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H.R. 5629 (ih) To permit the Asphalt Commander to be placed under a foreign registry. [Introduced in House] ...


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106th CONGRESS
  2d Session
                                H. R. 5628

   To amend the Employee Retirement Income Security Act of 1974, the 
  Public Health Service Act, and the Internal Revenue Code of 1986 to 
provide for a patients' bill of rights, patient access to information, 
and accountability of health plans, and to expand access to health care 
                    coverage through tax incentives.


_______________________________________________________________________


                    IN THE HOUSE OF REPRESENTATIVES

                            November 3, 2000

  Mr. Shadegg (for himself, Mr. Coburn, Mr. Salmon, and Mr. Aderholt) 
 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 such 
 provisions as fall within the jurisdiction of the committee concerned

_______________________________________________________________________

                                 A BILL


 
   To amend the Employee Retirement Income Security Act of 1974, the 
  Public Health Service Act, and the Internal Revenue Code of 1986 to 
provide for a patients' bill of rights, patient access to information, 
and accountability of health plans, and to expand access to health care 
                    coverage through tax incentives.

    Be it enacted by the Senate and House of Representatives of the 
United States of America in Congress assembled,

SECTION 1. SHORT TITLE; TABLE OF CONTENTS.

    (a) Short Title.--This Act may be cited as the ``Common Sense 
Patients' Bill of Rights Act''.
    (b) Table of Contents.--The table of contents of this Act is as 
follows:


Sec. 1. Short title; table of contents.
                   TITLE I--PATIENTS' BILL OF RIGHTS

                  Subtitle A--Right to Advice and Care

Sec. 101.``subpart c--patient right to medical advice and care.
        ``Sec. 721. Access to emergency care.
        ``Sec. 722. Offering of choice of coverage options.
        ``Sec. 723. Patient access to obstetric and gynecological care.
        ``Sec. 724. Access to pediatric care.
        ``Sec. 725. Timely access to specialists.
        ``Sec. 726. Continuity of care.
        ``Sec. 727. Prohibition of interference with certain medical 
                            communications.
        ``Sec. 728. Patient's right to prescription drugs.
        ``Sec. 729. Self-payment for behavioral health care services.
        ``Sec. 730. Coverage for individuals participating in approved 
                            cancer clinical trials.
        ``Sec. 730A. Prohibition of discrimination against providers 
                            based on licensure.
        ``Sec. 730B. Prohibition against improper incentive 
                            arrangements.
        ``Sec. 730C. Payment of clean claims.
        ``Sec. 730D. Generally applicable provision.
        ``Sec. 730E. Exclusion from access to managed care provisions 
                            for fee-for-service coverage.
        ``Sec. 730F. Additional definitions.
Sec. 102. Conforming amendments to the Public Health Service Act.
Sec. 103. Conforming amendments to the Internal Revenue Code of 1986.
       Subtitle B--Right to Information About Plans and Providers

Sec. 111. Information about plans and coverage under ERISA.
        ``Sec. 714. Patient access to information.
Sec. 112. Conforming amendments to Public Health Service Act.
Sec. 113. Conforming amendments to the Internal Revenue Code of 1986.
           Subtitle C--Right to Hold Health Plans Accountable

Sec. 121. Amendments to Employee Retirement Income Security Act of 
                            1974.
        ``Sec. 503A. Utilization review activities.
        ``Sec. 503B. Procedures for initial claims for benefits and 
                            prior authorization determinations.
        ``Sec. 503C. Internal appeals of claims denials.
        ``Sec. 503D. Independent external appeals procedures.
Sec. 122. Conforming amendments to Public Health Service Act.
Sec. 123. Conforming amendments to the Internal Revenue Code of 1986.
   Subtitle D--State Flexibility in Applying Requirements to Health 
                           Insurance Issuers

