I

106TH CONGRESS

2D SESSION H. R. 5628

To amend the Employee Retirement Income Security Act of 1974, the Public

Health Service Act, and the Internal Revenue Code of 1986 to provide

for a patients’ bill of rights, patient access to information, and accountability of health plans, and to expand access to health care coverage

through tax incentives.

IN THE HOUSE OF REPRESENTATIVES

NOVEMBER 3, 2000

Mr. SHADEGG (for himself, Mr. COBURN, Mr. SALMON, and Mr. ADERHOLT)

introduced the following bill; which was referred to the Committee on

Commerce, and in addition to the Committees on Education and the

Workforce, and Ways and Means, for a period to be subsequently determined by the Speaker, in each case for consideration of such provisions

as fall within the jurisdiction of the committee concerned

A BILL

To amend the Employee Retirement Income Security Act

of 1974, the Public Health Service Act, and the Internal

Revenue Code of 1986 to provide for a patients’ bill

of rights, patient access to information, and accountability of health plans, and to expand access to health

care coverage through tax incentives.

1 Be it enacted by the Senate and House of Representa2 tives of the United States of America in Congress assembled,
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1 SECTION 1. SHORT TITLE; TABLE OF CONTENTS.

2 (a) SHORT TITLE.—This Act may be cited as the

3 ‘‘Common Sense Patients’ Bill of Rights Act’’.

4 (b) TABLE OF CONTENTS.—The table of contents of

5 this Act is as follows:

Sec. 1. Short title; table of contents.

TITLE I—PATIENTS’ BILL OF RIGHTS

Subtitle A—Right to Advice and Care

Sec. 101. Patient right to medical advice and care under ERISA.

‘‘SUBPART C—PATIENT RIGHT TO MEDICAL ADVICE AND CARE

‘‘Sec. 721. Access to emergency care.

‘‘Sec. 722. Offering of choice of coverage options.

‘‘Sec. 723. Patient access to obstetric and gynecological care.

‘‘Sec. 724. Access to pediatric care.

‘‘Sec. 725. Timely access to specialists.

‘‘Sec. 726. Continuity of care.

‘‘Sec. 727. Prohibition of interference with certain medical communications.

‘‘Sec. 728. Patient’s right to prescription drugs.

‘‘Sec. 729. Self-payment for behavioral health care services.

‘‘Sec. 730. Coverage for individuals participating in approved cancer clinical trials.

‘‘Sec. 730A. Prohibition of discrimination against providers based on licensure.

‘‘Sec. 730B. Prohibition against improper incentive arrangements.

‘‘Sec. 730C. Payment of clean claims.

‘‘Sec. 730D. Generally applicable provision.

‘‘Sec. 730E. Exclusion from access to managed care provisions for fee-forservice coverage.

‘‘Sec. 730F. Additional definitions.

Sec. 102. Conforming amendments to the Public Health Service Act.

Sec. 103. Conforming amendments to the Internal Revenue Code of 1986.

Subtitle B—Right to Information About Plans and Providers

Sec. 111. Information about plans and coverage under ERISA.

‘‘Sec. 714. Patient access to information.

Sec. 112. Conforming amendments to Public Health Service Act.

Sec. 113. Conforming amendments to the Internal Revenue Code of 1986.

Subtitle C—Right to Hold Health Plans Accountable

Sec. 121. Amendments to Employee Retirement Income Security Act of 1974.

‘‘Sec. 503A. Utilization review activities.

‘‘Sec. 503B. Procedures for initial claims for benefits and prior authorization determinations.
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‘‘Sec. 503C. Internal appeals of claims denials.

‘‘Sec. 503D. Independent external appeals procedures.

Sec. 122. Conforming amendments to Public Health Service Act.

Sec. 123. Conforming amendments to the Internal Revenue Code of 1986.

Subtitle D—State Flexibility in Applying Requirements to Health Insurance

Issuers

Sec. 141. State flexibility in applying requirements to health insurance issuers

under ERISA; plan satisfaction of certain requirements.

Sec. 142. State flexibility in applying requirements to health insurance issuers

under the Public Health Service Act.

Subtitle E—Effective Dates; Coordination in Implementation; Miscellaneous

Provisions

Sec. 151. Effective dates.

Sec. 152. Regulations; coordination.

Sec. 153. No benefit requirements.

Sec. 154. Severability.

TITLE II—REMEDIES

Sec. 201. Availability of court remedies.

Sec. 202. Severability.

TITLE III—HEALTH CARE COVERAGE ACCESS TAX INCENTIVES

Sec. 301. Expanded availability of medical savings accounts.

Sec. 302. Deduction for 100 percent of health insurance costs of self-employed

individuals.

TITLE IV—HEALTH CARE PAPERWORK

Sec. 401. Health care paperwork simplification.

1 TITLE I—PATIENTS’ BILL OF

2 RIGHTS

3 Subtitle A—Right to Advice and

4 Care

5 SEC. 101. PATIENT RIGHT TO MEDICAL ADVICE AND CARE

6 UNDER ERISA.

7 (a) IN GENERAL.—Part 7 of subtitle B of title I of

8 the Employee Retirement Income Security Act of 1974

9 (29 U.S.C. 1181 et seq.) is amended—
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1 (1) by redesignating subpart C as subpart D;

2 and

3 (2) by inserting after subpart B the following:

4 ‘‘Subpart C—Patient Right to Medical Advice and

5 Care

6 ‘‘SEC. 721. ACCESS TO EMERGENCY CARE.

7 ‘‘(a) COVERAGE OF EMERGENCY SERVICES.—

8 ‘‘(1) IN GENERAL.—If a group health plan, or

9 health insurance coverage offered by a health insur10 ance issuer in connection with such a plan, provides

11 or covers any benefits with respect to services in an

12 emergency department of a hospital, the plan or

13 issuer shall cover emergency services (as defined in

14 paragraph (2)(B))—

15 ‘‘(A) without the need for any prior au16 thorization determination;

17 ‘‘(B) whether the health care provider fur18 nishing such services is a participating provider

19 with respect to such services;

20 ‘‘(C) in a manner so that, if such services

21 are provided to a participant or beneficiary—

22 ‘‘(i) by a nonparticipating health care

23 provider with or without prior authoriza24 tion, or
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1 ‘‘(ii) by a participating health care

2 provider without prior authorization,

3 the participant or beneficiary is not liable for

4 amounts that exceed the amounts of liability

5 that would be incurred if the services were pro6 vided by a participating health care provider

7 with prior authorization; and

8 ‘‘(D) without regard to any other term or

9 condition of such coverage (other than exclusion

10 or coordination of benefits, or an affiliation or

11 waiting period, permitted under section 2701 of

12 the Public Health Service Act, section 701, or

13 section 9801 of the Internal Revenue Code of

14 1986, and other than applicable cost-sharing).

15 ‘‘(2) DEFINITIONS.—In this section:

16 ‘‘(A) EMERGENCY MEDICAL CONDITION.—

17 The term ‘emergency medical condition’ means

18 a medical condition manifesting itself by acute

19 symptoms of sufficient severity (including se20 vere pain) such that a prudent layperson, who

21 possesses an average knowledge of health and

22 medicine, could reasonably expect the absence

23 of immediate medical attention to result in a

24 condition described in clause (i), (ii), or (iii) of
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1 section 1867(e)(1)(A) of the Social Security Act

2 (42 U.S.C. 1395dd(e)(1)(A)).

3 ‘‘(B) EMERGENCY SERVICES.—The term

4 ‘emergency services’ means with respect to an

5 emergency medical condition—

6 ‘‘(i) a medical screening examination

7 (as required under section 1867 of the So8 cial Security Act) that is within the capa9 bility of the emergency department of a

10 hospital, including ancillary services rou11 tinely available to the emergency depart12 ment to evaluate such emergency medical

13 condition, and

14 ‘‘(ii) within the capabilities of the

15 staff and facilities available at the hospital,

16 such further medical examination and

17 treatment as are required under section

18 1867 of such Act to stabilize the patient.

19 ‘‘(C) STABILIZE.—The term ‘to stabilize’

20 means, with respect to an emergency medical

21 condition, to provide such medical treatment of

22 the condition as may be necessary to assure,

23 within reasonable medical probability, that no

24 material deterioration of the condition is likely
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1 to result from or occur during the transfer of

2 the individual from a facility.

3 ‘‘(b) REIMBURSEMENT FOR MAINTENANCE CARE

4 AND POST-STABILIZATION CARE.—If benefits are avail5 able under a group health plan, or under health insurance

6 coverage offered by a health insurance issuer in connection

7 with such a plan, with respect to maintenance care or

8 post-stabilization care covered under the guidelines estab9 lished under section 1852(d)(2) of the Social Security Act,

10 the plan or issuer shall provide for reimbursement with

11 respect to such services provided to a participant or bene12 ficiary other than through a participating health care pro13 vider in a manner consistent with subsection (a)(1)(C)

14 (and shall otherwise comply with such guidelines).

15 ‘‘(c) COVERAGE OF EMERGENCY AMBULANCE SERV16 ICES.—

17 ‘‘(1) IN GENERAL.—If a group health plan, or

18 health insurance coverage provided by a health in19 surance issuer in connection with such a plan, pro20 vides any benefits with respect to ambulance services

21 and emergency services, the plan or issuer shall

22 cover emergency ambulance services (as defined in

23 paragraph (2)) furnished under the plan or coverage

24 under the same terms and conditions under subpara-
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1 graphs (A) through (D) of subsection (a)(1) under

2 which coverage is provided for emergency services.

3 ‘‘(2) EMERGENCY AMBULANCE SERVICES.—For

4 purposes of this subsection, the term ‘emergency

5 ambulance services’ means ambulance services (as

6 defined for purposes of section 1861(s)(7) of the So7 cial Security Act) furnished to transport an indi8 vidual who has an emergency medical condition (as

9 defined in subsection (a)(2)(A)) to a hospital for the

10 receipt of emergency services (as defined in sub11 section (a)(2)(B)) in a case in which the emergency

12 services are covered under the plan or coverage pur13 suant to subsection (a)(1) and a prudent layperson,

14 with an average knowledge of health and medicine,

15 could reasonably expect that the absence of such

16 transport would result in placing the health of the

17 individual in serious jeopardy, serious impairment of

18 bodily function, or serious dysfunction of any bodily

19 organ or part.

20 ‘‘(d) RULE OF CONSTRUCTION.—Nothing in this sec21 tion shall be construed to prohibit a group health plan or

22 a health insurance issuer from negotiating reimbursement

23 rates with a nonparticipating provider for items or services

24 provided under this section.
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1 ‘‘SEC. 722. OFFERING OF CHOICE OF COVERAGE OPTIONS.

2 ‘‘(a) REQUIREMENT.—If a group health plan provides

3 coverage for benefits only through a defined set of partici4 pating health care professionals, the plan shall offer each

5 participant the option to purchase point-of-service cov6 erage (as defined in subsection (b)) for all such benefits

7 for which coverage is otherwise so limited. Such option

8 shall be made available to the participant at the time of

9 enrollment under the plan and at such other times as the

10 plan offers the participant a choice of coverage options.

11 ‘‘(b) POINT-OF-SERVICE COVERAGE DEFINED.—In

12 this section, the term ‘point-of-service coverage’ means,

13 with respect to benefits covered under a group health plan,

14 coverage of such benefits when provided by a nonpartici15 pating health care professional.

16 ‘‘(c) SMALL EMPLOYER EXEMPTION.—

17 ‘‘(1) IN GENERAL.—The requirement of sub18 section (a) shall not apply to a group health plan

19 with respect to a small employer if the employer

20 demonstrates that compliance with such requirement

21 would result in an increase in overall costs to the

22 employer.

23 ‘‘(2) SMALL EMPLOYER DEFINED.—For pur24 poses of subparagraph (A), the term ‘small em25 ployer’ means, in connection with a group health

26 plan with respect to a calendar year and a plan year,
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1 an employer who employed an average of fewer than

2 25 employees on days during the preceding calendar

3 year and fewer than 25 employees on the first day

4 of the plan year.

5 ‘‘(3) DETERMINATION OF EMPLOYER SIZE.—

6 For purposes of this subsection, the provisions of

7 subparagraph (C) of section 712(c)(1) shall apply in

8 determining employer size.

9 ‘‘(d) RULE OF CONSTRUCTION.—Nothing in this sec10 tion shall be construed—

11 ‘‘(1) as requiring coverage for benefits for a

12 particular type of health care professional;

13 ‘‘(2) as requiring an increase in the level of em14 ployer contributions or as permitting an employer to

15 comply with the requirements of this section by

16 means of reducing the level of employer contribu17 tions attributable to coverage with respect to any

18 participant or group of participants in relation to

19 the level that would otherwise be maintained if such

20 requirements did not apply;

21 ‘‘(3) as preventing a group health plan from

22 imposing, on a participant who exercises the point23 of-service coverage option under subsection (a), the

24 additional cost of creation and maintenance of the

25 option as well as any additional other costs (includ-
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1 ing additional cost-sharing) attributable to the op2 tion; or

3 ‘‘(4) to require that a group health plan include

4 coverage of health care professionals that the plan

5 excludes because of fraud, quality of care, or other

6 similar reasons with respect to such professionals.

7 ‘‘SEC. 723. PATIENT ACCESS TO OBSTETRIC AND GYNECO8 LOGICAL CARE.

9 ‘‘(a) GENERAL RIGHTS.—

10 ‘‘(1) DIRECT ACCESS.—A group health plan, or

11 health insurance coverage offered by a health insur12 ance issuer in connection with such a plan, described

13 in subsection (b) may not require authorization or

14 referral by the plan, issuer, or any other person, in15 cluding the primary care provider described in sub16 section (b)(2), in the case of a female participant or

17 beneficiary who seeks coverage for obstetric or gyne18 cological care provided by a participating physician

19 who specializes in obstetrics or gynecology.

20 ‘‘(2) OBSTETRIC AND GYNECOLOGICAL CARE.—

21 Such a plan or issuer shall treat the provision of ob22 stetric and gynecological care, and the ordering of

23 related obstetric and gynecological items and serv24 ices, pursuant to the direct access described under

25 paragraph (1), by a participating physician who spe-
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1 cializes in obstetrics or gynecology as the authoriza2 tion of the primary care provider.

3 ‘‘(b) APPLICATION OF SECTION.—A group health

4 plan, or health insurance coverage offered by a health in5 surance issuer in connection with such a plan, described

6 in this subsection is a plan or coverage that—

7 ‘‘(1) provides coverage for obstetric or

8 gynecologic care; and

9 ‘‘(2) requires the designation by a participant

10 or beneficiary of a participating primary care pro11 vider other than a physician who specializes in ob12 stetrics or gynecology.

13 ‘‘(c) RULES OF CONSTRUCTION.—Nothing in this

14 section shall be construed—

15 ‘‘(1) to require that a group health plan or

16 health insurance issuer approve or provide coverage

17 for—

18 ‘‘(A) any items or services that are not

19 covered under the terms and conditions of the

20 group health plan or the health insurance cov21 erage;

22 ‘‘(B) any items or services that are not

23 medically necessary and appropriate; or

24 ‘‘(C) any items or services that are pro25 vided, ordered, or otherwise authorized under
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1 subsection (a)(2) by a physician unless such

2 items or services are related to obstetric or

3 gynecologic care; or

4 ‘‘(2) to preclude a group health plan or a health

5 insurance issuer from requiring that the physician

6 described in subsection (a) notify the designated pri7 mary care professional or case manager of treatment

8 decisions in accordance with a process implemented

9 by the plan or issuer, except that the plan or issuer

10 shall not impose such a notification requirement on

11 the participant or beneficiary involved in the treat12 ment decision.

13 ‘‘SEC. 724. ACCESS TO PEDIATRIC CARE.

14 ‘‘If a group health plan, or health insurance coverage

15 offered by a health insurance issuer in connection with

16 such a plan, requires or provides for a participant or bene17 ficiary to designate a participating primary care provider

18 for a child of such participant or beneficiary, the plan or

19 issuer shall permit the participant or beneficiary to des20 ignate a physician who specializes in pediatrics as the

21 child’s primary care provider if such provider participates

22 in the network of the plan or issuer.

23 ‘‘SEC. 725. TIMELY ACCESS TO SPECIALISTS.

24 ‘‘(a) TIMELY ACCESS.—
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1 ‘‘(1) IN GENERAL.—A group health plan, and a

2 health insurance issuer that offers health insurance

3 coverage in connection with such a plan, shall ensure

4 that participants and beneficiaries receive timely

5 coverage for access to specialists who are appro6 priate to the medical condition of the participant or

7 beneficiary, when such specialty care is a covered

8 benefit under the plan or coverage.

9 ‘‘(2) RULE OF CONSTRUCTION.—Nothing in

10 paragraph (1) shall be construed—

11 ‘‘(A) to require the coverage under a group

12 health plan or health insurance coverage of ben13 efits or services;

14 ‘‘(B) to prohibit a plan or issuer from in15 cluding providers in the network only to the ex16 tent necessary to meet the needs of the plan’s

17 participants and beneficiaries; or

18 ‘‘(C) to override any State licensure or

19 scope-of-practice law.

20 ‘‘(3) ACCESS TO CERTAIN PROVIDERS.—

21 ‘‘(A) PARTICIPATING PROVIDERS.—Noth22 ing in this section shall be construed to prohibit

23 a group health plan or health insurance issuer

24 from requiring that a participant or beneficiary
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1 obtain specialty care from a participating spe2 cialist.

3 ‘‘(B) NONPARTICIPATING PROVIDERS.—

4 ‘‘(i) IN GENERAL.—With respect to

5 specialty care under this section, if a group

6 health plan or health insurance issuer de7 termines that a participating specialist is

8 not available to provide such care to the

9 participant or beneficiary, the plan or

10 issuer shall provide for coverage of such

11 care by a nonparticipating specialist.

12 ‘‘(ii) TREATMENT OF NONPARTICI13 PATING PROVIDERS.—If a group health

14 plan or health insurance issuer refers a

15 participant or beneficiary to a nonpartici16 pating specialist pursuant to clause (i),

17 such specialty care shall be provided at no

18 additional cost to the participant or bene19 ficiary beyond what the participant or ben20 eficiary would otherwise pay for such spe21 cialty care if provided by a participating

22 specialist.

23 ‘‘(b) REFERRALS.—

24 ‘‘(1) AUTHORIZATION.—Nothing in this section

25 shall be construed to prohibit a group health plan or
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1 health insurance issuer from requiring an authoriza2 tion in order to obtain coverage for specialty services

3 so long as such authorization is for an appropriate

4 duration or number of referrals.

5 ‘‘(2) SPECIALISTS AS GATEKEEPER FOR TREAT6 MENT OF ONGOING SPECIAL CONDITIONS.—

7 ‘‘(A) IN GENERAL.—A group health plan,

8 or a health insurance issuer in connection with

9 the provision of group health insurance cov10 erage, shall have a procedure by which an indi11 vidual who is a participant or beneficiary and

12 who has an ongoing special condition (as de13 fined in subparagraph (C)) may request and re14 ceive a referral to a specialist for such condition

15 who shall be responsible for and capable of pro16 viding and coordinating the individual’s care

17 with respect to the condition. Under such proce18 dures if such an individual’s care would most

19 appropriately be coordinated by such a spe20 cialist, such plan or issuer shall refer the indi21 vidual to such specialist.

22 ‘‘(B) TREATMENT FOR RELATED REFER23 RALS.—Such specialists shall be permitted to

24 treat the individual without a referral from the

25 individual’s primary care provider and may au-
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1 thorize such referrals, procedures, tests, and

2 other medical services as the individual’s pri3 mary care provider would otherwise be per4 mitted to provide or authorize, subject to the

5 terms of the treatment (referred to in sub6 section (a)(3)(A)) with respect to the ongoing

7 special condition.

8 ‘‘(C) ONGOING SPECIAL CONDITION DE9 FINED.—In this paragraph, the term ‘ongoing

10 special condition’ means a condition or disease

11 that—

12 ‘‘(i) is life-threatening, degenerative,

13 congenital, or disabling, and

14 ‘‘(ii) requires specialized medical care

15 over a prolonged period of time.

16 ‘‘(D) TERMS OF REFERRAL.—The provi17 sions of paragraphs (3) through (5) of sub18 section (a) apply with respect to referrals under

19 subparagraph (A) in the same manner as they

20 apply to referrals under subsection (a)(1).

21 ‘‘(E) CONSTRUCTION.—Nothing in this

22 paragraph shall be construed as preventing an

23 individual who is a participant or beneficiary

24 and who has an ongoing special condition from

25 having the individual’s primary care physician
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1 assume the responsibilities for providing and co2 ordinating care described in subparagraph (A).

