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H.R.4577
Departments of Labor, Health and Human Services, and Education, and
Related Agencies Appropriations Act, 2001 (Public Print)
TITLE XXII--PATIENTS'
BILL OF RIGHTS
Subtitle A--Right to Advice and Care
SEC. 2201. PATIENT RIGHT TO MEDICAL ADVICE AND CARE.
(a) IN GENERAL- Part 7 of subtitle B of title I of the Employee
Retirement Income Security Act of 1974 (29 U.S.C. 1181 et seq.) is
amended--
(1) by redesignating subpart C as subpart D; and
(2) by inserting after subpart B the following:
`Subpart C--Patient Right to Medical Advice and Care
`SEC. 721. ACCESS TO EMERGENCY MEDICAL CARE.
`(a) COVERAGE OF EMERGENCY SERVICES- If a group health plan (other
than a fully insured group health plan) provides coverage for any benefits
consisting of emergency medical care, except for items or services
specifically excluded from coverage, the plan shall, without regard to prior
authorization or provider participation--
`(1) provide coverage for emergency medical screening examinations
to the extent that a prudent layperson, who possesses an average knowledge
of health and medicine, would determine such examinations to be necessary;
and
`(2) provide coverage for additional emergency medical care to
stabilize an emergency medical condition following an emergency medical
screening examination (if determined necessary), pursuant to the definition
of stabilize under section 1867(e)(3) of the Social Security Act (42 U.S.C.
1395dd(e)(3)).
`(b) COVERAGE OF EMERGENCY AMBULANCE SERVICES- If a group health plan
(other than a fully insured group health plan) provides coverage for any
benefits consisting of emergency ambulance services, except for items or
services specifically excluded from coverage, the plan shall, without regard
to prior authorization or provider participation, provide coverage for
emergency ambulance services to the extent that a prudent layperson, who
possesses an average knowledge of health and medicine, would determine such
emergency ambulance services to be necessary.
`(c) CARE AFTER STABILIZATION-
`(1) IN GENERAL- In the case of medically necessary and appropriate
items or services related to the emergency medical condition that may be
provided to a participant or beneficiary by a nonparticipating provider
after the participant or beneficiary is stabilized, the nonparticipating
provider shall contact the plan as soon as practicable, but not later than 2
hours after stabilization occurs, with respect to whether--
`(A) the provision of items or services is approved;
`(B) the participant or beneficiary will be transferred;
or
`(C) other arrangements will be made concerning the care and
treatment of the participant or beneficiary.
`(2) FAILURE TO RESPOND AND MAKE ARRANGEMENTS- If a group health
plan fails to respond and make arrangements within 2 hours of being
contacted in accordance with paragraph (1), then the plan shall be
responsible for the cost of any additional items or services provided by the
nonparticipating provider if--
`(A) coverage for items or services of the type furnished by the
nonparticipating provider is available under the plan;
`(B) the items or services are medically necessary and appropriate
and related to the emergency medical condition involved; and
`(C) the timely provision of the items or services is medically
necessary and appropriate.
`(3) RULE OF CONSTRUCTION- Nothing in this subsection shall be
construed to apply to a group health plan that does not require prior
authorization for items or services provided to a participant or beneficiary
after the participant or beneficiary is stabilized.
`(d) REIMBURSEMENT TO A NON-PARTICIPATING PROVIDER- The responsibility
of a group health plan to provide reimbursement to a nonparticipating provider
under this section shall cease accruing upon the earlier of--
`(1) the transfer or discharge of the participant or beneficiary;
or
`(2) the completion of other arrangements made by the plan and the
nonparticipating provider.
`(e) RESPONSIBILITY OF PARTICIPANT- With respect to items or services
provided by a nonparticipating provider under this section, the participant or
beneficiary shall not be responsible for amounts that exceed the amounts
(including co-insurance, co-payments, deductibles or any other form of
cost-sharing) that would be incurred if the care was provided by a
participating health care provider with prior authorization.
`(f) RULE OF CONSTRUCTION- Nothing in this section shall be construed
to prohibit a group health plan from negotiating reimbursement rates with a
nonparticipating provider for items or services provided under this
section.
`(g) DEFINITIONS- In this section:
`(1) EMERGENCY AMBULANCE SERVICES- The term `emergency ambulance
services' means, with respect to a participant or beneficiary under a group
health plan (other than a fully insured group health plan), ambulance
services furnished to transport an individual who has an emergency medical
condition to a treating facility for receipt of emergency medical care
if--
`(A) the emergency services are covered under the group health
plan (other than a fully insured group health plan) involved;
and
`(B) a prudent layperson who possesses an average knowledge of
health and medicine could reasonably expect the absence of such transport
to result in placing the health of the participant or beneficiary (or,
with respect to a pregnant woman, the health of the woman or her unborn
child) in serious jeopardy, serious impairment to bodily functions, or
serious dysfunction of any bodily organ or part.
