I
105TH CONGRESS
1ST SESSION
H. R. 66
To amend title XVIII of the Social Security Act to provide protections
for Medicare beneficiaries who enroll in Medicare managed care plans.
IN THE HOUSE OF REPRESENTATIVES
JANUARY 7, 1997
Mr. COBURN (for himself and Mr. BROWN of Ohio) introduced the following
bill; which was referred to the Committee on Ways and Means, and in
addition to the Committee on Commerce, for a period to be subsequently
determined by the Speaker, in each case for consideration of such provi-
sions as fall within the jurisdiction of the committee concerned
A BILL
To amend title XVIII of the Social Security Act to provide
protections for Medicare beneficiaries who enroll in Medi-
care 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 ‘‘Medicare Patient
Choice and Access Act of 1997’’.
SEC. 2. FINDINGS.
Congress finds the following:
(1) There should be no unreasonable barriers or
impediments to the ability of individuals enrolled in
health care plans to obtain appropriate specialized
medical services.
(2) The patient’s first point of contact in a
health care plan must be encouraged to make all ap-
propriate medical referrals and should not be con-
strained financially from making such referrals.
(3) Some health care plans may impede timely
access to specialty care.
(4) Some contracts between health care plans
and providers may contain provisions which impede
the provider in informing the patient of the full
range of treatment options.
(5) Patients cannot make appropriate health
care decisions without access to all relevant informa-
tion relating to those decisions.
(6) Restrictions on the ability of health care
providers to provide full disclosure of all relevant in-
formation to patients making health care decisions
violate the principles of informed consent and the
ethical standards of the health care professions.
Contractual clauses and other policies that interfere
with communications between health care providers
and patients can impact the quality of care received
by those patients.
(7) Patients should have the opportunity to ac-
cess out-of-network items, treatment, and services at
an additional cost to the patient which is not so pro-
hibitive that they are deterred from seeing the
health care provider of their own choice.
(8) Specialty care must be available for the full
duration of the patient’s medical needs and not lim-
ited by time or number of visits.
(9) Direct access to specialty care is essential
for patients in emergency and non-emergency situa-
tions and for patients with chronic and temporary
conditions.
SEC. 3. PROTECTION FOR MEDICARE HMO ENROLLEES.
(a) IN GENERAL.—Section 1876 of the Social Secu-
rity Act (42 U.S.C. 1395mm) is amended—
(1) in subsection (c)(1), by striking ‘‘subsection
(e)’’ and inserting ‘‘subsections (e) and (k)’’, and
(2) by adding at the end the following new sub-
section:
‘‘(k) BENEFICIARY PROTECTION.—
‘‘(1) ASSURING
ADEQUATE
IN-NETWORK
AC-
CESS.—
‘‘(A) TIMELY ACCESS.—An eligible organi-
zation that restricts the providers from whom
benefits may be obtained must guarantee to en-
rollees under this section timely access to pri-
mary and specialty health care providers who
are appropriate to the enrollee’s condition.
‘‘(B) ACCESS TO SPECIALIZED CARE.—En-
rollees must have access to specialized treat-
ment when necessary. This access may be satis-
fied through contractual arrangements with
specialized providers outside of the network.
‘‘(C) CONTINUITY OF CARE.—An eligible
organization’s use of case management may not
create an undue burden for enrollees under this
section. An organization must ensure direct ac-
cess to specialists for ongoing care as so deter-
mined by the case manager in consultation with
the specialty care provider. This continuity of
care may be satisfied for enrollees with chronic
conditions through the use of a specialist serv-
ing as case manager.
‘‘(2) OUT-OF-NETWORK ACCESS.—If an eligible
organization offers to members enrolled under this
section a plan which provides for coverage of services
covered under parts A and B only if such services
are furnished through providers and other persons
who are members of a network of providers and
other persons who have entered into a contract with
the organization to provide such services, the con-
tract with the organization under this section shall
provide that the organization shall also offer to
members enrolled under this section (at the time of
enrollment) a plan which provides for coverage of
such items which are not furnished through provid-
ers and other persons who are members of such a
network.
‘‘(3) GRIEVANCE PROCESS.—
‘‘(A) IN GENERAL.—An eligible organiza-
tion must provide a meaningful and expedited
procedure, which includes notice and hearing
requirements, for resolving grievances between
the organization (including any entity or indi-
vidual through which the organization provides
health care services) and members enrolled with
the organization under this section. Under the
procedure any member enrolled with the organi-
zation may at any time file a complaint to re-
solve grievances between the member and the
organization before a board of appeals estab-
lished under subparagraph (C).
‘‘(B) NOTICE REQUIREMENTS.—
‘‘(i) IN GENERAL.—The organization
must provide, in a timely manner, an en-
rollee a notice of any denial of services in-
network or denial of payment for out-of-
network care.
‘‘(ii) INFORMATION REQUIRED.—Such
notice shall include the following:
‘‘(I) A clear statement of the rea-
son for the denial.
‘‘(II) An explanation of the com-
plaint process under subparagraph
(C) which is available to the enrollee
upon request.
‘‘(III) An explanation of all other
appeal rights available to all enrollees.
‘‘(IV) A description of how to ob-
tain supporting evidence for this hear-
ing, including the patient’s medical
records from the organization, as well
as supporting affidavits from the at-
tending health care providers.
‘‘(C) HEARING BOARD.—
‘‘(i) IN GENERAL.—Each eligible or-
ganization shall establish a board of ap-
peals to hear and make determinations on
complaints by enrollees concerning denials
of coverage or payment for services
(whether in-network or out-of-network)
and the medical necessity and appropriate-
ness of covered items and services.
‘‘(ii) COMPOSITION.—A board of ap-
peals of an eligible organization shall con-
sist of—
‘‘(I) representatives of the orga-
nization, including physicians, non-
physicians, administrators, and enroll-
ees;
‘‘(II) consumers who are not en-
rollees; and
‘‘(III) providers with expertise in
the field of medicine which neces-
sitates treatment.
‘‘(iii) DEADLINE
FOR
DECISION.—A
board of appeals shall hear and resolve
complaints within 30 days after the date
the complaint is filed with the board.
‘‘(A) IN GENERAL.—
‘‘(i) PROHIBITION OF CERTAIN PROVI-
SIONS.—Subject to subparagraph (C), an
eligible organization may not include with
respect to its plan under this section any
provision that prohibits or restricts any
medical communication (as defined in sub-
paragraph (B)) as part of—
‘‘(I) a written contract or agree-
ment with a health care provider,
‘‘(II) a written statement to such
a provider, or
‘‘(III) an oral communication to
such a provider.
‘‘(ii) NULLIFICATION.—Any provision
described in clause (i) is null and void.
‘‘(B) 
MEDICAL
COMMUNICATION
DE-
FINED.—In this paragraph, the term ‘medical
communication’ means a communication made
by a health care provider with a patient of the
provider (or the guardian or legal representative
of such patient) with respect to any of the fol-
lowing:
‘‘(i) How participating physicians and
providers are paid.