[Congressional Bills 104th Congress]
[From the U.S. Government Publishing Office]
[H.R. 4315 Introduced in House (IH)]







104th CONGRESS
  2d Session
                                H. R. 4315

   To provide patients with information and rights to promote better 
                              health care.


_______________________________________________________________________


                    IN THE HOUSE OF REPRESENTATIVES

                           September 28, 1996

   Mr. Owens (for himself, Ms. Norton, Ms. McKinney, Mr. Frazer, Mr. 
Yates, Mr. Dellums, Mr. Payne of New Jersey, Mr. Hilliard, Mr. Kildee, 
   and Mrs. Mink of Hawaii) introduced the following bill; which was 
referred to the Committee on Commerce, and in addition to the Committee 
 on Ways and Means, 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 provide patients with information and rights to promote better 
                              health care.

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

SECTION 1. SHORT TITLE; TABLE OF CONTENTS.

    (a) Short Title.--This Act may be cited as the ``Patient and Health 
Care Provider Protection Act of 1996''.
    (b) Table of Contents.--The table of contents of this Act is as 
follows:

Sec. 1. Short title; table of contents.
Sec. 2. Findings.
Sec. 3. Definitions.
                   TITLE I--HEALTH PLAN REQUIREMENTS

Sec. 101. Interference with medical communication prohibited.
Sec. 102. Improper incentive plan prohibited.
Sec. 103. Provisions regarding denial of care.
Sec. 104. Quality of care.
Sec. 105. Privacy.
Sec. 106. Fee.
Sec. 107. Enforcement through civil penalties.
Sec. 108. Prohibition on adverse action.
            TITLE II--OFFICE OF CONSUMER ADVOCACY FOR HEALTH

Sec. 201. Establishment of office.
Sec. 202. Assistance to individuals with grievances against a health 
                            plan.
Sec. 203. Assurance of access by all individuals to quality health 
                            care.
Sec. 204. Federal investigation and emergency intervention.
Sec. 205. Annual report to the secretary.
Sec. 206. Office administration.
Sec. 207. Oversight.
Sec. 208. Funding of office.
          TITLE III--INDEPENDENT CONSUMER ADVISORY COMMITTEES

Sec. 301. Establishment of committees.
Sec. 302. Membership and chair.
Sec. 303. Functions of committee.
Sec. 304. Liability of members of committee.
Sec. 305. Annual report to office.
Sec. 306. Funding for committees.
     TITLE IV--COORDINATION AMONG OFFICE, COMMITTEES, AND SECRETARY

Sec. 401. Interaction among office and other organizations.
Sec. 402. Assistance to committees.
Sec. 403. Coordinated data analysis and dissemination procedure.

SEC. 2. FINDINGS.

    The Congress finds the following:
            (1) The largest category of health spending is hospital 
        services; in 1994, 35 percent of national health spending was 
        for hospital services worth $338,500,000,000.
            (2) The hospital industry exhibits the fastest rising costs 
        in the health care sector.
            (3) The largest expenditures for the hospital industry are 
        payroll (wages and salaries) and employee benefits; in 1992, 
        payroll and employee benefits accounted for almost 55 percent 
        of total hospital expenses.
            (4) Because registered nurses comprise the majority of a 
        hospital's expenses, in an effort to remain competitive, 
        hospitals are restructuring their operations by decreasing 
        payroll and benefit outlays for registered nurses and either 
        decreasing their number or replacing them with unlicensed aides 
        to care directly for patients.
            (5) While this reorganization is taking place, no 
        mandatory, national, and systematic compilation of data is 
        being undertaken to determine the correlation between skilled 
        nursing care and patient safety.
            (6) Several studies, however, have noted a basic 
        relationship between skilled nursing care and patient safety: 
        increased deaths result when inadequate nursing and lower 
        levels of registered nurses in combination with higher levels 
        of unlicensed aides are utilized by health care facilities.
            (7) A comprehensive effort is needed at the national level 
        to collect data and develop a research and evaluation agenda so 
        that informed policy development, implementation and evaluation 
        are undertaken in a timely manner to protect the safety of 
        patients, the well being of health care workers, and the 
        integrity of the United States medical system.
            (8) The quality of available health care will suffer in the 
        United States if health care delivery is allowed to set 
        priorities in which profit is made at the expense of patient 
        care quality and safety.
            (9) Core clinical staff, such as registered nurses, are a 
        key component in increasing quality, understanding patient care 
        needs, and balancing costs in any reformed health care system.
            (10) Health care is a basic and universal need; therefore, 
        the right of any consumer to have access to one's own 
        confidential medical records and pertinent information on the 
        health care facility that is delivering health care and to 
        participate effectively in the process of improving the 
        delivery and quality of such care should not be impaired.

SEC. 3. DEFINITIONS.

