Bill Summary & Status for the 106th Congress
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H.R.2723
Sponsor: Rep
Norwood, Charlie (introduced 8/5/1999)
Related Bills: H.RES.323, H.R.2990
Latest
Major Action: 10/7/1999 Pursuant to the provisions of H. Res. 323,
H.R. 2723
is laid on the table. (The text of H.R. 2723 was
added as new matter to H.R. 2990.)
(CR D1107)
Title: To amend title I of the Employee Retirement Income Security Act of
1974, title XXVII of the Public Health Service Act, and the Internal Revenue
Code of 1986 to protect consumers in managed care plans and other health
coverage.
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Status,
Committees,
Related
Bill Details, Amendments,
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Summary
TITLE(S): (italics indicate a title for a
portion of a bill)
- POPULAR TITLE(S):
Patient Protection bill (identified by
CRS)
Managed Care bill (identified by CRS)
- SHORT TITLE(S) AS INTRODUCED:
Bipartisan Consensus Managed Care
Improvement Act of 1999
- SHORT TITLE(S) AS PASSED HOUSE:
Bipartisan Consensus Managed Care
Improvement Act of 1999
- OFFICIAL TITLE AS INTRODUCED:
To amend title I of the Employee
Retirement Income Security Act of 1974, title XXVII of the Public Health
Service Act, and the Internal Revenue Code of 1986 to protect consumers in
managed care plans and other health coverage.
STATUS: (color indicates Senate actions) (Floor
Actions/Congressional Record Page References)
- 8/5/1999:
- Referred to the Committee on Commerce, and in addition to the Committees
on Education and the Workforce, and Ways and Means, 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.
- 8/5/1999:
- Referred to House Commerce
- 9/15/1999:
- Referred to the Subcommittee on Health and Environment.
- 8/5/1999:
- Referred to House Education and the Workforce
- 9/10/1999:
- Referred to the Subcommittee on Employer-Employee Relations.
- 8/5/1999:
- Referred to House Ways and Means
- 8/17/1999:
- Referred to the Subcommittee on Health.
- 10/5/1999 10:07pm:
- Rules Committee Resolution H. Res. 323
Reported to House. Rule provides for consideration of H.R. 2990
and H.R.
2723. Provides two hours of debate on H.R. 2990
and waives all points of order against the bill. Provides one motion to
recommit the bill. Provides three hours of debate on H.R. 2723
and waives all points of order against the bill. The amendments to H.R. 2723,
printed in Part A of H. Rept. 106-366
shall be considered as adopted. Further provides for consideration of
amendments printed in Part B of H. Rept. 106-366
and waives all points of order against them except that the adoption of an
amendment in the nature of a substitute shall constitute the conclusion of the
bill for amendment. In the engrossment of H.R. 2990,
the Clerk shall add the text of H.R. 2723,
as passed by the House, as a new matter at the end of H.R. 2990,
and then lay H.R. 2723 on
the table.
- 10/6/1999 2:04pm:
- Rule H.
Res. 323 passed House.
- 10/6/1999 5:24pm:
- Considered under the provisions of rule H. Res.
323.
- 10/6/1999 5:24pm:
- House resolved itself into the Committee of the Whole House on the state
of the Union pursuant to H. Res. 323
and Rule XXIII.
- 10/6/1999 5:24pm:
- The Speaker designated the Honorable Doc Hastings to act as Chairman of
the Committee.
- 10/6/1999 9:02pm:
- Committee of the Whole House on the state of the Union rises leaving H.R. 2723 as
unfinished business.
- 10/7/1999 11:06am:
- Considered as unfinished business.
- 10/7/1999 11:06am:
- The House resolved into Committee of the Whole House on the state of the
Union for further consideration.
- 10/7/1999 11:07am:
- Pursuant to H. Res.
323, the amendments printed in Part A of H. Rept. 106-366
were considered as adopted. The amendments make technical changes and clarify
provisions to ensure that employers cannot be held liable unless they are
making medical decisions.
- 10/7/1999 11:09am:
- H.AMDT.513
Amendment (A001) in the nature of a substitute offered by Mr. Boehner.
