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:...
``(A) Section 112 (relating to choice of
providers).
``(B) Section 113 (relating to access to emergency
care).
``(C) Section 114 (relating to access to specialty
care).
``(D) Section 115 (relating to access to
obstetrical and gynecological care).
``(E) Section 116 (relating to access to pediatric
care).
``(F) Section 117(a)(1) (relating to continuity in
case of termination of provider contract) and section
117(a)(2) (relating to continuity in case of
termination of issuer contract), but only insofar as a
replacement issuer assumes the obligation for
continuity of care.
``(G) Section 118 (relating to access to needed
prescription drugs).
``(H) Section 119 (relating to coverage for
individuals participating in approved clinical trials.)
``(I) Section 134 (relating to payment of claims).
``(2) Information.--With respect to information required to
be provided or made available under section 121, in the case of
a group health plan that provides benefits in the form of
health insurance coverage through a health insurance issuer,
the Secretary shall determine the circumstances under which the
plan is not required to provide or make available the
information (and is not liable for the issuer's failure to
provide or make available the information), if the issuer is
obligated to provide and make available (or provides and makes
available) such information.
``(3) Grievance and internal appeals.--With respect to the
internal appeals process and the grievance system required to
be established under sections 102 and 104, in the case of a
group health plan that provides benefits in the form of health
insurance coverage through a health insurance issuer, the
Secretary shall determine the circumstances under which the
plan is not required to provide for such process and system
(and is not liable for the issuer's failure to provide for such
process and system), if the issuer is obligated to provide for
(and provides for) such process and system.
``(4) External appeals.--Pursuant to rules of the
Secretary, insofar as a group health plan enters into a
contract with a qualified external appeal entity for the
conduct of external appeal activities in accordance with
section 103, the plan shall be treated as meeting the
requirement of such section and is not liable for the entity's
failure to meet any requirements under such section.
``(5) Application to prohibitions.--Pursuant to rules of
the Secretary, if a health insurance issuer offers health
insurance coverage in connection with a group health plan and
takes an action in violation of any of the following sections,
the group health plan shall not be liable for such violation
unless the plan caused such violation:
``(A) Section 131 (relating to prohibition of
interference with certain medical communications).
``(B) Section 132 (relating to prohibition of
discrimination against providers based on licensure).
``(C) Section 133 (relating to prohibition against
improper incentive arrangements).
``(D) Section 135 (relating to protection for
patient advocacy).
``(6) Construction.--Nothing in this subsection shall be
construed to affect or modify the responsibilities of the
fiduciaries of a group health plan under part 4 of subtitle B.
``(7) Application to certain prohibitions against
retaliation.--With respect to compliance with the requirements
of section 135(b)(1) of the Patients' Bill of Rights Act, for
purposes of this subtitle the term `group health plan' is
deemed to include a reference to an institutional health care
provider.
``(c) Enforcement of Certain Requirements.--
``(1) Complaints.--Any protected health care professional
who believes that the professional has been retaliated or
discriminated against in violation of section 135(b)(1) of the
Patients' Bill of Rights Act may file with the Secretary a
complaint within 180 days of the date of the alleged
retaliation or discrimination.
``(2) Investigation.--The Secretary shall investigate such
complaints and shall determine if a violation of such section
has occurred and, if so, shall issue an order to ensure that
the protected health care professional does not suffer any loss
of position, pay, or benefits in relation to the plan, issuer,
or provider involved, as a result of the violation found by the
Secretary.
``(d) Conforming Regulations.--The Secretary may issue regulations
to coordinate the requirements on group health plans under this section
with the requirements imposed under the other provisions of this
title.''.
(b) Satisfaction of ERISA Claims Procedure Requirement.--Section
503 of such Act (29 U.S.C. 1133) is amended by inserting ``(a)'' after
``Sec. 503.'' and by adding at the end the following new subsection:
``(b) In the case of a group health plan (as defined in section
733) compliance with the requirements of subtitle A of title I of the
Patients Bill of Rights Act in the case of a claims denial shall be
deemed compliance with subsection (a) with respect to such claims
denial.''.
