II

105TH CONGRESS

2D SESSION S. 1808

To amend title XXVII of the Public Health Service Act and part 7 of

subtitle B of title I of the Employee Retirement Income Security Act

of 1974 to establish standards for the health quality improvement of

children in managed care plans and other health plans.

IN THE SENATE OF THE UNITED STATES

MARCH 20, 1998

Mr. REED (for himself, Mr. KENNEDY, and Mrs. MURRAY) introduced the following bill; which was read twice and referred to the Committee on Labor

and Human Resources

A BILL

To amend title XXVII of the Public Health Service Act

and part 7 of subtitle B of title I of the Employee

Retirement Income Security Act of 1974 to establish

standards for the health quality improvement of children

in managed care plans and other health plans.

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 ‘‘Children’s Health In5 surance Accountability Act of 1998’’.

6 SEC. 2. FINDINGS.

7 Congress makes the following findings:
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1 (1) Children have health and development needs

2 that are markedly different than those for the adult

3 population.

4 (2) Children experience complex and continuing

5 changes during the continuum from birth to adult6 hood in which appropriate health care is essential

7 for optimal development.

8 (3) The vast majority of work done on develop9 ment methods to assess the effectiveness of health

10 care services and the impact of medical care on pa11 tient outcomes and patient satisfaction has been fo12 cused on adults.

13 (4) Health outcome measures need to be age,

14 gender, and developmentally appropriate to be useful

15 to families and children.

16 (5) Costly disorders of adulthood often have

17 their origins in childhood, making early access to ef18 fective health services in childhood essential.

19 (6) More than 200 chronic conditions, disabil20 ities and diseases affect children, including asthma,

21 diabetes, sickle cell anemia, spina bifida, epilepsy,

22 autism, cerebral palsy, congenital heart disease,

23 mental retardation, and cystic fibrosis. These chil24 dren need the services of specialists who have in25 depth knowledge about their particular condition.
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1 (7) Children’s patterns of illness, disability and

2 injury differ dramatically from adults.

3 SEC. 2. AMENDMENTS TO THE PUBLIC HEALTH SERVICE

4 ACT.

5 (a) PATIENT PROTECTION STANDARDS.—Title

6 XXVII of the Public Health Service Act is amended—

7 (1) by redesignating part C as part D; and

8 (2) by inserting after part B the following new

9 part:

10 ‘‘PART C—CHILDREN’S HEALTH PROTECTION

11 STANDARDS

12 ‘‘SEC. 2770. ACCESS TO CARE.

13 ‘‘(a) ACCESS TO APPROPRIATE PRIMARY CARE PRO14 VIDERS.—

15 ‘‘(1) IN GENERAL.—If a group health plan, or

16 a health insurance issuer, in connection with the

17 provision of health insurance coverage, requires or

18 provides for an enrollee to designate a participating

19 primary care provider for a child of such enrollee—

20 ‘‘(A) the plan or issuer shall permit the en21 rollee to designate a physician who specializes

22 in pediatrics as the child’s primary care pro23 vider; and

24 ‘‘(B) if such an enrollee has not designated

25 such a provider for the child, the plan or issuer
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1 shall consider appropriate pediatric expertise in

2 mandatorily assigning such an enrollee to a pri3 mary care provider.

4 ‘‘(2) CONSTRUCTION.—Nothing in paragraph

5 (1) shall waive any requirements of coverage relating

6 to medical necessity or appropriateness with respect

7 to coverage of services.

8 ‘‘(b) ACCESS TO PEDIATRIC SPECIALTY SERVICES.—

9 ‘‘(1) REFERRAL TO SPECIALITY CARE FOR

10 CHILDREN REQUIRING TREATMENT BY SPECIAL11 ISTS.—

12 ‘‘(A) IN GENERAL.—In the case of a child

13 who is covered under a group health plan, or

14 health insurance coverage offered by a health

15 insurance issuer and who has a mental or phys16 ical condition, disability, or disease of sufficient

17 seriousness and complexity to require diagnosis,

18 evaluation or treatment by a specialist, the plan

19 or issuer shall make or provide for a referral to

20 a specialist who has extensive experience or

21 training, and is available and accessible to pro22 vide the treatment for such condition or dis23 ease, including the choice of a nonprimary care

24 physician specialist participating in the plan or

25 a referral to a nonparticipating provider as pro-
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1 vided for under subparagraph (D) if such a pro2 vider is not available within the plan.