Amendment in the nature of a substitute sought to prohibit gag rules,
ensure access to emergency medical care, direct access to an OB/GYN, access to
a pediatrician as a primary care provider, establish continuity of care, make
health care lawsuit reform with limits on "non-economic damages", and require
a patient choice of provider option.
- 10/7/1999 12:46pm:
- H.AMDT.513 On
agreeing to the Boehner amendment (A001) Failed by recorded vote: 145 - 284
(Roll
no. 487).
- 10/7/1999 12:47pm:
- H.AMDT.514
Amendment (A002) in the nature of a substitute offered by Mr. Goss.
Amendment in the nature of a substitute sought to establish utilization
review procedures, require a timely appeals process and external review of
benefit disputes, allow patients to sue for denials that cause harm, provide
protection for employers, allow choice of medical professionals, prohibit gag
clauses, and expand access to clinical trials.
- 10/7/1999 2:39pm:
- H.AMDT.514 On
agreeing to the Goss amendment (A002) Failed by recorded vote: 193 - 238 (Roll
no. 488).
- 10/7/1999 2:39pm:
- H.AMDT.515
Amendment (A003) in the nature of a substitute offered by Mr. Houghton.
Amendment sought to allow lawsuits in Federal court, rather than State
court, against the final decision-maker who fails to exercise ordinary care
decisions including employers, cap non-economic damages and prohibit punitive
damages.
- 10/7/1999 4:22pm:
- H.AMDT.515 On
agreeing to the Houghton amendment (A003) Failed by recorded vote: 160 - 269
(Roll
no. 489).
- 10/7/1999 4:22pm:
- H.AMDT.516
Amendment (A004) offered by the Committee on Rules.
Pursuant to H. Res.
323, the amendments printed in Part A of H. Rept. 106-366
were considered as adopted. The amendments make technical changes and clarify
provisions to ensure that employers cannot be held liable unless they are
making medical decisions.
- 10/7/1999 4:22pm:
- H.AMDT.516 On
agreeing to the Rules amendment (A004) Agreed to without objection.
- 10/7/1999 4:22pm:
- The House rose from the Committee of the Whole House on the state of the
Union to report H.R. 2723.
- 10/7/1999 4:22pm:
- The previous question was ordered pursuant to the rule.
- 10/7/1999 4:40pm:
- On passage Passed by recorded vote: 275 - 151 (Roll
no. 490).
- 10/7/1999 4:40pm:
- Motion to reconsider laid on the table Agreed to without objection.
- 10/7/1999 4:41pm:
- The title of the measure was amended. Agreed to without objection.
- 10/7/1999 4:41pm:
- Pursuant to the provisions of H. Res.
323, H.R.
2723 is laid on the table. (The text of H.R. 2723
was added as new matter to H.R. 2990.)
(CR D1107)
COMMITTEE(S):
RELATED BILL DETAILS: (additional
related bills may be indentified in Status)
Bill: |
Relationship: |
H.RES.323 |
Rule related to H.R.2723 in House |
H.RES.323 |
Bill that causes H.R.2723 to be laid on table in House |
H.R.2990 |
This bill has text inserted from H.R.2723 |
AMENDMENT(S):
1. H.AMDT.513 to
H.R.2723
Amendment in the nature of a substitute sought to prohibit gag rules, ensure
access to emergency medical care, direct access to an OB/GYN, access to a
pediatrician as a primary care provider, establish continuity of care, make
health care lawsuit reform with limits on "non-economic damages", and require
a patient choice of provider option.
Sponsor: Rep
Boehner, John A. - Latest Major Action: 10/7/1999 House amendment
not agreed to
2. H.AMDT.514 to
H.R.2723
Amendment in the nature of a substitute sought to establish utilization review
procedures, require a timely appeals process and external review of benefit
disputes, allow patients to sue for denials that cause harm, provide
protection for employers, allow choice of medical professionals, prohibit gag
clauses, and expand access to clinical trials.
Sponsor: Rep
Goss, Porter J. - Latest Major Action: 10/7/1999 House amendment
not agreed to
3. H.AMDT.515 to
H.R.2723
Amendment sought to allow lawsuits in Federal court, rather than State court,
against the final decision-maker who fails to exercise ordinary care decisions
including employers, cap non-economic damages and prohibit punitive damages.
