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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. 2202. CONFORMING AMENDMENT TO THE INTERNAL REVENUE CODE OF
1986.
Subchapter B of chapter 100 of the Internal Revenue Code of 1986 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's bill of rights .';
(2) by inserting after section 9812 the following:
`SEC. 9813. STANDARD RELATING TO PATIENTS' BILL OF RIGHTS .
`A group health plan (other than a fully insured group health plan)
shall comply with the requirements of subpart C of part 7 of subtitle B of
title I of the Employee Retirement Income Security Act of 1974, as added by
section 2201 of the Patients'
Bill of Rights Plus Act, and such requirements
shall be deemed to be incorporated into this section.'.
SEC. 2203. EFFECTIVE DATE AND RELATED RULES.
(a) IN GENERAL- The amendments made by this subtitle shall apply with
respect to plan years beginning on or after January 1 of the second calendar
year following the date of the enactment of this Act. The Secretary shall
issue all regulations necessary to carry out the amendments made by this
section before the effective date thereof.
(b) LIMITATION ON ENFORCEMENT ACTIONS- No enforcement action shall be
taken, pursuant to the amendments made by this subtitle, against a group
health plan with respect to a violation of a requirement imposed by such
amendments before the date of issuance of regulations issued in connection
with such requirement, if the plan has sought to comply in good faith with
such requirement.
Subtitle B--Right to Information About Plans and
Providers
SEC. 2211. INFORMATION ABOUT PLANS.
(a) EMPLOYEE RETIREMENT INCOME SECURITY ACT OF 1974- Subpart B of part
7 of subtitle B of title I of the Employee Retirement Income Security Act of
1974 (29 U.S.C. 1185 et seq.) is amended by adding at the end the
following:
`SEC. 714. HEALTH PLAN INFORMATION.
`(A) IN GENERAL- A group health plan, and a health insurance
issuer that provides coverage in connection with group health insurance
coverage, shall provide for the disclosure of the information described in
subsection (b) to participants and beneficiaries--
`(i) at the time of the initial enrollment of the participant or
beneficiary under the plan or coverage;
`(ii) on an annual basis after enrollment--
`(I) in conjunction with the election period of the plan or
coverage if the plan or coverage has such an election period;
or
`(II) in the case of a plan or coverage that does not have an
election period, in conjunction with the beginning of the plan or
coverage year; and
`(iii) in the case of any material reduction to the benefits or
information described in paragraphs (1), (2) and (3) of subsection (b),
in the form of a summary notice provided not later than the date on
which the reduction takes effect.
`(B) PARTICIPANTS AND BENEFICIARIES- The disclosure required under
subparagraph (A) shall be provided--
`(i) jointly to each participant and beneficiary who reside at
the same address; or
`(ii) in the case of a beneficiary who does not reside at the
same address as the participant, separately to the participant and such
beneficiary.
`(2) RULE OF CONSTRUCTION- Nothing in this section shall be
construed to prevent a group health plan sponsor and health insurance issuer
from entering into an agreement under which either the plan sponsor or the
issuer agrees to assume responsibility for compliance with the requirements
of this section, in whole or in part, and the party delegating such
responsibility is released from liability for compliance with the
requirements that are assumed by the other party, to the extent the party
delegating such responsibility did not cause such noncompliance.
`(3) PROVISION OF INFORMATION- Information shall be provided to
participants and beneficiaries under this section at the last known address
maintained by the plan or issuer with respect to such participants or
beneficiaries, to the extent that such information is provided to
participants or beneficiaries via the United States Postal Service or other
private delivery service.
`(b) REQUIRED INFORMATION- The informational materials to be
distributed under this section shall include for each option available under
the group health plan or health insurance coverage the following:
`(1) BENEFITS- A description of the covered benefits,
including--
`(A) any in- and out-of-network benefits;
`(B) specific preventative services covered under the plan or
coverage if such services are covered;
`(C) any benefit limitations, including any annual or lifetime
benefit limits and any monetary limits or limits on the number of visits,
days, or services, and any specific coverage exclusions; and
`(D) any definition of medical necessity used in making coverage
determinations by the plan, issuer, or claims administrator.
`(2) COST SHARING- A description of any cost-sharing requirements,
including--
`(A) any premiums, deductibles, coinsurance, copayment amounts,
and liability for balance billing above any reasonable and customary
charges, for which the participant or beneficiary will be responsible
under each option available under the plan;
`(B) any maximum out-of-pocket expense for which the participant
or beneficiary may be liable;
`(C) any cost-sharing requirements for out-of-network benefits or
services received from nonparticipating providers; and
`(D) any additional cost-sharing or charges for benefits and
services that are furnished without meeting applicable plan or coverage
requirements, such as prior authorization or
precertification.
`(3) SERVICE AREA- A description of the plan or issuer's service
area, including the provision of any out-of-area coverage.
