H.R.1415 (Norwood)
Patient Access to Responsible Care Act of 1997
"PARCA"
Table of Contents:
To amend the Public Health Service Act and the Employee Retirement
Income Security Act of 1974 to establish standards for
relationships between group health plans and health insurance
issuers with enrollees, health professionals, and providers.
IN THE HOUSE OF REPRESENTATIVES
April 23, 1997
Mr. NORWOOD (for himself, Mr. BACHUS, Mr. BAKER, Mr. BARCIA, Mr.
BARR of Georgia, Mr. BARRETT of Wisconsin, Mr. BISHOP, Mr.
BROWN of Ohio, Mr. CANADY of Florida, Mr. CHAMBLISS, Mr. COBLE,
Mr. COBURN, Mr. COMBEST, Mr. COOKSEY, Mr. CRAMER, Mr. DAVIS of
Illinois, Mr. DAVIS of Virginia, Mr. DEAL of Georgia, Mr.
DEFAZIO, Mr. DICKEY, Mr. DUNCAN, Mr. FILNER, Mr. FOLEY, Mr. FOX
of Pennsylvania, Mr. FROST, Mr. GILMAN, Mr. GRAHAM, Mr. HALL of
Ohio, Mr. HILLEARY, Mr. HILLIARD, Mr. HINCHEY, Mr. JENKINS,
Mrs. KELLY, Mr. KENNEDY of Rhode Island, Mr. KIND, Mr. LAHOOD,
Mr. LEWIS of Kentucky, Mr. LINDER, Mr. LIVINGSTON, Mrs. MALONEY
of New York, Mr. MCHALE, Mr. MCHUGH, Mrs. MORELLA, Mrs. MYRICK,
Mr. NETHERCUTT, Mr. PALLONE, Mr. PICKERING, Mr. RANGEL, Mr.
RIGGS, Mrs. ROUKEMA, Mr. SANDERS, Mr. SCARBOROUGH, Mr.
SENSENBRENNER, Mr. SHADEGG, Mr. SOLOMON, Mr. SPENCE, Mr.
STRICKLAND, Mr. TOWNS, Mr. WALSH, Mr. WICKER, Mr. WISE, Ms.
WOOLSEY, Mr. WEYGAND, Mr. CHRISTENSEN, Mr. COLLINS, and Mr.
WAMP) introduced the following bill;
which was referred to the
Committee on Commerce, and in addition to the Committee on
Education and the Workforce, for a period to be subsequently
determined by the Speaker, in each case for consideration of
such provisions as fall within the jurisdiction of the
committee concerned
A BILL
To amend the Public Health Service Act and the Employee Retirement
Income Security Act of 1974 to establish standards for
relationships between group health plans and health insurance
issuers with enrollees, health professionals, and providers.
Be it enacted by the Senate and House of
Representatives of the United States of America in Congress
assembled,
SECTION 1. SHORT TITLE; TABLE OF CONTENTS.
- (a) SHORT TITLE- This Act may be cited as the `Patient Access to
Responsible Care Act of 1997'.
(b) TABLE OF CONTENTS- The table of contents of this Act is as
follows:
- Sec. 1. Short title; table of contents.
- Sec. 2. Patient protection standards under the Public Health
Service Act.
`PART C--PATIENT PROTECTION STANDARDS
- Sec. 3. Patient protection standards under the Employee Retirement
Income Security Act of 1974.
- Sec. 4. Non-preemption of State law respecting liability of group
health plans.
SEC. 2. PATIENT PROTECTION STANDARDS UNDER THE PUBLIC HEALTH
SERVICE ACT.
(a) PATIENT PROTECTION STANDARDS- Title XXVII of the Public
Health Service Act is amended--
(1) by redesignating part C as part D, and
(2) by inserting after part B the following new part:
`PART C--PATIENT PROTECTION STANDARDS
`SEC. 2770. NOTICE; ADDITIONAL DEFINITIONS; CONSTRUCTION.
- `(a) NOTICE- A health insurance issuer under this part shall
comply with the notice requirement under section 711(d) of the
Employee Retirement Income Security Act of 1974 with respect to the
requirements of this part as if such section applied to such issuer
and such issuer were a group health plan.
- `(b) ADDITIONAL DEFINITIONS- For purposes of this part:
- `(1) ENROLLEE- The term `enrollee' means, with respect to
health insurance coverage offered by a health insurance issuer,
an individual enrolled with the issuer to receive such coverage.
- `(2) HEALTH PROFESSIONAL- The term `health professional'
means a physician or other health care practitioner licensed,
accredited, or certified to perform specified health services
consistent with State law.
- `(3) NETWORK- The term `network' means, with respect to a
health insurance issuer offering health insurance coverage, the
participating health professionals and providers through whom
the plan or issuer provides health care items and services to
enrollees.
- `(4) NETWORK COVERAGE- The term `network coverage' means
health insurance coverage offered by a health insurance issuer
that provides or arranges for the provision of health care
items and services to enrollees through participating health
professionals and providers.