    In this Act:
            (1) Health care provider.--The term ``health care 
        provider'' means an individual or entity licensed or certified 
        under State law to provide health care services.
            (2) Health plan.--The term ``health plan'' means any 
        private health plan or arrangement (including an employee 
        welfare benefit plan) which provides, or pays the cost of, 
        health care services.
            (3) Secretary.--Except as otherwise expressly provided, the 
        term ``Secretary'' means Secretary of Health and Human 
        Services.
            (4) Coverage of third party administrators.--In the case of 
        a health plan that is an employee welfare benefit plan (as 
        defined in section 3(1) of the Employee Retirement Income 
        Security Act of 1974), any third party administrator or other 
        person with responsibility for contracts with health care 
        providers under the plan shall be considered, for purposes of 
        this Act, to be an entity offering such health plan.
            (5) Enrollee.--The term ``enrollee'' means a person 
        enrolled under a health plan.
            (6) Office.--The term ``Office'' means the Office of 
        Consumer Advocacy for Health as described in title II of this 
        Act.
            (7) Committee.--The term ``Committee'' means an Independent 
        Consumer Advisory Committee as described in title III of this 
        Act.

                   TITLE I--HEALTH PLAN REQUIREMENTS

SEC. 101. INTERFERENCE WITH MEDICAL COMMUNICATION PROHIBITED.

    (a) In General.--A health plan may not as part of any contract or 
agreement with a health care provider provide any restriction on or 
interference with any medical communication, as defined in subsection 
(b).
    (b) Medical Communication Defined.--For purposes of subsection (a), 
the term ``medical communication''--
            (1) means any communication, other than a knowing 
        misrepresentation, made by the health care provider--
                    (A) regarding the mental or physical health care 
                needs or treatment of a patient and the provisions, 
                terms, or requirements of the health plan or another 
                health plan relating to such needs or treatment; and
                    (B) between--
                            (i) the provider and a current, former, or 
                        prospective patient (or the guardian or legal 
                        representative of a patient);
                            (ii) the provider and any employee or 
                        representative of the such plan; or
                            (iii) the provider and any employee or 
                        representative of any State or Federal 
                        authority with responsibility for the licensing 
                        or oversight with respect to such plan; and
            (2) includes communications concerning--
                    (A) any tests, consultations, and treatment 
                options;
                    (B) any risks or benefits associated with such 
                test, consultations, and options;
                    (C) variation among any health care providers and 
                any institutions providing such services in experience, 
                quality, or outcomes;
                    (D) the basis or standard for the decision of a 
                health plan to authorize or deny health care services 
                or benefits;
                    (E) the process used by such a plan to determine 
                whether to authorize or deny health care services or 
                benefits; and
                    (F) any financial incentives or disincentives 
                provided by such a plan to a health care provider that 
                are based on service utilization.
    (c) Non-Preemption of State Law.--A State may establish or enforce 
requirements with respect to the subject matter of this section, but 
only if such requirements are more protective of a medical 
communication than the requirements established under this section.
    (d) Effective Date.--Subsection (a) shall apply to contracts or 
agreements entered into or renewed on or after the date of the 
enactment of this Act, and to contracts and agreements entered into 
before such date as of 30 days after the date of the enactment of this 
Act.

SEC. 102. IMPROPER INCENTIVE PLAN PROHIBITED.

    (a) In General.--A health plan may not as part of any contract or 
agreement with a health care provider operate an improper health care 
provider incentive plan as described in subsection (b).
    (b) Improper Incentive Plan.--For purposes of subsection (a), a 
health care provider incentive plan is improper, unless such plan meets 
the requirements of section 1876(i)(8)(A) of the Social Security Act 
(42 U.S.C. 1395mm(i)(8)(A)) for physician incentive plans in contracts 
with eligible organizations under section 1876 of such Act.
    (c) Incentive Plan Defined.--In this section, the term ``health 
care provider incentive plan'' means any compensation or other 
financial arrangement between a health plan and a health care provider 
that may directly or indirectly have the effect of limiting services 
provided with respect to an enrollee.
    (d) Effective Date.--Subsection (a) shall apply to contracts or 
agreements entered into or renewed on or after the date of the 
enactment of this Act, and to contracts and agreements entered into 
before such date as of 30 days after the date of the enactment of this 
Act.

SEC. 103. PROVISIONS REGARDING DENIAL OF CARE.

    (a) Criteria for Denial of Care.--A health plan shall establish 
criteria, in consultation with the health care providers who provide 
services under the plan, for the denial of services under the plan.
    (b) Preliminary Physical Examination.--A health plan shall provide 
for an initial physical examination of an enrollee in a timely manner 
before denying services under the plan to the enrollee. Such 
examination shall not constitute services under the health plan.
    (c) Reason for Denial of Care Provided to Enrollee.--A health plan 
shall provide in writing to an enrollee, and to the health care 
provider recommending care for the enrollee, the reason for the denial 
of services under the plan to the enrollee.
    (d) Publication of Criteria for Denial of Care.--A health plan 
shall put in writing, annually update, and make available to its 
enrollees through the Office and its Committee the written criteria 
established under subsection (a).
    (e) Effective Date.--The criteria under this section shall apply to 
plan years beginning on or after 180 days after the date of the 
enactment of this Act.

