I
104TH CONGRESS
1ST SESSION
H. R. 2400
To establish standards for health plan relationships with enrollees, health
professionals, and providers.
IN THE HOUSE OF REPRESENTATIVES
SEPTEMBER 27, 1995
Mr. NORWOOD (for himself and Mr. BREWSTER) introduced the following bill;
which was referred to the Committee on Commerce
A BILL
To establish standards for health plan relationships with
enrollees, health professionals, and providers.
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
‘‘Family Health Care Fairness Act of 1995’’.
(b) TABLE OF CONTENTS.—The table of contents of
this Act is as follows:
Sec. 1. Short title; table of contents.
TITLE I—DEFINITIONS; GENERAL PROVISIONS
Sec. 101. Definitions.
Sec. 102. Certification of health plans.
Sec. 103. Effect on certain State laws.
TITLE II—CERTIFICATION OF HEALTH PLANS
Sec. 201. Enrollee access to care.
Sec. 202. Enrollee choice of health professionals and providers.
Sec. 203. Nondiscrimination; equitable access to networks.
Sec. 204. Development of plan policies.
Sec. 205. Due process for enrollees.
Sec. 206. Due process for health professionals and providers.
Sec. 207. Information reporting and disclosure by network plans.
Sec. 208. Other health plan requirements.
Sec. 209. Quality assurance program; case review.
Sec. 210. Related provisions.
TITLE III—ENFORCEMENT
Sec. 301. Health plan standards.
Sec. 302. Health plan liability.
TITLE I—DEFINITIONS;
GENERAL PROVISIONS
SEC. 101. DEFINITIONS.
For purposes of this Act:
(1) EMERGENCY
MEDICAL
CONDITION.—The
term ‘‘emergency medical condition’’ means a medi-
cal condition (including emergency labor and deliv-
ery) manifesting itself by acute symptoms of suffi-
cient severity (including severe pain) such that the
absence of immediate medical attention could rea-
sonably be expected to result in—
(A) placing the patient’s health in serious
jeopardy,
(B) serious impairment to bodily functions,
or
(C) serious dysfunction of any bodily organ
or part.
(2) EMERGENCY SERVICES.—The term ‘‘emer-
gency services’’ means health care items and services
that are necessary for the treatment of an emer-
gency medical condition.
(3) ENROLLEE.—The term ‘‘enrollee’’ means,
with respect to a health plan, an individual enrolled
with the health plan.
(4) ENROLLEE WITH SPECIAL HEALTH CARE
NEEDS.—The term ‘‘enrollee with special health care
needs’’ means an enrollee who is an individual or a
member of a family that includes an individual with
a disability or chronic condition.
(A) For purposes of section 202(c)(2)(A),
relating to the Point-of-Service Option, such en-
rollee shall be additionally defined as having an
adjusted gross income that does not exceed 250
percent of the official poverty line (as defined
by the Office of Management and Budget, and
revised annually in accordance with section
673(2) of the Omnibus Budget Reconciliation
Act of 1981) applicable to a family of the size
involved.
(5) HEALTH PLAN.—The term ‘‘health plan’’ or
‘‘plan’’ refers to any plan or arrangement that pro-
vides, or pays the cost of, health benefits, whether
through insurance, reimbursement, or otherwise.
(6) 
HEALTH
PROFESSIONAL.—The 
term
‘‘health professional’’ means only an individual who
is licensed, certified, accredited, or otherwise
credentialed to provide health care items and serv-
ices as authorized by State law (or a State regu-
latory mechanism provided by State law).
(7) INDIVIDUALLY
IDENTIFIABLE
INFORMA-
TION.—The term ‘‘individually identifiable informa-
tion’’ means, with respect to an enrollee, a health
professional, or a provider, any information, whether
oral or recorded in any medium or form, that identi-
fies or can readily be associated with the identity of
the enrollee, the health professional, or the provider.
(8) MEDICALLY
UNDERSERVED
AREA.—The
term ‘‘medically underserved area’’ means an area
that is designated as a health professional shortage
area under section 332 of the Public Health Service
Act or as a medically underserved area for purposes
of section 330 or 1302(7) of such Act.
(9) NETWORK.—The term ‘‘network’’ means,
with respect to a network plan, the participating
health professionals and providers through whom the
plan provides health care items and services to en-
rollees.
(10) NETWORK
PLAN.—The term ‘‘network
plan’’ means a health plan that provides or arranges
for the provision of health care items and services to
enrollees through participating health professionals
and providers.