- `(5) PARTICIPATING- The term `participating' means, with
respect to a health professional or provider, a health
professional or provider that provides health care items and
services to enrollees under network coverage under an agreement
with the health insurance issuer offering the coverage.
- `(6) PRIOR AUTHORIZATION- The term `prior authorization'
means the process of obtaining prior approval from a health
insurance issuer as to the necessity or appropriateness of
receiving medical or clinical services for treatment of a
medical or clinical condition.
- `(7) PROVIDER- The term `provider' means a health
organization, health facility, or health agency that is
licensed, accredited, or certified to provide health care items
and services under applicable State law.
- `(8) SERVICE AREA- The term `service area' means, with
respect to a health insurance issuer with respect to health
insurance coverage, the geographic area served by the issuer
with respect to the coverage.
- `(9) UTILIZATION REVIEW- The term `utilization review' means
prospective, concurrent, or retrospective review of health care
items and services for medical necessity, appropriateness, or
quality of care that includes prior authorization requirements
for coverage of such items and services.
- `(c) NO REQUIREMENT FOR ANY WILLING PROVIDER- Nothing in this
part shall be construed as requiring a health insurance issuer that
offers network coverage to include for participation every willing
provider or health professional who meets the terms and conditions
of the plan or issuer.
`SEC. 2771. ENROLLEE ACCESS TO CARE.
- `(a) GENERAL ACCESS-
- `(1) IN GENERAL- Subject to paragraphs (2), and (3), a health
insurance issuer shall establish and maintain adequate
arrangements, as defined by the applicable State authority,
with a sufficient number, mix, and distribution of health
professionals and providers to assure that covered items and
services are available and accessible to each enrollee under
health insurance coverage--
- `(A) in the service area of the issuer;
- `(B) in a variety of sites of service;
- `(C) with reasonable promptness (including reasonable
hours of operation and after-hours services);
- `(D) with reasonable proximity to the residences and
workplaces of enrollees; and
- `(E) in a manner that--
`(i) takes into account the diverse needs of
enrollees, and
`(ii) reasonably assures continuity of care.
For a health insurance issuer that serves a rural or medically
underserved area, the issuer shall be treated as meeting the
requirement of this subsection if the issuer has arrangements
with a sufficient number, mix, and distribution of health
professionals and providers having a history of serving such
areas. The use of telemedicine and other innovative means to
provide covered items and services by a health insurance issuer
that serves a rural or medically underserved area shall also be
considered in determining whether the requirement of this
subsection is met.
- `(2) RULE OF CONSTRUCTION- Nothing in this subsection shall
be construed as requiring a health insurance issuer to have
arrangements that conflict with its responsibilities to
establish measures designed to maintain quality and control
costs.
- `(3) DEFINITIONS- For purposes of paragraph (1):
- `(A) MEDICALLY UNDERSERVED AREA- The term `medically
underserved area' means an area that is designated as a
health professional shortage area under section 332 of the
Public Health Service Act or as a medically underserved
area for purposes of section 330 or 1302(7) of such Act.
- `(B) RURAL AREA- The term `rural area' means an area that
is not within a Standard Metropolitan Statistical Area or a
New England County Metropolitan Area (as defined by the
Office of Management and Budget).
- `(b) EMERGENCY AND URGENT CARE-
- `(1) IN GENERAL- A health insurance issuer shall--
- `(A) assure the availability and accessibility of
medically or clinically necessary emergency services and
urgent care services within the service area of the issuer
24 hours a day, 7 days a week;
- `(B) require no prior authorization for items and
services furnished in a hospital emergency department to an
enrollee (without regard to whether the health professional
or hospital has a contractual or other arrangement with the
issuer) with symptoms that would reasonably suggest to a
prudent layperson an emergency medical condition (including
items and services described in subparagraph (C)(iii));
- `(C) cover (and make reasonable payments for)--
- `(i) emergency services,
- `(ii) services that are not emergency services but
are described in subparagraph (B),
- `(iii) medical screening examinations and other
ancillary services necessary to diagnose, treat, and
stabilize an emergency medical condition, and
- `(iv) urgent care services, without regard to whether
the health professional or provider furnishing such
services has a contractual (or other) arrangement with
the issuer; and
- `(D) make prior authorization determinations for--
- `(i) services that are furnished in a hospital
emergency department (other than services described in
clauses (i) and (iii) of subparagraph (C)), and
- `(ii) urgent care services, within the time periods
specified in (or pursuant to) section 2776(a)(8).
- `(2) DEFINITIONS- For purposes of this subsection:
- `(A) EMERGENCY MEDICAL CONDITION- The term `emergency
medical condition' means a medical condition (including
emergency labor and delivery) manifesting itself by acute
symptoms of sufficient severity (including severe pain)
such that a prudent layperson, who possesses an average
knowledge of health and medicine, could reasonably expect
the absence of immediate medical attention could reasonably
be expected to result in--
- `(i) placing the patient's health in serious jeopardy,
- `(ii) serious impairment to bodily functions, or
- `(iii) serious dysfunction of any bodily organ or part.