SEC. 104. QUALITY OF CARE.

    (a) Criteria For Quality Of Care.--
            (1) In general.--A health plan, in consultation with the 
        health care providers who provide health services under the 
        plan, shall establish criteria to assure the quality of care 
        provided under the plan. Such plan shall establish such 
        criteria utilizing the data collected and analyzed under 
        subsection (c) and (d), and under section 403.
            (2) Deadline.--The criteria under paragraph (1) shall apply 
        to plan years beginning on or after 2 years after the date of 
        the enactment of this Act.
    (b) Public Access to Information.--
            (1) Publication of criteria to assure quality of care.--A 
        health plan shall put in writing, annually update, and make 
        available the written criteria established under subsection (a) 
        to its enrollees through the plan's Committee.
            (2) Safe staffing levels.--
                    (A) In general.--Not later than 1 year after the 
                date of the enactment of this Act, the Secretary shall, 
                by rule, establish guidelines that determine the number 
                and classifications of health care providers necessary 
                to ensure safe and adequate staffing in relation to 
                enrollees under a health plan.
                    (B) Factors.--Such guidelines shall be based on--
                            (i) the severity of illness of each 
                        enrollee;
                            (ii) factors affecting the period and 
                        quality of recovery of each enrollee; and
                            (iii) any other factor substantially 
                        related to the condition and health care needs 
                        of each enrollee.
            (3) Safe and adequate staffing levels.--
                    (A) In general.--Not later than 180 days after the 
                date the Secretary establishes the guidelines under 
                paragraph (2), a health plan may not provide or pay for 
                health care services provided to an enrollee at an 
                institution unless such institution complies with such 
                guidelines.
                    (B) Submission of proposed standards to 
                committee.--In the case of an institution that elects 
                not to adopt the guidelines established under paragraph 
                (2), such institution shall submit proposed staffing 
                levels to the health plan and its Committee for review. 
                Such institution shall include with its submission an 
                explanation of the method and criteria used in 
                developing the proposed staffing levels.
                    (C) Default federal guidelines.--If the health 
                plan's Committee determines that the staffing levels 
                proposed by such institution fail to meet the 
                guidelines established under paragraph (2), then the 
                health plan may not provide or pay for health care 
                services provided to an enrollee at such institution 
                unless such institution adopts such guidelines as its 
                staffing levels.
                    (D) Criteria and certificate of compliance.--Such 
                plan shall file with the Secretary and the Office of 
                the State in which the plan offers health care services 
                a certificate of compliance with the staffing levels 
                adopted by the institutions where the plan provides or 
                pays for health care services for its enrollees.
                    (E) Public inspection.--Such institutions shall 
                keep on file, available for public inspection during 
                regular business hours, daily reports of staffing 
                levels by department and of patient census.
            (4) Identification tag.--
                    (A) In general.--A health plan may not provide or 
                pay for health care services provided to an enrollee at 
                an institution unless such institution prohibits a 
                health care provider who is not wearing an 
                identification tag from providing care to an enrollee.
                    (B) Licensure status.--An identification tag under 
                subparagraph (A) shall state the health care provider's 
                name and the health care position for which such 
                provider has been licensed or certified by the State.
                    (C) Visibility.--Such tag shall be visible to the 
                enrollee.
                    (D) Exception.--The requirement under subparagraph 
                (A) shall not apply where wearing such tag poses a 
                threat to the health of a patient (such as in an 
                operating room).
    (c) Data Collection.--
            (1) Medical data.--Except as provided in section 105(a), a 
        health plan, in conjunction with its Committee, shall compile 
        data on health care services provided to enrollees under the 
        health plan including--
                    (A) enrollee outcome information, including 
                nosocomial infections, medication errors, enrollee 
                injury, enrollee mortality, and rate of enrollee 
                readmission;
                    (B) structure of care provided, including nurse to 
                enrollee ratios, general staffing ratios, injuries to 
                nurses and other staff, and quality of staff; and
                    (C) process of care, including the planning and 
                delivery of care, an assessment of the delivery 
                mechanisms, and safety measures.
            (2) Financial data.--
                    (A) Financial report.--Not later than December 31st 
                of each year, a health plan that employs more than 150 
                individuals shall file, with the Office of the State in 
                which such plan offers health care services, a copy 
                of--
                            (i) any financial report or return filed 
                        under Federal or State tax or securities laws;
                            (ii) a statement of any financial interest 
                        greater than 5% or $5,000, whichever is less, 
                        in any other health plan; and
                            (iii) a statement of the nature and outcome 
                        of any complaint, lawsuit, arbitration, or 
                        other legal proceeding brought against the 
                        plan, unless such disclosure is prohibited by 
                        court order or law.
                    (B) Quality report.--Not later than December 31st 
                of each year, a health plan shall file, with the Office 
                of the State in which that plan offers health care 
                services, a report of all health care quality 
                indicators, criteria, data, or studies used to 
                evaluate, assess, or determine the nature, scope, 
                quality, or staffing of health care services, and for 
                reductions in or modifications of the provision of 
                health care services.
                    (C) First report.-- Such plan shall file its first 
                report not later than December 31st of its first plan 
                year beginning on or after the date of the enactment of 
                this Act.
    (d) Data Analysis and Dissemination.--
            (1) Information submitted to committee.--For purposes of 
        section 403, a health plan shall provide the data collected 
        under subsection (c)(1) to its Committee.
            (2) Disclosure of nursing care data to enrollees.--Such 
        plan shall provide information to an enrollee about the ratio 
        of nurses to enrollees provided under the plan.