Sponsor: Rep
Houghton, Amo - Latest Major Action: 10/7/1999 House amendment not
agreed to
4. H.AMDT.516 to
H.R.2723
Pursuant to H. Res. 323, the amendments printed in Part A of H. Rept. 106-366
were considered as adopted. The amendments make technical changes and clarify
provisions to ensure that employers cannot be held liable unless they are
making medical decisions.
Sponsor: House
Rules - Latest Major Action: 10/7/1999 House amendment agreed
to
Committees: House Rules
COSPONSORS(155), ALPHABETICAL [followed by Cosponsors
withdrawn]: (Sort: by date)
Rep
Abercrombie, Neil - 9/28/1999 |
Rep
Allen, Thomas H. - 9/28/1999 |
Rep
Andrews, Robert E. - 8/5/1999 |
Rep
Baird, Brian - 9/28/1999 |
Rep
Baldacci, John Elias - 8/5/1999 |
Rep
Baldwin, Tammy - 9/28/1999 |
Rep
Barr, Bob - 8/5/1999 |
Rep
Barrett, Thomas M. - 8/5/1999 |
Rep
Becerra, Xavier - 9/30/1999 |
Rep
Bentsen, Ken - 9/28/1999 |
Rep
Berkley, Shelley - 8/5/1999 |
Rep
Berry, Marion - 8/5/1999 |
Rep
Bishop, Sanford D. Jr. - 9/28/1999 |
Rep
Blumenauer, Earl - 9/28/1999 |
Rep
Boehlert, Sherwood L. - 8/5/1999 |
Rep
Bonior, David E. - 8/5/1999 |
Rep
Borski, Robert A. - 10/5/1999 |
Rep
Boswell, Leonard L. - 9/28/1999 |
Rep
Boucher, Rick - 8/5/1999 |
Rep
Brady, Robert - 8/5/1999 |
Rep
Brown, Sherrod - 8/5/1999 |
Rep
Capps, Lois - 8/5/1999 |
Rep
Capuano, Michael E. - 9/28/1999 |
Rep
Cardin, Benjamin L. - 8/5/1999 |
Rep
Christensen, Donna MC - 9/28/1999 |
Rep
Clay, William (Bill) - 8/5/1999 |
Rep
Clayton, Eva M. - 8/5/1999 |
Rep
Clement, Bob - 9/28/1999 |
Rep
Clyburn, James E. - 9/28/1999 |
Rep
Cooksey, John - 8/5/1999 |
Rep
Costello, Jerry F. - 9/28/1999 |
Rep
Coyne, William J. - 9/28/1999 |
Rep
Crowley, Joseph - 9/28/1999 |
Rep
Cubin, Barbara - 8/5/1999 |
Rep
Cummings, Elijah E. - 9/30/1999 |
Rep
Davis, Jim - 9/28/1999 |
Rep
DeGette, Diana - 9/28/1999 |
Rep
DeLauro, Rosa L. - 9/28/1999 |
Rep
Dicks, Norman D. - 8/5/1999 |
Rep
Dingell, John D. - 8/5/1999 |
Rep
Dixon, Julian C. - 9/28/1999 |
Rep
Doyle, Michael F. - 8/5/1999 |
Rep
Eshoo, Anna G. - 8/5/1999 |
Rep
Evans, Lane - 9/28/1999 |
Rep
Faleomavaega, Eni F. H. - 9/30/1999 |
Rep
Farr, Sam - 9/28/1999 |
Rep
Filner, Bob - 9/28/1999 |
Rep
Foley, Mark - 8/5/1999 |
Rep
Forbes, Michael P. - 8/5/1999 |
Rep
Ford, Harold, Jr. - 8/5/1999 |
Rep
Franks, Bob - 10/5/1999 |
Rep
Frelinghuysen, Rodney P. - 8/5/1999 |
Rep
Frost, Martin - 8/5/1999 |
Rep
Ganske, Greg - 8/5/1999 |
Rep
Gephardt, Richard A. - 8/5/1999 |
Rep
Gibbons, Jim - 8/5/1999 |
Rep
Gilchrest, Wayne T. - 8/5/1999 |
Rep
Gilman, Benjamin A. - 8/5/1999 |
Rep
Gonzalez, Charles A. - 10/5/1999 |
Rep
Gordon, Bart - 9/28/1999 |
Rep
Graham, Lindsey O. - 8/5/1999 |
Rep
Green, Gene - 9/28/1999 |
Rep
Gutierrez, Luis V. - 10/5/1999 |
Rep
Hall, Ralph M. - 8/5/1999 |
Rep
Hall, Tony P. - 10/5/1999 |
Rep
Hilliard, Earl F. - 9/30/1999 |
Rep
