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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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