SEC. 105. PRIVACY.

    (a) Enrollee's Privacy Rights.--Prior to the collection of data 
under section 104(c), a health plan shall establish standards and 
procedures to protect from public disclosure information that 
identifies an individual and relates to such individual's physical or 
mental health. Such standards and procedures may not adversely affect 
the integrity of the data.
    (b) Enrollee's Medical Records.--A health plan shall protect the 
privacy of a enrollee's medical records, and may only release such 
records--
            (1) to a third party with the informed written consent of 
        the enrollee given at the time the release is sought;
            (2) to a law enforcement agency pursuant to a warrant 
        issued under the Federal Rules of Criminal Procedure, an 
        equivalent State warrant, a grand jury subpoena, or a court 
        order; or
            (3) pursuant to a court order, in a civil proceeding upon a 
        showing of compelling need for the information that cannot be 
        accommodated by any other means, if--
                    (A) the enrollee is given reasonable notice, by the 
                person seeking the release, of the court proceeding 
                relevant to the issuance of the court order; and
                    (B) the enrollee is afforded the opportunity to 
                appear and contest the claim of the person seeking the 
                release.
    (c) Effective Date.--Subsection (b) takes effect 30 days after the 
date of the enactment of this Act.

SEC. 106. FEE.

    (a) In General.--A health plan, in each State where the plan offers 
health care services, shall pay to the State 1 percent of the total 
amount of the annual premiums for each year with respect to enrollment 
in the health plan for such year of individuals residing in the State, 
as described in section 208.
    (b) First Payment.--
            (1) In general.--A health plan shall make the first payment 
        under subsection (a) not later than 6 months after the first 
        day of the first full month after the date of the enactment of 
        this Act.
            (2) Payments prorated from date of enactment.--Payments due 
        under subsection (a) for the year in which this Act is enacted 
        shall be prorated to apply only with respect to months 
        beginning on or after the date of the enactment of this Act.
    (c) State Defined.--As used in subsection (a), the term ``State'' 
includes the District of Columbia, Puerto Rico, the Virgin Islands, 
Guam, American Samoa, and the Northern Mariana Islands.

SEC. 107. ENFORCEMENT THROUGH CIVIL PENALTIES.

    (a) Enforcement Through Imposition of Civil Money Penalty.--A 
health plan that violates any provision of sections 101 through 106 
shall be subject to a civil money penalty of--
            (1) up to $25,000 for each violation; or
            (2) up to $100,000 for each violation if the Secretary 
        determines that the plan has engaged, within the 5 years 
        immediately preceding such violation, in a pattern of such 
        violations.
    (b) Procedures.--The provisions of subsections (c) through (l) of 
section 1128A of the Social Security Act (42 U.S.C. 1320a-7a) 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. 108. PROHIBITION ON ADVERSE ACTION.

    (a) In General.--No health plan may terminate or take other adverse 
action against any health care provider for actions taken for the 
purpose of--
            (1) notifying such plan of conditions which the identifies, 
        in communications with the plan, as dangerous or potentially 
        dangerous or injurious to--
                    (A) enrollees who currently receive health care 
                services under the plan;
                    (B) individuals who are likely to receive such 
                services; or
                    (C) health care providers who provide such 
                services;
            (2) notifying a Federal or State agency or an accreditation 
        agency, compliance with the standards of which have been deemed 
        to demonstrate compliance with conditions of participation 
        under the Medicare program, of such conditions as are 
        identified in paragraph (1);
            (3) notifying other individuals of conditions which the 
        provider or group of providers reasonably believe to be such as 
        are described in paragraph (1);
            (4) discussing such conditions as are identified in 
        paragraph (1) with other providers for the purposes of 
        initiating action described in paragraph (1), (2), or (3);
            (5) a medical communication, as defined in section 101(b); 
        or
            (6) other related activities as specified in rules made by 
        the Secretary.
    (b) Exception.--The protections of this section shall not apply to 
any health care provider who knowingly or recklessly provides 
substantially false information to the Secretary.
    (c) Sanction.--A determination by the Secretary that a health plan 
has taken such action as described in subsection (a) shall result in 
termination from participation in the Medicare program for a period of 
time to be specified by the Secretary, such period to be not less than 
1 month.
    (d) Civil action.--A health care provider aggrieved by a violation 
of subsection (a) may in a civil action obtain appropriate relief. Such 
relief may include, with respect to a provider, the reinstatement of 
the provider to his or her former position under the health plan 
together with the compensation (including back pay), terms, conditions, 
and privileges associated with such position.
    (e) Effective Date.--Subsection (a) shall apply to actions taken on 
or after the date of the enactment of this Act, regardless of when the 
communication on which the action is based occurred.

