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S. 1052 (107th): Bipartisan Patient Protection Act
- Introduced:
- Jun 14, 2001 (107th Congress, 2001–2002)
- Sponsor:
- Sen. John McCain [R-AZ]
- Status:
- Died (Passed Senate)
- See Instead:
- This bill was re-introduced as S. 1945 (108th) on Nov 24, 2003.
The bill’s title was written by the bill’s sponsor. S. stands for Senate bill.
Library of Congress Summary
The summary below was written by the Congressional Research Service, which is a nonpartisan division of the Library of Congress.
6/29/2001.
Title
I
-
Improving Managed Care
Subtitle
A
-
Utilization Review; Claims; and Internal and External Appeals
Requires a group health plan, and a health insurance issuer (plan and issuer) providing health insurance coverage, to conduct utilization review activities in connection with the provision of benefits under such plan or coverage only in accordance with an approved utilization review program. Defines "utilization review" and "utilization review activities" to mean procedures used to monitor or evaluate the use or coverage, clinical necessity, appropriateness, efficacy, or efficiency of health care services, procedures or settings, and includes prospective review, concurrent review, second opinions, case management, discharge planning, or retrospective review. Requires a utilization review program to, among other things, be: (1) administered by qualified health care professionals; and (2) conducted consistent with written policies and procedures that govern all aspects of the program.
Section
102
-
Sets forth procedures concerning initial claims and notice for benefits, including setting forth a timeline for making benefit determinations and expedited determinations any time there is a serious threat to an individual's health or life.
Section
103
-
Provides an appeals procedure and appeals timeline.
Section
104
-
Requires a plan and issuer offering health insurance coverage, to provide beneficiaries, and enrollees (or authorized representatives), upon request, with access to an independent external review for any denial of a claim for benefits. Sets forth penalties for noncompliance. Sets forth standards for reviewers.
Section
105
-
Directs the Secretary of Health and Human Services to establish the Health Care Consumer Assistance Fund to be used to award grants to eligible States to carry out consumer assistance activities designed to provide information, assistance, and referrals to consumers of health insurance products. Authorizes appropriations.
Subtitle
B
-
Access to Care
Requires a plan and issuer providing coverage to provide for coverage of services only if the services are furnished through health care professionals and providers who are members of a network of health care professionals and providers who have entered into a contract with the plan or issuer to provide such services to offer (at the time of enrollment and during an annual open season) the option of health insurance coverage or health benefits which provide for coverage of such services which are not furnished through health care professionals and providers who are members of such a network unless there is also offered non-network coverage through another plan or issuer in the group market.
Section
112
-
Requires a plan or issuer providing for the designation of a participating primary care provider to permit each participant, beneficiary, and enrollee to designate any participating primary care provider or specialist who is available to accept such individual.
Section
113
-
Requires a plan or issuer offering emergency health services to cover emergency health services without prior authorization and by either a participating or nonparticipating health care provider.
Section
114
-
Requires the timely provision of access to specialists.
Section
115
-
Requires direct patient access for obstetrical and gynecological services.
Section
116
-
Requires a plan or issuer providing for the designation of a participating primary care provider for a child to permit the designation of pediatrician as a child's primary care provider.
Section
117
-
Sets forth provisions concerning continuation of care when a provider is terminated.
Section
118
-
Requires a plan or issuer, to the extent that there is coverage for benefits with respect to prescription drugs and such coverage is limited to drugs included in a formulary to: (1) ensure the participation of physicians and pharmacists in developing and reviewing such formulary; (2) provide for disclosure of the formulary to providers; and (3) in accordance with the applicable quality assurance and utilization review standards of the plan or issuer, provide for exceptions from the formulary limitation when a non-formulary alternative is medically necessary and appropriate and, in the case of such an exception, apply the same cost-sharing requirements that would have applied in the case of a drug covered under the formulary.
Prohibits a group health plan (or health insurance offered in connection with such a plan) covering drugs or medical devices from denying of coverage of a drug or device on the basis that the use is investigational, if the use: (1) in the case of a prescription drug, is included in the labeling authorized by the application in effect for the drug pursuant to specified provisions of the Federal Food, Drug, and Cosmetic Act or the Public Health Service Act, without regard to any postmarketing requirements that may apply under either such Act; or (2) in the case of a medical device, is included in the labeling authorized by a regulation or approved application under specified provisions of the Federal Food, Drug, and Cosmetic Act, without regard to any postmarketing requirements that may apply under such Act. States that coverage of prescription drugs or medical devices shall not be required by a group health plan (or health insurance coverage offered in connection with such a plan).
Section
119
-
Prohibits denying a "qualified individual" (an individual who, among other specifications, has a life threatening or serious illness for which there is no effective standard treatment) participation in an approved clinical trial.
