Promoting Responsible Managed Care Act of 1998

TABLE OF CONTENTS:

Title I: Promoting Responsible Managed Care

Subtitle A: Grievance and Appeals

Subtitle B: Consumer Information

Subtitle C: Patient Protection Standards

Subtitle D: Enhanced Enforcement Authority

Title II: Patient Protection Standards Under the Public

Health Service Act

Title III: Patient Protection Standards Under the Employee

Retirement Income Security Act of 1974

Title IV: Patient Protection Standards Under the Internal

Revenue Code of 1986

Title V: Effective Dates; Coordination in Implementation

Promoting Responsible Managed Care Act of 1998 - Title I: Promoting Responsible Managed Care - Subtitle A: Grievance and Appeals - Declares that a participant or beneficiary in a group health plan or an enrollee in health insurance coverage offered by a health insurance issuer (covered individual) has rights relating to grievances, timely coverage determinations, expedited coverage determinations, and determination appeals. Requires that a group health plan, and a health insurance issuer in connection with health coverage, maintain procedures in accordance with those sections.

(Sec. 102) Requires a plan or issuer to: (1) conduct utilization review; (2) provide procedures for timely hearings and resolution of grievances by covered individuals; (3) make timely coverage determinations and redeterminations, including expedited determinations and redeterminations in certain circumstances. Regulates review programs.

(Sec. 106) Allows a party to a reconsideration that receives an unfavorable determination to request external review by an entity under contract with the plan.

Subtitle B: Consumer Information - Requires plans and issuers to disclose specified information at certain times.

Authorizes appropriations for grants to States for contracts with organizations that are independent of plans and issuers for Health Insurance Ombudsmen to provide consumer assistance. Authorizes Federal provision of such a contract where States do not do so.

(Sec. 112) Requires: (1) plans and issuers to collect and submit to the Agency for Health Care Policy and Research certain aggregate quality data; and (2) the Agency to publicly disseminate the information (thereby allowing quality comparisons) and to conduct and support research demonstration projects, evaluations, and the dissemination of information regarding quality information. Authorizes appropriations.

(Sec. 113) Requires plans and issuers to have: (1) procedures to safeguard the privacy of individually identifiable health information; and (2) quality assurance and quality improvement programs meeting specified requirements.

Subtitle C: Patient Protection Standards - Imposes plan or issuer requirements regarding emergency services and related maintenance or post-stabilization care.

(Sec. 122) Provides for: (1) choice of primary (and, unless prior notice is given to the contrary, specialist) providers; (2) routine gynecological and pregnancy-related services from appropriate professionals without authorization; (3) referrals to specialists; (4) designation of a specialist as a primary provider in certain circumstances; (5) standing referrals; and (6) continuity of care on termination of a contract between a plan or issuer and a provider or between a plan and an issuer.

Prohibits involuntary disenrollment because an individual's behavior is disruptive, abusive, or uncooperative if the behavior is directly related to diminished mental capacity, severe and persistent mental illness, or a serious childhood mental and emotional disorder, unless the behavior directly threatens bodily injury.

Requires that plans and issuers have a sufficient number, distribution, and variety of providers.

(Sec. 123) Prohibits plans and issuers, in certain circumstances, from denying participation in a relevant clinical trial or otherwise discriminating against the individual on the basis of the enrollee's trial participation.

Imposes requirements on plans and issuers regarding drug formularies.

(Sec. 124) Prohibits plans and issuers from discriminating on the basis of race and other specified factors.

(Sec. 125) Prohibits an organization on behalf of a plan or issuer from penalizing a health professional for advocating on behalf of the professional's patient or for providing information or referral for medical care. Prohibits a plan or issuer: (1) from restricting a health professional from assisting enrollees who are appealing certain matters under subtitle A; (2) through its contract with its provider, from transferring to the provider any plan or issuer liability; or (3) from operating any physician incentive plan not meeting certain requirements.

(Sec. 127) Requires plans and issuers to have a written process for the selection of participating professionals. Prohibits discrimination on the basis of a high-risk patient base or the professional's race or other specified factors.

(Sec. 128) Sets forth plan and issuer requirements regarding breast cancer and related procedures, coverages, and practices.

Subtitle D: Enhanced Enforcement Authority - Authorizes the Secretary of Health and Human Services to: (1) enforce this Act; (2) require States that elect to assume enforcement authority to report on their efforts; (3) require issuers to report regarding compliance with this Act; and (4) bring a civil action for equitable relief regarding violations of this Act. Authorizes the Secretary of Labor to: (1) enforce this Act; and (2) bring such an action. Sets dollar limits on monetary penalties. Authorizes appropriations.

(Sec. 142) Amends the Employee Retirement Income Security Act of 1974 (ERISA) to authorize the Secretary of Labor to assess a civil penalty against a person acting as a fiduciary of a plan so as to cause a violation of certain amendments made by title III of this Act. Authorizes appropriations.

Title II: Patient Protection Standards Under Public Health Service Act - Amends the Public Health Service Act to require plans (and, with regard to group and individual insurance, issuers) to comply with patient protection requirements under title I of this Act.

Title III: Patient Protection Standards Under the Employee Retirement Income Security Act of 1974 - Amends ERISA to require plans and issuers to comply with the requirements of title I of this Act. Provides for situations in which a plan is not liable for the failure of an issuer's or external appeal entity's failure to meet those requirements.

(Sec. 302) Makes any person or persons responsible for making a coverage determination that is not made timely or in accordance with plan terms liable to the participant or beneficiary for economic loss.

Title IV: Patient Protection Standards Under the Internal Revenue Code of 1986 - Amends the Internal Revenue Code to require a plan to comply with the requirements of this Act.

Title V: Effective Dates; Coordination in Implementation - Sets forth the effective dates for this Act.

(Sec. 502) Amends the Health Insurance Portability and Accountability Act of 1996 to provide for coordination between the Secretaries of Health and Human Services, Labor, and the Treasury regarding regulations, rulings, interpretations, and policies relating to specified provisions of the Act.