SUMMARY AS OF:
6/9/1999--Introduced.
TABLE OF CONTENTS:
- Title I: Patient Right to Unrestricted Medical Advice
- Title II: Patient Right to Emergency Medical Care
- Title III: Patient Right to Obstetric and Gynecological Care
- Title IV: Patient Right to Pediatric Care
- Title V: Patient Access to Information
- Title VI: Group Health Plan Review Standards
- Title VII: Small Business Access and Choice for Entrepreneurs
- Title VIII: Health Care Access, Affordability, and Quality
Commission
Health Care Quality and Access Act of 1999 - Amends the Employee Retirement
Income Security Act of 1974 (ERISA) to revise provisions relating to group
health plans.
Title I: Patient Right to Unrestricted Medical Advice - Prohibits a
group health plan, or a health insurance issuer offering group coverage, from
imposing on a health professional any restriction on advice provided to a
participant or beneficiary.
Title II: Patient Right to Emergency Medical Care - Requires a group
health plan or issuer, if it provides benefits for emergencies, to provide
benefits (without preauthorization and without regard to network limitations)
for emergency medical screening examinations if a prudent layperson would
determine them necessary.
Title III: Patient Right to Obstetric and Gynecological Care -
Requires a group health plan or issuer, if it provides benefits for routine
gynecological or obstetric specialist care benefits, to: (1) provide those
benefits from a participating specialist without authorization or referral by a
primary care provider; and (2) treat the ordering of other routine care by such
participating specialist as an authorization by a primary care provider.
Title IV: Patient Right to Pediatric Care - Requires a group health
plan or issuer, if it provides benefits for routine pediatric specialist care
benefits, to allow designation of a participating pediatric specialist as the
primary care provider for any beneficiary under 18 years of age.
Title V: Patient Access to Information - Requires plan administrators
to include specified information in summary plan descriptions, and to provide
certain other information upon request of the participant or beneficiary.
Requires advance notice of exclusion from a drug formulary of a drug or
biological that is used in the treatment of a chronic illness or disease.
Title VI: Group Health Plan Review Standards - Requires group health
plans to provide written notice of adverse coverage decisions to participants or
beneficiaries and care providers.
(Sec. 601) Requires group health plans to meet specified time limits for: (1)
making decisions on requests for benefit payments, advance determination of
coverage, and medical necessity determinations; and (2) making coverage
decisions relating to accelerated need medical care, and for completing internal
reviews of initial denials of such coverage.
Requires internal reviews by medical professionals of initial coverage
decisions involving: (1) medical appropriateness or necessity; (2)
investigational items; or (3) experimental treatment or technology.
Allows participants or beneficiaries, under certain conditions, to request
external review by an independent medical expert of an adverse coverage decision
and reconsideration of the initial review decision.
Sets forth: (1) permitted alternatives to required internal reviews and
required external reviews; (2) review requirements; and (3) a fiduciary
standards compliance requirement.
Title VII: Small Business Access and Choice for Entrepreneurs -
Establishes rules governing health plans sponsored by certain associations,
including requirements for: (1) certification; (2) sponsors and boards of
trustees, and treatment of franchised networks and collectively bargained plans;
(3) participation and coverage of employers and individuals and of previously
uninsured employees; (4) plan documents, contribution rates, and benefit
options; (5) maintenance of reserves, excess-stop loss insurance, and solvency
indemnification for plans providing health benefits in addition to health
insurance coverage; (6) applications and related reporting; (7) notice for
voluntary termination; and (8) corrective actions and mandatory termination.
(Sec. 701) Directs the Secretary of Labor to apply, to the appropriate
Federal district court, to be appointed trustee of certain insolvent association
health plans which provide health benefits in addition to health insurance
coverage.
Allows a State to impose a contribution tax on an association health plan
that begins operations in such State after the enactment of this Act.
Directs the Secretary to report to specified congressional committees on the
effect association health plans have had, if any, on reducing the number of
uninsured individuals.
(Sec. 702) Revises requirements for treatment of single employer
arrangements.
(Sec. 703) Revises requirements for certain collectively bargained
arrangements.
(Sec. 704) Sets forth enforcement requirements relating to association health
plans.
(Sec. 705) Sets forth State responsibilities, and requirements for
cooperation between Federal and State authorities, with respect to association
health plans.
(Sec. 706) Prescribes special rules for certain existing health benefits
programs.
Title VIII: Health Care Access, Affordability, and Quality Commission
- Establishes the Health Care Access, Affordability, and Quality Commission to:
(1) establish model guidelines for independent expert external review programs,
consumer friendly information programs, systems for measuring patient
satisfaction and patient outcomes, and systems to ensure the timely processing
of claims; and (2) evaluate, upon congressional request, existing and proposed
benefit requirements for group health plans, taking into consideration the
overall cost effect, availability of treatment, and the effect on the health of
the general population.
(Sec. 801) Authorizes appropriations.