[Congressional Bills 108th Congress]
[From the U.S. Government Publishing Office]
[S. 1710 Introduced in Senate (IS)]
108th CONGRESS
1st Session
S. 1710
To amend title XXVII of the Public Health Service Act and part 7 of
subtitle B of title I of the Employee Retirement Income Security Act of
1974 to establish standards for the health quality improvement of
children in managed care plans and other health plans.
_______________________________________________________________________
IN THE SENATE OF THE UNITED STATES
October 3, 2003
Mr. Reed (for himself and Mrs. Murray) introduced the following bill;
which was read twice and referred to the Committee on Health,
Education, Labor, and Pensions
_______________________________________________________________________
A BILL
To amend title XXVII of the Public Health Service Act and part 7 of
subtitle B of title I of the Employee Retirement Income Security Act of
1974 to establish standards for the health quality improvement of
children in managed care plans and other health 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 ``Children's Health Insurance
Accountability Act of 2003''.
SEC. 2. FINDINGS.
Congress makes the following findings:
(1) Children have health and development needs that are
markedly different than those for the adult population.
(2) Children experience complex and continuing changes
during the continuum from birth to adulthood in which
appropriate health care is essential for optimal development.
(3) The vast majority of work done on development methods
to assess the effectiveness of health care services and the
impact of medical care on patient outcomes and patient
satisfaction has been focused on adults.
(4) Health outcome measures need to be age, gender, and
developmentally appropriate to be useful to families and
children.
(5) Costly disorders of adulthood often have their origins
in childhood, making early access to effective health services
in childhood essential.
(6) More than 200 chronic conditions, disabilities and
diseases affect children, including asthma, diabetes, sickle
cell anemia, spina bifida, epilepsy, autism, cerebral palsy,
congenital heart disease, mental retardation, and cystic
fibrosis. These children need the services of specialists who
have in depth knowledge about their particular condition.
(7) Children's patterns of illness, disability and injury
differ dramatically from adults.
SEC. 2. AMENDMENTS TO THE PUBLIC HEALTH SERVICE ACT.
(a) Patient Protection Standards.--Title XXVII of the Public Health
Service Act is amended--
(1) by redesignating part C as part D; and
(2) by inserting after part B the following:
``Part C--Children's Health Protection Standards
``SEC. 2770. ACCESS TO CARE.
``(a) Access to Appropriate Primary Care Providers.--
``(1) In general.--If a group health plan, or a health
insurance issuer in connection with the provision of health
insurance coverage, requires or provides for an enrollee to
designate a participating primary care provider for a child of
such enrollee--
``(A) the plan or issuer shall permit the enrollee
to designate a physician who specializes in pediatrics
as the child's primary care provider; and
``(B) if such an enrollee has not designated such a
provider for the child, the plan or issuer shall
consider appropriate pediatric expertise in mandatorily
assigning such an enrollee to a primary care provider.
``(2) Construction.--Nothing in paragraph (1) shall waive
any requirements of coverage relating to medical necessity or
appropriateness with respect to coverage of services.
``(b) Access to Pediatric Specialty Services.--
``(1) Referral to specialty care for children requiring
treatment by specialists.--
``(A) In general.--In the case of a child who is
covered under a group health plan, or health insurance
coverage offered by a health insurance issuer and who
has a mental or physical condition, disability, or
disease of sufficient seriousness and complexity to
require diagnosis, evaluation or treatment by a
specialist, the plan or issuer shall make or provide
for a referral to a specialist who has extensive
experience or training, and is available and accessible
to provide the treatment for such condition or disease,
including the choice of a nonprimary care physician
specialist participating in the plan or a referral to a
nonparticipating provider as provided for under
subparagraph (D) if such a provider is not available
within the plan.
``(B) Specialist defined.--For purposes of this
subsection, the term `specialist' means, with respect
to a condition, disability, or disease, a health care
practitioner, facility, or center (such as a center of
excellence) that has extensive pediatric expertise
through appropriate training or experience to provide
high quality care in treating the condition, disability
or disease.
``(C) Referrals to participating providers.--A plan
or issuer is not required under subparagraph (A) to
provide for a referral to a specialist that is not a
participating provider, unless the plan or issuer does
not have an appropriate specialist that is available
and accessible to treat the enrollee's condition and
that is a participating provider with respect to such
treatment.
``(D) Treatment of nonparticipating providers.--If
a plan or issuer refers a child enrollee to a
nonparticipating specialist, services provided pursuant
to the referral shall be provided at no additional cost
to the enrollee beyond what the enrollee would
otherwise pay for services received by such a
specialist that is a participating provider.
