I

106TH CONGRESS

1ST SESSION H. R. 2046

To amend title I of the Employee Retirement Income Security Act of 1974

to ensure access by participants and beneficiaries of group health plans

to information regarding plan coverage, managed care procedures, health

care providers, and quality of medical care.

IN THE HOUSE OF REPRESENTATIVES

JUNE 8, 1999

Mr. FLETCHER introduced the following bill; which was referred to the

Committee on Education and the Workforce

A BILL

To amend title I of the Employee Retirement Income Security Act of 1974 to ensure access by participants and

beneficiaries of group health plans to information regarding plan coverage, managed care procedures, health care

providers, and quality of medical care.

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 ‘‘Patient Access to In5 formation Act of 1999’’.
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1 SEC. 2. PATIENT ACCESS TO INFORMATION REGARDING

2 PLAN COVERAGE, MANAGED CARE PROCE3 DURES, HEALTH CARE PROVIDERS, AND

4 QUALITY OF MEDICAL CARE.

5 (a) IN GENERAL.—Part 1 of subtitle B of title I of

6 the Employee Retirement Income Security Act of 1974 is

7 amended—

8 (1) by redesignating section 111 as section 112;

9 and

10 (2) by inserting after section 110 the following

11 new section:

12 ‘‘DISCLOSURE BY GROUP HEALTH PLANS

13 ‘‘SEC. 111. (a) DISCLOSURE REQUIREMENT.—

14 ‘‘(1) GROUP HEALTH PLANS.—The adminis15 trator of each group health plan shall take such ac16 tions as are necessary to ensure that the summary

17 plan description of the plan required under section

18 102 (or each summary plan description in any case

19 in which different summary plan descriptions are ap20 propriate under part 1 for different options of cov21 erage) contains, among any information otherwise

22 required under this part, the information required

23 under subsections (b), (c), (d), and (e)(2)(A).

24 ‘‘(2) HEALTH INSURANCE ISSUERS.—Each

25 health insurance issuer offering health insurance

26 coverage in connection with a group health plan
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1 shall provide the administrator on a timely basis

2 with the information necessary to enable the admin3 istrator to comply with the requirements of para4 graph (1). To the extent that any such issuer pro5 vides on a timely basis to plan participants and

6 beneficiaries information otherwise required under

7 this part to be included in the summary plan de8 scription, the requirements of sections 101(a)(1) and

9 104(b) shall be deemed satisfied in the case of such

10 plan with respect to such information.

11 ‘‘(b) PLAN BENEFITS.—The information required

12 under subsection (a) includes the following:

13 ‘‘(1) COVERED ITEMS AND SERVICES.—

14 ‘‘(A) CATEGORIZATION OF INCLUDED BEN15 EFITS.—A description of covered benefits, cat16 egorized by—

17 ‘‘(i) types of items and services (in18 cluding any special disease management

19 program); and

20 ‘‘(ii) types of health care professionals

21 providing such items and services.

22 ‘‘(B) EMERGENCY MEDICAL CARE.—A de23 scription of the extent to which the plan covers

24 emergency medical care (including the extent to

25 which the plan provides for access to urgent
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1 care centers), and any definitions provided

2 under the plan for the relevant plan termi3 nology referring to such care.

4 ‘‘(C) PREVENTATIVE SERVICES.—A de5 scription of the extent to which the plan pro6 vides benefits for preventative services.

7 ‘‘(D) DRUG FORMULARIES.—A description

8 of the extent to which covered benefits are de9 termined by the use or application of a drug

10 formulary and a summary of the process for de11 termining what is included in such formulary.

12 ‘‘(E) COBRA CONTINUATION COV13 ERAGE.—A description of the benefits available

14 under the plan pursuant to part 6.

15 ‘‘(2) LIMITATIONS, EXCLUSIONS, AND RESTRIC16 TIONS ON COVERED BENEFITS.—

17 ‘‘(A) CATEGORIZATION OF EXCLUDED

18 BENEFITS.—A description of benefits specifi19 cally excluded from coverage, categorized by

20 types of items and services.

21 ‘‘(B) UTILIZATION REVIEW AND

22 PREAUTHORIZATION REQUIREMENTS.—Whether

23 coverage for medical care is limited or excluded

24 on the basis of utilization review or

25 preauthorization requirements.
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1 ‘‘(C) LIFETIME, ANNUAL, OR OTHER PE2 RIOD LIMITATIONS.—A description of the cir3 cumstances under which, and the extent to

4 which, coverage is subject to lifetime, annual, or

5 other period limitations, categorized by types of

6 benefits.

