[Congressional Bills 105th Congress]
[From the U.S. Government Publishing Office]
[H.R. 3547 Introduced in House (IH)]







105th CONGRESS
  2d Session
                                H. R. 3547

  To amend the Public Health Service Act and the Employee Retirement 
  Income Security Act of 1974 to assure patient choice and access to 
   services for enrollees in group health plans and health insurance 
                               coverage.


_______________________________________________________________________


                    IN THE HOUSE OF REPRESENTATIVES

                             March 25, 1998

Mr. Weldon of Florida (for himself, Mr. Brown of Ohio, Mr. Coburn, Mr. 
Strickland, Mr. Cooksey, and Mr. Green) introduced the following bill; 
 which was referred to the Committee on 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 assure patient choice and access to 
   services for enrollees in group health plans and health insurance 
                               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 ``Patient Choice and Access to Quality 
Health Care Act of 1998''.

SEC. 2. FINDINGS.

    Congress finds the following:
            (1) There should be no unreasonable barriers or impediments 
        to the ability of individuals enrolled in health care plans to 
        obtain appropriate specialized medical services.
            (2) The patient's first point of contact in a health care 
        plan must be encouraged to make all appropriate medical 
        referrals and should not be constrained financially from making 
        such referrals.
            (3) Some health care plans may impede timely access to 
        specialty care.
            (4) Some contracts between health care plans and health 
        care professionals may contain provisions which impede the 
        professional in informing the patient of the full range of 
        treatment options.
            (5) Patients cannot make appropriate health care decisions 
        without access to all relevant information relating to those 
        decisions.
            (6) Restrictions on the ability of health care 
        professionals to provide full disclosure of all relevant 
        information to patients making health care decisions violate 
        the principles of informed consent and the ethical standards of 
        the health care professions. Contractual clauses and other 
        policies that interfere with communications between health care 
        professionals and patients can impact the quality of care 
        received by those patients.
            (7) Patients should have the opportunity to access out-of-
        network items, treatment, and services at an additional cost to 
        the patient, recognizing prevalent market conditions, which is 
        not so prohibitive that they are deterred from seeing the 
        health care professional of their own choice.
            (8) Specialty care must be available for the full duration 
        of the patient's medical needs at the discretion of the 
        attending health care professional in consultation with the 
        patient.
            (9) Access to specialty care is essential for patients in 
        emergency and non-emergency situations and for patients with 
        chronic and temporary conditions.

SEC. 3. PROTECTION FOR HEALTH PLAN ENROLLEES.

    (a) Group Health Plans.--
            (1) Public health service act amendments.--
                    (A) In general.--Subpart 2 of part A of title XXVII 
                of the Public Health Service Act is amended by adding 
                at the end the following new section:

``SEC. 2706. ADDITIONAL ENROLLEE PROTECTIONS.

