HR 2990 EAS
In the Senate of the United States,
October 14, 1999.
Resolved, That the bill from the House of Representatives (H.R. 2990) entitled `An Act to amend the Internal Revenue Code of 1986 to allow individuals greater access to health insurance through a health care tax deduction, a long-term care deduction, and other health-related tax incentives, to amend the Employee Retirement Income Security Act of 1974 to provide access to and choice in health care through association health plans, to amend the Public Health Service Act to create new pooling opportunities for small employers to obtain greater access to health coverage through HealthMarts; to amend title I of the Employee Retirement Income Security Act of 1974, title XXVII of the Public Health Service Act, and the Internal Revenue Code of 1986 to protect consumers in managed care plans and other health coverage; and for other purposes.', do pass with the following
AMENDMENT:
Strike out all after the enacting clause and insert:
SECTION 1. SHORT TITLE; TABLE OF CONTENTS.
(a) SHORT TITLE- This Act may be cited as the `Patients' Bill of Rights Plus Act'.
(b) TABLE OF CONTENTS- The table of contents for this Act is as follows:
Sec. 1. Short title; table of contents.
TITLE I--PATIENTS' BILL OF RIGHTS
Subtitle A--Right to Advice and Care
Sec. 101. Patient right to medical advice and care.
`SUBPART C--PATIENT RIGHT TO MEDICAL ADVICE AND CARE
`Sec. 721. Patient access to emergency medical care.
`Sec. 722. Offering of choice of coverage options.
`Sec. 723. Patient access to obstetric and gynecological care.
`Sec. 724. Patient access to pediatric care.
`Sec. 725. Timely access to specialists.
`Sec. 726. Continuity of care.
`Sec. 727. Protection of patient-provider communications.
`Sec. 728. Patient's right to prescription drugs.
`Sec. 729. Self-payment for behavioral health care services.
`Sec. 730. Coverage for individuals participating in approved cancer clinical trials.
`Sec. 730A. Prohibiting discrimination against providers.
`Sec. 730B. Generally applicable provision.'.
Sec. 102. Conforming amendment to the Internal Revenue Code of 1986.
`SUBCHAPTER C--PATIENT RIGHT TO MEDICAL ADVICE AND CARE
`Sec. 9821. Patient access to emergency medical care.
`Sec. 9822. Offering of choice of coverage options.
`Sec. 9823. Patient access to obstetric and gynecological care.
`Sec. 9824. Patient access to pediatric care.
`Sec. 9825. Timely access to specialists.
`Sec. 9826. Continuity of care.
`Sec. 9827. Protection of patient-provider communications.
`Sec. 9828. Patient's right to prescription drugs.
`Sec. 9829. Self-payment for behavioral health care services.
`Sec. 9830. Coverage for individuals participating in approved cancer clinical trials.
`Sec. 9830A. Prohibiting discrimination against providers.
`Sec. 9830B. Generally applicable provision.'.
Sec. 103. Effective date and related rules.
Subtitle B--Right to Information About Plans and Providers
Sec. 111. Information about plans.
Sec. 112. Information about providers.
Subtitle C--Right to Hold Health Plans Accountable
Sec. 121. Amendment to Employee Retirement Income Security Act of 1974.
TITLE II--WOMEN'S HEALTH AND CANCER RIGHTS
Sec. 201. Women's health and cancer rights.
TITLE III--GENETIC INFORMATION AND SERVICES
Sec. 302. Amendments to Employee Retirement Income Security Act of 1974.
Sec. 303. Amendments to the Public Health Service Act.
Sec. 304. Amendments to the Internal Revenue Code of 1986.
TITLE IV--HEALTHCARE RESEARCH AND QUALITY
Sec. 402. Amendment to the Public Health Service Act.
`TITLE IX--AGENCY FOR HEALTHCARE RESEARCH AND QUALITY
`Part A--Establishment and General Duties
`Sec. 901. Mission and duties.
`Sec. 902. General authorities.
`Part B--Healthcare Improvement Research
`Sec. 911. Healthcare outcome improvement research.
`Sec. 912. Private-public partnerships to improve organization and delivery.
`Sec. 913. Information on quality and cost of care.
`Sec. 914. Information systems for healthcare improvement.
`Sec. 915. Research supporting primary care and access in underserved areas.
`Sec. 916. Clinical practice and technology innovation.
`Sec. 917. Coordination of Federal government quality improvement efforts.
`Part C--General Provisions
`Sec. 921. Advisory Council for Healthcare Research and Quality.
`Sec. 922. Peer review with respect to grants and contracts.
`Sec. 923. Certain provisions with respect to development, collection, and dissemination of data.
`Sec. 924. Dissemination of information.
`Sec. 925. Additional provisions with respect to grants and contracts.
`Sec. 926. Certain administrative authorities.
`Sec. 927. Funding.
`Sec. 928. Definitions.'.
TITLE V--ENHANCED ACCESS TO HEALTH INSURANCE COVERAGE
Sec. 501. Full deduction of health insurance costs for self-employed individuals.
Sec. 502. Full availability of medical savings accounts.
Sec. 503. Permitting contribution towards medical savings account through Federal employees health benefits program (FEHBP).
Sec. 504. Carryover of unused benefits from cafeteria plans, flexible spending arrangements, and health flexible spending accounts.
TITLE VI--PROVISIONS RELATING TO LONG-TERM CARE INSURANCE
Sec. 601. Inclusion of qualified long-term care insurance contracts in cafeteria plans, flexible spending arrangements, and health flexible spending accounts.
Sec. 602. Deduction for premiums for long-term care insurance.
Sec. 603. Study of long-term care needs in the 21st century.
TITLE VII--INDIVIDUAL RETIREMENT PLANS
Sec. 701. Modification of income limits on contributions and rollovers to Roth IRAs.
TITLE VIII--REVENUE PROVISIONS
Sec. 801. Modification to foreign tax credit carryback and carryover periods.
Sec. 802. Limitation on use of non-accrual experience method of accounting.
Sec. 803. Returns relating to cancellations of indebtedness by organizations lending money.
Sec. 804. Extension of Internal Revenue Service user fees.
Sec. 805. Property subject to a liability treated in same manner as assumption of liability.
Sec. 806. Charitable split-dollar life insurance, annuity, and endowment contracts.
Sec. 807. Transfer of excess defined benefit plan assets for retiree health benefits.
Sec. 808. Limitations on welfare benefit funds of 10 or more employer plans.
Sec. 809. Modification of installment method and repeal of installment method for accrual method taxpayers.
Sec. 810. Inclusion of certain vaccines against streptococcus pneumoniae to list of taxable vaccines.
TITLE IX--MISCELLANEOUS PROVISIONS
Sec. 901. Medicare competitive pricing demonstration project.
TITLE I--PATIENTS' BILL OF RIGHTS
Subtitle A--Right to Advice and Care
SEC. 101. PATIENT RIGHT TO MEDICAL ADVICE AND CARE.
(a) IN GENERAL- Part 7 of subtitle B of title I of the Employee Retirement Income Security Act of 1974 (29 U.S.C. 1181 et seq.) is amended--
(1) by redesignating subpart C as subpart D; and
(2) by inserting after subpart B the following:
`Subpart C--Patient Right to Medical Advice and Care
`SEC. 721. PATIENT ACCESS TO EMERGENCY MEDICAL CARE.
`(a) COVERAGE OF EMERGENCY CARE-
`(1) IN GENERAL- To the extent that the group health plan (other than a fully insured group health plan) provides coverage for benefits consisting of emergency medical care (as defined in subsection (c)) or emergency ambulance services, except for items or services specifically excluded--
`(A) the plan shall provide coverage for benefits, without requiring preauthorization, for emergency medical screening examinations or emergency ambulance services, to the extent that a prudent layperson, who possesses an average knowledge of health and medicine, would determine such examinations or emergency ambulance services to be necessary to determine whether emergency medical care (as so defined) is necessary; and
`(B) the plan shall provide coverage for benefits, without requiring preauthorization, for additional emergency medical care to stabilize an emergency medical condition following an emergency medical screening examination (if determined necessary under subparagraph (A)), pursuant to the definition of stabilize under section 1867(e)(3) of the Social Security Act (42 U.S.C. 1395dd(e)(3)).
`(2) REIMBURSEMENT FOR CARE TO MAINTAIN MEDICAL STABILITY-
`(A) IN GENERAL- In the case of services provided to a participant or beneficiary by a nonparticipating provider in order to maintain the medical stability of the participant or beneficiary, the group health plan involved shall provide for reimbursement with respect to such services if--
`(i) coverage for services of the type furnished is available under the group health plan;
`(ii) the services were provided for care related to an emergency medical condition and in an emergency department in order to maintain the medical stability of the participant or beneficiary; and
`(iii) the nonparticipating provider contacted the plan regarding approval for such services.
`(B) FAILURE TO RESPOND- If a group health plan fails to respond within 1 hours of being contacted in accordance with subparagraph (A)(iii), then the plan shall be liable for the cost of services provided by the nonparticipating provider in order to maintain the stability of the participant or beneficiary.
`(C) LIMITATION- The liability of a group health plan to provide reimbursement under subparagraph (A) shall terminate when the plan has contacted the nonparticipating provider to arrange for discharge or transfer.
`(D) LIABILITY OF PARTICIPANT- A participant or beneficiary shall not be liable for the costs of services to which subparagraph (A) in an amount that exceeds the amount of liability that would be incurred if the services were provided by a participating health care provider with prior authorization by the plan.
`(b) IN-NETWORK UNIFORM COSTS-SHARING AND OUT-OF-NETWORK CARE-
`(1) IN-NETWORK UNIFORM COST-SHARING- Nothing in this section shall be construed as preventing a group health plan (other than a fully insured group health plan) from imposing any form of cost-sharing applicable to any participant or beneficiary (including coinsurance, copayments, deductibles, and any other charges) in relation to coverage for benefits described in subsection (a), if such form of cost-sharing is uniformly applied under such plan, with respect to similarly situated participants and beneficiaries, to all benefits consisting of emergency medical care (as defined in subsection (c)) provided to such similarly situated participants and beneficiaries under the plan, and such cost-sharing is disclosed in accordance with section 714.
`(2) OUT-OF-NETWORK CARE- If a group health plan (other than a fully insured group health plan) provides any benefits with respect to emergency medical care (as defined in subsection (c)), the plan shall cover emergency medical care under the plan in a manner so that, if such care is provided to a participant or beneficiary by a nonparticipating health care provider, the participant or beneficiary is not liable for amounts that exceed any form of cost-sharing (including co-insurance, co-payments, deductibles, and any other charges) that would be incurred if the services were provided by a participating provider.
`(c) DEFINITION OF EMERGENCY MEDICAL CARE- In this section:
`(1) IN GENERAL- The term `emergency medical care' means, with respect to a participant or beneficiary under a group health plan (other than a fully insured group health plan), covered inpatient and outpatient services that--
`(A) are furnished by any provider, including a nonparticipating provider, that is qualified to furnish such services; and
`(B) are needed to evaluate or stabilize (as such term is defined in section 1867(e)(3) of the Social Security Act (42 U.S.C. 1395dd)(e)(3)) an emergency medical condition (as defined in paragraph (2)).