`(2) EMERGENCY MEDICAL CARE- The term `emergency medical care'
means, with respect to a participant or beneficiary under a group health
plan (other than a fully insured group health plan), covered inpatient and
outpatient items or services that--
`(A) are furnished by any provider, including a nonparticipating
provider, that is qualified to furnish such items or services;
and
`(B) are needed to evaluate or stabilize (as such term is defined
in section 1867(e)(3) of the Social Security Act (42 U.S.C. 1395dd(e)(3))
an emergency medical condition.
`(3) EMERGENCY MEDICAL CONDITION- 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 placing the
health of the participant or beneficiary (or, with respect to a pregnant
woman, the health of the woman or her unborn child) in serious jeopardy,
serious impairment to bodily functions, or serious dysfunction of any bodily
organ or part.
`SEC. 722. OFFERING OF CHOICE OF COVERAGE OPTIONS.
`(a) REQUIREMENT- If a group health plan (other than a fully insured
group health plan) provides coverage for benefits only through a defined set
of participating health care professionals, the plan 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 and at such other times as the plan offers the
participant a choice of coverage options.
`(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 (other than a fully insured group health plan), coverage of
such benefits when provided by a nonparticipating health care
professional.
`(c) SMALL EMPLOYER EXEMPTION-
`(1) IN GENERAL- This section shall not apply to any group health
plan (other than a fully insured group health plan) of a small
employer.
`(2) SMALL EMPLOYER- For purposes of paragraph (1), the term `small
employer' means, in connection with a group health plan (other than a fully
insured group health plan) with respect to a calendar year and a plan year,
an employer who employed an average of at least 2 but not more than 50
employees on business days during the preceding calendar year and who
employs at least 2 employees on the first day of the plan year. For purposes
of this paragraph, the provisions of subparagraph (C) of section 712(c)(1)
shall apply in determining employer size.
`(d) RULE OF CONSTRUCTION- Nothing in this section shall be
construed--
`(1) as requiring coverage for benefits for a particular type of
health care professional;
`(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;
`(3) as preventing a group health plan (other than a fully insured
group health plan) from imposing higher premiums or cost-sharing on a
participant for the exercise of a point-of-service coverage option;
or
`(4) to require that a group health plan (other than a fully insured
group health plan) include coverage of health care professionals that the
plan excludes because of fraud, quality of care, or other similar reasons
with respect to such professionals.
`SEC. 723. PATIENT ACCESS TO OBSTETRIC AND GYNECOLOGICAL CARE.
`(1) DIRECT ACCESS- A group health plan described in subsection (b)
may not require authorization or referral by the primary care provider
described in subsection (b)(2) in the case of a female participant or
beneficiary who seeks coverage for obstetrical or gynecological care
provided by a participating physician who specializes in obstetrics or
gynecology.
`(2) OBSTETRICAL AND GYNECOLOGICAL CARE- A group health plan
described in subsection (b) shall treat the provision of obstetrical and
gynecological care, and the ordering of related obstetrical and
gynecological items and services, pursuant to the direct access described
under paragraph (1), by a participating health care professional who
specializes in obstetrics or gynecology as the authorization of the primary
care provider.
`(b) APPLICATION OF SECTION- A group health plan described in this
subsection is a group health plan (other than a fully insured group health
plan), that--
`(1) provides coverage for obstetric or gynecologic care;
and
`(2) requires the designation by a participant or beneficiary of a
participating primary care provider other than a physician who specializes
in obstetrics or gynecology.
`(c) RULES OF CONSTRUCTION- Nothing in this section shall be
construed--
`(1) to require that a group health plan approve or provide coverage
for--
`(A) any items or services that are not covered under the terms
and conditions of the group health plan;
`(B) any items or services that are not medically necessary and
appropriate; or
`(C) any items or services that are provided, ordered, or
otherwise authorized under subsection (a)(2) by a physician unless such
items or services are related to obstetric or gynecologic
care;
`(2) to preclude a group health plan from requiring that the
physician described in subsection (a) notify the designated primary care
professional or case manager of treatment decisions in accordance with a
process implemented by the plan, except that the group health plan shall not
impose such a notification requirement on the participant or beneficiary
involved in the treatment decision;
`(3) to preclude a group health plan from requiring authorization,
including prior authorization, for certain items and services from the
physician described in subsection (a) who specializes in obstetrics and
gynecology if the designated primary care provider of the participant or
beneficiary would otherwise be required to obtain authorization for such
items or services;
`(4) to require that the participant or beneficiary described in
subsection (a)(1) obtain authorization or a referral from a primary care
provider in order to obtain obstetrical or gynecological care from a health
care professional other than a physician if the provision of obstetrical or
gynecological care by such professional is permitted by the group health
plan and consistent with State licensure, credentialing, and scope of
practice laws and regulations; or
`(5) to preclude the participant or beneficiary described in
subsection (a)(1) from designating a health care professional other than a
physician as a primary care provider if such designation is permitted by the
group health plan and the treatment by such professional is consistent with
State licensure, credentialing, and scope of practice laws and
regulations.