(c) Conforming Amendments.--(1) Section 732(a) of such Act (29
U.S.C. 1185(a)) is amended by striking ``section 711'' and inserting
``sections 711 and 714''.
(2) The table of contents in section 1 of such Act is amended by
inserting after the item relating to section 713 the following new
item:
``Sec. 714. Patient protection standards.''.
(3) Section 502(b)(3) of such Act (29 U.S.C. 1132(b)(3)) is amended
by inserting ``(other than section 135(b))'' after ``part 7''.
SEC. 302. ERISA PREEMPTION NOT TO APPLY TO CERTAIN ACTIONS INVOLVING
HEALTH INSURANCE POLICYHOLDERS.
(a) In General.--Section 514 of the Employee Retirement Income
Security Act of 1974 (29 U.S.C. 1144) (as amended by section 301(b)) is
amended further by adding at the end the following subsections:
``(f) Preemption Not To Apply to Certain Actions Arising Out of
Provision of Health Benefits.--
``(1) Non-preemption of certain causes of action.--
``(A) In general.--Except as provided in this
subsection, nothing in this title shall be construed to
invalidate, impair, or supersede any cause of action by
a participant or beneficiary (or the estate of a
participant or beneficiary) under State law to recover
damages resulting from personal injury or for wrongful
death against any person--
``(i) in connection with the provision of
insurance, administrative services, or medical
services by such person to or for a group
health plan as defined in section 733), or
``(ii) that arises out of the arrangement
by such person for the provision of such
insurance, administrative services, or medical
services by other persons.
``(B) Limitation on punitive damages.--
``(i) In general.--No person shall be
liable for any punitive, exemplary, or similar
damages in the case of a cause of action
brought under subparagraph (A) if--
``(I) it relates to an externally
appealable decision (as defined in
subsection (a)(2) of section 103 of the
Patients' Bill of Rights Act);
``(II) an external appeal with
respect to such decision was completed
under such section 103;
``(III) in the case such external
appeal was initiated by the plan or
issuer filing the request for the
external appeal, the request was filed
on a timely basis before the date the
action was brought or, if later, within
30 days after the date the externally
appealable decision was made; and
``(IV) the plan or issuer complied
with the determination of the external
appeal entity upon receipt of the
determination of the external appeal
entity.
The provisions of this clause supersede any
State law or common law to the contrary.
``(ii) Exception.--Clause (i) shall not
apply with respect to damages in the case of a
cause of action for wrongful death if the
applicable State law provides (or has been
construed to provide) for damages in such a
cause of action which are only punitive or
exemplary in nature.
``(C) Personal injury defined.--For purposes of
this subsection, the term `personal injury' means a
physical injury and includes an injury arising out of
the treatment (or failure to treat) a mental illness or
disease.
``(2) Exception for group health plans, employers, and
other plan sponsors.--
``(A) In general.--Subject to subparagraph (B),
paragraph (1) does not authorize--
``(i) any cause of action against a group
health plan or an employer or other plan
sponsor maintaining the plan (or against an
employee of such a plan, employer, or sponsor
acting within the scope of employment), or
``(ii) a right of recovery, indemnity, or
contribution by a person against a group health
plan or an employer or other plan sponsor (or
such an employee) for damages assessed against
the person pursuant to a cause of action under
paragraph (1).
``(B) Special rule.--Subparagraph (A) shall not
preclude any cause of action described in paragraph (1)
against group health plan or an employer or other plan
sponsor (or against an employee of such a plan,
employer, or sponsor acting within the scope of
employment) if--
``(i) such action is based on the exercise
by the plan, employer, or sponsor (or employee)
of discretionary authority to make a decision
on a claim for benefits covered under the plan
or health insurance coverage in the case at
issue; and
``(ii) the exercise by the plan, employer,
or sponsor (or employee) of such authority
resulted in personal injury or wrongful death.
