[Congressional Bills 106th Congress]
[From the U.S. Government Publishing Office]
[S. 479 Introduced in Senate (IS)]







106th CONGRESS
  1st Session
                                 S. 479

  To amend the title XXVII of the Public Health Service Act and other 
    laws to assure the rights of enrollees under managed care plans.


_______________________________________________________________________


                   IN THE SENATE OF THE UNITED STATES

                           February 25, 1999

  Mr. Schumer introduced the following bill; which was read twice and 
  referred to the Committee on Health, Education, Labor, and Pensions

_______________________________________________________________________

                                 A BILL


 
  To amend the title XXVII of the Public Health Service Act and other 
    laws to assure the rights of enrollees under managed care 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 ``Equity in Womens Health Act''.

SEC. 2. HEALTH INSURANCE BILL OF RIGHTS.

    Title XXVII of the Public Health Service Act (42 U.S.C. 300gg et 
seq.) is amended--
            (1) by redesignating part C as part D; and
            (2) by inserting after part B the following new part:

           ``Part C--Nondiscrimination and Health Prospectus

``SEC. 2770. NONDISCRIMINATION.

    ``(a) Enrollees.--A group health plan or health insurance issuer 
offering health insurance coverage (whether or not a managed care plan 
or coverage) may not discriminate or engage (directly or through 
contractual arrangements) in any activity, including the selection of 
service area, that has the effect of discriminating against an 
individual on the basis of race, culture, national origin, gender, 
sexual orientation, language, socio-economic status, age, disability, 
genetic makeup, health status, anticipated need for health care 
services, or payer source.
    ``(b) Providers.--Such a plan or issuer may not discriminate in the 
selection of members of the health provider or provider network (and in 
establishing the terms and conditions for membership in the network) of 
the plan or coverage based on any of the factors described in 
subsection (a).
    ``(c) Services.--Such a plan or issuer may not exclude coverage 
(including procedures and drugs) if the effect is to discriminate in 
violation of subsection (a) or (b).

``SEC. 2771. HEALTH PROSPECTUS; DISCLOSURE OF INFORMATION.

