HR 2824 IH

106th CONGRESS

1st Session

H. R. 2824

To amend title I of the Employee Retirement Income Security Act of 1974, title XXVII of the Public Health Service Act, and the Internal Revenue Code of 1986 to protect consumers in managed care plans and other health coverage.

IN THE HOUSE OF REPRESENTATIVES

September 9, 1999

Mr. COBURN (for himself, Mr. SHADEGG, Mr. COOKSEY, Mr. HILLEARY, Mr. VITTER, Mrs. EMERSON, Mr. GILLMOR, Mr. REGULA, Mrs. CUBIN, Mr. GRAHAM, Mr. CUNNINGHAM, and Mr. WELDON of Florida) introduced the following bill; which was referred to the Committee on Commerce, and in addition to the Committees on Education and the Workforce, and Ways and Means, for a period to be subsequently determined by the Speaker, in each case for consideration of sic provisions as fall within the jurisdiction of the committee concerned


A BILL

To amend title I of the Employee Retirement Income Security Act of 1974, title XXVII of the Public Health Service Act, and the Internal Revenue Code of 1986 to protect consumers in managed care plans and other health coverage.

SECTION 1. SHORT TITLE; TABLE OF CONTENTS.

TITLE I--IMPROVING MANAGED CARE

Subtitle A--Grievances and Appeals

Subtitle B--Access to Care

Subtitle C--Access to Information

Subtitle D--Protecting the Doctor-Patient Relationship

Subtitle E--Definitions

TITLE II--APPLICATION OF QUALITY STANDARDS TO GROUP HEALTH PLANS AND HEALTH INSURANCE COVERAGE UNDER THE PUBLIC HEALTH SERVICE ACT

TITLE III--AMENDMENTS TO THE EMPLOYEE RETIREMENT INCOME SECURITY ACT OF 1974

TITLE IV--APPLICATION TO GROUP HEALTH PLANS UNDER THE INTERNAL REVENUE CODE OF 1986

TITLE V--EFFECTIVE DATES; COORDINATION IN IMPLEMENTATION

TITLE VI--OTHER PROVISIONS

TITLE I--IMPROVING MANAGED CARE

Subtitle A--Grievance and Appeals

SEC. 101. UTILIZATION REVIEW ACTIVITIES.

SEC. 102. INTERNAL APPEALS PROCEDURES.

SEC. 103. EXTERNAL APPEALS PROCEDURES.

timely appeal is made either by the plan or issuer or by the participant, beneficiary, or enrollee (and any provider or other person acting on behalf of such an individual with the individual's consent or without such consent if such an individual is medically unable to provide such consent).

this subparagraph shall be construed as providing for coverage of items or services not provided or covered by the plan.

SEC. 104. ESTABLISHMENT OF A GRIEVANCE PROCESS.

Subtitle B--Access to Care

SEC. 111. CONSUMER CHOICE OPTION.

SEC. 112. CHOICE OF HEALTH CARE PROFESSIONAL.

SEC. 113. ACCESS TO EMERGENCY CARE.

SEC. 114. ACCESS TO SPECIALTY CARE.

pursuant to the approved treatment plan (if any) shall be provided at no additional cost to the individual beyond what the individual would otherwise pay for services received by such a specialist that is a participating provider.

SEC. 115. ACCESS TO OBSTETRICAL AND GYNECOLOGICAL CARE.

SEC. 116. ACCESS TO PEDIATRIC CARE.

SEC. 117. CONTINUITY OF CARE.

the terms of provider participation in a group health plan, and an individual who is a participant, beneficiary, or enrollee in the plan or coverage is undergoing treatment from the provider for an ongoing special condition (as defined in paragraph (3)(A)) at the time of such termination, the plan or issuer shall--

SEC. 118. NETWORK ADEQUACY.

such standards for network adequacy as are established by law pursuant to this section.

SEC. 119. ACCESS TO EXPERIMENTAL OR INVESTIGATIONAL PRESCRIPTION DRUGS.

