I
105TH CONGRESS
2D SESSION
H. R. 4202
To amend title XXVII of the Public Health Service Act to establish certain
standards with respect to health plans.
IN THE HOUSE OF REPRESENTATIVES
JULY 14, 1998
Mr. ENSIGN introduced the following bill; which was referred to the
Committee on Commerce
A BILL
To amend title XXVII of the Public Health Service Act
to establish certain standards with respect to health plans.
Be it enacted by the Senate and House of Representa-
tives of the United States of America in Congress assembled,
SECTION 1. SHORT TITLE; TABLE OF CONTENTS.
(a) SHORT TITLE.—This Act may be cited as the
‘‘Health Quality and Fairness Act of 1998’’.
(b) TABLE OF CONTENTS.—The table of contents of
this Act is as follows:
Sec. 1. Short title; table of contents.
Sec. 2. Patient protection standards under the Public Health Service Act.
‘‘PART C—PATIENT PROTECTION STANDARDS
‘‘Sec. 2770. Notice.
‘‘Sec. 2771. Coverage of services.
‘‘Sec. 2772. Access to emergency care.
‘‘Sec. 2773. Protecting the doctor-patient relationship.
‘‘Sec. 2774. Quality assurance.
‘‘Sec. 2775. Designation of primary care provider.
‘‘Sec. 2776. Grievance and appeals procedures.
‘‘Sec. 2777. Understandability of information.’’.
SEC. 2. PATIENT PROTECTION STANDARDS UNDER THE
PUBLIC HEALTH SERVICE ACT.
(a) 
PATIENT
PROTECTION
STANDARDS.—Title
XXVII of the Public Health Service Act is amended—
(1) by redesignating part C as part D, and
(2) by inserting after part B the following new
part:
‘‘PART C—PATIENT PROTECTION STANDARDS
‘‘SEC. 2770. NOTICE.
‘‘A health insurance issuer under this part shall com-
ply with the notice requirement under section 711(d) of
the Employee Retirement Income Security Act of 1974
with respect to the requirements of this part as if such
section applied to such issuer and such issuer were a
group health plan.
‘‘SEC. 2771. COVERAGE OF SERVICES.
‘‘(a) IN GENERAL.—If a health insurance issuer of-
fering health insurance coverage provides benefits with re-
spect to a service, and a physician recommends such serv-
ice for an enrollee, the issuer shall cover any service fur-
nished under the coverage unless a physician who has re-
viewed the notes of the attending physician and any medi-
cal records of the enrollee determines that such services
should not be covered.
‘‘(b) WRITTEN DENIAL OF COVERAGE.—In a case in
which a health insurance issuer denies coverage of a serv-
ice to an enrollee, issuer shall provide, in writing, to the
enrollee, the physician who recommended such service, and
the primary physician of the enrollee—
‘‘(1) the reasons for the denial of coverage;
‘‘(2) the criteria used to determine whether to
authorize or deny coverage; and
‘‘(3) the right of the enrollee to file a written
grievance.
‘‘SEC. 2772. ACCESS TO EMERGENCY CARE.
‘‘(a) COVERAGE OF EMERGENCY SERVICES.—
‘‘(1) IN
GENERAL.—If health insurance cov-
erage provides any benefits with respect to emer-
gency services (as defined in paragraph (2)(B)), the
plan or issuer shall cover emergency services fur-
nished under the plan or coverage—
‘‘(A) without the need for any prior au-
thorization determination;
‘‘(B) whether or not the physician or pro-
vider furnishing such services is a participating
physician or provider with respect to such serv-
ices; and
‘‘(C) without regard to any other term or
condition of such coverage (other than exclusion
or coordination of benefits, or an affiliation or
waiting period, permitted under section 2701 of
the Public Health Service Act, section 701 of
the Employee Retirement Income Security Act
of 1974, or section 9801 of the Internal Reve-
nue Code of 1986, and other than applicable
cost sharing).
‘‘(2) DEFINITIONS.—In this section:
‘‘(A) EMERGENCY
MEDICAL
CONDITION
BASED ON PRUDENT LAYPERSON STANDARD.—
The term ‘emergency medical condition’ means
a medical condition manifesting itself by acute
symptoms of sufficient severity (including se-
vere pain) such that a prudent layperson, who
possesses an average knowledge of health and
medicine, could reasonably expect the absence
of immediate medical attention to result in a
condition described in clause (i), (ii), or (iii) of
section 1867(e)(1)(A) of the Social Security
Act.
‘‘(B) EMERGENCY
SERVICES.—The term
‘emergency services’ means health care items
and services that are necessary for the diag-
nosis, treatment, and stabilization of an emer-
gency medical condition.
‘‘SEC. 2773. PROTECTING THE DOCTOR-PATIENT RELATION-
SHIP.