    ``(a) Disclosure.--Each group health plan, and each health 
insurance issuer providing health insurance coverage, shall provide to 
each enrollee at the time of enrollment and on an annual basis, and 
shall make available to each prospective enrollee upon request--
            ``(1) a prospectus that relates to the plan or coverage 
        offered and that meets the requirements of subsection (b); and
            ``(2) additional information described in subsection (c).
    ``(b) Prospectus.--
            ``(1) In general.--Each prospectus under this subsection 
        for a plan or coverage--
                    ``(A) shall contain the information described in 
                paragraphs (2) through (4) concerning the plan or 
                coverage,
                    ``(B) shall contain such additional information as 
                the Secretary deems appropriate, and
                    ``(C) shall be no longer than 3 pages in length and 
                in a format specified by the Secretary for purposes of 
                comparison by prospective enrollees.
            ``(2) Qualitative information.--The information described 
        in this paragraph is a summary of the quality assessment data 
        on the plan or coverage. The data shall--
                    ``(A) be the similar to the types of data as are 
                collected for managed care plans under title XVIII of 
                the Social Security Act, as determined by the Secretary 
                and taking into account differences between the 
                populations covered under such title and the 
                populations covered under this title;
                    ``(B) be collected by independent, auditing 
                agencies;
                    ``(C) include--
                            ``(i) a description of the types of 
                        methodologies (including capitation, financial 
                        incentive or bonuses, fee-for-service, salary, 
                        and withholds) used by the plan or issuer to 
                        reimburse physicians, including the proportions 
                        of physicians who have each of these types of 
                        arrangements; and
                            ``(ii) cost-sharing requirements for 
                        enrollees.
        The information under subparagraph (C) shall include, upon 
        request, information on the reimbursement methodology used by 
        the plan or issuer or medical groups for individual physicians, 
        but do not require the disclosure of specific reimbursement 
rates.
            ``(3) Quantitative information.--The information described 
        in this paragraph is measures of performance of the plan or 
        issuer (in relation to coverage offered) with respect to each 
        of the following and such other salient data as the Secretary 
        may specify:
                    ``(A) The ratio of physicians to enrollees, 
                including the ratio of physicians who are obstetrician/
                gynecologists to adult, female enrollees.
                    ``(B) The ratio of specialists to enrollees.
                    ``(C) The incentive structure used for payment of 
                primary care physicians and specialists.
                    ``(D) Patient outcomes for procedures, including 
                procedures specific to female enrollees.
                    ``(E) The number of grievances filed under the plan 
                or coverage.
                    ``(F) The number of requests for procedures for 
                which utilization review board review or approval is 
                required and the number (and percentage) of such 
                requests that are denied.
                    ``(G) The number of appeals filed from denial of 
                such requests and the number (and percentage) of such 
                appeals that are approved, such numbers and percentages 
                broken down by gender of the enrollee involved.
                    ``(H) Disenrollment data.
            ``(4) Description of benefits.--The information described 
        in this paragraph is a description of the benefits provided 
        under the plan or coverage, as well as explicit exclusions, 
        including a description of the following:
                    ``(A) Coverage policy with respect to coverage for 
                female-specific benefits, including screening 
                mammography, hormone replacement therapy, bone density 
                testing, osteoporosis screening, maternity care, and 
                reconstructive surgery following a mastectomy.
                    ``(B) The costs of copayments for treatments, 
                including any exceptions.
    ``(c) Additional Information.--The additional information described 
in this subsection is information about each of the following:
            ``(1) The plan's or issuer's structure and provider 
        network, including the names and credentials of physicians in 
        the network.
            ``(2) Coverage provided and excluded, including out-of-area 
        coverage.
            ``(3) Procedures for utilization management.
            ``(4) Procedures for determining coverage for 
        investigational or experimental treatments, as well as 
        definitions for coverage terms.
            ``(5) Any restrictive formularies or prior approval 
        requirements for obtaining prescription drugs, including, upon 
request, information on whether or not specific drugs are covered.
            ``(6) Use of voluntary or mandatory arbitration.
            ``(7) Procedures for receiving emergency care and out-of-
        network services when those services are not available in the 
        network and information on the coverage of emergency services, 
        including--
                    ``(A) the appropriate use of emergency services, 
                including use of the 911 telephone system or its local 
                equivalent in emergency situations and an explanation 
                of what constitutes an emergency situation;
                    ``(B) the process and procedures for obtaining 
                emergency services; and
                    ``(C) the locations of (i) emergency departments, 
                and (ii) other settings, in which physicians and 
                hospitals provide emergency services and post-
                stabilization care.
            ``(8) How to contact agencies that regulate the plan or 
        issuer.
            ``(9) How to contact consumer assistance agencies, such as 
        ombudsmen programs.
            ``(10) How to obtain covered services.
            ``(11) How to receive preventive health services and health 
        education.
            ``(12) How to select providers and obtain referrals.
            ``(13) How to appeal health plan decisions and file 
        grievances.
    ``(d) State Authority To Require Additional Information.--
            ``(1) In general.--Subject to paragraph (2), this section 
        shall not be construed as preventing a State from requiring 
        health insurance issuers, in relation to their offering of 
        health insurance coverage, to disclose separately information 
        (including comparative ratings of health insurance coverage) in 
        addition to the information required to be disclosed under this 
        section.
            ``(2) Continued preemption with respect to group health 
        plans.--Nothing in this part shall be construed to affect or 
        modify the provisions of section 514 with respect to group 
        health plans.''.

SEC. 3. AMENDMENTS TO THE PUBLIC HEALTH SERVICE ACT.

    (a) Application to Group Health Insurance Coverage.--Subpart 2 of 
part A of title XXVII of the Public Health Service Act, as amended by 
the Omnibus Consolidated and Emergency Supplemental Appropriations Act, 
1999 (Public Law 105-277), is amended by adding at the end the 
following new section:

``SEC. 2707. MANAGED CARE REQUIREMENTS.

    ``Each health insurance issuer shall comply with the applicable 
requirements under part C with respect to group health insurance 
coverage it offers.''.
    (b) Application to Individual Health Insurance Coverage.--Subpart 3 
of part B of title XXVII of the Public Health Service Act, as amended 
by the Omnibus Consolidated and Emergency Supplemental Appropriations 
Act, 1999 (Public Law 105-277), is amended by adding at the end the 
following new section:

``SEC. 2753. MANAGED CARE REQUIREMENTS.