`SEC. 724. ACCESS TO PEDIATRIC CARE.
`(a) PEDIATRIC CARE- If a group health plan (other than a fully
insured group health plan) requires or provides for a participant or
beneficiary to designate a participating primary care provider for a child of
such participant or beneficiary, the plan shall permit the participant or
beneficiary to designate a physician who specializes in pediatrics as the
child's primary care provider if such provider participates in the network of
the plan.
`(b) RULES OF CONSTRUCTION- With respect to the child of a participant
or beneficiary, nothing in subsection (a) shall be construed to--
`(1) require that the participant or beneficiary obtain prior
authorization or a referral from a primary care provider in order to obtain
pediatric care from a health care professional other than a physician if the
provision of pediatric care by such professional is permitted by the plan
and consistent with State licensure, credentialing, and scope of practice
laws and regulations; or
`(2) preclude the participant or beneficiary from designating a
health care professional other than a physician as a primary care provider
for the child if such designation is permitted by the plan and the treatment
by such professional is consistent with State licensure, credentialing, and
scope of practice laws.
`SEC. 725. TIMELY ACCESS TO SPECIALISTS.
`(1) IN GENERAL- A group health plan (other than a fully insured
group health plan) shall ensure that participants and beneficiaries receive
timely coverage for access to specialists who are appropriate to the medical
condition of the participant or beneficiary, when such specialty care is a
covered benefit under the plan.
`(2) RULE OF CONSTRUCTION- Nothing in paragraph (1) shall be
construed--
`(A) to require the coverage under a group health plan (other than
a fully insured group health plan) of benefits or services;
`(B) to prohibit a plan from including providers in the network
only to the extent necessary to meet the needs of the plan's participants
and beneficiaries;
`(C) to prohibit a plan from establishing measures designed to
maintain quality and control costs consistent with the responsibilities of
the plan; or
`(D) to override any State licensure or scope-of-practice
law.
`(3) ACCESS TO CERTAIN PROVIDERS-
`(A) PARTICIPATING PROVIDERS- Nothing in this section shall be
construed to prohibit a group health plan (other than a fully insured
group health plan) from requiring that a participant or beneficiary obtain
specialty care from a participating specialist.
`(B) NONPARTICIPATING PROVIDERS-
`(i) IN GENERAL- With respect to specialty care under this
section, if a group health plan (other than a fully insured group health
plan) determines that a participating specialist is not available to
provide such care to the participant or beneficiary, the plan shall
provide for coverage of such care by a nonparticipating
specialist.
`(ii) TREATMENT OF NONPARTICIPATING PROVIDERS- If a group health
plan (other than a fully insured group health plan) refers a participant
or beneficiary to a nonparticipating specialist pursuant to clause (i),
such specialty care shall be provided at no additional cost to the
participant or beneficiary beyond what the participant or beneficiary
would otherwise pay for such specialty care if provided by a
participating specialist.
`(1) AUTHORIZATION- Nothing in this section shall be construed to
prohibit a group health plan (other than a fully insured group health plan)
from requiring an authorization in order to obtain coverage for specialty
services so long as such authorization is for an appropriate duration or
number of referrals.
`(2) REFERRALS FOR ONGOING SPECIAL CONDITIONS-
`(A) IN GENERAL- A group health plan (other than a fully insured
group health plan) shall permit a participant or beneficiary who has an
ongoing special condition (as defined in subparagraph (B)) to receive a
referral to a specialist for the treatment of such condition and such
specialist may authorize such referrals, procedures, tests, and other
medical services with respect to such condition, or coordinate the care
for such condition, subject to the terms of a treatment plan referred to
in subsection (c) with respect to the condition.
`(B) ONGOING SPECIAL CONDITION DEFINED- In this subsection, the
term `ongoing special condition' means a condition or disease
that--
`(i) is life-threatening, degenerative, or disabling;
and
`(ii) requires specialized medical care over a prolonged period
of time.
`(1) IN GENERAL- Nothing in this section shall be construed to
prohibit a group health plan (other than a fully insured group health plan)
from requiring that specialty care be provided pursuant to a treatment plan
so long as the treatment plan is--
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