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Date: Thu, 8 Jul 1999 10:03:42 -0400

Subject: NAMI E-News    Managed Care Action Alert

_______________________________________________________________________
NAMI E-News              July 8, 1999              Vol. 00-3
_______________________________________________________________________

FULL SENATE SET TO TAKE UP MANAGED CARE
PATIENT BILL OF RIGHTS LEGISLATION NEXT WEEK

After two years of delay and weeks of partisan wrangling, Senate leaders reached
agreement on June 29 to take up managed care legislation the week of July 12.  
Under a "unanimous consent" agreement reached by Senate leaders, there will be
four days of debate, ending on July 15.  The breakthrough in partisan
negotiations came after more than a week gridlock in the Senate in which
Republicans were unable to stop Democrats from offering popular managed care
reform amendments to unrelated pending annual spending bills.  As part of the
agreement, Republican leaders agreed to a full and fair debate on managed care,
and Democrats agreed that they would stop holding up routine appropriations
bills.  

It is expected that on July 12, the Senate will start with the managed care
reform bill passed by the Senate Health, Education, Labor and Pensions (HELP)
Committee this past spring (S 326).  The base bill that will come before the
Senate next week is also expected to include separate provisions to expand
coverage for uninsured workers and their families through medical savings
accounts (MSAs), and possibly, multi-employer purchasing cooperatives, known as
AHPs (see below).  

NAMI has important concerns regarding S 326 that relate to both the lack of
specificity in the consumer protections that would apply to health plans and the
absence of legally enforceable remedies against plans. In addition, there are
also concerns that the bill, as currently written applies only to health plans
offered by employers that self-insure under the federal ERISA law.  This means
that the managed care standards in the bill would not apply to commercial plans
that are fully insured and regulated by the states (48 million of the 161
million insured Americans are enrolled in ERISA plans).  Under current law,
self-insured ERISA plans are exempt from state regulation.  

ACTION REQUESTED

Most of the four days of debate on the Senate floor next week are expected to be
consumed with consideration of amendments to add binding federal standards on
managed care plans to the legislation.  NAMI is supporting many of these changes
as positive additions to ensure that health plans adhere to standards governing
access to the most advanced treatment and make decisions regarding coverage on
the basis of clinical appropriateness, rather than economic concerns.  

NAMI advocates are urged to contact their senators and ask them to support
amendments to improve S 326 to make it more responsive to the needs of people
with severe mental illnesses and their families.  While it unclear at this point
which amendments will be brought up at which point during the four days of
debate on the Senate floor, it is critically important that senators be informed
about how each of these proposals affect people with severe mental illnesses and
their families.

As part of these efforts, personal experiences of consumers and family members
are the most effective means of communicating to senators how health plans are
failing to provide access to the newest and most effective treatments for
serious brain disorders and why binding federal standards on health plans are
needed. All members of Congress can be reached through the Capital Switchboard
(202-224-3121) or through the NAMI website at http://www.***.com/

NAMI Urges senators to act on and pass the following amendments:

1) access to "off-formulary" medications

The current version of S 326 requires self-insured health plans to provide
exceptions for "non-formulary" medications (i.e., {*filter*} not on a plans list).  
Plans would be able satisfy this requirement simply by charging enrollees a
higher co-payment when an off-formulary medication is selected.  An amendment is
expected to be offered to expand S 326 by barring health plans from imposing
higher co-payments for recommended medications that are off a plans formulary.

A second formulary amendment is also expected to prohibit health plans from
denying access to FDA-approved {*filter*} on the basis of the medication being
"investigational" or "experimental."  NAMI is strongly supporting both
amendments and urges that advocates contact all senators in support of the
strongest possible formulary provisions.  As NAMI members know first-hand, for
years HMOs have been blocking access to the newest and most effective
medications for schizophrenia and bipolar disorder out of concerns over cost,
rather than clinical benefit.

2) internal and external grievance procedures

Both S 326, and the Democratic alternative (S 6), require all health plans to
establish internal and external appeal processes and require that cases be
reviewed by doctors with relevant expertise.  Both proposals would require that
decisions are legally binding upon the health plan.  However, S 326 also
includes a provision allowing the plan to select the independent third-party
review panel.  NAMI urges all senators to support amendments that would make
external review processes completely independent of health plans and accessible
to enrollees, regardless of the cost of the medical service or treatment that a
health plan denies.

