Abbildungen der Seite
PDF
EPUB

TITLE II—AMENDMENTS TO THE PUBLIC 'health care professional' means a physician ate an emergency medical condition (as deHEALTH SERVICE ACT

(as defined in section 1861(r) of the Social Se fined in clause (i)) and also, within the capaSec. 201. Patient access to unrestricted med curity Act) or other health care professional bilities of the staff and facilities at the hos

ical advice, emergency medical if coverage for the professional's services is pital, such further medical examination and care, obstetric and gyneco

provided under the group health plan for the treatment as are required under section 1867 logical care, pediatric care, and

services of the professional. Such term in of such Act to stabilize the patient; or continuity of care.

cludes a podiatrist, optometrist, chiro “(II) with respect to an emergency medical Sec. 202. Requiring health maintenance or

practor, psychologist, dentist, physician as condition described in clause (i)(II), medical ganizations to offer option of sistant, physical or occupational therapist treatment for such condition rendered by a point-of-service coverage.

and therapy assistant, speech-language pa health care provider in a hospital to a Sec. 203. Effective date and related rules.

thologist, audiologist, registered or licensed neonate, including available hospital ancilSubtitle B-Patient Access to Information

practical nurse (including nurse practi lary services in response to an urgent re

tioner, clinical nurse specialist, certified quest of a health care professional and to the Sec. 211. Patient access to information re

registered nurse anesthetist, and certified extent necessary to stabilize the neonate. garding plan coverage, managed

nurse-midwife), licensed certified social “(iii) EMERGENCY AMBULANCE SERVICES.care procedures, health care

worker, registered respiratory therapist, and The term 'emergency ambulance services' providers, and quality of med

certified respiratory therapy technician. means ambulance services (as defined for ical care.

“(3) RULE OF CONSTRUCTION.—Nothing in Sec. 212. Effective date and related rules.

purposes of section 1861(s)(7) of the Social Sethis subsection shall be construed to require curity Act) furnished to transport an indiTITLE III-AMENDMENTS TO THE

the sponsor of a group health plan or a vidual who has an emergency medical condiINTERNAL REVENUE CODE OF 1986

health insurance issuer offering health insur tion (as defined in clause (i)) to a hospital for Sec. 301. Patient access to unrestricted med ance coverage in connection with the group the receipt of emergency services (as defined

ical advice, emergency medical health plan to engage in any practice that in clause (ii) in a case in which appropriate care, obstetric and gyneco would violate its religious beliefs or moral emergency medical screening examinations logical care, pediatric care, and convictions.

are covered under the plan or coverage purcontinuity of care.

“(b) PATIENT ACCESS TO EMERGENCY MED suant to paragraph (1)(A) and a prudent TITLE IV-HEALTH CARE LAWSUIT ICAL CARE.

layperson, with an average knowledge of REFORM

“(1) COVERAGE OF EMERGENCY SERVICES. health and medicine, could reasonably ex

“(A) IN GENERAL.-If a group health plan, Subtitle A-General Provisions

pect that the absence of such transport or health insurance coverage offered by a

would result in placing the health of the inSec. 401. Federal reform of health care li

health insurance issuer, provides any bene dividual in serious jeopardy, serious impairability actions.

fits with respect to emergency services (as ment of bodily function, or serious dysfuncSec. 402. Definitions.

defined in subparagraph (B)(ii)), or ambu tion of any bodily organ or part. Sec. 403. Effective date.

lance services, the plan or issuer shall cover “(iv) STABILIZE.—The term 'to stabilize' Subtitle B_Uniform Standards for Health emergency services (including emergency

means, with respect to an emergency medCare Liability Actions ambulance services as defined in subpara

ical condition, to provide such medical treatSec. 411. Statute of limitations. graph (B)(iii) furnished under the plan or

ment of the condition as may be necessary to Sec. 412. Calculation and payment of dam coverage

assure, within reasonable medical probages. “(i) without the need for any prior author

ability, that no material deterioration of the Sec. 413. Alternative dispute resolution. ization determination;

condition is likely to result from or occur Sec. 414. Reporting on fraud and abuse en “(ii) whether or not the health care pro

during the transfer of the individual from a forcement activities. vider furnishing such services is a partici

facility. TITLE I-AMENDMENTS THE EM pating provider with respect to such serv

“(v) NONPARTICIPATING.–The term 'nonPLOYEE RETIREMENT INCOME SECU. ices;

participating means, with respect to a RITY ACT OF 1974

“(iii) in a manner so that, if such services

health care provider that provides health Subtitle A-Patient Protections are provided to a participant or beneficiary

care items and services to a participant or by a nonparticipating health care provider, SEC. 101. PATIENT ACCESS TO UNRESTRICTED

beneficiary under group health plan or under MEDICAL ADVICE,

the participant or beneficiary is not liable EMERGENCY

group health insurance coverage, a health for amounts that exceed the amounts of liMEDICAL CARE, OBSTETRIC AND

care provider that is not a participating GYNECOLOGICAL CARE, PEDIATRIC ability that would be incurred if the services

health care provider with respect to such CARE, AND CONTINUITY OF CARE. were provided by a participating provider;

items and services. (a) IN GENERAL.-Subpart B of part 7 of and

“(vi) PARTICIPATING.–The term “particisubtitle B of title I of the Employee Retire

