Health Care QUEST Act

TABLE OF CONTENTS:

Title I: Health Quality Oversight

Title II: Quality Improvement

Title III: Health Care Information

Subtitle A: Plan Sponsor Responsibilities

Subtitle B: Health Plan Requirements and Consumer

Protection

Health Care Quality, Education, Security, and Trust Act or Health Care QUEST Act - Title I: Health Quality Oversight - Establishes the Health Quality Council (HQC) to advise the President and the Congress regarding health care quality.

(Sec. 102) Prohibits the Chairperson and the Executive Director of HQC from engaging in any other business, vocation, or employment.

(Sec. 105) Directs HQC to: (1) serve as a resource for the appropriate congressional committees and the President in providing information and scientific evidence with respect to health care quality and consumer protection legislation; (2) develop (on request) financial and socioeconomic impact statements for health care quality and consumer protection legislation; (3) develop, update, and disseminate population-based benchmarks and indicators of health care quality; (4) provide such committees and the President with national report cards on health care quality; (5) develop recommendations for measuring and reporting quality indicators for use in the fee-for-service market; (6) develop the data sampling methods to be used in data reporting for monitoring quality indicators and health outcomes measures as required under the Public Health Service Act (PHSA), as amended by this Act.

(Sec. 109) Directs the Secretary of Health and Human Services (HHS) to contract with the Institute of Medicine of the National Academy of Sciences to conduct studies to: (1) determine what standards should be used in the development of population-based benchmarks against which health care quality can be compared and measured; (2) determine, and validate, the optimal process for establishing such population-based benchmarks; (3) assess the optimal application of population-based benchmarks and how information concerning health care quality should be presented to users, including consumers, providers, and purchasers; (4) analyze the next steps necessary for a national continuous health care quality improvement process; (5) develop recommendations for linking payment for health services to health outcomes measures in order to recognize and reimburse health plans and health care providers that provide quality health care, particularly with respect to individuals with special needs or chronic health problems; and (6) consider the relationship between the need for public information to help consumers make informed health care choices and the processes necessary to create an environment that will promote the use of continuous quality improvement techniques. Requires a report on each such study to the Congress and the President.

Requires the General Accounting Office to review periodically the conduct of HQC and report findings to the appropriate congressional committees and the President.

(Sec. 110) Authorizes appropriations.

Title II: Quality Improvement - Amends PHSA to direct the Agency for Health Care Policy and Research (AHCPR) to collect, analyze, and disseminate health care quality information.

(Sec. 201) Requires AHCPR to: (1) provide administrative and scientific support to HQC; (2) develop risk and case mix adjustment methodology for use in comparing health outcomes data; (3) compile and publicly disseminate aggregate data regarding health care quality indicators and outcomes; (4) develop a model standard format that may be used by health insurance issuers in reporting; (5) provide assistance in the development of improved information systems, including computerized formats that may be used by health plans in providing specified required information; (6) collect, maintain, and publicly distribute health care quality population-based benchmarks established by HQC; (7) coordinate its activities with respect to health care quality with health plan accrediting bodies, the National Committee on Vital and Health Statistics, the National Center for Health Statistics, and State and local governments; and (8) develop survey tools to measure participant and beneficiary satisfaction as required by the Employee Retirement Income Security Act of 1974 (ERISA).

Requires health insurance issuers, group health plans, and health insurance issuers of group health plans to submit aggregate data, without patient identifiers, obtained in the process of reporting quality indicators and health outcomes measures to AHCPR for the purpose of HQC's report.

Directs the Secretaries of HHS and of Labor to develop data sampling methods for the submission of such aggregate data, based on HQC recommendation. Authorizes the Secretaries to adopt different data sampling methods, if more cost-reductive or more appropriate, than those recommended by HQC.

Title III: Health Care Information - Subtitle A: Plan Sponsor Responsibilities - Amends ERISA to establish requirements for group health plan distribution of information.

(Sec. 301) Requires group health plan administrators to furnish to each participant a copy of the most recent summary plan description for each plan option under which the participant or beneficiary may elect to receive benefits: (1) upon employment of the participant or at the time the group health plan first becomes subject to ERISA, whichever is later; and (2) at the beginning of any open enrollment period. Requires such administrators also to provide such descriptions to participants and beneficiaries: (1) at least annually if the plan has been materially modified or amended; and (2) upon the request of a participant or beneficiary.

Requires such administrators to notify participants and beneficiaries, within 30 days after the pertinent effective date, of any material changes in: (1) benefit coverage, including any new exclusions from coverage or new optional supplemental coverage (especially the associated premiums, deductibles, coinsurance, copayments for which the enrollee will be responsible, and any annual or lifetime limits on benefits); (2) the health insurance issuer's service area, including any changes in the number, mix, and geographic distribution of participating providers, including specialists; (3) out-of-area coverage or out-of-network services or additional payments required for these services; (4) prior authorization rules; and (5) plan grievance and appeals procedures.

Requires a group health plan sponsor to provide to participants and beneficiaries an annual summary report of participant satisfaction and disenrollment rates regarding each enrollment option offered, if such sponsor has: (1) 100 or more participants enrolled in a group health plan during a plan year; and (2) a contracting relationship with the health insurance issuer involved for at least two years. Allows such sponsors to use satisfaction measuring tools developed by AHCPR.

Requires group health plan administrators to notify participants and beneficiaries that the plan sponsor: (1) has stopped paying plan premiums or has terminated reimbursement for services covered under the plan, within 30 days after the date of the first nonpayment; or (2) in the case of a plan sponsor involved in a sale or merger, has made changes in the group health plan, by the date on which the plan sponsor's assets are transferred.

Directs the Secretary of Labor to establish an Internet site to provide technical support and information concerning ERISA rights of participants and beneficiaries.

Subtitle B: Health Plan Requirements And Consumer Protection - Amends PHSA to establish consumer protection standards and consumer information requirements for group health plans.

(Sec. 311) Authorizes the Secretary of HHS to exempt a group health plan or a health insurance issuer from compliance with one or more of such standards and requirements if certain requirements are met.

Establishes certain health plan comparative information requirements under PHSA. Directs the Secretary of HHS to develop quality indicators and health outcomes measures for use by health insurance issuers in providing such required information, taking into consideration HQC recommendations. Requires such indicators and measures to be consistent where appropriate with requirements applicable to Medicare+Choice health plans under the Social Security Act, while taking into consideration the different populations served (such as children and individuals with disabilities). Authorizes either Secretary to adopt different indicators or measures, if more cost-reductive or more appropriate, than those recommended by HQC.

Establishes consumer protection and plan standards for group health plans under PHSA. Sets forth such requirements with respect to: (1) emergency services; (2) advance directives and organ donation; (3) coverage determination, grievances and appeals; and (4) confidentiality and accuracy of participants' and beneficiaries' records.

Establishes health care professional protections with respect to group health plans under PHSA. Requires plan provision of specified information to such professionals. Prohibits group health plan organizations or insurance issuers from penalizing health care professionals for advocating on behalf of a patient or for providing information or referral for medical care consistent with the patient's health care needs and with the code of ethical conduct, professional responsibility, conscience, medical knowledge, and license of such professional.