- `(B) EMERGENCY SERVICES- The term `emergency services'
means health care items and services that are necessary for
the diagnosis, treatment, and stabilization of an emergency
medical condition.
- `(C) URGENT CARE SERVICES- The term `urgent care
services' means health care items and services that are
necessary for the treatment of a condition that--
- `(i) is not an emergency medical condition,
- `(ii) requires prompt medical or clinical treatment,
and
- `(iii) poses a danger to the patient if not treated
in a timely manner, as defined by the applicable State
authority in consultation with relevant treating health
professionals or providers.
- `(c) SPECIALIZED SERVICES-
- `(1) IN GENERAL- A health insurance issuer offering network
coverage shall demonstrate that enrollees have access to
specialized treatment expertise when such treatment is
medically or clinically indicated in the professional judgment
of the treating health professional, in consultation with the
enrollee.
- `(2) DEFINITION- For purposes of paragraph (1), the term
`specialized treatment expertise' means expertise in diagnosing
or treating--
- `(A) unusual diseases or conditions, or
- `(B) diseases and conditions that are unusually difficult to
diagnose or treat.
- `(d) INCENTIVE PLANS-
- `(1) IN GENERAL- In the case of a health insurance issuer
that offers network coverage, any health professional or
provider incentive plan operated by the issuer with respect to
such coverage shall meet the following requirements:
- `(A) No specific payment is made directly or indirectly
under the plan to a professional or provider or group of
professionals or providers as an inducement to reduce or
limit medically necessary services provided with respect to
a specific enrollee.
- `(B) If the plan places such a professional, provider, or
group at substantial financial risk (as determined by the
Secretary) for services not provided by the professional,
provider, or group, the issuer--
- `(i) provides stop-loss protection for the
professional, provider, or group that is adequate and
appropriate, based on standards developed by the
Secretary that take into account the number of
professionals or providers placed at such substantial
financial risk in the group or under the coverage and
the number of individuals enrolled with the issuer who
receive services from the professional, provider, or
group, and
- `(ii) conducts periodic surveys of both individuals
enrolled and individuals previously enrolled with the
issuer to determine the degree of access of such
individuals to services provided by the issuer and
satisfaction with the quality of such services.
- `(C) The issuer provides the Secretary with descriptive
information regarding the plan, sufficient to permit the
Secretary to determine whether the plan is in compliance
with the requirements of this paragraph.
- `(2) In this subsection, the term `health professional or
provider incentive plan' means any compensation arrangement
between a health insurance issuer and a health professional or
provider or professional or provide group that may directly or
indirectly have the effect of reducing or limiting services
provided with respect to individuals enrolled with the issuer.
`SEC. 2772. ENROLLEE CHOICE OF HEALTH PROFESSIONALS AND PROVIDERS.
- `(a) CHOICE OF PERSONAL HEALTH PROFESSIONAL- A health insurance
issuer shall permit each enrollee under network coverage to--
- `(1) select a personal health professional from among the
participating health professionals of the issuer, and
- `(2) change that selection as appropriate.
- `(b) POINT-OF-SERVICE OPTION-
- `(1) IN GENERAL- If a health insurance issuer offers to
enrollees health insurance coverage which provides for coverage
of services only if such services are furnished through health
professionals and providers who are members of a network of
health professionals and providers who have entered into a
contract with the issuer to provide such services, the issuer
shall also offer to such enrollees (at the time of enrollment)
the option of health insurance coverage which provides for
coverage of such services which are not furnished through
health professionals and providers who are members of such a
network.
- `(2) FAIR PREMIUMS- The amount of any additional premium
required for the option described in paragraph (1) may not
exceed an amount that is fair and reasonable, as established by
the applicable State authority, in consultation with the
National Association of Insurance Commissioners, based on the
nature of the additional coverage provided.
- `(3) COST-SHARING- Under the option described in paragraph
(1), the health insurance coverage shall provide for
reimbursement rates for covered services offered by health
professionals and providers who are not participating health
professionals or providers that are not less than the
reimbursement rates for covered services offered by
participating health professionals and providers. Nothing in
this paragraph shall be construed as protecting an enrollee
against balance billing by a health professional or provider
that is not a participating health professional or provider.
