I

104TH CONGRESS

1ST SESSION H. R. 2608

To require that health care practitioners determine medically necessary and

appropriate treatment and to require that insurers notify their enrollees

of the extent of their coverage.

IN THE HOUSE OF REPRESENTATIVES

NOVEMBER 9, 1995

Mr. NADLER (for himself, Mr. DELLUMS, Mr. ENGEL, Ms. MCKINNEY, and

Miss COLLINS of Michigan) introduced the following bill; which was referred to the Committee on Commerce

A BILL

To require that health care practitioners determine medically

necessary and appropriate treatment and to require that

insurers notify their enrollees of the extent of their coverage.

1 Be it enacted by the Senate and House of Representa2 tives of the United States of America in Congress assembled,

3 SECTION 1. SHORT TITLE.

4 This Act may be cited as the ‘‘Health Care Consumer

5 Protection Act of 1995’’.
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1 SEC. 2. NOTIFICATION OF COVERAGE PROVIDED BY THE

2 INSURER.

3 (a) NOTIFICATION TO CURRENT ENROLLEES.—An

4 insurer providing health insurance coverage under a health

5 plan shall provide annual notice to each current enrollee

6 under such plan regarding the extent of the coverage of

7 the plan. Such notice shall be in writing and shall include

8 a copy of the contract between the insurer and enrollee,

9 in addition to information regarding the terms and condi10 tions of the policy and the rights and obligations of the

11 parties including—

12 (1) covered and excluded services, equipment,

13 and devices;

14 (2) copayments, deductibles, and premiums;

15 (3) enrollee satisfaction statistics;

16 (4) financial responsibility of the enrollee;

17 (5) utilization review requirements;

18 (6) a list of the usual, customary, and reason19 able costs for procedures, tests, and examinations;

20 (7) physician credentialing standards; and

21 (8) the percentage of total annual premiums

22 used to reimburse practitioners for health care pro23 vided to enrollees and the percentage used for ad24 ministration and other costs incurred in administer25 ing the plan.
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1 (b) NOTIFICATION TO POTENTIAL ENROLLEES.—An

2 insurer providing health insurance coverage under a health

3 plan shall, upon request, provide notice to each potential

4 enrollee under such plan regarding the extent of the cov5 erage of the plan. Such notice shall be in writing and shall

6 include a copy of the potential contract between the in7 surer and potential enrollee, in addition to information re8 garding the terms and conditions of the policy and the

9 rights and obligations of the parties information including

10 the items listed in paragraphs (1) through (8) of sub11 section (a).

12 (c) REGULATIONS FOR FAILURE TO PROVIDE NOTI13 FICATION.—The Secretary of Health and Human Services

14 shall promulgate regulations to ensure that an insurer

15 providing health insurance coverage under a health plan

16 provide notification to current and potential enrollees as

17 described in subsections (a) and (b).

18 SEC. 3. DETERMINATION OF MEDICALLY NECESSARY AND

19 APPROPRIATE TREATMENT.

20 (a) IN GENERAL.—Under a health plan, the deter21 mination of what is medically necessary and appropriate

22 for the health of a patient may be made only by a health

23 care practitioner who is—
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1 (1) licensed and practicing within the scope of

2 the State practice act of the State in which the prac3 titioner practices; and

4 (2) directly involved in the care of such patient.

5 (b) INSURANCE COVERAGE.—An insurer must pay

6 for a service determined, as described in subsection (a),

7 to be medically necessary and appropriate if the service

8 is covered by the health plan.

9 (c) REGULATIONS TO DETER REWARDS, PENALTIES

10 OR INDUCEMENTS.—The Secretary of Health and Human

11 Services shall promulgate regulations to ensure that an

12 insurer not offer monetary rewards, penalties, or induce13 ments to a licensed health care practitioner, or condition

14 the continued participation of a licensed health care prac15 titioner in a plan on the basis of the health care practition16 er’s decisions to limit the availability of appropriate medi17 cal tests, services, or treatments.

18 SEC. 4. ENFORCEMENT AND PENALTIES.

19 (a) PENALTIES.— Any entity that offers a health

20 plan that violates the provisions of this Act shall be subject

21 to a civil money penalty in an amount to be determined

22 by the Secretary of Health and Human Services.

23 (b) PROCESS.—The provisions of section 1128A of

24 the Social Security Act (42 U.S.C. 1320a-7a) (other than

25 subsections (a) and (b)) shall apply to civil money pen-
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1 alties under this section in the same manner as they apply

2 to a penalty or proceeding under section 1128A(a) of such

3 Act.

4 SEC. 5. PROHIBITION OF HOLD HARMLESS PROVISIONS.

5 An insurer may not include provisions in a health

6 plan to hold itself harmless for any liability.

7 SEC. 6. PREEMPTION.

8 A State may not establish or enforce standards for

9 insurers or health insurance coverage with respect to the

10 subject matter of this Act that are weaker than the stand11 ards established under this Act.

12 SEC. 7. DEFINITIONS.—

13 For purposes of this Act:

14 (1) INSURER.—The term ‘‘insurer’’ means an

15 insurance company, insurance service, or insurance

16 organization licensed to engage in the business of in17 surance in a State, and a health maintenance orga18 nization.

19 (2) HEALTH CARE PRACTITIONER.—The term

20 ‘‘health care practitioner’’ has the meaning provided

21 by section 11151 of title 42, United States Code.

22 (3) HEALTH INSURANCE COVERAGE.—The term

23 ‘‘health insurance coverage’’ means any hospital or

24 medical service policy or certificate, hospital or medi-
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1 cal service plan contract, or health maintenance or2 ganization contract offered by an insurer.

3 (4) HEALTH PLAN.—The term ‘‘health plan’’

4 means a plan that provides health insurance cov5 erage.

6 (5) STATE.—The term ‘‘State’’ means any

7 State, the District of Columbia, Puerto Rico, the

8 Northern Mariana Islands, the Virgin Islands,

9 American Samoa, and Guam.

10 SEC. 8. EFFECTIVE DATE.

11 The provisions of this Act shall apply to all health

12 plans offered, sold, issued, or renewed after the date of

13 the enactment of this Act.

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