(Sec. 101) Requires a plan to cover additional emergency medical services to stabilize an emergency medical condition following such an examination to the extent that a prudent emergency medical professional would determine such services to be necessary to avoid specified serious consequences.
Requires a plan (other than a fully insured group health plan) providing benefit coverage only through a defined set of participating health care professionals to offer the option of point-of-service coverage (of the same benefits provided by a nonparticipating health care professional), unless the plan offers multiple issuer or coverage options. Exempts from this requirement any group health plan (other than a fully insured plan) of a small employer.
Requires any plan offering gynecological, obstetric, or pediatric care not to require prior authorization from a participant's primary care provider if such provider is not a gynecologist, obstetrician, or pediatrician.
Requires a plan to permit a participant or beneficiary undergoing a course of treatment to continue such treatment for a period of time even though the contract between the plan (other than a fully insured plan) and a health care provider is terminated, or the schedule of benefits or coverage is terminated by a change in the terms of the provider's participation in the plan. Specifies a 90-day continuation of coverage generally, and other transitional periods for institutionalization (until discharge), pregnancy (through post-partum care), and terminal illness (remainder of life).
Declares that a plan shall not prohibit a health care professional from advising a patient about the patient's health status, medical care, or treatment for the patient's condition or disease, regardless of whether coverage for such care or treatment is provided under the contract, if the professional is acting within the lawful scope of the practice.
Defines "fully insured group health plan" as a plan where benefits are provided pursuant to the terms of an arrangement between a group health plan and a health insurance issuer and are guaranteed by the health insurance issuer under a contract or policy of insurance.
Subtitle B: Right to Information about Plans and Providers - Amends ERISA, as amended by the Omnibus Consolidated and Emergency Supplemental Appropriations Act, 1999, to require plans and group health insurance issuers to disclose specified plan information to enrollees and (upon request) potential enrollees.
(Sec. 112) Directs the Secretary of Health and Human Services (HHS) to contract with the Institute of Medicine for a study and report to the appropriate congressional committees on: (1) health care professionals information currently available to patients, consumers, States, and professional societies, nationally and on a State-by-State basis; (2) the legal and other barriers to the sharing of information about health care professionals; and (3) recommendations for disclosure of such information on health care professionals, including their competencies and professional qualifications, to better facilitate patient choice, quality improvement, and market competition.
Subtitle C: Right to Hold Health Plans Accountable - Revises requirements for plan provision of a procedure for appealing denied claims.
(Sec. 121) Requires a plan or health insurance issuer conducting utilization review to have: (1) specified procedures in place for coverage determinations, including expedited determinations; (2) written procedures for addressing grievances between a plan and enrollees; (3) an internal procedure for coverage determination appeals; and (4) an external review procedure for enrollee appeals, involving specified entities and independent medical experts, whose determination shall be binding.
Prescribes external review standards.
Directs the General Accounting Office to study and report to the appropriate congressional committees on a statistically appropriate sample of completed external reviews.
Subtitle D: Miscellaneous Provisions - Amends the Internal Revenue Code to deem the requirements of subtitle B of this Act to be incorporated into the Code.
Title II: Individual Rights with Respect to Personal Medical Information - Personal Medical Information Access Act - Subtitle A: Access to Medical Records - Requires any health care provider, health plan, employer, health or life insurer, school, or university, except in specified circumstances, to: (1) permit an individual who is the subject of protected health information (or the individual's designee) to inspect and copy protected health information concerning the individual; (2) amend such information upon the individual's request; and (3) make reasonable efforts to inform any person to whom the unamended portion of the information was previously disclosed of any nontechnical amendment that has been made.
(Sec. 212) Prescribes procedures for: (1) an entity's denial of a request to amend such information; and (2) an individual's filing of a statement of disagreement with such denial, which shall accompany any subsequent disclosure of the disputed portion of the information.
(Sec. 213) Requires any health care provider, health plan, employer, health or life insurer, school, or university to post notice of the entity's confidentiality practices, including specified information. Requires the Secretary to develop and disseminate model notices of confidentiality practices.
Subtitle B: Establishment of Safeguards - Requires any health care provider, health plan, employer, health or life insurer, school, or university to establish and maintain appropriate administrative, technical, and physical safeguards to protect the confidentiality, security, accuracy, and integrity of protected health information the entity creates, receives, obtains, maintains, uses, transmits, or disposes of.
Subtitle C: Enforcement; Definitions - Prescribes civil money penalties for substantial and material failure to comply with this Act.
(Sec. 232) Sets forth definitions.
Title III: Genetic Information and Services - Genetic Information Nondiscrimination in Health Insurance Act of 1999 - Amends ERISA, the Public Health Service Act (PHSA) (as amended by the Omnibus Consolidated and Emergency Supplemental Appropriations Act, 1999), and the Internal Revenue Code to prohibit a health care plan or health insurance issuer from restricting enrollment or adjusting premium or contribution amounts for a group on the basis of predictive genetic information concerning an individual in the group or a family member of the individual (including information about a request for or receipt of genetic services).
(Sec. 302) Prohibits a plan or issuer from requesting or requiring predictive genetic information concerning an individual or a family member of the individual (including information about a request for or receipt of genetic services). Permits a plan or issuer to request, but not require, such information for diagnosis, treatment, or payment purposes only.
Title IV: Healthcare Research and Quality - Healthcare Research and Quality Act of 1999 - Amends PHSA to establish within the Public Health Service (PHS) an Agency for Healthcare Quality Research to replace the current Agency for Health Care Policy and Research.
(Sec. 402) Directs the Agency to identify and disseminate methods or systems used to assess healthcare research results, particularly to rate the strength of the scientific evidence behind healthcare practice and technology recommendations in the research.
Requires the Agency to employ research strategies and mechanisms that will link research directly with clinical practice in geographically diverse locations throughout the United States, including: (1) Healthcare Improvement Research Centers that combine demonstrated multidisciplinary expertise in outcomes or quality improvement research with linkages to relevant sites of care; (2) Provider-based Research Networks, including plan, facility, or delivery system sites of care (especially primary care), that can evaluate and promote quality improvement; and (3) other innovative mechanisms or strategies.
Directs the Agency to: (1) award grants to enable eligible entities at geographically diverse locations throughout the United States to carry out research training programs dedicated to health services research training at the doctoral, post-doctoral, and junior faculty levels; and (2) provide specified scientific and technical support for private and public efforts to improve healthcare quality, including accrediting organizations.
Directs the Secretary, acting through the Agency Director, to establish a program of grants for one or more centers to conduct: (1) state-of-the-art clinical research on drugs, biological products, and devices; (2) research on the comparative effectiveness, cost-effectiveness, and safety of drugs, biological products, and devices; and (3) other appropriate activities (excluding the review of new drugs).
Requires the Agency Director to: (1) collect certain data on the cost and quality of healthcare; (2) support research on and initiatives to advance the use of information systems for the study of healthcare quality; and (3) provide ongoing administrative, research, and technical support for the Preventive Services Task Force, which shall review scientific evidence on the effectiveness, appropriateness, and cost-effectiveness of clinical preventive services regarding their usefulness in daily clinical practice.
Establishes within the Agency a Center for Primary Care Delivery Research to serve as the principal funding source for HHS primary care delivery research and demonstrations with respect to the first contact when illness or health concerns arise, the diagnosis, treatment or referral to specialty care, preventive care, and the relationship between the clinician and the patient in the context of the family and community.
Requires the Agency Director by specified activities to promote innovation in evidence-based clinical practice and healthcare technologies.
Requires the Secretary, acting through the Director, to coordinate all research, evaluations, and demonstrations related to health services research and quality measurement and improvement activities undertaken and supported by the Federal Government.
Requires the Secretary to contract with the Institute of Medicine to: (1) describe and evaluate current quality improvement research and monitoring processes; and (2) recommend options to improve the efficiency and effectiveness of such processes, and optimize public-private sector accreditation bodies.
Establishes an Advisory Council for Healthcare Quality Research to replace the current Advisory Council for Health Care Policy, Research, and Evaluation.
Requires the Agency Director to establish technical and scientific peer review groups to review each application for a grant, cooperative agreement, or contract under this title.
Repeals the mandates for: (1) a demonstration program regarding centers for education and research on therapeutics; and (2) the Office of the Forum for Quality and Effectiveness in Health Care.
Authorizes appropriations.
(Sec. 404) Requires the Secretary, within 30 days after enactment of any Act providing for a qualifying health care benefit, to evaluate scientifically and report to the appropriate congressional committees on: (1) the safety, efficacy, cost, benefits and value of such benefit; (2) alternative approaches in improving care compared with such benefit; and (3) the benefit's overall impact on health care as measured through research.
Title V: Enhanced Access to Health Insurance Coverage - Amends the Internal Revenue Code to allow a full deduction from gross income of the health insurance costs of self-employed individuals.
(Sec. 502) Repeals the limitation of the availability of medical savings accounts (MSAs) to employees of small employers and the self-employed.
Reduces from $1,500 to $1,000 (self-only coverage) and from $3,000 to $2,000 (family coverage) the minimum annual deductible of a high deductible health plan.
Revises the formula for the monthly limitation on the allowable deduction for MSAs to increase the contribution limit to 100 percent of the annual deductible under a high deductible health plan.
Waives the additional tax on MSA distributions not used for qualified medical expenses to the extent any payment or distribution does not reduce the fair market value of the MSA assets to an amount less than the annual deductible for the account holder's high deductible health plan.
(Sec. 503) Allows the annual carryover of up to $500 of unused benefits from cafeteria plans, flexible spending arrangements, and health flexible spending accounts.
(Sec. 504) Authorizes the Office of Personnel Management to contract for or approve catastrophic FEHBP plans, whose covered expenses exceed $500.
Amends Federal civil service law, with respect to Government contributions under the Federal Employees Health Benefits Program (FEHBP), to require an additional Government contribution, according to a certain formula, to an individual's MSA with respect to a catastrophic plan.
Deems subscription charges for MSAs to be the amount of Government contributions.
[Congressional Bills 106th Congress]
[From the U.S. Government Printing Office]
[S. 300 Introduced in Senate (IS)]
106th CONGRESS
1st Session
S. 300
To improve the access and choice of patients to quality, affordable
health care.
_______________________________________________________________________
IN THE SENATE OF THE UNITED STATES
January 22, 1999
Mr. Lott (for himself, Mr. Nickles, Ms. Collins, Mr. Frist, Mr. Gramm,
Mr. Hagel, Mr. Jeffords, Mr. Roth, Mr. Santorum, Mr. Mack, Mr. Craig,
Mr. Coverdell, Mr. McConnell, Mr. Abraham, Mr. Allard, Mr. Ashcroft,
Mr. Bennett, Mr. Bond, Mr. Brownback, Mr. Bunning, Mr. Burns, Mr.
Campbell, Mr. Cochran, Mr. DeWine, Mr. Domenici, Mr. Enzi, Mr. Gorton,
Mr. Grams, Mr. Grassley, Mr. Gregg, Mr. Hatch, Mr. Helms, Mr.
Hutchinson, Mrs. Hutchison, Mr. Inhofe, Mr. Lugar, Mr. McCain, Mr.
Murkowski, Mr. Roberts, Mr. Sessions, Mr. Shelby, Mr. Smith of New
Hampshire, Mr. Smith of Oregon, Ms. Snowe, Mr. Stevens, Mr. Thomas, Mr.
Thompson, Mr. Thurmond, Mr. Voinovich, and Mr. Warner) introduced the
following bill; which was read twice and referred to the Committee on
Finance
_______________________________________________________________________
A BILL
To improve the access and choice of patients to quality, affordable
health care.
Be it enacted by the Senate and House of Representatives of the
United States of America in Congress assembled,
SECTION 1. SHORT TITLE; TABLE OF CONTENTS.
(a) Short Title.--This Act may be cited as the ``Patients' Bill of
Rights Plus Act''.
(b) Table of Contents.--The table of contents for this Act is as
follows:
Sec. 1. Short title; table of contents.
TITLE I--PATIENTS' BILL OF RIGHTS
Subtitle A--Right to Advice and Care
Sec. 101.``subpart c--patient right to medical advice and care
``Sec. 721. Patient access to emergency medical care.
``Sec. 722. Offering of choice of coverage options.
``Sec. 723. Patient access to obstetric and gynecological care.
``Sec. 724. Patient access to pediatric care.
``Sec. 725. Continuity of care.
``Sec. 726. Protection of patient-provider communications.
``Sec. 727. Generally applicable provision.
Sec. 102. Effective date and related rules.
Subtitle B--Right to Information About Plans and Providers
Sec. 111. Information about plans.
Sec. 112. Information about providers.
Subtitle C--Right to Hold Health Plans Accountable
Sec. 121. Amendment to Employee Retirement Income Security Act of 1974.
Subtitle D--Miscellaneous Provisions
Sec. 131. Amendments to the Internal Revenue Code of 1986.
TITLE II--INDIVIDUAL RIGHTS WITH RESPECT TO PERSONAL MEDICAL
INFORMATION
Sec. 201. Short title.
Subtitle A--Access to Medical Records
Sec. 211. Inspection and copying of protected health information.
Sec. 212. Amendment of protected health information.
Sec. 213. Notice of confidentiality practices.
Subtitle B--Establishment of Safeguards
Sec. 221. Establishment of safeguards.
Subtitle C--Enforcement; Definitions
Sec. 231. Civil penalty.
Sec. 232. Definitions.
Sec. 233. Effective date.
TITLE III--GENETIC INFORMATION AND SERVICES
Sec. 301. Short title.
Sec. 302. Amendments to Employee Retirement Income Security Act of
1974.
Sec. 303. Amendments to the Public Health Service Act.
Sec. 304. Amendments to the Internal Revenue Code of 1986.
TITLE IV--HEALTHCARE RESEARCH AND QUALITY
Sec. 401. Short title.
Sec. 402. Amendment to the Public Health Service Act.
``TITLE IX--AGENCY FOR HEALTHCARE RESEARCH AND QUALITY
``Part A--Establishment and General Duties
``Sec. 901. Mission and duties.
``Sec. 902. General authorities.
``Part B--Healthcare Improvement Research
``Sec. 911. Healthcare outcome improvement research.
``Sec. 912. Private-public partnerships to improve organization
and delivery.
``Sec. 913. Information on quality and cost of care.
``Sec. 914. Information systems for healthcare improvement.
``Sec. 915. Research supporting primary care and access in
underserved areas.
``Sec. 916. Clinical practice and technology innovation.
``Sec. 917. Coordination of Federal Government quality
improvement efforts.
``Part C--General Provisions
``Sec. 921. Advisory Council for Healthcare Research and
Quality.
``Sec. 922. Peer review with respect to grants and contracts.
``Sec. 923. Certain provisions with respect to development,
collection, and dissemination of data.
``Sec. 924. Dissemination of information.
``Sec. 925. Additional provisions with respect to grants and
contracts.
``Sec. 926. Certain administrative authorities.
``Sec. 927. Funding.
``Sec. 928. Definitions.
Sec. 403. References.
Sec. 404. Study.
TITLE V--ENHANCED ACCESS TO HEALTH INSURANCE COVERAGE
Sec. 501. Full deduction of health insurance costs for self-employed
individuals.
Sec. 502. Full availability of medical savings accounts.
Sec. 503. Carryover of unused benefits from cafeteria plans, flexible
spending arrangements, and health flexible
spending accounts.
Sec. 504. Permitting contribution towards medical savings account
through Federal employees health benefits
program (FEHBP).
TITLE I--PATIENTS' BILL OF RIGHTS
Subtitle A--Right to Advice and Care
SEC. 101. PATIENT RIGHT TO MEDICAL ADVICE AND CARE.
(a) In General.--Part 7 of subtitle B of title I of the Employee
Retirement Income Security Act of 1974 (29 U.S.C. 1185 et seq.) is
amended--
(1) by redesignating subpart C as subpart D; and
(2) by inserting after subpart B the following:
``Subpart C--Patient Right to Medical Advice and Care
``SEC. 721. PATIENT ACCESS TO EMERGENCY MEDICAL CARE.
