109th CONGRESS
1st Session
H. R. 2259
To amend the Public Health Service Act, the Employee Retirement Income
Security Act of 1974, and the Internal Revenue Code of 1986 to protect consumers
in managed care plans and other health coverage.
IN THE HOUSE OF REPRESENTATIVES
May 11, 2005
Mr. DINGELL (for himself, Ms. PELOSI, Mr. HOYER, Mr. BERRY, Mr. ANDREWS,
Mr. RANGEL, Mr. GEORGE MILLER of California, Mr. BROWN of Ohio, Mr. STARK,
Mr. WAXMAN, Mr. MARKEY, Mrs. CAPPS, Mr. DOYLE, Mr. RUSH, Ms. SOLIS, Mr. DAVIS
of Florida, Mr. GENE GREEN of Texas, Ms. SCHAKOWSKY, Mr. TOWNS, Mr. STRICKLAND,
Mr. PALLONE, Mr. ENGEL, Mr. BOUCHER, Ms. ESHOO, Ms. DEGETTE, Ms. MCCOLLUM
of Minnesota, Mr. TIERNEY, Mr. OWENS, Mrs. MCCARTHY, Mr. HOLT, Mr. KILDEE,
Mr. GRIJALVA, Ms. WOOLSEY, Mrs. DAVIS of California, Mr. NADLER, Mr. VAN HOLLEN,
Mr. MCNULTY, Mr. CUMMINGS, Mr. SCHIFF, Mr. HINCHEY, Ms. ROYBAL-ALLARD, Mr.
HONDA, Mr. ABERCROMBIE, Mr. FARR, Mr. WEXLER, Mr. BRADY of Pennsylvania, Mr.
MCDERMOTT, Mr. MCGOVERN, Mr. MOORE of Kansas, Mr. DICKS, Mr. CLAY, Mr. KUCINICH,
and Mr. HASTINGS of Florida) introduced the following bill; which was referred
to the Committee on Energy and Commerce, and in addition to the Committees
on Education and the Workforce and Ways and Means, for a period to be subsequently
determined by the Speaker, in each case for consideration of such provisions
as fall within the jurisdiction of the committee concerned
A BILL
To amend the Public Health Service Act, the Employee Retirement Income
Security Act of 1974, and the Internal Revenue Code of 1986 to protect consumers
in managed care plans and other health coverage.
Be it enacted by the Senate and House of Representatives of the United
States of America in Congress assembled,
SECTION 1. SHORT TITLE; TABLE OF CONTENTS.
(a) Short Title- This Act may be cited as the `Patients' Bill of Rights Act
of 2005'.
(b) Table of Contents- The table of contents of this Act is as follows:
Sec. 1. Short title; table of contents.
TITLE I--IMPROVING MANAGED CARE
Subtitle A--Utilization Review; Claims; and Internal and External Appeals
Sec. 101. Utilization review activities.
Sec. 102. Procedures for initial claims for benefits and prior authorization
determinations.
Sec. 103. Internal appeals of claims denials.
Sec. 104. Independent external appeals procedures.
Sec. 105. Health Care Consumer Assistance Fund.
Subtitle B--Access to Care
Sec. 111. Consumer choice option.
Sec. 112. Choice of health care professional.
Sec. 113. Access to emergency care.
Sec. 114. Timely access to specialists.
Sec. 115. Patient access to obstetrical and gynecological care.
Sec. 116. Access to pediatric care.
Sec. 117. Continuity of care.
Sec. 118. Access to needed prescription drugs.
Sec. 119. Coverage for individuals participating in approved clinical trials.
Sec. 120. Required coverage for minimum hospital stay for mastectomies and
lymph node dissections for the treatment of breast cancer and coverage for
secondary consultations.
Subtitle C--Access to Information
Sec. 121. Patient access to information.
Subtitle D--Protecting the Doctor-Patient Relationship
Sec. 131. Prohibition of interference with certain medical communications.
Sec. 132. Prohibition of discrimination against providers based on licensure.
Sec. 133. Prohibition against improper incentive arrangements.
Sec. 134. Payment of claims.
