II

106TH CONGRESS

2D SESSION S. 2819

To provide for the establishment of an assistance program for health

insurance consumers.

IN THE SENATE OF THE UNITED STATES

JUNE 29, 2000

Mr. REED (for himself and Mr. JEFFORDS) introduced the following bill;

which was read twice and referred to the Committee on Health, Education, Labor, and Pensions

A BILL

To provide for the establishment of an assistance program

for health insurance consumers.

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 Assistance Act’’.

6 SEC. 2. FINDINGS.

7 Congress makes the following findings:

8 (1) People with health care insurance or cov9 erage have many more options with respect to cov10 erage of, payment or payments for, items, services or
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1 treatments. Also, their health plans, coverages,

2 rights, and providers are frequently being reorga3 nized, expanded, or limited.

4 (2) All consumers need information and assist5 ance to understand their health insurance choices

6 and to maximize their access to needed health serv7 ices. Many do not understand their health care

8 rights or how to exercise them, despite the current

9 efforts of both the public and private sectors.

10 (3) Few people with health care coverage have

11 independent credible sources of information or as12 sistance to guide their decisionmaking or to help re13 solve problems.

14 (4) It is important to maintain and strengthen

15 a productive working relationship between all con16 sumers and their health care professionals and

17 health insurance providers.

18 (5) Federally initiated health care consumer as19 sistance and information programs targeted to con20 sumers of long-term care and to medicare bene21 ficiaries under title XVIII of the Social Security Act

22 (42 U.S.C. 1395 et seq.) are effective, as are a num23 ber of State and local consumer assistance initia24 tives.
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1 (6) The principles, policies, and practices of

2 health care providers for delivering safe, effective,

3 and accessible health care can be enriched by State4 based collaborative, independent education, problem

5 resolution, and feedback programs. Health care con6 sumer assistance programs have proven their ability

7 to meet this challenge.

8 (7) Health care consumers want and need reli9 able information about their health care options that

10 integrates data and effective resolution strategies

11 from the full range of available resources. Health

12 care consumer assistance programs can provide that

13 reliable, problem-solving information to help in navi14 gating the health care system.

15 (8) Health care delivered to individuals and

16 within communities can be improved by collecting

17 and examining consumers’ experiences, questions,

18 and problems and the ways in which their questions

19 and problems are resolved. Health care consumer as20 sistance programs can educate and inform con21 sumers to be more effective, self-directed health care

22 consumers.

23 (9) Many states have created health care con24 sumer assistance programs. The Federal Govern25 ment can assist the States in developing and main-
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1 taining effective health care consumer assistance

2 programs.

3 SEC. 3. GRANTS.

4 (a) IN GENERAL.—The Secretary of Health and

5 Human Services (referred to in this Act as the ‘‘Sec6 retary’’) shall award grants to States to enable such

7 States to establish and administer (including the adminis8 tration of programs established by States prior to the en9 actment of this Act) consumer assistance programs de10 signed to provide information, assistance, and referrals to

11 consumers of health insurance products.

12 (b) STATE ELIGIBILITY.—To be eligible to receive a

13 grant under this section a State shall prepare and submit

14 to the Secretary an application at such time, in such man15 ner, and containing such information as the Secretary may

16 require, including a State plan that describes—

17 (1) the manner in which the State will estab18 lish, or solicit proposals for, and enter into a con19 tract with, an entity eligible under subsection (d) to

20 serve as the health care consumer assistance office

21 for the State;

22 (2) the manner in which the State will ensure

23 that the health care consumer assistance office will

24 assist health care consumers in accessing needed
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1 care by educating and assisting health insurance en2 rollees to be responsible and informed consumers;

3 (3) the manner in which the State will coordi4 nate and distinguish the services provided by the

5 health care consumer assistance office with the serv6 ices provided by the long-term care ombudsman au7 thorized by the Older Americans Act of 1965 (42

8 U.S.C. 3001 et seq.), the State health insurance in9 formation program authorized under section 4360 of

10 the Omnibus Budget Reconciliation Act of 1990 (42

11 U.S.C. 1395b–4), the protection and advocacy pro12 gram authorized under the Protection and Advocacy

13 for Mentally Ill Individuals Act of 1986 (42 U.S.C.