``(a) In General.--To the extent that the group health plan (other
than a fully insured group health plan) provides coverage for benefits
consisting of emergency medical care (as defined in subsection (c)),
except for items or services specifically excluded--
``(1) the plan shall provide coverage for benefits, without
requiring preauthorization, for appropriate emergency medical
screening examinations (within the capability of the emergency
facility, including ancillary services routinely available to
the emergency facility) to the extent that a prudent layperson,
who possesses an average knowledge of health and medicine,
would determine such examinations to be necessary to determine
whether emergency medical care (as so defined) is necessary,
and
``(2) the plan shall provide coverage for benefits for
additional emergency medical care to stabilize an emergency
medical condition following an emergency medical screening
examination (if determined necessary under paragraph (1)),
pursuant to the definition of stabilize under section
1867(e)(3) of the Social Security Act (42 U.S.C. 1395dd(e)(3)).
``(b) Uniform Cost-Sharing Required.--Nothing in this section shall
be construed as preventing a group health plan (other than a fully
insured group health plan) from imposing any form of cost-sharing
applicable to any participant or beneficiary (including coinsurance,
copayments, deductibles, and any other charges) in relation to coverage
for benefits described in subsection (a), if such form of cost-sharing
is uniformly applied under such plan, with respect to similarly
situated participants and beneficiaries, to all benefits consisting of
emergency medical care (as defined in subsection (c)) provided to such
similarly situated participants and beneficiaries under the plan.
``(c) Definition of Emergency Medical Care.--In this section:
``(1) In general.--The term ``emergency medical care''
means, with respect to a participant or beneficiary under a
group health plan (other than a fully insured group health
plan), covered inpatient and outpatient services that--
``(A) are furnished by any provider, including a
nonparticipating provider, that is qualified to furnish
such services; and
``(B) are needed to evaluate or stabilize (as such
term is defined in section 1867(e)(3) of the Social
Security Act (42 U.S.C. 1395dd)) an emergency medical
condition (as defined in paragraph (2)).
``(2) Emergency medical condition.--The term ``emergency
medical condition'' means a medical condition manifesting
itself by acute symptoms of sufficient severity (including
severe pain) such that a prudent layperson, who possesses an
average knowledge of health and medicine, could reasonably
expect the absence of immediate medical attention to result
in--
``(A) placing the health of the participant or
beneficiary (or, with respect to a pregnant woman, the
health of the woman or her unborn child) in serious
jeopardy,
``(B) serious impairment to bodily functions, or
``(C) serious dysfunction of any bodily organ or
part.
``SEC. 722. OFFERING OF CHOICE OF COVERAGE OPTIONS.
``(a) Requirement.--
``(1) Offering of point-of-service coverage option.--Except
as provided in paragraph (2), if a group health plan (other
than a fully insured group health plan) provides coverage for
benefits only through a defined set of participating health
care professionals, the plan shall offer the participant the
option to purchase point-of-service coverage (as defined in
subsection (b)) for all such benefits for which coverage is
otherwise so limited. Such option shall be made available to
the participant at the time of enrollment under the plan and at
such other times as the plan offers the participant a choice of
coverage options.
``(2) Exception in the case of multiple issuer or coverage
options.--Paragraph (1) shall not apply with respect to a
participant in a group health plan (other than a fully insured
group health plan) if the plan offers the participant--
``(A) a choice of health insurance coverage through
more than one health insurance issuer; or
``(B) two or more coverage options that differ
significantly with respect to the use of participating
health care professionals or the networks of such
professionals that are used.
``(b) Point-of-Service Coverage Defined.--In this section, the term
`point-of-service coverage' means, with respect to benefits covered
under a group health plan (other than a fully insured group health
plan), coverage of such benefits when provided by a nonparticipating
health care professional.
``(c) Small Employer Exemption.--
``(1) In general.--This section shall not apply to any
group health plan (other than a fully insured group health
plan) of a small employer.
``(2) Small employer.--For purposes of paragraph (1), the
term `small employer' means, in connection with a group health
plan (other than a fully insured group health plan) with
respect to a calendar year and a plan year, an employer who
employed an average of at least 2 but not more than 50
employees on business days during the preceding calendar year
and who employs at least 2 employees on the first day of the
plan year. For purposes of this paragraph, the provisions of
subparagraph (C) of section 712(c)(1) shall apply in determining
employer size.
``(d) Rule of Construction.--Nothing in this section shall be
construed--
``(1) as requiring coverage for benefits for a particular
type of health care professional;
``(2) as requiring an employer to pay any costs as a result
of this section or to make equal contributions with respect to
different health coverage options;
``(3) as preventing a group health plan (other than a fully
insured group health plan) from imposing higher premiums or
cost-sharing on a participant for the exercise of a point-of-
service coverage option; or
``(4) to require that a group health plan (other than a
fully insured group health plan) include coverage of health
care professionals that the plan excludes because of fraud,
quality of care, or other similar reasons with respect to such
professionals.
``SEC. 723. PATIENT ACCESS TO OBSTETRIC AND GYNECOLOGICAL CARE.
``(a) In General.--In any case in which a group health plan (other
than a fully insured group health plan)--
``(1) provides coverage for benefits consisting of--
``(A) gynecological care (such as preventive
women's health examinations); or
``(B) obstetric care (such as pregnancy-related
services);
provided by a participating physician who specializes in such
care; and
``(2) requires or provides for designation by a participant
or beneficiary of a participating primary care provider;
if the primary care provider designated by such a participant or
beneficiary is not such a physician as described in paragraph (1), then
the plan shall meet the requirements of subsection (b).
``(b) Requirements.--A group health plan (other than a fully
insured group health plan) meets the requirements of this subsection,
in connection with the coverage of benefits described in subsection (a)
consisting of care described in subparagraph (A) or (B) of subsection
(a)(1), if the plan--
``(1) does not require authorization or a referral by the
primary care provider in order to obtain coverage for such
benefits, and
``(2) treats the ordering of other routine care related to
the care described in subparagraph (A) or (B) of subsection
(a)(1), by the participating physician providing the care
described in either such subparagraph, as the authorization of
the primary care provider with respect to such care.
``(c) Rule of Construction.--Nothing in subsection (b)(2) shall
waive any requirements of coverage relating to medical necessity or
appropriateness with respect to coverage of gynecological or obstetric
care so ordered. Nothing in subsection (b) shall be construed to
preclude the health plan from requiring that the obstetrician or
gynecologist notify the primary care provider or the plan of treatment
decisions.
``SEC. 724. PATIENT ACCESS TO PEDIATRIC CARE.
``(a) In General.--In any case in which a group health plan (other
than a fully insured group health plan)--
``(1) provides coverage for benefits consisting of
pediatric care by a participating pediatrician; and
``(2) requires or provides for designation by a participant
or beneficiary of a participating primary care provider;
if the primary care provider designated by such a participant or
beneficiary is not a physician as described in paragraph (1), then the
plan shall meet the requirements of subsection (b).
``(b) Requirements.--A group health plan (other than a fully
insured group health plan) meets the requirements of this subsection,
in connection with the coverage of benefits described in subsection (a)
consisting of care described in subsection (a)(1), if the plan--
``(1) does not require authorization or a referral by the
primary care provider in order to obtain coverage for such
benefits, and
``(2) treats the ordering of other routine care of the same
type, by the participating physician providing the care
described in subsection (a)(1), as the authorization of the
primary care provider with respect to such care.
``(c) Construction.--Nothing in subsection (b)(2) shall waive any
requirements of coverage relating to medical necessity or
appropriateness with respect to coverage of pediatric care so ordered.
``SEC. 725. CONTINUITY OF CARE.
``(a) In General.--
``(1) Termination of provider.--If a contract between a
group health plan (other than a fully insured group health
plan) and a health care provider is terminated (as defined in
paragraph (2)), or benefits or coverage provided by a health
care provider are terminated because of a change in the terms
of provider participation in such group health plan, and an
individual who is a participant or beneficiary in the plan is
undergoing a course of treatment from the provider at the time
of such termination, the plan shall--
``(A) notify the individual on a timely basis of
such termination;
``(B) provide the individual with an opportunity to
notify the plan of a need for transitional care; and
``(C) in the case of termination described in
paragraph (2), (3), or (4) of subsection (b), and
subject to subsection (c), permit the individual to
continue or be covered with respect to the course of
treatment with the provider's consent during a
transitional period (as provided under subsection (b)).
``(2) Terminated.--In this section, the term `terminated'
includes, with respect to a contract, the expiration or
nonrenewal of the contract by the group health plan, but does
not include a termination of the contract by the plan for
failure to meet applicable quality standards or for fraud.
``(3) Contracts.--For purposes of this section, the term
`contract between a group health plan (other than a fully
insured group health plan) and a health care provider' shall
include a contract between such a plan and an organized network
of providers.
``(b) Transitional Period.--
``(1) General rule.--Except as provided in paragraph (3),
the transitional period under this subsection shall extend for
up to 90 days from the date of the notice described in
subsection (a)(1)(A) of the provider's termination.
``(2) Institutional care.--Subject to paragraph (1), the
transitional period under this subsection for institutional or
inpatient care from a provider shall extend until the discharge
or termination of the period of institutionalization and also
shall include institutional care provided within a reasonable
time of the date of termination of the provider status if the
care was scheduled before the date of the announcement of the
termination of the provider status under subsection (a)(1)(A)
or if the individual on such date was on an established waiting
list or otherwise scheduled to have such care.
``(3) Pregnancy.--Notwithstanding paragraph (1), if--
``(A) a participant or beneficiary has entered the
second trimester of pregnancy at the time of a
provider's termination of participation; and
``(B) the provider was treating the pregnancy
before the date of the termination;
the transitional period under this subsection with respect to
provider's treatment of the pregnancy shall extend through the
provision of post-partum care directly related to the delivery.
``(4) Terminal illness.--Subject to paragraph (1), if--
``(A) a participant or beneficiary was determined
to be terminally ill (as determined under section
1861(dd)(3)(A) of the Social Security Act) prior to a
provider's termination of participation; and
``(B) the provider was treating the terminal
illness before the date of termination;
the transitional period under this subsection shall be for care
directly related to the treatment of the terminal illness.
``(c) Permissible Terms and Conditions.--A group health plan (other
than a fully insured group health plan) may condition coverage of
continued treatment by a provider under subsection (a)(1)(B) upon the
provider agreeing to the following terms and conditions:
``(1) The provider agrees to accept reimbursement from the
plan and individual involved (with respect to cost-sharing) at
the rates applicable prior to the start of the transitional
period as payment in full (or, in the case described in
subsection (b)(2), at the rates applicable under the
replacement plan after the date of the termination of the
contract with the group health plan) and not to impose cost-
sharing with respect to the individual in an amount that would
exceed the cost-sharing that could have been imposed if the
contract referred to in subsection (a)(1) had not been
terminated.
``(2) The provider agrees to adhere to the quality
assurance standards of the plan responsible for payment under
paragraph (1) and to provide to such plan necessary medical
information related to the care provided.
``(3) The provider agrees otherwise to adhere to such
plan's policies and procedures, including procedures regarding
referrals and obtaining prior authorization and providing
services pursuant to a treatment plan (if any) approved by the
plan.
``(d) Rule of Construction.--Nothing in this section shall be
construed to require the coverage of benefits which would not have been
covered if the provider involved remained a participating provider.
``(e) Definition.--In this section, the term `health care provider'
or `provider' means--
``(1) any individual who is engaged in the delivery of
health care services in a State and who is required by State
law or regulation to be licensed or certified by the State to
engage in the delivery of such services in the State; and
``(2) any entity that is engaged in the delivery of health
care services in a State and that, if it is required by State
law or regulation to be licensed or certified by the State to
engage in the delivery of such services in the State, is so
licensed.
``SEC. 726. PROTECTION OF PATIENT-PROVIDER COMMUNICATIONS.
``(a) In General.--Subject to subsection (b), a group health plan
(other than a fully insured group health plan and in relation to a
participant or beneficiary) shall not prohibit or otherwise restrict a
health care professional from advising such a participant or
beneficiary who is a patient of the professional about the health
status of the participant or beneficiary or medical care or treatment
for the condition or disease of the participant or beneficiary,
regardless of whether coverage for such care or treatment are provided
under the contract, if the professional is acting within the lawful
scope of practice.
``(b) Rule of Construction.--Nothing in this section shall be
construed as requiring a group health plan (other than a fully insured
group health plan) to provide specific benefits under the terms of such
plan.
``SEC. 727. GENERALLY APPLICABLE PROVISION.
``In the case of a group health plan that provides benefits under 2
or more coverage options, the requirements of sections 721, 723, 724,
725 and 726 shall apply separately with respect to each coverage
option.''.
(b) Rule With Respect to Certain Plans.--
(1) In general.--Notwithstanding any other provision of
law, health insurance issuers may offer, and eligible
individuals may purchase, high deductible health plans
described in section 220(c)(2)(A) of the Internal Revenue Code
of 1986. Effective for the 4-year period beginning on the date
of the enactment of this Act, such health plans shall not be
required to provide payment for any health care items or
services that are exempt from the plan's deductible.
(2) Existing state laws.--A State law relating to payment
for health care items and services in effect on the date of
enactment of this Act that is preempted under paragraph (1),
shall not apply to high deductible health plans after the
expiration of the 4-year period described in such paragraph
unless the State reenacts such law after such period.
(c) Definition.--Section 733(a) of the Employee Retirement Income
Security Act of 1974 (42 U.S.C. 1186(a)) is amended by adding at the
end the following:
``(3) Fully insured group health plan.--The term `fully
insured group health plan' means a group health plan where
benefits are provided pursuant to the terms of an arrangement
between a group health plan and a health insurance issuer and
are guaranteed by the health insurance issuer under a contract
or policy of insurance.''.
(d) Conforming Amendment.--The table of contents in section 1 of
such Act is amended--
(1) in the item relating to subpart C, by striking
``Subpart C'' and inserting ``Subpart D''; and
(2) by adding at the end of the items relating to subpart B
of part 7 of subtitle B of title I of such Act the following
new items:
``subpart c--patient right to medical advice and care
``Sec. 721. Patient access to emergency medical care.
``Sec. 722. Offering of choice of coverage options.
``Sec. 723. Patient access to obstetric and gynecological care.
``Sec. 724. Patient access to pediatric care.
``Sec. 725. Continuity of care.
``Sec. 726. Protection of patient-provider communications.
``Sec. 727. Generally applicable provisions.''.
SEC. 102. EFFECTIVE DATE AND RELATED RULES.
(a) In General.--The amendments made by this subtitle shall apply
with respect to plan years beginning on or after January 1 of the
second calendar year following the date of the enactment of this Act.
The Secretary shall issue all regulations necessary to carry out the
amendments made by this section before the effective date thereof.
(b) Limitation on Enforcement Actions.--No enforcement action shall
be taken, pursuant to the amendments made by this subtitle, against a
group health plan with respect to a violation of a requirement imposed
by such amendments before the date of issuance of regulations issued in
connection with such requirement, if the plan has sought to comply in
good faith with such requirement.
Subtitle B--Right to Information About Plans and Providers
SEC. 111. INFORMATION ABOUT PLANS.
(a) In General.--Subpart B of part 7 of subtitle B of title I of
the Employee Retirement Income Security Act of 1974, as amended by the
Omnibus Consolidated and Emergency Supplemental Appropriations Act,
1999 (Public Law 105-277), is amended by adding at the end the
following:
``SEC. 714. HEALTH PLAN COMPARATIVE INFORMATION.
``(a) Requirement.--A group health plan, or health insurance issuer
in connection with group health insurance coverage, shall, not later
than 12 months after the date of enactment of this section, provide for
the disclosure, in a clear and accurate form to each enrollee, or upon
request to a potential enrollee eligible to receive benefits under the
plan, or plan sponsor with which the plan or issuer has contracted, of
the information described in subsection (b).
``(b) Required Information.--The informational materials to be
distributed under this section shall include for each health benefit
plan the following:
``(1) A description of the covered items and services under
each such plan and any in- and out-of-network features of each
such plan.
``(2) A description of any cost-sharing, including
premiums, deductibles, coinsurance, and copayment amounts, for
which the enrollee will be responsible, including any annual or
lifetime limits on benefits, for each such plan.
``(3) A description of any optional supplemental benefits
offered by each such plan and the terms and conditions
(including premiums or cost-sharing) for such supplemental
coverage.
``(4) A description of any restrictions on payments for
services furnished to an enrollee by a health care professional
that is not a participating professional and the liability of
the enrollee for additional payments for these services.
``(5) A description of the service area of each such plan,
including the provision of any out-of-area coverage.
``(6) A description of the extent to which enrollees may
select the primary care provider of their choice, including
providers both within the network and outside the network of
each such plan (if the plan permits out-of-network services).
``(7) A description of the procedures for advance
directives and organ donation decisions if the plan maintains
such procedures.
