I
107TH CONGRESS
1ST SESSION
H. R. 2497
To amend the Public Health Service Act and the Employee Retirement
Income Security Act of 1974 to establish certain requirements for man-
aged care plans.
IN THE HOUSE OF REPRESENTATIVES
JULY 12, 2001
Ms. VELA´ZQUEZ introduced the following bill; which was referred to the Com-
mittee on Energy and 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 the Public Health Service Act and the Employee
Retirement Income Security Act of 1974 to establish
certain requirements for managed care 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
‘‘Managed Care Bill of Rights for Consumers Act of
2001’’.
(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. Guarantee of medically necessary and appropriate treatment.
‘‘Sec. 2771. Guaranteed adequate access to health care.
‘‘Sec. 2772. Right to adequate physician network.
‘‘Sec. 2773. Meaningful choice of providers.
‘‘Sec. 2774. Guaranteed continuity of care.
‘‘Sec. 2775. Right to specialty care.
‘‘Sec. 2776. Required obstetric and gynecological care.
‘‘Sec. 2777. Assuring equitable coverage of emergency services.
‘‘Sec. 2778. Requirement for service to areas that include a medically un-
derserved population.
‘‘Sec. 2779. Right to language assistance.
‘‘Sec. 2780. Prohibition on financial incentives to limit care.
‘‘Sec. 2781. Prohibition on gag clauses.
‘‘Sec. 2782. Right to appeal denial of care.
‘‘Sec. 2783. External review.
‘‘Sec. 2784. Nondiscrimination right.
‘‘Sec. 2785. Protection of patient confidentiality.
‘‘Sec. 2786. Establishment of Managed Care Consumer Advisory Commis-
sion.
‘‘Sec. 2787. Requirements for prescription drug coverage; definitions.
‘‘Sec. 2788. Notice; definitions; application of enforcement provisions.
Sec. 3. Patient protection standards under the Employee Retirement Income
Security Act of 1974.
Sec. 4. Nonpreemption of State law respecting liability of group health plans.
Sec. 5. Effective date.
SEC. 2. PATIENT PROTECTION STANDARDS UNDER THE
PUBLIC HEALTH SERVICE ACT.
(a) IN GENERAL.—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. GUARANTEE OF MEDICALLY NECESSARY AND
APPROPRIATE TREATMENT.
‘‘(a) IN GENERAL.—A managed care plan may not
impose limits on the delivery of services if such services
are—
‘‘(1) medically necessary and appropriate as de-
termined by the treating health professional, in con-
sultation with the enrollee; and
‘‘(2) otherwise a covered benefit.
‘‘(b) SECOND OPINION.—A managed care plan shall
provide to an enrollee, upon request, a referral to a health
care practitioner for a second opinion as to what con-
stitutes medically necessary and appropriate treatment,
and provide coverage for such opinion without regard to
whether such health care practitioner has a contractual
or other arrangement with the plan for the provision of
such services to such enrollee.
‘‘SEC. 2771. GUARANTEED ADEQUATE ACCESS TO HEALTH
CARE.
‘‘(a) ADEQUATE ACCESS.—A managed care plan
shall provide adequate access to health care services.
‘‘(b) AVAILABLE ITEMS AND SERVICES.—The Sec-
retary shall ensure that items and services, including lab-
oratory and specialist services, covered under the plan
shall be available through providers that are reasonably
geographically accessible to all enrollees of such plan.
‘‘SEC. 2772. RIGHT TO ADEQUATE PHYSICIAN NETWORK.
‘‘(a) IN GENERAL.—A managed care plan shall main-
tain an adequate number, mix, and distribution of health
professionals and providers to ensure that covered items
and services are available and accessible to each enrollee.
‘‘(b) ADEQUATE
DISTRIBUTION.—The Secretary
shall determine the adequate number, mix, and distribu-
tion of health professionals and providers within the serv-
ice area of the managed care plan, including—
‘‘(1) the existence of a primary care provider
network that is sufficient to meet adult, pediatric,
and primary obstetric and gynecological needs of all
enrollees;
‘‘(2) the existence of a network of specialists of
sufficient number and diversity to meet the specialty
needs of all enrollees;
‘‘(3) the access to quality health services from
institutional providers for all enrollees; and
‘‘(4) the existence of at least one primary care
physician for every 1,500 enrollees.
‘‘SEC. 2773. MEANINGFUL CHOICE OF PROVIDERS.
‘‘(a) MINIMUM NUMBER OF CHOICES.—A managed
care plan shall provide to enrollees a choice of at least
3 providers within each category of providers based on the
health care needs of such enrollees, taking into account
the age, gender, health, native language, acute or chronic
diseases, and special needs of the enrollee. The enrollee
may change the selection of provider at any time.
‘‘(b) ACCESS TO OUT-OF-NETWORK PROVIDER.—A
managed care plan shall cover services that are furnished
by a physician or provider obtained by the enrollee without
regard to whether such physician or provider has a con-
tractual or other arrangement with the plan for the provi-
sion of such services to such enrollees. The plan may im-
pose a reasonable deductible and reasonable copayment
subject to a reasonable annual limit on total annual out-
of-pocket expenses.
‘‘SEC. 2774. GUARANTEED CONTINUITY OF CARE.
‘‘If a contract between a managed care plan and a
health care provider is terminated (other than by the plan
for failure to meet applicable quality standards or for
fraud) and an enrollee is undergoing a course of treatment
from the provider at the time of such termination, the plan
shall—
‘‘(1) notify the enrollee of such termination;
and
‘‘(2) permit the enrollee to continue the course
of treatment with the provider during a transitional
period as determined by the Secretary.
‘‘SEC. 2775. RIGHT TO SPECIALTY CARE.
‘‘(a) REFERRAL TO SPECIALISTS.—
‘‘(1) CHOICE OF SPECIALIST.—A managed care
plan shall permit each enrollee to receive specialty
care from any qualified participating health care
provider when such treatment is medically or clini-
cally necessary. The plan shall make or provide for
a referral to at least 3 specialists who are available
and accessible to provide treatment for such condi-
tion or disease.
‘‘(2) COST
OF
TREATMENT
BY
NONPARTICI-
PATING PROVIDERS.—In a case in which a plan re-
fers an enrollee to a nonparticipating specialist, the
plan shall cover any services provided by such spe-
cialist at the rate it covers comparable services pro-
vided by participating providers.
‘‘(b) CONTINUOUS REFERRALS.—A managed care
plan shall have a procedure by which an enrollee who has
a condition that requires ongoing care from a specialist
may receive a continuous referral to such specialist for
treatment of such condition, without additional authoriza-
tion from the primary care physician.