105th CONGRESS
2d Session
H. R. 3605
IN THE HOUSE OF REPRESENTATIVES
March 31, 1998
Mr. DINGELL (for himself, and Co-sponsors)
introduced the following bill; which was referred to the Committee
on Commerce, and in addition to the Committees on Ways and Means, and
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, the Employee Retirement Income
Security Act of 1974, and the Internal Revenue Code of 1986 to protect
consumers in managed care plans and other health coverage.
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 `Patients' Bill of
Rights Act of 1998'.
(b) TABLE OF CONTENTS- The table of contents of this Act is as
follows:
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Sec. 1. Short title; table of contents.
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TITLE I--HEALTH INSURANCE BILL OF RIGHTS
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Subtitle A--Access to Care
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Sec. 101. Access to emergency care.
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Sec. 102. Offering of choice of coverage options under group
health plans.
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Sec. 103. Choice of providers.
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Sec. 104. Access to specialty care.
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Sec. 105. Continuity of care.
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Sec. 106. Coverage for individuals participating in approved
clinical trials.
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Sec. 107. Access to needed prescription drugs.
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Sec. 108. Adequacy of provider network.
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Sec. 109. Nondiscrimination in delivery of services.
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Subtitle B--Quality Assurance
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Sec. 111. Internal quality assurance program.
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Sec. 112. Collection of standardized data.
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Sec. 113. Process for selection of providers.
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Sec. 114. Drug utilization program.
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Sec. 115. Standards for utilization review activities.
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Sec. 116. Health Care Quality Advisory Board.
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Subtitle C--Patient Information
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Subtitle D--Grievance and Appeals Procedures
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Sec. 131. Establishment of grievance process.
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Sec. 132. Internal appeals of adverse determinations.
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Sec. 133. External appeals of adverse determinations.
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Subtitle E--Protecting the Doctor-Patient Relationship
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Sec. 141. Prohibition of interference with certain medical
communications.
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Sec. 142. Prohibition against transfer of indemnification or
improper incentive arrangements.
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Sec. 143. Additional rules regarding participation of health care
professionals.
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Sec. 144. Protection for patient advocacy.
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Subtitle F--Promoting Good Medical Practice
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Sec. 151. Promoting good medical practice.
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Sec. 152. Standards relating to benefits for certain breast
cancer treatment.
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Sec. 153. Standards relating to benefits for reconstructive
breast surgery.
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Subtitle G--Definitions
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TITLE II--APPLICATION OF PATIENT PROTECTION STANDARDS TO GROUP HEALTH PLANS
AND HEALTH INSURANCE COVERAGE UNDER PUBLIC HEALTH SERVICE ACT
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Sec. 201. Application to group health plans and group health
insurance coverage.
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Sec. 202. Application to individual health insurance coverage.
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TITLE III--AMENDMENTS TO THE EMPLOYEE RETIREMENT INCOME SECURITY ACT OF
1974
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Sec. 301. Application of patient protection standards to group
health plans and group health insurance coverage under the
Employee Retirement Income Security Act of 1974.
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Sec. 302. ERISA preemption not to apply to certain actions
involving health insurance policyholders.
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TITLE IV--APPLICATION TO GROUP HEALTH PLANS UNDER THE INTERNAL REVENUE CODE
OF 1986
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Sec. 401. Amendments to the Internal Revenue Code of 1986.
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TITLE V--EFFECTIVE DATES; COORDINATION IN IMPLEMENTATION
TITLE I--HEALTH INSURANCE BILL OF RIGHTS
Subtitle A--Access to Care
SEC. 101. ACCESS TO EMERGENCY CARE.
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(a) COVERAGE OF EMERGENCY SERVICES-
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(1) IN GENERAL- If a group health plan, or health insurance
coverage offered by a health insurance issuer, provides any
benefits with respect to emergency services (as defined in
paragraph (2)(B)), the plan or issuer shall cover emergency
services furnished under the plan or coverage--
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(A) without the need for any prior authorization
determination;
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(B) whether or not the health care provider furnishing such
services is a participating provider with respect to such
services;
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(C) in a manner so that, if such services are provided to a
participant, beneficiary, or enrollee by a nonparticipating
health care provider--
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(i) the participant, beneficiary, or enrollee is not
liable for amounts that exceed the amounts of liability
that would be incurred if the services were provided by
a participating health care provider, and
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(ii) the plan or issuer pays an amount that is not less
than the amount paid to a participating health care
provider for the same services; and
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(D) without regard to any other term or condition of such
coverage (other than exclusion or coordination of benefits,
or an affiliation or waiting period, permitted under section
2701 of the Public Health Service Act, section 701 of the
Employee Retirement Income Security Act of 1974, or section
9801 of the Internal Revenue Code of 1986, and other than
applicable cost-sharing).
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(2) DEFINITIONS- In this section:
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(A) EMERGENCY MEDICAL CONDITION BASED ON PRUDENT LAYPERSON
STANDARD- The term `emergency medical condition' means a
medical condition 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 to result in a condition
described in clause (i), (ii), or (iii) of section
1867(e)(1)(A) of the Social Security Act.
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(B) EMERGENCY SERVICES- The term `emergency services'
means--
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(i) a medical screening examination (as required under
section 1867 of the Social Security Act) that is within
the capability of the emergency department of a
hospital, including ancillary services routinely
available to the emergency department to evaluate an
emergency medical condition (as defined in subparagraph
(A)), and
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(ii) within the capabilities of the staff and
facilities available at the hospital, such further
medical examination and treatment as are required under
section 1867 of such Act to stabilize the patient.
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(b) REIMBURSEMENT FOR MAINTENANCE CARE AND POST-STABILIZATION CARE- In
the case of services (other than emergency services) for which
benefits are available under a group health plan, or under health
insurance coverage offered by a health insurance issuer, the plan or
issuer shall provide for reimbursement with respect to such services
provided to a participant, beneficiary, or enrollee other than through
a participating health care provider in a manner consistent with
subsection (a)(1)(C) if the services are maintenance care or
post-stabilization care covered under the guidelines established under
section 1852(d)(2) of the Social Security Act (relating to promoting
efficient and timely coordination of appropriate maintenance and
post-stabilization care of an enrollee after an enrollee has been
determined to be stable), or, in the absence of guidelines under such
section, such guidelines as the Secretary shall establish to carry out
this subsection.
SEC. 102. OFFERING OF CHOICE OF COVERAGE OPTIONS UNDER GROUP HEALTH PLANS.
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(a) REQUIREMENT-
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(1) OFFERING OF POINT-OF-SERVICE COVERAGE OPTION- Except as
provided in paragraph (2), if a group health plan (or health
insurance coverage offered by a health insurance issuer in
connection with a group health plan) provides benefits only
through participating health care providers, the plan or issuer
shall offer the participant the option to purchase
point-of-service coverage (as defined in subsection (b)) for all
such benefits for which coverage is otherwise so limited. Such
option shall be made available to the participant at the time of
enrollment under the plan or coverage and at such other times as
the plan or issuer offers the participant a choice of coverage
options.
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(2) EXCEPTION- Paragraph (1) shall not apply with respect to a
participant in a group health plan if the plan offers the
participant--
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(A) a choice of health insurance coverage through more than
one health insurance issuer; or
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(B) two or more coverage options that differ significantly
with respect to the use of participating health care
providers or the networks of such providers that are used.
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(b) POINT-OF-SERVICE COVERAGE DEFINED- In this section, the term
`point-of-service coverage' means, with respect to benefits covered
under a group health plan or health insurance issuer, coverage of such
benefits when provided by a nonparticipating health care provider.
Such coverage need not include coverage of providers that the plan or
issuer excludes because of fraud, quality, or similar reasons.
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(c) CONSTRUCTION- Nothing in this section shall be construed--
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(1) as requiring coverage for benefits for a particular type of
health care provider;
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(2) as requiring an employer to pay any costs as a result of this
section or to make equal contributions with respect to different
health coverage options; or
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(3) as preventing a group health plan or health insurance issuer
from imposing higher premiums or cost-sharing on a participant
for the exercise of a point-of-service coverage option.
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(d) NO REQUIREMENT FOR GUARANTEED AVAILABILITY- If a health insurance
issuer offers health insurance coverage that includes point-of-service
coverage with respect to an employer solely in order to meet the
requirement of subsection (a), nothing in section 2711(a)(1)(A) of the
Public Health Service Act shall be construed as requiring the offering of such coverage with respect to another employer.
SEC. 103. CHOICE OF PROVIDERS.
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(a) PRIMARY CARE- A group health plan, and a health insurance issuer
that offers health insurance coverage, shall permit each participant,
beneficiary, and enrollee to receive primary care from any
participating primary care provider who is available to accept such
individual.
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(b) SPECIALISTS-
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(1) IN GENERAL- Subject to paragraph (2), a group health plan and
a health insurance issuer that offers health insurance coverage
shall permit each participant, beneficiary, or enrollee to
receive medically necessary or appropriate specialty care,
pursuant to appropriate referral procedures, from any qualified
participating health care provider who is available to accept
such individual for such care.
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(2) LIMITATION- Paragraph (1) shall not apply to specialty care
if the plan or issuer clearly informs participants,
beneficiaries, and enrollees of the limitations on choice of
participating providers with respect to such care.
SEC. 104. ACCESS TO SPECIALTY CARE.
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(a) OBSTETRICAL AND GYNECOLOGICAL CARE-
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(1) IN GENERAL- If a group health plan, or a health insurance
issuer in connection with the provision of health insurance
coverage, requires or provides for a participant, beneficiary, or
enrollee to designate a participating primary care provider--
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(A) the plan or issuer shall permit such an individual who
is a female to designate a participating physician who
specializes in obstetrics and gynecology as the individual's
primary care provider; and
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(B) if such an individual has not designated such a provider
as a primary care provider, the plan or issuer--
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(i) may not require authorization or a referral by the
individual's primary care provider or otherwise for
coverage of routine gynecological care (such as
preventive women's health examinations) and
pregnancy-related services provided by a participating
health care professional who specializes in obstetrics
and gynecology to the extent such care is otherwise
covered, and
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(ii) may treat the ordering of other gynecological care
by such a participating physician as the authorization
of the primary care provider with respect to such care
under the plan or coverage.
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(2) CONSTRUCTION- Nothing in paragraph (1)(B)(ii) shall waive any
requirements of coverage relating to medical necessity or
appropriateness with respect to coverage of gynecological care so
ordered.
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(b) SPECIALTY CARE-
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(1) SPECIALTY CARE FOR COVERED SERVICES-
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(A) IN GENERAL- If--
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(i) an individual is a participant or beneficiary under
a group health plan or an enrollee who is covered under
health insurance coverage offered by a health insurance
issuer,
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(ii) the individual has a condition or disease of
sufficient seriousness and complexity to require
treatment by a specialist, and
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(iii) benefits for such treatment are provided under
the plan or coverage,
the plan or issuer shall make or provide for a referral to a
specialist who is available and accessible to provide the
treatment for such condition or disease.
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(B) SPECIALIST DEFINED- For purposes of this subsection, the
term `specialist' means, with respect to a condition, a
health care practitioner, facility, or center (such as a
center of excellence) that has adequate expertise through
appropriate training and experience (including, in the case
of a child, appropriate pediatric expertise) to provide high
quality care in treating the condition.
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(C) CARE UNDER REFERRAL- A group health plan or health
insurance issuer may require that the care provided to an
individual pursuant to such referral under subparagraph (A)
be--
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(i) pursuant to a treatment plan, only if the treatment
plan is developed by the specialist and approved by the
plan or issuer, in consultation with the designated
primary care provider or specialist and the individual
(or the individual's designee), and
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(ii) in accordance with applicable quality assurance
and utilization review standards of the plan or issuer.
Nothing in this subsection shall be construed as preventing
such a treatment plan for an individual from requiring a
specialist to provide the primary care provider with regular
updates on the specialty care provided, as well as all
necessary medical information.
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(D) REFERRALS TO PARTICIPATING PROVIDERS- A group health
plan or health insurance issuer is not required under
subparagraph (A) to provide for a referral to a specialist
that is not a participating provider, unless the plan or
issuer does not have an appropriate specialist that is
available and accessible to treat the individual's condition
and that is a participating provider with respect to such
treatment.
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(E) TREATMENT OF NONPARTICIPATING PROVIDERS- If a plan or
issuer refers an individual to a nonparticipating specialist
pursuant to subparagraph (A), services provided pursuant to
the approved treatment plan (if any) shall be provided at no
additional cost to the individual beyond what the individual
would otherwise pay for services received by such a
specialist that is a participating provider.
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(2) SPECIALISTS AS PRIMARY CARE PROVIDERS-
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(A) IN GENERAL- A group health plan, or a health insurance
issuer, in connection with the provision of health insurance
coverage, shall have a procedure by which an individual who
is a participant, beneficiary, or enrollee and who has an
ongoing special condition (as defined in subparagraph (C))
may receive a referral to a specialist for such condition
who shall be responsible for and capable of providing and
coordinating the individual's primary and specialty care. If
such an individual's care would most appropriately be
coordinated by such a specialist, such plan or issuer shall
refer the individual to such specialist.
