[Congressional Bills 104th Congress]
[From the U.S. Government Printing Office]
[H.R. 4315 Introduced in House (IH)]
104th CONGRESS
2d Session
H. R. 4315
To provide patients with information and rights to promote better
health care.
_______________________________________________________________________
IN THE HOUSE OF REPRESENTATIVES
September 28, 1996
Mr. Owens (for himself, Ms. Norton, Ms. McKinney, Mr. Frazer, Mr.
Yates, Mr. Dellums, Mr. Payne of New Jersey, Mr. Hilliard, Mr. Kildee,
and Mrs. Mink of Hawaii) introduced the following bill; which was
referred to the Committee on Commerce, and in addition to the Committee
on 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 provide patients with information and rights to promote better
health care.
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 ``Patient and Health
Care Provider Protection Act of 1996''.
(b) Table of Contents.--The table of contents of this Act is as
follows:
Sec. 1. Short title; table of contents.
Sec. 2. Findings.
Sec. 3. Definitions.
TITLE I--HEALTH PLAN REQUIREMENTS
Sec. 101. Interference with medical communication prohibited.
Sec. 102. Improper incentive plan prohibited.
Sec. 103. Provisions regarding denial of care.
Sec. 104. Quality of care.
Sec. 105. Privacy.
Sec. 106. Fee.
Sec. 107. Enforcement through civil penalties.
Sec. 108. Prohibition on adverse action.
TITLE II--OFFICE OF CONSUMER ADVOCACY FOR HEALTH
Sec. 201. Establishment of office.
Sec. 202. Assistance to individuals with grievances against a health
plan.
Sec. 203. Assurance of access by all individuals to quality health
care.
Sec. 204. Federal investigation and emergency intervention.
Sec. 205. Annual report to the secretary.
Sec. 206. Office administration.
Sec. 207. Oversight.
Sec. 208. Funding of office.
TITLE III--INDEPENDENT CONSUMER ADVISORY COMMITTEES
Sec. 301. Establishment of committees.
Sec. 302. Membership and chair.
Sec. 303. Functions of committee.
Sec. 304. Liability of members of committee.
Sec. 305. Annual report to office.
Sec. 306. Funding for committees.
TITLE IV--COORDINATION AMONG OFFICE, COMMITTEES, AND SECRETARY
Sec. 401. Interaction among office and other organizations.
Sec. 402. Assistance to committees.
Sec. 403. Coordinated data analysis and dissemination procedure.
SEC. 2. FINDINGS.
The Congress finds the following:
(1) The largest category of health spending is hospital
services; in 1994, 35 percent of national health spending was
for hospital services worth $338,500,000,000.
(2) The hospital industry exhibits the fastest rising costs
in the health care sector.
(3) The largest expenditures for the hospital industry are
payroll (wages and salaries) and employee benefits; in 1992,
payroll and employee benefits accounted for almost 55 percent
of total hospital expenses.
(4) Because registered nurses comprise the majority of a
hospital's expenses, in an effort to remain competitive,
hospitals are restructuring their operations by decreasing
payroll and benefit outlays for registered nurses and either
decreasing their number or replacing them with unlicensed aides
to care directly for patients.
(5) While this reorganization is taking place, no
mandatory, national, and systematic compilation of data is
being undertaken to determine the correlation between skilled
nursing care and patient safety.
(6) Several studies, however, have noted a basic
relationship between skilled nursing care and patient safety:
increased deaths result when inadequate nursing and lower
levels of registered nurses in combination with higher levels
of unlicensed aides are utilized by health care facilities.
(7) A comprehensive effort is needed at the national level
to collect data and develop a research and evaluation agenda so
that informed policy development, implementation and evaluation
are undertaken in a timely manner to protect the safety of
patients, the well being of health care workers, and the
integrity of the United States medical system.
(8) The quality of available health care will suffer in the
United States if health care delivery is allowed to set
priorities in which profit is made at the expense of patient
care quality and safety.
(9) Core clinical staff, such as registered nurses, are a
key component in increasing quality, understanding patient care
needs, and balancing costs in any reformed health care system.
(10) Health care is a basic and universal need; therefore,
the right of any consumer to have access to one's own
confidential medical records and pertinent information on the
health care facility that is delivering health care and to
participate effectively in the process of improving the
delivery and quality of such care should not be impaired.
SEC. 3. DEFINITIONS.
In this Act:
(1) Health care provider.--The term ``health care
provider'' means an individual or entity licensed or certified
under State law to provide health care services.
(2) Health plan.--The term ``health plan'' means any
private health plan or arrangement (including an employee
welfare benefit plan) which provides, or pays the cost of,
health care services.
