Patient Protection Act of 1998

TABLE OF CONTENTS:

Title I: Amendments to the Employee Retirement Income

Security Act of 1974

Subtitle A: Patient Protections

Subtitle B: Patient Access to Information

Subtitle C: New Procedures and Access to Courts for

Grievances Arising under Group Health Plans

Subtitle D: Affordable Health Coverage for Employees of

Small Businesses

Title II: Amendments to Public Health Service Act

Subtitle A: Patient Protections and Point of Service

Coverage Requirements

Subtitle B: Patient Access to Information

Subtitle C: HealthMarts

Subtitle D: Community Health Organizations

Title III: Amendments to the Internal Revenue Code of 1986

Subtitle A: Patient Protections

Subtitle B: Patient Access to Information

Subtitle C: Medical Savings Accounts

Subtitle D: Revenue Offsets

Title IV: Health Care Lawsuit Reform

Subtitle A: General Provisions

Subtitle B: Uniform Standards for Health Care Liability

Actions

Title V: Confidentiality of Health Information

Patient Protection Act of 1998 - Title I: Amendments to the Employee Retirement Income Security Act of 1974 - Subtitle A: Patient Protections - Amends the Employee Retirement Income Security Act of 1974 (ERISA) to prohibit a group health plan, or a health insurance issuer offering group coverage, from imposing on a health professional any restriction on advice provided to a participant or beneficiary.

Requires a plan or issuer, if it provides benefits for: (1) emergencies, to provide benefits (without preauthorization and without regard to network limitations) for emergency medical screening examinations if a prudent layperson would determine them necessary; (2) routine gynecological or obstetric specialist care benefits, to provide those benefits without authorization or referral by a primary care provider; or (3) routine pediatric specialist care benefits, to allow designation of a pediatric specialist as the primary provider.

Subtitle B: Patient Access to Information - Requires plans to include specified information in summary plan descriptions. Mandates advance notice of exclusion from a drug formulary of a drug or biological that is used in the treatment of a chronic illness or disease.

Subtitle C: New Procedures and Access to Courts for Grievance Arising Under Group Health Plans - Requires group health plans to: (1) provide written notice to participants or beneficiaries and providers of adverse coverage decisions; and (2) meet specified time limits for responding to routine, urgent, and emergency benefit payment requests, coverage advance determinations, and medical necessity determinations. Provides for initial coverage decision internal and, in certain circumstances, external review.

Makes a plan's fiduciary who, after an external review recommends coverage, causes a failure to provide a benefit liable to the participant or beneficiary for a civil penalty and attorney's fees and costs. Allows assessment of a civil penalty against a fiduciary for any pattern or practice of repeated adverse coverage decisions in violation of the terms of the plan or ERISA. Allows an action before exhaustion of administrative remedies. Provides for concurrent Federal-State court jurisdiction for actions relating to certain amendments made by this Act.

Subtitle D: Affordable Health Coverage for Employees of Small Businesses - Small Business Affordable Health Coverage Act of 1998 - Defines "association health plan" to mean a group health plan meeting specified requirements, including being sponsored by a trade, industry, or professional association, a chamber of commerce (or a similar business association) organized and maintained for substantial purposes other than obtaining or providing medical care. Provides for association plan certification and mandates a class certification procedure.

Regulates association plans' boards of trustees and sponsors.

Prohibits, for plans in existence on the date of enactment of this Act, a sponsor's affiliated members from being offered coverage unless the member: (1) was affiliated on the certification date; or (2) did not maintain or contribute to a group health plan during the 12 months before the offering of coverage.

Prohibits a participating employer from providing health coverage in the individual market for any employee who is eligible for plan coverage if the exclusion from plan coverage is based on health status.

Prohibits excluding an employer from an association plan if the employer and plan each meet specified requirements.

Prohibits contribution rates for any participating small employers from varying on the basis of claims experience or type of business. Requires, if any plan benefit option does not consist of health coverage, that the plan have at least 1,000 participants and beneficiaries. Requires, if a benefit option consisting of health coverage is offered under the plan, that State-licensed insurance agents be used to distribute to small employers coverage that is not health coverage in a manner comparable to the manner in which those agents are used to distribute health coverage.

Requires that a plan consist only of health coverage or, if the plan provides any additional benefit options, that the plan meet certain reserve and excess stop loss insurance and solvency indemnification requirements regarding the additional benefit options for which risk has not yet been transferred. Requires that all plans maintain a specified surplus.

