« ZurückWeiter »
cedure, or treatment under review or appeal and includes a pediatric specialist where appropriate; except that only a physician (allopathic or osteopathic) may be a clinical peer with respect to the review or appeal of treatment recommended or rendered by a physician.
(4) ENROLLEE.—The term "enrollee” means, with respect to health insurance coverage offered by a health insurance issuer, an individual enrolled with the issuer to receive such coverage.
(5) GROUP HEALTH PLAN.—The term "group health plan” has the meaning given such term in section 733(a) of the Employee Retirement Income Security Act of 1974 and in section 2791(a)(1) of the Public Health Service Act.
(6) HEALTH CARE PROFESSIONAL.-The term “health care professional” means an individual who is licensed, accredited, or certified under State law to provide specified health care services and who is operating within the scope of such licensure, accreditation, or certification.
(7) HEALTH CARE PROVIDER.—The term "health care provider" includes a physician or other health care professional, as well as an institutional or other facility or agency that provides health care services and that is licensed, accredited, or certified to provide health care items and services under applicable State law.
(8) NETWORK.—The term “network” means, with respect to a group health plan or health insurance issuer offering health insurance coverage, the participating health care professionals and providers through whom the plan or issuer provides health care items and services to participants, beneficiaries, or enrollees.
(9) NONPARTICIPATING.–The term “nonparticipating” means, with respect to a health care provider that provides health care items and services to a participant, beneficiary, or enrollee under group health plan or health insurance coverage, a health care provider that is not a participating health care provider with respect to such items and services.
(10) PARTICIPATING.–The term “participating” means, with respect to a health care provider that provides health care items and services to a participant, beneficiary, or enrollee under group health plan or health insurance coverage offered by a health insurance issuer, a health care provider that furnishes such items and services under a contract or other arrangement with the plan or issuer.
(11) PRIOR AUTHORIZATION.The term “prior authorization” means the process of obtaining prior approval from a health insurance issuer or group health plan for the provision or coverage of medical services. SEC. 152. PREEMPTION; STATE FLEXIBILITY; CON
STRUCTION. (a) CONTINUED APPLICABILITY OF STATE LAW WITH RESPECT TO HEALTH INSURANCE ISSUERS.
(1) IN GENERAL.-Subject to paragraph (2), this title shall not be construed to supersede any provision of State law which establishes, implements, or continues in effect any standard or requirement solely relating to health insurance issuers (in connection with group health insurance coverage or otherwise) except to the extent that such standard or requirement prevents the application of a requirement of this title.
(2) CONTINUED PREEMPTION WITH RESPECT TO GROUP HEALTH PLANS.—Nothing in this title shall be construed to affect or modify the provisions of section 514 of the Employee Retirement Income Security Act of 1974 with respect to group health plans.
(b) DEFINITIONS.- For purposes of this section:
(1) STATE LAW.—The term “State law” includes all laws, decisions, rules, regulations, or other State action having the effect of law, of any State. A law of the United States applicable only to the District of Columbia shall be treated as a State law rather than a law of the United States.
(2) STATE.—The term “State” includes a State, the District of Columbia, Puerto Rico, the Virgin Islands, Guam, American Samoa, the Northern Mariana Islands, any political subdivisions of such, or any agency or instrumentality of such. SEC. 153. EXCLUSIONS.
(a) No BENEFIT REQUIREMENTS.-Nothing in this title shall be construed to require a group health plan or a health insurance issuer offering health insurance coverage to include specific items and services (including abortions) under the terms of such plan or coverage, other than those provided under the terms of such plan or coverage.
(b) EXCLUSION FROM ACCESS TO CARE MANAGED CARE PROVISIONS FOR FEE-FOR-SERVICE COVERAGE.
(1) IN GENERAL.- The provisions of sections 111 through 117 shall not apply to a group health plan or health insurance coverage if the only coverage offered under the plan or coverage is fee-for-service coverage (as defined in paragraph (2)).
(2) FEE-FOR-SERVICE COVERAGE DEFINED.For purposes of this subsection, the term "fee-for-service coverage” means coverage under a group health plan or health insurance coverage that,
(A) reimburses hospitals, health professionals, and other providers on the basis of a rate determined by the plan or issuer on a fee-for-service basis without placing the provider at financial risk;
(B) does not vary reimbursement for such a provider based on an agreement to contract terms and conditions or the utilization of health care items or services relating to such provider;
(C) does not restrict the selection of providers among those who are lawfully authorized to provide the covered services and agree to accept the terms and conditions of payment established under the plan or by the issuer; and
(D) for which the plan or issuer does not require prior authorization before providing coverage for any services. SEC. 154. COVERAGE OF LIMITED SCOPE PLANS.
Only for purposes of applying the requirements of this title under sections 2707 and 2753 of the Public Health Service Act and section 714 of the Employee Retirement Income Security Act
1974, section 2791(c)(2)(A), and section 733(C)(2)(A) of the Employee Retirement Income Security Act of 1974 shall be deemed not to apply. SEC. 155. REGULATIONS.