3 ‘‘(B) SPECIALIST DEFINED.—For purposes

4 of this subsection, the term ‘specialist’ means,

5 with respect to a condition, disability, or dis6 ease, a health care practitioner, facility, or cen7 ter (such as a center of excellence) that has ex8 tensive pediatric expertise through appropriate

9 training or experience to provide high quality

10 care in treating the condition.

11 ‘‘(C) REFERRALS TO PARTICIPATING PRO12 VIDERS.—A plan or issuer is not required under

13 subparagraph (A) to provide for a referral to a

14 specialist that is not a participating provider,

15 unless the plan or issuer does not have an ap16 propriate specialist that is available and acces17 sible to treat the enrollee’s condition and that

18 is a participating provider with respect to such

19 treatment.

20 ‘‘(D) TREATMENT OF NONPARTICIPATING

21 PROVIDERS.—If a plan or issuer refers a child

22 enrollee to a nonparticipating specialist, services

23 provided pursuant to the referral shall be pro24 vided at no additional cost to the enrollee be25 yond what the enrollee would otherwise pay for
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1 services received by such a specialist that is a

2 participating provider.

3 ‘‘(E) SPECIALISTS AS PRIMARY CARE PRO4 VIDERS.—A plan or issuer shall have in place a

5 procedure under which a child who is covered

6 under health insurance coverage provided by

7 the plan or issuer who has a condition or dis8 ease that requires specialized medical care over

9 a prolonged period of time shall receive a refer10 ral to a pediatric specialist affilated with the

11 plan, or if not available within the plan, to a

12 nonparticipating provider for such condition

13 and such specialist may be responsible for and

14 capable of providing and coordinating the

15 child’s primary and specialty care.

16 ‘‘(2) STANDING REFERRALS.—

17 ‘‘(A) IN GENERAL.—A group health plan,

18 or health insurance issuer in connection with

19 the provision of health insurance coverage of a

20 child, shall have a procedure by which a child

21 who has a condition, disability, or disease that

22 requires ongoing care from a specialist may re23 quest and obtain a standing referral to such

24 specialist for treatment of such condition. If the

25 primary care provider in consultation with the
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1 medical director of the plan or issuer and the

2 specialist (if any), determines that such a

3 standing referral is appropriate, the plan or

4 issuer shall authorize such a referral to such a

5 specialist. Such standing referral shall be con6 sistent with a treatment plan.

7 ‘‘(B) TREATMENT PLANS.—A group health

8 plan, or health insurance issuer, with the par9 ticipation of the family and the health care pro10 viders of the child, shall develop a treatment

11 plan for a child who requires ongoing care that

12 covers a specified period of time (but in no

13 event less than a 6-month period). Services pro14 vided for under the treatment plan shall not re15 quire additional approvals or referrals through

16 a gatekeeper.

17 ‘‘(C) TERMS OF REFERRAL.—The provi18 sions of subparagraph (C) and (D) of para19 graph (1) shall apply with respect to referrals

20 under subparagraph (A) in the same manner as

21 they apply to referrals under paragraph (1)(A).

22 ‘‘(c) ADEQUACY OF ACCESS.—For purposes of sub23 sections (a) and (b), a group health plan or health insur24 ance issuer in connection with health insurance coverage

25 shall ensure that a sufficient number, distribution, and va-
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1 riety of qualified participating health care providers are

2 available so as to ensure that all covered health care serv3 ices, including specialty services, are available and acces4 sible to all enrollees in a timely manner.

