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:...
(c) Standing Referrals.--
(1) In general.--A group health plan, and 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 a condition that requires ongoing care from a
specialist may receive a standing referral to such specialist
for treatment of such condition. If the plan or issuer, or if
the primary care provider in consultation with the medical
director of the plan or issuer and the specialist (if any),
determines that such a standing referral is appropriate, the
plan or issuer shall make such a referral to such a specialist
if the individual so desires.
(2) 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).
SEC. 115. ACCESS TO OBSTETRICAL AND GYNECOLOGICAL CARE.
(a) 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 health care professional, the
plan or issuer--
(1) may not require authorization or a referral by the
individual's primary care health care professional or otherwise
for coverage of gynecological care (including preventive
women's health examinations) and pregnancy-related services
provided by a participating health care professional, including
a physician, who specializes in obstetrics and gynecology to
the extent such care is otherwise covered; and
(2) shall treat the ordering of other obstetrical or
gynecological care by such a participating professional as the
authorization of the primary care health care professional with
respect to such care under the plan or coverage.
(b) Construction.--Nothing in subsection (a) shall be construed
to--
(1) waive any exclusions of coverage under the terms of the
plan or health insurance coverage with respect to coverage of
obstetrical or gynecological care; or
(2) preclude the group health plan or health insurance
issuer involved from requiring that the obstetrical or
gynecological provider notify the primary care health care
professional or the plan or issuer of treatment decisions.
SEC. 116. ACCESS TO PEDIATRIC CARE.
(a) Pediatric Care.--If a group health plan, or a health insurance
issuer in connection with the provision of health insurance coverage,
requires or provides for an enrollee to designate a participating
primary care provider for a child of such enrollee, the plan or issuer
shall permit the enrollee to designate a physician who specializes in
pediatrics as the child's primary care provider.
(b) Construction.--Nothing in subsection (a) shall be construed to
waive any exclusions of coverage under the terms of the plan or health
insurance coverage with respect to coverage of pediatric care.
SEC. 117. CONTINUITY OF CARE.
(a) In General.--
(1) Termination of provider.--If a contract between a group
health plan, or a health insurance issuer in connection with
the provision of health insurance coverage, and a health care
provider is terminated (as defined in paragraph (3)(B)), or
benefits or coverage provided by a health care provider are
terminated because of a change in the terms of provider
participation in a group health plan, and an individual who is
a participant, beneficiary, or enrollee in the plan or coverage
is undergoing treatment from the provider for an ongoing
special condition (as defined in paragraph (3)(A)) at the time
of such termination, the plan or issuer shall--
(A) notify the individual on a timely basis of such
termination and of the right to elect continuation of
coverage of treatment by the provider under this
section; and
(B) subject to subsection (c), permit the
individual to elect to continue to be covered with
respect to treatment by the provider of such condition
during a transitional period (provided under subsection
(b)).
(2) Treatment of termination of contract with health
insurance issuer.--If a contract for the provision of health
insurance coverage between a group health plan and a health
insurance issuer is terminated and, as a result of such
termination, coverage of services of a health care provider is
terminated with respect to an individual, the provisions of
paragraph (1) (and the succeeding provisions of this section)
shall apply under the plan in the same manner as if there had
been a contract between the plan and the provider that had been
terminated, but only with respect to benefits that are covered
under the plan after the contract termination.
(3) Definitions.--For purposes of this section:
(A) Ongoing special condition.--The term ``ongoing
special condition'' has the meaning given such term in
section 114(b)(3), and also includes pregnancy.
(B) Termination.--The term ``terminated'' includes,
with respect to a contract, the expiration or
nonrenewal of the contract, but does not include a
termination of the contract by the plan or issuer for
failure to meet applicable quality standards or for
fraud.
(b) Transitional Period.--
(1) In general.--Except as provided in paragraphs (2)
through (4), the transitional period under this subsection
shall extend up to 90 days (as determined by the treating
health care professional) after the date of the notice
described in subsection (a)(1)(A) of the provider's
termination.
(2) Scheduled surgery and organ transplantation.--If
surgery or organ transplantation was scheduled for an
individual before the date of the announcement of the
termination of the provider status under subsection (a)(1)(A)
or if the individual on such date was on an established waiting
list or otherwise scheduled to have such surgery or
transplantation, the transitional period under this subsection
with respect to the surgery or transplantation shall extend
beyond the period under paragraph (1) and until the date of
discharge of the individual after completion of the surgery or
transplantation.
(3) Pregnancy.--If--
(A) a participant, beneficiary, or enrollee was
determined to be pregnant at the time of a provider's
termination of participation; and
(B) the provider was treating the pregnancy before
date of the termination,
the transitional period under this subsection with respect to
provider's treatment of the pregnancy shall extend through the
provision of post-partum care directly related to the delivery.
(4) Terminal illness.--If--
(A) a participant, beneficiary, or enrollee was
determined to be terminally ill (as determined under
section 1861(dd)(3)(A) of the Social Security Act) at
the time of a provider's termination of participation;
and
(B) the provider was treating the terminal illness
before the date of termination,
the transitional period under this subsection shall extend for
the remainder of the individual's life for care directly
related to the treatment of the terminal illness or its medical
manifestations.
(c) Permissible Terms and Conditions.--A group health plan or
health insurance issuer may condition coverage of continued treatment
by a provider under subsection (a)(1)(B) upon the individual notifying
the plan of the election of continued coverage and upon the provider
agreeing to the following terms and conditions:
(1) The provider agrees to accept reimbursement from the
plan or issuer and individual involved (with respect to cost-
sharing) at the rates applicable prior to the start of the
transitional period as payment in full (or, in the case
described in subsection (a)(2), at the rates applicable under
the replacement plan or issuer after the date of the
termination of the contract with the health insurance issuer)
and not to impose cost-sharing with respect to the individual
in an amount that would exceed the cost-sharing that could have
been imposed if the contract referred to in subsection (a)(1)
had not been terminated.