`(4) PARTICIPATING PROVIDERS- A directory of participating providers
(to the extent a plan or issuer provides coverage through a network of
providers) that includes, at a minimum, the name, address, and telephone
number of each participating provider, and information about how to inquire
whether a participating provider is currently accepting new patients .
`(5) CHOICE OF PRIMARY CARE PROVIDER- A description of any
requirements and procedures to be used by participants and beneficiaries in
selecting, accessing, or changing their primary care provider, including
providers both within and outside of the network (if the plan or issuer
permits out-of-network services), and the right to select a pediatrician as
a primary care provider under section 724 for a participant or beneficiary
who is a child if such section applies.
`(6) PREAUTHORIZATION REQUIREMENTS- A description of the
requirements and procedures to be used to obtain preauthorization for health
services, if such preauthorization is required.
`(7) EXPERIMENTAL AND INVESTIGATIONAL TREATMENTS- A description of
the process for determining whether a particular item, service, or treatment
is considered experimental or investigational, and the circumstances under
which such treatments are covered by the plan or issuer.
`(8) SPECIALTY CARE- A description of the requirements and
procedures to be used by participants and beneficiaries in accessing
specialty care and obtaining referrals to participating and nonparticipating
specialists, including the right to timely coverage for access to
specialists care under section 725 if such section applies.
`(9) CLINICAL TRIALS- A description the circumstances and conditions
under which participation in clinical trials is covered under the terms and
conditions of the plan or coverage, and the right to obtain coverage for
approved cancer clinical trials under section 729 if such section
applies.
`(10) PRESCRIPTION DRUGS- To the extent the plan or issuer provides
coverage for prescription drugs, a statement of whether such coverage is
limited to drugs included in a formulary, a description of any provisions
and cost-sharing required for obtaining on- and off-formulary medications,
and a description of the rights of participants and
beneficiaries in obtaining access to access to prescription drugs under
section 727 if such section applies.
`(11) EMERGENCY SERVICES- A summary of the rules and procedures for
accessing emergency services, including the right of a participant or
beneficiary to obtain emergency services under the prudent layperson
standard under section 721, if such section applies, and any educational
information that the plan or issuer may provide regarding the appropriate
use of emergency services.
`(12) CLAIMS AND APPEALS- A description of the plan or issuer's
rules and procedures pertaining to claims and appeals, a description of the
rights of participants and
beneficiaries under sections 503, 503A and 503B in obtaining covered
benefits, filing a claim for benefits, and appealing coverage decisions
internally and externally (including telephone numbers and mailing addresses
of the appropriate authority), and a description of any additional legal
rights and remedies available
under section 502.
`(13) ADVANCE DIRECTIVES AND ORGAN DONATION- A description of
procedures for advance directives and organ donation decisions if the plan
or issuer maintains such procedures.
`(14) INFORMATION ON PLANS AND ISSUERS- The name, mailing address,
and telephone number or numbers of the plan administrator and the issuer to
be used by participants and beneficiaries seeking information about plan or
coverage benefits and services, payment of a claim, or authorization for
services and treatment. The name of the designated decision-maker (or
decision-makers) appointed under section 502(n)(2) for purposes of making
final determinations under section 503A and approving coverage pursuant to
the written determination of an independent medical reviewer under section
503B. Notice of whether the benefits under the plan are provided under a
contract or policy of insurance issued by an issuer, or whether benefits are
provided directly by the plan sponsor who bears the insurance
risk.
`(15) TRANSLATION SERVICES- A summary description of any translation
or interpretation services (including the availability of printed
information in languages other than English, audio tapes, or information in
Braille) that are available for non-English speakers and participants and
beneficiaries with communication disabilities and a description of how to
access these items or services.
`(16) ACCREDITATION INFORMATION- Any information that is made public
by accrediting organizations in the process of accreditation if the plan or
issuer is accredited, or any additional quality indicators (such as the
results of enrollee satisfaction surveys) that the plan or issuer makes
public or makes available to participants and beneficiaries.
`(17) NOTICE OF REQUIREMENTS- A description of any rights of participants and
beneficiaries that are established by the Patients' Bill of Rights Plus Act (excluding those
described in paragraphs (1) through (16)) if such sections apply. The
description required under this paragraph may be combined with the notices
required under sections 711(d), 713(b), or 606(a)(1), and with any other
notice provision that the Secretary determines may be combined.
`(18) AVAILABILITY OF ADDITIONAL INFORMATION- A statement that the
information described in subsection (c), and instructions on obtaining such
information (including telephone numbers and, if available, Internet
websites), shall be made available upon request.