Requires association plans providing additional options to make annual payments to the Association Health Plan Fund. Requires that, when there is or will be a failure to maintain such reserves, excess stop loss insurance, and indemnification, the Secretary of Labor pay amounts as necessary to maintain the excess stop loss insurance or indemnification. Establishes the Fund.

Mandates advance notice to participants and beneficiaries of certified plan termination.

Requires, when a plan has failed or will fail to maintain required reserves, excess stop loss insurance, and indemnification, either corrective action or plan termination.

Provides for court appointment of the Secretary as trustee to administer a plan during insolvency.

Allows a State to impose a contribution tax on an association plan providing additional options if the plan began operations in the State after enactment of this Act.

Sets forth special rules for church plans.

Declares that the provisions of this subtitle supersede certain related State laws.

(Sec. 1303) Modifies the circumstances in which two or more trades or businesses must be deemed a single employer.

(Sec. 1304) Excludes from the definition of "multiple employer welfare arrangement" any arrangement: (1) established or maintained under specified Federal (or similar State) labor relations provisions; or (2) meeting certain collective bargaining and other requirements.

(Sec. 1305) Imposes criminal penalties for falsely representing any benefit as: (1) being a certified association plan; or (2) having been established or maintained under certain collective bargaining agreements.

(Sec. 1306) Allows a State to enter into an agreement with the Secretary for delegation to the State of some or all of the Secretary's enforcement or certification authority.

Title II: Amendments to Public Health Service Act - Subtitle A: Patient Protections and Point of Service Coverage Requirements - Amends the Public Health Service Act to prohibit a group health plan, or a health insurance issuer offering group coverage, from imposing on a health professional any restriction on advice provided to a participant or beneficiary.

Requires a plan or issuer, if it provides benefits for: (1) emergencies, to provide benefits (without preauthorization and without regard to network limitations) for emergency medical screening examinations if a prudent layperson would determine them necessary; (2) routine gynecological or obstetric specialist care benefits, to provide those benefits without an authorization or referral by a primary provider; or (3) routine pediatric specialist benefits, to allow designation of a pediatric specialist as the primary provider.

(Sec. 2002) Requires health maintenance organizations (HMOs) that provide coverage under a group health plan only if services are furnished exclusively through members of a closed panel to make available to the plan sponsor an option covering services without regard to whether the providers are panel members. Requires HMOs, when a plan sponsor declines that option, to make optional supplemental coverage available in the individual market to each plan participant.

Subtitle B: Patient Access to Information - Requires plans to include specified information in summary plan descriptions. Mandates advance notice of exclusion from a drug formulary of a drug or biological that is used in the treatment of a chronic illness or disease.

Subtitle C: HealthMarts - Health Care Consumer Empowerment Act of 1998 - Requires that HealthMarts: (1) be nonprofit legal entities composed of small employers, employees of small employers, health care providers, and entities that underwrite or administer health benefits coverage; and (2) make available health coverage to all small employers and eligible employees at rates established by the insurance issuer on a policy or product specific basis. Deems HealthMarts group health plans for purposes of specified provisions of ERISA and the Internal Revenue Code. Requires that coverage made available to an eligible employee in a geographic area be offered to all eligible employees in the same area.

Declares that the HealthMart: (1) provides coverage only through contracts with issuers and does not assume insurance risk; (2) provides administrative services for purchasers; and (3) collects and disseminates consumer information on all coverage options offered through the Healthmart.

Requires that HealthMart coverage provide full portability of creditable coverage for individuals who remain members of the same HealthMart notwithstanding that they change employers.

Allows HealthMart coverage to include coverage: (1) through an HMO, a preferred provider or licensed provider-sponsored organization, an insurance company, a medical savings or flexible spending account, or a community health organization; (2) that includes a point-of-service option; or (3) any combination of those coverages.

Requires a HealthMart to permit any small employer to contract for coverage and prohibits varying eligibility conditions. Prohibits the purchaser from obtaining or sponsoring coverage other than through the HealthMart. Prohibits enrollment discrimination based on health.

Supersedes certain related State laws.

Provides for the application of: (1) certain existing ERISA and Public Health Service Act requirements; and (2) renewability requirements when the contract between a HealthMart and an issuer is terminated.