(3) Secretary.--Except as otherwise expressly provided, the
term ``Secretary'' means Secretary of Health and Human
Services.
(4) Coverage of third party administrators.--In the case of
a health plan that is an employee welfare benefit plan (as
defined in section 3(1) of the Employee Retirement Income
Security Act of 1974), any third party administrator or other
person with responsibility for contracts with health care
providers under the plan shall be considered, for purposes of
this Act, to be an entity offering such health plan.
(5) Enrollee.--The term ``enrollee'' means a person
enrolled under a health plan.
(6) Office.--The term ``Office'' means the Office of
Consumer Advocacy for Health as described in title II of this
Act.
(7) Committee.--The term ``Committee'' means an Independent
Consumer Advisory Committee as described in title III of this
Act.
TITLE I--HEALTH PLAN REQUIREMENTS
SEC. 101. INTERFERENCE WITH MEDICAL COMMUNICATION PROHIBITED.
(a) In General.--A health plan may not as part of any contract or
agreement with a health care provider provide any restriction on or
interference with any medical communication, as defined in subsection
(b).
(b) Medical Communication Defined.--For purposes of subsection (a),
the term ``medical communication''--
(1) means any communication, other than a knowing
misrepresentation, made by the health care provider--
(A) regarding the mental or physical health care
needs or treatment of a patient and the provisions,
terms, or requirements of the health plan or another
health plan relating to such needs or treatment; and
(B) between--
(i) the provider and a current, former, or
prospective patient (or the guardian or legal
representative of a patient);
(ii) the provider and any employee or
representative of the such plan; or
(iii) the provider and any employee or
representative of any State or Federal
authority with responsibility for the licensing
or oversight with respect to such plan; and
(2) includes communications concerning--
(A) any tests, consultations, and treatment
options;
(B) any risks or benefits associated with such
test, consultations, and options;
(C) variation among any health care providers and
any institutions providing such services in experience,
quality, or outcomes;
(D) the basis or standard for the decision of a
health plan to authorize or deny health care services
or benefits;
(E) the process used by such a plan to determine
whether to authorize or deny health care services or
benefits; and
(F) any financial incentives or disincentives
provided by such a plan to a health care provider that
are based on service utilization.
(c) Non-Preemption of State Law.--A State may establish or enforce
requirements with respect to the subject matter of this section, but
only if such requirements are more protective of a medical
communication than the requirements established under this section.
(d) Effective Date.--Subsection (a) shall apply to contracts or
agreements entered into or renewed on or after the date of the
enactment of this Act, and to contracts and agreements entered into
before such date as of 30 days after the date of the enactment of this
Act.
SEC. 102. IMPROPER INCENTIVE PLAN PROHIBITED.
(a) In General.--A health plan may not as part of any contract or
agreement with a health care provider operate an improper health care
provider incentive plan as described in subsection (b).
(b) Improper Incentive Plan.--For purposes of subsection (a), a
health care provider incentive plan is improper, unless such plan meets
the requirements of section 1876(i)(8)(A) of the Social Security Act
(42 U.S.C. 1395mm(i)(8)(A)) for physician incentive plans in contracts
with eligible organizations under section 1876 of such Act.
(c) Incentive Plan Defined.--In this section, the term ``health
care provider incentive plan'' means any compensation or other
financial arrangement between a health plan and a health care provider
that may directly or indirectly have the effect of limiting services
provided with respect to an enrollee.
(d) Effective Date.--Subsection (a) shall apply to contracts or
agreements entered into or renewed on or after the date of the
enactment of this Act, and to contracts and agreements entered into
before such date as of 30 days after the date of the enactment of this
Act.
SEC. 103. PROVISIONS REGARDING DENIAL OF CARE.
(a) Criteria for Denial of Care.--A health plan shall establish
criteria, in consultation with the health care providers who provide
services under the plan, for the denial of services under the plan.
(b) Preliminary Physical Examination.--A health plan shall provide
for an initial physical examination of an enrollee in a timely manner
before denying services under the plan to the enrollee. Such
examination shall not constitute services under the health plan.
(c) Reason for Denial of Care Provided to Enrollee.--A health plan
shall provide in writing to an enrollee, and to the health care
provider recommending care for the enrollee, the reason for the denial
of services under the plan to the enrollee.
(d) Publication of Criteria for Denial of Care.--A health plan
shall put in writing, annually update, and make available to its
enrollees through the Office and its Committee the written criteria
established under subsection (a).
(e) Effective Date.--The criteria under this section shall apply to
plan years beginning on or after 180 days after the date of the
enactment of this Act.