3 ‘‘(c) TREATMENT PLANS.—

4 ‘‘(1) IN GENERAL.—Nothing in this section

5 shall be construed to prohibit a group health plan or

6 health insurance issuer from requiring that specialty

7 care be provided pursuant to a treatment plan so

8 long as the treatment plan is—

9 ‘‘(A) developed by the specialist, in con10 sultation with the case manager or primary

11 care provider, and the participant or bene12 ficiary;

13 ‘‘(B) approved by the plan or issuer in a

14 timely manner if the plan requires such ap15 proval; and

16 ‘‘(C) in accordance with the applicable

17 quality assurance and utilization review stand18 ards of the plan or issuer.

19 ‘‘(2) NOTIFICATION.—Nothing in paragraph (1)

20 shall be construed as prohibiting a plan or issuer

21 from requiring the specialist to provide the plan or

22 issuer with regular updates on the specialty care

23 provided, as well as all other necessary medical in24 formation.
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1 ‘‘(d) SPECIALIST DEFINED.—For purposes of this

2 section, the term ‘specialist’ means, with respect to the

3 medical condition of the participant or beneficiary, a

4 health care professional, facility, or center that has ade5 quate expertise (including age-appropriate expertise)

6 through appropriate training and experience or a physi7 cian pathologist who has adequate expertise through ap8 propriate training and experience.

9 ‘‘SEC. 726. CONTINUITY OF CARE.

10 ‘‘(a) TERMINATION OF PROVIDER.—If a contract be11 tween a group health plan, or health insurance issuer that

12 offers health insurance coverage in connection with such

13 a plan, and a treating health care provider is terminated

14 (as defined in paragraph (e)(4)), or benefits or coverage

15 provided by a health care provider are terminated because

16 of a change in the terms of provider participation in such

17 plan or coverage, and an individual who is a participant

18 or beneficiary in the plan is undergoing an active course

19 of treatment for a serious and complex condition, institu20 tional care, pregnancy, or terminal illness from the pro21 vider at the time the plan or issuer receives or provides

22 notice of such termination, the plan or issuer shall—

23 ‘‘(1) notify the individual, or arrange to have

24 the individual notified pursuant to subsection (d)(2),

25 on a timely basis of such termination;
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1 ‘‘(2) provide the individual with an opportunity

2 to notify the plan or issuer of the individual’s need

3 for transitional care; and

4 ‘‘(3) subject to subsection (c), permit the indi5 vidual to elect to continue to be covered with respect

6 to the active course of treatment with the provider’s

7 consent during a transitional period (as provided for

8 under subsection (b)).

9 ‘‘(b) TRANSITIONAL PERIOD.—

10 ‘‘(1) SERIOUS AND COMPLEX CONDITIONS.—

11 The transitional period under this section with re12 spect to a serious and complex condition shall extend

13 for up to 90 days from the date of the notice de14 scribed in subsection (a)(1) of the provider’s termi15 nation.

16 ‘‘(2) INSTITUTIONAL OR INPATIENT CARE.—

17 ‘‘(A) IN GENERAL.—The transitional pe18 riod under this section for institutional or non19 elective inpatient care from a provider shall ex20 tend until the earlier of—

21 ‘‘(i) the expiration of the 90-day pe22 riod beginning on the date on which the

23 notice described in subsection (a)(1) of the

24 provider’s termination is provided; or
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1 ‘‘(ii) the date of discharge of the indi2 vidual from such care or the termination of

3 the period of institutionalization.

4 ‘‘(B) SCHEDULED CARE.—The 90 day lim5 itation described in subparagraph (A)(i) shall

6 include post-surgical follow-up care relating to

7 non-elective surgery that has been scheduled be8 fore the date of the notice of the termination of

9 the provider under subsection (a)(1).

10 ‘‘(3) PREGNANCY.—If—

11 ‘‘(A) a participant or beneficiary was de12 termined to be pregnant at the time of a pro13 vider’s termination of participation, and

14 ‘‘(B) the provider was treating the preg15 nancy before date of the termination,

16 the transitional period under this subsection with re17 spect to provider’s treatment of the pregnancy shall

18 extend through the provision of post-partum care di19 rectly related to the delivery.

20 ‘‘(4) TERMINAL ILLNESS.—If—

21 ‘‘(A) a participant or beneficiary was de22 termined to be terminally ill (as determined

23 under section 1861(dd)(3)(A) of the Social Se24 curity Act) at the time of a provider’s termi25 nation of participation; and
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1 ‘‘(B) the provider was treating the ter2 minal illness before the date of termination;

3 the transitional period under this subsection shall

4 extend for the remainder of the individual’s life for

5 care that is directly related to the treatment of the

6 terminal illness.

7 ‘‘(c) PERMISSIBLE TERMS AND CONDITIONS.—A

8 group health plan, and a health insurance issuer that of9 fers health insurance coverage in connection with such a

10 plan, may condition coverage of continued treatment by

11 a provider under this section upon the provider agreeing

12 to the following terms and conditions:

13 ‘‘(1) The treating health care provider agrees to

14 accept reimbursement from the plan or issuer and

15 individual involved (with respect to cost-sharing) at

16 the rates applicable prior to the start of the transi17 tional period as payment in full (or at the rates ap18 plicable under the replacement plan or coverage

19 after the date of the termination of the contract with

20 the group health plan or health insurance issuer)

21 and not to impose cost-sharing with respect to the

22 individual in an amount that would exceed the cost23 sharing that could have been imposed if the contract

24 referred to in this section had not been terminated.
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1 ‘‘(2) The treating health care provider agrees to

2 adhere to the quality assurance standards of the

3 plan or issuer responsible for payment under para4 graph (1) (to the extent such quality assurance

5 standards meet the professionally accepted stand6 ards of care) and to provide to such plan or issuer

7 necessary medical information related to the care

8 provided.

9 ‘‘(3) The treating health care provider agrees

10 otherwise to adhere to such plan’s or issuer’s policies

11 and procedures (to the extent such policies and pro12 cedures meet the professionally accepted standards

13 of care), including procedures regarding referrals

14 and obtaining prior authorization and providing

15 services pursuant to a treatment plan (if any) ap16 proved by the plan or issuer.

17 ‘‘(d) RULES OF CONSTRUCTION.—Nothing in this

18 section shall be construed—

19 ‘‘(1) to require the coverage of benefits which

20 would not have been covered if the provider involved

21 remained a participating provider; or

22 ‘‘(2) with respect to the termination of a con23 tract under subsection (a) to prevent a group health

24 plan or health insurance issuer from requiring that

25 the health care provider—
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1 ‘‘(A) notify participants or beneficiaries of

2 their rights under this section; or

3 ‘‘(B) provide the plan or issuer with the

4 name of each participant or beneficiary who the

5 provider believes is eligible for transitional care

6 under this section.

7 ‘‘(e) DEFINITIONS.—In this section:

8 ‘‘(1) CONTRACT.—The term ‘contract between a

9 plan or issuer and a treating health care provider’

10 shall include a contract between such a plan or

11 issuer and an organized network of providers.

12 ‘‘(2) HEALTH CARE PROVIDER.—The term

13 ‘health care provider’ or ‘provider’ means—

14 ‘‘(A) any individual who is engaged in the

15 delivery of health care services in a State and

16 who is required by State law or regulation to

17 be licensed or certified by the State to engage

18 in the delivery of such services in the State; and

19 ‘‘(B) any entity that is engaged in the de20 livery of health care services in a State and

21 that, if it is required by State law or regulation

22 to be licensed or certified by the State to en23 gage in the delivery of such services in the

24 State, is so licensed.
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1 ‘‘(3) SERIOUS AND COMPLEX CONDITION.—The

2 term ‘serious and complex condition’ means, with re3 spect to a participant or beneficiary under the plan

4 or coverage, a condition that is medically deter5 minable and—

6 ‘‘(A) in the case of an acute illness, is a

7 condition serious enough to require specialized

8 medical treatment to avoid the reasonable possi9 bility of death or permanent harm; or

10 ‘‘(B) in the case of a chronic illness or con11 dition, is an illness or condition that—

12 ‘‘(i) is complex and difficult to man13 age;

14 ‘‘(ii) is disabling or life-threatening;

15 and

16 ‘‘(iii) requires—

17 ‘‘(I) frequent monitoring over a

18 prolonged period of time and requires

19 substantial on-going specialized med20 ical care; or

21 ‘‘(II) frequent ongoing specialized

22 medical care across a variety of do23 mains of care.

24 ‘‘(4) TERMINATED.—The term ‘terminated’ in25 cludes, with respect to a contract (as defined in
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1 paragraph (1)), the expiration or nonrenewal of the

2 contract by the group health plan or the health in3 surance issuer, but does not include a termination of

4 the contract by the plan or issuer for failure to meet

5 applicable quality standards or for fraud.

6 SEC. 727. PROHIBITION OF INTERFERENCE WITH CERTAIN

7 MEDICAL COMMUNICATIONS.

8 (a) GENERAL RULE.—The provisions of any contract

9 or agreement, or the operation of any contract or agree10 ment, between a group health plan or health insurance

11 issuer in relation to health insurance coverage (including

12 any partnership, association, or other organization that

13 enters into or administers such a contract or agreement)

14 and a health care provider (or group of health care pro15 viders) shall not prohibit or otherwise restrict a health

16 care professional from advising such a participant, bene17 ficiary, or enrollee who is a patient of the professional

18 about the health status of the individual or medical care

19 or treatment for the individual’s condition or disease, re20 gardless of whether benefits for such care or treatment

21 are provided under the plan or coverage, if the professional

22 is acting within the lawful scope of practice.

23 (b) NULLIFICATION.—Any contract provision or

24 agreement that restricts or prohibits medical communica25 tions in violation of subsection (a) shall be null and void.
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1 ‘‘SEC. 728. PATIENT’S RIGHT TO PRESCRIPTION DRUGS.

2 ‘‘To the extent that a group health plan, or health

3 insurance coverage offered by a health insurance issuer

4 in connection with such a plan, provides coverage for bene5 fits with respect to prescription drugs, and limits such cov6 erage to drugs included in a formulary, the plan or issuer

7 shall—

8 ‘‘(1) ensure the participation of physicians and

9 pharmacists in developing and reviewing such for10 mulary;

11 ‘‘(2) disclose the nature of such limits on such

12 coverage to providers whose services (or reimburse13 ment therefor) are included under the coverage of

14 the plan (in addition to disclosure to participants

15 and beneficiaries upon request in accordance with

16 section 714(c)(3)), and

17 ‘‘(3) in accordance with the applicable quality

18 assurance and utilization review standards of the

19 plan or issuer, provide for exceptions from the for20 mulary limitation when a non-formulary alternative

21 is medically necessary and appropriate.

22 ‘‘SEC. 729. SELF-PAYMENT FOR BEHAVIORAL HEALTH CARE

23 SERVICES.

24 ‘‘(a) IN GENERAL.—A group health plan, and a

25 health insurance issuer in relation to its offering of health
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1 insurance coverage in connection with such a plan, may

2 not—

3 ‘‘(1) prohibit or otherwise discourage a partici4 pant or beneficiary from self-paying for behavioral

5 health care services once the plan or issuer has de6 nied coverage for such services; or

7 ‘‘(2) terminate a health care provider because

8 such provider permits participants or beneficiaries to

9 self-pay for behavioral health care services—

10 ‘‘(A) that are not otherwise covered under

11 the plan or coverage; or

12 ‘‘(B) for which the group health plan or

13 coverage provides limited coverage, to the ex14 tent that the plan or issuer denies coverage of

15 the services.

16 ‘‘(b) RULE OF CONSTRUCTION.—Nothing in sub17 section (a)(2)(B) shall be construed as prohibiting a group

18 health plan or health insurance issuer from terminating

19 a contract with a health care provider for failure to meet

20 applicable quality standards or for fraud.

21 ‘‘SEC. 730. COVERAGE FOR INDIVIDUALS PARTICIPATING IN

22 APPROVED CANCER CLINICAL TRIALS.

23 ‘‘(a) COVERAGE.—

24 ‘‘(1) IN GENERAL.—If a group health plan, or

25 a health insurance issuer offering health insurance
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1 coverage in connection with such a plan, provides

2 coverage to a qualified individual (as defined in sub3 section (b)), the plan or issuer—

4 ‘‘(A) may not deny the individual partici5 pation in the clinical trial referred to in sub6 section (b)(2);

7 ‘‘(B) subject to subsections (b), (c), and

8 (d), may not deny (or limit or impose additional

9 conditions on) the coverage of routine patient

10 costs for items and services furnished in con11 nection with participation in the trial; and

12 ‘‘(C) may not discriminate against the in13 dividual on the basis of the individual’s partici14 pation in such trial.

15 ‘‘(2) EXCLUSION OF CERTAIN COSTS.—For pur16 poses of paragraph (1)(B), routine patient costs do

17 not include the cost of the tests or measurements

18 conducted primarily for the purpose of the clinical

19 trial involved.

20 ‘‘(3) USE OF IN-NETWORK PROVIDERS.—If one

21 or more participating providers is participating in a

22 clinical trial, nothing in paragraph (1) shall be con23 strued as preventing a plan or issuer from requiring

24 that a qualified individual participate in the trial

25 through such a participating provider if the provider
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1 will accept the individual as a participant in the

2 trial.

3 ‘‘(b) QUALIFIED INDIVIDUAL DEFINED.—For pur4 poses of subsection (a), the term ‘qualified individual’

5 means an individual who is a participant or beneficiary

6 in a group health plan who meets the following conditions:

7 ‘‘(1)(A) The individual has been diagnosed with

8 cancer.

9 ‘‘(B) The individual is eligible to participate in

10 an approved clinical trial according to the trial pro11 tocol with respect to treatment of such illness.

12 ‘‘(C) The individual’s participation in the trial

13 offers meaningful potential for significant clinical

14 benefit for the individual.

15 ‘‘(2) Either—

16 ‘‘(A) the referring physician is a partici17 pating health care professional and has con18 cluded that the individual’s participation in

19 such trial would be appropriate based upon the

20 individual meeting the conditions described in

21 paragraph (1); or

22 ‘‘(B) the individual provides medical and

23 scientific information establishing that the indi24 vidual’s participation in such trial would be ap-
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1 propriate based upon the individual meeting the

2 conditions described in paragraph (1).

3 ‘‘(c) PAYMENT.—

4 ‘‘(1) IN GENERAL.—Under this section a group

5 health plan (or health insurance issuer offering

6 health insurance) shall provide for payment for rou7 tine patient costs described in subsection (a)(2) but

8 is not required to pay for costs of items and services

9 that are reasonably expected to be paid for by the

10 sponsors of an approved clinical trial.

11 ‘‘(2) ROUTINE PATIENT CARE COSTS.—For pur12 poses of this section—

13 ‘‘(A) IN GENERAL.—The term ‘routine pa14 tient care costs’ includes the costs associated

15 with the provision of items and services that—

16 ‘‘(i) would otherwise be covered under

17 the group health plan if such items and

18 services were not provided in connection

19 with an approved clinical trial program;

20 and

21 ‘‘(ii) are furnished according to the

22 protocol of an approved clinical trial pro23 gram.

24 ‘‘(B) EXCLUSION.—Such term does include

25 the costs associated with the provision of—
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1 ‘‘(i) an investigational drug or device,

2 unless the Secretary has authorized the

3 manufacturer of such drug or device to

4 charge for such drug or device; or

5 ‘‘(ii) any item or service supplied

6 without charge by the sponsor of the ap7 proved clinical trial program.

8 ‘‘(3) PAYMENT RATE.—In the case of covered

9 items and services provided by—

10 ‘‘(A) a participating provider, the payment

11 rate shall be at the agreed upon rate, or

12 ‘‘(B) a nonparticipating provider, the pay13 ment rate shall be at the rate the plan or issuer

14 would normally pay for comparable items or

15 services under subparagraph (A).

16 ‘‘(d) APPROVED CLINICAL TRIAL DEFINED.—In this

17 section, the term ‘approved clinical trial’ means a cancer

18 clinical research study or cancer clinical investigation ap19 proved by an Institutional Review Board.

20 ‘‘(e) CONSTRUCTION.—Nothing in this section shall

21 be construed to limit a plan’s or issuer’s coverage with

22 respect to clinical trials.

23 ‘‘(f) PLAN SATISFACTION OF CERTAIN REQUIRE24 MENTS; RESPONSIBILITIES OF FIDUCIARIES.—
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1 ‘‘(1) IN GENERAL.—For purposes of this sec2 tion, insofar as a group health plan provides benefits

3 in the form of health insurance coverage through a

4 health insurance issuer, the plan shall be treated as

5 meeting the requirements of this section with respect

6 to such benefits and not be considered as failing to

7 meet such requirements because of a failure of the

8 issuer to meet such requirements so long as the plan

9 sponsor or its representatives did not cause such

10 failure by the issuer.

11 ‘‘(2) CONSTRUCTION.—Nothing in this section

12 shall be construed to affect or modify the respon13 sibilities of the fiduciaries of a group health plan

14 under part 4 of subtitle B.

15 ‘‘SEC. 730A. PROHIBITION OF DISCRIMINATION AGAINST

16 PROVIDERS BASED ON LICENSURE.

17 ‘‘(a) IN GENERAL.—A group health plan, and a

18 health insurance issuer in relation to its offering of health

19 insurance coverage in connection with such a plan, shall

20 not discriminate with respect to participation or indem21 nification as to any provider who is acting within the scope

22 of the provider’s license or certification under applicable

23 State law, solely on the basis of such license or certifi24 cation.
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1 ‘‘(b) CONSTRUCTION.—Subsection (a) shall not be

2 construed—

3 ‘‘(1) as requiring the coverage under a group

4 health plan or health insurance coverage of a par5 ticular benefit or service or to prohibit a plan or

6 issuer from including providers only to the extent

7 necessary to meet the needs of the plan’s partici8 pants or beneficiaries or from establishing any meas9 ure designed to maintain quality and control costs

10 consistent with the responsibilities of the plan or

11 issuer;

12 ‘‘(2) to override any State licensure or scope-of13 practice law;

14 ‘‘(3) as requiring a plan or issuer that offers

15 network coverage to include for participation every

16 willing provider who meets the terms and conditions

17 of the plan or issuer; or

18 ‘‘(4) as prohibiting a family practice physician

19 with appropriate expertise from providing pediatric

20 or obstetric or gynecological care.

21 ‘‘SEC. 730B. PROHIBITION AGAINST IMPROPER INCENTIVE

22 ARRANGEMENTS.

23 ‘‘(a) IN GENERAL.—A group health plan and a health

24 insurance issuer offering health insurance coverage in con25 nection with such a plan may not operate any physician
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1 incentive plan (as defined in subparagraph (B) of section

2 1876(i)(8) of the Social Security Act) unless the require3 ments described in clauses (i), (ii)(I), and (iii) of subpara4 graph (A) of such section are met with respect to such

5 a plan.

6 ‘‘(b) APPLICATION.—For purposes of carrying out

7 paragraph (1), any reference in section 1876(i)(8) of the

8 Social Security Act to the Secretary, an eligible organiza9 tion, or an individual enrolled with the organization shall

10 be treated as a reference to the applicable authority, a

11 group health plan or health insurance issuer, respectively,

12 and a participant or beneficiary with the plan or organiza13 tion, respectively.

14 ‘‘(c) CONSTRUCTION.—Nothing in this section shall

15 be construed as prohibiting all capitation and similar ar16 rangements or all provider discount arrangements.

17 ‘‘SEC. 730C. PAYMENT OF CLEAN CLAIMS.

18 ‘‘A group health plan, and a health insurance issuer

19 offering group health insurance coverage, shall provide for

20 prompt payment of claims submitted for health care serv21 ices or supplies furnished to a participant or beneficiary

22 with respect to benefits covered by the plan or issuer, in

23 a manner consistent with the provisions of sections

24 1816(c)(2) and 1842(c)(2) of the Social Security Act (42

25 U.S.C. 1395h(c)(2) and 42 U.S.C. 1395u(c)(2)), except
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1 that for purposes of this section, subparagraph (C) of sec2 tion 1816(c)(2) of the Social Security Act shall be treated

3 as applying to claims received from a participant or bene4 ficiary as well as claims referred to in such subparagraph.

5 ‘‘SEC. 730D. GENERALLY APPLICABLE PROVISION.

6 ‘‘In the case of a group health plan or health insur7 ance coverage that provides benefits under 2 or more cov8 erage options, the requirements of this subpart shall apply

9 separately with respect to each coverage option.

10 ‘‘SEC. 730E. EXCLUSION FROM ACCESS TO MANAGED CARE

11 PROVISIONS FOR FEE-FOR-SERVICE COV12 ERAGE.

13 ‘‘(a) IN GENERAL.—The provisions of sections 721

14 through 730D shall not apply to a group health plan or

15 health insurance coverage if the only coverage offered

16 under the plan or coverage is fee-for-service coverage (as

17 defined in subsection (b)).