`(2) EMERGENCY MEDICAL CONDITION- The term `emergency medical condition' means a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in--
`(A) placing the health of the participant or beneficiary (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy,
`(B) serious impairment to bodily functions, or
`(C) serious dysfunction of any bodily organ or part.
`SEC. 722. OFFERING OF CHOICE OF COVERAGE OPTIONS.
`(1) OFFERING OF POINT-OF-SERVICE COVERAGE OPTION- Except as provided in paragraph (2), if a group health plan (other than a fully insured group health plan) provides coverage for benefits only through a defined set of participating health care professionals, the plan shall offer the participant the option to purchase point-of-service coverage (as defined in subsection (b)) for all such benefits for which coverage is otherwise so limited. Such option shall be made available to the participant at the time of enrollment under the plan and at such other times as the plan offers the participant a choice of coverage options.
`(2) EXCEPTION IN CASE OF LACK OF AVAILABILITY- Paragraph (1) shall not apply with respect to a group health plan (other than a fully insured group health plan) if care relating to the point-of-service coverage would not be available and accessible to the participant with reasonable promptness (consistent with section 1301(b)(4) of the Public Health Service Act (42 U.S.C. 300e(b)(4))).
`(b) POINT-OF-SERVICE COVERAGE DEFINED- In this section, the term `point-of-service coverage' means, with respect to benefits covered under a group health plan (other than a fully insured group health plan), coverage of such benefits when provided by a nonparticipating health care professional.
`(c) SMALL EMPLOYER EXEMPTION-
`(1) IN GENERAL- This section shall not apply to any group health plan (other than a fully insured group health plan) of a small employer.
`(2) SMALL EMPLOYER- For purposes of paragraph (1), the term `small employer' means, in connection with a group health plan (other than a fully insured group health plan) with respect to a calendar year and a plan year, an employer who employed an average of at least 2 but not more than 50 employees on business days during the preceding calendar year and who employs at least 2 employees on the first day of the plan year. For purposes of this paragraph, the provisions of subparagraph (C) of section 712(c)(1) shall apply in determining employer size.
`(d) RULE OF CONSTRUCTION- Nothing in this section shall be construed--
`(1) as requiring coverage for benefits for a particular type of health care professional;
`(2) as requiring an employer to pay any costs as a result of this section or to make equal contributions with respect to different health coverage options;
`(3) as preventing a group health plan (other than a fully insured group health plan) from imposing higher premiums or cost-sharing on a participant for the exercise of a point-of-service coverage option; or
`(4) to require that a group health plan (other than a fully insured group health plan) include coverage of health care professionals that the plan excludes because of fraud, quality of care, or other similar reasons with respect to such professionals.
`SEC. 723. PATIENT ACCESS TO OBSTETRIC AND GYNECOLOGICAL CARE.
`(1) WAIVER OF PLAN REFERRAL REQUIREMENT- If a group health plan described in subsection (b) requires a referral to obtain coverage for specialty care, the plan shall waive the referral requirement in the case of a female participant or beneficiary who seeks coverage for obstetrical care and related follow-up obstetrical care or routine gynecological care (such as preventive gynecological care).
`(2) RELATED ROUTINE CARE- With respect to a participant or beneficiary described in paragraph (1), a group health plan described in subsection (b) shall treat the ordering of other routine care that is related to routine gynecologic care, by a physician who specializes in obstetrics and gynecology as the authorization of the primary care provider for such other care.
`(b) APPLICATION OF SECTION- A group health plan described in this subsection is a group health plan (other than a fully insured group health plan), that--
`(1) provides coverage for obstetric care (such as pregnancy-related services) or routine gynecologic care (such as preventive women's health examinations); and
`(2) requires the designation by a participant or beneficiary of a participating primary care provider who is not a physician who specializes in obstetrics or gynecology.
`(c) RULES OF CONSTRUCTION- Nothing in this section shall be construed--
`(1) as waiving any coverage requirement relating to medical necessity or appropriateness with respect to the coverage of obstetric or gynecologic care described in subsection (a);
`(2) to preclude the plan from requiring that the physician who specializes in obstetrics or gynecology notify the designated primary care provider or the plan of treatment decisions;
`(3) to preclude a group health plan from allowing health care professionals other than physicians to provide routine obstetric or routine gynecologic care; or
`(4) to preclude a group health plan from permitting a physician who specializes in obstetrics and gynecology from being a primary care provider under the plan.
`SEC. 724. PATIENT ACCESS TO PEDIATRIC CARE.
`(a) IN GENERAL- In the case of a group health plan (other than a fully insured group health plan) that provides coverage for routine pediatric care and that requires the designation by a participant or beneficiary of a participating primary care provider, if the designated primary care provider is not a physician who specializes in pediatrics--
`(1) the plan may not require authorization or referral by the primary care provider in order for a participant or beneficiary to obtain coverage for routine pediatric care; and
`(2) the plan shall treat the ordering of other routine care related to routine pediatric care by such a specialist as having been authorized by the designated primary care provider.
`(b) RULES OF CONSTRUCTION- Nothing in subsection (a) shall be construed--
`(1) as waiving any coverage requirement relating to medical necessity or appropriateness with respect to the coverage of any pediatric care provided to, or ordered for, a participant or beneficiary;
`(2) to preclude a group health plan from requiring that a specialist described in subsection (a) notify the designated primary care provider or the plan of treatment decisions; or
`(3) to preclude a group health plan from allowing health care professionals other than physicians to provide routine pediatric care.
`SEC. 725. TIMELY ACCESS TO SPECIALISTS.
`(1) IN GENERAL- A group health plan (other than a fully insured group health plan) shall ensure that participants and beneficiaries have timely, in accordance with the medical exigencies of the case, access to primary and specialty health care professionals who are appropriate to the condition of the participant or beneficiary, when such care is covered under the plan. Such access may be provided through contractual arrangements with specialized providers outside of the network of the plan.
`(2) RULE OF CONSTRUCTION- Nothing in paragraph (1) shall be construed--
`(A) to require the coverage under a group health plan of particular benefits or services or to prohibit a plan from including providers only to the extent necessary to meet the needs of the plan's participants or beneficiaries or from establishing any measure designed to maintain quality and control costs consistent with the responsibilities of the plan; or
`(B) to override any State licensure or scope-of-practice law.
`(1) IN GENERAL- Nothing in this section shall be construed to prohibit a group health plan (other than a fully insured group health plan) from requiring that specialty care be provided pursuant to a treatment plan so long as the treatment plan is--
`(A) developed by the specialist, in consultation with the case manager or primary care provider, and the participant or beneficiary;
`(B) approved by the plan in a timely manner in accordance with the medical exigencies of the case; and
`(C) in accordance with the applicable quality assurance and utilization review standards of the plan.
`(2) NOTIFICATION- Nothing in paragraph (1) shall be construed as prohibiting a plan from requiring the specialist to provide the case manager or primary care provider with regular updates on the specialty care provided, as well as all other necessary medical information.
`(c) REFERRALS- Nothing in this section shall be construed to prohibit a plan from requiring an authorization by the case manager or primary care provider of the participant or beneficiary in order to obtain coverage for specialty services so long as such authorization is for an adequate number of referrals.
`(d) SPECIALTY CARE DEFINED- For purposes of this subsection, the term `specialty care' means, with respect to a condition, care and treatment provided by a health care practitioner, facility, or center (such as a center of excellence) that has adequate expertise (including age-appropriate expertise) through appropriate training and experience.
`SEC. 726. CONTINUITY OF CARE.
`(1) TERMINATION OF PROVIDER- If a contract between a group health plan (other than a fully insured group health plan) and a health care provider is terminated (as defined in paragraph (2)), or benefits or coverage provided by a health care provider are terminated because of a change in the terms of provider participation in such group health plan, and an individual who is a participant or beneficiary in the plan is undergoing a course of treatment from the provider at the time of such termination, the plan shall--
`(A) notify the individual on a timely basis of such termination;
`(B) provide the individual with an opportunity to notify the plan of a need for transitional care; and
`(C) in the case of termination described in paragraph (2), (3), or (4) of subsection (b), and subject to subsection (c), permit the individual to continue or be covered with respect to the course of treatment with the provider's consent during a transitional period (as provided under subsection (b)).
`(2) TERMINATED- In this section, the term `terminated' includes, with respect to a contract, the expiration or nonrenewal of the contract by the group health plan, but does not include a termination of the contract by the plan for failure to meet applicable quality standards or for fraud.
`(3) CONTRACTS- For purposes of this section, the term `contract between a group health plan (other than a fully insured group health plan) and a health care provider' shall include a contract between such a plan and an organized network of providers.
`(b) TRANSITIONAL PERIOD-
`(1) GENERAL RULE- Except as provided in paragraph (3), the transitional period under this subsection shall permit the participant or beneficiary to extend the coverage involved for up to 90 days from the date of the notice described in subsection (a)(1)(A) of the provider's termination.
`(2) INSTITUTIONAL CARE- Subject to paragraph (1), the transitional period under this subsection for institutional or inpatient care from a provider shall extend until the discharge or termination of the period of institutionalization and also shall include institutional care provided within a reasonable time of the date of termination of the provider status if the care was scheduled before the date of the announcement of the termination of the provider status under subsection (a)(1)(A) or if the individual on such date was on an established waiting list or otherwise scheduled to have such care.
`(3) PREGNANCY- Notwithstanding paragraph (1), if--
`(A) a participant or beneficiary has entered the second trimester of pregnancy at the time of a provider's termination of participation; and
`(B) the provider was treating the pregnancy before the date of the termination;
the transitional period under this subsection with respect to provider's treatment of the pregnancy shall extend through the provision of post-partum care directly related to the delivery.
`(4) TERMINAL ILLNESS- Notwithstanding paragraph (1), if--
`(A) a participant or beneficiary was determined to be terminally ill (as determined under section 1861(dd)(3)(A) of the Social Security Act) prior to a provider's termination of participation; and
`(B) the provider was treating the terminal illness before the date of termination;
the transitional period under this subsection shall be for care directly related to the treatment of the terminal illness and shall extend for the remainder of the individual's life for such care.
`(c) PERMISSIBLE TERMS AND CONDITIONS- A group health plan (other than a fully insured group health plan) may condition coverage of continued treatment by a provider under subsection (a)(1)(C) upon the provider agreeing to the following terms and conditions:
`(1) The provider agrees to accept reimbursement from the plan and individual involved (with respect to cost-sharing) at the rates applicable prior to the start of the transitional period as payment in full (or at the rates applicable under the replacement plan after the date of the termination of the contract with the group health plan) and not to impose cost-sharing with respect to the individual in an amount that would exceed the cost-sharing that could have been imposed if the contract referred to in subsection (a)(1) had not been terminated.
`(2) The provider agrees to adhere to the quality assurance standards of the plan responsible for payment under paragraph (1) and to provide to such plan necessary medical information related to the care provided.