``(8) A description of the requirements and procedures to
be used to obtain preauthorization for health services
(including telephone numbers and mailing addresses), including
referrals for specialty care.
``(9) A summary of the rules and methods for appealing
coverage decisions and filing grievances (including telephone
numbers and mailing addresses), as well as other available
remedies.
``(10) A summary of the rules for access to emergency room
care. Also, any available educational material regarding proper
use of emergency services.
``(11) A description of whether or not coverage is provided
for experimental treatments, investigational treatments, or
clinical trials and the circumstances under which access to
such treatments or trials is made available.
``(12) A description of the specific preventative services
covered under the plan if such services are covered.
``(13) A statement regarding--
``(A) the manner in which an enrollee may access an
obstetrician, gynecologist, or pediatrician in
accordance with section 723 or 724;
``(B) the manner in which an enrollee obtains
continuity of care as provided for in section 725; and
``(C) the manner in which an enrollee has access to
the medical records of the enrollee in accordance with
subtitle A of title II of the Patients' Bill of Rights
Plus Act.
``(14) A statement that the following information, and
instructions on obtaining such information (including telephone
numbers and, if available, Internet websites), shall be made
available upon request:
``(A) The names, addresses, telephone numbers, and
State licensure status of the plan's participating
health care professionals and participating health care
facilities, and, if available, the education, training,
speciality qualifications or certifications of such
professionals.
``(B) A summary description of the methods used for
compensating participating health care professionals,
such as capitation, fee-for-service, salary, or a
combination thereof. The requirement of this
subparagraph shall not be construed as requiring plans
to provide information concerning proprietary payment
methodology.
``(C) A summary description of the methods used for
compensating health care facilities, including per
diem, fee-for-service, capitation, bundled payments, or
a combination thereof. The requirement of this
subparagraph shall not be construed as requiring plans
to provide information concerning proprietary payment
methodology.
``(D) A summary description of the procedures used
for utilization review.
``(E) The list of the specific prescription
medications included in the formulary of the plan, if
the plan uses a defined formulary, and any provision
for obtaining off-formulary medications.
``(F) A description of the specific exclusions from
coverage under the plan.
``(G) Any available information related to the
availability of translation or interpretation services
for non-English speakers and people with communication
disabilities, including the availability of audio tapes
or information in Braille.
``(H) Any information that is made public by
accrediting organizations in the process of
accreditation if the plan is accredited, or any
additional quality indicators that the plan makes
available.
``(c) Manner of Distribution.--
``(1) In general.--The information described in this
section shall be distributed in an accessible format that is
understandable to an average plan enrollee.
``(2) Rule of construction.--For purposes of this section,
a group health plan, or health insurance issuer in connection
with group health insurance coverage, in reliance on records
maintained by the plan or issuer, shall be deemed to have met
the requirements of this section if the plan or issuer provides
the information requested under this section--
``(A) in the case of the plan, to participants and
beneficiaries at the address contained in such records
with respect to such participants and beneficiaries; or
``(B) in the case of the issuer, to the employer of
a participant if the employer provides for the coverage
of such participant under the plan involved or to
participants and beneficiaries at the address contained
in such records with respect to such participants and
beneficiaries.
``(d) Rule of Construction.--Nothing in this section may be
construed to prohibit a group health plan, or health insurance issuer
in connection with group health insurance coverage, from distributing
any other additional information determined by the plan or issuer to be
important or necessary in assisting participants and beneficiaries
enrollees or upon request potential participants in the selection of a
health plan or from providing information under subsection (b)(13) as
part of the required information.
``(e) Health Care Professional.--In this section, the term `health
care professional' means a physician (as defined in section 1861(r) of
the Social Security Act) or other health care professional if coverage
for the professional's services is provided under the health plan
involved for the services of the professional. Such term includes a
podiatrist, optometrist, chiropractor, psychologist, dentist, physician
assistant, physical or occupational therapist and therapy assistant,
speech-language pathologist, audiologist, registered or licensed
practical nurse (including nurse practitioner, clinical nurse
specialist, certified registered nurse anesthetist, and certified
nurse-midwife), licensed certified social worker, registered
respiratory therapist, and certified respiratory therapy technician.''.
(b) Conforming Amendments.--
(1) Section 732(a) of the Employee Retirement Income
Security Act of 1974 (29 U.S.C. 1185(a)) is amended by striking
``section 711, and inserting ``sections 711 and 714''.
(2) The table of contents in section 1 of the Employee
Retirement Income Security Act of 1974 (29 U.S.C. 1001) is
amended by inserting after the item relating to section 713,
the following:
``Sec. 714. Health plan comparative information.''.
SEC. 112. INFORMATION ABOUT PROVIDERS.
(a) Study.--The Secretary of Health and Human Services shall enter
into a contract with the Institute of Medicine for the conduct of a
study, and the submission to the Secretary of a report, that includes--
(1) an analysis of information concerning health care
professionals that is currently available to patients,
consumers, States, and professional societies, nationally and
on a State-by-State basis, including patient preferences with
respect to information about such professionals and their
competencies;
(2) an evaluation of the legal and other barriers to the
sharing of information concerning health care professionals;
and
(3) recommendations for the disclosure of information on
health care professionals, including the competencies and
professional qualifications of such practitioners, to better
facilitate patient choice, quality improvement, and market
competition.
(b) Report.--Not later than 18 months after the date of enactment
of this Act, the Secretary of Health and Human Services shall forward
to the appropriate committees of Congress a copy of the report and
study conducted under subsection (a).
Subtitle C--Right to Hold Health Plans Accountable
SEC. 121. AMENDMENT TO EMPLOYEE RETIREMENT INCOME SECURITY ACT OF 1974.
(a) In General.--Section 503 of the Employee Retirement Income
Security Act of 1974 (29 U.S.C. 1133) is amended to read as follows:
``SEC. 503. CLAIMS PROCEDURE, COVERAGE DETERMINATION, GRIEVANCES AND
APPEALS.
``(a) Claims Procedure.--In accordance with regulations of the
Secretary, every employee benefit plan shall--
``(1) provide adequate notice in writing to any participant
or beneficiary whose claim for benefits under the plan has been
denied, setting forth the specific reasons for such denial,
written in a manner calculated to be understood by the
participant, and
``(2) afford a reasonable opportunity to any participant
whose claim for benefits has been denied for a full and fair
review by the appropriate named fiduciary of the decision
denying the claim.
``(b) Coverage Determinations Under Group Health Plans.--
``(1) Procedures.--
``(A) In general.--A group health plan or health
insurance issuer conducting utilization review shall
ensure that procedures are in place for--
``(i) making determinations regarding
whether an enrollee is eligible to receive a
payment or coverage for health services under
the plan or coverage involved and any cost-
sharing amount that the enrollee is required to
pay with respect to such service;
``(ii) notifying covered enrollees (or the
legal representative of such enrollees) and the
treating health care professionals involved
regarding determinations made under the plan or
issuer and any additional payments that the
enrollee may be required to make with respect
to such service; and
``(iii) responding to requests, either
written or oral, for coverage determinations or
for internal appeals from an enrollee (or the
legal representative of such enrollee) or the
treating health care professional.
``(B) Oral requests.--With respect to an oral
request described in subparagraph (A)(iii), a group
health plan or health insurance issuer may require that
the requesting individual provide written evidence of
such request.
``(2) Timeline for making determinations.--
``(A) Routine determination.--A group health plan
or a health insurance issuer shall maintain procedures
to ensure that prior authorization determinations
concerning the provision of non-emergency items or
services are made within 30 days from the date on which
the request for a determination is submitted, except
that such period may be extended where certain
circumstances exist that are determined by the
Secretary to be beyond control of the plan or issuer.
``(B) Expedited determination.--
``(i) In general.--A prior authorization
determination under this subsection shall be
made within 72 hours after a request is
received by the plan or issuer under clause
(ii) or (iii).
``(ii) Request by enrollee.--A plan or
issuer shall maintain procedures for expediting
a prior authorization determination under this
subsection upon the request of an enrollee if,
based on such a request, the plan or issuer
determines that the normal time for making such
a determination could seriously jeopardize the
life or health of the enrollee.
``(iii) Documentation by health care
professional.--A plan or issuer shall maintain
procedures for expediting a prior authorization
determination under this subsection if the
request involved indicates that the treating
health care professional has documented, based
on the medical exigencies, that a determination
under the procedures described in subparagraph
(A) could seriously jeopardize the life or
health of the enrollee.
``(C) Concurrent determinations.--A plan or issuer
shall maintain procedures to certify or deny coverage
of an extended stay or additional services.
``(D) Retrospective determination.--A plan or
issuer shall maintain procedures to ensure that, with
respect to the retrospective review of a determination
made under paragraph (1), the determination shall be
made within 30 working days of the date on which the
plan or issuer receives all necessary information.
``(3) Notice of determinations.--
``(A) Routine determination.--With respect to a
coverage determination of a plan or issuer under
paragraph (2)(A), the plan or issuer shall issue notice
of such determination to the enrollee (or the legal
representative of the enrollee), and consistent with
the medical exigencies of the case, to the treating
health care professional involved not later than 2
working days after the date on which the determination
is made.
``(B) Expedited determination.--With respect to a
coverage determination of a plan or issuer under
paragraph (2)(B), the plan or issuer shall issue notice
of such determination to the enrollee (or the legal
representative of the enrollee), and consistent with
the medical exigencies of the case, to the treating
health care professional involved within the 72 hour
period described in paragraph (2)(B).
``(C) Concurrent reviews.--With respect to the
determination under a plan or issuer under paragraph
(1) to certify or deny coverage of an extended stay or
additional services, the plan or issuer shall issue
notice of such determination to the treating health
care professional and to the enrollee involved (or the
legal representative of the enrollee) within 1 working
day of the date on which the initial notice was issued.
``(D) Retrospective reviews.--With respect to the
retrospective review under a plan or issuer of a
determination made under paragraph (1), a determination
shall be made within 30 working days of the date on
which the plan or issuer receives all necessary
information. The plan or issuer shall issue written
notice of an approval or disapproval of a determination
under this subparagraph to the enrollee (or the legal
representative of the enrollee) and health care
provider involved within 5 working days of the date on
which such determination is made.
``(E) Requirements of notice of adverse coverage
determinations.--A written or electronic notice of an
adverse coverage determination under this subsection,
or of an expedited adverse coverage determination under
paragraph (2)(B), shall be provided to the enrollee (or
the legal representative of the enrollee) and treating
health care professional (if any) involved and shall
include--
``(i) the reasons for the determination
(including the clinical or scientific-evidence
based rationale used in making the
determination) written in a manner to be
understandable to the average enrollee;
``(ii) the procedures for obtaining
additional information concerning the
determination; and
``(iii) notification of the right to appeal
the determination and instructions on how to
initiate an appeal in accordance with
subsection (d).
``(c) Grievances.--A group health plan or a health insurance issuer
shall have written procedures for addressing grievances between the
plan and enrollees. Determinations under such procedures shall be non-
appealable.
``(d) Internal Appeal of Coverage Determinations.--
``(1) In general.--An enrollee (or the legal representative
of the enrollee) and the treating health care professional with
the consent of the enrollee (or the legal representative of the
enrollee), may appeal any adverse coverage determination under
subsection (b) under the procedures described in this
subsection.
``(2) Records.--A group health plan and a health insurance
issuer shall maintain written records, for at least 6 years,
with respect to any appeal under this subsection for purposes
of internal quality assurance and improvement.
``(3) Routine determinations.--A group health plan or a
health insurance issuer shall provide for the consideration of
an appeal of an adverse routine determination under this
subsection not later than 30 working days after the date on
which a request for such appeal is received.
``(4) Expedited determination.--
``(A) In general.--An expedited determination with
respect to an appeal under this subsection shall be
made in accordance with the medical exigencies of the
case, but in no case more than 72 hours after the
request for such appeal is received by the plan or
issuer under subparagraph (B) or (C).
``(B) Request by enrollee.--A plan or issuer shall
maintain procedures for expediting a prior
authorization determination under this subsection upon
the request of an enrollee if, based on such a request,
the plan or issuer determines that the normal time for
making such a determination could seriously jeopardize
the life or health of the enrollee.
``(C) Documentation by health care professional.--A
plan or issuer shall maintain procedures for expediting
a prior authorization determination under this
subsection if the request involved indicates that the
treating health care professional has documented, based
on the medical exigencies that a determination under
the procedures described in paragraph (2) could
seriously jeopardize the life or health of the
enrollee.
``(5) Conduct of review.--A review of an adverse coverage
determination under this subsection shall be conducted by an
individual with appropriate expertise who was not involved in
the initial determination.
``(6) Lack of medical necessity.--A review of an appeal
under this subsection relating to a determination to deny
coverage based on a lack of medical necessity or
appropriateness, or based on an experimental or investigational
treatment, shall be made only by a physician with appropriate
expertise in the field of medicine involved who was not
involved in the initial determination.
``(7) Notice.--
``(A) In general.--Written notice of a
determination made under an internal review process
shall be issued to the enrollee (or the legal
representative of the enrollee) and the treating health
care professional not later than 2 working days after
the completion of the review (or within the 72-hour
period referred to in paragraph (4) if applicable).
``(B) Adverse coverage determinations.--With
respect to an adverse coverage determination made under
this subsection, the notice described in subparagraph
(A) shall include--
``(i) the reasons for the determination
(including the clinical or scientific-evidence
based rationale used in making the
determination) written in a manner to be
understandable to the average enrollee;
``(ii) the procedures for obtaining
additional information concerning the
determination; and
``(iii) notification of the right to an
external review under subsection (e) and
instructions on how to initiate such a review.
``(e) External Review.--
``(1) In general.--A group health plan or a health
insurance issuer shall have written procedures to permit an
enrollee (or the legal representative of the enrollee) access
to an external review with respect to a coverage determination
concerning a particular item or service where--
``(A) the particular item or service involved, when
medically appropriate and necessary, is a covered
benefit under the terms and conditions of the contract
between the plan or issuer and the enrollee;
``(B) the coverage determination involved denied
coverage for such item or service because the provision
of such item or service--
``(i) does not meet the plan's or issuer's
requirements for medical appropriateness or
necessity and the amount involved exceeds a
significant financial threshold; or
``(ii) would constitute experimental or
investigational treatment and there is a
significant risk of placing the life or health
of the enrollee in jeopardy; and
``(C) the enrollee has completed the internal
appeals process with respect to such determination.
``(2) Initiation of the external review process.--
``(A) Filing of request.--An enrollee (or the legal
representative of the enrollee) who desires to have an
external review conducted under this subsection shall
file a written request for such a review with the plan
or issuer involved not later than 30 working days after
the receipt of a final denial of a claim under
subsection (d). Any such request shall include the
consent of the enrollee (or the legal representative of
the enrollee) for the release of medical information
and records to external reviewers regarding the
enrollee if such information is necessary for the
proper conduct of the external review.
``(B) Information and notice.--Not later than 5
working days after the receipt of a request under
subparagraph (A), or earlier in accordance with the
medical exigencies of the case, the plan or issuer
involved shall select an external appeals entity under
paragraph (3)(A) that shall be responsible for
designating an external reviewer under paragraph
(3)(B).
``(C) Provision of information.--The plan or issuer
involved shall forward all necessary information
(including medical records, any relevant review
criteria, the clinical rationale consistent with the
terms and conditions of the contract between the plan
or issuer and the enrollee for the coverage denial, and
evidence of the enrollee's coverage) to the external
reviewer selected under paragraph (3)(B).
``(D) Notification.--The plan or issuer involved
shall send a written notification to the enrollee (or
the legal representative of the enrollee) and the plan
administrator, indicating that an external review has
been initiated.
``(3) Conduct of external review.--
``(A) Designation of external appeals entity by
plan or issuer.--A plan or issuer that receives a
request for an external review under paragraph (2)(A)
shall designate one of the following entities to serve
as the external appeals entity:
``(i) An external review entity licensed or
credentialed by a State.
``(ii) A State agency established for the
purpose of conducting independent external
reviews.
``(iii) Any entity under contract with the
Federal Government to provide external review
services.
``(iv) Any entity accredited as an external
review entity by an accrediting body recognized
by the Secretary for such purpose.
``(v) Any fully accredited teaching
hospital.
``(vi) Any other entity meeting criteria
established by the Secretary for purposes of
this subparagraph.
