Patient Protection bill

Health Care Quality and Choice Act of 1999 - Title I: Improving Managed Care - Subtitle A: Grievances and Appeals - Requires a group health plan, and a health insurance issuer that provides health insurance coverage, to conduct utilization review activities that monitor or evaluate the use or coverage, clinical necessity, appropriateness, efficacy, or efficiency of health care services, procedures, or settings.

(Sec. 102) Requires a plan and an issuer to provide appropriate notices to the participant, beneficiary, or enrollee for benefit claims it has denied that include reasons for denial and instructions for initiating specified internal appeals procedures, which must include procedures for an expedited review process in emergency situations.

(Sec. 103) Outlines external appeals procedures for the timely resolution of certain denied claims through the use of qualified external appeal entities, which shall determine whether the plan's or issuer's decision is in accordance with the patient's medical needs. Declares that an external appeal entity's determination is binding on the plan and issuer involved.

Provides for court-imposed civil monetary penalties and cease and desist orders against authorized officials of plan or issuers who refuse to timely follow the determination of an external appeal entity to provide a benefit.

(Sec. 104) Requires a plan and an issuer to establish a system featuring specified components for the presentation and resolution of grievances brought by participants, beneficiaries, or enrollees, or health care providers or other individuals acting on behalf of an individual either with the individual's consent or without it if the individual is medically unable to provide it. Declares that grievances are not subject to appeal under this subtitle.

Subtitle B: Access to Care - Provides that if an issuer offers coverage of services only if they are furnished through members of a network of health care professionals and providers contracting with the issuer, the issuer shall also offer the option of coverage of such services which are not furnished through members of such a network, unless enrollees are offered such non-network coverage through another health insurance issuer. Makes the enrollee bear the cost of any additional premium the issuer charges for such option, and the amount of any additional cost sharing, unless it is paid by the health plan sponsor through agreement with the issuer.

(Sec. 112) States that if a plan or an issuer requires or provides for designation of a participating primary care provider by a participant, a beneficiary, or an enrollee, then the plan or issuer shall permit each such person to designate any participating primary care provider available to accept such individual.

Requires a plan and an issuer to permit each participant, beneficiary, or enrollee to receive medically necessary or appropriate specialty care, pursuant to appropriate referral procedures, from any qualified participating health care professional available to accept such individual.

(Sec. 113) Requires a plan or an issuer providing or covering any emergency hospital benefits to cover emergency services: (1) without the need for any prior authorization determination; (2) whether or not the health care provider furnishing such services is a participating health care provider; and (3) without regard to any other term or condition of such coverage (other than exclusion or coordination of benefits, or an affiliation or waiting period, permitted under the Public Health Service Act, the Employee Retirement Income Security Act of 1974 (ERISA), or the Internal Revenue Code, and other than applicable cost-sharing).

Requires such coverage in a manner so that, if the emergency services are provided by a nonparticipating health care provider with or without prior authorization or by a participating provider without such authorization, the participant, beneficiary, or enrollee is not liable for amounts exceeding the liability that would be incurred if the services were provided by a participating provider with prior authorization.

Prescribes the same coverage for maintenance care or post-stabilization care (subject to certain guidelines) by nonparticipating health care providers.

Sets out provisions with regard to the coverage of emergency ambulance services.

(Sec. 114) Requires plans and issuers to refer participants, beneficiaries, or enrollees who have a serious disease or condition requiring treatment by a specialist, or who require physician pathology services, to an appropriate specialist who is available and accessible (regardless of whether the specialist is participating or nonparticipating), provided the benefits for such treatment are covered by the plan or issuer. Sets forth rules governing referrals and specialists.

(Sec. 115) Prohibits a plan or an issuer that requires or provides for designation of a participating primary care professional from requiring authorization or a referral by such primary care professional for routine gynecological care and pregnancy-related services provided by a participating physician who specializes or is trained and experienced in obstetrics and gynecology. Requires the plan or issuer to treat the ordering of other obstetrical or gynecological care by such a participating professional as the authorization of the primary care professional.

(Sec. 116) Requires certain plans and issuers to permit an enrollee to designate a pediatrician as a primary care provider for the enrollee's child.

(Sec. 117) Prescribes requirements for continuity of care during a transition period for participants, beneficiaries, or enrollees undergoing treatment for an ongoing special condition in the event of a termination of: (1) a contract between the plan or an issuer and a health care provider; or (2) a contract between a plan and an issuer that results in the termination of coverage of services of a health care provider. Prescribes a 90-day basic transition period, with specified extensions in the case of scheduled surgery and organ transplantation, pregnancy, or terminal illness.

