Home > 106th Congressional Bills > S. 3058 (pcs) To amend the Public Health Service Act, the Employee Retirement Income Security Act of 1974, and the Internal Revenue Code of 1986 to protect consumers in managed care plans and other health coverage. [Placed on Calendar Senate] %%Filename:...S. 3058 (pcs) To amend the Public Health Service Act, the Employee Retirement Income Security Act of 1974, and the Internal Revenue Code of 1986 to protect consumers in managed care plans and other health coverage. [Placed on Calendar Senate] %%Filename:...
the capacity of authorizing a benefit determined by an
external review entity for one or more group health
plans, or health insurance issuers offering health
insurance coverage, for--
(i) any pattern or practice of repeated
refusal to authorize a benefit determined by an
external appeal entity in violation of the
terms of such a plan, coverage, or this title;
or
(ii) any pattern or practice of repeated
violations of the requirements of this section
with respect to such plan or plans or coverage.
(B) Standard of proof and amount of penalty.--Such
penalty shall be payable only upon proof by clear and
convincing evidence of such pattern or practice and
shall be in an amount not to exceed the lesser of--
(i) 25 percent of the aggregate value of
benefits shown by the appropriate Secretary to
have not been provided, or unlawfully delayed,
in violation of this section under such pattern
or practice; or
(ii) $500,000.
(4) Removal and disqualification.--Any person acting in the
capacity of authorizing benefits who has engaged in any such
pattern or practice described in paragraph (3)(A) with respect
to a plan or coverage, upon the petition of the appropriate
Secretary, may be removed by the court from such position, and
from any other involvement, with respect to such a plan or
coverage, and may be precluded from returning to any such
position or involvement for a period determined by the court.
(f) Protection of Legal Rights.--Nothing in this subtitle shall be
construed as altering or eliminating any cause of action or legal
rights or remedies of participants, beneficiaries, enrollees, and
others under State or Federal law (including sections 502 and 503 of
the Employee Retirement Income Security Act of 1974), including the
right to file judicial actions to enforce rights.
SEC. 104. ESTABLISHMENT OF A GRIEVANCE PROCESS.
(a) Establishment of Grievance System.--
(1) In general.--A group health plan, and a health
insurance issuer in connection with the provision of health
insurance coverage, shall establish and maintain a system to
provide for the presentation and resolution of oral and written
grievances brought by individuals who are participants,
beneficiaries, or enrollees, or health care providers or other
individuals acting on behalf of an individual and with the
individual's consent or without such consent if the individual
is medically unable to provide such consent, regarding any
aspect of the plan's or issuer's services.
(2) Grievance defined.--In this section, the term
``grievance'' means any question, complaint, or concern brought
by a participant, beneficiary or enrollee that is not a claim
for benefits (as defined in section 101(f)(1)).
(b) Grievance System.--Such system shall include the following
components with respect to individuals who are participants,
beneficiaries, or enrollees:
(1) Written notification to all such individuals and
providers of the telephone numbers and business addresses of
the plan or issuer personnel responsible for resolution of
grievances and appeals.
(2) A system to record and document, over a period of at
least three previous years, all grievances and appeals made and
their status.
(3) A process providing for timely processing and
resolution of grievances.
(4) Procedures for follow-up action, including the methods
to inform the person making the grievance of the resolution of
the grievance.
Grievances are not subject to appeal under the previous provisions of
this subtitle.
Subtitle B--Access to Care
SEC. 111. CONSUMER CHOICE OPTION.