Hinchey, Maurice D. - 9/28/1999 |
Rep
Hoeffel, Joseph M. - 9/28/1999 |
Rep
Holden, Tim - 9/30/1999 |
Rep
Holt, Rush D. - 8/5/1999 |
Rep
Horn, Stephen - 8/5/1999 |
Rep
Houghton, Amo - 8/5/1999 |
Rep
Hoyer, Steny H. - 9/28/1999 |
Rep
Inslee, Jay - 9/28/1999 |
Rep
Jackson-Lee, Sheila - 9/28/1999 |
Rep
Jefferson, William J. - 10/5/1999 |
Rep
John, Christopher - 8/5/1999 |
Rep
Johnson, Eddie Bernice - 9/28/1999 |
Rep
Jones, Stephanie Tubbs - 9/28/1999 |
Rep
Kanjorski, Paul E. - 9/28/1999 |
Rep
Kaptur, Marcy - 9/28/1999 |
Rep
Kennedy, Patrick J. - 9/28/1999 |
Rep
Kildee, Dale E. - 9/28/1999 |
Rep
Kilpatrick, Carolyn C. - 8/5/1999 |
Rep
Kind, Ron - 9/30/1999 |
Rep
Kleczka, Gerald D. - 9/28/1999 |
Rep
Klink, Ron - 8/5/1999 |
Rep
Kucinich, Dennis J. - 9/28/1999 |
Rep
LaFalce, John J. - 9/28/1999 |
Rep
Lampson, Nick - 10/5/1999 |
Rep
LaTourette, Steve C. - 8/5/1999 |
Rep
Leach, James A. - 8/5/1999 |
Rep
Lee, Barbara - 9/28/1999 |
Rep
Levin, Sander M. - 9/28/1999 |
Rep
LoBiondo, Frank A. - 8/5/1999 |
Rep
Lowey, Nita M. - 9/28/1999 |
Rep
Maloney, Carolyn B. - 9/28/1999 |
Rep
Maloney, James H. - 9/28/1999 |
Rep
Mascara, Frank - 9/28/1999 |
Rep
Matsui, Robert T. - 9/28/1999 |
Rep
McCarthy, Carolyn - 8/5/1999 |
Rep
McCarthy, Karen - 9/28/1999 |
Rep
McDermott, Jim - 8/5/1999 |
Rep
McGovern, James P. - 9/28/1999 |
Rep
McNulty, Michael R. - 9/30/1999 |
Rep
Meeks, Gregory W. - 9/28/1999 |
Rep
Menendez, Robert - 9/28/1999 |
Rep
Moore, Dennis - 9/28/1999 |
Rep
Morella, Constance A. - 8/5/1999 |
Rep
Murtha, John P. - 8/5/1999 |
Rep
Owens, Major R. - 9/28/1999 |
Rep
Pallone, Frank, Jr. - 8/5/1999 |
Rep
Pascrell, Bill, Jr. - 8/5/1999 |
Rep
Pastor, Ed - 9/28/1999 |
Rep
Pelosi, Nancy - 9/28/1999 |
Rep
Phelps, David D. - 8/5/1999 |
Rep
Price, David E. - 9/30/1999 |
Rep
Rahall, Nick J., II - 9/28/1999 |
Rep
Rangel, Charles B. - 8/5/1999 |
Rep
Rivers, Lynn N. - 9/28/1999 |
Rep
Rodriguez, Ciro - 9/30/1999 |
Rep
Romero-Barcelo, Carlos A. - 9/28/1999 |
Rep
Rothman, Steve R. - 9/28/1999 |
Rep
Roukema, Marge - 8/5/1999 |
Rep
Rush, Bobby L. - 8/5/1999 |
Rep
Sabo, Martin Olav - 9/28/1999 |
Rep
Sandlin, Max - 8/5/1999 |
Rep
Sawyer, Tom - 9/30/1999 |
Rep
Saxton, Jim - 9/30/1999 |
Rep
Schakowsky, Janice D. - 8/5/1999 |
Rep
Scott, Robert C. - 10/5/1999 |
Rep
Shaw, E. Clay, Jr. - 8/5/1999 |
Rep
Shays, Christopher - 8/5/1999 |
Rep
Sherman, Brad - 9/28/1999 |
Rep
Smith, Christopher H. - 9/30/1999 |
Rep
Snyder, Vic - 8/5/1999 |
Rep
Spratt, John M., Jr. - 9/28/1999 |
Rep
Stabenow, Debbie - 8/5/1999 |
Rep
Stark, Fortney Pete - 8/5/1999 |
Rep
Strickland, Ted - 9/28/1999 |
Rep
Stupak, Bart - 9/28/1999 |
Rep
Tanner, John S. - 8/5/1999 |
Rep
Thompson, Mike - 9/30/1999 |
Rep
Thurman, Karen L. - 8/5/1999 |
Rep
Tierney, John F. - 9/28/1999 |
Rep
Turner, Jim - 8/5/1999 |
Rep
Vento, Bruce F. - 9/30/1999 |
Rep