18 ‘‘(b) FEE-FOR-SERVICE COVERAGE DEFINED.—For

19 purposes of this section, the term ‘fee-for-service coverage’

20 means coverage under a group health plan or health insur21 ance coverage that—

22 ‘‘(1) reimburses hospitals, health professionals,

23 and other providers on a fee-for-service basis without

24 placing the provider at financial risk;
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1 ‘‘(2) does not vary reimbursement for such a

2 provider based on an agreement to contract terms

3 and conditions or the utilization of health care items

4 or services relating to such provider;

5 ‘‘(3) allows access to any provider that is law6 fully authorized to provide the covered services and

7 that agrees to accept the terms and conditions of

8 payment established under the plan or by the issuer;

9 and

10 ‘‘(4) for which the plan or issuer does not re11 quire prior authorization before providing for any

12 health care services.

13 ‘‘SEC. 730F. ADDITIONAL DEFINITIONS.

14 ‘‘For purposes of this subpart, section 714, and sec15 tions 503A through 503D:

16 ‘‘(1) APPLICABLE AUTHORITY.—The term ‘ap17 plicable authority’ means—

18 ‘‘(A) in the case of a group health plan,

19 the Secretary of Health and Human Services

20 and the Secretary of Labor; and

21 ‘‘(B) in the case of a health insurance

22 issuer with respect to a specific provision of this

23 subpart, the applicable State authority (as de24 fined in section 2791(d) of the Public Health

25 Service Act), or the Secretary of Health and
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1 Human Services, if such Secretary is enforcing

2 such provision under section 2722(a)(2) or

3 2761(a)(2) of the Public Health Service Act.

4 ‘‘(2) GROUP HEALTH PLAN.—The term ‘group

5 health plan’ has the meaning given such term in sec6 tion 733(a), except that such term includes a em7 ployee welfare benefit plan treated as a group health

8 plan under section 732(d) or defined as such a plan

9 under section 607(1).

10 ‘‘(3) HEALTH CARE PROFESSIONAL.—The term

11 ‘health care professional’ means an individual who is

12 licensed, accredited, or certified under State law to

13 provide specified health care services and who is op14 erating within the scope of such licensure, accredita15 tion, or certification.

16 ‘‘(4) HEALTH CARE PROVIDER.—The term

17 ‘health care provider’ includes an allopathic or osteo18 pathic physician or other health care professional, as

19 well as an institutional or other facility or agency

20 that provides health care services and that is li21 censed, accredited, or certified to provide health care

22 items and services under applicable State law.

23 ‘‘(5) NETWORK.—The term ‘network’ means,

24 with respect to a group health plan or health insur25 ance issuer offering health insurance coverage, the
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1 participating health care professionals and providers

2 through whom the plan or issuer provides health

3 care items and services to participants or bene4 ficiaries.

5 ‘‘(6) NONPARTICIPATING.—The term ‘non6 participating’ means, with respect to a health care

7 provider that provides health care items and services

8 to a participant or beneficiary under group health

9 plan or health insurance coverage, a health care pro10 vider that is not a participating health care provider

11 with respect to such items and services.

12 ‘‘(7) PARTICIPATING.—The term ‘participating’

13 means, with respect to a health care provider that

14 provides health care items and services to a partici15 pant or beneficiary under group health plan or

16 health insurance coverage offered by a health insur17 ance issuer, a health care provider that furnishes

18 such items and services under a contract or other

19 arrangement with the plan or issuer.

20 ‘‘(8) PRIOR AUTHORIZATION.—The term ‘prior

21 authorization’ means the process of obtaining prior

22 approval from a health insurance issuer or group

23 health plan for the provision or coverage of medical

24 services.
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1 ‘‘(9) TERMS AND CONDITIONS.—The term

2 ‘terms and conditions’ includes, with respect to a

3 group health plan or health insurance coverage, re4 quirements imposed under this subpart (and section

5 714 and sections 503A through 503D) with respect

6 to the plan or coverage.’’.

7 (b) RULE WITH RESPECT TO CERTAIN PLANS.—

8 (1) IN GENERAL.—Notwithstanding any other

9 provision of law, health insurance issuers may offer,

10 and eligible individuals may purchase, high deduct11 ible health plans described in section 220(c)(2)(A) of

12 the Internal Revenue Code of 1986. Effective for the

13 5-year period beginning on the date of the enact14 ment of this Act, such health plans shall not be re15 quired to provide payment for any health care items

16 or services that are exempt from the plan’s deduct17 ible.

18 (2) EXISTING STATE LAWS.—A State law relat19 ing to payment for health care items and services in

20 effect on the date of enactment of this Act that is

21 preempted under paragraph (1), shall not apply to

22 high deductible health plans after the expiration of

23 the 5-year period described in such paragraph unless

24 the State reenacts such law after such period.
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1 (c) CONFORMING AMENDMENT.—The table of con2 tents in section 1 of the Employee Retirement Income Se3 curity Act of 1974 is amended—

4 (1) in the item relating to subpart C of part 7

5 of subtitle B of title I, by striking ‘‘Subpart C’’ and

6 inserting ‘‘Subpart D’’; and

7 (2) by adding at the end of the items relating

8 to subpart B of part 7 of subtitle B of title I, the

9 following:

‘‘SUBPART C—PATIENT RIGHT TO MEDICAL ADVICE AND CARE

‘‘Sec. 721. Access to emergency medical care.

‘‘Sec. 722. Offering of choice of coverage options.

‘‘Sec. 723. Patient access to obstetric and gynecological care.

‘‘Sec. 724. Access to pediatric care.

‘‘Sec. 725. Timely access to specialists.

‘‘Sec. 726. Continuity of care.

‘‘Sec. 727. Protection of patient-provider communications.

‘‘Sec. 728. Patient’s right to prescription drugs.

‘‘Sec. 729. Self-payment for behavioral health care services.

‘‘Sec. 730. Coverage for individuals participating in approved cancer clinical

trials.

‘‘Sec. 730B. Prohibition against improper incentive arrangements.

‘‘Sec. 730C. Payment of clean claims.

‘‘Sec. 730D. Generally applicable provision.’’.

10 SEC. 102. CONFORMING AMENDMENTS TO THE PUBLIC

11 HEALTH SERVICE ACT.

12 (a) GROUP HEALTH PLANS.—Title XXVII of the

13 Public Health Service Act is amended by inserting after

14 section 2706 the following new section:

15 ‘‘SEC. 2707. STANDARD RELATING TO PATIENTS’ BILL OF

16 RIGHTS.

17 ‘‘Subject to section 2724, a group health plan, and

18 health insurance coverage offered in connection with a
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1 group health plan, shall comply with the requirements of

2 subpart C of part 7 of subtitle B of title I of the Employee

3 Retirement Income Security Act of 1974 (as in effect as

4 of the date of the enactment of such Act) and such re5 quirements shall be deemed to be incorporated into this

6 section.’’.

7 (b) INDIVIDUAL HEALTH PLANS.—Title XXVII of

8 the Public Health Service Act is amended by inserting

9 after section 2752 the following new section:

10 ‘‘SEC. 2753. STANDARD RELATING TO PATIENTS’ BILL OF

11 RIGHTS.

12 ‘‘The provisions of section 2706 shall apply to health

13 insurance coverage offered by a health insurance issuer

14 in the individual market for an enrollee in the same man15 ner as they apply to health insurance coverage offered by

16 a health insurance issuer in connection with a group

17 health plan for a participant or beneficiary in the small

18 or large group market and the requirements referred to

19 in such section shall be deemed to be incorporated into

20 this section.’’.

21 SEC. 103. CONFORMING AMENDMENTS TO THE INTERNAL

22 REVENUE CODE OF 1986.

23 Subchapter B of chapter 100 of the Internal Revenue

24 Code of 1986 is amended—
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1 (1) in the table of sections, by inserting after

2 the item relating to section 9812 the following new

3 item:

‘‘Sec. 9813. Standard relating to patients’ bill of rights.’’;

4 and

5 (2) by inserting after section 9812 the fol6 lowing:

7 ‘‘SEC. 9813. STANDARD RELATING TO PATIENTS’ BILL OF

8 RIGHTS.

9 ‘‘A group health plan shall comply with the require10 ments of subpart C of part 7 of subtitle B of title I of

11 the Employee Retirement Income Security Act of 1974 (as

12 in effect as of the date of the enactment of such Act) and

13 such requirements shall be deemed to be incorporated into

14 this section.’’.

15 Subtitle B—Right to Information

16 About Plans and Providers

17 SEC. 111. INFORMATION ABOUT PLANS AND COVERAGE

18 UNDER ERISA.

19 (a) EMPLOYEE RETIREMENT INCOME SECURITY ACT

20 OF 1974.—Subpart B of part 7 of subtitle B of title I

21 of the Employee Retirement Income Security Act of 1974

22 (29 U.S.C. 1185 et seq.) is amended by adding at the end

23 the following:

24 ‘‘SEC. 714. PATIENT ACCESS TO INFORMATION.

25 ‘‘(a) DISCLOSURE REQUIREMENT.—
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1 ‘‘(1) GROUP HEALTH PLANS.—A group health

2 plan shall—

3 ‘‘(A) provide to participants and bene4 ficiaries at the time of initial coverage under

5 the plan (or the effective date of this section, in

6 the case of individuals who are participants or

7 beneficiaries as of such date), and at least an8 nually thereafter, the information described in

9 subsection (b);

10 ‘‘(B) provide to participants and bene11 ficiaries, within a reasonable period (as speci12 fied by the Secretary) before or after the date

13 of significant changes in the information de14 scribed in subsection (b), information on such

15 significant changes; and

16 ‘‘(C) upon request, make available to par17 ticipants and beneficiaries, the Secretary, and

18 prospective participants and beneficiaries, the

19 information described in subsection (b) or (c).

20 The plan may charge a reasonable fee for provision

21 in printed form of any of the information described

22 in subsection (b) or (c) more than once during any

23 plan year.

24 ‘‘(2) HEALTH INSURANCE ISSUERS.—A health

25 insurance issuer in connection with the provision of
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1 health insurance coverage in connection with a group

2 health plan shall—

3 ‘‘(A) provide to participants and bene4 ficiaries enrolled under such coverage at the

5 time of enrollment, and at least annually there6 after, the information described in subsection

7 (b);

8 ‘‘(B) provide to such participants and

9 beneficiaries, within a reasonable period (as

10 specified by the Secretary) before or after the

11 date of significant changes in the information

12 described in subsection (b), information in

13 printed form on such significant changes; and

14 ‘‘(C) upon request, make available to the

15 Secretary, to individuals who are prospective

16 participants and beneficiaries, and to the public

17 the information described in subsection (b) or

18 (c).

19 ‘‘(3) EMPLOYERS.—Effective 5 years after the

20 date this part first becomes effective, each employer

21 (other than an employer described in paragraph (1)

22 of subsection (d)) shall provide to each employee at

23 least annually information (consistent with such sub24 section) on the amount that the employer contrib-
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1 utes on behalf of the employee (and any dependents

2 of the employee) for health benefits coverage.

3 ‘‘(b) INFORMATION PROVIDED.—The information de4 scribed in this subsection with respect to a group health

5 plan or health insurance coverage offered by a health in6 surance issuer shall be provided to a participant or bene7 ficiary free of charge at least once a year and includes

8 the following:

9 ‘‘(1) SERVICE AREA.—The service area of the

10 plan or issuer.

11 ‘‘(2) BENEFITS.—Benefits offered under the

12 plan or coverage, including—

13 ‘‘(A) those that are covered benefits, limits

14 and conditions on such benefits, and those ben15 efits that are explicitly excluded from coverage;

16 ‘‘(B) cost sharing, such as deductibles, co17 insurance, and copayment amounts, including

18 any liability for balance billing, any maximum

19 limitations on out of pocket expenses, and the

20 maximum out of pocket costs for services that

21 are provided by nonparticipating providers or

22 that are furnished without meeting the applica23 ble utilization review requirements;

24 ‘‘(C) the extent to which benefits may be

25 obtained from nonparticipating providers;
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1 ‘‘(D) the extent to which a participant or

2 beneficiary may select from among participating

3 providers and the types of providers partici4 pating in the plan or issuer network;

5 ‘‘(E) process for determining experimental

6 coverage;

7 ‘‘(F) use of a prescription drug formulary

8 (if any); and

9 ‘‘(G) any definition of medical necessity

10 used in making coverage determinations by the

11 plan, issuer, or claims administrator.

12 ‘‘(3) ACCESS.—A description of the following:

13 ‘‘(A) The number, mix, and distribution of

14 providers under the plan or coverage.

15 ‘‘(B) Out-of-network coverage (if any) pro16 vided by the plan or coverage.

17 ‘‘(C) Any point-of-service option (including

18 any supplemental premium or cost-sharing for

19 such option).

20 ‘‘(D) The procedures for participants and

21 beneficiaries to select, access, and change par22 ticipating primary and specialty providers.

23 ‘‘(E) The rights and procedures for obtain24 ing referrals (including standing referrals) to

25 participating and nonparticipating providers.
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1 ‘‘(F) The name, address, and telephone

2 number of participating health care providers

3 and an indication of whether each such provider

4 is available to accept new patients.

5 ‘‘(G) Any limitations imposed on the selec6 tion of qualifying participating health care pro7 viders, including any limitations imposed under

8 section 812(b)(2).

9 ‘‘(4) OUT-OF-AREA COVERAGE.—Out-of-area

10 coverage provided by the plan or issuer.

11 ‘‘(5) EMERGENCY COVERAGE.—Coverage of

12 emergency services, including—

13 ‘‘(A) the appropriate use of emergency

14 services, including use of the 911 telephone sys15 tem or its local equivalent in emergency situa16 tions and an explanation of what constitutes an

17 emergency situation;

18 ‘‘(B) the process and procedures of the

19 plan or issuer for obtaining emergency services;

20 and

21 ‘‘(C) the locations of (i) emergency depart22 ments, and (ii) other settings, in which plan

23 physicians and hospitals provide emergency

24 services and post-stabilization care.
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1 ‘‘(6) PRIOR AUTHORIZATION RULES.—Rules re2 garding prior authorization or other review require3 ments that could result in noncoverage or non4 payment.

5 ‘‘(7) GRIEVANCE AND APPEALS PROCEDURES.—

6 All appeal or grievance rights and procedures under

7 the plan or coverage, including the method for filing

8 grievances and the time frames and circumstances

9 for acting on grievances and appeals, who is the ap10 plicable authority with respect to the plan or issuer.

11 ‘‘(8) ACCOUNTABILITY.—A description of the

12 legal recourse options available for participants and

13 beneficiaries under the plan including—

14 ‘‘(A) the preemption that applies under

15 section 514 to certain actions arising out of the

16 provision of health benefits; and

17 ‘‘(B) the extent to which coverage decisions

18 made by the plan are subject to internal review

19 or any external review and the proper time

20 frames under

21 ‘‘(9) QUALITY ASSURANCE.—Any information

22 made public by an accrediting organization in the

23 process of accreditation of the plan or issuer or any

24 additional quality indicators the plan or issuer

25 makes available.
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1 ‘‘(10) INFORMATION ON ISSUER.—Notice of ap2 propriate mailing addresses and telephone numbers

3 to be used by participants and beneficiaries in seek4 ing information or authorization for treatment.

5 ‘‘(11) AVAILABILITY OF INFORMATION ON RE6 QUEST.—Notice that the information described in

7 subsection (c) is available upon request.

8 ‘‘(c) INFORMATION MADE AVAILABLE UPON RE9 QUEST.—The information described in this subsection is

10 the following:

11 ‘‘(1) UTILIZATION REVIEW ACTIVITIES.—A de12 scription of procedures used and requirements (in13 cluding circumstances, time frames, and appeal

14 rights) under any utilization review program under

15 section 801.

16 ‘‘(2) GRIEVANCE AND APPEALS INFORMA17 TION.—Information on the number of grievances

18 and appeals and on the disposition in the aggregate

19 of such matters.

20 ‘‘(3) FORMULARY RESTRICTIONS.—A descrip21 tion of the nature of any drug formulary restric22 tions.

23 ‘‘(4) PARTICIPATING PROVIDER LIST.—A list of

24 current participating health care providers.

25 ‘‘(d) EMPLOYER INFORMATION.—
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1 ‘‘(1) SMALL EMPLOYER EXEMPTION.—Sub2 section (a)(3) shall not apply to an employer that is

3 a small employer (as defined in section

4 712(c)(1)(B)) or would be such an employer if ‘100’

5 were substituted for ‘50’ in such section.

6 ‘‘(2) COMPUTATION.—The amount described in

7 subsection (a)(3) may be computed on an average,

8 per employee basis, and may be based on rules simi9 lar to the rules applied in computing the applicable

10 premium under section 604.

11 ‘‘(3) FORM OF DISCLOSURE.—The information

12 under subsection (a)(3) may be provided in any rea13 sonable form, including as part of the summary plan

14 description, a letter, or information accompanying a

15 W–2 form.

16 ‘‘(e) CONSTRUCTION.—Nothing in this section shall

17 be construed as requiring public disclosure of individual

18 contracts or financial arrangements between a group

19 health plan or health insurance issuer and any provider.’’.

20 (b) CONFORMING AMENDMENTS.—

21 (1) Section 732(a) of the Employee Retirement

22 Income Security Act of 1974 (29 U.S.C. 1191a(a))

23 is amended by striking ‘‘section 711’’ and inserting

24 ‘‘sections 711 and 714’’.
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1 (2) The table of contents in section 1 of the

2 Employee Retirement Income Security Act of 1974

3 (29 U.S.C. 1001) is amended by inserting after the

4 item relating to section 713, the following:

‘‘Sec 714. Patient access to information.’’.

5 (3) Section 502(b)(3) of the Employee Retire6 ment Income Security Act of 1974 (29 U.S.C.

7 1132(b)(3)) is amended by striking ‘‘733(a)(1))’’

8 and inserting ‘‘733(a)(1)), except with respect to the

9 requirements of section 714’’.

10 SEC. 112. CONFORMING AMENDMENTS TO PUBLIC HEALTH

11 SERVICE ACT.

12 (a) GROUP HEALTH PLANS.—Title XXVII of the

13 Public Health Service Act, as amended by section 102(a),

14 is amended by inserting after section 2707 the following

15 new section:

16 ‘‘SEC. 2708. STANDARD RELATING TO PATIENT ACCESS TO

17 INFORMATION.

18 ‘‘A group health plan, and health insurance coverage

19 offered in connection with a group health plan, shall com20 ply with the requirements of section 714 of the Employee

21 Retirement Income Security Act of 1974 (as in effect as

22 of the date of the enactment of such Act) and such re23 quirements shall be deemed to be incorporated into this

24 section.’’.
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1 (b) INDIVIDUAL HEALTH PLANS.—Title XXVII of

2 the Public Health Service Act, as amended by section

3 102(b), is amended by inserting after section 2753 the fol4 lowing new section:

5 ‘‘SEC. 2754. STANDARD RELATING TO PATIENT ACCESS TO

6 INFORMATION.

7 ‘‘The provisions of section 2707 shall apply to health

8 insurance coverage offered by a health insurance issuer

9 in the individual market for an enrollee in the same man10 ner as they apply to health insurance coverage offered by

11 a health insurance issuer in connection with a group

12 health plan for a participant or beneficiary in the small

13 or large group market and the requirements referred to

14 in such section shall be deemed to be incorporated into

15 this section.’’.

16 SEC. 113. CONFORMING AMENDMENTS TO THE INTERNAL

17 REVENUE CODE OF 1986.

18 Subchapter B of chapter 100 of the Internal Revenue

19 Code of 1986, as amended by section 103, is amended—

20 (1) in the table of sections, by inserting after

21 the item relating to section 9813 the following new

22 item:

‘‘Sec. 9814. Standard relating to patient access to information.’’;

23 and

24 (2) by inserting after section 9812 the fol25 lowing:
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1 ‘‘SEC. 9814. STANDARD RELATING TO PATIENT ACCESS TO

2 INFORMATION.

3 ‘‘A group health plan shall comply with the require4 ments of section 714 of the Employee Retirement Income

5 Security Act of 1974 (as in effect as of the day after the

6 date of the enactment of such Act) and such requirements

7 shall be deemed to be incorporated into this section.’’.

8 Subtitle C—Right to Hold Health

9 Plans Accountable

10 SEC. 121. AMENDMENTS TO EMPLOYEE RETIREMENT IN11 COME SECURITY ACT OF 1974.

12 (a) IN GENERAL.—Part 5 of subtitle B of title I of

13 the Employee Retirement Income Security Act of 1974 is

14 amended by inserting after section 503 (29 U.S.C. 1133)

15 the following new sections:

16 ‘‘SEC. 503A. UTILIZATION REVIEW ACTIVITIES.

17 ‘‘(a) COMPLIANCE WITH REQUIREMENTS.—

18 ‘‘(1) IN GENERAL.—A group health plan, and a

19 health insurance issuer that provides health insur20 ance coverage, shall conduct utilization review activi21 ties in connection with the provision of benefits

22 under such plan or coverage only in accordance with

23 a utilization review program that meets the require24 ments of this section and section 503B.

25 ‘‘(2) USE OF OUTSIDE AGENTS.—Nothing in

26 this section shall be construed as preventing a group
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1 health plan or health insurance issuer from arrang2 ing through a contract or otherwise for persons or

3 entities to conduct utilization review activities on be4 half of the plan or issuer, so long as such activities

5 are conducted in accordance with a utilization review

6 program that meets the requirements of this section.