(a) In General.--If--
(1) a health insurance issuer providing health insurance
coverage in connection with a group health plan offers to
enrollees health insurance coverage which provides for coverage
of services only if such services are furnished through health
care professionals and providers who are members of a network
of health care professionals and providers who have entered
into a contract with the issuer to provide such services, or
(2) a group health plan offers to participants or
beneficiaries health benefits which provide for coverage of
services only if such services are furnished through health
care professionals and providers who are members of a network
of health care professionals and providers who have entered
into a contract with the plan to provide such services,
then the issuer or plan shall also offer or arrange to be offered to
such enrollees, participants, or beneficiaries (at the time of
enrollment and during an annual open season as provided under
subsection (c)) the option of health insurance coverage or health
benefits which provide for coverage of such services which are not
furnished through health care professionals and providers who are
members of such a network unless such enrollees, participants, or
beneficiaries are offered such non-network coverage through another
group health plan or through another health insurance issuer in the
group market.
(b) Additional Costs.--The amount of any additional premium charged
by the health insurance issuer or group health plan for the additional
cost of the creation and maintenance of the option described in
subsection (a) and the amount of any additional cost sharing imposed
under such option shall be borne by the enrollee, participant, or
beneficiary unless it is paid by the health plan sponsor or group
health plan through agreement with the health insurance issuer.
(c) Open Season.--An enrollee, participant, or beneficiary, may
change to the offering provided under this section only during a time
period determined by the health insurance issuer or group health plan.
Such time period shall occur at least annually.
SEC. 112. CHOICE OF HEALTH CARE PROFESSIONAL.
(a) Primary Care.--If a group health plan, or a health insurance
issuer that offers health insurance coverage, requires or provides for
designation by a participant, beneficiary, or enrollee of a
participating primary care provider, then the plan or issuer shall
permit each participant, beneficiary, and enrollee to designate 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 professional 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 health care professionals with respect to such
care.
(3) Construction.--Nothing in this subsection shall be
construed as affecting the application of section 114 (relating
to access to specialty care).
SEC. 113. 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 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 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--
(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, 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; 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.
(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.--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), if
the services are maintenance care or post-stabilization care covered
under such guidelines.
SEC. 114. ACCESS TO SPECIALTY CARE.
(a) Specialty Care for Covered Services.--
(1) In general.--If--
(A) 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;
(B) the individual has a condition or disease of
sufficient seriousness and complexity to require
treatment by a specialist; and
(C) 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.
(2) Specialist defined.--For purposes of this subsection,
the term ``specialist'' means, with respect to a condition, a
health care practitioner, facility, or center 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.
(3) 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 paragraph (1) be--
(A) 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
(B) 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.
(4) Referrals to participating providers.--A group health
plan or health insurance issuer is not required under paragraph
(1) 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.
(5) Treatment of nonparticipating providers.--If a plan or
issuer refers an individual to a nonparticipating specialist
pursuant to paragraph (1), 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.
(b) Specialists as Gatekeeper for Treatment of Ongoing Special
Conditions.--
(1) In general.--A group health plan, or a health insurance
issuer, in connection with the provision of health insurance
coverage, shall have a procedure by which an individual who is
a participant, beneficiary, or enrollee and who has an ongoing
special condition (as defined in paragraph (3)) may request and
receive a referral to a specialist for such condition who shall
be responsible for and capable of providing and coordinating
the individual's care with respect to the condition. Under such
procedures if such an individual's care would most
appropriately be coordinated by such a specialist, such plan or
issuer shall refer the individual to such specialist.
(2) Treatment for related referrals.--Such specialists
shall be permitted to treat the individual without a referral
from the individual's primary care provider and may authorize
such referrals, procedures, tests, and other medical services
as the individual's primary care provider would otherwise be
permitted to provide or authorize, subject to the terms of the
treatment (referred to in subsection (a)(3)(A)) with respect to
the ongoing special condition.
(3) Ongoing special condition defined.--In this subsection,
the term ``ongoing special condition'' means a condition or
disease that--
(A) is life-threatening, degenerative, or
disabling; and
(B) requires specialized medical care over a
prolonged period of time.
(4) Terms of referral.--The provisions of paragraphs (3)
through (5) of subsection (a) apply with respect to referrals
under paragraph (1) of this subsection in the same manner as
they apply to referrals under subsection (a)(1).
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