``(B) Designation of external reviewer by external
appeals entity.--The external appeals entity designated
under subparagraph (A) shall, not later than 30 days
after the date on which such entity is designated under
subparagraph (A), or earlier in accordance with the
medical exigencies of the case, designate one or more
individuals to serve as external reviewers with respect
to a request receives under paragraph (2)(A). Such
reviewers shall be independent medical experts who
shall--
``(i) be appropriately credentialed or
licensed in any State to deliver health care
services;
``(ii) not have any material, professional,
familial, or financial affiliation with the
case under review, the enrollee involved, the
treating health care professional, the
institution where the treatment would take
place, or the manufacturer of any drug, device,
procedure, or other therapy proposed for the
enrollee whose treatment is under review;
``(iii) be experts in the diagnosis or
treatment under review and, when reasonably
available, be of the same speciality of the
physician prescribing the treatment in
question;
``(iv) receive only reasonable and
customary compensation from the group health
plan or health insurance issuer in connection
with the external review that is not contingent
on the decision rendered by the reviewer; and
``(v) not be held liable for decisions
regarding medical determinations (but may be
held liable for actions that are arbitrary and
capricious).
``(4) Standard of review.--
``(A) In general.--An external reviewer shall--
``(i) make a determination based on the
medical necessity, appropriateness,
experimental or investigational nature of the
coverage denial;
``(ii) take into consideration any
evidence-based decision making or clinical
practice guidelines used by the group health
plan or health insurance issuer in conducting
utilization review; and
``(iii) submit a report on the final
determinations of the review involved to--
``(I) the plan or issuer involved;
``(II) the enrollee involved (or
the legal representative of the
enrollee); and
``(III) the health care
professional involved.
``(B) Notice.--The plan or issuer involved shall
ensure that the enrollee receives notice, within 30
days after the determination of the independent medical
expert, regarding the actions of the plan or issuer
with respect to the determination of such expert under
the external review.
``(5) Timeframe for review.--
``(A) In general.--An external reviewer shall
complete a review of an adverse coverage determination
in accordance with the medical exigencies of the case.
``(B) Limitation.--Notwithstanding subparagraph
(A), a review described in such subparagraph shall be
completed not later than 30 working days after the
later of--
``(i) the date on which such reviewer is
designated; or
``(ii) the date on which all information
necessary to completing such review is
received.
``(6) Binding determination.--The determination of an
external reviewer under this subsection shall be binding upon
the plan or issuer if the provisions of this subsection or the
procedures implemented under such provisions were complied with
by the external reviewer.
``(7) Study.--Not later than 2 years after the date of
enactment of this section, the General Accounting Office shall
conduct a study of a statistically appropriate sample of
completed external reviews. Such study shall include an
assessment of the process involved during an external review
and the basis of decisionmaking by the external reviewer. The
results of such study shall be submitted to the appropriate
committees of Congress.
``(8) Effect on certain provisions.--Nothing in this
section shall be construed as affecting or modifying section
514 of this Act with respect to a group health plan.
``(f) Rule of Construction.--Nothing in this section shall be
construed to prohibit a plan administrator or plan fiduciary or health
plan medical director from requesting an external review by an external
reviewer without first completing the internal review process.
``(g) Definitions.--In this section:
``(1) Adverse coverage determination.--The term `adverse
coverage determination' means a coverage determination under
the plan which results in a denial of coverage or
reimbursement.
``(2) Coverage determination.--The term `coverage
determination' means with respect to items and services for
which coverage may be provided under a health plan, a
determination of whether or not such items and services are
covered or reimbursable under the coverage and terms of the
contract.
``(3) Enrollee.--The term enrollee means a participant or
beneficiary.
``(4) Grievance.--The term `grievance' means any enrollee
complaint that does not involve a coverage determination.
``(5) Group health plan.--The term `group health plan'
shall have the meaning given such term in section 733(a). In
applying this paragraph, excepted benefits described in section
733(c) shall not be treated as benefits consisting of medical
care.
``(6) Health insurance coverage.--The term `health
insurance coverage' has the meaning given such term in section
733(b)(1). In applying this paragraph, excepted benefits
described in section 733(c) shall not be treated as benefits
consisting of medical care.
``(7) Health insurer.--The term `health insurer' means an
insurance company, insurance service, or an insurance
organization that meets the requirements of section 733(b)(2)
and that offers health insurance coverage in connection with a
group health plan.
``(8) Prior authorization determination.--The term `prior
authorization determination' means a coverage determination
prior to the provision of the items and services as a condition
of coverage of the items and services under the coverage.
``(9) Treating health care professional.--The term
`treating health care professional' with respect to a group
health plan, health insurance issuer or provider sponsored
organization means a practitioner who is acting within the
scope of their State licensure or certification for the
delivery of health care services and who is primarily
responsible for delivering those services to the enrollee.
``(10) Utilization review.--The term `utilization review'
with respect to a group health plan or health insurance
coverage means a set of formal techniques designed to monitor
the use of, or evaluate the clinical necessity,
appropriateness, efficacy, or efficiency of, health care
services, procedures, or settings. Techniques may include
ambulatory review, prospective review, second opinion,
certification, concurrent review, case management, discharge
planning or retrospective review.''
(b) Enforcement.--Section 502(c)(1) of the Employee Retirement
Income Security Act of 1974 (29 U.S.C. 1132(c)(1)) is amended by
inserting after ``or section 101(e)(1)'' the following: ``, or fails to
comply with a coverage determination as required under section
503(e)(6),''.
(c) Conforming Amendment.--The table of contents in section 1 of
the Employee Retirement Income Security Act of 1974 is amended by
striking the item relating to section 503 and inserting the following
new item:
``Sec. 503. Claims procedures, coverage determination, grievances and
appeals.''.
(d) Effective Date.--The amendments made by this section shall
apply with respect to plan years beginning on or after 1 year after the
date of enactment of this Act. The Secretary shall issue all
regulations necessary to carry out the amendments made by this section
before the effective date thereof.
Subtitle D--Miscellaneous Provisions
SEC. 131. AMENDMENTS TO THE INTERNAL REVENUE CODE OF 1986.
Subchapter B of chapter 100 of the Internal Revenue Code of 1986
(as amended by section 1531(a) of the Taxpayer Relief Act of 1997) is
amended--
(1) in the table of sections, by inserting after the item
relating to section 9812 the following new item:
``Sec. 9813. Standard relating to
Patients' bill of rights.'';
and
(2) by inserting after section 9812 the following:
``SEC. 9813. STANDARD RELATING TO PATIENTS' BILL OF RIGHTS.
``A group health plan shall comply with the requirements of section
714 and subpart C of part 7 of subtitle B of title I of the Employee
Retirement Income Security Act of 1974 (as in effect as of the date of
the enactment of the Patients' Bill of Rights Plus Act), and such
requirements shall be deemed to be incorporated into this section.''.
TITLE II--INDIVIDUAL RIGHTS WITH RESPECT TO PERSONAL MEDICAL
INFORMATION
SEC. 201. SHORT TITLE.
This title may be cited as the ``Personal Medical Information
Access Act''.
Subtitle A--Access to Medical Records
SEC. 211. INSPECTION AND COPYING OF PROTECTED HEALTH INFORMATION.
(a) In General.--At the request of an individual and except as
provided in subsection (b), a health care provider, health plan,
employer, health or life insurer, school, or university shall permit an
individual who is the subject of protected health information or the
individual's designee, to inspect and copy protected health information
concerning the individual, including records created under section 212
that such entity maintains. Such entity may set forth appropriate
procedures to be followed for such inspection or copying and may
require an individual to pay reasonable costs associated with such
inspection or copying.
(b) Exceptions.--Unless ordered by a court of competent
jurisdiction, an entity described in subsection (a) is not required to
permit the inspection or copying of protected health information if any
of the following conditions are met:
(1) Endangerment to life or safety.--The entity determines
that the disclosure of the information could reasonably be
expected to endanger the life or physical safety of an
individual.
(2) Confidential source.--The information identifies, or
could reasonably lead to the identification of, a person who
provided information under a promise of confidentiality
concerning the individual who is the subject of the
information.
(3) Information compiled in anticipation of litigation.--
The information is compiled principally--
(A) in the reasonable anticipation of a civil,
criminal, or administrative action or proceeding; or
(B) for use in such an action or proceeding.
(4) Research purposes.--The information was collected for a
research project monitored by an institutional review board,
such project is not complete, and the researcher involved
reasonably believes that access to such information would harm
the conduct of the research or invalidate or undermine the
validity of the research.
(c) Denial of a Request for Inspection or Copying.--If an entity
described in subsection (a) denies a request for inspection or copying
pursuant to subsection (b), the entity shall inform the individual in
writing of--
(1) the reasons for the denial of the request for
inspection or copying;
(2) any procedures for further review of the denial; and
(3) the individual's right to file with the entity a
concise statement setting forth the request for inspection or
copying.
(d) Statement Regarding Request.--If an individual has filed a
statement under subsection (c)(3), the entity in any subsequent
disclosure of the portion of the information requested under subsection
(a) shall include--
(1) a copy of the individual's statement; and
(2) a concise statement of the reasons for denying the
request for inspection or copying.
(e) Inspection and Copying of Segregable Portion.--An entity
described in subsection (a) shall permit the inspection and copying
under subsection (a) of any reasonably segregable portion of protected
health information after deletion of any portion that is exempt under
subsection (b).
(f) Deadline.--An entity described in subsection (a) shall comply
with or deny, in accordance with subsection (c), a request for
inspection or copying of protected health information under this
section not later than 45 days after the date on which the entity
receives the request.
(g) Rules Governing Agents.--An agent of an entity described in
subsection (a) shall not be required to provide for the inspection and
copying of protected health information, except where--
(1) the protected health information is retained by the
agent; and
(2) the agent has received in writing a request from the
entity involved to fulfill the requirements of this section;
at which time such information shall be provided to the requesting
entity. Such requesting entity shall comply with subsection (f) with
respect to any such information.
(h) Rule of Construction.--This section shall not be construed to
require an entity described in subsection (a) to conduct a formal,
informal, or other hearing or proceeding concerning a request for
inspection or copying of protected health information.
SEC. 212. AMENDMENT OF PROTECTED HEALTH INFORMATION.
(a) Requirement.--
(1) In general.--Except as provided in subsection (b) and
subject to paragraph (2), a health care provider, health plan,
employer, health or life insurer, school, or university that
receives from an individual a request in writing to amend
protected health information shall--
(A) amend such information as requested;
(B) inform the individual of the amendment that has
been made; and
(C) make reasonable efforts to inform any person to
whom the unamended portion of the information was
previously disclosed, of any nontechnical amendment
that has been made.
(2) Compliance.--An entity described in paragraph (1) shall
comply with the requirements of such paragraph within 45 days
of the date on which the request involved is received if the
entity--
(A) created the protected health information
involved; and
(B) determines that such information is in fact
inaccurate.
(b) Refusal To Amend.--If an entity described in subsection (a)
refuses to make the amendment requested under such subsection, the
entity shall inform the individual in writing of--
(1) the reasons for the refusal to make the amendment;
(2) any procedures for further review of the refusal; and
(3) the individual's right to file with the entity a
concise statement setting forth the requested amendment and the
individual's reasons for disagreeing with the refusal.
(c) Statement of Disagreement.--If an individual has filed a
statement of disagreement under subsection (b)(3), the entity involved,
in any subsequent disclosure of the disputed portion of the
information--
(1) shall include a copy of the individual's statement; and
(2) may include a concise statement of the reasons for not
making the requested amendment.
(d) Rules Governing Agents.--The agent of an entity described in
subsection (a) shall not be required to make amendments to protected
health information, except where--
(1) the protected health information is retained by the
agent; and
(2) the agent has been asked by such entity to fulfill the
requirements of this section.
If the agent is required to comply with this section as provided for in
paragraph (2), such agent shall be subject to the 45-day deadline
described in subsection (a).
(e) Repeated Requests for Amendments.--If an entity described in
subsection (a) receives a request for an amendment of information as
provided for in such subsection and a statement of disagreement has
been filed pursuant to subsection (c), the entity shall inform the
individual of such filing and shall not be required to carry out the
procedures required under this section.
(f) Rules of Construction.--This section shall not be construed
to--
(1) require that an entity described in subsection (a)
conduct a formal, informal, or other hearing or proceeding
concerning a request for an amendment to protected health
information;
(2) require a provider to amend an individual's protected
health information as to the type, duration, or quality of
treatment the individual believes he or she should have been
provided; or
(3) permit any deletions or alterations of the original
information.
SEC. 213. NOTICE OF CONFIDENTIALITY PRACTICES.
(a) Preparation of Written Notice.--A health care provider, health
plan, health oversight agency, public health authority, employer,
health or life insurer, health researcher, school or university shall
post or provide, in writing and in a clear and conspicuous manner,
notice of the entity's confidentiality practices, that shall include--
(1) a description of an individual's rights with respect to
protected health information;
(2) the procedures established by the entity for the
exercise of the individual's rights; and
(3) the right to obtain a copy of the notice of the
confidentiality practices required under this subtitle.
(b) Model Notice.--The Secretary, in consultation with the National
Committee on Vital and Health Statistics and the National Association
of Insurance Commissioners, and after notice and opportunity for public
comment, shall develop and disseminate model notices of confidentiality
practices. Use of the model notice shall serve as a defense against
claims of receiving inappropriate notice.
Subtitle B--Establishment of Safeguards
SEC. 221. ESTABLISHMENT OF SAFEGUARDS.
A health care provider, health plan, health oversight agency,
public health authority, employer, health or life insurer, health
researcher, law enforcement official, school or university shall
establish and maintain appropriate administrative, technical, and
physical safeguards to protect the confidentiality, security, accuracy,
and integrity of protected health information created, received,
obtained, maintained, used, transmitted, or disposed of by such entity.
Subtitle C--Enforcement; Definitions
SEC. 231. CIVIL PENALTY.
(a) Violation.--A health care provider, health researcher, health
plan, health oversight agency, public health agency, law enforcement
agency, employer, health or life insurer, school, or university, or the
agent of any such individual or entity, who the Secretary, in
consultation with the Attorney General, determines has substantially
and materially failed to comply with this Act shall, for a violation of
this title, be subject, in addition to any other penalties that may be
prescribed by law, to a civil penalty of not more than $500 for each
such violation, but not to exceed $5,000 in the aggregate for multiple
violations.
(b) Procedures for Imposition of Penalties.--Section 1128A of the
Social Security Act, other than subsections (a) and (b) and the second
sentence of subsection (f) of that section, shall apply to the
imposition of a civil, monetary, or exclusionary penalty under this
section in the same manner as such provisions apply with respect to the
imposition of a penalty under section 1128A of such Act.
SEC. 232. DEFINITIONS.
In this title:
(1) Agent.--The term ``agent'' means a person who
represents and acts for another under the contract or relation
of agency, or whose function is to bring about, modify, affect,
accept performance of, or terminate contractual obligations
between the principal and a third person, including a
contractor.
(2) Disclose.--The term ``disclose'' means to release,
transfer, provide access to, or otherwise divulge protected
health information to any person other than the individual who
is the subject of such information. Such term includes the
initial disclosure and any subsequent redisclosures of
protected health information.
(3) Employer.--The term ``employer'' has the meaning given
such term under section 3(5) of the Employee Retirement Income
Security Act of 1974 (29 U.S.C. 1002(5)), except that such term
shall include only employers of 2 or more employees.
(4) Health care provider.--The term ``health care
provider'' means a person who, with respect to a specific item
of protected health information, receives, creates, uses,
maintains, or discloses the information while acting in whole
or in part in the capacity of--
(A) a person who is licensed, certified,
registered, or otherwise authorized by Federal or State
law to provide an item or service that constitutes
health care in the ordinary course of business, or
practice of a profession;
(B) a Federal, State, or employer-sponsored program
that directly provides items or services that
constitute health care to beneficiaries; or
(C) an officer, employee, or agent of a person
described in subparagraph (A) or (B).
(5) Health or life insurer.--The term ``health or life
insurer'' means a health insurance issuer as defined in section
2791 of the Public Health Service Act (42 U.S.C. 300gg-91) or a
life insurance company as defined in section 816 of the
Internal Revenue Code of 1986.
(6) Health plan.--The term ``health plan'' means any health
insurance plan, including any hospital or medical service plan,
dental or other health service plan or health maintenance
organization plan, provider sponsored organization, or other
program providing or arranging for the provision of health
benefits, whether or not funded through the purchase of
insurance.
