Family Health Care Fairness Act of 1995

TABLE OF CONTENTS:

Title I: Definitions; General Provisions

Title II: Certification of Health Plans

Title III: Enforcement

Family Health Care Fairness Act of 1995 - Title I: Definitions; General Provisions - Defines terms for purposes of this Act.

Mandates a process under which a health plan may apply to be certified under this Act. Provides for certification review, termination, and nonrenewal. Conditions certification on meeting the requirements of this Act.

Title II: Certification of Health Plans - Sets forth requirements plans must meet for certification, including regarding: (1) access to care (including emergency and urgent care and specialized services); (2) choice of health professionals, a point-of-service option, and continuity of care; (3) nondiscrimination against individuals or providers on the basis of race and other factors, including the individual's (or the providers' patients') health status and anticipated need for services; (4) mechanisms used in development of plan policies; (5) certain procedures relating to utilization review and appeals processes; (6) certain due process rights for providers; (7) marketing materials and information provided by plans to enrollees and prospective enrollees; (8) confidentiality; (9) plan financial reserves and solvency; and (10) a quality assurance program and case review.

(Sec. 210) Mandates a study and report to the Congress on the feasibility and desirability of voluntary health plan participation in a system that: (1) uses a risk adjustment mechanism for enhanced premium payments to plans serving high risk or underserved populations; and (2) requires part of such premiums to be passed through to providers serving such populations.

Title III: Enforcement - Mandates regulations to enforce this Act.

(Sec. 302) Prohibits plans from inappropriately limiting or denying care through any utilization review or cost containment technique. Allows any individual alleging injury caused by a clinically or medically inappropriate decision resulting from the design or application of utilization review or cost containment to commence a civil action against the plan in State or Federal court. Prohibits plans from requiring any provider to indemnify the plan for recovery in such an action. Prohibits States from limiting plan liability under such an action.