            TITLE II--OFFICE OF CONSUMER ADVOCACY FOR HEALTH

SEC. 201. ESTABLISHMENT OF OFFICE.

    (a) In General.--The Secretary, in consultation with the Secretary 
of Labor, shall establish for each State an independent Office for such 
State to assist consumers in dealing with problems that arise with 
respect to health plans and health care providers operating in such 
State.
    (b) Establishment Through Grant Process.--
            (1) In general.--The Secretary shall carry out the 
        requirements of subsection (a) with respect to each State by 
        designating a non-profit organization located in the State to 
        serve as the Office for the State, under a grant awarded, in 
        consultation with the Secretary of Labor, under a competitive 
        selection process. The grant may be awarded only to 
        organizations headed by an individual with expertise and 
        experience in the fields of health care and consumer advocacy, 
        who shall be designated the Consumer Advocate for Health for 
        the State. In awarding such grant, the Secretary, in 
        consultation with the Secretary of Labor, shall--
                    (A) consider any nominations submitted by consumer 
                advocacy organizations in the State; and
                    (B) give preference to organizations that represent 
                a broad spectrum of the diverse consumer interests in 
                the State and that have demonstrated a capability of 
                representing, and working with, a broad diversity of 
                consumers, including members of medically underserved 
                communities.
            (2) Requirements.--Each grant awarded under this subsection 
        shall provide as follows:
                    (A) Central office.--A central office of the 
                organization awarded the grant which is located in the 
                State shall be designated as the Office.
                    (B) Local offices.--The organization awarded the 
                grant shall establish and maintain local offices of the 
                Office in accordance with subsection (c).
                    (C) Performance of specified functions.--The 
                organization shall perform the functions of the Office 
                specified in this title and otherwise ensure that the 
                requirements of this section applicable to the Office 
                are met.
                    (D) Evaluation of quality and effectiveness of 
                grantee.--The Secretary, in consultation with the 
                Secretary of Labor, shall evaluate the quality and 
                effectiveness of the organization in carrying out the 
                functions of the Office.
                    (E) Term of grant and renewability.--Each grant 
                shall be awarded for a term of 4 years and shall be 
                renewable for succeeding 4-year terms without reopening 
                the competitive selection process if the grantee has 
                performed properly pursuant to this section and the 
                terms of the grant.
                    (F) Notice of intent not to renew; 
                reconsideration.--Not later than 180 days before the 
                expiration of any term under a grant awarded to an 
                organization, if the Secretary at such time intends not 
                to renew the grant with such organization, the 
                Secretary shall notify such organization of such 
                intent, and shall provide such organization an 
                opportunity for reconsideration by the Secretary, in 
                consultation with the Secretary of Labor, of the 
                Secretary's intent not to renew and to present 
                information in support of renewal.
                    (G) Termination by grantee.--The organization may 
                terminate the grant prior to its expiration upon 180 
                days notice to the Secretary.
                    (H) Termination by the secretary.--The Secretary, 
                in consultation with the Secretary of Labor, may 
                terminate the grant prior to its expiration upon 180 
                days notice to the organization if the Secretary, in 
                consultation with the Secretary of Labor, determines 
                that the organization is not meeting the requirements 
                of this section or that the organization is failing 
                substantially to carry out the grant. The Secretary, in 
                consultation with the Secretary of Labor, shall provide 
                for an appropriate appeals mechanism, including 
                establishment of a panel of peers, to implement this 
                subparagraph.
    (c) Delegations to Local Offices.--
            (1) In general.--The Secretary, in consultation with the 
        Secretary of Labor, shall provide for appropriate delegation by 
        the Consumer Advocate for Health of the authority and 
        responsibilities of the Office to local offices to the extent 
        necessary to effectively carry out the duties and 
        responsibilities of the Consumer Advocate for Health throughout 
        the State.
            (2) Monitoring.--The Secretary, in consultation with the 
        Secretary of Labor, shall develop and maintain policies and 
        procedures for monitoring such local offices and ensuring 
        compliance by such local offices with the terms of such 
        delegation.
            (3) Placement of local office in each community rating 
        area.--
                    (A) In general.--Pursuant to such delegation, the 
                Consumer Advocate for Health shall ensure that there is 
                located in each community rating area in the State an 
                officer or employee of the Office who is designated to 
                assist individuals residing in the area with respect to 
                matters relating to health plans and health care 
                providers operating in the area.
                    (B) Assignment of staff for each plan.--Each such 
                office for such area shall have an individual who is 
                assigned with respect to each health plan that enrolls 
                individuals residing in the area. Such an individual 
                may be assigned to more than one plan.
                    (C) Appropriate staffing.--The Office shall ensure 
                that sufficient staff in each local office is assigned 
                to work with respect to matters relating to each health 
                plan whose enrollees are served by the local office so 
                as to ensure effective and efficient service in such 
                local office with respect to matters relating to such 
                plan.
    (d) Establishment of Community Rating Areas.--
            (1) In general.--The Secretary shall provide for the 
        division of each State into 1 or more community rating areas. 
        Each portion of the State shall be within 1, and only 1, 
        community rating area. The Secretary may revise the boundaries 
        of such areas from time to time consistent with this 
        subsection.
            (2) Multiple areas.--With respect to a community rating 
        area--
                    (A) no metropolitan statistical area in a State may 
                be incorporated into more than 1 such area in the 
                State;
                    (B) the number of individuals residing within such 
                an area may not be less than 250,000; and
                    (C) no area incorporated in a community rating area 
                may be incorporated into another such area.
            (3) Boundaries.--
                    (A) In general.--In establishing boundaries for 
                community rating areas, the Secretary may not 
                discriminate on the basis of or otherwise take into 
                account race, age, language, religion, national origin, 
                socio-economic status, sexual orientation, disability, 
                or perceived health status.
                    (B) Treatment of consolidated metropolitan 
                statistical areas.--A community rating area that 
                includes all of a Consolidated Metropolitan Statistical 
                Area that is within a State is presumed to meet the 
                requirement of subparagraph (A).