14 10801 et seq.), and any other programs that provide

15 information and assistance to health care consumers;

16 (4) the manner in which the State will coordi17 nate and distinguish the health care consumer as18 sistance office and its services from enrollment serv19 ices provided under the medicaid and State chil20 dren’s health insurance programs under titles XIX

21 and XXI of the Social Security Act (42 U.S.C. 1396

22 et seq. and 1397aa et seq.), and medicare and med23 icaid health care fraud and abuse activities including

24 those authorized by Federal law under title 11 of the

25 Social Security Act (42 U.S.C. 1301 et seq.);
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1 (5) the manner in which the State will provide

2 services to underserved and minority populations

3 and populations residing in rural areas;

4 (6) the manner in which the State will establish

5 and implement procedures and protocols to ensure

6 the confidentiality of all information shared by con7 sumers and their health care providers, health plans,

8 or insurers with the office established under sub9 section (d)(1) and to ensure that no such informa10 tion is used, released or referred without the express

11 permission of the consumer, except to the extent

12 that the office collects or uses aggregate information

13 as described in section 4(c)(8);

14 (7) the manner in which the State will provide

15 for the collection of non-Federal contributions for

16 the operations of the office in an amount that is not

17 less than 30 percent of the amount of Federal funds

18 provided under this Act; and

19 (8) the manner in which the State will ensure

20 that funds made available under this Act will be

21 used to supplement, and not supplant, any other

22 Federal, State, or local funds expended to provide

23 services for programs described under this Act and

24 those described in paragraphs (3) and (4).

25 (c) AMOUNT OF GRANT.—
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1 (1) IN GENERAL.—From amounts appropriated

2 under section 4 for a fiscal year, the Secretary shall

3 award a grant to a State in an amount that bears

4 the same ratio to such amounts as the number of in5 dividuals within the State covered under a health in6 surance plan (as determined by the Secretary) bears

7 to the total number of individuals covered under a

8 health insurance plan in all States (as determined by

9 the Secretary). Any amounts provided to a State

10 under this section that are not used by the State

11 shall be remitted to the Secretary and reallocated in

12 accordance with this paragraph.

13 (2) MINIMUM AMOUNT.—In no case shall the

14 amount provided to a State under a grant under this

15 section for a fiscal year be less than an amount

16 equal to .5 percent of the amount appropriated for

17 such fiscal year under section 5.

18 (d) PROVISION OF FUNDS FOR ESTABLISHMENT OF

19 OFFICE.—

20 (1) IN GENERAL.—From amounts provided

21 under a grant under this section, a State shall, di22 rectly or through a contract with an independent,

23 nonprofit entity with demonstrated experience in

24 serving the needs of health care consumers, provide
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1 for the establishment and operation of a State

2 health care consumer assistance office.

3 (2) ELIGIBILITY OF ENTITY.—To be eligible to

4 enter into a contract under paragraph (1), an entity

5 shall demonstrate that the entity has the technical,

6 organizational, and professional capacity to deliver

7 the services described in section 4 throughout the

8 State to all public and private health insurance con9 sumers.

10 SEC. 4. USE OF FUNDS.

11 (a) BY STATE.—

12 (1) IN GENERAL.—A State shall use amounts

13 received under a grant under this Act to establish

14 and operate a health insurance consumer assistance

15 office as provided for in this section and section

16 3(d).

17 (2) NONCOMPLIANCE.—If the State fails to

18 enter into or renew a contract for the operation of

19 a State health insurance consumer assistance office,

20 the Secretary shall reallocate amounts to be provided

21 to the State under this Act.

22 (b) BY ENTITY.—An entity that enters into a con23 tract with a State under section 3(d) shall use amounts

24 received under the contract to establish and operate a

25 health insurance consumer assistance office.
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1 (c) ACTIVITIES OF OFFICE.—A health insurance con2 sumer assistance office established under this Act shall—

3 (1) operate a toll-free telephone hotline to re4 spond to requests for information and assistance

5 with health care problems and assist all health in6 surance consumers to navigate the health care sys7 tem;

8 (2) acquire or produce and disseminate cul9 turally and language appropriate educational mate10 rials concerning health insurance products available

11 within the State, how best to access health care, and

12 the rights and responsibilities of the health care con13 sumer;

14 (3) educate health care consumers about strate15 gies that such consumers can implement to promptly

16 and efficiently resolve inquiries, problems, and griev17 ances related to health insurance and access to

18 health care;

19 (4) refer health care consumers to appropriate

20 private and public entities so that inquiries, prob21 lems, and grievances with respect to health insur22 ance and access to health care can be handled

23 promptly and efficiently;

24 (5) coordinate with health organizations in the

25 State, State health-insurance related agencies, and
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1 State organizations responsible for administering the

2 programs described listed in paragraphs (3) and (4)

3 of section 3(b) so as to maximize the ability of con4 sumers to resolve health care questions and prob5 lems and achieve the best health care outcomes;

6 (6) conduct education and outreach within the

7 State in partnership with consumers, health plans,

8 health care providers, health care payers and govern9 mental agencies with health oversight responsibil10 ities;

11 (7) provide information to consumers about an

12 internal, external, or administrative grievance or ap13 peals procedure (in nonlitigative settings) to appeal

14 the denial, termination, or reduction of health care

15 services, or the refusal to pay for such services,

16 under a health insurance plan; and

17 (8) provide information to State agencies, em18 ployers, health plans, insurers, and the general pub19 lic concerning the kinds of inquiries, problems, and

20 grievances handled by the office.

