| Home > 107th Congressional Bills > S. 873 (is) To preserve and protect the free choice of individual employees to form, join, or assist labor organizations, or to refrain from such activities. [Introduced in Senate] ...
S. 873 (is) To preserve and protect the free choice of individual employees to form, join, or assist labor organizations, or to refrain from such activities. [Introduced in Senate] ...
Calendar No. 42 107th CONGRESS 1st Session S. 872 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 May 14, 2001 Mr. McCain (for himself, Mr. Edwards, and Mr. Kennedy) introduced the following bill; which was read the first time May 15, 2001 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 ``Bipartisan Patient Protection 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--Utilization Review; Claims; and Internal and External Appeals Sec. 101. Utilization review activities. Sec. 102. Procedures for initial claims for benefits and prior authorization determinations. Sec. 103. Internal appeals of claims denials. Sec. 104. Independent external appeals procedures. 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. Timely access to specialists. Sec. 115. Patient 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. Sec. 120. Required coverage for minimum hospital stay for mastectomies and lymph node dissections for the treatment of breast cancer and coverage for secondary consultations. 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. Sec. 156. Incorporation into plan or coverage documents. 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. Availability of civil remedies. Sec. 303. Limitations on actions. TITLE IV--AMENDMENTS TO THE INTERNAL REVENUE CODE OF 1986 Sec. 401. Application of requirements to group health plans under the Internal Revenue Code of 1986. Sec. 402. Conforming enforcement for women's health and cancer rights. TITLE V--EFFECTIVE DATES; COORDINATION IN IMPLEMENTATION Sec. 501. Effective dates. Sec. 502. Coordination in implementation. Sec. 503. Severability. TITLE VI--MISCELLANEOUS PROVISIONS Sec. 601. No impact on Social Security Trust Fund. Sec. 602. Customs user fees. Sec. 603. Fiscal year 2002 medicare payments. TITLE I--IMPROVING MANAGED CARE Subtitle A--Utilization Review; Claims; and Internal and External 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 and section 102. (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 a participant, beneficiary, or 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 a periodic 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 and appropriate. SEC. 102. PROCEDURES FOR INITIAL CLAIMS FOR BENEFITS AND PRIOR AUTHORIZATION DETERMINATIONS. (a) Procedures of Initial Claims for Benefits.-- (1) In general.--A group health plan, or health insurance issuer offering health insurance coverage, shall-- (A) make a determination on an initial claim for benefits by a participant, beneficiary, or enrollee (or authorized representative) regarding payment or coverage for items or services under the terms and conditions of the plan or coverage involved, including any cost-sharing amount that the participant, beneficiary, or enrollee is required to pay with respect to such claim for benefits; and (B) notify a participant, beneficiary, or enrollee (or authorized representative) and the treating health care professional involved regarding a determination on an initial claim for benefits made under the terms and conditions of the plan or coverage, including any cost- sharing amounts that the participant, beneficiary, or enrollee may be required to make with respect to such claim for benefits, and of the right of the participant, beneficiary, or enrollee to an internal appeal under section 103. (2) Access to information.-- (A) Timely provision of necessary information.-- With respect to an initial claim for benefits, the participant, beneficiary, or enrollee (or authorized representative) and the treating health care professional (if any) shall provide the plan or issuer with access to information requested by the plan or issuer that is necessary to make a determination relating to the claim. Such access shall be provided not later than 5 days after the date on which the request for information is received, or, in a case described in subparagraph (B) or (C) of subsection (b)(1), by such earlier time as may be necessary to comply with the applicable timeline under such subparagraph. (B) Limited effect of failure on plan or issuer's obligations.--Failure of the participant, beneficiary, or enrollee to comply with the requirements of subparagraph (A) shall not remove the obligation of the plan or issuer to make a decision in accordance with the medical exigencies of the case and as soon as possible, based on the available information, and failure to comply with the time limit established by this paragraph shall not remove the obligation of the plan or issuer to comply with the requirements of this section. (3) Oral requests.--In the case of a claim for benefits involving an expedited or concurrent determination, a participant, beneficiary, or enrollee (or authorized representative) may make an initial claim for benefits orally, but a group health plan, or health insurance issuer offering health insurance coverage, may require that the participant, beneficiary, or enrollee (or authorized representative) provide written confirmation of such request in a timely manner on a form provided by the plan or issuer. In the case of such an oral request for benefits, the making of the request (and the timing of such request) shall be treated as the making at that time of a claims for such benefits without regard to whether and when a written confirmation of such request is made. (b) Timeline for Making Determinations.-- (1) Prior authorization determination.-- (A) In general.--A group health plan, or health insurance issuer offering health insurance coverage, shall make a prior authorization determination on a claim for benefits (whether oral or written) in accordance with the medical exigencies of the case and as soon as possible, but in no case later than 14 days from the date on which the plan or issuer receives information that is reasonably necessary to enable the plan or issuer to make a determination on the request for prior authorization and in no case later than 28 days after the date of the claim for benefits is received. (B) Expedited determination.--Notwithstanding subparagraph (A), a group health plan, or health insurance issuer offering health insurance coverage, shall expedite a prior authorization determination on a claim for benefits described in such subparagraph when a request for such an expedited determination is made by a participant, beneficiary, or enrollee (or
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