5 ‘‘(d) COVERAGE OF EMERGENCY SERVICES.—

6 ‘‘(1) IN GENERAL.—If a group health plan, or

7 health insurance coverage offered by a health insur8 ance issuer, provides any benefits for children with

9 respect to emergency services (as defined in para10 graph (2)(A)), the plan or issuer shall cover emer11 gency services furnished under the plan or cov12 erage—

13 ‘‘(A) without the need for any prior au14 thorization determination;

15 ‘‘(B) whether or not the physician or pro16 vider furnishing such services is a participating

17 physician or provider with respect to such serv18 ices; and

19 ‘‘(C) without regard to any other term or

20 condition of such coverage (other than exclusion

21 of benefits, or an affiliation or waiting period,

22 permitted under section 2701).

23 ‘‘(2) DEFINITIONS.—In this subsection:

24 ‘‘(A) EMERGENCY MEDICAL CONDITION

25 BASED ON PRUDENT LAYPERSON STANDARD.—
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1 The term ‘emergency medical condition’ means

2 a medical condition manifesting itself by acute

3 symptoms of sufficient severity (including se4 vere pain) such that a prudent layperson, who

5 possesses an average knowledge of health and

6 medicine, could reasonably expect the absence

7 of immediate medical attention to result in a

8 condition described in clause (i), (ii), or (iii) of

9 section 1867(e)(1)(A) of the Social Security

10 Act.

11 ‘‘(B) EMERGENCY SERVICES.—The term

12 ‘emergency services’ means—

13 ‘‘(i) a medical screening examination

14 (as required under section 1867 of the So15 cial Security Act) that is within the capa16 bility of the emergency department of a

17 hospital, including ancillary services rou18 tinely available to the emergency depart19 ment to evaluate an emergency medical

20 condition (as defined in subparagraph

21 (A)); and

22 ‘‘(ii) within the capabilities of the

23 staff and facilities available at the hospital,

24 such further medical examination and
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1 treatment as are required under section

2 1867 of such Act to stabilize the patient.

3 ‘‘(3) REIMBURSEMENT FOR MAINTENANCE

4 CARE AND POST-STABILIZATION CARE.—A group

5 health plan, and health insurance issuer offering

6 health insurance coverage, shall provide, in covering

7 services other than emergency services, for reim8 bursement with respect to services which are other9 wise covered and which are provided to an enrollee

10 other than through the plan or issuer if the services

11 are maintenance care or post-stabilization care cov12 ered under the guidelines established under section

13 1852(d) of the Social Security Act (relating to pro14 moting efficient and timely coordination of appro15 priate maintenance and post-stabilization care of an

16 enrollee after an enrollee has been determined to be

17 stable).

18 ‘‘(e) PROHIBITION ON FINANCIAL BARRIERS.—A

19 health insurance issuer in connection with the provision

20 of health insurance coverage may not impose any cost

21 sharing for pediatric specialty services provided under

22 such coverage to enrollee children in amounts that exceed

23 the cost-sharing required for other specialty care under

24 such coverage.
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1 ‘‘(f) CHILDREN WITH SPECIAL HEALTH CARE

2 NEEDS.—A health insurance issuer in connection with the

3 provision of health insurance coverage shall ensure that

4 such coverage provides special consideration for the provi5 sion of services to enrollee children with special health care

6 needs. Appropriate procedures shall be implemented to

7 provide care for children with special health care needs.

8 The development of such procedures shall include partici9 pation by the families of such children.

10 ‘‘(g) DEFINITIONS.—In this part:

11 ‘‘(1) CHILD.—The term ‘child’ means an indi12 vidual who is under 19 years of age.

13 ‘‘(2) CHILDREN WITH SPECIAL HEALTH CARE

14 NEEDS.—The term ‘children with special health care

15 needs’ means those children who have or are at ele16 vated risk for chronic physical, developmental, be17 havioral or emotional conditions and who also re18 quire health and related services of a type and

19 amount not usually required by children.