Sec. 135. Protection for patient advocacy.
Subtitle E--Definitions
Sec. 152. Preemption; State flexibility; construction.
Sec. 154. Treatment of excepted benefits.
Sec. 156. Incorporation into plan or coverage documents.
Sec. 157. Preservation of protections.
TITLE II--APPLICATION OF QUALITY CARE STANDARDS TO GROUP HEALTH PLANS AND
HEALTH INSURANCE COVERAGE UNDER THE PUBLIC HEALTH SERVICE ACT
Sec. 201. Application to group health plans and group health insurance coverage.
Sec. 202. Application to individual health insurance coverage.
Sec. 203. Cooperation between Federal and State authorities.
TITLE III--APPLICATION OF PATIENT PROTECTION STANDARDS TO FEDERAL HEALTH
INSURANCE PROGRAMS
Sec. 301. Application of patient protection standards to Federal health
insurance programs.
TITLE IV--AMENDMENTS TO THE EMPLOYEE RETIREMENT INCOME SECURITY ACT OF 1974
Sec. 401. Application of patient protection standards to group health plans
and group health insurance coverage under the Employee Retirement Income
Security Act of 1974.
Sec. 402. Availability of civil remedies.
Sec. 403. Cooperation between Federal and State authorities.
TITLE V--AMENDMENTS TO THE INTERNAL REVENUE CODE OF 1986
Subtitle A--Application of Patient Protection Provisions
Sec. 501. Application to group health plans under the Internal Revenue Code
of 1986.
Sec. 502. Conforming enforcement for women's health and cancer rights.
Subtitle B--Health Care Coverage Access Tax Incentives
Sec. 511. Credit for health insurance expenses of small businesses.
Sec. 512. Certain grants by private foundations to qualified health benefit
purchasing coalitions.
Sec. 513. State grant program for market innovation.
Sec. 514. Grant program to facilitate health benefits information for small
employers.
Sec. 515. State grant program for market innovation.
TITLE VI--EFFECTIVE DATES; COORDINATION IN IMPLEMENTATION
Sec. 601. Effective dates.
Sec. 602. Coordination in implementation.
TITLE VII--MISCELLANEOUS PROVISIONS
Sec. 701. No impact on Social Security Trust Fund.
TITLE I--IMPROVING MANAGED CARE
Subtitle A--Utilization Review; Claims; and Internal and External Appeals
SEC. 101. UTILIZATION REVIEW ACTIVITIES.
(a) Compliance With Requirements-
(1) IN GENERAL- A group health plan, and a health insurance issuer that
provides health insurance coverage, shall conduct utilization review activities
in connection with the provision of benefits under such plan or coverage
only in accordance with a utilization review program that meets the requirements
of this section and section 102.
(2) USE OF OUTSIDE AGENTS- Nothing in this section shall be construed as
preventing a group health plan or health insurance issuer from arranging
through a contract or otherwise for persons or entities to conduct utilization
review activities on behalf of the plan or issuer, so long as such activities
are conducted in accordance with a utilization review program that meets
the requirements of this section.
(3) UTILIZATION REVIEW DEFINED- For purposes of this section, the terms
`utilization review' and `utilization review activities' mean procedures
used to monitor or evaluate the use or coverage, clinical necessity, appropriateness,
efficacy, or efficiency of health care services, procedures or settings,
and includes prospective review, concurrent review, second opinions, case
management, discharge planning, or retrospective review.
(b) Written Policies and Criteria-
(1) WRITTEN POLICIES- A utilization review program shall be conducted consistent
with written policies and procedures that govern all aspects of the program.
(2) USE OF WRITTEN CRITERIA-
(A) IN GENERAL- Such a program shall utilize written clinical review criteria
developed with input from a range of appropriate actively practicing health
care professionals, as determined by the plan, pursuant to the program.
Such criteria shall include written clinical review criteria that are
based on valid clinical evidence where available and that are directed
specifically at meeting the needs of at-risk populations and covered individuals
with chronic conditions or severe illnesses, including gender-specific
criteria and pediatric-specific criteria where available and appropriate.