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(B) TREATMENT AS PRIMARY CARE PROVIDER- Such specialist
shall be permitted to treat the individual without a
referral from the individual's primary care provider and may
authorize such referrals, procedures, tests, and other
medical services as the individual's primary care provider
would otherwise be permitted to provide or authorize,
subject to the terms of the treatment plan (referred to in
paragraph (1)(C)(i)).
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(C) ONGOING SPECIAL CONDITION DEFINED- In this paragraph,
the term `special condition' means a condition or disease
that--
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(i) is life-threatening, degenerative, or disabling,
and
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(ii) requires specialized medical care over a prolonged
period of time.
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(D) TERMS OF REFERRAL- The provisions of subparagraphs (C)
through (E) of paragraph (1) apply with respect to referrals
under subparagraph (A) of this paragraph in the same manner
as they apply to referrals under paragraph (1)(A).
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(3) STANDING REFERRALS-
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(A) IN GENERAL- A group health plan, and a health insurance
issuer in connection with the provision of health insurance
coverage, shall have a procedure by which an individual who
is a participant, beneficiary, or enrollee and who has a
condition that requires ongoing care from a specialist may
receive a standing referral to such specialist for treatment of such condition. If the plan or issuer, or if the primary care provider in consultation with the medical director of the plan or issuer and the specialist (if any), determines that such a standing referral is appropriate, the plan or issuer shall make such a referral to such a specialist.
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(B) TERMS OF REFERRAL- The provisions of subparagraphs (C)
through (E) of paragraph (1) apply with respect to referrals
under subparagraph (A) of this paragraph in the same manner
as they apply to referrals under paragraph (1)(A).
SEC. 105. CONTINUITY OF CARE.
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(a) IN GENERAL-
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(1) TERMINATION OF PROVIDER- If a contract between a group health
plan, or a health insurance issuer in connection with the
provision of health insurance coverage, and a health care
provider is terminated (as defined in paragraph (3)), or benefits
or coverage provided by a health care provider are terminated
because of a change in the terms of provider participation in a
group health plan, and an individual who is a participant,
beneficiary, or enrollee in the plan or coverage is undergoing a
course of treatment from the provider at the time of such
termination, the plan or issuer shall--
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(A) notify the individual on a timely basis of such
termination, and
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(B) subject to subsection (c), permit the individual to
continue or be covered with respect to the course of
treatment with the provider during a transitional period
(provided under subsection (b)).
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(2) TREATMENT OF TERMINATION OF CONTRACT WITH HEALTH INSURANCE
ISSUER- If a contract for the provision of health insurance
coverage between a group health plan and a health insurance
issuer is terminated and, as a result of such termination,
coverage of services of a health care provider is terminated with
respect to an individual, the provisions of paragraph (1) (and
the succeeding provisions of this section) shall apply under the
plan in the same manner as if there had been a contract between
the plan and the provider that had been terminated, but only with
respect to benefits that are covered under the plan after the
contract termination.
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(3) TERMINATION- In this section, the term `terminated' includes,
with respect to a contract, the expiration or nonrenewal of the
contract, but does not include a termination of the contract by
the plan or issuer for failure to meet applicable quality
standards or for fraud.
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(b) TRANSITIONAL PERIOD-
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(1) IN GENERAL- Except as provided in paragraphs (2) through (4),
the transitional period under this subsection shall extend for at
least 90 days from the date of the notice described in subsection
(a)(1)(A) of the provider's termination.
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(2) INSTITUTIONAL CARE- The transitional period under this
subsection for institutional or inpatient care from a provider
shall extend until the discharge or termination of the period of
institutionalization and also shall include institutional care
provided within a reasonable time of the date of termination of
the provider status if the care was scheduled before the date of
the announcement of the termination of the provider status under
subsection (a)(1)(A) or if the individual on such date was on an
established waiting list or otherwise scheduled to have such
care.
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(3) PREGNANCY- If--
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(A) a participant, beneficiary, or enrollee has entered the
second trimester of pregnancy at the time of a provider's
termination of participation, and
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(B) the provider was treating the pregnancy before date of
the termination,
the transitional period under this subsection with respect to
provider's treatment of the pregnancy shall extend through the
provision of post-partum care directly related to the delivery.
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(4) TERMINAL ILLNESS- If--
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(A) a participant, beneficiary, or enrollee was determined
to be terminally ill (as determined under section
1861(dd)(3)(A) of the Social Security Act) at the time of a
provider's termination of participation, and
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(B) the provider was treating the terminal illness before
the date of termination,
the transitional period under this subsection shall extend for
the remainder of the individual's life for care directly related
to the treatment of the terminal illness.
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(c) PERMISSIBLE TERMS AND CONDITIONS- A group health plan or health
insurance issuer may condition coverage of continued treatment by a
provider under subsection (a)(1)(B) upon the provider agreeing to the
following terms and conditions:
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(1) The provider agrees to accept reimbursement from the plan or
issuer and individual involved (with respect to cost-sharing) at
the rates applicable prior to the start of the transitional
period as payment in full (or, in the case described in
subsection (a)(2), at the rates applicable under the replacement
plan or issuer after the date of the termination of the contract
with the health insurance issuer) and not to impose cost-sharing
with respect to the individual in an amount that would exceed the
cost-sharing that could have been imposed if the contract
referred to in subsection (a)(1) had not been terminated.
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(2) The provider agrees to adhere to the quality assurance
standards of the plan or issuer responsible for payment under
paragraph (1) and to provide to such plan or issuer necessary
medical information related to the care provided.
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(3) The provider agrees otherwise to adhere to such plan's or
issuer's policies and procedures, including procedures regarding
referrals and obtaining prior authorization and providing
services pursuant to a treatment plan (if any) approved by the
plan or issuer.
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(d) CONSTRUCTION- Nothing in this section shall be construed to
require the coverage of benefits which would not have been covered if the provider involved remained a participating provider.
SEC. 106. COVERAGE FOR INDIVIDUALS PARTICIPATING IN APPROVED CLINICAL
TRIALS.
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(a) COVERAGE-
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(1) IN GENERAL- If a group health plan, or health insurance
issuer that is providing health insurance coverage, provides
coverage to a qualified individual (as defined in subsection
(b)), the plan or issuer--
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(A) may not deny the individual participation in the
clinical trial referred to in subsection (b)(2);
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(B) subject to subsection (c), may not deny (or limit or
impose additional conditions on) the coverage of routine
patient costs for items and services furnished in connection
with participation in the trial; and
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(C) may not discriminate against the individual on the basis
of the enrollee's participation in such trial.
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(2) EXCLUSION OF CERTAIN COSTS- For purposes of paragraph (1)(B),
routine patient costs do not include the cost of the tests or
measurements conducted primarily for the purpose of the clinical
trial involved.
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(3) USE OF IN-NETWORK PROVIDERS- If one or more participating
providers is participating in a clinical trial, nothing in
paragraph (1) shall be construed as preventing a plan or issuer
from requiring that a qualified individual participate in the
trial through such a participating provider if the provider will
accept the individual as a participant in the trial.
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(b) QUALIFIED INDIVIDUAL DEFINED- For purposes of subsection (a), the
term `qualified individual' means an individual who is a participant
or beneficiary in a group health plan, or who is an enrollee under
health insurance coverage, and who meets the following conditions:
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(1)
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(A) The individual has a life-threatening or serious illness
for which no standard treatment is effective.
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(B) The individual is eligible to participate in an approved
clinical trial according to the trial protocol with respect to
treatment of such illness.
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(C) The individual's participation in the trial offers meaningful
potential for significant clinical benefit for the individual.
(2) Either--
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(A) the referring physician is a participating health care
professional and has concluded that the individual's
participation in such trial would be appropriate based upon
the individual meeting the conditions described in paragraph
(1); or
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(B) the participant, beneficiary, or enrollee provides
medical and scientific information establishing that the
individual's participation in such trial would be
appropriate based upon the individual meeting the conditions
described in paragraph (1).
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(c) PAYMENT-
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(1) IN GENERAL- Under this section a group health plan or health
insurance issuer shall provide for payment for routine patient
costs described in subsection (a)(2) but is not required to pay
for costs of items and services that are reasonably expected (as
determined by the Secretary) to be paid for by the sponsors of an
approved clinical trial.
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(2) PAYMENT RATE- In the case of covered items and services
provided by--
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(A) a participating provider, the payment rate shall be at
the agreed upon rate, or
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(B) a nonparticipating provider, the payment rate shall be
at the rate the plan or issuer would normally pay for
comparable services under subparagraph (A).
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(d) APPROVED CLINICAL TRIAL DEFINED-
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(1) IN GENERAL- In this section, the term `approved clinical
trial' means a clinical research study or clinical investigation
approved and funded (which may include funding through in-kind
contributions) by one or more of the following:
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(A) The National Institutes of Health.
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(B) A cooperative group or center of the National Institutes
of Health.
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(C) Either of the following if the conditions described in
paragraph (2) are met:
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(i) The Department of Veterans Affairs.
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(ii) The Department of Defense.
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(2) CONDITIONS FOR DEPARTMENTS- The conditions described in this
paragraph, for a study or investigation conducted by a
Department, are that the study or investigation has been reviewed
and approved through a system of peer review that the Secretary
determines--
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(A) to be comparable to the system of peer review of studies
and investigations used by the National Institutes of
Health, and
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(B) assures unbiased review of the highest scientific
standards by qualified individuals who have no interest in
the outcome of the review.
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(e) CONSTRUCTION- Nothing in this section shall be construed to limit
a plan's or issuer's coverage with respect to clinical trials.
SEC. 107. ACCESS TO NEEDED PRESCRIPTION DRUGS.
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(a) IN GENERAL- If a group health plan, or health insurance issuer
that offers health insurance coverage, provides benefits with respect
to prescription drugs but the coverage limits such benefits to drugs
included in a formulary, the plan or issuer shall--
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(1) ensure participation of participating physicians and
pharmacists in the development of the formulary;
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(2) disclose to providers and, disclose upon request under
section 121(c)(6) to participants, beneficiaries, and enrollees,
the nature of the formulary restrictions; and
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(3) consistent with the standards for a utilization review
program under section 115, provide for exceptions from the
formulary limitation when a non-formulary alternative is
medically indicated.
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(b) COVERAGE OF APPROVED DRUGS AND MEDICAL DEVICES-
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(1) IN GENERAL- A group health plan (or health insurance coverage
offered in connection with such a plan) that provides any
coverage of prescription drugs or medical devices shall not deny
coverage of such a drug or device on the basis that the use is
investigational, if the use--
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(A) in the case of a prescription drug--
-
(i) is included in the labeling authorized by the
application in effect for the drug pursuant to
subsection (b) or (j) of section 505 of the Federal
Food, Drug, and Cosmetic Act, without regard to any
postmarketing requirements that may apply under such
Act; or
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(ii) is included in the labeling authorized by the
application in effect for the drug under section 351 of
the Public Health Service Act, without regard to any
postmarketing requirements that may apply pursuant to
such section; or
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(B) in the case of a medical device, is included in the
labeling authorized by a regulation under subsection (d) or
(3) of section 513 of the Federal Food, Drug, and Cosmetic
Act, an order under subsection (f) of such section, or an
application approved under section 515 of such Act, without
regard to any postmarketing requirements that may apply
under such Act.
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(2) CONSTRUCTION- Nothing in this subsection shall be construed
as requiring a group health plan (or health insurance coverage
offered in connection with such a plan) to provide any coverage
of prescription drugs or medical devices.
SEC. 108. ADEQUACY OF PROVIDER NETWORK.
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(a) IN GENERAL- Each group health plan, and each health insurance
issuer offering health insurance coverage, that provides benefits, in
whole or in part, through participating health care providers shall
have (in relation to the coverage) a sufficient number, distribution,
and variety of qualified participating health care providers to ensure
that all covered health care services, including specialty services,
will be available and accessible in a timely manner to all
participants, beneficiaries, and enrollees under the plan or coverage.
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(b) TREATMENT OF CERTAIN PROVIDERS- The qualified health care
providers under subsection (a) may include Federally qualified health
centers, rural health clinics, migrant health centers, and other
essential community providers located in the service area of the plan
or issuer and shall include such providers if necessary to meet the
standards established to carry out such subsection.
SEC. 109. NONDISCRIMINATION IN DELIVERY OF SERVICES.
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(a) APPLICATION TO DELIVERY OF SERVICES- Subject to subsection (b), a
group health plan, and health insurance issuer in relation to health
insurance coverage, may not discriminate against a participant,
beneficiary, or enrollee in the delivery of health care services
consistent with the benefits covered under the plan or coverage or as
required by law based on race, color, ethnicity, national origin,
religion, sex, age, mental or physical disability, sexual orientation,
genetic information, or source of payment.
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(b) CONSTRUCTION- Nothing in subsection (a) shall be construed as
relating to the eligibility to be covered, or the offering (or
guaranteeing the offer) of coverage, under a plan or health insurance
coverage, the application of any pre-existing condition exclusion
consistent with applicable law, or premiums charged under such plan or
coverage.
