DOCUMENT RESUME

ED 434 284 CG 029 445

TITLE Managed Care: A Primer on Issues and Legislation.INSTITUTION American Counseling Association, Office of Public Policy and

Information, Alexandria, VA.PUB DATE 1997-09-00NOTE 60p.

AVAILABLE FROM American Counseling Association, Office of Public Policy andInformation, 5999 Stevenson Ave., Alexandria, VA 22304-3300.Tel: 800-347-6647 ext. 222 (Toll Free).

PUB TYPE Guides Non-Classroom (055) Reference MaterialsGeneral (130)

EDRS PRICE MF01/PC03 Plus Postage.DESCRIPTORS Costs; Counselor Role; *Federal Legislation; Federal

Regulation; *Health Insurance; *Health MaintenanceOrganizations; *Health Services; *State Legislation; StateRegulation

IDENTIFIERS Employee Retirement Income Security Act; *ProposedLegislation

ABSTRACTThis report is designed to familiarize American Counseling

Association members with the concepts and terminology of managed care, andthe various options for regulating managed care to safeguard the interestsand rights of professional counselors and their clients. Topics covered inthis report include controlling costs, private sector oversight, growingfederal interest in regulation of managed care, and coalition efforts.Summaries of New York's Managed Care Law and the Patient Access toResponsible Care Act (PACRA) of 1997 are provided. A glossary of managed careterms and information on the Employee Retirement and Income Security Act andthe Mental Health Bill of Rights are also provided. A sample letter insupport of PACRA and a copy of Bill S.644 proposed to amend PACRA areincluded. (MKA)

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Reproductions supplied by EDRS are the best that can be madefrom the original document.

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Office of Public Policy and InformationAmerican Counseling AssociationSeptember 1997

04BEST COPY AVALABLE

U.S. DEPARTMENT OF EDUCATIONOffice of Educational Research and Improvement

EDUCATIONAL RESOURCES INFORMATIONCENTER (ERIC)

O This document has been reproduced asreceived from the person or organizationoriginating it

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Points of view or opinions stated in this docu-ment do not necessarily represent officialOEM position or policy.

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TO THE EDUCATIONAL RESOURCESINFORMATION CENTER (ERIC)."

INTRODUCTION

Today, health care in the United States means managed care. Gone are thedays of traditional indemnity insurance, where insurers paid the bills and lefttreatment decisions to individual health care providers and hospitals. Undercontinual pressure from employers to keep costs down, insurers have nowgotten into the business of both assuming financial risk involved incontracting for employees' needed health care services and overseeing andorchestrating the services actually provided. This sea change is beingmatched by efforts in federal and state legislatures and by the private sectorto ensure that managed care does not result in poor quality care.

This report is designed to familiarize ACA members with the concepts andterminology of managed care, and the various options for regulating managedcare to safeguard the interests and rights of professional counselors and theirclients.

As this report will be updated in the future, we encourage your feedback.Please contact us at (800) 347-6647 x234 to share your thoughts,comments, or other information.

Office of Public Policy and InformationAmerican Counseling Association

5999 Stevenson AvenueAlexandria, VA 22304

(800) 347-6647fax (800) 473-2329

Braden Goetz, Director (x216)Scott Barstow, Assistant Director (x234)Patty Farrell, Legislative Assistant (x241)

e-mail: bgoetz@counseling.orge-mail: sbarstow@counseling.orge-mail: pfarrell@counseling.org

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Table of Contents

Glossary of managed care termsControlling CostsPrivate Sector OversightRegulation of Managed Care -- State and Federal Legislation

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Summary of New York's Managed Care Law (S. 7553) 7-8The ERISA Wall 9Federal Interest in Regulation Growing 10

Summary of the Patient Access to Responsible Care Act of 1997 11

Coalition efforts 12Mental Health Bill of Rights 13-14Sample letter in support of PARCA 15

Managed Care Takes Over

In a report released July 24th, 1997, the U.S. General Accounting Office (GAO) calculated that 70.5percent of Americans under the age of 65 had private health insurance coverage. Of that population, it is

estimated that roughly 4 out of 5 are covered by a managed care organization (MCO). By the year 2000,some experts predict that fewer than one in 10 employees will be covered by a traditional fee-for-service

indemnity plan.

Managed care is coming to dominate the public health care sector, as well. Under the Balanced BudgetAct of 1997, lawmakers made significant changes in both the Medicare and Medicaid programs in orderto speed up the enrollment of beneficiaries in managed care organizations. The proliferation of managedcare coverage in public sector health care programs will have a significant impact on the delivery ofmental health services. Private sector MCO's typically provide care for people with mild to moderateaffective disorders, while the public sector provides care primarily for those with long-term and severemental and emotional disorders.

Managed care can create increased opportunities for professional counselors and other non physicianproviders, and in greater access and in better patient care; it can also result in providers getting shutout of health plans and in reduced access to care. Professional counselors must be familiar withmanaged care, and should become actively involved in state, federal, and private sector initiatives toensure that managed care works for both consumers and providers.

Managed care enrollment has been growing so rapidly because of its impact on health care costs. Arecent study commissioned by the American Association of Health Plans, a managed care trade organi-zation, estimated that between 1990 and 1996 managed care saved private employers over $80 billion inhealth care costs. Since mental health care costs have risen faster than general medical costs, the trendtoward managed care in this sector has also been pronounced. As of 1996, an estimated 124 millionAmericans with private health insurance received their mental health and substance abuse servicesthrough a managed behavioral healthcare plan.

While there is some debate as to whether managed care savings are a one-time phenomenon lasting onlyfor the first year or so of implementation, or are more permanent, there is general agreement that man-aged care does reduce costs. The question increasingly being asked by the public and by policymakersat the state and federal level is how those cost savings are achieved: is it through increased efficiencyand quality of care, or is it through inappropriate denial of coverage and decreased payment levels?

Before discussing this issue in more detail, a definition of terms is in order. Although when someonehears the term "managed care organization" they typically envision a health maintenance organization,or "HMO", there are in fact many different kinds of managed care organizations. In fact, many considerthe very term "managed care organization" to be outdated. In any case, what we usually think of as amanaged care organization can take one of many forms. The short glossary on page three helps clarifysome of the different varieties of managed care organizations, and common terms used in describingmanaged care plans.

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A GLOSSARY OF MANAGED CARE TERMS

Managed Care Organization (MCO), Health Maintenance Organization (HMO) a health care planwhich delivers certain health care services to a group of individuals on a prepaid basis.

Carve-Out an arrangement wherein a portion of a health benefit package is administered orprovided by a subcontracting organization separate from the managed care organization respon-sible for the benefit package as a whole. Most carve-outs pertain to mental health and substanceabuse benefits, which are provided by a managed behavioral healthcare organization.

Staff-model HMO a health maintenance organization in which all health care providers aresalaried employees of the organization, and the facilities and clinics in which enrollees receiveservices are owned by the organization. Patients generally may receive services only from thesehealth care providers.

Group-model HMO an HMO made up of one or more physician group practices that are notowned by the HMO, but that instead operate as independent partnerships or corporations. TheHMO pays the group a negotiated rate, and each group in turn is responsible for paying its healthcare providers and other staff and for paying for hospital care or care from outside specialists.

Preferred Provider Organization (PPO) uses a specific, select group of health care providers whoagree to follow certain practice guidelines and accept specified payment levels for services. Enroll-ees are usually able to obtain services from PPO providers at lower cost than from non-networkproviders.

Managed Behavioral Healthcare Organization (MBHO) contracts with a larger entity, typicallyanother managed care organization, for the provision of mental health and substance abuse ser-vices to plan enrollees. This arrangement, wherein a portion of the benefit package is adminis-tered by a separate subcontracting organization, is known as a "carve out".

Provider Sponsored Organization IPSO) an organization established by a group of health careproviders who join together to set up their own network of service-delivery personnel and facilities.

Management Services Organization (MSO) a company which contracts with health careprovider groups for handling their business needs, including billing, collecting fees, and the like.

Network the collection of physicians, health care providers, clinics, hospitals, and other facilitiesand personnel that a managed care plan has selected to provide services to its enrollees.

Point Of Service option (POS) a type of managed care plan coverage under which an enrollee isallowed to see providers outside of the managed care plan's network, usually at a slightly highercopayment or deductible cost.

Capitation a method of paying for health care services on a per-person (or "per covered life")basis rather than on a per-procedure basis (as in traditional indemnity insurance). Under this formof payment, a managed care plan pays a health care provider a fixed amount of money for everyplan enrollee he or she sees, regardless of how much or how little care the member receives.

Termination without Cause many managed care plan provider contracts allow the plan to termi-nate the provider's contract "without cause," thus allowing the managed care plan to unilaterallyend the contract without providing an explanation or access to an appeals procedure.

Incentive clause a provision in a managed care plan employee contract which links compensa-tion to denial or limiting of services provided to plan enrollees.

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In any of its forms, a managed care organization is an entity which provides a specific set of benefits fora pre-determined amount of money, accepting the financial risk associated with being responsible forproviding care. Managed care organizations exercise a degree of control over how services are providedand how providers are paid which traditional indemnity plans do not. Consequently, MCO's see them-selvesand their providersas responsible for the entire enrollee population, and thus obligated toensure that limited resources are distributed equitably. This perspective often conflicts with the tradi-tional caregiver-patient dyad, in which the individual patient is of paramount importance.

Managed care plans' control over service delivery manifests itself in many different ways. One is thatMCOs typically exhibit a high degree of "vertical integration". In fact, many analysts prefer to use theterm "integrated systems of care" instead of "managed care". When fee-for-service health care ruled theland, a hospital, independent health service provider, and health clinic would each operate largely inde-pendently. Each would see a patient, and then bill the patient's health insurance for the care provided.Today that same hospital, health clinic, and a number of health providers may be under contract with (ifnot "owned" by) a managed care firm. Thus, an individual enrollee receives careor payment forcarefrom the same organization, regardless of whether that care is provided in a therapist's office, anoutpatient clinic or day treatment facility, or a hospital.

Controlling Costs

Managed care plans control costs in a number of ways:

limiting who gets on provider pools and networksIn general, the fewer providers a managedcare plan has on staff, the fewer health care services it is likely to have to pay for. The influenceof this practice can be subtle. A health plan could choose to sign up fewer specialists, whoprovide higher-cost services more frequently, or could choose to sign up fewer providers in low-income neighborhoods, whose residents may need more health care services.

limiting access to network providersEven though a managed care plan signs you up as ahealth care provider, it may simply decide not to refer any of its enrollees to you. Most managedcare plans require enrollees to obtain care by first going through a primary care provider (PCP),often a family or general practitioner, who acts as a gatekeeper to any specialty care needed.

negotiating lower reimbursement rates with hospitals, clinics, providers, and providergroupsThis is a common occurrence. Managed care plans are frequently able to convincehealth care providers to accept lower payment rates in return for access to a large pool of pa-tients. In New York, a class action lawsuit has been filed against nine managed care firms,alleging price fixing in their payments for mental health services.

limiting providers' use of servicesThis is the most visible, and most complained about,aspect of managed care. Almost all managed care plans conduct utilization review ("UR") ofproviders' claims and activities, essentially employing someone to look over the practitioner'sshoulder. Unfortunately, utilization reviewers are frequently not as highly trained as the healthcare providers administering the health care services in question, and as a rule tend to look athealth care services with a skeptical eye. In fact, managed care plans have been known to paytheir utilization reviewers based on the quantity of health care services they deny. One of themore frustrating managed care practices is the retrospective denial of coverage for needed ser-viceseven including emergency room services(!)following which the patient may be stuckwith the bill.

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This control over expenditures is causing increasing concern among many health care providers andpatients. Although studies have not conclusively shown that managed care results in poorer quality care,horror stories regarding inappropriate denials of care by managed care companies abound. Patients havebeen forced to wait for months to see a specialist, and in many cases have been denied coverage forneeded treatments. In some cases, such denials are claimed to have led to the death of the patient.Individuals needing mental health treatment may find that their managed care plan will only pay foreight outpatient therapy sessions for their diagnosis, forcing them to either begin paying out-of-pocket orforcing the provider to enter into a negotiations with the plan's utilization reviewer. Utilization review-ers frequently request copies of the therapist's notes regarding a patient before approving payment.

Managed care's dominance has dramatically reduced the degree of control health care providers haveover patient treatment. The traditional provider-patient relationship has been replaced with a newconfiguration: provider-patient-payer. There are now essentially three people in the room, and one ofthem holds the purse strings.

Private Sector Oversight

Although they are usually pleased with managed care's ability to hold down costs, employers havestarted paying more attention to what they are getting for their coverage dollar. In response, organiza-tions have emerged to help gauge HMO's quality. Many people are familiar with JCAHO, the JointCommission on Accrediation of Healthcare Organizations, a non-profit organization whose mission is toimprove the quality of health care services. Over the years, JCAHO accreditation became the primaryquality of care yardstick for hospitals and institutions, and was recognized by the Medicare and Medic-aid programs as evidence of an acceptable level of care quality.

Similar accreditation and quality measurement efforts have developed in regard to managed care plans,involving a number of organizations. The most influential of these is the National Committee for Qual-ity Assurance (NCQA), non-profit organization which accredits managed care organizations and reportson their quality of care. More than 75% of all Americans covered by HMOs are in HMOs that havebeen reviewed by NCQA; many employers require NCQA accredition of the managed care plans withwhich they contract. NCQA's 1997 standards for accreditation of managed behavioral healthcareorganizations (MBHOs) include requirements for quality management and improvement programs,utilization management, credentialing and recredentialing of practitioners, members' rights and responsi-bilities, preventive health services, and use and maintenance of medical records.