SEC. 202. ASSISTANCE TO INDIVIDUALS WITH GRIEVANCES AGAINST A HEALTH 
              PLAN.

    (a) In General.--An Office shall provide an individual assistance 
with determining, in connection with any stated grievance against a 
health plan, the manner and extent to which such grievance may be 
presented as--
            (1) an issue of denial of items or services, or 
        reimbursement therefor;
            (2) an issue of denial of medical records;
            (3) an issue of malpractice;
            (4) an issue of discrimination;
            (5) an issue of eligibility and payment of subsidies for 
        premium payments and cost sharing;
            (6) an issue of enrollment; or
            (7) any other violation actionable under this Act.
    (b) Grievance Assistance.--Such Office shall provide, in person and 
by toll-free telephone access, assistance to an individual with a 
grievance under subsection (a).
    (c) Complaint Forms.--Such Office shall create an instruction sheet 
that explains how to file, maintain, and resolve a complaint against a 
health plan, and provide such sheet to an individual seeking to file a 
complaint against a health plan. Such instruction sheet shall be 
written in plain language understandable by a layperson, and it shall 
use a step-by-step format to guide the layperson through each stage of 
the complaint process.

SEC. 203. ASSURANCE OF ACCESS BY ALL INDIVIDUALS TO QUALITY HEALTH 
              CARE.

    (a) In General.--An Office shall identify, investigate, publicize, 
promote solutions to, and resolve grievances stemming from, any 
practice, policy, law, or regulation of a health plan that may 
adversely affect access by an individual to quality health care, 
including a practice, policy, law, or regulation relating to--
            (1) marketing of the plan;
            (2) availability of premium and cost sharing subsidies;
            (3) accessibility of services and resources in 
        traditionally underserved areas;
            (4) targeting of resources to traditionally underserved 
        areas; and
            (5) elimination of practices that impede access to 
        available choices for individuals at health risk, including the 
        proper implementation of community rating and risk adjustments.
    (b) Monitoring of Health Plan Denial Procedures.--Such Office shall 
monitor procedures used by health plans for denial of services and for 
reconsideration of such denials.

SEC. 204. FEDERAL INVESTIGATION AND EMERGENCY INTERVENTION.

    (a) In General.--An Office shall provide, in person and by toll-
free telephone access, assistance to an individual who seeks to report 
dangerous conditions in health care services offered under a health 
plan.
    (b) Federal Intervention.--The Secretary may, in cases of 
compromised safety that are life threatening, initiate emergency 
investigation of or remedial intervention in services provided or 
practices undertaken by a health plan.
    (c) Rules.--
            (1) In general.--For purposes of subsection (b), the 
        Secretary shall, by rule, establish guidelines for safety.
            (2) Consideration of data.--In establishing and reviewing 
        the guidelines under paragraph (1), the Secretary shall base 
        the guidelines to the maximum extent practicable on the data 
        collected and the analysis performed under this Act.

SEC. 205. ANNUAL REPORT TO THE SECRETARY.

    (a) In General.--Not later than December 31st of each year, an 
Office shall submit a report to the Secretary.
    (b) Content of Report.--The report required by subsection (a) shall 
include--
            (1) the nature of consumer complaints against health plans;
            (2) the percentage of unresolved or outstanding complaints 
        against health plans;
            (3) discernible patterns from the data collected;
            (4) recommendations for resolution of unresolved or 
        outstanding complaints;
            (5) recommendations to sanction a certain health plan;
            (6) a copy of any report received from a health plan; and
            (7) a copy of any report received from the Committee which 
        reports to such Office.
    (c) Date of First Report.--An Office shall file its first report 
not later than December 31st of the first full calendar year after such 
Office is established.

