Summary: S.326 — 106th Congress (1999-2000)All Information (Except Text)

Bill summaries are authored by CRS.

Shown Here:
Reported to Senate with amendment(s) (06/17/1999)

TABLE OF CONTENTS:

Title I: Patients' Bill of Rights

Subtitle A: Right to Advice and Care

Subtitle B: Right to Information About Plans and

Providers

Subtitle C: Right to Hold Health Plans Accountable

Title II: Genetic Information and Services

Title III: Healthcare Research and Quality

Title IV: Miscellaneous Provisions

Patients' Bill of Rights Act - Title I: Patients' Bill of Rights - Subtitle A: Right to Advice and Care - Amends the Employee Retirement Income Security Act of 1974 (ERISA) to define "fully insured group health plan" as one under which benefits are provided pursuant to the terms of an arrangement between a group health plan and a health insurance issuer and are guaranteed by the issuer under a contract or policy of insurance. Requires a group health plan (for purposes of benefits and protections discussed in this subtitle, one other than a fully insured group health plan) covering emergency medical care to provide coverage, without requiring preauthorization, for appropriate emergency medical screening examinations to the extent that a prudent layperson, possessing an average knowledge of health and medicine, would determine such examinations to be necessary to determine whether emergency medical care is necessary.

Requires a plan to cover additional emergency medical care to stabilize an emergency medical condition following an emergency screening examination.

Requires a plan (other than certain small employer plans) providing benefit coverage only through a defined set of participating health care professionals to offer the option of point-of-service coverage (of the same benefits provided by a nonparticipating health care professional), unless the plan offers multiple coverage options.

Prohibits a plan that covers routine obstetrical, gynecological, or pediatric care from requiring a referral for that care and requires a plan to treat certain referrals by an obstetrician, gynecologist, or pediatrician as a referral by a primary provider.

Requires a plan to ensure that participants and beneficiaries have access to covered specialty care.

Requires a plan to permit a participant or beneficiary undergoing a course of treatment to continue such treatment for a period of time even though the contract between the plan and a health care provider is terminated, or the schedule of benefits or coverage is terminated by a change in the terms of the provider's participation in the plan. Specifies a 90-day continuation of coverage generally, and other transitional periods for institutionalization (until discharge), pregnancy (through postpartum care), and terminal illness.

Prohibits a plan from restricting a health care professional from advising a patient about the patient's health status, medical care, or treatment, regardless of whether such care or treatment is covered.

Requires a plan that covers prescription drugs only if included in a formulary to ensure the participation of physicians and pharmacists in developing and reviewing the formulary and to provide for exceptions to the formulary when medically necessary and appropriate.

Prohibits a plan from: (1) discouraging a participant or beneficiary from self-paying for behavioral health services once the plan has denied coverage; or (2) terminating a provider because the provider permits participants or beneficiaries to self-pay for non- covered behavioral services.

Applies most of the above requirements of this Act separately to each coverage option with regard to a plan that has more than one coverage option.

(Sec. 102) Mandates a study and report to a specified Senate committee of patient access to clinical trials and the coverage of routine patient care costs by private health plans and insurers. Directs the Secretary to provide for necessary funding.

Subtitle B: Right to Information about Plans and Providers - Requires plans and group health insurance issuers to disclose specified plan information to participants, beneficiaries, and (upon request) potential enrollees.

Amends the Internal Revenue Code to require plans to disclose specified plan information to participants, beneficiaries, and (upon request) potential enrollees.

(Sec. 112) Mandates a study and report to appropriate congressional committees on: (1) health care professionals information currently available to patients, consumers, States, and professional societies, nationally and on a State-by-State basis; (2) the legal and other barriers to the sharing of information about health care professionals; and (3) recommendations for disclosure of such information on health care professionals, including their competencies and professional qualifications, to better facilitate patient choice, quality improvement, and market competition.

Subtitle C: Right to Hold Health Plans Accountable - Amends ERISA to revise requirements for denied claim appeal procedures.

Requires a plan or health insurance issuer conducting utilization review to have: (1) specified procedures in place for coverage determinations, including expedited determinations; (2) written procedures for addressing grievances between a plan or issuer and a participant or beneficiary; (3) an internal procedure for coverage determination appeals; and (4) an external review procedure for participant or beneficiary appeals, involving specified entities and independent medical experts, whose determination shall be binding.

Prescribes external review standards.

Directs the General Accounting Office to study and report to the appropriate congressional committees on a statistically appropriate sample of completed external reviews.