- `(c) CONTINUITY OF CARE- A health insurance issuer offering
network coverage shall--
- `(1) ensure that any process established by the issuer to
coordinate care and control costs does not create an undue
burden, as defined by the applicable State authority, for
enrollees with special health care needs or chronic conditions;
- `(2) ensure direct access to relevant specialists for the
continued care of such enrollees when medically or clinically
indicated in the judgment of the treating health professional,
in consultation with the enrollee;
- `(3) in the case of an enrollee with special health care
needs or a chronic condition, determine whether, based on the
judgment of the treating health professional, in consultation
with the enrollee, it is medically or clinically necessary to
use a specialist or a care coordinator from an
interdisciplinary team to ensure continuity of care; and
- `(4) in circumstances under which a change of health
professional or provider might disrupt the continuity of care
for an enrollee, such as--
`(A) hospitalization, or
`(B) dependency on high-technology home medical equipment,
provide for continued coverage of items and services furnished
by the health professional or provider that was treating the
enrollee before such change for a reasonable period of time.
For purposes of paragraph (4), a change of health professional or
provider may be due to changes in the membership of an issuer's
health professional and provider network, changes in the health
coverage made available by an employer, or other similar
circumstances.
`SEC. 2773. NONDISCRIMINATION AGAINST ENROLLEES AND IN THE
SELECTION OF HEALTH PROFESSIONALS; EQUITABLE
ACCESS TO NETWORKS.
- `(a) NONDISCRIMINATION AGAINST ENROLLEES- No health insurance
issuer may discriminate (directly or through contractual
arrangements) in any activity that has the effect of discriminating
against an individual on the basis of race, national origin,
gender, language, socioeconomic status, age, disability, health
status, or anticipated need for health services.
- `(b) NONDISCRIMINATION IN SELECTION OF NETWORK HEALTH
PROFESSIONALS- A health insurance issuer offering network coverage
shall not discriminate in selecting the members of its health
professional network (or in establishing the terms and conditions
for membership in such network) on the basis of--
- `(1) the race, national origin, gender, age, or disability
(other than a disability that impairs the ability of an
individual to provide health care services or that may threaten
the health of enrollees) of the health professional; or
- `(2) the health professional's lack of affiliation with, or
admitting privileges at, a hospital (unless such lack of
affiliation is a result of infractions of quality standards and
is not due to a health professional's type of license).
- `(c) NONDISCRIMINATION IN ACCESS TO HEALTH PLANS- While nothing
in this section shall be construed as an `any willing provider'
requirement (as referred to in section 2770(c)), a health insurance
issuer shall not discriminate in participation, reimbursement, or
indemnification against a health professional, who is acting within
the scope of the health professional's license or certification
under applicable State law, solely on the basis of such license or
certification.
`SEC. 2774. PROHIBITION OF INTERFERENCE WITH CERTAIN MEDICAL
COMMUNICATIONS.
- `(a) IN GENERAL- The provisions of any contract or agreement, or
the operation of any contract or agreement, between a health
insurance issuer and a health professional shall not prohibit or
restrict the health professional from engaging in medical
communications with his or her patient.
- `(b) NULLIFICATION- Any contract provision or agreement described
in subsection (a) shall be null and void.
- `(c) MEDICAL COMMUNICATION DEFINED- For purposes of this section,
the term `medical communication' means a communication made by a
health professional with a patient of the health professional (or
the guardian or legal representative of the patient) with respect
to--
- `(1) the patient's health status, medical care, or legal
treatment options;
- `(2) any utilization review requirements that may affect
treatment options for the patient; or
- `(3) any financial incentives that may affect the treatment
of the patient.
`SEC. 2775. DEVELOPMENT OF PLAN POLICIES.
`A health insurance issuer that offers network coverage shall
establish mechanisms to consider the recommendations, suggestions,
and views of enrollees and participating health professionals and
providers regarding--
- `(1) the medical policies of the issuer (including policies
relating to coverage of new technologies, treatments, and
procedures);
- `(2) the utilization review criteria and procedures of the
issuer;
- `(3) the quality and credentialing criteria of the issuer; and
- `(4) the medical management procedures of the issuer.
`SEC. 2776. DUE PROCESS FOR ENROLLEES.
- `(a) UTILIZATION REVIEW- The utilization review program of a
health insurance issuer shall--
- `(1) be developed (including any screening criteria used by
such program) with the involvement of participating health
professionals and providers;
- `(2) to the extent consistent with the protection of
proprietary business information (as defined for purposes of
section 552 of title 5, United States Code) release, upon
request, to affected health professionals, providers, and
enrollees the screening criteria, weighting elements, and
computer algorithms used in reviews and a description of the
method by which they were developed;
- `(3) uniformly apply review criteria that are based on sound
scientific principles and the most recent medical evidence;
- `(4) use licensed, accredited, or certified health
professionals to make review determinations (and for services
requiring specialized training for their delivery, use a health
professional who is qualified through equivalent specialized
training and experience);
- `(5) subject to reasonable safeguards, disclose to health
professionals and providers, upon request, the names and
credentials of individuals conducting utilization review;
- `(6) not compensate individuals conducting utilization review
for denials of payment or coverage of benefits;
- `(7) comply with the requirement of section 2771 that prior
authorization not be required for emergency and related
services furnished in a hospital emergency department;
- `(8) make prior authorization determinations--
`(A) in the case of services that are urgent care
services described in section 2771(b)(2)(C), within 30
minutes of a request for such determination, and
`(B) in the case of other services, within 24 hours after
the time of a request for determination;
- `(9) include in any notice of such determination an
explanation of the basis of the determination and the right to
an immediate appeal;
- `(10) treat a favorable prior authorization review
determination as a final determination for purposes of making
payment for a claim submitted for the item or service involved
unless such determination was based on false information
knowingly supplied by the person requesting the determination;
- `(11) provide timely access, as defined by the applicable
State authority, to utilization review personnel and, if such
personnel are not available, waives any prior authorization
that would otherwise be required; and
- `(12) provide notice of an initial determination on payment
of a claim within 30 days after the date the claim is submitted
for such item or service, and include in such notice an
explanation of the reasons for such determination and of the
right to an immediate appeal.
