[Congressional Bills 106th Congress]
[From the U.S. Government Publishing Office]
[H.R. 2046 Introduced in House (IH)]







106th CONGRESS
  1st Session
                                H. R. 2046

To amend title I of the Employee Retirement Income Security Act of 1974 
  to ensure access by participants and beneficiaries of group health 
plans to information regarding plan coverage, managed care procedures, 
          health care providers, and quality of medical care.


_______________________________________________________________________


                    IN THE HOUSE OF REPRESENTATIVES

                              June 8, 1999

 Mr. Fletcher introduced the following bill; which was referred to the 
                Committee on Education and the Workforce

_______________________________________________________________________

                                 A BILL


 
To amend title I of the Employee Retirement Income Security Act of 1974 
  to ensure access by participants and beneficiaries of group health 
plans to information regarding plan coverage, managed care procedures, 
          health care providers, and quality of medical 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 ``Patient Access to Information Act of 
1999''.

SEC. 2. PATIENT ACCESS TO INFORMATION REGARDING PLAN COVERAGE, MANAGED 
              CARE PROCEDURES, HEALTH CARE PROVIDERS, AND QUALITY OF 
              MEDICAL CARE.

    (a) In General.--Part 1 of subtitle B of title I of the Employee 
Retirement Income Security Act of 1974 is amended--
            (1) by redesignating section 111 as section 112; and
            (2) by inserting after section 110 the following new 
        section:

