[Congressional Record Volume 144, Number 32 (Friday, March 20, 1998)]
[Senate]
[Pages S2364-S2367]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]
STATEMENTS ON INTRODUCED BILLS AND JOINT RESOLUTIONS
By Mr. REED (for himself, Mr. Kennedy, and Mrs. Murray):
S. 1808. 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;
to the Committee on Labor and Human Resources.
THE CHIDREN's HEALTH INSURANCE ACCOUNTABILITY ACT of 1998
Mr. REED. Children should not be left out of the health care quality
debate. I rise today to introduce legislation that provides common
sense consumer protections for children in managed care. I am pleased
that Senators Kennedy and Murray are cosponsors of this legislation.
Not one of us can deny that managed care plays a valid role in our
health care system. Managed care's emphasis on preventive care has
benefits for young and old alike. And HMOs have resulted in lower co-
payments for consumers and higher immunization rates for our children.
But all too often these days we read a story in the paper about a child
whose unique health care needs have not been met.
While the problems are clear, it is difficult to say how big a
problem we have on our hands. However, the anecdotal evidence is
overwhelming. And when it comes to our children, we should not take
risks.
While there has not been a great deal of child-specific research in
this area, one recent study by Elizabeth Jameson at the University of
California compared the experiences of chronically ill children in
California's Medicaid program to those in private managed care. There
was an interesting irony in the study's findings--low income children
in public programs receive age appropriate care that is consistent with
recognized clinical guidelines, while those in private health plans
often do not.
The study also found that: some managed care plans impose
restrictions on referrals to pediatric specialists and subspecialists
for children with complex conditions; and, an increasing number of
providers in managed care plans are attempting to treat complex
pediatric conditions for which they have little experience.
The bill I am introducing is an attempt to address these issues by
providing common sense protections for children in managed care. It is
this simple: if we don't have health plan standards, there's no
guarantee that we are providing adequate care for our children.
Our bill, The Children's Health Insurance Accountability Act,
provides common sense protections for children in managed care plans--
protections regarding access, appeals and accountability. These
protections include: access to necessary pediatric services; appeal
rights that address the special needs of children, such as an expedited
review if the child's life or development is in jeopardy; quality
programs that measure health outcomes unique to children; utilization
review rules that are specific to children with evaluation from those
with pediatric expertise; and child-specific information requirements
that will help parents and employers choose health plans on the basis
of care provided to children.
Mr. President, there is overwhelming public support for the ideas
embodied in this legislation. According to a February 1998 survey by
Lake Sosin Snell Perry and Associates and the Tarrance Group, 89
percent of adults surveyed favor having ``Congress require HMO's and
other insurance companies to allow parents to choose a pediatrician as
their child's primary care physician.'' And 90 percent favor having
``Congress require HMO's and other insurance companies to allow parents
of children with special health care needs, like cerebral palsy, cystic
fibrosis, or severe asthma, to choose a pediatric specialist to be
their child's primary care physician.'' The poll also shows that people
are willing to pay additional premiums adequate protections for
children.
I am pleased that this legislation has the support of many groups,
including the National Association of Childrens Hospitals, the American
Academy of Pediatricians, the Childrens Defense Fund, Families USA, the
National Organization of Rare Diseases, The Arc of the United States,
Service Employees International Union, American Federation of State,
County and Municipal Employees, the Association of Maternal and Child
Health Programs, the National Mental Health Association, the American
Academy of Child and Adolescent Psychiatry, the American Psychiatric
Association, and the American College of Emergency Room Physicians.
Mr. President, the time is now for Congress to act. I urge my
colleagues to join us in cosponsoring this bill, and to pass
comprehensive managed care legislation that meets the needs of all of
our citizens, including our children.
Mr. President, I ask unanimous consent that the text of the bill and
a summary be printed in the Record.
There being no objection, the material was ordered to be printed in
the Record, as follows:
S. 1808
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 1998''.
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 indepth 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 new part:
``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
appropriations with respect to coverage of services.
``(b) Access to Pediatric Speciality Services.--
``(1) Referral to speciality 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
[[Page S2365]]
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.
``(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
affilated 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.
[[Page S2366]]
``(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 is amended by adding at the end
the following new section:
``SEC. 2706. 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 713 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 2706(b)'' after ``of 1996''.
(c) Application to Individual Health Insurance Coverage.--
Part B of title XXVII of the Public Health Service Act is
amended by inserting after section 2751 the following new
section:
``SEC. 2752. 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 2706 and part C, and part D insofar
as it applies to section 2706 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), as added
by section 605(b)(3)(B) of Public Law 104-204, 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:
[[Page S2367]]
``(c) Special Rules in Case of Children's Health
Accountability Requirements.--Subject to subsection (b), the
provisions of section 2752 and part C, and part D insofar as
it applies to section 2752 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 the Employee Retirement Income Security Act of 1974 is
amended by adding at the end the following:
``SEC. 713. 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, and 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
such Act (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 713, 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 such Act (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 such Act is
amended by inserting after the item relating to section 712
the following new item:
``Sec. 713. 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
Labor and Human Resources 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 Labor and Human
Resources 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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The Children's Health Insurance Accountability Act Summary
access to appropriate primary care providers
Health plans that require designation of a primary care
provider shall permit enrollees to designate a physician who
specializes in pediatrics.
access to pediatric specialty services
Health plans must demonstrate the capacity to adequately
serve child enrollees through an appropriate mix, quantity
and access to pediatric and child health specialists,
including centers of excellence and tertiary care centers for
children. Health plans' definition of specialist must include
pediatric specialty in the case of care for children. Health
plans shall also establish procedures through which an
enrollee with a condition that requires ongoing care from a
pediatric specialist may obtain a standing referral to that
specialist. Health plans must have a process for selecting a
specialist as primary care provider.
continuity of care
Enrollees who are being treated for a serious or chronic
illness are allowed to continue receiving treatment from
their specialists for a period of time if their physician is
terminated from the plan or if their health plan is changed
by the employer and the enrollees no longer have the option
of continuing to receive care from their previous physician
specialist.
emergency care
The bill requires the ``prudent layperson'' standard for
access to emergency services for children.
special provision for children with special health care needs
Plans must have in place procedures for the provision of
services to enrollee children with special health care needs.
This would include a requirement of participation by families
of such children in the development of those procedures and a
treatment plan.
internal and external appeals and grievances
The legislation requires internal and independent external
appeals and grievance procedures that require review by
appropriate pediatric experts. Such a system shall also
provide for expedited procedures for a child enrollee in
situations in which the time frame of a standard appeal would
jeopardize the life, physical or mental health, or
development of the child.
disclosure of health information
The health plan must provide information to consumers that
includes measures of structures, processes and outcomes in a
manner that is separate for both the adult and child
enrollees using measures that are specific to each group.
continuous quality improvement
Each health plan must have an ongoing internal quality
assurance program that measures health outcomes that are
unique to children.
utilization review
Plans must maintain written protocols that are specific to
children with evaluation from those with expertise in
pediatrics. Utilization review criteria must be established
with input from those with expertise in pediatrics.
studies
The legislation requires studies on (1) the characteristics
of illness in children and the development of quality of care
measures and outcomes related to the health care of children;
(2) how private and public managed care plans are serving
children with special health care needs; and, (3) health
plans activities that address the unique health needs of
adolescents; and, (4) children's access to mental health
services.
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