In addition to accrediting managed care plans, NCQA has developed the Health Plan/Employer Data andInformation Set ( HEDIS, pronounced "HEE-dis"), a standardized performance measurement data set tomeasure health plan quality. Many states and employers require managed care plans to report HEDISdata to enable them to gauge plans' quality and performance, and the Health Care Financing Administra-tion (HCFA) also requires all Medicare managed care plans to report such data. It is worth mentioningthat one of the pieces of information regarding an MCO called for by the most recent version of HEDISin use, HEDIS 3.0, is the number of mental health professionals it has on staff. ACA was able to con-vince NCQA that mental health counselors should be explicitly included in the definition of 'mentalhealth professionals'.

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Other organizations monitoring managed care plan service quality include JCAHO, which began accred-

iting managed care organizations in 1989. The American Accreditation Health Care Commission(formerly known as the Utilization Review Accreditation Commission, or URAC) accredits utilizationreview organizations, and is developing standards for measuring the performance of provider networks.

Although a help, private-sector accreditation of managed care plans has not eliminated "bad" managedcare plan practices, nor should it be expected to. A managed care version of the Better Business Bureaucan help smart consumers in purchasing quality health care. However, just as state and federal laws helpmaintain order and prevent abusive business practices in other areas of the economy, they are needed todo the same for the health insurance industry, including managed care.

Regulation of Managed Care State and Federal Legislation

Managed care plans are principally regulated by states, which under the McCarran-Ferguson Act of1945 are given authority to regulate the business of insurance. All states regulate HMOs to some extent,either through their insurance department or through other agencies, such as health departments. Asdiscussed below, however, there are important limitations on states' authority to regulate health insur-ance. Despite this fact, states remain where the action is on managed care regulation.

Concerns about managed care's impact on patients' access to care, on the quality of that care, and on the

provider-patient relationship have helped spur this action. According to a report by the organizationFamilies USA, during 1996 managed care legislation and regulations were passed or issued in 40 states.More such laws were enacted in 1997. Because of the complex nature of health services and the way in

which they are provided, managed care's influence over how services are delivered is omnipresent.States are fighting the general incentive to undertreatand the specific managed care plan practices in

which it manifests itselfthrough a number of initiatives. As with traditional insurance plans, moststates regulate HMOs' protections against insolvency, consumer greivance systems, and marketingactivities, and require that they cover a basic set of benefits. Types of laws designed specifically toprotect consumer and providers from certain managed care plan practices include the following.

Access to providerssome states require health plans to offer point-of-service coverage options,thus making it possible for consumers to maintain choice of health care practitioner. States may alsorequire health plans to accept on their network or panel any health care practitioner willing to adhereto the plan's contract and practice requirements. These laws are known as "any willing provider"laws. Many states have enacted laws requiring health plans to provide direct access to certain typesof specialists, such as obstetricians and gynecologists, and to ensure that plans cover needed emer-gency room care. Also in this category are laws prohibiting discrimination against providers basedon their type of license or certification.

Plan informationstates are increasingly requiring plans to provide information regarding theirpractices to consumers and providers alike. In 1995 and 1996, 13 states passed laws or implementedregulations requiring health plans to provide information to enrollees and prospective enrolleesregarding their referral, prior authorization, and utilization review policies and requirements. In thesame time period, 12 states took the same step with regard to information about plans' providercompensation arrangements.

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Provision of careMany states have placed restrictions on plans' use of gag-rule provisions in theircontracts with providers. As of March of 1997, seven states had enacted laws requiring plans toallow enrollees, in certain circumstances, for a period of time, to continue seeing providers whosecontracts with the plan had been terminated. A number of states have laws on the books requiringthat plans' utilization review operations adhere to certain standards for timeliness of decisions, andfor development and implementation of standards by appropriate specialists and medical personnel.

The primary example of legislation focused directly on managed care's impact on health care providersis known as "any willing provider" legislation. Under such a law, managed care plans are required tocontract with or employ any provider willing to agree to the managed care plan's terms and conditions.States which have passed "any willing provider" laws include Washington, Idaho, Wyoming, Colorado,Illinois, Indiana, Kentucky, Virginia, and Arkansas. Generally, "any willing provider" laws apply toprofessional counselors if they are licensed or certified by the state. However, many states have passedsuch laws pertaining only to pharmacy services.

Any willing provider laws seem to be becoming less popular among policymakers. They are frequentlynot as effective as billed, as the laws may not apply to all forms of managed care plans, particularlystaff-model HMO's. Those plans to whom the laws do apply often use delaying tactics to stall provid-ers; for example, a plan may admit a practitioner onto their network, but may simply not refer anypatients to the practitioner. Also, questions have been raised as to whether point-of-service plans meet"any willing provider" law requirements, and on whether the federal Employee Retirement IncomeSecurity Act (ERISA) preempts "any willing provider" laws. Insurers and managed care plans arefighting these laws and similar legislative proposals aggressively.

In the same category of provider-oriented legislation are laws establishing certain "due process" protec-tions for health care practitioners. One example is legislation prohibiting managed care plans fromterminating or not renewing a provider's contract unless the plan gives the provider, prior to termination,a written explanation of the reasons for the proposed termination, and gives the provider an opportunityfor a review or hearing regarding the termination. Other such provisions are laws forbidding managedcare plan-provider contracts from including "termination without cause" provisions.

In addition to regulating specific practices of managed care organizations, some states are considering abroader approach. Last year, New York enacted an initiative covering a range of consumer protectionissues (see box on pages 7-8). Earlier this year, the state of Texas enacted a law holding managed careplans liable for negligent decisions when the denial of medically necessary treatment results in harm orinjury to a patient. This law, the first of its kind enacted by a state, is viewed by many advocates as asuitable response to managed care plans' often intense micromanagement of patient care, and the fre-quency with which managed care plan administrators involve themselves in treatment decisions. Man-aged care plan liability legislation was also considered in 1997 by state legislatures in California, Con-necticut, Georgia, Maine, Maryland, New York, Rhode Island, South Carolina, Tennessee, and WestVirginia. A similar bill was passed by the Florida state legislature in 1996, but was vetoed by the gover-nor. Other statesincluding Arkansas, Alabama, Hawaii, Idaho, Illinois, Missouri, New Hampshire,New York, Ohio, South Carolina, Washington, and West Virginiaare considering legislation prohibit-ing plans from including "hold harmless" provisions in their provider contracts.

These and other state laws show the widespread interest among states in making sure that managed careplans provide accessible, high-quality care to the patients they serve.

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SUMMARY OF NEW YORK'S MANAGED CARE LAW (S. 7553)

ACCESS TO CARE

HMOs must have a sufficient number of geographically accessible providers tomeet enrollees' needs, and services provided must be culturally and linguisticallyappropriate;

HMOs must have procedures for providing enrollees with a "standing referral" tospecialists in cases where the enrollee needs ongoing specialty care;

HMOs must permit new enrollees with life-threatening or disabling and degenera-tive conditions to continue seeing their current provider for 90 days, if the pro-vider meets HMO requirements. For a provider disaffiliating with an HMO, theHMO must allow these enrollees (including enrollees in the 2nd or 3rd trimesterof pregnancy, through post-partum care) to continue seeing the provider for upto 90 days;

HMOs must provide out-of-network referrals for patients if the HMO does nothave network providers with appropriate training and experience;

HMOs cannot require prior authorization for emergency services, and may notdeny payment for services needed to stabilize or treat an emergency condition;

UTILIZATION REVIEW

Utilization review (UR) companies, including HMOs conducting UR on enrolleeclaims, must register with state's Commissioner of Insurance, and must providea UR plan to the Commissioner. The plan must describe the process used fordeveloping written clinical review criteria; practice guidelines and standards usedto determine medical necessity; procedures for evaluation of written clinicalreview criteria; and the qualifications and experience of those involved in devel-oping, evaluating, and interpreting UR criteria. Utilization review entities mustdevelop written UR policies and procedures, and make a written description ofthese procedures available to enrollees and providers;

Reviews of adverse coverage determinations made by an UR company/entitymay only be made by a "clinical peer" of the practitioner who provided the ser-vice in question;

UR companies/entities may not compensate employees or contractors using anymethod which would encourage the rendering of adverse coverage decisions;

GRIEVANCE PROCEDURES

HMOs must notify enrollees of the grievance procedure in the member hand-book, and upon any denial of coverage or service referral;

HMOs must allow enrollees to file grievances orally, including through a toll-freephone number open 40 hours a week during normal business hours;

HMOs must resolve grievances within 48 hours if a delay would significantlyharm the enrollee's health, and within 30 days in cases regarding referrals ordeterminations on benefit coverage;

HMO grievance determinations must be in writing, and include detailed reasonsfor the determination and the relevant clinical basis for the determination, infor-mation on how to file an appeal of the determination, and the appeal form;

Personnel responding to an appeal must be qualified to review the appeal andmust not have been involved in the initial determination; at least one of the peerreviewers must be a licensed physician in the same or similar specialty as thepractitioner managing the treatment under review;

PROVIDER PROTECTIONS

HMOs cannot terminate a provider's contract or employment, or refuse to renewa contract solely because a provider advocates on behalf of an enrollee, has fileda complaint against the plan, appealed a plan decision, or provided informationon plan quality to state agencies;

Prior to terminating a provider's contract, HMOs must provide a notice includingthe reasons for the termination and notice of the right to request a hearingor review (this provision does not apply in cases of provider fraud, disciplinaryaction against the provider, or imminent harm to patient care);

HMOS must inform providers of the information maintained to evaluate theprovider's performance, including profiling data and analysis. Plans must takeinto account the health needs of the provider's patients when evaluating theprovider's performance;

Health plans may not adopt contracts or written policies or procedures thatprohibit or restrict providers from disclosing to an enrollee (or prospective en-rollee) information regarding a condition or course of treatment, the availability oftherapies or tests, or the terms of the plan's coverage;

Health plans may not prohibit or restrict a provider from advocating on behalf ofan enrollee for coverage of a particular course of treatment or service;

Health plans may not prohibit or restrict a provider's ability to file a complaint,make a report, or comment to a governmental body regarding the plan's policiesor practices.

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However, states frequently find themselves hamstrung by federal preemption of their general author-

ity to regulate insurance plans, under a law known as "ERISA" the Employee Retirement andIncome Security Act. ERISA divides the the private health insurance universe into two parts: thosebusinesses who purchase health insurance coverage from a health plan, and those businesses whichself-insure, using their own money to pay for health services. These self-insured planswhichprovide coverage to millions of Americansare not subject to state regulation.

The ERISA Wall

ERISA has formed a long-standing barrier to state activity in the health insurance field. Passed byCongress and signed into law in 1974, ERISA was enacted to correct problems of fraud and misman-agement of employee benefit plans, and particularly pension funds. However, while the law placesmany specific requirements on pension programs, it imposes few standards on other benefit plans,including health benefit plans.

States have traditionally held primary responsibility for regulating the insurance industry within theirborders. Although federal laws usually permit states to regulate in areas where federal law is silent,ERISA contains language which virtually prohibits states from enacting laws regulating or affectingemployee health benefit plans. Thus, although a state can pass laws dictating specific practicesamong health insurance companies, it is forbidden from interfering with employers who operate theirown health plans for their employees. As a result of ERISA, more and more employers are choosingto "self-insure"and thus operate their health plans outside of state lawrather than purchasehealth insurance from an insurance company such as Blue Cross/Blue Shield. This broad preemp-tion of state law was intended by lawmakers, although few could have foreseen its long-term effecton U.S. health policy. At the time of its enactment, few states were considering health care reformlegislation, and many expected sweeping federal health care reform legislation to be enacted shortly.

ERISA preemption is affecting a large and growing number of people. According to a report by thefederal General Accounting Office (GAO), of the 114 million Americans with employer-providedhealth coverage in 1993, roughly 40 percent were enrolled in a plan self-funded by their employer.Thus, the health insurance policies and practices applying to this population are outside the jurisdic-tion of state regulation. As the GAO report states, "Although ERISA includes fiduciary standards toprotect employee benefit plan participants and beneficiaries from plan mismanagement and otherrequirements, in other areas no federal requirements comparable with state requirements for healthinsurers exist for self-funded health plans."

ERISA has preempted many different kinds of state laws, including laws requiring reimbursement ofcertain classes of health care providers or requiring coverage of specific benefits. In January of1997, the U.S. District Court for the Eastern District of Arkansas ruled that Arkansas' Patient Protec-tion Act, which required health plans to include any qualified health care service provider willing tomeet the plan's participation terms, is preempted by ERISA, and issued an order permanently enjoin-ing the Act's enforcement. In May, a similar ruling was issued against a Washington state lawrequiring health carriers to make available to subscribers all categories of certified health care pro-viders. Texas' recent law allowing managed care plans to be held liable for inappropriate denials ofcare, mentioned above, is currently being held up in court. Aetna Health Plans of Texas is suing thestate in federal court to block the law, arguing that it is preempted by ERISA. It is unclear whether

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or not the law will ultimately be upheld.

This ongoing barrier to state action places added pressure on Congress to take up the slack. Somewhatsurprisingly, there is currently no movement at the federal level towards lifting ERISA's preemptionprovisions. Instead, consideration is being given to allowing small employers to band together to formmultiple employer welfare arrangements (MEWAs) for the purposes of buying health insurance. Underthis proposal, MEWAs would be exempt from state regulation under ERISA, thus placing even moreAmericans out of the reach of state health insurance laws.