7 ‘‘(3) UTILIZATION REVIEW DEFINED.—For pur8 poses of this section, the terms ‘utilization review’

9 and ‘utilization review activities’ mean procedures

10 used to monitor or evaluate the use or coverage,

11 clinical necessity, appropriateness, efficacy, or effi12 ciency of health care services, procedures or settings,

13 and includes prospective review, concurrent review,

14 second opinions, case management, discharge plan15 ning, or retrospective review.

16 ‘‘(b) WRITTEN POLICIES AND CRITERIA.—

17 ‘‘(1) WRITTEN POLICIES.—A utilization review

18 program shall be conducted consistent with written

19 policies and procedures that govern all aspects of the

20 program.

21 ‘‘(2) USE OF WRITTEN CRITERIA.—

22 ‘‘(A) IN GENERAL.—Such a program shall

23 utilize written clinical review criteria developed

24 with input from a range of appropriate actively

25 practicing physicians or dentists, as determined
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•HR 5628 IH

1 by the plan, pursuant to the program. Such cri2 teria shall include written clinical review criteria

3 that are based on valid clinical evidence where

4 available and that are directed specifically at

5 meeting the needs of at-risk populations and

6 covered individuals with chronic conditions or

7 severe illnesses, including gender-specific cri8 teria and pediatric-specific criteria where avail9 able and appropriate.

10 ‘‘(B) CONTINUING USE OF STANDARDS IN

11 RETROSPECTIVE REVIEW.—If a health care

12 service has been specifically pre-authorized or

13 approved for a participant or beneficiary under

14 such a program, the program shall not, pursu15 ant to retrospective review, revise or modify the

16 specific standards, criteria, or procedures used

17 for the utilization review for procedures, treat18 ment, and services delivered to the participant

19 or beneficiary during the same course of treat20 ment.

21 ‘‘(C) REVIEW OF SAMPLE OF CLAIMS DE22 NIALS.—Such a program shall provide for an

23 evaluation of the clinical appropriateness of at

24 least a sample of denials of claims for benefits.

25 ‘‘(c) CONDUCT OF PROGRAM ACTIVITIES.—
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•HR 5628 IH

1 ‘‘(1) ADMINISTRATION BY PHYSICIANS OR DEN2 TISTS.—A utilization review program shall be ad3 ministered by qualified physicians or dentists who

4 shall oversee review decisions.

5 ‘‘(2) USE OF QUALIFIED, INDEPENDENT PER6 SONNEL.—

7 ‘‘(A) IN GENERAL.—A utilization review

8 program shall provide for the conduct of utiliza9 tion review activities only through personnel

10 who are qualified and have received appropriate

11 training in the conduct of such activities under

12 the program.

13 ‘‘(B) PROHIBITION OF CONTINGENT COM14 PENSATION ARRANGEMENTS.—Such a program

15 shall not, with respect to utilization review ac16 tivities, permit or provide compensation or any17 thing of value to its employees, agents, or con18 tractors in a manner that encourages denials of

19 claims for benefits.

20 ‘‘(C) PROHIBITION OF CONFLICTS.—Such

21 a program shall not permit a health care pro22 fessional who is providing health care services

23 to an individual to perform utilization review

24 activities in connection with the health care

25 services being provided to the individual.
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1 ‘‘(3) ACCESSIBILITY OF REVIEW.—Such a pro2 gram shall provide that appropriate personnel per3 forming utilization review activities under the pro4 gram, including the utilization review administrator,

5 are reasonably accessible by toll-free telephone dur6 ing normal business hours to discuss patient care

7 and allow response to telephone requests, and that

8 appropriate provision is made to receive and respond

9 promptly to calls received during other hours.

10 ‘‘(4) LIMITS ON FREQUENCY.—Such a program

11 shall not provide for the performance of utilization

12 review activities with respect to a class of services

13 furnished to an individual more frequently than is

14 reasonably required to assess whether the services

15 under review are medically necessary or appropriate.

16 ‘‘SEC. 503B. PROCEDURES FOR INITIAL CLAIMS FOR BENE17 FITS AND PRIOR AUTHORIZATION DETER18 MINATIONS.

19 ‘‘(a) PROCEDURES OF INITIAL CLAIMS FOR BENE20 FITS.—

21 ‘‘(1) IN GENERAL.—A group health plan, or

22 health insurance issuer offering health insurance

23 coverage in connection with a group health plan,

24 shall—
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1 ‘‘(A) make a determination on an initial

2 claim for benefits by a participant or bene3 ficiary (or authorized representative) regarding

4 payment or coverage for items or services under

5 the terms and conditions of the plan or cov6 erage involved, including any cost-sharing

7 amount that the participant or beneficiary is re8 quired to pay with respect to such claim for

9 benefits; and

10 ‘‘(B) notify a participant or beneficiary (or

11 authorized representative) and the treating

12 health care professional involved regarding a

13 determination on an initial claim for benefits

14 made under the terms and conditions of the

15 plan or coverage, including any cost-sharing

16 amounts that the participant or beneficiary may

17 be required to make with respect to such claim

18 for benefits, and of the right of the participant

19 or beneficiary to an internal appeal under sec20 tion 503C.

21 ‘‘(2) ACCESS TO INFORMATION.—With respect

22 to an initial claim for benefits, the participant or

23 beneficiary (or authorized representative) and the

24 treating health care professional (if any) shall pro25 vide the plan or issuer with access to information re-
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1 quested by the plan or issuer that is necessary to

2 make a determination relating to the claim. Such ac3 cess shall be provided not later than 5 days after the

4 date on which the request for information is re5 ceived, or, in a case described in subparagraph (B)

6 or (C) of subsection (b)(1), by such earlier time as

7 may be necessary to comply with the applicable

8 timeline under such subparagraph.

9 ‘‘(3) ORAL REQUESTS.—In the case of a claim

10 for benefits involving an expedited or concurrent de11 termination, a participant or beneficiary (or author12 ized representative) may make an initial claim for

13 benefits orally, but a group health plan, or health in14 surance issuer offering health insurance coverage,

15 may require that the participant or beneficiary (or

16 authorized representative) provide written confirma17 tion of such request in a timely manner on a form

18 provided by the plan or issuer. In the case of such

19 an oral request for benefits, the making of the re20 quest (and the timing of such request) shall be

21 treated as the making at that time of a claim for

22 such benefits without regard to whether and when a

23 written confirmation of such request is made.

24 ‘‘(b) TIMELINE FOR MAKING DETERMINATIONS.—
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1 ‘‘(1) PRIOR AUTHORIZATION DETERMINA2 TION.—

3 ‘‘(A) IN GENERAL.—A group health plan,

4 or health insurance issuer offering health insur5 ance coverage in connection with a group health

6 plan, shall make a prior authorization deter7 mination on a claim for benefits (whether oral

8 or written) as soon as possible in accordance

9 with the medical exigencies of the case but in

10 no case later than 14 days from the date on

11 which the plan or issuer receives information

12 that is reasonably necessary to enable the plan

13 or issuer to make a determination on the re14 quest for prior authorization and in no case

15 later than 28 days after the date of the claim

16 for benefits is received.

17 ‘‘(B) EXPEDITED DETERMINATION.—Not18 withstanding subparagraph (A), a group health

19 plan, or health insurance issuer offering health

20 insurance coverage in connection with a group

21 health plan, shall expedite a prior authorization

22 determination on a claim for benefits described

23 in such subparagraph when a request for such

24 an expedited determination is made by a partic25 ipant or beneficiary (or authorized representa-
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1 tive) at any time during the process for making

2 a determination and a health care professional

3 certifies, with the request, that a determination

4 under the procedures described in subparagraph

5 (A) would seriously jeopardize the life or health

6 of the participant or beneficiary or the ability of

7 the participant or beneficiary to maintain or re8 gain maximum function. Such determination

9 shall be made as soon as possible based on the

10 medical exigencies of the case involved and in

11 no case later than 72 hours after the time the

12 request is received by the plan or issuer under

13 this subparagraph.

14 ‘‘(C) ONGOING CARE.—

15 ‘‘(i) CONCURRENT REVIEW.—

16 ‘‘(I) IN GENERAL.—Subject to

17 clause (ii), in the case of a concurrent

18 review of ongoing care (including hos19 pitalization), which results in a termi20 nation or reduction of such care, the

21 plan or issuer must provide by tele22 phone and in printed form notice of

23 the concurrent review determination

24 to the individual or the individual’s

25 designee and the individual’s health
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1 care provider as soon as possible in

2 accordance with the medical exigen3 cies of the case, with sufficient time

4 prior to the termination or reduction

5 to allow for an appeal under section

6 503C(b)(3) to be completed before the

7 termination or reduction takes effect.

8 ‘‘(II) CONTENTS OF NOTICE.—

9 Such notice shall include, with respect

10 to ongoing health care items and serv11 ices, the number of ongoing services

12 approved, the new total of approved

13 services, the date of onset of services,

14 and the next review date, if any, as

15 well as a statement of the individual’s

16 rights to further appeal.

17 ‘‘(ii) RULE OF CONSTRUCTION.—

18 Clause (i) shall not be construed as requir19 ing plans or issuers to provide coverage of

20 care that would exceed the coverage limita21 tions for such care.

22 ‘‘(2) RETROSPECTIVE DETERMINATION.—A

23 group health plan, or health insurance issuer offer24 ing health insurance coverage in connection with a

25 group health plan, shall make a retrospective deter-
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1 mination on a claim for benefits as soon as possible

2 in accordance with the medical exigencies of the case

3 but not later than 30 days after the date on which

4 the plan or issuer receives information that is rea5 sonably necessary to enable the plan or issuer to

6 make a determination on the claim, or, if earlier, 60

7 days after the date of receipt of the claim for bene8 fits.

9 ‘‘(c) NOTICE OF A DENIAL OF A CLAIM FOR BENE10 FITS.—Written notice of a denial made under an initial

11 claim for benefits shall be issued to the participant or ben12 eficiary (or authorized representative) and the treating

13 health care professional as soon as possible in accordance

14 with the medical exigencies of the case and in no case later

15 than 2 days after the date of the determination (or, in

16 the case described in subparagraph (B) or (C) of sub17 section (b)(1), within the 72-hour or applicable period re18 ferred to in such subparagraph).

19 ‘‘(d) REQUIREMENTS OF NOTICE OF DETERMINA20 TIONS.—The written notice of a denial of a claim for bene21 fits determination under subsection (c) shall be provided

22 in printed form and written in a manner calculated to be

23 understood by the average participant or beneficiary and

24 shall include—
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1 ‘‘(1) the specific reasons for the determination

2 (including a summary of the clinical or scientific evi3 dence used in making the determination);

4 ‘‘(2) the procedures for obtaining additional in5 formation concerning the determination; and

6 ‘‘(3) notification of the right to appeal the de7 termination and instructions on how to initiate an

8 appeal in accordance with section 503C.

9 ‘‘(e) DEFINITIONS.—For purposes of this part:

10 ‘‘(1) AUTHORIZED REPRESENTATIVE.—The

11 term ‘authorized representative’ means, with respect

12 to an individual who is a participant or beneficiary,

13 any health care professional or other person acting

14 on behalf of the individual with the individual’s con15 sent or without such consent if the individual is

16 medically unable to provide such consent.

17 ‘‘(2) CLAIM FOR BENEFITS.—The term ‘claim

18 for benefits’ means any request for coverage (includ19 ing authorization of coverage), for eligibility, or for

20 payment in whole or in part, for an item or service

21 under a group health plan or health insurance cov22 erage.

23 ‘‘(3) DENIAL OF CLAIM FOR BENEFITS.—The

24 term ‘denial’ means, with respect to a claim for ben25 efits, a denial (in whole or in part) of, or a failure
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1 to act on a timely basis upon, the claim for benefits

2 and includes a failure to provide benefits (including

3 items and services) required to be provided under

4 this title.

5 ‘‘(4) TREATING HEALTH CARE PROFES6 SIONAL.—The term ‘treating health care profes7 sional’ means, with respect to services to be provided

8 to a participant or beneficiary, a health care profes9 sional who is primarily responsible for delivering

10 those services to the participant or beneficiary.

11 ‘‘SEC. 503C. INTERNAL APPEALS OF CLAIMS DENIALS.

12 ‘‘(a) RIGHT TO INTERNAL APPEAL.—

13 ‘‘(1) IN GENERAL.—A participant or beneficiary

14 of a group health plan (or authorized representative)

15 may appeal any denial of a claim for benefits under

16 section 503B under the procedures described in this

17 section.

18 ‘‘(2) TIME FOR APPEAL.—

19 ‘‘(A) IN GENERAL.—A group health plan,

20 or health insurance issuer offering health insur21 ance coverage in connection with a group health

22 plan, shall ensure that a participant or bene23 ficiary (or authorized representative) has a pe24 riod of not less than 180 days beginning on the

25 date of a denial of a claim for benefits under
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1 section 503B in which to appeal such denial

2 under this section.

3 ‘‘(B) DATE OF DENIAL.—For purposes of

4 subparagraph (A), the date of the denial shall

5 be deemed to be the date as of which the partic6 ipant or beneficiary knew of the denial of the

7 claim for benefits.

8 ‘‘(3) FAILURE TO ACT.—The failure of a plan

9 or issuer to issue a determination on a claim for

10 benefits under section 503B within the applicable

11 timeline established for such a determination under

12 such section is a denial of a claim for benefits for

13 purposes this section and section 503D as of the

14 date of the applicable deadline.

15 ‘‘(4) PLAN WAIVER OF INTERNAL REVIEW.—A

16 group health plan, or health insurance issuer offer17 ing health insurance coverage in connection with a

18 group health plan, may waive the internal review

19 process under this section. In such case the plan or

20 issuer shall provide notice to the participant or bene21 ficiary (or authorized representative) involved, the

22 participant or beneficiary (or authorized representa23 tive) involved shall be relieved of any obligation to

24 complete the internal review involved, and may, at

25 the option of such participant, beneficiary, or rep-
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1 resentative proceed directly to seek further appeal

2 through external review under section 503D or oth3 erwise.

4 ‘‘(b) TIMELINES FOR MAKING DETERMINATIONS.—

5 ‘‘(1) ORAL REQUESTS.—In the case of an ap6 peal of a denial of a claim for benefits under this

7 section that involves an expedited or concurrent de8 termination, a participant or beneficiary (or author9 ized representative) may request such appeal orally.

10 A group health plan, or health insurance issuer of11 fering health insurance coverage in connection with

12 a group health plan, may require that the partici13 pant or beneficiary (or authorized representative)

14 provide written confirmation of such request in a

15 timely manner on a form provided by the plan or

16 issuer. In the case of such an oral request for an ap17 peal of a denial, the making of the request (and the

18 timing of such request) shall be treated as the mak19 ing at that time of a request for an appeal without

20 regard to whether and when a written confirmation

21 of such request is made.

22 ‘‘(2) ACCESS TO INFORMATION.—With respect

23 to an appeal of a denial of a claim for benefits, the

24 participant or beneficiary (or authorized representa25 tive) and the treating health care professional (if
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1 any) shall provide the plan or issuer with access to

2 information requested by the plan or issuer that is

3 necessary to make a determination relating to the

4 appeal. Such access shall be provided not later than

5 5 days after the date on which the request for infor6 mation is received, or, in a case described in sub7 paragraph (B) or (C) of paragraph (3), by such ear8 lier time as may be necessary to comply with the ap9 plicable timeline under such subparagraph.

10 ‘‘(3) PRIOR AUTHORIZATION DETERMINA11 TIONS.—

12 ‘‘(A) IN GENERAL.—A group health plan,

13 or health insurance issuer offering health insur14 ance coverage in connection with a group health

15 plan, shall make a determination on an appeal

16 of a denial of a claim for benefits under this

17 subsection as soon as possible in accordance

18 with the medical exigencies of the case but in

19 no case later than 14 days from the date on

20 which the plan or issuer receives information

21 that is reasonably necessary to enable the plan

22 or issuer to make a determination on the appeal

23 and in no case later than 28 days after the date

24 the request for the appeal is received.
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1 ‘‘(B) EXPEDITED DETERMINATION.—Not2 withstanding subparagraph (A), a group health

3 plan, or health insurance issuer offering health

4 insurance coverage in connection with a group

5 health plan, shall expedite a prior authorization

6 determination on an appeal of a denial of a

7 claim for benefits described in subparagraph

8 (A), when a request for such an expedited de9 termination is made by a participant or bene10 ficiary (or authorized representative) at any

11 time during the process for making a deter12 mination and a health care professional cer13 tifies, with the request, that a determination

14 under the procedures described in subparagraph

15 (A) would seriously jeopardize the life or health

16 of the participant or beneficiary or the ability of

17 the participant or beneficiary to maintain or re18 gain maximum function. Such determination

19 shall be made as soon as possible based on the

20 medical exigencies of the case involved and in

21 no case later than 72 hours after the time the

22 request for such appeal is received by the plan

23 or issuer under this subparagraph.

24 ‘‘(C) ONGOING CARE DETERMINATIONS.—
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1 ‘‘(i) IN GENERAL.—Subject to clause

2 (ii), in the case of a concurrent review de3 termination described in section

4 503B(b)(1)(C)(i)(I), which results in a ter5 mination or reduction of such care, the

6 plan or issuer must provide notice of the

7 determination on the appeal under this

8 section by telephone and in printed form to

9 the individual or the individual’s designee

10 and the individual’s health care provider as

11 soon as possible in accordance with the

12 medical exigencies of the case, with suffi13 cient time prior to the termination or re14 duction to allow for an external appeal

15 under section 503D to be completed before

16 the termination or reduction takes effect.

17 ‘‘(ii) RULE OF CONSTRUCTION.—

18 Clause (i) shall not be construed as requir19 ing plans or issuers to provide coverage of

20 care that would exceed the coverage limita21 tions for such care.

22 ‘‘(4) RETROSPECTIVE DETERMINATION.—A

23 group health plan, or health insurance issuer offer24 ing health insurance coverage in connection with a

25 group health plan, shall make a retrospective deter-
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1 mination on an appeal of a claim for benefits in no

2 case later than 30 days after the date on which the

3 plan or issuer receives necessary information that is

4 reasonably necessary to enable the plan or issuer to

5 make a determination on the appeal and in no case

6 later than 60 days after the date the request for the

7 appeal is received.

8 ‘‘(c) CONDUCT OF REVIEW.—

9 ‘‘(1) IN GENERAL.—A review of a denial of a

10 claim for benefits under this section shall be con11 ducted by an individual with appropriate expertise

12 who was not involved in the initial determination.

13 ‘‘(2) APPROPRIATE REVIEW OF MEDICAL DECI14 SIONS.—A review of an appeal of a denial of a claim

15 for benefits that is based on a lack of medical neces16 sity and appropriateness, or based on an experi17 mental or investigational treatment, or requires an

18 evaluation of medical facts, shall be made by a phy19 sician (allopathic or osteopathic) or dentist with ap20 propriate expertise (including, in the case of a child,

21 appropriate pediatric expertise) who was not in22 volved in the initial determination.

23 ‘‘(d) NOTICE OF DETERMINATION.—

24 ‘‘(1) IN GENERAL.—Written notice of a deter25 mination made under an internal appeal of a denial
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1 of a claim for benefits shall be issued to the partici2 pant or beneficiary (or authorized representative)

3 and the treating health care professional as soon as

4 possible in accordance with the medical exigencies of

5 the case and in no case later than 2 days after the

6 date of completion of the review (or, in the case de7 scribed in subparagraph (B) or (C) of subsection

8 (b)(3), within the 72-hour or applicable period re9 ferred to in such subparagraph).

10 ‘‘(2) FINAL DETERMINATION.—The decision by

11 a plan or issuer under this section shall be treated

12 as the final determination of the plan or issuer on

13 a denial of a claim for benefits. The failure of a plan

14 or issuer to issue a determination on an appeal of

15 a denial of a claim for benefits under this section

16 within the applicable timeline established for such a

17 determination shall be treated as a final determina18 tion on an appeal of a denial of a claim for benefits

19 for purposes of proceeding to external review under

20 section 503D.

21 ‘‘(3) REQUIREMENTS OF NOTICE.—With re22 spect to a determination made under this section,

23 the notice described in paragraph (1) shall be pro24 vided in printed form and written in a manner cal-
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1 culated to be understood by the average participant

2 or beneficiary and shall include—

3 ‘‘(A) the specific reasons for the deter4 mination (including a summary of the clinical

5 or scientific evidence used in making the deter6 mination);

7 ‘‘(B) the procedures for obtaining addi8 tional information concerning the determina9 tion; and

10 ‘‘(C) notification of the right to an inde11 pendent external review under section 503D

12 and instructions on how to initiate such a re13 view.

14 ‘‘SEC. 503D. INDEPENDENT EXTERNAL APPEALS PROCE15 DURES.

