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What is the Patient’s Bill of Rights?

There’s more than one Patient’s Bill of Rights

In the early 1970’s the American Hospital Association (AHA) drafted a Bill of Rights to inform patients of what they could reasonably expect while in the hospital. Since then, various groups have developed a number of different declarations, so that there’s more than one version of the Patient’s Bill of Rights.

As health care has changed, newer bills of rights tend to discuss patients’ rights in dealing with insurance companies and other specific situations. For the most part, the older bills of rights still apply to the situations and settings for which they were written.

Patient’s rights and health insurance: the Affordable Care Act

In 2010, a new Patient’s Bill of Rights was created along with the Affordable Care Act. This bill of rights was designed to give new patient protections in dealing with insurance companies. Some of the protections started in 2010, but others were phased in more slowly and take full effect in 2014.

Here are some of the protections that apply to health plans under the new laws:

  • Annual and lifetime dollar limits to coverage of essential benefits have been removed. (Essential benefits include doctor and specialist visits, home and hospice services, emergency services, hospitalization, preventive and wellness services, chronic disease management, laboratory services, prescription drugs, maternity and newborn care, pediatric services, mental health and substance use disorder services, and rehabilitative services and devices. Non-essential benefits include things like adult dental care.)
  • People will be able to get health insurance in spite of pre-existing medical conditions (medical problems they have before getting insurance).
  • You have the right to an easy-to-understand summary of benefits and coverage.
  • Young adults are able to stay on a parent’s policy until age 26 if they meet certain requirements.
  • You’re entitled to certain preventive screening without paying extra fees or co-pays.
  • If your plan denies payment for a medical treatment or service, you must be told why it was refused, and how to appeal (fight) that decision.
  • You have the right to appeal the payment decisions of private health plans (called an “internal appeal”). You also have the right to a review by an independent organization (called an “outside review”) if the company still doesn’t want to pay.
  • Larger insurance companies must spend 80 to 85% of their premiums on health care and improvement of care rather than on salaries, overhead, and marketing.
  • If you made an honest mistake on your insurance application, health insurance companies will no longer be able to rescind (take back) your health coverage after you get sick. (They can still cancel coverage if you don’t pay premiums on time, if you lied on your application form, or if they no longer offer plans in your region.)
  • If a company does cancel your coverage, they must give you at least 30 days’ notice.
  • Premium increases of more than 10% must be explained and clearly justified.

Still, there are exceptions to some of these rights. The new rules apply to plans issued or renewed on or after September 23, 2010. Going into 2014, some existing health plans are still “grandfathered,” meaning they don’t have to follow all of the new rules as long as they keep an old plan in effect. You’ll need to check your plan’s materials or ask your employer or benefits person to find out if your health plan is grandfathered.

Besides the grandfathered plans, there are other ways insurance companies can bypass some of the rules. Insurance plans may ask the U.S. Department of Health and Human Services (DHHS) for waivers (exceptions) to some of the new requirements. The DHHS has already granted a number of these exceptions, so you’ll still have to check with each plan to find out exactly what they do and don’t do. 

The Consumer Bill of Rights and Responsibilities

While these new rights from 2010 are taking effect, older bills of rights still apply. Here is a summary of the Consumer Bill of Rights and Responsibilities that was adopted by the US Advisory Commission on Consumer Protection and Quality in the Health Care Industry in 1998.

This bill of rights applies to the insurance plans offered to federal employees. Many other health insurance plans and facilities have also adopted these values. Even Medicare and Medicaid stand by many of them. This bill of rights addresses 8 key areas:

Information for Patients

You have the right to accurate and easy-to-understand information about your health plan, health care professionals, and health care facilities. If you speak another language, have a physical or mental disability, or just don’t understand something, help should be given so you can make informed health care decisions.

Choice of Providers and Plans

Consumers have the right to a choice of health care providers that is sufficient to ensure access to appropriate high-quality health care.

Access to Emergency Services

If you have severe pain, an injury, or sudden illness that makes you believe your health is in danger, you have the right to be screened and stabilized using emergency services. You should be able to use these services whenever and wherever you need them, even if they’re out of your network, without needing to wait for authorization and without any financial penalty.

Taking Part in Treatment Decisions

You have the right to be informed about your treatment options and take part in decisions about your care. You have the right to ask about the pros and cons of any treatment, including no treatment at all. As long as you are able to make sound decisions, you have the right to refuse any test or treatment, even if it means you might have a bad health outcome as a result. You can also legally choose someone who can speak for you if you cannot make your own decisions. Click on Advance Directives for more information on appointing someone to do this.

Respect and Non-discrimination

You have a right to considerate, respectful care from your doctors, health plan representatives, and other health care providers that does not discriminate against you based on race, ethnicity, national origin, religion, sex, age, mental or physical disability, sexual orientation, genetic information, or source of payment.

Confidentiality (Privacy) of Health Information

You have the right to talk privately with health care providers and have your health care information protected. You also have the right to read and copy your own medical record. You have the right to ask that your doctor change your record if it’s not correct, relevant, or complete.

Complaints and Appeals

You have the right to a fair, fast, and objective review of any complaint you have against your health plan, doctors, hospitals, or other health care personnel. This includes complaints about waiting times, operating hours, the actions of health care personnel, and the adequacy of health care facilities.

Consumer Responsibilities

In a health care system that protects consumer or patients’ rights, patients have certain responsibilities. For instance, patients must tell their health care providers about any drugs or supplements they are taking, and about health conditions and medical or surgical problems in the past or present. Patients must ask questions or request further information from health care providers if they do not completely understand health information and/or instructions they’ve been given.

Patients must also take responsibility for their lifestyles to help improve their own health. (For instance, following a treatment plan, exercising, and not using tobacco.) Having patients involved in their care increases the chance of the best possible outcomes and helps support a high quality, cost-conscious health care system.

Patients are also expected to do things like treat health care workers and other patients with respect, try to pay their medical bills, and follow the rules and benefits of their health plan coverage.

Other Bills of Rights

The 2 bills of rights discussed so far focus on health insurance plans, but there are others for different settings, like these:

  • Mental health bill of rights
  • Hospice patient’s bill of rights
  • Rights of people in hospitals

Certain US states have their own bills of rights for patients. Insurance plans sometimes have lists of rights for subscribers. Many of these lists of rights tell you where to go or whom to talk with if you have a problem with your care.

The American Hospital Association (AHA) has a list of patient rights and responsibilities that can help a person be a more active partner in his or her health care when in the hospital. It’s an updated version of the first bill of rights from the AHA. (See below.)

Health Insurance Problems

If you have concerns about your insurance, it’s sometimes helpful to start with customer service or a case manager at your health insurance company.

National Organizations and Websites:

US Department of Health and Human Services

This site explains new patient rights with regard to health insurance under the 2010 Affordable Care Act.

American Hospital Association
Toll-free number: 1-800-242-2626 (this is the customer service/publication order line)

AHA’s Patient Care Partnership brochure teaches patients about rights and responsibilities in regard to their hospital stay. (It comes in English, Arabic, Chinese, Russian, Spanish, Tagalog, and Vietnamese.) The brochure is sold in bulk orders only and there’s a fee for non-members. To view the online version, click here.

National Library of Medicine

This site has information on patient rights along with many links to other sources of related information

Medicare Rights Center (for those with Medicare)
Toll-free number: 1-800-333-4114

This service can help you understand your rights and benefits, work through the Medicare system, and get quality care. They have newsletters, fact sheets, and a place to submit questions. They can also help you find programs that help reduce your costs for prescription drugs and medical care, and guide you through the appeals process if Medicare denies coverage for drugs or care you need.