7 ‘‘(D) CUSTODIAL CARE.—A description of

8 the circumstances under which, and the extent

9 to which, the coverage of benefits for custodial

10 care is limited or excluded, and a statement of

11 the definition used by the plan for custodial

12 care.

13 ‘‘(E) EXPERIMENTAL TREATMENTS.—

14 Whether coverage for any medical care is lim15 ited or excluded because it constitutes experi16 mental treatment or technology, and any defini17 tions provided under the plan for the relevant

18 plan terminology referring to such limited or

19 excluded care.

20 ‘‘(F) MEDICAL APPROPRIATENESS OR NE21 CESSITY.—Whether coverage for medical care

22 may be limited or excluded by reason of a fail23 ure to meet the plan’s requirements for medical

24 appropriateness or necessity, and any defini25 tions provided under the plan for the relevant
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1 plan terminology referring to such limited or

2 excluded care.

3 ‘‘(G) SECOND OR SUBSEQUENT OPIN4 IONS.—A description of the circumstances

5 under which, and the extent to which, coverage

6 for second or subsequent opinions is limited or

7 excluded.

8 ‘‘(H) SPECIALTY CARE.—A description of

9 the circumstances under which, and the extent

10 to which, coverage of benefits for specialty care

11 is conditioned on referral from a primary care

12 provider.

13 ‘‘(I) CONTINUITY OF CARE.—A description

14 of the circumstances under which, and the ex15 tent to which, coverage of items and services

16 provided by any health care professional is lim17 ited or excluded by reason of the departure by

18 the professional from any defined set of pro19 viders.

20 ‘‘(J) RESTRICTIONS ON COVERAGE OF

21 EMERGENCY SERVICES.—A description of the

22 circumstances under which, and the extent to

23 which, the plan, in covering emergency medical

24 care furnished to a participant or beneficiary of

25 the plan imposes any financial responsibility de-
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1 scribed in subsection (c) on participants or

2 beneficiaries or limits or conditions benefits for

3 such care subject to any other term or condition

4 of such plan.

5 ‘‘(c) PARTICIPANT’S FINANCIAL RESPONSIBIL6 ITIES.—The information required under subsection (a) in7 cludes an explanation of—

8 ‘‘(1) a participant’s financial responsibility for

9 payment of premiums, coinsurance, copayments,

10 deductibles, and any other charges; and

11 ‘‘(2) the circumstances under which, and the

12 extent to which, the participant’s financial responsi13 bility described in paragraph (1) may vary, including

14 any distinctions based on whether a health care pro15 vider from whom covered benefits are obtained is in16 cluded in a defined set of providers.

17 ‘‘(d) DISPUTE RESOLUTION PROCEDURES.—The in18 formation required under subsection (a) includes a de19 scription of the processes adopted by the plan pursuant

20 to section 503, including—

21 ‘‘(1) descriptions thereof relating specifically

22 to—

23 ‘‘(A) coverage decisions;

24 ‘‘(B) internal review of coverage decisions;

25 and
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1 ‘‘(C) any external review of coverage deci2 sions; and

3 ‘‘(2) the procedures and time frames applicable

4 to each step of the processes referred to in subpara5 graphs (A), (B), and (C) of paragraph (1).

6 ‘‘(e) INFORMATION AVAILABLE ON REQUEST.—

7 ‘‘(1) ACCESS TO PLAN BENEFIT INFORMATION

8 IN ELECTRONIC FORM.—

9 ‘‘(A) IN GENERAL.—In addition to the in10 formation required to be provided under section

11 104(b)(4), a group health plan (and a health

12 insurance issuer offering health insurance cov13 erage in connection with a group health plan)

14 shall, upon written request (made not more fre15 quently than annually), make available to par16 ticipants and beneficiaries, in a generally recog17 nized electronic format—

18 ‘‘(i) the latest summary plan descrip19 tion, including the latest summary of ma20 terial modifications, and

21 ‘‘(ii) the actual plan provisions setting

22 forth the benefits available under the plan,

23 to the extent such information relates to the

24 coverage options under the plan available to the

25 participant or beneficiary. A reasonable charge
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1 may be made to cover the cost of providing

2 such information in such generally recognized

3 electronic format. The Secretary may by regula4 tion prescribe a maximum amount which will

5 constitute a reasonable charge under the pre6 ceding sentence.

