Such seemingly technical questions can be vital to patients. For example, Dr. Ganske said, H.M.O.'s often refuse to pay for surgery on children to correct cleft lip and cleft palate, contending that such procedures are a form of cosmetic surgery and are therefore not covered by the insurance policy. But Dr. Ganske said that in many cases the surgery was not a cosmetic procedure, because without it children could not eat or speak properly. Under the compromise legislation, lawmakers said, if a health plan promised to cover 30 days of hospital care for people with a mental illness, the appeals board could not order coverage for a 31st day. But Democrats want to make sure that patients have an independent way of determining whether the H.M.O. is right in saying that a particular service is limited or excluded under the terms of a contract.
Insurers often refuse to pay for experimental treatments.
Democrats and some Republicans like Representative Charlie Norwood of Georgia say patients must be able to challenge an H.M.O.'s decision about what is experimental. Congressional aides said that an unusual and interesting dynamic had developed in negotiations on the patient's bill of rights. Often, they said, Senate Republicans pull aside Democrats from the House and the Senate, hoping to make deals, and House Republicans are excluded from the discussions. Mr. Nickles, the assistant Republican leader of the Senate, has made clear that he wants to wrap up an agreement before the discussions are embroiled in the politics of election campaigns. Some lawmakers and Congressional aides said Mr. Nickles had excluded House Republicans from some discussions as part of a strategy to speed the negotiations.