“(iv) without regard to any other term or

pating' means, with respect to a health care ment Income Security Act of 1974 is amended

condition of such plan or coverage (other by adding at the end the following new secthan exclusion or coordination of benefits, or

provider that provides health care items and

services to a participant or beneficiary under tion:

an affiliation or waiting period, permitted “SEC. 714. PATIENT ACCESS TO UNRESTRICTED

group health plan or health insurance covunder section 701 and other than applicable

erage offered by a health insurance issuer in MEDICAL ADVICE, EMERGENCY

cost sharing).
MEDICAL CARE, OBSTETRIC AND
“(B) DEFINITIONS.—In this subsection:

connection with such a plan, a health care

provider that furnishes such items and servGYNECOLOGICAL CARE, PEDIATRIC “(i) EMERGENCY MEDICAL CONDITION.—The CARE, AND CONTINUITY OF CARE.

ices under a contract or other arrangement term “emergency medical condition' means“(a) PATIENT ACCESS TO UNRESTRICTED "(I) a medical condition manifesting itself

with the plan or issuer.

“(c) PATIENT RIGHT TO OBSTETRIC AND GYNMEDICAL ADVICE.by acute symptoms of sufficient severity (in

ECOLOGICAL CARE.“(1) IN GENERAL.-In the case of any health cluding severe pain) such that a prudent

“(1) IN GENERAL.-In any case in which a care professional acting within the lawful layperson, who possesses an average knowlscope of practice in the course of carrying

group health plan (or a health insurance edge of health and medicine, could reason

issuer offering health insurance coverage in out a contractual employment arrangement ably expect the absence of immediate med

connection with the plan)or other direct contractual arrangement be ical attention to result in a condition de

“(A) provides benefits under the terms of tween such professional and a group health scribed in clause (i), (ii), or (iii) of section

the plan consisting ofplan or a health insurance issuer offering 1867(e)(1)(A) of the Social Security Act (42 health insurance coverage in connection U.S.C. 1395dd(e)(1)(A)); and

“(i) gynecological care (such as preventive with a group health plan, the plan or issuer

women's health examinations); or "(II) a medical condition manifesting itself

“(ii) obstetric care (such as pregnancy-rewith which such contractual employment ar in a neonate by acute symptoms of sufficient

lated services), rangement or other direct contractual ar severity (including severe pain) such that a rangement is maintained by the professional prudent health care professional could rea

provided by a participating health care promay not impose on such professional under sonably expect the absence of immediate

fessional who specializes in such care (or prosuch arrangement any prohibition or restric medical attention to result in a condition de

vides benefits consisting of payment for such tion with respect to advice, provided to a scribed in clause (i), (ii), or (iii) of section

care); and participant or beneficiary under the plan 1867(e)(1)(A) of the Social Security Act.

"(B) requires or provides for designation by who is a patient, about the health status of

"(ii) EMERGENCY SERVICES.—The term a participant or beneficiary of a particithe participant or beneficiary or the medical 'emergency services' means

pating primary care provider, care or treatment for the condition or dis “(I) with respect to an emergency medical if the primary care provider designated by ease of the participant or beneficiary, re condition described in clause (i)(I), a medical such a participant or beneficiary is not such gardless of whether benefits for such care or screening examination (as required under a health care professional, then the plan (or treatment are provided under the plan or section 1867 of the Social Security Act, 42 issuer) shall meet the requirements of parahealth insurance coverage offered in connec U.S.C. 1395dd)) that is within the capability graph (2). tion with the plan.

of the emergency department of a hospital, “(2) REQUIREMENTS.-A group health plan “(2) H LTH CARE PROFESSIONAL DEFINED. including ancillary services routinely avail (or a health insurance issuer offering health For purposes of this paragraph, the term able to the emergency department to evalu insurance coverage in connection with the

plan) meets the requirements of this paragraph, in connection with benefits described in paragraph (1) consisting of care described in clause (i) or (ii) of paragraph (1)(A) (or consisting of payment therefor), if the plan (or issuer)

“(A) does not require authorization or a referral by the primary care provider in order to obtain such benefits; and

“(B) treats the ordering of other care of the same type, by the participating health care professional providing the care described in clause (i) or (ii) of paragraph (1)(A), as the authorization of the primary care provider with respect to such care.

“(3) HEALTH CARE PROFESSIONAL DEFINED.For purposes of this subsection, the term health care professional' means an individual (including, but not limited to, a nurse midwife or nurse practitioner) who is licensed, accredited, or certified under State law to provide obstetric and gynecological health care services and who is operating within the scope of such licensure, accreditation, or certification.

“(4) CONSTRUCTION.—Nothing in paragraph (1) shall be construed as preventing a plan from offering (but not requiring a participant or beneficiary to accept) a health care professional trained, credentialed, and operating within the scope of their licensure to perform obstetric and gynecological health care services. Nothing in paragraph (2)(B) shall waive any requirements of coverage relating to medical necessity or appropriateness with respect to coverage of gynecological or obstetric care so ordered.

“(5) TREATMENT OF MULTIPLE COVERAGE OPTIONS.—In the case of a plan providing benefits under two or more coverage options, the requirements of this subsection shall apply separately with respect to each coverage option.

“(d) PATIENT RIGHT TO PEDIATRIC CARE.

“(1) IN GENERAL.-In any case in which a group health plan (or a health insurance issuer offering health insurance coverage in connection with the plan) provides benefits consisting of routine pediatric care provided by a participating health care professional who specializes in pediatrics (or consisting of payment for such care) and the plan requires or provides for designation by a participant or beneficiary of a participating primary care provider, the plan (or issuer) shall provide that such a participating health care professional may be designated, if available, by a parent or guardian of any beneficiary under the plan is who under 18 years of age, as the primary care provider with respect to any such benefits.