(7) Person.--The term ``person'' means a government,
governmental subdivision, agency or authority; corporation;
company; association; firm; partnership; society; estate;
trust; joint venture; individual; individual representative;
tribal government; and any other legal entity.
(8) Protected health information.--The term ``protected
health information'' means any information (including
demographic information) whether or not recorded in any form or
medium--
(A) that relates to the past, present or future--
(i) physical or mental health or condition
of an individual (including the condition or
other attributes of individual cells or their
components);
(ii) provision of health care to an
individual; or
(iii) payment for the provision of health
care to an individual;
(B) that is created by a health care provider,
health plan, health researcher, health oversight
agency, public health authority, employer, law
enforcement official, health or life insurer, school or
university; and
(C) that is not nonidentifiable health information.
(9) School or university.--The term ``school or
university'' means an institution or place for instruction or
education, including an elementary school, secondary school, or
institution of higher learning, a college, or an assemblage of
colleges united under one corporate organization or government.
(10) Secretary.--The term ``Secretary'' means the Secretary
of Health and Human Services.
(11) Writing.--The term ``writing'' means writing in either
a paper-based or computer-based form, including electronic
signatures.
SEC. 233. EFFECTIVE DATE.
The provisions of this title shall become effective beginning on
the date that is 1 year after the date of enactment of this Act. The
Secretary shall issue regulations necessary to carry out this title
before the effective date thereof.
TITLE III--GENETIC INFORMATION AND SERVICES
SEC. 301. SHORT TITLE.
This title may be cited as the ``Genetic Information
Nondiscrimination in Health Insurance Act of 1999''.
SEC. 302. AMENDMENTS TO EMPLOYEE RETIREMENT INCOME SECURITY ACT OF
1974.
(a) Prohibition of Health Discrimination on the Basis of Genetic
Information or Genetic Services.--
(1) No enrollment restriction for genetic services.--
Section 702(a)(1)(F) of the Employee Retirement Income Security
Act of 1974 (29 U.S.C. 1182(a)(1)(F)) is amended by inserting
before the period the following: ``(including information about
a request for or receipt of genetic services)''.
(2) No discrimination in group premiums based on predictive
genetic information.--Subpart B of part 7 of subtitle B of
title I of the Employee Retirement Income Security Act of 1974
(29 U.S.C. 1185 et seq.) (as amended by section 111) is further
amended by adding at the end the following:
``SEC. 714. PROHIBITING PREMIUM DISCRIMINATION AGAINST GROUPS ON THE
BASIS OF PREDICTIVE GENETIC INFORMATION.
``A group health plan, or a health insurance issuer offering group
health insurance coverage in connection with a group health plan, shall
not adjust premium or contribution amounts for a group on the basis of
predictive genetic information concerning an individual in the group or
a family member of the individual (including information about a
request for or receipt of genetic services).''.
(3) Conforming amendment.--Section 702(b) of the Employee
Retirement Income Security Act of 1974 (29 U.S.C. 1182(b)) is
amended by adding at the end the following:
``(3) Reference to related provision.--For a provision
prohibiting the adjustment of premium or contribution amounts
for a group under a group health plan on the basis of
predictive genetic information (including information about a
request for or receipt of genetic services), see section
714.''.
(b) Limitation on Collection of Predictive Genetic Information.--
Section 702 of the Employee Retirement Income Security Act of 1974 (29
U.S.C. 1182) is amended by adding at the end the following:
``(c) Collection of Predictive Genetic Information.--
``(1) Limitation on requesting or requiring predictive
genetic information.--Except as provided in paragraph (2), a
group health plan, or a health insurance issuer offering health
insurance coverage in connection with a group health plan,
shall not request or require predictive genetic information
concerning an individual or a family member of the individual
(including information about a request for or receipt of
genetic services).
``(2) Information needed for diagnosis, treatment, or
payment.--
``(A) In general.--Notwithstanding paragraph (1), a
group health plan or health insurance issuer that
provides health care items and services to an
individual or dependent may request (but may not
require) that such individual or dependent disclose, or
authorize the collection or disclosure of, predictive
genetic information for purposes of diagnosis,
treatment, or payment relating to the provision of
health care items and services to such individual or
dependent.
``(B) Notice of confidentiality practices and
description of safeguards.--As a part of a request
under subparagraph (A), the group health plan or health
insurance issuer shall provide to the individual or
dependent a description of the procedures in place to
safeguard the confidentiality, as described in sections
213 and 221 of the Patients' Bill of Rights Plus Act,
of such individually identifiable information.''.
(c) Definitions.--Section 733(d) of the Employee Retirement Income
Security Act of 1974 (29 U.S.C. 1191b(d)) is amended by adding at the
end the following:
``(5) Family member.--The term `family member' means with
respect to an individual--
``(A) the spouse of the individual;
``(B) a dependent child of the individual,
including a child who is born to or placed for adoption
with the individual; and
``(C) all other individuals related by blood to the
individual or the spouse or child described in
subparagraph (A) or (B).
``(6) Genetic information.--The term `genetic information'
means information about genes, gene products, or inherited
characteristics that may derive from an individual or a family
member (including information about a request for or receipt of
genetic services).
``(7) Genetic services.--The term `genetic services' means
health services provided to obtain, assess, or interpret
genetic information for diagnostic and therapeutic purposes,
and for genetic education and counseling.
``(8) Predictive genetic information.--
``(A) In general.--The term `predictive genetic
information' means--
``(i) information about an individual's
genetic tests which are associated with a
statistically significant increased risk of
developing a disease or disorder;
``(ii) information about genetic tests of
family members of the individual; or
``(iii) information about the occurrence of
a disease or disorder in family members that
predicts a statistically significant increased
risk of a disease or disorder in the
individual.
``(B) Exceptions.--The term `predictive genetic
information' shall not include--
``(i) information about the sex or age of
the individual;
``(ii) information derived from routine
physical tests, such as the chemical, blood, or
urine analyses of the individual, unless such
analyses are genetic tests; and
``(iii) information about physical exams of
the individual and other information relevant
to determining the current health status of the
individual so long as such information does not
include information described in clauses (i),
(ii), or (iii) of subparagraph (A).
``(9) Genetic test.--The term `genetic test' means the
analysis of human DNA, RNA, chromosomes, proteins, and certain
metabolites, in order to detect disease-related genotypes,
mutations, phenotypes, or karyotypes.''.
(d) Effective Date.--Except as provided in this section, this
section and the amendments made by this section shall apply with
respect to group health plans for plan years beginning 1 year after the
date of the enactment of this Act.
SEC. 303. AMENDMENTS TO THE PUBLIC HEALTH SERVICE ACT.
(a) Amendments Relating to the Group Market.--
(1) Prohibition of health discrimination on the basis of
genetic information in the group market.--
(A) In general.--Subpart 2 of part A of title XXVII
of the Public Health Service Act, as amended by the
Omnibus Consolidated and Emergency Supplemental
Appropriations Act, 1999 (Public Law 105-277), is
amended by adding at the end the following new section:
``SEC. 2707. PROHIBITING PREMIUM DISCRIMINATION AGAINST GROUPS ON THE
BASIS OF PREDICTIVE GENETIC INFORMATION IN THE GROUP
MARKET.
``A group health plan, or a health insurance issuer offering group
health insurance coverage in connection with a group health plan shall
not adjust premium or contribution amounts for a group on the basis of
predictive genetic information concerning an individual in the group or
a family member of the individual (including information about a
request for or receipt of genetic services).''.
(B) Conforming amendment.--Section 2702(b) of the
Public Health Service Act (42 U.S.C. 300gg-1(b)) is
amended by adding at the end the following:
``(3) Reference to related provision.--For a provision
prohibiting the adjustment of premium or contribution amounts
for a group under a group health plan on the basis of
predictive genetic information (including information about a
request for or receipt of genetic services), see section
2707.''.
(C) Limitation on collection and disclosure of
predictive genetic information.--Section 2702 of the
Public Health Service Act (42 U.S.C. 300gg-1) is
amended by adding at the end the following:
``(c) Collection of Predictive Genetic Information.--
``(1) Limitation on requesting or requiring predictive
genetic information.--Except as provided in paragraph (2), a
group health plan, or a health insurance issuer offering health
insurance coverage in connection with a group health plan,
shall not request or require predictive genetic information
concerning an individual or a family member of the individual
(including information about a request for or receipt of
genetic services).
``(2) Information needed for diagnosis, treatment, or
payment.--
``(A) In general.--Notwithstanding paragraph (1), a
group health plan or health insurance issuer that
provides health care items and services to an
individual or dependent may request (but may not
require) that such individual or dependent disclose, or
authorize the collection or disclosure of, predictive
genetic information for purposes of diagnosis,
treatment, or payment relating to the provision of
health care items and services to such individual or
dependent.
``(B) Notice of confidentiality practices and
description of safeguards.--As a part of a request
under subparagraph (A), the group health plan or health
insurance issuer shall provide to the individual or
dependent a description of the procedures in place to
safeguard the confidentiality, as described in sections
213 and 221 of the Patients' Bill of Rights Plus Act,
of such individually identifiable information.''.
(2) Definitions.--Section 2791(d) of the Public Health
Service Act (42 U.S.C. 300gg-91(d)) is amended by adding at the
end the following:
``(15) Family member.--The term `family member' means, with
respect to an individual--
``(A) the spouse of the individual;
``(B) a dependent child of the individual,
including a child who is born to or placed for adoption
with the individual; and
``(C) all other individuals related by blood to the
individual or the spouse or child described in
subparagraph (A) or (B).
``(16) Genetic information.--The term `genetic information'
means information about genes, gene products, or inherited
characteristics that may derive from an individual or a family
member.
``(17) Genetic services.--The term `genetic services' means
health services provided to obtain, assess, or interpret
genetic information for diagnostic and therapeutic purposes,
and for genetic education and counseling.
``(18) Predictive genetic information.--
``(A) In general.--The term `predictive genetic
information' means--
``(i) information about an individual's
genetic tests which is associated with a
statistically significant increased risk of
developing a disease or disorder;
``(ii) information about genetic tests of
family members of the individual; or
``(iii) information about the occurrence of
a disease or disorder in family members that
predicts a statistically significant increased
risk of a disease or disorder in the
individual.
``(B) Exceptions.--The term `predictive genetic
information' shall not include--
``(i) information about the sex or age of
the individual;
``(ii) information derived from routine
physical tests, such as the chemical, blood, or
urine analyses of the individual, unless such
analyses are genetic tests; and
``(iii) information about physical exams of
the individual and other information relevant
to determining the current health status of the
individual so long as such information does not
include information described in clauses (i),
(ii), or (iii) of subparagraph (A).
``(19) Genetic test.--The term `genetic test' means the
analysis of human DNA, RNA, chromosomes, proteins, and certain
metabolites, in order to detect disease-related genotypes,
mutations, phenotypes, or karyotypes.''.
(b) Amendment Relating to the Individual Market.--The first subpart
3 of part B of title XXVII of the Public Health Service Act (42 U.S.C.
300gg-11 et seq.) (relating to other requirements), as amended by the
Omnibus Consolidated and Emergency Supplemental Appropriations Act,
1999 (Public Law 105-277) is amended--
(1) by redesignating such subpart as subpart 2; and
(2) by adding at the end the following:
``SEC. 2753. PROHIBITION OF HEALTH DISCRIMINATION ON THE BASIS OF
PREDICTIVE GENETIC INFORMATION.
``(a) Prohibition on Predictive Genetic Information as a Condition
of Eligibility.--A health insurance issuer offering health insurance
coverage in the individual market may not use predictive genetic
information as a condition of eligibility of an individual to enroll in
individual health insurance coverage (including information about a
request for or receipt of genetic services).
``(b) Prohibition on Predictive Genetic Information in Setting
Premium Rates.--A health insurance issuer offering health insurance
coverage in the individual market shall not adjust premium rates for
individuals on the basis of predictive genetic information concerning
such an enrollee or a family member of the enrollee (including
information about a request for or receipt of genetic services).
``(c) Collection of Predictive Genetic Information.--
``(1) Limitation on requesting or requiring predictive
genetic information.--Except as provided in paragraph (2), a
health insurance issuer offering health insurance coverage in
the individual market shall not request or require predictive
genetic information concerning an individual or a family member
of the individual (including information about a request for or
receipt of genetic services).
``(2) Information needed for diagnosis, treatment, or
payment.--
``(A) in general.--Notwithstanding paragraph (1), a
health insurance issuer that provides health care items
and services to an individual or dependent may request
(but may not require) that such individual or dependent
disclose, or authorize the collection or disclosure of,
predictive genetic information for purposes of
diagnosis, treatment, or payment relating to the
provision of health care items and services to such
individual or dependent.
``(B) Notice of confidentiality practices and
description of safeguards.--As a part of a request
under subparagraph (A), the health insurance issuer shall provide to
the individual or dependent a description of the procedures in place to
safeguard the confidentiality, as described in sections 213 and 221 of
the Patients' Bill of Rights Plus Act, of such individually
identifiable information.''.
(c) Effective Date.--The amendments made by this section shall
apply with respect to--
(1) group health plans, and health insurance coverage
offered in connection with group health plans, for plan years
beginning after 1 year after the date of enactment of this Act;
and
(2) health insurance coverage offered, sold, issued,
renewed, in effect, or operated in the individual market after
1 year after the date of enactment of this Act.
SEC. 304. AMENDMENTS TO THE INTERNAL REVENUE CODE OF 1986.
(a) Prohibition of Health Discrimination on the Basis of Predictive
Genetic Information.--
(1) In general.--Subchapter B of chapter 100 of the
Internal Revenue Code of 1986 (as amended by section 131) is
further amended by adding at the end the following:
``SEC. 9814. PROHIBITING HEALTH DISCRIMINATION AGAINST GROUPS ON THE
BASIS OF PREDICTIVE GENETIC INFORMATION.
``A group health plan shall not adjust premium or contribution
amounts for a group on the basis of predictive genetic information
concerning an individual in the group or a family member of the
individual (including information about a request for or receipt of
genetic services).''.
(2) Conforming amendment.--Section 9802(b) of the Internal
Revenue Code of 1986 is amended by adding at the end the
following:
``(3) Reference to related provision.--For a provision
prohibiting the adjustment of premium or contribution amounts
for a group under a group health plan on the basis of
predictive genetic information (including information about a
request for or the receipt of genetic services), see section
9814.''.
(3) Amendment to table of sections.--The table of sections
for subchapter B of chapter 100 of the Internal Revenue Code of
1986 (as amended by section 131) is further amended by adding
at the end the following:
``Sec. 9814. Prohibiting premium discrimination against groups on the
basis of predictive genetic information.''.
(b) Limitation on Collection of Predictive Genetic Information.--
Section 9802 of the Internal Revenue Code of 1986 is amended by adding
at the end the following:
``(c) Collection of Predictive Genetic Information.--
``(1) Limitation on requesting or requiring predictive
genetic information.--Except as provided in paragraph (2), a
group health plan shall not request or require predictive
genetic information concerning an individual or a family member
of the individual (including information about a request for or
receipt of genetic services).
``(2) Information needed for diagnosis, treatment, or
payment.--
``(A) In general.--Notwithstanding paragraph (1), a
group health plan that provides health care items and
services to an individual or dependent may request (but
may not require) that such individual or dependent
disclose, or authorize the collection or disclosure of,
predictive genetic information for purposes of
diagnosis, treatment, or payment relating to the
provision of health care items and services to such
individual or dependent.
``(B) Notice of confidentiality practices;
description of safeguards.--As a part of a request
under subparagraph (A), the group health plan shall
provide to the individual or dependent a description of
the procedures in place to safeguard the
confidentiality, as described in sections 213 and 221
of the Patients' Bill of Rights Plus Act, of such
individually identifiable information.''.
(c) Definitions.--Section 9832(d) of the Internal Revenue Code of
1986 is amended by adding at the end the following:
``(6) Family member.--The term `family member' means, with
respect to an individual--
``(A) the spouse of the individual;
``(B) a dependent child of the individual,
including a child who is born to or placed for adoption
with the individual; and
``(C) all other individuals related by blood to the
individual or the spouse or child described in
subparagraph (A) or (B).
``(7) Genetic information.--The term `genetic information'
means information about genes, gene products, or inherited
characteristics that may derive from an individual or a family
member.
``(8) Genetic services.--The term `genetic services' means
health services provided to obtain, assess, or interpret
genetic information for diagnostic and therapeutic purposes,
and for genetic education and counseling.