SEC. 206. OFFICE ADMINISTRATION.

    (a) In General.--An Office shall ensure that individuals in each 
community rating area, as defined in section 201(d), have regular and 
timely access to the services provided through the Office and that the 
individual receives timely responses from a representative of the 
Office to a request for assistance with a complaint against a health 
plan.
    (b) Confidentiality of Complainants.--An Office shall provide for a 
system in the Office to treat as confidential any identifying 
information regarding complainants and other individuals with respect 
to whom the Office maintain files or records.
    (c) Personnel Qualifications.--An Office shall establish and 
implement minimum qualification and training requirements for 
personnel, including volunteers.

SEC. 207. OVERSIGHT.

    The Secretary shall ensure that an Office carries out the functions 
under this title, and such other activities as the Office and the 
Secretary determine to be appropriate.

SEC. 208. FUNDING OF OFFICE.

    (a) Funds Held in Escrow.--In accordance with procedures which 
shall be made by rule under subsection (d), each State shall provide 
for a mechanism under which the State shall hold in an escrow account 1 
percent of the total amount of the annual premiums for each year with 
respect to enrollment in a health plan for such year of individuals 
residing in the State. Any funds held in such escrow account shall be 
available solely for remittance to the Secretary under subsection (b).
    (b) Remittance to Secretary.--Not later than December 31 of each 
calendar year, each State shall remit to the Secretary, in such form 
and manner as shall be prescribed in regulations, the amounts held in 
escrow pursuant to subsection (a) for the applicable fiscal year ending 
with or during such calendar year.
    (c) Allocations.--The amounts remitted by each State to the 
Secretary for each year under subsection (b) shall be applied towards 
the establishment and operation of the Office for such State under 
section 201 (including amounts to be distributed to escrow accounts for 
Committees pursuant to section 306).
    (d) Rules.--Not later than 180 days after the date of the enactment 
of this Act, the Secretary shall make rules to carry out this section.

          TITLE III--INDEPENDENT CONSUMER ADVISORY COMMITTEES

SEC. 301. ESTABLISHMENT OF COMMITTEES.

    Each health plan shall establish and maintain an Committee.

SEC. 302. MEMBERSHIP AND CHAIR.

    (a) Membership.--
            (1) In general.--A Committee shall consist of not fewer 
        than 25 and not more than 50 members.
            (2) Qualifications.--Except as provided in paragraph 
        (3)(B), members of a Committee shall be selected from enrollees 
        who indicate interest in such positions and who are not health 
        care providers, officers or employees of any health plan, or 
        employees of a health care provider.
            (3) Method of selection.--
                    (A) Enrollees.--Except as provided in subparagraph 
                (B), members of a Committee shall be selected 
                biennially at random from each of 4 categories of 
                enrollees, in proportion to their numbers among 
                enrollees represented by the Committee, as follows: 
                senior citizens; parents of children under 18 years of 
                age; individuals with disabilities; and all other 
                enrollees.
                    (B) Employees of health plan.--Each committee shall 
                have as members at least 3, but in no case more than 5, 
                employees of the health plan selected biennially at 
                random from each of 3 categories as follows: staff 
                nurses; physicians; and administrators of the health 
                plan.
    (b) Chair.--Each Committee shall be headed by a chair who shall 
be--
            (1) a member of the Committee other than a member who is an 
        employee of a health plan; and
            (2) elected by the Committee at its first meeting.
    (c) Compensation and Expenditures for Services.--
            (1) Compensation of members.--Members of each Committee 
        shall serve without compensation, except that the members shall 
        be reimbursed by the Committee for the reasonable expenses 
        incurred in carrying out their duties as members.
            (2) Expenditures for services.--The Committee may provide 
        for acquiring the services of such staff and temporary 
        consultants as may be necessary from time to time to carry out 
        the requirements of this title.

SEC. 303. FUNCTIONS OF COMMITTEE.

    (a) Outreach Programs.--Each Committee shall develop and coordinate 
programs for outreach to the community.
    (b) Forum to Facilitate Communication.--Each Committee shall 
conduct regular meetings of enrollees and representatives of the health 
plan under such procedural rules as the Committee considers 
appropriate, so that such meetings will serve as effective forums for 
facilitating communication between such plan and enrollees.
    (c) Ensure Enrollee Grievances Are Addressed.--Each Committee shall 
conduct such ad hoc meetings and other activities as may enable the 
Committee to ensure that the grievances of enrollees in the area are 
generally heard and addressed by the health plan.
    (d) Dissemination of Criteria for Enrollee Care Quality.--Each 
Committee shall provide to the community the enrollee care quality 
criteria established by the health plan under section 104(c).
    (e) Evaluation of Performance of Office of Consumer Advocacy.--Each 
Committee shall evaluate annually the performance of the Office for the 
State in which the health plan is located and make recommendations to 
the Secretary regarding the appropriateness for continued service of 
the Office.

