I
105TH CONGRESS
2D SESSION
H. R. 3469
To amend the Public Health Service Act, the Employee Retirement Income
Security Act of 1974, and the Internal Revenue Code of 1986 to require
that group and individual health insurance coverage and group health
plans provide for external appeals in the case of adverse determinations
involving experimental treatment, significant costs, or a serious medical
condition.
IN THE HOUSE OF REPRESENTATIVES
MARCH 17, 1998
Mr. CARDIN introduced the following bill; which was referred to the Commit-
tee on Commerce, and in addition to the Committees on Education and
the Workforce, and Ways and Means, for a period to be subsequently de-
termined 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, the Employee Re-
tirement Income Security Act of 1974, and the Internal
Revenue Code of 1986 to require that group and individ-
ual health insurance coverage and group health plans
provide for external appeals in the case of adverse deter-
minations involving experimental treatment, significant
costs, or a serious medical condition.
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 ‘‘Patient Right to Inde-
pendent Appeal Act of 1998’’.
SEC. 2. EXTERNAL APPEALS PROCESS FOR HEALTH PLANS.
(a) GROUP HEALTH PLANS.—
(1) PUBLIC
HEALTH
SERVICE
ACT
AMEND-
MENTS.—(A) Subpart 2 of part A of title XXVII of
the Public Health Service Act is amended by adding
at the end the following new section:
‘‘SEC. 2706. EXTERNAL APPEALS OF ADVERSE DETERMINA-
TIONS.
‘‘(a) RIGHT TO EXTERNAL APPEAL.—
‘‘(1) IN GENERAL.—A group health plan, and a
health insurance issuer offering group health insur-
ance coverage, shall provide for an external appeals
process that meets the requirements of this section
in the case of an externally appealable decision de-
scribed in paragraph (2). The Secretary shall estab-
lish standards to carry out such requirements.
‘‘(2) EXTERNALLY APPEALABLE DECISION DE-
FINED.—For purposes of this section, the term ‘ex-
ternally appealable decision’ means a benefit denial,
reduction, or termination of, or failure to provide or
make, payment (in whole or in part) for, a benefit
(including a denial of choice of provider to the ex-
tent such a choice is permitted under a plan), if—
‘‘(A) the denial or failure involves a deter-
mination that a treatment is experimental or in-
vestigational in nature;
‘‘(B) the denial or failure is based on a de-
termination that services are not medically nec-
essary or appropriate and the amount involved
exceeds a significant threshold; or
‘‘(C) the patient’s life or health is jeopard-
ized as a consequence of the denial or failure.
Such term does not include a denial of (or failure to
provide) coverage for services that are specifically
stated in plan or coverage documents as an exclusion
from coverage.
‘‘(3) CONDITIONING APPEAL ON INTERNAL AP-
PEALS PROCESS.—A plan or issuer may condition
the use of an external appeal process in the case of
an externally appealable decision upon completion of
an internal review process but only if the internal re-
view process provides for a determination on the de-
cision in accordance with the medical exigencies of
the case involved, but in no event later than 15 busi-
ness days (or 72 hours in the case of a decision in-
volving emergency or urgent care) of the time of the
filing of the request for the internal review.
‘‘(b) GENERAL ELEMENTS OF PROCESS.—