``(9) Predictive genetic information.--
``(A) In general.--The term `predictive genetic
information' means--
``(i) information about an individual's
genetic tests which is associated with a
statistically significant increased risk of
developing a disease or disorder;
``(ii) information about genetic tests of
family members of the individual; or
``(iii) information about the occurrence of
a disease or disorder in family members that
predicts a statistically significant increased
risk of a disease or disorder in the
individual.
``(B) Exceptions.--The term `predictive genetic
information' shall not include--
``(i) information about the sex or age of
the individual;
``(ii) information derived from routine
physical tests, such as the chemical, blood, or
urine analyses of the individual, unless such
analyses are genetic tests; and
``(iii) information about physical exams of
the individual and other information relevant
to determining the current health status of the
individual so long as such information does not
include information described in clauses (i),
(ii), or (iii) of subparagraph (A).
``(10) Genetic test.--The term `genetic test' means the
analysis of human DNA, RNA, chromosomes, proteins, and certain
metabolites, in order to detect disease-related genotypes,
mutations, phenotypes, or karyotypes.''.
(d) Effective Date.--Except as provided in this section, this
section and the amendments made by this section shall apply with
respect to group health plans for plan years beginning after 1 year
after the date of the enactment of this Act.
TITLE IV--HEALTHCARE RESEARCH AND QUALITY
SEC. 401. SHORT TITLE.
This title may be cited as the ``Healthcare Research and Quality
Act of 1999''.
SEC. 402. AMENDMENT TO THE PUBLIC HEALTH SERVICE ACT.
Title IX of the Public Health Service Act (42 U.S.C. 299 et seq.)
is amended to read as follows:
``TITLE IX--AGENCY FOR HEALTHCARE RESEARCH AND QUALITY
``PART A--ESTABLISHMENT AND GENERAL DUTIES
``SEC. 901. MISSION AND DUTIES.
``(a) In General.--There is established within the Public Health
Service an agency to be known as the Agency for Healthcare Research and
Quality. In carrying out this subsection, the Secretary shall
redesignate the Agency for Health Care Policy and Research as the
Agency for Healthcare Research and Quality.
``(b) Mission.--The purpose of the Agency is to enhance the
quality, appropriateness, and effectiveness of healthcare services, and
access to such services, through the establishment of a broad base of
scientific research and through the promotion of improvements in
clinical and health system practice, including the prevention of
diseases and other health conditions. The Agency shall promote
healthcare quality improvement by--
``(1) conducting and supporting research that develops and
presents scientific evidence regarding all aspects of
healthcare, including--
``(A) the development and assessment of methods for
enhancing patient participation in their own care and
for facilitating shared patient-physician decision-
making;
``(B) the outcomes, effectiveness, and cost-
effectiveness of healthcare practices, including
preventive measures and primary, acute and long-term
care;
``(C) existing and innovative technologies;
``(D) the costs and utilization of, and access to
healthcare;
``(E) the ways in which healthcare services are
organized, delivered, and financed and the interaction
and impact of these factors on the quality of patient
care;
``(F) methods for measuring quality and strategies
for improving quality; and
``(G) ways in which patients, consumers,
purchasers, and practitioners acquire new information
about best practices and health benefits, the
determinants and impact of their use of this
information;
``(2) synthesizing and disseminating available scientific
evidence for use by patients, consumers, practitioners,
providers, purchasers, policy makers, and educators; and
``(3) advancing private and public efforts to improve
healthcare quality.
``(c) Requirements With Respect to Rural Areas and Priority
Populations.--In carrying out subsection (b), the Director shall
undertake and support research, demonstration projects, and evaluations
with respect to--
``(1) the delivery of health services in rural areas
(including frontier areas);
``(2) health services for low-income groups, and minority
groups;
``(3) the health of children;
``(4) the elderly; and
``(5) people with special healthcare needs, including
disabilities, chronic care and end-of-life healthcare.
``(d) Appointment of Director.--There shall be at the head of the
Agency an official to be known as the Director for Healthcare Research
and Quality. The Director shall be appointed by the Secretary. The
Secretary, acting through the Director, shall carry out the authorities
and duties established in this title.
``SEC. 902. GENERAL AUTHORITIES.
``(a) In General.--In carrying out section 901(b), the Director
shall support demonstration projects, conduct and support research,
evaluations, training, research networks, multi-disciplinary centers,
technical assistance, and the dissemination of information, on
healthcare, and on systems for the delivery of such care, including
activities with respect to--
``(1) the quality, effectiveness, efficiency,
appropriateness and value of healthcare services;
``(2) quality measurement and improvement;
``(3) the outcomes, cost, cost-effectiveness, and use of
healthcare services and access to such services;
``(4) clinical practice, including primary care and
practice-oriented research;
``(5) healthcare technologies, facilities, and equipment;
``(6) healthcare costs, productivity, organization, and
market forces;
``(7) health promotion and disease prevention, including
clinical preventive services;
``(8) health statistics, surveys, database development, and
epidemiology; and
``(9) medical liability.
``(b) Health Services Training Grants.--
``(1) In general.--The Director may provide training grants
in the field of health services research related to activities
authorized under subsection (a), to include pre- and post-
doctoral fellowships and training programs, young investigator
awards, and other programs and activities as appropriate. In
carrying out this subsection, the Director shall make use of
funds made available under section 487.
``(2) Requirements.--In developing priorities for the
allocation of training funds under this subsection, the
Director shall take into consideration shortages in the number
of trained researchers addressing the priority populations.
``(c) Multidisciplinary Centers.--The Director may provide
financial assistance to assist in meeting the costs of planning and
establishing new centers, and operating existing and new centers, for
multidisciplinary health services research, demonstration projects,
evaluations, training, and policy analysis with respect to the matters
referred to in subsection (a).
``(d) Relation to Certain Authorities Regarding Social Security.--
Activities authorized in this section may include, and shall be
appropriately coordinated with experiments, demonstration projects, and
other related activities authorized by the Social Security Act and the
Social Security Amendments of 1967. Activities under subsection (a)(2)
of this section that affect the programs under titles XVIII, XIX and
XXI of the Social Security Act shall be carried out consistent with
section 1142 of such Act.
``(e) Disclaimer.--The Agency shall not mandate national standards
of clinical practice or quality healthcare standards. Recommendations
resulting from projects funded and published by the Agency shall
include a corresponding disclaimer.
``(f) Rule of Construction.--Nothing in this section shall be
construed to imply that the Agency's role is to mandate a national
standard or specific approach to quality measurement and reporting. In
research and quality improvement activities, the Agency shall consider
a wide range of choices, providers, healthcare delivery systems, and
individual preferences.
``PART B--HEALTHCARE IMPROVEMENT RESEARCH
``SEC. 911. HEALTHCARE OUTCOME IMPROVEMENT RESEARCH.
``(a) Evidence Rating Systems.--In collaboration with experts from
the public and private sector, the Agency shall identify and
disseminate methods or systems used to assess healthcare research
results, particularly to rate the strength of the scientific evidence
behind healthcare practice, recommendations in the research literature,
and technology assessments. The Agency shall make methods or systems
for evidence rating widely available. Agency publications containing
healthcare recommendations shall indicate the level of substantiating
evidence using such methods or systems.
``(b) Healthcare Improvement Research Centers and Provider-Based
Research Networks.--
``(1) In general.--In order to address the full continuum
of care and outcomes research, to link research to practice
improvement, and to speed the dissemination of research
findings to community practice settings, the Agency shall
employ research strategies and mechanisms that will link
research directly with clinical practice in geographically
diverse locations throughout the United States, including--
``(A) Healthcare Improvement Research Centers that
combine demonstrated multidisciplinary expertise in
outcomes or quality improvement research with linkages
to relevant sites of care;
``(B) Provider-based Research Networks, including
plan, facility, or delivery system sites of care
(especially primary care), that can evaluate and
promote quality improvement; and
``(C) other innovative mechanisms or strategies to
link research with clinical practice.
``(2) Requirements.--The Director is authorized to
establish the requirements for entities applying for grants
under this subsection.
``SEC. 912. PRIVATE-PUBLIC PARTNERSHIPS TO IMPROVE ORGANIZATION AND
DELIVERY.
``(a) Support for Efforts To Develop Information on Quality.--
``(1) Scientific and technical support.--In its role as the
principal agency for healthcare research and quality, the
Agency may provide scientific and technical support for private
and public efforts to improve healthcare quality, including the
activities of accrediting organizations.
``(2) Role of the agency.--With respect to paragraph (1),
the role of the Agency shall include--
``(A) the identification and assessment of--
``(i) methods for the evaluation of the
health of enrollees in health plans by type of
plan, provider, and provider arrangements; and
``(ii) other populations, including those
receiving long-term care services;
``(B) the ongoing development, testing, and
dissemination of quality measures, including measures
of health and functional outcomes;
``(C) the compilation and dissemination of
healthcare quality measures developed in the private
and public sector;
``(D) assistance in the development of improved
healthcare information systems;
``(E) the development of survey tools for the
purpose of measuring participant and beneficiary
assessments of their healthcare; and
``(F) identifying and disseminating information on
mechanisms for the integration of information on
quality into purchaser and consumer decision-making
processes.
``(b) Centers for Education and Research on Therapeutics.--
``(1) In general.--The Secretary, acting through the
Director and in consultation with the Commissioner of Food and
Drugs, shall establish a program for the purpose of making one
or more grants for the establishment and operation of one or
more centers to carry out the activities specified in paragraph
(2).
``(2) Required activities.--The activities referred to in
this paragraph are the following:
``(A) The conduct of state-of-the-art clinical
research for the following purposes:
``(i) To increase awareness of--
``(I) new uses of drugs, biological
products, and devices;
``(II) ways to improve the
effective use of drugs, biological
products, and devices; and
``(III) risks of new uses and risks
of combinations of drugs and biological
products.
``(ii) To provide objective clinical
information to the following individuals and
entities:
``(I) Healthcare practitioners and
other providers of Healthcare goods or
services.
``(II) Pharmacists, pharmacy
benefit managers and purchasers.
``(III) Health maintenance
organizations and other managed
healthcare organizations.
``(IV) Healthcare insurers and
governmental agencies.
``(V) Patients and consumers.
``(iii) To improve the quality of
healthcare while reducing the cost of
Healthcare through--
``(I) an increase in the
appropriate use of drugs, biological
products, or devices; and
``(II) the prevention of adverse
effects of drugs, biological products,
and devices and the consequences of
such effects, such as unnecessary
hospitalizations.
``(B) The conduct of research on the comparative
effectiveness, cost-effectiveness, and safety of drugs,
biological products, and devices.
``(C) Such other activities as the Secretary
determines to be appropriate, except that a grant may
not be expended to assist the Secretary in the review
of new drugs.
``(c) Reducing Errors in Medicine.--The Director shall conduct and
support research and build private-public partnerships to--
``(1) identify the causes of preventable healthcare errors
and patient injury in healthcare delivery;
``(2) develop, demonstrate, and evaluate strategies for
reducing errors and improving patient safety; and
``(3) promote the implementation of effective strategies
throughout the healthcare industry.
``SEC. 913. INFORMATION ON QUALITY AND COST OF CARE.
``(a) In General.--In carrying out 902(a), the Director shall--
``(1) collect data on a nationally representative sample of
the population on the cost, use and, for fiscal year 2000 and
subsequent fiscal years, quality of healthcare, including the
types of healthcare services Americans use, their access to
healthcare services, frequency of use, how much is paid for the
services used, the source of those payments, the types and
costs of private health insurance, access, satisfaction, and
quality of care for the general population and also for
children, uninsured persons, poor and near-poor individuals,
and persons with special healthcare needs;
``(2) develop databases and tools that enable States to
track the quality, access, and use of healthcare services
provided to their residents; and
``(3) enter into agreements with public or private entities
to use, link, or acquire databases for research authorized
under this title.
``(b) Quality and Outcomes Information.--
``(1) In general.--To enhance the understanding of the
quality of care, the determinants of health outcomes and
functional status, the needs of special populations as well as
an understanding of these changes over time, their relationship
to healthcare access and use, and to monitor the overall
national impact of Federal and State policy changes on
healthcare, the Director, beginning in fiscal year 2000, shall
ensure that the survey conducted under subsection (a)(1) will--
``(A) provide information on the quality of care
and patient outcomes for frequently occurring clinical
conditions for a nationally representative sample of
the population; and
``(B) provide reliable national estimates for
children and persons with special healthcare needs
through the use of supplements or periodic expansions
of the survey.
In expanding the Medical Expenditure Panel Survey, as in
existence on the date of enactment of this title) in fiscal
year 2000 to collect information on the quality of care, the
Director shall take into account any outcomes measurements
generally collected by private sector accreditation
organizations.
``(2) Annual report.--Beginning in fiscal year 2002, the
Secretary, acting through the Director, shall submit to
Congress an annual report on national trends in the quality of
healthcare provided to the American people.
``SEC. 914. INFORMATION SYSTEMS FOR HEALTHCARE IMPROVEMENT.
``In order to foster a range of innovative approaches to the
management and communication of health information, the Agency shall
support research, evaluations and initiatives to advance--
``(1) the use of information systems for the study of
healthcare quality, including the generation of both individual
provider and plan-level comparative performance data;
``(2) training for healthcare practitioners and researchers
in the use of information systems;
``(3) the creation of effective linkages between various
sources of health information, including the development of
information networks;
``(4) the delivery and coordination of evidence-based
healthcare services, including the use of real-time healthcare
decision-support programs;
``(5) the structure, content, definition, and coding of
health information data and medical vocabularies in
consultation with appropriate Federal and private entities;
``(6) the use of computer-based health records in
outpatient and inpatient settings as a personal health record
for individual health assessment and maintenance, and for
monitoring public health and outcomes of care within
populations; and
``(7) the protection of individually identifiable
information in health services research and healthcare quality
improvement.
``SEC. 915. RESEARCH SUPPORTING PRIMARY CARE AND ACCESS IN UNDERSERVED
AREAS.
``(a) Preventive Services Task Force.--
``(1) Purpose.--The Agency shall provide ongoing
administrative, research, and technical support for the
operation of the Preventive Services Task Force. The Agency
shall coordinate and support the dissemination of the
Preventive Services Task Force recommendations.
``(2) Operation.--The Preventive Services Task Force shall
review the scientific evidence related to the effectiveness,
appropriateness, and cost-effectiveness of clinical preventive
services for the purpose of developing recommendations, and
updating previous recommendations, regarding their usefulness
in daily clinical practice. In carrying out its
responsibilities under paragraph (1), the Task Force shall not
be subject to the provisions of Appendix 2 of title 5, United
States Code.
``(b) Primary Care Research.--
``(1) In general.--There is established within the Agency a
Center for Primary Care Research (referred to in this
subsection as the `Center') that shall serve as the principal
source of funding for primary care research in the Department
of Health and Human Services. For purposes of this paragraph,
primary care research focuses on the first contact when illness
or health concerns arise, the diagnosis, treatment or referral
to specialty care, preventive care, and the relationship
between the clinician and the patient in the context of the
family and community.
``(2) Research.--In carrying out this section, the Center
shall conduct and support research on--
``(A) the nature and characteristics of primary
care practice;
``(B) the management of commonly occurring clinical
problems;
``(C) the management of undifferentiated clinical
problems; and
``(D) the continuity and coordination of health
services.
``(3) Demonstration.--The Agency shall support
demonstrations into the use of new information tools aimed at
improving shared decision-making between patients and their
care-givers.
``SEC. 916. CLINICAL PRACTICE AND TECHNOLOGY INNOVATION.
``(a) In General.--The Director shall promote innovation in
evidence-based clinical practice and healthcare technologies by--
``(1) conducting and supporting research on the
development, diffusion, and use of healthcare technology;
``(2) developing, evaluating, and disseminating
methodologies for assessments of healthcare practices and
healthcare technologies;
``(3) conducting intramural and supporting extramural
assessments of existing and new healthcare practices and
technologies;
``(4) promoting education, training, and providing
technical assistance in the use of healthcare practice and
healthcare technology assessment methodologies and results; and
``(5) working with the National Library of Medicine and the
public and private sector to develop an electronic
clearinghouse of currently available assessments and those in
progress.
``(b) Specification of Process.--
``(1) In general.--Not later than December 31, 2000, the
Director shall develop and publish a description of the methods
used by the Agency and its contractors for practice and
technology assessment.