16 ‘‘(a) RIGHT TO EXTERNAL APPEAL.—A group health

17 plan, and a health insurance issuer offering health insur18 ance coverage in connection with a group health plan, shall

19 provide in accordance with this section participants and

20 beneficiaries (or authorized representatives) with access to

21 an independent external review for any denial of a claim

22 for benefits in any case in which the amount involved ex23 ceeds $100.

24 ‘‘(b) INITIATION OF THE INDEPENDENT EXTERNAL

25 REVIEW PROCESS.—
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1 ‘‘(1) TIME TO FILE.—A request for an inde2 pendent external review under this section shall be

3 filed with the plan or issuer not later than 180 days

4 after the date on which the participant or bene5 ficiary receives notice of the denial under section

6 503C(d) or notice of waiver of internal review under

7 section 503C(a)(4) or the date on which the plan or

8 issuer has failed to make a timely decision under

9 section 503C(d)(2).

10 ‘‘(2) FILING OF REQUEST.—

11 ‘‘(A) IN GENERAL.—Subject to the suc12 ceeding provisions of this subsection, a group

13 health plan, and a health insurance issuer offer14 ing health insurance coverage, may—

15 ‘‘(i) except as provided in subpara16 graph (B)(i), require that a request for re17 view be in writing;

18 ‘‘(ii) limit the filing of such a request

19 to the participant or beneficiary involved

20 (or an authorized representative);

21 ‘‘(iii) except if waived by the plan or

22 issuer under section 503C(a)(4), condition

23 access to an independent external review

24 under this section upon a final determina25 tion of a denial of a claim for benefits
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1 under the internal review procedure under

2 section 503C;

3 ‘‘(iv) except as provided in subpara4 graph (B)(ii), require payment of a filing

5 fee to the plan or issuer of a sum that does

6 not exceed $25; and

7 ‘‘(v) require that a request for review

8 include the consent of the participant or

9 beneficiary (or authorized representative)

10 for the release of medical information or

11 records of the participant or beneficiary to

12 the qualified external review entity for the

13 sole purpose of conducting external review

14 activities.

15 ‘‘(B) REQUIREMENTS AND EXCEPTION RE16 LATING TO GENERAL RULE.—

17 ‘‘(i) ORAL REQUESTS PERMITTED IN

18 EXPEDITED OR CONCURRENT CASES.—In

19 the case of an expedited or concurrent ex20 ternal review as provided for under sub21 section (e), the request may be made oral22 ly. A group health plan, or health insur23 ance issuer offering health insurance cov24 erage, may require that the participant or

25 beneficiary (or authorized representative)
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1 provide written confirmation of such re2 quest in a timely manner on a form pro3 vided by the plan or issuer. Such written

4 confirmation shall be treated as a consent

5 for purposes of subparagraph (A)(v). In

6 the case of such an oral request for such

7 a review, the making of the request (and

8 the timing of such request) shall be treated

9 as the making at that time of a request for

10 such an external review without regard to

11 whether and when a written confirmation

12 of such request is made.

13 ‘‘(ii) EXCEPTION TO FILING FEE RE14 QUIREMENT.—

15 ‘‘(I) INDIGENCY.—Payment of a

16 filing fee shall not be required under

17 subparagraph (A)(iv) where there is a

18 certification (in a form and manner

19 specified in guidelines established by

20 the Secretary) that the participant or

21 beneficiary is indigent (as defined in

22 such guidelines).

23 ‘‘(II) FEE NOT REQUIRED.—Pay24 ment of a filing fee shall not be re25 quired under subparagraph (A)(iv) if
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1 the plan or issuer waives the internal

2 appeals process under section

3 503C(a)(4).

4 ‘‘(III) REFUNDING OF FEE.—

5 The filing fee paid under subpara6 graph (A)(iv) shall be refunded if the

7 determination under the independent

8 external review is to reverse the denial

9 which is the subject of the review.

10 ‘‘(IV) COLLECTION OF FILING

11 FEE.—The failure to pay such a filing

12 fee shall not prevent the consideration

13 of a request for review but, subject to

14 the preceding provisions of this clause,

15 shall constitute a legal liability to pay.

16 ‘‘(c) REFERRAL TO QUALIFIED EXTERNAL REVIEW

17 ENTITY UPON REQUEST.—

18 ‘‘(1) IN GENERAL.—Upon the filing of a re19 quest for independent external review with the group

20 health plan, or health insurance issuer offering

21 health insurance coverage, the plan or issuer shall

22 immediately refer such request, and forward the

23 plan or issuer’s initial decision (including the infor24 mation described in section 503C(d)(3)(A)), to a
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1 qualified external review entity selected in accord2 ance with this section.

3 ‘‘(2) ACCESS TO PLAN OR ISSUER AND HEALTH

4 PROFESSIONAL INFORMATION.—With respect to an

5 independent external review conducted under this

6 section, the participant or beneficiary (or authorized

7 representative), the plan or issuer, and the treating

8 health care professional (if any) shall provide the ex9 ternal review entity with information that is nec10 essary to conduct a review under this section, as de11 termined and requested by the entity. Such informa12 tion shall be provided not later than 5 days after the

13 date on which the request for information is re14 ceived, or, in a case described in clause (ii) or (iii)

15 of subsection (e)(1)(A), by such earlier time as may

16 be necessary to comply with the applicable timeline

17 under such clause.

18 ‘‘(3) SCREENING OF REQUESTS BY QUALIFIED

19 EXTERNAL REVIEW ENTITIES.—

20 ‘‘(A) IN GENERAL.—With respect to a re21 quest referred to a qualified external review en22 tity under paragraph (1) relating to a denial of

23 a claim for benefits, the entity shall refer such

24 request for the conduct of an independent med25 ical review unless the entity determines that—
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1 ‘‘(i) any of the conditions described in

2 clauses (ii) or (iii) of subsection (b)(2)(A)

3 have not been met;

4 ‘‘(ii) the denial of the claim for bene5 fits does not involve a medically reviewable

6 decision under subsection (d)(2);

7 ‘‘(iii) the denial of the claim for bene8 fits relates to a decision regarding whether

9 an individual is a participant or beneficiary

10 who is enrolled under the terms and condi11 tions of the plan or coverage (including the

12 applicability of any waiting period under

13 the plan or coverage); or

14 ‘‘(iv) the denial of the claim for bene15 fits is a decision as to the application of

16 cost-sharing requirements or the applica17 tion of a specific exclusion or express limi18 tation on the amount, duration, or scope of

19 coverage of items or services under the

20 terms and conditions of the plan or cov21 erage unless the decision is a denial de22 scribed in subsection (d)(2).

23 Upon making a determination that any of

24 clauses (i) through (iv) applies with respect to

25 the request, the entity shall determine that the
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1 denial of a claim for benefits involved is not eli2 gible for independent medical review under sub3 section (d), and shall provide notice in accord4 ance with subparagraph (C).

5 ‘‘(B) PROCESS FOR MAKING DETERMINA6 TIONS.—

7 ‘‘(i) NO DEFERENCE TO PRIOR DE8 TERMINATIONS.—In making determina9 tions under subparagraph (A), there shall

10 be no deference given to determinations

11 made by the plan or issuer or the rec12 ommendation of a treating health care pro13 fessional (if any).

14 ‘‘(ii) USE OF APPROPRIATE PER15 SONNEL.—A qualified external review enti16 ty shall use appropriately qualified per17 sonnel to make determinations under this

18 section.

19 ‘‘(C) NOTICES AND GENERAL TIMELINES

20 FOR DETERMINATION.—

21 ‘‘(i) NOTICE IN CASE OF DENIAL OF

22 REFERRAL.—If the entity under this para23 graph does not make a referral for the

24 conduct of an independent medical review,

25 the entity shall provide notice to the plan
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1 or issuer, the participant or beneficiary (or

2 authorized representative) filing the re3 quest, and the treating health care profes4 sional (if any) that the denial is not sub5 ject to independent medical review. Such

6 notice—

7 ‘‘(I) shall be written (and, in ad8 dition, may be provided orally) in a

9 manner calculated to be understood

10 by an average participant or bene11 ficiary;

12 ‘‘(II) shall include the reasons for

13 the determination;

14 ‘‘(III) include any relevant terms

15 and conditions of the plan or cov16 erage; and

17 ‘‘(IV) include a description of

18 any further recourse available to the

19 individual.

20 ‘‘(ii) GENERAL TIMELINE FOR DETER21 MINATIONS.—Upon receipt of information

22 under paragraph (2), the qualified external

23 review entity, and if required the inde24 pendent medical review panel conducting

25 independent medical review under sub-
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1 section (d), shall make a determination

2 within the overall timeline that is applica3 ble to the case under review as described

4 in subsection (e), except that if the entity

5 determines that a referral to an inde6 pendent medical review panel is not re7 quired, the entity shall provide notice of

8 such determination to the participant or

9 beneficiary (or authorized representative)

10 within such timeline and within 2 days of

11 the date of such determination.

12 ‘‘(d) INDEPENDENT MEDICAL REVIEW.—

13 ‘‘(1) IN GENERAL.—If a qualified external re14 view entity determines under subsection (c) that a

15 denial of a claim for benefits is eligible for inde16 pendent medical review, the entity shall refer the de17 nial involved to an independent medical review panel

18 comprised of 3 members meeting the requirements

19 of subsection (g) for the conduct of an independent

20 medical review under this subsection.

21 ‘‘(2) MEDICALLY REVIEWABLE DECISIONS.—A

22 denial of a claim for benefits is eligible for inde23 pendent medical review if the benefit for the item or

24 service for which the claim is made would be a cov25 ered benefit under the terms and conditions of the
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1 plan or coverage but for one (or more) of the fol2 lowing determinations:

3 ‘‘(A) DENIALS BASED ON MEDICAL NECES4 SITY AND APPROPRIATENESS.—A determination

5 that the item or service is not covered because

6 it is not medically necessary and appropriate or

7 based on the application of substantially equiva8 lent terms.

9 ‘‘(B) DENIALS BASED ON EXPERIMENTAL

10 OR INVESTIGATIONAL TREATMENT.—A deter11 mination that the item or service is not covered

12 because it is experimental or investigational or

13 based on the application of substantially equiva14 lent terms.

15 ‘‘(C) DENIALS OTHERWISE BASED ON AN

16 EVALUATION OF MEDICAL FACTS.—A deter17 mination that the item or service or condition

18 is not covered based on grounds that require an

19 evaluation of the medical facts by a health care

20 professional in the specific case involved to de21 termine the coverage and extent of coverage of

22 the item or service or condition.

23 ‘‘(3) INDEPENDENT MEDICAL REVIEW DETER24 MINATION.—
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1 ‘‘(A) IN GENERAL.—An independent med2 ical review panel under this section shall make

3 a new independent determination with respect

4 to whether or not the denial of a claim for a

5 benefit that is the subject of the review should

6 be upheld, reversed, or modified.

7 ‘‘(B) STANDARD FOR DETERMINATION.—

8 The independent medical review panel’s deter9 mination relating to the medical necessity and

10 appropriateness, or the experimental or inves11 tigation nature, or the evaluation of the medical

12 facts of the item, service, or condition shall be

13 based on the medical condition of the partici14 pant or beneficiary (including the medical

15 records of the participant or beneficiary) and

16 valid, relevant scientific evidence and clinical

17 evidence, including peer-reviewed medical lit18 erature or findings and including expert opin19 ion.

20 ‘‘(C) NO COVERAGE FOR EXCLUDED BENE21 FITS.—Nothing in this subsection shall be con22 strued to permit an independent medical review

23 panel to require that a group health plan, or

24 health insurance issuer offering health insur25 ance coverage, provide coverage for items or
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1 services for which benefits are specifically ex2 cluded or expressly limited under the plan or

3 coverage in the plain language of the plan docu4 ment (and which are disclosed under section

5 121(b)(1)(C)) except to the extent that the ap6 plication or interpretation of the exclusion or

7 limitation involves a determination described in

8 paragraph (2).

9 ‘‘(D) EVIDENCE AND INFORMATION TO BE

10 USED IN MEDICAL REVIEWS.—In making a de11 termination under this subsection, the inde12 pendent medical review panel shall also consider

13 appropriate and available evidence and informa14 tion, including the following:

15 ‘‘(i) The determination made by the

16 plan or issuer with respect to the claim

17 upon internal review and the evidence,

18 guidelines, or rationale used by the plan or

19 issuer in reaching such determination.

20 ‘‘(ii) The recommendation of the

21 treating health care professional and the

22 evidence, guidelines, and rationale used by

23 the treating health care professional in

24 reaching such recommendation.
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1 ‘‘(iii) Additional relevant evidence or

2 information obtained by the independent

3 medical review panel or submitted by the

4 plan, issuer, participant or beneficiary (or

5 an authorized representative), or treating

6 health care professional.

7 ‘‘(iv) The plan or coverage document.

8 ‘‘(E) INDEPENDENT DETERMINATION.—In

9 making determinations under this subtitle, a

10 qualified external review entity and an inde11 pendent medical review panel shall—

12 ‘‘(i) consider the claim under review

13 without deference to the determinations

14 made by the plan or issuer or the rec15 ommendation of the treating health care

16 professional (if any); and

17 ‘‘(ii) consider, but not be bound by

18 the definition used by the plan or issuer of

19 ‘medically necessary and appropriate’, or

20 ‘experimental or investigational’, or other

21 substantially equivalent terms that are

22 used by the plan or issuer to describe med23 ical necessity and appropriateness or ex24 perimental or investigational nature of the

25 treatment.
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1 ‘‘(F) DETERMINATION OF INDEPENDENT

2 MEDICAL REVIEW PANEL.—An independent

3 medical review panel shall, in accordance with

4 the deadlines described in subsection (e), pre5 pare a written determination to uphold or re6 verse the denial under review. Such written de7 termination shall include—

8 ‘‘(i) the determination of the panel;

9 ‘‘(ii) the specific reasons of the panel

10 for such determination, including a sum11 mary of the clinical or scientific evidence

12 used in making the determination; and

13 ‘‘(iii) with respect to a determination

14 to reverse the denial under review, a time15 frame within which the plan or issuer must

16 comply with such determination.

17 ‘‘(G) NONBINDING NATURE OF ADDI18 TIONAL RECOMMENDATIONS.—In addition to

19 the determination under subparagraph (F), the

20 independent medical review panel may provide

21 the plan or issuer and the treating health care

22 professional with additional recommendations in

23 connection with such a determination, but any

24 such recommendations shall not affect (or be
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1 treated as part of) the determination and shall

2 not be binding on the plan or issuer.

3 ‘‘(e) TIMELINES AND NOTIFICATIONS.—

4 ‘‘(1) TIMELINES FOR INDEPENDENT MEDICAL

5 REVIEW.—

6 ‘‘(A) PRIOR AUTHORIZATION DETERMINA7 TION.—

8 ‘‘(i) IN GENERAL.—The independent

9 medical review panel shall make a deter10 mination under subsection (d) on a denial

11 of a claim for benefits in accordance with

12 the medical exigencies of the case but not

13 later than 14 days after the date of receipt

14 of information under subsection (c)(2) if

15 the review involves a prior authorization of

16 items or services and in no case later than

17 21 days after the date the request for ex18 ternal review is received.

19 ‘‘(ii) EXPEDITED DETERMINATION.—

20 Notwithstanding clause (i) and subject to

21 clause (iii), the independent medical review

22 panel shall make an expedited determina23 tion under subsection (d) on a denial of a

24 claim for benefits described in clause (i),

25 when a request for such an expedited de-
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1 termination is made by a participant or

2 beneficiary (or authorized representative)

3 at any time during the process for making

4 a determination, and a health care profes5 sional certifies, with the request, that a de6 termination under the timeline described in

7 clause (i) would seriously jeopardize the

8 life or health of the participant or bene9 ficiary or the ability of the participant or

10 beneficiary to maintain or regain maximum

11 function. Such determination shall be

12 made as soon as possible based on the

13 medical exigencies of the case involved and

14 in no case later than 72 hours after the

15 time the request for external review is re16 ceived by the qualified external review enti17 ty.

18 ‘‘(iii) ONGOING CARE DETERMINA19 TION.—Notwithstanding clause (i), in the

20 case of a review described in such sub21 clause that involves a termination or reduc22 tion of care, the notice of the determina23 tion shall be completed not later than 24

24 hours after the time the request for exter25 nal review is received by the qualified ex-
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1 ternal review entity and before the end of

2 the approved period of care.

3 ‘‘(B) RETROSPECTIVE DETERMINATION.—

4 The independent medical review panel shall

5 complete a review under subsection (d) in the

6 case of a retrospective determination concerting

7 a denial of a claim for benefits not later than

8 30 days after the date of receipt of information

9 under subsection (c)(2) and in no case later

10 than 60 days after the date the request for ex11 ternal review is received by the qualified exter12 nal review entity.

13 ‘‘(2) NOTIFICATION OF DETERMINATION.—The

14 external review entity shall ensure that the plan or

15 issuer, the participant or beneficiary (or authorized

16 representative) and the treating health care profes17 sional (if any) receives a copy of the written deter18 mination of the independent medical review panel

19 prepared under subsection (d)(3)(F). Nothing in this

20 paragraph shall be construed as preventing an entity

21 or panel from providing an initial oral notice of the

22 determination.

23 ‘‘(3) FORM OF NOTICES.—Determinations and

24 notices under this subsection shall be written in a
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1 manner calculated to be understood by an average

2 participant.

3 ‘‘(f) COMPLIANCE.—

4 ‘‘(1) APPLICATION OF DETERMINATIONS.—

5 ‘‘(A) EXTERNAL REVIEW DETERMINATIONS

6 BINDING ON PLAN.—The determinations of an

7 external review entity and an independent med8 ical review panel under this section shall be

9 binding upon the plan or issuer involved.

10 ‘‘(B) COMPLIANCE WITH DETERMINA11 TION.—If the determination of an independent

12 medical review panel is to reverse the denial,

13 the plan or issuer, upon the receipt of such de14 termination, shall authorize coverage to comply

15 with the panel’s determination in accordance

16 with the timeframe established by the panel.

17 ‘‘(2) FAILURE TO COMPLY.—

18 ‘‘(A) IN GENERAL.—If a plan or issuer

19 fails to comply with the timeframe established

20 under paragraph (1)(B) with respect to a par21 ticipant or beneficiary, where such failure to

22 comply is caused by the plan or issuer, the par23 ticipant or beneficiary may obtain the items or

24 services involved (in a manner consistent with

25 the determination of the independent external
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1 review entity) from any provider regardless of

2 whether such provider is a participating pro3 vider under the plan or coverage.

4 ‘‘(B) REIMBURSEMENT.—

5 ‘‘(i) IN GENERAL.—Where a partici6 pant or beneficiary obtains items or serv7 ices in accordance with subparagraph (A),

8 the plan or issuer involved shall provide for

9 reimbursement of the costs of such items

10 or services. Such reimbursement shall be

11 made to the treating health care profes12 sional or to the participant or beneficiary

13 (in the case of a participant or beneficiary

14 who pays for the costs of such items or

15 services).

16 ‘‘(ii) AMOUNT.—The plan or issuer

17 shall fully reimburse a professional, partici18 pant or beneficiary under clause (i) for the

19 total costs of the items or services provided

20 (regardless of any plan limitations that

21 may apply to the coverage of such items or

22 services) so long as the items or services

23 were provided in a manner consistent with

24 the determination of the independent med25 ical review panel.
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1 ‘‘(C) FAILURE TO REIMBURSE.—Where a

2 plan or issuer fails to provide reimbursement to

3 a professional, participant or beneficiary in ac4 cordance with this paragraph, the professional,

5 participant or beneficiary may commence a civil

6 action (or utilize other remedies available under

7 law) to recover only the amount of any such re8 imbursement that is owed by the plan or issuer

9 and any necessary legal costs or expenses (in10 cluding attorney’s fees) incurred in recovering

11 such reimbursement.

12 ‘‘(D) AVAILABLE REMEDIES.—The rem13 edies provided under this paragraph are in ad14 dition to any other available remedies.

15 ‘‘(3) PENALTIES AGAINST AUTHORIZED OFFI16 CIALS FOR REFUSING TO AUTHORIZE THE DETER17 MINATION OF AN INDEPENDENT MEDICAL REVIEW

18 PANEL.—

19 ‘‘(A) MONETARY PENALTIES.—

20 ‘‘(i) IN GENERAL.—In any case in

21 which the determination of an independent

22 medical review panel under this section is

23 not followed by a group health plan, or by

24 a health insurance issuer offering health

25 insurance coverage, any person who, acting
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1 in the capacity of authorizing the benefit,

2 causes such refusal may, in the discretion

3 in a court of competent jurisdiction, be lia4 ble to an aggrieved participant or bene5 ficiary for a civil penalty in an amount of

6 up to $1,000 a day from the date on which

7 the determination was transmitted to the

8 plan or issuer by the external review entity

9 until the date the refusal to provide the

10 benefit is corrected.