    ``(a) Assuring Adequate In-network Access.--
            ``(1) Timely access.--A group health plan, and a health 
        insurance issuer offering group health insurance coverage, that 
        restricts the health care professionals from whom benefits may 
        be obtained shall guarantee to enrollees timely access to 
        primary and specialty health care professionals who are 
        appropriate to the enrollee's condition.
            ``(2) Access to specialized care.--A group health plan, and 
        a health insurance issuer offering group health insurance 
        coverage, shall assure that enrollees have access to 
        specialized treatment when medically necessary. This access may 
        be satisfied through contractual arrangements with specialized 
        providers outside of the network.
            ``(3) Continuity of care.--A group health plan, and a 
        health insurance issuer offering group health insurance 
        coverage, shall assure that the plan's or issuer's use of case 
        management may not create an undue burden for enrollees under 
        this section. The plan and issuer shall ensure direct access to 
        specialists for ongoing care as so determined by the case 
        manager in consultation with the specialty care professional. 
        This continuity of care may be satisfied for enrollees with 
        chronic conditions through the use of a specialist serving as 
        case manager.
    ``(b) Grievance Process.--
            ``(1) In general.--A group health plan, and a health 
        insurance issuer offering group health insurance coverage, 
        shall provide a meaningful and expedited procedure, which 
        includes notice and hearing requirements, for resolving 
        grievances between the plan or issuer (including any entity or 
        individual through which the plan or issuer provides health 
        care services) and enrollees. Under the procedure any such 
        enrollee may at any time file a complaint to resolve grievances 
        between the enrollee and the plan or issuer before a board of 
        appeals established under paragraph (3).
            ``(2) Notice requirements.--
                    ``(A) In general.--Such a plan or issuer shall 
                provide, in a timely manner, an enrollee a notice of 
                any denial of services in-network or denial of payment 
                for out-of-network care.
                    ``(B) Information required.--Such notice shall 
                include the following:
                            ``(i) A clear statement of the reason for 
                        the denial.
                            ``(ii) An explanation of the complaint 
                        process under paragraph (3) which is available 
                        to the enrollee upon request.
                            ``(iii) An explanation of all other appeal 
                        rights available to all enrollees.
                            ``(iv) A description of how to obtain 
                        supporting evidence for the hearing described 
                        in paragraph (3), including the patient's 
                        medical records from the plan or issuer, as 
                        well as supporting affidavits from the 
                        attending health care professionals.
            ``(3) Hearing board.--
                    ``(A) In general.--Each group health plan, and each 
                health insurance issuer offering group health insurance 
                coverage, shall establish a board of appeals to hear 
                and make determinations on complaints by enrollees 
                concerning denials of coverage or payment for services 
                (whether in-network or out-of-network) and the medical 
                necessity and appropriateness of covered items and 
                services.
                    ``(B) Composition.--A board of appeals of a plan or 
                issuer shall consist of--
                            ``(i) representatives of the plan or 
                        issuer, including physicians, nonphysicians, 
                        administrators, and enrollees;
                            ``(ii) consumers who are not enrollees and 
                        who have no financial interest in the plan or 
                        issuer; and
                            ``(iii) health care professionals who are 
                        not under contract with and have no financial 
                        interest in the plan or issuer and who are 
                        experts in the field of medicine which 
                        necessitates treatment.
                    ``(C) Deadline for decision.--
                            ``(i) In general.--Except as provided in 
                        clause (ii), a board of appeals shall hear and 
                        resolve complaints within 30 days after the 
                        date the complaint is filed with the board.
                            ``(ii) Expedited procedure.--A board of 
                        appeals shall have an expedited procedure in 
                        order to hear and resolve complaints regarding 
                        urgent care.
    ``(c) Notice of Enrollee Rights and Enrollee Information 
Checklist.--
            ``(1) In general.--Each group health plan, and each health 
        insurance issuer offering group health insurance coverage, 
        shall provide each enrollee, at the time of enrollment and not 
        less frequently than annually thereafter, an explanation of the 
        enrollee's rights under this section and a copy of the most 
        recent enrollee information checklist for the plan or issuer 
        (as described in paragraph (3)).
            ``(2) Rights described.--The explanation of rights under 
        paragraph (1) shall include an explanation of--
                    ``(A) the enrollee's rights to benefits from the 
                plan or issuer;
                    ``(B) the restrictions on payments (if any) under 
                the plan or coverage for services furnished other than 
                by or through the plan or issuer;
                    ``(C) out-of-area coverage provided under the plan 
                or coverage;
                    ``(D) the plan's or issuer's coverage of emergency 
                services and urgently needed care;
                    ``(E) the plan's or issuer's coverage of out-of-
                network services; and
                    ``(F) appeal rights of enrollees.
            ``(3) Enrollee information checklist.--For purposes of 
        paragraph (1), the term `enrollee information checklist' means, 
        with respect to a plan or issuer for a year, a list containing 
        the following information (provided in a manner that permits 
        consumers to compare plans and issuers with respect to the 
        information):
                    ``(A) For each plan or coverage offered, 
                information on the following:
                            ``(i) The premium for the plan or coverage.
                            ``(ii) The benefits offered under the plan 
                        or coverage.
                            ``(iii) the amount of any deductibles, 
                        coinsurance, or any monetary limits on 
                        benefits.
                            ``(iv) The identity, location, 
                        qualifications, and availability of health care 
                        professionals in any networks of the plan or 
                        issuer.
                            ``(v) The procedures used by the plan or 
                        issuer to control utilization of services and 
                        expenditures, including any financial 
                        incentives.
                            ``(vi) The procedures used by the plan or 
                        issuer to ensure quality of care.
                            ``(vii) The rights and responsibilities of 
                        enrollees.
                            ``(viii) The number of applications during 
