II 

108TH CONGRESS 

1ST SESSION S. 1710

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 

OCTOBER 3, 2003

Mr. REED (for himself and Mrs. MURRAY) introduced the following bill; which 

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

Labor, and Pensions 

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 2003’’. 

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 in 

25 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: 

9 ‘‘PART C—CHILDREN’S HEALTH PROTECTION

10 STANDARDS

11 ‘‘SEC. 2770. ACCESS TO CARE. 

12 ‘‘(a) ACCESS TO APPROPRIATE PRIMARY CARE PRO13 VIDERS.—

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

15 a health insurance issuer in connection with the pro16 vision of health insurance coverage, requires or pro17 vides for an enrollee to designate a participating pri18 mary care provider for a child of such enrollee—

19 ‘‘(A) the plan or issuer shall permit the en20 rollee to designate a physician who specializes 

21 in pediatrics as the child’s primary care pro22 vider; and

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

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

25 shall consider appropriate pediatric expertise in 
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1 mandatorily assigning such an enrollee to a pri2 mary care provider. 

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

4 (1) shall waive any requirements of coverage relating 

5 to medical necessity or appropriateness with respect 

6 to coverage of services. 

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

8 ‘‘(1) REFERRAL TO SPECIALTY CARE FOR CHIL9 DREN REQUIRING TREATMENT BY SPECIALISTS.—

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

11 who is covered under a group health plan, or 

12 health insurance coverage offered by a health 

13 insurance issuer and who has a mental or phys14 ical condition, disability, or disease of sufficient 

15 seriousness and complexity to require diagnosis, 

16 evaluation or treatment by a specialist, the plan 

17 or issuer shall make or provide for a referral to 

18 a specialist who has extensive experience or 

19 training, and is available and accessible to pro20 vide the treatment for such condition or dis21 ease, including the choice of a nonprimary care 

22 physician specialist participating in the plan or 

23 a referral to a nonparticipating provider as pro24 vided for under subparagraph (D) if such a pro25 vider is not available within the plan. 
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1 ‘‘(B) SPECIALIST DEFINED.—For purposes 

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

3 with respect to a condition, disability, or dis4 ease, a health care practitioner, facility, or cen5 ter (such as a center of excellence) that has ex6 tensive pediatric expertise through appropriate 

7 training or experience to provide high quality 

8 care in treating the condition, disability or dis9 ease. 

10 ‘‘(C) REFERRALS TO PARTICIPATING PRO11 VIDERS.—A plan or issuer is not required under 

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

13 specialist that is not a participating provider, 

14 unless the plan or issuer does not have an ap15 propriate specialist that is available and acces16 sible to treat the enrollee’s condition and that 

17 is a participating provider with respect to such 

18 treatment. 

19 ‘‘(D) TREATMENT OF NONPARTICIPATING

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

21 enrollee to a nonparticipating specialist, services 

22 provided pursuant to the referral shall be pro23 vided at no additional cost to the enrollee be24 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 affiliated 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 pro4 vider’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 clin7 ical review criteria specific to children and de8 veloped pursuant to the program with the input 

9 of appropriate physicians, including pediatri10 cians, nonprimary care pediatric specialists, and 

11 other 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 (42 U.S.C. 

10 300gg–4 et seq.) is amended by adding at the end 

11 the following: 

12 ‘‘SEC. 2707. CHILDREN’S HEALTH ACCOUNTABILITY STAND13 ARDS. 

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

15 shall comply with children’s health accountability require16 ment under part C with respect to group health insurance 

17 coverage it offers. 

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

19 Health and Human Services and the Secretary of Labor 

20 shall ensure, through the execution of an interagency 

21 memorandum of understanding between such Secretaries, 

22 that—

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

24 issued by such Secretaries relating to the same mat25 ter over which such Secretaries have responsibility 
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1 under part C (and this section) and section 714 of 

2 the Employee Retirement Income Security Act of 

3 1974 are administered so as to have the same effect 

4 at all times; and 

5 ‘‘(2) coordination of policies relating to enforc6 ing the same requirements through such Secretaries 

7 in order to have a coordinated enforcement strategy 

8 that avoids duplication of enforcement efforts and 

9 assigns priorities in enforcement.’’. 