Federal Interest in Regulation Growing

Due to widespread public concern over managed care's impact on quality of care, federal lawmakers arebeginning to follow state legislators down the path of managed care regulation. Federal legislation inthis area would have the added benefit of applying to all health plans, including self-insured plansimmune to state regulation due to ERISA. In 1996, Congress for the first time passed legislation, latersigned into law by the President, to specifically mandate certain managed care plan practices. Under theNewborns' and Mothers' Health Protection Act (enacted as part of Public Law 104-204), all grouphealth plans and individual insurers providing maternity benefits must cover no less than 48 hours ofinpatient hospital care for mothers and their newborns. Inpatient stays for cesarean births must becovered for no less than 96 hours.

That same law included the Mental Health Parity Act, which prohibits health insurance policies fromproviding different lifetime and annual dollar coverage limits for mental health services than are pro-vided for general medical services. Enactment of these laws demonstrates a new-found willingness onthe part of the federal government to dictate private sector health benefit plan practices.

Just as states are considering broad legislative proposals to regulate HMOs, such legislation is beingbrought before Congress. Perhaps the leading proposal before the 105th Congress is the "Patient Accessto Responsible Care Act of 1997" (PARCA). This legislation (H.R. 1415/S. 644), sponsored by Rep.Charles Norwood (R-GA) and Senator Alfonse D'Amato (R-NY), would place a number of require-ments on health plans, including managed care plans (see page 11).

Perhaps most importantly for professional counselors, the legislation includes a provision prohibitinghealth plans from discriminating against a health care practitioner based on that practitioners' particulartype of licensure or certification. Closed-panel HMOs would be required to offer point-of-servicecoverage, and would be required to ensure direct access to specialists as needed by enrollees withchronic conditions or special needs.

The Patient Access to Responsible Care Act ("PARCA") is unique because it includes a broad range ofconsumer and provider protections, and is sponsored by Republican members in the House and Senate.Counselors are encouraged to write or call their Representative and Senators to urge them to cosponsorthe PARCA bills. A sample letter is included in this report on page 15. It is crucial that members ofCongress know that this legislation is supported by their constituents. Other managed care bills havebeen introduced in the 105th Congress, and it is hoped that hearings on managed care issues will be heldlater in the Congress by the committees with jurisdiction over health care issues.

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SUMMARY OF THE PATIENT ACCESS TO RESPONSIBLE CARE ACT OF 1997

(H.R. 1415/S. 644)

ACCESS TO CARE

health plans would be required to maintain asufficient number, mix, and distribution ofhealth professionals and providers to ensureadequate access to care for enrollees;

health plans would be prohibited from requir-ing prior authorization for coverage of emer-gency services to enrollees with symptomsthat reasonably suggest an emergencymedical condition;

health plans must allow enrollees to selecttheir provider from among the plan's partici-pating health professionals, and to changethat selection as appropriate;

if the health plan utilizes a closed panel ofhealth care providers, the plans must offer apoint-of-service option to its enrollees;

health plans must ensure direct access torelevant specialists as needed for the contin-ued care of enrollees with special needs orchronic conditions;

health plans would be required to establishan appeals process for adverse coveragedecisions;

NONDISCRIMINATION/PROVIDER PROTECTIONS

health plans would be prohibited from dis-criminating against an individual on the basisof race, gender, socio-economic status, age,health status, or anticipated need for healthservices;

health plans would be prohibited fromdisciminating in the selection of the mem-bers of its health professional network onthe basis of race, age, gender, health status,or lack of affiliation with, or admitting privi-leges at, a hospital;

health plans would be prohibited from dis-criminating in the selection, reimbursement,or indemnification of a licensed or certifiedhealth professional solely on the basis of theprofessional's license or certification;

(NONDISCRIMINATION/PROVIDER PROTECTIONS CONTINUED)

health plans would be prohibited from inter-fering with a health professional's medicalcommunications with his or her patient;

at least once each year, health plans wouldbe required to provide all health professionalsand providers in its service area with anopportunity to apply to become a participat-ing provider;

health plans would be prohibited from includ-ing in its contracts with participating healthproviders a provision permitting the healthplan to terminate the contract withoutcause;

health plans would be required to providereasonable notice of any decision to termi-nate a health professional, and to provide anopportunity to review and discuss all of theinformation on which the determination isbased;

PLAN INFORMATION

health plans would be required to provideenrollees and prospective enrollees withinformation regarding...

benefits and benefit exclusions;the percentage of premium used for

administration and marketing of theplan, and the percentage expendeddirectly for patient care;

the number, mix, and distribution ofparticipating health professionals;

the ratio of enrollees to participatinghealth professionals;utilization review requirements issuer;financial arrangements and incentivesthat may limit or restrict access toservices;

the percentage of utilization reviewdeterminations that disagree with thejudgement of the treating health profes-sional and the percentage of suchdeterminations that are reversed onappeal.

ii 15

As in state legislatures, proponents of bills in Congress to regulate certain managed care plan practicesare likely to find the going tough. Managed care plans and insurers argue that `micromanagemene oftheir practices will lead to increased costs of operation, and will make health insurance less affordable tobusinesses and individuals. Not surprisingly, business groups have also typically opposed managed careregulation bills. Both insurers and business wield considerable influence on Capitol Hill, using a largecorps of lobbyists and generous political campaign contributions. According to the watchdog organiza-tion Common Cause, in the first six months of 1997 the insurance industry contributed $1.67 milliondollars in 'soft' money political contributions to the Republican Party, which currently controls Con-gress. Since 1987, the National Association of Business PACs has made similar contributions totaling$174 million. Neither of these dollar totals account for direct contributions made by these groups to thecampaign committees of individual members of Congress. However, groups supporting initiativesaimed at regulating managed care plan practices enjoy broad public support, and include some organiza-tions with deep pockets of their own, such as the American Medical Association.

Coalition Efforts

Although managed care plans and the insurance and business sectors are powerful, managed care regula-tion legislation can be enacted over their opposition. Typically, coalitions in support of managed careregulation legislation are comprised of health care consumer and health care provider groups. Some ofthe more well-known such groups are listed below, along with the acronyms of the correspondingnational organizations.

ACA is currently involved in three different coalitions working specifically on managed care issues: acoalition supporting the Patient Access to Responsible Care Act; a group of mental health professionalorganizations which has drafted a set of principles for the provision of mental health and substanceabuse treatment services within managed care organizations, released in February of this year (see pages14-15); and a group of non-physician health practitioner organizations which have joined together towork with the National Committee on Quality Assurance on non-physician provider issues.

National Consumer groups Phone number web address e-mail

Citizen Action 202 775-1580 www.citizenaction.orgU.S. Public Interest Research Group 202 546-9707 www.pirg.org/pirg uspirg@pirg.orgNational Mental Health Association 703 684-7722 www.nmha.org nmhainfo@aol.com

National Alliance for the Mentally Ill 800 950-6264 www.nami.org namiofc@aol.com

A number of other state consumer organizations exist, under a variety of names. These can often befound by checking the phone book under "Consumer", trying one of the groups above, and/or asking thepeople you talk to for the names of other consumer organizations working on healthcare or managedcare issues.

National Provider groups Phone number web address e-mailNational Association of Social Workers 202 408-8600 www.naswdc.org info@naswdc.orgAmerican Chiropractic Association 703 276-8800 www.amerchiro.org memberinfo@amerchiro.orgAmerican Physical Therapy Association 703 684-2782 www.apta.org components@apta.orgAmerican Nurses Association 800 274-4262 www.ana.org webfeedback@ana.orgAmerican Medical Association 312 464-5000 www.ama-assn.org WebAdmin@ama-assn.orgAmerican Psychological Association 202 336-5500 www.apa.org webmaster@apa.orgAmerican Psychiatric Association 202 682-6060 www.psych.org

12 16

MENTAL HEALTH BILL OF RIGHTS PROJECT

A Joint Initiative of Mental Health Professional Organizations

Principles for the Provision ofMental Health and Substance Abuse Treatment Services

A BILL OF RIGHTS

Our commitment is to provide quality mental health and substance abuse services to all individuals without regardto race, color, religion, national origin, gender, age, sexual orientation, or disabilities.

Right to Know

Benefits

Individuals have the right to be provided informationfrom the purchasing entity (such as employer or union orpublic purchaser) and the insurance/third party payerdescribing the nature and extent of their mental healthand substance abuse treatment benefits. This informationshould include details on procedures to obtain access toservices, on utilization management procedures, and onappeal rights. The information should be presentedclearly in writing with language that the individual canunderstand.

Professional Expertise

Individuals have the right to receive full informationfrom the potential treating professional about thatpro-fessional's knowledge, skills, preparation, experience,and credentials. Individuals have the right to be informedabout the options available for treatment interventionsand the effectiveness of the recommended treatment.

Contractual Limitations

Individuals have the right to be informed by the treatingprofessional of any arrangements, restrictions, and/orcovenants established between third party payer and thetreating professional that could interfere with or influencetreatment recommendations. Individuals have the right tobe informed of the nature of information that may bedisclosed for the purposes of paying benefits.

Appeals and Grievances

Individuals have the right to receive information aboutthe methods they can use to submit complaints or griev-ances regarding provision of care by the treating

1 "( 13

(Appeals and Grievances, continued)professional to that profession's regulatory board and tothe professional association.

Individuals have the right to be provided informationabout the procedures they can use to appeal benefitutilization decisions to the third party payer systems, tothe employer or purchasing entity, and to external regula-tory entities.

Confidentiality

Individuals have the right to be guaranteed the protectionof the confidentiality of their relationship with theirmental health and substance abuse professional, exceptwhen laws or ethics dictate otherwise. Any disclosure toanother party will be time limited and made with the fullwritten, informed consent of the individuals.

Individuals shall not be required to disclose confidential,privileged or other information other than: diagnosis,prognosis, type of treatment, time and length of treat-ment, and cost.

Entities receiving information for the purposes ofbenefits determination, public agencies receiving infor-mation for health care planning, or any other organizationwith legitimate right to information will maintain clinicalinformation in confidence with the same rigor and besubject to the same penalties for violation as is the directprovider of care.

Information technology will be used for transmission,storage, or data management only with methodologiesthat remove individual identifying information and assurethe protection of the individual's privacy. Informationshould not be transferred, sold or otherwise utilized.

Choice

Individuals have the right to choose any duly licensed/certified professional for mental health andsubstance abuse services. Individuals have the right to

receive full information regarding the education andtraining of professionals, treatment options (includingrisks and benefits), and cost implications to make aninformed choice regarding the selection of care deemedappropriate by individual and professional.

Determination of Treatment

Recommendations regarding mental health and substanceabuse treatment shall be made only by a dulylicensed/certified professional in conjunction with the

individual and his or her family as appropriate.Treatment decisions should not be made by third partypayers. The individual has the right to make finaldecisions regarding treatment.

Parity

Individuals have the right to receive benefits for mentalhealth and substance abuse treatment on the same basis asthey do for any other illnesses, with the same provisions,co-payments, lifetime benefits, and catastrophic coveragein both insurance and self-funded/self-insured healthplans.

Discrimination

Individuals who use mental health and substance abusebenefits shall not be penalized when seeking other healthinsurance or disability, life or any other insurance benefit.

Benefit Usage

The individual is entitled to the entire scope of thebenefits within the benefit plan that will address his orher clinical needs.

Benefit Design

Whenever both federal and state law and/or regulationsare applicable, the professional and all payers shall usewhichever affords the individual the greatest level ofprotection and access.

Treatment Review

To assure that treatment review processes are fair andvalid, individuals have the right to be guaranteed that anyreview of their mental health and substance abuse treat-ment shall involve a professional having the training,credentials and licensure required to provide the treat-ment in the jurisdiction in which it will be provided. Thereviewer should have no financial interest in the decisionand is subject to the section on confidentiality.

Accountability

Treating professionals may be held accountable andliable to individuals for any injury caused by grossincompetence or negligence on the part of the profes-

sional. The treating professional has the obligationto advocate for and document necessity of care and toadvise the individual of options if payment authorizationis denied.

Payers and other third parties may be held accountableand liable to individuals for any injury caused by grossincompetence or negligence or by their clinically unjusti-fied decisions.

Participating Groups:

American Association for Marriage and Family Therapy(membership: 25,000)

American Counseling Association (membership: 56,000)American Family Therapy Academy (membership: (1,000)American Nurses Association (membership: 180,000)American Psychological Association (membership: 142,000)American Psychiatric Association (membership: 42,000)American Psychiatric Nurses Association (membership: 3,000)National Association of Social Workers (membership: 155,000)National Federation of Societies for Clinical Social Work

(membership: 11,000)

Supporting Groups:

National Mental Health AssociationNational Depressive and Manic-Depressive AssociationAmerican Group Psychotherapy AssociationAmerican Psychoanalytic AssociationNational Association of Drug and Alcohol Abuse Counselors

Sample Letter in Support of H.R. 1415 / S. 644"The Patient Access to Responsible Care Act of 1997"

Please try to put the following in your own words, and feel free to includeanecdotes or descriptions of your experiences with managed care, and why youbelieve managed care legislation is needed.

The Honorable {full name}U.S. House of RepresentativesWashington, D.C. 20515

Dear (Representative/Senator) {last name):

The Honorable {full name)U.S. SenateWashington, D.C. 20510

I am writing to ask for your support for legislation to help ensure that managed care delivers on its potential toimprove patient quality of care. I am concerned that too many managed care firms go for short term profits at the

expense of taking good care of their enrollees.

I do not believe that Congress should try to prohibit inappropriate managed care practices one body part at atime.

Instead, 1 support holding managed care plans to more general quality standards to protect patients, and to help

ensure that health care providers can give them the care they need. Consequently, I urge you to cosponsor the"Patient Access to Responsible Care Act", sponsored in the House (H.R. 1415) by Rep. Charles Norwood (R-GA)

and in the Senate (S. 644) by Senator Al D'Amato (R-NY).

