To provide new patient protections under group health plans and through health insurance issuers in the group market.
(Sec. 101) Requires a plan or health insurance coverage offered by a health insurance issuer, if it provides benefits for: (1) emergency or ambulance services, to cover emergency services, including emergency ambulance services, without preauthorization and without regard to whether or not the health care provider is a participating one, among other specified conditions; (2) 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 care provider.
Outlines rules permitting continuity of care for scheduled surgery, pregnancy, and terminal illness during specified transition periods because of provider termination as well as rules governing individual participation in approved clinical cancer trials. Requires a Secretary of Health and Human Services (HHS) study of, and report to Congress with regard to, cancer clinical research and its cost implications for managed care.
(Sec. 102) Amends ERISA to require certain plan disclosures to network providers under specified conditions.
Subtitle B: Patient Access to Information - Requires plans to include specified information in summary plan descriptions and to include certain information with adverse coverage decisions. 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: Group Health Plan Review Standards - Amends ERISA to require group health plans, in the case of included group health benefits, to: (1) provide written notice to participants or beneficiaries and providers of adverse coverage decisions; and (2) meet specified time limits for responding to requests for benefit payments, accelerated need requests, advance coverage determinations, medical necessity determinations, and experimental treatment determinations. Provides for internal and, in certain circumstances, external review of initial coverage decisions. Establishes certain review requirements.
(Sec. 121) Outlines sanctions, which include civil monetary penalties, cease and desist orders, and removal (in the case of a fiduciary) for review violations. Provides for: (1) expedited court review; (2) awarding of attorney fees; and (3) concurrent Federal-State court jurisdiction for actions relating to certain amendments made by this Act.
(Sec. 122) Amends ERISA to: (1) establish a special rule for access to specialty care; and (2) set out requirements for treatment of prescription drugs and medical devices as experimental or investigational.
(Sec. 124) 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 specified other information developed by a health care provider, including internal review, to reduce mortality, morbidity, or for improving patient care or safety.
Subtitle D: Small Business Access and Choice for Entrepreneurs - Amends ERISA to define "association health plan" to mean a group health plan meeting specified requirements, including being sponsored by a bona fide trade, industry, or professional association, or a chamber of commerce (or a similar bona fide business association) organized and maintained for substantial purposes other than that of obtaining or providing medical care. Provides for association and self-insured association plan certification and mandates a class certification procedure for association plans.
(Sec. 131) 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 minimum 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.
Directs the applicable authority to establish a Solvency Standards Working Group to make appropriate recommendations.
Mandates advance notice to participants and beneficiaries of voluntary certified plan termination.
Requires either corrective action or plan termination whenever it is determined that a plan has failed or will fail to maintain required reserves, excess stop loss insurance, and indemnification.
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.
Makes the requirements for certification under this subtitle with regard to association health plans applicable only in connection with included group health plan benefits provided under the plan.
Declares that the provisions of this subtitle supersede certain related State laws.
Directs the Secretary to report to Congress the effect association health plans have had (if any) on reducing the number of uninsured individuals.
(Sec. 132) Modifies the circumstances in which two or more trades or businesses must be deemed a single employer.
(Sec. 133) 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. 134) Imposes criminal penalties for falsely representing any plan or other arrangement providing certain benefits as: (1) being a certified association plan; or (2) having been established or maintained under certain collective bargaining agreements.
(Sec. 135) 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.
Subtitle E: Health Care Access, Affordability, and Quality Commission - Amends ERISA to establish the Health Care Access, Affordability, and Quality Commission to: (1) conduct studies of certain critical areas, which include independent expert external review programs and consumer friendly information programs; (2) develop a form for remittance of claims to providers; (3) evaluate existing and proposed benefit requirements for group health plans, upon appropriate congressional request; and (4) submit to appropriate congressional committees written comments on certain reports by the Secretary to such committees. Authorizes appropriations.
Title II: Amendments to Public Health Service Act - Subtitle A: Patient Protections and Point of Service Coverage Requirements - Amends the Public Health Service Act (PHSA) 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.
(Sec. 201) Requires a plan or health insurance coverage offered by a health insurance issuer, if it provides benefits for: (1) emergency or ambulance services, to cover emergency services, including emergency ambulance services, without preauthorization and without regard to whether or not the health care provider is a participating one, among other specified conditions; (2) gynecological or obstetric specialist care benefits, to provide those benefits without authorization or referral by a primary provider; or (3) routine pediatric specialist care benefits, to allow designation of a pediatric specialist as the primary care provider.
Outlines rules on continuity of care and individual participation in approved clinical cancer trials that are similar to those outlined above in title I of this Act. Requires, as well, a similar HHS Secretary study of, and report to, Congress concerning cancer clinical research and managed care.
(Sec. 202) 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 - Amends PHSA to require disclosure by health insurance issuers of group health plans to plan administrators of information necessary to: (1) provide participants and beneficiaries with information in a manner and to an extent consistent with that above under subtitle B of title I of this Act; and (2) include a similar mandate for advance notice with regard to drug formularies that is also under such subtitle.
(Sec. 212) Details requirements for treatment of prescription drugs and medical devices as experimental or investigational.