`(c) ADDITIONAL INFORMATION- The informational materials to be
provided upon the request of a participant or beneficiary shall include for
each option available under a group health plan or health insurance coverage
the following:
`(1) STATUS OF PROVIDERS- The State licensure status of the plan or
issuer's participating health care professionals and participating health
care facilities, and, if available, the education, training, specialty
qualifications or certifications of such professionals.
`(2) COMPENSATION METHODS- A summary description of the methods
(such as capitation, fee-for-service, salary, bundled payments, per diem, or
a combination thereof) used for compensating participating health care
professionals (including primary care providers and specialists) and
facilities in connection with the provision of health care under the plan or
coverage. The requirement of this paragraph shall not be construed as
requiring plans or issuers to provide information concerning proprietary
payment methodology.
`(3) PRESCRIPTION DRUGS- Information about whether a specific
prescription medication is included in the formulary of the plan or issuer,
if the plan or issuer uses a defined formulary.
`(4) EXTERNAL APPEALS INFORMATION- Aggregate information on the
number and outcomes of external medical reviews, relative to the sample size
(such as the number of covered lives) determined for the plan or issuer's
book of business.
`(d) MANNER OF DISCLOSURE- The information described in this section
shall be disclosed in an accessible medium and format that is calculated to be
understood by the average participant.
`(e) RULES OF CONSTRUCTION- Nothing in this section shall be construed
to prohibit a group health plan, or a health insurance issuer in connection
with group health insurance coverage, from--
`(1) distributing any other additional information determined by the
plan or issuer to be important or necessary in assisting participants and
beneficiaries in the selection of a health plan; and
`(2) complying with the provisions of this section by providing
information in brochures, through the Internet or other electronic media, or
through other similar means, so long as participants and beneficiaries are
provided with an opportunity to request that informational materials be
provided in printed form.
`(f) CONFORMING REGULATIONS- The Secretary shall issue regulations to
coordinate the requirements on group health plans and health insurance issuers
under this section with the requirements imposed under part 1, to reduce
duplication with respect to any information that is required to be provided
under any such requirements.
`(g) SECRETARIAL ENFORCEMENT AUTHORITY-
`(1) IN GENERAL- The Secretary may assess a civil monetary penalty
against the administrator of a plan or issuer in connection with the failure
of the plan or issuer to comply with the requirements of this
section.
`(A) IN GENERAL- The amount of the penalty to be imposed under
paragraph (1) shall not exceed $100 for each day for each participant and
beneficiary with respect to which the failure to comply with the
requirements of this section occurs.
`(B) INCREASE IN AMOUNT- The amount referred to in subparagraph
(A) shall be increased or decreased, for each calendar year that ends
after December 31, 2000, by the same percentage as the percentage by which
the medical care expenditure category of the Consumer Price Index for All
Urban Consumers (United States city average), published by the Bureau of
Labor Statistics, for September of the preceding calendar year has
increased or decreased from the such Index for September of
2000.
`(3) FAILURE DEFINED- For purposes of this subsection, a plan or
issuer shall have failed to comply with the requirements of this section
with respect to a participant or beneficiary if the plan or issuer failed or
refused to comply with the requirements of this section within 30
days--
`(A) of the date described in subsection
(a)(1)(A)(i);
`(B) of the date described in subsection (a)(1)(A)(ii);
or
`(C) of the date on which additional information was requested
under subsection (c).'.
(b) CONFORMING AMENDMENTS-
(1) Section 732(a) of the Employee Retirement Income Security Act of
1974 (29 U.S.C. 1191a(a)) is amended by striking `section 711' and inserting
`sections 711 and 714'.
(2) The table of contents in section 1 of the Employee Retirement
Income Security Act of 1974 (29 U.S.C. 1001) is amended by inserting after
the item relating to section 713, the following:
`Sec 714. Health plan comparative information.'.
(3) Section 502(b)(3) of the Employee Retirement Income Security Act
of 1974 (29 U.S.C. 1132(b)(3)) is amended by striking `733(a)(1))' and
inserting `733(a)(1)), except with respect to the requirements of section
714'.
SEC. 2212. INFORMATION ABOUT PROVIDERS.
(a) STUDY- The Secretary of Health and Human Services shall enter into
a contract with the Institute of Medicine for the conduct of a study, and the
submission to the Secretary of a report, that includes--
(1) an analysis of information concerning health care professionals
that is currently available to patients , consumers, States, and
professional societies, nationally and on a State-by-State basis, including
patient preferences with respect to information about such professionals and
their competencies;
(2) an evaluation of the legal and other barriers to the sharing of
information concerning health care professionals; and
(3) recommendations for the disclosure of information on health care
professionals, including the competencies and professional qualifications of
such practitioners, to better facilitate patient choice, quality
improvement, and market competition.
(b) REPORT- Not later than 18 months after the date of enactment of
this Act, the Secretary of Health and Human Services shall forward to the
appropriate committees of Congress a copy of the report and study conducted
under subsection (a).
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