Subtitle B--Quality Assurance
SEC. 111. INTERNAL QUALITY ASSURANCE PROGRAM.
-
(a) REQUIREMENT- A group health plan, and a health insurance issuer
that offers health insurance coverage, shall establish and maintain an
ongoing, internal quality assurance and continuous quality improvement
program that meets the requirements of subsection (b).
-
(b) PROGRAM REQUIREMENTS- The requirements of this subsection for a quality improvement program of a plan or issuer are as follows:
-
(1) ADMINISTRATION- The plan or issuer has a separate
identifiable unit with responsibility for administration of the
program.
-
(2) WRITTEN PLAN- The plan or issuer has a written plan for the
program that is updated annually and that specifies at least the
following:
-
(A) The activities to be conducted.
-
(B) The organizational structure.
-
(C) The duties of the medical director.
-
(D) Criteria and procedures for the assessment of quality.
-
(3) SYSTEMATIC REVIEW- The program provides for systematic review
of the type of health services provided, consistency of services
provided with good medical practice, and patient outcomes.
-
(4) QUALITY CRITERIA- The program--
-
(A) uses criteria that are based on performance and patient
outcomes where feasible and appropriate;
-
(B) includes criteria that are directed specifically at
meeting the needs of at-risk populations and covered
individuals with chronic conditions or severe illnesses,
including gender-specific criteria and pediatric-specific
criteria where available and appropriate;
-
(C) includes methods for informing covered individuals of
the benefit of preventive care and what specific benefits
with respect to preventive care are covered under the plan
or coverage; and
-
(D) makes available to the public a description of the
criteria used under subparagraph (A).
-
(5) SYSTEM FOR REPORTING- The program has procedures for
reporting of possible quality concerns by providers and enrollees
and for remedial actions to correct quality problems, including
written procedures for responding to concerns and taking
appropriate corrective action.
-
(6) DATA ANALYSIS- The program provides, using data that include
the data collected under section 112, for an analysis of the
plan's or issuer's performance on quality measures.
-
(7) DRUG UTILIZATION REVIEW- The program provides for a drug
utilization review program in accordance with section 114.
-
(c) DEEMING- For purposes of subsection (a), the requirements of--
-
(1) subsection (b) (other than paragraph (5)) are deemed to be
met with respect to a health insurance issuer that is a qualified
health maintenance organization (as defined in section 1310(c) of
the Public Health Service Act); or
-
(2) subsection (b) are deemed to be met with respect to a health
insurance issuer that is accredited by a national accreditation
organization that the Secretary certifies as applying, as a
condition of certification, standards at least a stringent as
those required for a quality improvement program under subsection
(b).
-
(d) VARIATION PERMITTED- The Secretary may provide for variations in
the application of the requirements of this section to group health
plans and health insurance issuers based upon differences in the
delivery system among such plans and issuers as the Secretary deems
appropriate.
SEC. 112. COLLECTION OF STANDARDIZED DATA.
-
(a) IN GENERAL- A group health plan and a health insurance issuer that
offers health insurance coverage shall collect uniform quality data
that include a minimum uniform data set described in subsection (b).
-
(b) MINIMUM UNIFORM DATA SET- The Secretary shall specify (and may
from time to time update) the data required to be included in the
minimum uniform data set under subsection (a) and the standard format
for such data. Such data shall include at least--
-
(1) aggregate utilization data;
-
(2) data on the demographic characteristics of participants,
beneficiaries, and enrollees;
-
(3) data on disease-specific and age-specific mortality rates and
(to the extent feasible) morbidity rates of such individuals;
-
(4) data on satisfaction of such individuals, including data on
voluntary disenrollment and grievances; and
-
(5) data on quality indicators and health outcomes, including, to
the extent feasible and appropriate, data on pediatric cases and
on a gender-specific basis.
-
(c) AVAILABILITY- A summary of the data collected under subsection (a) shall be disclosed under section 121(b)(9). The Secretary shall be
provided access to all the data so collected.
-
(d) VARIATION PERMITTED- The Secretary may provide for variations in
the application of the requirements of this section to group health
plans and health insurance issuers based upon differences in the
delivery system among such plans and issuers as the Secretary deems
appropriate.
SEC. 113. PROCESS FOR SELECTION OF PROVIDERS.
-
(a) IN GENERAL- A group health plan and a health insurance issuer that
offers health insurance coverage shall, if it provides benefits
through participating health care professionals, have a written
process for the selection of participating health care professionals,
including minimum professional requirements.
-
(b) VERIFICATION OF BACKGROUND- Such process shall include
verification of a health care provider's license and a history of
suspension or revocation.
-
(c) RESTRICTION- Such process shall not use a high-risk patient base
or location of a provider in an area with residents with poorer health
status as a basis for excluding providers from participation.
-
(d) NONDISCRIMINATION BASED ON LICENSURE-
-
(1) IN GENERAL- Such process shall not discriminate with respect
to participation or indemnification as to any provider who is
acting within the scope of the provider's license or
certification under applicable State law, solely on the basis of
such license or certification.
-
(2) CONSTRUCTION- Paragraph (1) shall not be construed--
-
(A) as requiring the coverage under a plan or coverage of
particular benefits or services or to prohibit a plan or
issuer from including providers only to the extent necessary
to meet the needs of the plan's or issuer's participants,
beneficiaries, or enrollees or from establishing any measure
designed to maintain quality and control costs consistent
with the responsibilities of the plan or issuer; or
-
(B) to override any State licensure or scope-of-practice
law.
-
(e) GENERAL NONDISCRIMINATION-
-
(1) IN GENERAL- Subject to paragraph (2), such process shall not
discriminate with respect to selection of a health care
professional to be a participating health care provider, or with
respect to the terms and conditions of such participation, based
on the professional's race, color, religion, sex, national
origin, age, sexual orientation, or disability (consistent with
the Americans with Disabilities Act of 1990).
-
(2) RULES- The appropriate Secretary may establish such
definitions, rules, and exceptions as may be appropriate to carry
out paragraph (1), taking into account comparable definitions,
rules, and exceptions in effect under employment-based
nondiscrimination laws and regulations that relate to each of the
particular bases for discrimination described in such paragraph.
SEC. 114. DRUG UTILIZATION PROGRAM.
A group health plan, and a health insurance issuer that provides
health insurance coverage, that includes benefits for prescription
drugs shall establish and maintain, as part of its internal quality
assurance and continuous quality improvement program under section
111, a drug utilization program which--
-
(1) encourages appropriate use of prescription drugs by
participants, beneficiaries, and enrollees and providers, and
-
(2) takes appropriate action to reduce the incidence of improper
drug use and adverse drug reactions and interactions.
SEC. 115. STANDARDS FOR UTILIZATION REVIEW ACTIVITIES.
-
(a) COMPLIANCE WITH REQUIREMENTS-
-
(1) IN GENERAL- A group health plan, and a health insurance
issuer that provides health insurance coverage, shall conduct
utilization review activities in connection with the provision of
benefits under such plan or coverage only in accordance with a
utilization review program that meets the requirements of this
section.
-
(2) USE OF OUTSIDE AGENTS- Nothing in this section shall be
construed as preventing a group health plan or health insurance
issuer from arranging through a contract or otherwise for persons
or entities to conduct utilization review activities on behalf of
the plan or issuer, so long as such activities are conducted in
accordance with a utilization review program that meets the
requirements of this section.
-
(3) UTILIZATION REVIEW DEFINED- For purposes of this section, the
terms `utilization review' and `utilization review activities'
mean procedures used to monitor or evaluate the clinical
necessity, appropriateness, efficacy, or efficiency of health
care services, procedures or settings, and includes prospective
review, concurrent review, second opinions, case management,
discharge planning, or retrospective review.
-
(b) WRITTEN POLICIES AND CRITERIA-
-
(1) WRITTEN POLICIES- A utilization review program shall be
conducted consistent with written policies and procedures that
govern all aspects of the program.
-
(2) USE OF WRITTEN CRITERIA-
-
(A) IN GENERAL- Such a program shall utilize written
clinical review criteria developed pursuant to the program
with the input of appropriate physicians. Such criteria
shall include written clinical review criteria described in
section 111(b)(4)(B).
-
(B) CONTINUING USE OF STANDARDS IN RETROSPECTIVE REVIEW- If
a health care service has been specifically pre-authorized
or approved for an enrollee under such a program, the
program shall not, pursuant to retrospective review, revise
or modify the specific standards, criteria, or procedures
used for the utilization review for procedures, treatment,
and services delivered to the enrollee during the same
course of treatment.
-
(c) CONDUCT OF PROGRAM ACTIVITIES-
-
(1) ADMINISTRATION BY HEALTH CARE PROFESSIONALS- A utilization
review program shall be administered by qualified health care
professionals who shall oversee review decisions. In this
subsection, the term `health care professional' means a physician
or other health care practitioner licensed, accredited, or
certified to perform specified health services consistent with
State law.
-
(2) USE OF QUALIFIED, INDEPENDENT PERSONNEL-
-
(A) IN GENERAL- A utilization review program shall provide
for the conduct of utilization review activities only
through personnel who are qualified and, to the extent
required, who have received appropriate training in the
conduct of such activities under the program.
-
(B) PEER REVIEW OF SAMPLE OF ADVERSE CLINICAL
DETERMINATIONS- Such a program shall provide that clinical
peers (as defined in section 191(c)(2)) shall evaluate the
clinical appropriateness of at least a sample of adverse
clinical determinations.
-
(C) PROHIBITION OF CONTINGENT COMPENSATION ARRANGEMENTS-
Such a program shall not, with respect to utilization review
activities, permit or provide compensation or anything of
value to its employees, agents, or contractors in a manner
that--
-
(i) provides incentives, direct or indirect, for such
persons to make inappropriate review decisions, or
-
(ii) is based, directly or indirectly, on the quantity
or type of adverse determinations rendered.
-
(D) PROHIBITION OF CONFLICTS- Such a program shall not
permit a health care professional who provides health care
services to an individual to perform utilization review
activities in connection with the health care services being
provided to the individual.
-
(3) ACCESSIBILITY OF REVIEW- Such a program shall provide that
appropriate personnel performing utilization review activities
under the program are reasonably accessible by toll-free
telephone during normal business hours to discuss patient care
and allow response to telephone requests, and that appropriate
provision is made to receive and respond promptly to calls
received during other hours.
-
(4) LIMITS ON FREQUENCY- Such a program shall not provide for the
performance of utilization review activities with respect to a
class of services furnished to an individual more frequently than
is reasonably required to assess whether the services under
review are medically necessary or appropriate.
-
(5) LIMITATION ON INFORMATION REQUESTS- Under such a program,
information shall be required to be provided by health care
providers only to the extent it is necessary to perform the
utilization review activity involved.
-
(6) REVIEW OF PRELIMINARY UTILIZATION REVIEW DECISION- Under such
program a participant, beneficiary, or enrollee or any provider
acting on behalf of such an individual with the individual's
consent, who is dissatisfied with a preliminary utilization
review decision has the opportunity to discuss the decision with,
and have such decision reviewed by, the medical director of the
plan or issuer involved (or the director's designee) who has the authority to reverse the decision.
-
(d) DEADLINE FOR DETERMINATIONS-
-
(1) PRIOR AUTHORIZATION SERVICES- Except as provided in paragraph
(2), in the case of a utilization review activity involving the
prior authorization of health care items and services for an
individual, the utilization review program shall make a
determination concerning such authorization, and provide notice
of the determination to the individual or the individual's
designee and the individual's health care provider by telephone
and in printed form, as soon as possible in accordance with the
medical exigencies of the cases, and in no event later than 3
business days after the date of receipt of information that is
reasonably necessary to make such determination.
-
(2) CONTINUED CARE- In the case of a utilization review activity
involving authorization for continued or extended health care
services for an individual, or additional services for an
individual undergoing a course of continued treatment prescribed
by a health care provider, the utilization review program shall
make a determination concerning such authorization, and provide
notice of the determination to the individual or the individual's
designee and the individual's health care provider by telephone
and in printed form, as soon as possible in accordance with the
medical exigencies of the cases, and in no event later than 1
business day after the date of receipt of information that is
reasonably necessary to make such determination. Such notice
shall include, with respect to continued or extended health care
services, the number of extended services approved, the new total
of approved services, the date of onset of services, and the next
review date, if any.
-
(3) PREVIOUSLY PROVIDED SERVICES- In the case of a utilization
review activity involving retrospective review of health care
services previously provided for an individual, the utilization
review program shall make a determination concerning such
services, and provide notice of the determination to the
individual or the individual's designee and the individual's
health care provider by telephone and in printed form, within 30
days of the date of receipt of information that is reasonably
necessary to make such determination.
-
(4) REFERENCE TO SPECIAL RULES FOR EMERGENCY SERVICES,
MAINTENANCE CARE, AND POST-STABILIZATION CARE- For waiver of
prior authorization requirements in certain cases involving
emergency services and maintenance care and post-stabilization
care, see subsections (a)(1) and (b) of section 101,
respectively.