                        the previous plan year requesting that the plan 
                        or issuer cover certain medical services that 
                        were denied by the plan or issuer (and the 
                        number of such denials that were subsequently 
                        reversed by the plan or issuer), stated as a 
                        percentage of the total number of applications 
                        during such period requesting that the plan or 
                        issuer cover such services.
                            ``(ix) The number of times during the 
                        previous plan year that a court of law upheld 
                        or reversed a denial of a request that the plan 
                        or issuer cover certain medical services.
                            ``(x) The restrictions (if any) on payment 
                        for services provided outside the plan's or 
                        issuer's health care professional network.
                            ``(xi) The process by which services may be 
                        obtained through the plan's or issuer's health 
                        care professional network.
                            ``(xii) Coverage for out-of-area services.
                            ``(xiii) Any exclusions in the types of 
                        health care professionals participating in the 
                        plan's or issuer's health care professional 
                        network.
    ``(d) Restrictions on Health Care Professional Incentive Plans.--A 
group health plan, and a health insurance issuer offering group health 
insurance coverage, may not operate any health care professional 
incentive plan under which a specific payment is made directly or 
indirectly under the plan to a health care professional or professional 
group as an inducement to reduce or limit medically necessary services 
provided with respect to enrollees.
    ``(e) Prohibition of Interference With Certain Medical 
Communications.--
            ``(1) In general.--
                    ``(A) Prohibition of certain provisions.--Subject 
                to paragraph (3), a group health plan, and a health 
                insurance issuer offering group health insurance 
                coverage, may not include under the plan or coverage 
                any provision that prohibits or restricts any medical 
                communication (as defined in paragraph (2)) as part 
                of--
                            ``(i) a written contract or agreement with 
                        a health care professional,
                            ``(ii) a written statement to such a 
                        professional, or
                            ``(iii) an oral communication to such a 
                        professional.
                    ``(B) Nullification.--Any provision described in 
                clause (i) is null and void.
            ``(2) Medical communication defined.--In this paragraph, 
        the term `medical communication' means a communication made by 
        a health care professional with a patient of the professional 
        (or the guardian or legal representative of such patient) with 
        respect to any of the following:
                    ``(A) How participating physicians and health care 
                professionals are paid.
                    ``(B) Utilization review procedures.
                    ``(C) The basis for specific utilization review 
                decisions.
                    ``(D) Whether a specific prescription drug or 
                biological is included in the formulary.
                    ``(E) How the plan or organization decides whether 
                a treatment or procedure is experimental.
                    ``(F) The patient's physical or mental condition or 
                treatment options.
            ``(3) Construction.--Nothing in this subsection shall be 
        construed as preventing an entity from--
                    ``(A) acting on information relating to the 
                provision of (or failure to provide) treatment to a 
                patient, or
                    ``(B) restricting a medical communication that 
                recommends one health plan over another if the sole 
                purpose of the communication is to secure financial 
                gain for the health care professional.
    ``(f) Out-of-Network Access.--
            ``(1) In general.--Subject to paragraph (2), if a group 
        health plan, or a health insurance issuer offering group health 
        insurance coverage, offers to enrollees coverage for benefits 
        for services only if such services are furnished through 
        professionals and other persons who are members of a network of 
        professionals and other persons who have entered into a 
        contract with the plan or issuer to provide such services, the 
        plan or issuer shall also offer to such enrollees (at the time 
        of enrollment) the option of coverage of such services which 
        are not furnished through professionals and other persons who 
        are members of such a network.
            ``(2) Effectiveness.--Paragraph (1) shall apply only in 
        accordance with section 3(b)(2) of the Patient Choice and 
        Access to Quality Health Care Act of 1998 (relating to a 
        finding by the Secretary that the other patient protections 
        have not assured quality of care).
    ``(g) Additional Definitions.--For purposes of this section:
            ``(1) Health care professional.--The term `health care 
        professional' means a physician or other health care 
        practitioner licensed, accredited, or certified to perform 
        specified health services consistent with State law.
            ``(2) In-network.--The term `in-network' means services 
        provided by health care professionals who have entered into a 
        contract or agreement with a group health plan, or health 
        insurance issuer offering group health insurance coverage in 
        connection with such a plan, under which such professionals are 
        obligated to provide items, treatment, and services under this 
        section to individuals enrolled under the plan.
            ``(3) Network.--The term `network' means, with respect to a 
        group health plan or a health insurance issuer that offers 
        group health insurance coverage in connection with such a plan, 
        the health care professionals who have entered into a contract 
        or agreement with the plan or issuer under which such 
        professionals are obligated to provide items, treatment, and 
        services under this section to individuals enrolled under the 
        plan.
            ``(4) Out-of-network.--The term `out-of-network' means 
        services provided by health care professionals who have not 
        entered into a contract or agreement described in paragraph 
        (2).
    ``(h) Notice.--A group health plan under this part shall comply 
with the notice requirement under section 713(b) of the Employee 
Retirement Income Security Act of 1974 with respect to the requirements 
of this section as if such section applied to such plan.''.
                    (B) Reference to non-preemption provision.--
                Pursuant to section 2723 of the Public Health Service 
                Act, States may provide protections for individuals 
                that are equivalent to or stricter than the protections 
                provided under the amendment made by subparagraph (A).
                    (C) Conforming amendment.--Section 2723(c) of such 
                Act (42 U.S.C. 300gg-23(c)), as amended by section 
                604(b)(2) of Public Law 104-204, is amended by striking 
                ``section 2704'' and inserting ``sections 2704 and 
                2706''.
            (2) ERISA amendments.--
                    (A) In general.--Subpart B of part 7 of subtitle B 
                of title I of the Employee Retirement Income Security 
                Act of 1974 is amended by adding at the end the 
                following new section:

