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S. 1257 (eah) [Engrossed Amendment House] ...
Calendar No. 164 106th CONGRESS 1st Session S. 1256 _______________________________________________________________________ A BILL Entitled the ``Patients' Bill of Rights''. _______________________________________________________________________ June 22, 1999 Read the second time and placed on the calendar Calendar No. 164 106th CONGRESS 1st Session S. 1256 Entitled the ``Patients' Bill of Rights''. _______________________________________________________________________ IN THE SENATE OF THE UNITED STATES June 21, 1999 Mr. Daschle introduced the following bill; which was read the first time June 22, 1999 Read the second time and placed on the calendar _______________________________________________________________________ A BILL Entitled the ``Patients' Bill of Rights''. Be it enacted by the Senate and House of Representatives of the United States of America in Congress assembled, SEC. ____01. SHORT TITLE. This title may be cited as the ``Patients' Bill of Rights Act of 1999''. Subtitle A--Health Insurance Bill of Rights CHAPTER 1--ACCESS TO CARE SEC. ____101. 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, provides any benefits with respect to emergency services (as defined in paragraph (2)(B)), 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 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, beneficiary, or enrollee by a nonparticipating health care provider without prior authorization by the plan or issuer, the participant, beneficiary, or enrollee 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 by the plan or issuer; 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 of the Employee Retirement Income Security Act of 1974, 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 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. (b) Reimbursement for Maintenance Care and Post-Stabilization Care.--In the case of services (other than emergency services) for which benefits are available under a group health plan, or under health insurance coverage offered by a health insurance issuer, the plan or issuer shall provide for reimbursement with respect to such services provided to a participant, beneficiary, or enrollee other than through a participating health care provider in a manner consistent with subsection (a)(1)(C) (and shall otherwise comply with the guidelines established under section 1852(d)(2) 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), or, in the absence of guidelines under such section, such guidelines as the Secretary shall establish to carry out this subsection), if the services are maintenance care or post-stabilization care covered under such guidelines. SEC. ____102. OFFERING OF CHOICE OF COVERAGE OPTIONS UNDER GROUP HEALTH PLANS. (a) Requirement.-- (1) Offering of point-of-service coverage option.--Except as provided in paragraph (2), if a group health plan (or health insurance coverage offered by a health insurance issuer in connection with a group health plan) provides benefits only through participating health care providers, the plan or issuer shall offer the 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 or coverage and at such other times as the plan or issuer offers the participant a choice of coverage options. (2) Exception.--Paragraph (1) shall not apply with respect to a participant in a group health plan if the plan offers the participant-- (A) a choice of health insurance coverage; and (B) one or more coverage options that do not provide benefits only through participating health care providers. (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 or health insurance issuer, coverage of such benefits when provided by a nonparticipating health care provider. Such coverage need not include coverage of providers that the plan or issuer excludes because of fraud, quality, or similar reasons. (c) Construction.--Nothing in this section shall be construed-- (1) as requiring coverage for benefits for a particular type of health care provider; (2) as requiring an employer to pay any costs as a result of this section or to make equal contributions with respect to different health coverage options; or (3) as preventing a group health plan or health insurance issuer from imposing higher premiums or cost-sharing on a participant for the exercise of a point-of-service coverage option. (d) No Requirement for Guaranteed Availability.--If a health insurance issuer offers health insurance coverage that includes point- of-service coverage with respect to an employer solely in order to meet the requirement of subsection (a), nothing in section 2711(a)(1)(A) of the Public Health Service Act shall be construed as requiring the offering of such coverage with respect to another employer. SEC. ____103. CHOICE OF PROVIDERS. (a) Primary Care.--A group health plan, and a health insurance issuer that offers health insurance coverage, shall permit each participant, beneficiary, and enrollee to receive primary care from any participating primary care provider who is available to accept such individual. (b) Specialists.-- (1) In general.--Subject to paragraph (2), a group health plan and a health insurance issuer that offers health insurance coverage shall permit each participant, beneficiary, or enrollee to receive medically necessary or appropriate specialty care, pursuant to appropriate referral procedures, from any qualified participating health care provider who is available to accept such individual for such care. (2) Limitation.--Paragraph (1) shall not apply to specialty care if the plan or issuer clearly informs participants, beneficiaries, and enrollees of the limitations on choice of participating providers with respect to such care. SEC. ____104. ACCESS TO SPECIALTY CARE. (a) Obstetrical and Gynecological Care.-- (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 a participant, beneficiary, or enrollee to designate a participating primary care provider-- (A) the plan or issuer shall permit such an individual who is a female to designate a participating physician who specializes in obstetrics and gynecology as the individual's primary care provider; and (B) if such an individual has not designated such a provider as a primary care provider, the plan or issuer-- (i) may not require authorization or a referral by the individual's primary care provider or otherwise for coverage of routine gynecological care (such as preventive women's health examinations) and pregnancy-related services provided by a participating health care professional who specializes in obstetrics and gynecology to the extent such care is otherwise covered, and (ii) may treat the ordering of other gynecological care by such a participating health professional as the authorization of the primary care provider with respect to such care under the plan or coverage. (2) Construction.--Nothing in paragraph (1)(B)(ii) shall waive any requirements of coverage relating to medical necessity or appropriateness with respect to coverage of gynecological care so ordered. (b) Specialty Care.-- (1) Specialty care for covered services.-- (A) In general.--If-- (i) an individual is a participant or beneficiary under a group health plan or an enrollee who is covered under health insurance coverage offered by a health insurance issuer, (ii) the individual has a condition or disease of sufficient seriousness and complexity to require treatment by a specialist, and (iii) benefits for such treatment are provided under the plan or coverage, the plan or issuer shall make or provide for a referral to a specialist who is available and accessible to provide the treatment for such condition or disease. (B) Specialist defined.--For purposes of this subsection, the term ``specialist'' means, with respect to a condition, a health care practitioner, facility, or center (such as a center of excellence) that has adequate expertise through appropriate training and experience (including, in the case of a child, appropriate pediatric expertise) to provide high quality care in treating the condition. (C) Care under referral.--A group health plan or health insurance issuer may require that the care provided to an individual pursuant to such referral under subparagraph (A) be-- (i) pursuant to a treatment plan, only if the treatment plan is developed by the specialist and approved by the plan or issuer, in consultation with the designated primary care provider or specialist and the individual (or the individual's designee), and (ii) in accordance with applicable quality assurance and utilization review standards of the plan or issuer. Nothing in this subsection shall be construed as preventing such a treatment plan for an individual from requiring a specialist to provide the primary care provider with regular updates on the specialty care provided, as well as all necessary medical information. (D) Referrals to participating providers.--A group health plan or health insurance 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 individual's condition and that is a participating provider with respect to such treatment. (E) Treatment of nonparticipating providers.--If a plan or issuer refers an individual to a nonparticipating specialist pursuant to subparagraph (A), services provided 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.
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