|House Ways and Means||Referral|
|Subcommittee on Health and Environment||Referral|
|House Education and the Workforce||Referral|
|Subcommittee on Employer-Employee Relations||Referral|
|Rep Frost, Martin - 3/16/1999||Rep Owens, Major R. - 9/14/1999|
Comprehensive Managed Health Care Reform Act of 1999 - Applies this Act as though its provisions were included in specified provisions of the Public Health Service Act, the Employee Retirement Income Security Act of 1974, and the Internal Revenue Code relating to group and individual health insurance. Requires compliance with this Act with regard to a Medicare+Choice or a Medicaid (titles XVIII and XIX of the Social Security Act) managed care organization. Declares that this Act does not supersede State laws providing greater protection. Nullifies any contract provision or agreement in violation of this Act.
(Sec. 4) Requires a managed care organization to: (1) maintain an adequate number, mix, and distribution of health care professionals; (2) provide access to specialized treatment expertise; (3) permit use of a specialist as a primary care provider; (4) allow standing specialist referrals; (5) permit use, without referral, of specialists in obstetrics and gynecology; (6) make emergency or urgent care services available 24 hours a day, seven days a week, without prior authorization; (7) permit referrals to nonparticipating providers if the organization does not have appropriate participating providers; (8) provide access to specialized treatment expertise at designated centers of excellence (directs the Secretary of Health and Human Services to establish a designation process); (9) not limit coverage in connection with enrollee participation in an approved clinical study; (10) provide, for enrollees with a life-threatening condition, access to experimental treatments; and (11) provide coverage for a prescribed drug, approved by the Food and Drug Administration, whether or not the drug is on a formulary used by the organization.
(Sec. 5) Requires a managed care organization to: (1) cover prescription drugs, preventive services, and inpatient and outpatient services; (2) cover annual screening mammography for certain enrollees; (3) not restrict benefits for breast cancer mastectomy or lymph node dissection, prescription contraceptive drugs or devices, or outpatient contraceptive services; (4) not distinguish in the amount, duration, or scope of coverage based on whether items and services relate to mental or physical health; (5) if required by the Secretary, contract with essential community providers to join the organization's network; (6) offer an enrollment option to receive services by nonparticipating professionals; (7) provide for continuity of care; and (8) provide access to a second opinion regarding treatment options.
(Sec. 6) Prohibits a managed care organization from: (1) denying payment for services as not medically necessary or appropriate unless that determination is made solely by the treating professional; (2) using penalties or incentives for professionals regarding reducing or limiting the availability of tests, services, or treatment (imposes criminal penalties for the organization and its executives); (3) restricting medical communications between a patient and a medical professional; (4) discriminating against whistleblowers; and (5) taking certain adverse actions against medical professionals for advocating for an enrollee, filing a complaint against the organization, or other actions.
(Sec. 7) Prohibits discrimination against enrollees and professionals on specified bases, including: (1) for enrollees, health status, genetic information, or anticipated need for services; and (2) for professionals, lack of affiliation with or admitting privileges at a hospital or on the basis of the professional's license or certification.
(Sec. 8) Regulates: (1) information provided by a plan to enrollees and prospective enrollees; (2) enrollee grievance procedures; (3) organization response to enrollee requests and appeals of denial of coverage; and (4) provision by a managed care organization of due process for health care professionals.
(Sec. 11) Requires a managed care organization to establish a quality improvement program. Imposes requirements on the organization's utilization review program.
(Sec. 12) Prohibits a managed care organization's loss ratio from being less than 85 percent with respect to managed care plans it offers.
Requires an organization to have procedures for: (1) allowing enrollees to participate in development of the organization's policies; and (2) addressing the needs of enrollees who are not proficient in English.