Principles of Consumer Protection

The Epilepsy Foundation supports federal legislation that meets the health care needs of people with epilepsy. The Foundation supports affordable and quality health care for all Americans and strongly believes that consumers should be given a choice of health plans. Therefore, the Foundation urges Members of Congress to support the following consumer protection principles approved by the Board of Directors, June 1998:

I. Choice of Health Care Provider

• Timely access to a selection of qualified specialists.
• Availability of an affordable Point-of-Service (POS) Option.
• Access to treatment at comprehensive epilepsy centers.

II. Confidentiality of Health Plan Information

• Health plans should ensure that the confidentiality of patient medical records and other identifiable health information is protected.
• Health plans should ensure non-discrimination against enrollees.
• Health plans should have written policies governing confidentiality.

III. Access and Coverage of Emergency and Health Care Services

• Access to medically necessary emergency care without prior authorization using the prudent layperson standard.
• Coverage of necessary diagnostic procedures.
• Elimination of policies that limit a physician's ability to discuss all treatment options with the patient.

IV. Disclosure of Health Plan Information

• Access to clearly understandable information about the health plan.
• Disclosure of reimbursement methodologies/financial arrangements between physicians and the plan that may affect treatment decisions.
• Information on coverage of experimental or investigational treatments; drugs included or excluded from coverage; how off-label uses of drugs listed in the formulary are covered; and how to get a drug added to the formulary.

V. Grievance and Appeals Procedures

• Disclosure of grievance and the utilization review process in a clear and easy format.
• Ability to obtain more information through an Ombudsman program.
• Decision-making should be administered by personnel with appropriate training and expertise.
• Enrollees should be informed of their right to appeal adverse decisions and the time frames that apply.
• Expedited appeals and shorter time frames in emergency circumstances.

VI. Health Plan Liability

• Permit individuals enrolled in an employer sponsored group health plan to pursue legal actions and seek damages in state court for personal injury or wrongful death caused by improper denial of benefits.