SUMMARY OF
H.R.1415 (Norwood)
Patient Access to Responsible Care Act of 1997
"PARCA"

• HMOs must give members notice of their rights
• No requirement for any willing provider to be hired by HMO.
• HMOs must assure that covered services are available
  • with reasonable promptness,
  • at reasonable hours of operation, and
  • reasonably close to the homes and workplaces of enrollees
• HMOs must:
  • provide 24 hour/day emergency and urgent care services,
  • and pay for such care in any emergency room,
  • without prior authorization if symptoms would reasonably suggest an emergency to a layman
  • with expedited prior authorization for urgent care for conditions posing a danger if not timely treated
• HMOs must provide access to specialists when medically indicated in the professional judgment of the treating health professional
• No specific payment may be made directly or indirectly to a provider as an inducement to reduce or limit medically necessary services provided to a specific enrollee.
• If an HMO places a provider group at substantial financial risk for services not provided by himself, the HMO must
  • provide adequate stop-loss protection, and
  • conduct periodic surveys to evaluate access to services and satisfaction with the quality of such services.
• HMOs must permit each enrollee to
  • select a personal health professional from among the participating health professionals of the HMO, and
  • change that selection as appropriate.
• HMOs must offer, at the time of enrollment, at a fair premium, the option of health insurance coverage for services furnished by providers outside the HMO network, who may, nevertheless balance bill.
• HMOs must ensure continuity of care for enrollees with special health care needs or chronic conditions, and, if judged necessary by the treating physician, ensure direct access to relevant specialists or teams, and upon change of status, continued coverage of home medical equipment and services, for a reasonable time.
• HMOs must not discriminate against enrollees on the basis of socioeconomic status, age, disability, health status, or anticipated need for health services.
• HMOs must not discriminate against providers on the basis of lack of affiliation with, or admitting privileges at, a hospital, or solely on the basis of the type of license.
• HMOs must not restrict a health professional from engaging in medical communications with his or her patient, concerning
  • the patient's health status, medical care, or legal treatment options;
  • any utilization review requirements that may affect treatment options for the patient; or
  • any financial incentives that may affect the treatment of the patient.
• An HMOs Utilization review program must
  • be developed with the involvement of participating providers;
  • release, upon request, the screening criteria and a description of how they were developed;
  • uniformly apply review criteria based on sound scientific principles and the most recent medical evidence;
  • use licensed, accredited, or certified health professionals to make review determinations, and specialists where necessary.
  • disclose to providers, upon request, the names and credentials of individuals conducting utilization review;
  • not compensate individuals conducting utilization review for denials of payment or coverage of benefits;
  • comply with the requirement that prior authorization not be required for emergency and related services furnished in a hospital emergency department;
  • make prior authorization determinations--
    within 30 minutes in the case of urgent care services
    within 24 hours otherwise
  • include in any notice of such determination an explanation of the basis of the determination and the right to an immediate appeal;
  • treat a favorable prior authorization review determination as a final determination of payment
  • provide timely access to utilization review personnel and, if such personnel are not available, waive any prior authorization that would otherwise be required; and
  • provide notice of an initial determination on payment of a claim within 30 days, with an explanation of the reasons and of the right to an immediate appeal.
• An HMO shall maintain an accessible appeals process that--
  • reviews an adverse prior authorization determination--
    for urgent care services within 1 hour
    for other services, within 24 hours
  • reviews an initial determination on payment of claims within 30 days
  • provides for review by an appropriate clinical peer professional in the same or similar specialty
  • provides for review of--
    the above determinations, and
    enrollee complaints about inadequate access
    by an appropriate clinical peer professional in the same or similar specialty that is not involved in the operation of the plan or in making the determination or policy being appealed.
• HMOs may not terminate providers `without cause';
• HMOs must
  • select participating providers based on open objective standards of quality developed with the advice of professional associations, health professionals, and providers;
  • if economic considerations are taken into account, use open objective criteria
  • adjust any economic profiling to account for patient characteristics
  • notify any provider being reviewed under this process of any information indicating that he or she fails to meet the standards of the issuer;
  • offer a provider receiving notice with an opportunity to--
    review the information
    submit supplemental or corrected information;
  • provide a due process appeal for all determinations that are adverse to a provider; and
  • unless a provider poses an imminent harm to enrollees provide--
    • reasonable notice of any decision to terminate a provider `for cause' (including an explanation of the reasons for the determination),
    • an opportunity to review and discuss all of the information on which the determination is based, and
    • an opportunity to enter into a corrective action plan, before the determination becomes subject to appeal
• HMOs must provide enrollees and prospective enrollees with information about--
  • coverage provisions, benefits, and any exclusions--
    by category of service,
    by category or type of health professional or provider, and
    if applicable, by specific service, including experimental treatments;
  • the percentage of the premium that is set aside for administration and marketing of the issuer;
  • the percentage of the premium that is expended directly for patient care;
  • the number, mix, and distribution of participating providers;
  • the ratio of enrollees to providers by category and type
  • the expenditures and utilization per enrollee by category and type of provider;
  • 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--
    those furnished by providers that are not participating, and
    those furnished to an enrollee who is outside the service area of the coverage;
  • 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);
  • financial arrangements and incentives that may--
    limit the items and services furnished to an enrollee,
    restrict referral or treatment options, or
    negatively affect the fiduciary responsibility of a provider to an enrollee;
  • other incentives for providers to deny or limit needed items or services;
  • quality indicators for the issuer and providers, including performance measures such as appropriate referrals and prevention of secondary complications following treatment;
  • 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
  • the percentage of utilization review determinations made by the issuer that disagree with the judgment of the treating provider and the percentage of such determinations that are reversed on appeal.
• HMOs must meet such financial reserve or other solvency-related requirements as the applicable State authority may establish.
• HMOs must establish a quality improvement program
• States may enact Patient Protection rules equivalent to or stricter than the Federal rules.
• These rules apply to ERISA HMOs.
• State personal injury or wrongful death suits against any person that provides insurance or administrative services for an HMO, will not be preempted by ERISA.