Visclosky, Peter J. - 9/28/1999 |
Rep
Waxman, Henry A. - 8/5/1999 |
Rep
Weiner, Anthony D. - 9/28/1999 |
Rep
Wexler, Robert - 9/28/1999 |
Rep
Weygand, Robert A. - 8/5/1999 |
Rep
Wise, Robert E., Jr. - 9/28/1999 |
Rep
Woolsey, Lynn C. - 9/28/1999 |
Rep
Wynn, Albert Russell - 8/5/1999 |
SUMMARY AS OF:
10/7/1999--Passed House,
amended. (There is 1 other
summary)
TABLE OF CONTENTS:
- Title I: Improving Managed Care
- Subtitle A: Grievances and Appeals
- Subtitle B: Access to Care
- Subtitle C: Access to Information
- Subtitle D: Protecting the Doctor-Patient Relationship
- Subtitle E: Definitions
- Title II: Application of Quality Care Standards to Group Health Plans and
Health
- Insurance Coverage Under the Public Health Service Act
- Title III: Amendments to the Employee Retirement Income Security Act of
1974
- Title IV: Application to Group Health Plans Under the Internal Revenue
Code of 1986
- Title V: Effective Dates; Coordination in Implementation
- Title VI: Health Care Paperwork Simplification
Bipartisan Consensus Managed Care Improvement Act of 1999 - Title I:
Improving Managed Care - Subtitle A: Grievances and Appeals -
Requires a group health plan, and a health insurance issuer that provides health
insurance coverage, to conduct utilization review activities that monitor or
evaluate the use or coverage, clinical necessity, appropriateness, efficacy, or
efficiency of health care services, procedures, or settings.
(Sec. 102) Requires a plan and an issuer to provide appropriate notices to
the participant, beneficiary, or enrollee for benefit claims it has denied that
include reasons for denial and instructions for initiating specified internal
appeals procedures, which must include procedures for an expedited review
process in emergency situations.
(Sec. 103) Outlines external appeals procedures for the timely resolution of
certain denied claims through the use of qualified external appeal entities,
which shall determine whether the plan's or issuer's decision is in accordance
with the patient's medical needs. Declares that an external appeal entity's
determination is binding on the plan and issuer involved.
Provides for court-imposed civil monetary penalties and cease and desist
orders against authorized officials of plan or issuers who refuse to timely
follow the determination of an external appeal entity to provide a benefit.
(Sec. 104) Requires a plan and an issuer to establish a system featuring
specified components for the presentation and resolution of grievances brought
by participants, beneficiaries, or enrollees, or health care providers or other
individuals acting on behalf of an individual either with the individual's
consent or without it if the individual is medically unable to provide it.
Declares that grievances are not subject to appeal under this subtitle.
