I

106TH CONGRESS

1ST SESSION H. R. 1661

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 HOUSE OF REPRESENTATIVES

MAY 4, 1999

Mrs. MORELLA (for herself, Mr. BALDACCI, Mr. SAWYER, and Mr. HILLIARD)

introduced the following bill; which was referred to the Committee on

Commerce, and in addition to the Committee on Education and the

Workforce, for a period to be subsequently determined by the Speaker,

in each case for consideration of such provisions as fall within the jurisdiction of the committee concerned

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 1999’’.
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1 SEC. 2. FINDINGS; PURPOSE.

2 (a) FINDINGS.—Congress makes the following find3 ings:

4 (1) Children have health and development needs

5 that are markedly different than those for the adult

6 population.

7 (2) Children experience complex and continuing

8 changes during the continuum from birth to adult9 hood in which appropriate health care is essential

10 for optimal development. Their organ systems,

11 bones, immunologic and cognitive systems all go

12 through different developmental stages before reach13 ing maturation and therefore, depending on age and

14 state of development, respond differently to both ill15 ness and treatment.

16 (3) The vast majority of work done on develop17 ment methods to assess the effectiveness of health

18 care services and the impact of medical care on pa19 tient outcomes and patient satisfaction has been fo20 cused on adults.

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

22 gender, and developmentally appropriate to be useful

23 to families and children.

24 (5) Costly disorders of adulthood often have

25 their origins in childhood, making early access to ef26 fective health services in childhood essential.
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1 (6) More than 200 chronic conditions, disabil2 ities and diseases affect children, including asthma,

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

4 autism, cerebral palsy, congenital heart disease,

5 mental retardation, and cystic fibrosis. These chil6 dren need the services of specialists who have in7 depth knowledge about their particular condition.

8 (7) Children’s patterns of illness, disability and

9 injury differ dramatically from adults.

10 (8) Children are dependent on adults and com11 munity institutions to promote their health and well12 being and so they are a particularly vulnerable popu13 lation.

14 (9) Children are smaller than adults, ranging in

15 size from very premature infants to adult-sized ado16 lescents. As a result, smaller children are vulnerable

17 to sudden shifts in conditions, medication must be

18 more finely calibrated, and procedures can be more

19 difficult.

20 (10) Children are our nation’s poorest popu21 lation and with that poverty often comes increased

22 vulnerability and reduced access to needed health

23 care services that are characterized by lack of con24 tinuity of care, delays in obtaining care, and limited
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1 choices about where and from whom care may be re2 ceived.

3 (11) Children with special health care needs are

4 particularly vulnerable because only a very small

5 percentage of children have a major illness, injury,

6 or congenital condition, and private managed care

7 plans often have little experience in serving such

8 children.

9 (12) Children do not command a large amount

10 of influence in the health care marketplace; they ac11 count for less than 15 percent of national health

12 care spending.

13 (13) Research related to child and adolescent

14 health and development is underrepresented in com15 parison to our nation’s research commitment to

16 other national priorities.

17 (14) In comparison to children in other indus18 trialized nations, the health status of children in this

19 country continues to fall short in areas such as in20 fant mortality, death by injury or accident, and sui21 cide.

22 (15) An excellent delivery health care system

23 promoting improved pediatric health would be child

24 and family centered, accessible, continuous, com25 prehensive, coordinated, compassionate, offer spe-
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1 cialized services, ensure quality assurance, and pro2 vide relevant data and information.

3 (16) Assuring that children receive what they

4 need from the health system is a special responsi5 bility of adults—individually as parents and collec6 tively as a society— and problems found in the

7 health care system for children should be identified

8 and corrected quickly so that our children grow into

9 healthy and productive adults.

10 (b) PURPOSE.—It is the purpose of this Act to estab11 lish and implement quality standards for the protection

12 of children under group health plans and health insurance

13 coverage that are intended to supplement any consumer

14 protections intended to cover all individuals covered under

15 such plans or coverage.

