Summary: H.R.820 — 105th Congress (1997-1998)All Information (Except Text)

There is one summary for H.R.820. Bill summaries are authored by CRS.

Shown Here:
Introduced in House (02/25/1997)

Health Insurance Bill of Rights Act of 1997 - Amends the Public Health Service Act to require a health insurance issuer under provisions of this Act to comply with certain notice requirements of the Employee Retirement Income Security Act of 1974 (ERISA).

Requires an issuer, if coverage provides any emergency services benefits, to cover emergency services without authorization, participating provider, or (subject to exception) other restrictions.

Requires an issuer, if the issuer requires or provides for an enrollee to designate a participating primary care provider, to permit a female enrollee to designate an obstetrics and gynecology specialist as the enrollee's primary care provider. Prohibits an issuer, if an enrollee has not designated such a specialist as a primary care provider, from requiring prior authorization for coverage of routine gynecological care and pregnancy-related services provided by such a specialist.

Requires an issuer to refer to a specialist an enrollee who requires treatment by a specialist. Provides, in certain circumstances, for: (1) a specialist to provide and coordinate an enrollee's primary and specialty care; and (2) standing referrals.

Requires an issuer, if a contract between the issuer and a provider is terminated, to permit an enrollee undergoing a course of treatment to continue with the provider during a transitional period.

Requires an issuer to permit each enrollee to receive: (1) primary care from any available participating primary care provider; and (2) subject to limitation, specialty care from any available qualified participating provider.

Prohibits issuer discrimination against an enrollee on the basis of the enrollee's participation in a clinical study or investigation approved and funded by specified Federal agencies.

Regulates coverage of prescription drugs when an issuer uses a formulary.

Requires issuers to: (1) maintain a quality assurance and improvement program; (2) collect uniform quality data; (3) have a written process for the selection of participating professionals; (4) maintain a drug utilization program; (5) conduct utilization review; (6) disclose specified information to enrollees and prospective enrollees; (7) ensure compliance with confidentiality laws; and (8) maintain a complaints and appeals system.

Authorizes appropriations for grants to States to establish and maintain a Health Insurance Ombudsman.

Prohibits agreements between issuers and providers from: (1) restricting the provider from engaging in medical communications with a patient (allowing the issuer to advise of the coverage's limitations on particular services based on the religious or moral convictions of the issuer); or (2) transferring to the provider any liability relating to actions or omissions of the issuer or agent. Imposes requirements on physician incentive plans.

Prohibits an issuer from limiting the manner in which covered services are delivered.

Requires each health issuer to comply with patient protection requirements of this Act regarding group and individual health insurance coverage it offers.

Allows a State to establish requirements at least as stringent on issuers as the requirements of this Act.