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:...
Calendar No. 808
106th CONGRESS
2d Session
S. 3057
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.
_______________________________________________________________________
IN THE SENATE OF THE UNITED STATES
September 15, 2000
Mr. Kennedy (for himself and Mr. Daschle) introduced the following
bill; which was read the first time
September 18, 2000
Read the second time and placed on the calendar
_______________________________________________________________________
A BILL
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.
Be it enacted by the Senate and House of Representatives of the
United States of America in Congress assembled,
SECTION 1. SHORT TITLE; TABLE OF CONTENTS.
(a) Short Title.--This Act may be cited as the ``Patients' Bill of
Rights Act''.
(b) Table of Contents.--The table of contents of this Act is as
follows:
Sec. 1. Short title; table of contents.
TITLE I--IMPROVING MANAGED CARE
Subtitle A--Grievance and Appeals
Sec. 101. Utilization review activities.
Sec. 102. Internal appeals procedures.
Sec. 103. External appeals procedures.
Sec. 104. Establishment of a grievance process.
Subtitle B--Access to Care
Sec. 111. Consumer choice option.
Sec. 112. Choice of health care professional.
Sec. 113. Access to emergency care.
Sec. 114. Access to specialty care.
Sec. 115. Access to obstetrical and gynecological care.
Sec. 116. Access to pediatric care.
Sec. 117. Continuity of care.
Sec. 118. Access to needed prescription drugs.
Sec. 119. Coverage for individuals participating in approved clinical
trials.
Subtitle C--Access to Information
Sec. 121. Patient access to information.
Subtitle D--Protecting the Doctor-Patient Relationship
Sec. 131. Prohibition of interference with certain medical
communications.
Sec. 132. Prohibition of discrimination against providers based on
licensure.
Sec. 133. Prohibition against improper incentive arrangements.
Sec. 134. Payment of claims.
Sec. 135. Protection for patient advocacy.
Subtitle E--Definitions
Sec. 151. Definitions.
Sec. 152. Preemption; State flexibility; construction.
Sec. 153. Exclusions.
Sec. 154. Coverage of limited scope plans.
Sec. 155. Regulations.
TITLE II--APPLICATION OF QUALITY CARE STANDARDS TO GROUP HEALTH PLANS
AND HEALTH INSURANCE COVERAGE UNDER THE PUBLIC HEALTH SERVICE ACT
Sec. 201. Application to group health plans and group health insurance
coverage.
Sec. 202. Application to individual health insurance coverage.
TITLE III--AMENDMENTS TO THE EMPLOYEE RETIREMENT INCOME SECURITY ACT OF
1974
Sec. 301. Application of patient protection standards to group health
plans and group health insurance coverage
under the Employee Retirement Income
Security Act of 1974.
Sec. 302. ERISA preemption not to apply to certain actions involving
health insurance policyholders.
Sec. 303. Limitations on actions.
TITLE IV--APPLICATION TO GROUP HEALTH PLANS UNDER THE INTERNAL REVENUE
CODE OF 1986
Sec. 401. Amendments to the Internal Revenue Code of 1986.
TITLE V--EFFECTIVE DATES; COORDINATION IN IMPLEMENTATION
Sec. 501. Effective dates.
Sec. 502. Coordination in implementation.
TITLE VI--MISCELLANEOUS PROVISIONS
Sec. 601. Health care paperwork simplification.
Sec. 602. No impact on social security trust fund.
Sec. 603. FMAP reduction for other than substantial noncompliance with
medicaid State plan requirements.
Sec. 604. Customs user fees.
TITLE I--IMPROVING MANAGED CARE
Subtitle A--Grievance and Appeals
SEC. 101. UTILIZATION REVIEW ACTIVITIES.
(a) Compliance With Requirements.--
(1) In general.--A group health plan, and a health
insurance issuer that provides health insurance coverage, shall
conduct utilization review activities in connection with the
provision of benefits under such plan or coverage only in
accordance with a utilization review program that meets the
requirements of this section.
(2) Use of outside agents.--Nothing in this section shall
be construed as preventing a group health plan or health
insurance issuer from arranging through a contract or otherwise
for persons or entities to conduct utilization review
activities on behalf of the plan or issuer, so long as such
activities are conducted in accordance with a utilization
review program that meets the requirements of this section.
(3) Utilization review defined.--For purposes of this
section, the terms ``utilization review'' and ``utilization
review activities'' mean procedures used to monitor or evaluate
the use or coverage, clinical necessity, appropriateness,
efficacy, or efficiency of health care services, procedures or
settings, and includes prospective review, concurrent review,
second opinions, case management, discharge planning, or
retrospective review.
(b) Written Policies and Criteria.--
(1) Written policies.--A utilization review program shall
be conducted consistent with written policies and procedures
that govern all aspects of the program.