The Secretaries of Health and Human Services and Labor shall issue such regulations as may be necessary or appropriate to carry out this title. Such regulations shall be issued consistent with section 104 of Health Insurance Portability and Accountability Act of 1996. Such Secretaries may promulgate any interim final rules as the Secretaries determine are appropriate to carry out this title. TITLE II-APPLICATION OF QUALITY
CARE STANDARDS TO GROUP HEALTH PLANS AND HEALTH INSURANCE COV. ERAGE UNDER THE PUBLIC HEALTH
SERVICE ACT SEC. 201. APPLICATION TO GROUP HEALTH
PLANS AND GROUP HEALTH INSUR
ANCE COVERAGE. (a) IN GENERAL.-Subpart 2 of part A of title XXVII of the Public Health Service Act is amended by adding at the end the following new section:
“SEC. 2707. PATIENT PROTECTION STANDARDS.
"(a) IN GENERAL.- Each group health plan shall comply with patient protection requirements under title I of the Bipartisan Consensus Managed Care Improvement Act of 1999, and each health insurance issuer shall comply with patient protection requirements under such title with respect to group health insurance coverage it offers, and such requirements shall be deemed to be incorporated into this subsection.
"(b) NOTICE.-A group health plan shall comply with the notice requirement under section 711(d) of the Employee Retirement Income Security Act of 1974 with respect to the requirements referred to in subsection (a) and a health insurance issuer shall comply with such notice requirement as if such section applied to such issuer and such issuer were a group health plan.”.
(b) CONFORMING AMENDMENT.-Section 2721(b)(2)(A) of such Act (42 U.S.C. 300gg21(b)(2)(A)) is amended by inserting “(other than section 2707)" after requirements of such subparts". SEC. 202. APPLICATION TO INDIVIDUAL HEALTH
INSURANCE COVERAGE. Part B of title XXVII of the Public Health Service Act is amended by inserting after section 2752 the following new section: “SEC. 2753. PATIENT PROTECTION STANDARDS.
“(a) IN GENERAL.—Each health insurance issuer shall comply with patient protection requirements under title I of the Bipartisan Consensus Managed Care Improvement Act of 1999 with respect to individual health insurance coverage it offers, and such requirements shall be deemed to be incorporated into this subsection.
“(b) NOTICE.-A health insurance issuer under this part shall comply with the notice requirement under section 711(d) of the Employee Retirement Income Security Act of 1974 with respect to the requirements of such title as if such section applied to such issuer and such issuer were a group health plan.”. TITLE III-AMENDMENTS TO THE EM
PLOYEE RETIREMENT INCOME SECU
RITY ACT OF 1974
STANDARDS TO GROUP HEALTH
CURITY ACT OF 1974. Subpart B of part 7 of subtitle B of title I of the Employee Retirement Income Security Act of 1974 is amended by adding at the end the following new section: "SEC. 714. PATIENT PROTECTION STANDARDS.
"(a) IN GENERAL.-Subject to subsection (b), a group health plan (and a health insurance issuer offering group health insurance coverage in connection with such a plan) shall comply with the requirements of title I of the Bipartisan Consensus Managed Care Improvement Act of 1999 (as in effect as of the date of the enactment of such Act), and such requirements shall be deemed to be incorporated into this subsection.
“(b) PLAN SATISFACTION OF CERTAIN REQUIREMENTS.
“(1) SATISFACTION OF CERTAIN REQUIREMENTS THROUGH INSURANCE.--For purposes of subsection (a), insofar as a group health plan provides benefits in the form of health insurance coverage through a health insurance issuer, the plan shall be treated as meeting the following requirements of title I of the Bipartisan Consensus Managed Care Improvement Act of 1999 with respect to such benefits and not be considered as failing to meet such requirements because of a failure of the issuer to meet such requirements so long as the plan sponsor or its representatives did not cause such failure by the issuer:
“(A) Section 112 (relating to choice of providers).
“(B) Section 113 (relating to access to “(c) ENFORCEMENT OF CERTAIN REQUIRE- (b) JUDICIAL REMEDIES FOR DENIAL OF emergency care). MENTS.
HEALTH BENEFITS.-Section 502 of such Act "(C) Section 114 (relating to access to spe- “(1) COMPLAINTS.-Any protected health (29 U.S.C. 1132) is amended by adding at the cialty care).
care professional who believes that the pro- end the following new subsections: “(D) Section 115 (relating to access to ob- fessional has been retaliated or discrimi- "(n) ADDITIONAL REMEDIES FOR DENIAL OF stetrical and gynecological care).
nated against in violation of section 135(b)(1) HEALTH BENEFITS.“(E) Section 116 (relating to access to pedi- of the Bipartisan Consensus Managed Care “(1) IN GENERAL.-In an action commenced atric care).
