Question

Patient’s Bill of Rights Imagine some of the issues that may require you, as a health care professional, to recall information in the Patient’s Bill of Rights and use it as the basis for your actions.For this assignment, you will post: What you would do if faced with the scenarios below. Include the following three items in your posting. I would suggest numbering your answer to make sure you have included everything. ITEMS: 1. Which component/s of the Patient’s Bill of Rights addresses the scenario? Write them out. 2. Write what you would say to the patient and/ or do for the patient in this situation, and why. 3. After you care for the patients, what could you suggest to the managers about facility policy or procedure to prevent this same issue from repeating over and over. #1. A patient has been denied a medication by his insurance company, which states that a substitute medication must be used. The physician who prescribed the medication insists he will not accept a substitute. In regard to the newly enacted Affordable Care Act, what do you discuss with the patient with regard to his rights? IN YOUR ANSWERS: 1. State any additional ideas or thoughts you may have related to the situation. 2. State any additional suggestions you may have related to changing the facility policy or procedure.

Answer 1

1. Under federal rules, plans that provide Essential Health Benefits must have procedures in place that allow an enrollee to “request and gain access to clinically appropriate drugs not covered by the health plan.”

Most health plans have an exceptions process for requesting coverage for non-formulary drugs. In addition, states may have requirements for what those processes must include to meet state licensing standards. In the Federal Marketplace, health plans must have an exceptions process that meets federal standards. This exceptions process is separate from the ACA-required process for appealing a benefit denial.

The federal standards note that plans can use their existing exceptions processes, as long as they allow a consumer to request both an internal review by the plan and an independent review of the exception request. If it doesn’t allow for both, CMS “encourages” health plans to use a CMS-outlined process that includes both an internal review and an independent review, with detailed timeframes for quick turnaround of a response to the request, particularly where a consumer’s health condition requires a timely answer.

Federal rules also suggest plans follow Medicare Part D guidelines for determining whether a drug is clinically appropriate. Under those guidelines, a drug is clinically appropriate and should be covered if the consumer’s prescribing physician has determined that the alternatives available to the consumer – other covered drugs, the same drug in a different dose, or an alternative drug that must be tried first – would be ineffective, cause harm, or affect patient compliance with the prescription treatment.

And finally, CMS strongly encourages plans to allow the consumer to have access to the medication in dispute as the exceptions process is underway, and, if coverage is granted, to continue to allow the consumer access to the drug in future plan years if they remain enrolled.

Of course having an exceptions process does not ensure patients will ultimately gain access to non-formulary drugs. But having such a process makes access at least possible, with the potential added benefit of lower costs and inclusion in the out-of-pocket limit.

2. There must be amendments in the existing policy regarding insurance coverage . People take insurance so that they get help in their disease period but if they won't even provide the medicines prescribed by physicians then it's not of any worth . Government should take actions towards these actions of the insurance company's .