Sec. 1. Short title; table of contents.
Sec. 2. Patient protection standards under the Public Health Service Act.
‘‘PART C—PATIENT PROTECTION STANDARDS
‘‘Sec. 2770. Guarantee of medically necessary and appropriate treatment.
‘‘Sec. 2771. Guaranteed adequate access to health care.
‘‘Sec. 2772. Right to adequate physician network.
‘‘Sec. 2773. Meaningful choice of providers.
‘‘Sec. 2774. Guaranteed continuity of care.
‘‘Sec. 2775. Right to specialty care.
‘‘Sec. 2776. Required obstetric and gynecological care.
‘‘Sec. 2777. Assuring equitable coverage of emergency services.
‘‘Sec. 2778. Requirement for service to areas that include a medically un-
derserved population.
‘‘Sec. 2779. Right to language assistance.
‘‘Sec. 2780. Prohibition on financial incentives to limit care.
‘‘Sec. 2781. Prohibition on gag clauses.
‘‘Sec. 2782. Right to appeal denial of care.
‘‘Sec. 2783. External review.
‘‘Sec. 2784. Nondiscrimination right.
‘‘Sec. 2785. Protection of patient confidentiality.
‘‘Sec. 2786. Establishment of Managed Care Consumer Advisory Commis-
sion.
‘‘Sec. 2787. Requirements for Prescription Drug Coverage; Definitions.
‘‘Sec. 2788. Notice; Definitions.
Sec. 3. Patient protection standards under the Employee Retirement Income
Security Act of 1974.
‘‘Sec. 714. Patient protection standards.
Sec. 4. Nonpreemption of State law respecting liability of group health plans.
Sec. 5. Effective date.
SEC. 2. PATIENT PROTECTION STANDARDS UNDER THE
PUBLIC HEALTH SERVICE ACT.
Title XXVII of the Public Health Service Act is
amended—
(1) by redesignating part C as part D; and
(2) by inserting after part B the following new
part:
‘‘PART C—PATIENT PROTECTION STANDARDS
‘‘SEC. 2770. GUARANTEE OF MEDICALLY NECESSARY AND
APPROPRIATE TREATMENT.
‘‘(a) IN GENERAL.—A managed care plan may not
impose limits on the delivery of services if such services
are—
‘‘(1) medically necessary and appropriate as de-
termined by the treating health professional, in con-
sultation with the enrollee; and
‘‘(2) otherwise a covered benefit.
‘‘(b) SECOND OPINION.—A managed care plan shall
provide to an enrollee, upon request, a referral to a health
care practitioner for a second opinion as to what con-
stitutes medically necessary and appropriate treatment,
and provide coverage for such opinion without regard to
whether such health care practitioner has a contractual
or other arrangement with the plan for the provision of
such services to such enrollee.
‘‘SEC. 2771. GUARANTEED ADEQUATE ACCESS TO HEALTH
CARE.
‘‘(a) ADEQUATE ACCESS.—A managed care plan
shall provide adequate access to health care services.
‘‘(b) AVAILABLE ITEMS AND SERVICES.—The Sec-
retary shall ensure that items and services, including lab-
oratory and specialist services, covered under the plan
shall be available through providers that are reasonably
geographically accessible to all enrollees of such plan.
‘‘SEC. 2772. RIGHT TO ADEQUATE PHYSICIAN NETWORK.
‘‘(a) IN GENERAL.—A managed care plan shall main-
tain an adequate number, mix, and distribution of health
professionals and providers to ensure that covered items
and services are available and accessible to each enrollee.
‘‘(b) ADEQUATE
DISTRIBUTION.—The Secretary
shall determine the adequate number, mix, and distribu-
tion of health professionals and providers within the serv-
ice area of the managed care plan, including—
‘‘(1) the existence of a primary care provider
network that is sufficient to meet adult, pediatric,
and primary obstetric and gynecological needs of all
enrollees;
‘‘(2) the existence of a network of specialists of
sufficient number and diversity to meet the specialty
needs of all enrollees;
‘‘(3) the access to quality health services from
institutional providers for all enrollees; and
‘‘(4) the existence of at least one primary care
physician for every 1,500 enrollees.
‘‘SEC. 2773. MEANINGFUL CHOICE OF PROVIDERS.
‘‘(a) MINIMUM NUMBER OF CHOICES.—A managed
care plan shall provide to enrollees a choice of at least
3 providers within each category of providers based on the
health care needs of such enrollees, taking into account
the age, gender, health, native language, acute or chronic
diseases, and special needs of the enrollee. The enrollee
may change the selection of provider at any time.
‘‘(b) ACCESS TO OUT–OF–NETWORK PROVIDER.—A
managed care plan shall cover services that are furnished
by a physician or provider obtained by the enrollee without
regard to whether such physician or provider has a con-
tractual or other arrangement with the plan for the provi-
sion of such services to such enrollees. The plan may im-
pose a reasonable deductible and reasonable copayment
subject to a reasonable annual limit on total annual out-
of-pocket expenses.
‘‘SEC. 2774. GUARANTEED CONTINUITY OF CARE.