(11) PARTICIPATING.—The term ‘‘participat-
ing’’ means, with respect to a health professional or
provider, a health professional or provider that pro-
vides health care items and services to enrollees of
a network plan under an agreement with the plan.
(12) PROVIDER.—The term ‘‘provider’’ means a
health organization, health facility, or health agency
that is licensed, certified, credentialed, or otherwise
authorized to provide health care items and services
under applicable State law.
(13) RURAL
AREA.—The term ‘‘rural area’’
means an area that is not within a Standard Metro-
politan Statistical Area or a New England County
Metropolitan Area (as defined by the Office of Man-
agement and Budget).
(14) 
SECRETARY.—The 
term 
‘‘Secretary’’
means the Secretary of Health and Human Services.
(15) SERVICE AREA.—The term ‘‘service area’’
means, with respect to a health plan, the geographic
area served by the plan.
(16) SPECIALIZED
TREATMENT
EXPERTISE.—
The term ‘‘specialized treatment expertise’’ means—
(A) expertise in diagnosing and treating
unusual diseases and conditions,
(B) diagnosing and treating diseases and
conditions that are unusually difficult to diag-
nose or treat, and
(C) providing other specialized health care.
(17) URGENT CARE SERVICES.—The term ‘‘ur-
gent care services’’ means health care items and
services that are necessary for the treatment of a
condition that—
(A) is not an emergency medical condition,
(B) requires prompt medical or clinical
treatment, and
(C) poses a danger to the patient if not
treated in a timely manner (as defined by the
Secretary).
(18) UTILIZATION REVIEW.—The term ‘‘utiliza-
tion review’’ means prospective, concurrent, or retro-
spective review of health care items and services for
medical necessity, appropriateness, or quality of care
that includes preauthorization requirements for cov-
erage of such items and services.
SEC. 102. CERTIFICATION OF HEALTH PLANS.
(a) IN GENERAL.—The Secretary, shall establish a
process under which—
(1) a health plan may apply to be certified
under this Act;
(2) such certification is periodically reviewed;
and
(3) such certification is terminated or not re-
newed if the health plan fails substantially to meet
the requirements of this Act.
To the extent practicable, the process shall be the same
as the process used to determine if an entity is an eligible
organization under section 1876 of the Social Security
Act. To the extent the Secretary does not use that process,
the Secretary shall submit a report to Congress that ex-
plains the reasons for the differences.
(b) CONDITIONS OF CERTIFICATION.—The Secretary
shall certify a health plan under this Act if the Secretary
finds that the plan meets the applicable requirements of—
(1) section 201 (relating to enrollee access to
care);
(2) section 202 (relating to enrollee choice for
network plans);
(2) a network plan to include as a participating
health professional or provider any health profes-
sional or provider that accepts the terms and condi-
tions established by the plan for other participating
providers; or
(3) a health plan to permit enrollees access to
a specified category, class, or type of health profes-
sional or provider without a referral from a physi-
cian.
TITLE II—CERTIFICATION OF
HEALTH PLANS
SEC. 201. ENROLLEE ACCESS TO CARE.
(a) IN GENERAL.—A health plan meets the require-
ments of this section if the plan meets—
(1) the general access requirements of sub-
section (b);
(2) the requirements for access to emergency
and urgent care services of subsection (c); and
(3) in the case of a network plan—
(A) the requirements for access to special-
ized services of subsection (d); and
(B) the requirements of subsection (e) re-
lating to incentive plans.
(b) GENERAL ACCESS.—
(1) IN GENERAL.—Subject to paragraphs (2),
(3), and (4), a health plan meets the requirements
of this subsection if the plan establishes and main-
tains adequate arrangements with a sufficient num-
ber, mix, and distribution of health professionals and
providers to assure that covered items and services
are available and accessible to each enrollee—
(A) in the service area of the plan;
(B) in a variety of sites of service;
(C) with reasonable promptness (including
reasonable hours of operation and after-hours
services);
(D) with reasonable proximity to the resi-
dences and workplaces of enrollees; and
(E) in a manner that—
(i) takes into account the diverse
needs of enrollees, and
(ii) reasonably assures continuity of
care.
(2) EXCLUSIVE
CONTRACTS.—A health plan
that has an arrangement with only 1 provider to fur-
nish a particular service or category of services to
enrollees may not be treated as meeting the require-
ments of this subsection unless such provider is the
only provider of such service or category of service
in the service area of the plan and otherwise meets
the requirements of this Act.
