Lott (R-Miss.) told GOP senators last week that he and Senate Minority Leader Tom Daschle (D-S.D.) have agreed to a vote on the bill in June.
-With Kristen Hallam