SEC. 104. QUALITY OF CARE.
(a) Criteria For Quality Of Care.--
(1) In general.--A health plan, in consultation with the
health care providers who provide health services under the
plan, shall establish criteria to assure the quality of care
provided under the plan. Such plan shall establish such
criteria utilizing the data collected and analyzed under
subsection (c) and (d), and under section 403.
(2) Deadline.--The criteria under paragraph (1) shall apply
to plan years beginning on or after 2 years after the date of
the enactment of this Act.
(b) Public Access to Information.--
(1) Publication of criteria to assure quality of care.--A
health plan shall put in writing, annually update, and make
available the written criteria established under subsection (a)
to its enrollees through the plan's Committee.
(2) Safe staffing levels.--
(A) In general.--Not later than 1 year after the
date of the enactment of this Act, the Secretary shall,
by rule, establish guidelines that determine the number
and classifications of health care providers necessary
to ensure safe and adequate staffing in relation to
enrollees under a health plan.
(B) Factors.--Such guidelines shall be based on--
(i) the severity of illness of each
enrollee;
(ii) factors affecting the period and
quality of recovery of each enrollee; and
(iii) any other factor substantially
related to the condition and health care needs
of each enrollee.
(3) Safe and adequate staffing levels.--
(A) In general.--Not later than 180 days after the
date the Secretary establishes the guidelines under
paragraph (2), a health plan may not provide or pay for
health care services provided to an enrollee at an
institution unless such institution complies with such
guidelines.
(B) Submission of proposed standards to
committee.--In the case of an institution that elects
not to adopt the guidelines established under paragraph
(2), such institution shall submit proposed staffing
levels to the health plan and its Committee for review.
Such institution shall include with its submission an
explanation of the method and criteria used in
developing the proposed staffing levels.
(C) Default federal guidelines.--If the health
plan's Committee determines that the staffing levels
proposed by such institution fail to meet the
guidelines established under paragraph (2), then the
health plan may not provide or pay for health care
services provided to an enrollee at such institution
unless such institution adopts such guidelines as its
staffing levels.
(D) Criteria and certificate of compliance.--Such
plan shall file with the Secretary and the Office of
the State in which the plan offers health care services
a certificate of compliance with the staffing levels
adopted by the institutions where the plan provides or
pays for health care services for its enrollees.
(E) Public inspection.--Such institutions shall
keep on file, available for public inspection during
regular business hours, daily reports of staffing
levels by department and of patient census.
(4) Identification tag.--
(A) In general.--A health plan may not provide or
pay for health care services provided to an enrollee at
an institution unless such institution prohibits a
health care provider who is not wearing an
identification tag from providing care to an enrollee.
(B) Licensure status.--An identification tag under
subparagraph (A) shall state the health care provider's
name and the health care position for which such
provider has been licensed or certified by the State.
(C) Visibility.--Such tag shall be visible to the
enrollee.
(D) Exception.--The requirement under subparagraph
(A) shall not apply where wearing such tag poses a
threat to the health of a patient (such as in an
operating room).
(c) Data Collection.--
(1) Medical data.--Except as provided in section 105(a), a
health plan, in conjunction with its Committee, shall compile
data on health care services provided to enrollees under the
health plan including--
(A) enrollee outcome information, including
nosocomial infections, medication errors, enrollee
injury, enrollee mortality, and rate of enrollee
readmission;
(B) structure of care provided, including nurse to
enrollee ratios, general staffing ratios, injuries to
nurses and other staff, and quality of staff; and
(C) process of care, including the planning and
delivery of care, an assessment of the delivery
mechanisms, and safety measures.
(2) Financial data.--
(A) Financial report.--Not later than December 31st
of each year, a health plan that employs more than 150
individuals shall file, with the Office of the State in
which such plan offers health care services, a copy
of--
(i) any financial report or return filed
under Federal or State tax or securities laws;
(ii) a statement of any financial interest
greater than 5% or $5,000, whichever is less,
in any other health plan; and
(iii) a statement of the nature and outcome
of any complaint, lawsuit, arbitration, or
other legal proceeding brought against the
plan, unless such disclosure is prohibited by
court order or law.
(B) Quality report.--Not later than December 31st
of each year, a health plan shall file, with the Office
of the State in which that plan offers health care
services, a report of all health care quality
indicators, criteria, data, or studies used to
evaluate, assess, or determine the nature, scope,
quality, or staffing of health care services, and for
reductions in or modifications of the provision of
health care services.
(C) First report.-- Such plan shall file its first
report not later than December 31st of its first plan
year beginning on or after the date of the enactment of
this Act.