16 SEC. 3. AMENDMENTS TO THE PUBLIC HEALTH SERVICE

17 ACT.

18 (a) IN GENERAL.—Title XXVII of the Public Health

19 Service Act is amended—

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

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

22 part:
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1 ‘‘PART C—CHILDREN’S HEALTH PROTECTION

2 STANDARDS

3 ‘‘SEC. 2770. ACCESS TO CARE.

4 ‘‘(a) ACCESS TO APPROPRIATE PRIMARY CARE PRO5 VIDERS.—

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

7 a health insurance issuer, in connection with the

8 provision of health insurance coverage, requires or

9 provides for an enrollee to designate a participating

10 primary care provider for a child of such enrollee—

11 ‘‘(A) the plan or issuer shall permit the en12 rollee to designate a physician who specializes

13 in pediatrics as the child’s primary care pro14 vider; and

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

16 such a provider for the child, the plan or issuer

17 shall consider appropriate pediatric expertise in

18 mandatorily assigning such an enrollee to a pri19 mary care provider.

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

21 (1) shall waive any requirements of coverage relating

22 to medical necessity or appropriateness with respect

23 to coverage of services.

24 ‘‘(b) ACCESS TO PEDIATRIC SPECIALTY SERVICES.—
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1 ‘‘(1) REFERRAL TO SPECIALITY CARE FOR

2 CHILDREN REQUIRING TREATMENT BY SPECIAL3 ISTS.—

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

5 who is covered under a group health plan, or

6 under health insurance coverage offered by a

7 health insurance issuer, and who has a mental

8 or physical condition, disability, or disease of

9 sufficient seriousness and complexity to require

10 diagnosis, evaluation or treatment by a spe11 cialist, the plan or issuer shall make or provide

12 for a referral to a specialist who has extensive

13 experience or training, and is available and ac14 cessible to provide the treatment for such condi15 tion or disease, including the choice of a nonpri16 mary care physician specialist participating in

17 the plan or a referral to a nonparticipating pro18 vider as provided for under subparagraph (D) if

19 such a provider is not available within the plan.

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

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

22 with respect to a condition, disability, or dis23 ease, a health care practitioner, facility, or cen24 ter (such as a center of excellence) that has ex25 tensive pediatric expertise through appropriate
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1 training or experience to provide high quality

2 care in treating the condition, disability, or dis3 ease.

4 ‘‘(C) REFERRALS TO PARTICIPATING PRO5 VIDERS.—A plan or issuer is not required under

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

7 specialist that is not a participating provider,

8 unless the plan or issuer does not have an ap9 propriate specialist that is available and acces10 sible to treat the enrollee’s condition and that

11 is a participating provider with respect to such

12 treatment.

13 ‘‘(D) TREATMENT OF NONPARTICIPATING

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

15 enrollee to a nonparticipating specialist, services

16 provided pursuant to the referral shall be pro17 vided at no additional cost to the enrollee be18 yond what the enrollee would otherwise pay for

19 services received by such a specialist that is a

20 participating provider.

21 ‘‘(E) SPECIALISTS AS PRIMARY CARE PRO22 VIDERS.—A plan or issuer shall have in place a

23 procedure under which a child who is covered

24 under the coverage provided by the plan or

25 issuer who has a condition or disease that re-
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1 quires specialized medical care over a prolonged

2 period of time shall receive a referral to a pedi3 atric specialist affiliated with the plan or issuer,

4 or if not available within the plan or coverage,

5 to a nonparticipating provider for such condi6 tion and such specialist may be responsible for

7 and capable of providing and coordinating the

8 child’s primary and specialty care.