20 ‘‘SEC. 2771. CONTINUITY OF CARE.

21 ‘‘(a) IN GENERAL.—If a contract between a health

22 insurance issuer, in connection with the provision of health

23 insurance coverage, and a health care provider is termi24 nated (other than by the issuer for failure to meet applica25 ble quality standards or for fraud) and an enrollee is un-
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1 dergoing a course of treatment from the provider at the

2 time of such termination, the issuer shall—

3 ‘‘(1) notify the enrollee of such termination,

4 and

5 ‘‘(2) subject to subsection (c), permit the en6 rollee to continue the course of treatment with the

7 provider during a transitional period (provided under

8 subsection (b)).

9 ‘‘(b) TRANSITIONAL PERIOD.—

10 ‘‘(1) IN GENERAL.—Except as provided in para11 graphs (2) through (4), the transitional period under

12 this subsection shall extend for at least—

13 ‘‘(A) 60 days from the date of the notice

14 to the enrollee of the provider’s termination in

15 the case of a primary care provider, or

16 ‘‘(B) 120 days from such date in the case

17 of another provider.

18 ‘‘(2) INSTITUTIONAL CARE.—The transitional

19 period under this subsection for institutional or in20 patient care from a provider shall extend until the

21 discharge or termination of the period of institu22 tionalization and shall include reasonable follow-up

23 care related to the institutionalization and shall also

24 include institutional care scheduled prior to the date

25 of termination of the provider status.
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1 ‘‘(3) PREGNANCY.—If—

2 ‘‘(A) an enrollee has entered the second

3 trimester of pregnancy at the time of a provid4 er’s termination of participation, and

5 ‘‘(B) the provider was treating the preg6 nancy before date of the termination,

7 the transitional period under this subsection with re8 spect to provider’s treatment of the pregnancy shall

9 extend through the provision of post-partum care di10 rectly related to the delivery.

11 ‘‘(4) TERMINAL ILLNESS.—

12 ‘‘(A) IN GENERAL.—If—

13 ‘‘(i) an enrollee was determined to be

14 terminally ill (as defined in subparagraph

15 (B)) at the time of a provider’s termi16 nation of participation, and

17 ‘‘(ii) the provider was treating the ter18 minal illness before the date of termi19 nation,

20 the transitional period under this subsection

21 shall extend for the remainder of the enrollee’s

22 life for care directly related to the treatment of

23 the terminal illness.

24 ‘‘(B) DEFINITION.—In subparagraph (A),

25 an enrollee is considered to be ‘terminally ill’ if
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1 the enrollee has a medical prognosis that the

2 enrollee’s life expectancy is 6 months or less.

3 ‘‘(c) PERMISSIBLE TERMS AND CONDITIONS.—An

4 issuer may condition coverage of continued treatment by

5 a provider under subsection (a)(2) upon the provider

6 agreeing to the following terms and conditions:

7 ‘‘(1) The provider agrees to continue to accept

8 reimbursement from the issuer at the rates applica9 ble prior to the start of the transitional period as

10 payment in full.

11 ‘‘(2) The provider agrees to adhere to the

12 issuer’s quality assurance standards and to provide

13 to the issuer necessary medical information related

14 to the care provided.

15 ‘‘(3) The provider agrees otherwise to adhere to

16 the issuer’s policies and procedures, including proce17 dures regarding referrals and obtaining prior au18 thorization and providing services pursuant to a

19 treatment plan approved by the issuer.

20 ‘‘SEC. 2772. CONTINUOUS QUALITY IMPROVEMENT.