Section
120
-
Requires a plan or issuer providing medical and surgical benefits to ensure that inpatient coverage with respect to the treatment of breast cancer is provided for a period of time as is determined by the attending physician, in consultation with the patient, to be medically necessary and appropriate following a mastectomy, a lumpectomy, or a lymph node dissection for the treatment of breast cancer.
Subtitle
C
-
Access to Information
Requires specific covered benefit, cost sharing, disrenrollment, service area, provider, preauthorization requirement, experimental and investigational treatment, specialty care, clinical trial, prescription drug coverage, emergency services, claims and appeals, advance directives and organ donation, and other information to be provided upon initial enrollment and annually. Requires information relating to benefits reduction to be provided at least 30 days before the reduction is effective.
Section
122
-
Prohibits a plan or issuer establishing rules for eligibility (including continued eligibility) of any individual to enroll based on genetic information (or information about a request for or the receipt of genetic services by such individual or a family member of such individual) in relation to an individual or a dependent of such individual.
Prohibits requesting or requiring predictive genetic information concerning an individual or a family member of the individual (including information about a request for or the receipt of genetic services by such individual or a family member of such individual), except as necessary for diagnosis, treatment, or payment.
Requires notice of confidentiality practices, the establishment and maintenance of confidentiality safeguards, and the compliance with specified standards with respect to genetic information.
Subtitle
D
-
Protecting the Doctor-Patient Relationship
Prohibits restricting a health care professional from advising a plan or issuer participant, beneficiary, or enrollee about the health status of the individual or medical care or treatment for the individual's condition or disease based on the coverage provided (or not provided) by the plan or issuer, if the professional is acting within the lawful scope of practice.
Section
132
-
Prohibits a plan from discriminating against a provider, with respect to participation or indemnification, as long as the provider is acting within the scope the provider's license.
Section
133
-
Prohibits a plan or issuer from operating any physician incentive system.
Section
134
-
Requires a plan or issuer to provide for prompt payment of claims.
Section
135
-
Prohibits a plan or issuer from retaliating against a participant or provider due to the utilization of any grievance or utilization review process by a participant or provider.
Subtitle
E
-
Definitions
Sets forth definitions.
Section
152
-
Sets forth provisions concerning preemption of State laws.
Section
153
-
Prohibits anything in this title from being construed to require a plan or issuer to offer specific items or services, other than those provided by the plan or issuer, except that the provisions of sections 111 through 117 shall not apply to a plan when the only coverage offered is fee-for-service coverage.
Title
II
-
Application of Quality Care Standards to Group Health Plans and Health Insurance Coverage Under the Public Health Service Act
Amends the Public Health Service Act to require plans and issuers to adhere to the patient protection requirements of the Bipartisan Patient Protection Act and provides for cooperation between Federal and State authorities.
Section
204
-
Eliminates the option of non-Federal governmental plans to be excepted from requirements concerning genetic information.
Title
III
-
Application of Patient Protection Standards to Federal Health Care Programs
Requires the application of patient protection standards to Federal health care programs.
Title
IV
-
Amendments to the Employee Retirement Income Security Act of 1974
Amends the Employee Retirement Income Security Act of 1974 to require compliance with the patient protection requirements of the Bipartisan Patient Protection Act.
Section
402
-
Sets forth provisions concerning the availability of Federal civil remedies in cases not involving medically reviewable decisions to provide, as a general rule, for liability to a participant or beneficiary (or the estate of such participant or beneficiary) for economic and noneconomic damages (but not exemplary or punitive damages) in connection with the personal injury or death of a participant or beneficiary if a plan or issuer fails to exercise ordinary care in making a decision with respect to the denial of a claim for benefits and such failure to provide benefits is a proximate cause of personal injury to, or the death of, the participant or beneficiary.
Section
403
-
Sets forth provisions concerning: (1) certain limitations on class actions; (2) cooperation between Federal and State authorities; and (3) expressing the sense of the Senate that a court should consider the loss of a nonwage earning spouse or parent as an economic loss.
Title
V
-
Effective Dates; Coordination in Implementation
Sets forth provisions concerning: (1) effective dates; (2) coordination in implementation; (3) severability; and (4) the treatment of religious nonmedical providers.
Title
VI
-
Miscellaneous Provisions
States that: (1) nothing in this Act shall be construed to alter the Social Security Act; and (2) if the Secretary of the Treasury estimates that the enactment of this Act has a negative impact on the income and balances of the Social Security trust funds, the Secretary shall transfer from the general revenues of the Federal Government an amount sufficient so as to ensure that the income and balances of such trust funds are not reduced as a result of the enactment of such Act.
Section
602
-
Amends the Consolidated Omnibus Budget Reconciliation Act of 1985 to extend the fees for certain customs services from September 30, 2003, to September 30, 2011, and March 31, 2006.
