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Comprehensive Managed Health Care Reform Act of 1999 (Introduced in
SEC. 5. ASSURING ADEQUATE SCOPE OF COVERAGE .
(a) COVERAGE OF PRESCRIPTION
DRUGS, PREVENTIVE SERVICES, AND INPATIENT AND OUTPATIENT SERVICES- A managed
care organization, in offering coverage under a managed care plan,
shall include coverage of
prescription drugs, preventive services, and inpatient and outpatient
services, and shall--
(1) include coverage of
annual screening mammography for any female enrollee who is 40 years of age
or older and for any female enrollee who is less than 40 years of age and
who has a medical condition that makes such coverage medically necessary and
(2) not restrict benefits for any hospital length of stay in connection
(A) a mastectomy for the treatment of breast cancer to less than 48
(B) a lymph node dissection for the treatment of breast cancer to less
than 24 hours; and
(3) not exclude or restrict benefits--
(A) for prescription contraceptive drugs or devices
approved by the Food and Drug Administration, or generic equivalents
approved as substitutable by the Food and Drug Administration, or
(B) for outpatient contraceptive services (including
consultations, examinations, procedures, and medical services, provided on
an outpatient basis and related to the use of contraceptive methods (including
natural family planning) to prevent an unintended pregnancy).
(b) MENTAL HEALTH PARITY- A managed care organization, in offering a
managed care plan, may not distinguish in the amount, duration, or scope of
coverage under the plan among
items and services based on whether the items and services relate to mental
health (or treatment of mental illness or disease) or to physical health (or
treatment of physical illness or disease).
(c) COVERAGE OF SERVICES OF
ESSENTIAL COMMUNITY PROVIDERS-
(1) IN GENERAL- The Secretary may require a managed care organization to
enter into agreements with essential community providers serving the
organization's service area (in relation to the coverage ) to join the
organization's provider network if such Secretary finds that such agreements
are necessary for the organization to make contracted for services (A)
available and accessible to each enrollee, within the area served by the
organization (in relation to such coverage ), with reasonable
promptness and in a manner which assures continuity, and (B) when medically
necessary, available and accessible 24 hours a day and 7 days a week.
(2) ESSENTIAL COMMUNITY PROVIDER DEFINED- For purposes of paragraph (1),
the term `essential community provider' means a rural health clinic
(described in paragraph (2) of section 1861(aa) of the Social Security Act,
42 U.S.C. 1395x(aa)), a Federally qualified health center (described in
paragraph (4) of such section), and any other provider meeting such
standards as the Secretary may require.
(d) COVERAGE OF EMERGENCY
SERVICES- A managed care organization shall provide for coverage of emergency services (as
defined in section 4(d)(2)(B)), 24-hours a day, 7-days-a-week, without the
need for any prior approval for coverage of such services.
(e) REQUIREMENT FOR POINT OF SERVICE OPTION- A managed care organization
that offers a managed care plan shall offer each enrollee an enrollment option
under which the enrollee may receive benefits for services provided by
nonparticipating health care professionals and providers. The organization may
require that the enrollee pay a reasonable premium to reflect the cost of such
(f) REQUIREMENT FOR CONTINUITY OF CARE- A managed care organization shall
provide for continuity of care following enrollment, including appropriate
continuity of care following termination of participation of a provider that
is providing a course of treatment to an enrollee at the time of the
(g) COVERAGE OF CONSULTATION
FOR SECOND OPINIONS- A managed care organization shall provide enrollees with
access to a consultation for a second opinion regarding treatment options.
SEC. 6. ASSURING UNBIASED MEDICAL DETERMINATIONS BY HEALTH CARE
PROFESSIONALS AND PROVIDERS.
(a) REQUIRING MEDICAL DETERMINATIONS BY TREATING PROFESSIONAL- A managed
care organization may not deny payment for services covered under a managed
care plan based upon the fact that the services are not medically necessary or
appropriate with respect to an enrollee unless the determination is made
solely by the health care professional treating the enrollee.