Subtitle B: Access to Care - Provides that if an issuer offers
coverage of services only if they are furnished through members of a network of
health care professionals and providers contracting with the issuer, the issuer
shall also offer the option of coverage of such services which are not furnished
through members of such a network, unless enrollees are offered such non-network
coverage through another plan or issuer in the group market. Makes the enrollee
bear the cost of any additional premium the issuer charges for such option, and
the amount of any additional cost sharing, unless it is paid by the health plan
sponsor through agreement with the issuer.
(Sec. 112) States that if a plan or an issuer requires or provides for
designation of a participating primary care provider by a participant, a
beneficiary, or an enrollee, then the plan or issuer shall permit each such
person to designate any participating primary care provider available to accept
such individual.
Requires a plan and an issuer to permit each participant, beneficiary, or
enrollee to receive medically necessary or appropriate speciality care, pursuant
to appropriate referral procedures, from any qualified participating health care
professional available to accept such individual. Waives such requirement in the
case of specialty care if the plan or issuer clearly informs each participant,
beneficiary, and enrollee of the limitations on choice of participating
professionals with respect to such care.
(Sec. 113) Requires a plan or an issuer providing any emergency hospital
benefits to cover emergency services: (1) without the need for any prior
authorization determination; (2) whether or not the health care provider
furnishing such services is a participating health care provider; and (3)
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 the Public Health Service Act, the Employee Retirement Income
Security Act of 1974 (ERISA), or the Internal Revenue Code, and other than
applicable cost-sharing).
Requires such coverage in a manner so that, if the emergency services are
provided by a nonparticipating health care provider with or without prior
authorization or by a participating provider without such authorization, the
participant, beneficiary, or enrollee is not liable for amounts exceeding the
liability that would be incurred if the services were provided by a
participating provider with prior authorization.
Prescribes the same coverage for maintenance care or post-stabilization care
(subject to certain guidelines) by nonparticipating health care providers.
(Sec. 114) Requires plans and issuers to refer participants, beneficiaries,
or enrollees who have a serious disease or condition requiring treatment by a
specialist to an appropriate specialist who is available and accessible
(regardless of whether the specialist is participating or nonparticipating),
provided the benefits for such treatment are covered by the plan or issuer. Sets
forth rules governing referrals and specialists.
(Sec. 115) Prohibits a plan or an issuer that requires or provides for
designation of a participating primary care professional from requiring
authorization or a referral by such primary care professional for gynecological
care and pregnancy-related services provided by a participating health care
professional (including a specialist). Requires the plan or issuer to treat the
ordering of other obstetrical or gynecological care by such a participating
professional as the authorization of the primary care professional.
(Sec. 116) Requires certain plans and issuers to permit an enrollee to
designate a pediatrician as a primary care provider for the enrollee's child.
(Sec. 117) Prescribes requirements for continuity of care during a transition
period for participants, beneficiaries, or enrollees undergoing treatment for an
ongoing special condition in the event of a termination of: (1) a contract
between the plan or an issuer and a health care provider; or (2) a contract
between a plan and an issuer that results in the termination of coverage of
services of a health care provider. Prescribes a 90-day basic transition period,
with specified extensions in the case of scheduled surgery and organ
transplantation, pregnancy, or terminal illness.
(Sec. 118) Provides that a plan or issuer restricting prescription drug
benefits to drugs included in a formulary to: (1) ensure participation of
participating physicians in development of the formulary; (2) disclose to
providers, and upon request to participants, beneficiaries, and enrollees, the
nature of the formulary restrictions; and (3) consistent with the standards for
a utilization review program, provide for exceptions from the formulary
limitation when a non-formulary alternative is medically indicated.
(Sec. 119) Prohibits a plan or issuer from: (1) denying individual
participation in an approved clinical trial; (2) denying or limiting or imposing
additional conditions on the coverage of routine patient costs for items and
services furnished in connection with participation in the trial; and (3)
discriminating against the individual on the basis of the enrollee's
participation in such trial.
Subtitle C: Access to Information - Specifies benefits, access,
emergency coverage, prior authorization, grievance and appeals, and other
pertinent information which plans and issuers shall provide to participants and
beneficiaries at the time of initial coverage, annually, within a reasonable
period before or after the date of significant changes, and upon request.