Improvement Act of 1999 may file with the under paragraph (10) of subsection (a) by a “(F) Section 117(a)(1) (relating to con- Secretary a complaint within 180 days of the participant or beneficiary of a group health tinuity in case of termination of provider date of the alleged retaliation or discrimina- plan (or by the estate of such a participant contract) and section 117(a)(2) (relating to tion.
or beneficiary) against a person described in continuity in case of termination of issuer “(2) INVESTIGATION.-The Secretary shall subparagraphs (A), (B), and (C) of such paracontract), but only insofar as a replacement investigate such complaints and shall deter- graph, the court may award, in addition to issuer assumes the obligation for continuity mine if a violation of such section has oc- other appropriate equitable relief under this of care.
curred and, if so, shall issue an order to en- section, monetary compensatory relief which “(G) Section 118 (relating to access to sure that the protected health care profes- may include both economic and nonneeded prescription drugs).
sional does not suffer any loss of position, economic damages (but which shall exclude “(H) Section 119 (relating to coverage for pay, or benefits in relation to the plan, punitive damages). The amount of any such individuals participating in approved clinical issuer, or provider involved, as a result of noneconomic damages awarded as monetary trials.) the violation found by the Secretary.
compensatory relief (I) Section 134 (relating to payment of "(d) CONFORMING REGULATIONS.—The Sec- “(A) in a case in which 2 times the amount claims). retary may issue regulations to coordinate
of the economic damages awarded as mone“(2) INFORMATION.—With respect to infor- the requirements on group health plans
tary compensatory relief is less than or mation required to be provided or made under this section with the requirements im
equal to $250,000, may not exceed the greater available under section 121, in the case of a posed under the other provisions of this
ofgroup health plan that provides benefits in title.”.
“(i) 2 times the amount of such economic the form of health insurance coverage
(b) SATISFACTION OF ERISA CLAIMS PROCE
damages so awarded, or through a health insurance issuer, the Sec- DURE REQUIREMENT.-Section 503 of such Act
“(ii) $250,000; and retary shall determine the circumstances (29 U.S.C. 1133) is amended by inserting “(a)”
“(B) in a case in which 2 times the amount under which the plan is not required to proafter “SEC. 503." and by adding at the end
of the economic damages awarded as monevide or make available the information (and the following new subsection: is not liable for the issuer's failure to pro
“(b) In the case of a group health plan (as
tary compensatory relief is greater than
$250,000, may not exceed $500,000. vide or make available the information), if defined in section 733) compliance with the
“(2) APPLICATION TO DECISIONS INVOLVING the issuer is obligated to provide and make requirements of subtitle A of title I of the
MEDICAL NECESSITY AND MEDICAL JUDGMENT.— available (or provides and makes available) Bipartisan Consensus Managed Care Im
This subsection and subsection (a)(10) apply such information.
provement Act of 1999 in the case of a claims “(3) GRIEVANCE AND INTERNAL APPEALS.denial shall be deemed compliance with sub
only with respect to final decisions described With respect to the internal appeals process section (a) with respect to such claims de
in section 103(a)(2) of the Bipartisan Connial.”. and the grievance system required to be es
sensus Managed Care Improvement Act of
1999. tablished under sections 102 and 104, in the
(c) CONFORMING AMENDMENTS.—(1) Section case of a group health plan that provides 732(a) of such Act (29 U.S.C. 1185(a)) is
“(3) DEFINITIONS.—For purposes of this subbenefits in the form of health insurance covamended by striking “section 711” and in
section and subsection (a)(10)erage through a health insurance issuer, the serting “sections 711 and 714”.
“(A) GROUP HEALTH PLAN; HEALTH INSUR(2) The table of contents in section 1 of
ANCE ISSUER; HEALTH INSURANCE COVERAGE.Secretary shall determine the circumstances under which the plan is not required to pro
such Act is amended by inserting after the The terms 'group health plan', 'health insurvide for such process and system (and is not
item relating to section 713 the following ance issuer', and 'health insurance coverage' liable for the issuer's failure to provide for new item:
shall have the meanings provided such terms such process and system), if the issuer is ob- “Sec. 714. Patient protection standards.”.
under section 733, respectively. (3) Section 502(b)(3) of such Act (29 U.S.C.
“(B) FINAL DECISION.—The term “final deciligated to provide for (and provides for) such process and system.
sion' means, with respect to a group health 1132(b)(3) is amended by inserting “(other “(4) EXTERNAL APPEALS.-Pursuant to rules than section 135(b))” after part 7”.
plan, the final decision of the plan under sec
tion 102 of the Bipartisan Consensus Manof the Secretary, insofar as a group health SEC. 302. ADDITIONAL JUDICIAL REMEDIES.
aged Care Improvement Act of 1999. plan enters into a contract with a qualified (a) CAUSE OF ACTION RELATING TO DENIAL external appeal entity for the conduct of ex- OF HEALTH BENEFITS.-Section 502(a) of the
“(C) PERSONAL INJURY.—The term “perternal appeal activities in accordance with Employee Retirement Income Security Act
sonal injury' means loss of life, loss or sigsection 103, the plan shall be treated as of 1974 (29 U.S.C. 1132(a)) is amended
nificant impairment of limb or bodily funcmeeting the requirement of such section and (1) by striking "or" at the end of paragraph
tion, significant disfigurement, or severe and is not liable for the entity's failure to meet (8):
chronic physical pain, and includes a physany requirements under such section.