Section
603
-
Requires any letter of credit under part B (Supplementary Medical Insurance Benefits for Aged and Disabled) of title XVIII (Medicare) of the Social Security Act that would otherwise be sent to the Treasury or the Federal Reserve Board on September 30, 2002, by a carrier with a contract under such part to be sent on October 1, 2002.
Section
604
-
Expresses the sense of the Senate with respect to: (1) participation in clinical trials and access to specialty care; and (2) fair review process.
Section
606
-
Requires the Secretary of Health and Human Services to annually request that the Institute of Medicine of the National Academy of Sciences prepare and submit to the appropriate committees of Congress a report concerning the impact of this Act on the number of individuals in the United States with health insurance coverage.
Provides for the repeal of section 402 of this Act if the Secretary, in any report submitted, determines that more than one million individuals in the United States have lost their health insurance coverage as a result of the enactment of this Act, as compared to the number of individuals with health insurance coverage in the 12-month period preceding the date of enactment of this Act.
Section
607
-
Amends general provisions of Federal law to state that the terms "person," "human being," and "individual" include a born-alive infant.
House Republican Conference Summary
The summary below was written by the House Republican Conference, which is the caucus of Republicans in the House of Representatives.
No summary available.
House Democratic Caucus Summary
The House Democratic Caucus does not provide summaries of bills.
So, yes, we display the House Republican Conference’s summaries when available even if we do not have a Democratic summary available. That’s because we feel it is better to give you as much information as possible, even if we cannot provide every viewpoint.
We’ll be looking for a source of summaries from the other side in the meanwhile.
The bill contains the following citations to other parts of U.S. law:
United States Code
The United States Code is the compilation of permanent laws enacted by Congress. Temporary and other non-permanent laws do not appear in the United States Code. (About half of the United States Code is the law itself, called positive law. The other half is merely a compilation of the laws but has no legal significance.)
- Title 19: CUSTOMS DUTIES
- Chapter 1: COLLECTION DISTRICTS, PORTS, AND OFFICERS
- Section 58c: Fees for certain customs services
- Title 28: JUDICIARY AND JUDICIAL PROCEDURE
- Part III: COURT OFFICERS AND EMPLOYEES
- Chapter 44: ALTERNATIVE DISPUTE RESOLUTION
- Section 651: Authorization of alternative dispute resolution
- Title 29: LABOR
- Chapter 18: EMPLOYEE RETIREMENT INCOME SECURITY PROGRAM
- Subchapter I: PROTECTION OF EMPLOYEE BENEFIT RIGHTS
- Subtitle B: Regulatory Provisions
- Part 5: administration and enforcement
- Section 1132: Civil enforcement
- Section 1133: Claims procedure
- Section 1144: Other laws
- Part 7: group health plan requirements
- Subpart B: Other Requirements
- Section 1185: Standards relating to benefits for mothers and newborns
- Subpart C: General Provisions
- Section 1191: Preemption; State flexibility; construction
- Title 42: THE PUBLIC HEALTH AND WELFARE
- Chapter 6A: PUBLIC HEALTH SERVICE
- Subchapter XXV: REQUIREMENTS RELATING TO HEALTH INSURANCE COVERAGE
- Part A: Individual and Group Market Reforms
- Subpart 2: exclusion of plans; enforcement; preemption
- Section 300gg-21: Exclusion of certain plans
- Part C: Definitions; Miscellaneous Provisions
- Section 300gg-91: Definitions
- Chapter 7: SOCIAL SECURITY
- Subchapter II: FEDERAL OLD-AGE, SURVIVORS, AND DISABILITY INSURANCE BENEFITS
- Section 401: Trust Funds
- Subchapter XI: GENERAL PROVISIONS, PEER REVIEW, AND ADMINISTRATIVE SIMPLIFICATION
- Part A: General Provisions
- Section 1320a-7b: Criminal penalties for acts involving Federal health care programs
- Part C: Administrative Simplification
- Section 1320d: Definitions
- Section 1320d-2: Standards for information transactions and data elements
- Subchapter XVIII: HEALTH INSURANCE FOR AGED AND DISABLED
- Section 1395: Prohibition against any Federal interference
- Part B: Supplementary Medical Insurance Benefits for Aged and Disabled
- Section 1395j: Establishment of supplementary medical insurance program for aged and disabled
- Section 1395u: Provisions relating to the administration of part B
- Section 1395w: Appropriations to cover Government contributions and contingency reserve
- Part E: Miscellaneous Provisions
- Section 1395dd: Examination and treatment for emergency medical conditions and women in labor
- Subchapter XIX: GRANTS TO STATES FOR MEDICAL ASSISTANCE PROGRAMS
- Section 1396: Medicaid and CHIP Payment and Access Commission
Other Citations
- 1 U.S.C. Chapter 1
- 28 U.S.C. Chapter 44