-
(e) NOTICE OF ADVERSE DETERMINATIONS-
-
(1) IN GENERAL- Notice of an adverse determination under a
utilization review program shall be provided in printed form and
shall include--
-
(A) the reasons for the determination (including the
clinical rationale);
-
(B) instructions on how to initiate an appeal under section
132; and
-
(C) notice of the availability, upon request of the
individual (or the individual's designee) of the clinical
review criteria relied upon to make such determination.
-
(2) SPECIFICATION OF ANY ADDITIONAL INFORMATION- Such a notice
shall also specify what (if any) additional necessary information
must be provided to, or obtained by, the person making the
determination in order to make a decision on such an appeal.
SEC. 116. HEALTH CARE QUALITY ADVISORY BOARD.
-
(a) ESTABLISHMENT- The President shall establish an advisory board to
provide information to Congress and the administration on issues
relating to quality monitoring and improvement in the health care
provided under group health plans and health insurance coverage.
-
(b) NUMBER AND APPOINTMENT- The advisory board shall be composed of
the Secretary of Health and Human Services (or the Secretary's
designee), the Secretary of Labor (or the Secretary's designee), and
20 additional members appointed by the President, in consultation with
the Majority and Minority Leaders of the Senate and House of
Representatives. The members so appointed shall include individuals
with expertise in--
-
(1) consumer needs;
-
(2) education and training of health professionals;
-
(3) health care services;
-
(4) health plan management;
-
(5) health care accreditation, quality assurance, improvement,
measurement, and oversight;
-
(6) medical practice, including practicing physicians;
-
(7) prevention and public health; and
-
(8) public and private group purchasing for small and large
employers or groups.
-
(c) DUTIES- The advisory board shall--
-
(1) identify, update, and disseminate measures of health care
quality for group health plans and health insurance issuers,
including network and non-network plans;
-
(2) advise the Secretary on the development and maintenance of
the minimum data set in section 112(b); and
-
(3) advise the Secretary on standardized formats for information
on group health plans and health insurance coverage.
The measures identified under paragraph (1) may be used on a voluntary
basis by such plans and issuers. In carrying out paragraph (1), the
advisory board shall consult and cooperate with national health care
standard setting bodies which define quality indicators, the Agency
for Health Care Policy and Research, the Institute of Medicine, and
other public and private entities that have expertise in health care
quality.
-
(d) REPORT- The advisory board shall provide an annual report to
Congress and the President on the quality of the health care in the
United States and national and regional trends in health care quality.
Such report shall include a description of determinants of health care
quality and measurements of practice and quality variability within
the United States.
-
(e) SECRETARIAL CONSULTATION- In serving on the advisory board, the
Secretaries of Health and Human Services and Labor (or their
designees) shall consult with the Secretaries responsible for other
Federal health insurance and health care programs.
-
(f) VACANCIES- Any vacancy on the board shall be filled in such manner
as the original appointment. Members of the board shall serve without
compensation but shall be reimbursed for travel, subsistence, and
other necessary expenses incurred by them in the performance of their
duties. Administrative support, scientific support, and technical
assistance for the advisory board shall be provided by the Secretary
of Health and Human Services.
-
(g) CONTINUATION- Section 14(a)(2)(B) of the Federal Advisory
Committee Act (5 U.S.C. App.; relating to the termination of advisory
committees) shall not apply to the advisory board.
Subtitle C--Patient Information
SEC. 121. PATIENT INFORMATION.
-
(a) DISCLOSURE REQUIREMENT-
-
(1) GROUP HEALTH PLANS- A group health plan shall--
-
(A) provide to participants and beneficiaries at the time of
initial coverage under the plan (or the effective date of
this section, in the case of individuals who are
participants or beneficiaries as of such date), and at least
annually thereafter, the information described in subsection
(b) in printed form;
-
(B) provide to participants and beneficiaries, within a
reasonable period (as specified by the appropriate
Secretary) before or after the date of significant changes
in the information described in subsection (b), information
in printed form on such significant changes; and
-
(C) upon request, make available to participants and
beneficiaries, the applicable authority, and prospective
participants and beneficiaries, the information described in
subsection (b) or (c) in printed form.
-
(2) HEALTH INSURANCE ISSUERS- A health insurance issuer in
connection with the provision of health insurance coverage
shall--
-
(A) provide to individuals enrolled under such coverage at
the time of enrollment, and at least annually thereafter,
the information described in subsection (b) in printed form;
-
(B) provide to enrollees, within a reasonable period (as
specified by the appropriate Secretary) before or after the
date of significant changes in the information described in
subsection (b), information in printed form on such
significant changes; and
-
(C) upon request, make available to the applicable
authority, to individuals who are prospective enrollees, and
to the public the information described in subsection (b) or
(c) in printed form.
-
(b) INFORMATION PROVIDED- The information described in this subsection
with respect to a group health plan or health insurance coverage
offered by a health insurance issuer includes the following:
-
(1) SERVICE AREA- The service area of the plan or issuer.
-
(2) BENEFITS- Benefits offered under the plan or coverage,
including--
-
(A) covered benefits, including benefit limits and coverage
exclusions;
-
(B) cost sharing, such as deductibles, coinsurance, and
copayment amounts, including any liability for balance
billing, any maximum limitations on out of pocket expenses,
and the maximum out of pocket costs for services that are
provided by non participating providers or that are
furnished without meeting the applicable utilization review
requirements;
-
(C) the extent to which benefits may be obtained from
nonparticipating providers;
-
(D) the extent to which a participant, beneficiary, or
enrollee may select from among participating providers and
the types of providers participating in the plan or issuer
network;
-
(E) process for determining experimental coverage; and
-
(F) use of a prescription drug formulary.
-
(3) ACCESS- A description of the following:
-
(A) The number, mix, and distribution of providers under the
plan or coverage.
-
(B) Out-of-network coverage (if any) provided by the plan or
coverage.
-
(C) Any point-of-service option (including any supplemental
premium or cost-sharing for such option).
-
(D) The procedures for participants, beneficiaries, and
enrollees to select, access, and change participating
primary and specialty providers.
-
(E) The rights and procedures for obtaining referrals
(including standing referrals) to participating and
nonparticipating providers.
-
(F) The name, address, and telephone number of participating
health care providers and an indication of whether each such
provider is available to accept new patients.
-
(G) Any limitations imposed on the selection of qualifying
participating health care providers, including any
limitations imposed under section 103(b)(2).
-
(H) How the plan or issuer addresses the needs of
participants, beneficiaries, and enrollees and others who do
not speak English or who have other special communications
needs in accessing providers under the plan or coverage,
including the provision of information described in this
subsection and subsection (c) to such individuals and
including the provision of information in a language other
than English if 5 percent of the number of participants,
beneficiaries, and enrollees communicate in that language
instead of English.
-
(4) OUT-OF-AREA COVERAGE- Out-of-area coverage provided by the plan or issuer.
-
(5) EMERGENCY COVERAGE- Coverage of emergency services,
including--
-
(A) the appropriate use of emergency services, including use
of the 911 telephone system or its local equivalent in
emergency situations and an explanation of what constitutes
an emergency situation;
-
(B) the process and procedures of the plan or issuer for
obtaining emergency services; and
-
(C) the locations of (i) emergency departments, and (ii)
other settings, in which plan physicians and hospitals
provide emergency services and post-stabilization care.
-
(6) PERCENTAGE OF PREMIUMS USED FOR BENEFITS (LOSS-RATIOS)- In
the case of health insurance coverage only (and not with respect
to group health plans that do not provide coverage through health
insurance coverage), a description of the overall loss-ratio for
the coverage (as defined in accordance with rules established or
recognized by the Secretary of Health and Human Services).
-
(7) PRIOR AUTHORIZATION RULES- Rules regarding prior
authorization or other review requirements that could result in
noncoverage or nonpayment.
-
(8) GRIEVANCE AND APPEALS PROCEDURES- All appeal or grievance
rights and procedures under the plan or coverage, including the
method for filing grievances and the time frames and
circumstances for acting on grievances and appeals, who is the
applicable authority with respect to the plan or issuer, and the
availability of assistance through an ombudsman to individuals in
relation to group health plans and health insurance coverage.
-
(9) QUALITY ASSURANCE- A summary description of the data on
quality collected under section 112(a), including a summary
description of the data on satisfaction of participants,
beneficiaries, and enrollees (including data on individual
voluntary disenrollment and grievances and appeals) described in
section 112(b)(4).
-
(10) SUMMARY OF PROVIDER FINANCIAL INCENTIVES- A summary
description of the information on the types of financial payment
incentives (described in section 1852(j)(4) of the Social
Security Act) provided by the plan or issuer under the coverage.
-
(11) INFORMATION ON ISSUER- Notice of appropriate mailing
addresses and telephone numbers to be used by participants,
beneficiaries, and enrollees in seeking information or
authorization for treatment.
-
(12) AVAILABILITY OF INFORMATION ON REQUEST- Notice that the
information described in subsection (c) is available upon
request.
-
(c) INFORMATION MADE AVAILABLE UPON REQUEST- The information described
in this subsection is the following:
-
(1) UTILIZATION REVIEW ACTIVITIES- A description of procedures
used and requirements (including circumstances, time frames, and
appeal rights) under any utilization review program under section
115, including under any drug formulary program under section
107.
-
(2) GRIEVANCE AND APPEALS INFORMATION- Information on the number
of grievances and appeals and on the disposition in the aggregate
of such matters.
-
(3) METHOD OF PHYSICIAN COMPENSATION- An overall summary
description as to the method of compensation of participating
physicians, including information on the types of financial
payment incentives (described in section 1852(j)(4) of the Social
Security Act) provided by the plan or issuer under the coverage.
-
(4) SPECIFIC INFORMATION ON CREDENTIALS OF PARTICIPATING
PROVIDERS- In the case of each participating provider, a
description of the credentials of the provider.
-
(5) CONFIDENTIALITY POLICIES AND PROCEDURES- A description of the
policies and procedures established to carry out section 122.
-
(6) FORMULARY RESTRICTIONS- A description of the nature of any drug formula restrictions.
-
(7) PARTICIPATING PROVIDER LIST- A list of current participating health care providers.
-
(d) FORM OF DISCLOSURE-
-
(1) UNIFORMITY- Information required to be disclosed under this
section shall be provided in accordance with uniform, national
reporting standards specified by the Secretary, after
consultation with applicable State authorities, so that
prospective enrollees may compare the attributes of different
issuers and coverage offered within an area.
-
(2) INFORMATION INTO HANDBOOK- Nothing in this section shall be
construed as preventing a group health plan or health insurance
issuer from making the information under subsections (b) and (c)
available to participants, beneficiaries, and enrollees through
an enrollee handbook or similar publication.
-
(3) UPDATING PARTICIPATING PROVIDER INFORMATION- The information
on participating health care providers described in subsection
(b)(3)(C) shall be updated within such reasonable period as
determined appropriate by the Secretary. Nothing in this section
shall prevent an issuer from changing or updating other
information made available under this section.
-
(e) CONSTRUCTION- Nothing in this section shall be construed as
requiring public disclosure of individual contracts or financial
arrangements between a group health plan or health insurance issuer
and any provider.
SEC. 122. PROTECTION OF PATIENT CONFIDENTIALITY.
Insofar as a group health plan, or a health insurance issuer that
offers health insurance coverage, maintains medical records or other
health information regarding participants, beneficiaries, and
enrollees, the plan or issuer shall establish procedures--
-
(1) to safeguard the privacy of any individually identifiable
enrollee information;
-
(2) to maintain such records and information in a manner that is
accurate and timely, and
-
(3) to assure timely access of such individuals to such records
and information.
SEC. 123. HEALTH INSURANCE OMBUDSMEN.
-
(a) IN GENERAL- Each State that obtains a grant under subsection (c)
shall provide for creation and operation of a Health Insurance
Ombudsman through a contract with a not-for-profit organization that
operates independent of group health plans and health insurance
issuers. Such Ombudsman shall be responsible for at least the
following:
-
(1) To assist consumers in the State in choosing among health
insurance coverage or among coverage options offered within group
health plans.
-
(2) To provide counseling and assistance to enrollees
dissatisfied with their treatment by health insurance issuers and
group health plans in regard to such coverage or plans and with
respect to grievances and appeals regarding determinations under
such coverage or plans.
-
(b) FEDERAL ROLE- In the case of any State that does not provide for
such an Ombudsman under subsection (a), the Secretary shall provide
for the creation and operation of a Health Insurance Ombudsman through
a contract with a not-for-profit organization that operates
independent of group health plans and health insurance issuers and
that is responsible for carrying out with respect to that State the
functions otherwise provided under subsection (a) by a Health
Insurance Ombudsman.
-
(c) AUTHORIZATION OF APPROPRIATIONS- There are authorized to be
appropriated to the Secretary of Health and Human Services such
amounts as may be necessary to provide for grants to States for
contracts for Health Insurance Ombudsmen under subsection (a) or
contracts for such Ombudsmen under subsection (b).