(3) RURAL
AND
UNDERSERVED
AREAS.—A
health plan that serves a geographic area that is
rural or medically underserved shall be treated as
meeting the requirement that it have a sufficient
number, mix, and distribution of health professionals
and providers with respect to such area if the plan—
(A) has arrangements with a sufficient
number of health professionals and providers in
those categories of health professionals and pro-
viders specified by the Secretary as having a
history of serving rural or medically under-
served areas, or
(B) meets such other conditions as the
Secretary may establish.
(4) RULE OF CONSTRUCTION.—Nothing in this
subsection shall be construed as requiring a health
plan to have arrangements that conflict with its re-
sponsibilities to establish measures designed to
maintain quality and control costs.
(c) EMERGENCY AND URGENT CARE.—A health plan
meets the requirements of this subsection if the plan—
(1) assures the availability and accessibility of
medically or clinically necessary emergency services
and urgent care services within the service area of
the plan 24 hours a day, 7 days a week;
(2) requires no preauthorization for items and
services furnished in a hospital emergency depart-
ment to an enrollee with symptoms that reasonably
suggest an emergency medical condition (including
items and services described in paragraph (3)(C));
(3) covers (and makes reasonable payments
for)—
(A) emergency services,
(B) services that are not emergency serv-
ices but are described in paragraph (2),
(C) medical screening examinations and
other ancillary services necessary to determine
if a medical condition is an emergency medical
condition, and
(D) urgent care services,
without regard to whether the health professional or
provider furnishing such services has a contractual
(or other) arrangement with the plan; and
(4) make preauthorization determinations for—
(A) services that are furnished in a hos-
pital emergency department (other than services
described in paragraph (3)), and
(B) urgent care services,
within the time periods specified in (or pursuant to)
section 205(b)(8).
(d) SPECIALIZED SERVICES.—
(1) IN GENERAL.—A network plan meets the
requirement of this subsection if the plan dem-
onstrates that enrollees have access to specialized
treatment expertise when such treatment is medi-
cally or clinically indicated in the professional judg-
ment of the treating health professional, in consulta-
tion with the enrollee.
(2) METHOD OF MEETING REQUIREMENT.—A
network plan may meet the requirement of this sub-
section by entering into agreements with, and dem-
onstrating sufficient referrals to, centers of special-
ized treatment expertise designated by the Secretary.
(e) INCENTIVE PLANS.—A network plan meets the
requirements of this subsection if any health professional
or provider incentive plan operated by the plan meets the
requirements of section 1876(i)(8)(A) of the Social Secu-
rity Act.
SEC. 202. ENROLLEE CHOICE OF HEALTH PROFESSIONALS
AND PROVIDERS.
(a) IN GENERAL.—A health plan meets the require-
ments of this section if the plan meets—
(1) the requirement of subsection (b) that en-
rollees have a choice of personal health professional;
(2) the requirement of subsection (c) that a
plan cover services furnished by out-of-network pro-
viders; and
(3) the requirements of subsection (d) that the
plan assure continuity of care.
(b) CHOICE
OF
PERSONAL
HEALTH
PROFES-
SIONAL.—The requirement of this subsection is that a net-
work plan permit each enrollee—
(1) to select a personal health professional from
among the participating health professionals of the
plan, and
(2) to change that selection as appropriate.
(c) POINT-OF-SERVICE OPTION.—
(1) IN GENERAL.—The requirement of this sub-
section is that a network plan—
(A) cover items and services furnished to
an enrollee by a health professional or provider
that is not a participating health professional or
provider; and
(B) establish cost-sharing requirements for
items and services described in subparagraph
(A) that do not exceed the limits on such cost
sharing established under paragraph (2).
(2) LIMITS.—The Secretary shall establish—
(A) a schedule of limits on cost sharing for
items and services described in paragraph
(1)(A) for enrollees with special health care
needs or a chronic condition, as defined in sec-
tion 101(4)(A), and
(B) a schedule of limits on cost sharing for
such items and services for other enrollees.
The limits established under subparagraph (A) shall,
on average, provide for cost-sharing requirements
that are at least 40 percent lower than the limits es-
tablished under subparagraph (B).