- `(b) APPEALS PROCESS- A health insurance issuer shall establish
and maintain an accessible appeals process that--
- `(1) reviews an adverse prior authorization determination--
`(A) for urgent care services, described in subsection
(a)(8)(A), within 1 hour after the time of a request for
such review, and
`(B) for other services, within 24 hours after the time
of a request for such review;
- `(2) reviews an initial determination on payment of claims
described in subsection (a)(12) within 30 days after the date
of a request for such review;
- `(3) provides for review of determinations described in
paragraphs (1) and (2) by an appropriate clinical peer
professional who is in the same or similar specialty as would
typically provide the item or service involved (or another
licensed, accredited, or certified health professional
acceptable to the plan and the person requesting such review);
and
- `(4) provides for review of--
`(A) the determinations described in paragraphs (1), (2),
and (3), and
`(B) enrollee complaints about inadequate access to any
category or type of health professional or provider in the
network of the issuer or other matters specified by this
part,
by an appropriate clinical peer professional who is in the same
or similar specialty as would typically provide the item or
service involved (or another licensed, accredited, or certified
health professional acceptable to the issuer and the person
requesting such review) that is not involved in the operation
of the plan or in making the determination or policy being
appealed.
The procedures specified in this subsection shall not be construed
as preempting or superseding any other reviews or appeals an issuer
is required by law to make available.
`SEC. 2777. DUE PROCESS FOR HEALTH PROFESSIONALS AND PROVIDERS.
- `(a) IN GENERAL- A health insurance issuer with respect to its
offering of network coverage shall--
- `(1) allow all health professionals and providers in its
service area to apply to become a participating health
professional or provider during at least one period in each
calendar year;
- `(2) provide reasonable notice to such health professionals
and providers of the opportunity to apply and of the period
during which applications are accepted;
- `(3) provide for review of each application by a
credentialing committee with appropriate representation of the
category or type of health professional or provider;
- `(4) select participating health professionals and providers
based on objective standards of quality developed with the
suggestions and advice of professional associations, health
professionals, and providers;
- `(5) make such selection standards available to--
`(A) those applying to become a participating provider or
health professional;
`(B) health plan purchasers, and
`(C) enrollees;
- `(6) when economic considerations are taken into account in
selecting participating health professionals and providers, use
objective criteria that are available to those applying to
become a participating provider or health professional and
enrollees;
- `(7) adjust any economic profiling to take into account
patient characteristics (such as severity of illness) that may
result in atypical utilization of services;
- `(8) make the results of such profiling available to
insurance purchasers, enrollees, and the health professional or
provider involved;
- `(9) notify any health professional or provider being
reviewed under the process referred to in paragraph (3) of any
information indicating that the health professional or provider
fails to meet the standards of the issuer;
- `(10) offer a health professional or provider receiving
notice pursuant to the requirement of paragraph (9) with an
opportunity to--
`(A) review the information referred to in such
paragraph, and
`(B) submit supplemental or corrected information;
- `(11) not include in its contracts with participating health
professionals and providers a provision permitting the issuer
to terminate the contract `without cause';
- `(12) provide a due process appeal that conforms to the
process specified in section 412 of the Health Care Quality
Improvement Act of 1986 (42 U.S.C. 11112) for all
determinations that are adverse to a health professional or
provider; and
- `(13) unless a health professional or provider poses an
imminent harm to enrollees or an adverse action by a
governmental agency effectively impairs the ability to provide
health care items and services, provide--
- `(A) reasonable notice of any decision to terminate a
health professional or provider `for cause' (including an
explanation of the reasons for the determination),
- `(B) an opportunity to review and discuss all of the
information on which the determination is based, and
- `(C) an opportunity to enter into a corrective action
plan, before the determination becomes subject to appeal
under the process referred to in paragraph (12).
- `(b) RULE OF CONSTRUCTION- The requirements of subsection (a)
shall not be construed as preempting or superseding any other
reviews and appeals a health insurance issuer is required by law to
make available.
`SEC. 2778. INFORMATION REPORTING AND DISCLOSURE.