“(2) HEALTH CARE PROFESSIONAL DEFINED.For purposes of this subsection, the term ‘health care professional' means an individual (including, but not limited to, a nurse practitioner) who is licensed, accredited, or certified under State law to provide pediatric health care services and who is operating within the scope of such licensure, accreditation, or certification.

"(3) CONSTRUCTION.-Nothing in paragraph (1) shall be construed as preventing a plan from offering (but not requiring a participant or beneficiary to accept) a health care professional trained, credentialed, and operating within the scope of their licensure to perform pediatric health care services. Nothing in paragraph (1) shall waive any requirements of coverage relating to medical necessity or appropriateness with respect to coverage of pediatric care so ordered.

“(4) TREATMENT OF MULTIPLE COVERAGE OPTIONS.-In the case of a plan providing benefits under two or more coverage options, the requirements of this subsection shall apply separately with respect to each coverage option.

“(e) CONTINUITY OF CARE.“(1) IN GENERAL.

“(A) TERMINATION OF PROVIDER.-If a contract between a group health plan, or a health insurance issuer offering health insurance coverage in connection with a group health plan, and a health care provider is terminated (as defined in subparagraph (D)(ii)), or benefits or coverage provided by a health care provider are terminated because of a change in the terms of provider participation in a group health plan, and an individual who, at the time of such termination, is a participant or beneficiary in the plan and is scheduled to undergo surgery (including an organ transplantation), is undergoing treatment for pregnancy, or is determined to be terminally ill (as defined in section 1861(dd)(3)(A) of the Social Security Act) and is undergoing treatment for the terminal illness, the plan or issuer shall

"(i) notify the individual on a timely basis of such termination and of the right to elect continuation of coverage of treatment by the provider under this subsection; and

“(ii) subject to paragraph (3), permit the individual to elect to continue to be covered with respect to treatment by the provider for such surgery, pregnancy, or illness during a transitional period (provided under paragraph (2)).

“(B) TREATMENT OF TERMINATION OF CONTRACT WITH HEALTH INSURANCE ISSUER.-If a contract for the provision of health insurance coverage between a group health plan and a health insurance issuer is terminated and, as a result of such termination, coverage of services of a health care provider is terminated with respect to an individual, the provisions of subparagraph (A) (and the succeeding provisions of this subsection) shall apply under the plan in the same manner as if there had been a contract between the plan and the provider that had been terminated, but only with respect to benefits that are covered under the plan after the contract termination.

“(C) TERMINATION DEFINED.-For purposes of this subsection, the term 'terminated' includes, with respect to a contract, the expiration or nonrenewal of the contract, but does not include a termination of the contract by the plan or issuer for failure to meet applicable quality standards or for fraud.

“(2) TRANSITIONAL PERIOD.

“(A) IN GENERAL.-Except as provided in subparagraphs (B) through (D), the transitional period under this paragraph shall extend up to 90 days (as determined by the treating health care professional) after the date of the notice described in paragraph (1)(A)(i) of the provider's termination.

“(B) SCHEDULED SURGERY.-If surgery was scheduled for an individual before the date of the announcement of the termination of the provider status under paragraph (1)(A)(i), the transitional period under this paragraph with respect to the surgery shall extend beyond the period under subparagraph (A) and until the date of discharge of the individual after completion of the surgery.

“(C) PREGNANCY.-If

"(i) a participant or beneficiary was determined to be pregnant at the time of a provider's termination of participation, and

“(ii) the provider was treating the pregnancy before date of the termination, the transitional period under this paragraph with respect to provider's treatment of the pregnancy shall extend through the provision of post-partum care directly related to the delivery.

“(D) TERMINAL ILLNESS.-If

"(i) a participant or beneficiary was determined to be terminally ill (as determined under section 1861(dd)(3)(A) of the Social Security Act) at the time of a provider's termination of participation, and

“(ii) the provider was treating the terminal illness before the date of termination,

the transitional period under this paragraph shall extend for the remainder of the individual's life for care directly related to the treatment of the terminal illness or its medical manifestations.

“(3) PERMISSIBLE TERMS AND CONDITIONS.— A group health plan or health insurance issuer may condition coverage of continued treatment by a provider under paragraph (1)(A)(i) upon the individual notifying the plan of the election of continued coverage and upon the provider agreeing to the following terms and conditions:

“(A) The provider agrees to accept reimbursement from the plan or issuer 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, in the case described in paragraph (1)(B), at the rates applicable under the replacement plan or issuer after the date of the termination of the contract with the health insurance issuer) 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 paragraph (1)(A) had not been terminated.

“(B) The provider agrees to adhere to the quality assurance standards of the plan or issuer responsible for payment under subparagraph (A) and to provide to such plan or issuer necessary medical information related to the care provided.

“(C) The provider agrees otherwise to adhere to such plan's or issuer'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 or issuer.

“(D) The provider agrees to provide transitional care to all participants and beneficiaries who are eligible for and elect to have coverage of such care from such provider.

"(E) If the provider initiates the termination, the provider has notified the plan within 30 days prior to the effective date of the termination of

"(i) whether the provider agrees to permissible terms and conditions (as set forth in this paragraph) required by the plan, and

“(ii) if the provider agrees to the terms and conditions, the specific plan beneficiaries and participants undergoing a course of treatment from the provider who the provider believes, at the time of the notification, would be eligible for transitional care under this subsection.

