I
104TH CONGRESS
2D SESSION
H. R. 2976
To prohibit health plans from interfering with health care provider
communications with their patients.
IN THE HOUSE OF REPRESENTATIVES
FEBRUARY 27, 1996
Mr. GANSKE (for himself, Mr. MARKEY, Mr. BARR of Georgia, Mr. BOUCHER,
Mr. COBURN, Mr. DURBIN, Mr. GENE GREEN of Texas, Mr. JOHNSTON
of Florida, Mr. KENNEDY
of Massachusetts, Mr. KLECZKA, Ms.
LOFGREN, Mr. MCDERMOTT, Mrs. MEEK of Florida, Mr. MORAN, Mr.
NADLER, Mr. SANDERS, Mr. SERRANO, Mrs. SMITH of Washington, Mr.
STARK, Mr. STUDDS, Mr. TRAFICANT, Mr. WAXMAN, Mr. WHITFIELD,
and Mr. WISE) introduced the following bill; which was referred to the
Committee on Commerce, and in addition to the Committee on Ways and
Means, Economic and Educational Opportunities, and Government Re-
form and Oversight, 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 prohibit health plans from interfering with health care
provider communications with their patients.
Be it enacted by the Senate and House of Representa-
tives of the United States of America in Congress assembled,
SECTION 1. SHORT TITLE; FINDINGS.
(a) SHORT TITLE.—This Act may be cited as the
‘‘Patient Right To Know Act of 1996’’.
SEC. 2. PROHIBITION OF INTERFERENCE WITH CERTAIN
MEDICAL COMMUNICATIONS.
(a) IN GENERAL.—
(1) PROHIBITION
OF
CONTRACTUAL
PROVI-
SION.—An entity offering a health plan (as defined
in subsection (d)(2)) may not provide, as part of any
contract or agreement with a health care provider,
any restriction on or interference with any medical
communication, as defined in subsection (b).
(2) PROHIBITION
OF
ADVERSE
ACTION.—An
entity offering a health plan may not take any of the
following actions against a health care provider on
the basis of a medical communication:
(A) Refusal to contract with the health
care provider.
(B) Termination or refusal to renew a con-
tract with the health care provider.
(C) Refusal to refer patients to or allow
others to refer patients to the health care pro-
vider.
(D) Refusal to compensate the health care
provider for covered services.
(E) Any other retaliatory action against
the health care provider.
(3) NULLIFICATION.—Any provision that is
prohibited under paragraph (1) is null and void.
(b) MEDICAL COMMUNICATION DEFINED.—In this
section, the term ‘‘medical communication’’—
(1) means any communication, other than a
knowing and willful misrepresentation, made by the
health care provider—
(A) regarding the mental or physical
health care needs or treatment of a patient and
the provisions, terms, or requirements of the
health plan or another health plan relating to
such needs or treatment, and
(B) between—
(i) the provider and a current, former,
or prospective patient (or the guardian or
legal representative of a patient),
(ii) the provider and any employee or
representative of the entity offering such
plan, or
(iii) the provider and any employee or
representative of any State or Federal au-
thority with responsibility for the licensing
or oversight with respect to such entity or
plan; and
(2) includes communications concerning—
(A) any tests, consultations, and treatment
options,
(B) any risks or benefits associated with
such tests, consultations, and options,
(C) variation among any health care pro-
viders and any institutions providing such serv-
ices in experience, quality, or outcomes,
(D) the basis or standard for the decision
of an entity offering a health plan to authorize
or deny health care services or benefits,
(E) the process used by such an entity to
determine whether to authorize or deny health
care services or benefits, and
(F) any financial incentives or disincen-
tives provided by such an entity to a health care
provider that are based on service utilization.
(c) ENFORCEMENT THROUGH IMPOSITION OF CIVIL
MONEY PENALTY.—
(1) IN
GENERAL.—Any entity that violates
paragraph (1) or (2) of subsection (a) shall be sub-
ject to a civil money penalty of—
(A) up to $25,000 for each violation, or
(B) up to $100,000 for each violation if
the Secretary determines that the entity has en-
gaged, within the 5 years immediately preceding
such violation, in a pattern of such violations.
(2) PROCEDURES.—The provisions of sub-
sections (c) through (l) of section 1128A of the So-
cial Security Act (42 U.S.C. 1320a–7a) shall apply
to civil money penalties under this paragraph in the
same manner as they apply to a penalty or proceed-
ing under section 1128A(a) of such Act.
(d) DEFINITIONS.—For purposes of this section:
(1) HEALTH
CARE
PROVIDER.—The term
‘‘health care provider’’ means anyone licensed under
State law to provide health care services.
(2) HEALTH PLAN.—The term ‘‘health plan’’
means any public or private health plan or arrange-
ment (including an employee welfare benefit plan)
which provides, or pays the cost of, health benefits,
and includes an organization of health care providers
that furnishes health services under a contract or
agreement with such a plan.
(3) SECRETARY.—The term ‘‘Secretary’’ means
Secretary of Health and Human Services.
(4) COVERAGE OF THIRD PARTY ADMINISTRA-
TORS.—In the case of a health plan that is an em-
ployee welfare benefit plan (as defined in section
3(1) of the Employee Retirement Income Security
Act of 1974), any third party administrator or other
person with responsibility for contracts with health
care providers under the plan shall be considered,
for purposes of this section, to be an entity offering
such health plan.
(e) NON-PREEMPTION OF STATE LAW.—A State may
establish or enforce requirements with respect to the sub-
ject matter of this section, but only if such requirements
are more protective of medical communications than the
requirements established under this section.
(f) CONSTRUCTION.—Nothing in this section shall be
construed as—
(1) as requiring an entity offering a health plan
to enter into or renew a contract or agreement with
any willing health care provider, or
(2) preventing an entity from acting on infor-
mation relating to treatment actually provided to a
patient or the failure of a health care provider to
comply with legal standards relating to the provision
of care.
(g) EFFECTIVE DATES.—
(1) CONTRACTS.—Subsection (a)(1) shall apply
to contracts or agreements entered into or renewed
on or after the date of the enactment of this Act,
and to contracts and agreements entered into before
such date as of 30 days after the date of the enact-
ment of this Act.