(b) PROHIBITION OF CERTAIN INCENTIVE ARRANGEMENTS-
(1) IN GENERAL- No managed care organization shall offer monetary
rewards, penalties, or inducements (including varying the amount of
compensation) to a health care professional or provider, or condition the
initial or continued participation of such a professional or provider in a
managed care plan offered by the organization, on the basis of the
professional's or provider's decision (or decisions) to reduce or limit the
availability of appropriate medical tests, services, or treatment, on the
basis of any utilization review decisions relating to the professional or
provider, or the number of referrals, tests, or other procedures ordered or
performed by the professional or provider.
(2) PENALTY- Any managed care organization, or executive of such an
organization, that knowingly offers a reward, penalty, or inducement in
violation of paragraph (1) shall be fined in accordance with title 18,
United States Code, imprisoned for not more than 2 years, or both.
(c) PROHIBITION OF INTERFERENCE WITH CERTAIN MEDICAL COMMUNICATIONS-
(1) IN GENERAL- The provisions of any contract or agreement, or the
operation of any contract or agreement, between a managed care organization
and a health care professional shall not prohibit or restrict the health
care professional from engaging
in medical communications with a patient of the professional.
(2) MEDICAL COMMUNICATION DEFINED- For purposes of this subsection, the
term `medical communication' means a communication made by a health care
professional with a patient of the health care professional (or the guardian
or legal representative of the patient) with respect to--
(A) the patient's health status, medical care, or treatment
(B) any utilization review requirements that may affect treatment
options for the patient; or
(C) any financial incentives that may affect the treatment of the
(d) WHISTLEBLOWER PROTECTION-
(1) IN GENERAL- No managed care organization may discharge or otherwise
discriminate against any employee with respect to compensation, terms,
conditions, or privileges of employment because the employee (or any person
acting pursuant to the request of the employee) provided information to a
Federal or State official with any enforcement responsibility or authority
concerning the provisions of this Act regarding a possible violation of any
provision of this Act, or any regulation under any such provision, by the
organization or any director, officer, or employee of the
(2) ENFORCEMENT- Any employee or former employee who believes that such
employee has been discharged or discriminated against in violation of
paragraph (1) may file a civil action in the appropriate United States
District Court before the end of the 2-year period beginning on the date of
such discharge or discrimination.
(3) REMEDIES- If the District Court determines that a violation has
occurred, the court may order the organization which committed the
(A) to reinstate the employee to the employee's former
(B) to pay compensatory damages; or
(C) to take other appropriate actions to remedy any past
(4) LIMITATION- The protections of this subsection shall not apply to
any employee who--
(A) deliberately causes or participates in the alleged violation of
law or regulation; or
(B) knowingly or recklessly provides substantially false information
to the Federal or State official involved.
(e) PROTECTION OF ADVOCACY FUNCTIONS- No managed care organization shall
terminate, vary the compensation or working conditions, or refuse to renew a
contract for participation with a health care professional because the
(1) advocated on behalf of an enrollee,
(2) filed a complaint against the organization,
(3) appealed a decision of the organization,
(4) provided information or filed a report with an appropriate Federal
or State official, or
(5) requested a hearing or review pursuant to this Act.
SEC. 7. NONDISCRIMINATION AGAINST ENROLLEES AND IN THE SELECTION OF
PARTICIPATING PROVIDERS; EQUITABLE ACCESS TO NETWORKS.
(a) NONDISCRIMINATION AGAINST ENROLLEES- No managed care organization may
discriminate (directly or through contractual arrangements) against any
enrollee on the basis of age, gender, disability, health status, genetic
information, or anticipated need for health services.
