[Congressional Bills 105th Congress]
[From the U.S. Government Publishing Office]
[H.R. 4674 Introduced in House (IH)]







105th CONGRESS
  2d Session
                                H. R. 4674

 To amend part C of title XVIII of the Social Security Act to prohibit 
  Medicare+Choice organizations from arbitrarily limiting coverage of 
       medically necessary services under Medicare+Choice plans.


_______________________________________________________________________


                    IN THE HOUSE OF REPRESENTATIVES

                            October 1, 1998

Mr. Stark (for himself and Mr. Kleczka) 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 subseqently 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 part C of title XVIII of the Social Security Act to prohibit 
  Medicare+Choice organizations from arbitrarily limiting coverage of 
       medically necessary services under Medicare+Choice plans.

    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+Choice Medical Necessity 
Protection Act of 1998''.

SEC. 2. PROHIBITING ARBITRARY LIMITATIONS OR CONDITIONS FOR THE 
              PROVISION OF SERVICES UNDER MEDICARE+CHOICE PLANS.

    (a) In General.--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) Prohibiting Arbitrary Limitations or Conditions for the 
Provision of Services.--
            ``(1) In general.--A Medicare+Choice organization, may not 
        arbitrarily interfere with or alter the decision of the 
        treating physician regarding the manner or setting in which 
        particular services are delivered to an enrollee under a 
        Medicare+Choice plan if the services are medically necessary or 
        appropriate for treatment or diagnosis to the extent that such 
        treatment or diagnosis is otherwise a covered benefit.
            ``(2) Construction.--Paragraph (1) shall not be construed 
        as prohibiting a Medicare+Choice organization from limiting the 
        delivery of services to one or more health care providers 
        within a network of such providers.
            ``(3) Manner or setting defined.--In paragraph (1), the 
        term `manner or setting' means the location of treatment, such 
        as whether treatment is provided on an inpatient or outpatient 
        basis, and the duration of treatment, such as the number of 
        days in a hospital. Such term does not include the coverage of 
        a particular service or treatment.
            ``(4) No change in coverage.--Paragraph (1) shall not be 
        construed as requiring coverage of particular services the 
        coverage of which is otherwise not covered under the terms of 
        the Medicare+Choice plan or from conducting utilization review 
        activities consistent with this subsection.
            ``(5) Medical necessity or appropriateness defined.--In 
        paragraph (1), the term `medically necessary or appropriate' 
        means, with respect to a service or benefit, a service or 
        benefit which is consistent with generally accepted principles 
        of professional medical practice.''.
    (b) Effective Date.--The amendment made by subsection (a) applies 
as of January 1, 1999, to contracts with Medicare+Choice organizations 
entered into (or renewed) under section 1857 of the Social Security Act 
before, on, or after such date.
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