This legislation would require plans to give their enrollees the option of choosing a point-of-service coveragepackage. It would give consumers standardized information regarding plan policies and performance, so they can

make informed decisions about which plan to purchase. It would require plans to have appeals processes for

patients who believe they are inappropriately denied care, and it would require plans to cover needed emergencycare. The legislation does NOT mandate that plans cover specific benefits. It simply gives people the ability tomake good health care choices, and to regain a measure of control over their health care services.

I firmly believe that this legislation will actually help the better managed care firms who are already providinghigh-quality care. These plans are not the problem. The Patient Access to Responsible Care Act will make itharder for those managed care plans which are skimping on services to operate. Managed care plans shouldn't be

allowed to make money by denying services, they should be pushed to make money by providing more efficientand effective care.

Please cosponsor the Patient Access to Responsible Care Act. I believe enactment of this bill would go a longway toward improving the quality of health care for the large majority of our nation's citizens who are enrolled inmanaged care plans, whether by choice or by the choice of their employer. Thank you for your time and attentionon this issue. I look forward to hearing your reply, and I hope I can count on your support.

Sincerely,

{name)

la15

105T CONGRESS1ST SESSION S. 644

II

To amend the Public Health Service Act and the Employee RetirementIncome Security Act of 1974 to establish standards for relationshipsbetween group health plans and health insurance issuers with enrollees,health professionals, and providers.

IN THE SENATE OF THE UNITED STATES

APRIL 24, 1997

Mr. D'AMATo introduced the following bill; which was read twice and referredto the Committee on Labor and Human Resources

A BILLTo amend the Public Health Service Act and the Employee

Retirement Income Security Act of 1974 to establishstandards for relationships between group health plansand health insurance issuers with enrollees, health pro-fessionals, and providers.

1 Be it enacted by the Senate and House of Representa-

2 tives of the United States of America in Congress assembled,

3 SECTION 1. SHORT TITLE; TABLE OF CONTENTS.

4 (a) SHORT TimE.This Act may be cited as the

5 "Patient Access to Responsible Care Act of 1997".

6 (b) TABLE OP CONTENTS.The table of contents of

7 this Act is as follows:

20

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16

2

Sm. I

. Sho

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vera

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19"(

A)

in th

e se

rvic

e ar

ea o

f the

issu

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20"(

11)

in a

var

iety

of s

ites

of s

ervi

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21"(

C)

with

rea

sona

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prom

ptne

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incl

ud-

22in

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hou

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d af

te -

23!lo

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);

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the

resi

-

25de

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and

wor

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of e

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; and

S 64

4 IS

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25

ti

"(E

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a m

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take

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to a

ccou

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this

sub

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the

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as a

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with

asu

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1111

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11:4

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insu

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SI1

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hav

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at.

conf

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with

its

resp

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toes

tabl

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mea

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desi

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to m

aint

ain

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1)E

PIN

ITIo

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Por

purp

oses

of p

arag

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S 64

4 IS

"(A

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BA

UN

DE

RSE

RV

ED

AR

EA

.

The

term

'med

ical

ly u

ndes

erve

dar

ea' m

eans

2v

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25

7

an a

rea

that

. is

desi

gnat

ed a

s a

heal

th p

mfe

s-

sion

al s

hort

age

area

und

er s

ectio

n 33

2 of

the

Publ

ic H

ealth

Ser

vice

Act

. or

as a

med

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n-

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or p

urpo

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of s

ectio

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0 or

1302

(7)

of s

uch

Act

.

"(B

) R

UR

AL

AR

EA

.The

term

'rur

al a

rea'

mea

ns a

n ar

ea th

at is

not,

with

in a

Sta

ndar

d

Met

ropo

litan

Sta

tistic

al A

rea

or a

New

Eng

land

Cou

nty

Met

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Are

a (a

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fine

d by

the

Off

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anag

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d B

udge

t).

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EM

ER

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NC

Y A

ND

UR

GE

NT

CA

RE

.

"(1)

IN

(1E

NE

RM

..A h

ealth

lie-

Mr:

Mee

issu

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shal

l-

-S 6

44 I

S

"(A

) as

sure

the

avai

labi

lity

and

acce

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f m

edic

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or

clin

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ly n

eces

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(qu

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). s

et-v

ices

111

111

urge

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are

serv

ices

with

in

the

serv

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area

of th

e is

suer

24

hour

s a

day,

7 (l

ays

a w

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) re

quir

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0pr

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auth

oriz

atio

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item

s an

d se

rvic

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urni

shed

in a

hos

pita

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er-

genc

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part

men

t to

an e

nrol

lee

(with

out.

re-

gard

to w

heth

er th

e he

alth

pro

fess

iona

l or

hos-

pita

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a c

ontr

actu

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r ot

her

arra

ngem

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with

the

issu

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with

sym

ptom

s th

at w

ould

rea

-

sona

bly

sugg

est.

toa

prud

ent l

aype

rson

an

26

1em

erge

ncy

med

ical

con

ditio

n (in

clud

ing

item

s

2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24

S 64

4 IS

and

serv

ices

desc

ribed

insu

bpar

agra

ph

((;)

(iii))

;

"WO

MV

O'

(and

mak

e re

ason

able

jray

inen

ts

"(i)

emer

genc

y se

rvic

es,

"(ii)

ser

vice

s th

at a

re n

ot e

mer

genc

y

serv

ices

but

are

des

crib

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sub

para

grap

h

(B),

"(iii

) m

edic

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cree

ning

exa

min

atio

ns

and

othe

r an

cilla

ry s

ervi

ces

nece

ssar

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diag

nose

, tre

at, a

nd s

tabi

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an e

mer

genc

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med

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con

ditio

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nd

"(iv

) ur

gent

car

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rvic

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ithou

t re-

gard

to w

heth

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e he

alth

pro

fess

iona

l or

prov

ider

furn

ishi

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uch

serv

ices

has

a

cont

ract

ual (

or o

ther

)11

-ran

gem

ent w

ith

the

issu

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nd

"(I)

) m

ake

prio

r au

thor

izat

ion

dete

rmin

a-

tions

for

"(i)

serv

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that

are

furn

ishe

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a

hosp

ital e

mer

genc

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part

men

t. (o

ther

than

serv

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des

crib

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cla

uses

(i)

and

(iii)

of

subp

arag

raph

(C

) ),

and

9

"(ii)

urg

ent c

are

serv

ices

, with

in th

e

2tim

e pe

riods

spe

cifie

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(or

pur

suan

t to)

3se

ctio

n 27

76(a

)(8)

.

4"(

2) D

EP

INrr

IoN

s.--

For

pur

pose

s of

this

sub-

5se

ctio

n:

6"(

A)

EM

ER

GE

NC

Y M

ED

ICA

L C

ON

DIT

ION

.-

7T

he te

rm 'e

mer

genc

y m

edic

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ondi

tion'

mea

ns

8a

med

ical

con

ditio

n (in

clud

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emer

genc

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bor

9an

d de

liver

y) m

anife

stin

g its

elf b

y ac

ute

sym

p-

10to

ms

of s

uffic

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sev

erity

(in

clud

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seve

re

11pa

in)

such

that

a p

rude

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son,

who

lios-

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an

aver

age

know

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hea

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red-

13ic

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cou

ld r

easo

nabl

y ex

pect

the

abse

nce

of

14im

med

iate

med

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atte

ntio

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uld

reas

onab

ly

15be

exp

ecte

d to

res

ult i

n-

16"(

i) pl

acin

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e pa

tient

's h

ealth

in s

erio

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17.je

opar

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ii)se

rious

impa

irmen

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bodi

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r

20"(

iii)

serio

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orga

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par

t.

22"(

13)

EM

ER

GE

N(!

Y S

ER

VIC

ES

.--T

he te

rm

23`e

mer

genc

y se

rvic

es' m

eans

hea

lth c

are

ileiti

s

24an

d se

rvic

es th

at a

re n

eces

sary

for

the

diag

-

S 64

4 IS

10

nosi

s, tr

eatm

ent,

and

stab

iliza

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of a

n em

er-

2ge

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med

ical

con

ditio

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3IC

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RG

EN

T A

RE

BE

RM

( 5.

The

term

4'u

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are

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-

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9tr

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10"(

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the

12ap

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Sta

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13re

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or

prov

id-

14(T

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15"(

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Env

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S.

16"(

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I..A

hea

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sura

nce

issu

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17of

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twor

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hall

dem

onst

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that

. en-

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e ac

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to s

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rtis

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med

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inic

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imli-

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in th

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ofes

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udgm

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of th

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pro

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22"(

2) D

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iTio

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or p

urpo

ses

of p

arag

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23(1

), th

e te

rm 's

peci

aliz

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24ex

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in d

iagn

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trea

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25"(

A)

unus

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orco

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or

S 6

44 IS

29

1 2 3 4 5 6 7 8 9

10 II

12 13 14 15 16 17 18 19 20 21 22 23 24 25

BE

ST C

OPY

AV

AIL

AB

LE

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the

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ny

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plan

ope

r-

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by

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cov

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follo

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ly

or in

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prov

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grou

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med

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spec

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3) If

the

plan

pla

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apr

ofes

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prov

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grou

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. sub

stan

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inan

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(as

dete

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by

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prof

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grou

p, th

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suer

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prov

ides

sto

p-lo

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rote

ctio

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r

the

prof

essi

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, pro

vide

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rgr

oup

that

is

adeq

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and

app

ropr

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, 101

50(1

011

sta

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dev

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into

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num

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als

or p

rovi

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S 6

44 IS

3 0

1 2 3 4 5 6 7 8 9

10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25

12

'muc

k)l r

isk

in th

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Or

unde

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mbe

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en-

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rec

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vice

s

from

the

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, pro

vide

r, o

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and

"(ii)

con

duct

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s of

bot

h

indi

vidu

als

enro

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and

indi

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pre-

viou

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%vi

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e is

suer

to d

eter

-

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gree

of a

cces

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suc

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divi

d-

uals

to s

ervi

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prov

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by

the

issu

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nd

satis

fact

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with

the

qual

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rv-

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"((,

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pro

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info

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rega

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an,

suffi

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perm

it th

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dete

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whe

ther

the

plan

is in

com

plia

nce

with

the

re-

quire

men

ts o

f thi

s pa

ragr

aph.

"(2)

In th

is s

ubse

ctio

n, th

e te

rm 'h

ealth

pro

fes-

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al o

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ovid

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cent

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plan

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ny c

om-

pens

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rang

emen

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twee

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heal

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sura

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issu

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hea

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prov

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p th

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ay d

irect

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di-

rect

ly h

ave

the

effe

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rvic

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prov

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with

res

pect

to in

divi

dual

s en

rolle

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ith th

e

issu

er.

.S 6

44 IS

31

13

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C. 2

772.

EN

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11"(

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RA

L.If

a he

alth

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fers

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nrol

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hea

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sura

nce

cove

rage

whi

ch

13pr

ovid

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r co

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f ser

vice

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nly

if su

chse

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14ar

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rnis

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thro

ugh

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rofe

ssio

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and

pro-

15vi

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who

are

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of a

net

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ro-

16te

ssio

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pro

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ave

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into

a17

cont

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, with

the

issu

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pro

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the

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also

offe

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suc

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rolle

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atth

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the

optio

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lth in

sura

nce

cov-

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ase

whi

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rovi

des

for

cove

rage

of s

uch

serv

ices

21w

hich

are

not

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shed

thro

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heal

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ofes

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d pr

ovid

ers

who

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a ne

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23"(

2) F

AIR

PR

EM

IUM

S.T

he a

mou

nt o

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-

24di

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miu

m r

equi

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for

the

optio

n de

scrib

ed

25in

par

agra

ph (

1) m

ay n

ot e

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l am

ount

.th

at. i

s

26fa

ir an

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ason

able

, as

esta

blis

hed

by th

eap

plic

able

.S 6

44 L

S

32

14

Sta

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utho

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in c

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2A

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Insu

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the

natu

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ition

al c

over

age

prov

ided

.

"(3)

Cos

T-s

itAR

ING

.Und

er th

eop

tion

de-

scrib

ed in

par

agra

ph (

1), t

he h

ealth

insu

ranc

e co

y-

3 4 5 6 7 8 9

10 I i 12 13 14 15 16 17 18 19 20 21 22 23 24 25

el'il

ge s

hall

prov

ide

for

reim

burs

emen

t rat

es fo

r co

v-

ered

ser

vice

s of

fere

d by

hea

lth p

rofe

ssio

nals

and

pro

-

vide

rs w

ho a

re n

ot. p

artic

ipat

ing'

hea

lth p

rofe

ssio

nals

or p

rovi

ders

that

, are

110

t les

s th

an th

e re

imbu

rse-

men

t. ra

tes

for

cove

red

serv

ices

offe

red

by p

artie

ipat

-

ing

heal

th p

rofe

ssio

nals

and

pro

vide

rs. N

othi

ng-

in

this

par

agra

ph s

hall

be c

onst

rued

as

prot

ectin

g an

enro

llee

agai

nst.

bala

nce

billi

ng b

y a

heal

th p

rofe

s-

sion

al o

r pr

ovid

er th

at. i

s no

t a p

artic

ipat

ing

heal

th

pmfe

ssio

nal o

r pr

ovid

er.