(B) CONTINUING USE OF STANDARDS IN RETROSPECTIVE REVIEW- If a health care
service has been specifically pre-authorized or approved for a participant,
beneficiary, or enrollee under such a program, the program shall not,
pursuant to retrospective review, revise or modify the specific standards,
criteria, or procedures used for the utilization review for procedures,
treatment, and services delivered to the enrollee during the same course
of treatment.
(C) REVIEW OF SAMPLE OF CLAIMS DENIALS- Such a program shall provide for
a periodic evaluation of the clinical appropriateness of at least a sample
of denials of claims for benefits.
(c) Conduct of Program Activities-
(1) ADMINISTRATION BY HEALTH CARE PROFESSIONALS- A utilization review program
shall be administered by qualified health care professionals who shall oversee
review decisions.
(2) USE OF QUALIFIED, INDEPENDENT PERSONNEL-
(A) IN GENERAL- A utilization review program shall provide for the conduct
of utilization review activities only through personnel who are qualified
and have received appropriate training in the conduct of such activities
under the program.
(B) PROHIBITION OF CONTINGENT COMPENSATION ARRANGEMENTS- Such a program
shall not, with respect to utilization review activities, permit or provide
compensation or anything of value to its employees, agents, or contractors
in a manner that encourages denials of claims for benefits.
(C) PROHIBITION OF CONFLICTS- Such a program shall not permit a health
care professional who is providing health care services to an individual
to perform utilization review activities in connection with the health
care services being provided to the individual.
(3) ACCESSIBILITY OF REVIEW- Such a program shall provide that appropriate
personnel performing utilization review activities under the program, including
the utilization review administrator, are reasonably accessible by toll-free
telephone during normal business hours to discuss patient care and allow
response to telephone requests, and that appropriate provision is made to
receive and respond promptly to calls received during other hours.
(4) LIMITS ON FREQUENCY- Such a program shall not provide for the performance
of utilization review activities with respect to a class of services furnished
to an individual more frequently than is reasonably required to assess whether
the services under review are medically necessary and appropriate.
SEC. 102. PROCEDURES FOR INITIAL CLAIMS FOR BENEFITS AND PRIOR AUTHORIZATION
DETERMINATIONS.
(a) Procedures of Initial Claims for Benefits-
(1) IN GENERAL- A group health plan, and a health insurance issuer offering
health insurance coverage, shall--
(A) make a determination on an initial claim for benefits by a participant,
beneficiary, or enrollee (or authorized representative) regarding payment
or coverage for items or services under the terms and conditions of the
plan or coverage involved, including any cost-sharing amount that the
participant, beneficiary, or enrollee is required to pay with respect
to such claim for benefits; and
(B) notify a participant, beneficiary, or enrollee (or authorized representative)
and the treating health care professional involved regarding a determination
on an initial claim for benefits made under the terms and conditions of
the plan or coverage, including any cost-sharing amounts that the participant,
beneficiary, or enrollee may be required to make with respect to such
claim for benefits, and of the right of the participant, beneficiary,
or enrollee to an internal appeal under section 103.
(2) ACCESS TO INFORMATION-
(A) TIMELY PROVISION OF NECESSARY INFORMATION- With respect to an initial
claim for benefits, the participant, beneficiary, or enrollee (or authorized
representative) and the treating health care professional (if any) shall
provide the plan or issuer with access to information requested by the
plan or issuer that is necessary to make a determination relating to the
claim. Such access shall be provided not later than 5 days after the date
on which the request for information is received, or, in a case described
in subparagraph (B) or (C) of subsection (b)(1), by such earlier time
as may be necessary to comply with the applicable timeline under such
subparagraph.
(B) LIMITED EFFECT OF FAILURE ON PLAN OR ISSUER'S OBLIGATIONS- Failure
of the participant, beneficiary, or enrollee to comply with the requirements
of subparagraph (A) shall not remove the obligation of the plan or issuer
to make a decision in accordance with the medical exigencies of the case
and as soon as possible, based on the available information, and failure
to comply with the time limit established by this paragraph shall not
remove the obligation of the plan or issuer to comply with the requirements
of this section.