                   ``disclosure by group health plans

    ``Sec. 111. (a) Disclosure Requirement.--
            ``(1) Group health plans.--The administrator of each group 
        health plan shall take such actions as are necessary to ensure 
        that the summary plan description of the plan required under 
        section 102 (or each summary plan description in any case in 
        which different summary plan descriptions are appropriate under 
        part 1 for different options of coverage) contains, among any 
        information otherwise required under this part, the information 
        required under subsections (b), (c), (d), and (e)(2)(A).
            ``(2) Health insurance issuers.--Each health insurance 
        issuer offering health insurance coverage in connection with a 
        group health plan shall provide the administrator on a timely 
        basis with the information necessary to enable the 
        administrator to comply with the requirements of paragraph (1). 
        To the extent that any such issuer provides on a timely basis 
        to plan participants and beneficiaries information otherwise 
        required under this part to be included in the summary plan 
        description, the requirements of sections 101(a)(1) and 104(b) 
        shall be deemed satisfied in the case of such plan with respect 
        to such information.
    ``(b) Plan Benefits.--The information required under subsection (a) 
includes the following:
            ``(1) Covered items and services.--
                    ``(A) Categorization of included benefits.--A 
                description of covered benefits, categorized by--
                            ``(i) types of items and services 
                        (including any special disease management 
                        program); and
                            ``(ii) types of health care professionals 
                        providing such items and services.
                    ``(B) Emergency medical care.--A description of the 
                extent to which the plan covers emergency medical care 
                (including the extent to which the plan provides for 
                access to urgent care centers), and any definitions 
                provided under the plan for the relevant plan 
                terminology referring to such care.
                    ``(C) Preventative services.--A description of the 
                extent to which the plan provides benefits for 
                preventative services.
                    ``(D) Drug formularies.--A description of the 
                extent to which covered benefits are determined by the 
                use or application of a drug formulary and a summary of 
                the process for determining what is included in such 
                formulary.
                    ``(E) COBRA continuation coverage.--A description 
                of the benefits available under the plan pursuant to 
                part 6.
            ``(2) Limitations, exclusions, and restrictions on covered 
        benefits.--
                    ``(A) Categorization of excluded benefits.--A 
                description of benefits specifically excluded from 
                coverage, categorized by types of items and services.
                    ``(B) Utilization review and preauthorization 
                requirements.--Whether coverage for medical care is 
                limited or excluded on the basis of utilization review 
                or preauthorization requirements.
                    ``(C) Lifetime, annual, or other period 
                limitations.--A description of the circumstances under 
                which, and the extent to which, coverage is subject to 
                lifetime, annual, or other period limitations, 
                categorized by types of benefits.
                    ``(D) Custodial care.--A description of the 
                circumstances under which, and the extent to which, the 
                coverage of benefits for custodial care is limited or 
                excluded, and a statement of the definition used by the 
                plan for custodial care.
                    ``(E) Experimental treatments.--Whether coverage 
                for any medical care is limited or excluded because it 
                constitutes experimental treatment or technology, and 
                any definitions provided under the plan for the 
                relevant plan terminology referring to such limited or 
                excluded care.
                    ``(F) Medical appropriateness or necessity.--
                Whether coverage for medical care may be limited or 
                excluded by reason of a failure to meet the plan's 
                requirements for medical appropriateness or necessity, 
                and any definitions provided under the plan for the 
                relevant plan terminology referring to such limited or 
                excluded care.
                    ``(G) Second or subsequent opinions.--A description 
                of the circumstances under which, and the extent to 
                which, coverage for second or subsequent opinions is 
                limited or excluded.
                    ``(H) Specialty care.--A description of the 
                circumstances under which, and the extent to which, 
                coverage of benefits for specialty care is conditioned 
                on referral from a primary care provider.
                    ``(I) Continuity of care.--A description of the 
                circumstances under which, and the extent to which, 
                coverage of items and services provided by any health 
                care professional is limited or excluded by reason of 
                the departure by the professional from any defined set 
                of providers.
                    ``(J) Restrictions on coverage of emergency 
                services.--A description of the circumstances under 
                which, and the extent to which, the plan, in covering 
                emergency medical care furnished to a participant or 
                beneficiary of the plan imposes any financial 
                responsibility described in subsection (c) on 
                participants or beneficiaries or limits or conditions 
                benefits for such care subject to any other term or 
                condition of such plan.
    ``(c) Participant's Financial Responsibilities.--The information 
required under subsection (a) includes an explanation of--
            ``(1) a participant's financial responsibility for payment 
        of premiums, coinsurance, copayments, deductibles, and any 
        other charges; and
            ``(2) the circumstances under which, and the extent to 
        which, the participant's financial responsibility described in 
        paragraph (1) may vary, including any distinctions based on 
        whether a health care provider from whom covered benefits are 
        obtained is included in a defined set of providers.
    ``(d) Dispute Resolution Procedures.--The information required 
under subsection (a) includes a description of the processes adopted by 
the plan pursuant to section 503, including--
            ``(1) descriptions thereof relating specifically to--
                    ``(A) coverage decisions;
                    ``(B) internal review of coverage decisions; and
                    ``(C) any external review of coverage decisions; 
                and
            ``(2) the procedures and time frames applicable to each 
        step of the processes referred to in subparagraphs (A), (B), 
        and (C) of paragraph (1).
    ``(e) Information Available on Request.--
            ``(1) Access to plan benefit information in electronic 
        form.--
                    ``(A) In general.--In addition to the information 
                required to be provided under section 104(b)(4), a 
                group health plan (and a health insurance issuer 
                offering health insurance coverage in connection with a 
                group health plan) shall, upon written request (made 
                not more frequently than annually), make available to 
                participants and beneficiaries, in a generally 
                recognized electronic format--
                            ``(i) the latest summary plan description, 
                        including the latest summary of material 
                        modifications, and
                            ``(ii) the actual plan provisions setting 
                        forth the benefits available under the plan,
                to the extent such information relates to the coverage 
                options under the plan available to the participant or 
                beneficiary. A reasonable charge may be made to cover 
                the cost of providing such information in such 
                generally recognized electronic format. The Secretary 
                may by regulation prescribe a maximum amount which will 
                constitute a reasonable charge under the preceding 
                sentence.
                    ``(B) Alternative access.--The requirements of this 
                paragraph may be met by making such information 
                generally available (rather than upon request) on the 
                Internet or on a proprietary computer network in a 
                format which is readily accessible to participants and 
                beneficiaries.
            ``(2) Additional information to be provided on request.--
                    ``(A) Inclusion in summary plan description of 
                summary of additional information.--The information 
                required under subsection (a) includes a summary 
                description of the types of information required by 
                this subsection to be made available to participants 
                and beneficiaries on request.
                    ``(B) Information required from plans and issuers 
                on request.--In addition to information required to be 
                included in summary plan descriptions under this 
                subsection, a group health plan (and a health insurance 