(2) by striking “amounts." at the end of
ical injury arising out of a failure to treat a “(5) APPLICATION TO PROHIBITIONS.—Pursu- paragraph (9) and inserting "amounts; or”;
mental illness or disease. and ant to rules of the Secretary, if a health in
“(D) CLAIM FOR BENEFITS.—The term 'claim surance issuer offers health insurance cov- (3) by adding at the end the following new
for benefits' has the meaning provided in secerage in connection with a group health plan paragraph:
tion 101(f)(1) of the Bipartisan Consensus and takes an action in violation of any of the “(10) by a participant or beneficiary of a
Managed Care Improvement Act of 1999. group health plan (or the estate of such a
“(E) following sections, the group health plan
TO EXERCISE ORDINARY shall not be liable for such violation unless participant or beneficiary), for relief de
CARE.—The term 'failure to exercise ordinary the plan caused such violation: scribed in subsection (n), against a person
care' means a negligent failure to provide “(A) Section 131 (relating to prohibition of who
"(i) the consideration of appropriate medinterference with certain medical commu- “(A) is a fiduciary of such plan, a health
ical evidence, or nications). insurance issuer offering health insurance
“(ii) the regard for the health and safety of "(B) Section 132 (relating to prohibition of coverage in connection with such plan, or an the participant or beneficiary, discrimination against providers based on li- agent of such plan or the plan sponsor,
that a prudent individual acting in a like cacensure).
“(B) under such plan, has authority to pacity and familiar with such matters would “(C) Section 133 (relating to prohibition make the sole final decision described in sub- use in the conduct of an enterprise of a like against improper incentive arrangements). section (n)(2) regarding claims for benefits, character and with same or similar cir“(D) Section 135 (relating to protection for and
cumstances. patient advocacy).
“(C) has exercised such authority in mak- “(4) EXCEPTION FOR DENIALS IN ACCORDANCE “(6) CONSTRUCTION.—Nothing in this sub- ing such final decision denying such a claim WITH RECOMMENDATION OF EXTERNAL APPEAL section shall be construed to affect or modify by such participant or beneficiary in viola- ENTITY.-No person shall be liable under subthe responsibilities of the fiduciaries of a tion of the terms of the plan or this title section (a)(10) for additional monetary comgroup health plan under part 4 of subtitle B. and, in making such final decision, failed to pensatory relief described in paragraph (1) in
“(7) APPLICATION TO CERTAIN PROHIBITIONS exercise ordinary care in making an incor- any case in which the denial referred to in AGAINST RETALIATION.–With respect to com
rect determination in the case of such par- subsection (a)(10) is upheld by the pliance with the requirements of section
ticipant or beneficiary that an item or serv- ommendation of an external appeal entity 135(b)(1) of the Bipartisan Consensus Man- ice is excluded from coverage under the
issued with respect to such denial under secaged Care Improvement Act of 1999, for purterms of the plan,
tion 103 of the Bipartisan Consensus Manposes of this subtitle the term 'group health if the denial is the proximate cause of per- aged Care Improvement Act of 1999. plan' is deemed to include a reference to an sonal injury to, or the wrongful death of, “(5) EXCEPTION FOR EMPLOYERS AND OTHER institutional health care provider. such participant or beneficiary.".
“(A) IN GENERAL.-Subject to subparagraph (B), subsection (a)(10) does not authorize
“(i) any cause of action against an employer or other plan sponsor maintaining a group health plan (or against an employee of such an employer or sponsor acting within the scope of employment), or
“(ii) a right of recovery or indemnity by a person against such an employer or sponsor (or such an employee) for relief assessed against the person pursuant to a cause of action under subsection (a)(10).
"(B) SPECIAL RULE.-Subparagraph (A) shall not preclude any cause of action under subsection (a)(10) commenced against an employer or other plan sponsor (or against an employee of such an employer or sponsor acting within the scope of employment), if
“(i) such action is based on the direct participation of the employer or sponsor (or employee) in the sole final decision of the plan referred to in paragraph (2) with respect to a specific participant or beneficiary on a claim for benefits covered under the plan or health insurance coverage in the case at issue; and
“(ii) the decision on the claim resulted in personal injury to, or the wrongful death of, such participant or beneficiary.