- `(a) IN GENERAL- A health insurance issuer offering health
insurance coverage shall provide enrollees and prospective
enrollees with information about--
- `(1) coverage provisions, benefits, and any exclusions--
`(A) by category of service,
`(B) by category or type of health professional or
provider, and
`(C) if applicable, by specific service, including
experimental treatments;
- `(2) the percentage of the premium charged by the issuer that
is set aside for administration and marketing of the issuer;
- `(3) the percentage of the premium charged by the issuer that
is expended directly for patient care;
- `(4) the number, mix, and distribution of participating
health professionals and providers;
- `(5) the ratio of enrollees to participating health
professionals and providers by category and type of health
professional and provider;
- `(6) the expenditures and utilization per enrollee by
category and type of health professional and provider;
- `(7) the financial obligations of the enrollee and the
issuer, including premiums, copayments, deductibles, and
established aggregate maximums on out-of-pocket costs, for all
items and services, including--
`(A) those furnished by health professionals and
providers that are not participating health professionals
and providers, and
`(B) those furnished to an enrollee who is outside the
service area of the coverage;
- `(8) utilization review requirements of the issuer (including
prior authorization review, concurrent review, post-service
review, post-payment review, and any other procedures that may
lead to denial of coverage or payment for a service);
- `(9) financial arrangements and incentives that may--
`(A) limit the items and services furnished to an enrollee,
`(B) restrict referral or treatment options, or
`(C) negatively affect the fiduciary responsibility of a
health professional or provider to an enrollee;
- `(10) other incentives for health professionals and providers
to deny or limit needed items or services;
- `(11) quality indicators for the issuer and participating
health professionals and providers, including performance
measures such as appropriate referrals and prevention of
secondary complications following treatment;
- `(12) grievance procedures and appeals rights under the
coverage, and summary information about the number and
disposition of grievances and appeals in the most recent period
for which complete and accurate information is available; and
- `(13) the percentage of utilization review determinations
made by the issuer that disagree with the judgment of the
treating health professional or provider and the percentage of
such determinations that are reversed on appeal.
- `(b) REGULATIONS- The Secretary, in collaboration with the
Secretary of Labor, shall issue regulations to establish--
- `(1) the styles and sizes of type to be used with respect to
the appearance of the publication of the information required
under subsection (a);
- `(2) standards for the publication of information to ensure
that such publication is--
`(A) readily accessible, and
`(B) in common language easily understood,
by individuals with little or no connection to or understanding
of the language employed by health professionals and providers,
health insurance issuers, or other entities involved in the
payment or delivery of health care services, and
- `(3) the placement and positioning of information in health
plan marketing materials.
`SEC. 2779. CONFIDENTIALITY; ADEQUATE RESERVES.
- `(a) CONFIDENTIALITY-
- `(1) IN GENERAL- A health insurance issuer shall establish
mechanisms and procedures to ensure compliance with applicable
Federal and State laws to protect the confidentiality of
individually identifiable information held by the issuer with
respect to an enrollee, health professional, or provider.
- `(2) DEFINITION- For purposes of paragraph (1), the term
`individually identifiable information' means, with respect to
an enrollee, a health professional, or a provider, any
information, whether oral or recorded in any medium or form,
that identifies or can readily be associated with the identity
of the enrollee, the health professional, or the provider.
- `(b) FINANCIAL RESERVES; SOLVENCY- A health insurance issuer
shall--
- `(1) meet such financial reserve or other solvency-related
requirements as the applicable State authority may establish to
assure the continued availability of (and appropriate payment
for) covered items and services for enrollees; and
- `(2) establish mechanisms specified by the applicable State
authority to protect enrollees, health professionals, and
providers in the event of failure of the issuer.
Such requirements shall not unduly impede the establishment of
health insurance issuers owned and operated by health care
professionals or providers or by non-profit community-based
organizations.
`SEC. 2780. QUALITY IMPROVEMENT PROGRAM.
- `(a) IN GENERAL- A health insurance issuer shall establish a
quality improvement program (consistent with subsection (b)) that
systematically and continuously assesses and improves--
- `(1) enrollee health status, patient outcomes, processes of
care, and enrollee satisfaction associated with health care
provided by the issuer; and
- `(2) the administrative and funding capacity of the issuer to
support and emphasize preventive care, utilization, access and
availability, cost effectiveness, acceptable treatment
modalities, specialists referrals, the peer review process, and
the efficiency of the administrative process.
- `(b) FUNCTIONS- A quality improvement program established
pursuant to subsection (a) shall--
- `(1) assess the performance of the issuer and its
participating health professionals and providers and report the
results of such assessment to purchasers, participating health
professionals and providers, and administrative personnel;
- `(2) demonstrate measurable improvements in clinical outcomes
and plan performance measured by identified criteria, including
those specified in subsection (a)(1); and
- `(3) analyze quality assessment data to determine specific
interactions in the delivery system (both the design and
funding of the health insurance coverage and the clinical
provision of care) that have an adverse impact on the quality
of care.'.