Subtitle C--Access to Information

SEC. 121. PATIENT ACCESS TO INFORMATION.

least annually thereafter, the information described in subsection (b);

Subtitle D--Protecting the Doctor-Patient Relationship

SEC. 131. PROHIBITION OF INTERFERENCE WITH CERTAIN MEDICAL COMMUNICATIONS.

SEC. 132. PROHIBITION OF DISCRIMINATION AGAINST PROVIDERS BASED ON LICENSURE.

SEC. 133. PROHIBITION AGAINST IMPROPER INCENTIVE ARRANGEMENTS.

SEC. 134. PAYMENT OF CLEAN CLAIMS.

Subtitle E--Definitions

SEC. 151. DEFINITIONS.

SEC. 152. PREEMPTION; STATE FLEXIBILITY; CONSTRUCTION.

SEC. 153. EXCLUSIONS.

SEC. 154. COVERAGE OF LIMITED SCOPE PLANS.

SEC. 155. REGULATIONS; COORDINATION; APPLICATION UNDER DIFFERENT LAWS.

TITLE II--APPLICATION OF QUALITY CARE STANDARDS TO GROUP HEALTH PLANS AND HEALTH INSURANCE COVERAGE UNDER THE PUBLIC HEALTH SERVICE ACT

SEC. 201. APPLICATION TO GROUP HEALTH PLANS AND GROUP HEALTH INSURANCE COVERAGE.

`SEC. 2707. PATIENT PROTECTION STANDARDS.

SEC. 202. APPLICATION TO INDIVIDUAL HEALTH INSURANCE COVERAGE.

`SEC. 2753. PATIENT PROTECTION STANDARDS.

TITLE III--AMENDMENTS TO THE EMPLOYEE RETIREMENT INCOME SECURITY ACT OF 1974

SEC. 301. APPLICATION OF PATIENT PROTECTION STANDARDS TO GROUP HEALTH PLANS AND GROUP HEALTH INSURANCE COVERAGE UNDER THE EMPLOYEE RETIREMENT INCOME SECURITY ACT OF 1974.

`SEC. 714. PATIENT PROTECTION STANDARDS.

SEC. 302. AVAILABILITY OF COURT REMEDIES.

review elected under section 103 of the Health Care Quality and Choice Act of 1999 and such presumption may be overcome only upon a showing of clear and convincing evidence to the contrary.

SEC. 303. AVAILABILITY OF BINDING ARBITRATION.

plan with respect to similarly situated participants and beneficiaries and which meets the requirements of subparagraph (B); or

the arbitration and shall be enforcible under section 502 as if the terms of the decision were the terms of the plan, except that the court may vacate any award made pursuant to the arbitration for any cause described in paragraph (1), (2), (3), (4), or (5) of section 10(a) of title 9, United States Code.

TITLE IV--APPLICATION TO GROUP HEALTH PLANS UNDER THE INTERNAL REVENUE CODE OF 1986.

SEC. 401. AMENDMENTS TO THE INTERNAL REVENUE CODE OF 1986.

`Sec. 9813. Standard relating to Health Care Quality and Choice Act.'; and

`SEC. 9813. STANDARD RELATING TO HEALTH CARE QUALITY AND CHOICE ACT.

TITLE V--EFFECTIVE DATES; COORDINATION IN IMPLEMENTATION

SEC. 501. EFFECTIVE DATES.

SEC. 502. COORDINATION IN IMPLEMENTATION.

TITLE VI--OTHER PROVISIONS

SEC. 601. HEALTH CARE PAPERWORK SIMPLIFICATION.

House of Representatives, shall determine the number of members and the composition of the Panel. Such Panel shall include equal numbers of representatives of private insurance organizations, consumer groups, State insurance commissioners, State medical societies, State hospital associations, and State medical specialty societies.

SEC. 602. PROTECTION FOR CERTAIN INFORMATION.

and the provider's plans of action in response to such event).

SEC. 603. MEDICARE COMPETITIVE PRICING DEMONSTRATION PROJECT.

END