-
(d) CONSTRUCTION- Nothing in this section shall be construed to
prevent the use of other forms of enrollee assistance.
Subtitle D--Grievance and Appeals Procedures
SEC. 131. ESTABLISHMENT OF GRIEVANCE PROCESS.
-
(a) ESTABLISHMENT OF GRIEVANCE SYSTEM-
-
(1) IN GENERAL- A group health plan, and a health insurance
issuer in connection with the provision of health insurance
coverage, shall establish and maintain a system to provide for
the presentation and resolution of oral and written grievances
brought by individuals who are participants, beneficiaries, or
enrollees, or health care providers or other individuals acting
on behalf of an individual and with the individual's consent,
regarding any aspect of the plan's or issuer's services.
-
(2) SCOPE- The system shall include grievances regarding access
to and availability of services, quality of care, choice and
accessibility of providers, network adequacy, and compliance with
the requirements of this title.
-
(b) GRIEVANCE SYSTEM- Such system shall include the following
components with respect to individuals who are participants,
beneficiaries, or enrollees:
-
(1) Written notification to all such individuals and providers of
the telephone numbers and business addresses of the plan or
issuer personnel responsible for resolution of grievances and
appeals.
-
(2) A system to record and document, over a period of at least 3
previous years, all grievances and appeals made and their status.
-
(3) A process providing for timely processing and resolution of
grievances.
-
(4) Procedures for follow-up action, including the methods to
inform the person making the grievance of the resolution of the
grievance.
-
(5) Notification to the continuous quality improvement program
under section 111(a) of all grievances and appeals relating to
quality of care.
SEC. 132. INTERNAL APPEALS OF ADVERSE DETERMINATIONS.
-
(a) RIGHT OF APPEAL-
-
(1) IN GENERAL- A participant or beneficiary in a group health
plan, and an enrollee in health insurance coverage offered by a
health insurance issuer, and any provider or other person acting
on behalf of such an individual with the individual's consent,
may appeal any appealable decision (as defined in paragraph (2))
under the procedures described in this section and (to the extent
applicable) section 133. Such individuals and providers shall be
provided with a written explanation of the appeal process and the
determination upon the conclusion of the appeals process and as
provided in section 121(b)(8).
-
(2) APPEALABLE DECISION DEFINED- In this section, the term
`appealable decision' means any of the following:
-
(A) Denial, reduction, or termination of, or failure to
provide or make payment (in whole or in part) for, a
benefit, including a failure to cover an item or service for
which benefits are otherwise provided because it is
determined to be experimental or investigational or not
medically necessary or appropriate.
-
(B) Failure to provide coverage of emergency services or
reimbursement of maintenance care or post-stabilization care
under section 101.
-
(C) Failure to provide a choice of provider under section
103.
-
(D) Failure to provide qualified health care providers under
section 103.
-
(E) Failure to provide access to specialty and other care
under section 104.
-
(F) Failure to provide continuation of care under section
105.
-
(G) Failure to provide coverage of routine patient costs in
connection with an approval clinical trial under section
106.
-
(H) Failure to provide access to needed drugs under section
107(a)(3) or 107(b).
-
(I) Discrimination in delivery of services in violation of
section 109.
-
(J) An adverse determination under a utilization review
program under section 115.
-
(K) The imposition of a limitation that is prohibited under
section 151.
-
(b) INTERNAL APPEAL PROCESS-
-
(1) IN GENERAL- Each group health plan and health insurance
issuer shall establish and maintain an internal appeal process
under which any participant, beneficiary, enrollee, or provider
acting on behalf of such an individual with the individual's
consent, who is dissatisfied with any appealable decision has the
opportunity to appeal the decision through an internal appeal
process. The appeal may be communicated orally.
-
(2) CONDUCT OF REVIEW-
-
(A) IN GENERAL- The process shall include a review of the
decision by a physician or other health care professional
(or professionals) who has been selected by the plan or
issuer and who has not been involved in the appealable
decision at issue in the appeal.
-
(B) AVAILABILITY AND PARTICIPATION OF CLINICAL PEERS- The
individuals conducting such review shall include one or more
clinical peers (as defined in section 191(c)(2)) who have
not been involved in the appealable decision at issue in the
appeal.
-
(3) DEADLINE-
-
(A) IN GENERAL- Subject to subsection (c), the plan or
issuer shall conclude each appeal as soon as possible after
the time of the receipt of the appeal in accordance with
medical exigencies of the case involved, but in no event
later than--
-
(i) 72 hours after the time of receipt of an expedited
appeal, and
-
(ii) except as provided in subparagraph (B), 15
business days after such time in the case of all other
appeals.
-
(B) EXTENSION- A group health plan or health insurance
issuer may extend the deadline for an appeal that does not
relate to a decision regarding an expedited appeal and that
does not involve medical exigencies up to an additional 10
business days where it can demonstrate to the applicable
authority reasonable cause for the delay beyond its control
and where it provides, within the original deadline under
subparagraph (A), a written progress report and explanation
for the delay to such authority and to the participant,
beneficiary, or enrollee and provider involved.
-
(4) NOTICE- If a plan or issuer denies an appeal, the plan or
issuer shall provide the participant, beneficiary, or enrollee
and provider involved with notice in printed form of the denial
and the reasons therefore, together with a notice in printed form
of rights to any further appeal.
-
(c) EXPEDITED REVIEW PROCESS-
-
(1) IN GENERAL- A group health plan, and a health insurance
issuer, shall establish procedures in writing for the expedited
consideration of appeals under subsection (b) in situations in
which the application of the normal timeframe for making a
determination could seriously jeopardize the life or health of
the participant, beneficiary, or enrollee or such an individual's
ability to regain maximum function.
-
(2) PROCESS- Under such procedures--
-
(A) the request for expedited appeal may be submitted orally
or in writing by an individual or provider who is otherwise
entitled to request the appeal;
-
(B) all necessary information, including the plan's or
issuer's decision, shall be transmitted between the plan or
issuer and the requester by telephone, facsimile, or other
similarly expeditious available method; and
-
(C) the plan or issuer shall expedite the appeal if the
request for an expedited appeal is submitted under
subparagraph (A) by a physician and the request indicates
that the situation described in paragraph (1) exists.
-
(d) DIRECT USE OF FURTHER APPEALS- In the event that the plan or
issuer fails to comply with any of the deadlines for completion of
appeals under this section or in the event that the plan or issuer for
any reason expressly waives its rights to an internal review of an
appeal under subsection (b), the participant, beneficiary, or enrollee
involved and the provider involved shall be relieved of any obligation
to complete the appeal involved and may, at such an individual's or
provider's option, proceed directly to seek further appeal through any
applicable external appeals process.
SEC. 133. EXTERNAL APPEALS OF ADVERSE DETERMINATIONS.
-
(a) RIGHT TO EXTERNAL APPEAL-
-
(1) IN GENERAL- A group health plan, and a health insurance
issuer offering group health insurance coverage, shall provide
for an external appeals process that meets the requirements of
this section in the case of an externally appealable decision
described in paragraph (2). The appropriate Secretary shall
establish standards to carry out such requirements.
-
(2) EXTERNALLY APPEALABLE DECISION DEFINED- For purposes of this
section, the term `externally appealable decision' means an
appealable decision (as defined in section 132(a)(2)) if--
-
(A) the amount involved exceeds a significant threshold; or
-
(B) the patient's life or health is jeopardized as a
consequence of the decision.
Such term does not include a denial of coverage for services that
are specifically listed in plan or coverage documents as excluded
from coverage.
-
(3) EXHAUSTION OF INTERNAL APPEALS PROCESS- A plan or issuer may
condition the use of an external appeal process in the case of an
externally appealable decision upon completion of the internal
review process provided under section 132, but only if the
decision is made in a timely basis consistent with the deadlines
provided under this subtitle.
-
(b) GENERAL ELEMENTS OF EXTERNAL APPEALS PROCESS-
-
(1) CONTRACT WITH QUALIFIED EXTERNAL APPEAL ENTITY-
-
(A) CONTRACT REQUIREMENT- Subject to subparagraph (B), the external appeal process under this section of a plan or
issuer shall be conducted under a contract between the plan
or issuer and one or more qualified external appeal entities
(as defined in subsection (c)).
-
(B) RESTRICTIONS ON QUALIFIED EXTERNAL APPEAL ENTITY-
-
(i) BY STATE FOR HEALTH INSURANCE ISSUERS- With respect
to health insurance issuers in a State, the State may
provide for external review activities to be conducted
by a qualified external appeal entity that is
designated by the State or that is selected by the
State in such a manner as to assure an unbiased
determination.
-
(ii) BY FEDERAL GOVERNMENT FOR GROUP HEALTH PLANS- With
respect to group health plans, the appropriate
Secretary may exercise the same authority as a State
may exercise with respect to health insurance issuers
under clause (i). Such authority may include requiring
the use of the qualified external appeal entity
designated or selected under such clause.
-
(iii) LIMITATION ON PLAN OR ISSUER SELECTION- If an
applicable authority permits more than one entity to
qualify as a qualified external appeal entity with
respect to a group health plan or health insurance
issuer and the plan or issuer may select among such
qualified entities, the applicable authority--
-
(I) shall assure that the selection process will
not create any incentives for external appeal
entities to make a decision in a biased manner,
and
-
(II) shall implement procedures for auditing a
sample of decisions by such entities to assure
that no such decisions are made in a biased
manner.
-
(C) OTHER TERMS AND CONDITIONS- The terms and conditions of
a contract under this paragraph shall be consistent with the
standards the appropriate Secretary shall establish to
assure there is no real or apparent conflict of interest in
the conduct of external appeal activities. Such contract
shall provide that the direct costs of the process (not
including costs of representation of a participant,
beneficiary, or enrollee) shall be paid by the plan or
issuer, and not by the participant, beneficiary, or
enrollee.
-
(2) ELEMENTS OF PROCESS- An external appeal process shall be
conducted consistent with standards established by the
appropriate Secretary that include at least the following:
-
(A) FAIR PROCESS; DE NOVO DETERMINATION- The process shall provide for a fair, de novo determination.
-
(B) DETERMINATION CONCERNING EXTERNALLY APPEALABLE
DECISIONS- A qualified external appeal entity shall
determine whether a decision is an externally appealable
decision and related decisions, including--
-
(i) whether such a decision involves an expedited
appeal;
-
(ii) the appropriate deadlines for internal review
process required due to medical exigencies in a case;
and
-
(iii) whether such a process has been completed.
-
(C) OPPORTUNITY TO SUBMIT EVIDENCE, HAVE REPRESENTATION, AND
MAKE ORAL PRESENTATION- Each party to an externally
appealable decision--
-
(i) may submit and review evidence related to the
issues in dispute,
-
(ii) may use the assistance or representation of one or
more individuals (any of whom may be an attorney), and
-
(iii) may make an oral presentation.
-
(D) PROVISION OF INFORMATION- The plan or issuer involved
shall provide timely access to all its records relating to
the matter of the externally appealable decision and to all
provisions of the plan or health insurance coverage
(including any coverage manual) relating to the matter.
-
(E) TIMELY DECISIONS- A determination by the external appeal
entity on the decision shall--
-
(i) be made orally or in writing and, if it is made
orally, shall be supplied to the parties in writing as
soon as possible;
-
(ii) be binding on the plan or issuer;
-
(iii) be made in accordance with the medical exigencies
of the case involved, but in no event later than 60
days (or 72 hours in the case of an expedited appeal)
from the date of completion of the filing of notice of
external appeal of the decision;
-
(iv) state, in layperson's language, the basis for the
determination, including, if relevant, any basis in the
terms or conditions of the plan or coverage; and
-
(v) inform the participant, beneficiary, or enrollee of
the individual's rights to seek further review by the
courts (or other process) of the external appeal
determination.
-
(c) QUALIFICATIONS OF EXTERNAL APPEAL ENTITIES-
-
(1) IN GENERAL- For purposes of this section, the term `qualified
external appeal entity' means, in relation to a plan or issuer,
an entity (which may be a governmental entity) that is certified
under paragraph (2) as meeting the following requirements:
-
(A) There is no real or apparent conflict of interest that
would impede the entity conducting external appeal
activities independent of the plan or issuer.
-
(B) The entity conducts external appeal activities through
clinical peers.
-
(C) The entity has sufficient medical, legal, and other
expertise and sufficient staffing to conduct external appeal
activities for the plan or issuer on a timely basis
consistent with subsection (b)(3)(E).
-
(D) The entity meets such other requirements as the
appropriate Secretary may impose.
-
(2) CERTIFICATION OF EXTERNAL APPEAL ENTITIES-
-
(A) IN GENERAL- In order to be treated as a qualified
external appeal entity with respect to--
-
(i) a group health plan, the entity must be certified
(and, in accordance with subparagraph (B), periodically
recertified) as meeting the requirements of paragraph
(1) by the Secretary of Labor (or under a process
recognized or approved by the Secretary of Labor); or
-
(ii) a health insurance issuer operating in a State,
the entity must be certified (and, in accordance with
subparagraph (B), periodically recertified) as meeting
such requirements by the applicable State authority
(or, if the States has not established an adequate
certification and recertification process, by the
Secretary of Health and Human Services, or under a
process recognized or approved by such Secretary).
