Health Care Consumer Protection Act of 1997

TABLE OF CONTENTS:

Title I: Patient Choice; Access; Quality of Care

Title II: Contracting and Termination Rights

Title III: Information Reporting

Title IV: Patient-Provider Communication

Title V: Utilization Review and Management

Title VI: Additional Amendments; Effective Dates

Health Care Consumer Protection Act of 1997 - Title I: Patient Choice; Access; Quality of Care - Amends the Public Health Service Act (PHSA) to require a health insurer: (1) to permit enrollees to select a personal health professional and to change that selection; (2) that requires use of network providers to also offer optional coverage for out-of-network providers; (3) for enrollees with special needs or chronic conditions to ensure that care coordination and cost control processes do not create an undue burden; and (4) to provide for continuity of care.

Amends title XVIII (Medicare) of the Social Security Act to require a Medicare+Choice organization that requires use of network providers to also offer optional coverage for out-of-network providers.

(Sec. 102) Amends the PHSA to require a health insurer to: (1) maintain a sufficient number, mix, and distribution of providers; (2) assure the availability and accessibility of emergency and urgent care services 24 hours a day, seven days a week without prior authorization, defining emergency according to a prudent layperson; (3) allow designation of a specialist in obstetrics and gynecology as a primary care provider and not require prior authorization for referrals to such a specialist; (4) provide for referrals to specialists; (5) ensure that care coordination and cost control processes do not create an undue burden for enrollees with special needs or chronic conditions; and (6) provide for continuity of care.

(Sec. 103) Requires a health insurer to establish a quality improvement program meeting specified requirements. Regulates provider incentive plans.

Amends Medicare to establish, in the Health Care Financing Administration, an office of Medicare advocacy to provide an independent review of problems and concerns of Medicare beneficiaries. Authorizes expedited resolution of complaints in emergencies.

Amends the PHSA to authorize appropriations for grants to States for the maintenance of a State Health Insurance Ombudsman. Mandates a Federal Ombudsman for any State without a State Ombudsman.

(Sec. 104) Requires an insurer to establish confidentiality policies and procedures.

(Sec. 105) Prohibits discrimination against an enrollee for participation in an approved clinical trial when the enrollee has a life-threatening or serious illness for which no standard treatment is effective.

(Sec. 106) Requires an insurer that covers prescription drugs: (1) only when included in a formulary to meet certain requirements, including allowing exceptions when medically necessary; and (2) to maintain a drug utilization program.

Title II: Contracting and Termination Rights - Prohibits a health insurer from discriminating in selecting its network providers on specified bases, including genetic makeup, sexual orientation, place or institution of professional education, disability, or (while acting within the scope of licensure or certification) nature of license or certification.

(Sec. 202) Requires an insurer offering network coverage to establish mechanisms to consider enrollee and provider suggestions.

(Sec. 203) Requires an insurer to provide certain provider due process.

(sec. 204) Amends the Employee Retirement Income Security Act of 1974 (ERISA) to allow State causes of action for personal injury or wrongful death against a person who provides insurance or administrative services for an employee welfare benefit plan maintained to provide health benefits.

Title III: Information Reporting - Amends the PHSA to set forth the information insurers must disclose to enrollees and prospective enrollees.

Requires that any entity that is receiving prepaid payments for services under titles XVIII (Medicare) or XIX (Medicaid) of the Social Security Act and that submits quality information that is material and false be excluded from continuing to qualify for payments or be subject to intermediate sanctions.

Title IV: Patient-Provider Communication - Patient Right to Know Act - Prohibits any agreement between a health plan and a provider from restricting the provider from engaging in medical communications with his or her patient. Requires State enforcement, mandating Federal enforcement if a State fails to do so.

Mandates a civil money penalty. Allows State requirements equal to or more protective of medical communications than this Act.

Title V: Utilization Review and Management - Regulates utilization review programs. Mandates a right of review of certain decisions. Requires each issuer to maintain informal and formal internal appeal processes. Requires an external independent review process regarding a decision not to cover experimental therapies for enrollees with certain terminal conditions for which there is no standard, medically appropriate therapy.

Title VI: Additional Amendments; Effective Dates - Requires each health insurer to comply with consumer protection requirements of this Act's PHSA amendments. Mandates coordination between the Secretaries of Health and Human Services and Labor in regulations, rulings, interpretations, and policies. Requires health insurers to comply with consumer protection requirements of this Act's amendments of the PHSA regarding individual coverage.

Amends titles XVIII (Medicare) and XIX (Medicaid) of the Social Security Act to require Medicare+Choice plans and Medicaid managed care organizations to comply with the consumer protection requirements of this Act's PHSA amendments.

Amends the PHSA to allow State laws (relating to group or individual health insurance) providing protections for individuals equivalent to or stricter than the protections provided under the PHSA amendments of this Act.

(Sec. 602) Amends ERISA to require a group health plan (and a health issuer offering group coverage) to comply with the consumer protection requirements of this Act's PHSA amendments. Mandates coordination between the Secretaries of Health and Human Services and Labor in regulations, rulings, interpretations, and policies. Allows State laws providing protections for individuals equivalent to or stricter than the protections provided under this Act's PHSA amendments.