‘‘If a contract between a managed care plan and a
health care provider is terminated (other than by the plan
for failure to meet applicable quality standards or for
fraud) and an enrollee is undergoing a course of treatment
from the provider at the time of such termination, the plan
shall—
‘‘(1) notify the enrollee of such termination;
and
‘‘(2) permit the enrollee to continue the course
of treatment with the provider during a transitional
period as determined by the Secretary.
‘‘SEC. 2775. RIGHT TO SPECIALTY CARE.
‘‘(a) REFERRAL TO SPECIALISTS.—
‘‘(1) CHOICE OF SPECIALIST.—A managed care
plan shall permit each enrollee to receive specialty
care from any qualified participating health care
provider when such treatment is medically or clini-
cally necessary. The plan shall make or provide for
a referral to at least 3 specialists who are available
and accessible to provide treatment for such condi-
tion or disease.
‘‘(2) COST
OF
TREATMENT
BY
NONPARTICI-
PATING PROVIDERS.—In a case in which a plan re-
fers an enrollee to a nonparticipating specialist, the
plan shall cover any services provided by such spe-
cialist at the rate it covers comparable services pro-
vided by participating providers.
‘‘(b) CONTINUOUS REFERRALS.—A managed care
plan shall have a procedure by which an enrollee who has
a condition that requires ongoing care from a specialist
may receive a continuous referral to such specialist for
treatment of such condition, without additional authoriza-
tion from the primary care physician.
‘‘SEC. 2776. REQUIRED OBSTETRIC AND GYNECOLOGICAL
CARE.
‘‘(a) OBSTETRICIAN-GYNECOLOGIST
AS
PRIMARY
CARE PROVIDER.—In a case in which a managed care
plan provides for an enrollee to designate a participating
primary care provider, a female enrollee may designate a
physician who specializes in obstetrics and gynecology as
primary care provider.
‘‘(b) NO
DESIGNATION
OF OBSTETRICIAN-GYNE-
COLOGIST.—In a case in which an enrollee does not des-
ignate an obstetrician-gynecologist under subsection (a) as
a primary care provider, the plan shall not require prior
authorization by the enrollee’s primary care provider for
coverage of routine gynecological care and pregnancy-re-
lated services provided by a participating physician who
specializes in obstetrics and gynecology.
‘‘SEC. 2777. ASSURING EQUITABLE COVERAGE OF EMER-
GENCY SERVICE.
‘‘(a) IN GENERAL.—A managed care plan shall cover
emergency services furnished to an enrollee of the plan—
‘‘(1) whether or not the provider furnishing the
emergency services has a contractual or other ar-
rangement with the plan for the provision of such
services to such enrollee; and
‘‘(2) without regard to prior authorization.
‘‘(b) EMERGENCY SERVICES.—Emergency services
shall include—
‘‘(1) health care items and services furnished in
the emergency department of a hospital; and
‘‘(2) ancillary services routinely available to
such department.
‘‘(c) EMERGENCY MEDICAL CONDITION.—An emer-
gency medical condition is a medical condition manifesting
itself by acute symptoms of sufficient severity (including
severe pain) such that a prudent layperson, who possesses
an average knowledge of health and medicine, could rea-
sonably expect the absence of immediate medical attention
to result in—
‘‘(1) placing the health of the individual (or,
with respect to a pregnant woman, the health of the
woman or her unborn child) in serious jeopardy;
‘‘(2) serious impairment to bodily functions; or
‘‘(3) serious dysfunction of any bodily organ or
part.
‘‘SEC. 2778. REQUIREMENT FOR SERVICE TO AREAS THAT
INCLUDE A MEDICALLY UNDERSERVED POP-
ULATION.
‘‘A managed care plan seeking to provide services in
an area that includes a medically underserved population
must submit a plan to the Secretary outlining a proposal
for service that ensures access to quality care that is ap-
propriate to the medically underserved population. The
plan shall include the health needs of the medically under-
served population with special consideration given to fac-
tors including age, gender, race, and potential chronic con-
ditions.
‘‘SEC. 2779. RIGHT TO LANGUAGE ASSISTANCE.
‘‘In a case in which 2 percent of the enrollees of a
managed care plan in a service area (as defined in section
2788(b)(9)) are members of a group that speaks English
as a second language or requires special communication
needs, the Secretary shall ensure that the managed care
plan provides communication assistance and bilingual in-
formation, on a continuous basis, to such enrollees. The
plan shall ensure that—
‘‘(1) trained medical interpreters, whose pri-
mary responsibility is to interpret, are present in all
health care settings; and
‘‘(2) an adequate number of health profes-
sionals receive training in cultural competency and
communication skills development as it relates to
medical interviews.
‘‘SEC. 2780. PROHIBITION ON FINANCIAL INCENTIVES TO
LIMIT CARE.
‘‘A managed care plan may not offer any financial
incentives, directly or indirectly, to health professionals as
an inducement to reduce or limit medically necessary serv-
ices provided to an enrollee.
‘‘SEC. 2781. PROHIBITION ON GAG CLAUSES.
‘‘(a) IN GENERAL.—The provisions of any contract
or agreement, or the operation of any contract or agree-
ment, between a managed care plan and a health profes-
sional shall not prohibit or restrict a health professional
from engaging in medical communication with his or her
patient.