(d) Data Analysis and Dissemination.--
(1) Information submitted to committee.--For purposes of
section 403, a health plan shall provide the data collected
under subsection (c)(1) to its Committee.
(2) Disclosure of nursing care data to enrollees.--Such
plan shall provide information to an enrollee about the ratio
of nurses to enrollees provided under the plan.
SEC. 105. PRIVACY.
(a) Enrollee's Privacy Rights.--Prior to the collection of data
under section 104(c), a health plan shall establish standards and
procedures to protect from public disclosure information that
identifies an individual and relates to such individual's physical or
mental health. Such standards and procedures may not adversely affect
the integrity of the data.
(b) Enrollee's Medical Records.--A health plan shall protect the
privacy of a enrollee's medical records, and may only release such
records--
(1) to a third party with the informed written consent of
the enrollee given at the time the release is sought;
(2) to a law enforcement agency pursuant to a warrant
issued under the Federal Rules of Criminal Procedure, an
equivalent State warrant, a grand jury subpoena, or a court
order; or
(3) pursuant to a court order, in a civil proceeding upon a
showing of compelling need for the information that cannot be
accommodated by any other means, if--
(A) the enrollee is given reasonable notice, by the
person seeking the release, of the court proceeding
relevant to the issuance of the court order; and
(B) the enrollee is afforded the opportunity to
appear and contest the claim of the person seeking the
release.
(c) Effective Date.--Subsection (b) takes effect 30 days after the
date of the enactment of this Act.
SEC. 106. FEE.
(a) In General.--A health plan, in each State where the plan offers
health care services, shall pay to the State 1 percent of the total
amount of the annual premiums for each year with respect to enrollment
in the health plan for such year of individuals residing in the State,
as described in section 208.
(b) First Payment.--
(1) In general.--A health plan shall make the first payment
under subsection (a) not later than 6 months after the first
day of the first full month after the date of the enactment of
this Act.
(2) Payments prorated from date of enactment.--Payments due
under subsection (a) for the year in which this Act is enacted
shall be prorated to apply only with respect to months
beginning on or after the date of the enactment of this Act.
(c) State Defined.--As used in subsection (a), the term ``State''
includes the District of Columbia, Puerto Rico, the Virgin Islands,
Guam, American Samoa, and the Northern Mariana Islands.
SEC. 107. ENFORCEMENT THROUGH CIVIL PENALTIES.
(a) Enforcement Through Imposition of Civil Money Penalty.--A
health plan that violates any provision of sections 101 through 106
shall be subject to a civil money penalty of--
(1) up to $25,000 for each violation; or
(2) up to $100,000 for each violation if the Secretary
determines that the plan has engaged, within the 5 years
immediately preceding such violation, in a pattern of such
violations.
(b) Procedures.--The provisions of subsections (c) through (l) of
section 1128A of the Social Security Act (42 U.S.C. 1320a-7a) shall
apply to civil money penalties under this section in the same manner as
they apply to a penalty or proceeding under section 1128A(a) of such
Act.
SEC. 108. PROHIBITION ON ADVERSE ACTION.
(a) In General.--No health plan may terminate or take other adverse
action against any health care provider for actions taken for the
purpose of--
(1) notifying such plan of conditions which the identifies,
in communications with the plan, as dangerous or potentially
dangerous or injurious to--
(A) enrollees who currently receive health care
services under the plan;
(B) individuals who are likely to receive such
services; or
(C) health care providers who provide such
services;
(2) notifying a Federal or State agency or an accreditation
agency, compliance with the standards of which have been deemed
to demonstrate compliance with conditions of participation
under the Medicare program, of such conditions as are
identified in paragraph (1);
(3) notifying other individuals of conditions which the
provider or group of providers reasonably believe to be such as
are described in paragraph (1);
(4) discussing such conditions as are identified in
paragraph (1) with other providers for the purposes of
initiating action described in paragraph (1), (2), or (3);
(5) a medical communication, as defined in section 101(b);
or
(6) other related activities as specified in rules made by
the Secretary.
(b) Exception.--The protections of this section shall not apply to
any health care provider who knowingly or recklessly provides
substantially false information to the Secretary.
(c) Sanction.--A determination by the Secretary that a health plan
has taken such action as described in subsection (a) shall result in
termination from participation in the Medicare program for a period of
time to be specified by the Secretary, such period to be not less than
1 month.
(d) Civil action.--A health care provider aggrieved by a violation
of subsection (a) may in a civil action obtain appropriate relief. Such
relief may include, with respect to a provider, the reinstatement of
the provider to his or her former position under the health plan
together with the compensation (including back pay), terms, conditions,
and privileges associated with such position.