“(C) DIRECT PARTICIPATION.–For purposes of this subsection, in determining whether an employer or other plan sponsor (or employee of an employer or other plan sponsor) is engaged in direct participation in the sole final decision of the plan on a claim under section 102 of the Bipartisan Consensus Managed Care Improvement Act of 1999, the employer or plan sponsor (or employee) shall not be construed to be engaged in such direct participation solely because of any form of decisionmaking or conduct, whether or not fiduciary in nature, that does not involve the final decision with respect to a specific claim for benefits by a specific participant or beneficiary, including but not limited to any participation in a decision relating to:
“(i) the selection or retention of the group health plan or health insurance coverage involved or the third party administrator or other agent, including any related cost-benefit analysis undertaken in connection with the selection of, or continued maintenance of, the plan or coverage involved;
"(ii) the creation, continuation, modification, or termination of the plan or of any coverage, benefit, or item or service covered by the plan affecting a cross-section of the plan participants and beneficiaries;
“(iii) the design of any coverage, benefit, or item or service covered by the plan, including the amount of copayments and limits connected with such coverage, and the specification of protocols, procedures, or policies for determining whether any such coverage, benefit, or item or service is medically necessary and appropriate or is experimental or investigational;
“(iv) any action by an agent of the employer or plan sponsor (other than an employee of the employer or plan sponsor) in making such a final decision on behalf of such employer or plan sponsor;
"(v) any decision by an employer or plan sponsor (or employee) or agent acting on behalf of an employer or plan sponsor either to authorize coverage for, or to intercede or not to intercede as an advocate for or on behalf of, any specific participant or beneficiary (or group of participants or beneficiaries) under the plan; or
“(vi) any other form of decisionmaking or other conduct performed by the employer or plan sponsor (or employee) in connection with the plan or coverage involved, unless the employer makes the sole final decision of the plan consisting of a failure described in paragraph (1)(A) as to specific participants or beneficiaries who suffer personal injury or wrongful death as a proximate cause of such decision.
“(6) REQUIRED DEMONSTRATION OF DIRECT PARTICIPATION.-An action under subsection (a)(10) against an employer or plan sponsor (or employee thereof) for remedies described in paragraph (1) shall be immediately dismissed
“(A) in the absence of an evidentiary demonstration in the complaint of direct participation by the employer or plan sponsor (or employee) in the sole final decision of the plan with respect to a specific participant or beneficiary who suffers personal injury or wrongful death,
“(B) upon a demonstration to the court that such employer or plan sponsor (or employee) did not directly participate in the final decision of the plan, or
“(C) in the absence of an evidentiary demonstration that a personal injury to, or wrongful death of, the participant or beneficiary resulted.
“(7) TREATMENT OF THIRD-PARTY PROVIDERS OF NONDISCRETIONARY ADMINISTRATIVE SERVICES.–Subsection (a)(10) does not authorize any action against any person providing nondiscretionary administrative services to employers or other plan sponsors.
“(8) REQUIREMENT OF EXHAUSTION OF ADMINISTRATIVE REMEDIES.
“(A) IN GENERAL.-Subsection (a)(10) applies in the case of any cause of action only if all remedies under section 503 (including remedies under sections 102 and 103 of the Bipartisan Consensus Managed Care Improvement Act of 1999 made applicable under section 714) with respect to such cause of action have been exhausted.
“(B) EXTERNAL REVIEW REQUIRED.-For purposes of subparagraph (A), administrative remedies under section 503 shall not be deemed exhausted until available remedies under section 103 of the Bipartisan Consensus Managed Care Improvement Act of 1999 have been elected and are exhausted.
“(C) CONSIDERATION OF ADMINISTRATIVE DETERMINATIONS.—Any determinations under section 102 or 103 of the Bipartisan Consensus Managed Care Improvement Act of 1999 made while an action under subsection (a)(10) is pending shall be given due consideration by the court in such action.
“(9) SUBSTANTIAL WEIGHT GIVEN TO EXTERNAL REVIEW DECISIONS.—In the case of any action under subsection (a)(10) for remedies described in paragraph (1), the external review decision under section 103 shall be given substantial weight when considered along with other available evidence.
“(10) LIMITATION OF ACTION.–Subsection (a)(10) shall not apply in connection with any action commenced after the later of
“(A) 1 year after (i) the date of the last action which constituted a part of the failure, or (ii) in the case of an omission, the latest date on which the fiduciary could have cured the failure, or
“(B) 1 year after the earliest date on which the plaintiff first knew, or reasonably should have known, of the personal injury or wrongful death resulting from the failure.
“(11) COORDINATION WITH FIDUCIARY REQUIREMENTS.—A fiduciary shall not be treated as failing to meet any requirement of part 4 solely by reason of any action taken by the fiduciary which consists of full compliance with the reversal under section 103 of the Bipartisan Consensus Managed Care Improvement Act of 1999 of denial of a claim for benefits.
“(12) CONSTRUCTION.—Nothing in this subsection or subsection (a)(10) shall be construed as authorizing an action
“(A) for the failure to provide an item or service which is not covered under the group health plan involved, or
“(B) for any action taken by a fiduciary which consists of compliance with the reversal or modification under section 103 of the Bipartisan Consensus Managed Care Im
provement Act of 1999 of a final decision under section 102 of such Act.
“(13) PROTECTION OF MEDICAL MALPRACTICE UNDER STATE LAW.—This subsection and subsection (a)(10) shall not be construed to preclude any action under State law not otherwise preempted under this section or section 503 or 514 with respect to the exercise of a specified professional standard of care in the provision of medical services.
“(14) REFERENCES TO THE BIPARTISAN CONSENSUS MANAGED CARE IMPROVEMENT ACT OF 1999.—Any reference in this subsection to any provision of the Bipartisan Consensus Managed Care Improvement Act of 1999 shall be deemed a reference to such provision as in effect on the date of the enactment of such Act.