21 (d) CONFIDENTIALITY AND ACCESS TO INFORMA22 TION.—The health insurance consumer assistance office of

23 a State shall establish and implement procedures and pro24 tocols to ensure the confidentiality of all information

25 shared by consumers and their health care providers,
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1 health plans, or insurers with the office and to ensure that

2 no such information is used, released, or referred to State

3 agencies or outside entities without the expressed permis4 sion of the consumer, except to the extent that the office

5 collects or uses aggregate information described in sub6 section (c)(8).

7 (e) AVAILABILITY OF SERVICES.—The health insur8 ance consumer assistance office of a State shall not dis9 criminate in the provision of information and referrals re10 gardless of the source of the individual’s health insurance

11 coverage or prospective coverage, including individuals

12 covered under employer-provided insurance, self-funded

13 plans, the medicare or medicaid programs under title

14 XVII or XIX of the Social Security Act (42 U.S.C. 1395

15 and 1396 et seq.), or under any other Federal or State

16 health care program.

17 (f) DESIGNATION OF RESPONSIBILITIES.—

18 (1) WITHIN EXISTING STATE ENTITY.—If the

19 health insurance consumer assistance office of a

20 State is located within an existing State regulatory

21 agency or office of an elected State official, the

22 State shall ensure that—

23 (A) there is a separate delineation of the

24 funding, activities, and responsibilities of the of-
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1 fice as compared to the other funding, activi2 ties, and responsibilities of the agency; and

3 (B) the office establishes and implements

4 procedures and protocols to ensure the con5 fidentiality of all information shared by con6 sumers and their health care providers, health

7 plans, or insurers with the office and to ensure

8 that no information is transferred or released to

9 the State agency or office without the expressed

10 permission of the consumer.

11 (2) CONTRACT ENTITY.—In the case of an enti12 ty that enters into a contract with a State under

13 section 3(d), the entity shall provide assurances that

14 the entity has no real or perceived conflict of inter15 est in providing advice and assistance to consumers

16 regarding health insurance and that the entity is

17 independent of health insurance plans, companies,

18 providers, payers, and regulators of care.

19 (g) SUBCONTRACTS.—The health insurance con20 sumer assistance office of a State may carry out activities

21 and provide services through contracts entered into with

22 1 or more nonprofit entities so long as the office can dem23 onstrate that all of the requirements of this Act are com24 plied with by the office.

25 (i) TRAINING.—
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1 (1) IN GENERAL.—The health insurance con2 sumer assistance office of a State shall ensure that

3 personnel employed by the office possess the skills,

4 expertise, and information necessary to provide the

5 services described in subsection (c).

6 (2) CONTRACTS.—To meet the requirement of

7 paragraph (1), an office may enter into contracts

8 with 1 or more nonprofit entities for the training

9 (both through technical and educational assistance)

10 of personnel and volunteers. To be eligible to receive

11 a contract under this paragraph, an entity shall be

12 independent of health insurance plans, companies,

13 providers, payers, and regulators of care.

14 (3) LIMITATION.—An amount not to exceed 7

15 percent of the amount awarded to an entity under

16 a contract under section 3(d) for a fiscal year may

17 be used for the provision of training under this sec18 tion.

19 (j) ADMINISTRATIVE COSTS.—An amount not to ex20 ceed 1 percent of the amount of a grant awarded to the

21 State under this Act for a fiscal year may be used by the

22 State for administrative expenses.

23 (k) TERM.—A contract entered into under this sec24 tion shall be for a term of 3 years.
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1 SEC. 5. FUNDING.

2 There are authorized to be appropriated

3 $100,000,000 to carry out this Act.

4 SEC. 6. REPORT OF THE SECRETARY.

5 Not later than 1 year after the date of enactment

6 of this Act, and annually thereafter, the Secretary shall

7 prepare and submit to the appropriate committees of Con8 gress a report that contains—

9 (1) a determination by the Secretary of whether

10 amounts appropriated to carry out this Act for the

11 fiscal year for which the report is being prepared are

12 sufficient to fully fund this Act in such fiscal year;

13 (2) with respect to a fiscal year for which the

14 Secretary determines under paragraph (1) that suf15 ficient amounts are not appropriated, the rec16 ommendations of the Secretary for fully funding this

17 Act through the use of additional funding sources;

18 and

19 (3) information on States that have been

20 awarded a grant under this Act and a summary of

21 the activities of such States and the data that is

22 produced.

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