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S. 3059 (is) To amend title 49, United States Code, to require motor vehicle [Introduced in Senate] ...
Calendar No. 809 106th CONGRESS 2d Session S. 3058 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. 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 determination on a claim for benefit under paragraph (1), (2)(A), or (3) by the applicable deadline established under the respective paragraph, the failure shall be treated under this
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