``(C) Exception.--The exercise of discretionary
authority described in subparagraph (B)(i) shall not be
construed to include--
``(i) the decision to include or exclude
from the plan any specific benefit;
``(ii) any decision to provide extra-
contractual benefits; or
``(iii) any decision not to consider the
provision of a benefit while internal or
external review is being conducted.
``(3) Futility of exhaustion.--An individual bringing an
action under this subsection is required to exhaust
administrative processes under sections 102 and 103 of the
Patients' Bill of Rights Act, unless the injury to or death of
such individual has occurred before the completion of such
processes.
``(4) Construction.--Nothing in this subsection shall be
construed as--
``(A) permitting a cause of action under State law
for the failure to provide an item or service which is
specifically excluded under the group health plan
involved;
``(B) as preempting a State law which requires an
affidavit or certificate of merit in a civil action; or
``(C) permitting a cause of action or remedy under
State law in connection with the provision or
arrangement of excepted benefits (as defined in section
733(c)), other than those described in section
733(c)(2)(A).
``(g) Rules of Construction Relating to Health Care.--Nothing in
this title shall be construed as--
``(1) permitting the application of State laws that are
otherwise superseded by this title and that mandate the
provision of specific benefits by a group health plan (as
defined in section 733(a)) or a multiple employer welfare
arrangement (as defined in section 3(40)), or
``(2) affecting any State law which regulates the practice
of medicine or provision of medical care, or affecting any
action based upon such a State law.''.
(b) Effective Date.--The amendment made by subsection (a) shall
apply to acts and omissions occurring on or after the date of enactment
of this Act, from which a cause of action arises.
SEC. 303. LIMITATIONS ON ACTIONS.
Section 502 of the Employee Retirement Income Security Act of 1974
(29 U.S.C. 1132) (as amended by section 304(b)) is amended further by
adding at the end the following new subsection:
``(o)(1) Except as provided in this subsection, no action may be
brought under subsection (a)(1)(B), (a)(2), or (a)(3) by a participant
or beneficiary seeking relief based on the application of any provision
in section 101, subtitle B, or subtitle D of title I of the Patients'
Bill of Rights Act (as incorporated under section 714).
``(2) An action may be brought under subsection (a)(1)(B), (a)(2),
or (a)(3) by a participant or beneficiary seeking relief based on the
application of section 101, 113, 114, 115, 116, 117, 119, or 118(3) of
the Patients' Bill of Rights Act (as incorporated under section 714) to
the individual circumstances of that participant or beneficiary, except
that--
``(A) such an action may not be brought or maintained as a
class action; and
``(B) in such an action, relief may only provide for the
provision of (or payment of) benefits, items, or services
denied to the individual participant or beneficiary involved
(and for attorney's fees and the costs of the action, at the
discretion of the court) and shall not provide for any other
relief to the participant or beneficiary or for any relief to
any other person.
``(3) Nothing in this subsection shall be construed as affecting
any action brought by the Secretary.''.
TITLE IV--APPLICATION TO GROUP HEALTH PLANS UNDER THE INTERNAL REVENUE
CODE OF 1986
SEC. 401. AMENDMENTS TO THE INTERNAL REVENUE CODE OF 1986.
Subchapter B of chapter 100 of the Internal Revenue Code of 1986 is
amended--
(1) in the table of sections, by inserting after the item
relating to section 9812 the following new item:
``Sec. 9813. Standard relating to patient
freedom of choice.'';
and
(2) by inserting after section 9812 the following:
``SEC. 9813. STANDARD RELATING TO PATIENTS' BILL OF RIGHTS.
``A group health plan shall comply with the requirements of title I
of the Patients' Bill of Rights Act (as in effect as of the date of the
enactment of such Act), and such requirements shall be deemed to be
incorporated into this section.''.
TITLE V--EFFECTIVE DATES; COORDINATION IN IMPLEMENTATION
SEC. 501. EFFECTIVE DATES.
(a) Group Health Coverage.--
(1) In general.--Subject to paragraph (2), the amendments
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