                issuer offering health insurance coverage in connection 
                with a group health plan) shall provide the following 
                information to a participant or beneficiary on request:
                            ``(i) Network characteristics.--If the plan 
                        (or issuer) utilizes a defined set of providers 
                        under contract with the plan (or issuer), a 
                        detailed list of the names of such providers 
                        and their geographic location, set forth 
                        separately with respect to primary care 
                        providers and with respect to specialists.
                            ``(ii) Care management information.--A 
                        description of the circumstances under which, 
                        and the extent to which, the plan has special 
                        disease management programs or programs for 
                        persons with disabilities, indicating whether 
                        these programs are voluntary or mandatory and 
                        whether a significant benefit differential 
                        results from participation in such programs.
                            ``(iii) Inclusion of drugs and biologicals 
                        in formularies.--A statement of whether a 
                        specific drug or biological is included in a 
                        formulary used to determine benefits under the 
                        plan and a description of the procedures for 
                        considering requests for any patient-specific 
                        waivers.
                            ``(iv) Procedures for determining 
                        exclusions based on medical necessity or 
                        experimental treatments.--Upon receipt by the 
                        participant or beneficiary of any notification 
                        of an adverse coverage decision based on a 
                        determination relating to medical necessity or 
                        an experimental treatment or technology, a 
                        description of the procedures and medically-
                        based criteria used in such decision.
                            ``(v) Preauthorization and utilization 
                        review procedures.--Upon receipt by the 
                        participant or beneficiary of any notification 
                        of an adverse coverage decision, a description 
                        of the basis on which any preauthorization 
                        requirement or any utilization review 
                        requirement has resulted in such decision.
                            ``(vi) Accreditation status of health 
                        insurance issuers and service providers.--A 
                        description of the accreditation and licensing 
                        status (if any) of each health insurance issuer 
                        offering health insurance coverage in 
                        connection with the plan and of any utilization 
                        review organization utilized by the issuer or 
                        the plan, together with the name and address of 
                        the accrediting or licensing authority.
                            ``(vii) Measures of enrollee 
                        satisfaction.--The latest information (if any) 
                        maintained by the plan, or by any health 
                        insurance issuer offering health insurance 
                        coverage in connection with the plan, relating 
                        to enrollee satisfaction.
                            ``(viii) Quality performance measures.--The 
                        latest information (if any) maintained by the 
                        plan, or by any health insurance issuer 
                        offering health insurance coverage in 
                        connection with the plan, relating to quality 
                        of performance of the delivery of medical care 
                        with respect to coverage options offered under 
                        the plan and of health care professionals and 
                        facilities providing medical care under the 
                        plan.
                            ``(ix) Information relating to external 
                        reviews.--The number of any external reviews 
                        under section 503 that have been completed 
                        during the prior plan year and the number of 
                        such reviews in which a recommendation is made 
                        for modification or reversal of an internal 
                        review decision under the plan.
                    ``(C) Information required from health care 
                professionals on request.--Any health care professional 
                treating a participant or beneficiary under a group 
                health plan shall provide to the participant or 
                beneficiary, on request, a description of his or her 
                professional qualifications (including board 
                certification status, licensing status, and 
                accreditation status, if any), privileges, and 
                experience and a general description by category 
                (including salary, fee-for-service, capitation, and 
                such other categories as may be specified in 
                regulations of the Secretary) of the applicable method 
                by which such professional is compensated in connection 
                with the provision of such medical care.
                    ``(D) Information required from health care 
                facilities on request.--Any health care facility from 
                which a participant or beneficiary has sought treatment 
                under a group health plan shall provide to the 
                participant or beneficiary, on request, a description 
                of the facility's corporate form or other 
                organizational form and all forms of licensing and 
                accreditation status (if any) assigned to the facility 
                by standard-setting organizations.
    ``(f) Access to Information Relevant to the Coverage Options Under 
Which the Participant or Beneficiary is Eligible to Enroll.--In 
addition to information otherwise required to be made available under 
this section, a group health plan (and a health insurance issuer 
offering health insurance coverage in connection with a group health 
plan) shall, upon written request (made not more frequently than 
annually), make available to a participant (and an employee who, under 
the terms of the plan, is eligible for coverage but not enrolled) in 
connection with a period of enrollment the summary plan description for 
any coverage option under the plan under which the participant is 
eligible to enroll and any information described in clauses (i), (ii), 
(iii), (vi), (vii), and (viii) of subsection (e)(2)(B).
    ``(g) Advance Notice of Changes in Drug Formularies.--Not later 
than 30 days before the effective of date of any exclusion of a 
specific drug or biological from any drug formulary under the plan that 
is used in the treatment of a chronic illness or disease, the plan 
shall take such actions as are necessary to reasonably ensure that plan 
participants are informed of such exclusion. The requirements of this 
subsection may be satisfied--
            ``(1) by inclusion of information in publications broadly 
        distributed by plan sponsors, employers, or employee 
        organizations;
            ``(2) by electronic means of communication (including the 
        Internet or proprietary computer networks in a format which is 
        readily accessible to participants);
            ``(3) by timely informing participants who, under an 
        ongoing program maintained under the plan, have submitted their 
        names for such notification; or
            ``(4) by any other reasonable means of timely informing 
        plan participants.
    ``(h) Definitions.--For purposes of this section--
            ``(1) Group health plan.--The term `group health plan' has 
        the meaning provided such term under section 733(a)(1).
            ``(2) Medical care.--The term `medical care' has the 
        meaning provided such term under section 733(a)(2).
            ``(3) Health insurance coverage.--The term `health 
        insurance coverage' has the meaning provided such term under 
        section 733(b)(1).
            ``(4) Health insurance issuer.--The term `health insurance 
        issuer' has the meaning provided such term under section 
        733(b)(2).''.
    (b) Conforming Amendments.--
            (1) Section 102(b) of such Act (29 U.S.C. 1022(b)) is 
        amended by inserting before the period at the end the 
        following: ``; and, in the case of a group health plan (as 
        defined in section 111(h)(1)), the information required to be 
        included under section 111(a)''.
            (2) The table of contents in section 1 of such Act is 
        amended by striking the item relating to section 111 and 
        inserting the following new items:

``Sec. 111. Disclosure by group health plans.
``Sec. 112. Repeal and effective date.''.

SEC. 3. EFFECTIVE DATE AND RELATED RULES.

    (a) In General.--The amendments made by this Act shall apply with 
respect to plan years beginning on or after January 1 of the second 
calendar year following the date of the enactment of this Act. The 
Secretary shall first issue all regulations necessary to carry out the 
amendments made by this subtitle before such date.
    (b) Limitation on Enforcement Actions.--No enforcement action shall 
be taken, pursuant to the amendments made by this Act, against a group 
health plan or health insurance issuer with respect to a violation of a 
requirement imposed by such amendments before the date of issuance of 
final regulations issued in connection with such requirement, if the 
plan or issuer has sought to comply in good faith with such 
requirement.
                                 <all>