“(0) EXPEDITED COURT REVIEW.-In any case in which exhaustion of administrative remedies in accordance with section 102 or 103 of the Bipartisan Consensus Managed Care Improvement Act of 1999 otherwise necessary for an action for injunctive relief under paragraph (1)(B) or (3) of subsection (a) has not been obtained and it is demonstrated to the court by clear and convincing evidence that such exhaustion is not reasonably attainable under the facts and circumstances without any further undue risk of irreparable harm to the health of the participant or beneficiary, a civil action may be brought by a participant or beneficiary to obtain such relief. Any determinations which already have been made under section 102 or 103 in such case, or which are made in such case while an action under this paragraph is pending, shall be given due consideration by the court in any action under this subsection in such case.".
(C) EFFECTIVE DATE.—The amendments made by this section shall apply to acts and omissions (from which a cause of action arises) occurring on or after the date of the enactment of this Act. SEC. 304. AVAILABILITY OF BINDING ARBITRA
TION. (a) IN GENERAL.-Section 502 of the Employee Retirement Income Security Act of 1974 (as amended by the preceding provisions of this Act) is amended further by adding at the end the following new subsection:
“(p) BINDING ARBITRATION PERMITTED AS ALTERNATIVE MEANS OF DISPUTE RESOLUTION.—
“(1) IN GENERAL.—This subsection shall apply with respect to any adverse coverage decision rendered under a group health plan under section 102 or 103, if
“(A) all administrative remedies under section 503 required for an action in court under this section have been exhausted,
"(B) under the terms of the plan, the aggrieved participant or beneficiary may elect to resolve the dispute by means of a procedure of binding arbitration which is available with respect to all similarly situated participants and beneficiaries (or which is available under the plan pursuant to a bona fide collective bargaining agreement pursuant to which the plan is established and maintained), and which meets the requirements of paragraph (3), and
“(C) the participant or beneficiary has elected such procedure in accordance with the terms of the plan.
“(2) EFFECT OF ELECTION.-In the case of an election by a participant or beneficiary pursuant to paragraph (1)—
“(A) decisions rendered under the procedure of binding arbitration shall be binding on all parties to the procedure and shall be enforceable under the preceding subsections of this section as if the terms of the decision were the terms of the plan, except that the court in an action brought under this section may vacate any award made pursuant to the arbitration for any cause described in paragraph (1), (2), (3), (4), or (5) of section 10(a) of title 9, United States Code, and
"(B) subject to subparagraph (A), such participant or beneficiary shall be treated as having effectively waived any right to further review of the decision by a court under the preceding subsections of this section.
“(3) ADDITIONAL REQUIREMENTS.—The requirements of this paragraph consist of the following:
“(A) ARBITRATION PANEL.—The arbitration shall be conducted by an arbitration panel meeting the requirements of paragraph (4).
“(B) FAIR PROCESS; DE NOVO DETERMINATION.—The procedure shall provide for a fair, de novo determination.
“(C) OPPORTUNITY TO SUBMIT EVIDENCE, HAVE REPRESENTATION, AND MAKE ORAL PRESENTATION.—Each party to the arbitration procedure
“(i) may submit and review evidence related to the issues in dispute;
“(ii) may use the assistance or representation of one or more individuals (any of whom may be an attorney); and
"(iii) may make an oral presentation.
“(D) PROVISION OF INFORMATION.—The plan shall provide timely access to all its records relating to the matters under arbitration and to all provisions of the plan relating to such matters.
"(E) TIMELY DECISIONS.—A determination by the arbitration panel on the decision shall
*(i) be made in writing;
"(iii) be made in accordance with the medical exigencies of the case involved.
“(4) ARBITRATION PANEL.
"(A) IN GENERAL.-Arbitrations commenced pursuant to this subsection shall be conducted by a panel of arbitrators selected by the parties made up of 3 individuals, including at least one physician and one attorney.
"(B) QUALIFICATIONS.-Any individual who is a member of an arbitration panel shall meet the following requirements:
"(i) There is no real or apparent conflict of interest that would impede the individual conducting arbitration independent of the plan and meets the independence requirements of subparagraph (C).
"(ii) The individual has sufficient medical or legal expertise to conduct the arbitration for the plan on a timely basis.
"(iii) The individual has appropriate credentials and has attained recognized expertise in the applicable medical or legal field.
"(iv) The individual was not involved in the initial adverse coverage decision or any other review thereof.
“(C) INDEPENDENCE REQUIREMENTS.-An individual described in subparagraph (B) meets the independence requirements of this subparagraph if
"(i) the individual is not affiliated with any related party,
"(ii) any compensation received by such individual in connection with the binding arbitration procedure is reasonable and not contingent on any decision rendered by the individual,
"(iii) under the terms of the plan, the plan has no recourse against the individual or entity in connection with the binding arbitration procedure, and
"(iv) the individual does not otherwise have a conflict of interest with a related party as determined under such regulations as the Secretary may prescribe.
“(D) RELATED PARTY.-For purposes of subparagraph (C), the term 'related party' means
"(i) the plan or any health insurance issuer offering health insurance coverage in connection with the plan (or any officer, director, or management employee of such plan or issuer).