-
(B) RECERTIFICATION PROCESS- The appropriate Secretary shall develop standards for the recertification of external appeal
entities. Such standards shall include a specification of--
-
(i) the information required to be submitted as a
condition of recertification on the entity's
performance of external appeal activities, which
information shall include the number of cases reviewed,
a summary of the disposition of those cases, the length
of time in making determinations on those cases, and
such information as may be necessary to assure the
independence of the entity from the plans or issuers
for which external appeal activities are being
conducted; and
-
(ii) the periodicity which recertification will be
required.
-
(d) CONTINUING LEGAL RIGHTS OF ENROLLEES- Nothing in this title shall
be construed as removing any legal rights of participants,
beneficiaries, enrollees, and others under State or Federal law,
including the right to file judicial actions to enforce rights.
Subtitle E--Protecting the Doctor-Patient Relationship
SEC. 141. PROHIBITION OF INTERFERENCE WITH CERTAIN MEDICAL COMMUNICATIONS.
-
(a) PROHIBITION-
-
(1) GENERAL RULE- The provisions of any contract or agreement, or
the operation of any contract or agreement, between a group
health plan or health insurance issuer in relation to health
insurance coverage (including any partnership, association, or
other organization that enters into or administers such a
contract or agreement) and a health care provider (or group of
health care providers) shall not prohibit or restrict the
provider from engaging in medical communications with the
provider's patient.
-
(2) NULLIFICATION- Any contract provision or agreement described
in paragraph (1) shall be null and void.
-
(b) RULES OF CONSTRUCTION- Nothing in this section shall be
construed--
-
(1) to prohibit the enforcement, as part of a contract or
agreement to which a health care provider is a party, of any
mutually agreed upon terms and conditions, including terms and
conditions requiring a health care provider to participate in,
and cooperate with, all programs, policies, and procedures
developed or operated by a group health plan or health insurance
issuer to assure, review, or improve the quality and effective
utilization of health care services (if such utilization is
according to guidelines or protocols that are based on clinical
or scientific evidence and the professional judgment of the
provider) but only if the guidelines or protocols under such
utilization do not prohibit or restrict medical communications
between providers and their patients; or
-
(2) to permit a health care provider to misrepresent the scope of
benefits covered under the group health plan or health insurance
coverage or to otherwise require a group health plan health
insurance issuer to reimburse providers for benefits not covered
under the plan or coverage.
-
(c) MEDICAL COMMUNICATION DEFINED- In this section:
-
(1) IN GENERAL- The term `medical communication' means any
communication made by a health care provider with a patient of
the health care provider (or the guardian or legal representative
of such patient) with respect to--
-
(A) the patient's health status, medical care, or treatment
options;
-
(B) any utilization review requirements that may affect
treatment options for the patient; or
-
(C) any financial incentives that may affect the treatment
of the patient.
-
(2) MISREPRESENTATION- The term `medical communication' does not
include a communication by a health care provider with a patient
of the health care provider (or the guardian or legal
representative of such patient) if the communication involves a
knowing or willful misrepresentation by such provider.
SEC. 142. PROHIBITION AGAINST TRANSFER OF INDEMNIFICATION OR IMPROPER
INCENTIVE ARRANGEMENTS.
-
(a) PROHIBITION OF TRANSFER OF INDEMNIFICATION-
-
(1) IN GENERAL- No contract or agreement between a group health
plan or health insurance issuer (or any agent acting on behalf of
such a plan or issuer) and a health care provider shall contain
any provision purporting to transfer to the health care provider
by indemnification or otherwise any liability relating to
activities, actions, or omissions of the plan, issuer, or agent
(as opposed to the provider).
-
(2) NULLIFICATION- Any contract or agreement provision described
in paragraph (1) shall be null and void.
-
(b) PROHIBITION OF IMPROPER PHYSICIAN INCENTIVE PLANS-
-
(1) IN GENERAL- A group health plan and a health insurance issuer
offering health insurance coverage may not operate any physician
incentive plan (as defined in subparagraph (B) of section
1876(i)(8) of the Social Security Act) unless the requirements
described in subparagraph (A) of such section are met with
respect to such a plan.
-
(2) APPLICATION- For purposes of carrying out paragraph (1), any
reference in section 1876(i)(8) of the Social Security Act to the
Secretary, an eligible organization, or an individual enrolled
with the organization shall be treated as a reference to the
applicable authority, a group health plan or health insurance
issuer, respectively, and a participant, beneficiary, or enrollee
with the plan or organization, respectively.
SEC. 143. ADDITIONAL RULES REGARDING PARTICIPATION OF HEALTH CARE
PROFESSIONALS.
-
(a) PROCEDURES- Insofar as a group health plan, or health insurance
issuer that offers health insurance coverage, provides benefits
through participating health care professionals, the plan or issuer
shall establish reasonable procedures relating to the participation
(under an agreement between a professional and the plan or issuer) of
such professionals under the plan or coverage. Such procedures shall
include--
-
(1) providing notice of the rules regarding participation;
-
(2) providing written notice of participation decisions that are
adverse to professionals; and
-
(3) providing a process within the plan or issuer for appealing
such adverse decisions, including the presentation of information
and views of the professional regarding such decision.
-
(b) CONSULTATION IN MEDICAL POLICIES- A group health plan, and health
insurance issuer that offers health insurance coverage, shall consult
with participating physicians (if any) regarding the plan's or
issuer's medical policy, quality, and medical management procedures.
SEC. 144. PROTECTION FOR PATIENT ADVOCACY.
-
(a) PROTECTION FOR USE OF UTILIZATION REVIEW AND GRIEVANCE PROCESS- A
group health plan, and a health insurance issuer with respect to the
provision of health insurance coverage, may not retaliate against a
participant, beneficiary, enrollee, or health care provider based on
the participant's, beneficiary's, enrollee's or provider's use of, or
participation in, a utilization review process or a grievance process
of the plan or issuer (including an internal or external review or
appeal process) under this title.
-
(b) PROTECTION FOR QUALITY ADVOCACY BY HEALTH CARE PROFESSIONALS-
-
(1) IN GENERAL- A group health plan or health insurance issuer
may not retaliate or discriminate against a protected health care
professional because the professional in good faith--
-
(A) discloses information relating to the care, services, or
conditions affecting one or more participants,
beneficiaries, or enrollees of the plan or issuer to an
appropriate public regulatory agency, an appropriate private
accreditation body, or appropriate management personnel of
the plan or issuer; or
-
(B) initiates, cooperates, or otherwise participates in an
investigation or proceeding by such an agency with respect
to such care, services, or conditions.
If an institutional health care provider is a participating
provider with such a plan or issuer or otherwise receives
payments for benefits provided by such a plan or issuer, the
provisions of the previous sentence shall apply to the provider
in relation to care, services, or conditions affecting one or
more patients within an institutional health care provider in the
same manner as they apply to the plan or issuer in relation to
care, services, or conditions provided to one or more
participants, beneficiaries, or enrollees; and for purposes of
applying this sentence, any reference to a plan or issuer is
deemed a reference to the institutional health care provider.
-
(2) GOOD FAITH ACTION- For purposes of paragraph (1), a protected
health care professional is considered to be acting in good faith
with respect to disclosure of information or participation if,
with respect to the information disclosed as part of the action--
-
(A) the disclosure is made on the basis of personal
knowledge and is consistent with that degree of learning and
skill ordinarily possessed by health care professionals with
the same licensure or certification and the same experience;
-
(B) the professional reasonably believes the information to
be true;
-
(C) the information evidences either a violation of a law,
rule, or regulation, of an applicable accreditation
standard, or of a generally recognized professional or clinical standard or that a patient is in imminent hazard of loss of life or serious injury; and
-
(D) subject to subparagraphs (B) and (C) of paragraph (3),
the professional has followed reasonable internal procedures
of the plan, issuer, or institutional health care provider
established or the purpose of addressing quality concerns
before making the disclosure.
-
(3) EXCEPTION AND SPECIAL RULE-
-
(A) GENERAL EXCEPTION- Paragraph (1) does not protect
disclosures that would violate Federal or State law or
diminish or impair the rights of any person to the continued
protection of confidentiality of communications provided by
such law.
-
(B) NOTICE OF INTERNAL PROCEDURES- Subparagraph (D) of
paragraph (2) shall not apply unless the internal procedures
involved are reasonably expected to be known to the health
care professional involved. For purposes of this
subparagraph, a health care professional is reasonably
expected to know of internal procedures if those procedures
have been made available to the professional through
distribution or posting.
-
(C) INTERNAL PROCEDURE EXCEPTION- Subparagraph (D) of
paragraph (2) also shall not apply if--
-
(i) the disclosure relates to an imminent hazard of
loss of life or serious injury to a patient;
-
(ii) the disclosure is made to an appropriate private
accreditation body pursuant to disclosure procedures
established by the body; or
-
(iii) the disclosure is in response to an inquiry made
in an investigation or proceeding of an appropriate
public regulatory agency and the information disclosed
is limited to the scope of the investigation or
proceeding.
-
(4) ADDITIONAL CONSIDERATIONS- It shall not be a violation of
paragraph (1) to take an adverse action against a protected
health care professional if the plan, issuer, or provider taking
the adverse action involved demonstrates that it would have taken
the same adverse action even in the absence of the activities
protected under such paragraph.
-
(5) NOTICE- A group health plan, health insurance issuer, and
institutional health care provider shall post a notice, to be
provided or approved by the Secretary of Labor, setting forth
excerpts from, or summaries of, the pertinent provisions of this
subsection and information pertaining to enforcement of such
provisions.
-
(6) CONSTRUCTIONS-
-
(A) DETERMINATIONS OF COVERAGE- Nothing in this subsection
shall be construed to prohibit a plan or issuer from making
a determination not to pay for a particular medical
treatment or service or the services of a type of health
care professional.
-
(B) ENFORCEMENT OF PEER REVIEW PROTOCOLS AND INTERNAL
PROCEDURES- Nothing in this subsection shall be construed to
prohibit a plan, issuer, or provider from establishing and
enforcing reasonable peer review or utilization review
protocols or determining whether a protected health care
professional has complied with those protocols or from
establishing and enforcing internal procedures for the
purpose of addressing quality concerns.
-
(C) RELATION TO OTHER RIGHTS- Nothing in this subsection
shall be construed to abridge rights of participants,
beneficiaries, enrollees, and protected health care
professionals under other applicable Federal or State laws.
-
(7) PROTECTED HEALTH CARE PROFESSIONAL DEFINED- For purposes of
this subsection, the term `protected health care professional'
means an individual who is a licensed or certified health care
professional and who--
-
(A) with respect to a group health plan or health insurance
issuer, is an employee of the plan or issuer or has a
contract with the plan or issuer for provision of services
for which benefits are available under the plan or issuer;
or
-
(B) with respect to an institutional health care provider,
is an employee of the provider or has a contract or other
arrangement with the provider respecting the provision of
health care services.
Subtitle F--Promoting Good Medical Practice
SEC. 151. PROMOTING GOOD MEDICAL PRACTICE.
-
(a) PROHIBITING ARBITRARY LIMITATIONS OR CONDITIONS FOR THE PROVISION
OF SERVICES-
-
(1) IN GENERAL- A group health plan, and a health insurance
issuer in connection with the provision of health insurance
coverage, may not arbitrarily interfere with or alter the
decision of the treating physician regarding the manner or
setting in which particular services are delivered if the
services are medically necessary or appropriate for treatment or
diagnosis to the extent that such treatment or diagnosis is
otherwise a covered benefit.
-
(2) CONSTRUCTION- Paragraph (1) shall not be construed as
prohibiting a plan or issuer from limiting the delivery of
services to one or more health care providers within a network of
such providers.
-
(b) NO CHANGE IN COVERAGE- Subsection (a) shall not be construed as
requiring coverage of particular services the coverage of which is
otherwise not covered under the terms of the plan or coverage or from
conducting utilization review activities consistent with this
subsection.
-
(c) MEDICAL NECESSITY OR APPROPRIATENESS DEFINED- In subsection (a),
the term `medically necessary or appropriate' means, with respect to a
service or benefit, a service or benefit which is consistent with
generally accepted principles of professional medical practice.
SEC. 152. STANDARDS RELATING TO BENEFITS FOR CERTAIN BREAST CANCER
TREATMENT.
-
(a) REQUIREMENTS FOR MINIMUM HOSPITAL STAY FOLLOWING MASTECTOMY OR
LYMPH NODE DISSECTION-
-
(1) IN GENERAL- A group health plan, and a health insurance
issuer offering group health insurance coverage, may not--
-
(A) except as provided in paragraph (2)--
-
(i) restrict benefits for any hospital length of stay
in connection with a mastectomy for the treatment of
breast cancer to less than 48 hours, or
-
(ii) restrict benefits for any hospital length of stay
in connection with a lymph node dissection for the
treatment of breast cancer to less than 24 hours, or
-
(B) require that a provider obtain authorization from the
plan or the issuer for prescribing any length of stay
required under subparagraph (A) (without regard to paragraph
(2)).