SEC. 304. LIABILITY OF MEMBERS OF COMMITTEE.

    No member of a Committee established under this section shall be 
liable under any law for the good faith performance of the functions 
specified in this title.

SEC. 305. ANNUAL REPORT TO OFFICE.

    (a) In General.--Not later than December 31st of each year, each 
Committee shall submit to the Office for the State in which the health 
plan offers health care services a report providing recommendations for 
improvements in health care delivery under the plan, and including 
assessments of--
            (1) the accessibility (by location) of offices and clinics 
        providing items and services under the plan;
            (2) the condition of health care facilities employed under 
        the plan;
            (3) the ease with which prescriptions are filled under the 
        plan;
            (4) delays occurring under the plan in receiving requested 
        medical attention;
            (5) the time spent by enrollees in waiting rooms under the 
        plan;
            (6) the complexity of paperwork required under the plan;
            (7) the courtesy of plan personnel; and
            (8) such other concerns regarding the plan's system of 
        delivering health care services that the Committee may choose 
        to assess.
    (b) Date of First Report.--Each committee shall file its first 
report not later than December 31st of the first full calendar year 
after such Committee is established.

SEC. 306. FUNDING FOR COMMITTEES.

    (a) Escrow Account for Committees.--In accordance with procedures 
which shall be made by rule under subsection (e), an Office shall 
establish and maintain an escrow account for each Committee established 
in the State served by the Office.
    (b) Distribution of Funds to Escrow Account for Committees.--The 
Office shall annually distribute an amount equal to 25 percent of the 
total amount remitted for the year to the Secretary by the State under 
section 208, on the basis of which funds are made available to the 
Office for the year under title II, in the form of deposits to the 
escrow accounts maintained by the Office for Committees pursuant to 
subsection (a). The amounts deposited to such escrow accounts shall be 
in proportion to the numbers of enrollees represented by the Committees 
for which such escrow accounts are maintained.
    (c) Withdrawal of Funds for Committee at the Request of the 
Chair.--The funds maintained in each such escrow account for a 
Committee shall be made available for withdrawal by the chair of the 
Committee upon request of the chair, specifying in writing the purpose 
for the withdrawal.
    (d) Annual Accounting.--The Office shall provide the Secretary an 
annual accounting of the receipts and disbursements made with respect 
to each such escrow account.
    (e) Rules.--Not later than 180 days after the date of the enactment 
of this Act, the Secretary shall make rules to carry out this section.
    (f) Restriction on Use of Funds.--Funds withdrawn from an escrow 
account maintained pursuant to this section for a Committee established 
pursuant to this title shall be used by the Committee solely for 
purposes of carrying out its duties under this title.

     TITLE IV--COORDINATION AMONG OFFICE, COMMITTEES, AND SECRETARY

SEC. 401. INTERACTION AMONG OFFICE AND OTHER ORGANIZATIONS.

    An Office shall establish and maintain a system of referrals among 
the Office, other consumer advocacy organizations, legal assistance 
providers serving low-income persons, and protection and advocacy 
systems for individuals with disabilities.

SEC. 402. ASSISTANCE TO COMMITTEES.

    An Office shall provide technical assistance to the Committees 
maintained by health plans pursuant to section 301, and distribute and 
account for funding for such Committees in accordance with section 306.

SEC. 403. COORDINATED DATA ANALYSIS AND DISSEMINATION PROCEDURE.

    (a) Data Compilation and Submission.--
            (1) In general.--Not later than December 31st of each year, 
        each Committee shall compile the enrollee quality care data 
        collected under section 104(c) and shall submit such data to 
        the Office from which such Committee received its funds under 
        section 306.
            (2) Transmission from office to secretary.--Not later than 
        30 days after the receipt of the data submitted by the 
        Committees under paragraph (1), the Office shall compile all 
        data received from the Committees to which it transmits funds 
        under section 306 and shall submit such data to the Secretary.
    (b) Data Analysis and Publication.--The Secretary shall analyze the 
data received under subsection (a)(2) with the purpose of using such 
data to develop Federal guidelines for patient care quality and shall 
publish its findings.
    (c) Use of Guidelines for Evaluation of Health Plan.--An Office and 
the Committees shall use such findings and guidelines to evaluate the 
performance of health plans operating in their community rating areas. 
If an order is granted pursuant to subparagraph (C) or (F), the court 
shall impose appropriate safeguards against unauthorized disclosure. 
Court orders authorizing disclosure under subparagraph (C) shall issue 
only with prior notice to the consumer and only if the law enforcement 
agency shows that there is probable cause to believe that the records 
or other information sought are relevant to a legitimate law 
enforcement inquiry. In the case of a State government authority, such 
a court order shall not issue if prohibited by the law of such State. A 
court issuing an order pursuant to this section, on a motion made 
promptly by the video tape service provider, may quash or modify such 
order if the information or records requested are unreasonably 
voluminous in nature or if compliance with such order otherwise would 
cause an unreasonable burden on such provider.
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