Directs the Secretary of Health and Human Services to administer this subtitle through a separate Health Care Marketplace Division.

Subtitle D: Community Health Organizations - Allows a community health organization to offer health coverage in a State in spite of not being licensed in that State if the organization has received a licensure waiver from the Secretary of Health and Human Services and other requirements are met.

Mandates the establishment of Federal financial solvency and capital adequacy standards.

Title III: Amendments to the Internal Revenue Code of 1986 - Subtitle A: Patient Protections - Amends the Internal Revenue Code to prohibit a group health plan from imposing on a health professional any restriction on advice provided to a participant or beneficiary.

Requires a plan, if it provides benefits for: (1) emergencies, to provide benefits (without preauthorization and without regard to network limitations) for emergency medical screening examinations if a prudent layperson would determine the examinations necessary; or (2) routine gynecological or obstetric specialist care benefits, to provide those benefits without an authorization or referral by a primary provider. Requires a plan or issuer, if it provides benefits for routine pediatric specialist benefits, to allow designation of a pediatric specialist as the primary provider.

Subtitle B: Patient Access to Information - Requires plans to include specified information in summary plan descriptions. Mandates advance notice of exclusion from a drug formulary of a drug or biological that is used in the treatment of a chronic illness or disease.

Subtitle C: Medical Savings Accounts - Repeals provisions limiting the number of individuals having medical savings accounts. Allows all employers to offer the accounts. Modifies requirements regarding: (1) the monthly limitation on related deductions; (2) coordination with the exclusion for employer contributions; and (3) the deductible amounts that will qualify as a high deductible plan. Allows the accounts to be included in cafeteria plans. Sets forth special rules for individuals receiving immediate Federal annuities.

(Sec. 3202) Allows medical savings accounts to be used by persons with incomes under a certain amount to pay for insurance offered by a community health center.

(Sec. 3203) Declares that it is the sense of the House of Representatives that: (1) patients are best served when they are empowered to make informed choices about their health care and their health insurance; and (2) a system that gives people the power to choose coverage, combined with insurance market reforms, offers great promise of increased choices and greater access to health insurance for Americans.

Subtitle D: Revenue Offsets - Modifies the definition of "specified liability loss."

(Sec. 3302) Removes, from provisions relating to the assumption of liability, references to another party (as part of the consideration for property received by the taxpayer) acquiring from the taxpayer property subject to a liability. Removes similar references from provisions relating to corporate reorganizations defining "reorganization." Provides for the determination of the amount of liability assumed with regard to recourse and nonrecourse liability. Prohibits increasing the basis of corporate property above fair market value by any gain recognized to the transferor as a result of the assumption of a liability. Provides for the treatment of: (1) gain that is not subject to tax; and (2) assumptions of liability. Amends provisions relating to the exchange of property held for productive use or investment to remove references to acquiring property subject to a liability.

(Sec. 3303) Amends provisions relating to limitations on the use of the cash method of accounting to limit an existing special rule (applicable to any person using the accrual method of accounting) for services to amounts received for services in the fields of health, law, engineering, architecture, accounting, actuarial science, performing arts, or consulting.

(Sec. 3304) Amends provisions involving returns relating to the cancellation of indebtedness by certain entities to include within the definition of "applicable financial entity" any organization a significant trade or business of which is the lending of money.

(Sec. 3305) Modifies the definition of "mathematical or clerical error" to: (1) require that a taxpayer be treated as having omitted a correct TIN (taxpayer identification number) if return information differs from the information from the TIN issuer; and (2) add inclusion of a TIN on a return under specified IRC sections if the TIN is of an individual whose age affects the amount of the credit and the return's credit computation reflects the individual as being of an age different from the age based on the TIN.

(Sec. 3306) Adds any vaccine against rotavirus gastroenteritis to the list of taxable vaccines.

Title IV: Health Care Lawsuit Reform - Subtitle A: General Provisions - Declares that this title applies to any health care liability action in any State or Federal court, except actions: (1) relating to vaccine-related injury to which title XXI (Vaccines) of the Public Health Service Act applies; or (2) under the Employee Retirement Income Security Act of 1974 (ERISA). Preempts State laws inconsistent with this title, but not that impose greater restrictions than those in this title. Excludes economic or punitive damages and attorneys' fees or costs from the determination of the amount in controversy.