    ``Each health insurance issuer shall comply with the applicable 
requirements under part C with respect to individual health insurance 
coverage it offers, in the same manner as such requirements apply to 
group health insurance coverage.''.
    (c) Modification of Preemption Standards.--
            (1) Group health insurance coverage.--Section 2723 of such 
        Act (42 U.S.C. 300gg-23) is amended--
                    (A) in subsection (a)(1), by striking ``subsection 
                (b)'' and inserting ``subsections (b) and (c)'';
                    (B) by redesignating subsections (c) and (d) as 
                subsections (d) and (e), respectively; and
                    (C) by inserting after subsection (b) the following 
                new subsection:
    ``(c) Special Rules in Case of Managed Care Requirements.--Subject 
to subsection (a)(2), the provisions of section 2707 and part C, and 
part D insofar as it applies to section 2707 or part C, shall not 
prevent a State from establishing requirements relating to the subject 
matter of such provisions so long as such requirements are at least as 
stringent on health insurance issuers as the requirements imposed under 
such provisions.''.
            (2) Individual health insurance coverage.--Section 2762 of 
        the Public Health Service Act (42 U.S.C. 300gg-62) is amended--
                    (A) in subsection (a), by striking ``subsection 
                (b), nothing in this part'' and inserting ``subsections 
                (b) and (c)'', and
                    (B) by adding at the end the following new 
                subsection:
    ``(c) Special Rules in Case of Managed Care Requirements.--Subject 
to subsection (b), the provisions of section 2753 and part C, and part 
D insofar as it applies to section 2753 or part C, shall not prevent a 
State from establishing requirements relating to the subject matter of 
such provisions so long as such requirements are at least as stringent 
on health insurance issuers as the requirements imposed under such 
section.''.
    (d) Additional Conforming Amendments.--
            (1) Section 2723(a)(1) of the Public Health Service Act (42 
        U.S.C. 300gg-23(a)(1)) is amended by striking ``part C'' and 
        inserting ``parts C and D''.
            (2) Section 2762(b)(1) of the Public Health Service Act (42 
        U.S.C. 300gg-62(b)(1)) is amended by striking ``part C'' and 
        inserting ``part D''.
    (e) Assuring Coordination.--Section 104(1) of the Health Insurance 
Portability and Accountability Act of 1996 (Public Law 104-191) is 
amended by striking ``under this subtitle (and the amendments made by 
this subtitle and section 401)'' and inserting ``title XXVII of the 
Public Health Service Act, under part 7 of subtitle B of title I of the 
Employee Retirement Income Security Act of 1974, and chapter 100 of the 
Internal Revenue Code of 1986''.

SEC. 4. MANAGED CARE REQUIREMENTS UNDER THE EMPLOYEE RETIREMENT INCOME 
              SECURITY ACT OF 1974.

    (a) In General.--Subpart B of part 7 of subtitle B of title I of 
the Employee Retirement Income Security Act of 1974, as amended by the 
Omnibus Consolidated and Emergency Supplemental Appropriations Act, 
1999 (Public Law 105-277), is amended by adding at the end the 
following:

``SEC. 714. MANAGED CARE REQUIREMENTS.

    ``(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 applicable 
requirements of part C of title XXVII of the Public Health Service Act.
    ``(b) References in Application.--In applying subsection (a) under 
this part, any reference in such part C--
            ``(1) to a health insurance issuer and health insurance 
        coverage offered by such an issuer is deemed to include a 
        reference to a group health plan and coverage under such plan, 
        respectively;
            ``(2) to the Secretary is deemed a reference to the 
        Secretary of Labor;
            ``(3) to an applicable State authority is deemed a 
        reference to the Secretary of Labor; and
            ``(4) 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) Modification of Preemption Standards.--Section 731 of the 
Employee Retirement Income Security Act of 1974 (42 U.S.C. 1191) is 
amended--
            (1) in subsection (a)(1), by striking ``subsection (b)'' 
        and inserting ``subsections (b) and (c)'';
            (2) by redesignating subsections (c) and (d) as subsections 
        (d) and (e), respectively; and
            (3) by inserting after subsection (b) the following new 
        subsection:
    ``(c) Special Rules in Case of Managed Care Requirements.--Subject 
to subsection (a)(2), the provisions of section 714 and part C of title 
XXVII of the Public Health Service Act, and subpart C insofar as it 
applies to section 714 or such part, shall not be construed to preempt 
any State law, or the enactment or implementation of such a State law, 
that provides protections for individuals that are equivalent to or 
stricter than the protections provided under such provisions.''.
    (c) Conforming Amendments.--
            (1) Section 732(a) of the Employee Retirement Income 
        Security Act of 1974 (29 U.S.C. 1185(a)) is amended by striking 
        ``section 711'' and inserting ``sections 711 and 713''.
            (2) The table of contents in section 1 of the Employee 
        Retirement Income Security Act of 1974 is amended by inserting 
        after the item relating to section 713 the following new item:

``Sec. 714. Managed care requirements.''.