`(3) The provider agrees otherwise to adhere to such plan's policies and procedures, including procedures regarding referrals and obtaining prior authorization and providing services pursuant to a treatment plan (if any) approved by the plan.
`(d) RULE OF CONSTRUCTION- Nothing in this section shall be construed to require the coverage of benefits which would not have been covered if the provider involved remained a participating provider.
`(e) DEFINITION- In this section, the term `health care provider' or `provider' means--
`(1) any individual who is engaged in the delivery of health care services in a State and who is required by State law or regulation to be licensed or certified by the State to engage in the delivery of such services in the State; and
`(2) any entity that is engaged in the delivery of health care services in a State and that, if it is required by State law or regulation to be licensed or certified by the State to engage in the delivery of such services in the State, is so licensed.
`(f) COMPREHENSIVE STUDY OF COST, QUALITY AND COORDINATION OF COVERAGE FOR PATIENTS AT THE END OF LIFE-
`(1) STUDY BY THE MEDICARE PAYMENT ADVISORY COMMISSION- The Medicare Payment Advisory Commission shall conduct a study of the costs and patterns of care for persons with serious and complex conditions and the possibilities of improving upon that care to the degree it is triggered by the current category of terminally ill as such term is used for purposes of section 1861(dd) of the Social Security Act (relating to hospice benefits) or of utilizing care in other payment settings in Medicare.
`(2) AGENCY FOR HEALTH CARE POLICY AND RESEARCH- The Agency for Health Care Policy and Research shall conduct studies of the possible thresholds for major conditions causing serious and complex illness, their administrative parameters and feasibility, and their impact upon costs and quality.
`(3) HEALTH CARE FINANCING ADMINISTRATION- The Health Care Financing Administration shall conduct studies of the merits of applying similar thresholds in Medicare+Choice programs, including adapting risk adjustment methods to account for this category.
`(A) IN GENERAL- Not later than 12 months after the date of enactment of this section, the Medicare Payment Advisory Commission and the Agency for Health Care Policy and Research shall each prepare and submit to the Committee on Health, Education, Labor and Pensions of the Senate a report concerning the results of the studies conducted under paragraphs (1) and (2), respectively.
`(B) COPY TO SECRETARY- Concurrent with the submission of the reports under subparagraph (A), the Medicare Payment Advisory Commission and the Agency for health Care Policy and Research shall transmit a copy of the reports under such subparagraph to the Secretary.
`(A) CONTRACT WITH INSTITUTE OF MEDICINE- Not later than 1 year after the submission of the reports under paragraph (4), the Secretary of Health and Human Services shall contract with the Institute of Medicine to conduct a study of the practices and their effects arising from the utilization of the category `serious and complex' illness.
`(B) REPORT- Not later than 1 year after the date of the execution of the contract referred to in subparagraph (A), the Institute of Medicine shall prepare and submit to the Committee on Health, Education, Labor and Pensions of the Senate a report concerning the study conducted pursuant to such contract.
`(6) FUNDING- From funds appropriated to the Department of Health and Human Services, the Secretary of Health and Human Services shall make available such funds as the Secretary determines is necessary to carry out this subsection.
`SEC. 727. PROTECTION OF PATIENT-PROVIDER COMMUNICATIONS.
`(a) IN GENERAL- Subject to subsection (b), a group health plan (other than a fully insured group health plan and in relation to a participant or beneficiary) shall not prohibit or otherwise restrict a health care professional from advising such a participant or beneficiary who is a patient of the professional about the health status of the participant or beneficiary or medical care or treatment for the condition or disease of the participant or beneficiary, regardless of whether coverage for such care or treatment are provided under the contract, if the professional is acting within the lawful scope of practice.
`(b) RULE OF CONSTRUCTION- Nothing in this section shall be construed as requiring a group health plan (other than a fully insured group health plan) to provide specific benefits under the terms of such plan.
`SEC. 728. PATIENT'S RIGHT TO PRESCRIPTION DRUGS.
`To the extent that a group health plan (other than a fully insured group health plan) provides coverage for benefits with respect to prescription drugs, and limits such coverage to drugs included in a formulary, the plan shall--
`(1) ensure the participation of physicians and pharmacists in developing and reviewing such formulary; and
`(2) in accordance with the applicable quality assurance and utilization review standards of the plan, provide for exceptions from the formulary limitation when a non-formulary alternative is medically necessary and appropriate.
`SEC. 729. SELF-PAYMENT FOR BEHAVIORAL HEALTH CARE SERVICES.
`(a) IN GENERAL- A group health plan (other than a fully insured group health plan) may not--
`(1) prohibit or otherwise discourage a participant or beneficiary from self-paying for behavioral health care services once the plan has denied coverage for such services; or
`(2) terminate a health care provider because such provider permits participants or beneficiaries to self-pay for behavioral health care services--
`(A) that are not otherwise covered under the plan; or
`(B) for which the group health plan provides limited coverage, to the extent that the group health plan denies coverage of the services.
`(b) RULE OF CONSTRUCTION- Nothing in subsection (a)(2)(B) shall be construed as prohibiting a group health plan from terminating a contract with a health care provider for failure to meet applicable quality standards or for fraud.
`SEC. 730. COVERAGE FOR INDIVIDUALS PARTICIPATING IN APPROVED CANCER CLINICAL TRIALS.
`(1) IN GENERAL- If a group health plan (other than a fully insured group health plan) provides coverage to a qualified individual (as defined in subsection (b)), the plan--
`(A) may not deny the individual participation in the clinical trial referred to in subsection (b)(2);
`(B) subject to subsections (b), (c), and (d) may not deny (or limit or impose additional conditions on) the coverage of routine patient costs for items and services furnished in connection with participation in the trial; and
`(C) may not discriminate against the individual on the basis of the participant's or beneficiaries participation in such trial.
`(2) EXCLUSION OF CERTAIN COSTS- For purposes of paragraph (1)(B), routine patient costs do not include the cost of the tests or measurements conducted primarily for the purpose of the clinical trial involved.
`(3) USE OF IN-NETWORK PROVIDERS- If one or more participating providers is participating in a clinical trial, nothing in paragraph (1) shall be construed as preventing a plan from requiring that a qualified individual participate in the trial through such a participating provider if the provider will accept the individual as a participant in the trial.
`(b) QUALIFIED INDIVIDUAL DEFINED- For purposes of subsection (a), the term `qualified individual' means an individual who is a participant or beneficiary in a group health plan and who meets the following conditions:
`(1)(A) The individual has been diagnosed with cancer for which no standard treatment is effective.
`(B) The individual is eligible to participate in an approved clinical trial according to the trial protocol with respect to treatment of such illness.
`(C) The individual's participation in the trial offers meaningful potential for significant clinical benefit for the individual.
`(A) the referring physician is a participating health care professional and has concluded that the individual's participation in such trial would be appropriate based upon the individual meeting the conditions described in paragraph (1); or
`(B) the participant or beneficiary provides medical and scientific information establishing that the individual's participation in such trial would be appropriate based upon the individual meeting the conditions described in paragraph (1).
`(1) IN GENERAL- Under this section a group health plan (other than a fully insured group health plan) shall provide for payment for routine patient costs described in subsection (a)(2) but is not required to pay for costs of items and services that are reasonably expected to be paid for by the sponsors of an approved clinical trial.
`(2) STANDARDS FOR DETERMINING ROUTINE PATIENT COSTS ASSOCIATED WITH CLINICAL TRIAL PARTICIPATION-
`(A) IN GENERAL- The Secretary shall establish, on an expedited basis and using a negotiated rulemaking process under subchapter III of chapter 5 of title 5, United States Code, standards relating to the coverage of routine patient costs for individuals participating in clinical trials that group health plans must meet under this section.
`(B) FACTORS- In establishing routine patient cost standards under subparagraph (A), the Secretary shall consult with interested parties and take into account --
`(i) quality of patient care;
`(ii) routine patient care costs versus costs associated with the conduct of clinical trials, including unanticipated patient care costs as a result of participation in clinical trials; and
`(iii) previous and on-going studies relating to patient care costs associated with participation in clinical trials.
`(C) PUBLICATION OF NOTICE- In carrying out the rulemaking process under this paragraph, the Secretary, after consultation with organizations representing cancer patients, health care practitioners, medical researchers, employers, group health plans, manufacturers of drugs, biologics and medical devices, medical economists, hospitals, and other interested parties, shall publish notice provided for under section 564(a) of title 5, United States Code, by not later than 45 days after the date of the enactment of this section.
`(D) TARGET DATE FOR PUBLICATION OF RULE- As part of the notice under subparagraph (C), and for purposes of this paragraph, the `target date for publication' (referred to in section 564(a)(5) of such title 5) shall be June 30, 2000.
`(E) ABBREVIATED PERIOD FOR SUBMISSION OF COMMENTS- In applying section 564(c) of such title 5 under this paragraph, `15 days' shall be substituted for `30 days'.
`(F) APPOINTMENT OF NEGOTIATED RULEMAKING COMMITTEE AND FACILITATOR- The Secretary shall provide for--
`(i) the appointment of a negotiated rulemaking committee under section 565(a) of such title 5 by not later than 30 days after the end of the comment period provided for under section 564(c) of such title 5 (as shortened under subparagraph (E)), and
`(ii) the nomination of a facilitator under section 566(c) of such title 5 by not later than 10 days after the date of appointment of the committee.
`(G) PRELIMINARY COMMITTEE REPORT- The negotiated rulemaking committee appointed under subparagraph (F) shall report to the Secretary, by not later than March 29, 2000, regarding the committee's progress on achieving a consensus with regard to the rulemaking proceeding and whether such consensus is likely to occur before 1 month before the target date for publication of the rule. If the committee reports that the committee has failed to make significant progress towards such consensus or is unlikely to reach such consensus by the target date, the Secretary may terminate such process and provide for the publication of a rule under this paragraph through such other methods as the Secretary may provide.
`(H) FINAL COMMITTEE REPORT- If the committee is not terminated under subparagraph (G), the rulemaking committee shall submit a report containing a proposed rule by not later than 1 month before the target date of publication.
`(I) FINAL EFFECT- The Secretary shall publish a rule under this paragraph in the Federal Register by not later than the target date of publication.
`(J) PUBLICATION OF RULE AFTER PUBLIC COMMENT- The Secretary shall provide for consideration of such comments and republication of such rule by not later than 1 year after the target date of publication.
`(K) EFFECTIVE DATE- The provisions of this paragraph shall apply to group health plans (other than a fully insured group health plan) for plan years beginning on or after January 1, 2001.
`(3) PAYMENT RATE- In the case of covered items and services provided by--
`(A) a participating provider, the payment rate shall be at the agreed upon rate, or
`(B) a nonparticipating provider, the payment rate shall be at the rate the plan would normally pay for comparable services under subparagraph (A).
`(d) APPROVED CLINICAL TRIAL DEFINED-
`(1) IN GENERAL- In this section, the term `approved clinical trial' means a cancer clinical research study or cancer clinical investigation approved and funded (which may include funding through in-kind contributions) by one or more of the following:
`(A) The National Institutes of Health.
