Sec. 701. Receipt and response to requests for claim information
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Title XXVII of the Public Health Service Act is amended by inserting after section 2713 the following new section: In the case of health insurance coverage offered in connection with a group health plan, not later than the 30th day after the date a health insurance issuer receives a written request for a written report of claim information from the plan, plan sponsor, or plan administrator, the health insurance issuer shall provide the requesting party the report, subject to the succeeding provisions of this section.
The health insurance issuer is not obligated to provide a report under this subsection regarding a particular employer or group health plan more than twice in any 12-month period and is not obligated to provide such a report in the case of an employer with fewer than 50 employees. A plan, plan sponsor, or plan administrator must request a report under this subsection before or on the second anniversary of the date of termination of coverage under a group health plan issued by the health insurance issuer.
A health insurance issuer shall provide the report of claim information under subsection (a)— in a written report; through an electronic file transmitted by secure electronic mail or a file transfer protocol site; or by making the required information available through a secure Web site or Web portal accessible by the requesting plan, plan sponsor, or plan administrator. A report of claim information provided under subsection
(a)shall contain all information available to the health insurance issuer that is responsive to the request made under such subsection, including, subject to subsection (c), protected health information, for the 36-month period preceding the date of the report or the period specified by subparagraphs (D), (E), and
(F)of paragraph (3), if applicable, or for the entire period of coverage, whichever period is shorter. Subject to subsection (c), a report provided under subsection
(a)shall include the following: Aggregate paid claims experience by month, including claims experience for medical, dental, and pharmacy benefits, as applicable. Total premium paid by month. Total number of covered employees on a monthly basis by coverage tier, including whether coverage was for— an employee only; an employee with dependents only; an employee with a spouse only; or an employee with a spouse and dependents. The total dollar amount of claims pending as of the date of the report. A separate description and individual claims report for any individual whose total paid claims exceed $15,000 during the 12-month period preceding the date of the report, including the following information related to the claims for that individual— a unique identifying number, characteristic, or code for the individual; the amounts paid; dates of service; and applicable procedure codes and diagnosis codes. For claims that are not part of the information described in a previous subparagraph, a statement describing precertification requests for hospital stays of 5 days or longer that were made during the 30-day period preceding the date of the report. A health insurance issuer may not disclose protected health information in a report of claim information provided under this section if the health insurance issuer is prohibited from disclosing that information under another State or Federal law that imposes more stringent privacy restrictions than those imposed under Federal law under the HIPAA privacy regulations. To withhold information in accordance with this subsection, the health insurance issuer must— notify the plan, plan sponsor, or plan administrator requesting the report that information is being withheld; and provide to the plan, plan sponsor, or plan administrator a list of categories of claim information that the health insurance issuer has determined are subject to the more stringent privacy restrictions under another State or Federal law. A plan sponsor is entitled to receive protected health information under subparagraphs
(E)and
(F)of subsection (b)(3) and subsection
(d)only after an appropriately authorized representative of the plan sponsor makes to the health insurance issuer a certification substantially similar to the following certification: I hereby certify that the plan documents comply with the requirements of . section 164.504(f)(2) of title 45, Code of Federal Regulations, and that the plan sponsor will safeguard and limit the use and disclosure of protected health information that the plan sponsor may receive from the group health plan to perform the plan administration functions. A plan sponsor that does not provide the certification required by paragraph
(2)is not entitled to receive the protected health information described by subparagraphs
(E)and
(F)of subsection (b)(3) and subsection (d), but is entitled to receive a report of claim information that includes the information described by subparagraphs
(A)through
(D)of subsection (b)(3). In the case of a request made under subsection
(a)after the date of termination of coverage, the report must contain all information available to the health insurance issuer as of the date of the report that is responsive to the request, including protected health information, and including the information described by subsection (b)(3), for the period described by subsection (b)(2) preceding the date of termination of coverage or for the entire policy period, whichever period is shorter. Notwithstanding this subsection, the report may not include the protected health information described by subparagraphs
(E)and
(F)of subsection (b)(3) unless a certification has been provided in accordance with paragraph (2). On receipt of the report required by subsection (a), the plan, plan sponsor, or plan administrator may review the report and, not later than the 10th day after the date the report is received, may make a written request to the health insurance issuer for additional information in accordance with this subsection for specified individuals. With respect to a request for additional information concerning specified individuals for whom claims information has been provided under subsection (b)(3)(E), the health insurance issuer shall provide additional information on the prognosis or recovery if available and, for individuals in active case management, the most recent case management information, including any future expected costs and treatment plan, that relate to the claims for that individual. The health insurance issuer must respond to the request for additional information under this subsection not later than the 15th day after the date of such request unless the requesting plan, plan sponsor, or plan administrator agrees to a request for additional time. The health insurance issuer is not required to produce the report described by this subsection unless a certification has been provided in accordance with subsection (c)(2). A health insurance issuer that releases information, including protected health information, in accordance with this subsection has not violated a standard of care and is not liable for civil damages resulting from, and is not subject to criminal prosecution for, releasing that information. Nothing in this section is meant to limit States from enacting additional laws in addition to the provisions of this section, but not in lieu of such provisions. In this section: The terms employer , plan administrator , and plan sponsor have the meanings given such terms in section 3 of the Employee Retirement Income Security Act of 1974. The term HIPAA privacy regulations has the meaning given such term in section 1180(b)(3) of the Social Security Act. The term protected health information has the meaning given such term under the HIPAA privacy regulations. . The amendment made by subsection
(a)shall take effect on the date of the enactment of this Act.