(e) Effective Date.--Subsection (a) shall apply to actions taken on
or after the date of the enactment of this Act, regardless of when the
communication on which the action is based occurred.
TITLE II--OFFICE OF CONSUMER ADVOCACY FOR HEALTH
SEC. 201. ESTABLISHMENT OF OFFICE.
(a) In General.--The Secretary, in consultation with the Secretary
of Labor, shall establish for each State an independent Office for such
State to assist consumers in dealing with problems that arise with
respect to health plans and health care providers operating in such
State.
(b) Establishment Through Grant Process.--
(1) In general.--The Secretary shall carry out the
requirements of subsection (a) with respect to each State by
designating a non-profit organization located in the State to
serve as the Office for the State, under a grant awarded, in
consultation with the Secretary of Labor, under a competitive
selection process. The grant may be awarded only to
organizations headed by an individual with expertise and
experience in the fields of health care and consumer advocacy,
who shall be designated the Consumer Advocate for Health for
the State. In awarding such grant, the Secretary, in
consultation with the Secretary of Labor, shall--
(A) consider any nominations submitted by consumer
advocacy organizations in the State; and
(B) give preference to organizations that represent
a broad spectrum of the diverse consumer interests in
the State and that have demonstrated a capability of
representing, and working with, a broad diversity of
consumers, including members of medically underserved
communities.
(2) Requirements.--Each grant awarded under this subsection
shall provide as follows:
(A) Central office.--A central office of the
organization awarded the grant which is located in the
State shall be designated as the Office.
(B) Local offices.--The organization awarded the
grant shall establish and maintain local offices of the
Office in accordance with subsection (c).
(C) Performance of specified functions.--The
organization shall perform the functions of the Office
specified in this title and otherwise ensure that the
requirements of this section applicable to the Office
are met.
(D) Evaluation of quality and effectiveness of
grantee.--The Secretary, in consultation with the
Secretary of Labor, shall evaluate the quality and
effectiveness of the organization in carrying out the
functions of the Office.
(E) Term of grant and renewability.--Each grant
shall be awarded for a term of 4 years and shall be
renewable for succeeding 4-year terms without reopening
the competitive selection process if the grantee has
performed properly pursuant to this section and the
terms of the grant.
(F) Notice of intent not to renew;
reconsideration.--Not later than 180 days before the
expiration of any term under a grant awarded to an
organization, if the Secretary at such time intends not
to renew the grant with such organization, the
Secretary shall notify such organization of such
intent, and shall provide such organization an
opportunity for reconsideration by the Secretary, in
consultation with the Secretary of Labor, of the
Secretary's intent not to renew and to present
information in support of renewal.
(G) Termination by grantee.--The organization may
terminate the grant prior to its expiration upon 180
days notice to the Secretary.
(H) Termination by the secretary.--The Secretary,
in consultation with the Secretary of Labor, may
terminate the grant prior to its expiration upon 180
days notice to the organization if the Secretary, in
consultation with the Secretary of Labor, determines
that the organization is not meeting the requirements
of this section or that the organization is failing
substantially to carry out the grant. The Secretary, in
consultation with the Secretary of Labor, shall provide
for an appropriate appeals mechanism, including
establishment of a panel of peers, to implement this
subparagraph.
(c) Delegations to Local Offices.--
(1) In general.--The Secretary, in consultation with the
Secretary of Labor, shall provide for appropriate delegation by
the Consumer Advocate for Health of the authority and
responsibilities of the Office to local offices to the extent
necessary to effectively carry out the duties and
responsibilities of the Consumer Advocate for Health throughout
the State.
(2) Monitoring.--The Secretary, in consultation with the
Secretary of Labor, shall develop and maintain policies and
procedures for monitoring such local offices and ensuring
compliance by such local offices with the terms of such
delegation.
(3) Placement of local office in each community rating
area.--
(A) In general.--Pursuant to such delegation, the
Consumer Advocate for Health shall ensure that there is
located in each community rating area in the State an
officer or employee of the Office who is designated to
assist individuals residing in the area with respect to
matters relating to health plans and health care
providers operating in the area.
(B) Assignment of staff for each plan.--Each such
office for such area shall have an individual who is
assigned with respect to each health plan that enrolls
individuals residing in the area. Such an individual
may be assigned to more than one plan.
(C) Appropriate staffing.--The Office shall ensure
that sufficient staff in each local office is assigned
to work with respect to matters relating to each health
plan whose enrollees are served by the local office so
as to ensure effective and efficient service in such
local office with respect to matters relating to such
plan.