Subtitle D: Protecting the Doctor-Patient Relationship - Prohibits any
contract or agreement between a plan or issuer and a health care provider from
prohibiting or otherwise restricting a health care professional from advising a
participant, beneficiary, or enrollee who is the professional's patient about
his or her health status or medical care or treatment for his or her condition
or disease, regardless of whether benefits for such care or treatment are
provided under the plan or coverage, if the professional is acting within the
lawful scope of practice. Declares null and void any such contract or agreement
provisions.
(Sec. 132) Prohibits a plan or issuer from discriminating with respect to
participation or indemnification as to any provider acting within the scope of
the provider's license or certification, solely on the basis of such license or
certification.
(Sec. 133) Prohibits any plan or issuer from operating any physician
incentive plan that does not meet certain requirements under title XVIII
(Medicare) of the Social Security Act.
(Sec. 134) Requires a plan or issuer to provide for prompt payment of claims
in a manner consistent with Medicare clean claims requirements.
(Sec. 135) Sets forth prohibitions and requirements for protection of: (1)
participants, beneficiaries, enrollees, and health care providers in their use
of a utilization review or grievance process; and (2) health care professionals
for good faith disclosure of information to an appropriate agency or body in the
interest of quality advocacy.
Subtitle E: Definitions - Sets forth definitions.
Title II: Application of Quality Care Standards to Group Health Plans and
Health Insurance Coverage Under The Public Health Service Act - Amends the
Public Health Service Act to require each plan and issuer to comply with the
patient protection requirements of this Act.
(Sec. 202) Requires each health insurance issuer to comply with such
requirements with respect to individual health insurance coverage.
Title III: Amendments to the Employee Retirement Income Security Act of
1974 - Amends ERISA to: (1) require each plan and issuer to comply with the
patient protection requirements of this Act; and (2) deem a plan in compliance
with subtitle A of title I of this Act to be in compliance with ERISA's claim
procedure requirement with respect to claims denial.
(Sec. 302) Declares that nothing in ERISA shall be construed to invalidate,
impair, or supersede any cause of action under State law by a participant or
beneficiary (or by his or her estate) to recover damages resulting from personal
injury or wrongful death against any person (except employers and other plan
sponsors) in connection with the provision of insurance, administrative
services, or medical services by that person to or for a group health plan, or
that arises out of the arrangement by that person for the provision of
insurance, administrative services, or medical services by other persons.
Declares that no person shall be liable for punitive damages (unless with
respect to wrongful death State law provides for damages which are only punitive
or exemplary in nature) in any cause of action relating to an externally
appealable decision when: (1) the appeal has been completed; and (2) the plan or
issuer has complied with the determination of the external appeal entity.
Allows an action against an employer or other plan sponsor (or an employee of
one or the other acting within the scope of employment) if it is based on the
employer's or sponsor's exercise of discretionary authority to decide a claim
for covered benefits, and such exercise has resulted in personal injury or
wrongful death.
(Sec. 303) Places limitations on actions seeking relief (other than any
brought by the Secretary) based on certain provisions of title I of this Act.
Allows a participant or beneficiary to seek relief with respect to utilization
review activities, access to emergency care, access to specialty care, access to
obstetrical and gynecological care, access to pediatric care, continuity of
care, access to non-formulary alternative prescription drugs, or coverage of
participation in clinical trials, subject to certain conditions. Prohibits a
class action for such relief. Limits relief in any individual action to the
provision or payment of benefits, items, or services denied to the individual
participant or beneficiary involved (and, at the court's discretion, attorney's
fees and court costs). Prohibits any other relief to the participant or
beneficiary, and any relief to any other person.
Title IV: Application to Group Health Plans Under the Internal Revenue
Code of 1986 - Amends the Internal Revenue Code to require a group health
plan to comply with this Act. Deems the requirements of this Act to be
incorporated into the Internal Revenue Code.
Title V: Effective Dates; Coordination in Implementation - Sets forth
effective dates for provisions of this Act.
(Sec. 502) Requires the Secretaries of Labor, of Health and Human Services,
and of the Treasury to ensure coordination in the implementation of this Act.
Title VI: Health Care Paperwork Simplification - Establishes the
Health Care Panel to Devise a Uniform Explanation of Benefits to devise a single
form for use by third-party health care payers for the remittance of claims to
providers.