"(e)

CoN

TiN

tirry

CA

RE

.A h

ealth

insu

ranc

e is

-

suer

offe

ring

netw

ork

cove

rage

sha

ll

"(1)

ens

ure

that

. any

pro

cess

est

ablis

hed

by th

e

issu

er to

coo

rdin

ate

care

and

con

trol

cos

ts d

oes

not

crea

te a

n un

due

burd

en, a

s de

fined

by

the

appl

icab

le

Sta

te a

utho

rity,

for

enro

llees

with

spe

cial

hea

lth c

are

need

s or

dio

nic

cond

ition

s;

"(2)

ens

ure

dire

ct a

cces

s to

rel

evan

t. sp

ecia

lists

for

the

cont

inue

d ca

re o

f suc

h en

rolle

es w

hen

med

i-

cally

or

clin

ical

ly in

dica

ted

in th

e ju

dgm

ent o

f the

S 64

4 IS

33

15

1tr

eatin

g he

alth

pro

fess

iona

l, in

con

sulta

tion

with

the

2en

rolle

e;

3"(

3)in

the

case

of a

n en

rolle

e w

ith s

peci

al

4he

alth

car

e ne

eds

or a

chr

onic

con

ditio

n, d

eter

min

e

5w

heth

er, b

ased

on

the

judg

men

t of t

he tr

eatin

g

6he

alth

pro

fess

iona

l, in

con

sulta

tion

with

the

enro

llee,

7it

is m

edic

ally

or

clin

ical

ly n

eces

sary

to u

sea

spe-

8ci

alis

t or

a ca

re c

oord

inat

or fr

om a

n in

terd

isci

pli-

9na

ry te

am to

ens

ure

cont

inui

ty o

f car

e; a

nd

10"(

4) in

circ

umst

ance

s un

der

whi

ch a

cha

nge

of

11he

alth

pro

fess

iona

l or

prov

ider

Wrig

ht, d

isru

pt. t

he

12co

ntin

uity

of c

are

for

an e

nrol

lee,

suc

has

-13

"(A

) ho

spita

lizat

ion,

or

14"(

13)

depe

nden

cy o

n hi

gh-t

echn

okw

hom

e

15m

edic

al e

quip

men

t,

16pr

ovid

e fo

r co

ntin

ued

cove

rage

of i

tem

s an

d se

rvic

es

17fu

rnis

hed

by th

e he

alth

pro

fess

iona

l or

prov

ider

that

18w

as tr

eatin

g th

e en

rolle

e be

fore

suc

h ch

ange

for

a

19re

ason

able

per

iod

of ti

me.

20 P

or p

urpo

ses

of p

arag

raph

(4)

, a c

hang

e of

hea

lth p

rofe

s-

21si

onal

or

prov

ider

may

be

due

to c

hang

es in

the

mem

be

22 s

hip

of a

n is

suer

's h

ealth

pro

fess

iona

l and

pro

vide

r ne

t-

23 w

ork,

cha

nges

in th

e he

alth

cov

erag

e m

ade

avai

labl

e by

24 a

n em

ploy

er, o

r ot

her

sim

ilar

circ

umst

ance

s.

.S 6

44 I

S

34

16

1"S

EC

. 277

3. N

ON

DIS

CR

IMIN

AT

ION

AG

AIN

ST E

NR

OL

LE

ES

2A

ND

IN

TH

E S

EL

EC

TIO

N O

F H

EA

LT

H P

RO

FES-

3SI

ON

AL

S; E

QU

ITA

BL

E A

CC

ESS

TO

NE

TW

OR

KS.

4"(

a) N

oNtp

isct

uNi1

NA

TH

iNA

GA

INST

EN

RO

LL

EE

S.-

5 N

o he

alth

insu

ranc

e is

suer

may

dis

crim

inat

e (d

irect

ly o

r

6 th

roug

h co

ntra

ctua

l arr

ange

men

ts)

in a

ny a

ctiv

ity th

at.

7 ha

s th

e ef

fect

. of d

iscr

imin

atin

g, a

gain

st a

n in

divi

dual

on

8 th

e ba

sis

of r

ace,

nat

iona

l orig

in, g

ende

r, la

ngua

ge, s

ocio

-

9 ec

onom

ic s

tatu

s, a

ge, d

isab

ility

, hea

lth s

tatu

s, o

r an

tiei-

10 p

ated

nee

d fo

r he

alth

ser

vice

s.

11"(

b) M

iND

Isci

timIN

Au)

NIN

SE

LE

CT

ION

OE

NE

T-

12xv

oit6

HE

ALT

H l'

Itor.

'Ess

toN

ALs

.A h

ealth

insu

ranc

e is

-

13 s

uer

offe

ring

netw

ork

cove

rage

sha

ll no

t dis

crim

inat

e in

14se

lect

ing

the

mem

bers

of i

ts h

ealth

pro

fess

iona

l net

wor

k

15or

in e

stab

lishi

ng-

the

term

s an

d co

nditi

ons

for

mem

be-

16 s

hip

in s

uch

netw

ork)

on

the

basi

s of

-

17"(

1) th

e ra

ce, n

atio

nal o

rigin

, gen

der,

age

, or

18di

sabi

lity

(oth

er th

an .a

dis

abili

ty th

at im

pairs

the

19ab

ility

of a

n in

divi

dual

to p

rovi

de h

ealth

car

e se

rv-

20ic

es o

r th

at. '

na th

reat

en th

e he

alth

of e

nrol

lees

) of

21th

e he

alth

pro

fess

iona

l; or

22"(

2) th

e he

alth

pro

fess

iona

l's la

ck o

f affi

liatio

n

23w

ith, o

r ad

mitt

ing-

priv

ilege

s at

, a h

ospi

tal (

unle

ss

24su

ch la

ck o

f affi

liatio

nis

a r

esul

t of i

nfra

ctio

ns o

f

25qu

ality

sta

ndar

ds a

nd is

not

. due

to a

hea

lth p

rofe

s-

26si

onal

's ty

pe o

f lic

ense

).

S 6

44 IS

17

"(c)

NO

ND

ISC

RIM

INA

TIO

N I

N A

c(,E

ss T

oE

mi

2 P

LAN

S. W

hile

not

hing

in th

is s

ectio

n sh

all b

e co

nstr

ued

3as

an

`any

will

ing

prov

ider

' req

uire

men

t. (a

s re

ferr

ed to

4in

sec

tion

2770

(c))

, a h

ealth

insu

ranc

e is

suer

sha

llno

t. di

s-

5 cr

imin

ate

in p

artic

ipat

ion,

rei

mbu

rsem

ent,

or in

dem

nific

a-

6 tio

n ag

ains

t a h

ealth

pro

fess

iona

l, w

ho is

act

ing

with

in th

e

7 sc

ope

of th

e he

alth

pro

fess

iona

l's li

cens

e or

cer

tific

atio

n

8 un

der

appl

icab

le S

tate

law

, sol

ely

on th

e ba

sis

of s

ueli

li-

9 ce

nse

or c

ertif

icat

ion.

10 "

SEC

. 277

4. P

RO

HIB

ITIO

N O

F IN

TE

RFE

RE

NC

E W

ITH

CE

R-

TA

IN M

ED

ICA

L C

OM

MU

NIC

AT

ION

S.

12"(

a)IN

GE

NE

RA

LT

hepr

ovis

ions

of a

ny c

ontr

act

13 o

r ag

reem

ent,

or th

e op

erat

ion

of a

ny e

mitr

act.

or a

gree

-

14 m

ent,

betw

een

a he

alth

insu

ranc

e is

suer

and

a h

ealth

pro-

15fe

ssio

nal s

hall

not.

proh

ibit.

Or

rest

rict.

the

heal

th p

role

s-

16si

onal

from

eng

agin

g in

med

ical

eom

mun

icat

ions

with

his

17 o

r he

r pa

tient

..

18"(

b) N

ur,L

iFic

ialo

N.A

ny c

ontr

act p

rovi

sion

or

19 a

gree

men

t. de

scrib

ed in

sub

sect

ion

(a)

shal

l be

1111

11 a

nd

20 v

oid.

21"(

c)M

ED

ICA

L.C

OM

M(

'AT

IoN

1)E

PIN

ED

.For

22 p

urpo

ses

of th

is s

ectio

n, th

e te

rm `

med

ical

com

mun

icat

ion'

23 m

eans

a c

omm

unic

atio

n m

ade

by a

hea

lth p

rofe

ssio

nal

24 w

ith a

pat

ient

of t

he h

ealth

pro

fess

iona

l (or

the

guar

dian

25 o

r le

gal r

epre

sent

ativ

e of

the

patie

nt)

with

res

pect

. to

S 6

44 IS

36

18

1"(

1) th

e pa

tient

's h

ealth

sta

tus,

med

ical

car

e,1

2or

lega

l tre

atm

ent.

optio

ns;

2

3"(

2) a

ny u

tiliz

atio

n re

view

req

uire

men

ts th

at3

4m

ay a

ffect

. tre

atm

ent.

optio

ns fi

n. th

e pa

tient

; Or

4

5"(

3) a

ny fi

nanc

ial i

ncen

tives

that

. may

affe

ct5

6th

e tr

eatm

ent,

of th

e pa

tient

.6 7

7"S

EC

. 277

5. D

EV

EL

OPM

EN

T O

F PL

AN

PO

LIC

IES.

8"A

hea

lth in

sura

nce

issu

er th

at o

ffers

net

wor

k co

y-8 9

9 er

age

shal

l est

ablis

h m

echa

nism

s to

con

side

r th

e re

e-

1010

om

men

datio

ns, s

ugge

stio

ns, a

nd v

iew

s of

enr

olle

es a

nd

11pa

rtic

ipat

ing

heal

th p

rofe

ssio

nals

and

pro

vide

rs r

egar

d-

1212

ing,

1313

"(I)

the

med

ical

pol

icie

s of

the

issu

er (

incl

udin

g

1414

polic

ies

rela

ting

to c

over

age

of n

ew te

chno

logi

es,

1515

trea

tmen

ts, a

nd p

roce

dure

s);

1616

"(2)

the

utili

zatio

n re

view

crit

eria

and

pro

m.-

1717

dare

s of

the

issu

er;

1818

"(3)

the

qual

ity a

nd c

rede

ntia

ling

crite

ria o

f the

1919

issu

er; a

nd

2020

"(4)

the

med

ical

man

agem

ent.

proc

edur

es o

f the

2121

issu

er.

2222

"SE

C. 2

776.

DU

E P

RO

CE

SS F

OR

EN

RO

LL

EE

S.

2323

"(a)

IIT

HA

zAT

ioN

RE

VIE

W.T

he u

tiliz

atio

n re

view

2424

pro

gram

of a

hea

lth in

sura

nce

issu

er s

hall

S 64

4 IS

37

19

"(1)

be

deve

lope

d (in

clud

ing

any

scre

enin

g tr

i-

teria

use

d by

suc

h pr

ogra

m)

with

the

invo

lvem

ent.

of

part

icip

atin

g he

alth

pro

fess

iona

ls a

nd p

rovi

ders

;

"(2)

to th

e ex

tent

con

sist

ent.

with

the

prot

ectio

n

of p

ropr

ieta

ry b

usin

ess

info

rmat

ion

(as

defin

edfo

r

purp

oses

of s

ectio

n 55

2 of

title

5, U

nite

d S

tate

s

Cod

e) r

elea

se, u

pon

requ

est.,

to a

ffect

ed h

ealth

pro-

fess

iona

ls, p

rovi

ders

, and

enr

olle

es th

e sc

reen

ing

cri-

teria

, wei

ghtin

g el

emen

ts, a

nd c

ompu

ter

a4,,o

rithm

s

used

in r

evie

ws

and

a de

scrip

tion

of th

e m

etho

dby

whi

ch th

ey w

ere

deve

lope

d;

"(3)

uni

form

ly a

pply

rev

iew

crit

eria

that

are

base

d O

n so

und

scie

ntifi

c pr

inci

ples

and

the

mos

t re-

med

ical

evi

denc

e;

"(4)

use

lice

nsed

, acc

redi

ted,

or

cert

ified

hea

lth

prof

essi

onal

s to

mak

e re

view

det

erm

inat

ions

(an

dfo

r

serv

ices

req

uirin

g sp

ecia

lized

trai

ning

for

thei

r itc

hy-

cry,

use

a he

alth

prof

essi

onal

wt(

)is

qual

ified

thro

ugh

equi

vale

nt. s

peci

aliz

ed tr

aini

ng a

ndex

peri-

cute

); "(5)

sul

liett.

to r

easo

nabl

e sa

fegu

ards

, dis

clos

e

to h

ealth

pro

fess

iona

ls a

nd p

rovi

ders

, upo

nre

ques

t,

the

nam

es a

nd c

rede

ntia

ls o

f ind

ivid

uals

em

aluc

ting

utili

zatio

n re

view

;

S 64

4 IS

38

20

1"(

6) n

ot c

ompe

nsat

e in

divi

dual

s co

nduc

ting

uti-

2liz

atio

n re

view

for

deni

als

of p

aym

ent.

or c

over

age

of

3be

nefit

s;

4"(

7) c

ompl

y w

ith th

e re

quire

men

t of s

ectio

n

527

71 th

at p

rior

auth

oriz

atio

n no

t be

requ

ired

for

6em

erge

ncy

and

rela

ted

serv

ices

furn

ishe

d in

a h

os-

pita

l em

erge

ncy

depa

rtm

ent;

"(8)

mak

e pr

ior

auth

oriz

atio

n de

term

inat

ions

"(A

) in

the

case

of s

ervi

ces

that

are

urg

ent

caw

serv

ices

desc

ribed

inse

ctio

n

2771

(b)(

2)(C

), w

ithin

30

min

utes

of a

req

uest

for

such

det

erm

inat

ion,

and

"(13

) in

the

case

of o

ther

ser

vice

s, w

ithin

24 1

1011

1's

afte

r th

e tim

e of

a r

eque

st. f

or d

eter

-

min

atiim

;

"(9)

incl

ude

in a

ny n

otic

e of

suc

h de

term

inat

ion

an e

xpla

natio

n of

the

basi

s of

the

dete

rmin

atio

n an

d

the

right

to a

n im

med

iate

app

eal;

"(10

) tr

eat a

favo

rabl

e pr

ior

auth

oriz

atio

n re

-

view

det

erm

inat

ion

as a

fina

l det

erm

inat

ion

for

pur-

pose

s of

mak

ing

paym

ent f

or a

cla

im s

ubm

itted

finr

the

item

or

serv

ice

invo

lved

unl

ess

such

det

erm

ina-

tion

was

bas

ed o

n fa

lse

info

rmat

ion

know

ingl

y su

p-

plie

d by

the

pers

on r

eque

stin

g th

e de

term

inat

ion;

7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24

.S 6

44 I

S

39

21

"(11

) pr

ovid

e tim

ely

acce

ss, a

s de

fined

by

the

2ap

plic

able

Sta

te a

utho

rity,

to u

tiliz

atio

n re

view

per

-

3so

und

and,

if su

ch p

erso

nnel

are

not.

avai

labl

e,

4w

aive

s an

y pr

im-

auth

oriz

atio

n th

at. %

voul

d ot

herw

ise

5be

req

uire

d; a

nd

6"(

12)

prov

ide

notic

e of

an

initi

al d

eter

min

atio

n

7on

pay

men

t of a

cla

im w

ithin

30

days

afte

r th

e da

te

8th

e cl

aim

is s

ubm

itted

for

such

item

or

serv

ice,

and

9in

clud

e in

suc

h no

tice

au e

xpla

natio

n of

the

reas

ons

10fo

r su

ch d

eter

min

atio

n an

d of

the

right

. to

au u

nme-

t 1di

ate

appe

al.