-
(2) EXCEPTION- Paragraph (1)(A) shall not apply in connection
with any group health plan or health insurance issuer in any case
in which the decision to discharge the woman involved prior to
the expiration of the minimum length of stay otherwise required
under paragraph (1)(A) is made by the attending provider in
consultation with the woman or in a case involving a partial
mastectomy without lymph node dissection.
-
(b) PROHIBITIONS- A group health plan, and a health insurance issuer
offering group health insurance coverage in connection with a group
health plan, may not--
-
(1) deny to a woman eligibility, or continued eligibility, to
enroll or to renew coverage under the terms of the plan, solely
for the purpose of avoiding the requirements of this section;
-
(2) provide monetary payments or rebates to women to encourage
such women to accept less than the minimum protections available
under this section;
-
(3) penalize or otherwise reduce or limit the reimbursement of an
attending provider because such provider provided care to an
individual participant or beneficiary in accordance with this
section;
-
(4) provide incentives (monetary or otherwise) to an attending
provider to induce such provider to provide care to an individual
participant or beneficiary in a manner inconsistent with this
section; or
-
(5) subject to subsection (c)(3), restrict benefits for any
portion of a period within a hospital length of stay required
under subsection (a) in a manner which is less favorable than the
benefits provided for any preceding portion of such stay.
-
(c) RULES OF CONSTRUCTION-
-
(1) Nothing in this section shall be construed to require a woman
who is a participant or beneficiary--
-
(A) to undergo a mastectomy or lymph node dissection in a
hospital; or
-
(B) to stay in the hospital for a fixed period of time
following a mastectomy or lymph node dissection.
-
(2) This section shall not apply with respect to any group health
plan, or any group health insurance coverage offered by a health
insurance issuer, which does not provide benefits for hospital
lengths of stay in connection with a mastectomy or lymph node
dissection for the treatment of breast cancer.
-
(3) Nothing in this section shall be construed as preventing a
group health plan or issuer from imposing deductibles,
coinsurance, or other cost-sharing in relation to benefits for
hospital lengths of stay in connection with a mastectomy or lymph
node dissection for the treatment of breast cancer under the plan
(or under health insurance coverage offered in connection with a
group health plan), except that such coinsurance or other
cost-sharing for any portion of a period within a hospital length
of stay required under subsection (a) may not be greater than
such coinsurance or cost-sharing for any preceding portion of
such stay.
-
(d) LEVEL AND TYPE OF REIMBURSEMENTS- Nothing in this section shall be
construed to prevent a group health plan or a health insurance issuer
offering group health insurance coverage from negotiating the level
and type of reimbursement with a provider for care provided in
accordance with this section.
-
(e) EXCEPTION FOR HEALTH INSURANCE COVERAGE IN CERTAIN STATES-
-
(1) IN GENERAL- The requirements of this section shall not apply
with respect to health insurance coverage if there is a State law
(as defined in section 2723(d)(1) of the Public Health Service
Act) for a State that regulates such coverage that is described
in any of the following subparagraphs:
-
(A) Such State law requires such coverage to provide for at
least a 48-hour hospital length of stay following a
mastectomy performed for treatment of breast cancer and at
least a 24-hour hospital length of stay following a lymph
node dissection for treatment of breast cancer.
-
(B) Such State law requires, in connection with such
coverage for surgical treatment of breast cancer, that the
hospital length of stay for such care is left to the
decision of (or required to be made by) the attending
provider in consultation with the woman involved.
-
(2) CONSTRUCTION- Section 2723(a)(1) of the Public Health Service
Act and section 731(a)(1) of the Employee Retirement Income
Security Act of 1974 shall not be construed as superseding a
State law described in paragraph (1).
SEC. 153. STANDARDS RELATING TO BENEFITS FOR RECONSTRUCTIVE BREAST SURGERY.
-
(a) REQUIREMENTS FOR RECONSTRUCTIVE BREAST SURGERY-
-
(1) IN GENERAL- A group health plan, and a health insurance
issuer offering group health insurance coverage, that provides
coverage for breast surgery in connection with a mastectomy shall provide coverage for reconstructive breast surgery
resulting from the mastectomy. Such coverage shall include coverage for all
stages of reconstructive breast surgery performed on a nondiseased breast
to establish symmetry with the diseased when reconstruction on the diseased
breast is performed and coverage of prostheses and complications of
mastectomy including lymphedema.
-
(2) RECONSTRUCTIVE BREAST SURGERY DEFINED- In this section, the term `reconstructive breast surgery' means surgery performed as a result of a mastectomy to reestablish symmetry between two
breasts, and includes augmentation mammoplasty, reduction
mammoplasty, and mastopexy.
-
(3) MASTECTOMY DEFINED- In this section, the term `mastectomy'
means the surgical removal of all or part of a breast.
-
(b) PROHIBITIONS-
-
(1) DENIAL OF COVERAGE BASED ON COSMETIC SURGERY- A group health
plan, and a health insurance issuer offering group health
insurance coverage in connection with a group health plan, may
not deny coverage described in subsection (a)(1) on the basis
that the coverage is for cosmetic surgery.
-
(2) APPLICATION OF SIMILAR PROHIBITIONS- Paragraphs (2) through
(5) of section 152 shall apply under this section in the same
manner as they apply with respect to section 152.
-
(c) RULES OF CONSTRUCTION-
-
(1) Nothing in this section shall be construed to require a woman
who is a participant or beneficiary to undergo reconstructive
breast surgery.
-
(2) This section shall not apply with respect to any group health
plan, or any group health insurance coverage offered by a health
insurance issuer, which does not provide benefits for
mastectomies.
-
(3) Nothing in this section shall be construed as preventing a
group health plan or issuer from imposing deductibles,
coinsurance, or other cost-sharing in relation to benefits for
reconstructive breast surgery under the plan (or under health
insurance coverage offered in connection with a group health
plan), except that such coinsurance or other cost-sharing for any
portion may not be greater than such coinsurance or cost-sharing
that is otherwise applicable with respect to benefits for
mastectomies.
-
(e) LEVEL AND TYPE OF REIMBURSEMENTS- Nothing in this section shall be
construed to prevent a group health plan or a health insurance issuer
offering group health insurance coverage from negotiating the level
and type of reimbursement with a provider for care provided in
accordance with this section.
-
(f) EXCEPTION FOR HEALTH INSURANCE COVERAGE IN CERTAIN STATES-
-
(1) IN GENERAL- The requirements of this section shall not apply
with respect to health insurance coverage if there is a State law
(as defined in section 2723(d)(1) of the Public Health Service
Act) for a State that regulates such coverage and that requires
coverage of at least the coverage of reconstructive breast
surgery otherwise required under this section.
-
(2) CONSTRUCTION- Section 2723(a)(1) of the Public Health Service
Act and section 731(a)(1) of the Employee Retirement Income
Security Act of 1974 shall not be construed as superseding a
State law described in paragraph (1).
Subtitle G--Definitions
SEC. 191. DEFINITIONS.
-
(a) INCORPORATION OF GENERAL DEFINITIONS- The provisions of section
2971 of the Public Health Service Act shall apply for purposes of this
title in the same manner as they apply for purposes of title XXVII of
such Act.
-
(b) SECRETARY- Except as otherwise provided, the term `Secretary'
means the Secretary of Health and Human Services, in consultation with
the Secretary of Labor and the Secretary of the Treasury and the term
`appropriate Secretary' means the Secretary of Health and Human
Services in relation to carrying out this title under sections 2706
and 2751 of the Public Health Service Act, the Secretary of Labor in
relation to carrying out this title under section 713 of the Employee
Retirement Income Security Act of 1974, and the Secretary of the
Treasury in relation to carrying out this title under chapter 100 and
section 4980D of the Internal Revenue Code of 1986.
-
(c) ADDITIONAL DEFINITIONS- For purposes of this title:
-
(1) APPLICABLE AUTHORITY- The term `applicable authority' means--
-
(A) in the case of a group health plan, the Secretary of
Health and Human Services and the Secretary of Labor; and
-
(B) in the case of a health insurance issuer with respect to
a specific provision of this title, the applicable State
authority (as defined in section 2791(d) of the Public
Health Service Act), or the Secretary of Health and Human
Services, if such Secretary is enforcing such provision
under section 2722(a)(2) or 2761(a)(2) of the Public Health
Service Act.
-
(2) CLINICAL PEER- The term `clinical peer' means, with respect
to a review or appeal, a physician (allopathic or osteopathic) or
other health care professional who holds a non-restricted license
in a State and who is appropriately credentialed in the same or
similar specialty as typically manages the medical condition,
procedure, or treatment under review or appeal and includes a
pediatric specialist where appropriate; except that only a
physician may be a clinical peer with respect to the review or
appeal of treatment rendered by a physician.
-
(3) HEALTH CARE PROVIDER- The term `health care provider'
includes a physician or other health care professional, as well
as an institutional provider of health care services.
-
(4) NONPARTICIPATING- The term `nonparticipating' means, with
respect to a health care provider that
provides health care items and services to a participant, beneficiary, or
enrollee under group health plan or health insurance coverage, a health
care provider that is not a participating health care provider with respect
to such items and services.
-
(5) PARTICIPATING- The term `participating' mean, with respect to
a health care provider that provides health care items and
services to a participant, beneficiary, or enrollee under group
health plan or health insurance coverage offered by a health
insurance issuer, a health care provider that furnishes such
items and services under a contract or other arrangement with the
plan or issuer.
SEC. 192. PREEMPTION; STATE FLEXIBILITY; CONSTRUCTION.
-
(a) CONTINUED APPLICABILITY OF STATE LAW WITH RESPECT TO HEALTH INSURANCE ISSUERS-
-
(1) IN GENERAL- Subject to paragraph (2), this title shall not be
construed to supersede any provision of State law which
establishes, implements, or continues in effect any standard or
requirement solely relating to health insurance issuers in
connection with group health insurance coverage except to the
extent that such standard or requirement prevents the application
of a requirement of this title.
-
(2) CONTINUED PREEMPTION WITH RESPECT TO GROUP HEALTH PLANS-
Nothing in this title shall be construed to affect or modify the
provisions of section 514 of the Employee Retirement Income
Security Act of 1974 with respect to group health plans.
-
(b) RULES OF CONSTRUCTION- Except as provided in sections 152 and 153,
nothing in this title shall be construed as requiring a group health
plan or health insurance coverage to provide specific benefits under
the terms of such plan or coverage.
-
(c) DEFINITIONS- For purposes of this section:
-
(1) STATE LAW- The term `State law' includes all laws, decisions,
rules, regulations, or other State action having the effect of
law, of any State. A law of the United States applicable only to
the District of Columbia shall be treated as a State law rather
than a law of the United States.
-
(2) STATE- The term `State' includes a State, the Northern
Mariana Islands, any political subdivisions of a State or such
Islands, or any agency or instrumentality of either.
SEC. 193. REGULATIONS.
The Secretaries of Health and Human Services, Labor, and the Treasury
shall issue such regulations as may be necessary or appropriate to
carry out this title. Such regulations shall be issued consistent with
section 104 of Health Insurance Portability and Accountability Act of
1996. Such Secretaries may promulgate any interim final rules as the
Secretaries determine are appropriate to carry out this title.
TITLE II--APPLICATION OF PATIENT PROTECTION STANDARDS TO GROUP HEALTH PLANS
AND HEALTH INSURANCE COVERAGE UNDER PUBLIC HEALTH SERVICE ACT
SEC. 201. APPLICATION TO GROUP HEALTH PLANS AND GROUP HEALTH INSURANCE COVERAGE.
-
(a) IN GENERAL- 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 group health plan shall comply with patient
protection requirements under title I of the Patients' Bill of Rights
Act of 1998, and each health insurance issuer shall comply with
patient protection requirements under such title with respect to group
health insurance coverage it offers, and such requirements shall be
deemed to be incorporated into this subsection.
-
`(b) NOTICE- A group health plan shall comply with the notice
requirement under section 711(d) of the Employee Retirement Income
Security Act of 1974 with respect to the requirements referred to in
subsection (a) and a health insurance issuer shall comply with such
notice requirement as if such section applied to such issuer and such
issuer were a group health plan.'.
-
(b) CONFORMING AMENDMENT- Section 2721(b)(1)(A) of such Act (42 U.S.C. 300gg-21(b)(1)(A)) is amended by inserting
-
`(other than section 2706)'
after `requirements of such subparts'.
SEC. 202. 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.
-
`(a) IN GENERAL- Each health insurance issuer shall comply with
patient protection requirements under title I of the Patients' Bill of
Rights Act of 1998 with respect to individual health insurance
coverage it offers, and such requirements shall be deemed to be
incorporated into this subsection.
-
`(b) 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 such title as if such section applied to such issuer
and such issuer were a group health plan.'.