“(4) CONSTRUCTION.-Nothing in this subsection shall be construed to

“(A) require the coverage of benefits which would not have been covered if the provider involved remained a participating provider, or

"(B) prohibit a group health plan from conditioning a provider's participation on the provider's agreement to provide transitional care to all participants and beneficiaries eligible to obtain coverage of such care furnished by the provider as set forth under this subsection.

“(f) COVERAGE FOR INDIVIDUALS PARTICIPATING

IN

APPROVED CANCER CLINICAL TRIALS. “(1) COVERAGE.-

(A) IN GENERAL.-If a group health plan (or a health insurance issuer offering health insurance coverage in connection with the plan) provides coverage to a qualified individual (as defined in paragraph (2)), the plan or issuer

“(i) may not deny the individual participation in the clinical trial referred to in paragraph (2)(B);

“(ii) subject to paragraphs (2), (3), and (4), may not deny (or limit or impose additional conditions on) the coverage of routine pa

tient costs for items and services furnished mally pay for comparable items or services “Sec. 714. Patient access to unrestricted in connection with participation in the trial; under clause (i).

medical advice, emergency and “(4) APPROVED CLINICAL TRIAL DEFINED.

medical care, obstetric and “(iii) may not discriminate against the in “(A) IN GENERAL.–For purposes of this sub

gynecological care, pediatric dividual on the basis of the participation of section, the term “approved clinical trial'

care, and continuity of care.". the participant or beneficiary in such trial.

means a cancer clinical research study or SEC. 102. REQUIRED DISCLOSURE TO NETWORK “(B) EXCLUSION OF CERTAIN COSTS.-For cancer clinical investigation approved by an

PROVIDERS. purposes of subparagraph (A)(ii), routine paInstitutional Review Board.

(a) IN GENERAL.-Subpart B of part 7 of tient costs do not include the cost of the

“(B) CONDITIONS FOR DEPARTMENTS.The

subtitle B of title I of the Employee Retiretests or measurements conducted primarily conditions described in this paragraph, for a

ment Income Security Act of 1974 (as amendfor the purpose of the clinical trial involved. study or investigation conducted by a De

ed by section 101) is amended further by add“(C) USE OF IN-NETWORK PROVIDERS.—If one partment, are that the study or investiga

ing at the end the following new section: or more participating providers is particition has been reviewed and approved through

"SEC. 715. REQUIRED DISCLOSURE TO NETWORK pating in a clinical trial, nothing in subpara

PROVIDERS. a system of peer review that the Secretary graph (A) shall be construed as preventing a

“(a) IN GENERAL.-If a group health plan determinesplan from requiring that a qualified indi

“(i) to be comparable to the system of peer

reimburses, through a contract or other arvidual participate in the trial through such a

rangement, a health care provider at a disparticipating provider if the provider will acreview of studies and investigations used by

counted payment rate because the provider cept the individual as a participant in the the National Institutes of Health, and

participates in a provider network, the plan trial.

“(ii) assures unbiased review of the highest

shall disclose to the provider the following “(2) QUALIFIED INDIVIDUAL DEFINED.–For scientific standards by qualified individuals

information before the provider furnishes purposes of paragraph (1), the term 'qualified who have no interest in the outcome of the covered items or services under the plan: individual' means an individual who is a parreview.

“(1) The identity of the plan sponsor or ticipant or beneficiary in a group health plan “(5) CONSTRUCTION.-Nothing in this sub other entity that is to utilize the discounted and who meets the following conditions: section shall be construed to limit a plan's payment rates in reimbursing network pro“(A)(i) The individual has been diagnosed coverage with respect to clinical trials.

viders in that network. with cancer.

“(6) PLAN SATISFACTION OF CERTAIN RE “(2) The existence of any substantial ben"(ii) The individual is eligible to partici QUIREMENTS; RESPONSIBILITIES OF FIDU efit differentials established for the purpose pate in an approved clinical trial according CIARIES.

of actively encouraging participants or beneto the trial protocol with respect to treat “(A) IN GENERAL.-For purposes of this sub ficiaries under the plan to utilize the proment of cancer. section, insofar as a group health plan pro

viders in that network. “(iii) The individual's participation in the vides benefits in the form of health insur “(3) The methods and materials by which trial offers meaningful potential for signifi ance coverage through a health insurance providers in the network are identified to cant clinical benefit for the individual. issuer, the plan shall be treated as meeting

such participants or beneficiaries as part of “(B) Eitherthe requirements of this subsection with re

the network. “(i) the referring physician is a particispect to such benefits and not be considered

“(b) PERMITTED MEANS OF DISCLOSURE.pating health care professional and has con

Disclosure required under subsection (a) by a as failing to meet such requirements because cluded that the individual's participation in of a failure of the issuer to meet such re

plan may be madesuch trial would be appropriate based upon

“(1) by another entity under a contract or quirements so long as the plan sponsor or its satisfaction by the individual of the condi

other arrangement between the plan and the representatives did not cause such failure by tions described in subparagraph (A); or

entity; and the issuer. “(ii) the individual provides medical and

"(2) by making such information available scientific information establishing that the

“(B) CONSTRUCTION.-Nothing in this sub

in written format, in an electronic format, individual's participation in such trial would section shall be construed to affect or modify

on the Internet, or on a proprietary combe appropriate based upon the satisfaction the responsibilities of the fiduciaries of a

puter network which is readily accessible to by the individual of the conditions described group health plan under part 4.

the network providers. in subparagraph (A).