“(ii) the physician or other medical care provider that provided the medical care involved in the coverage decision,
“(iii) the institution at which the medical care involved in the coverage decision is provided,
“(iv) the manufacturer of any drug or other item that was included in the medical care involved in the coverage decision, or
“(v) any other party determined under such regulations as the Secretary may prescribe to have a substantial interest in the coverage decision.
"(E) AFFILIATED.-For purposes of subparagraph (C), the term 'affiliated' means, in connection with any entity, having a familial, financial, or professional relationship with, or interest in, such entity.
“(5) ALLOWABLE REMEDIES.—The remedies which may be implemented by the arbitration panel shall consist of those remedies which would be available in an action timely commenced by a participant or beneficiary under section 502, taking into account the administrative remedies exhausted by the participant or beneficiary under section 503.".
(b) EFFECTIVE DATE.-The amendment made by this section shall apply to adverse coverage decisions initially rendered by group health plans on or after the date of the enactment of this Act. TITLE IV-APPLICATION TO GROUP
HEALTH PLANS UNDER THE INTERNAL
REVENUE CODE OF 1986 SEC. 401. AMENDMENTS TO THE INTERNAL REV.
ENUE CODE OF 1986. Subchapter B of chapter 100 of the Internal Revenue Code of 1986 is amended
(1) in the table of sections, by inserting after the item relating to section 9812 the following new item: “Sec. 9813. Standard relating to patient free
dom of choice."'; and
(2) by inserting after section 9812 the following: "SEC. 9813. STANDARD RELATING TO PATIENTS'
BILL OF RIGHTS. "A group health plan shall comply with the requirements of title I of the Bipartisan Consensus Managed Care Improvement Act of 1999 (as in effect as of the date of the enactment of such Act), and such requirements shall be deemed to be incorporated into this section.".
TITLE V_EFFECTIVE DATES; COORDINATION IN IMPLEMENTATION SEC. 501. EFFECTIVE DATES.
(a) GROUP HEALTH COVERAGE.
(1) IN GENERAL.-Subject to paragraph (2), the amendments made by sections 201(a), 301, and 401 (and title I insofar as it relates to such sections) shall apply with respect to group health plans, and health insurance coverage offered in connection with group health plans, for plan years beginning on or after January 1, 2000 (in this section referred to as the “general effective date”) and also shall apply to portions of plan years occurring on and after such date.
(2) TREATMENT OF COLLECTIVE BARGAINING AGREEMENTS.-In the case of a group health plan maintained pursuant to 1 or more collective bargaining agreements between employee representatives and 1 or more employers ratified before the date of enactment of this Act, the amendments made by sections 201(a), 301, and 401 (and title I insofar as it relates to such sections) shall not apply to plan years beginning before the later of
(A) the date on which the last collective bargaining 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) the general effective date.
For purposes of subparagraph (A), any plan amendment made pursuant to a collective bargaining agreement relating to the plan which amends the plan solely to conform to any requirement added by this Act shall not be treated as a termination of such collective bargaining agreement.
(b) INDIVIDUAL HEALTH INSURANCE CovERAGE.-The amendments made by section 202 shall apply with respect to individual health insurance coverage offered, sold, issued, renewed, in effect, or operated in the individual market on or after the general effective date. SEC. 502. COORDINATION IN IMPLEMENTATION.
The Secretary of Labor, the Secretary of Health and Human Services, and the Secretary of the Treasury shall ensure, through the execution of an interagency memorandum of understanding among such Secretaries, that
(1) regulations, rulings, and interpretations issued by such Secretaries relating to the same matter over which such Secretaries have responsibility under the provisions of this Act (and the amendments made thereby) are administered so as to have the same effect at all times; and
(2) coordination of policies relating to enforcing 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. TITLE VI-HEALTH CARE PAPERWORK
SIMPLIFICATION SEC. 601. HEALTH CARE PAPERWORK SIM
PLIFICATION. (a) ESTABLISHMENT OF PANEL.
(1) ESTABLISHMENT.-There is established a panel to be known as the Health Care Panel to Devise a Uniform Explanation of Benefits (in this section referred to as the “Panel"').
(2) DUTIES OF PANEL.
(A) IN GENERAL.-The Panel shall devise a single form for use by third-party health care payers for the remittance of claims to providers.
(B) DEFINITION.-For purposes of this section, the term “third-party health care payer" means any entity that contractually pays health care bills for an individual.
(A) SIZE AND COMPOSITION.—The Secretary of Health and Human Services shall determine the number of members and the composition of the Panel. Such Panel shall include equal numbers of representatives of private insurance organizations, consumer groups, State insurance commissioners, State medical societies, State hospital associations, and State medical specialty societies.
(B) TERMS OF APPOINTMENT.—The members of the Panel shall serve for the life of the Panel.
(C) VACANCIES.—A vacancy in the Panel shall not affect the power of the remaining members to execute the duties of the Panel, but any such vacancy shall be filled in the same manner in which the original appointment was made.
(A) MEETINGS.—The Panel shall meet at the call of a majority of its members.