12"(

b) A

PP

EA

LS P

Roc

Ess

.A h

ealth

insu

ranc

e is

suer

13sh

all e

stab

lish

and

mai

ntai

n an

acc

essi

ble

appe

als

proc

ess

14 th

at-

15"(

1) r

evie

ws

an a

dver

se p

rior

auth

oriz

atio

n de

-

16te

min

atio

n-

17"(

A)

for

urge

nt c

am s

ervi

ces,

des

crib

ed in

18su

bsec

tion

(a)(

8)(A

), w

ithin

1ho

ur a

fter

the

19tim

e of

a r

eque

st. f

or s

uch

revi

ew, a

nd

20"(

13)

fin-

othe

r se

rvic

es, w

ithin

24

hour

s

21af

ter

the

time

of a

req

uest

. for

suc

h re

view

;

22"(

2) r

evie

ws

an in

itial

det

erm

inat

ion

on p

ay-

23m

ent o

f cla

ims

desc

ribed

in s

ubse

ctio

n (a

)(12

) w

ith-

24in

:30

days

afte

r th

e da

te o

f it

requ

est f

or s

uch

re-

25vi

ew;

S 64

4is

40

22

1"(

3) p

rovi

des

for

revi

ew o

f det

erm

inat

ions

de-

2sc

ribed

in p

arag

raph

s (1

) an

d (2

) by

an

appr

opria

te

3cl

inic

al p

eer

prof

essi

onal

who

is in

the

sam

e or

sitn

i-

4la

r sp

ecia

lty a

s w

ould

typi

cally

pro

vide

the

item

or

5se

rvic

e in

volv

ed (

or a

noth

er li

cens

ed)

accr

edite

d) o

r

6ce

rtifi

ed h

ealth

pro

fess

iona

l acc

epta

ble

to th

e pl

an

7an

d tli

e pe

rson

req

uest

ing

such

rev

iew

); a

nd

8"(

4) p

rovi

des

for

revi

ew o

f-

9"(

A)

the

dete

rmin

atio

ns d

escr

ibed

in ll

ama-

10gr

aphs

(1)

, (2)

, and

(3)

, and

1 I

"(B

) en

rolle

e co

mpl

aint

s ab

out i

nade

quat

e

12ae

diS

S to

any

cat

egor

y or

type

of h

ealth

pm

fes-

13sl

ow! O

r pr

ovid

er in

the

netw

ork

of th

e is

suer

14or

oth

er m

atte

rs s

peci

fied

1)y

this

flai

l.,

15by

an

appr

opria

te c

linic

al p

eer

prof

essi

onal

who

is in

16th

e st

one

or s

imila

r sp

ecia

lty a

s w

ould

typi

cally

pro

-

17vi

de th

e ite

m o

r se

rvic

e in

volv

ed(o

r an

othe

rli-

18(t

ense

d, a

ccre

dite

d, o

r ce

rtifi

ed h

ealth

pro

fess

iona

l

19ac

cept

able

to th

e is

suer

and

the

pers

onre

ques

ting.

20su

ch r

evie

w)

that

. is

not.

invo

lved

in th

e op

erat

ion

or

21th

e pl

an o

r in

mak

ing

the

dete

rmin

atio

n or

pol

icy

22be

ing

appe

aled

.

23 T

he p

roce

dure

s sp

ecifi

ed in

this

sub

sect

ion

shal

l not

be

24 c

onst

rued

as

pree

mpt

ing

or s

uper

sedi

ng a

nyot

her

revi

ews

25 o

r ap

peal

s an

issu

er is

req

uire

d by

law

tom

ake

avai

labl

e.

.S 6

44 IS

41

BE

STC

OPY

AV

AIL

AB

LE

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20

23

"SE

C. 2

777.

DU

E P

RO

CE

SS F

OR

HE

AL

TH

PR

OFE

SSIO

NA

LS

AN

D P

RO

VID

ER

S.

"(a)

ING

EN

ER

AL.

A h

ealth

insu

ranc

e is

suer

with

resp

ect.

to it

s of

ferin

g of

net

wor

k co

vera

ge s

hall

"(1)

allo

w a

ll he

alth

pro

fess

iona

ls a

nd p

rovi

ders

in it

s se

rvic

e ar

ea to

app

ly to

bec

ome

a pa

rtic

ipat

ing

heal

th p

rofe

ssio

nal o

r pr

ovid

er d

urin

g at

. lea

st. o

ne

perio

d in

eac

h ca

lend

ar y

ear;

"(2)

pro

vide

rea

sona

ble

notic

e to

suc

h he

alth

prof

essi

onal

s an

d pr

ovid

ers

of th

e op

port

unity

to

appl

y an

d of

the

perio

d du

ring

whi

ch a

pplic

atio

ns

are

acce

pted

;

13)

prov

ide

for

revi

ew u

t eac

h ap

pii,,

atio

n by

it

cred

entia

ling

com

mitt

ee w

ith a

ppro

pria

te r

epre

sent

a-

tion

of th

e ca

tego

ry o

r ty

pe o

f hea

lth p

rofe

ssio

nal o

r

prov

ider

;

"(4)

sele

ctpa

rtic

ipat

ing

heal

thpr

ofes

sion

als

11.1

1(1

Pro

vide

rs b

ased

011

obj

ectiv

e st

anda

rds

of q

ual-

ity d

evel

oped

with

the

sugg

estio

ns a

nd a

dvie

e of

pro

-

fess

iona

l ass

ocia

tions

, hea

lth p

rofe

ssio

nals

, and

pro

-

21vi

ders

;

22"(

5) m

ake

such

sel

ectio

n st

anda

rds

avai

labl

e

23to

-24

"(A

) th

ose

appl

ying

to b

eem

ne a

par

tici-

25pa

ting

prov

ider

or

heal

th p

rofe

ssio

nal;

26"(

1) h

ealth

pla

n pu

reha

sers

, and

S 6

44 IS

42

24

I"(

C)

enro

llees

;

2"(

6) w

hen

econ

omic

con

side

ratio

ns a

reta

ken

3in

to a

ccou

nt. i

n se

lect

ing

part

icip

atin

g he

alth

pro

fes-

4si

onal

s an

d pr

OV

ider

S, u

se o

bjec

tive

crite

ria th

at a

re

5av

aila

ble

to th

ose

appl

ying

to b

ecom

e a

part

icip

atin

g

6pr

ovid

er o

r he

alth

pro

fess

iona

l and

enr

olle

es;

7"(

7) a

djus

t any

eco

nom

ic p

rofil

ing

tota

ke in

to

8ac

coun

t pat

ient

. cha

ract

eris

tics

(suc

h as

sev

erity

of

9ill

ness

)th

at m

ay r

esul

tin

atyp

ical

utili

zatio

n of

10se

rvic

es;

I 1"(

8) m

ake

the

resu

lts o

f suc

h pr

ofili

ngav

aila

ble

12to

insu

ranc

e pu

rcha

sers

, enr

olle

es,

and

the

heal

th

13pr

ofes

sion

al o

r pr

ovid

er in

volv

ed;

14"(

9) n

otify

any

hea

lth p

rofe

ssio

nal o

r pr

ovid

er

15be

ing

revi

ewed

tind

er th

e pr

oces

sre

ferr

ed to

in p

ari:-

16gr

aph

(3)

of a

ny in

form

atio

n in

dica

ting

that

the

17he

alth

pro

fess

iona

l or

prov

ider

fails

tom

eet.

the

18st

anda

rds

of th

e is

suer

;

19"(

10)

offe

r a

heal

th p

rotis

sion

al o

r pr

ovid

er r

e-

20ce

ivin

g no

tice

purs

uant

, to

the

requ

irem

ent.

of p

ara-

21gr

aph

(9)

with

an

oppo

rtun

ity to

-

22"(

A)

revi

ew th

e in

form

atio

n re

ferr

ed to

in

23su

ch p

arag

raph

, and

24"(

1i)

subm

it. s

uppl

emen

tal o

r co

rrec

ted

in-

25fo

rmat

ion;

S 64

4 IS

43

25

1"(

11)

not.

incl

ude

inits

con

trac

ts w

ith p

artic

i-

2'K

iting

hea

lth p

rofe

ssio

nals

and

pro

vide

rs a

pro

visi

on

3pe

rmitt

ing

the

issu

erto

term

inat

e th

eco

ntra

ct.

4'w

ithou

t cau

se',

5"(

12)

prov

ide

a du

e pr

oces

s ap

peal

that

con

-

6fo

rms

to th

e pr

oces

s sp

ecifi

ed in

sec

tion

412

of th

e

7H

ealth

Car

e Q

ualit

y Im

prov

emen

t, A

ct. o

f 198

6 (4

2

8U

.S.C

. 111

12)

for

all d

eter

min

atio

ns th

at, a

re a

d-

9ve

rse

to a

hea

lth p

rofe

ssio

nal o

r pr

ovid

er; a

nd

10"(

13)

unle

ss a

hea

lth p

rofe

ssio

nal o

r pr

ovid

er

pose

s an

imm

inen

t har

m to

enr

olle

es o

r an

adv

erse

actio

n by

a g

over

nmen

tal a

genc

y ef

fect

ivel

y im

pairs

the

abili

ty to

pro

vide

hea

lth c

are

item

s an

d se

rvic

es,

prov

ide

11 12 13 14 15 16 17 18 19 20 21 22 23 24 25

S 64

4 IS

"(A

) re

ason

able

not

ice

of a

ny d

ecis

ion

to

term

inat

e a

heal

th p

rofe

ssio

nal O

r pr

ovid

er fo

r

caus

e' (

incl

udin

g, a

ll ex

plan

atio

n of

the

reas

ons

fin-

the

dete

rmin

atio

n),

"(B

) an

opp

ortu

nity

to r

evie

w a

nd d

iscu

ss

all o

f the

intb

rinat

ion

on w

hich

the

dete

rmin

a-

tion

is b

ased

, and

"(C

) an

opp

ortu

nity

to e

nter

into

a c

orre

c-

tive

actio

n pl

an, b

efor

e th

e de

term

inat

ion

be-

com

es s

ubje

ct. t

o ap

peal

und

er th

e pr

oces

s re

-

ferr

ed to

in p

arag

raph

(12

).

44

1 2 3 4 5 6 7 8 9 10 I I 12 13 14

26

"(b)

Ittr

ix tr

y C

oNsT

ittim

oN.T

he r

equi

rem

ents

of

subs

ectio

n (a

) sh

all n

ot. b

e co

nstr

ued

as p

reem

ptin

g or

su-

pers

edin

g an

y ot

her

revi

ews

and

appe

als

a he

alth

insu

r-

ance

issu

er is

req

uire

d by

law

to m

ake

avai

labl

e.

"SE

C. 2

778.

INFO

RM

AT

ION

RE

POR

TIN

G A

ND

DIS

CL

OSU

RE

.

"(a)

ING

EN

ER

AL.