9 ‘‘(2) STANDING REFERRALS.—

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

11 or health insurance issuer in connection with

12 the provision of health insurance coverage, shall

13 have a procedure by which a child who is a par14 ticipant, beneficiary, or enrollee under the plan

15 or coverage and who has a condition, disability,

16 or disease that requires ongoing care from a

17 specialist may request and obtain a standing re18 ferral to such specialist for treatment of such

19 condition. If the primary care provider in con20 sultation with the medical director of the plan

21 or issuer and the specialist (if any), determines

22 that such a standing referral is appropriate, the

23 plan or issuer shall authorize such a referral to

24 such a specialist. Such standing referral shall

25 be consistent with a treatment plan.
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1 ‘‘(B) TREATMENT PLANS.—A group health

2 plan, or health insurance issuer, with the par3 ticipation of the family and the health care pro4 viders of the child, shall develop a treatment

5 plan for a child who requires ongoing care that

6 covers a specified period of time (but in no

7 event less than a 6-month period). Services pro8 vided for under the treatment plan shall not re9 quire additional approvals or referrals through

10 a gatekeeper.

11 ‘‘(C) TERMS OF REFERRAL.—The provi12 sions of subparagraph (C) and (D) of para13 graph (1) shall apply with respect to referrals

14 under subparagraph (A) in the same manner as

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

16 ‘‘(c) ADEQUACY OF ACCESS.—For purposes of sub17 sections (a) and (b), a group health plan or health insur18 ance issuer in connection with health insurance coverage

19 shall ensure that a sufficient number, distribution, and va20 riety of qualified participating health care providers are

21 available so as to ensure that all covered health care serv22 ices, including specialty services, are available and acces23 sible to all enrollees who are children in a timely manner.

24 ‘‘(d) COVERAGE OF EMERGENCY SERVICES.—
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1 ‘‘(1) IN GENERAL.—If a group health plan, or

2 health insurance coverage offered by a health insur3 ance issuer, provides any benefits for children with

4 respect to emergency services (as defined in para5 graph (2)(A)), the plan or issuer shall cover emer6 gency services furnished under the plan or coverage

7 to such enrollees—

8 ‘‘(A) without the need for any prior au9 thorization determination;

10 ‘‘(B) whether or not the physician or pro11 vider furnishing such services is a participating

12 physician or provider with respect to such serv13 ices; and

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

15 condition of such coverage (other than exclusion

16 of benefits, or an affiliation or waiting period,

17 permitted under section 2701).

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

19 ‘‘(A) EMERGENCY MEDICAL CONDITION

20 BASED ON PRUDENT LAYPERSON STANDARD.—

21 The term ‘emergency medical condition’ means

22 a medical condition manifesting itself by acute

23 symptoms of sufficient severity (including se24 vere pain) such that a prudent layperson, who

25 possesses an average knowledge of health and
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1 medicine, could reasonably expect the absence

2 of immediate medical attention to result in a

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

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

5 Act.

6 ‘‘(B) EMERGENCY SERVICES.—The term

7 ‘emergency services’ means—

8 ‘‘(i) a medical screening examination

9 (as required under section 1867 of the So10 cial Security Act) that is within the capa11 bility of the emergency department of a

12 hospital, including ancillary services rou13 tinely available to the emergency depart14 ment to evaluate an emergency medical

15 condition (as defined in subparagraph

16 (A)); and

17 ‘‘(ii) within the capabilities of the

18 staff and facilities available at the hospital,

19 such further medical examination and

20 treatment as are required under section

21 1867 of such Act to stabilize the patient.

22 ‘‘(3) REIMBURSEMENT FOR MAINTENANCE

23 CARE AND POST-STABILIZATION CARE.—A group

24 health plan, and health insurance issuer offering

25 health insurance coverage, shall provide, in covering
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1 services other than emergency services for enrollees

2 who are children, for reimbursement with respect to

3 services which are otherwise covered and which are

4 provided to an enrollee other than through the plan

5 or issuer if the services are maintenance care or

6 post-stabilization care covered under the guidelines

7 established under section 1852(d) of the Social Se8 curity Act (relating to promoting efficient and timely

9 coordination of appropriate maintenance and post10 stabilization care of an enrollee after an enrollee has

11 been determined to be stable).

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

13 health insurance issuer in connection with the provision

14 of health insurance coverage may not impose any cost

15 sharing for pediatric specialty services provided under

16 such coverage to children who are enrollees in amounts

17 that exceed the cost-sharing required for other specialty

18 care under such coverage.