(B) FIRST MEETING.–The Panel shall convene not later than 60 days after the date of the enactment of the Bipartisan Consensus Managed Care Improvement Act of 1999.
(C) QUORUM.-A quorum shall consist of a majority of the members of the Panel.
(D) HEARINGS.-For the purpose of carrying out its duties, the Panel may hold such hearings and undertake such other activities as the Panel determines to be necessary to carry out its duties.
(A) COMPENSATION.-Except as provided in subparagraph (B), members of the Panel shall receive no additional pay, allowances, or benefits by reason of their service on the Panel.
(B) TRAVEL EXPENSES AND PER DIEM.—Each member of the Panel who is not an officer or employee of the Federal Government shall receive travel expenses and per diem in lieu of subsistence in accordance with sections 5702 and 5703 of title 5, United States Code.
(C) CONTRACT AUTHORITY.—The Panel may contract with and compensate government and private agencies or persons for items and services, without regard to section 3709 of the Revised Statutes (41 U.S.C. 5).
(D) USE OF MAILS.—The Panel may use the United States mails in the same manner and under the same conditions as Federal agencies and shall, for purposes of the frank, be considered a commission of Congress as described in section 3215 of title 39, United States Code.
(E) ADMINISTRATIVE SUPPORT SERVICES.Upon the request of the Panel, the Secretary of Health and Human Services shall provide to the Panel on a reimbursable basis such administrative support services as the Panel may request.
(6) SUBMISSION OF FORM.—Not later than 2 years after the first meeting, the Panel shall submit a form to the Secretary of Health and Human Services for use by third-party health care payers.
(7) TERMINATION.—The Panel shall terminate on the day after submitting the form under paragraph (6).
(b) REQUIREMENT FOR USE OF FORM BY THIRD-PARTY CARE PAYERS.-A third-party health care payer shall be required to use the form devised under subsection (a) for plan years beginning on or after 5 years following the date of the enactment of this Act.
It was decided in the Yeas ....... 160 negative
[Roll No. 489]
Green (WI) Bliley
Hansen Brady (TX) Hastert Bryant
Hastings (WA) Callahan
Hill (MT) Cannon
Houghton Chambliss Hulshof Chenoweth-Hage Hunter Coble
La Tourette Duncan
Lewis (CA) Ehlers
Lewis (KY) Ehrlich
Lucas (KY) English
Lucas (OK) Everett
Scarborough So the amendment was not agreed to. After some further time,
The SPEAKER pro tempore, Mr. PEASE, assumed the Chair.
When Mr. HASTINGS of Washington, Chairman, pursuant to House Resolution 323, reported the bill, as amended, pursuant to said resolution back to the House.
The previous question having been ordered by said resolution.
Pursuant to House Resolution 323, the following amendments in section A of House Report 106-366 were considered as adopted:
Page 17, beginning on line 24, strike “, as determined by the plan or issuer or as certified in writing by a treating health care professional.".
Page 40, line 17, strike “enforce actions" and insert "enforce rights".
Page 42, line 15, insert “or arrange to be offered" after “shall offer".
Page 44, after line 8, insert the following:
(3) CONSTRUCTION.-Nothing in this subsection shall be construed as affecting the application of section 114 (relating to access to specialty care).
Page 47, amend lines 7 through 18 to read as follows:
(b) REIMBURSEMENT FOR MAINTENANCE CARE AND POST-STABILIZATION CARE. In the case of services (other than emergency services) for which benefits are available under a group health plan, or under health insurance coverage offered by a health insurance issuer, the plan or issuer shall provide for reimbursement with respect to such services provided to a participant, beneficiary, or enrollee other than through a participating health care provider in a manner consistent with subsection (a)(1)(C) (and shall otherwise comply with the guidelines established under section 1852(d)(2) of the Social Security Act), if the services are maintenance care or poststabilization care covered under such guidelines.
Page 86, amend lines 10 through 16 to read as follows:
(a) NO BENEFIT REQUIREMENTS.-Nothing in this title shall be construed to require a group health plan or a health insurance issuer offering health insurance coverage to provide items and services (including abortions) that are specifically excluded under the plan or coverage.
Page 102, line 25, strike "January 1, 2000" and insert “January 1, 2001".
Page 96, strike line 20 and all that follows through line 15 on page 101 and insert the following and conform the table of contents accordingly): SEC. 302. ERISA PREEMPTION NOT TO APPLY TO
CERTAIN ACTIONS INVOLVING
HOLDERS. (a) IN GENERAL.-Section 514 of the Employee Retirement Income Security Act of 1974 (29 U.S.C. 1144) is amended by adding at the end the following subsections:
“(e) PREEMPTION NOT TO APPLY TO CERTAIN ACTIONS ARISING OUT OF PROVISION OF HEALTH BENEFITS.
“(1) NON-PREEMPTION OF CERTAIN CAUSES OF ACTION.
"(A) IN GENERAL.—Except as provided in this subsection, nothing in this title shall be construed to invalidate, impair, or supersede any cause of action by a participant or beneficiary (or the estate of a participant or beneficiary) under State law to recover damages resulting from personal injury or for wrongful death against any person