I
104TH CONGRESS
2D SESSION
H. R. 3751
To establish certain requirements for managed care plans.
IN THE HOUSE OF REPRESENTATIVES
JUNE 27, 1996
Ms. VELA´ZQUEZ (for herself, Mr. OWENS, Mr. NADLER, Mr. CONYERS, Mr.
HILLIARD, Mr. THOMPSON, Mr. EVANS, and Mr. JOHNSTON of Florida)
introduced the following bill; which was referred to the Committee on
Commerce
A BILL
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.
This Act may be cited as the ‘‘Managed Care Bill
of Rights for Consumers Act of 1996’’.
SEC. 2. REQUIREMENTS FOR MANAGED CARE PLANS.
(a) REQUIRED
COVERAGE
FOR
SERVICES
FUR-
NISHED BY SPECIALIST NOT CONTRACTED WITH MAN-
AGED CARE PLAN.—In a case in which an enrollee of a
managed care plan demonstrates to the plan that the plan
does not provide a specialist with knowledge of a specific
condition for which the enrollee requires treatment, the
plan shall cover such services covered by the plan, under
comparable terms and conditions, furnished by a specialist
obtained by the enrollee without regard to whether or not
the specialist has a contractual or other arrangement with
the plan for the provision of such services to such enroll-
ees.
(b) REQUIREMENT FOR CONTINUED SERVICES OF A
SPECIALIST WITHOUT PRE-AUTHORIZATION.—In a case
in which an enrollee of a managed care plan requires con-
tinued treatment of a specific condition from a specialist
with knowledge of the specific condition, and such enrollee
has been referred by a primary care physician to a special-
ist, the enrollee may continue to obtain services from the
specialist without additional authorization from the pri-
mary care physician.
(c) ASSURING EQUITABLE COVERAGE WITH RE-
SPECT TO EMERGENCY SERVICES.—A managed care plan
that provides any coverage with respect to emergency serv-
ices (as defined in section 5(4)) shall cover emergency
services furnished to an enrollee of the plan—
(1) without regard to whether or not the pro-
vider furnishing the emergency services has a con-
tractual or other arrangement with the plan for the
provision of such services to such enrollees, and
(2) without regard to prior authorization.
(d) REQUIREMENT FOR TRANSLATION BILINGUAL
RESOURCES.—In a case in which 5 percent of the enroll-
ees of a managed care plan in an area (as defined in sec-
tion 5(1)) are members of a single ethnic-minority group
that speaks English as a second language, the managed
care plan shall have available, on a continuous basis, a
person in the area to provide translation to such enrollees
in obtaining information and services under the plan. Such
person may be a doctor, nurse, or counselor who is em-
ployed by the managed care plan.
(e) PROHIBITION OF FINANCIAL BONUSES TO PHYSI-
CIANS WHO LIMIT SERVICES.—A managed care plan shall
ensure that no specific payment is made directly or indi-
rectly under the plan to a physician or physician group
as an inducement to reduce or limit medically necessary
services provided with respect to an enrollee.
(f) DETERMINATION
OF MEDICALLY NECESSARY
AND APPROPRIATE TREATMENT.—
(1) IN GENERAL.—Under a managed care plan,
the determination of what is medically necessary and
appropriate for the health of an enrollee may be
made only by a licensed health care practitioner.
(2) SECOND OPINION AS TO MEDICALLY NEC-
ESSARY.—Any licensed health care practitioner who