Subtitle C: HealthMarts - Amends PHSA to require that HealthMarts: (1) be legal entities composed of small employers, employees of small employers, certain other individuals, 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 and their dependents and to certain other individuals 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 any coverage made available to an eligible employee or individual in a geographic area be offered to all eligible employees or individuals in the same area.
(Sec. 221) 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: (1) coverage through an HMO, a preferred provider or licensed provider-sponsored organization, an insurance company, or a medical savings or flexible spending account; (2) coverage that includes a point-of-service option; or (3) any combination of those coverages.
Requires a HealthMart to permit employers or certain individuals, if coverage is offered through the HealthMart for such an employer or individual, to contract for such coverage. Prohibits the HealthMart from varying eligibility conditions (including premium rates and membership fees). Prohibits the purchaser from obtaining or sponsoring coverage other than through the HealthMart. Prohibits a HealthMart from denying enrollment to eligible individuals based on health, except as otherwise permitted.
Supersedes certain related State laws and makes them inapplicable, except with regard to coverage option availability, with respect to coverage through a HealthMart.
Provides for the application of: (1) certain existing ERISA and PHSA requirements; and (2) renewability requirements when the contract between a HealthMart and an issuer is terminated.
Directs the HHS Secretary to administer this subtitle.
Subtitle D: Community Health Organizations - Amends PHSA to allow 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 HHS Secretary and other requirements are met.
(Sec. 231) 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 (IRC) to prohibit a group health plan from imposing on a health professional any restriction on advice provided to a participant or beneficiary.
(Sec. 301) Requires a plan, if it provides benefits for: (1) emergency or ambulance services, to cover emergency services, including emergency ambulance services, without preauthorization and without regard to whether or not the health care provider is a participating provider, among other specified conditions; (2) gynecological or obstetric specialist care benefits, to provide those benefits without authorization or referral by a primary care provider; or (3) routine pediatric specialist benefits, to allow designation of a pediatric specialist as the primary care provider.
Outlines rules on continuity of care and individual participation in approved clinical cancer trials that are similar to those outlined above in titles I and II of this Act. Provides for associated study and reporting requirements similar to those in titles I and II of this Act.
Subtitle B: Medical Savings Accounts - Amends IRC to repeal 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.
Subtitle C: Tax Incentives for Health Care - Amends the IRC to provide, among other changes, for: (1) a graduated tax deduction for health and long-term care insurance coverage costs of an individual, with such deduction increased to100 percent of the amount paid during a taxable year for such coverage costs for taxable years after calendar year 2006, while disallowing such tax deduction for coverage costs under certain subsidized employer plans; (2) a limited, refundable tax credit for qualified health insurance coverage costs of an individual taxpayer, his spouse, and dependents; (3) a requirement that any person who conducts a trade or business and receives payments during any calendar year from any individual for coverage of such individual or any other individual under creditable health insurance shall make a prescribed tax return relating to such payments; (4) advance payment of health insurance credit for purchasers of qualified health insurance; and (5) carryover of unused benefits from cafeteria plans and flexible spending or similar arrangements to later taxable years.
(Sec. 323) Directs the HHS Secretary to provide for a study and report to Congress on State safety-net health insurance programs for the medically uninsurable.
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 PHSA title XXI (Vaccines) applies; or (2) under ERISA. Preempts State laws inconsistent with this title, but not those that impose greater restrictions than those in this title. Excludes non-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. 412) Limits non-economic damages that may be awarded to an injured claimant. Substitutes any different level set by a State after enactment of this Act. Makes defendants liable only for the proportion of the non-economic damages due to the defendant's fault.
Allows limited 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. 413) Limits contingent fees.
Requires any alternative dispute resolution used to resolve a health care liability action or claim to contain provisions consistent with this title.
(Sec. 414) 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 in civil health care matters; and (2) the Office of the Inspector General of the Department of Health and Human Services with specified protocols and best practice guidelines.
Introduced in House
Introduced in House
Referred to the Committee on Commerce, and in addition to the Committees on Education and the Workforce, Ways and Means, and the Judiciary, for a period to be subsequently determined by the Speaker, in each case for consideration of such provisions as fall within the jurisdiction of the committee concerned.
Referred to the Committee on Commerce, and in addition to the Committees on Education and the Workforce, Ways and Means, and the Judiciary, for a period to be subsequently determined by the Speaker, in each case for consideration of such provisions as fall within the jurisdiction of the committee concerned.
Referred to the Committee on Commerce, and in addition to the Committees on Education and the Workforce, Ways and Means, and the Judiciary, for a period to be subsequently determined by the Speaker, in each case for consideration of such provisions as fall within the jurisdiction of the committee concerned.
Referred to the Committee on Commerce, and in addition to the Committees on Education and the Workforce, Ways and Means, and the Judiciary, for a period to be subsequently determined by the Speaker, in each case for consideration of such provisions as fall within the jurisdiction of the committee concerned.
Referred to the Committee on Commerce, and in addition to the Committees on Education and the Workforce, Ways and Means, and the Judiciary, for a period to be subsequently determined by the Speaker, in each case for consideration of such provisions as fall within the jurisdiction of the committee concerned.
Referred to the Subcommittee on Health.
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Referred to the Subcommittee on Health and Environment.