(d) Establishment of Community Rating Areas.--
(1) In general.--The Secretary shall provide for the
division of each State into 1 or more community rating areas.
Each portion of the State shall be within 1, and only 1,
community rating area. The Secretary may revise the boundaries
of such areas from time to time consistent with this
subsection.
(2) Multiple areas.--With respect to a community rating
area--
(A) no metropolitan statistical area in a State may
be incorporated into more than 1 such area in the
State;
(B) the number of individuals residing within such
an area may not be less than 250,000; and
(C) no area incorporated in a community rating area
may be incorporated into another such area.
(3) Boundaries.--
(A) In general.--In establishing boundaries for
community rating areas, the Secretary may not
discriminate on the basis of or otherwise take into
account race, age, language, religion, national origin,
socio-economic status, sexual orientation, disability,
or perceived health status.
(B) Treatment of consolidated metropolitan
statistical areas.--A community rating area that
includes all of a Consolidated Metropolitan Statistical
Area that is within a State is presumed to meet the
requirement of subparagraph (A).
SEC. 202. ASSISTANCE TO INDIVIDUALS WITH GRIEVANCES AGAINST A HEALTH
PLAN.
(a) In General.--An Office shall provide an individual assistance
with determining, in connection with any stated grievance against a
health plan, the manner and extent to which such grievance may be
presented as--
(1) an issue of denial of items or services, or
reimbursement therefor;
(2) an issue of denial of medical records;
(3) an issue of malpractice;
(4) an issue of discrimination;
(5) an issue of eligibility and payment of subsidies for
premium payments and cost sharing;
(6) an issue of enrollment; or
(7) any other violation actionable under this Act.
(b) Grievance Assistance.--Such Office shall provide, in person and
by toll-free telephone access, assistance to an individual with a
grievance under subsection (a).
(c) Complaint Forms.--Such Office shall create an instruction sheet
that explains how to file, maintain, and resolve a complaint against a
health plan, and provide such sheet to an individual seeking to file a
complaint against a health plan. Such instruction sheet shall be
written in plain language understandable by a layperson, and it shall
use a step-by-step format to guide the layperson through each stage of
the complaint process.
SEC. 203. ASSURANCE OF ACCESS BY ALL INDIVIDUALS TO QUALITY HEALTH
CARE.
(a) In General.--An Office shall identify, investigate, publicize,
promote solutions to, and resolve grievances stemming from, any
practice, policy, law, or regulation of a health plan that may
adversely affect access by an individual to quality health care,
including a practice, policy, law, or regulation relating to--
(1) marketing of the plan;
(2) availability of premium and cost sharing subsidies;
(3) accessibility of services and resources in
traditionally underserved areas;
(4) targeting of resources to traditionally underserved
areas; and
(5) elimination of practices that impede access to
available choices for individuals at health risk, including the
proper implementation of community rating and risk adjustments.
(b) Monitoring of Health Plan Denial Procedures.--Such Office shall
monitor procedures used by health plans for denial of services and for
reconsideration of such denials.
SEC. 204. FEDERAL INVESTIGATION AND EMERGENCY INTERVENTION.
(a) In General.--An Office shall provide, in person and by toll-
free telephone access, assistance to an individual who seeks to report
dangerous conditions in health care services offered under a health
plan.
(b) Federal Intervention.--The Secretary may, in cases of
compromised safety that are life threatening, initiate emergency
investigation of or remedial intervention in services provided or
practices undertaken by a health plan.
(c) Rules.--
(1) In general.--For purposes of subsection (b), the
Secretary shall, by rule, establish guidelines for safety.
(2) Consideration of data.--In establishing and reviewing
the guidelines under paragraph (1), the Secretary shall base
the guidelines to the maximum extent practicable on the data
collected and the analysis performed under this Act.
SEC. 205. ANNUAL REPORT TO THE SECRETARY.
(a) In General.--Not later than December 31st of each year, an
Office shall submit a report to the Secretary.
(b) Content of Report.--The report required by subsection (a) shall
include--
(1) the nature of consumer complaints against health plans;
(2) the percentage of unresolved or outstanding complaints
against health plans;
(3) discernible patterns from the data collected;
(4) recommendations for resolution of unresolved or
outstanding complaints;
(5) recommendations to sanction a certain health plan;
(6) a copy of any report received from a health plan; and
(7) a copy of any report received from the Committee which
reports to such Office.
(c) Date of First Report.--An Office shall file its first report
not later than December 31st of the first full calendar year after such
Office is established.
SEC. 206. OFFICE ADMINISTRATION.
