‘‘(C) The process shall include verification
of the individual practitioner’s license, history
of suspension or revocation, and liability claims
history.
‘‘(D) The plan or issuer shall establish a
formal, written, ongoing, process for the re-
evaluation of all participating health care pro-
fessionals within a specified number of years
after the initial acceptance. Such reevaluations
shall include updates of the previous review cri-
teria and an assessment of the performance
pattern based on criteria including enrollee clin-
ical outcomes, number of complaints, and mal-
practice actions.
‘‘(3) 
LIMITATION
ON
USE
OF
PROFES-
SIONALS.—A managed care group health plan (and
a health insurance issuer offering managed care
group health insurance) shall not use a health care
professional beyond, or outside of, the professional’s
legally authorized scope of practice.
‘‘(g) DATA SYSTEMS AND CONFIDENTIALITY.—
‘‘(1) IN
GENERAL.—A managed care group
health plan (and a health insurance issuer offering
managed care group health insurance) shall provide
information on the plan’s or issuer’s structure, deci-
sion making process, health care benefits and exclu-
sions, cost and cost-sharing requirements, list of
participating providers and health care professionals
as well as grievance and appeal procedures, to all
potential enrollees, all enrollees covered by the plan
or coverage, and, to the Secretary (or, with respect
to a health insurance issuer, to the State oversight
agency).
‘‘(2) REPORTING OF DATA.—A managed care
group health plan (and a health insurance issuer of-
fering managed care group health insurance) shall
collect and report annually to the Secretary (or, in
the case of a health insurance issuer, State oversight
agency) specified data including—
‘‘(A) gross outpatient and hospital utiliza-
tion data;
‘‘(B) enrollee clinical outcome data;
‘‘(C) the number and types of enrollee
grievances or complaints during the year, the
status of decisions, and the average time re-
quired to reach a decision; and
‘‘(D) the number, amount, and disposition
of malpractice claims resolved during the year
by the plan or issuer and any of its participat-
ing health care providers and professionals.
‘‘(3) REPORTING.—All data specified in para-
graphs (1) and (2) shall be reported to the Secretary
or, in the case of a health insurance issuer, the
State oversight agency and shall be available to the
public on a timely basis.
‘‘(4) MEDICAL RECORDS AND CONFIDENTIAL-
ITY.—A managed care group health plan (and a
health insurance issuer offering managed care group
health insurance) shall—
‘‘(A) establish written policies and proce-
dures for the handling of medical records and
enrollee communications to ensure enrollee con-
fidentiality;
‘‘(B) ensure the confidentiality of specified
enrollee information, including, prior medical
history, medical record information and claims
information, except where disclosure of this in-
formation is required by law; and
‘‘(C) not release any individual patient
record information, unless such a release is au-
thorized in writing by the enrollee or otherwise
required be law.
‘‘(h) CLINICAL DECISION MAKING.—
‘‘(1) APPOINTMENT OF MEDICAL DIRECTOR.—A
managed care group health plan (and a health insur-
ance issuer offering managed care group health in-
surance) shall appoint a medical director who is a li-
censed physician in the State in which the plan or
issuer operates, who shall be responsible for treat-
ment policies protocols, quality assurance activities,
and utilization management decisions of the plan or
issuer.
‘‘(2) DISCLOSURE ABOUT FINANCIAL ARRANGE-
MENTS.—A managed care group health plan (and a
health insurance issuer offering managed care group
health insurance) shall inform enrollees of the finan-
cial arrangements between the plan or issuer and
participating providers and professionals (including
pharmacists), if those arrangements include incen-
tives or bonuses for restriction of services.
‘‘(3) QUALITY ASSURANCE DEFINED.—In this
subsection, the term ‘quality assurance’ means the
ongoing evaluation of the quality of health care pro-
vided to enrollees.
‘‘(4) OVERSIGHT.—The Secretary is responsible
for performance of annual audits of managed care
group health plans and, in the case of a health in-
surance issuer, the State oversight agency is respon-
sible for performance of annual audits of managed
care health insurance coverage offered by such issu-
ers, in order to review enrollee clinical outcome data,
enrollee service data, and operational and other fi-
nancial data.
‘‘(i) GRIEVANCE PROCEDURES, REVIEWS, AND AP-
PEALS.—
‘‘(1) IN
GENERAL.—A managed care group
health plan (and a health insurance issuer offering
managed care group health insurance) shall provide
written notification to enrollees, in a language en-
rollees understand, regarding the right to file a
grievance concerning denials or limitations of cov-
erage under the plan or coverage. At a minimum,
such notification shall be given—
‘‘(A) prior to enrollment in the plan or
under the coverage; and
‘‘(B) at the time care is denied or limited
under the plan or coverage.
‘‘(2) NOTICE OF RIGHT TO FILE GRIEVANCE.—
At the time of such a denial, such a plan or issuer
shall notify the enrollee of the right to file a griev-
ance. Such notice shall be in writing and shall in-
clude the reason for denial, the name of the individ-
ual responsible for the decision, the criteria for de-
termination, and the enrollee’s right to file a griev-
ance.
‘‘(3) GRIEVANCE PROCEDURES.—The grievance
procedures under the plan or coverage shall in-
clude—
‘‘(A) identification of the reviewing body
and an explanation of the process of review;
‘‘(B) an initial investigation and review;
‘‘(C) notification within a reasonable
amount of time of the outcome of the grievance;
and
‘‘(D) an appeal procedure.
