Managed Care Bill of Rights for Consumers Act of 1996

Summary: Managed Care Bill of Rights for Consumers Act of 1996 - Establishes certain requirements for managed care plans, including:  (1) coverage for services furnished by a specialist not contracted with a managed care plan; (2) continued services of a specialist without pre-authorization; (3) assurance of equitable coverage with respect to emergency services; (4) availability on a continuous basis of translation bilingual resources in areas where enrollees speak English as a second language; (5) prohibition for payment of financial bonuses to physicians who reduce or limit medically necessary services; (6) submission of a plan outlining a proposal for service to a medically underserved population in an area a plan is seeking to provide services; (7) certification that a plan in an area provides a minimum number of doctors; (8) disclosure of information on certain financial arrangements; (9) geographical accessibility of items and services covered under the plan; and (10) right of an enrollee to seek care from an out of network provider. 
Establishes a civil money penalty.  Applies provisions of the Social Security Act to civil money penalties in the same manner as they apply under such Act.

SECTION 1. SHORT TITLE.

    This Act may be cited as the ``Managed Care Bill of Rights for 
Consumers Act of 1996''.

SEC. 2. REQUIREMENTS FOR MANAGED CARE PLANS.

    (a) Required Coverage for Services Furnished by Specialist Not 
Contracted with Managed Care Plan.--In a case in which an enrollee of a 
managed care plan demonstrates to the plan that the plan does not 
provide a specialist with knowledge of a specific condition for which 
the enrollee requires treatment, the plan shall cover such services 
covered by the plan, under comparable terms and conditions, furnished 
by a specialist obtained by the enrollee without regard to whether or 
not the specialist has a contractual or other arrangement with the plan 
for the provision of such services to such enrollees.
    (b) Requirement for Continued Services of a Specialist Without Pre-
authorization.--In a case in which an enrollee of a managed care plan 
requires continued treatment of a specific condition from a specialist 
with knowledge of the specific condition, and such enrollee has been 
referred by a primary care physician to a specialist, the enrollee may 
continue to obtain services from the specialist without additional 
authorization from the primary care physician.
    (c) Assuring Equitable Coverage With Respect to Emergency 
Services.--A managed care plan that provides any coverage with respect 
to emergency services (as defined in section 5(4)) shall cover 
emergency services furnished to an enrollee of the plan--
            (1) without regard to whether or not the provider 
        furnishing the emergency services has a contractual or other 
        arrangement with the plan for the provision of such services to 
        such enrollees, and
            (2) without regard to prior authorization.
    (d) Requirement for Translation Bilingual Resources.--In a case in 
which 5 percent of the enrollees of a managed care plan in an area (as 
defined in section 5(1)) are members of a single ethnic-minority group 
that speaks English as a second language, the managed care plan shall 
have available, on a continuous basis, a person in the area to provide 
translation to such enrollees in obtaining information and services 
under the plan. Such person may be a doctor, nurse, or counselor who is 
employed by the managed care plan.
    (e) Prohibition of Financial Bonuses to Physicians Who Limit 
Services.--A managed care plan shall ensure that no specific payment is 
made directly or indirectly under the plan to a physician or physician 
group as an inducement to reduce or limit medically necessary services 
provided with respect to an enrollee.
    (f) Determination of Medically Necessary and Appropriate 
Treatment.--
            (1) In general.--Under a managed care plan, the 
        determination of what is medically necessary and appropriate 
        for the health of an enrollee may be made only by a licensed 
        health care practitioner.
            (2) Second opinion as to medically necessary.--Any licensed 
        health care practitioner who has a contractual or other 
        arrangement with a managed care plan may, upon request, provide 
        an enrollee of the plan with a second opinion as to what 
        constitutes medically necessary and appropriate treatment for 
        the health of such enrollee.
            (3) Insurance coverage.--A managed care plan must determine 
        and pay a reasonable and appropriate amount for a service 
        determined, as described in paragraphs (1) and (2), to be 
        medically necessary and appropriate if the service is covered 
        by the plan.
    (g) Requirement for Service to Areas that Include a Medically 
Underserved Population.--A managed care plan seeking to provide 
services in an area that includes a medically underserved population 
must submit a plan to the Secretary outlining a proposal for service to 
the medically underserved population.
    (h) Requirement for Minimum Number of Doctors.--A managed care plan 
seeking to provide services in an area must certify to the Secretary 
that the plan provides at least one physician for every 2,000 
enrollees.
    (i) Disclosure of Financial Arrangements.--A managed care plan 
shall disclose information to enrollees on any financial arrangements 
which may restrict referral or treatment options or limit the services 
offered by the plan to such enrollees.
    (j) Requirement for Geographical Accessibility.--A managed care 
plan shall ensure that items and services (including laboratory and 
specialist services) covered under the plan shall be available through 
providers that are geographically accessible to enrollees of such plan.
    (k) Meaningful Choice of Providers.--A managed care plan shall 
provide to enrollees a choice of at least three providers within each 
category of providers based on the health care needs of such enrollees, 
taking into account the age, gender, health, native language, acute or 
chronic diseases, and special needs.
    (l) Right To Seek Care From Out of Network Provider.--A managed 
care plan shall cover services covered by the plan that are furnished 
by a physician or provider obtained by the enrollee without regard to 
whether such physician or provider has a contractual or other 
arrangement with the plan for the provision of such services to such 
enrollees. The plan may impose a reasonable deductible and reasonable 
co-payment subject to a reasonable annual limit on total annual out of 
pocket expenses.
    (m) Confidentiality of Information.--A managed care plan shall 
provide that information collected by the plan on items and services 
used by the enrollees be protected as confidential information.
    (n) Requirement for Grievance Procedures.--Not later than 90 days 
after the date of the enactment of this Act, the Health Care Financing 
Administration shall establish complaint and grievance procedures for 
enrollees of managed care plans.

