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:...
and beneficiaries, the applicable authority, and
prospective participants and beneficiaries, the
information described in subsection (b) or (c) in
printed form.
(2) Health insurance issuers.--A health insurance issuer in
connection with the provision of health insurance coverage
shall--
(A) provide to individuals enrolled under such
coverage at the time of enrollment, and at least
annually thereafter, the information described in
subsection (b) in printed form;
(B) provide to enrollees, 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 the applicable
authority, to individuals who are prospective
enrollees, and to the public the information described
in subsection (b) or (c) in printed form.
(b) Information Provided.--The information described in this
subsection with respect to a group health plan or health insurance
coverage offered by a health insurance issuer includes the following:
(1) Service area.--The service area of the plan or issuer.
(2) Benefits.--Benefits offered under the plan or coverage,
including--
(A) covered benefits, including benefit limits and
coverage exclusions;
(B) cost sharing, such as deductibles, coinsurance,
and copayment amounts, including any liability for
balance billing, any maximum limitations on out of
pocket expenses, and the maximum out of pocket costs
for services that are provided by nonparticipating
providers or that are furnished without meeting the
applicable utilization review requirements;
(C) the extent to which benefits may be obtained
from nonparticipating providers;
(D) the extent to which a participant, beneficiary,
or enrollee may select from among participating
providers and the types of providers participating in
the plan or issuer network;
(E) process for determining experimental coverage;
and
(F) use of a prescription drug formulary.
(3) Access.--A description of the following:
(A) The number, mix, and distribution of providers
under the plan or coverage.
(B) Out-of-network coverage (if any) provided by
the plan or coverage.
(C) Any point-of-service option (including any
supplemental premium or cost-sharing for such option).
(D) The procedures for participants, beneficiaries,
and enrollees to select, access, and change
participating primary and specialty providers.
(E) The rights and procedures for obtaining
referrals (including standing referrals) to
participating and nonparticipating providers.
(F) The name, address, and telephone number of
participating health care providers and an indication
of whether each such provider is available to accept
new patients.
(G) Any limitations imposed on the selection of
qualifying participating health care providers,
including any limitations imposed under section
112(b)(2).
(H) How the plan or issuer addresses the needs of
participants, beneficiaries, and enrollees and others
who do not speak English or who have other special
communications needs in accessing providers under the
plan or coverage, including the provision of
information described in this subsection and subsection
(c) to such individuals.
(4) Out-of-area coverage.--Out-of-area coverage provided by
the plan or issuer.
(5) Emergency coverage.--Coverage of emergency services,
including--
(A) the appropriate use of emergency services,
including use of the 911 telephone system or its local
equivalent in emergency situations and an explanation
of what constitutes an emergency situation;
(B) the process and procedures of the plan or
issuer for obtaining emergency services; and
(C) the locations of (i) emergency departments, and
(ii) other settings, in which plan physicians and
hospitals provide emergency services and post-
stabilization care.
(6) Percentage of premiums used for benefits (loss-
ratios).--In the case of health insurance coverage only (and
not with respect to group health plans that do not provide
coverage through health insurance coverage), a description of
the overall loss-ratio for the coverage (as defined in
accordance with rules established or recognized by the
Secretary of Health and Human Services).
(7) Prior authorization rules.--Rules regarding prior
authorization or other review requirements that could result in
noncoverage or nonpayment.
(8) Grievance and appeals procedures.--All appeal or
grievance rights and procedures under the plan or coverage,
including the method for filing grievances and the time frames
and circumstances for acting on grievances and appeals, who is
the applicable authority with respect to the plan or issuer.
(9) Quality assurance.--Any information made public by an
accrediting organization in the process of accreditation of the
plan or issuer or any additional quality indicators the plan or
issuer makes available.
(10) Information on issuer.--Notice of appropriate mailing
addresses and telephone numbers to be used by participants,
beneficiaries, and enrollees in seeking information or
authorization for treatment.