(b) NONDISCRIMINATION IN SELECTION OF PARTICIPATING HEALTH CARE
PROFESSIONALS- A managed care organization shall not discriminate in selecting
participating health care professionals (or in establishing the terms and
conditions for such participation) on the basis of--
(1) the race, national origin, gender, age, or disability (other than a
disability that impairs the ability of an individual to provide health care
services or that may threaten the health of enrollees) of the professional;
(2) the professional's lack of affiliation with, or admitting privileges
at, a hospital (unless such lack of affiliation is a result of infractions
of quality standards and is not due to a professional's type of
(c) NONDISCRIMINATION IN ACCESS TO HEALTH PLANS-
(1) IN GENERAL- Subject to paragraph (2), a managed care organization
shall not discriminate in participation, reimbursement, or indemnification
against a health care professional, who is acting within the scope of the
professional's license or certification under applicable State law, solely
on the basis of such license or certification.
(2) CONSTRUCTION- Nothing in this subsection shall be construed as a
requirement to include
for participation every willing health care professional who meets the terms
and conditions of a managed care organization.
SEC. 8. DISCLOSURE OF INFORMATION.
(a) PROVISION OF INFORMATION AND ORIENTATION-
(1) GENERAL REQUIREMENT- A managed care organization offering a managed
care plan shall provide enrollees and, upon request, prospective enrollees
with written information concerning the terms and conditions of the plan,
including the information described in subsection (c).
(2) INFORMATION UPON REQUEST- In addition to the information provided
under subsection (c), a managed care organization offering a managed care
plan shall provide, upon request of an enrollee or prospective enrollee, the
information described in subsection (d).
(3) REQUIREMENT FOR INITIAL INFORMATION SESSION-
(A) IN GENERAL- Within 30 days of enrolling an individual under a
managed care plan, the managed care organization shall provide for an
in-person information session with the enrollee for the purpose of
outlining the information described in this section.
(B) PAYMENT- Such a session shall be held with an enrollee before the
enrollee is required to pay for services. This subparagraph shall not
affect the coverage of items
and services under the plan immediately upon the effective date of
(4) COMPARATIVE FORM- The information provided under this section shall
be in a form, specified by the Secretary, so that prospective enrollees may
compare the attributes of all such plans offered within a coverage area.
(b) UNDERSTANDABILITY- Information provided under this section, whether
written or oral shall be easily understandable, truthful, linguistically
appropriate and objective with respect to the terms used.
(c) REQUIRED INFORMATION- Information required under subsection (a)(1)
shall include information concerning each of the following:
(1) COVERAGE AND BENEFITS-
Coverage provisions, benefits,
and any exclusions by category of service or product, including 24-hour
coverage of emergency services
without a requirement for prior approval.
(2) PRIOR AUTHORIZATION REQUIREMENTS- Prior authorization requirements
for coverage of
(3) UTILIZATION REVIEW POLICIES- Utilization review procedures and
policies (including preauthorization review, concurrent review, post-service
review, post-payment review procedures that may lead an enrollee to be
denied coverage for or not be
provided a particular service or product), including time frames for review
decisions and enrollee rights relating to notice, reconsideration, and
appeal of utilization review decisions, and including information on the
percentage of utilization review determinations that disagree with the
judgment of the initial treating health care professional and the percentage
of such determinations which are reversed (whether internally or externally)
(4) PAYMENT METHODS- Types of methodologies used by the organization to
reimburse types of providers or for types of services.
(5) ENROLLEE FINANCIAL RESPONSIBILITIES- Enrollees' financial
responsibility for services, including any variation in the responsibility
based on whether the provider is a participating provider.
(6) GRIEVANCE PROCEDURES- Grievance procedures.
(7) PROVIDER SELECTION PROCEDURES- Procedures used by enrollees to
select and change primary and specialty providers and to be referred to
nonparticipating providers and appropriate specialists, consistent with the
requirements of this Act.