(7) STUDY AND REPORT.

"(c) CONSTRUCTION.-Nothing in this sec“(3) PAYMENT.

"(A) STUDY.-The Secretary shall analyze tion shall be construed to require, directly or “(A) IN GENERAL.-A group health plan (or

cancer clinical research and its cost implica indirectly, disclosure of specific fee arrangea health insurance issuer offering health in tions for managed care, including differen ments or other reimbursement surance coverage in connection with the tiation in

arrangementsplan) shall provide for payment for routine “(i) the cost of patient care in trials versus “(1) between (i) group health plans or propatient costs described in paragraph (1)(B) standard care;

vider networks and (ii) health care providers, but is not required to pay for costs of items “(ii) the cost effectiveness achieved in difand services that are reasonably expected to ferent sites of service;

“(2) among health care providers. be paid for by the sponsors of an approved “(iii) research outcomes;

"(d) DEFINITIONS.—For purposes of this clinical trial.

"(iv) volume of research subjects available subsection: “(B) ROUTINE PATIENT CARE COSTS.-in different sites of service;

“(1) BENEFIT DIFFERENTIAL.-The term (i) IN GENERAL.-For purposes of this “(v) access to research sites and clinical 'benefit differential' means, with respect to a paragraph, the term “routine patient care trials by cancer patients;

group health plan, differences in the case of costs' shall include the costs associated with "(vi) patient cost sharing or copayment any participant or beneficiary, in the finanthe provision of items and services that, costs realized in different sites of service; cial responsibility for payment of coinsur

“(I) would otherwise be covered under the "(vii) health outcomes experienced in dif ance, copayments, deductibles, balance billgroup health plan if such items and services ferent sites of service;

ing requirements, or any other charge, based were not provided in connection with an ap

“(viii) long term health care services and upon whether a health care provider from proved clinical trial program; and

costs experienced in different sites of serv whom covered items or services are obtained “(II) are furnished according to the proice;

is a network provider. tocol of an approved clinical trial program.

"(ix) morbidity and mortality experienced

“(2) DISCOUNTED PAYMENT RATE.-The term “(ii) EXCLUSION.-For purposes of this in different sites of service; and

"discounted payment rate' means, with reparagraph, 'routine patient care costs' shall

"(x) patient satisfaction and preference of

spect to a provider, a payment rate that is not include the costs associated with the sites of service.

below the charge imposed by the provider. provision of,

“(B) REPORT TO CONGRESS.-Not later than

“(3) NETWORK PROVIDER.—The term 'net(I) an investigational drug or device, unless January 1, 2005, the Secretary shall submit a

work provider' means, with respect to a the Secretary has authorized the manufacreport to Congress that contains

group health plan, a health care provider turer of such drug or device to charge for

“(i) an assessment of any incremental cost

that furnishes health care items and services such drug or device; or to group health plans resulting from the pro

to participants or beneficiaries under the (II) any item or service supplied without visions of this section;

plan pursuant to a contract or other arrangecharge by the sponsor of the approved clinical trial program.

“(ii) a projection of expenditures to such

ment with a provider network in which the plans resulting from this section;

provider is participating. “(C) PAYMENT RATE.-For purposes of this “(iii) an assessment of any impact on pre

“(4) PROVIDER NETWORK.—The term 'prosubsectionmiums resulting from this section; and

vider network' means, with respect to a “(i) PARTICIPATING PROVIDERS.—In the case of covered items and services provided by a

"(iv) recommendations regarding action on

group health plan offering health insurance other diseases."'.

coverage, an association of network proparticipating provider, the payment rate

viders through whom the plan provides, shall be at the agreed upon rate.

(b) CONFORMING AMENDMENT.-The table of through contract or other arrangement, “(ii) NONPARTICIPATING PROVIDERS.-In the contents in section 1 of such Act is amended

health care items and services to particicase of covered items and services provided by adding at the end of the items relating to pants and beneficiaries.". by a nonparticipating provider, the payment subpart B of part 7 of subtitle B of title I of (b) CONFORMING AMENDMENT.-The table of rate shall be at the rate the plan would nor such Act the following new item:

contents in section 1 of such Act is amended

or

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 item: “Sec. 715. Required disclosure to network

providers.”. 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, except that the Secretary of Labor may issue regulations before such date under such amendments. The Secretary shall first issue regulations necessary to carry out the amendments made by this subtitle 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 or health insurance issuer 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 or issuer has sought to comply in good faith with such requirement.

(c) SPECIAL RULE FOR COLLECTIVE BARGAINING AGREEMENTS.-In the case of a group health plan maintained pursuant to one or more collective bargaining agreements between employee representatives and one or more employers ratified before the date of the enactment of this Act, the amendments made by this subtitle shall not apply with respect to plan years beginning before the later of

(1) the date on which the last of the collective bargaining agreements relating to the plan terminates (determined without regard to any extension thereof agreed to after the date of the enactment of this Act); or

(2) January 1, 2002. For purposes of this subsection, any plan amendment made pursuant to a collective bargaining agreement relating to the plan which amends the plan solely to conform to any requirement added by this subtitle shall not be treated as a termination of such collective bargaining agreement.