21 ‘‘(a) IN GENERAL.—A health insurance issuer that

22 offers health insurance coverage for children shall estab23 lish and maintain an ongoing, internal quality assurance

24 program that at a minimum meets the requirements of

25 subsection (b).
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1 ‘‘(b) REQUIREMENTS.—The internal quality assur2 ance program of an issuer under subsection (a) shall—

3 ‘‘(1) establish and measure a set of health care,

4 functional assessments, structure, processes and out5 comes, and quality indicators that are unique to chil6 dren and based on nationally accepted standards or

7 guidelines of care;

8 ‘‘(2) maintain written protocols consistent with

9 recognized clinical guidelines or current consensus

10 on the pediatric field, to be used for purposes of in11 ternal utilization review, with periodic updating and

12 evaluation by pediatric specialists to determine effec13 tiveness in controlling utilization;

14 ‘‘(3) provide for peer review by health care pro15 fessionals of the structure, processes, and outcomes

16 related to the provision of health services, including

17 pediatric review of pediatric cases;

18 ‘‘(4) include in member satisfaction surveys,

19 questions on child and family satisfaction and expe20 rience of care, including care to children with special

21 needs;

22 ‘‘(5) monitor and evaluate the continuity of

23 care with respect to children;

24 ‘‘(6) include pediatric measures that are di25 rected at meeting the needs of at-risk children and
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1 children with chronic conditions, disabilities and se2 vere illnesses;

3 ‘‘(7) maintain written guidelines to ensure the

4 availability of medications appropriate to children;

5 ‘‘(8) use focused studies of care received by

6 children with certain types of chronic conditions and

7 disabilities and focused studies of specialized services

8 used by children with chronic conditions and disabil9 ities;

10 ‘‘(9) monitor access to pediatric specialty serv11 ices; and

12 ‘‘(10) monitor child health care professional

13 satisfaction.

14 ‘‘(c) UTILIZATION REVIEW ACTIVITIES.—

15 ‘‘(1) COMPLIANCE WITH REQUIREMENTS.—

16 ‘‘(A) IN GENERAL.—A health insurance

17 issuer that offers health insurance coverage for

18 children shall conduct utilization review activi19 ties in connection with the provision of such

20 coverage only in accordance with a utilization

21 review program that meets at a minimum the

22 requirements of this subsection.

23 ‘‘(B) DEFINITIONS.—In this subsection:

24 ‘‘(i) CLINICAL PEERS.—The term

25 ‘clinical peer’ means, with respect to a re-
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1 view, a physician or other health care pro2 fessional who holds a non-restricted license

3 in a State and in the same or similar spe4 cialty as typically manages the pediatric

5 medical condition, procedure, or treatment

6 under review.

7 ‘‘(ii) HEALTH CARE PROFESSIONAL.—

8 The term ‘health care professional’ means

9 a physician or other health care practi10 tioner licensed or certified under State law

11 to provide health care services and who is

12 operating within the scope of such licen13 sure or certification.

14 ‘‘(iii) UTILIZATION REVIEW.—The

15 terms ‘utilization review’ and ‘utilization

16 review activities’ mean procedures used to

17 monitor or evaluate the clinical necessity,

18 appropriateness, efficacy, or efficiency of

19 health care services, procedures or settings

20 for children, and includes prospective re21 view, concurrent review, second opinions,

22 case management, discharge planning, or

23 retrospective review specific to children.

24 ‘‘(2) WRITTEN POLICIES AND CRITERIA.—
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1 ‘‘(A) WRITTEN POLICIES.—A utilization

2 review program shall be conducted consistent

3 with written policies and procedures that govern

4 all aspects of the program.

5 ‘‘(B) USE OF WRITTEN CRITERIA.—A utili6 zation review program shall utilize written clini7 cal review criteria specific to children and devel8 oped pursuant to the program with the input of

9 appropriate physicians, including pediatricians,

10 nonprimary care pediatric specialists, and other

11 child health professionals.

12 ‘‘(C) ADMINISTRATION BY HEALTH CARE

13 PROFESSIONALS.—A utilization review program

14 shall be administered by qualified health care

15 professionals, including health care profes16 sionals with pediatric expertise who shall over17 see review decisions.