A h

ealth

insu

ranc

e is

suer

offe

r-

ing

heal

th in

sura

nce

cove

rage

sha

ll pr

ovid

e en

rolle

esan

d

pros

pect

ive

enro

llees

with

info

rmat

ion

abou

t

"(I )

cov

erag

e pr

ovis

ions

, ben

efits

, and

any

ex-

elus

ions

"(A

) by

cat

egor

y of

ser

vice

,

"(li)

by

cate

gory

or

type

of h

ealth

pro

fes-

sion

al o

r pr

ovid

er, a

nd

"((;

)if

appl

icab

le, b

y sp

ecifi

c se

rvic

e, in

-

15ch

idin

g ex

perim

enta

l tre

atm

ents

;

16"(

2) th

e pe

rcen

tage

of t

he p

rem

ium

cha

rged

by

17th

e is

suer

that

. is

set.

asid

e ro

adm

inis

trat

ion

and

18m

arke

ting

of th

e is

suer

;

19"(

3) th

e pe

rcen

tage

of t

he p

rem

ium

cha

rged

by

20th

e is

suer

that

is e

xpen

ded

dire

ctly

for

patie

nt, c

am;

21"(

4) th

e nu

mbe

r, m

ix, a

nd d

istr

ibut

ion

of p

ar-

22tic

ipat

ing

heal

th p

rofe

ssio

nals

and

pro

vide

rs;

23"(

5)th

era

tioof

enr

olle

esto

part

icip

atin

g

24he

alth

pro

fess

iona

ls a

nd p

rovi

ders

by

cate

gory

and

25ty

pe o

f hea

lth p

rofe

ssio

nal a

ndpr

ovid

er;

S 84

4 IS

45

2 3 4 5 6 7 8 9 10 I I 12 13 14 15 16 17 18 19 20 21 22 23 24

27

"(6)

the

expe

nditu

res

and

utili

zatio

npe

r en

-

rolle

e by

cat

egor

y an

d ty

pe o

f hea

lth p

rofe

ssio

nal

and

prov

ider

;

"(7)

the

finan

cial

obl

igat

ions

of t

he e

nrol

lee

and

the

issu

er,

incl

udin

gpr

emiu

ms,

copa

ymen

ts,

dedu

ctib

les,

and

est

ablis

hed

aggr

egat

e m

axim

ums

on

out-

of-p

ocke

t cos

ts, f

or a

ll ite

ms

and

serv

ices

,

"(A

)th

ose

furn

ishe

dby

hea

lthpr

ofes

-

sion

als

anti

prov

ider

s th

at. a

re n

ot p

artic

ipat

ing

heal

th p

rofe

ssio

nals

and

pro

vide

rs, a

nd

"(1)

thos

e fu

rnis

hed

to a

n en

rolle

e w

ho is

outs

ide

the

serv

ice

aria

of t

ic' (

-ove

rage

;

"(8)

util

izat

ion

revi

ew r

equi

rem

ents

of t

he is

-

sue

(incl

udin

g pr

ior

auth

oriz

atio

n re

view

, con

cur-

rent

.re

view

, pos

t-se

rvic

e re

view

, pos

t-pa

ymen

t re-

view

, and

any

oth

er p

roce

dure

s th

at tu

nic

lead

to d

e-

nial

of c

over

age

or p

aym

ent f

or a

ser

vice

);

"(9)

fina

ncia

l arr

ange

men

ts a

nd in

cent

ives

that

.

may

S 84

4 IS

"(A

) lim

it, th

e ite

ms

and

serv

ices

furn

ishe

d

to a

n en

rolle

e,

"(B

) re

stric

t, re

ferr

al o

r tr

eatm

ent.

optio

ns,

or

46

1 2 3 4 5 6 7 8 9 10 I I 12 13 14 15 16 17 18 19 20 21 22 23 24

28

"((;

) ne

gativ

ely

affe

ct th

e fid

ucia

ry e

spon

-

sibi

lity

of a

hea

lth p

rofe

ssio

nal o

r pr

ovid

er to

an e

nrol

lee;

"(10

) ot

her

ince

ntiv

es fo

r he

alth

pro

fess

iona

ls

and

prov

ider

s to

den

y or

lim

it. n

eede

d ite

ms

or s

erv-

ices

;

"(1

1 )

qual

ity in

dica

tors

for

the

issu

er a

nd p

ar-

ticip

atin

g- h

ealth

pro

fess

iona

ls a

nd p

rovi

ders

, inc

lud-

ing

perf

orm

ance

mea

sure

s su

ch a

s ap

prop

riate

ref

er-

rals

and

pre

vent

ion

of s

econ

dary

com

plic

atio

ns fo

l-

low

ing

trea

tmen

t;

"(12

) gr

ieva

nce

proc

edur

es a

nd a

ppea

ls r

ight

s

unde

r th

e co

vera

ge, a

nd s

umm

ary

info

rmat

ion

abou

t

the

num

ber

and

disp

ositi

on o

f grie

vanc

es a

nd a

p-

peal

s in

the

mos

t. re

cent

. per

iod

for

(1/1

1111

1(4.

e

curl

il(!(

111'

ilte

illri

filli

al01

1 IS

avai

labl

e; a

nd

"(13

) th

e pe

rcen

tage

of u

tiliz

atio

n re

view

det

er-

initi

atio

ns m

ade

by th

e is

suer

that

. dis

agre

e w

ith th

e

judg

men

t or

the

trea

ting

heal

th p

rofe

ssio

nal o

r pr

o-

vide

r an

d th

e pe

rcen

tage

of s

uch

dete

rmin

atio

ns th

at

are

reve

rsed

on

appe

al.

"(b)

ItE

m3,

AT

IoN

s.T

he S

ecre

tary

, in

colla

bora

tion

with

the

Sec

reta

ry o

f IJa

lmr,

sha

ll is

sue

regu

latio

ns to

es-

tabl

isl

eS 6

44 I

S

47

29

"(1)

the

styl

es a

nd s

izes

or

type

to b

e us

ed w

ith

2re

spec

t. to

the

appe

aran

ce o

f the

pub

licat

ion

of th

e

3in

form

atio

n re

quire

d un

der

subs

ectio

n (a

);

4"(

2) s

tand

ards

for

the

publ

icat

ion

of in

form

a-

5tio

n to

ens

ure

that

suc

h pu

blic

atio

n is

-

6"(

A)

mai

nly

acce

ssib

le, a

nd

7"(

B)

in c

omm

on la

llgtla

ge e

asily

und

er-

8st

ood,

9by

indi

vidu

als

with

littl

e or

no

conn

ectio

n to

or

un-

10de

rsta

ndin

g of

the

lang

uage

em

ploy

ed b

y he

alth

pro

-

1 I

fess

iona

ls a

nd p

rovi

ders

, hea

lth in

sura

nce

issu

ers,

or

12ot

her

entit

ies

invo

lved

in th

e pa

ymen

t. or

del

iver

y of

13he

alth

car

e se

rvic

es, a

nd

14"(

3) th

e pl

acem

ent a

nd p

ositi

onin

g of

info

rma-

15tio

n in

hea

lth p

lan

mar

ketin

g m

ater

ials

.

16"S

EC

. 277

9. C

ON

FID

EN

TIA

LIT

Y; A

DE

QU

AT

E R

ESE

RV

ES.

17"(

a) C

oNriD

EN

riALI

TY

.

I 8"(

1) IN

GE

NE

RA

L.A

hea

lth in

sura

nce

issu

er

19sh

all e

stab

lish

mec

hani

sms

and

proc

edur

es to

ens

ure

20co

mpl

ianc

e w

ith a

pplic

able

Ped

eral

and

Sta

te la

ws

21to

pro

tect

. the

con

fiden

tialit

y of

indi

vidu

ally

iden

tili-

22ab

le in

form

atio

n he

ld b

y th

e is

suer

with

res

pect

. to

23an

enr

olle

e, h

ealth

pro

fess

iona

l, or

pro

vide

r.

24"(

2) D

EF

INrr

ioN

.For

pur

pose

s of

par

agra

ph

25(1

), th

e te

rm 'i

ndiv

idua

lly id

entif

iabl

e in

form

atio

n'

8 64

4 IS

48

30

Mea

ns, W

ith r

espe

ct. t

o an

enr

olle

e, a

hea

lth p

rofe

s-1

2si

onal

, or

a pr

ovid

er, a

ny in

form

atio

n, w

heth

er o

ral

2

3or

rec

orde

d in

any

med

ium

Or

form

, tha

tid

entif

ies

3

4or

can

rea

dily

be

asso

ciat

ed w

ith th

e id

entit

yor

the

4

5en

rolle

e, th

e he

alth

pro

fess

iona

l, or

the

prov

ider

.5

6"(

1) F

INA

NC

IAL

RE

SER

VE

S; S

OL

VE

NC

Y.A

hea

lth6

7in

sura

nce

issu

er s

hall-

7

8"(

1) n

ieet

suc

h fin

anci

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eser

ve o

r ot

her

sol-

8

9ve

ncy-

rela

ted

requ

irem

ents

as

the

appl

icab

le S

tate

9

10au

thor

ity m

ay e

stab

lish

to a

ssur

e th

e co

ntin

ued

10

11av

aila

bilit

y of

(an

d ap

prop

riate

pay

men

t for

) en

tere

d11

12ite

ms

and

serv

ices

for

enro

llees

; and

12

13"(

2) e

stab

lish

mec

hani

sms

spec

ified

by

the

;11)

-13

14pl

icab

le S

tate

aut

horit

y to

pro

tect

enr

olle

es, h

ealth

14

15pr

ofes

sion

als,

and

pro

vide

rs in

the

even

t of f

ailu

re O

f15

16th

e is

suer

.16

17 S

uch

requ

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sha

ll no

t und

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impe

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tabl

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17

18 M

em. o

f hea

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sura

nce

issu

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owne

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dop

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y18

19 h

ealth

car

e pr

ofes

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als

or p

rovi

ders

or

byno

n-pr

otit.

19

20 c

omm

unity

-bas

ed o

rgan

izat

ions

.20

21"S

EC

. 278

0. Q

UA

LIT

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MPR

OV

EM

EN

T P

RO

GR

AM

.21

22"(

a) IN

GE

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RA

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ealth

insu

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sha

ll22

23 e

stab

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a qu

ality

impr

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rogr

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23

24 s

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)) th

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yste

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ly a

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ntin

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ly a

s-24

25 s

esse

s an

d im

prov

es25

.S 6

44 I

S

49

31

"(1)

enr

olle

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alth

sta

tus,

pat

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. out

com

es,

proc

esse

s of

car

e, a

nd e

nrol

lee

satis

fact

ion

asso

ci-

ated

with

hea

lth c

are

prov

ided

by

the

issu

er; a

nd

"(2)

the

adm

inis

trat

ive

and

fund

ing

capa

city

of

the

issu

er to

sup

port

and

em

phas

ize

prev

entiv

e ca

re,

utili

zatio

n, a

cces

s an

d av

aila

bilit

y, c

ost e

ffect

iven

ess,

acce

ptab

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eatm

ent.

mod

aliti

es, s

peci

alis

ts r

efer

rals

,

the

peer

rev

iew

pro

cess

, and

the

effic

ienc

y of

the

ad-

min

istr

ativ

e pr

oces

s.

"(b)

PuN

(rrio

Nti.

A q

ualit

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prov

emen

t. pr

ogra

m

esta

blis

hed

purs

uant

to s

ubse

ctio

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) sh

all-

"(I)

ass

ess

the

perf

Orm

ance

of t

he is

suer

and

its p

artic

ipat

ing

heal

th p

rofe

ssio

nals

and

pro

vide

rs

and

repo

rt, t

he r

esul

ts o

f suc

h as

sess

men

t. to

pur

-

chas

ers,

par

ticip

atin

g he

alth

pro

fess

iona

ls a

nd p

ro-

eide

rs, a

nd a

dmin

istr

ativ

e pe

rson

nel;

"(2)

dem

onst

rate

mea

sura

ble

impr

ovem

ents

in

clin

ical

out

com

es a

nd p

lan

perf

orm

ance

mea

sure

d by

iden

tifie

d cr

iteria

, inc

ludi

ng th

ose

spec

ified

in s

ub-

sect

ion

(a)(

1); a

nd

"(3)

ana

lyze

qua

lity

asse

ssm

ent.

data

to d

eter

-

min

e sp

ecifi

c in

tera

ctio

nsin

the

deliv

ery

syst

em

(bot

h th

e de

sign

and

fund

ing

of th

e he

alth

insu

ranc

e

cove

rage

and

the

clin

ical

pro

visi

on o

f car

e) th

at. h

ave

an a

dver

se im

paet

. On

the

qual

ity o

f car

e.".

.S 6

44 I

S

50

:32

1(h

) A

ril.ic

AT

IoN

To

Cho

mp

I1E

AI,T

nIN

SUltA

NC

E

2 C

ovE

RA

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.

3(1

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ubpa

rt. 2

of p

art A

of t

itle

XX

VII

of th

e

4P

ublic

I le

alth

Ser

vice

Act

is a

men

ded

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ddin

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.

5th

e en

d th

e fo

llow

ing

new

sec

tion:

6"S

EC

. 270

6. P

AT

IEN

T P

RO

TE

CT

ION

ST

AN

DA

RD

S.

7"(

a)IN

CIE

NE

RA

L.E

ach

heal

th in

sura

nce

issu

er

8 sh

all c

ompl

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atie

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quire

men

tsun

der

9 pa

rt. C

with

res

pect

. to

grou

p he

alth

insu

ranc

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vera

ge

10it

offe

rs.

11"(

b) A

sstIR

IC

DO

RD

INA

TIO

N.T

he S

ecre

tary

of

12I

lean

and

Hum

an S

ervi

ces

and

the

Sec

reta

ry o

fL

xbor

13sh

all e

nsur

e, th

roug

h th

e ex

ecut

ion

of a

n in

tera

genc

y

14 m

emor

andu

m o

f und

erst

andi

ng b

etw

een

such

Sec

reta

ries,

15 th

at-

16"(

1 )

reg

ulat

ions

, rul

ings

, and

inte

rpre

tatio

nsis

-

17su

ed b

y su

ch S

ecre

tarie

s re

latin

g to

the

san'

mat

ter

18ov

erw

hich

such

Sec

reta

ries

have

resp

onsi

bilit

y

19un

der

part

. C (

and

this

sec

tion)

and

sec

tion

713

of

20th

e E

mpl

oyee

Ret

irem

ent.