Subtitle B—Patient Access to Information SEC. 111. PATIENT ACCESS TO INFORMATION RE

GARDING PLAN COVERAGE, MAN-
AGED CARE PROCEDURES, HEALTH
CARE PROVIDERS, AND QUALITY OF

MEDICAL CARE. (a) IN GENERAL.-Part 1 of subtitle B of title I of the Employee Retirement Income Security Act of 1974 is amended

(1) by redesignating section 111 as section 112; and

(2) by inserting after section 110 the following new section:

“DISCLOSURE BY GROUP HEALTH PLANS “SEC. 111. (a) DISCLOSURE REQUIREMENT.The administrator of each group health plan shall take such actions as are necessary to ensure that the summary plan description of the plan required under section 102 (or each summary plan description in any case in which different summary plan descriptions are appropriate under part 1 for different options of coverage) contains, among any information otherwise required under this part, the information required under subsections (b), (c), (d), and (e)(2)(A).

“(b) PLAN BENEFITS.—The information required under subsection (a) includes the following:

“(1) COVERED ITEMS AND SERVICES.

(A) CATEGORIZATION OF INCLUDED BENEFITS.--A description of covered benefits, categorized by

"(i) types of items and services (including any special disease management program); and

"(ii) types of health care professionals providing such items and services.

“(B) EMERGENCY MEDICAL CARE.-A description of the extent to which the plan covers emergency medical care (including the extent to which the plan provides for access to urgent care centers), and any definitions provided under the plan for the relevant plan terminology referring to such care.

"(C) PREVENTATIVE SERVICES.-A description of the extent to which the plan provides benefits for preventative services.

"(D) DRUG FORMULARIES.-A description of the extent to which covered benefits are determined by the use or application of a drug formulary and a summary of the process for determining what is included in such formulary.

“(E) COBRA CONTINUATION COVERAGE.-A description of the benefits available under the plan pursuant to part 6.

“(2) LIMITATIONS, EXCLUSIONS, AND RESTRICTIONS ON COVERED BENEFITS.

(A) CATEGORIZATION OF EXCLUDED BENEFITS.-A description of benefits specifically excluded from coverage, categorized by types of items and services.

“(B) UTILIZATION REVIEW AND PREAUTHORIZATION REQUIREMENTS.—Whether coverage for medical care is limited or excluded on the basis of utilization review or preauthorization requirements.

“(C) LIFETIME, ANNUAL, OR OTHER PERIOD LIMITATIONS.-A description of the circumstances under which, and the extent to which, coverage is subject to lifetime, annual, or other period limitations, categorized by types of benefits.

“(D) CUSTODIAL CARE.-A description of the circumstances under which, and the extent to which, the coverage of benefits for custodial care is limited or excluded, and a statement of the definition used by the plan for custodial care.

“(E) EXPERIMENTAL TREATMENTS.-Whether coverage for any medical care is limited or excluded because it constitutes an investigational item or experimental treatment or technology, and any definitions provided under the plan for the relevant plan terminology referring to such limited or excluded care.

“(F) MEDICAL APPROPRIATENESS OR NECESSITY.-Whether coverage for medical care may be limited or excluded by reason of a failure to meet the plan's requirements for medical appropriateness or necessity, and any definitions provided under the plan for the relevant plan terminology referring to such limited or excluded care.

"(G) SECOND OR SUBSEQUENT OPINIONS.—A description of the circumstances under which, and the extent to which, coverage for second or subsequent opinions is limited or excluded.

“(H) SPECIALTY CARE.-A description of the circumstances under which, and the extent to which, coverage of benefits for specialty care is conditioned on referral from a primary care provider.

“(I) CONTINUITY OF CARE.-A description of the circumstances under which, and the extent to which, coverage of items and services provided by any health care professional is limited or excluded by reason of the departure by the professional from any defined set of providers.

(J) RESTRICTIONS ON COVERAGE OF EMERGENCY SERVICES.-A description of the circumstances under which, and the extent to which, the plan, in covering emergency medical care furnished to a participant or beneficiary of the plan imposes any financial responsibility described in subsection (c) on participants or beneficiaries or limits or conditions benefits for such care subject to any other term or condition of such plan.

“(3) NETWORK CHARACTERISTICS.-If the plan (or health insurance issuer offering health insurance coverage in connection with the plan) utilizes a defined set of pro

viders under contract with the plan (or issuer), a detailed list of the names of such providers and their geographic location, set forth separately with respect to primary care providers and with respect to specialists.

"(c) PARTICIPANT'S FINANCIAL RESPONSIBILITIES.—The information required under subsection (a) includes an explanation of

“(1) a participant's financial responsibility for payment of premiums, coinsurance, copayments, deductibles, and

any

other charges; and

"(2) the circumstances under which, and the extent to which, the participant's financial responsibility described in paragraph (1) may vary, including any distinctions based on whether a health care provider from whom covered benefits are obtained is included in a defined set of providers.

(d) DISPUTE RESOLUTION PROCEDURES.The information required under subsection (a) includes a description of the processes adopted by the plan pursuant to section 503, including

“(1) descriptions thereof relating specifically to

"(A) coverage decisions;

“(B) internal review of coverage decisions; and

(C) any external review of coverage decisions; and

“(2) the procedures and time frames applicable to each step of the processes referred to in subparagraphs (A), (B), and (C) of paragraph (1).

“(e) INFORMATION ON PLAN PERFORMANCE.Any information required under subsection (a) shall include information concerning the number of external reviews under section 503 that have been completed during the prior plan year and the number of such reviews in which a recommendation is made for modification or reversal of an internal review decision under the plan.