``SEC. 713. ADDITIONAL ENROLLEE PROTECTIONS.

    ``(a) In General.--Subject to subsection (b), a group health plan 
(and a health insurance issuer offering group health insurance coverage 
in connection with such a plan) shall comply with the requirements of 
section 2706 of the Public Health Service Act. For purposes of applying 
this subsection, any reference in such section 2706 to an enrollee with 
respect to health insurance coverage is deemed to include a reference 
to a participant or beneficiary with respect to a group health plan.
    ``(b) Notice Under Group Health Plan.--The imposition of the 
requirement of this section shall be treated as a material modification 
in the terms of the plan described in section 102(a)(1), for purposes 
of assuring notice of such requirements under the plan; except that the 
summary description required to be provided under the last sentence of 
section 104(b)(1) with respect to such modification shall be provided 
by not later than 60 days after the first day of the first plan year in 
which such requirement apply.''.
                    (B) Reference to non-preemption provision.--
                Pursuant to section 731 of the Employee Retirement 
                Income Security Act of 1974, States may provide 
                protections for individuals that are equivalent to or 
                stricter than the protections provided under the 
                amendment made by subparagraph (A).
                    (C) Conforming amendments.--(i) Section 731(c) of 
                such Act (29 U.S.C. 1191(c)) is amended by striking 
                ``section 711'' and inserting ``sections 711 and 713''.
                    (ii) Section 732(a) of such Act (29 U.S.C. 
                1191a(a)) is amended by striking ``section 711'' and 
                inserting ``sections 711 and 713''.
                    (D) The table of contents in section 1 of such Act 
                is amended by inserting after the item relating to 
                section 712 the following new item:

``Sec. 713. Additional enrollee protections.''.
    (b) Individual Health Insurance.--
            (1) In general.--Part B of title XXVII of the Public Health 
        Service Act is amended by inserting after section 2751 the 
        following new section:

``SEC. 2752. ADDITIONAL ENROLLEE PROTECTIONS.