SEC. 5. MANAGED CARE REQUIREMENTS UNDER THE INTERNAL REVENUE CODE OF 
              1986.

    (a) In General.--Subchapter B of part B of part 7 of subtitle B of 
title I of the Internal Revenue Code of 1986 is amended by adding at 
the end the following new section:

``SEC. 9813. MANAGED CARE REQUIREMENTS.

    ``(a) In General.--Subject to subsection (b), a group health plan 
shall comply with the applicable requirements of part C of title XXVII 
of the Public Health Service Act.
    ``(b) References in Application.--In applying subsection (a) under 
this subchapter, any reference in such part C--
            ``(1) to the Secretary is deemed a reference to the 
        Secretary of the Treasury; and
            ``(2) to an applicable State authority is deemed a 
        reference to the Secretary.''.
    (b) Clerical Amendment.--The table of sections in subchapter B of 
chapter 100 of such Code is amended by inserting after the item 
relating to section 9812 the following new item:

                              ``Sec. 9813. Managed care 
                                        requirements.''.

SEC. 6. MANAGED CARE REQUIREMENTS UNDER MEDICARE, MEDICAID, AND THE 
              FEDERAL EMPLOYEES HEALTH BENEFITS PROGRAM (FEHBP).

    (a) Medicare.--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) Managed Care Requirements.--Each Medicare+Choice organization 
that offers a Medicare+Choice plan described in section 1851(a)(1)(A) 
shall comply with the applicable requirements of part C of title XXVII 
of the Public Health Service Act in the same manner as such 
requirements apply with respect to health insurance coverage offered by 
a health insurance issuer, except to the extent such requirements are 
less protective of enrollees than the requirements established under 
this part.''.
    (b) Medicaid.--Section 1932(b)(8) of the Social Security Act (42 
U.S.C. 1396u-2(b)(8))--
            (1) by striking ``and mental health'' and inserting ``, 
        mental health, and managed care'',
            (2) by inserting ``and of part C'' after ``of part A'', and
            (3) by inserting before the period at the end the 
        following: ``, except to the extent such requirements are less 
        protective of enrollees than the requirements established under 
        this title''.
    (c) Federal Employees' Health Benefits Program (FEHBP).--Chapter 89 
of title 5, United States Code, is amended--
            (1) by inserting after the item relating to section 8905a 
        the following new section:
``Sec. 8905b. Application of managed care requirements
    ``Each health benefit plan offered under this chapter shall comply 
with the applicable requirements of part C of title XXVII of the Public 
Health Service Act in the same manner as such requirements apply with 
respect to health insurance coverage offered by a health insurance 
issuer, except to the extent such requirements are less protective of 
enrollees than the requirements established under this chapter.''; and
            (2) in the table of sections, by inserting the following 
        item after the item relating to section 8905a:

``8905b. Application of managed care requirements.''.

SEC. 7. EFFECTIVE DATES.

    (a) General Effective Date for Group Health Plans.--
            (1) In general.--Subject to paragraph (2), the amendments 
        made by section 2, subsections (a), (c)(1), and (d) of section 
        3, and sections 5 and 6 shall apply with respect to group 
        health insurance coverage for group health plan years beginning 
        on or after July 1, 2000 (in this section referred to as the 
        ``general effective date'') and also shall apply to portions of 
        plan years occurring on and after January 1, 2001.
            (2) Treatment of group health plans maintained pursuant to 
        certain collective bargaining agreements.--In the case of a 
        group health plan, or group health insurance coverage provided 
        pursuant to 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 described in 
        paragraph (1) shall not apply to plan years beginning before 
        the later of--
                    (A) 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
                    (B) the general effective date.
        For purposes of subparagraph (A), 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 such amendments shall not be treated as a termination 
        of such collective bargaining agreement.
    (b) General Effective Date for Health Insurance Coverage.--The 
amendments made by section 2 and subsections (b), (c)(2), and (d) of 
section 3 shall apply with respect to individual health insurance 
coverage offered, sold, issued, renewed, in effect, or operated in the 
individual market on or after the general effective date.
    (c) Effective Date for Coordination.--The amendment made by section 
3(e) shall take effect on the date of the enactment of this Act.
    (d) Federal Programs.--The amendments made by section 6 shall take 
effect on January 1, 2001.
                                 <all>