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NAMI - National Managed Care Patient Bill of Rights

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NAMI - National Managed Care Patient Bill of Rights
3803 N. Fairfax Dr., Ste. 100
Arlington, VA, VA 22203
United States
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Phone
(703) 524-7600
Fax
(703) 524-9094
Website
http://www.nami.org/Content/ContentGroups/Policy/WhereWeStand/National_Managed_C...



NAMI - National Managed Care Patient Bill of Rights

NAMI supports health care for all persons with brain disorders that is affordable, nondiscriminatory, and includes coverage for effective and appropriate treatment. NAMI supports federally mandated, minimum standards for health insurance coverage. NAMI supports efforts of states to gain waivers of ERISA (the federal Employee Retirement Income Security Act) so self-insured employer health plans would comply with state-mandated minimum benefit laws. Managed care organizations must be held accountable for delivering a comprehensive array of community support services, and appeal and grievance procedures must be in place that are user-friendly and time-sensitive.

Enactment of a federal "Patients Bill of Rights" remains one of the most contentious issues facing the 107th Congress and the new Bush Administration. The most divisive issue in this debate is, as it has been over the past several years, the right of consumers to sue their health plans in state courts over decisions to deny coverage for recommended treatment. In addition, major struggles are expected over legal authority to define medical necessity (a key to determining whether treatment and services are covered by a health plan) and over whether to extend protections to all health-plan enrollees or to only those in self-insured plans, which are exempt from state regulation.

In recent years, the number of states that have enacted mental illness parity laws has expanded to 32. In each of these states, the parity laws do not cover individuals and families enrolled in ERISA self-insured policies. While the federal Mental Health Parity Act (MHPA) does apply to ERISA plans, its requirements are far below most of the existing state laws. (Parity is limited to annual and lifetime dollar limits.) Because the expansion of healthcare coverage through AHPs would certainly have a negative effect on state mental-health parity laws, NAMI remains opposed to AHPs being included in any final patient protection bill. It also important to note that, collectively, these proposals to increase coverage for the uninsured are estimated to cost as much as $48 billion over 10 years while they are projected by the congressional Joint Economic Committee to benefit only one percent of those who are now uninsured.

NAMI's Advocacy Strategies and Goals

NAMI is supportive of many of the provisions in the separate House and Senate managed care Patients’ Bill of Rights proposals.

  • NAMI supports enactment of mandatory third-party, independent, clinical review with prompt timelines for binding decisions. Such clinical review entities must be composed of specialists who understand and deliver clinical care to persons with severe mental illnesses, and the clinical review must be independent of the health plan, completed promptly, and binding on the health plan. While the appeal of a denial is in progress, the patient must continue to receive necessary services. Access to immediate, necessary, and appropriate care is the highest patient-rights priority of NAMI.
  • NAMI supports enactment of mandatory access to medications. Health plans must offer access to all effective and medically appropriate medications. If a health plan uses a formulary, exceptions must be allowed when a non-formulary alternative is medically indicated. Health plans must establish procedures for members to appeal a decision to prescribe a medication. Medication appeals must comply with the third-party, independent, clinical review advocated above; and until the appeals process is finalized, the enrollee shall remain on his or her previously prescribed medication. Plans must not require enrolled individuals to switch medications that have been effective for them. (See separate Where We Stand paper on access to medications.)

In addition, NAMI supports many other consumer-protection provisions, such as complete public sharing of health plan procedures, restrictions, and coverage information and the creation of ombudsmen programs to help enrollees understand and take advantage of their rights. Finally, NAMI believes that all health plans, not just managed plans, must comply with a national patient bill of rights. Such compliance must apply to all treating providers within health plans, not just the health-plan administrators.

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