Sec. 141. State flexibility in applying requirements to health 
                            insurance issuers under ERISA; plan 
                            satisfaction of certain requirements.
Sec. 142. State flexibility in applying requirements to health 
                            insurance issuers under the Public Health 
                            Service Act.
     Subtitle E--Effective Dates; Coordination in Implementation; 
                        Miscellaneous Provisions

Sec. 151. Effective dates.
Sec. 152. Regulations; coordination.
Sec. 153. No benefit requirements.
Sec. 154. Severability.
                           TITLE II--REMEDIES

Sec. 201. Availability of court remedies.
Sec. 202. Severability.
         TITLE III--HEALTH CARE COVERAGE ACCESS TAX INCENTIVES

Sec. 301. Expanded availability of medical savings accounts.
Sec. 302. Deduction for 100 percent of health insurance costs of self-
                            employed individuals.
                    TITLE IV--HEALTH CARE PAPERWORK

Sec. 401. Health care paperwork simplification.

                   TITLE I--PATIENTS' BILL OF RIGHTS

                  Subtitle A--Right to Advice and Care

SEC. 101. PATIENT RIGHT TO MEDICAL ADVICE AND CARE UNDER ERISA.

    (a) In General.--Part 7 of subtitle B of title I of the Employee 
Retirement Income Security Act of 1974 (29 U.S.C. 1181 et seq.) is 
amended--
            (1) by redesignating subpart C as subpart D; and
            (2) by inserting after subpart B the following:

         ``Subpart C--Patient Right to Medical Advice and Care

``SEC. 721. ACCESS TO EMERGENCY CARE.

    ``(a) Coverage of Emergency Services.--
            ``(1) In general.--If a group health plan, or health 
        insurance coverage offered by a health insurance issuer in 
        connection with such a plan, provides or covers any benefits 
        with respect to services in an emergency department of a 
        hospital, the plan or issuer shall cover emergency services (as 
        defined in paragraph (2)(B))--
                    ``(A) without the need for any prior authorization 
                determination;
                    ``(B) whether the health care provider furnishing 
                such services is a participating provider with respect 
                to such services;
                    ``(C) in a manner so that, if such services are 
                provided to a participant or beneficiary--
                            ``(i) by a nonparticipating health care 
                        provider with or without prior authorization, 
                        or
                            ``(ii) by a participating health care 
                        provider without prior authorization,
                the participant or beneficiary is not liable for 
                amounts that exceed the amounts of liability that would 
                be incurred if the services were provided by a 
                participating health care provider with prior 
                authorization; and
                    ``(D) without regard to any other term or condition 
                of such coverage (other than exclusion or coordination 
                of benefits, or an affiliation or waiting period, 
                permitted under section 2701 of the Public Health 
                Service Act, section 701, or section 9801 of the 
                Internal Revenue Code of 1986, and other than 
                applicable cost-sharing).
            ``(2) Definitions.--In this section:
                    ``(A) Emergency medical condition.--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 (42 U.S.C. 
                1395dd(e)(1)(A)).
                    ``(B) Emergency services.--The term `emergency 
                services' means with respect to an emergency medical 
                condition--
                            ``(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 such emergency medical condition, 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.
                    ``(C) Stabilize.--The term `to stabilize' means, 
                with respect to an emergency medical condition, to 
                provide such medical treatment of the condition as may 
                be necessary to assure, within reasonable medical 
                probability, that no material deterioration of the 
                condition is likely to result from or occur during the 
                transfer of the individual from a facility.
    ``(b) Reimbursement for Maintenance Care and Post-Stabilization 
Care.--If benefits are available under a group health plan, or under 
health insurance coverage offered by a health insurance issuer in 
connection with such a plan, with respect to maintenance care or post-
stabilization care covered under the guidelines established under 
section 1852(d)(2) of the Social Security Act, the plan or issuer shall 
provide for reimbursement with respect to such services provided to a 
participant or beneficiary other than through a participating health 
care provider in a manner consistent with subsection (a)(1)(C) (and 
shall otherwise comply with such guidelines).
    ``(c) Coverage of Emergency Ambulance Services.--
            ``(1) In general.--If a group health plan, or health 
        insurance coverage provided by a health insurance issuer in 
        connection with such a plan, provides any benefits with respect 
        to ambulance services and emergency services, the plan or 
        issuer shall cover emergency ambulance services (as defined in 
        paragraph (2)) furnished under the plan or coverage under the 
        same terms and conditions under subparagraphs (A) through (D) 
        of subsection (a)(1) under which coverage is provided for 
        emergency services.
            ``(2) Emergency ambulance services.--For purposes of this 
        subsection, the term `emergency ambulance services' means 
        ambulance services (as defined for purposes of section 
        1861(s)(7) of the Social Security Act) furnished to transport 
        an individual who has an emergency medical condition (as 
        defined in subsection (a)(2)(A)) to a hospital for the receipt 
        of emergency services (as defined in subsection (a)(2)(B)) in a 
        case in which the emergency services are covered under the plan 
        or coverage pursuant to subsection (a)(1) and a prudent 
        layperson, with an average knowledge of health and medicine, 
        could reasonably expect that the absence of such transport 
        would result in placing the health of the individual in serious 
        jeopardy, serious impairment of bodily function, or serious 
        dysfunction of any bodily organ or part.
    ``(d) Rule of Construction.--Nothing in this section shall be 
construed to prohibit a group health plan or a health insurance issuer 
from negotiating reimbursement rates with a nonparticipating provider 
for items or services provided under this section.