``(2) Consultations.--In carrying out this subsection, the
Director shall cooperate and consult with the Assistance
Secretary for Health, the Administrator of the Health Care
Financing Administration, the Director of the National
Institutes of Health, the Commissioner of Food and Drugs, and
the heads of any other interested Federal department or agency,
professional societies, and other private and public entities.
``(3) Methodology.--The methods employed in practice and
technology assessments under paragraph (1) shall consider--
``(A) safety, efficacy, and effectiveness;
``(B) legal, social, and ethical implications;
``(C) costs, benefits, and cost-effectiveness;
``(D) comparisons to alternative technologies and
practices; and
``(E) requirements of Food and Drug Administration
approval to avoid duplication.
``(c) Specific Assessments.--
``(1) In general.--The Director shall conduct or support
specific assessments of healthcare technologies and practices.
``(2) Requests for assessments.--The Director is authorized
to conduct or support assessments, on a reimbursable basis, for
the Health Care Financing Administration, the Department of
Defense, the Department of Veterans Affairs, the Office of
Personnel Management, and other public or private entities.
``(3) Grants and contracts.--In addition to conducting
assessments, the Director may make grants to, or enter into
cooperative agreements or contracts with, entities described in
paragraph (4) for the purpose of conducting assessments of
experimental, emerging, existing, or potentially outmoded healthcare
technologies, and for related activities.
``(4) Eligible entities.--An entity described in this
paragraph is an entity that is determined to be appropriate by
the Director, including academic medical centers, research
institutions, professional organizations, third party payers,
other governmental agencies, and consortia of appropriate
research entities established for the purpose of conducting
technology assessments.
``SEC. 917. COORDINATION OF FEDERAL GOVERNMENT QUALITY IMPROVEMENT
EFFORTS.
``(a) Requirement.--
``(1) In general.--To avoid duplication and ensure that
Federal resources are used efficiently and effectively, the
Secretary, acting through the Director, shall coordinate all
research, evaluations, and demonstrations related to health
services research and quality measurement and improvement
activities undertaken and supported by the Federal Government.
``(2) Specific activities.--The Director, in collaboration
with the appropriate Federal officials representing all
concerned executive agencies and departments, shall develop and
manage a process to--
``(A) improve interagency coordination, priority
setting, and the use and sharing of research findings
and data pertaining to Federal quality improvement
programs and health services research;
``(B) strengthen the research information
infrastructure, including databases, pertaining to
Federal health services research and healthcare quality
improvement initiatives;
``(C) set specific goals for participating agencies
and departments to further health services research and
healthcare quality improvement; and
``(D) strengthen the management of Federal
healthcare quality improvement programs.
``(b) Study by the Institute of Medicine.--
``(1) In general.--To provide the Department of Health and
Human Services with an independent, external review of its
quality oversight, and quality research programs, the Secretary
shall enter into a contract with the Institute of Medicine--
``(A) to describe and evaluate current quality
improvement research and monitoring processes through--
``(i) an overview of pertinent health
services research activities and quality
improvement efforts including those currently
performed by the peer review organizations and
the exploration of additional activities that
could be undertaken by the peer review
organizations to improve quality;
``(ii) an analysis of the various
partnership activities that the Department of
Health and Human Services has pursued with
private sector accreditation and other quality measurement
organizations;
``(iii) the exploration of programmatic
areas where partnership activities between the
Federal Government and the private sector or
within the Federal Government could be pursued
to improve quality oversight of the medicare,
medicaid and child health insurance programs
under titles XVIII, XIX and XXI of the Social
Security Act; and
``(iv) an identification of opportunities
for enhancing health system efficiency through
simplification and reduction in redundancy of
Federal agency quality improvement efforts,
including areas in which Federal efforts
unnecessarily duplicate existing private sector
efforts; and
``(B) to identify options and make recommendations
to improve the efficiency and effectiveness of such
quality improvement programs through--
``(i) the improved coordination of
activities across the medicare, medicaid and
child health insurance programs under titles
XVIII, XIX and XXI of the Social Security Act
and various health services research programs;
``(ii) the strengthening of patient choice
and participation by incorporating state-of-
the-art quality monitoring tools and making
information on quality available; and
``(iii) the enhancement of the most
effective programs, consolidation as
appropriate, and elimination of duplicative
activities within various federal agencies.
``(2) Requirements.--
``(A) In general.--The Secretary shall enter into a
contract with the Institute of Medicine for the
preparation--
``(i) not later than 12 months after the
date of enactment of this title, of a report
providing an overview of the quality
improvement programs of the Department of
Health and Human Services for the medicare,
medicaid, and CHIP programs under titles XVIII,
XIX, and XXI of the Social Security Act; and
``(ii) not later than 24 months after the
date of enactment of this title, of a final
report containing recommendations.
``(B) Reports.--The Secretary shall submit the
reports described in subparagraph (A) to the Committee
on Finance and the Committee on Health, Education,
Labor, and Pensions of the Senate and the Committee on
Ways and Means and the Committee on Commerce of the
House of Representatives.
``PART C--GENERAL PROVISIONS
``SEC. 921. ADVISORY COUNCIL FOR HEALTHCARE RESEARCH AND QUALITY.
``(a) Establishment.--There is established an advisory council to
be known as the Advisory Council for Healthcare Research and Quality.
``(b) Duties.--
``(1) In general.--The Advisory Council shall advise the
Secretary and the Director with respect to activities proposed
or undertaken to carry out the purpose of the Agency under
section 901(b).
``(2) Certain recommendations.--Activities of the Advisory
Council under paragraph (1) shall include making
recommendations to the Director regarding--
``(A) priorities regarding healthcare research,
especially studies related to quality, outcomes, cost
and the utilization of, and access to, healthcare
services;
``(B) the field of healthcare research and related
disciplines, especially issues related to training
needs, and dissemination of information pertaining to
healthcare quality; and
``(C) the appropriate role of the Agency in each of
these areas in light of private sector activity and
identification of opportunities for public-private
sector partnerships.
``(c) Membership.--
``(1) In general.--The Advisory Council shall, in
accordance with this subsection, be composed of appointed
members and ex officio members. All members of the Advisory
Council shall be voting members other than the individuals
designated under paragraph (3)(B) as ex officio members.
``(2) Appointed members.--The Secretary shall appoint to
the Advisory Council 21 appropriately qualified individuals. At
least 17 members of the Advisory Council shall be
representatives of the public who are not officers or employees
of the United States. The Secretary shall ensure that the
appointed members of the Council, as a group, are representative of
professions and entities concerned with, or affected by, activities
under this title and under section 1142 of the Social Security Act. Of
such members--
``(A) 4 shall be individuals distinguished in the
conduct of research, demonstration projects, and
evaluations with respect to healthcare;
``(B) 4 shall be individuals distinguished in the
practice of medicine of which at least 1 shall be a
primary care practitioner;
``(C) 3 shall be individuals distinguished in the
other health professions;
``(D) 4 shall be individuals either representing
the private healthcare sector, including health plans,
providers, and purchasers or individuals distinguished
as administrators of healthcare delivery systems;
``(E) 4 shall be individuals distinguished in the
fields of healthcare quality improvement, economics,
information systems, law, ethics, business, or public
policy; and
``(F) 2 shall be individuals representing the
interests of patients and consumers of healthcare.
``(3) Ex officio members.--The Secretary shall designate as
ex officio members of the Advisory Council--
``(A) the Assistant Secretary for Health, the
Director of the National Institutes of Health, the
Director of the Centers for Disease Control and
Prevention, the Administrator of the Health Care
Financing Administration, the Assistant Secretary of
Defense (Health Affairs), and the Chief Medical Officer
of the Department of Veterans Affairs; and
``(B) such other Federal officials as the Secretary
may consider appropriate.
``(d) Terms.--Members of the Advisory Council appointed under
subsection (c)(2) shall serve for a term of 3 years. A member of the
Council appointed under such subsection may continue to serve after the
expiration of the term of the members until a successor is appointed.
``(e) Vacancies.--If a member of the Advisory Council appointed
under subsection (c)(2) does not serve the full term applicable under
subsection (d), the individual appointed to fill the resulting vacancy
shall be appointed for the remainder of the term of the predecessor of
the individual.
``(f) Chair.--The Director shall, from among the members of the
Advisory Council appointed under subsection (c)(2), designate an
individual to serve as the chair of the Advisory Council.
``(g) Meetings.--The Advisory Council shall meet not less than once
during each discrete 4-month period and shall otherwise meet at the
call of the Director or the chair.
``(h) Compensation and Reimbursement of Expenses.--
``(1) Appointed members.--Members of the Advisory Council
appointed under subsection (c)(2) shall receive compensation
for each day (including travel time) engaged in carrying out
the duties of the Advisory Council unless declined by the
member. Such compensation may not be in an amount in excess of
the maximum rate of basic pay payable for GS-18 of the General
Schedule.
``(2) Ex officio members.--Officials designated under
subsection (c)(3) as ex officio members of the Advisory Council
may not receive compensation for service on the Advisory
Council in addition to the compensation otherwise received for
duties carried out as officers of the United States.
``(i) Staff.--The Director shall provide to the Advisory Council
such staff, information, and other assistance as may be necessary to
carry out the duties of the Council.
``SEC. 922. PEER REVIEW WITH RESPECT TO GRANTS AND CONTRACTS.
``(a) Requirement of Review.--
``(1) In general.--Appropriate technical and scientific
peer review shall be conducted with respect to each application
for a grant, cooperative agreement, or contract under this
title.
``(2) Reports to director.--Each peer review group to which
an application is submitted pursuant to paragraph (1) shall
report its finding and recommendations respecting the
application to the Director in such form and in such manner as
the Director shall require.
``(b) Approval as Precondition of Awards.--The Director may not
approve an application described in subsection (a)(1) unless the
application is recommended for approval by a peer review group
established under subsection (c).
``(c) Establishment of Peer Review Groups.--
``(1) In general.--The Director shall establish such
technical and scientific peer review groups as may be necessary
to carry out this section. Such groups shall be established
without regard to the provisions of title 5, United States
Code, that govern appointments in the competitive service, and
without regard to the provisions of chapter 51, and subchapter
III of chapter 53, of such title that relate to classification
and pay rates under the General Schedule.
``(2) Membership.--The members of any peer review group
established under this section shall be appointed from among
individuals who by virtue of their training or experience are
eminently qualified to carry out the duties of such peer review
group. Officers and employees of the United States may not
constitute more than 25 percent of the membership of any such
group. Such officers and employees may not receive compensation
for service on such groups in addition to the compensation
otherwise received for these duties carried out as such
officers and employees.
``(3) Duration.--Notwithstanding section 14(a) of the
Federal Advisory Committee Act, peer review groups established
under this section may continue in existence until otherwise
provided by law.
``(4) Qualifications.--Members of any peer-review group
shall, at a minimum, meet the following requirements:
``(A) Such members shall agree in writing to treat
information received, pursuant to their work for the
group, as confidential information, except that this
subparagraph shall not apply to public records and
public information.
``(B) Such members shall agree in writing to recuse
themselves from participation in the peer-review of
specific applications which present a potential
personal conflict of interest or appearance of such
conflict, including employment in a directly affected
organization, stock ownership, or any financial or
other arrangement that might introduce bias in the
process of peer-review.
``(d) Authority for Procedural Adjustments in Certain Cases.--In
the case of applications for financial assistance whose direct costs
will not exceed $100,000, the Director may make appropriate adjustments
in the procedures otherwise established by the Director for the conduct
of peer review under this section. Such adjustments may be made for the
purpose of encouraging the entry of individuals into the field of
research, for the purpose of encouraging clinical practice-oriented or
provider-based research, and for such other purposes as the Director
may determine to be appropriate.
``(e) Regulations.--The Director shall issue regulations for the
conduct of peer review under this section.
``SEC. 923. CERTAIN PROVISIONS WITH RESPECT TO DEVELOPMENT, COLLECTION,
AND DISSEMINATION OF DATA.
``(a) Standards With Respect to Utility of Data.--
``(1) In general.--To ensure the utility, accuracy, and
sufficiency of data collected by or for the Agency for the
purpose described in section 901(b), the Director shall
establish standards and methods for developing and collecting
such data, taking into consideration--
``(A) other Federal health data collection
standards; and
``(B) the differences between types of healthcare
plans, delivery systems, healthcare providers, and
provider arrangements.
``(2) Relationship with other department programs.--In any
case where standards under paragraph (1) may affect the
administration of other programs carried out by the Department
of Health and Human Services, including the programs under
titles XVIII, XIX and XXI of the Social Security Act, they
shall be in the form of recommendations to the Secretary for
such program.
``(b) Statistics and Analyses.--The Director shall--
``(1) take appropriate action to ensure that statistics and
analyses developed under this title are of high quality,
timely, and duly comprehensive, and that the statistics are
specific, standardized, and adequately analyzed and indexed;
and
``(2) publish, make available, and disseminate such
statistics and analyses on as wide a basis as is practicable.
``(c) Authority Regarding Certain Requests.--Upon request of a
public or private entity, the Director may conduct or support research
or analyses otherwise authorized by this title pursuant to arrangements
under which such entity will pay the cost of the services provided.
Amounts received by the Director under such arrangements shall be
available to the Director for obligation until expended.
``SEC. 924. DISSEMINATION OF INFORMATION.
``(a) In General.--The Director shall--
``(1) without regard to section 501 of title 44, United
States Code, promptly publish, make available, and otherwise
disseminate, in a form understandable and on as broad a basis
as practicable so as to maximize its use, the results of
research, demonstration projects, and evaluations conducted or
supported under this title;
``(2) ensure that information disseminated by the Agency is
science-based and objective and undertakes consultation as
necessary to assess the appropriateness and usefulness of the
presentation of information that is targeted to specific
audiences;
``(3) promptly make available to the public data developed
in such research, demonstration projects, and evaluations;
``(4) provide, in collaboration with the National Library
of Medicine where appropriate, indexing, abstracting,
translating, publishing, and other services leading to a more
effective and timely dissemination of information on research,
demonstration projects, and evaluations with respect to
healthcare to public and private entities and individuals
engaged in the improvement of healthcare delivery and the
general public, and undertake programs to develop new or
improved methods for making such information available; and
``(5) as appropriate, provide technical assistance to State
and local government and health agencies and conduct liaison
activities to such agencies to foster dissemination.
``(b) Prohibition Against Restrictions.--Except as provided in
subsection (c), the Director may not restrict the publication or
dissemination of data from, or the results of, projects conducted or
supported under this title.
``(c) Limitation on Use of Certain Information.--No information, if
an establishment or person supplying the information or described in it
is identifiable, obtained in the course of activities undertaken or
supported under this title may be used for any purpose other than the
purpose for which it was supplied unless such establishment or person
has consented (as determined under regulations of the Secretary) to its
use for such other purpose. Such information may not be published or
released in other form if the person who supplied the information or
who is described in it is identifiable unless such person has consented
(as determined under regulations of the Secretary) to its publication
or release in other form.
``(d) Penalty.--Any person who violates subsection (c) shall be
subject to a civil monetary penalty of not more than $10,000 for each
such violation involved. Such penalty shall be imposed and collected in
the same manner as civil money penalties under subsection (a) of
section 1128A of the Social Security Act are imposed and collected.
``SEC. 925. ADDITIONAL PROVISIONS WITH RESPECT TO GRANTS AND CONTRACTS.
``(a) Financial Conflicts of Interest.--With respect to projects
for which awards of grants, cooperative agreements, or contracts are
authorized to be made under this title, the Director shall by
regulation define--
``(1) the specific circumstances that constitute financial
interests in such projects that will, or may be reasonably
expected to, create a bias in favor of obtaining results in the
projects that are consistent with such interests; and
``(2) the actions that will be taken by the Director in
response to any such interests identified by the Director.
``(b) Requirement of Application.--The Director may not, with
respect to any program under this title authorizing the provision of
grants, cooperative agreements, or contracts, provide any such
financial assistance unless an application for the assistance is
submitted to the Secretary and the application is in such form, is made
in such manner, and contains such agreements, assurances, and
information as the Director determines to be necessary to carry out the
program involved.
``(c) Provision of Supplies and Services in Lieu of Funds.--
``(1) In general.--Upon the request of an entity receiving
a grant, cooperative agreement, or contract under this title,
the Secretary may, subject to paragraph (2), provide supplies,
equipment, and services for the purpose of aiding the entity in
carrying out the project involved and, for such purpose, may
detail to the entity any officer or employee of the Department
of Health and Human Services.