`(B) A cooperative group or center of the National Institutes of Health.
`(C) Either of the following if the conditions described in paragraph (2) are met:
`(i) The Department of Veterans Affairs.
`(ii) The Department of Defense.
`(2) CONDITIONS FOR DEPARTMENTS- The conditions described in this paragraph, for a study or investigation conducted by a Department, are that the study or investigation has been reviewed and approved through a system of peer review that the Secretary determines--
`(A) to be comparable to the system of peer review of studies and investigations used by the National Institutes of Health, and
`(B) assures unbiased review of the highest scientific standards by qualified individuals who have no interest in the outcome of the review.
`(e) CONSTRUCTION- Nothing in this section shall be construed to limit a plan's coverage with respect to clinical trials.
`(f) PLAN SATISFACTION OF CERTAIN REQUIREMENTS; RESPONSIBILITIES OF FIDUCIARIES-
`(1) IN GENERAL- For purposes of this section, insofar as a group health plan provides benefits in the form of health insurance coverage through a health insurance issuer, the plan shall be treated as meeting the requirements of this section with respect to such benefits and not be considered as failing to meet such requirements because of a failure of the issuer to meet such requirements so long as the plan sponsor or its representatives did not cause such failure by the issuer.
`(2) CONSTRUCTION- Nothing in this section shall be construed to affect or modify the responsibilities of the fiduciaries of a group health plan under part 4 of subtitle B.
`(1) STUDY- The Secretary shall study the impact on group health plans for covering routine patient care costs for individuals who are entitled to benefits under this section and who are enrolled in an approved cancer clinical trial program.
`(2) REPORT TO CONGRESS- Not later than January 1, 2005, the Secretary shall submit a report to Congress that contains an assessment of--
`(A) any incremental cost to group health plans resulting from the provisions of this section;
`(B) a projection of expenditures to such plans resulting from this section; and
`(C) any impact on premiums resulting from this section.
`SEC. 730A. PROHIBITING DISCRIMINATION AGAINST PROVIDERS.
`(a) IN GENERAL- A group health plan (other than a fully insured group health plan) 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. This subsection shall not be construed as requiring the coverage under a plan of particular benefits or services or to prohibit a plan from including providers only to the extent necessary to meet the needs of the plan's participants and beneficiaries or from establishing any measure designed to maintain quality and control costs consistent with the responsibilities of the plan.
`(b) NO REQUIREMENT FOR ANY WILLING PROVIDER- Nothing in this section shall be construed as requiring a group health plan that offers network coverage to include for participation every willing provider or health professional who meets the terms and conditions of the plan.
`SEC. 730B. GENERALLY APPLICABLE PROVISION.
`In the case of a group health plan that provides benefits under 2 or more coverage options, the requirements of this subpart shall apply separately with respect to each coverage option.'.
(b) RULE WITH RESPECT TO CERTAIN PLANS-
(1) IN GENERAL- Notwithstanding any other provision of law, health insurance issuers may offer, and eligible individuals may purchase, high deductible health plans described in section 220(c)(2)(A) of the Internal Revenue Code of 1986. Effective for the 4-year period beginning on the date of the enactment of this Act, such health plans shall not be required to provide payment for any health care items or services that are exempt from the plan's deductible.
(2) EXISTING STATE LAWS- A State law relating to payment for health care items and services in effect on the date of enactment of this Act that is preempted under paragraph (1), shall not apply to high deductible health plans after the expiration of the 4-year period described in such paragraph unless the State reenacts such law after such period.
(c) DEFINITION- Section 733(a) of the Employee Retirement Income Security Act of 1974 (42 U.S.C. 1191(a)) is amended by adding at the end the following:
`(3) FULLY INSURED GROUP HEALTH PLAN- The term `fully insured group health plan' means a group health plan where benefits under the plan are provided pursuant to the terms of an arrangement between a group health plan and a health insurance issuer and are guaranteed by the health insurance issuer under a contract or policy of insurance.'.
(d) CONFORMING AMENDMENT- The table of contents in section 1 of such Act is amended--
(1) in the item relating to subpart C, by striking `Subpart C' and inserting `Subpart D'; and
(2) by adding at the end of the items relating to subpart B of part 7 of subtitle B of title I of such Act the following new items:
`SUBPART C--PATIENT RIGHT TO MEDICAL ADVICE AND CARE
`Sec. 721. Patient access to emergency medical care.
`Sec. 722. Offering of choice of coverage options.
`Sec. 723. Patient access to obstetric and gynecological care.
`Sec. 724. Patient access to pediatric care.
`Sec. 725. Timely access to specialists.
`Sec. 726. Continuity of care.
`Sec. 727. Protection of patient-provider communications.
`Sec. 728. Patient's right to prescription drugs.
`Sec. 729. Self-payment for behavioral health care services.
`Sec. 730. Coverage for individuals participating in approved cancer clinical trials.
`Sec. 730A. Prohibiting discrimination against providers.
`Sec. 730B. Generally applicable provision.'.
SEC. 102. CONFORMING AMENDMENT TO THE INTERNAL REVENUE CODE OF 1986.
(a) IN GENERAL- Chapter 100 of the Internal Revenue Code of 1986 is amended--
(1) by redesignating subchapter C as subchapter D; and
(2) by inserting after subchapter B the following:
`Subchapter C--Patient Right to Medical Advice and Care
`Sec. 9821. Patient access to emergency medical care.
`Sec. 9822. Offering of choice of coverage options.
`Sec. 9823. Patient access to obstetric and gynecological care.
`Sec. 9824. Patient access to pediatric care.
`Sec. 9825. Timely access to specialists.
`Sec. 9826. Continuity of care.
`Sec. 9827. Protection of patient-provider communications.
`Sec. 9828. Patient's right to prescription drugs.
`Sec. 9829. Self-payment for behavioral health care services.
`Sec. 9830. Coverage for individuals participating in approved cancer clinical trials.
`Sec. 9830A. Prohibiting discrimination against providers.
`Sec. 9830B. Generally applicable provision.
`SEC. 9821. PATIENT ACCESS TO EMERGENCY MEDICAL CARE.
`(a) COVERAGE OF EMERGENCY CARE-
`(1) IN GENERAL- To the extent that the group health plan (other than a fully insured group health plan) provides coverage for benefits consisting of emergency medical care (as defined in subsection (c)) or emergency ambulance services, except for items or services specifically excluded--
`(A) the plan shall provide coverage for benefits, without requiring preauthorization, for emergency medical screening examinations or emergency ambulance services, to the extent that a prudent layperson, who possesses an average knowledge of health and medicine, would determine such examinations or emergency ambulance services to be necessary to determine whether emergency medical care (as so defined) is necessary; and
`(B) the plan shall provide coverage for benefits, without requiring preauthorization, for additional emergency medical care to stabilize an emergency medical condition following an emergency medical screening examination (if determined necessary under subparagraph (A)), pursuant to the definition of stabilize under section 1867(e)(3) of the Social Security Act (42 U.S.C. 1395dd(e)(3)).
`(2) REIMBURSEMENT FOR CARE TO MAINTAIN MEDICAL STABILITY-
`(A) IN GENERAL- In the case of services provided to a participant or beneficiary by a nonparticipating provider in order to maintain the medical stability of the participant or beneficiary, the group health plan involved shall provide for reimbursement with respect to such services if--
`(i) coverage for services of the type furnished is available under the group health plan;
`(ii) the services were provided for care related to an emergency medical condition and in an emergency department in order to maintain the medical stability of the participant or beneficiary; and
`(iii) the nonparticipating provider contacted the plan regarding approval for such services.
`(B) FAILURE TO RESPOND- If a group health plan fails to respond within 1 hours of being contacted in accordance with subparagraph (A)(iii), then the plan shall be liable for the cost of services provided by the nonparticipating provider in order to maintain the stability of the participant or beneficiary.
`(C) LIMITATION- The liability of a group health plan to provide reimbursement under subparagraph (A) shall terminate when the plan has contacted the nonparticipating provider to arrange for discharge or transfer.
`(D) LIABILITY OF PARTICIPANT- A participant or beneficiary shall not be liable for the costs of services to which subparagraph (A) in an amount that exceeds the amount of liability that would be incurred if the services were provided by a participating health care provider with prior authorization by the plan.
`(b) IN-NETWORK UNIFORM COSTS-SHARING AND OUT-OF-NETWORK CARE-
`(1) IN-NETWORK UNIFORM COST-SHARING- Nothing in this section shall be construed as preventing a group health plan (other than a fully insured group health plan) from imposing any form of cost-sharing applicable to any participant or beneficiary (including coinsurance, copayments, deductibles, and any other charges) in relation to coverage for benefits described in subsection (a), if such form of cost-sharing is uniformly applied under such plan, with respect to similarly situated participants and beneficiaries, to all benefits consisting of emergency medical care (as defined in subsection (c)) provided to such similarly situated participants and beneficiaries under the plan, and such cost-sharing is disclosed in accordance with section 9814.
`(2) OUT-OF-NETWORK CARE- If a group health plan (other than a fully insured group health plan) provides any benefits with respect to emergency medical care (as defined in subsection (c)), the plan shall cover emergency medical care under the plan in a manner so that, if such care is provided to a participant or beneficiary by a nonparticipating health care provider, the participant or beneficiary is not liable for amounts that exceed any form of cost-sharing (including coinsurance, copayments, deductibles, and any other charges) that would be incurred if the services were provided by a participating provider.
`(c) DEFINITION OF EMERGENCY MEDICAL CARE- In this section:
`(1) IN GENERAL- The term `emergency medical care' means, with respect to a participant or beneficiary under a group health plan (other than a fully insured group health plan), covered inpatient and outpatient services that--
`(A) are furnished by any provider, including a nonparticipating provider, that is qualified to furnish such services; and
`(B) are needed to evaluate or stabilize (as such term is defined in section 1867(e)(3) of the Social Security Act (42 U.S.C. 1395dd)(e)(3)) an emergency medical condition (as defined in paragraph (2)).
`(2) EMERGENCY MEDICAL CONDITION- The term `emergency medical condition' means a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in--
`(A) placing the health of the participant or beneficiary (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy,
`(B) serious impairment to bodily functions, or
`(C) serious dysfunction of any bodily organ or part.
`SEC. 9822. OFFERING OF CHOICE OF COVERAGE OPTIONS.
`(1) OFFERING OF POINT-OF-SERVICE COVERAGE OPTION- Except as provided in paragraph (2), if a group health plan (other than a fully insured group health plan) provides coverage for benefits only through a defined set of participating health care professionals, the plan shall offer the participant the option to purchase point-of-service coverage (as defined in subsection (b)) for all such benefits for which coverage is otherwise so limited. Such option shall be made available to the participant at the time of enrollment under the plan and at such other times as the plan offers the participant a choice of coverage options.
`(2) EXCEPTION IN CASE OF LACK OF AVAILABILITY- Paragraph (1) shall not apply with respect to a group health plan (other than a fully insured group health plan) if care relating to the point-of-service coverage would not be available and accessible to the participant with reasonable promptness (consistent with section 1301(b)(4) of the Public Health Service Act (42 U.S.C. 300e(b)(4))).