Subtitle B: Uniform Standards for Health Care Liability Actions - Establishes a statute of limitations for bringing a health care liability action.

(Sec. 4012) Limits non-economic damages. Substitutes any different level set by a State after enactment of this Act. Makes defendants liable only for the proportion of the damages due to the defendant's fault.

Allows punitive damages, to the extent permitted by State law, if the claimant establishes by clear and convincing evidence that the defendant's conduct intended to cause harm or manifested a conscious, flagrant indifference to the rights or safety of others.

Prohibits punitive damages against a manufacturer or product seller of a drug or medical device where the drug or device was subject to Food and Drug Administration (FDA) premarket approval or the drug is generally recognized as safe and effective by the FDA. Prohibits punitive damages relating to packaging or labeling of a drug that is required to have tamper-resistant packaging unless the packaging or labeling is found by clear and convincing evidence to be substantially out of compliance.

Prohibits requiring lump-sum payment of future economic and non- economic damages over $50,000.

Allows any defendant to introduce evidence of collateral source payments. Prohibits any collateral source payments provider from recovering any amount against the claimant, receiving any lien or credit against the recovery, or being subrogated to the claimant's rights.

(Sec. 4013) Requires any alternative dispute resolution used to resolve a health care liability action or claim to contain provisions consistent with this title.

(Sec. 4014) Requires the General Accounting Office to report to specified congressional committees on the compliance of: (1) the Department of Justice and all U.S. Attorneys with a specified guideline relating to false claims and civil health care; and (2) the Office of the Inspector General of the Department of Health and Human Services with specified protocols and best practice guidelines.

Title V: Confidentiality of Health Information - Amends title XI (General Provisions, Peer Review, Administrative Simplification, and Confidentiality of Protected Health Information) of the Social Security Act to require health care providers, health plans, employers, health or life insurers, or educational institutions to permit an individual who is the subject of protected health information to inspect and copy the information. Requires, if the individual requests addition of a supplemental statement to the information, that those parties: (1) add the statement and make reasonable efforts to inform any person to whom the information was disclosed during the preceding year; or (2) if addition of the statement is refused, allow the individual to file a statement of disagreement.

Requires health care providers, health plans, health oversight agencies, public health authorities, employers, health or life insurers, health researchers, or educational institutions to maintain safeguards to ensure the confidentiality, security, accuracy, and integrity of protected health information.

Requires any person who maintains protected health information to disclose the information to a health care provider or health plan to permit the provider or plan to conduct health care operations, but prohibits providers and plans from selling or bartering protected health information.

Preempts State law provisions that: (1) are inconsistent with certain provisions of this title under Article VI (dealing with national supremacy, among other matters) of the Constitution; or (2) relate to specified matters dealt with in this title.

Imposes civil fines for substantially and materially failing to comply with the above provisions of this title.

Amends title XVIII (Medicare) of the Social Security Act to authorize the Secretary of Health and Human Services to refuse to enter into, terminate, or refuse to renew an agreement with a physician or supplier that has violated the above provisions of this title.

Requires compliance with certain provisions of this title by Medicare+Choice organizations, Medicare providers, and HMOs with risk-sharing contracts.

(Sec. 5002) Requires the Comptroller General to report to the Congress on the effect of State laws on health-related research subject to review by an institutional review board or institutional review committee with regard to the protection of human subjects.

(Sec. 5003) Requires the Comptroller General to submit to the Congress a compilation of State laws on the confidentiality of protected health information and an analysis of the effect of those laws on the provision of, and securing payment for, health care.

(Sec. 5004) Exempts information developed by a health care provider in response to a serious, adverse, patient-related event and for specified purposes (health care response information) from any disclosure requirement, in connection with a civil or administrative proceeding under Federal or State law, to the same extent as information developed by the provider regarding peer review, utilization review, quality management or improvement, quality control, risk management, or internal review to reduce mortality, morbidity, or patient care or safety. Prohibits deeming the protection of health care response information from disclosure modified by the development of such information in connection with a request or requirement of an accrediting body or the transfer of that information to an accrediting body.

(Sec. 5005) Amends title XI of the Social Security Act to prohibit the Secretary of Health and Human Services from promulgating or adopting a final standard under specified provisions relating to a unique health identifier for an individual until legislation is enacted specifically approving, or containing provisions consistent with, the standard.