``(2) Corresponding reduction in funds.--With respect to a
request described in paragraph (1), the Secretary shall reduce
the amount of the financial assistance involved by an amount
equal to the costs of detailing personnel and the fair market
value of any supplies, equipment, or services provided by the
Director. The Secretary shall, for the payment of expenses
incurred in complying with such request, expend the amounts
withheld.
``(d) Applicability of Certain Provisions With Respect to
Contracts.--Contracts may be entered into under this part without
regard to sections 3648 and 3709 of the Revised Statutes (31 U.S.C.
529; 41 U.S.C. 5).
``SEC. 926. CERTAIN ADMINISTRATIVE AUTHORITIES.
``(a) Deputy Director and Other Officers and Employees.--
``(1) Deputy director.--The Director may appoint a deputy
director for the Agency.
``(2) Other officers and employees.--The Director may
appoint and fix the compensation of such officers and employees
as may be necessary to carry out this title. Except as
otherwise provided by law, such officers and employees shall be
appointed in accordance with the civil service laws and their
compensation fixed in accordance with title 5, United States
Code.
``(b) Facilities.--The Secretary, in carrying out this title--
``(1) may acquire, without regard to the Act of March 3,
1877 (40 U.S.C. 34), by lease or otherwise through the Director
of General Services, buildings or portions of buildings in the
District of Columbia or communities located adjacent to the
District of Columbia for use for a period not to exceed 10
years; and
``(2) may acquire, construct, improve, repair, operate, and
maintain laboratory, research, and other necessary facilities
and equipment, and such other real or personal property
(including patents) as the Secretary deems necessary.
``(c) Provision of Financial Assistance.--The Director, in carrying
out this title, may make grants to public and nonprofit entities and
individuals, and may enter into cooperative agreements or contracts
with public and private entities and individuals.
``(d) Utilization of Certain Personnel and Resources.--
``(1) Department of health and human services.--The
Director, in carrying out this title, may utilize personnel and
equipment, facilities, and other physical resources of the
Department of Health and Human Services, permit appropriate (as
determined by the Secretary) entities and individuals to
utilize the physical resources of such Department, and provide
technical assistance and advice.
``(2) Other agencies.--The Director, in carrying out this
title, may use, with their consent, the services, equipment,
personnel, information, and facilities of other Federal, State,
or local public agencies, or of any foreign government, with or
without reimbursement of such agencies.
``(e) Consultants.--The Secretary, in carrying out this title, may
secure, from time to time and for such periods as the Director deems
advisable but in accordance with section 3109 of title 5, United States
Code, the assistance and advice of consultants from the United States
or abroad.
``(f) Experts.--
``(1) In general.--The Secretary may, in carrying out this
title, obtain the services of not more than 50 experts or
consultants who have appropriate scientific or professional
qualifications. Such experts or consultants shall be obtained
in accordance with section 3109 of title 5, United States Code,
except that the limitation in such section on the duration of
service shall not apply.
``(2) Travel expenses.--
``(A) In general.--Experts and consultants whose
services are obtained under paragraph (1) shall be paid
or reimbursed for their expenses associated with
traveling to and from their assignment location in
accordance with sections 5724, 5724a(a), 5724a(c), and
5726(C) of title 5, United States Code.
``(B) Limitation.--Expenses specified in
subparagraph (A) may not be allowed in connection with
the assignment of an expert or consultant whose
services are obtained under paragraph (1) unless and
until the expert agrees in writing to complete the
entire period of assignment, or 1 year, whichever is
shorter, unless separated or reassigned for reasons
that are beyond the control of the expert or consultant
and that are acceptable to the Secretary. If the expert
or consultant violates the agreement, the money spent
by the United States for the expenses specified in
subparagraph (A) is recoverable from the expert or
consultant as a statutory obligation owed to the United
States. The Secretary may waive in whole or in part a
right of recovery under this subparagraph.
``(g) Voluntary and Uncompensated Services.--The Director, in
carrying out this title, may accept voluntary and uncompensated
services.
``SEC. 927. FUNDING.
``(a) Intent.--To ensure that the United States's investment in
biomedical research is rapidly translated into improvements in the
quality of patient care, there must be a corresponding investment in
research on the most effective clinical and organizational strategies
for use of these findings in daily practice. The authorization levels
in subsections (b) and (c) provide for a proportionate increase in
healthcare research as the United State's investment in biomedical
research increases.
``(b) Authorization of Appropriations.--For the purpose of carrying
out this title, there are authorized to be appropriated $185,000,000
for fiscal year 2000, and such sums as may be necessary for each of the
fiscal years 2001 through 2006.
``(c) Evaluations.--In addition to amounts available pursuant to
subsection (b) for carrying out this title, there shall be made
available for such purpose, from the amounts made available pursuant to
section 241 (relating to evaluations), an amount equal to 40 percent of
the maximum amount authorized in such section 241 to be made available
for a fiscal year.
``SEC. 929. DEFINITIONS.
``In this title:
``(1) Advisory council.--The term `Advisory Council' means
the Advisory Council on Healthcare Research and Quality
established under section 921.
``(2) Agency.--The term `Agency' means the Agency for
Healthcare Research and Quality.
``(3) Director.--The term `Director' means the Director for
the Agency for Healthcare Research and Quality.''.
SEC. 403. REFERENCES.
Effective upon the date of enactment of this Act, any reference in
law to the ``Agency for Health Care Policy and Research'' shall be
deemed to be a reference to the ``Agency for Healthcare Research and
Quality''.
SEC. 404. STUDY.
(a) Study.--Not later than 30 days after the date of enactment of
any Act providing for a qualifying health care benefit (as defined in
subsection (b), the Secretary of Health and Human Services, in
consultation with the Agency for Healthcare Research and Quality, the
National Institutes of Health, and the Institute of Medicine, shall
conduct a study concerning such benefit that scientifically evaluates--
(1) the safety and efficacy of the benefit, particularly
the effect of the benefit on outcomes of care;
(2) the cost, benefits and value of such benefit;
(3) the benefit in comparison to alternative approaches in
improving care; and
(4) the overall impact that such benefit will have on
health care as measured through research.
(b) Qualifying Health Care Benefit.--In this section, the term
``qualifying health care benefit'' means a health care benefit that--
(1) is disease- or health condition-specific;
(2) requires the provision of or coverage for health care
items or services;
(3) applies to group health plan, individual health plans,
or health insurance issuers under part 7 of subtitle B of title
I of the Employee Retirement Income Security Act of 1974 (29
U.S.C. 1181 et seq.) or under title XXVII of the Public Health
Service Act (42 U.S.C. 300gg et seq.); and
(4) was provided under an Act (or amendment) enacted on or
after January 1, 1999.
(c) Reports.--Not later than 3 years after the date of enactment of
any Act described in subsection (a), the Secretary of Health and Human
Services shall prepare and submit to the appropriate committees of
Congress a report based on the study conducted under such subsection
with respect to the qualifying health care benefit involved.
TITLE V--ENHANCED ACCESS TO HEALTH INSURANCE COVERAGE
SEC. 501. FULL DEDUCTION OF HEALTH INSURANCE COSTS FOR SELF-EMPLOYED
INDIVIDUALS.
(a) In General.--Section 162(l)(1) of the Internal Revenue Code of
1986 (relating to allowance of deductions) is amended to read as
follows:
``(1) Allowance of deduction.--In the case of an individual
who is an employee within the meaning of section 401(c)(1),
there shall be allowed as a deduction under this section an
amount equal to the amount paid during the taxable year for
insurance which constitutes medical care for the taxpayer, his
spouse, and his dependents.''
(b) Effective Date.--The amendments made by this section shall
apply to taxable years beginning after December 31, 1999.
SEC. 502. FULL AVAILABILITY OF MEDICAL SAVINGS ACCOUNTS.
(a) Availability Not Limited To Accounts for Employees of Small
Employers and Self-Employed Individuals.--
(1) In general.--Section 220(c)(1)(A) of the Internal
Revenue Code of 1986 (relating to eligible individual) is
amended to read as follows:
``(A) In general.--The term `eligible individual'
means, with respect to any month, any individual if--
``(i) such individual is covered under a
high deductible health plan as of the 1st day
of such month, and
``(ii) such individual is not, while
covered under a high deductible health plan,
covered under any health plan--
``(I) which is not a high
deductible health plan, and
``(II) which provides coverage for
any benefit which is covered under the
high deductible health plan.''.
(2) Conforming amendments.--
(A) Section 220(c)(1) of such Code is amended by
striking subparagraphs (C) and (D).
(B) Section 220(c) of such Code is amended by
striking paragraph (4) (defining small employer) and by
redesignating paragraph (5) as paragraph (4).
(C) Section 220(b) of such Code is amended by
striking paragraph (4) (relating to deduction limited
by compensation) and by redesignating paragraphs (5),
(6), and (7) as paragraphs (4), (5), and (6),
respectively.
(b) Removal of Limitation on Number of Taxpayers Having Medical
Savings Accounts.--
(1) In general.--Section 220 of the Internal Revenue Code
of 1986 (relating to medical savings accounts) is amended by
striking subsections (i) and (j).
(2) Medicare+choice.--Section 138 of such Code (relating to
Medicare+Choice MSA) is amended by striking subsection (f).
(c) Reduction in High Deductible Plan Minimum Annual Deductible.--
Section 220(c)(2)(A) of the Internal Revenue Code of 1986 (relating to
high deductible health plan) is amended--
(1) by striking ``$1,500'' in clause (i) and inserting
``$1,000'', and
(2) by striking ``$3,000'' in clause (ii) and inserting
``$2,000''.
(d) Increase in Contribution Limit to 100 Percent of Annual
Deductible.--
(1) In general.--Section 220(b)(2) of the Internal Revenue
Code of 1986 (relating to monthly limitation) is amended to
read as follows:
``(2) Monthly limitation.--The monthly limitation for any
month is the amount equal to \1/12\ of the annual deductible of
the high deductible health plan of the individual.''
(2) Conforming amendment.--Section 220(d)(1)(A) of such
Code is amended by striking ``75 percent of''.
(e) Limitation on Additional Tax on Distributions Not Used for
Qualified Medical Expenses.--Section 220(f)(4) of the Internal Revenue
Code of 1986 (relating to additional tax on distributions not used for
qualified medical expenses) is amended by adding at the end the
following:
``(D) Exception in case of sufficient account
balance.--Subparagraph (A) shall not apply to any
payment or distribution in any taxable year, but only
to the extent such payment or distribution does not
reduce the fair market value of the assets of the
medical savings account to an amount less than the
annual deductible for the high deductible health plan
of the account holder (determined as of January 1 of
the calendar year in which the taxable year begins).''.
(f) Effective Date.--The amendments made by this section shall
apply to taxable years beginning after December 31, 1999.
SEC. 503. CARRYOVER OF UNUSED BENEFITS FROM CAFETERIA PLANS, FLEXIBLE
SPENDING ARRANGEMENTS, AND HEALTH FLEXIBLE SPENDING
ACCOUNTS.
(a) In General.--Section 125 of the Internal Revenue Code of 1986
(relating to cafeteria plans) is amended by redesignating subsections
(h) and (i) as subsections (i) and (j) and by inserting after
subsection (g) the following new subsection:
``(h) Allowance of Carryovers of Unused Benefits to Later Taxable
Years.--
``(1) In general.--For purposes of this title--
``(A) notwithstanding subsection (d)(2), a plan or
other arrangement shall not fail to be treated as a
cafeteria plan or flexible spending or similar
arrangement, and
``(B) no amount shall be required to be included in
gross income by reason of this section or any other
provision of this chapter,
solely because under such plan or other arrangement any
nontaxable benefit which is unused as of the close of a taxable
year may be carried forward to 1 or more succeeding taxable
years.
``(2) Limitation.--Paragraph (1) shall not apply to amounts
carried from a plan to the extent such amounts exceed $500
(applied on an annual basis). For purposes of this paragraph,
all plans and arrangements maintained by an employer or any
related person shall be treated as 1 plan.
``(3) Allowance of rollover.--
``(A) In general.--In the case of any unused
benefit described in paragraph (1) which consists of
amounts in a health flexible spending account or
dependent care flexible spending account, the plan or
arrangement shall provide that a participant may elect,
in lieu of such carryover, to have such amounts
distributed to the participant.
``(B) Amounts not included in income.--Any
distribution under subparagraph (A) shall not be
included in gross income to the extent that such amount
is transferred in a trustee-to-trustee transfer, or is contributed
within 60 days of the date of the distribution, to--
``(i) a qualified cash or deferred
arrangement described in section 401(k),
``(ii) a plan under which amounts are
contributed by an individual's employer for an
annuity contract described in section 403(b),
``(iii) an eligible deferred compensation
plan described in section 457, or
``(iv) a medical savings account (within
the meaning of section 220).
Any amount rolled over under this subparagraph shall be
treated as a rollover contribution for the taxable year
from which the unused amount would otherwise be
carried.
``(C) Treatment of rollover.--Any amount rolled
over under subparagraph (B) shall be treated as an
eligible rollover under section 220, 401(k), 403(b), or
457, whichever is applicable, and shall be taken into
account in applying any limitation (or participation
requirement) on employer or employee contributions
under such section or any other provision of this
chapter for the taxable year of the rollover.
``(4) Cost-of-living adjustment.--In the case of any
taxable year beginning in a calendar year after 1999, the $500
amount under paragraph (2) shall be adjusted at the same time
and in the same manner as under section 415(d)(2), except that
the base period taken into account shall be the calendar
quarter beginning October 1, 1998, and any increase which is
not a multiple of $50 shall be rounded to the next lowest
multiple of $50.''
``(5) Applicability.--This subsection shall apply to
taxable years beginning after December 31, 1999.''
(b) Effective Date.--The amendments made by this section shall
apply to taxable years beginning after December 31, 1999.
SEC. 504. PERMITTING CONTRIBUTION TOWARDS MEDICAL SAVINGS ACCOUNT
THROUGH FEDERAL EMPLOYEES HEALTH BENEFITS PROGRAM
(FEHBP).
(a) Government Contribution to Medical Savings Account.--
(1) In general.--Section 8906 of title 5, United States
Code, is amended by adding at the end the following:
``(j)(1) In the case of an employee or annuitant who is enrolled in
a catastrophic plan described by section 8903(5), there shall be a
Government contribution under this subsection to a medical savings
account established or maintained for the benefit of the individual.
The contribution under this subsection shall be in addition to the
Government contribution under subsection (b).
``(2) The amount of the Government contribution under this
subsection with respect to an individual is equal to the amount by
which--
``(A) the maximum contribution allowed under subsection
(b)(1) with respect to any employee or annuitant, exceeds
``(B) the amount of the Government contribution actually
made with respect to the individual under subsection (b) for
coverage under the catastrophic plan.
``(3) The Government contributions under this subsection shall be
paid into a medical savings account (designated by the individual
involved) in a manner that is specified by the Office and consistent
with the timing of contributions under subsection (b).
``(4) Subsections (f) and (g) shall apply to contributions under
this section in the same manner as they apply to contributions under
subsection (b).
``(5) For the purpose of this subsection, the term `medical savings
account' has the meaning given such term by section 220(d) of the
Internal Revenue Code of 1986.''.
(2) Allowing payment of full amount of charge for
catastrophic plan.--Section 8906(b)(2) of such title is amended
by inserting ``(or 100 percent of the subscription charge in
the case of a catastrophic plan)'' after ``75 percent of the
subscription charge''.
(b) Offering of Catastrophic Plans.--
(1) In general.--Section 8903 of title 5, United States
Code, is amended by adding at the end the following:
``(5) Catastrophic plans.--One or more plans described in
paragraph (1), (2), or (3), but which provide benefits of the
types referred to by paragraph (5) of section 8904(a), instead
of the types referred to in paragraphs (1), (2), and (3) of
such section.''.
(2) Types of benefits.--Section 8904(a) of such title is
amended by inserting after paragraph (4) the following new
paragraph:
``(5) Catastrophic plans.--Benefits of the types named
under paragraph (1) or (2) of this subsection or both, to the
extent expenses covered by the plan exceed $500.''.
(3) Determining level of government contributions.--Section
8906(b) of such title is amended by adding at the end the
following: ``Subscription charges for medical savings accounts
shall be deemed to be the amount of Government contributions
made under subsection (j)(2).''.
(c) Effective Date.--The amendments made by this section shall
apply to contract terms beginning on or after January 1, 2000.
<all>
Introduced in Senate
Read twice and referred to the Committee on Finance.
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