7 ‘‘(B) ALTERNATIVE ACCESS.—The require8 ments of this paragraph may be met by making

9 such information generally available (rather

10 than upon request) on the Internet or on a pro11 prietary computer network in a format which is

12 readily accessible to participants and bene13 ficiaries.

14 ‘‘(2) ADDITIONAL INFORMATION TO BE PRO15 VIDED ON REQUEST.—

16 ‘‘(A) INCLUSION IN SUMMARY PLAN DE17 SCRIPTION OF SUMMARY OF ADDITIONAL IN18 FORMATION.—The information required under

19 subsection (a) includes a summary description

20 of the types of information required by this

21 subsection to be made available to participants

22 and beneficiaries on request.

23 ‘‘(B) INFORMATION REQUIRED FROM

24 PLANS AND ISSUERS ON REQUEST.—In addition

25 to information required to be included in sum-
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1 mary plan descriptions under this subsection, a

2 group health plan (and a health insurance

3 issuer offering health insurance coverage in

4 connection with a group health plan) shall pro5 vide the following information to a participant

6 or beneficiary on request:

7 ‘‘(i) NETWORK CHARACTERISTICS.—If

8 the plan (or issuer) utilizes a defined set of

9 providers under contract with the plan (or

10 issuer), a detailed list of the names of such

11 providers and their geographic location, set

12 forth separately with respect to primary

13 care providers and with respect to special14 ists.

15 ‘‘(ii) CARE MANAGEMENT INFORMA16 TION.—A description of the circumstances

17 under which, and the extent to which, the

18 plan has special disease management pro19 grams or programs for persons with dis20 abilities, indicating whether these pro21 grams are voluntary or mandatory and

22 whether a significant benefit differential

23 results from participation in such pro24 grams.
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1 ‘‘(iii) INCLUSION OF DRUGS AND

2 BIOLOGICALS IN FORMULARIES.—A state3 ment of whether a specific drug or biologi4 cal is included in a formulary used to de5 termine benefits under the plan and a de6 scription of the procedures for considering

7 requests for any patient-specific waivers.

8 ‘‘(iv) PROCEDURES FOR DETERMINING

9 EXCLUSIONS BASED ON MEDICAL NECES10 SITY OR EXPERIMENTAL TREATMENTS.—

11 Upon receipt by the participant or bene12 ficiary of any notification of an adverse

13 coverage decision based on a determination

14 relating to medical necessity or an experi15 mental treatment or technology, a descrip16 tion of the procedures and medically-based

17 criteria used in such decision.

18 ‘‘(v) PREAUTHORIZATION AND UTILI19 ZATION REVIEW PROCEDURES.—Upon re20 ceipt by the participant or beneficiary of

21 any notification of an adverse coverage de22 cision, a description of the basis on which

23 any preauthorization requirement or any

24 utilization review requirement has resulted

25 in such decision.
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1 ‘‘(vi) ACCREDITATION STATUS OF

2 HEALTH INSURANCE ISSUERS AND SERV3 ICE PROVIDERS.—A description of the ac4 creditation and licensing status (if any) of

5 each health insurance issuer offering

6 health insurance coverage in connection

7 with the plan and of any utilization review

8 organization utilized by the issuer or the

9 plan, together with the name and address

10 of the accrediting or licensing authority.

11 ‘‘(vii) MEASURES OF ENROLLEE SAT12 ISFACTION.—The latest information (if

13 any) maintained by the plan, or by any

14 health insurance issuer offering health in15 surance coverage in connection with the

16 plan, relating to enrollee satisfaction.

17 ‘‘(viii) QUALITY PERFORMANCE MEAS18 URES.—The latest information (if any)

19 maintained by the plan, or by any health

20 insurance issuer offering health insurance

21 coverage in connection with the plan, relat22 ing to quality of performance of the deliv23 ery of medical care with respect to cov24 erage options offered under the plan and
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1 of health care professionals and facilities

2 providing medical care under the plan.

3 ‘‘(ix) INFORMATION RELATING TO EX4 TERNAL REVIEWS.—The number of any

5 external reviews under section 503 that

6 have been completed during the prior plan

7 year and the number of such reviews in

8 which a recommendation is made for modi9 fication or reversal of an internal review

10 decision under the plan.

