I
106TH CONGRESS
1ST SESSION
H. R. 2723
To amend title I of the Employee Retirement Income Security Act of 1974,
title XXVII of the Public Health Service Act, and the Internal Revenue
Code of 1986 to protect consumers in managed care plans and other
health coverage.
IN THE HOUSE OF REPRESENTATIVES
AUGUST 5, 1999
Mr. NORWOOD (for himself, Mr. DINGELL, Mr. GANSKE, Mr. COOKSEY, Mr.
BERRY, Mrs. CLAYTON, Mr. GRAHAM, Mr. PALLONE, Mrs. ROUKEMA,
Mrs. CAPPS, Mr. SHAW, Mr. JOHN, Mr. SHAYS, Mr. TURNER, Mrs.
CUBIN, Mr. BALDACCI, Mr. FOLEY, Mr. GEPHARDT, Mr. HOUGHTON,
Mr. RANGEL, Mr. HORN, Mr. CLAY, Mr. GIBBONS, Mr. BROWN of Ohio,
Mr. FRELINGHUYSEN, Mr. ANDREWS, Mr. GILCHREST, Mr. STARK, Mr.
LEACH, Mr. WAXMAN, Mr. GILMAN, Mr. CARDIN, Mr. LATOURETTE, Mr.
FORD, Mr. LOBIONDO, Mr. SANDLIN, Mr. BARR of Georgia, Mrs. THUR-
MAN, Mr. BOEHLERT, Mr. KLINK, Mrs. MORELLA, Mr. SNYDER, Ms.
ESHOO, Mr. DOYLE, Mr. MCDERMOTT, Mr. BRADY of Pennsylvania, Mr.
PASCRELL, Mr. HOLT, Mr. FROST, Ms. KILPATRICK, Mr. DICKS, Ms.
SCHAKOWSKY, Mr. RUSH, Mrs. MCCARTHY of New York, Mr. MURTHA,
Ms. STABENOW, Mr. PHELPS, Mr. HALL of Texas, Mr. WEYGAND, Ms.
BERKLEY, Mr. WYNN, Mr. TANNER, Mr. BOUCHER, Mr. BARRETT of
Wisconsin, Mr. FORBES, and Mr. BONIOR) introduced the following bill;
which was referred to the Committee on Commerce, and in addition to
the Committees on Education and the Workforce, and Ways and Means,
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 title I of the Employee Retirement Income Secu-
rity Act of 1974, title XXVII of the Public Health Serv-
ice Act, and the Internal Revenue Code of 1986 to pro-
tect consumers in managed care plans and other health
coverage.
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
‘‘Bipartisan Consensus Managed Care Improvement Act
of 1999’’.
(b) TABLE OF CONTENTS.—The table of contents of
this Act is as follows:
Sec. 1. Short title; table of contents.
TITLE I—IMPROVING MANAGED CARE
Subtitle A—Grievances and Appeals
Sec. 101. Utilization review activities.
Sec. 102. Internal appeals procedures.
Sec. 103. External appeals procedures.
Sec. 104. Establishment of a grievance process.
Subtitle B—Access to Care
Sec. 111. Consumer choice option.
Sec. 112. Choice of health care professional.
Sec. 113. Access to emergency care.
Sec. 114. Access to specialty care.
Sec. 115. Access to obstetrical and gynecological care.
Sec. 116. Access to pediatric care.
Sec. 117. Continuity of care.
Sec. 118. Access to needed prescription drugs.
Sec. 119. Coverage for individuals participating in approved clinical trials.
Subtitle C—Access to Information
Sec. 121. Patient access to information.
Subtitle D—Protecting the Doctor-Patient Relationship
Sec. 131. Prohibition of interference with certain medical communications.
Sec. 132. Prohibition of discrimination against providers based on licensure.
Sec. 133. Prohibition against improper incentive arrangements.
Sec. 134. Payment of claims.
Sec. 135. Protection for patient advocacy.
Subtitle E—Definitions
Sec. 151. Definitions.
Sec. 152. Preemption; State flexibility; construction.
Sec. 153. Exclusions.
Sec. 154. Coverage of limited scope plans.
Sec. 155. Regulations.
TITLE II—APPLICATION OF QUALITY STANDARDS TO GROUP
HEALTH PLANS AND HEALTH INSURANCE COVERAGE UNDER
THE PUBLIC HEALTH SERVICE ACT
Sec. 201. Application to group health plans and group health insurance cov-
erage.