(8) ENROLLEE PARTICIPATION IN POLICY DEVELOPMENT- Procedures which
enrollees may use to participate in development of policy of the
(9) PROCEDURES FOR NON-ENGLISH PROFICIENT ENROLLEES- Procedures which
the organization has established to meet the needs of enrollees who are not
proficient in English.
(10) INFORMATION- An address and phone number at which enrollees and
prospective enrollees can obtain information about the organization and
managed care plans offered by the organization.
(11) LIST OF CONTRACT FACILITIES- A list, annually updated, of the
facilities and providers, by specialty, through which the organization
provides its benefits. For each such facility or provider the list shall
include the name, address, phone number, and (in the case of a physician)
(12) NON-HEALTH CARE EXPENDITURES- A statement of the percentage of
health-care related revenues of the organization used for administration,
the percentage of such revenues used for marketing, and the percentage of
such revenues attributable to profit.
(13) ENROLLEE SATISFACTION- Statistics on enrollee satisfaction, stated
separately for those who continue enrollment and those who discontinue
enrollment, and on the proportion of enrollees who disenroll.
(14) AVAILABILITY OF PROVIDERS; PROVIDER INCENTIVES- The characteristics
and availability of participating health care providers and professionals,
including a description of any financial or contractual arrangements with
hospitals, utilization review organizations, physicians, or other health
care providers or professionals that would affect the services offered,
referral or treatment options, or providers' fiduciary responsibility to
patients, including any financial or other incentives regarding the
provision, denial, or limitation of needed services.
(15) QUALITY INDICATORS- Indicators that measure the quality of services
provided by the organization and by participating health providers with the
organization, including population-based statistics such as immunization
rates and performance measures such as survival after surgery, adjusted for
(16) PHYSICIAN CREDENTIALING STANDARDS- Standards used by the
organization in the credentialing of participating physicians.
(17) FORMULARIES- Information on prescription drug formularies used by
the organization, consistent with section 4(i).
(18) LOSS-RATIO- Its loss-ratio.
(d) INFORMATION SUPPLIED UPON REQUEST- For purposes of subsection (a)(2),
the information described in this subsection concerning a managed care
organization offering a managed care plan is as follows:
(1) ANNUAL FINANCIAL STATEMENT- The most recent annual financial
statement of the organization.
(2) SUBSCRIBER CONTRACT- A copy of the most recent individual, direct
pay subscriber contract, or, in the case of a group health plan, any
contract between the plan and a health insurance issuer providing coverage under the plan.
(3) CONSUMER COMPLAINTS- Information relating to consumer complaints
compiled pursuant to insurance or other law.
(4) CHARGES AND BENEFITS FOR SERVICES- Information on the enrollee
charges for all covered items and services, including, for the point of
service option described in section 5(e), the amounts that are payable with
respect to items and services furnished by nonparticipating health care
professionals and providers.
(5) CONFIDENTIALITY OF MEDICAL RECORDS- Information on the procedures
used by the organization to protect the confidentiality of medical records
maintained in relation to enrollees.
(6) QUALITY ASSURANCE PROGRAMS- A description of quality assurance
programs maintained by the organization in relation to the plan.
(7) COVERAGE OF
EXPERIMENTAL OR INVESTIGATIONAL DRUGS- A description of procedures used by
the organization to determine whether drugs, devices, or treatments in
clinical trials are experimental or investigational.
(8) PROVIDER AFFILIATIONS- Information on affiliations of participating
health care professionals with participating hospitals.
(9) CLINICAL REVIEW CRITERIA- Upon written request, a description of the
specific clinical written review criteria relating to a particular condition
or disease and how such criteria are used.
(10) PARTICIPATION PROCEDURES AND QUALIFICATIONS- A description of the
written application procedures and qualification requirements for providers
to be considered for participation under the plan.
(11) OFFICIALS- A list of the names, business addresses, and official
positions of the membership of the board of directors, officers, or persons
with an ownership or control interest in the organization.
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