(b) APPLICATION TO GROUP HEALTH INSURANCE COVERAGE-
(1) Subpart 2 of part A of title XXVII of the Public Health
Service Act is amended by adding at the end the following new
section:
`SEC. 2706. PATIENT PROTECTION STANDARDS.
- `(a) IN GENERAL- Each health insurance issuer shall comply with
patient protection requirements under part C with respect to group
health insurance coverage it offers.
- `(b) ASSURING COORDINATION- The Secretary of Health and Human
Services and the Secretary of Labor shall ensure, through the
execution of an interagency memorandum of understanding between
such Secretaries, that--
- `(1) regulations, rulings, and interpretations issued by such
Secretaries relating to the same matter over which such
Secretaries have responsibility under part C (and this section)
and section 713 of the Employee Retirement Income Security Act
of 1974 are administered so as to have the same effect at all
times; and
- `(2) coordination of policies relating to enforcing the same
requirements through such Secretaries in order to have a
coordinated enforcement strategy that avoids duplication of
enforcement efforts and assigns priorities in enforcement.'.
(2) Section 2792 of such Act (42 U.S.C. 300gg-92) is amended
by inserting `and section 2706(b)' after `of 1996'.
(c) APPLICATION TO INDIVIDUAL HEALTH INSURANCE COVERAGE- Part B
of title XXVII of the Public Health Service Act is amended by
inserting after section 2751 the following new section:
`SEC. 2752. PATIENT PROTECTION STANDARDS.
`Each health insurance issuer shall comply with patient
protection requirements under part C with respect to individual
health insurance coverage it offers.'.
(d) MODIFICATION OF PREEMPTION STANDARDS-
- (1) GROUP HEALTH INSURANCE COVERAGE- Section 2723 of such Act
(42 U.S.C. 300gg-23) is amended--
- (A) in subsection (a)(1), by striking `subsection (b)'
and inserting `subsections (b) and (c)';
- (B) by redesignating subsections (c) and (d) as
subsections (d) and (e), respectively; and
- (C) by inserting after subsection (b) the following new
subsection:
`(c) SPECIAL RULES IN CASE OF PATIENT PROTECTION REQUIREMENTS-
Subject to subsection (a)(2), the provisions of section 2706 and
part C, and part D insofar as it applies to section 2706 or part C,
shall not be construed to preempt any State law, or the enactment
or implementation of such a State law, that provides protections
for individuals that are equivalent to or stricter than the
protections provided under such provisions.'.
- (2) INDIVIDUAL HEALTH INSURANCE COVERAGE- Section 2762 of
such Act (42 U.S.C. 300gg-62), as added by section 605(b)(3)(B)
of Public Law 104-204, is amended--
- (A) in subsection (a), by striking `subsection (b),
nothing in this part' and inserting `subsections (b) and
(c)', and
- (B) by adding at the end the following new subsection:
`(c) SPECIAL RULES IN CASE OF PATIENT PROTECTION REQUIREMENTS-
Subject to subsection (b), the provisions of section 2752 and part
C, and part D insofar as it applies to section 2752 or part C,
shall not be construed to preempt any State law, or the enactment
or implementation of such a State law, that provides protections
for individuals that are equivalent to or stricter than the
protections provided under such provisions.'.
(e) ADDITIONAL CONFORMING AMENDMENTS-
- (1) Section 2723(a)(1) of such Act (42 U.S.C. 300gg-23(a)(1))
is amended by striking `part C' and inserting `parts C and D'.
- (2) Section 2762(b)(1) of such Act (42 U.S.C.
300gg-62(b)(1)) is amended by striking `part C' and inserting
`part D'.
(f) EFFECTIVE DATES-
- (1)
- (A) Subject to subparagraph (B), the
amendments made by subsections (a), (b), (d)(1), and (e) shall
apply with respect to group health insurance coverage for group
health plan years beginning on or after July 1, 1998 (in this
subsection referred to as the `general effective date') and also
shall apply to portions of plan years occurring on and after
January 1, 1999.
- (B) In the case of group health insurance coverage provided
pursuant to a group health plan maintained pursuant to 1 or more
collective bargaining agreements between employee representatives
and 1 or more employers ratified before the date of enactment of
this Act, the amendments made by subsections (a), (b), (d)(1), and
(e) shall not apply to plan years beginning before the later of--
- (i) the date on which the last collective bargaining
agreements relating to the plan terminates (determined without
regard to any extension thereof agreed to after the date of
enactment of this Act), or
- (ii) the general effective date.
For purposes of clause (i), any plan amendment made pursuant to a
collective bargaining agreement relating to the plan which amends
the plan solely to conform to any requirement added by subsection
(a) or (b) shall not be treated as a termination of such collective
bargaining agreement.
- (2) The amendments made by subsections (a), (c), (d)(2), and (e)
shall apply with respect to individual health insurance coverage
offered, sold, issued, renewed, in effect, or operated in the
individual market on or after the general effective date.