Sec. 202. Application to individual health insurance coverage.
TITLE III—AMENDMENTS TO THE EMPLOYEE RETIREMENT
INCOME SECURITY ACT OF 1974
Sec. 301. Application of patient protection standards to group health plans and
group health insurance coverage under the Employee Retire-
ment Income Security Act of 1974.
Sec. 302. ERISA preemption not to apply to certain actions involving health in-
surance policyholders.
TITLE IV—APPLICATION TO GROUP HEALTH PLANS UNDER THE
INTERNAL REVENUE CODE OF 1986
Sec. 401. Amendments to the Internal Revenue Code of 1986.
TITLE V—EFFECTIVE DATES; COORDINATION IN
IMPLEMENTATION
Sec. 501. Effective dates.
Sec. 502. Coordination in implementation.
TITLE VI—HEALTH CARE PAPERWORK SIMPLIFICATION
Sec. 601. Health care paperwork simplification.
TITLE I—IMPROVING MANAGED
CARE
Subtitle A—Grievance and Appeals
SEC. 101. UTILIZATION REVIEW ACTIVITIES.
(a) COMPLIANCE WITH REQUIREMENTS.—
(1) IN GENERAL.—A group health plan, and a
health insurance issuer that provides health insur-
ance coverage, shall conduct utilization review activi-
ties in connection with the provision of benefits
under such plan or coverage only in accordance with
a utilization review program that meets the require-
ments of this section.
(2) USE OF OUTSIDE AGENTS.—Nothing in this
section shall be construed as preventing a group
health plan or health insurance issuer from arrang-
ing through a contract or otherwise for persons or
entities to conduct utilization review activities on be-
half of the plan or issuer, so long as such activities
are conducted in accordance with a utilization review
program that meets the requirements of this section.
(3) UTILIZATION REVIEW DEFINED.—For pur-
poses of this section, the terms ‘‘utilization review’’
and ‘‘utilization review activities’’ mean procedures
used to monitor or evaluate the use or coverage,
clinical necessity, appropriateness, efficacy, or effi-
ciency of health care services, procedures or settings,
and includes prospective review, concurrent review,
second opinions, case management, discharge plan-
ning, or retrospective review.
(b) WRITTEN POLICIES AND CRITERIA.—
(1) WRITTEN POLICIES.—A utilization review
program shall be conducted consistent with written
policies and procedures that govern all aspects of the
program.
(2) USE OF WRITTEN CRITERIA.—
(A) IN GENERAL.—Such a program shall
utilize written clinical review criteria developed
with input from a range of appropriate actively
practicing health care professionals, as deter-
mined by the plan, pursuant to the program.
Such criteria shall include written clinical re-
view criteria that are based on valid clinical evi-
dence where available and that are directed spe-
cifically at meeting the needs of at-risk popu-
lations and covered individuals with chronic
conditions or severe illnesses, including gender-
specific criteria and pediatric-specific criteria
where available and appropriate.
(B) CONTINUING USE OF STANDARDS IN
RETROSPECTIVE
REVIEW.—If a health care
service has been specifically pre-authorized or
approved for an enrollee under such a program,
the program shall not, pursuant to retrospective
review, revise or modify the specific standards,
criteria, or procedures used for the utilization
review for procedures, treatment, and services
delivered to the enrollee during the same course
of treatment.
(C) REVIEW OF SAMPLE OF CLAIMS DENI-
ALS.—Such a program shall provide for an
evaluation of the clinical appropriateness of at
least a sample of denials of claims for benefits.
(c) CONDUCT OF PROGRAM ACTIVITIES.—
(1) ADMINISTRATION BY HEALTH CARE PRO-
FESSIONALS.—A utilization review program shall be
administered by qualified health care professionals
who shall oversee review decisions.
(2) USE
OF
QUALIFIED, INDEPENDENT
PER-
SONNEL.—
(A) IN
GENERAL.—A utilization review
program shall provide for the conduct of utiliza-
tion review activities only through personnel
who are qualified and have received appropriate
training in the conduct of such activities under
the program.
(B) PROHIBITION
OF
CONTINGENT
COM-
PENSATION ARRANGEMENTS.—Such a program
shall not, with respect to utilization review ac-
tivities, permit or provide compensation or any-
thing of value to its employees, agents, or con-
tractors in a manner that encourages denials of
claims for benefits.