``SEC. 722. OFFERING OF CHOICE OF COVERAGE OPTIONS.

    ``(a) Requirement.--If a group health plan provides coverage for 
benefits only through a defined set of participating health care 
professionals, the plan shall offer each participant the option to 
purchase point-of-service coverage (as defined in subsection (b)) for 
all such benefits for which coverage is otherwise so limited. Such 
option shall be made available to the participant at the time of 
enrollment under the plan and at such other times as the plan offers 
the participant a choice of coverage options.
    ``(b) Point-of-Service Coverage Defined.--In this section, the term 
`point-of-service coverage' means, with respect to benefits covered 
under a group health plan, coverage of such benefits when provided by a 
nonparticipating health care professional.
    ``(c) Small Employer Exemption.--
            ``(1) In general.--The requirement of subsection (a) shall 
        not apply to a group health plan with respect to a small 
        employer if the employer demonstrates that compliance with such 
        requirement would result in an increase in overall costs to the 
        employer.
            ``(2) Small employer defined.--For purposes of subparagraph 
        (A), the term `small employer' means, in connection with a 
        group health plan with respect to a calendar year and a plan 
        year, an employer who employed an average of fewer than 25 
        employees on days during the preceding calendar year and fewer 
        than 25 employees on the first day of the plan year.
            ``(3) Determination of employer size.--For purposes of this 
        subsection, the provisions of subparagraph (C) of section 
        712(c)(1) shall apply in determining employer size.
    ``(d) Rule of Construction.--Nothing in this section shall be 
construed--
            ``(1) as requiring coverage for benefits for a particular 
        type of health care professional;
            ``(2) as requiring an increase in the level of employer 
        contributions or as permitting an employer to comply with the 
        requirements of this section by means of reducing the level of 
        employer contributions attributable to coverage with respect to 
        any participant or group of participants in relation to the 
        level that would otherwise be maintained if such requirements 
        did not apply;
            ``(3) as preventing a group health plan from imposing, on a 
        participant who exercises the point-of-service coverage option 
        under subsection (a), the additional cost of creation and 
        maintenance of the option as well as any additional other costs 
        (including additional cost-sharing) attributable to the option; 
        or
            ``(4) to require that a group health plan include coverage 
        of health care professionals that the plan excludes because of 
        fraud, quality of care, or other similar reasons with respect 
        to such professionals.

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