(Sec. 118) Establishes the Health Care Panel to Establish Network Adequacy Standards to devise standards for plans and issuers to meet to ensure network adequacy (i.e. access of participants, beneficiaries, and enrollees to a sufficient number, mix, and distribution of health care professionals and providers, and availability and accessibility of covered items and services at a variety of sites in the plan or issuer service area) .

(Sec. 119) Provides that no use of a prescription drug or medical device shall be considered experimental or investigational under a plan or by an issuer if such use is included in labeling authorized by the U.S. Food and Drug Administration under the Federal Food, Drug, and Cosmetic Act or under the Public Health Service Act, unless such use is demonstrated to be unsafe or ineffective.

Subtitle C: Access to Information - Specifies benefits, access, emergency coverage, prior authorization, grievance and appeals, and other pertinent information which plans and issuers shall provide to participants and beneficiaries at the time of initial coverage, annually, within a reasonable period before or after the date of significant changes, and upon request.

Subtitle D: Protecting the Doctor-Patient Relationship - Prohibits any contract or agreement between a plan or issuer and a health care provider from prohibiting or otherwise restricting a health care professional from advising a participant, beneficiary, or enrollee who is the professional's patient about his or her health status or medical care or treatment for his or her condition or disease, regardless of whether benefits for such care or treatment are provided under the plan or coverage, if the professional is acting within the lawful scope of practice. Declares null and void any such contract or agreement provisions.

(Sec. 132) Prohibits a plan or issuer from discriminating with respect to participation or indemnification as to any provider acting within the scope of the provider's license or certification, solely on the basis of such license or certification.

(Sec. 133) Prohibits any plan or issuer from operating any physician incentive plan that does not meet certain requirements under title XVIII (Medicare) of the Social Security Act.

(Sec. 134) Requires a plan or issuer to provide for prompt payment of claims in a manner consistent with Medicare clean claims requirements.

Subtitle E: Definitions - Sets forth definitions.

Title II: Application of Quality Care Standards to Group Health Plans and Health Insurance Coverage Under The Public Health Service Act - Amends the Public Health Service Act to require each plan and issuer to comply with the patient protection requirements of this Act.

(Sec. 202) Requires each health insurance issuer to comply with such requirements with respect to individual health insurance coverage.

Title III: Amendments to the Employee Retirement Income Security Act of 1974 - Amends ERISA to: (1) require each plan and issuer to comply with the patient protection requirements of this Act; and (2) deem a plan in compliance with subtitle A of title I of this Act to be in compliance with ERISA's claim procedure requirement with respect to claims denial.

(Sec. 302) Makes liable to a participant or beneficiary (or his or her estate) for economic and noneconomic damages any fiduciary of a plan, issuer, or an agent of the plan or plan sponsor: (1) who has authority to make final decisions in the internal appeals process established by this Act; and (2) fails to exercise ordinary care in making an incorrect determination that an item or service is excluded from coverage, and such failure is the proximate cause of personal injury to, or wrongful death of, such participant or beneficiary. Exempts employers and other plan sponsors from such liability, unless they participated directly in the final decision that resulted in such injury or death. Specifies maximum noneconomic damages and, in limited circumstances, punitive damages.

(Sec. 303) Allows a plan to provide for binding arbitration, at the election of an aggrieved participant or beneficiary, for review of adverse coverage decisions.

Title IV: Application to Group Health Plans Under the Internal Revenue Code of 1986 - Amends the Internal Revenue Code to require a group health plan to comply with this Act. Deems the requirements of this Act to be incorporated into the Internal Revenue Code.

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

(Sec. 502) Requires the Secretaries of Labor, of Health and Human Services, and of the Treasury to ensure coordination in the implementation of this Act.

Title VI: Other Provisions - Establishes the Health Care Panel to Devise a Uniform Explanation of Benefits to devise a single form for use by third-party health care payers for the remittance of claims to providers.

(Sec. 602) Exempts 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 a health care provider with respect to any of the following: (1) peer review; (2) utilization review; (3) quality management or improvement; (4) quality control; (5) risk management; or (6) internal review for purposes of reducing mortality, morbidity, or for improving patient care or safety.

(Sec. 603) Prohibits the Secretary of Health and Human Services from implementing the Medicare Competitive Pricing Demonstration Project under the Balanced Budget Act of 1997 in Kansas City, Missouri, or Kansas City, Kansas, or in any area in Arizona. Prohibits the Secretary from implementing such project in any area before January 1, 2001.

Directs the Secretary to study and report to Congress on the different approaches of implementing such project on a voluntary basis.