Whereas consumers may continue to confront a variety of
problems with a reformed health care system;
Whereas those problems may range from difficulties in
choosing an appropriate health plan, problems with calculation of premiums and
cost-sharing, the possibility of a denial of benefits, and issues with
enrollment and access to providers;
Whereas the Institute of Medicine estimates that as many
as 30 percent of people in the United States suffer from health treatment
illiteracy;
Whereas the Office of Disease Prevention and Health
Promotion of the Department of Health and Human Services reports that only 12
percent of the population can use a table to calculate the share of health
insurance costs for an individual;
Whereas a study by RAND Corporation found that increasing
the ease of access to information regarding insurance products and simplifying
the application process would increase purchase rates of insurance products as
much as modest subsidies would;
Whereas the reports from the Institute of Medicine, the
Office of Disease Prevention and Health Promotion, and RAND Corporation prove
there is a need for a fundamental improvement in the manner in which consumers
learn about insurance choices;
Whereas many consumers lack avenues or mechanisms to
present grievances both to the managers of health plans and to external
reviewers and fail to receive timely decisions with respect to those
grievances;
Whereas consumers often need expert guidance to pursue
claims for denied health care benefits and other coverage disputes;
Whereas some States have documented a number of cases of
improperly rescinded health insurance policies, inappropriate billing for
out-of-network services, and fraudulent and deceptive marketing of health
plans;
Whereas the Federal Government lacks oversight mechanisms
to prevent health care coverage problems from recurring in other States;
Whereas the appropriate resolution of a health coverage
complaint may involve multiple Federal and State agencies;
Whereas health plans sometimes make mid-year changes to
provider networks, benefit offerings, or other elements of the plan important
to enrollees;
Whereas people need assistance enforcing consumer rights
in the health care system; and
Whereas Federal laws have created successful models of
consumer assistance with health dispute resolution, such as the Long Term Care
Ombudsman program that assists nursing home residents in every State and the
Senior Health Insurance Assistance Program that assists those eligible for
Medicare: Now, therefore, be it
That it is the sense of Congress that
any health care reform legislation should include, with respect to health
plans—
(1)support for
consumer education and assistance with enrollment, particularly for vulnerable
populations, at both the Federal and State levels;
(2)assistance for
people asserting consumer rights;
(3)a strengthened
system of consumer protections, including—
(A)an appeal
mechanism within a health plan, and an appeal mechanism with an external entity
independent of the health plan, which could address a variety of coverage
problems;
(B)coverage for
emergency care without prior authorization;
(C)protections
against balance billing in emergency situations and in situations in which
in-network providers are unavailable;
(D)protections
against mid-year health plan changes that could have an impact on the
cost-sharing or access to services of an enrollee;
(E)verification of
accurate out-of-network co-payment charges; and
(F)protections
against misleading marketing; and
(4)a strengthened
enforcement system of consumer rights for claims, with respect to health plans,
involving systemic violations of consumer protections, including remedies for
individuals, civil penalties, and other appropriate sanctions.