19 ‘‘(f) CHILDREN WITH SPECIAL HEALTH CARE

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

21 provision of health insurance coverage shall ensure that

22 such coverage provides special consideration for the provi23 sion of services to children with special health care needs

24 who are enrolled under the coverage. Appropriate proce25 dures shall be implemented to provide care for children
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1 with special health care needs. The development of such

2 procedures shall include participation by the families of

3 such children.

4 ‘‘(g) DEFINITIONS.—In this part:

5 ‘‘(1) CHILD.—The term ‘child’ means an indi6 vidual who is under 19 years of age.

7 ‘‘(2) CHILDREN WITH SPECIAL HEALTH CARE

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

9 needs’ means those children who have or are at ele10 vated risk for chronic physical, developmental, be11 havioral or emotional conditions and who also re12 quire health and related services of a type and

13 amount not usually required by other children.

14 ‘‘SEC. 2771. CONTINUITY OF CARE.

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

16 insurance issuer, in connection with the provision of health

17 insurance coverage, and a health care provider is termi18 nated (other than by the issuer for failure to meet applica19 ble quality standards or for fraud) and an enrollee who

20 is a child is undergoing a course of treatment from the

21 provider at the time of such termination, the issuer shall—

22 ‘‘(1) notify the parent or guardian of the en23 rollee of such termination, and

24 ‘‘(2) subject to subsection (c), permit the en25 rollee to continue the course of treatment with the
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1 provider during a transitional period (provided under

2 subsection (b)).

3 ‘‘(b) TRANSITIONAL PERIOD.—

4 ‘‘(1) IN GENERAL.—Except as provided in para5 graphs (2) through (4), the transitional period under

6 this subsection shall extend for at least—

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

8 to the enrollee’s parent or guardian of the pro9 vider’s termination in the case of a primary

10 care provider, or

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

12 of another provider.

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

14 period under this subsection for institutional or in15 patient care from a provider shall extend until the

16 discharge or termination of the period of institu17 tionalization and shall include reasonable follow-up

18 care related to the institutionalization and shall also

19 include institutional care scheduled prior to the date

20 of termination of the provider status.

21 ‘‘(3) PREGNANCY.—If—

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

23 trimester of pregnancy at the time of a pro24 vider’s termination of participation, and
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1 ‘‘(B) the provider was treating the preg2 nancy before date of the termination,

3 the transitional period under this subsection with re4 spect to provider’s treatment of the pregnancy shall

5 extend through the provision of post-partum care di6 rectly related to the delivery.

7 ‘‘(4) TERMINAL ILLNESS.—

8 ‘‘(A) IN GENERAL.—If—

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

10 terminally ill (as defined in subparagraph

11 (B)) at the time of a provider’s termi12 nation of participation, and

13 ‘‘(ii) the provider was treating the ter14 minal illness before the date of termi15 nation,

16 the transitional period under this subsection

17 shall extend for the remainder of the enrollee’s

18 life for care directly related to the treatment of

19 the terminal illness.

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

21 an enrollee is considered to be ‘terminally ill’ if

22 the enrollee has a medical prognosis that the

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

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

25 issuer may condition coverage of continued treatment by
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1 a provider under subsection (a)(2) upon the provider

2 agreeing to the following terms and conditions:

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

4 reimbursement from the issuer at the rates applica5 ble prior to the start of the transitional period as

6 payment in full.

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

8 issuer’s quality assurance standards and to provide

9 to the issuer necessary medical information related

10 to the care provided.

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

12 the issuer’s policies and procedures, including proce13 dures regarding referrals and obtaining prior au14 thorization and providing services pursuant to a

15 treatment plan approved by the issuer.

16 ‘‘SEC. 2772. CONTINUOUS QUALITY IMPROVEMENT.

17 ‘‘(a) IN GENERAL.—A group health plan that covers

18 children, and a health insurance issuer that offers health

19 insurance coverage for children, shall establish and main20 tain an ongoing, internal quality assurance program that

21 at a minimum meets the requirements of subsection (b)

22 with respect to the coverage of children.