‘‘(b) NULLIFICATION.—Any contract provision or
agreement described in subsection (a) shall be null and
void.
‘‘(c) MEDICAL
COMMUNICATION
DEFINED.—For
purposes of this section, the term ‘medical communication’
means a communication made by a health professional
with a patient of the health professional (or the guardian
or legal representative of the patient) with respect to—
‘‘(1) the patient’s health status, medical care,
or legal treatment options;
‘‘(2) any utilization review requirements that
may affect treatment options for the patient; or
‘‘(3) any financial incentives that may affect
the treatment of the patient.
‘‘SEC. 2782. RIGHT TO APPEAL DENIAL OF CARE.
‘‘(a) ESTABLISHMENT OF SYSTEM.—Not later than
90 days after the date of the enactment of the Managed
Care Bill of Rights for Consumers Act of 1999, the Sec-
retary, through the Health Care Financing Administra-
tion, shall establish and implement guidelines for griev-
ance and appeals procedures regarding any aspect of a
managed care plan’s services, including complaints regard-
ing quality of care, choice and accessibility of providers,
network adequacy, and compliance with the requirements
of this part.
‘‘(b) NO REPRISAL FOR EXERCISE OF RIGHTS.—A
managed care plan shall not take any action with respect
to an enrollee or a health care provider that is intended
to penalize the enrollee, a designee of the enrollee, or the
health care provider for discussing or exercising any rights
provided under this part (including the filing of a com-
plaint or appeal pursuant to this section).
‘‘SEC. 2783. EXTERNAL REVIEW.
‘‘An external review process shall be available to en-
rollees after all internal appeal options have been exer-
cised. The requirements for an external review process are
as follows:
‘‘(1) The process is established under State law
and provides for review of decisions made pursuant
to section 2784 by an independent review organiza-
tion certified by the State.
‘‘(2) If the process provides that decisions in
such process are not binding on managed care plans,
the process must provide for public methods of dis-
closing frequency of noncompliance with such deci-
sions and for sanctioning plans that consistently
refuse to take appropriate actions in response to
such decisions.
‘‘(3) Results of all such reviews under the proc-
ess are disclosed to the public, along with at least
annual disclosure of information on managed care
plan compliance.
‘‘(4) All decisions under the process shall be in
writing and shall be accompanied by an explanation
of the basis for the decision.
‘‘(5) Direct costs of the process shall be borne
by the managed care plan, and not by the enrollee.
‘‘(6) The managed care plan shall provide for
publication at least annually of information on the
number of appeals and decisions considered under
the process.
‘‘SEC. 2784. NONDISCRIMINATION RIGHT.
‘‘A managed care plan may not discriminate (directly
or through contractual arrangements) against an enrollee
or a provider on the basis of race, national origin, gender,
language, socioeconomic status, age, disability, health sta-
tus, or anticipated need for health services.
‘‘SEC. 2785. PROTECTION OF PATIENT CONFIDENTIALITY.
‘‘A managed care plan shall establish policies and
procedures to ensure that all applicable laws that protect
the confidentiality of an individual’s medical information
are followed.
‘‘SEC. 2786. ESTABLISHMENT OF MANAGED CARE CON-
SUMER ADVISORY COMMISSION.
‘‘(a) ESTABLISHMENT.—The Secretary shall estab-
lish and appoint a 5 member Managed Care Consumer
Advisory Commission.
‘‘(b) PURPOSE.—The purpose of the Commission is
to assist consumers in the following areas:
‘‘(1) Accessing appropriate and high–quality
health care services.
‘‘(2) Understanding and exercising their rights
and responsibilities as managed care plan enrollees.
‘‘(3) Making an informed and appropriate
choice of a managed care plan.
‘‘(c) MEMBERSHIP.—Members of the Commission
shall—
‘‘(1) regulations, rulings, and interpretations
issued by such Secretaries relating to the same mat-
ter over which such Secretaries have responsibility
under such part C (and section 2706 of the Public
Health Service Act) and this section are adminis-
tered so as to have the same effect at all times; and
‘‘(2) coordination of policies relating to enforc-
ing the same requirements through such Secretaries
in order to have a coordinated enforcement strategy
that avoids duplication of enforcement efforts and
assigns priorities in enforcement.’’.
(b) MODIFICATION OF PREEMPTION STANDARDS.—
Section 731 of such Act (42 U.S.C. 1191) is amended—
(1) in subsection (a)(1), by striking ‘‘subsection
(b)’’ and inserting ‘‘subsections (b) and (c)’’;
(2) by redesignating subsections (c) and (d) as
subsections (d) and (e), respectively; and
(3) by inserting after subsection (b) the fol-
lowing new subsection:
‘‘(c) SPECIAL RULES IN CASE OF PATIENT PROTEC-
TION REQUIREMENTS.—Subject to subsection (a)(2), the
provisions of section 714 and part C of title XXVII of
the Public Health Service Act, and subpart C insofar as
it applies to section 714 or such part, shall not be con-
strued to preempt any State law, or the enactment or im-