18 ‘‘(3) USE OF QUALIFIED, INDEPENDENT PER19 SONNEL.—

20 ‘‘(A) IN GENERAL.—A utilization review

21 program shall provide for the conduct of utiliza22 tion review activities only through personnel

23 who are qualified and, to the extent required,

24 who have received appropriate pediatric or child
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1 health training in the conduct of such activities

2 under the program.

3 ‘‘(B) PEER REVIEW OF ADVERSE CLINICAL

4 DETERMINATIONS.—A utilization review pro5 gram shall provide that clinical peers shall

6 evaluate the clinical appropriateness of adverse

7 clinical determinations and divergent clinical

8 options.

9 ‘‘SEC. 2773. APPEALS AND GRIEVANCE MECHANISMS FOR

10 CHILDREN.

11 ‘‘(a) INTERNAL APPEALS PROCESS.—A health insur12 ance issuer in connection with the provision of health in13 surance coverage for children shall establish and maintain

14 a system to provide for the resolution of complaints and

15 appeals regarding all aspects of such coverage. Such a sys16 tem shall include an expedited procedure for appeals on

17 behalf of a child enrollee in situations in which the time

18 frame of a standard appeal would jeopardize the life,

19 health, or development of the child.

20 ‘‘(b) EXTERNAL APPEALS PROCESS.—A health in21 surance issuer in connection with the provision of health

22 insurance coverage for children shall provide for an inde23 pendent external review process that meets the following

24 requirements:
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1 ‘‘(1) External appeal activities shall be con2 ducted through clinical peers, a physician or other

3 health care professional who is appropriately

4 credentialed in pediatrics with the same or similar

5 specialty and typically manages the condition, proce6 dure, or treatment under review or appeal.

7 ‘‘(2) External appeal activities shall be con8 ducted through an entity that has sufficient pedi9 atric expertise, including subspeciality expertise, and

10 staffing to conduct external appeal activities on a

11 timely basis.

12 ‘‘(3) Such a review process shall include an ex13 pedited procedure for appeals on behalf of a child

14 enrollee in which the time frame of a standard ap15 peal would jeopardize the life, health, or development

16 of the child.

17 ‘‘SEC. 2774. ACCOUNTABILITY THROUGH DISTRIBUTION OF

18 INFORMATION.

19 ‘‘(a) IN GENERAL.—A health insurance issuer in con20 nection with the provision of health insurance coverage for

21 children shall submit to enrollees (and prospective enroll22 ees), and make available to the public, in writing the

23 health-related information described in subsection (b).

24 ‘‘(b) INFORMATION.—The information to be provided

25 under subsection (a) shall include a report of measures
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1 of structures, processes, and outcomes regarding each

2 health insurance product offered to participants and de3 pendents in a manner that is separate for both the adult

4 and child enrollees, using measures that are specific to

5 each group.’’.

6 (b) APPLICATION TO GROUP HEALTH INSURANCE

7 COVERAGE.—

8 (1) IN GENERAL.—Subpart 2 of part A of title

9 XXVII of the Public Health Service Act is amended

10 by adding at the end the following new section:

11 ‘‘SEC. 2706. CHILDREN’S HEALTH ACCOUNTABILITY STAND12 ARDS.

13 ‘‘(a) IN GENERAL.—Each health insurance issuer

14 shall comply with children’s health accountability require15 ment under part C with respect to group health insurance

16 coverage it offers.

17 ‘‘(b) ASSURING COORDINATION.—The Secretary of

18 Health and Human Services and the Secretary of Labor

19 shall ensure, through the execution of an interagency

20 memorandum of understanding between such Secretaries,

21 that—

22 ‘‘(1) regulations, rulings, and interpretations

23 issued by such Secretaries relating to the same mat24 ter over which such Secretaries have responsibility

25 under part C (and this section) and section 713 of
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1 the Employee Retirement Income Security Act of

2 1974 are administered so as to have the same effect

3 at all times; and

4 ‘‘(2) coordination of policies relating to enforc5 ing the same requirements through such Secretaries

6 in order to have a coordinated enforcement strategy

7 that avoids duplication of enforcement efforts and

8 assigns priorities in enforcement.’’.

