I
106TH CONGRESS
1ST SESSION
H. R. 2089
To amend title I of the Employee Retirement Income Security Act of 1974
to provide new procedures and access to review for grievances arising
under group health plans.
IN THE HOUSE OF REPRESENTATIVES
JUNE 9, 1999
Mr. BOEHNER introduced the following bill; which was referred to the
Committee on Education and the Workforce
A BILL
To amend title I of the Employee Retirement Income Secu-
rity Act of 1974 to provide new procedures and access
to review for grievances arising under group health 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 ‘‘Group Health Plan
Review Standards Act of 1999’’.
SEC. 2. SPECIAL RULES FOR GROUP HEALTH PLANS.
(a) IN GENERAL.—Section 503 of the Employee Re-
tirement Income Security Act of 1974 (29 U.S.C. 1133)
is amended—
(1) by inserting ‘‘(a) IN GENERAL.—’’ after
‘‘SEC. 503.’’;
(2) by inserting ‘‘(other than a group health
plan)’’ after ‘‘employee benefit plan’’; and
(3) by adding at the end the following new sub-
section:
‘‘(b) SPECIAL RULES FOR GROUP HEALTH PLANS.—
‘‘(1) 
COVERAGE
DETERMINATIONS.—Every
group health plan shall—
‘‘(A) provide adequate notice in writing in
accordance with this subsection to any partici-
pant or beneficiary of any adverse coverage de-
cision with respect to benefits of such partici-
pant or beneficiary under the plan, setting forth
the specific reasons for such coverage decision
and any rights of review provided under the
plan, written in a manner calculated to be un-
derstood by the average participant;
‘‘(B) provide such notice in writing also to
any treating medical care provider of such par-
ticipant or beneficiary, if such provider has
claimed reimbursement for any item or service
involved in such coverage decision, or if a claim
submitted by the provider initiated the pro-
ceedings leading to such decision;
‘‘(C) afford a reasonable opportunity to
any participant or beneficiary who is in receipt
of the notice of such adverse coverage decision,
and who files a written request for review of the
initial coverage decision within 90 days after re-
ceipt of the notice of the initial decision, for a
full and fair review of the decision by an appro-
priate named fiduciary who did not make the
initial decision; and
‘‘(D) meet the additional requirements of
this subsection.
‘‘(2) TIME LIMITS FOR MAKING INITIAL COV-
ERAGE DECISIONS FOR BENEFITS AND COMPLETING
INTERNAL APPEALS.—
‘‘(A) TIME
LIMITS
FOR
DECIDING
RE-
QUESTS
FOR
BENEFIT
PAYMENTS, REQUESTS
FOR ADVANCE DETERMINATION OF COVERAGE,
AND
REQUESTS
FOR
REQUIRED
DETERMINA-
TION OF MEDICAL NECESSITY.—Except as pro-
vided in subparagraph (B)—
‘‘(i) INITIAL DECISIONS.—If a request
for benefit payments, a request for advance
determination of coverage, or a request for
required determination of medical necessity
is submitted to a group health plan in such
reasonable form as may be required under
the plan, the plan shall issue in writing an
initial coverage decision on the request be-
fore the end of the initial decision period
under paragraph (10)(I) following the fil-
ing completion date. Failure to issue a cov-
erage decision on such a request before the
end of the period required under this
clause shall be treated as an adverse cov-
erage decision for purposes of internal re-
view under clause (ii).
‘‘(ii) INTERNAL REVIEWS OF INITIAL
DENIALS.—Upon the written request of a
participant or beneficiary for review of an
initial adverse coverage decision under
clause (i), a review by an appropriate
named fiduciary (subject to paragraph (3))
of the initial coverage decision shall be
completed, including issuance by the plan
of a written decision affirming, reversing,
or modifying the initial coverage decision,
setting forth the grounds for such decision,
before the end of the internal review period
following the review filing date. Such deci-
sion shall be treated as the final decision
of the plan, subject to any applicable re-
consideration under paragraph (4). Failure
to issue before the end of such period such
a written decision requested under this
clause shall be treated as a final decision
affirming the initial coverage decision.
‘‘(B) TIME LIMITS FOR MAKING COVERAGE
DECISIONS RELATING TO ACCELERATED NEED
MEDICAL CARE AND FOR COMPLETING INTER-
NAL APPEALS.—
‘‘(i) INITIAL
DECISIONS.—A group
health plan shall issue in writing an initial
coverage decision on any request for expe-
dited advance determination of coverage or
for expedited required determination of
medical necessity submitted, in such rea-
sonable form as may be required under the
plan before the end of the accelerated need
decision period under paragraph (10)(K),
in cases involving accelerated need medical
care, following the filing completion date.
Failure to approve or deny such a request
before the end of the applicable decision
period shall be treated as a denial of the
request for purposes of internal review
under clause (ii).
‘‘(ii) INTERNAL REVIEWS OF INITIAL
DENIALS.—Upon the written request of a
participant or beneficiary for review of an
initial adverse coverage decision under
clause (i), a review by an appropriate
named fiduciary (subject to paragraph (3))
of the initial coverage decision shall be
completed, including issuance by the plan
of a written decision affirming, reversing,
or modifying the initial converge decision,
setting forth the grounds for the decision
before the end of the accelerated need deci-
sion period under paragraph (10)(K) fol-
lowing the review filing date. Such decision
shall be treated as the final decision of the
plan, subject to any applicable reconsider-
ation under paragraph (4). Failure to issue
before the end of the applicable decision
period such a written decision requested
under this clause shall be treated as a final
decision affirming the initial coverage deci-
sion.