11 ‘‘(ii) ADDITIONAL PENALTY FOR FAIL12 ING TO FOLLOW TIMELINE.—In any case

13 in which treatment was not commenced by

14 the plan in accordance with the determina15 tion of an independent external review en16 tity, the Secretary shall assess a civil pen17 alty of $10,000 against the plan and the

18 plan shall pay such penalty to the partici19 pant or beneficiary involved.

20 ‘‘(B) CEASE AND DESIST ORDER AND

21 ORDER OF ATTORNEY’S FEES.—In any action

22 described in subparagraph (A) brought by a

23 participant or beneficiary with respect to a

24 group health plan, or a health insurance issuer

25 offering health insurance coverage, in which a
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1 plaintiff alleges that a person referred to in

2 such subparagraph has taken an action result3 ing in a refusal of a benefit determined by an

4 external appeal entity to be covered, or has

5 failed to take an action for which such person

6 is responsible under the terms and conditions of

7 the plan or coverage and which is necessary

8 under the plan or coverage for authorizing a

9 benefit, the court shall cause to be served on

10 the defendant an order requiring the

11 defendant—

12 ‘‘(i) to cease and desist from the al13 leged action or failure to act; and

14 ‘‘(ii) to pay to the plaintiff a reason15 able attorney’s fee and other reasonable

16 costs relating to the prosecution of the ac17 tion on the charges on which the plaintiff

18 prevails.

19 ‘‘(C) ADDITIONAL CIVIL PENALTIES.—

20 ‘‘(i) IN GENERAL.—In addition to any

21 penalty imposed under subparagraph (A)

22 or (B), the Secretary may assess a civil

23 penalty against a person acting in the ca24 pacity of authorizing a benefit determined

25 by an external review entity for one or
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1 more group health plans, or health insur2 ance issuers offering health insurance cov3 erage, for—

4 ‘‘(I) any pattern or practice of

5 repeated refusal to authorize a benefit

6 determined by an external appeal enti7 ty to be covered; or

8 ‘‘(II) any pattern or practice of

9 repeated violations of the require10 ments of this section with respect to

11 such plan or coverage.

12 ‘‘(ii) STANDARD OF PROOF AND

13 AMOUNT OF PENALTY.—Such penalty shall

14 be payable only upon proof by clear and

15 convincing evidence of such pattern or

16 practice and shall be in an amount not to

17 exceed the lesser of—

18 ‘‘(I) 25 percent of the aggregate

19 value of benefits shown by the Sec20 retary to have not been provided, or

21 unlawfully delayed, in violation of this

22 section under such pattern or prac23 tice; or

24 ‘‘(II) $500,000.
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1 ‘‘(4) PROTECTION OF LEGAL RIGHTS.—Nothing

2 in this subsection or subtitle shall be construed as

3 altering or eliminating any cause of action or legal

4 rights or remedies of participants, beneficiaries, and

5 others under State or Federal law (including sec6 tions 502 and 503), including the right to file judi7 cial actions to enforce rights.

8 ‘‘(g) QUALIFICATIONS OF MEMBERS OF INDE9 PENDENT MEDICAL REVIEW PANELS.—

10 ‘‘(1) IN GENERAL.—In referring a denial to an

11 independent medical review panel to conduct inde12 pendent medical review under subsection (c), the

13 qualified external review entity shall ensure that—

14 ‘‘(A) each member of the panel meets the

15 qualifications described in paragraphs (2) and

16 (3);

17 ‘‘(B) with respect to each review the re18 quirements described in paragraphs (4) and (5)

19 for the panel are met; and

20 ‘‘(C) compensation provided by the entity

21 to each member of the panel is consistent with

22 paragraph (6).

23 ‘‘(2) LICENSURE AND EXPERTISE.—Each mem24 ber of the independent medical review panel shall be
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1 a physician (allopathic or osteopathic) or health care

2 professional who—

3 ‘‘(A) is appropriately credentialed or li4 censed in 1 or more States to deliver health

5 care services; and

6 ‘‘(B) typically treats the condition, makes

7 the diagnosis, or provides the type of treatment

8 under review.

9 ‘‘(3) INDEPENDENCE.—

10 ‘‘(A) IN GENERAL.—Subject to subpara11 graph (B), each member of the independent

12 medical review panel in a case shall—

13 ‘‘(i) not be a related party (as defined

14 in paragraph (7));

15 ‘‘(ii) not have a material familial, fi16 nancial, or professional relationship with

17 such a party; and

18 ‘‘(iii) not otherwise have a conflict of

19 interest with such a party (as determined

20 under regulations).

21 ‘‘(B) EXCEPTION.—Nothing in subpara22 graph (A) shall be construed to—

23 ‘‘(i) prohibit an individual, solely on

24 the basis of affiliation with the plan or
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1 issuer, from serving as a member of an

2 independent medical review panel if—

3 ‘‘(I) a non-affiliated individual is

4 not reasonably available;

5 ‘‘(II) the affiliated individual is

6 not involved in the provision of items

7 or services in the case under review;

8 ‘‘(III) the fact of such an affili9 ation is disclosed to the plan or issuer

10 and the participant or beneficiary (or

11 authorized representative) and neither

12 party objects; and

13 ‘‘(IV) the affiliated individual is

14 not an employee of the plan or issuer

15 and does not provide services exclu16 sively or primarily to or on behalf of

17 the plan or issuer;

18 ‘‘(ii) prohibit an individual who has

19 staff privileges at the institution where the

20 treatment involved takes place from serv21 ing as a member of an independent med22 ical review panel merely on the basis of

23 such affiliation if the affiliation is disclosed

24 to the plan or issuer and the participant or
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1 beneficiary (or authorized representative),

2 and neither party objects; or

3 ‘‘(iii) prohibit receipt of compensation

4 by a member of an independent medical re5 view panel from an entity if the compensa6 tion is provided consistent with paragraph

7 (6).

8 ‘‘(4) PRACTICING HEALTH CARE PROFESSIONAL

9 IN SAME FIELD.—

10 ‘‘(A) IN GENERAL.—In a case involving

11 treatment, or the provision of items or

12 services—

13 ‘‘(i) by a physician, the members of

14 an independent medical review panel shall

15 be practicing physicians (allopathic or os16 teopathic) of the same or similar specialty

17 as a physician who typically treats the con18 dition, makes the diagnosis, or provides the

19 type of treatment under review; or

20 ‘‘(ii) by a health care professional

21 (other than a physician), at least two of

22 the members of an independent medical re23 view panel shall be practicing physicians

24 (allopathic or osteopathic) of the same or

25 similar specialty as the health care profes-
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1 sional who typically treats the condition,

2 makes the diagnosis, or provides the type

3 of treatment under review, and, if deter4 mined appropriate by the qualified external

5 review entity, the third member of such

6 panel shall be a practicing health care pro7 fessional (other than such a physician) of

8 such a same or similar specialty.

9 ‘‘(B) PRACTICING DEFINED.—For pur10 poses of this paragraph, the term ‘practicing’

11 means, with respect to an individual who is a

12 physician or other health care professional that

13 the individual provides health care services to

14 individual patients on average at least 2 days

15 per week.

16 ‘‘(5) PEDIATRIC EXPERTISE.—In the case of an

17 external review relating to a child, a member of an

18 independent medical review panel shall have exper19 tise under paragraph (2) in pediatrics.

20 ‘‘(6) LIMITATIONS ON REVIEWER COMPENSA21 TION.—Compensation provided by a qualified exter22 nal review entity to a member of an independent

23 medical review panel in connection with a review

24 under this section shall—

25 ‘‘(A) not exceed a reasonable level; and
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1 ‘‘(B) not be contingent on the decision ren2 dered by the reviewer.

3 ‘‘(7) RELATED PARTY DEFINED.—For purposes

4 of this section, the term ‘related party’ means, with

5 respect to a denial of a claim under a plan or cov6 erage relating to a participant or beneficiary, any of

7 the following:

8 ‘‘(A) The plan, plan sponsor, or issuer in9 volved, or any fiduciary, officer, director, or em10 ployee of such plan, plan sponsor, or issuer.

11 ‘‘(B) The participant or beneficiary (or au12 thorized representative).

13 ‘‘(C) The health care professional that pro14 vides the items or services involved in the de15 nial.

16 ‘‘(D) The institution at which the items or

17 services (or treatment) involved in the denial

18 are provided.

19 ‘‘(E) The manufacturer of any drug or

20 other item that is included in the items or serv21 ices involved in the denial.

22 ‘‘(F) Any other party determined under

23 any regulations to have a substantial interest in

24 the denial involved.

25 ‘‘(h) QUALIFIED EXTERNAL REVIEW ENTITIES.—
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1 ‘‘(1) SELECTION OF QUALIFIED EXTERNAL RE2 VIEW ENTITIES.—

3 ‘‘(A) LIMITATION ON PLAN OR ISSUER SE4 LECTION.—The Secretary shall implement

5 procedures—

6 ‘‘(i) to assure that the selection proc7 ess among qualified external review entities

8 will not create any incentives for external

9 review entities to make a decision in a bi10 ased manner; and

11 ‘‘(ii) for auditing a sample of deci12 sions by such entities to assure that no

13 such decisions are made in a biased man14 ner.

15 ‘‘(B) STATE AUTHORITY WITH RESPECT

16 TO QUALIFIED EXTERNAL REVIEW ENTITIES

17 FOR HEALTH INSURANCE ISSUERS.—With re18 spect to health insurance issuers offering health

19 insurance coverage in a State, the State may

20 provide for external review activities to be con21 ducted by a qualified external appeal entity that

22 is designated by the State or that is selected

23 by the State in a manner determined by the

24 State to assure an unbiased determination.
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1 ‘‘(2) CONTRACT WITH QUALIFIED EXTERNAL

2 REVIEW ENTITY.—Except as provided in paragraph

3 (1)(B), the external review process of a plan or

4 issuer under this section shall be conducted under a

5 contract between the plan or issuer and 1 or more

6 qualified external review entities (as defined in para7 graph (4)(A)).

8 ‘‘(3) TERMS AND CONDITIONS OF CONTRACT.—

9 The terms and conditions of a contract under para10 graph (2) shall—

11 ‘‘(A) be consistent with the standards the

12 Secretary shall establish to assure there is no

13 real or apparent conflict of interest in the con14 duct of external review activities; and

15 ‘‘(B) provide that the costs of the external

16 review process shall be borne by the plan or

17 issuer.

18 Subparagraph (B) shall not be construed as apply19 ing to the imposition of a filing fee under subsection

20 (b)(2)(A)(iv) or costs incurred by the participant or

21 beneficiary (or authorized representative) or treating

22 health care professional (if any) in support of the re23 view, including the provision of additional evidence

24 or information.

25 ‘‘(4) QUALIFICATIONS.—
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1 ‘‘(A) IN GENERAL.—In this section, the

2 term ‘qualified external review entity’ means, in

3 relation to a plan or issuer, an entity that is

4 initially certified (and periodically recertified)

5 under subparagraph (C) as meeting the fol6 lowing requirements:

7 ‘‘(i) The entity has (directly or

8 through contracts or other arrangements)

9 sufficient medical, legal, and other exper10 tise and sufficient staffing to carry out du11 ties of a qualified external review entity

12 under this section on a timely basis, in13 cluding making determinations under sub14 section (b)(2)(A) and providing for inde15 pendent medical reviews under subsection

16 (d).

17 ‘‘(ii) The entity is not a plan or issuer

18 or an affiliate or a subsidiary of a plan or

19 issuer, and is not an affiliate or subsidiary

20 of a professional or trade association of

21 plans or issuers or of health care providers.

22 ‘‘(iii) The entity has provided assur23 ances that it will conduct external review

24 activities consistent with the applicable re25 quirements of this section and standards
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1 specified in subparagraph (C), including

2 that it will not conduct any external review

3 activities in a case unless the independence

4 requirements of subparagraph (B) are met

5 with respect to the case.

6 ‘‘(iv) The entity has provided assur7 ances that it will provide information in a

8 timely manner under subparagraph (D).

9 ‘‘(v) The entity meets such other re10 quirements as the Secretary provides by

11 regulation.

12 ‘‘(B) INDEPENDENCE REQUIREMENTS.—

13 ‘‘(i) IN GENERAL.—Subject to clause

14 (ii), an entity meets the independence re15 quirements of this subparagraph with re16 spect to any case if the entity—

17 ‘‘(I) is not a related party (as de18 fined in subsection (g)(7));

19 ‘‘(II) does not have a material fa20 milial, financial, or professional rela21 tionship with such a party; and

22 ‘‘(III) does not otherwise have a

23 conflict of interest with such a party

24 (as determined under regulations).
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1 ‘‘(ii) EXCEPTION FOR REASONABLE

2 COMPENSATION.—Nothing in clause (i)

3 shall be construed to prohibit receipt by a

4 qualified external review entity of com5 pensation from a plan or issuer for the

6 conduct of external review activities under

7 this section if the compensation is provided

8 consistent with clause (iii).

9 ‘‘(iii) LIMITATIONS ON ENTITY COM10 PENSATION.—Compensation provided by a

11 plan or issuer to a qualified external review

12 entity in connection with reviews under

13 this section shall—

14 ‘‘(I) not exceed a reasonable

15 level; and

16 ‘‘(II) not be contingent on any

17 decision rendered by the entity or by

18 any independent medical review panel.

19 ‘‘(C) CERTIFICATION AND RECERTIFI20 CATION PROCESS.—

21 ‘‘(i) IN GENERAL.—The initial certifi22 cation and recertification of a qualified ex23 ternal review entity shall be made—
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1 ‘‘(I) under a process that is rec2 ognized or approved by the Secretary;

3 or

4 ‘‘(II) by a qualified private

5 standard-setting organization that is

6 approved by the Secretary under

7 clause (iii).

8 In taking action under subclause (I), the

9 Secretary shall give deference to entities

10 that are under contract with the Federal

11 Government or with an applicable State

12 authority to perform functions of the type

13 performed by qualified external review en14 tities.

15 ‘‘(ii) PROCESS.—The Secretary shall

16 not recognize or approve a process under

17 clause (i)(I) unless the process applies

18 standards (as promulgated in regulations)

19 that ensure that a qualified external review

20 entity—

21 ‘‘(I) will carry out (and has car22 ried out, in the case of recertification)

23 the responsibilities of such an entity

24 in accordance with this section, in25 cluding meeting applicable deadlines;
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1 ‘‘(II) will meet (and has met, in

2 the case of recertification) appropriate

3 indicators of fiscal integrity;

4 ‘‘(III) will maintain (and has

5 maintained, in the case of recertifi6 cation) appropriate confidentiality

7 with respect to individually identifi8 able health information obtained in

9 the course of conducting external re10 view activities; and

11 ‘‘(IV) in the case recertification,

12 shall review the matters described in

13 clause (iv).

14 ‘‘(iii) APPROVAL OF QUALIFIED PRI15 VATE STANDARD-SETTING ORGANIZA16 TIONS.—For purposes of clause (i)(II), the

17 Secretary may approve a qualified private

18 standard-setting organization if such Sec19 retary finds that the organization only cer20 tifies (or recertifies) external review enti21 ties that meet at least the standards re22 quired for the certification (or recertifi23 cation) of external review entities under

24 clause (ii).
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1 ‘‘(iv) CONSIDERATIONS IN RECERTIFI2 CATIONS.—In conducting recertifications of

3 a qualified external review entity under

4 this paragraph, the Secretary or organiza5 tion conducting the recertification shall re6 view compliance of the entity with the re7 quirements for conducting external review

8 activities under this section, including the

9 following:

10 ‘‘(I) Provision of information

11 under subparagraph (D).

12 ‘‘(II) Adherence to applicable

13 deadlines (both by the entity and by

14 independent medical review panels it

15 refers cases to).

16 ‘‘(III) Compliance with limita17 tions on compensation (with respect to

18 both the entity and independent med19 ical review panels it refers cases to).

20 ‘‘(IV) Compliance with applicable

21 independence requirements.

22 ‘‘(v) PERIOD OF CERTIFICATION OR

23 RECERTIFICATION.—A certification or re24 certification provided under this paragraph
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1 shall extend for a period not to exceed 2

2 years.

3 ‘‘(vi) REVOCATION.—A certification or

4 recertification under this paragraph may

5 be revoked by the Secretary or by the or6 ganization providing such certification

7 upon a showing of cause.

8 ‘‘(D) PROVISION OF INFORMATION.—

9 ‘‘(i) IN GENERAL.—A qualified exter10 nal review entity shall provide to the Sec11 retary (or the State in the case of external

12 review activities provided for by a State

13 pursuant to paragraph (1)(B)), in such

14 manner and at such times as such Sec15 retary (or State) may require, such infor16 mation (relating to the denials which have

17 been referred to the entity for the conduct

18 of external review under this section) as

19 such Secretary (or State) determines ap20 propriate to assure compliance with the

21 independence and other requirements of

22 this section to monitor and assess the qual23 ity of its external review activities and lack

24 of bias in making determinations. Such in25 formation shall include information de-
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1 scribed in clause (ii) but shall not include

2 individually identifiable medical informa3 tion.

4 ‘‘(ii) INFORMATION TO BE IN5 CLUDED.—The information described in

6 this subclause with respect to an entity is

7 as follows:

8 ‘‘(I) The number and types of de9 nials for which a request for review

10 has been received by the entity.

11 ‘‘(II) The disposition by the enti12 ty of such denials, including the num13 ber referred to an independent med14 ical review panel and the reasons for

15 such dispositions (including the appli16 cation of exclusions), on a plan or

17 issuer-specific basis and on a health

18 care specialty-specific basis.

19 ‘‘(III) The length of time in mak20 ing determinations with respect to

21 such denials.

22 ‘‘(IV) Updated information on

23 the information required to be sub24 mitted as a condition of certification
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1 with respect to the entity’s perform2 ance of external review activities.

3 ‘‘(iii) INFORMATION TO BE PROVIDED

4 TO CERTIFYING ORGANIZATION.—

5 ‘‘(I) IN GENERAL.—In the case

6 of a qualified external review entity

7 which is certified (or recertified)

8 under this subsection by a qualified

9 private standard-setting organization,

10 at the request of the organization, the

11 entity shall provide the organization

12 with the information provided to the

13 Secretary under clause (i).

14 ‘‘(II) ADDITIONAL INFORMA15 TION.—Nothing in this subparagraph

16 shall be construed as preventing such

17 an organization from requiring addi18 tional information as a condition of

19 certification or recertification of an

20 entity.

21 ‘‘(iv) USE OF INFORMATION.—Infor22 mation provided under this subparagraph

23 may be used by the Secretary and qualified

24 private standard-setting organizations to

25 conduct oversight of qualified external re-
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1 view entities, including recertification of

2 such entities, and shall be made available

3 to the public in an appropriate manner.

4 ‘‘(E) LIMITATION ON LIABILITY.—No

5 qualified external review entity having a con6 tract with a plan or issuer, and no person who

7 is employed by any such entity or who furnishes

8 professional services to such entity (including as

9 a member of an independent medical review

10 panel), shall be held by reason of the perform11 ance of any duty, function, or activity required

12 or authorized pursuant to this section, to be

13 civilly liable under any law of the United States

14 or of any State (or political subdivision thereof)

15 if there was no actual malice or gross mis16 conduct in the performance of such duty, func17 tion, or activity.’’.

18 (b) CONFORMING AMENDMENT.—The table of con19 tents in section 1 of the Employee Retirement Income Se20 curity Act of 1974 is amended by inserting after the item

21 relating to section 503 the following:

‘‘Sec. 503A. Utilization review activities.

‘‘Sec. 503B. Procedures for initial claims for benefits and prior authorization

determinations.

‘‘Sec. 503C. Internal appeals of claims denials.

‘‘Sec. 503D. Independent external appeals procedures.’’.
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1 SEC. 122. CONFORMING AMENDMENTS TO PUBLIC HEALTH

2 SERVICE ACT.

3 (a) GROUP HEALTH PLANS.—Title XXVII of the

4 Public Health Service Act, as amended by sections 102(a)

5 and 112(a), is amended by inserting after section 2708

6 the following new section:

7 ‘‘SEC. 2709. STANDARD RELATING TO ACCOUNTABILITY.

8 ‘‘Subject to section 2724(c), a group health plan, and

9 health insurance coverage offered in connection with a

10 group health plan, shall comply with the requirements of

11 sections 503A through 503D of the Employee Retirement

12 Income Security Act of 1974 (as in effect as of the day

13 after the date of the enactment of such Act) and such re14 quirements shall be deemed to be incorporated into this

15 section. For purposes of this section, references in such

16 sections 503A through 503D to the Secretary shall be

17 deemed references to the Secretary of Health and Human

18 Services.’’.

19 (b) INDIVIDUAL HEALTH PLANS.—Title XXVII of

20 the Public Health Service Act, as amended by sections

21 102(b) and 112(b), is amended by inserting after section

22 2754 the following new section:

23 ‘‘SEC. 2755. STANDARD RELATING TO ACCOUNTABILITY.