23 ‘‘(b) REQUIREMENTS.—The internal quality assur24 ance program of a plan or issuer under subsection (a)

25 shall—
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1 ‘‘(1) establish and measure a set of health care,

2 functional assessments, structure, processes and out3 comes, and quality indicators that are unique to chil4 dren and based on nationally accepted standards or

5 guidelines of care;

6 ‘‘(2) maintain written protocols consistent with

7 recognized clinical guidelines or current consensus

8 on the pediatric field, to be used for purposes of in9 ternal utilization review, with periodic updating and

10 evaluation by pediatric specialists to determine effec11 tiveness in controlling utilization;

12 ‘‘(3) provide for peer review by health care pro13 fessionals of the structure, processes, and outcomes

14 related to the provision of health services, including

15 pediatric review of pediatric cases;

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

17 questions on child and family satisfaction and expe18 rience of care, including care to children with special

19 needs;

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

21 care with respect to children;

22 ‘‘(6) include pediatric measures that are di23 rected at meeting the needs of children with special

24 health care needs, including 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 group health plan

17 that covers children, and a health insurance

18 issuer that offers health insurance coverage for

19 children, shall conduct utilization review activi20 ties in connection with the provision of such

21 coverage only in accordance with a utilization

22 review program that meets at a minimum the

23 requirements of this subsection.

24 ‘‘(B) DEFINITIONS.—In this subsection:
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1 ‘‘(i) CLINICAL PEERS.—The term

2 ‘clinical peer’ means, with respect to a re3 view, a physician or other health care pro4 fessional who holds a non-restricted license

5 in a State and in the same or similar spe6 cialty as typically manages the pediatric

7 medical condition, procedure, or treatment

8 under review.

9 ‘‘(ii) HEALTH CARE PROFESSIONAL.—

10 The term ‘health care professional’ means

11 a physician or other health care practi12 tioner licensed or certified under State law

13 to provide health care services and who is

14 operating within the scope of such licen15 sure or certification.

16 ‘‘(iii) UTILIZATION REVIEW.—The

17 terms ‘utilization review’ and ‘utilization

18 review activities’ mean procedures used to

19 monitor or evaluate the clinical necessity,

20 appropriateness, efficacy, or efficiency of

21 health care services, procedures or settings

22 for children, and includes prospective re23 view, concurrent review, second opinions,

24 case management, discharge planning, or

25 retrospective review specific to children.
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1 ‘‘(2) WRITTEN POLICIES AND CRITERIA.—

2 ‘‘(A) WRITTEN POLICIES.—A utilization

3 review program shall be conducted consistent

4 with written policies and procedures that govern

5 all aspects of the program.

6 ‘‘(B) USE OF WRITTEN CRITERIA.—A utili7 zation review program shall utilize written clin8 ical review criteria specific to children and de9 veloped pursuant to the program with the input

10 of appropriate physicians, including pediatri11 cians, nonprimary care pediatric specialists, and

12 other child health professionals.

13 ‘‘(C) ADMINISTRATION BY HEALTH CARE

14 PROFESSIONALS.—A utilization review program

15 shall be administered by qualified health care

16 professionals, including health care profes17 sionals with pediatric expertise who shall over18 see review decisions.

19 ‘‘(3) USE OF QUALIFIED, INDEPENDENT PER20 SONNEL.—

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

22 program shall provide for the conduct of utiliza23 tion review activities only through personnel

24 who are qualified and, to the extent required,

25 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 group health

12 plan with respect to covered children, and a health insur13 ance issuer in connection with the provision of health in14 surance coverage for children, shall establish and maintain

15 a system to provide for the resolution of complaints and

16 appeals regarding all aspects of such coverage for children.

17 Such a system shall include an expedited procedure for

18 appeals on behalf of a child enrollee in situations in which

19 the time frame of a standard appeal would jeopardize the

20 life, health, or development of the child.

