Bill summaries are authored by CRS.

Shown Here:
Passed House amended (10/07/1999)

Bipartisan Consensus Managed Care Improvement Act of 1999 - Title I: Improving Managed Care - Subtitle A: Grievances and Appeals - Requires a group health plan, and a health insurance issuer that provides health insurance coverage, to conduct utilization review activities that monitor or evaluate the use or coverage, clinical necessity, appropriateness, efficacy, or efficiency of health care services, procedures, or settings.

(Sec. 102) Requires a plan and an issuer to provide appropriate notices to the participant, beneficiary, or enrollee for benefit claims it has denied that include reasons for denial and instructions for initiating specified internal appeals procedures, which must include procedures for an expedited review process in emergency situations.

(Sec. 103) Outlines external appeals procedures for the timely resolution of certain denied claims through the use of qualified external appeal entities, which shall determine whether the plan's or issuer's decision is in accordance with the patient's medical needs. Declares that an external appeal entity's determination is binding on the plan and issuer involved.

Provides for court-imposed civil monetary penalties and cease and desist orders against authorized officials of plan or issuers who refuse to timely follow the determination of an external appeal entity to provide a benefit.

(Sec. 104) Requires a plan and an issuer to establish a system featuring specified components for the presentation and resolution of grievances brought by participants, beneficiaries, or enrollees, or health care providers or other individuals acting on behalf of an individual either with the individual's consent or without it if the individual is medically unable to provide it. Declares that grievances are not subject to appeal under this subtitle.

Subtitle B: Access to Care - Provides that if an issuer offers coverage of services only if they are furnished through members of a network of health care professionals and providers contracting with the issuer, the issuer shall also offer the option of coverage of such services which are not furnished through members of such a network, unless enrollees are offered such non-network coverage through another plan or issuer in the group market. Makes the enrollee bear the cost of any additional premium the issuer charges for such option, and the amount of any additional cost sharing, unless it is paid by the health plan sponsor through agreement with the issuer.

(Sec. 112) States that if a plan or an issuer requires or provides for designation of a participating primary care provider by a participant, a beneficiary, or an enrollee, then the plan or issuer shall permit each such person to designate any participating primary care provider available to accept such individual.

Requires a plan and an issuer to permit each participant, beneficiary, or enrollee to receive medically necessary or appropriate speciality care, pursuant to appropriate referral procedures, from any qualified participating health care professional available to accept such individual. Waives such requirement in the case of specialty care if the plan or issuer clearly informs each participant, beneficiary, and enrollee of the limitations on choice of participating professionals with respect to such care.

(Sec. 113) Requires a plan or an issuer providing any emergency hospital benefits to cover emergency services: (1) without the need for any prior authorization determination; (2) whether or not the health care provider furnishing such services is a participating health care provider; and (3) without regard to any other term or condition of such coverage (other than exclusion or coordination of benefits, or an affiliation or waiting period, permitted under the Public Health Service Act, the Employee Retirement Income Security Act of 1974 (ERISA), or the Internal Revenue Code, and other than applicable cost-sharing).

Requires such coverage in a manner so that, if the emergency services are provided by a nonparticipating health care provider with or without prior authorization or by a participating provider without such authorization, the participant, beneficiary, or enrollee is not liable for amounts exceeding the liability that would be incurred if the services were provided by a participating provider with prior authorization.

Prescribes the same coverage for maintenance care or post-stabilization care (subject to certain guidelines) by nonparticipating health care providers.

(Sec. 114) Requires plans and issuers to refer participants, beneficiaries, or enrollees who have a serious disease or condition requiring treatment by a specialist to an appropriate specialist who is available and accessible (regardless of whether the specialist is participating or nonparticipating), provided the benefits for such treatment are covered by the plan or issuer. Sets forth rules governing referrals and specialists.

(Sec. 115) Prohibits a plan or an issuer that requires or provides for designation of a participating primary care professional from requiring authorization or a referral by such primary care professional for gynecological care and pregnancy-related services provided by a participating health care professional (including a specialist). Requires the plan or issuer to treat the ordering of other obstetrical or gynecological care by such a participating professional as the authorization of the primary care professional.

(Sec. 116) Requires certain plans and issuers to permit an enrollee to designate a pediatrician as a primary care provider for the enrollee's child.

(Sec. 117) Prescribes requirements for continuity of care during a transition period for participants, beneficiaries, or enrollees undergoing treatment for an ongoing special condition in the event of a termination of: (1) a contract between the plan or an issuer and a health care provider; or (2) a contract between a plan and an issuer that results in the termination of coverage of services of a health care provider. Prescribes a 90-day basic transition period, with specified extensions in the case of scheduled surgery and organ transplantation, pregnancy, or terminal illness.

(Sec. 118) Provides that a plan or issuer restricting prescription drug benefits to drugs included in a formulary to: (1) ensure participation of participating physicians in development of the formulary; (2) disclose to providers, and upon request to participants, beneficiaries, and enrollees, the nature of the formulary restrictions; and (3) consistent with the standards for a utilization review program, provide for exceptions from the formulary limitation when a non-formulary alternative is medically indicated.