‘‘(a) PROHIBITION
ON RESTRICTING COMMUNICA-
TION.—A health insurance issuer offering health insur-
ance coverage may not restrict or interfere with any com-
munication between a health care professional and an en-
rollee with respect to information that the health care pro-
fessional determines is relevant to the health care of the
enrollee.
‘‘(b) PROHIBITION ON FINANCIAL INCENTIVES.—A
health insurance issuer offering health insurance coverage
may not offer or pay any financial incentive to a provider
of health care services to deny, reduce, withhold, limit, or
delay services to an enrollee.
‘‘(c) PROHIBITION ON RETALIATION.—A health in-
surance issuer offering health insurance coverage may not
terminate a contract, demote, refuse to contract with, or
refuse to compensate a health care professional because
the professional—
‘‘(1) advocates on behalf of an enrollee;
‘‘(2) assists an enrollee in seeking reconsider-
ation of a decision by the issuer to deny coverage for
a service; or
‘‘(3) reports a violation of law to an appropriate
authority.
‘‘SEC. 2774. QUALITY ASSURANCE.
‘‘(a) REQUIREMENT.—A health insurance issuer of-
fering health insurance coverage shall establish and main-
tain an ongoing quality assurance program that meets the
requirements of subsection (b).
‘‘(b) PROGRAM REQUIREMENTS.—The requirements
of this subsection for a quality assurance program of an
issuer are as follows:
‘‘(1) ADMINISTRATION.—The issuer has an
identifiable unit with responsibility for administra-
tion of the program.
‘‘(2) WRITTEN PLAN.—The issuer has a written
plan, developed in consultation with health care pro-
fessionals, that is updated annually and that speci-
fies at least the following:
‘‘(A) Criteria and procedures for the as-
sessment of quality.
‘‘(B) Criteria and procedures for determin-
ing coverage of services.
‘‘(3) REVIEW.—The program provides for sys-
tematic review of the following:
‘‘(A) Outcomes of health care services;
‘‘(B) Peer review;
‘‘(1) payment or reimbursement for covered
services;
‘‘(2) availability, delivery, and quality of serv-
ices; and
‘‘(3) terms and conditions of the plan or cov-
erage.
‘‘(b) GENERAL ELEMENTS.—The system shall in-
clude—
‘‘(1) the general components described in sub-
section (c); and
‘‘(2) a process for appeals of adverse denials of
benefits—
‘‘(A) through an internal appeal process;
‘‘(B) through an external appeal process;
and
‘‘(C) through a process for expediting re-
view of the internal appeals process.
‘‘(c) COMPONENTS OF THE SYSTEM.—Such system
shall include the following components with respect indi-
viduals who are enrollees:
‘‘(1) The availability of a services representative
to assist such individuals, as requested, with the
grievance procedures.
‘‘(2) A system to record and document, over a
period of at least 3 years, all grievances made and
their status.
‘‘(3) A process providing for timely processing
and resolution of grievances.
‘‘(d) INTERNAL APPEALS PROCESS.—
‘‘(1) IN
GENERAL.—Each health insurance
issuer shall establish and maintain an internal ap-
peals process under which any enrollee, or provider
acting on behalf of such an individual with the indi-
vidual’s consent, who is dissatisfied with the results
of the issuer has the opportunity to appeal the re-
sults before a review panel.
‘‘(2) DEADLINE.—
‘‘(A) IN GENERAL.—The issuer shall con-
clude each appeal as soon as possible after the
time of the receipt of the appeal in accordance
with medical exigencies of the case involved, but
in no event later than—
‘‘(i) 72 hours after the time of receipt
of the appeal in the case of appeals from
decisions regarding urgent care, and
‘‘(ii) 30 business days after such time
in the case of all other appeals.
‘‘(3) NOTICE.—If an issuer denies an appeal,
the issuer shall provide the enrollee and provider in-
volved with written notification of the denial and the
reasons therefor, together with a written notification
of rights to any further appeal.
‘‘(e) EXTERNAL APPEALS PROCESS.—A health insur-
ance issuer offering group health insurance coverage, shall
provide for an external appeals process which may be used
upon completion of the internal review process under sub-
section (d). The process shall be conducted consistent with
standards established by the Secretary.
‘‘(f) EXPEDITED REVIEW PROCESS.—A health insur-
ance issuer shall establish written procedures for the expe-
dited consideration of appeals in situations in which the
timeframe of a standard appeal under the respective sub-
section has reasonable potential to jeopardize seriously the
life or health of the participant, beneficiary, or enrollee
involved or has reasonable potential to jeopardize such an
individual’s ability to regain maximum function.
‘‘SEC. 2777. UNDERSTANDABILITY OF INFORMATION.
‘‘Information provided to or made available to enroll-
ees under this part, whether written or oral, shall be easily
understandable by an average layperson, with respect to
the terms used.’’.
(b) EFFECTIVE DATE.—The amendments made by
subsection (a) shall apply to causes of action arising on
or after the date of the enactment of this Act.
Æ