`(b) POINT-OF-SERVICE COVERAGE DEFINED- In this section, the term `point-of-service coverage' means, with respect to benefits covered under a group health plan (other than a fully insured group health plan), coverage of such benefits when provided by a nonparticipating health care professional.
`(c) SMALL EMPLOYER EXEMPTION-
`(1) IN GENERAL- This section shall not apply to any group health plan (other than a fully insured group health plan) of a small employer.
`(2) SMALL EMPLOYER- For purposes of paragraph (1), the term `small employer' means, in connection with a group health plan (other than a fully insured group health plan) with respect to a calendar year and a plan year, an employer who employed an average of at least 2 but not more than 50 employees on business days during the preceding calendar year and who employs at least 2 employees on the first day of the plan year. For purposes of this paragraph, the provisions of subparagraph (C) of section 4980D(d)(2) shall apply in determining employer size.
`(d) RULE OF CONSTRUCTION- Nothing in this section shall be construed--
`(1) as requiring coverage for benefits for a particular type of health care professional;
`(2) as requiring an employer to pay any costs as a result of this section or to make equal contributions with respect to different health coverage options;
`(3) as preventing a group health plan (other than a fully insured group health plan) from imposing higher premiums or cost-sharing on a participant for the exercise of a point-of-service coverage option; or
`(4) to require that a group health plan (other than a fully insured group health plan) include coverage of health care professionals that the plan excludes because of fraud, quality of care, or other similar reasons with respect to such professionals.
`SEC. 9823. PATIENT ACCESS TO OBSTETRIC AND GYNECOLOGICAL CARE.
`(1) WAIVER OF PLAN REFERRAL REQUIREMENT- If a group health plan described in subsection (b) requires a referral to obtain coverage for specialty care, the plan shall waive the referral requirement in the case of a female participant or beneficiary who seeks coverage for obstetrical care and related follow-up obstetrical care or routine gynecological care (such as preventive gynecological care).
`(2) RELATED ROUTINE CARE- With respect to a participant or beneficiary described in paragraph (1), a group health plan described in subsection (b) shall treat the ordering of other routine care that is related to routine gynecologic care, by a physician who specializes in obstetrics and gynecology as the authorization of the primary care provider for such other care.
`(b) APPLICATION OF SECTION- A group health plan described in this subsection is a group health plan (other than a fully insured group health plan), that--
`(1) provides coverage for obstetric care (such as pregnancy-related services) or routine gynecologic care (such as preventive women's health examinations); and
`(2) requires the designation by a participant or beneficiary of a participating primary care provider who is not a physician who specializes in obstetrics or gynecology.
`(c) RULES OF CONSTRUCTION- Nothing in this section shall be construed--
`(1) as waiving any coverage requirement relating to medical necessity or appropriateness with respect to the coverage of obstetric or gynecologic care described in subsection (a);
`(2) to preclude the plan from requiring that the physician who specializes in obstetrics or gynecology notify the designated primary care provider or the plan of treatment decisions;
`(3) to preclude a group health plan from allowing health care professionals other than physicians to provide routine obstetric or routine gynecologic care; or
`(4) to preclude a group health plan from permitting a physician who specializes in obstetrics and gynecology from being a primary care provider under the plan.
`SEC. 9824. PATIENT ACCESS TO PEDIATRIC CARE.
`(a) IN GENERAL- In the case of a group health plan (other than a fully insured group health plan) that provides coverage for routine pediatric care and that requires the designation by a participant or beneficiary of a participating primary care provider, if the designated primary care provider is not a physician who specializes in pediatrics--
`(1) the plan may not require authorization or referral by the primary care provider in order for a participant or beneficiary to obtain coverage for routine pediatric care; and
`(2) the plan shall treat the ordering of other routine care related to routine pediatric care by such a specialist as having been authorized by the designated primary care provider.
`(b) RULES OF CONSTRUCTION- Nothing in subsection (a) shall be construed--
`(1) as waiving any coverage requirement relating to medical necessity or appropriateness with respect to the coverage of any pediatric care provided to, or ordered for, a participant or beneficiary;
`(2) to preclude a group health plan from requiring that a specialist described in subsection (a) notify the designated primary care provider or the plan of treatment decisions; or
`(3) to preclude a group health plan from allowing health care professionals other than physicians to provide routine pediatric care.
`SEC. 9825. TIMELY ACCESS TO SPECIALISTS.
`(1) IN GENERAL- A group health plan (other than a fully insured group health plan) shall ensure that participants and beneficiaries have timely, in accordance with the medical exigencies of the case, access to primary and specialty health care professionals who are appropriate to the condition of the participant or beneficiary, when such care is covered under the plan. Such access may be provided through contractual arrangements with specialized providers outside of the network of the plan.
`(2) RULE OF CONSTRUCTION- Nothing in paragraph (1) shall be construed--
`(A) to require the coverage under a group health plan of particular benefits or services or to prohibit a plan from including providers only to the extent necessary to meet the needs of the plan's participants or beneficiaries or from establishing any measure designed to maintain quality and control costs consistent with the responsibilities of the plan; or
`(B) to override any State licensure or scope-of-practice law.
`(1) IN GENERAL- Nothing in this section shall be construed to prohibit a group health plan (other than a fully insured group health plan) from requiring that specialty care be provided pursuant to a treatment plan so long as the treatment plan is--
`(A) developed by the specialist, in consultation with the case manager or primary care provider, and the participant or beneficiary;
`(B) approved by the plan in a timely manner in accordance with the medical exigencies of the case; and
`(C) in accordance with the applicable quality assurance and utilization review standards of the plan.
`(2) NOTIFICATION- Nothing in paragraph (1) shall be construed as prohibiting a plan from requiring the specialist to provide the case manager or primary care provider with regular updates on the specialty care provided, as well as all other necessary medical information.
`(c) REFERRALS- Nothing in this section shall be construed to prohibit a plan from requiring an authorization by the case manager or primary care provider of the participant or beneficiary in order to obtain coverage for specialty services so long as such authorization is for an adequate number of referrals.
`(d) SPECIALTY CARE DEFINED- For purposes of this subsection, the term `specialty care' means, with respect to a condition, care and treatment provided by a health care practitioner, facility, or center (such as a center of excellence) that has adequate expertise (including age-appropriate expertise) through appropriate training and experience.
`SEC. 9826. CONTINUITY OF CARE.
`(1) TERMINATION OF PROVIDER- If a contract between a group health plan (other than a fully insured group health plan) and a health care provider is terminated (as defined in paragraph (2)), or benefits or coverage provided by a health care provider are terminated because of a change in the terms of provider participation in such group health plan, and an individual who is a participant or beneficiary in the plan is undergoing a course of treatment from the provider at the time of such termination, the plan shall--
`(A) notify the individual on a timely basis of such termination;
`(B) provide the individual with an opportunity to notify the plan of a need for transitional care; and
`(C) in the case of termination described in paragraph (2), (3), or (4) of subsection (b), and subject to subsection (c), permit the individual to continue or be covered with respect to the course of treatment with the provider's consent during a transitional period (as provided under subsection (b)).
`(2) TERMINATED- In this section, the term `terminated' includes, with respect to a contract, the expiration or nonrenewal of the contract by the group health plan, but does not include a termination of the contract by the plan for failure to meet applicable quality standards or for fraud.
`(3) CONTRACTS- For purposes of this section, the term `contract between a group health plan (other than a fully insured group health plan) and a health care provider' shall include a contract between such a plan and an organized network of providers.
`(b) TRANSITIONAL PERIOD-
`(1) GENERAL RULE- Except as provided in paragraph (3), the transitional period under this subsection shall permit the participant or beneficiary to extend the coverage involved for up to 90 days from the date of the notice described in subsection (a)(1)(A) of the provider's termination.
`(2) INSTITUTIONAL CARE- Subject to paragraph (1), the transitional period under this subsection for institutional or inpatient care from a provider shall extend until the discharge or termination of the period of institutionalization and also shall include institutional care provided within a reasonable time of the date of termination of the provider status if the care was scheduled before the date of the announcement of the termination of the provider status under subsection (a)(1)(A) or if the individual on such date was on an established waiting list or otherwise scheduled to have such care.
`(3) PREGNANCY- Notwithstanding paragraph (1), if--
`(A) a participant or beneficiary has entered the second trimester of pregnancy at the time of a provider's termination of participation; and
`(B) the provider was treating the pregnancy before the date of the termination;
the transitional period under this subsection with respect to provider's treatment of the pregnancy shall extend through the provision of post-partum care directly related to the delivery.
`(4) TERMINAL ILLNESS- Notwithstanding paragraph (1), if--
`(A) a participant or beneficiary was determined to be terminally ill (as determined under section 1861(dd)(3)(A) of the Social Security Act) prior to a provider's termination of participation; and
`(B) the provider was treating the terminal illness before the date of termination;
the transitional period under this subsection shall be for care directly related to the treatment of the terminal illness and shall extend for the remainder of the individual's life for such care.
`(c) PERMISSIBLE TERMS AND CONDITIONS- A group health plan (other than a fully insured group health plan) may condition coverage of continued treatment by a provider under subsection (a)(1)(C) upon the provider agreeing to the following terms and conditions:
`(1) The provider agrees to accept reimbursement from the plan and individual involved (with respect to cost-sharing) at the rates applicable prior to the start of the transitional period as payment in full (or at the rates applicable under the replacement plan after the date of the termination of the contract with the group health plan) and not to impose cost-sharing with respect to the individual in an amount that would exceed the cost-sharing that could have been imposed if the contract referred to in subsection (a)(1) had not been terminated.
`(2) The provider agrees to adhere to the quality assurance standards of the plan responsible for payment under paragraph (1) and to provide to such plan necessary medical information related to the care provided.
`(3) The provider agrees otherwise to adhere to such plan's policies and procedures, including procedures regarding referrals and obtaining prior authorization and providing services pursuant to a treatment plan (if any) approved by the plan.
`(d) RULE OF CONSTRUCTION- Nothing in this section shall be construed to require the coverage of benefits which would not have been covered if the provider involved remained a participating provider.
`(e) DEFINITION- In this section, the term `health care provider' or `provider' means--
`(1) any individual who is engaged in the delivery of health care services in a State and who is required by State law or regulation to be licensed or certified by the State to engage in the delivery of such services in the State; and
`(2) any entity that is engaged in the delivery of health care services in a State and that, if it is required by State law or regulation to be licensed or certified by the State to engage in the delivery of such services in the State, is so licensed.
`(f) COMPREHENSIVE STUDY OF COST, QUALITY AND COORDINATION OF COVERAGE FOR PATIENTS AT THE END OF LIFE-
`(1) STUDY BY THE MEDICARE PAYMENT ADVISORY COMMISSION- The Medicare Payment Advisory Commission shall conduct a study of the costs and patterns of care for persons with serious and complex conditions and the possibilities of improving upon that care to the degree it is triggered by the current category of terminally ill as such term is used for purposes of section 1861(dd) of the Social Security Act (relating to hospice benefits) or of utilizing care in other payment settings in Medicare.