10 (2) CONFORMING AMENDMENT.—Section 2792 

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

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

13 after ‘‘of 1996’’. 

14 (c) APPLICATION TO INDIVIDUAL HEALTH INSUR15 ANCE COVERAGE.—Part B of title XXVII of the Public 

16 Health Service Act (42 U.S.C. 300gg–41 et seq.) is 

17 amended by inserting after section 2752 the following: 

18 ‘‘SEC. 2753. CHILDREN’S HEALTH ACCOUNTABILITY STAND19 ARDS. 

20 ‘‘Each health insurance issuer shall comply with chil21 dren’s health accountability requirements under part C 

22 with respect to individual health insurance coverage it of23 fers.’’. 

24 (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 2707 and part 

14 C, and part D insofar as it applies to section 2707 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) is amended—

23 (A) in subsection (a), by striking ‘‘sub24 section (b), nothing in this part’’ and inserting 

25 ‘‘subsections (b) and (c)’’; and 
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1 (B) by adding at the end the following new 

2 subsection: 

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

4 HEALTH ACCOUNTABILITY REQUIREMENTS.—Subject to 

5 subsection (b), the provisions of section 2753 and part C, 

6 and part D insofar as it applies to section 2753 or part 

7 C, shall not prevent a State from establishing require8 ments relating to the subject matter of such provisions 

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

10 health insurance issuers as the requirements imposed 

11 under such section.’’. 

12 SEC. 3. AMENDMENTS TO THE EMPLOYEE RETIREMENT IN13 COME SECURITY ACT OF 1974. 

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

15 B of title I of (29 U.S.C. 1185 et seq.) is amended by 

16 adding at the end the following: 

17 ‘‘SEC. 714. CHILDREN’S HEALTH ACCOUNTABILITY STAND18 ARDS. 

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

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

21 Service Act shall apply under this subpart and part to a 

22 group health plan (and group health insurance coverage 

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

24 part were incorporated in this section.
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1 ‘‘(b) APPLICATION.—In applying subsection (a) 

2 under this subpart and part, any reference in such part 

3 C—

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

5 be a reference only to group health insurance cov6 erage offered in connection with a group health plan 

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

8 health plan; 

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

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

11 group health insurance coverage or, with respect to 

12 a group health plan, to the plan; 

13 ‘‘(3) to the Secretary is deemed to be a ref14 erence to the Secretary of Labor; 

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

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

17 ‘‘(5) to an enrollee with respect to health insur18 ance coverage is deemed to include a reference to a 

19 participant or beneficiary with respect to a group 

20 health plan.’’. 

21 (b) MODIFICATION OF PREEMPTION STANDARDS.—

22 Section 731 of the Employee Retirement Income Security 

23 Act of 1974 (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 the Employee Retirement 

16 Income Security Act of 1974 (29 U.S.C. 1185(a)) is 

17 amended by striking ‘‘section 711’’ and inserting 

18 ‘‘sections 711 and 714’’. 

19 (2) The table of contents in section 1 of the 

20 Employee Retirement Income Security Act of 1974 

21 is amended by inserting after the item relating to 

22 section 713 the following new item:

‘‘Sec. 714. 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 
27

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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 Health, Edu16 cation, Labor, and Pensions of the Senate and the 

17 Committee on Commerce of the House of Represent18 atives a report, 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. 
28

•S 1710 IS 

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 med6 icaid managed care organizations under title 

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

8 et 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 Health, Education, Labor, and Pen18 sions of the Senate and the Committee on Commerce 

19 of the House of Representatives a report that con20 tains a survey of health plan activities that address 

21 the unique health needs of adolescents, including 

22 quality measures for adolescents and innovative 

23 practice arrangement.

Æ