(a) In General.--An Office shall ensure that individuals in each
community rating area, as defined in section 201(d), have regular and
timely access to the services provided through the Office and that the
individual receives timely responses from a representative of the
Office to a request for assistance with a complaint against a health
plan.
(b) Confidentiality of Complainants.--An Office shall provide for a
system in the Office to treat as confidential any identifying
information regarding complainants and other individuals with respect
to whom the Office maintain files or records.
(c) Personnel Qualifications.--An Office shall establish and
implement minimum qualification and training requirements for
personnel, including volunteers.
SEC. 207. OVERSIGHT.
The Secretary shall ensure that an Office carries out the functions
under this title, and such other activities as the Office and the
Secretary determine to be appropriate.
SEC. 208. FUNDING OF OFFICE.
(a) Funds Held in Escrow.--In accordance with procedures which
shall be made by rule under subsection (d), each State shall provide
for a mechanism under which the State shall hold in an escrow account 1
percent of the total amount of the annual premiums for each year with
respect to enrollment in a health plan for such year of individuals
residing in the State. Any funds held in such escrow account shall be
available solely for remittance to the Secretary under subsection (b).
(b) Remittance to Secretary.--Not later than December 31 of each
calendar year, each State shall remit to the Secretary, in such form
and manner as shall be prescribed in regulations, the amounts held in
escrow pursuant to subsection (a) for the applicable fiscal year ending
with or during such calendar year.
(c) Allocations.--The amounts remitted by each State to the
Secretary for each year under subsection (b) shall be applied towards
the establishment and operation of the Office for such State under
section 201 (including amounts to be distributed to escrow accounts for
Committees pursuant to section 306).
(d) Rules.--Not later than 180 days after the date of the enactment
of this Act, the Secretary shall make rules to carry out this section.
TITLE III--INDEPENDENT CONSUMER ADVISORY COMMITTEES
SEC. 301. ESTABLISHMENT OF COMMITTEES.
Each health plan shall establish and maintain an Committee.
SEC. 302. MEMBERSHIP AND CHAIR.
(a) Membership.--
(1) In general.--A Committee shall consist of not fewer
than 25 and not more than 50 members.
(2) Qualifications.--Except as provided in paragraph
(3)(B), members of a Committee shall be selected from enrollees
who indicate interest in such positions and who are not health
care providers, officers or employees of any health plan, or
employees of a health care provider.
(3) Method of selection.--
(A) Enrollees.--Except as provided in subparagraph
(B), members of a Committee shall be selected
biennially at random from each of 4 categories of
enrollees, in proportion to their numbers among
enrollees represented by the Committee, as follows:
senior citizens; parents of children under 18 years of
age; individuals with disabilities; and all other
enrollees.
(B) Employees of health plan.--Each committee shall
have as members at least 3, but in no case more than 5,
employees of the health plan selected biennially at
random from each of 3 categories as follows: staff
nurses; physicians; and administrators of the health
plan.
(b) Chair.--Each Committee shall be headed by a chair who shall
be--
(1) a member of the Committee other than a member who is an
employee of a health plan; and
(2) elected by the Committee at its first meeting.
(c) Compensation and Expenditures for Services.--
(1) Compensation of members.--Members of each Committee
shall serve without compensation, except that the members shall
be reimbursed by the Committee for the reasonable expenses
incurred in carrying out their duties as members.
(2) Expenditures for services.--The Committee may provide
for acquiring the services of such staff and temporary
consultants as may be necessary from time to time to carry out
the requirements of this title.
SEC. 303. FUNCTIONS OF COMMITTEE.
(a) Outreach Programs.--Each Committee shall develop and coordinate
programs for outreach to the community.
(b) Forum to Facilitate Communication.--Each Committee shall
conduct regular meetings of enrollees and representatives of the health
plan under such procedural rules as the Committee considers
appropriate, so that such meetings will serve as effective forums for
facilitating communication between such plan and enrollees.
(c) Ensure Enrollee Grievances Are Addressed.--Each Committee shall
conduct such ad hoc meetings and other activities as may enable the
Committee to ensure that the grievances of enrollees in the area are
generally heard and addressed by the health plan.
(d) Dissemination of Criteria for Enrollee Care Quality.--Each
Committee shall provide to the community the enrollee care quality
criteria established by the health plan under section 104(c).
(e) Evaluation of Performance of Office of Consumer Advocacy.--Each
Committee shall evaluate annually the performance of the Office for the
State in which the health plan is located and make recommendations to
the Secretary regarding the appropriateness for continued service of
the Office.
SEC. 304. LIABILITY OF MEMBERS OF COMMITTEE.