Inco

me

Sec

urity

Act

of

2119

74 a

re a

dmin

iste

red

so a

s to

hav

e th

e sa

me

effe

ct

22at

all

times

; and

23"(

2) c

oord

inat

ion

of p

olic

ies

rela

ting

toca

irn:-

24in

g th

e sa

me

requ

irem

ents

thro

ugh

such

Sec

reta

ries

25in

ord

er to

hav

e a

coor

dina

ted

enfo

rcem

ent s

trat

egy

S 64

4 IS

51

:33

that

avo

ids

dupl

icat

ion

of e

nfor

cem

ent,

efth

rts

and

2as

sign

s pr

iorit

ies

in e

nfor

cem

ent."

.

3(2

)S

ectio

n 27

92 o

f suc

hA

ct (

42U

.S.C

.

430

0gg-

92)

is a

men

ded

by in

sert

ing

"am

l sec

tion

527

06(b

)" a

fter

"of 1

996"

.

6(e

) A

P11

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o IN

DIV

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n1,T

IIIN

SU

R1

7 A

NC

E C

OV

ER

AG

E.P

art,

B o

f titl

e X

XV

II of

the

Pub

lic

8H

ealth

Ser

vice

Act

is a

men

ded

by in

sert

ing

afte

r se

ctio

n

9 27

51 th

e fo

llow

ing

new

sec

tion:

10"S

EC

. 275

2. P

AT

IEN

T P

RO

TE

CT

ION

ST

AN

DA

RD

S.

11"E

ach

heal

th in

sura

nce

issu

er s

hall

com

ply

with

pa-

12tie

nt. p

rote

ctio

n re

quire

men

ts u

nder

par

t. C

with

res

pect

13to

indi

vidu

al h

ealth

insu

ranc

e co

vera

ge it

offe

rs."

.

14(d

) M

onw

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TIo

NP

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:mm

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ST

AN

DA

rtnr

i.

15(1

) G

uoul

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ALT

II IN

SU

RA

NC

E C

OV

ER

AG

E.

16S

ectio

n 27

2:3

or s

uch

Act

. (42

11.

S.C

. 300

gg-2

3) is

17am

ende

d-

18(A

) in

sub

sect

ion

(a)(

1 ),

by

strik

ing

"sub

-

19se

ctio

n (h

)" a

nd in

sert

ing

"sub

sect

ions

(h)

and

20(c

) ";

21(1

1) b

y re

rlesi

l.ora

ting

subs

ectio

ns (

e) a

nd

22(d

) as

sub

sect

ions

(d)

and

(e)

, req

rect

ivel

y; a

nd

23((

;) b

y in

sert

ing

afte

r su

bsec

tion

(b)

the

24fo

llow

ing

new

sub

sect

ion:

S 64

4 IS

52

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25

34

"(c)

SE

cni.A

1.,

BA

IN C

AS

E O

K P

AT

IEN

T P

RO

TE

C-

I 2T

ION

RE

QU

IRE

ME

NT

S. S

ubje

ct. t

o su

bsec

tion

(a)(

2), t

he

prov

isio

ns o

f sec

tion

270(

i and

par

t C, a

nd p

art 1

) in

sofa

r3

as it

app

lies

to s

ectio

n 27

06 o

r pa

rt. C

, sha

ll no

t. be

con

-4

stru

ed t.

o pr

eem

pt a

ny S

tate

law

, or

the

enac

tmen

t or

im-

5

plem

enta

tion

of s

uch

a S

tate

law

, tha

t pro

vide

s pr

otec

tions

6

for

indi

vidu

als

that

are

equ

ival

ent t

o or

str

icte

r th

an th

e7

prot

ectio

ns p

rovi

ded

unde

r su

ch p

rovi

sion

s. "

.8 9

(2)

IND

IvIn

t 1A

LH

EA

LTH

INS

UR

AN

CE

CO

V-

Eitm

:E.S

eaio

n 27

62 o

f suc

h A

ct (

4211

.S.(

;.

300g

g-62

), a

s ad

ded

by s

ectio

n 60

5(6)

(3)(

B)

of

Pub

lic 1

iIN

V 1

04-2

04, i

s am

ende

d

(A)

in s

ubse

ctio

n(a

), b

y st

rikin

g "s

ub-

sect

ion

(h),

not

hing

in th

is p

art."

and

inse

rtin

g

"sub

sect

ions

(h)

and

(c)

", a

nd

(11)

by

addi

ng a

t the

end

the

billo

win

g ne

w

subs

ectio

n:

IC)

SP

EC

IAL

RU

LES

IN C

AS

E O

E P

AT

IEN

T P

le /T

EC

-

'PIO

N R

EQ

uim

mE

NT

s.S

ubje

ct to

sub

sect

ion

(b),

the

prov

isio

ns o

f sec

tion

2752

and

par

t C, a

nd p

art.

1) in

sofa

r

as it

app

lies

to s

ectio

n 27

52 o

r pa

rt. C

, sha

ll no

t.be

con

-

stru

ed to

pre

empt

any

Sta

te la

w, o

r th

e en

actm

ent o

r im

-

plem

enta

tion

of s

uch

a S

tate

law

, tha

t pro

vide

s pr

otec

tions

for

indi

vidu

als

that

. are

equ

ival

ent,

to o

r st

ricte

r th

an th

e

prot

ectio

ns p

rovi

ded

unde

r su

ch p

rovi

sion

s.".

.S 8

44 IS

53

35

(c)

AD

DIT

IoN

AL

CO

NE

OR

M 'N

O A

ME

ND

NI E

NT

S.

(1)

Sec

tion

2723

(a)(

1) o

f suc

h A

ct. (

42 U

.S.C

.

300g

g-23

(a)(

1))

is a

men

ded

by s

trik

ing

"par

t. C

"

and

inse

rtin

g "p

arts

C a

nd 1

)".

(2)

Sec

tion

2762

(b)(

1) o

f suc

h A

ct (

42 U

.S.C

.

300g

g-62

(b)(

1))

is a

men

ded

by s

trik

ing

"par

t. C

''

and

inse

rtin

g "p

art.

1)".

(f)

EP

FE

cTN

E D

AT

Es.

(1 )

(A)

Sub

ject

to s

ubpa

ra-

grap

h (B

), th

e am

endm

ents

mad

e IT

sub

sect

ions

(a)

, (b)

,

10(d

)(1)

, and

(e)

sha

ll ap

ply

with

res

pect

to g

roup

hea

lth

11in

sura

nce

cove

rage

for

grou

p he

alth

pla

n ye

ars

begi

nnin

g

12 o

n rir

afte

r Ju

ly 1

, 190

8 (in

this

sub

sect

ion

refe

rred

to

13as

the

"gen

eral

effe

etiv

e da

te")

and

als

o sh

all a

pply

to

14 p

ortio

ns o

f pla

n ye

ars

Occ

urrin

g on

and

afte

r Ja

nuar

y 1,

1519

99.

16(B

) In

the

case

of g

roup

hea

lth in

sura

nce.

cov

erag

e

17pr

ovid

ed p

ursu

ant t

o a

grou

p he

alth

pla

n m

aint

aine

d pu

r-

18 s

cant

. to

1or

mor

e co

llect

ive

barg

aini

ng a

gree

men

ts b

e-

19 'm

em e

mpl

oyee

rep

rese

ntat

ives

and

1 o

r m

ore

empl

oyer

s

20 r

atifi

ed b

efor

e th

e da

te o

f ena

ctm

ent o

f thi

s A

ct, t

he

21am

endm

ents

mad

e by

sub

sect

ions

(a)

, (In

), (

d)(1

), a

nd (

c)

22 s

hall

not a

pply

to p

lain

yea

rs b

egin

ning

bef

ore

the

late

r

23 o

f-24

(i) th

e da

te o

n w

hich

the

last

col

lect

ive

barg

ain-

25in

g ag

reem

ents

rel

atin

g to

the

plan

term

inat

es (

de-

3 64

4 IS

5 4

36

1te

rnin

ed w

ithou

t. re

gard

to a

ny e

xten

sion

ther

eof

2ag

reed

to a

fter

the

date

of e

nact

men

t. of

this

Act

.),

3or

4(ii

) th

e ge

nera

l effe

ctiv

e da

te.

51'

or p

urpo

ses

of c

laus

e (i)

, any

pla

n am

endm

ent m

ade

pur-

6 su

ant t

o a

colle

ctiv

e ba

rgai

ning

agr

eem

ent

rela

ting

to tl

IC

7 pl

an w

hich

am

ends

the

plan

sol

ely

toco

nfor

m to

any

re-

8 qu

irem

ent a

dded

by

subs

ectio

n (a

) or

(b)

shal

l not

, be

9 tr

eate

dits

a te

rmin

atio

n of

suc

h co

llect

ive

barg

aini

ng

10 a

gree

men

t..

11(2

) T

he a

z»en

dmen

ts m

ade

lw s

ubse

ctio

ns (

a),

(c),

12(d

)(2)

, and

(e)

sha

ll ap

ply

with

res

pect

. to

indi

vidu

al h

ealth

13in

sura

nce

cove

rage

offe

red,

sol

d, is

sued

, ren

ewed

,in

effe

tt,

14 O

r op

erat

ed in

the

indi

vidu

al m

arke

t on

oraf

ter

the

gen-

15 e

al e

ffect

ive

date

.

16 S

EC

. 3. P

AT

IEN

T P

RO

TE

CT

ION

ST

AN

DA

RD

S U

ND

ER

TH

EE

M-

17PL

OY

EE

RE

TIR

EM

EN

T I

NC

OM

E S

EC

UR

ITY

18A

CT

OF

1974

.

19(a

) IN

GE

NE

RA

I,.S

ubpa

rt B

of p

art.

7of

sub

title

2013

of t

itle

I of t

he E

mpl

oyee

Ret

irem

ent.

Inco

me

Sec

urity

21A

ct o

f 197

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22 n

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3tit

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the

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6 C

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2 3 4 5 6 7 8 9 10 I I 12 13 14 15 16 17 18 19 20 21 22 23 24

38

over

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and

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2706

of

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731

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Act

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(I.

S.C

. 119

1) is

am

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(I)

in s

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(b)"

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b) a

nd (

c)";

(2)

by r

edes

igna

ting

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ectio

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c) a

nd (

d) a

s

subs

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d) a

nd (

e), r

espe

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(3)

hin

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the

ing

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3 an

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XX

VII

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the

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Act

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713

or s

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part

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tbe

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-

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Sta

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w, o

r th

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ate

law

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spr

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tions

S 6

44 IS

57

39

Ifo

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divi

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s th

at, a

re e

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the

2 pr

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der

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3(c

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(1)

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732(

a)

4 of

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29 U

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;. 11

85(a

)) is

am

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5 "s

ectio

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1" a

nd in

sert

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"sec

tions

711

and

713

".

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) T

he ta

ble

of c

onte

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in s

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of s

uch

Act

7is

am

ende

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inse

rtin

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ter

the

item

rel

atin

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sec

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8 71

2 th

e fo

llow

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item

:

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. 713

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...

9(3

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4 of

suc

h A

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29 U

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;. 11

87)

is

10 a

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713(

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1119

96".

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13(2

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sec

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shal

l app

ly w

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14 r

espe

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gro

up h

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pla

ns f

or p

lan

year

s be

ginn

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on

15 o

r af

ter

July

1, 1

998

(in

this

sub

sect

ion

refi

wre

d to

as

16 th

e "g

ener

al e

ffec

tive

date

") a

nd a

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ly to

1)(

11.-

17tio

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an y

ears

occ

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d af

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Janu

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1819

99.

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the

case

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1.11

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22 e

rs r

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actm

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is A

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23 a

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dmen

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ade

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is s

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all n

ot a

pply

to p

lan

24 y

ears

beg

inni

ng b

etO

re th

e la

ter

of

S 6

44 IS

53

4041

(A)

the

date

on

whi

ch th

e la

st. c

olle

ctiv

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r-1

bene

fit p

lan

mai

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2ga

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reem

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rel

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the

plan

term

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fits

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the

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this

Act

),4

subs

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) sh

all a

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to c

ause

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act

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aris

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on

5O

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or a

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enac

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Act

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6(1

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7 Po

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A),

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8 m

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9 in

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conf

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10 to

any

req

uire

men

t add

ed b

y su

bsec

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(a)

shal

l not

. he

I I

trea

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as a

term

inat

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of s

uch

colle

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eba

rgai

ning

12 a

gree

men

t.

13 S

EC

. 4. N

ON

-PR

EE

MPT

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OF

STA

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LA

W R

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GL

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BIL

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OF

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P H

EA

LT

H P

LA

NS.

15(a

) IN

GE

NE

RA

L.S

ectio

n 51

4(h)

of

the

Em

ploy

ee

16R

etir

emen

t. In

com

e Se

curi

ty A

ct. o

f 19

74 (

29U

.S.C

.

1711

44(b

)) is

am

ende

d by

red

esig

liatin

g pa

ragr

aph

(9)

as

18 p

arag

raph

(1(

1) a

nd in

sert

ing

the

hollo

win

g ne

w p

at-

19 g

raph

:

20"(

9) S

ubse

ctio

n (a

) of

this

sec

tion

shal

l not

he

21co

nstr

ued

to p

recl

ude

any

Stat

e ca

use

of a

etio

n to

22re

cove

r da

mag

es f

or p

erso

nal

inju

ry o

r w

rong

ful

23de

ath

agai

nst a

ny p

erso

n th

at p

rovi

des

insu

ranc

e or

24ad

min

istr

ativ

e se

rvic

es to

or

for

all e

mpl

oyee

wel

fare

S 64

4 IS

S 64

4 IS

5960

U.S. Department of EducationOffice of Educational Research and Improvement (OERI)

National Library of Education (NLE)Educational Resources Information Center (ERIC)

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