(2) The provider agrees to adhere to the quality assurance
standards of the plan or issuer responsible for payment under
paragraph (1) and to provide to such plan or issuer necessary
medical information related to the care provided.
(3) The provider agrees otherwise to adhere to such plan's
or issuer's policies and procedures, including procedures
regarding referrals and obtaining prior authorization and
providing services pursuant to a treatment plan (if any)
approved by the plan or issuer.
(d) Construction.--Nothing in this section shall be construed to
require the coverage of benefits which would not have been covered if
the provider involved remained a participating provider.
SEC. 118. ACCESS TO NEEDED PRESCRIPTION DRUGS.
If a group health plan, or health insurance issuer that offers
health insurance coverage, provides benefits with respect to
prescription drugs but the coverage limits such benefits to drugs
included in a formulary, the plan or issuer shall--
(1) ensure participation of participating physicians and
pharmacists in the development of the formulary;
(2) disclose to providers and, disclose upon request under
section 121(c)(5) to participants, beneficiaries, and
enrollees, the nature of the formulary restrictions; and
(3) consistent with the standards for a utilization review
program under section 101, provide for exceptions from the
formulary limitation when a non-formulary alternative is
medically indicated.
SEC. 119. COVERAGE FOR INDIVIDUALS PARTICIPATING IN APPROVED CLINICAL
TRIALS.
(a) Coverage.--
(1) In general.--If a group health plan, or health
insurance issuer that is providing health insurance coverage,
provides coverage to a qualified individual (as defined in
subsection (b)), the plan or issuer--
(A) may not deny the individual participation in
the clinical trial referred to in subsection (b)(2);
(B) subject to subsection (c), may not deny (or
limit or impose additional conditions on) the coverage
of routine patient costs for items and services
furnished in connection with participation in the
trial; and
(C) may not discriminate against the individual on
the basis of the enrollee's participation in such
trial.
(2) Exclusion of certain costs.--For purposes of paragraph
(1)(B), routine patient costs do not include the cost of the
tests or measurements conducted primarily for the purpose of
the clinical trial involved.
(3) Use of in-network providers.--If one or more
participating providers is participating in a clinical trial,
nothing in paragraph (1) shall be construed as preventing a
plan or issuer from requiring that a qualified individual
participate in the trial through such a participating provider
if the provider will accept the individual as a participant in
the trial.
(b) Qualified Individual Defined.--For purposes of subsection (a),
the term ``qualified individual'' means an individual who is a
participant or beneficiary in a group health plan, or who is an
enrollee under health insurance coverage, and who meets the following
conditions:
(1)(A) The individual has a life-threatening or serious
illness for which no standard treatment is effective.
(B) The individual is eligible to participate in an
approved clinical trial according to the trial protocol with
respect to treatment of such illness.
(C) The individual's participation in the trial offers
meaningful potential for significant clinical benefit for the
individual.
(2) Either--
(A) the referring physician is a participating
health care professional and has concluded that the
individual's participation in such trial would be
appropriate based upon the individual meeting the
conditions described in paragraph (1); or
(B) the participant, beneficiary, or enrollee
provides medical and scientific information
establishing that the individual's participation in
such trial would be appropriate based upon the
individual meeting the conditions described in
paragraph (1).
(c) Payment.--
(1) In general.--Under this section a group health plan or
health insurance issuer shall provide for payment for routine
patient costs described in subsection (a)(2) but is not
required to pay for costs of items and services that are
reasonably expected (as determined by the Secretary) to be paid
for by the sponsors of an approved clinical trial.
(2) Payment rate.--In the case of covered items and
services provided by--
(A) a participating provider, the payment rate
shall be at the agreed upon rate; or
(B) a nonparticipating provider, the payment rate
shall be at the rate the plan or issuer would normally
pay for comparable services under subparagraph (A).
(d) Approved Clinical Trial Defined.--
(1) In general.--In this section, the term ``approved
clinical trial'' means a clinical research study or clinical
investigation approved and funded (which may include funding
through in-kind contributions) by one or more of the following:
(A) The National Institutes of Health.
(B) A cooperative group or center of the National
Institutes of Health.
(C) Either of the following if the conditions
described in paragraph (2) are met:
(i) The Department of Veterans Affairs.
(ii) The Department of Defense.
(2) Conditions for departments.--The conditions described
in this paragraph, for a study or investigation conducted by a
Department, are that the study or investigation has been
reviewed and approved through a system of peer review that the
Secretary determines--
(A) to be comparable to the system of peer review
of studies and investigations used by the National
Institutes of Health; and
(B) assures unbiased review of the highest
scientific standards by qualified individuals who have
no interest in the outcome of the review.
(e) Construction.--Nothing in this section shall be construed to
limit a plan's or issuer's coverage with respect to clinical trials.
Subtitle C--Access to Information
SEC. 121. PATIENT ACCESS TO INFORMATION.
(a) Disclosure Requirement.--
(1) Group health plans.--A group health plan shall--
(A) provide to participants and beneficiaries at
the time of initial coverage under the plan (or the
effective date of this section, in the case of
individuals who are participants or beneficiaries as of
such date), and at least annually thereafter, the
information described in subsection (b) in printed
form;
(B) provide to participants and beneficiaries,
within a reasonable period (as specified by the
appropriate Secretary) before or after the date of
significant changes in the information described in
subsection (b), information in printed form on such
significant changes; and
(C) upon request, make available to participants
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