[Congressional Bills 105th Congress]
[From the U.S. Government Publishing Office]
[H.R. 3997 Introduced in House (IH)]







105th CONGRESS
  2d Session
                                H. R. 3997

      To amend title XVIII of the Social Security Act to require 
    Medicare+Choice organizations to assure access to obstetrician-
            gynecologists and to assure continuity of care.


_______________________________________________________________________


                    IN THE HOUSE OF REPRESENTATIVES

                              June 4, 1998

Mr. Stark (for himself, Mr. Cardin, Mr. Kleczka, Mr. Lewis of Georgia, 
 and Mr. Becerra) introduced the following bill; which was referred to 
 the Committee on Ways and Means, and in addition to the Committee on 
Commerce, 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 title XVIII of the Social Security Act to require 
    Medicare+Choice organizations to assure access to obstetrician-
            gynecologists and to assure continuity of care.

    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 ``Medicare Consumer Bill of Rights 
Conforming Act of 1998''.

SEC. 2. ASSURING ACCESS TO OBSTETRICIAN-GYNECOLOGISTS.

    Section 1852(d) of the Social Security Act (42 U.S.C. 1395w-22(d)) 
is amended--
            (1) by striking ``A Medicare+Choice organization'' and 
        inserting ``Subject to paragraph (5), a Medicare+Choice 
        organization'', and
            (2) by adding at the end the following new paragraph:
            ``(5) Assuring access to obstetrical and gynecological 
        care.--
                    ``(A) In general.--If a Medicare+Choice 
                organization requires or provides for an enrollee to 
                designate a participating primary care provider--
                            ``(i) the organization shall permit such an 
                        individual to designate a participating 
                        physician who specializes in obstetrics and 
                        gynecology as the individual's primary care 
                        provider; and
                            ``(ii) if such an individual has not 
                        designated such a provider as a primary care 
                        provider, the organization--
                                    ``(I) may not require authorization 
                                or a referral by the individual's 
                                primary care provider or otherwise for 
                                coverage of routine gynecological care 
                                (such as preventive women's health 
                                examinations) and pregnancy-related 
                                services provided by a participating 
                                health care professional who 
                                specializes in obstetrics and 
                                gynecology to the extent such care is 
                                otherwise covered, and
                                    ``(II) may treat the ordering of 
                                other gynecological care by such a 
                                participating physician as the 
                                authorization of the primary care 
                                provider with respect to such care 
                                under the Medicare+Choice plan.
                    ``(B) Construction.--Nothing in subparagraph 
                (A)(ii)(II) shall waive any requirements of coverage 
                relating to medical necessity or appropriateness with 
                respect to coverage of gynecological care so 
                ordered.''.

SEC. 3. ASSURING CONTINUITY OF CARE.

    Section 1852 of the Social Security Act (42 U.S.C. 1395w-22) is 
amended by adding at the end the following new subsection:
    ``(l) Assuring Continuity of Care.--
            ``(1) In general.--
                    ``(A) Termination of provider.--If a contract 
                between a Medicare+Choice organization and a health 
                care provider is terminated (as defined in subparagraph 
                (B)), or benefits or coverage provided by a health care 
                provider are terminated because of a change in the 
                terms of provider participation in a Medicare+Choice 
                plan, and an individual who is an enrollee in the plan 
                is undergoing a course of treatment from the provider 
                at the time of such termination, the organization 
                shall--
                            ``(i) notify the individual on a timely 
                        basis of such termination, and
                            ``(ii) subject to paragraph (3), permit the 
                        individual to continue or be covered with 
                        respect to the course of treatment with the 
                        provider during a transitional period (provided 
                        under paragraph (2)).
                    ``(B) Termination.--In this subsection, the term 
                `terminated' includes, with respect to a contract, the 
                expiration or nonrenewal of the contract, but does not 
                include a termination of the contract by the 
                organization for failure to meet applicable quality 
                standards or for fraud.
            ``(2) Transitional period.--
                    ``(A) In general.--Except as provided in 
                subparagraphs (B) through (D), the transitional period 
                under this paragraph shall extend for at least 90 days 
                from the date of the notice described in paragraph 
                (1)(A)(i) of the provider's termination.
                    ``(B) Institutional care.--The transitional period 
                under this paragraph for institutional or inpatient 
                care from a provider shall extend until the discharge 
                or termination of the period of institutionalization 
                and also shall include institutional care provided 
                within a reasonable time of the date of termination of 
                the provider status if the care was scheduled before 
                the date of the announcement of the termination of the 
                provider status under paragraph (1))(A)(i) or if the 
                individual on such date was on an established waiting 
                list or otherwise scheduled to have such care.
                    ``(C) Pregnancy.--If--
                            ``(i) an enrollee has entered the second 
                        trimester of pregnancy at the time of a 
                        provider's termination of participation, and
                            ``(ii) the provider was treating the 
                        pregnancy before date of the termination,
                the transitional period under this paragraph with 
                respect to provider's treatment of the pregnancy shall 
                extend through the provision of post-partum care 
                directly related to the delivery.
                    ``(D) Terminal illness.--If--
                            ``(i) an enrollee was determined to be 
                        terminally ill (as determined under section 
                        1861(dd)(3)(A)) at the time of a provider's 
                        termination of participation, and
                            ``(ii) the provider was treating the 
                        terminal illness before the date of 
                        termination,
                the transitional period under this paragraph shall 
                extend for the remainder of the individual's life for 
                care directly related to the treatment of the terminal 
                illness.
            ``(3) Permissible terms and conditions.--A Medicare+Choice 
        organization may condition coverage of continued treatment by a 
        provider under paragraph (1)(A)(ii) upon the provider agreeing 
        to the following terms and conditions:
                    ``(A) The provider agrees to accept reimbursement 
                from the organization and individual involved (with 
                respect to cost-sharing) at the rates applicable prior 
                to the start of the transitional period as payment in 
                full (or, in the case described in paragraph (1)(B), at 
                the rates applicable under the replacement organization 
                after the date of the termination of the contract with 
                the organization) and not to impose cost-sharing with 
                respect to the individual in an amount that would 
                exceed the cost-sharing that could have been imposed if 
                the contract referred to in paragraph (1)(A) had not 
                been terminated.
                    ``(B) The provider agrees to adhere to the quality 
                assurance standards of the organization responsible for 
                payment under subparagraph (A) and to provide to such 
                organization necessary medical information related to 
                the care provided.
                    ``(C) The provider agrees otherwise to adhere to 
                such organization's policies and procedures, including 
                procedures regarding referrals and obtaining prior 
                authorization and providing services pursuant to a 
                treatment plan (if any) approved by the organization.
            ``(4) Construction.--Nothing in this subsection shall be 
        construed to require the coverage of benefits which would not 
        have been covered if the provider involved remained a 
        participating provider.''

SEC. 4. EFFECTIVE DATE.

    The amendments made by this Act shall apply to Medicare+Choice 
organizations with respect to contracts with the Secretary of Health 
and Human Services for contract years beginning more than 90 days after 
the date of the enactment of this Act.
                                 <all>