TITLE III--AMENDMENTS TO THE EMPLOYEE RETIREMENT INCOME SECURITY ACT OF 1974
SEC. 301. APPLICATION OF PATIENT PROTECTION STANDARDS TO GROUP HEALTH PLANS
AND GROUP HEALTH INSURANCE COVERAGE 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
title I of the Patients' Bill of Rights Act of 1998 (as in effect as
of the date of the enactment of such Act), and such requirements shall
be deemed to be incorporated into this subsection.
-
`(b) PLAN SATISFACTION OF CERTAIN REQUIREMENTS-
-
`(1) SATISFACTION OF CERTAIN REQUIREMENTS THROUGH INSURANCE- For
purposes of subsection (a), insofar as a group health plan
provides benefits in the form of health insurance coverage
through a health insurance issuer, the plan shall be treated as
meeting the following requirements of title I of the Patients'
Bill of Rights Act of 1998 with respect to such benefits and not
be considered as failing to meet such requirements because of a
failure of the issuer to meet such requirements so long as the
plan sponsor or its representatives did not cause such failure by
the issuer:
-
`(A) Section 101 (relating to access to emergency care).
-
`(B) Section 102(a)(1) (relating to offering option to
purchase point-of-service coverage), but only insofar as the
plan is meeting such requirement through an agreement with
the issuer to offer the option to purchase point-of-service
coverage under such section.
-
`(C) Section 103 (relating to choice of providers).
-
`(D) Section 104 (relating to access to specialty care).
-
`(E) Section 105(a)(1) (relating to continuity in case of
termination of provider contract) and section 105(a)(2)
(relating to continuity in case of termination of issuer
contract), but only insofar as a replacement issuer assumes
the obligation for continuity of care.
-
`(F) Section 106 (relating to coverage for individuals
participating in approved clinical trials.)
-
`(G) Section 107 (relating to access to needed prescription
drugs).
-
`(H) Section 108 (relating to adequacy of provider network).
-
`(I) Subtitle B (relating to quality assurance).
-
`(J) Section 143 (relating to additional rules regarding
participation of health care professionals).
-
`(K) Section 152 (relating to standards relating to benefits
for certain breast cancer treatment).
-
`(L) Section 153 (relating to standards relating to benefits
for reconstructive breast surgery).
-
`(2) INFORMATION- With respect to information required to be
provided or made available under section 121, in the case of a
group health plan that provides benefits in the form of health
insurance coverage through a health insurance issuer, the
Secretary shall determine the circumstances under which the plan
is not required to provide or make available the information (and
is not liable for the issuer's failure to provide or make
available the information), if the issuer is obligated to provide
and make available (or provides and makes available) such
information.
-
`(3) GRIEVANCE AND INTERNAL APPEALS- With respect to the
grievance system and internal appeals process required to be
established under sections 131 and 132, in the case of a group
health plan that provides benefits in the form of health
insurance coverage through a health insurance issuer, the
Secretary shall determine the circumstances under which the plan
is not required to provide for such system and process (and is
not liable for the issuer's failure to provide for such system
and process), if the issuer is obligated to provide for (and
provides for) such system and process.
-
`(4) EXTERNAL APPEALS- Pursuant to rules of the Secretary,
insofar as a group health plan enters into a contract with a
qualified external appeal entity for the conduct of external
appeal activities in accordance with section 133, the plan shall
be treated as meeting the requirement of such section and is not
liable for the entity's failure to meet any requirements under
such section.
-
`(5) APPLICATION TO PROHIBITIONS- Pursuant to rules of the
Secretary, if a health insurance issuer offers health insurance
coverage in connection with a group health plan and takes an
action in violation of any of the following sections, the group
health plan shall not be liable for such violation unless the
plan caused such violation:
-
`(A) Section 109 (relating to nondiscrimination in delivery
of services).
-
`(B) Section 141 (relating to prohibition of interference
with certain medical communications).
-
`(C) Section 142 (relating to prohibition against transfer
of indemnification or improper incentive arrangements).
-
`(D) Section 144 (relating to prohibition on retaliation).
-
`(E) Section 151 (relating to promoting good medical
practice).
-
`(6) CONSTRUCTION- Nothing in this subsection shall be construed
to affect or modify the responsibilities of the fiduciaries of a
group health plan under part 4 of subtitle B.
-
`(7) APPLICATION TO CERTAIN PROHIBITIONS AGAINST RETALIATION-
With respect to compliance with the requirements of section
144(b)(1) of the Patients' Bill of Rights Act of 1998, for
purposes of this subtitle the term `group health plan' is deemed
to include a reference to an institutional health care provider.
-
`(c) ENFORCEMENT OF CERTAIN REQUIREMENTS-
-
`(1) COMPLAINTS- Any protected health care professional who
believes that the professional has been retaliated or
discriminated against in violation of section 144(b)(1) of the
Patients' Bill of Rights Act of 1998 may file with the Secretary
a complaint within 180 days of the date of the alleged
retaliation or discrimination.
-
`(2) INVESTIGATION- The Secretary shall investigate such
complaints and shall determine if a violation of such section has
occurred and, if so, shall issue an order to ensure that the
protected health care professional does not suffer any loss of
position, pay, or benefits in relation to the plan, issuer, or
provider involved, as a result of the violation found by the
Secretary.
-
`(d) CONFORMING REGULATIONS- The Secretary may issue regulations to
coordinate the requirements on group health plans under this section
with the requirements imposed under the other provisions of this
title.'.
-
(b) SATISFACTION OF ERISA CLAIMS PROCEDURE REQUIREMENT- Section 503 of
such Act (29 U.S.C. 1133) is amended by inserting `(a)' after `SEC.
503.' and by adding at the end the following new subsection:
-
`(b) In the case of a group health plan (as defined in section 733)
compliance with the requirements of subtitle D (and section 115) of
title I of the Patients' Bill of Rights Act of 1998 in the case of a
claims denial shall be deemed compliance with subsection (a) with
respect to such claims denial.'.
-
(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 502(b)(3) of such Act (29 U.S.C. 1132(b)(3)) is amended by
inserting `(other than section 144(b))' after `part 7'.
SEC. 302. ERISA PREEMPTION NOT TO APPLY TO CERTAIN ACTIONS INVOLVING HEALTH
INSURANCE POLICYHOLDERS.
-
(a) IN GENERAL- Section 514 of the Employee Retirement Income Security Act of 1974 (29 U.S.C. 1144) is amended by adding at the end the
following subsection:
-
`(e) PREEMPTION NOT TO APPLY TO CERTAIN ACTIONS ARISING OUT OF PROVISION OF HEALTH BENEFITS-
-
`(1) IN GENERAL- Except as provided in this subsection, nothing
in this title shall be construed to invalidate, impair, or
supersede any cause of action under State law to recover damages
resulting from personal injury or for wrongful death against any
person--
-
`(A) in connection with the provision of insurance,
administrative services, or medical services by such person
to or for a group health plan (as defined in section 733),
or
-
`(B) that arises out of the arrangement by such person for
the provision of such insurance, administrative services, or
medical services by other persons.
-
`(2) EXCEPTION FOR EMPLOYERS AND OTHER PLAN SPONSORS-
-
`(A) IN GENERAL- Subject to subparagraph (B), paragraph (1)
does not authorize--
-
`(i) any cause of action against an employer or other
plan sponsor maintaining the group health plan, or
-
`(ii) a right of recovery or indemnity by a person
against an employer or other plan sponsor for damages
assessed against the person pursuant to a cause of
action under paragraph (1).
-
`(B) SPECIAL RULE- Subparagraph (A) shall not preclude any
cause of action described in paragraph (1) against an
employer or other plan sponsor if--
-
`(i) such action is based on the employer's or other
plan sponsor's exercise of discretionary authority to
make a decision on a claim for benefits covered under
the plan or health insurance coverage in the case at
issue; and
-
`(ii) the exercise by such employer or other plan
sponsor of such authority resulted in personal injury
or wrongful death.'.
-
(b) EFFECTIVE DATE- The amendment made by subsection (a) shall apply to acts and omissions occurring on or after the date of the enactment
of this Act from which a cause of action arises.
TITLE IV--APPLICATION TO GROUP HEALTH PLANS UNDER THE INTERNAL REVENUE CODE OF 1986.
SEC. 401. AMENDMENTS TO THE INTERNAL REVENUE CODE OF 1986.
Subchapter B of chapter 100 of the Internal Revenue Code of 1986 (as
amended by section 1531(a) of the Taxpayer Relief Act of 1997) is
amended--
-
(1) in the table of sections, by inserting after the item
relating to section 9812 the following new item:
`Sec. 9813. Standard relating to patient freedom of choice.'; and
-
(2) by inserting after section 9812 the following:
-
`SEC. 9813. STANDARD RELATING TO PATIENTS' BILL OF RIGHTS.
`A group health plan shall comply with the requirements of title I of
the Patients' Bill of Rights Act of 1998 (as in effect as of the date
of the enactment of such Act), and such requirements shall be deemed
to be incorporated into this section.'.
TITLE V--EFFECTIVE DATES; COORDINATION IN IMPLEMENTATION
SEC. 501. EFFECTIVE DATES.
-
(a) GROUP HEALTH COVERAGE-
-
(1) IN GENERAL- Subject to paragraph (2), the amendments made by
sections 201(a), 301, and 401 (and title I insofar as it relates
to such sections) shall apply with respect to group health plans,
and health insurance coverage offered in connection with group
health plans, for plan years beginning on or after January 1,
1999 (in this section referred to as the `general effective
date') and also shall apply to portions of plan years occurring
on and after such date.
-
(2) TREATMENT OF COLLECTIVE BARGAINING AGREEMENTS- 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 sections 201(a), 301, and 401 (and title I
insofar as it relates to such sections) 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 this Act shall not be treated as a termination of such
collective bargaining agreement.
-
(b) INDIVIDUAL HEALTH INSURANCE COVERAGE- The amendments made by
section 202 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. 502. COORDINATION IN IMPLEMENTATION.
Section 104(1) of Health Insurance Portability and Accountability Act
of 1996 is amended by striking `this subtitle (and the amendments made
by this subtitle and section 401)' and inserting `the provisions of
part 7 of subtitle B of title I of the Employee Retirement Income
Security Act of 1974, the provisions of parts A and C of title XXVII
of the Public Health Service Act, chapter 100 of the Internal Revenue
Code of 1986, and title I of the Patients' Bill of Rights Act of
1998'.
Co-sponsors
(Mr. GEPHARDT, Mr. BROWN of Ohio, Mr. RANGEL, Mr.
STARK, Mr. CLAY, Mr. PAYNE, Mr. FAZIO of California, Mr. WAXMAN, Mr.
ABERCROMBIE, Mr. ALLEN, Mr. ANDREWS, Mr. BAESLER, Mr. BENTSEN, Mr. BERMAN,
Mr. BOSWELL, Mr. BOUCHER, Ms. BROWN of Florida, Mr. BROWN of California,
Mrs. CAPPS, Mr. CARDIN, Ms. CARSON, Ms. CHRISTIAN-GREEN, Mrs. CLAYTON, Mr.
CLEMENT, Mr. COYNE, Mr. CUMMINGS, Ms. DEGETTE, Mr. DELAHUNT, Ms. DELAURO,
Ms. ESHOO, Mr. EVANS, Mr. FILNER, Mr. FORD, Mr. FRANK of Massachusetts, Mr.
FROST, Ms. FURSE, Mr. GEJDENSON, Mr. GREEN, Mr. HASTINGS of Florida, Mr.
HILLIARD, Mr. HINCHEY, Mr. HOYER, Mr. JACKSON of Illinois, Ms. JACKSON-LEE
of Texas, Ms. EDDIE BERNICE JOHNSON of Texas, Ms. KAPTUR, Mr. KENNEDY of
Massachusetts, Mrs. KENNELLY of Connecticut, Mr. KLINK, Mr. LAFALCE, Mr.
LANTOS, Mr. LEWIS of Georgia, Ms. LOFGREN, Mrs. MALONEY of New York, Mr.
MANTON, Mr. MARKEY, Mr. MARTINEZ, Mr. MATSUI, Ms. MCCARTHY of Missouri, Mr.
MCGOVERN, Ms. MCKINNEY, Mrs. MEEK of Florida, Mr. MENENDEZ, Mr. MILLER of
California, Mr. MINGE, Mr. NADLER, Ms. NORTON, Mr. OLVER, Mr. OWENS, Mr.
PALLONE, Mr. PASCRELL, Ms. PELOSI, Mr. PETERSON of Minnesota, Mr. RAHALL,
Ms. RIVERS, Mr. ROMERO-BARCELO, Mr. SANDLIN, Mr. ROTHMAN, Mr. RUSH, Mr.
SABO, Mr. SANDERS, Mr. SAWYER, Mr. SERRANO, Ms. STABENOW, Mr. STRICKLAND,
Mr. STUPAK, Mr. THOMPSON, Mrs. THURMAN, Mr. TOWNS, Ms. VELAZQUEZ, Mr.
VENTO, Mr. WEXLER, Mr. WEYGAND, Mr. WISE, Ms. WOOLSEY, Mr. WYNN, and Mr.
YATES)