(11) Notice of requirements.--Notice of the requirements of
this title.
(12) Availability of information on request.--Notice that
the information described in subsection (c) is available upon
request.
(c) Information Made Available Upon Request.--The information
described in this subsection is the following:
(1) Utilization review activities.--A description of
procedures used and requirements (including circumstances, time
frames, and appeal rights) under any utilization review program
under section 101, including under any drug formulary program
under section 118.
(2) Grievance and appeals information.--Information on the
number of grievances and appeals and on the disposition in the
aggregate of such matters.
(3) Method of physician compensation.--A general
description by category (including salary, fee-for-service,
capitation, and such other categories as may be specified in
regulations of the Secretary) of the applicable method by which
a specified prospective or treating health care professional is
(or would be) compensated in connection with the provision of
health care under the plan or coverage.
(4) Specific information on credentials of participating
providers.--In the case of each participating provider, a
description of the credentials of the provider.
(5) Formulary restrictions.--A description of the nature of
any drug formula restrictions.
(6) Participating provider list.--A list of current
participating health care providers.
(d) Construction.--Nothing in this section shall be construed as
requiring public disclosure of individual contracts or financial
arrangements between a group health plan or health insurance issuer and
any provider.
Subtitle D--Protecting the Doctor-Patient Relationship
SEC. 131. PROHIBITION OF INTERFERENCE WITH CERTAIN MEDICAL
COMMUNICATIONS.
(a) General Rule.--The provisions of any contract or agreement, or
the operation of any contract or agreement, between a group health plan
or health insurance issuer in relation to health insurance coverage
(including any partnership, association, or other organization that
enters into or administers such a contract or agreement) and a health
care provider (or group of health care providers) shall not prohibit or
otherwise restrict a health care professional from advising such a
participant, beneficiary, or enrollee who is a patient of the
professional about the health status of the individual or medical care
or treatment for the individual's condition or disease, regardless of
whether benefits for such care or treatment are provided under the plan
or coverage, if the professional is acting within the lawful scope of
practice.
(b) Nullification.--Any contract provision or agreement that
restricts or prohibits medical communications in violation of
subsection (a) shall be null and void.
SEC. 132. PROHIBITION OF DISCRIMINATION AGAINST PROVIDERS BASED ON
LICENSURE.
(a) In General.--A group health plan and a health insurance issuer
offering health insurance coverage shall not discriminate with respect
to participation or indemnification as to any provider who is acting
within the scope of the provider's license or certification under
applicable State law, solely on the basis of such license or
certification.
(b) Construction.--Subsection (a) shall not be construed--
(1) as requiring the coverage under a group health plan or
health insurance coverage of particular benefits or services or
to prohibit a plan or issuer from including providers only to
the extent necessary to meet the needs of the plan's or
issuer's participants, beneficiaries, or enrollees or from
establishing any measure designed to maintain quality and
control costs consistent with the responsibilities of the plan
or issuer;
(2) to override any State licensure or scope-of-practice
law; or
(3) as requiring a plan or issuer that offers network
coverage to include for participation every willing provider
who meets the terms and conditions of the plan or issuer.
SEC. 133. PROHIBITION AGAINST IMPROPER INCENTIVE ARRANGEMENTS.
(a) In General.--A group health plan and a health insurance issuer
offering health insurance coverage may not operate any physician
incentive plan (as defined in subparagraph (B) of section 1876(i)(8) of
the Social Security Act) unless the requirements described in clauses
(i), (ii)(I), and (iii) of subparagraph (A) of such section are met
with respect to such a plan.
(b) Application.--For purposes of carrying out paragraph (1), any
reference in section 1876(i)(8) of the Social Security Act to the
Secretary, an eligible organization, or an individual enrolled with the
organization shall be treated as a reference to the applicable
authority, a group health plan or health insurance issuer,
respectively, and a participant, beneficiary, or enrollee with the plan
or organization, respectively.