3) protection against involuntary disenrollment

During HELP Committee debate on S 326, Senator Paul Wellstone (D-MN) offered an
amendment to bar plans from involuntarily disenrolling individuals with severe
mental illnesses for conduct or behavior related to the very symptoms of their
illness.  Several recent studies of the managed care industry have found
instances where plans have been able to expel enrollees for disruptive behavior,
missed appointments, etc. in many cases, the very symptoms of schizophrenia,
manic-depression and other brain disorders.  Several senators argued that such
protection is already covered by the Americans with Disabilities Act (ADA) and
the Health Insurance Portability and Accountability Act (HIPAA).  While the
amendment was defeated on a party-line vote by the HELP Committee, Senator
Wellstone is considering offering his amendment on the Senate floor next week.  
NAMI strongly supports the Wellstone Amendment and urges all senators to bar
health plans from disenrolling participants for the very symptoms of their
illness.

4) access to specialists

Both S 326 and S 6 would require health plans to ensure that patients have
access to covered specialty care within the network, or, if necessary, through
contractual arrangements with specialists outside the network.  Both bills would
also require networks to have specialists of "age-specific" expertise (i.e.
pediatric specialists, including child and adolescent psychiatrists).  However,
S 326 does not contain proposals, strongly supported by NAMI, for a "standing
referral" (allowing unobstructed access to a specialist over a longer period
without authorization from a plan) and to permit certain specialists to act as
primary care physicians.  Both of these amendments were rejected by the HELP
Committee.  NAMI strongly urges senators to support meaningful access to
specialists, standing referral and allowing specialists to serve as primary care
doctors for enrollees with special health care needs such as severe mental
illness.  

5) medical necessity

One of the key issues expected to be debated next week in the Senate is where to
rest authority for defining medical necessity a key consideration in insurance
coverage decisions.  S 326 would grant health plans wide discretion to establish
and enforce their own criteria for defining medical necessity.  By contrast, S 6
would give doctors and clinicians authority to determine whether treatment is
medically necessary according to "generally accepted medical practice."  NAMI
is supporting an amendment, expected to be offered by Senator Dianne Feinstein
(D-CA) that would give doctors the ability to determine medical necessity within
the parameters of "generally accepted medical practice."  NAMI is also
supporting a further refinement to the criteria for medical necessity, insisting
that medical necessity reflect the importance of maintaining and restoring
function, not just improving function.  

6) continuity of care

Both S 326 and S 6 require plans who terminate or non-renew providers from their
networks to notify enrollees and allow continued use of the provider (at the
same payment and cost-sharing rates) for up to 90 days if the enrollee is
receiving institutional care, or is terminally ill.  However, S 326 does not
specifically spell out the circumstances upon which continuous care and
treatment could occur.  NAMI is supporting an amendment that would expand the
ability of enrollees to require their health plans to extend coverage with a
specific provider by adding "serious ongoing health conditions" (e.g. severe and
chronic mental illness) to the list of criteria for which continuity of care
would be required.  

House Action

In the House, action on managed care patient bill of rights legislation is
moving at a slower pace.  House Democratic leaders are continuing efforts to
bring their bill (HR 358) to the full House through a procedure known as a
discharge petition.  A discharge petition requires 218 signatures for a bill to
bypass the normal committee process (170 members have signed thus far).  A
separate consensus package that includes both patient protections and coverage
expansion (put forward by Rep. Charles Norwood (R-GA) and key leaders of the
Commerce Committee) appears to be stalled.  

At the same time, the leadership of the House Education and the Workforce
Committee, which has jurisdiction over ERISA self-insured health plans, has been
working on a package of 8 separate bills (HR 2041 through 2047, 2089).  These
bills contain a range of managed care reforms including requirements for plans
to establish external appeals, disclose what benefits are available, and cover
emergency room services based on a "prudent layperson" standard.  However, this
package limits provisions governing access to specialists (pediatricians and
ob-gyns) and removes all other decisions regarding binding managed care
standards to a proposed federal commission.  

NAMI Opposes AHP/MEWA Proposal

The Education and the Workforce Committee package also contains a proposal to
vastly expand the use of multi-employer purchasing cooperatives (known as MEWAs
and AHPs) to expand coverage to uninsured workers and their families.  While
NAMI strongly supports the goal of expanding coverage to the 41 million
Americans without health insurance, we are opposed to doing so through extension
of ERISA the federal law that allows employers to self insure and exempt their
plans from state law.  

In recent weeks, the number of states that have enacted mental illness parity
bills has expanded to 25.  In each of these 25 states, these state 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 (parity is limited to annual and lifetime dollar limits) are far
below most of the existing state laws.  Because of the potential impact that
expansion of coverage through AHPs and MEWAs could have on state parity laws,
NAMI is urging advocates to oppose these measures.  In particular, NAMI is
urging House members to oppose HR 2047 and an expected amendment on the Senate
floor next week to include AHPs in the Senate managed care bill (S 326).    

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