    ``(a) In General.--The provisions of section 2706 (other than 
subsection (i)) shall apply to health insurance coverage offered by a 
health insurance issuer in the individual market in the same manner as 
they apply to health insurance coverage offered by a health insurance 
issuer in connection with a group health plan in the small or large 
group market.
    ``(b) Notice.--A health insurance issuer under this part shall 
comply with the notice requirement under section 713(b) of the Employee 
Retirement Income Security Act of 1974 with respect to the requirements 
referred to in subsection (a) as if such section applied to such issuer 
and such issuer were a group health plan.''.
            (2) Reference to non-preemption provision.--Pursuant to 
        section 2762 of the Public Health Service Act, States may 
        provide protections for individuals that are equivalent to or 
        stricter than the protections provided under the amendment made 
        by paragraph (1).
            (3) Conforming amendment.--Section 2762(b)(2) of such Act 
        (42 U.S.C. 300gg-62(b)(2)) is amended by striking ``section 
        2751'' and inserting ``sections 2751 and 2752''.
    (c) Effective Dates.--
            (1) Group health plans.--
                    (A) In general.--Subject to subparagraph (B), the 
                amendments made by subsection (a) shall apply with 
                respect to group health plans for plan years beginning 
                on or after January 1, 1999.
            (B) Rule for certain collective bargaining agreements.--In 
        the case of a group health plan maintained pursuant to 1 or 
        more collective bargaining agreements between employee 
        representatives and 1 or more employers ratified before the 
        date of enactment of this Act, the amendments made subsection 
        (a) shall not apply to plan years beginning before the later 
        of--
                    (i) the date on which the last collective 
                bargaining agreements relating to the plan terminates 
                (determined without regard to any extension thereof 
                agreed to after the date of enactment of this Act), or
                    (ii) January 1, 1999.
        For purposes of clause (i), any plan amendment made pursuant to 
        a collective bargaining agreement relating to the plan which 
        amends the plan solely to conform to any requirement added by 
        subsection (a) shall not be treated as a termination of such 
        collective bargaining agreement.
            (2) Individual health insurance coverage.--The amendment 
        made by subsection (b) shall apply with respect to health 
        insurance coverage offered, sold, issued, renewed, in effect, 
        or operated in the individual market on or after such date.
    (d) Coordinated Regulations.--Section 104(1) of Health Insurance 
Portability and Accountability Act of 1996 is amended by striking 
``this subtitle (and the amendments made by this subtitle and section 
401)'' and inserting ``the provisions of part 7 of subtitle B of title 
I of the Employee Retirement Income Security Act of 1974, the 
provisions of parts A and C of title XXVII of the Public Health Service 
Act, and chapter 100 of the Internal Revenue Code of 1986''.

SEC. 4. REPORT ON EFFECTIVENESS OF PATIENT PROTECTIONS.

    (a) Study.--The Secretary of Health and Human Services shall 
provide for a study on the effectiveness of the amendments made by 
section 3 in assuring quality of care for patients. Such study shall 
also examine any additional costs imposed as a result of the enactment 
of such amendments.
    (b) Report.--
            (1) In general.--The Secretary shall submit to Congress a 
        report on such study not later than January 1, 2001.
            (2) Finding regarding quality care.--The Secretary shall 
        include in the report a specific finding as to whether, taking 
        into account the patient protections provided under such 
        amendments, individuals covered under health plans are not 
        being provided quality care. If the Secretary makes such a 
        finding that individuals covered under health plans are not 
        being provided quality care and if Congress concurs by joint 
        resolution or Act with such a finding, then subsection (f)(1) 
        of section 2706 of the Public Health Service Act shall become 
        effective in the same manner as amendments made by subsections 
        (a) and (b) of section 3 become effective under section 3(c), 
        except that (for purposes of this paragraph) any reference in 
        such section 3(c) to January 1, 1999, shall be deemed a 
        reference to January 1, 2002.
                                 <all>