“(f) INFORMATION INCLUDED WITH ADVERSE COVERAGE DECISIONS.-A group health plan shall provide to each participant and beneficiary, together with any notification of the participant or beneficiary of an adverse coverage decision, the following information:

“(1) PREAUTHORIZATION AND UTILIZATION REVIEW PROCEDURES.-A description of the basis on which any preauthorization requirement or any utilization review requirement has resulted in the adverse coverage decision.

“(2) PROCEDURES FOR DETERMINING EXCLUSIONS BASED ON MEDICAL NECESSITY OR ON INVESTIGATIONAL ITEMS OR EXPERIMENTAL TREATMENTS.-If the adverse coverage decision is based on a determination relating to medical necessity or to an investigational item or an experimental treatment or technology, a description of the procedures and medically-based criteria used in such decision.

"(g) INFORMATION AVAILABLE ON REQUEST.

“(1) ACCESS TO PLAN BENEFIT INFORMATION IN ELECTRONIC FORM.

“(A) IN GENERAL.-In addition to the information required to be provided under section 104(b)(4), a group health plan may, upon written request (made not more frequently than annually), make available to participants and beneficiaries, in a generally recognized electronic format

“(i) the latest summary plan description, including the latest summary of material modifications, and

"(ii) the actual plan provisions setting forth the benefits available under the plan, to the extent such information relates to the coverage options under the plan available to the participant or beneficiary. A reasonable charge may be made to cover the cost of providing such information in such generally recognized electronic format. The Secretary may by regulation prescribe a maximum

amount which will constitute a reasonable care facility from which a participant or “Sec. 111. Disclosure by group health plans. charge under the preceding sentence.

beneficiary has sought treatment under a “Sec. 112. Repeal and effective date.”. “(B) ALTERNATIVE ACCESS.—The require group health plan shall provide to the partic SEC. 112. EFFECTIVE DATE AND RELATED RULES. ments of this paragraph may be met by mak ipant or beneficiary, on request, a descrip (a) IN GENERAL.-The amendments made by ing such information generally available tion of the facility's corporate form or other this subtitle shall apply with respect to plan (rather than upon request) on the Internet or organizational form and all forms of licens years beginning on or after January 1 of the on a proprietary computer network in a for ing and accreditation status (if any) assigned second calendar year following the date of mat which is readily accessible to partici to the facility by standard-setting organiza the enactment of this Act. The Secretary of pants and beneficiaries. tions.

Labor shall first issue all regulations nec“(2) ADDITIONAL INFORMATION TO BE PRO “(h) ACCESS TO INFORMATION RELEVANT TO

essary to carry out the amendments made by VIDED ON REQUEST.

THE COVERAGE OPTIONS UNDER WHICH THE this subtitle before such date. (A) INCLUSION IN SUMMARY PLAN DESCRIP PARTICIPANT OR BENEFICIARY IS ELIGIBLE TO

(b) LIMITATION ON ENFORCEMENT ACTIONS.TION OF SUMMARY OF ADDITIONAL INFORMA ENROLL.-In addition to information other No enforcement action shall be taken, pursuTION.—The information required under sub wise required to be made available under

ant to the amendments made by this subsection (a) includes a summary description this section, a group health plan shall, upon title, against a group health plan or health of the types of information required by this written request (made not more frequently insurance issuer with respect to a violation subsection to be made available to particithan annually), make available to a partici

of a requirement imposed by such amendpants and beneficiaries on request. pant (and an employee who, under the terms

ments before the date of issuance of final “(B) INFORMATION REQUIRED FROM PLANS of the plan, is eligible for coverage but not

regulations issued in connection with such AND ISSUERS ON REQUEST.-In addition to in enrolled) in connection with a period of en

requirement, if the plan or issuer has sought formation required to be included in sumrollment the summary plan description for

to comply in good faith with such requiremary plan descriptions under this sub any coverage option under the plan under

ment. section, a group health plan shall provide the which the participant is eligible to enroll

Subtitle C-Group Health Plan Review following information to a participant or and any information described in clauses (i),

Standards beneficiary on request:

(ii), (iii), (vi), (vii), and (viii) of subsection “(i) CARE MANAGEMENT INFORMATION.—A

SEC. 121. SPECIAL RULES FOR GROUP HEALTH (e) (2)(B).

PLANS. “(i) ADVANCE NOTICE OF CHANGES IN DRUG description of the circumstances under which, and the extent to which, the plan has FORMULARIES.-Not later than 30 days before

(a) IN GENERAL.-Section 503 of the Emspecial disease management programs or the effective of date of any exclusion of a

ployee Retirement Income Security Act of programs for persons with disabilities, indi specific drug or biological from any drug for

1974 (29 U.S.C. 1133) is amendedcating whether these programs are voluntary mulary under the plan that is used in the

(1) by inserting “(a) IN GENERAL.—” after or mandatory and whether a significant bentreatment of a chronic illness or disease, the

“SEC. 503.”; efit differential results from participation in plan shall take such actions as are necessary

(2) by inserting (after and below paragraph such programs. to reasonably ensure that plan participants

(2)) the following new flush-left sentence: “(ii) INCLUSION OF DRUGS AND BIOLOGICALS are informed of such exclusion. The require

“This subsection does not apply in the case IN FORMULARIES.-A statement of whether a

ments of this subsection may be satisfied of included group health plan benefits (as despecific drug or biological is included in a “(1) by inclusion of information in publica fined in subsection (b)(10)(S))."; and formulary used to determine benefits under tions broadly distributed by plan sponsors,

(3) by adding at the end the following new the plan and a description of the procedures employers, or employee organizations;

subsection: “(2) by electronic means of communication

“(b) SPECIAL RULES FOR GROUP HEALTH for considering requests for any patient-spe

PLANS.— cific waivers.

