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                                                       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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