24 ‘‘Subject to section 2762A(c), the provisions of sec25 tions 503A through 503D of the Employee Retirement In26 come Security Act of 1974 (as in effect as of the day after
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•HR 5628 IH

1 the date of the enactment of such Act) shall apply to

2 health insurance coverage offered by a health insurance

3 issuer in the individual market for an enrollee in the same

4 manner as they apply to health insurance coverage offered

5 by a health insurance issuer for a participant or bene6 ficiary in connection with a group health plan in the small

7 or large group market and the requirements referred to

8 in such section shall be deemed to be incorporated into

9 this section. For purposes of this section, references in

10 such sections 503A through 503D to the Secretary shall

11 be deemed references to the Secretary of Health and

12 Human Services.’’.

13 SEC. 123. CONFORMING AMENDMENTS TO THE INTERNAL

14 REVENUE CODE OF 1986.

15 Subchapter B of chapter 100 of the Internal Revenue

16 Code of 1986, as amended by sections 103 and 113, is

17 amended—

18 (1) in the table of sections, by inserting after

19 the item relating to section 9814 the following new

20 item:

‘‘Sec. 9815. Standard relating to plan accountability.’’;

21 and

22 (2) by inserting after section 9814 the fol23 lowing:
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1 ‘‘SEC. 9815. STANDARD RELATING TO PLAN ACCOUNT2 ABILITY.

3 ‘‘A group health plan shall comply with the require4 ments of sections 503A through 503D of the Employee

5 Retirement Income Security Act of 1974 (as in effect as

6 of the day after the date of the enactment of such Act)

7 and such requirements shall be deemed to be incorporated

8 into this section. For purposes of this section, references

9 in such sections 503A through 503D to the Secretary shall

10 be deemed references to the Secretary of the Treasury.’’.

11 Subtitle D—State Flexibility in Ap12 plying Requirements to Health

13 Insurance Issuers

14 SEC. 141. STATE FLEXIBILITY IN APPLYING REQUIRE15 MENTS TO HEALTH INSURANCE ISSUERS

16 UNDER ERISA; PLAN SATISFACTION OF CER17 TAIN REQUIREMENTS.

18 (a) IN GENERAL.—Section 731(a) of the Employee

19 Retirement Income Security Act of 1974 is amended—

20 (1) in section 731(a)(1) (29 U.S.C. 1191(a)),

21 by inserting ‘‘and section 731A’’ after ‘‘Subject to

22 paragraph (2)’’; and

23 (2) by inserting after section 731 the following

24 new section:
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1 ‘‘SEC. 731A. STATE FLEXIBILITY IN APPLYING PATIENTS’

2 BILL OF RIGHTS AND PATIENT ACCESS TO IN3 FORMATION REQUIREMENTS; PLAN SATIS4 FACTION OF CERTAIN REQUIREMENTS.

5 ‘‘(a) STATE FLEXIBILITY.—The requirements of a

6 section of subpart C (relating to patients’ bill of rights)

7 and of section 714 (relating to patient access to informa8 tion) shall not apply with respect to health insurance cov9 erage (and to a group health plan insofar as it provides

10 benefits in the form of health insurance coverage) in a

11 State—

12 ‘‘(1) before January 1, 2003; and

13 ‘‘(2) on or after such date, during any period

14 for which the State certifies to the Patients’ Protec15 tion Certification Board (established under sub16 section (c)) that the State has in effect a State law

17 (as defined in section 2723(d)(1) of the Public

18 Health Service Act) that—

19 ‘‘(A) addresses the patient protections or

20 access to information in such section; and

21 ‘‘(B)(i) adopts the Federal standard

22 under such section with respect to the re23 quirements; or

24 ‘‘(ii) is consistent with the purposes of

25 the section and the Board has not found
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1 such certification invalid under subsection

2 (b)(2)(A).

3 ‘‘(b) PATIENTS’ PROTECTION CERTIFICATION

4 BOARD; CERTIFICATION REVIEW PROCESS.—

5 ‘‘(1) ESTABLISHMENT OF BOARD.—

6 ‘‘(A) IN GENERAL.—There is hereby estab7 lished in the Health Resources and Services Ad8 ministration of the Department of Health and

9 Human Services a Patients’ Protection Certifi10 cation Board (in this section referred to as the

11 ‘Board’).

12 ‘‘(B) COMPOSITION.—The Board shall be

13 composed of 13 members appointed by the

14 President, by and with the advice and consent

15 of the Senate, from among individuals who rep16 resent consumers and employers or have exper17 tise in law, medicine, insurance, employee bene18 fits, and related fields. Members shall first be

19 appointed to the Board not earlier than Feb20 ruary 1, 2001, and no later than May 1, 2001.

21 ‘‘(C) TERMS.—The terms of members of

22 the Board shall be for 3 years except that for

23 the members first appointed the President shall

24 designate staggered terms of 3 years for 2

25 members, 2 years for 2 members, and 1 year
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1 for one member. A vacancy in the Board shall

2 be filled in the same manner in which the origi3 nal appointment was made and a member ap4 pointed to fill a vacancy occurring before the

5 expiration of the term for which the member’s

6 predecessor was appointed shall be appointed

7 only for the remainder of that term.

8 ‘‘(D) COMPENSATION.—To the extent pro9 vided in advance in appropriations Acts, while

10 serving on the business of the Board (including

11 travel time), each member of the Board—

12 ‘‘(i) shall be entitled to receive com13 pensation at the daily equivalent of the an14 nual rate of basic pay provided for level IV

15 of the Executive Schedule under section

16 5315 of title 5, United States Code for

17 each day (including travel time) during

18 which the member is engaged in the actual

19 performance of duties as such a member;

20 and

21 ‘‘(ii) while so serving away from home

22 and the member’s regular place of busi23 ness, may be allowed travel expenses, as

24 authorized by the Board.

25 ‘‘(2) DUTIES.—
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1 ‘‘(A) REVIEW OF CERTIFICATIONS SUB2 MITTED.—

3 ‘‘(i) IN GENERAL.—The Board shall

4 review certifications submitted under sub5 section (a)(2).

6 ‘‘(ii) DEFERENCE TO STATES.—Such

7 a certification submitted for a State law

8 with respect to the requirements of a sec9 tion is deemed valid unless, within 90 days

10 after the date of its submittal to the

11 Board, the Board finds that there is clear

12 and convincing evidence of substantial non13 compliance of the State law with the re14 quirements of such section.

15 ‘‘(B) ANNUAL CONGRESSIONAL RE16 PORTS.—The Board shall submit to Congress

17 an annual report on its activities. The first an18 nual report shall focus specifically on the devel19 opment by the Board of criteria for the evalua20 tion of State laws and any other activities of

21 the Board during its first year of operation.

22 ‘‘(3) ORGANIZATION.—

23 ‘‘(A) CHAIR.—The Board shall elect a

24 member of the Board to serve as chair.
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1 ‘‘(B) MEETINGS.—The Board shall meet

2 at least quarterly and otherwise at the call of

3 the chair or upon the written request of a ma4 jority of its members.

5 ‘‘(C) QUORUM.—Seven members of the

6 Board shall constitute a quorum thereof, but a

7 lesser number may hold hearings and take testi8 mony.

9 ‘‘(4) DIRECTOR AND STAFF; EXPERTS AND

10 CONSULTANTS.—To the extent provided in advance

11 in appropriations Acts, the Board may—

12 ‘‘(A) employ and fix the compensation of

13 an Executive Director and such other personnel

14 as may be necessary to carry out the Board’s

15 duties, without regard to the provisions of title

16 5, United States Code, governing appointments

17 in the competitive service;

18 ‘‘(B) procure temporary and intermittent

19 services under section 3109(b) of title 5, United

20 States Code; and

21 ‘‘(C) provide transportation and subsist22 ence for persons serving the Board without

23 compensation.

24 ‘‘(5) POWERS.—

25 ‘‘(A) OBTAINING OFFICIAL DATA.—
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1 ‘‘(i) IN GENERAL.—The Board may

2 secure directly from any department or

3 agency of the United States information

4 necessary to enable it to carry out its du5 ties.

6 ‘‘(ii) REQUEST OF CHAIR.—Upon re7 quest of the chair, the head of that depart8 ment or agency shall furnish that informa9 tion to the Board on an agreed upon

10 schedule.

11 ‘‘(B) AGENCY ASSISTANCE.—The Board

12 may seek such assistance and support as may

13 be required in the performance of its duties

14 from the Secretary of Health and Human Serv15 ices, acting through the Health Resources and

16 Services Administration. Any employee of such

17 Administration may be detailed to the Board to

18 assist the Board in carrying out its duties.

19 ‘‘(C) CONTRACT AUTHORITY.—To the ex20 tent provided in advance in appropriations Act,

21 the Board may enter into contracts or make

22 other arrangements for facilities and services as

23 may be necessary for the conduct of the work

24 of the Board (without regard to section 3709 of

25 the Revised Statutes (41 U.S.C. 5)).
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1 ‘‘(D) HEARINGS.—The Board may, for the

2 purpose of carrying out its duties, hold hear3 ings, sit and act at times and places, take testi4 mony, and receive evidence as the Board con5 siders appropriate. The Board may administer

6 oaths or affirmations to witnesses appearing be7 fore it. To the extent provided in advance in

8 appropriation Acts, the Board may pay reason9 able travel expenses to witnesses for travel inci10 dent to hearings held by the Board. Nothing in

11 this subsection shall be construed as author12 izing the issuance of subpoenas in support of

13 its duties.

14 ‘‘(E) RULES.—The Board may prescribe

15 such rules and regulations as it deems nec16 essary to carry out this subsection.

17 ‘‘(6) AUTHORIZATION OF APPROPRIATIONS.—

18 There are authorized to be appropriated to carry out

19 this subsection—

20 ‘‘(A) for fiscal year 2001, $500,000,

21 ‘‘(B) for fiscal year 2002, $1,000,000, and

22 ‘‘(C) for subsequent fiscal years, such

23 sums as may be necessary.

24 ‘‘(c) RELATIONSHIP TO GROUP HEALTH PLAN RE25 QUIREMENTS.—Nothing in this section shall be construed
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1 to affect or modify the provisions of section 514 with re2 spect to group health plans (insofar as it provides benefits

3 other than in the form of health insurance coverage).

4 ‘‘(d) PLAN SATISFACTION OF CERTAIN REQUIRE5 MENTS.—

6 ‘‘(1) SATISFACTION OF CERTAIN REQUIRE7 MENTS THROUGH INSURANCE.—For purposes of this

8 part, insofar as a group health plan provides bene9 fits in the form of health insurance coverage through

10 a health insurance issuer and, under the arrange11 ment to offer such coverage, the issuer is legally re12 sponsible for compliance with any of the following

13 requirements of this subpart (or of section 714), the

14 plan shall be treated as meeting such requirements

15 and not be considered as failing to meet such re16 quirements because of a failure of the issuer to meet

17 such requirements so long as the plan sponsor or its

18 representatives did not cause such failure by the

19 issuer:

20 ‘‘(A) Section 721 (relating to access to

21 emergency care).

22 ‘‘(B) Section 722 (relating to offering of

23 choice of coverage options).

24 ‘‘(C) Section 723 (relating to access to ob25 stetric and gynecological care).
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1 ‘‘(D) Section 724 (relating to access to pe2 diatric care).

3 ‘‘(E) Section 725 (relating to access to

4 specialty care).

5 ‘‘(F) Section 726(a)(1) (relating to con6 tinuity in case of termination of provider con7 tract) and section 726(a)(2) (relating to con8 tinuity in case of termination of issuer con9 tract), but only insofar as a replacement issuer

10 assumes the obligation for continuity of care.

11 ‘‘(G) Section 728 (relating to access to

12 needed prescription drugs).

13 ‘‘(H) Section 730 (relating to coverage for

14 individuals participating in approved clinical

15 trials.)

16 ‘‘(I) Section 730C (relating to payment of

17 claims).

18 ‘‘(J) Section 714 (relating to access to in19 formation).

20 ‘‘(2) APPLICATION TO PROHIBITIONS.—If a

21 health insurance issuer offers health insurance cov22 erage in connection with a group health plan and

23 takes an action in violation of any of the following

24 sections, the group health plan shall not be liable for

25 such violation unless the plan caused such violation:
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1 ‘‘(A) Section 727 (relating to prohibition of

2 interference with certain medical communica3 tions).

4 ‘‘(B) Section 729 (relating to self-payment

5 for behavioral health).

6 ‘‘(C) Section 730A (relating to prohibition

7 of discrimination against providers based on li8 censure).

9 ‘‘(D) Section 730B (relating to prohibition

10 against improper incentive arrangements).

11 ‘‘(3) CONSTRUCTION.—Nothing in this sub12 section shall be construed to affect or modify the re13 sponsibilities of the fiduciaries of a group health

14 plan under part 4 of subtitle B.

15 ‘‘(e) CONFORMING REGULATIONS.—The Secretary

16 may issue regulations to coordinate the requirements on

17 group health plans under subpart C, section 714, and sec18 tions 503A through 503D with the requirements imposed

19 under the other provisions of this title.’’.

20 (b) SATISFACTION OF ERISA CLAIMS PROCEDURE

21 REQUIREMENT.—Section 503 of such Act (29 U.S.C.

22 1133) is amended by inserting ‘‘(a)’’ after ‘‘SEC. 503.’’

23 and by adding at the end the following new subsection:

24 ‘‘(b) In the case of a group health plan (as defined

25 in section 733) compliance with the requirements of sec-
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1 tions 503A through 503D in the case of a claims denial

2 shall be deemed compliance with subsection (a) with re3 spect to such claims denial.’’.

4 (c) CLERICAL AMENDMENT.—The table of contents

5 in section 1 of such Act (29 U.S.C. 1001) is amended by

6 inserting after the item relating to section 731, the fol7 lowing:

‘‘Sec. 731A. State flexibility in applying patients’ bill of rights and patient access to information requirements; plan satisfaction of certain

requirements.’’.

8 SEC. 142. STATE FLEXIBILITY IN APPLYING REQUIRE9 MENTS UNDER THE PUBLIC HEALTH SERV10 ICE ACT.

11 (a) GROUP HEALTH PLANS AND GROUP HEALTH IN12 SURANCE COVERAGE.—Title XXVII of the Public Health

13 Service Act is amended—

14 (1) in section 2723(a)(1) (42 U.S.C. 300gg–

15 23(a)(1)), by inserting ‘‘and section 2724’’ after

16 ‘‘Subject to paragraph (2)’’; and

17 (2) by inserting after section 2723 the following

18 new section:

19 ‘‘SEC. 2724. STATE FLEXIBILITY IN APPLYING PATIENTS’

20 BILL OF RIGHTS, PATIENT ACCESS TO INFOR21 MATION, AND ACCOUNTABILITY REQUIRE22 MENTS.

23 ‘‘(a) IN GENERAL.—The provisions of section 731A

24 of the Employee Retirement Income Security Act of 1974,
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1 apply to the requirements of section 2707 (relating to pa2 tients’ bill of rights), section 2708 (relating to access to

3 information), and (only with respect to group health plans

4 as applied under section 2721(b)) section 2709 (relating

5 to accountability) in the same manner as such provisions

6 apply to comparable requirements with respect to health

7 insurance coverage provided in connection with a group

8 health plan.

9 ‘‘(b) RELATIONSHIP TO GROUP HEALTH PLAN RE10 QUIREMENTS.—Nothing in this section shall be construed

11 to affect or modify the provisions of section 514 of the

12 Employee Retirement Income Security Act of 1974 with

13 respect to group health plans (insofar as it provides bene14 fits other than in the form of health insurance coverage).’’.

15 (b) INDIVIDUAL HEALTH INSURANCE COVERAGE.—

16 Title XXVII of the Public Health Service Act is

17 amended—

18 (1) in section 2762(a) (42 U.S.C. 300gg–

19 62(a)(1)), by inserting ‘‘and section 2762A’’ after

20 ‘‘Subject to subsection (b)’’; and

21 (2) by inserting after section 2762 the following

22 new section:
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1 ‘‘SEC. 2762A. STATE FLEXIBILITY IN APPLYING PATIENTS’

2 BILL OF RIGHTS, PATIENT ACCESS TO INFOR3 MATION, AND ACCOUNTABILITY REQUIRE4 MENTS.

5 ‘‘The provisions of section 2724 apply in relation to

6 the requirements of section 2753 (relating to patients’ bill

7 of rights), section 2754 (relating to access to information),

8 and section 2755 (relating to accountability) with respect

9 to individual health insurance coverage in the same man10 ner as those provisions apply in relation to the require11 ments of sections 2707, 2708, and 2709, respectively, as

12 applied to group health plans under section 2721(b).’’.

13 Subtitle E—Effective Dates; Coordi14 nation in Implementation; Mis15 cellaneous Provisions

16 SEC. 151. EFFECTIVE DATES.

17 (a) GROUP HEALTH COVERAGE.—

18 (1) IN GENERAL.—Subject to paragraph (2)

19 and subsection (d), the amendments made by sec20 tions 101, 102(a), 103, 111, 112(a), 113, 121,

21 122(a), and 123 shall apply with respect to group

22 health plans, and health insurance coverage offered

23 in connection with group health plans, for plan years

24 beginning on or after January 1, 2002 (in this sec25 tion referred to as the ‘‘general effective date’’) and
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1 also shall apply to portions of plan years occurring

2 on and after such date.

3 (2) TREATMENT OF COLLECTIVE BARGAINING

4 AGREEMENTS.—In the case of a group health plan

5 maintained pursuant to one or more collective bar6 gaining agreements between employee representa7 tives and one or more employers ratified before the

8 date of the enactment of this Act, the amendments

9 made by the provisions referred to in paragraph (1)

10 shall not apply to plan years beginning before the

11 later of—

12 (A) the date on which the last collective

13 bargaining agreements relating to the plan ter14 minates (determined without regard to any ex15 tension thereof agreed to after the date of the

16 enactment of this Act); or

17 (B) the general effective date.

18 For purposes of subparagraph (A), any plan amend19 ment made pursuant to a collective bargaining

20 agreement relating to the plan which amends the

21 plan solely to conform to any requirement added by

22 this title shall not be treated as a termination of

23 such collective bargaining agreement.

24 (b) INDIVIDUAL HEALTH INSURANCE COVERAGE.—

25 Subject to subsection (d), the amendments made by sec-
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1 tion 102(b), 112(b), and 122(b) shall apply with respect

2 to individual health insurance coverage offered, sold,

3 issued, renewed, in effect, or operated in the individual

4 market on or after the general effective date.

5 (c) TREATMENT OF RELIGIOUS NONMEDICAL PRO6 VIDERS.—

7 (1) IN GENERAL.—Nothing in this Act (or the

8 amendments made thereby) shall be construed to—

9 (A) restrict or limit the right of group

10 health plans, and of health insurance issuers of11 fering health insurance coverage, to include as

12 providers religious nonmedical providers;

13 (B) require such plans or issuers to—

14 (i) utilize medically based eligibility

15 standards or criteria in deciding provider

16 status of religious nonmedical providers;

17 (ii) use medical professionals or cri18 teria to decide patient access to religious

19 nonmedical providers;

20 (iii) utilize medical professionals or

21 criteria in making decisions in internal or

22 external appeals regarding coverage for

23 care by religious nonmedical providers; or

24 (iv) compel a participant or bene25 ficiary to undergo a medical examination
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1 or test as a condition of receiving health

2 insurance coverage for treatment by a reli3 gious nonmedical provider; or

4 (C) require such plans or issuers to ex5 clude religious nonmedical providers because

6 they do not provide medical or other required

7 data, if such data is inconsistent with the reli8 gious nonmedical treatment or nursing care

9 provided by the provider.

10 (2) RELIGIOUS NONMEDICAL PROVIDER.—For

11 purposes of this subsection, the term ‘‘religious non12 medical provider’’ means a provider who provides no

13 medical care but who provides only religious non14 medical treatment or religious nonmedical nursing

15 care.

16 (d) TRANSITION FOR NOTICE REQUIREMENT.—The

17 disclosure of information required under the amendments

18 made by subtitle B of this title shall first be provided pur19 suant to—

20 (1) subsection (a) with respect to a group

21 health plan that is maintained as of the general ef22 fective date, not later than 30 days before the begin23 ning of the first plan year to which the amendments

24 made by such subtitle apply in connection with the

25 plan under such subsection; or
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1 (2) subsection (b) with respect to an individual

2 health insurance coverage that is in effect as of the

3 general effective date, not later than 30 days before

4 the first date as of which the amendments made by

5 such subtitle apply to the coverage under such sub6 section.

7 (e) CONSTRUCTION.—In applying section 731(a) of

8 the Employee Retirement Income Security Act of 1974

9 and sections 2723(a) and 2762 of the Public Health Serv10 ice Act, a State law that provides for equal access to, and

11 availability of, all categories of licensed health care pro12 viders and services shall not be treated as preventing the

13 application of any requirement of either such Act.

14 (f) COVERAGE OF LIMITED SCOPE PLANS.—Section

15 2791(c)(2)(A) of the Public Health Service Act (42 U.S.C.

