H.R.1749 (Stark)
Managed Care Plan Accountability Act of 1997
"MCPAA"
Table of Contents:
SECTION 1. SHORT TITLE.
This Act may be cited as the `Managed Care Plan Accountability
Act of 1997'.
SEC. 2. IMPROVEMENTS IN ERISA ENFORCEMENT WITH RESPECT TO MANAGED
CARE GROUP HEALTH PLANS.
-
(a) ADDITIONAL REMEDIES FOR COST-DRIVEN VIOLATIONS OF PLAN TERMS-
-
(1) IN GENERAL- Section 502(c) of the Employee Retirement
Income Security Act of 1974 (29 U.S.C. 1132(c)) is amended--
-
(A) by redesignating paragraph (6) as paragraph (7); and
-
(B) by inserting after paragraph (5) the following new
paragraph:
-
`(6)(A) In any case in which a group health plan, or a health
insurance issuer offering health insurance coverage in connection
with such plan, provides benefits under such plan under managed
care, and such plan or issuer fails to provide any such benefit in
accordance with the terms of the plan or such coverage, insofar as
such failure occurs pursuant to a clinically or medically
inappropriate decision or determination resulting from--
- `(i) the application of any cost containment technique,
- `(ii) any utilization review directed at cost containment, or
- `(iii) any other medical care delivery policy decision which
restricts the ability of providers of medical care from
utilizing their full discretion for treatment of patients,
each specified defendant shall be jointly and severally liable to
any participant or beneficiary aggrieved by such failure for actual
damages (including compensatory and consequential damages)
proximately caused by such failure, and may, in the court's
discretion, be liable to such participant or beneficiary for
punitive damages.
-
`(C) Remedies under this paragraph are in addition to remedies
otherwise provided under this section.'.
-
(2) CONCURRENT JURISDICTION- Section 502(e)(1) of such Act
(29 U.S.C. 1132(e)(1)) is amended--
- (A) in the first sentence, by inserting `and except for
actions under subsection (a)(1)(A) of this section for the
relief provided in subsection (c)(6) of this section,'
after `this section,'; and
- (B) in the last sentence, by inserting `and under
subsection (a)(1)(A) of this section for the relief
provided in subsection (c)(6) of this section' after `this
section'.
-
(b) INDEMNIFICATION FOR LIABILITY OF PROVIDERS BOUND BY PLAN
RESTRICTIONS ON MEDICAL COMMUNICATIONS- Section 502 of such Act (29
U.S.C. 1132) is amended further by adding at the end the following
new subsection:
- `(n)(1) In any case in which a group health plan, or a health
insurance issuer offering health insurance coverage in connection
with such plan, provides benefits under such plan under managed
care, the plan shall provide for full indemnification of any
participating provider of medical care for any liability incurred
by such provider for any failure to provide any such benefit in
accordance with the terms of the plan or such coverage, if such
failure
is the direct result of a plan restriction on medical
communications under the plan.
- `(2) For purposes of this subsection--
- `(A) the term `plan restriction on medical communications'
under a group health plan means a provision of the plan, or of
any health insurance coverage offered in connection with the
plan, which prohibits, restricts, or interferes with any
medical communication as part of--
- `(i) a written contract or agreement with a participating
provider of medical care,
- `(ii) a written statement to a participating provider of
medical care, or
- `(iii) an oral communication to a participating provider
of medical care.
- `(B) The term `medical communication'--
- `(i) means any communication made by the provider of
medical care--
- `(I) regarding the mental or physical health care
needs or treatment of a patient and the provisions,
terms, or requirements of the group health plan or
health insurance coverage or another plan or coverage
relating to such needs or treatment, and
- `(II) between the provider and a current, former, or
prospective patient (or the guardian or legal
representative of a patient), between the provider and
any employee or representative of the plan or issuer,
or between the provider and any employee or
representative of any State or Federal authority with
responsibility for the licensing or oversight with
respect to the plan or issuer; and
- `(ii) includes communications concerning--
- `(I) any tests, consultations, and treatment options,
- `(II) any risks or benefits associated with such
tests, consultations, and options,
- `(III) variation among any providers of medical care
and any institutions providing such services in
experience, quality, or outcomes,
- `(IV) the basis or standard for the decision of a
managed care group health plan, or a health insurance
issuer offering health insurance coverage in connection
with such a plan, to authorize or deny particular
benefits consisting of medical care,
- `(V) the process used by the plan or issuer to
determine whether to authorize or deny particular
benefits consisting of medical care, and
- `(VI) any financial incentives or disincentives
provided by the plan or issuer to a provider of medical
care that are based on service utilization.