``(E) Specialists as primary care providers.--A
plan or issuer shall have in place a procedure under
which a child who is covered under health insurance
coverage provided by the plan or issuer who has a
condition or disease that requires specialized medical
care over a prolonged period of time shall receive a
referral to a pediatric specialist affiliated with the
plan, or if not available within the plan, to a
nonparticipating provider for such condition and such
specialist may be responsible for and capable of
providing and coordinating the child's primary and
specialty care.
``(2) Standing referrals.--
``(A) In general.--A group health plan, or health
insurance issuer in connection with the provision of
health insurance coverage of a child, shall have a
procedure by which a child who has a condition,
disability, or disease that requires ongoing care from
a specialist may request and obtain a standing referral
to such specialist for treatment of such condition. If
the primary care provider in consultation with the
medical director of the plan or issuer and the
specialist (if any), determines that such a standing
referral is appropriate, the plan or issuer shall
authorize such a referral to such a specialist. Such
standing referral shall be consistent with a treatment
plan.
``(B) Treatment plans.--A group health plan, or
health insurance issuer, with the participation of the
family and the health care providers of the child,
shall develop a treatment plan for a child who requires
ongoing care that covers a specified period of time
(but in no event less than a 6-month period). Services
provided for under the treatment plan shall not require
additional approvals or referrals through a gatekeeper.
``(C) Terms of referral.--The provisions of
subparagraph (C) and (D) of paragraph (1) shall apply
with respect to referrals under subparagraph (A) in the
same manner as they apply to referrals under paragraph
(1)(A).
``(c) Adequacy of Access.--For purposes of subsections (a) and (b),
a group health plan or health insurance issuer in connection with
health insurance coverage shall ensure that a sufficient number,
distribution, and variety of qualified participating health care
providers are available so as to ensure that all covered health care
services, including specialty services, are available and accessible to
all enrollees in a timely manner.
``(d) Coverage of Emergency Services.--
``(1) In general.--If a group health plan, or health
insurance coverage offered by a health insurance issuer,
provides any benefits for children with respect to emergency
services (as defined in paragraph (2)(A)), the plan or issuer
shall cover emergency services furnished under the plan or
coverage--
``(A) without the need for any prior authorization
determination;
``(B) whether or not the physician or provider
furnishing such services is a participating physician
or provider with respect to such services; and
``(C) without regard to any other term or condition
of such coverage (other than exclusion of benefits, or
an affiliation or waiting period, permitted under
section 2701).
``(2) Definitions.--In this subsection:
``(A) Emergency medical condition based on prudent
layperson standard.--The term `emergency medical
condition' means a medical condition manifesting itself
by acute symptoms of sufficient severity (including
severe pain) such that a prudent layperson, who
possesses an average knowledge of health and medicine,
could reasonably expect the absence of immediate
medical attention to result in a condition described in
clause (i), (ii), or (iii) of section 1867(e)(1)(A) of
the Social Security Act.
``(B) Emergency services.--The term `emergency
services' means--
``(i) a medical screening examination (as
required under section 1867 of the Social
Security Act) that is within the capability of
the emergency department of a hospital,
including ancillary services routinely
available to the emergency department to
evaluate an emergency medical condition (as
defined in subparagraph (A)); and
``(ii) within the capabilities of the staff
and facilities available at the hospital, such
further medical examination and treatment as
are required under section 1867 of such Act to
stabilize the patient.
``(3) Reimbursement for maintenance care and post-
stabilization care.--A group health plan, and health insurance
issuer offering health insurance coverage, shall provide, in
covering services other than emergency services, for
reimbursement with respect to services which are otherwise
covered and which are provided to an enrollee other than
through the plan or issuer if the services are maintenance care
or post-stabilization care covered under the guidelines
established under section 1852(d) of the Social Security Act
(relating to promoting efficient and timely coordination of
appropriate maintenance and post-stabilization care of an
enrollee after an enrollee has been determined to be stable).
``(e) Prohibition on Financial Barriers.--A health insurance issuer
in connection with the provision of health insurance coverage may not
impose any cost sharing for pediatric specialty services provided under
such coverage to enrollee children in amounts that exceed the cost-
sharing required for other specialty care under such coverage.
``(f) Children With Special Health Care Needs.--A health insurance
issuer in connection with the provision of health insurance coverage
shall ensure that such coverage provides special consideration for the
provision of services to enrollee children with special health care
needs. Appropriate procedures shall be implemented to provide care for
children with special health care needs. The development of such
procedures shall include participation by the families of such
children.