11 ‘‘(C) INFORMATION REQUIRED FROM

12 HEALTH CARE PROFESSIONALS ON REQUEST.—

13 Any health care professional treating a partici14 pant or beneficiary under a group health plan

15 shall provide to the participant or beneficiary,

16 on request, a description of his or her profes17 sional qualifications (including board certifi18 cation status, licensing status, and accreditation

19 status, if any), privileges, and experience and a

20 general description by category (including sal21 ary, fee-for-service, capitation, and such other

22 categories as may be specified in regulations of

23 the Secretary) of the applicable method by

24 which such professional is compensated in con25 nection with the provision of such medical care.
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1 ‘‘(D) INFORMATION REQUIRED FROM

2 HEALTH CARE FACILITIES ON REQUEST.—Any

3 health care facility from which a participant or

4 beneficiary has sought treatment under a group

5 health plan shall provide to the participant or

6 beneficiary, on request, a description of the fa7 cility’s corporate form or other organizational

8 form and all forms of licensing and accredita9 tion status (if any) assigned to the facility by

10 standard-setting organizations.

11 ‘‘(f) ACCESS TO INFORMATION RELEVANT TO THE

12 COVERAGE OPTIONS UNDER WHICH THE PARTICIPANT

13 OR BENEFICIARY IS ELIGIBLE TO ENROLL.—In addition

14 to information otherwise required to be made available

15 under this section, a group health plan (and a health in16 surance issuer offering health insurance coverage in con17 nection with a group health plan) shall, upon written re18 quest (made not more frequently than annually), make

19 available to a participant (and an employee who, under

20 the terms of the plan, is eligible for coverage but not en21 rolled) in connection with a period of enrollment the sum22 mary plan description for any coverage option under the

23 plan under which the participant is eligible to enroll and

24 any information described in clauses (i), (ii), (iii), (vi),

25 (vii), and (viii) of subsection (e)(2)(B).
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1 ‘‘(g) ADVANCE NOTICE OF CHANGES IN DRUG

2 FORMULARIES.—Not later than 30 days before the effec3 tive of date of any exclusion of a specific drug or biological

4 from any drug formulary under the plan that is used in

5 the treatment of a chronic illness or disease, the plan shall

6 take such actions as are necessary to reasonably ensure

7 that plan participants are informed of such exclusion. The

8 requirements of this subsection may be satisfied—

9 ‘‘(1) by inclusion of information in publications

10 broadly distributed by plan sponsors, employers, or

11 employee organizations;

12 ‘‘(2) by electronic means of communication (in13 cluding the Internet or proprietary computer net14 works in a format which is readily accessible to par15 ticipants);

16 ‘‘(3) by timely informing participants who,

17 under an ongoing program maintained under the

18 plan, have submitted their names for such notifica19 tion; or

20 ‘‘(4) by any other reasonable means of timely

21 informing plan participants.

22 ‘‘(h) DEFINITIONS.—For purposes of this section—

23 ‘‘(1) GROUP HEALTH PLAN.—The term ‘group

24 health plan’ has the meaning provided such term

25 under section 733(a)(1).
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1 ‘‘(2) MEDICAL CARE.—The term ‘medical care’

2 has the meaning provided such term under section

3 733(a)(2).

4 ‘‘(3) HEALTH INSURANCE COVERAGE.—The

5 term ‘health insurance coverage’ has the meaning

6 provided such term under section 733(b)(1).

7 ‘‘(4) HEALTH INSURANCE ISSUER.—The term

8 ‘health insurance issuer’ has the meaning provided

9 such term under section 733(b)(2).’’.

10 (b) CONFORMING AMENDMENTS.—

11 (1) Section 102(b) of such Act (29 U.S.C.

12 1022(b)) is amended by inserting before the period

13 at the end the following: ‘‘; and, in the case of a

14 group health plan (as defined in section 111(h)(1)),

15 the information required to be included under sec16 tion 111(a)’’.

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

18 Act is amended by striking the item relating to sec19 tion 111 and inserting the following new items:

‘‘Sec. 111. Disclosure by group health plans.

‘‘Sec. 112. Repeal and effective date.’’.

20 SEC. 3. EFFECTIVE DATE AND RELATED RULES.

21 (a) IN GENERAL.—The amendments made by this

22 Act shall apply with respect to plan years beginning on

23 or after January 1 of the second calendar year following

24 the date of the enactment of this Act. The Secretary shall
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1 first issue all regulations necessary to carry out the

2 amendments made by this subtitle before such date.

3 (b) LIMITATION ON ENFORCEMENT ACTIONS.—No

4 enforcement action shall be taken, pursuant to the amend5 ments made by this Act, against a group health plan or

6 health insurance issuer with respect to a violation of a re7 quirement imposed by such amendments before the date

8 of issuance of final regulations issued in connection with

9 such requirement, if the plan or issuer has sought to com10 ply in good faith with such requirement.

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