I
104TH CONGRESS
1ST SESSION
H. R. 2608
To require that health care practitioners determine medically necessary and
appropriate treatment and to require that insurers notify their enrollees
of the extent of their coverage.
IN THE HOUSE OF REPRESENTATIVES
NOVEMBER 9, 1995
Mr. NADLER (for himself, Mr. DELLUMS, Mr. ENGEL, Ms. MCKINNEY, and
Miss COLLINS of Michigan) introduced the following bill; which was re-
ferred to the Committee on Commerce
A BILL
To require that health care practitioners determine medically
necessary and appropriate treatment and to require that
insurers notify their enrollees of the extent of their cov-
erage.
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 ‘‘Health Care Consumer
Protection Act of 1995’’.
SEC. 2. NOTIFICATION OF COVERAGE PROVIDED BY THE
INSURER.
(a) NOTIFICATION TO CURRENT ENROLLEES.—An
insurer providing health insurance coverage under a health
plan shall provide annual notice to each current enrollee
under such plan regarding the extent of the coverage of
the plan. Such notice shall be in writing and shall include
a copy of the contract between the insurer and enrollee,
in addition to information regarding the terms and condi-
tions of the policy and the rights and obligations of the
parties including—
(1) covered and excluded services, equipment,
and devices;
(2) copayments, deductibles, and premiums;
(3) enrollee satisfaction statistics;
(4) financial responsibility of the enrollee;
(5) utilization review requirements;
(6) a list of the usual, customary, and reason-
able costs for procedures, tests, and examinations;
(7) physician credentialing standards; and
(8) the percentage of total annual premiums
used to reimburse practitioners for health care pro-
vided to enrollees and the percentage used for ad-
ministration and other costs incurred in administer-
ing the plan.
(b) NOTIFICATION TO POTENTIAL ENROLLEES.—An
insurer providing health insurance coverage under a health
plan shall, upon request, provide notice to each potential
enrollee under such plan regarding the extent of the cov-
erage of the plan. Such notice shall be in writing and shall
include a copy of the potential contract between the in-
surer and potential enrollee, in addition to information re-
garding the terms and conditions of the policy and the
rights and obligations of the parties information including
the items listed in paragraphs (1) through (8) of sub-
section (a).
(c) REGULATIONS FOR FAILURE TO PROVIDE NOTI-
FICATION.—The Secretary of Health and Human Services
shall promulgate regulations to ensure that an insurer
providing health insurance coverage under a health plan
provide notification to current and potential enrollees as
described in subsections (a) and (b).
SEC. 3. DETERMINATION OF MEDICALLY NECESSARY AND
APPROPRIATE TREATMENT.
(a) IN GENERAL.—Under a health plan, the deter-
mination of what is medically necessary and appropriate
for the health of a patient may be made only by a health
care practitioner who is—
(1) licensed and practicing within the scope of
the State practice act of the State in which the prac-
titioner practices; and
(2) directly involved in the care of such patient.
(b) INSURANCE COVERAGE.—An insurer must pay
for a service determined, as described in subsection (a),
to be medically necessary and appropriate if the service
is covered by the health plan.
(c) REGULATIONS TO DETER REWARDS, PENALTIES
OR INDUCEMENTS.—The Secretary of Health and Human
Services shall promulgate regulations to ensure that an
insurer not offer monetary rewards, penalties, or induce-
ments to a licensed health care practitioner, or condition
the continued participation of a licensed health care prac-
titioner in a plan on the basis of the health care practition-
er’s decisions to limit the availability of appropriate medi-
cal tests, services, or treatments.
SEC. 4. ENFORCEMENT AND PENALTIES.
(a) PENALTIES.— Any entity that offers a health
plan that violates the provisions of this Act shall be subject
to a civil money penalty in an amount to be determined
by the Secretary of Health and Human Services.
(b) PROCESS.—The provisions of section 1128A of
the Social Security Act (42 U.S.C. 1320a-7a) (other than
subsections (a) and (b)) shall apply to civil money pen-
alties under this section in the same manner as they apply
to a penalty or proceeding under section 1128A(a) of such
Act.
SEC. 5. PROHIBITION OF HOLD HARMLESS PROVISIONS.
An insurer may not include provisions in a health
plan to hold itself harmless for any liability.
SEC. 6. PREEMPTION.
A State may not establish or enforce standards for
insurers or health insurance coverage with respect to the
subject matter of this Act that are weaker than the stand-
ards established under this Act.
SEC. 7. DEFINITIONS.—
For purposes of this Act:
(1) INSURER.—The term ‘‘insurer’’ means an
insurance company, insurance service, or insurance
organization licensed to engage in the business of in-
surance in a State, and a health maintenance orga-
nization.
(2) HEALTH CARE PRACTITIONER.—The term
‘‘health care practitioner’’ has the meaning provided
by section 11151 of title 42, United States Code.
(3) HEALTH INSURANCE COVERAGE.—The term
‘‘health insurance coverage’’ means any hospital or
medical service policy or certificate, hospital or medi-
cal service plan contract, or health maintenance or-
ganization contract offered by an insurer.
(4) HEALTH PLAN.—The term ‘‘health plan’’
means a plan that provides health insurance cov-
erage.
(5) STATE.—The term ‘‘State’’ means any
State, the District of Columbia, Puerto Rico, the
Northern Mariana Islands, the Virgin Islands,
American Samoa, and Guam.
SEC. 8. EFFECTIVE DATE.
The provisions of this Act shall apply to all health
plans offered, sold, issued, or renewed after the date of
the enactment of this Act.
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