HR 719 IH

106th CONGRESS

1st Session

H. R. 719

To amend the Public Health Service Act and the Employee Retirement Income Security Act of 1974 to protect consumers in managed care plans and other health coverage.

IN THE HOUSE OF REPRESENTATIVES

February 11, 1999

Mr. GANSKE (for himself, Mrs. ROUKEMA, Mr. LEACH, Mr. WAMP, Mr. FORBES, Mr. PETRI, Mr. SHAYS, Mr. HORN, Mr. FRELINGHUYSEN, Mr. FOLEY, and Mr. COOKSEY) introduced the following bill; which was referred to the Committee on Commerce, and in addition to the Committee on Education and the Workforce, 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


A BILL

To amend the Public Health Service Act and the Employee Retirement Income Security Act of 1974 to protect consumers in managed care plans and other health coverage.

SECTION 1. SHORT TITLE; TABLE OF CONTENTS.

TITLE I--MANAGED CARE CONSUMER PROTECTIONS

Subtitle A--Access to Care

Subtitle B--Quality Assurance

Subtitle C--Patient Information

Subtitle D--Grievance and Appeals Procedures

Subtitle E--Protecting the Doctor-Patient Relationship

Subtitle F--Promoting Good Medical Practice

Subtitle G--Definitions

TITLE II--APPLICATION OF PATIENT PROTECTION STANDARDS TO GROUP HEALTH PLANS AND HEALTH INSURANCE COVERAGE UNDER PUBLIC HEALTH SERVICE ACT

TITLE III--AMENDMENTS TO THE EMPLOYEE RETIREMENT INCOME SECURITY ACT OF 1974

TITLE IV--EFFECTIVE DATES; COORDINATION IN IMPLEMENTATION

TITLE I--MANAGED CARE CONSUMER PROTECTIONS

Subtitle A--Access to Care

SEC. 101. ACCESS TO EMERGENCY CARE.

`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 a condition described in clause (i), (ii), or (iii) of section 1867(e)(1)(A) of the Social Security Act.

SEC. 102. OFFERING OF CHOICE OF COVERAGE OPTIONS UNDER GROUP HEALTH PLANS.

SEC. 103. CHOICE OF PROVIDERS.

SEC. 104. ACCESS TO SPECIALTY CARE.

SEC. 105. CONTINUITY OF CARE.

the transitional period as payment in full (or, in the case described in subsection (a)(2), at the rates applicable under the replacement plan or issuer after the date of the termination of the contract with the health insurance issuer) 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 subsection (a)(1) had not been terminated.

SEC. 106. COVERAGE FOR INDIVIDUALS PARTICIPATING IN APPROVED CLINICAL TRIALS.

SEC. 107. ACCESS TO NEEDED PRESCRIPTION DRUGS.

SEC. 108. ADEQUACY OF PROVIDER NETWORK.

Subtitle B--Quality Assurance

SEC. 111. STANDARDS FOR UTILIZATION REVIEW ACTIVITIES.

under such a program, the program shall not, pursuant to retrospective review, revise or modify the specific standards, criteria, or procedures used for the utilization review for procedures, treatment, and services delivered to the enrollee during the same course of treatment.

Subtitle C--Patient Information

SEC. 121. PATIENT INFORMATION.

equivalent in emergency situations and an explanation of what constitutes an emergency situation;

SEC. 122. PROTECTION OF PATIENT CONFIDENTIALITY.

SEC. 123. HEALTH INSURANCE OMBUDSMEN.

health plans and health insurance issuers. Such Ombudsman shall be responsible for at least the following:

Subtitle D--Grievance and Appeals Procedures

SEC. 131. ESTABLISHMENT OF GRIEVANCE PROCESS.

SEC. 132. INTERNAL APPEALS OF ADVERSE DETERMINATIONS.

SEC. 133. EXTERNAL APPEALS OF ADVERSE DETERMINATIONS.

section of a plan or issuer shall be conducted under a contract between the plan or issuer and one or more qualified external appeal entities (as defined in subsection (c)).

courts (or other process) of the external appeal determination.

Subtitle E--Protecting the Doctor-Patient Relationship

SEC. 141. PROHIBITION OF INTERFERENCE WITH CERTAIN MEDICAL COMMUNICATIONS.

therapy assistant, speech-language pathologist, audiologist, registered or licensed practical nurse (including nurse practitioner, clinical nurse specialist, certified registered nurse anesthetist, and certified nurse-midwife), licensed clinical social worker, registered respiratory therapist, and certified respiratory therapy technician.

SEC. 142. PROHIBITION AGAINST TRANSFER OF INDEMNIFICATION OR IMPROPER INCENTIVE ARRANGEMENTS.

SEC. 143. ADDITIONAL RULES REGARDING PARTICIPATION OF HEALTH CARE PROFESSIONALS.

SEC. 144. PROTECTION FOR PATIENT ADVOCACY.

disclosed is limited to the scope of the investigation or proceeding.

Subtitle F--Promoting Good Medical Practice

SEC. 151. PROMOTING GOOD MEDICAL PRACTICE.

SEC. 152. STANDARDS RELATING TO BENEFITS FOR CERTAIN BREAST CANCER TREATMENT.

Subtitle G--Definitions

SEC. 191. DEFINITIONS.

typically manages the medical condition, procedure, or treatment under review or appeal and includes a pediatric specialist where appropriate; except that only a physician may be a clinical peer with respect to the review or appeal of treatment recommended or rendered by a physician.

SEC. 192. PREEMPTION; STATE FLEXIBILITY; CONSTRUCTION.

SEC. 193. REGULATIONS.

TITLE II--APPLICATION OF PATIENT PROTECTION STANDARDS TO GROUP HEALTH PLANS AND HEALTH INSURANCE COVERAGE UNDER PUBLIC HEALTH SERVICE ACT

SEC. 201. APPLICATION TO GROUP HEALTH PLANS AND GROUP HEALTH INSURANCE COVERAGE.

`SEC. 2706. PATIENT PROTECTION STANDARDS.

SEC. 202. APPLICATION TO INDIVIDUAL HEALTH INSURANCE COVERAGE.

`SEC. 2752. PATIENT PROTECTION STANDARDS.

TITLE III--AMENDMENTS TO THE EMPLOYEE RETIREMENT INCOME SECURITY ACT OF 1974

SEC. 301. APPLICATION OF PATIENT PROTECTION STANDARDS TO GROUP HEALTH PLANS AND GROUP HEALTH INSURANCE COVERAGE UNDER THE EMPLOYEE RETIREMENT INCOME SECURITY ACT OF 1974.

`SEC. 714. PATIENT PROTECTION STANDARDS.

SEC. 302. ERISA PREEMPTION NOT TO APPLY TO CERTAIN ACTIONS INVOLVING HEALTH INSURANCE POLICYHOLDERS.

TITLE IV--EFFECTIVE DATES; COORDINATION IN IMPLEMENTATION

SEC. 401. EFFECTIVE DATES.

SEC. 402. COORDINATION IN IMPLEMENTATION.

END