``(g) Definitions.--In this part:
``(1) Child.--The term `child' means an individual who is
under 19 years of age.
``(2) Children with special health care needs.--The term
`children with special health care needs' means those children
who have or are at elevated risk for chronic physical,
developmental, behavioral or emotional conditions and who also
require health and related services of a type and amount not
usually required by children.
``SEC. 2771. CONTINUITY OF CARE.
``(a) In General.--If a contract between a health insurance issuer,
in connection with the provision of health insurance coverage, and a
health care provider is terminated (other than by the issuer for
failure to meet applicable quality standards or for fraud) and an
enrollee is undergoing a course of treatment from the provider at the
time of such termination, the issuer shall--
``(1) notify the enrollee of such termination, and
``(2) subject to subsection (c), permit the enrollee to
continue the course of treatment with the provider during a
transitional period (provided under subsection (b)).
``(b) Transitional Period.--
``(1) In general.--Except as provided in paragraphs (2)
through (4), the transitional period under this subsection
shall extend for at least--
``(A) 60 days from the date of the notice to the
enrollee of the provider's termination in the case of a
primary care provider, or
``(B) 120 days from such date in the case of
another provider.
``(2) Institutional care.--The transitional period under
this subsection for institutional or inpatient care from a
provider shall extend until the discharge or termination of the
period of institutionalization and shall include reasonable
follow-up care related to the institutionalization and shall
also include institutional care scheduled prior to the date of
termination of the provider status.
``(3) Pregnancy.--If--
``(A) an enrollee has entered the second trimester
of pregnancy at the time of a provider's termination of
participation, and
``(B) the provider was treating the pregnancy
before date of the termination,
the transitional period under this subsection with respect to
provider's treatment of the pregnancy shall extend through the
provision of post-partum care directly related to the delivery.
``(4) Terminal illness.--
``(A) In general.--If--
``(i) an enrollee was determined to be
terminally ill (as defined in subparagraph (B))
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 subsection shall
extend for the remainder of the enrollee's life for
care directly related to the treatment of the terminal
illness.
``(B) Definition.--In subparagraph (A), an enrollee
is considered to be `terminally ill' if the enrollee
has a medical prognosis that the enrollee's life
expectancy is 6 months or less.
``(c) Permissible Terms and Conditions.--An issuer may condition
coverage of continued treatment by a provider under subsection (a)(2)
upon the provider agreeing to the following terms and conditions:
``(1) The provider agrees to continue to accept
reimbursement from the issuer at the rates applicable prior to
the start of the transitional period as payment in full.
``(2) The provider agrees to adhere to the issuer's quality
assurance standards and to provide to the issuer necessary
medical information related to the care provided.
``(3) The provider agrees otherwise to adhere to the
issuer's policies and procedures, including procedures
regarding referrals and obtaining prior authorization and
providing services pursuant to a treatment plan approved by the
issuer.
``SEC. 2772. CONTINUOUS QUALITY IMPROVEMENT.
``(a) In General.--A health insurance issuer that offers health
insurance coverage for children shall establish and maintain an
ongoing, internal quality assurance program that at a minimum meets the
requirements of subsection (b).
``(b) Requirements.--The internal quality assurance program of an
issuer under subsection (a) shall--
``(1) establish and measure a set of health care,
functional assessments, structure, processes and outcomes, and
quality indicators that are unique to children and based on
nationally accepted standards or guidelines of care;
``(2) maintain written protocols consistent with recognized
clinical guidelines or current consensus on the pediatric
field, to be used for purposes of internal utilization review,
with periodic updating and evaluation by pediatric specialists
to determine effectiveness in controlling utilization;
``(3) provide for peer review by health care professionals
of the structure, processes, and outcomes related to the
provision of health services, including pediatric review of
pediatric cases;
``(4) include in member satisfaction surveys, questions on
child and family satisfaction and experience of care, including
care to children with special needs;
``(5) monitor and evaluate the continuity of care with
respect to children;
``(6) include pediatric measures that are directed at
meeting the needs of at-risk children and children with chronic
conditions, disabilities and severe illnesses;
``(7) maintain written guidelines to ensure the
availability of medications appropriate to children;
``(8) use focused studies of care received by children with
certain types of chronic conditions and disabilities and
focused studies of specialized services used by children with
chronic conditions and disabilities;
``(9) monitor access to pediatric specialty services; and
``(10) monitor child health care professional satisfaction.