‘‘(4) TIME LIMITS.—
‘‘(A) IN GENERAL.—Such a plan or issuer
shall set reasonable time limits for each part of
the review process, but in no case shall the re-
view extend beyond 30 days.
‘‘(B) EXPEDITED REVIEW.—Such a plan
or issuer shall provide for expedited review for
cases involving an imminent, emergent, or seri-
ous threat to the health of an enrollee. In such
case the plan or issuer shall—
‘‘(i) immediately inform the enrollee
of this right, and
‘‘(ii) provide the enrollee with a writ-
ten statement of the disposition or pending
status of the grievance within 72 hours of
the commencement of the review process.
‘‘(5) REPORTING.—Such a plan or issuer shall
report to the Secretary or, in the case of a health
insurance issuer, the State oversight agency, the
number of grievances and appeals received by the
plan or issuer within a specified time period, includ-
ing if applicable, the outcomes or current status of
the grievance and appeals as well as the average
time taken to resolve both grievances and appeals.
‘‘(6) DEFINITIONS.—In this subsection:
‘‘(A) APPEAL.—The term ‘appeal’ means a
formal process whereby an enrollee whose care
has been reduced, denied, or terminated, or
whereby the enrollee deems the care inappropri-
ate, can contest an adverse grievance decision
by the plan or issuer.
‘‘(B) The term ‘expedited review’ means a
review process which takes no more than 72
hours after the review is commenced.
‘‘(C) The term ‘grievance’ means a written
complaint submitted by or on behalf of the en-
rollee.
‘‘(j) NOTICE.—A group health plan under this part
shall comply with the notice requirement under section
a group health plan or health insurance coverage of-
fered by a health insurance issuer, such a provider
or professional that has entered into an agreement
with the plan or issuer with respect to the provision
of health care services to enrollees under the plan or
coverage.
‘‘(6) The term ‘primary care practitioner’
means, with respect to a group health plan or health
insurance coverage offered by a health insurance is-
suer, a health care professional (who may be a fam-
ily practice physician, general practice physician, in-
ternist, obstetrician/gynecologist, or pediatrician)
designated by the plan or issuer to coordinate, su-
pervise, or provide ongoing care to enrollees.
‘‘(7) The term ‘State oversight agency’ means,
with respect to a health insurance issuer, the State
agency responsible for the regulation of the issuer.’’.
(2) Section 2723(c) of such Act (42 U.S.C. 300gg–
23(c)), as amended by section 604(b)(2) of Public Law
104–204, is amended by striking ‘‘section 2704’’ and in-
serting ‘‘sections 2704 and 2706’’.
SEC. 4. MANAGED CARE CONSUMER PROTECTIONS UNDER
INDIVIDUAL HEALTH INSURANCE COVERAGE.
(a) IN GENERAL.—Part B of title XXVII of the Pub-
lic Health Service Act, as amended by section 605(a) of
Public Law 104–204, is amended by inserting after sec-
tion 2751 the following new section:
‘‘SEC. 2752. MANAGED CARE CONSUMER PROTECTIONS.
‘‘(a) IN GENERAL.—The provisions of section 2706
(other than subsection (j)) shall apply to health insurance
coverage offered by a health insurance issuer in the indi-
vidual market in the same manner as it applies to health
insurance coverage offered by a health insurance issuer
in connection with a group health plan.
‘‘(b) NOTICE.—A health insurance issuer under this
part shall comply with the notice requirement under sec-
tion 713(j) of the Employee Retirement Income Security
Act of 1974 with respect to the requirements referred to
in subsection (a) as if such section applied to such issuer
and such issuer were a group health plan.’’.
(b) CONFORMING AMENDMENT.—Section 2762(b)(2)
of such Act (42 U.S.C. 300gg–62(b)(2)), as added by sec-
tion 605(b)(3)(B) of Public Law 104–204, is amended by
striking ‘‘section 2751’’ and inserting ‘‘sections 2751 and
2752’’.
SEC. 5. EFFECTIVE DATES.
(a) GROUP HEALTH PLANS AND GROUP HEALTH IN-
SURANCE COVERAGE.—(1) Subject to paragraph (2), the
amendments made by section 3 shall apply with respect
to group health plans for plan years beginning on or after
January 1, 1998.
(2) In the case of a group health plan maintained
pursuant to 1 or more collective bargaining agreements
between employee representatives and 1 or more employ-
ers ratified before the date of enactment of this Act, the
amendments made by section 3 shall not apply to plan
years beginning before the later of—
(A) the date on which the last collective bar-
gaining agreements relating to the plan terminates
(determined without regard to any extension thereof
agreed to after the date of enactment of this Act),
or
(B) January 1, 1998.
For purposes of subparagraph (A), any plan amendment
made pursuant to a collective bargaining agreement relat-
ing to the plan which amends the plan solely to conform
to any requirement added by section 3 shall not be treated
as a termination of such collective bargaining agreement.
(b) INDIVIDUAL HEALTH INSURANCE COVERAGE.—
The amendments made by section 4 shall apply with re-
spect to health insurance coverage offered, sold, issued,
renewed, in effect, or operated in the individual market
on or after January 1, 1998.
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