[Congressional Bills 104th Congress]
[From the U.S. Government Publishing Office]
[H.R. 2608 Introduced in House (IH)]







104th CONGRESS
  1st Session
                                H. R. 2608

To require that health care practitioners determine medically necessary 
  and appropriate treatment and to require that insurers notify their 
               enrollees of the extent of their coverage.


_______________________________________________________________________


                    IN THE HOUSE OF REPRESENTATIVES

                            November 9, 1995

Mr. Nadler (for himself, Mr. Dellums, Mr. Engel, Ms. McKinney, and Miss 
Collins of Michigan) introduced the following bill; which was referred 
                      to the Committee on Commerce

_______________________________________________________________________

                                 A BILL


 
To require that health care practitioners determine medically necessary 
  and appropriate treatment and to require that insurers notify their 
               enrollees of the extent of their coverage.

    Be it enacted by the Senate and House of Representatives of the 
United States of America in Congress assembled,

SECTION 1. SHORT TITLE.

    This Act may be cited as the ``Health Care Consumer Protection Act 
of 1995''.

SEC. 2. NOTIFICATION OF COVERAGE PROVIDED BY THE INSURER.

    (a) Notification to Current Enrollees.--An insurer providing health 
insurance coverage under a health plan shall provide annual notice to 
each current enrollee under such plan regarding the extent of the 
coverage of the plan. Such notice shall be in writing and shall include 
a copy of the contract between the insurer and enrollee, in addition to 
information regarding the terms and conditions of the policy and the 
rights and obligations of the parties including--
            (1) covered and excluded services, equipment, and devices;
            (2) copayments, deductibles, and premiums;
            (3) enrollee satisfaction statistics;
            (4) financial responsibility of the enrollee;
            (5) utilization review requirements;
            (6) a list of the usual, customary, and reasonable costs 
        for procedures, tests, and examinations;
            (7) physician credentialing standards; and
            (8) the percentage of total annual premiums used to 
        reimburse practitioners for health care provided to enrollees 
        and the percentage used for administration and other costs 
        incurred in administering the plan.
    (b) Notification to Potential Enrollees.--An insurer providing 
health insurance coverage under a health plan shall, upon request, 
provide notice to each potential enrollee under such plan regarding the 
extent of the coverage of the plan. Such notice shall be in writing and 
shall include a copy of the potential contract between the insurer and 
potential enrollee, in addition to information regarding the terms and 
conditions of the policy and the rights and obligations of the parties 
information including the items listed in paragraphs (1) through (8) of 
subsection (a).
    (c) Regulations for Failure To Provide Notification.--The Secretary 
of Health and Human Services shall promulgate regulations to ensure 
that an insurer providing health insurance coverage under a health plan 
provide notification to current and potential enrollees as described in 
subsections (a) and (b).

SEC. 3. DETERMINATION OF MEDICALLY NECESSARY AND APPROPRIATE TREATMENT.

    (a) In General.--Under a health plan, the determination of what is 
medically necessary and appropriate for the health of a patient may be 
made only by a health care practitioner who is--
            (1) licensed and practicing within the scope of the State 
        practice act of the State in which the practitioner practices; 
        and
            (2) directly involved in the care of such patient.
    (b) Insurance Coverage.--An insurer must pay for a service 
determined, as described in subsection (a), to be medically necessary 
and appropriate if the service is covered by the health plan.
    (c) Regulations To Deter Rewards, Penalties or Inducements.--The 
Secretary of Health and Human Services shall promulgate regulations to 
ensure that an insurer not offer monetary rewards, penalties, or 
inducements to a licensed health care practitioner, or condition the 
continued participation of a licensed health care practitioner in a 
plan on the basis of the health care practitioner's decisions to limit 
the availability of appropriate medical tests, services, or treatments.

SEC. 4. ENFORCEMENT AND PENALTIES.

    (a) Penalties.-- Any entity that offers a health plan that violates 
the provisions of this Act shall be subject to a civil money penalty in 
an amount to be determined by the Secretary of Health and Human 
Services.
    (b) Process.--The provisions of section 1128A of the Social 
Security Act (42 U.S.C. 1320a-7a) (other than subsections (a) and (b)) 
shall apply to civil money penalties under this section in the same 
manner as they apply to a penalty or proceeding under section 1128A(a) 
of such Act.

SEC. 5. PROHIBITION OF HOLD HARMLESS PROVISIONS.

    An insurer may not include provisions in a health plan to hold 
itself harmless for any liability.

SEC. 6. PREEMPTION.

    A State may not establish or enforce standards for insurers or 
health insurance coverage with respect to the subject matter of this 
Act that are weaker than the standards established under this Act.

SEC. 7. DEFINITIONS.--

    For purposes of this Act:
            (1) Insurer.--The term ``insurer'' means an insurance 
        company, insurance service, or insurance organization licensed 
        to engage in the business of insurance in a State, and a health 
        maintenance organization.
            (2) Health care practitioner.--The term ``health care 
        practitioner'' has the meaning provided by section 11151 of 
        title 42, United States Code.
            (3) Health insurance coverage.--The term ``health insurance 
        coverage'' means any hospital or medical service policy or 
        certificate, hospital or medical service plan contract, or 
        health maintenance organization contract offered by an insurer.
            (4) Health plan.--The term ``health plan'' means a plan 
        that provides health insurance coverage.
            (5) State.--The term ``State'' means any State, the 
        District of Columbia, Puerto Rico, the Northern Mariana 
        Islands, the Virgin Islands, American Samoa, and Guam.

SEC. 8. EFFECTIVE DATE.

    The provisions of this Act shall apply to all health plans offered, 
sold, issued, or renewed after the date of the enactment of this Act.
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