``(c) Utilization Review Activities.--
``(1) Compliance with requirements.--
``(A) In general.--A health insurance issuer that
offers health insurance coverage for children shall
conduct utilization review activities in connection
with the provision of such coverage only in accordance
with a utilization review program that meets at a
minimum the requirements of this subsection.
``(B) Definitions.--In this subsection:
``(i) Clinical peers.--The term `clinical
peer' means, with respect to a review, a
physician or other health care professional who
holds a non-restricted license in a State and
in the same or similar specialty as typically
manages the pediatric medical condition,
procedure, or treatment under review.
``(ii) Health care professional.--The term
`health care professional' means a physician or
other health care practitioner licensed or
certified under State law to provide health
care services and who is operating within the
scope of such licensure or certification.
``(iii) Utilization review.--The terms
`utilization review' and `utilization review
activities' mean procedures used to monitor or
evaluate the clinical necessity,
appropriateness, efficacy, or efficiency of
health care services, procedures or settings
for children, and includes prospective review,
concurrent review, second opinions, case
management, discharge planning, or
retrospective review specific to children.
``(2) Written policies and criteria.--
``(A) Written policies.--A utilization review
program shall be conducted consistent with written
policies and procedures that govern all aspects of the
program.
``(B) Use of written criteria.--A utilization
review program shall utilize written clinical review
criteria specific to children and developed pursuant to
the program with the input of appropriate physicians,
including pediatricians, nonprimary care pediatric
specialists, and other child health professionals.
``(C) Administration by health care
professionals.--A utilization review program shall be
administered by qualified health care professionals,
including health care professionals with pediatric
expertise who shall oversee review decisions.
``(3) Use of qualified, independent personnel.--
``(A) In general.--A utilization review program
shall provide for the conduct of utilization review
activities only through personnel who are qualified
and, to the extent required, who have received
appropriate pediatric or child health training in the
conduct of such activities under the program.
``(B) Peer review of adverse clinical
determinations.--A utilization review program shall
provide that clinical peers shall evaluate the clinical
appropriateness of adverse clinical determinations and
divergent clinical options.
``SEC. 2773. APPEALS AND GRIEVANCE MECHANISMS FOR CHILDREN.
``(a) Internal Appeals Process.--A health insurance issuer in
connection with the provision of health insurance coverage for children
shall establish and maintain a system to provide for the resolution of
complaints and appeals regarding all aspects of such coverage. Such a
system shall include an expedited procedure for appeals on behalf of a
child enrollee in situations in which the time frame of a standard
appeal would jeopardize the life, health, or development of the child.
``(b) External Appeals Process.--A health insurance issuer in
connection with the provision of health insurance coverage for children
shall provide for an independent external review process that meets the
following requirements:
``(1) External appeal activities shall be conducted through
clinical peers, a physician or other health care professional
who is appropriately credentialed in pediatrics with the same
or similar specialty and typically manages the condition,
procedure, or treatment under review or appeal.
``(2) External appeal activities shall be conducted through
an entity that has sufficient pediatric expertise, including
subspeciality expertise, and staffing to conduct external
appeal activities on a timely basis.
``(3) Such a review process shall include an expedited
procedure for appeals on behalf of a child enrollee in which
the time frame of a standard appeal would jeopardize the life,
health, or development of the child.
``SEC. 2774. ACCOUNTABILITY THROUGH DISTRIBUTION OF INFORMATION.
``(a) In General.--A health insurance issuer in connection with the
provision of health insurance coverage for children shall submit to
enrollees (and prospective enrollees), and make available to the
public, in writing the health-related information described in
subsection (b).
``(b) Information.--The information to be provided under subsection
(a) shall include a report of measures of structures, processes, and
outcomes regarding each health insurance product offered to
participants and dependents in a manner that is separate for both the
adult and child enrollees, using measures that are specific to each
group.''.
(b) Application to Group Health Insurance Coverage.--
(1) In general.--Subpart 2 of part A of title XXVII of the
Public Health Service Act (42 U.S.C. 300gg-4 et seq.) is
amended by adding at the end the following:
``SEC. 2707. CHILDREN'S HEALTH ACCOUNTABILITY STANDARDS.
``(a) In General.--Each health insurance issuer shall comply with
children's health accountability requirement under part C with respect
to group health insurance coverage it offers.