(including the Internet or proprietary com“(iii) ACCREDITATION STATUS OF HEALTH IN

"(1) puter networks in a format which is readily

COVERAGE DETERMINATIONS.—Every SURANCE ISSUERS AND SERVICE PROVIDERS.-A accessible to participants);

group health plan shall, in the case of indescription of the accreditation and licens "(3) by timely informing participants who,

cluded group health plan benefits ing status (if any) of each health insurance under an ongoing program maintained under "(A) provide adequate notice in writing in issuer offering health insurance coverage in the plan, have submitted their names for

accordance with this subsection to any parconnection with the plan and of any utiliza such notification; or

ticipant or beneficiary of any adverse covtion review organization utilized by the “(4) by any other reasonable means of erage decision with respect to such benefits issuer or the plan, together with the name timely informing plan participants.

of such participant or beneficiary under the and address of the accrediting or licensing “(j) DEFINITIONS AND RELATED RULES.

plan, setting forth the specific reasons for authority

“(1) IN GENERAL.-For purposes of this such coverage decision and any rights of re“(iv) QUALITY PERFORMANCE MEASURES. section

view provided under the plan, written in a The latest information (if any) maintained (A) GROUP HEALTH PLAN.—The term manner calculated to be understood by the by the plan relating to quality of perform 'group health plan' has the meaning provided average participant; ance of the delivery of medical care with re such term under section 733(a)(1).

"(B) provide such notice in writing also to spect to coverage options offered under the “(B) MEDICAL CARE.—The term 'medical any treating medical care provider of such plan and of health care professionals and fa care' has the meaning provided such term participant or beneficiary, if such provider cilities providing medical care under the under section 733(a)(2).

has claimed reimbursement for any item or plan.

“(C) HEALTH INSURANCE COVERAGE.—The service involved in such coverage decision, (C) INFORMATION REQUIRED FROM HEALTH term 'health insurance coverage' has the or if a claim submitted by the provider initiCARE PROFESSIONALS.

meaning provided such term under section ated the proceedings leading to such deci“(i) QUALIFICATIONS, PRIVILEGES, AND METH 733(b)(1).

sion; OD OF COMPENSATION.—Any health care pro “(D) HEALTH INSURANCE ISSUER.—The term

"(C) afford a reasonable opportunity to any fessional treating a participant or bene ‘health insurance issuer' has the meaning participant or beneficiary who is in receipt ficiary under a group health plan shall pro provided such term under section 733(b)(2). of the notice of such adverse coverage decivide to the participant or beneficiary, on re “(2) APPLICABILITY ONLY IN CONNECTION sion, and who files a written request for request, a description of his or her professional WITH INCLUDED GROUP HEALTH PLAN BENE view of the initial coverage decision within qualifications (including board certification FITS.

90 days after receipt of the notice of the inistatus, licensing status, and accreditation “(A) IN GENERAL.--The requirements of tial decision, for a full and fair review of the status, if any), privileges, and experience and this section shall apply only in connection decision by an appropriate named fiduciary a general description by category (including with included group health plan benefits. who did not make the initial decision; and salary, fee-for-service, capitation, and such “(B) INCLUDED GROUP HEALTH PLAN BEN “(D) meet the additional requirements of other categories as may be specified in regu EFIT.--For purposes of subparagraph (A), the

this subsection, which shall apply solely lations of the Secretary) of the applicable term 'included group health plan benefit with respect to such benefits. method by which such professional is com means a benefit which is not an excepted “(2) TIME LIMITS FOR MAKING INITIAL COVpensated in connection with the provision of benefit (as defined in section 733(c)).".

ERAGE DECISIONS FOR BENEFITS AND COMsuch medical care.

(b) CONFORMING AMENDMENTS.

PLETING INTERNAL APPEALS.“(ii) COST OF PROCEDURES.-Any health (1) Section 102(b) of such Act (29 U.S.C. “(A) TIME LIMITS FOR DECIDING REQUESTS care professional who recommends an elec 1022(b)) is amended by inserting before the FOR BENEFIT PAYMENTS, REQUESTS FOR ADtive procedure or treatment while treating a period at the end the following: “; and, in the VANCE DETERMINATION OF COVERAGE, AND REparticipant or beneficiary under a group case of a group health plan (as defined in sec QUESTS FOR REQUIRED DETERMINATION OF MEDhealth plan that requires a participant or tion 112(1)(1)(A)) providing included group ICAL NECESSITY.-Except as provided in subbeneficiary to share in the cost of treatment health plan benefits (as defined in section paragraph (B) shall inform such participant or beneficiary 111(1)(2)(B)), the information required to be “(i) INITIAL DECISIONS.-If a request for of each cost associated with the procedure or included under section 111(a)”.

benefit payments, a request for advance detreatment and an estimate of the magnitude (2) The table of contents in section 1 of termination of coverage, or a request for reof such costs.

such Act is amended by striking the item re quired determination of medical necessity is “(D) INFORMATION REQUIRED FROM HEALTH lating to section 111 and inserting the fol submitted to a group health plan in such reaCARE FACILITIES ON REQUEST.-Any health lowing new items:

sonable form as may be required under the

« ZurückWeiter »