`(2) AGENCY FOR HEALTH CARE POLICY AND RESEARCH- The Agency for Health Care Policy and Research shall conduct studies of the possible thresholds for major conditions causing serious and complex illness, their administrative parameters and feasibility, and their impact upon costs and quality.
`(3) HEALTH CARE FINANCING ADMINISTRATION- The Health Care Financing Administration shall conduct studies of the merits of applying similar thresholds in Medicare+Choice programs, including adapting risk adjustment methods to account for this category.
`(A) IN GENERAL- Not later than 12 months after the date of enactment of this section, the Medicare Payment Advisory Commission and the Agency for Health Care Policy and Research shall each prepare and submit to the Committee on Health, Education, Labor and Pensions of the Senate a report concerning the results of the studies conducted under paragraphs (1) and (2), respectively.
`(B) COPY TO SECRETARY- Concurrent with the submission of the reports under subparagraph (A), the Medicare Payment Advisory Commission and the Agency for health Care Policy and Research shall transmit a copy of the reports under such subparagraph to the Secretary.
`(A) CONTRACT WITH INSTITUTE OF MEDICINE- Not later than 1 year after the submission of the reports under paragraph (4), the Secretary of Health and Human Services shall contract with the Institute of Medicine to conduct a study of the practices and their effects arising from the utilization of the category `serious and complex' illness.
`(B) REPORT- Not later than 1 year after the date of the execution of the contract referred to in subparagraph (A), the Institute of Medicine shall prepare and submit to the Committee on Health, Education, Labor and Pensions of the Senate a report concerning the study conducted pursuant to such contract.
`(6) FUNDING- From funds appropriated to the Department of Health and Human Services, the Secretary of Health and Human Services shall make available such funds as the Secretary determines is necessary to carry out this subsection.
`SEC. 9827. PROTECTION OF PATIENT-PROVIDER COMMUNICATIONS.
`(a) IN GENERAL- Subject to subsection (b), a group health plan (other than a fully insured group health plan and in relation to a participant or beneficiary) shall not prohibit or otherwise restrict a health care professional from advising such a participant or beneficiary who is a patient of the professional about the health status of the participant or beneficiary or medical care or treatment for the condition or disease of the participant or beneficiary, regardless of whether coverage for such care or treatment are provided under the contract, if the professional is acting within the lawful scope of practice.
`(b) RULE OF CONSTRUCTION- Nothing in this section shall be construed as requiring a group health plan (other than a fully insured group health plan) to provide specific benefits under the terms of such plan.
`SEC. 9828. PATIENT'S RIGHT TO PRESCRIPTION DRUGS.
`To the extent that a group health plan (other than a fully insured group health plan) provides coverage for benefits with respect to prescription drugs, and limits such coverage to drugs included in a formulary, the plan shall--
`(1) ensure the participation of physicians and pharmacists in developing and reviewing such formulary; and
`(2) in accordance with the applicable quality assurance and utilization review standards of the plan, provide for exceptions from the formulary limitation when a non-formulary alternative is medically necessary and appropriate.
`SEC. 9829. SELF-PAYMENT FOR BEHAVIORAL HEALTH CARE SERVICES.
`(a) IN GENERAL- A group health plan (other than a fully insured group health plan) may not--
`(1) prohibit or otherwise discourage a participant or beneficiary from self-paying for behavioral health care services once the plan has denied coverage for such services; or
`(2) terminate a health care provider because such provider permits participants or beneficiaries to self-pay for behavioral health care services--
`(A) that are not otherwise covered under the plan; or
`(B) for which the group health plan provides limited coverage, to the extent that the group health plan denies coverage of the services.
`(b) RULE OF CONSTRUCTION- Nothing in subsection (a)(2)(B) shall be construed as prohibiting a group health plan from terminating a contract with a health care provider for failure to meet applicable quality standards or for fraud.
`SEC. 9830. COVERAGE FOR INDIVIDUALS PARTICIPATING IN APPROVED CANCER CLINICAL TRIALS.
`(1) IN GENERAL- If a group health plan (other than a fully insured group health plan) provides coverage to a qualified individual (as defined in subsection (b)), the plan--
`(A) may not deny the individual participation in the clinical trial referred to in subsection (b)(2);
`(B) subject to subsections (b), (c), and (d) may not deny (or limit or impose additional conditions on) the coverage of routine patient costs for items and services furnished in connection with participation in the trial; and
`(C) may not discriminate against the individual on the basis of the participant's or beneficiaries participation in such trial.
`(2) EXCLUSION OF CERTAIN COSTS- For purposes of paragraph (1)(B), routine patient costs do not include the cost of the tests or measurements conducted primarily for the purpose of the clinical trial involved.
`(3) USE OF IN-NETWORK PROVIDERS- If one or more participating providers is participating in a clinical trial, nothing in paragraph (1) shall be construed as preventing a plan from requiring that a qualified individual participate in the trial through such a participating provider if the provider will accept the individual as a participant in the trial.
`(b) QUALIFIED INDIVIDUAL DEFINED- For purposes of subsection (a), the term `qualified individual' means an individual who is a participant or beneficiary in a group health plan and who meets the following conditions:
`(1)(A) The individual has been diagnosed with cancer for which no standard treatment is effective.
`(B) The individual is eligible to participate in an approved clinical trial according to the trial protocol with respect to treatment of such illness.
`(C) The individual's participation in the trial offers meaningful potential for significant clinical benefit for the individual.
`(A) the referring physician is a participating health care professional and has concluded that the individual's participation in such trial would be appropriate based upon the individual meeting the conditions described in paragraph (1); or
`(B) the participant or beneficiary provides medical and scientific information establishing that the individual's participation in such trial would be appropriate based upon the individual meeting the conditions described in paragraph (1).
`(1) IN GENERAL- Under this section a group health plan (other than a fully insured group health plan) shall provide for payment for routine patient costs described in subsection (a)(2) but is not required to pay for costs of items and services that are reasonably expected to be paid for by the sponsors of an approved clinical trial.
`(2) STANDARDS FOR DETERMINING ROUTINE PATIENT COSTS ASSOCIATED WITH CLINICAL TRIAL PARTICIPATION-
`(A) IN GENERAL- The Secretary shall establish, on an expedited basis and using a negotiated rulemaking process under subchapter III of chapter 5 of title 5, United States Code, standards relating to the coverage of routine patient costs for individuals participating in clinical trials that group health plans must meet under this section.
`(B) FACTORS- In establishing routine patient cost standards under subparagraph (A), the Secretary shall consult with interested parties and take into account --
`(i) quality of patient care;
`(ii) routine patient care costs versus costs associated with the conduct of clinical trials, including unanticipated patient care costs as a result of participation in clinical trials; and
`(iii) previous and on-going studies relating to patient care costs associated with participation in clinical trials.
`(C) PUBLICATION OF NOTICE- In carrying out the rulemaking process under this paragraph, the Secretary, after consultation with organizations representing cancer patients, health care practitioners, medical researchers, employers, group health plans, manufacturers of drugs, biologics and medical devices, medical economists, hospitals, and other interested parties, shall publish notice provided for under section 564(a) of title 5, United States Code, by not later than 45 days after the date of the enactment of this section.
`(D) TARGET DATE FOR PUBLICATION OF RULE- As part of the notice under subparagraph (C), and for purposes of this paragraph, the `target date for publication' (referred to in section 564(a)(5) of such title 5) shall be June 30, 2000.
`(E) ABBREVIATED PERIOD FOR SUBMISSION OF COMMENTS- In applying section 564(c) of such title 5 under this paragraph, `15 days' shall be substituted for `30 days'.
`(F) APPOINTMENT OF NEGOTIATED RULEMAKING COMMITTEE AND FACILITATOR- The Secretary shall provide for--
`(i) the appointment of a negotiated rulemaking committee under section 565(a) of such title 5 by not later than 30 days after the end of the comment period provided for under section 564(c) of such title 5 (as shortened under subparagraph (E)), and
`(ii) the nomination of a facilitator under section 566(c) of such title 5 by not later than 10 days after the date of appointment of the committee.
`(G) PRELIMINARY COMMITTEE REPORT- The negotiated rulemaking committee appointed under subparagraph (F) shall report to the Secretary, by not later than March 29, 2000, regarding the committee's progress on achieving a consensus with regard to the rulemaking proceeding and whether such consensus is likely to occur before 1 month before the target date for publication of the rule. If the committee reports that the committee has failed to make significant progress towards such consensus or is unlikely to reach such consensus by the target date, the Secretary may terminate such process and provide for the publication of a rule under this paragraph through such other methods as the Secretary may provide.
`(H) FINAL COMMITTEE REPORT- If the committee is not terminated under subparagraph (G), the rulemaking committee shall submit a report containing a proposed rule by not later than 1 month before the target date of publication.
`(I) FINAL EFFECT- The Secretary shall publish a rule under this paragraph in the Federal Register by not later than the target date of publication.
`(J) PUBLICATION OF RULE AFTER PUBLIC COMMENT- The Secretary shall provide for consideration of such comments and republication of such rule by not later than 1 year after the target date of publication.
`(K) EFFECTIVE DATE- The provisions of this paragraph shall apply to group health plans (other than a fully insured group health plan) for plan years beginning on or after January 1, 2001.
`(3) PAYMENT RATE- In the case of covered items and services provided by--
`(A) a participating provider, the payment rate shall be at the agreed upon rate, or
`(B) a nonparticipating provider, the payment rate shall be at the rate the plan would normally pay for comparable services under subparagraph (A).
`(d) APPROVED CLINICAL TRIAL DEFINED-
`(1) IN GENERAL- In this section, the term `approved clinical trial' means a cancer clinical research study or cancer clinical investigation approved and funded (which may include funding through in-kind contributions) by one or more of the following:
`(A) The National Institutes of Health.
`(B) A cooperative group or center of the National Institutes of Health.
`(C) Either of the following if the conditions described in paragraph (2) are met:
`(i) The Department of Veterans Affairs.
`(ii) The Department of Defense.
`(2) CONDITIONS FOR DEPARTMENTS- The conditions described in this paragraph, for a study or investigation conducted by a Department, are that the study or investigation has been reviewed and approved through a system of peer review that the Secretary determines--
`(A) to be comparable to the system of peer review of studies and investigations used by the National Institutes of Health, and
`(B) assures unbiased review of the highest scientific standards by qualified individuals who have no interest in the outcome of the review.
`(e) CONSTRUCTION- Nothing in this section shall be construed to limit a plan's coverage with respect to clinical trials.
`(f) PLAN SATISFACTION OF CERTAIN REQUIREMENTS; RESPONSIBILITIES OF FIDUCIARIES-
`(1) IN GENERAL- For purposes of this section, insofar as a group health plan provides benefits in the form of health insurance coverage through a health insurance issuer, the plan shall be treated as meeting the requirements of this section with respect to such benefits and not be considered as failing to meet such requirements because of a failure of the issuer to meet such requirements so long as the plan sponsor or its representatives did not cause such failure by the issuer.