(Sec. 119) Prohibits a plan or issuer from: (1) denying individual participation in an approved clinical trial; (2) denying or limiting or imposing additional conditions on the coverage of routine patient costs for items and services furnished in connection with participation in the trial; and (3) discriminating against the individual on the basis of the enrollee's participation in such trial.

Subtitle C: Access to Information - Specifies benefits, access, emergency coverage, prior authorization, grievance and appeals, and other pertinent information which plans and issuers shall provide to participants and beneficiaries at the time of initial coverage, annually, within a reasonable period before or after the date of significant changes, and upon request.

Subtitle D: Protecting the Doctor-Patient Relationship - Prohibits any contract or agreement between a plan or issuer and a health care provider from prohibiting or otherwise restricting a health care professional from advising a participant, beneficiary, or enrollee who is the professional's patient about his or her health status or medical care or treatment for his or her condition or disease, regardless of whether benefits for such care or treatment are provided under the plan or coverage, if the professional is acting within the lawful scope of practice. Declares null and void any such contract or agreement provisions.

(Sec. 132) Prohibits a plan or issuer from discriminating with respect to participation or indemnification as to any provider acting within the scope of the provider's license or certification, solely on the basis of such license or certification.

(Sec. 133) Prohibits any plan or issuer from operating any physician incentive plan that does not meet certain requirements under title XVIII (Medicare) of the Social Security Act.

(Sec. 134) Requires a plan or issuer to provide for prompt payment of claims in a manner consistent with Medicare clean claims requirements.

(Sec. 135) Sets forth prohibitions and requirements for protection of: (1) participants, beneficiaries, enrollees, and health care providers in their use of a utilization review or grievance process; and (2) health care professionals for good faith disclosure of information to an appropriate agency or body in the interest of quality advocacy.

Subtitle E: Definitions - Sets forth definitions.

Title II: Application of Quality Care Standards to Group Health Plans and Health Insurance Coverage Under The Public Health Service Act - Amends the Public Health Service Act to require each plan and issuer to comply with the patient protection requirements of this Act.

(Sec. 202) Requires each health insurance issuer to comply with such requirements with respect to individual health insurance coverage.

Title III: Amendments to the Employee Retirement Income Security Act of 1974 - Amends ERISA to: (1) require each plan and issuer to comply with the patient protection requirements of this Act; and (2) deem a plan in compliance with subtitle A of title I of this Act to be in compliance with ERISA's claim procedure requirement with respect to claims denial.

(Sec. 302) Declares that nothing in ERISA shall be construed to invalidate, impair, or supersede any cause of action under State law by a participant or beneficiary (or by his or her estate) to recover damages resulting from personal injury or wrongful death against any person (except employers and other plan sponsors) in connection with the provision of insurance, administrative services, or medical services by that person to or for a group health plan, or that arises out of the arrangement by that person for the provision of insurance, administrative services, or medical services by other persons.

Declares that no person shall be liable for punitive damages (unless with respect to wrongful death State law provides for damages which are only punitive or exemplary in nature) in any cause of action relating to an externally appealable decision when: (1) the appeal has been completed; and (2) the plan or issuer has complied with the determination of the external appeal entity.

Allows an action against an employer or other plan sponsor (or an employee of one or the other acting within the scope of employment) if it is based on the employer's or sponsor's exercise of discretionary authority to decide a claim for covered benefits, and such exercise has resulted in personal injury or wrongful death.

(Sec. 303) Places limitations on actions seeking relief (other than any brought by the Secretary) based on certain provisions of title I of this Act. Allows a participant or beneficiary to seek relief with respect to utilization review activities, access to emergency care, access to specialty care, access to obstetrical and gynecological care, access to pediatric care, continuity of care, access to non-formulary alternative prescription drugs, or coverage of participation in clinical trials, subject to certain conditions. Prohibits a class action for such relief. Limits relief in any individual action to the provision or payment of benefits, items, or services denied to the individual participant or beneficiary involved (and, at the court's discretion, attorney's fees and court costs). Prohibits any other relief to the participant or beneficiary, and any relief to any other person.

Title IV: Application to Group Health Plans Under the Internal Revenue Code of 1986 - Amends the Internal Revenue Code to require a group health plan to comply with this Act. Deems the requirements of this Act to be incorporated into the Internal Revenue Code.

Title V: Effective Dates; Coordination in Implementation - Sets forth effective dates for provisions of this Act.

(Sec. 502) Requires the Secretaries of Labor, of Health and Human Services, and of the Treasury to ensure coordination in the implementation of this Act.

Title VI: Health Care Paperwork Simplification - Establishes the Health Care Panel to Devise a Uniform Explanation of Benefits to devise a single form for use by third-party health care payers for the remittance of claims to providers.