(d) CONTINUITY OF CARE.—The requirements of this
subsection are that a network plan—
(1) ensure that any process established by the
plan to coordinate care and control costs does not
create an undue burden for enrollees with special
health care needs or chronic conditions;
(2) ensure direct access to relevant specialists
for the continued care of such enrollees when medi-
cally or clinically indicated in the judgment of the
treating health professional, in consultation with the
enrollee;
(3) in the case of an enrollee with special health
care needs or a chronic condition, determine wheth-
er, based on the judgment of the treating health pro-
fessional, in consultation with the enrollee, it is
medically or clinically necessary or appropriate to
use a specialist or a care coordinator from an inter-
disciplinary team to ensure continuity of care; and
(4) in circumstances under which a change of
health professional or provider might disrupt the
continuity of care for an enrollee, such as—
(A) hospitalization, or
(B) dependency on high-technology home
medical equipment,
provide for continued coverage of items and services
furnished by the health professional or provider that
was treating the enrollee before such change for a
reasonable period of time (as specified by the Sec-
retary) after such change would otherwise occur.
For purposes of paragraph (4), the Secretary shall specify
such reasonable period of time, ranging from no fewer
than 1 to no greater than 150 days (or not greater than
60 days after delivery in the case of a pregnancy), with
extension of such a period permitted in the cases of medi-
cal necessity. For purposes of such paragraph a change
of health professional or provider may be due to changes
in the membership of a plan’s health professional and pro-
vider network, changes in the health plan made available
by an employer, and other similar circumstances specified
by the Secretary as beyond the control of an enrollee.
SEC. 203. NONDISCRIMINATION; EQUITABLE ACCESS TO
NETWORKS.
(a) IN GENERAL.—A health plan meets the require-
ments of this section if the plan—
(1) meets the requirement of subsection (b)
that the plan not discriminate;
(2) in the case of a network plan, meets the re-
quirement of subsection (c) that the plan not dis-
criminate in the selection of providers and health
professionals; and
(3) meets the requirement of subsection (d)
that the plan not discriminate in the payment of
health professionals and providers.
(b) NONDISCRIMINATION.—No health plan may dis-
criminate (directly or through contractual arrangements)
in any activity, including the selection of a service area,
that has the effect of discriminating against an individual
on the basis of race, national origin, gender, language, so-
cioeconomic status, age, disability, health status, or antici-
pated need for health services.
(c) NONDISCRIMINATION
IN SELECTION
OF NET-
WORK MEMBERS.—The requirement of this subsection is
that a network plan does not discriminate in selecting the
members of its health professional and provider network
(or in establishing the terms and conditions for member-
ship in such network) on the basis of—
(1) the race, national origin, gender, language,
age or disability of the health professional;
(2) the socioeconomic status, disability, health
status, or anticipated need for health services of the
patients of a health professional or provider; or
(3) the health professional or provider’s lack of
affiliation with, or admitting privileges at, a hospital
(unless such lack of affiliation is a result of infrac-
tions of quality standards and is not due to a provid-
er’s type of license).
(d) NONDISCRIMINATION
IN ACCESS
TO HEALTH
PLANS.—A health plan meets the requirements of this
subsection if the plan—
(1) does not—
(A) in the case of a network plan, discrimi-
nate in participation of, and
(B) in the case of a health plan that is not
a network plan, deny reimbursement or indem-
nification to,
a health professional who is acting within the scope
of the health professional’s license under applicable
State law solely on the basis of such license or cer-
tification; and
(2) does not—
(A) in the case of a network plan, discrimi-
nate in participation of, and
(B) in the case of a health plan that is not
a network plan, deny reimbursement or indem-
nification to,
a provider that is providing services that are within
the scope of services that the provider is authorized
to provide under State law.
SEC. 204. DEVELOPMENT OF PLAN POLICIES.
The requirement of this section is that a network
plan establish mechanisms to incorporate the rec-
ommendations, suggestions, and views of enrollees and
participating health professionals and providers into—
(1) the medical policies of the plan (including
policies relating to coverage of new technologies,
treatments, and procedures);
(2) the utilization review criteria and proce-
dures of the plan;
(3) the quality and credentialing criteria of the
plan; and
(4) the medical management procedures of the
plan.
(8) make the results of such profiling available
to plan purchasers, enrollees, and the health profes-
sional or provider involved;
(9) notify any health professional or provider
being reviewed under the process referred to in para-
graph (3) of any information indicating that the
health professional or provider fails to meet the
standards of the plan;
(10) offer a health professional or provider re-
ceiving notice pursuant to the requirement of para-
graph (9) with an opportunity to—
(A) review the information referred to in
such paragraph, and
(B) submit supplemental or corrected in-
formation;
(11) not include in its contracts with participat-
ing health professionals and providers a provision
permitting the plan to terminate the contract ‘‘with-
out cause’’;
(12) provide a due process appeal that con-
forms to the process specified in section 412 of the
Health Care Quality Improvement Act of 1986 (42
U.S.C. 11112) for all determinations that are ad-
verse to a health professional or provider; and