`(2) CONSTRUCTION- Nothing in this section shall be construed to affect or modify the responsibilities of the fiduciaries of a group health plan under part 4 of subtitle B of title I of the Employee Retirement Income Security Act of 1974.
`(1) STUDY- The Secretary shall study the impact on group health plans for covering routine patient care costs for individuals who are entitled to benefits under this section and who are enrolled in an approved cancer clinical trial program.
`(2) REPORT TO CONGRESS- Not later than January 1, 2005, the Secretary shall submit a report to Congress that contains an assessment of--
`(A) any incremental cost to group health plans resulting from the provisions of this section;
`(B) a projection of expenditures to such plans resulting from this section; and
`(C) any impact on premiums resulting from this section.
`SEC. 9830A. PROHIBITING DISCRIMINATION AGAINST PROVIDERS.
`(a) IN GENERAL- A group health plan (other than a fully insured group health plan) 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. This subsection shall not be construed as requiring the coverage under a plan of particular benefits or services or to prohibit a plan from including providers only to the extent necessary to meet the needs of the plan's participants and beneficiaries or from establishing any measure designed to maintain quality and control costs consistent with the responsibilities of the plan.
`(b) NO REQUIREMENT FOR ANY WILLING PROVIDER- Nothing in this section shall be construed as requiring a group health plan that offers network coverage to include for participation every willing provider or health professional who meets the terms and conditions of the plan.
`SEC. 9830B. GENERALLY APPLICABLE PROVISION.
`In the case of a group health plan that provides benefits under 2 or more coverage options, the requirements of this subchapter shall apply separately with respect to each coverage option.'.
(b) DEFINITION- Section 9832(b) of the Internal Revenue Code of 1986 is amended by adding at the end the following:
`(4) FULLY INSURED GROUP HEALTH PLAN- The term `fully insured group health plan' means a group health plan where benefits under the plan are provided pursuant to the terms of an arrangement between a group health plan and a health insurance issuer and are guaranteed by the health insurance issuer under a contract or policy of insurance.'.
(c) CONFORMING AMENDMENT- Chapter 98 of the Internal Revenue Code of 1986 is amended in the table of subchapters in the item relating to subchapter C, by striking `Subchapter C' and inserting `Subchapter D'.
SEC. 103. EFFECTIVE DATE AND RELATED RULES.
(a) IN GENERAL- The amendments made by this subtitle shall apply with respect to plan years beginning on or after January 1 of the second calendar year following the date of the enactment of this Act. The Secretary shall issue all regulations necessary to carry out the amendments made by this section before the effective date thereof.
(b) LIMITATION ON ENFORCEMENT ACTIONS- No enforcement action shall be taken, pursuant to the amendments made by this subtitle, against a group health plan with respect to a violation of a requirement imposed by such amendments before the date of issuance of regulations issued in connection with such requirement, if the plan has sought to comply in good faith with such requirement.
Subtitle B--Right to Information About Plans and Providers
SEC. 111. INFORMATION ABOUT PLANS.
(a) EMPLOYEE RETIREMENT INCOME SECURITY ACT OF 1974-
(1) IN GENERAL- Subpart B of part 7 of subtitle B of title I of the Employee Retirement Income Security Act of 1974 (29 U.S.C. 1185 et seq.) is amended by adding at the end the following:
`SEC. 714. HEALTH PLAN COMPARATIVE INFORMATION.
`(1) IN GENERAL- A group health plan, and a health insurance issuer that provides coverage in connection with group health insurance coverage, shall, not later than 12 months after the date of enactment of this section, and at least annually thereafter, provide for the disclosure, in a clear and accurate form to each participant and each beneficiary who does not reside at the same address as the participant, or upon request to an individual eligible for coverage under the plan, of the information described in subsection (b).
`(2) RULE OF CONSTRUCTION- Nothing in this section shall be construed to prevent a plan or issuer from entering into any agreement under which the issuer agrees to assume responsibility for compliance with the requirements of this section and the plan is released from liability for such compliance.
`(3) PROVISION OF INFORMATION- Information shall be provided to participants and beneficiaries under this section at the address maintained by the plan or issuer with respect to such participants or beneficiaries.
`(b) REQUIRED INFORMATION- The informational materials to be distributed under this section shall include for each package option available under a group health plan the following:
`(1) A description of the covered items and services under each such plan and any in- and out-of-network features of each such plan, including a summary description of the specific exclusions from coverage under the plan.
`(2) A description of any cost-sharing, including premiums, deductibles, coinsurance, and copayment amounts, for which the participant or beneficiary will be responsible, including any annual or lifetime limits on benefits, for each such plan.
`(3) A description of any optional supplemental benefits offered by each such plan and the terms and conditions (including premiums or cost-sharing) for such supplemental coverage.
`(4) A description of any restrictions on payments for services furnished to a participant or beneficiary by a health care professional that is not a participating professional and the liability of the participant or beneficiary for additional payments for these services.
`(5) A description of the service area of each such plan, including the provision of any out-of-area coverage.
`(6) A description of the extent to which participants and beneficiaries may select the primary care provider of their choice, including providers both within the network and outside the network of each such plan (if the plan permits out-of-network services).
`(7) A description of the procedures for advance directives and organ donation decisions if the plan maintains such procedures.
`(8) A description of the requirements and procedures to be used to obtain preauthorization for health services (including telephone numbers and mailing addresses), including referrals for specialty care.
`(9) A description of the definition of medical necessity used in making coverage determinations by each such plan.
`(10) A summary of the rules and methods for appealing coverage decisions and filing grievances (including telephone numbers and mailing addresses), as well as other available remedies.
`(11) A summary description of any provisions for obtaining off-formulary medications if the plan utilizes a defined formulary for providing specific prescription medications.
`(12) A summary of the rules for access to emergency room care. Also, any available educational material regarding proper use of emergency services.
`(13) A description of whether or not coverage is provided for experimental treatments, investigational treatments, or clinical trials and the circumstances under which access to such treatments or trials is made available.
`(14) A description of the specific preventative services covered under the plan if such services are covered.
`(15) A statement regarding--
`(A) the manner in which a participant or beneficiary may access an obstetrician, gynecologist, or pediatrician in accordance with section 723 or 724; and
`(B) the manner in which a participant or beneficiary obtains continuity of care as provided for in section 726.
`(16) A statement that the following information, and instructions on obtaining such information (including telephone numbers and, if available, Internet websites), shall be made available upon request:
`(A) The names, addresses, telephone numbers, and State licensure status of the plan's participating health care professionals and participating health care facilities, and, if available, the education, training, specialty qualifications or certifications of such professionals.
`(B) A summary description of the methods used for compensating participating health care professionals, such as capitation, fee-for-service, salary, or a combination thereof. The requirement of this subparagraph shall not be construed as requiring plans to provide information concerning proprietary payment methodology.
`(C) A summary description of the methods used for compensating health care facilities, including per diem, fee-for-service, capitation, bundled payments, or a combination thereof. The requirement of this subparagraph shall not be construed as requiring plans to provide information concerning proprietary payment methodology.
`(D) A summary description of the procedures used for utilization review.
`(E) The list of the specific prescription medications included in the formulary of the plan, if the plan uses a defined formulary.
`(F) A description of the specific exclusions from coverage under the plan.
`(G) Any available information related to the availability of translation or interpretation services for non-English speakers and people with communication disabilities, including the availability of audio tapes or information in Braille.
`(H) Any information that is made public by accrediting organizations in the process of accreditation if the plan is accredited, or any additional quality indicators that the plan makes available.
`(c) MANNER OF DISTRIBUTION- The information described in this section shall be distributed in an accessible format that is understandable to an average plan participant or beneficiary.
`(d) RULE OF CONSTRUCTION- Nothing in this section may be construed to prohibit a group health plan, or health insurance issuer in connection with group health insurance coverage, from distributing any other additional information determined by the plan or issuer to be important or necessary in assisting participants and beneficiaries or upon request potential participants and beneficiaries in the selection of a health plan or from providing information under subsection (b)(15) as part of the required information.
`(e) CONFORMING REGULATIONS- The Secretary shall issue regulations to coordinate the requirements on group health plans and health insurance issuers under this section with the requirements imposed under part 1, to reduce duplication with respect to any information that is required to be provided under any such requirements.
`(f) HEALTH CARE PROFESSIONAL- In this section, the term `health care professional' means a physician (as defined in section 1861(r) of the Social Security Act) or other health care professional if coverage for the professional's services is provided under the health plan involved for the services of the professional. Such term includes a podiatrist, optometrist, chiropractor, psychologist, dentist, physician assistant, physical or occupational therapist and therapy assistant, speech-language pathologist, audiologist, registered or licensed practical nurse (including nurse practitioner, clinical nurse specialist, certified registered nurse anesthetist, and certified nurse-midwife), licensed certified social worker, registered respiratory therapist, and certified respiratory therapy technician.'.
(2) CONFORMING AMENDMENTS-
(A) Section 732(a) of the Employee Retirement Income Security Act of 1974 (29 U.S.C. 1191a(a)) is amended by striking `section 711, and inserting `sections 711 and 714'.
(B) The table of contents in section 1 of the Employee Retirement Income Security Act of 1974 (29 U.S.C. 1001) is amended by inserting after the item relating to section 713, the following:
`Sec. 714. Health plan comparative information.'.
(b) 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. Health plan comparative information.';
(2) by inserting after section 9812 the following:
`SEC. 9813. HEALTH PLAN COMPARATIVE INFORMATION.
`(1) IN GENERAL- A group health plan shall, not later than 12 months after the date of enactment of this section, and at least annually thereafter, provide for the disclosure, in a clear and accurate form to each participant and each beneficiary who does not reside at the same address as the participant, or upon request to an individual eligible for coverage under the plan, of the information described in subsection (b).
`(2) RULES OF CONSTRUCTION- Nothing in this section shall be construed to prevent a plan from entering into any agreement under which a health insurance issuer agrees to assume responsibility for compliance with the requirements of this section and the plan is released from liability for such compliance.
`(3) PROVISION OF INFORMATION- Information shall be provided to participants and beneficiaries under this section at the address maintained by the plan with respect to such participants or beneficiaries.
`(b) REQUIRED INFORMATION- The informational materials to be distributed under this section shall include for each package option available under a group health plan the following:
`(1) A description of the covered items and services under each such plan and any in- and out-of-network features of each such plan, including a summary description of the specific exclusions from coverage under the plan.
`(2) A description of any cost-sharing, including premiums, deductibles, coinsurance, and copayment amounts, for which the participant or beneficiary will be responsible, including any annual or lifetime limits on benefits, for each such plan.
`(3) A description of any optional supplemental benefits offered by each such plan and the terms and conditions (including premiums or cost-sharing) for such supplemental coverage.
`(4) A description of any restrictions on payments for services furnished to a participant or beneficiary by a health care professional that is not a participating professional and the liability of the participant or beneficiary for additional payments for these services.