21 ‘‘(b) EXTERNAL APPEALS PROCESS.—A group health

22 plan that covers children, and a health insurance issuer

23 in connection with the provision of health insurance cov24 erage for children, shall provide for an independent exter-
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1 nal review process with respect to claims for children that

2 meets the following requirements:

3 ‘‘(1) External appeal activities shall be con4 ducted through clinical peers, a physician or other

5 health care professional who is appropriately

6 credentialed in pediatrics with the same or similar

7 specialty and typically manages the condition, proce8 dure, or treatment under review or appeal.

9 ‘‘(2) External appeal activities shall be con10 ducted through an entity that has sufficient pedi11 atric expertise, including subspecialty expertise, and

12 staffing to conduct external appeal activities on a

13 timely basis.

14 ‘‘(3) Such a review process shall include an ex15 pedited procedure for appeals on behalf of a child in

16 which the time frame of a standard appeal would

17 jeopardize the life, health, or development of the

18 child.

19 ‘‘SEC. 2774. ACCOUNTABILITY THROUGH DISTRIBUTION OF

20 INFORMATION.

21 ‘‘(a) IN GENERAL.—A group health plan that covers

22 children and a health insurance issuer in connection with

23 the provision of health insurance coverage for children

24 shall submit to participants and enrollees (and prospective

25 participants and enrollees), and make available to the pub-
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1 lic, in writing the health-related information described in

2 subsection (b).

3 ‘‘(b) INFORMATION.—The health-related information

4 to be provided under subsection (a) shall include a descrip5 tion of the distinctions in the benefits, processes and out6 comes under the plan or coverage between adult partici7 pants, beneficiaries, and enrollees and child beneficiaries

8 and enrollees and shall include measures with respect to

9 outcomes that are specific to each such group.’’.

10 (b) APPLICATION TO GROUP HEALTH INSURANCE

11 COVERAGE.—

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

13 XXVII of the Public Health Service Act is amended

14 by adding at the end the following new section:

15 ‘‘SEC. 2707. CHILDREN’S HEALTH ACCOUNTABILITY STAND16 ARDS.

17 ‘‘(a) IN GENERAL.—Each group health plan, and

18 each health insurance issuer with respect to group health

19 insurance coverage it offers, shall comply with children’s

20 health accountability requirements under part C.

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

22 Health and Human Services and the Secretary of Labor

23 shall ensure, through the execution of an interagency

24 memorandum of understanding between such Secretaries,

25 that—
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1 ‘‘(1) regulations, rulings, and interpretations

2 issued by such Secretaries relating to the same mat3 ter over which such Secretaries have responsibility

4 under part C (and this section) and section 714 of

5 the Employee Retirement Income Security Act of

6 1974 are administered so as to have the same effect

7 at all times; and

8 ‘‘(2) coordination of policies relating to enforc9 ing the same requirements through such Secretaries

10 in order to have a coordinated enforcement strategy

11 that avoids duplication of enforcement efforts and

12 assigns priorities in enforcement.’’.

13 (2) CONFORMING AMENDMENT.—Section 2792

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

15 92) is amended by inserting ‘‘and section 2707(b)’’

16 after ‘‘of 1996’’.

17 (c) APPLICATION TO INDIVIDUAL HEALTH INSUR18 ANCE COVERAGE.—Part B of title XXVII of the Public

19 Health Service Act is amended by inserting after section

20 2752 the following new section:

21 ‘‘SEC. 2753. CHILDREN’S HEALTH ACCOUNTABILITY STAND22 ARDS.

23 ‘‘Each health insurance issuer shall comply with chil24 dren’s health accountability requirements under part C
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1 with respect to individual health insurance coverage it of2 fers.’’.

