[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]

      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.
                                  ____


       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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