- `(C) For purposes of this paragraph, the provisions of
subsection (c)(6)(B) apply in the same manner and to the same
extent as they apply for purposes of subsection (c)(6), and the
provisions of section 733 apply in the same manner and to the
same extent as they apply for purposes of part 7.'.
SEC. 3. EXCISE TAX FOR COST-DRIVEN VIOLATIONS OF PLAN TERMS.
-
(a) IN GENERAL- Chapter 100 of the Internal Revenue Code of 1986
is amended by adding at the end the following new subchapter:
`SUBCHAPTER B--FAILURE TO PROVIDE HEALTH BENEFITS DUE TO
IMPROPER COST-DRIVEN DELIVERY POLICY DECISIONS
`SEC. 9811. FAILURE TO PROVIDE HEALTH BENEFITS DUE TO IMPROPER
COST-DRIVEN DELIVERY POLICY DECISIONS.
- `(a) GENERAL RULE- In the case of a group health coverage to
which this section applies, there is a failure to meet the
requirements of this chapter if--
- `(1) the provider of such coverage fails to provide any
benefit in accordance with the terms of the coverage, and
- `(2) such failure occurs pursuant to a clinically or
medically inappropriate decision or determination resulting
from the application of--
- `(A) any cost containment technique,
- `(B) any utilization review directed at cost containment,
or
- `(C) any other medical care delivery policy decision
which restricts the ability of providers of medical care
from utilizing their full discretion for treatment of
patients.
- `(b) HEALTH COVERAGE PROVIDERS TO WHICH SECTION APPLIES- This
section shall apply to any group health coverage which is provided
under managed care.
- `(c) DEFINITIONS- For purposes of this section--
- `(1) GROUP HEALTH COVERAGE- The term `group health coverage'
means--
- `(A) coverage under any group health plan, and
- `(B) health insurance coverage provided by a health
insurance issuer.
- `(2) MANAGED CARE- Group health coverage is provided under
managed care if--
- `(A) such coverage is provided primarily through
participating providers of medical care, or
- `(B) the provider of such coverage provides financial
incentives (such as variable copayments and deductibles) to
induce participants and beneficiaries to obtain the
benefits primarily through participating providers of
medical care,
or both.
- `(3) PROVIDER- The term `provider' means--
- `(A) the group health plan in the case of coverage
described in paragraph (2)(A), and
- `(B) the health insurance issuer in the case of coverage
described in paragraph (2)(B).
- `(4) OTHER DEFINITIONS- The terms `group health plan',
`health insurance coverage', and `health insurance issuer' have
the respective meanings given such terms by section 9805.'.
-
(b) CONFORMING AMENDMENTS-
- (1) Subtitle K of such Code is amended by striking all that
precedes section 9801 and inserting the following:
`SUBTITLE K--GROUP HEALTH PLAN REQUIREMENTS
`CHAPTER 100--GROUP HEALTH PLAN REQUIREMENTS
`SUBCHAPTER A. REQUIREMENTS RELATING TO PORTABILITY, ACCESS, AND
RENEWABILITY.
`SUBCHAPTER B. FAILURE TO PROVIDE HEALTH BENEFITS DUE TO IMPROPER
COST-DRIVEN DELIVERY POLICY DECISIONS.'
- (2) The table of subtitles for such Code is amended by
striking the item relating to subtitle K and inserting the
following new item:
`SUBTITLE K. GROUP HEALTH PLAN REQUIREMENTS.'
SEC. 4. EFFECTIVE DATE.
The amendments made by this Act shall apply with respect to plan
years beginning after on or after January 1, 1998.
Webmaster:hsfrey@harp.org