SEC. 3. PATIENT PROTECTION STANDARDS UNDER THE EMPLOYEE RETIREMENT
INCOME SECURITY ACT OF 1974.
(a) IN GENERAL- Subpart B of part 7 of subtitle B of title I of
the Employee Retirement Income Security Act of 1974 is amended by
adding at the end the following new section:
`SEC. 713. PATIENT PROTECTION STANDARDS.
- `(a) IN GENERAL- Subject to subsection (b), a group health plan
(and a health insurance issuer offering group health insurance
coverage in connection with such a plan) shall comply with the
requirements of part C of title XXVII of the Public Health Service
Act.
- `(b) REFERENCES IN APPLICATION- In applying subsection (a) under
this part, any reference in such part C--
- `(1) to a health insurance issuer and health insurance
coverage offered by such an issuer is deemed to include a
reference to a group health plan and coverage under such plan,
respectively;
- `(2) to the Secretary is deemed a reference to the Secretary
of Labor;
- `(3) to an applicable State authority is deemed a reference
to the Secretary of Labor; and
- `(4) to an enrollee with respect to health insurance coverage
is deemed to include a reference to a participant or
beneficiary with respect to a group health plan.
- `(c) ASSURING COORDINATION- The Secretary of Health and Human
Services and the Secretary of Labor shall ensure, through the
execution of an interagency memorandum of understanding between
such Secretaries, that--
- `(1) regulations, rulings, and interpretations issued by such
Secretaries relating to the same matter over which such
Secretaries have responsibility under such part C (and section
2706 of the Public Health Service Act) and this section are
administered so as to have the same effect at all times; and
- `(2) coordination of policies relating to enforcing the same
requirements through such Secretaries in order to have a
coordinated enforcement strategy that avoids duplication of
enforcement efforts and assigns priorities in enforcement.'.
(b) MODIFICATION OF PREEMPTION STANDARDS- Section 731 of such Act
(42 U.S.C. 1191) is amended--
- (1) in subsection (a)(1), by striking `subsection (b)' and
inserting `subsections (b) and (c)';
- (2) by redesignating subsections (c) and (d) as subsections
(d) and (e), respectively; and
- (3) by inserting after subsection (b) the following new
subsection:
`(c) SPECIAL RULES IN CASE OF PATIENT PROTECTION REQUIREMENTS-
Subject to subsection (a)(2), the provisions of section 713 and
part C of title XXVII of the Public Health Service Act, and subpart
C insofar as it applies to section 713 or such part, shall not be
construed to preempt any State law, or the enactment or
implementation of such a State law, that provides protections for
individuals that are equivalent to or stricter than the protections
provided under such provisions.'.
(c) CONFORMING AMENDMENTS-
- (1) Section 732(a) of such Act (29
U.S.C. 1185(a)) is amended by striking `section 711' and inserting
`sections 711 and 713'.
- (2) The table of contents in section 1 of such Act is amended by
inserting after the item relating to section 712 the following new
item:
`Sec. 713. Patient protection standards.'.
- (3) Section 734 of such Act (29 U.S.C. 1187) is amended by
inserting `and section 713(d)' after `of 1996'.
(d) EFFECTIVE DATE-
- (1) Subject to paragraph (2), the amendments
made by this section shall apply with respect to group health plans
for plan years beginning on or after July 1, 1998 (in this
subsection referred to as the `general effective date') and also
shall apply to portions of plan years occurring on and after
January 1, 1999.
- (2) In the case of a group health plan maintained pursuant to 1
or more collective bargaining agreements between employee
representatives and 1 or more employers ratified before the date of
enactment of this Act, the amendments made by this section shall
not apply to plan years beginning before the later of--
- (A) the date on which the last collective bargaining
agreements relating to the plan terminates (determined without
regard to any extension thereof agreed to after the date of
enactment of this Act), or
- (B) the general effective date.
For purposes of subparagraph (A), any plan amendment made pursuant
to a collective bargaining agreement relating to the plan which
amends the plan solely to conform to any requirement added by
subsection (a) shall not be treated as a termination of such
collective bargaining agreement.
SEC. 4. NON-PREEMPTION OF STATE LAW RESPECTING LIABILITY OF GROUP
HEALTH PLANS.
- (a) IN GENERAL- Section 514(b) of the Employee Retirement Income
Security Act of 1974 (29 U.S.C. 1144(b)) is amended by
redesignating paragraph (9) as paragraph (10) and inserting the
following new paragraph:
`(9) Subsection (a) of this section shall not be construed to
preclude any State cause of action to recover damages for
personal injury or wrongful death against any person that
provides insurance or administrative services to or for an
employee welfare benefit plan maintained to provide health care
benefits.'.
- (b) EFFECTIVE DATE- The amendment made by subsection (a) shall
apply to causes of action arising on or after the date of the
enactment of this Act.
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