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H.R.4577
Departments of Labor, Health and Human Services, and Education, and
Related Agencies Appropriations Act, 2001 (Public Print)
`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--
`(A) developed by the specialist, in consultation with the case
manager or primary care provider, and the participant or
beneficiary;
`(B) approved by the plan in a timely manner if the plan requires
such approval; and
`(C) in accordance with the applicable quality assurance and
utilization review standards of the plan.
`(2) NOTIFICATION- Nothing in paragraph (1) shall be construed as
prohibiting a plan from requiring the specialist to provide the plan with
regular updates on the specialty care provided, as well as all other
necessary medical information.
`(d) SPECIALIST DEFINED- For purposes of this section, the term
`specialist' means, with respect to the medical condition of the participant
or beneficiary, a health care professional, facility, or center (such as a
center of excellence) that has adequate expertise (including age-appropriate
expertise) through appropriate training and experience.
`(e) RIGHT TO EXTERNAL REVIEW- Pursuant to the requirements of section
503B, a participant or beneficiary shall have the right to an independent
external review if the denial of an item or service or condition that is
required to be covered under this section is eligible for such review.
`SEC. 726. CONTINUITY OF CARE.
`(a) TERMINATION OF PROVIDER- If a contract between a group health
plan (other than a fully insured group health plan) and a treating health care
provider is terminated (as defined in paragraph (e)(4)), or benefits or
coverage provided by a health care provider are terminated because of a change
in the terms of provider participation in such plan, and an individual who is
a participant or beneficiary in the plan is undergoing an active course of
treatment for a serious and complex condition, institutional care, pregnancy,
or terminal illness from the provider at the time the plan receives or
provides notice of such termination, the plan shall--
`(1) notify the individual, or arrange to have the individual
notified pursuant to subsection (d)(2), on a timely basis of such
termination;
`(2) provide the individual with an opportunity to notify the plan
of the individual's need for transitional care; and
`(3) subject to subsection (c), permit the individual to elect to
continue to be covered with respect to the active course of treatment with
the provider's consent during a transitional period (as provided for under
subsection (b)).
`(b) TRANSITIONAL PERIOD-
`(1) SERIOUS AND COMPLEX CONDITIONS- The transitional period under
this section with respect to a serious and complex condition shall extend
for up to 90 days from the date of the notice described in subsection (a)(1)
of the provider's termination.
`(2) INSTITUTIONAL OR INPATIENT CARE-
`(A) IN GENERAL- The transitional period under this section for
institutional or non-elective inpatient care from a provider shall extend
until the earlier of--
`(i) the expiration of the 90-day period beginning on the date
on which the notice described in subsection (a)(1) of the provider's
termination is provided; or
`(ii) the date of discharge of the individual from such care or
the termination of the period of institutionalization.
`(B) SCHEDULED CARE- The 90 day limitation described in
subparagraph (A)(i) shall include post-surgical follow-up care relating to
non-elective surgery that has been scheduled before the date of the notice
of the termination of the provider under subsection (a)(1).
`(A) a participant or beneficiary has entered the second trimester
of pregnancy at the time of a provider's termination of participation;
and
`(B) the provider was treating the pregnancy before the 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.
`(4) TERMINAL ILLNESS- If--
`(A) a participant or beneficiary 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
`(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 that is directly related to the
treatment of the terminal illness.
`(c) PERMISSIBLE TERMS AND CONDITIONS- A group health plan (other than
a fully insured group health plan) may condition coverage of continued
treatment by a provider under this section upon the provider agreeing to the
following terms and conditions:
`(1) The treating health care provider agrees to accept
reimbursement from the plan 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 at the rates applicable under the replacement
plan after the date of the termination of the contract with the group health
plan) 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 this section had not been terminated.
`(2) The treating health care provider agrees to adhere to the
quality assurance standards of the plan responsible for payment under
paragraph (1) and to provide to such plan necessary medical information
related to the care provided.
`(3) The treating health care provider agrees otherwise to adhere to
such plan'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.
`(d) RULES OF CONSTRUCTION- Nothing in this section shall be
construed--
`(1) to require the coverage of benefits which would not have been
covered if the provider involved remained a participating provider;
or
`(2) with respect to the termination of a contract under subsection
(a) to prevent a group health plan from requiring that the health care
provider--
`(A) notify participants or beneficiaries of their rights under this section;
or
`(B) provide the plan with the name of each participant or
beneficiary who the provider believes is eligible for transitional care
under this section.
`(e) DEFINITIONS- In this section:
`(1) CONTRACT- The term `contract between a plan and a treating
health care provider' shall include a contract between such a plan and an
organized network of providers.
`(2) HEALTH CARE PROVIDER- The term `health care provider' or
`provider' means--
`(A) any individual who is engaged in the delivery of health care
services in a State and who is required by State law or regulation to be
licensed or certified by the State to engage in the delivery of such
services in the State; and
`(B) any entity that is engaged in the delivery of health care
services in a State and that, if it is required by State law or regulation
to be licensed or certified by the State to engage in the delivery of such
services in the State, is so licensed.
`(3) SERIOUS AND COMPLEX CONDITION- The term `serious and complex
condition' means, with respect to a participant or beneficiary under the
plan, a condition that is medically determinable and--
`(A) in the case of an acute illness, is a condition serious
enough to require specialized medical treatment to avoid the reasonable
possibility of death or permanent harm; or
`(B) in the case of a chronic illness or condition, is an illness
or condition that--
`(i) is complex and difficult to manage;
`(ii) is disabling or life-threatening; and
`(I) frequent monitoring over a prolonged period of time and
requires substantial on-going specialized medical care;
or
`(II) frequent ongoing specialized medical care across a
variety of domains of care.
`(4) TERMINATED- The term `terminated' includes, with respect to a
contract (as defined in paragraph (1)), the expiration or nonrenewal of the
contract by the group health plan, but does not include a termination of the
contract by the plan for failure to meet applicable quality standards or for
fraud.
`(f) RIGHT TO EXTERNAL REVIEW- Pursuant to the requirements of section
503B, a participant or beneficiary shall have the right to an independent
external review if the denial of an item or service or condition that is
required to be covered under this section is eligible for such review.
`SEC. 727. PROTECTION OF PATIENT-PROVIDER COMMUNICATIONS.
`(a) IN GENERAL- Subject to subsection (b), a group health plan (other
than a fully insured group health plan and in relation to a participant or
beneficiary) shall not prohibit or otherwise restrict a health care
professional from advising such a participant or beneficiary who is a patient
of the professional about the health status of the participant or beneficiary
or medical care or treatment for the condition or disease of the participant
or beneficiary, regardless of whether coverage for such care or treatment are
provided under the contract, if the professional is acting within the lawful
scope of practice.
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