`(5) A description of the service area of each such plan, including the provision of any out-of-area coverage.
`(6) A description of the extent to which participants and beneficiaries may select the primary care provider of their choice, including providers both within the network and outside the network of each such plan (if the plan permits out-of-network services).
`(7) A description of the procedures for advance directives and organ donation decisions if the plan maintains such procedures.
`(8) A description of the requirements and procedures to be used to obtain preauthorization for health services (including telephone numbers and mailing addresses), including referrals for specialty care.
`(9) A description of the definition of medical necessity used in making coverage determinations by each such plan.
`(10) A summary of the rules and methods for appealing coverage decisions and filing grievances (including telephone numbers and mailing addresses), as well as other available remedies.
`(11) A summary description of any provisions for obtaining off-formulary medications if the plan utilizes a defined formulary for providing specific prescription medications.
`(12) A summary of the rules for access to emergency room care. Also, any available educational material regarding proper use of emergency services.
`(13) A description of whether or not coverage is provided for experimental treatments, investigational treatments, or clinical trials and the circumstances under which access to such treatments or trials is made available.
`(14) A description of the specific preventative services covered under the plan if such services are covered.
`(15) A statement regarding--
`(A) the manner in which a participant or beneficiary may access an obstetrician, gynecologist, or pediatrician in accordance with section 723 or 724; and
`(B) the manner in which a participant or beneficiary obtains continuity of care as provided for in section 726.
`(16) A statement that the following information, and instructions on obtaining such information (including telephone numbers and, if available, Internet websites), shall be made available upon request:
`(A) The names, addresses, telephone numbers, and State licensure status of the plan's participating health care professionals and participating health care facilities, and, if available, the education, training, specialty qualifications or certifications of such professionals.
`(B) A summary description of the methods used for compensating participating health care professionals, such as capitation, fee-for-service, salary, or a combination thereof. The requirement of this subparagraph shall not be construed as requiring plans to provide information concerning proprietary payment methodology.
`(C) A summary description of the methods used for compensating health care facilities, including per diem, fee-for-service, capitation, bundled payments, or a combination thereof. The requirement of this subparagraph shall not be construed as requiring plans to provide information concerning proprietary payment methodology.
`(D) A summary description of the procedures used for utilization review.
`(E) The list of the specific prescription medications included in the formulary of the plan, if the plan uses a defined formulary.
`(F) A description of the specific exclusions from coverage under the plan.
`(G) Any available information related to the availability of translation or interpretation services for non-English speakers and people with communication disabilities, including the availability of audio tapes or information in Braille.
`(H) Any information that is made public by accrediting organizations in the process of accreditation if the plan is accredited, or any additional quality indicators that the plan makes available.
`(c) MANNER OF DISTRIBUTION- The information described in this section shall be distributed in an accessible format that is understandable to an average plan participant or beneficiary.
`(d) RULE OF CONSTRUCTION- Nothing in this section may be construed to prohibit a group health plan from distributing any other additional information determined by the plan to be important or necessary in assisting participants and beneficiaries or upon request potential participants and beneficiaries in the selection of a health plan or from providing information under subsection (b)(15) as part of the required information.
`(e) HEALTH CARE PROFESSIONAL- In this section, the term `health care professional' means a physician (as defined in section 1861(r) of the Social Security Act) or other health care professional if coverage for the professional's services is provided under the health plan involved for the services of the professional. Such term includes a podiatrist, optometrist, chiropractor, psychologist, dentist, physician assistant, physical or occupational therapist and therapy assistant, speech-language pathologist, audiologist, registered or licensed practical nurse (including nurse practitioner, clinical nurse specialist, certified registered nurse anesthetist, and certified nurse-midwife), licensed certified social worker, registered respiratory therapist, and certified respiratory therapy technician.'.
SEC. 112. INFORMATION ABOUT PROVIDERS.
(a) STUDY- The Secretary of Health and Human Services shall enter into a contract with the Institute of Medicine for the conduct of a study, and the submission to the Secretary of a report, that includes--
(1) an analysis of information concerning health care professionals that is currently available to patients, consumers, States, and professional societies, nationally and on a State-by-State basis, including patient preferences with respect to information about such professionals and their competencies;
(2) an evaluation of the legal and other barriers to the sharing of information concerning health care professionals; and
(3) recommendations for the disclosure of information on health care professionals, including the competencies and professional qualifications of such practitioners, to better facilitate patient choice, quality improvement, and market competition.
(b) REPORT- Not later than 18 months after the date of enactment of this Act, the Secretary of Health and Human Services shall forward to the appropriate committees of Congress a copy of the report and study conducted under subsection (a).
Subtitle C--Right to Hold Health Plans Accountable
SEC. 121. AMENDMENT TO EMPLOYEE RETIREMENT INCOME SECURITY ACT OF 1974.
(a) IN GENERAL- Section 503 of the Employee Retirement Income Security Act of 1974 (29 U.S.C. 1133) is amended to read as follows:
`SEC. 503. CLAIMS PROCEDURE, COVERAGE DETERMINATION, GRIEVANCES AND APPEALS.
`(a) CLAIMS PROCEDURE- In accordance with regulations of the Secretary, every employee benefit plan shall--
`(1) provide adequate notice in writing to any participant or beneficiary whose claim for benefits under the plan has been denied, setting forth the specific reasons for such denial, written in a manner calculated to be understood by the participant; and
`(2) afford a reasonable opportunity to any participant whose claim for benefits has been denied for a full and fair review by the appropriate named fiduciary of the decision denying the claim.
`(b) COVERAGE DETERMINATIONS UNDER GROUP HEALTH PLANS-
`(A) IN GENERAL- A group health plan or health insurance issuer conducting utilization review shall ensure that procedures are in place for--
`(i) making determinations regarding whether a participant or beneficiary is eligible to receive a payment or coverage for health services under the plan or coverage involved and any cost-sharing amount that the participant or beneficiary is required to pay with respect to such service;
`(ii) notifying a covered participant or beneficiary (or the authorized representative of such participant or beneficiary) and the treating health care professionals involved regarding determinations made under the plan or issuer and any additional payments that the participant or beneficiary may be required to make with respect to such service; and
`(iii) responding to requests, either written or oral, for coverage determinations or for internal appeals from a participant or beneficiary (or the authorized representative of such participant or beneficiary) or the treating health care professional with the consent of the participant or beneficiary.
`(B) ORAL REQUESTS- With respect to an oral request described in subparagraph (A)(iii), a group health plan or health insurance issuer may require that the requesting individual provide written evidence of such request.
`(2) TIMELINE FOR MAKING DETERMINATIONS-
`(A) ROUTINE DETERMINATION- A group health plan or a health insurance issuer shall maintain procedures to ensure that prior authorization determinations concerning the provision of non-emergency items or services are made within 30 days from the date on which the request for a determination is submitted, except that such period may be extended where certain circumstances exist that are determined by the Secretary to be beyond control of the plan or issuer.
`(B) EXPEDITED DETERMINATION-
`(i) IN GENERAL- A prior authorization determination under this subsection shall be made within 72 hours, in accordance with the medical exigencies of the case, after a request is received by the plan or issuer under clause (ii) or (iii).
`(ii) REQUEST BY PARTICIPANT OR BENEFICIARY- A plan or issuer shall maintain procedures for expediting a prior authorization determination under this subsection upon the request of a participant or beneficiary if, based on such a request, the plan or issuer determines that the normal time for making such a determination could seriously jeopardize the life or health of the participant or beneficiary.
`(iii) DOCUMENTATION BY HEALTH CARE PROFESSIONAL- A plan or issuer shall maintain procedures for expediting a prior authorization determination under this subsection if the request involved indicates that the treating health care professional has reasonably documented, based on the medical exigencies, that a determination under the procedures described in subparagraph (A) could seriously jeopardize the life or health of the participant or beneficiary.
`(C) CONCURRENT DETERMINATIONS- A plan or issuer shall maintain procedures to certify or deny coverage of an extended stay or additional services.
`(D) RETROSPECTIVE DETERMINATION- A plan or issuer shall maintain procedures to ensure that, with respect to the retrospective review of a determination made under paragraph (1), the determination shall be made within 30 working days of the date on which the plan or issuer receives necessary information.
`(3) NOTICE OF DETERMINATIONS-
`(A) ROUTINE DETERMINATION- With respect to a coverage determination of a plan or issuer under paragraph (2)(A), the plan or issuer shall issue notice of such determination to the participant or beneficiary (or the authorized representative of the participant or beneficiary) and, consistent with the medical exigencies of the case, to the treating health care professional involved not later than 2 working days after the date on which the determination is made.
`(B) EXPEDITED DETERMINATION- With respect to a coverage determination of a plan or issuer under paragraph (2)(B), the plan or issuer shall issue notice of such determination to the participant or beneficiary (or the authorized representative of the participant or beneficiary), and consistent with the medical exigencies of the case, to the treating health care professional involved within the 72 hour period described in paragraph (2)(B).
`(C) CONCURRENT REVIEWS- With respect to the determination under a plan or issuer under paragraph (2)(C) to certify or deny coverage of an extended stay or additional services, the plan or issuer shall issue notice of such determination to the treating health care professional and to the participant or beneficiary involved (or the authorized representative of the participant or beneficiary) within 1 working day of the determination.
`(D) RETROSPECTIVE REVIEWS- With respect to the retrospective review under a plan or issuer of a determination made under paragraph (2)(D), the plan or issuer shall issue written notice of an approval or disapproval of a determination under this subparagraph to the participant or beneficiary (or the authorized representative of the participant or beneficiary) and health care provider involved within 5 working days of the date on which such determination is made.
`(E) REQUIREMENTS OF NOTICE OF ADVERSE COVERAGE DETERMINATIONS- A written notice of an adverse coverage determination under this subsection, or of an expedited adverse coverage determination under paragraph (2)(B), shall be provided to the participant or beneficiary (or the authorized representative of the participant or beneficiary) and treating health care professional (if any) involved and shall include--
`(i) the reasons for the determination (including the clinical or scientific-evidence based rationale used in making the determination) written in a manner to be understandable to the average participant or beneficiary;
`(ii) the procedures for obtaining additional information concerning the determination; and
`(iii) notification of the right to appeal the determination and instructions on how to initiate an appeal in accordance with subsection (d).
`(c) GRIEVANCES- A group health plan or a health insurance issuer shall have written procedures for addressing grievances between the plan or issuer offering health insurance coverage in connection with a group health plan and a participant or beneficiary. Determinations under such procedures shall be non-appealable.
`(d) INTERNAL APPEAL OF COVERAGE DETERMINATIONS-
`(A) IN GENERAL- A participant or beneficiary (or the authorized representative of the participant or beneficiary) or the treating health care professional with the consent of the participant or beneficiary (or the authorized representative of the participant or beneficiary), may appeal any adverse coverage determination under subsection (b) under the procedures described in this subsection.
`(B) TIME FOR APPEAL- A plan or issuer shall ensure that a participant or beneficiary has a period of not less than 180 days beginning on the date of an adverse coverage determination under subsection (b) in which to appeal such determination