9 (2) CONFORMING AMENDMENT.—Section 2792

10 of the Public Health Service Act (42 U.S.C. 300gg–

11 92) is amended by inserting ‘‘and section 2706(b)’’

12 after ‘‘of 1996’’.

13 (c) APPLICATION TO INDIVIDUAL HEALTH INSUR14 ANCE COVERAGE.—Part B of title XXVII of the Public

15 Health Service Act is amended by inserting after section

16 2751 the following new section:

17 ‘‘SEC. 2752. CHILDREN’S HEALTH ACCOUNTABILITY STAND18 ARDS.

19 ‘‘Each health insurance issuer shall comply with chil20 dren’s health accountability requirements under part C

21 with respect to individual health insurance coverage it of22 fers.’’.

23 (d) MODIFICATION OF PREEMPTION STANDARDS.—
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1 (1) GROUP HEALTH INSURANCE COVERAGE.—

2 Section 2723 of the Public Health Service Act (42

3 U.S.C. 300gg–23) is amended—

4 (A) in subsection (a)(1), by striking ‘‘sub5 section (b)’’ and inserting ‘‘subsection (b) and

6 (c)’’;

7 (B) by redesignating subsections (c) and

8 (d) as subsections (d) and (e), respectively; and

9 (C) by inserting after subsection (b) the

10 following new subsection:

11 ‘‘(c) SPECIAL RULES IN CASE OF CHILDREN’S

12 HEALTH ACCOUNTABILITY REQUIREMENTS.—Subject to

13 subsection (a)(2), the provisions of section 2706 and part

14 C, and part D insofar as it applies to section 2706 or part

15 C, shall not prevent a State from establishing require16 ments relating to the subject matter of such provisions

17 so long as such requirements are at least as stringent on

18 health insurance issuers as the requirements imposed

19 under such provisions.’’.

20 (2) INDIVIDUAL HEALTH INSURANCE COV21 ERAGE.—Section 2762 of the Public Health Service

22 Act (42 U.S.C. 300gg–62), as added by section

23 605(b)(3)(B) of Public Law 104–204, is amended—
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1 (A) in subsection (a), by striking ‘‘sub2 section (b), nothing in this part’’ and inserting

3 ‘‘subsections (b) and (c)’’, and

4 (B) by adding at the end the following new

5 subsection:

6 ‘‘(c) SPECIAL RULES IN CASE OF CHILDREN’S

7 HEALTH ACCOUNTABILITY REQUIREMENTS.—Subject to

8 subsection (b), the provisions of section 2752 and part C,

9 and part D insofar as it applies to section 2752 or part

10 C, shall not prevent a State from establishing require11 ments relating to the subject matter of such provisions

12 so long as such requirements are at least as stringent on

13 health insurance issuers as the requirements imposed

14 under such section.’’.

15 SEC. 3. AMENDMENTS TO THE EMPLOYEE RETIREMENT IN16 COME SECURITY ACT OF 1974.

17 (a) IN GENERAL.—Subpart B of part 7 of subtitle

18 B of title I of the Employee Retirement Income Security

19 Act of 1974 is amended by adding at the end the follow20 ing:

21 ‘‘SEC. 713. CHILDREN’S HEALTH ACCOUNTABILITY STAND22 ARDS.

23 ‘‘(a) IN GENERAL.—Subject to subsection (b), the

24 provisions of part C of title XXVII of the Public Health

25 Service Act shall apply under this subpart and part to a
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1 group health plan (and group health insurance coverage

2 offered in connection with a group health plan) as if such

3 part were incorporated in this section.