No member of a Committee established under this section shall be
liable under any law for the good faith performance of the functions
specified in this title.
SEC. 305. ANNUAL REPORT TO OFFICE.
(a) In General.--Not later than December 31st of each year, each
Committee shall submit to the Office for the State in which the health
plan offers health care services a report providing recommendations for
improvements in health care delivery under the plan, and including
assessments of--
(1) the accessibility (by location) of offices and clinics
providing items and services under the plan;
(2) the condition of health care facilities employed under
the plan;
(3) the ease with which prescriptions are filled under the
plan;
(4) delays occurring under the plan in receiving requested
medical attention;
(5) the time spent by enrollees in waiting rooms under the
plan;
(6) the complexity of paperwork required under the plan;
(7) the courtesy of plan personnel; and
(8) such other concerns regarding the plan's system of
delivering health care services that the Committee may choose
to assess.
(b) Date of First Report.--Each committee shall file its first
report not later than December 31st of the first full calendar year
after such Committee is established.
SEC. 306. FUNDING FOR COMMITTEES.
(a) Escrow Account for Committees.--In accordance with procedures
which shall be made by rule under subsection (e), an Office shall
establish and maintain an escrow account for each Committee established
in the State served by the Office.
(b) Distribution of Funds to Escrow Account for Committees.--The
Office shall annually distribute an amount equal to 25 percent of the
total amount remitted for the year to the Secretary by the State under
section 208, on the basis of which funds are made available to the
Office for the year under title II, in the form of deposits to the
escrow accounts maintained by the Office for Committees pursuant to
subsection (a). The amounts deposited to such escrow accounts shall be
in proportion to the numbers of enrollees represented by the Committees
for which such escrow accounts are maintained.
(c) Withdrawal of Funds for Committee at the Request of the
Chair.--The funds maintained in each such escrow account for a
Committee shall be made available for withdrawal by the chair of the
Committee upon request of the chair, specifying in writing the purpose
for the withdrawal.
(d) Annual Accounting.--The Office shall provide the Secretary an
annual accounting of the receipts and disbursements made with respect
to each such escrow account.
(e) Rules.--Not later than 180 days after the date of the enactment
of this Act, the Secretary shall make rules to carry out this section.
(f) Restriction on Use of Funds.--Funds withdrawn from an escrow
account maintained pursuant to this section for a Committee established
pursuant to this title shall be used by the Committee solely for
purposes of carrying out its duties under this title.
TITLE IV--COORDINATION AMONG OFFICE, COMMITTEES, AND SECRETARY
SEC. 401. INTERACTION AMONG OFFICE AND OTHER ORGANIZATIONS.
An Office shall establish and maintain a system of referrals among
the Office, other consumer advocacy organizations, legal assistance
providers serving low-income persons, and protection and advocacy
systems for individuals with disabilities.
SEC. 402. ASSISTANCE TO COMMITTEES.
An Office shall provide technical assistance to the Committees
maintained by health plans pursuant to section 301, and distribute and
account for funding for such Committees in accordance with section 306.
SEC. 403. COORDINATED DATA ANALYSIS AND DISSEMINATION PROCEDURE.
(a) Data Compilation and Submission.--
(1) In general.--Not later than December 31st of each year,
each Committee shall compile the enrollee quality care data
collected under section 104(c) and shall submit such data to
the Office from which such Committee received its funds under
section 306.
(2) Transmission from office to secretary.--Not later than
30 days after the receipt of the data submitted by the
Committees under paragraph (1), the Office shall compile all
data received from the Committees to which it transmits funds
under section 306 and shall submit such data to the Secretary.
(b) Data Analysis and Publication.--The Secretary shall analyze the
data received under subsection (a)(2) with the purpose of using such
data to develop Federal guidelines for patient care quality and shall
publish its findings.
(c) Use of Guidelines for Evaluation of Health Plan.--An Office and
the Committees shall use such findings and guidelines to evaluate the
performance of health plans operating in their community rating areas.
If an order is granted pursuant to subparagraph (C) or (F), the court
shall impose appropriate safeguards against unauthorized disclosure.
Court orders authorizing disclosure under subparagraph (C) shall issue
only with prior notice to the consumer and only if the law enforcement
agency shows that there is probable cause to believe that the records
or other information sought are relevant to a legitimate law
enforcement inquiry. In the case of a State government authority, such
a court order shall not issue if prohibited by the law of such State. A
court issuing an order pursuant to this section, on a motion made
promptly by the video tape service provider, may quash or modify such
order if the information or records requested are unreasonably
voluminous in nature or if compliance with such order otherwise would
cause an unreasonable burden on such provider.
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