(3) ORAL REQUESTS- In the case of a claim for benefits involving an expedited
or concurrent determination, a participant, beneficiary, or enrollee (or
authorized representative) may make an initial claim for benefits orally,
but a group health plan, or health insurance issuer offering health insurance
coverage, may require that the participant, beneficiary, or enrollee (or
authorized representative) provide written confirmation of such request
in a timely manner on a form provided by the plan or issuer. In the case
of such an oral request for benefits, the making of the request (and the
timing of such request) shall be treated as the making at that time of a
claim for such benefits without regard to whether and when a written confirmation
of such request is made.
(b) Timeline for Making Determinations-
(1) PRIOR AUTHORIZATION DETERMINATION-
(A) IN GENERAL- A group health plan, and a health insurance issuer offering
health insurance coverage, shall make a prior authorization determination
on a claim for benefits (whether oral or written) in accordance with the
medical exigencies of the case and as soon as possible, but in no case
later than 14 days from the date on which the plan or issuer receives
information that is reasonably necessary to enable the plan or issuer
to make a determination on the request for prior authorization and in
no case later than 28 days after the date of the claim for benefits is
received.
(B) EXPEDITED DETERMINATION- Notwithstanding subparagraph (A), a group
health plan, and a health insurance issuer offering health insurance coverage,
shall expedite a prior authorization determination on a claim for benefits
described in such subparagraph when a request for such an expedited determination
is made by a participant, beneficiary, or enrollee (or authorized representative)
at any time during the process for making a determination and a health
care professional certifies, with the request, that a determination under
the procedures described in subparagraph (A) would seriously jeopardize
the life or health of the participant, beneficiary, or enrollee or the
ability of the participant, beneficiary, or enrollee to maintain or regain
maximum function. Such determination shall be made in accordance with
the medical exigencies of the case and as soon as possible, but in no
case later than 72 hours after the time the request is received by the
plan or issuer under this subparagraph.
(I) IN GENERAL- Subject to clause (ii), in the case of a concurrent
review of ongoing care (including hospitalization), which results
in a termination or reduction of such care, the plan or issuer must
provide by telephone and in printed form notice of the concurrent
review determination to the individual or the individual's designee
and the individual's health care provider in accordance with the medical
exigencies of the case and as soon as possible, with sufficient time
prior to the termination or reduction to allow for an appeal under
section 103(b)(3) to be completed before the termination or reduction
takes effect.
(II) CONTENTS OF NOTICE- Such notice shall include, with respect to
ongoing health care items and services, the number of ongoing services
approved, the new total of approved services, the date of onset of
services, and the next review date, if any, as well as a statement
of the individual's rights to further appeal.
(ii) RULE OF CONSTRUCTION- Clause (i) shall not be construed as requiring
plans or issuers to provide coverage of care that would exceed the coverage
limitations for such care.
(2) RETROSPECTIVE DETERMINATION- A group health plan, and a health insurance
issuer offering health insurance coverage, shall make a retrospective determination
on a claim for benefits in accordance with the medical exigencies of the
case and as soon as possible, but not later than 30 days after the date
on which the plan or issuer receives information that is reasonably necessary
to enable the plan or issuer to make a determination on the claim, or, if
earlier, 60 days after the date of receipt of the claim for benefits.
(c) Notice of a Denial of a Claim for Benefits- Written notice of a denial
made under an initial claim for benefits shall be issued to the participant,
beneficiary, or enrollee (or authorized representative) and the treating health
care professional in accordance with the medical exigencies of the case and
as soon as possible, but in no case later than 2 days after the date of the
determination (or, in the case described in subparagraph (B) or (C) of subsection
(b)(1), within the 72-hour or applicable period referred to in such subparagraph).
(d) Requirements of Notice of Determinations- The written notice of a denial
of a claim for benefits determination under subsection (c) shall be provided
in printed form and written in a manner calculated to be understood by the
participant, beneficiary, or enrollee and shall include--
(1) the specific reasons for the determination (including a summary of the
clinical or scientific evidence used in making the determination);
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