``(b) Assuring Coordination.--The Secretary of Health and Human
Services and the Secretary of Labor shall ensure, through the execution
of an interagency memorandum of understanding between such Secretaries,
that--
``(1) regulations, rulings, and interpretations issued by
such Secretaries relating to the same matter over which such
Secretaries have responsibility under part C (and this section)
and section 714 of the Employee Retirement Income Security Act
of 1974 are administered so as to have the same effect at all
times; and
``(2) coordination of policies relating to enforcing the
same requirements through such Secretaries in order to have a
coordinated enforcement strategy that avoids duplication of
enforcement efforts and assigns priorities in enforcement.''.
(2) Conforming amendment.--Section 2792 of the Public
Health Service Act (42 U.S.C. 300gg-92) is amended by inserting
``and section 2707(b)'' after ``of 1996''.
(c) Application to Individual Health Insurance Coverage.--Part B of
title XXVII of the Public Health Service Act (42 U.S.C. 300gg-41 et
seq.) is amended by inserting after section 2752 the following:
``SEC. 2753. CHILDREN'S HEALTH ACCOUNTABILITY STANDARDS.
``Each health insurance issuer shall comply with children's health
accountability requirements under part C with respect to individual
health insurance coverage it offers.''.
(d) Modification of Preemption Standards.--
(1) Group health insurance coverage.--Section 2723 of the
Public Health Service Act (42 U.S.C. 300gg-23) is amended--
(A) in subsection (a)(1), by striking ``subsection
(b)'' and inserting ``subsection (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 Children's Health Accountability
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 Children's Health Accountability
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.''.
SEC. 3. AMENDMENTS TO THE EMPLOYEE RETIREMENT INCOME SECURITY ACT OF
1974.
(a) In General.--Subpart B of part 7 of subtitle B of title I of
(29 U.S.C. 1185 et seq.) is amended by adding at the end the following:
``SEC. 714. CHILDREN'S HEALTH ACCOUNTABILITY STANDARDS.
``(a) In General.--Subject to subsection (b), the provisions of
part C of title XXVII of the Public Health Service Act shall apply
under this subpart and part to a group health plan (and group health
insurance coverage offered in connection with a group health plan) as
if such part were incorporated in this section.
``(b) Application.--In applying subsection (a) under this subpart
and part, any reference in such part C--
``(1) to health insurance coverage is deemed to be a
reference only to group health insurance coverage offered in
connection with a group health plan and to also be a reference
to coverage under a group health plan;
``(2) to a health insurance issuer is deemed to be a
reference only to such an issuer in relation to group health
insurance coverage or, with respect to a group health plan, to
the plan;
``(3) to the Secretary is deemed to be a reference to the
Secretary of Labor;
``(4) to an applicable State authority is deemed to be a
reference to the Secretary of Labor; and
``(5) 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 Patient Accountability
Requirements.--Subject to subsection (a)(2), the provisions of section
714, 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 group health plans and health insurance
issuers in connection with group health insurance coverage as the
requirements imposed 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 714''.
(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. Children's health accountability standards.''.
SEC. 4. STUDIES.
(a) By Secretary.--Not later than 1 year after the date of
enactment of this Act, the Secretary of Health and Human Services shall
conduct a study, and prepare and submit to Congress a report,
concerning--
(1) the unique characteristics of patterns of illness,
disability, and injury in children;
(2) the development of measures of quality of care and
outcomes related to the health care of children; and
(3) the access of children to primary mental health
services and the coordination of managed behavioral health
services.
(b) By GAO.--
(1) Managed care.--Not later than 1 year after the date of
enactment of this Act, the General Accounting Office shall
conduct a study, and prepare and submit to the Committee on
Health, Education, Labor, and Pensions of the Senate and the
Committee on Commerce of the House of Representatives a report,
concerning--
(A) an assessment of the structure and performance
of non-governmental health plans, medicaid managed care
organizations, plans under title XIX of the Social
Security Act (42 U.S.C. 1396 et seq.), and the program
under title XXI of the Social Security Act (42 U.S.C.
1397aa et seq.) serving the needs of children with
special health care needs;
(B) an assessment of the structure and performance
of non-governmental plans in serving the needs of
children as compared to medicaid managed care
organizations under title XIX of the Social Security
Act (42 U.S.C. 1396 et seq.); and
(C) the emphasis that private managed care health
plans place on primary care and the control of services
as it relates to care and services provided to children
with special health care needs.
(2) Plan survey.--Not later than 1 year after the date of
enactment of this Act, the General Accounting Office shall
prepare and submit to the Committee on Health, Education,
Labor, and Pensions of the Senate and the Committee on Commerce
of the House of Representatives a report that contains a survey
of health plan activities that address the unique health needs
of adolescents, including quality measures for adolescents and
innovative practice arrangement.
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