article: SECTION 1. SHORT TITLE. This Act may be cited as the ``Health Care Consumer Protection Act of 1995''. SEC. 2. NOTIFICATION OF COVERAGE PROVIDED BY THE INSURER. (a) Notification to Current Enrollees.--An insurer providing health insurance coverage under a health plan shall provide annual notice to each current enrollee under such plan regarding the extent of the coverage of the plan. Such notice shall be in writing and shall include a copy of the contract between the insurer and enrollee, in addition to information regarding the terms and conditions of the policy and the rights and obligations of the parties including-- (1) covered and excluded services, equipment, and devices; (2) copayments, deductibles, and premiums; (3) enrollee satisfaction statistics; (4) financial responsibility of the enrollee; (5) utilization review requirements; (6) a list of the usual, customary, and reasonable costs for procedures, tests, and examinations; (7) physician credentialing standards; and (8) the percentage of total annual premiums used to reimburse practitioners for health care provided to enrollees and the percentage used for administration and other costs incurred in administering the plan. (b) Notification to Potential Enrollees.--An insurer providing health insurance coverage under a health plan shall, upon request, provide notice to each potential enrollee under such plan regarding the extent of the coverage of the plan. Such notice shall be in writing and shall include a copy of the potential contract between the insurer and potential enrollee, in addition to information regarding the terms and conditions of the policy and the rights and obligations of the parties information including the items listed in paragraphs (1) through (8) of subsection (a). (c) Regulations for Failure To Provide Notification.--The Secretary of Health and Human Services shall promulgate regulations to ensure that an insurer providing health insurance coverage under a health plan provide notification to current and potential enrollees as described in subsections (a) and (b). SEC. 3. DETERMINATION OF MEDICALLY NECESSARY AND APPROPRIATE TREATMENT. (a) In General.--Under a health plan, the determination of what is medically necessary and appropriate for the health of a patient may be made only by a health care practitioner who is-- (1) licensed and practicing within the scope of the State practice act of the State in which the practitioner practices; and (2) directly involved in the care of such patient. (b) Insurance Coverage.--An insurer must pay for a service determined, as described in subsection (a), to be medically necessary and appropriate if the service is covered by the health plan. (c) Regulations To Deter Rewards, Penalties or Inducements.--The Secretary of Health and Human Services shall promulgate regulations to ensure that an insurer not offer monetary rewards, penalties, or inducements to a licensed health care practitioner, or condition the continued participation of a licensed health care practitioner in a plan on the basis of the health care practitioner's decisions to limit the availability of appropriate medical tests, services, or treatments. SEC. 4. ENFORCEMENT AND PENALTIES. (a) Penalties.-- Any entity that offers a health plan that violates the provisions of this Act shall be subject to a civil money penalty in an amount to be determined by the Secretary of Health and Human Services. (b) Process.--The provisions of section 1128A of the Social Security Act (42 U.S.C. 1320a-7a) (other than subsections (a) and (b)) shall apply to civil money penalties under this section in the same manner as they apply to a penalty or proceeding under section 1128A(a) of such Act. SEC. 5. PROHIBITION OF HOLD HARMLESS PROVISIONS. An insurer may not include provisions in a health plan to hold itself harmless for any liability. SEC. 6. PREEMPTION. A State may not establish or enforce standards for insurers or health insurance coverage with respect to the subject matter of this Act that are weaker than the standards established under this Act. SEC. 7. DEFINITIONS.-- For purposes of this Act: (1) Insurer.--The term ``insurer'' means an insurance company, insurance service, or insurance organization licensed to engage in the business of insurance in a State, and a health maintenance organization. (2) Health care practitioner.--The term ``health care practitioner'' has the meaning provided by section 11151 of title 42, United States Code. (3) Health insurance coverage.--The term ``health insurance coverage'' means any hospital or medical service policy or certificate, hospital or medical service plan contract, or health maintenance organization contract offered by an insurer. (4) Health plan.--The term ``health plan'' means a plan that provides health insurance coverage. (5) State.--The term ``State'' means any State, the District of Columbia, Puerto Rico, the Northern Mariana Islands, the Virgin Islands, American Samoa, and Guam. SEC. 8. EFFECTIVE DATE. The provisions of this Act shall apply to all health plans offered, sold, issued, or renewed after the date of the enactment of this Act.
summary: Health Care Consumer Protection Act of 1995 - Requires health insurers to provide notice regarding the extent of plan coverage to enrollees annually and to potential enrollees on request. Requires that, under a health plan, the determination of what is medically necessary and appropriate for a patient be made only by a health care practitioner directly involved in the patient's care. Requires an insurer to pay for a service that is so determined if the service is covered by the plan. Mandates regulations to ensure against insurers offering monetary rewards, penalties, or inducements to a practitioner, or conditioning continued practitioner participation in the plan, on the basis of the practitioner's decisions to limit the availability of appropriate tests, services, or treatments. Imposes a civil monetary penalty for violations of this Act. Prohibits insurers from including provisions in a plan to hold itself harmless for liability. Prohibits States from establishing or enforcing standards weaker than those of this Act.