3 (d) MODIFICATION OF PREEMPTION STANDARDS.—

4 (1) GROUP HEALTH INSURANCE COVERAGE.—

5 Section 2723 of the Public Health Service Act (42

6 U.S.C. 300gg–23) is amended—

7 (A) in subsection (a)(1), by striking ‘‘sub8 section (b)’’ and inserting ‘‘subsection (b) and

9 (c)’’;

10 (B) by redesignating subsections (c) and

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

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

13 following new subsection:

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

15 HEALTH ACCOUNTABILITY REQUIREMENTS.—Subject to

16 subsection (a)(2), the provisions of section 2707 and part

17 C, and part D insofar as it applies to section 2707 or part

18 C, shall not prevent a State from establishing require19 ments relating to the subject matter of such provisions

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

21 health insurance issuers as the requirements imposed

22 under such provisions.’’.

23 (2) INDIVIDUAL HEALTH INSURANCE COV24 ERAGE.—Section 2762 of the Public Health Service

25 Act (42 U.S.C. 300gg–62) 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 2753 and part C,

9 and part D insofar as it applies to section 2753 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 fol20 lowing:

21 ‘‘SEC. 714. 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; and

18 ‘‘(4) to an enrollee with respect to health insur19 ance coverage is deemed to include a reference to a

20 participant or beneficiary with respect to a group

21 health plan.’’.

22 (b) MODIFICATION OF PREEMPTION STANDARDS.—

23 Section 731 of such Act (42 U.S.C. 1191) is amended—

24 (1) in subsection (a)(1), by striking ‘‘subsection

25 (b)’’ and inserting ‘‘subsections (b) and (c)’’;
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1 (2) by redesignating subsections (c) and (d) as

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

3 (3) by inserting after subsection (b) the fol4 lowing new subsection:

5 ‘‘(c) SPECIAL RULES IN CASE OF PATIENT AC6 COUNTABILITY REQUIREMENTS.—Subject to subsection

7 (a)(2), the provisions of section 714, shall not prevent a

8 State from establishing requirements relating to the sub9 ject matter of such provisions so long as such require10 ments are at least as stringent on group health plans and

11 health insurance issuers in connection with group health

12 insurance coverage as the requirements imposed under

13 such provisions.’’.

14 (c) CONFORMING AMENDMENTS.—

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

16 1185(a)) is amended by striking ‘‘section 711’’ and

17 inserting ‘‘sections 711 and 714’’.

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

19 Act is amended by inserting after the item relating

20 to section 713 the following new item:

‘‘Sec. 714. Children’s health accountability standards.’’.

21 SEC. 4. STUDIES.

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

23 date of enactment of this Act, the Secretary of Health and

24 Human Services shall conduct a study, and prepare and

25 submit to Congress a report, concerning—
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1 (1) the unique characteristics of patterns of ill2 ness, disability, and injury in children;

3 (2) the development of measures of quality of

4 care and outcomes related to the health care of chil5 dren; and

6 (3) the access of children to primary mental

7 health services and the coordination of managed be8 havioral health services.

9 (b) BY GAO.—

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

11 after the date of enactment of this Act, the Comp12 troller General of the United States shall conduct a

13 study, and prepare and submit to the Committee on

14 Labor and Human Resources of the Senate and the

15 Committee on Commerce of the House of Represent16 atives a report, concerning—

17 (A) an assessment of the structure and

18 performance of non-governmental health plans,

19 medicaid managed care organizations, plans

20 under title XIX of the Social Security Act (42

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

22 title XXI of the Social Security Act (42 U.S.C.

23 1397aa et seq.) serving the needs of children

24 with special health care needs;
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1 (B) an assessment of the structure and

2 performance of non-governmental plans in serv3 ing the needs of children as compared to med4 icaid managed care organizations under title

5 XIX of the Social Security Act (42 U.S.C. 1396

6 et seq.); and

7 (C) the emphasis that private managed

8 care health plans place on primary care and the

9 control of services as it relates to care and serv10 ices provided to children with special health

11 care needs.

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

13 the date of enactment of this Act, the Comptroller

14 General of the United States shall prepare and sub15 mit to the Committee on Labor and Human Re16 sources of the Senate and the Committee on Com17 merce of the House of Representatives a report that

18 contains a survey of health plan activities that ad19 dress the unique health needs of adolescents, includ20 ing quality measures for adolescents and innovative

21 practice arrangement.

Æ