(2) Use of written criteria.--
(A) In general.--Such a program shall utilize
written clinical review criteria developed with input
from a range of appropriate actively practicing health
care professionals, as determined by the plan, pursuant
to the program. Such criteria shall include written
clinical review criteria that are based on valid
clinical evidence where available and that are directed
specifically at meeting the needs of at-risk
populations and covered individuals with chronic
conditions or severe illnesses, including gender-
specific criteria and pediatric-specific criteria where
available and appropriate.
(B) Continuing use of standards in retrospective
review.--If a health care service has been specifically
pre-authorized or approved for an enrollee under such a
program, the program shall not, pursuant to
retrospective review, revise or modify the specific
standards, criteria, or procedures used for the
utilization review for procedures, treatment, and
services delivered to the enrollee during the same
course of treatment.
(C) Review of sample of claims denials.--Such a
program shall provide for an evaluation of the clinical
appropriateness of at least a sample of denials of
claims for benefits.
(c) Conduct of Program Activities.--
(1) Administration by health care professionals.--A
utilization review program shall be administered by qualified
health care professionals who shall oversee review decisions.
(2) Use of qualified, independent personnel.--
(A) In general.--A utilization review program shall
provide for the conduct of utilization review
activities only through personnel who are qualified and
have received appropriate training in the conduct of
such activities under the program.
(B) Prohibition of contingent compensation
arrangements.--Such a program shall not, with respect
to utilization review activities, permit or provide
compensation or anything of value to its employees,
agents, or contractors in a manner that encourages
denials of claims for benefits.
(C) Prohibition of conflicts.--Such a program shall
not permit a health care professional who is providing
health care services to an individual to perform
utilization review activities in connection with the
health care services being provided to the individual.
(3) Accessibility of review.--Such a program shall provide
that appropriate personnel performing utilization review
activities under the program, including the utilization review
administrator, are reasonably accessible by toll-free telephone
during normal business hours to discuss patient care and allow
response to telephone requests, and that appropriate provision
is made to receive and respond promptly to calls received
during other hours.
(4) Limits on frequency.--Such a program shall not provide
for the performance of utilization review activities with
respect to a class of services furnished to an individual more
frequently than is reasonably required to assess whether the
services under review are medically necessary or appropriate.
(d) Deadline for Determinations.--
(1) Prior authorization services.--
(A) In general.--Except as provided in paragraph
(2), in the case of a utilization review activity
involving the prior authorization of health care items
and services for an individual, the utilization review
program shall make a determination concerning such
authorization, and provide notice of the determination
to the individual or the individual's designee and the
individual's health care provider by telephone and in
printed form, as soon as possible in accordance with
the medical exigencies of the case, and in no event
later than the deadline specified in subparagraph (B).
(B) Deadline.--
(i) In general.--Subject to clauses (ii)
and (iii), the deadline specified in this
subparagraph is 14 days after the date of
receipt of the request for prior authorization.
(ii) Extension permitted where notice of
additional information required.--If a
utilization review program--
(I) receives a request for a prior
authorization;
(II) determines that additional
information is necessary to complete
the review and make the determination
on the request; and
(III) notifies the requester, not
later than five business days after the
date of receiving the request, of the
need for such specified additional
information,
the deadline specified in this subparagraph is
14 days after the date the program receives the
specified additional information, but in no
case later than 28 days after the date of
receipt of the request for the prior
authorization. This clause shall not apply if
the deadline is specified in clause (iii).
(iii) Expedited cases.--In the case of a
situation described in section 102(c)(1)(A),
the deadline specified in this subparagraph is
72 hours after the time of the request for
prior authorization.
(2) Ongoing care.--
(A) Concurrent review.--
(i) In general.--Subject to subparagraph
(B), in the case of a concurrent review of
ongoing care (including hospitalization), which
results in a termination or reduction of such
care, the plan must provide by telephone and in
printed form notice of the concurrent review
determination to the individual or the
individual's designee and the individual's
health care provider as soon as possible in
accordance with the medical exigencies of the
case, with sufficient time prior to the
termination or reduction to allow for an appeal
under section 102(c)(1)(A) to be completed
before the termination or reduction takes
effect.
(ii) Contents of notice.--Such notice shall
include, with respect to ongoing health care
items and services, the number of ongoing
services approved, the new total of approved
services, the date of onset of services, and
the next review date, if any, as well as a
statement of the individual's rights to further
appeal.
(B) Exception.--Subparagraph (A) shall not be
interpreted as requiring plans or issuers to provide
coverage of care that would exceed the coverage
limitations for such care.
(3) Previously provided services.--In the case of a
utilization review activity involving retrospective review of
health care services previously provided for an individual, the
utilization review program shall make a determination
concerning such services, and provide notice of the
determination to the individual or the individual's designee
and the individual's health care provider by telephone and in
printed form, within 30 days of the date of receipt of
information that is reasonably necessary to make such
determination, but in no case later than 60 days after the date
of receipt of the claim for benefits.
(4) Failure to meet deadline.--In a case in which a group
health plan or health insurance issuer fails to make a
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