SEC. 3. ENFORCEMENT.

    (a) In General.--Any entity that offers a managed care plan that 
violates a requirement of section 2 shall be subject to a civil money 
penalty in an amount determined by the Secretary.
    (b) Process.--The provisions of section 1128A of the Social 
Security Act (42 U.S.C. 1320a-7a) (other than subsections (a) and (b)) 
shall apply to civil money penalties under this section in the same 
manner as they apply to a penalty or proceeding under section 1128A(a) 
of such Act.

SEC. 4. REGULATIONS.

    The Secretary shall promulgate such regulations as may be necessary 
or appropriate to carry out this Act.

SEC. 5. DEFINITIONS.

    For purposes of this Act:
            (1) Area.--The term ``area'' means the local health-service 
        area as designated in the managed care plan of operations.
            (2) Emergency department.--The term ``emergency 
        department'' includes, with respect to a hospital, a trauma 
        center in the hospital if the center--
                    (A) is designated under section 1213 of the Public 
                Health Service Act, or
                    (B) is in a State that has not made such 
                designations and is determined by the Secretary to meet 
                the standards under such section for such designation.
            (3) Emergency medical condition.--The term ``emergency 
        medical condition'' means a medical condition, the onset of 
        which is sudden, that manifests itself by symptoms of 
        sufficient severity, including severe pain, 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 person's health in serious 
                jeopardy,
                    (B) serious impairment to bodily functions, or
                    (C) serious dysfunction of any bodily organ or 
                part.
            (4) Emergency services.--The term ``emergency services'' 
        means--
                    (A) health care items and services furnished in the 
                emergency department of a hospital, and
                    (B) ancillary services routinely available to such 
                department,
        to the extent they are required to evaluate and treat an 
        emergency medical condition until the condition is stabilized.
            (5) Licensed health care practitioner.--The term ``licensed 
        health care practitioner'' has the meaning given such term in 
        section 431(6) of the Health Care Quality Improvement Act of 
        1986 (Public Law 99-660; 42 U.S.C. 11151(6)).
            (6) Managed care plan.--The term ``managed care plan'' 
        means a health plan that provides or arranges for the provision 
        of health care items and services to enrollees primarily 
        through participating physicians and providers.
            (7) Medically underserved population.--The term ``medically 
        underserved population'' means the population of an urban or 
        rural area designated by the Secretary as an area with a 
        shortage of personal health services or a population group 
        designated by the Secretary as having a shortage of such 
        services.
            (8) Participating.--The term ``participating'' means, with 
        respect to a physician or provider in relation to managed care, 
        a physician or provider that furnishes health care items and 
        services to enrollees of the plan under an agreement with the 
        plan.
            (9) Secretary.--The term ``Secretary'' means of the 
        Secretary of Health and Human Services.
            (10) Stabilized.--The term ``stabilized'' means, with 
        respect to an emergency medical condition, that no material 
        deterioration of the condition is likely, within reasonable 
        medical probability, to result or occur before an individual 
        can be transferred in compliance with the requirements of 
        section 1867 of the Social Security Act.

SEC. 6. EFFECTIVE DATE.

    The provisions of this Act shall apply to managed care plans 
offered or renewed 90-days after the date of the enactment of this Act.