Title II: Genetic Information and Services - Genetic Information Nondiscrimination in Health Insurance Act of 1999 - Amends ERISA and the Public Health Service Act to prohibit a plan or issuer from: (1) basing enrollment eligibility on information about a request for or receipt of genetic services; (2) adjusting premium or contribution amounts for a group based on predictive genetic information concerning any individual, including information about a request for or receipt of genetic services; or (3) except as needed for diagnosis, treatment, or payment, requesting or requiring predictive genetic information concerning any individual. Mandates notice of a plan's or issuer's confidentiality practices regarding predictive genetic information. Requires development and dissemination of model notices. Requires a plan or issuer to maintain safeguards to protect the confidentiality, security, accuracy, and integrity of predictive genetic information.

(Sec. 203) Amends the Public Health Service Act to apply the requirements of this title to issuers offering coverage in the individual market.

(Sec. 204) Amends the Internal Revenue Code to apply the requirements of this title to group health plans.

Title III: Healthcare Research and Quality - Healthcare Research and Quality Act of 1999 - Amends the Public Health Service Act to establish in the Public Health Service an Agency for Healthcare Research and Quality to replace the current Agency for Health Care Policy and Research.

Authorizes: (1) training grants in health services research including pre- and post-doctoral fellowships and training programs and young investigator awards; and (2) financial assistance to establish and operate centers for multidisciplinary health services research, demonstration projects, evaluations, training, and policy analysis.

Directs the Agency to identify and disseminate methods or systems used to assess health care research results, particularly to rate the strength of the scientific evidence behind health care practice, recommendations in research literature, and technology assessments.

Requires the Agency to employ research strategies and mechanisms that will link research directly with clinical practice in geographically diverse locations throughout the United States, including: (1) Healthcare Improvement Research Centers that combine demonstrated multidisciplinary expertise in outcomes or quality improvement research with linkages to relevant sites of care; (2) Provider-based Research Networks, including plan, facility, or delivery system sites of care (especially primary care), that can evaluate and promote quality improvement; and (3) other innovative mechanisms or strategies.

Authorizes the Agency to provide specified scientific and technical support for private and public efforts to improve health care quality, including activities of accrediting organizations.

Directs the Secretary, acting through the Agency Director, to establish a demonstration program of grants for one or more centers to conduct: (1) state-of-the-art clinical, laboratory, or health services research on drugs, biological products, and devices; (2) research on the comparative effectiveness, cost-effectiveness, and safety of drugs, biological products, and devices; and (3) other appropriate activities (excluding the review of new drugs).

Mandates conducting and supporting research and building private-public partnerships to: (1) identify the causes of preventable healthcare errors; (2) develop, demonstrate, and evaluate strategies for reducing errors and improving patient safety; and (3) promote implementation of effective strategies.

Requires the Agency Director to: (1) collect certain data on the cost and quality of health care; and (2) support research on and initiatives to advance the use of information systems for the study of health care quality.

Authorizes the Director to periodically convene a Preventive Services Task Force to review scientific evidence related to the effectiveness, appropriateness, and cost-effectiveness of clinical preventive services.

Establishes within the Agency a Center for Primary Care Research to serve as the principal funding source for Department of Health and Human Services primary care research and demonstrations with respect to the first contact when illness or health concerns arise, the diagnosis, treatment or referral to specialty care, preventive care, and the relationship between the clinician and the patient in the context of the family and community.

Mandates the promotion of innovation in evidence-based clinical practice and health care technologies.

Requires coordination of all research, evaluations, and demonstrations related to health services research and quality measurement and improvement activities undertaken and supported by the Federal Government.

Requires the Institute of Medicine to describe and evaluate current quality improvement research and monitoring processes and recommend improvements.

Establishes an Advisory Council for Healthcare Research and Quality.

Requires that appropriate technical and scientific peer review be conducted regarding each application for a grant, cooperative agreement, or contract under this title and prohibits approving an application unless the peer review so recommended.

Mandates establishment of standard methods for developing and collecting the Agency's data.

Authorizes the Agency, on request of a public or private entity, to conduct or support research or analyses otherwise authorized under this title, with the entity paying service costs.

Authorizes appropriations.

Title IV: Miscellaneous Provisions - Expresses the sense of the Senate Committee on Health, Education, Labor, and Pensions that Congress should take measures to further the purposes of this Act, including necessary changes to the Internal Revenue Code or other Acts to: (1) promote equity and prohibit discrimination based on genetic information with respect to the availability of health benefits; (2) allow the full deduction of health insurance costs for the self- employed; (3) provide for the full availability of medical savings accounts; (4) provide for the carryover of unused benefits from cafeteria plans and other flexible arrangements; and (5) permit contributions to medical savings accounts through the Federal employees health benefits program.