4 ‘‘(b) APPLICATION.—In applying subsection (a)

5 under this subpart and part, and reference in such part

6 C—

7 ‘‘(1) to health insurance coverage is deemed to

8 be a reference only to group health insurance cov9 erage offered in connection with a group health plan

10 and to also be a reference to coverage under a group

11 health plan;

12 ‘‘(2) to a health insurance issuer is deemed to

13 be a reference only to such an issuer in relation to

14 group health insurance coverage or, with respect to

15 a group health plan, to the plan;

16 ‘‘(3) to the Secretary is deemed to be a ref17 erence to the Secretary of Labor;

18 ‘‘(4) to an applicable State authority is deemed

19 to be a reference to the Secretary of Labor; and

20 ‘‘(5) to an enrollee with respect to health insur21 ance coverage is deemed to include a reference to a

22 participant or beneficiary with respect to a group

23 health plan.’’.

24 (b) MODIFICATION OF PREEMPTION STANDARDS.—

25 Section 731 of such Act (42 U.S.C. 1191) is amended—
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1 (1) in subsection (a)(1), by striking ‘‘subsection

2 (b)’’ and inserting ‘‘subsections (b) and (c)’’;

3 (2) by redesignating subsections (c) and (d) as

4 subsections (d) and (e), respectively; and

5 (3) by inserting after subsection (b) the follow6 ing new subsection:

7 ‘‘(c) SPECIAL RULES IN CASE OF PATIENT AC8 COUNTABILITY REQUIREMENTS.—Subject to subsection

9 (a)(2), the provisions of section 713, shall not prevent a

10 State from establishing requirements relating to the sub11 ject matter of such provisions so long as such require12 ments are at least as stringent on group health plans and

13 health insurance issuers in connection with group health

14 insurance coverage as the requirements imposed under

15 such provisions.’’.

16 (c) CONFORMING AMENDMENTS.—

17 (1) Section 732(a) of such Act (29 U.S.C.

18 1185(a)) is amended by striking ‘‘section 711’’ and

19 inserting ‘‘sections 711 and 713’’.

20 (2) The table of contents in section 1 of such

21 Act is amended by inserting after the item relating

22 to section 712 the following new item:

‘‘Sec. 713. Children’s health accountability standards.’’.

23 SEC. 4. STUDIES.

24 (a) BY SECRETARY.—Not later than 1 year after the

25 date of enactment of this Act, the Secretary of Health and
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1 Human Services shall conduct a study, and prepare and

2 submit to Congress a report, concerning—

3 (1) the unique characteristics of patterns of ill4 ness, disability, and injury in children;

5 (2) the development of measures of quality of

6 care and outcomes related to the health care of chil7 dren; and

8 (3) the access of children to primary mental

9 health services and the coordination of managed be10 havioral health services.

11 (b) BY GAO.—

12 (1) MANAGED CARE.—Not later than 1 year

13 after the date of enactment of this Act, the General

14 Accounting Office shall conduct a study, and pre15 pare and submit to the Committee on Labor and

16 Human Resources of the Senate and the Committee

17 on Commerce of the House of Representatives a re18 port, concerning—

19 (A) an assessment of the structure and

20 performance of non-governmental health plans,

21 medicaid managed care organizations, plans

22 under title XIX of the Social Security Act (42

23 U.S.C. 1396 et seq.), and the program under

24 title XXI of the Social Security Act (42 U.S.C.
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1 1397aa et seq.) serving the needs of children

2 with special health care needs;

3 (B) an assessment of the structure and

4 performance of non-governmental plans in serv5 ing the needs of children as compared to medic6 aid managed care organizations under title XIX

7 of the Social Security Act (42 U.S.C. 1396 et

8 seq.); and

9 (C) the emphasis that private managed

10 care health plans place on primary care and the

11 control of services as it relates to care and serv12 ices provided to children with special health

13 care needs.

14 (2) PLAN SURVEY.—Not later than 1 year after

15 the date of enactment of this Act, the General Ac16 counting Office shall prepare and submit to the

17 Committee on Labor and Human Resources of the

18 Senate and the Committee on Commerce of the

19 House of Representatives a report that contains a

20 survey of health plan activities that address the

21 unique health needs of adolescents, including quality

22 measures for adolescents and innovative practice ar23 rangement.

Æ