(c) Construction.--Nothing in this section shall be construed as
prohibiting all capitation and similar arrangements or all provider
discount arrangements.
SEC. 134. PAYMENT OF CLAIMS.
A group health plan, and a health insurance issuer offering group
health insurance coverage, shall provide for prompt payment of claims
submitted for health care services or supplies furnished to a
participant, beneficiary, or enrollee with respect to benefits covered
by the plan or issuer, in a manner consistent with the provisions of
sections 1816(c)(2) and 1842(c)(2) of the Social Security Act (42
U.S.C. 1395h(c)(2) and 42 U.S.C. 1395u(c)(2)), except that for purposes
of this section, subparagraph (C) of section 1816(c)(2) of the Social
Security Act shall be treated as applying to claims received from a
participant, beneficiary, or enrollee as well as claims referred to in
such subparagraph.
SEC. 135. PROTECTION FOR PATIENT ADVOCACY.
(a) Protection for Use of Utilization Review and Grievance
Process.--A group health plan, and a health insurance issuer with
respect to the provision of health insurance coverage, may not
retaliate against a participant, beneficiary, enrollee, or health care
provider based on the participant's, beneficiary's, enrollee's or
provider's use of, or participation in, a utilization review process or
a grievance process of the plan or issuer (including an internal or
external review or appeal process) under this title.
(b) Protection for Quality Advocacy by Health Care Professionals.--
(1) In general.--A group health plan or health insurance
issuer may not retaliate or discriminate against a protected
health care professional because the professional in good
faith--
(A) discloses information relating to the care,
services, or conditions affecting one or more
participants, beneficiaries, or enrollees of the plan
or issuer to an appropriate public regulatory agency,
an appropriate private accreditation body, or
appropriate management personnel of the plan or issuer;
or
(B) initiates, cooperates, or otherwise
participates in an investigation or proceeding by such
an agency with respect to such care, services, or
conditions.
If an institutional health care provider is a participating
provider with such a plan or issuer or otherwise receives
payments for benefits provided by such a plan or issuer, the
provisions of the previous sentence shall apply to the provider
in relation to care, services, or conditions affecting one or
more patients within an institutional health care provider in
the same manner as they apply to the plan or issuer in relation
to care, services, or conditions provided to one or more
participants, beneficiaries, or enrollees; and for purposes of
applying this sentence, any reference to a plan or issuer is
deemed a reference to the institutional health care provider.
(2) Good faith action.--For purposes of paragraph (1), a
protected health care professional is considered to be acting
in good faith with respect to disclosure of information or
participation if, with respect to the information disclosed as
part of the action--
(A) the disclosure is made on the basis of personal
knowledge and is consistent with that degree of
learning and skill ordinarily possessed by health care
professionals with the same licensure or certification
and the same experience;
(B) the professional reasonably believes the
information to be true;
(C) the information evidences either a violation of
a law, rule, or regulation, of an applicable
accreditation standard, or of a generally recognized
professional or clinical standard or that a patient is
in imminent hazard of loss of life or serious injury;
and
(D) subject to subparagraphs (B) and (C) of
paragraph (3), the professional has followed reasonable
internal procedures of the plan, issuer, or
institutional health care provider established for the
purpose of addressing quality concerns before making
the disclosure.
(3) Exception and special rule.--
(A) General exception.--Paragraph (1) does not
protect disclosures that would violate Federal or State
law or diminish or impair the rights of any person to
the continued protection of confidentiality of
communications provided by such law.
(B) Notice of internal procedures.--Subparagraph
(D) of paragraph (2) shall not apply unless the
internal procedures involved are reasonably expected to
be known to the health care professional involved. For
purposes of this subparagraph, a health care
professional is reasonably expected to know of internal
procedures if those procedures have been made available
to the professional through distribution or posting.
(C) Internal procedure exception.--Subparagraph (D)
of paragraph (2) also shall not apply if--
(i) the disclosure relates to an imminent
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