16 300gg–91(c)(2)(A)) and section 733(c)(2)(A) of the Em17 ployee Retirement Income Security Act of 1974 (29

18 U.S.C. 1186(c)(2)(A)) shall be deemed not to apply for

19 purposes of applying the requirements imposed by the

20 amendments made by this title.

21 SEC. 152. REGULATIONS; COORDINATION.

22 (a) AUTHORITY.—The Secretaries of Health and

23 Human Services, Labor, and the Treasury shall issue such

24 regulations as may be necessary or appropriate to carry
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1 out the amendments made by this title before the effective

2 date thereof.

3 (b) COORDINATION IN IMPLEMENTATION.—The Sec4 retary of Labor, the Secretary of Health and Human Serv5 ices, and the Secretary of the Treasury shall ensure,

6 through the execution of an interagency memorandum of

7 understanding among such Secretaries, that—

8 (1) regulations, rulings, and interpretations

9 issued by such Secretaries relating to the same mat10 ter over which such Secretaries have responsibility

11 under the amendments made by this title are admin12 istered so as to have the same effect at all times;

13 and

14 (2) coordination of policies relating to enforcing

15 the same requirements through such Secretaries in

16 order to have a coordinated enforcement strategy

17 that avoids duplication of enforcement efforts and

18 assigns priorities in enforcement.

19 (c) USE OF INTERIM FINAL RULES.—Such Secre20 taries may promulgate any interim final rules as the Sec21 retaries determine are appropriate to carry out this title.

22 (d) LIMITATION ON ENFORCEMENT ACTIONS.—No

23 enforcement action shall be taken, pursuant to the amend24 ments made by this title, against a group health plan or

25 health insurance issuer with respect to a violation of a re-
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1 quirement imposed by such amendments before the date

2 of issuance of regulations issued in connection with such

3 requirement, if the plan or issuer has sought to comply

4 in good faith with such requirement.

5 SEC. 153. NO BENEFIT REQUIREMENTS.

6 Nothing in the amendments made by this title shall

7 be construed to require a group health plan or a health

8 insurance issuer offering health insurance coverage to in9 clude specific items and services under the terms of such

10 a plan or coverage, other than those provided under the

11 terms and conditions of such plan or coverage.

12 SEC. 154. SEVERABILITY.

13 If any provision of this title, an amendment made by

14 this title, or the application of such provision or amend15 ment to any person or circumstance is held to be unconsti16 tutional, the remainder of this title, the amendments made

17 by this title, and the application of the provisions of such

18 to any person or circumstance shall not be affected there19 by.

20 TITLE II—REMEDIES

21 SEC. 201. AVAILABILITY OF COURT REMEDIES.

22 (a) CAUSE OF ACTION RELATING TO MEDICALLY RE23 VIEWABLE DETERMINATIONS AND TIMELY REVIEW OF

24 CLAIMS.—Section 502 of the Employee Retirement In-
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1 come Security Act of 1974 (29 U.S.C. 1132) is

2 amended—

3 (1) in subsection (a)(1), by striking ‘‘or’’ at the

4 end of subparagraph (A), by striking ‘‘plan;’’ in sub5 paragraph (B) and inserting ‘‘plan, or’’, and by add6 ing after subparagraph (B) the following new sub7 paragraph:

8 ‘‘(C) in the case of a group health plan, for

9 the relief provided for in subsection (n) of this

10 section;’’; and

11 (2) by adding at the end the following:

12 ‘‘(n) CAUSE OF ACTION RELATING TO MEDICALLY

13 REVIEWABLE DETERMINATIONS AND TIMELY REVIEW OF

14 CLAIMS.—

15 ‘‘(1) IN GENERAL.—In any case in which—

16 ‘‘(A) a person who is a designated health

17 care decision-maker of a group health plan

18 breaches the covenant of good faith and fair

19 dealing in—

20 ‘‘(i) making a medically reviewable de21 termination regarding a benefit for items

22 or services under the plan, or

23 ‘‘(ii) failing to ensure that—

24 ‘‘(I) any denial of claim for bene25 fits, or
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1 ‘‘(II) any decision by the plan on

2 a request, made by a participant or

3 beneficiary under section 503C or

4 503D, for a reversal of an earlier de5 cision of the plan,

6 is made and issued to the participant or

7 beneficiary (in such form and manner as

8 may be prescribed in regulations of the

9 Secretary) before the end of the applicable

10 period specified in section 503B, 503C, or

11 503D, and

12 ‘‘(B) such breach is the proximate cause of

13 substantial harm to, or wrongful death of, the

14 participant or beneficiary,

15 such person shall be liable to the participant or ben16 eficiary (or the estate of such participant or bene17 ficiary) for economic and noneconomic damages in

18 connection with such breach and such substantial

19 harm or death (subject to paragraphs (5) and (6)).

20 ‘‘(2) DESIGNATED HEALTH CARE DECISION21 MAKER.—

22 ‘‘(A) IN GENERAL.—A group health plan

23 shall name a designated health care decision24 maker for purposes of paragraph (1) with re-
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1 spect to any benefits that are not provided

2 through group health insurance coverage.

3 ‘‘(B) DEFINITION.—For purposes of this

4 subsection, the term ‘designated health care de5 cision-maker’ means a person who—

6 ‘‘(i) is named in the plan as the des7 ignated health care decision-maker,

8 ‘‘(ii) agrees in writing to accept ap9 pointment as a designated health care deci10 sion-maker,

11 ‘‘(iii) is any of the following:

12 ‘‘(I) the plan sponsor,

13 ‘‘(II) a health insurance issuer,

14 or

15 ‘‘(III) any other person who can

16 satisfy requirements set forth in regu17 lations promulgated by the Secretary,

18 including the abilities specified in sub19 paragraph (C), and

20 ‘‘(iv) is not the treating physician or

21 other health care professional in the case

22 involved.

23 ‘‘(C) ABILITIES.—The abilities specified in

24 this subparagraph are the abilities to—
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1 ‘‘(i) carry out the responsibilities set

2 forth in the plan,

3 ‘‘(ii) carry out the applicable require4 ments of this subsection, and

5 ‘‘(iii) meet other applicable require6 ments, including any financial obligation

7 for liability under this subsection.

8 ‘‘(D) GROUP HEALTH INSURANCE COV9 ERAGE.—With respect to benefits provided

10 through group health insurance coverage, the

11 health insurance issuer providing the group

12 health insurance coverage shall be deemed the

13 designated health care decision-maker of the

14 plan.

15 ‘‘(E) ABSENCE OF NAMED DESIGNATED

16 HEALTH CARE DECISION-MAKER.—In any case

17 in which a designated health care decision18 maker is not named in the plan with respect to

19 benefits that are not provided through group

20 health insurance coverage, the plan sponsor

21 shall be treated as the designated health care

22 decision-maker for purposes of liability under

23 this section with respect to such benefits.

24 ‘‘(3) DEFINITIONS.—For purposes of this

25 section—
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1 ‘‘(A) MEDICALLY REVIEWABLE DETER2 MINATION.—The term ‘medically reviewable de3 termination’ means a determination described

4 in section 503D(d)(2).

5 ‘‘(B) SUBSTANTIAL HARM.—The term

6 ‘substantial harm’ means loss of life, loss or

7 significant impairment of limb, bodily, or men8 tal function, significant disfigurement, or severe

9 and chronic pain.

10 ‘‘(C) CLAIM FOR BENEFITS; DENIAL.—The

11 terms ‘claim for benefits’ and ‘denial of a claim

12 for benefits’, in connection with a group health

13 plan or health insurance coverage, have the

14 meanings provided such terms in section

15 503B(e).

16 ‘‘(D) TERMS AND CONDITIONS.—The term

17 ‘terms and conditions’ includes, with respect to

18 a group health plan or health insurance cov19 erage, requirements imposed under section 714

20 and subpart C of part 7.

21 ‘‘(E) GROUP HEALTH PLAN AND OTHER

22 RELATED TERMS.—The provisions of sections

23 732(d) and 733 apply for purposes of this sub24 section in the same manner as they apply for

25 purposes of part 7, except that the term ‘group
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1 health plan’ includes a group health plan (as

2 defined in section 607(1)).

3 ‘‘(F) ECONOMIC AND NONECONOMIC DAM4 AGES.—The terms ‘economic damages’ and

5 ‘noneconomic damages’ do not include punitive

6 damages.

7 ‘‘(4) REQUIREMENT OF EXHAUSTION OF AD8 MINISTRATIVE REMEDIES.—

9 ‘‘(A) IN GENERAL.—In the case of a cause

10 of action described in paragraph (1)(A)(i),

11 paragraph (1) applies only if all remedies under

12 sections 503C and 503D with respect to such

13 cause of action have been exhausted.

14 ‘‘(B) EXTERNAL REVIEW REQUIRED

15 WHERE AVAILABLE.—For purposes of subpara16 graph (A), all remedies described in subpara17 graph (A) shall be deemed not to be exhausted

18 until such remedies under section 503D (to the

19 extent they are available) have been elected and

20 are exhausted by issuance of a final determina21 tion by a qualified external review entity or an

22 independent medical reviewer under such sec23 tion.

24 ‘‘(C) RECEIPT OF BENEFITS DURING AP25 PEALS PROCESS.—Receipt by the participant or
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1 beneficiary of the benefits involved in the claim

2 for benefits during the pendency of any admin3 istrative processes referred to in subparagraph

4 (A) or of any action commenced under this

5 subsection—

6 ‘‘(i) shall not preclude continuation of

7 all such administrative processes to their

8 conclusion if so moved by any party, and

9 ‘‘(ii) shall not preclude any liability

10 under subsection (a)(1)(C) and this sub11 section in connection with such claim.

12 The court in any action commenced under this

13 subsection shall take into account any receipt of

14 benefits during such administrative processes or

15 such action in determining the amount of the

16 damages awarded.

17 ‘‘(D) CONSIDERATION OF ADMINISTRATIVE

18 DETERMINATIONS.—Any determinations made

19 under section 503C or 503D regarding matters

20 before the court in an action under this section

21 shall be given due consideration by the court in

22 such action.

23 ‘‘(5) LIMITATIONS ON RECOVERY OF DAM24 AGES.—
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1 ‘‘(A) MAXIMUM AWARD OF NONECONOMIC

2 DAMAGES.—The aggregate amount of liability

3 for noneconomic damages in an action under

4 paragraph (1) may not exceed $500,000.

5 ‘‘(B) INCREASE IN AMOUNT.—The amount

6 referred to in subparagraph (A) shall be in7 creased or decreased, for each calendar year

8 that ends after December 31, 2001, by the

9 same percentage as the percentage by which the

10 Consumer Price Index for All Urban Con11 sumers (United States city average), published

12 by the Bureau of Labor Statistics, for Sep13 tember of the preceding calendar year has in14 creased or decreased from the such Index for

15 September of 2001.

16 ‘‘(6) PROHIBITION OF AWARD OF PUNITIVE

17 DAMAGES.—

18 ‘‘(A) GENERAL RULE.—Except as provided

19 in this paragraph, nothing in this subsection

20 shall be construed as authorizing a cause of ac21 tion for punitive, exemplary, or similar dam22 ages.

23 ‘‘(B) EXCEPTION.—In addition other dam24 ages authorized under paragraph (1), punitive

25 damages are authorized in any case described
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1 in such paragraph in which such other damages

2 are authorized and the plaintiff establishes by

3 clear and convincing evidence that conduct car4 ried out by the defendant with willful or wanton

5 disregard for the rights or safety of others was

6 the proximate cause of the substantial harm

7 that is the subject of the action.

8 ‘‘(C) LIMITATION ON AMOUNT.—

9 ‘‘(i) IN GENERAL.—The aggregate

10 amount of liability for punitive damages in

11 an action under paragraph (1) may not ex12 ceed $5,000,000.

13 ‘‘(ii) INCREASE IN AMOUNT.—The

14 amount referred to in clause (i) shall be in15 creased or decreased, for each calendar

16 year that ends after December 31, 2001,

17 by the same percentage as the percentage

18 by which the Consumer Price Index for All

19 Urban Consumers (United States city av20 erage), published by the Bureau of Labor

21 Statistics, for September of the preceding

22 calendar year has increased or decreased

23 from the such Index for September of

24 2001.
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1 ‘‘(D) NO PUNITIVE DAMAGES WHERE DE2 FENDANT’S POSITION PREVIOUSLY SUPPORTED

3 BY MEDICAL REVIEW PANEL UPON EXTERNAL

4 REVIEW.—In any case in which the court finds

5 the defendant to be liable in an action under

6 this subsection, to the extent that—

7 ‘‘(i) such liability is based on a find8 ing by the court of a particular breach de9 scribed in paragraph (1), and

10 ‘‘(ii) such finding is contrary to a de11 termination by a medical review panel in a

12 decision previously rendered under section

13 503D with respect to such defendant,

14 the defendant shall not be liable for punitive

15 damages under this subsection in connection

16 with such breach.

17 ‘‘(7) LIMITATION OF ACTION.—Paragraph (1)

18 shall not apply in connection with any action com19 menced after 2 years after the later of—

20 ‘‘(A) the date on which the plaintiff first

21 knew, or reasonably should have known, of the

22 personal injury or death resulting from the fail23 ure described in paragraph (1), or

24 ‘‘(B) the date as of which the requirements

25 of paragraph (4), if applicable, are first met.
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1 ‘‘(8) PURCHASE OF INSURANCE TO COVER LI2 ABILITY.—Nothing in section 410 shall be construed

3 to preclude the purchase by a group health plan of

4 insurance to cover any liability or losses arising

5 under a cause of action under subsection (a)(1)(C)

6 and this subsection.

7 ‘‘(9) EXCLUSION OF DIRECTED RECORD8 KEEPERS.—

9 ‘‘(A) IN GENERAL.—Subject to subpara10 graph (C), paragraph (1) shall not apply with

11 respect to a directed recordkeeper in connection

12 with a group health plan.

13 ‘‘(B) DIRECTED RECORDKEEPER.—For

14 purposes of this paragraph, the term ‘directed

15 recordkeeper’ means, in connection with a

16 group health plan, a person engaged in directed

17 recordkeeping activities pursuant to the specific

18 instructions of the plan or the employer or

19 other plan sponsor, including the distribution of

20 enrollment information and distribution of dis21 closure materials under this title and whose du22 ties do not include making decisions on claims

23 for benefits.

24 ‘‘(C) LIMITATION.—Subparagraph (A)

25 does not apply in connection with any directed
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1 recordkeeper to the extent that the directed rec2 ordkeeper fails to follow the specific instruction

3 of the plan or the employer or other plan spon4 sor.

5 ‘‘(10) CONSTRUCTION.—Nothing in this sub6 section shall be construed as authorizing a cause of

7 action for the failure to provide an item or service

8 which is not covered under the group health plan in9 volved.

10 ‘‘(11) APPLICABILITY OF STATE LAW.—No pro11 vision of State law (as defined in section 514(c)(1))

12 relating to the regulation of quality of care shall be

13 treated as superseded, preempted, or modified by

14 reason of the provisions of subsection (a)(1)(C) and

15 this subsection, nor shall anything in this subsection

16 be construed to supersede, preempt, or modify sec17 tion 514 with respect to group health plans or the

18 preemptive effect of this section or section 503D

19 with respect to such plans.

20 ‘‘(12) LIMITATION ON CLASS ACTION LITIGA21 TION.—A claim or cause of action under this sub22 section may not be maintained as a class action.’’.

23 (b) EXPANDED REMEDIES FOR EXISTING CAUSES OF

24 ACTION.—
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1 (1) IN GENERAL.—Section 502 of such Act (as

2 amended by subsection (a)) is amended further—

3 (A) in subsection (a)(1)(B), by striking

4 ‘‘or’’ before ‘‘to clarify’’ and by striking ‘‘plan;’’

5 and inserting ‘‘plan, or, in the case of a group

6 health plan, for the additional relief provided in

7 subsection (o);’’; and

8 (B) by adding after subsection (n) the fol9 lowing new subsection:

10 ‘‘(o) EXPANDED REMEDIES RELATING TO GROUP

11 HEALTH PLAN DETERMINATIONS THAT ARE NOT MEDI12 CALLY REVIEWABLE.—In the case of any determination

13 under a group health plan constituting a denial of a claim

14 for benefits by a participant or beneficiary under the plan

15 which is not a medically reviewable determination, if such

16 determination is the proximate cause of substantial harm

17 to, or wrongful death of, the participant or beneficiary,

18 the relief for which the civil action may be brought under

19 subsection (a)(1)(B) shall include liability of the des20 ignated health care decision-maker of the plan for eco21 nomic and noneconomic damages in connection with such

22 determination and such substantial harm or death, except

23 that the aggregate amount of such liability for non24 economic damages may not exceed the maximum amount

25 allowable under subsection (n)(5).’’.
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1 (2) SPECIAL RULE.—Nothing in the amend2 ment made by paragraph (1) shall affect the stand3 ard of review applicable under section 502(a)(1)(B)

4 of the Employee Retirement Income Security Act of

5 1974 (29 U.S.C. 1132(a)(1)(B)).

6 (c) EFFECTIVE DATE.—The amendments made by

7 this section shall apply to acts and omissions (from which

8 a cause of action arises) occurring on or after the date

9 of the enactment of this Act.

10 SEC. 202. SEVERABILITY.

11 If any provision of this title, an amendment made by

12 this title, or the application of such provision or amend13 ment to any person or circumstance is held to be unconsti14 tutional, the remainder of this title, the amendments made

15 by this title, and the application of the provisions of such

16 to any person or circumstance shall not be affected there17 by.

18 TITLE III—HEALTH CARE COV19 ERAGE ACCESS TAX INCEN20 TIVES

21 SEC. 301. EXPANDED AVAILABILITY OF MEDICAL SAVINGS

22 ACCOUNTS.

23 (a) REPEAL OF LIMITATIONS ON NUMBER OF MED24 ICAL SAVINGS ACCOUNTS.—
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1 (1) IN GENERAL.—Subsections (i) and (j) of

2 section 220 of the Internal Revenue Code of 1986

3 are hereby repealed.

4 (2) CONFORMING AMENDMENTS.—

5 (A) Paragraph (1) of section 220(c) of

6 such Code is amended by striking subparagraph

7 (D).

8 (B) Section 138 of such Code is amended

9 by striking subsection (f).

10 (b) AVAILABILITY NOT LIMITED TO ACCOUNTS FOR

11 EMPLOYEES OF SMALL EMPLOYERS AND SELF-EM12 PLOYED INDIVIDUALS.—

13 (1) IN GENERAL.—Section 220(c)(1)(A) of such

14 Code (relating to eligible individual) is amended to

15 read as follows:

16 ‘‘(A) IN GENERAL.—The term ‘eligible in17 dividual’ means, with respect to any month, any

18 individual if—

19 ‘‘(i) such individual is covered under a

20 high deductible health plan as of the 1st

21 day of such month, and

22 ‘‘(ii) such individual is not, while cov23 ered under a high deductible health plan,

24 covered under any health plan—
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1 ‘‘(I) which is not a high deduct2 ible health plan, and

3 ‘‘(II) which provides coverage for

4 any benefit which is covered under the

5 high deductible health plan.’’.

6 (2) CONFORMING AMENDMENTS.—

7 (A) Section 220(c)(1) of such Code is

8 amended by striking subparagraph (C).

9 (B) Section 220(c) of such Code is amend10 ed by striking paragraph (4) (defining small

11 employer) and by redesignating paragraph (5)

12 as paragraph (4).

13 (C) Section 220(b) of such Code is amend14 ed by striking paragraph (4) (relating to deduc15 tion limited by compensation) and by redesig16 nating paragraphs (5), (6), and (7) as para17 graphs (4), (5), and (6), respectively.

18 (c) INCREASE IN AMOUNT OF DEDUCTION ALLOWED

19 FOR CONTRIBUTIONS TO MEDICAL SAVINGS ACCOUNTS.—

20 (1) IN GENERAL.—Paragraph (2) of section

21 220(b) of such Code is amended to read as follows:

22 ‘‘(2) MONTHLY LIMITATION.—The monthly limitation for any month is the amount equal to 1 23 ⁄12 of

24 the annual deductible (as of the first day of such
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1 month) of the individual’s coverage under the high

2 deductible health plan.’’.

3 (2) CONFORMING AMENDMENT.—Clause (ii) of

4 section 220(d)(1)(A) of such Code is amended by

5 striking ‘‘75 percent of’’.

6 (d) BOTH EMPLOYERS AND EMPLOYEES MAY CON7 TRIBUTE TO MEDICAL SAVINGS ACCOUNTS.—Paragraph

8 (4) of section 220(b) of such Code (as redesignated by

9 subsection (b)(2)(C)) is amended to read as follows:

10 ‘‘(4) COORDINATION WITH EXCLUSION FOR EM11 PLOYER CONTRIBUTIONS.—The limitation which

12 would (but for this paragraph) apply under this sub13 section to the taxpayer for any taxable year shall be

14 reduced (but not below zero) by the amount which

15 would (but for section 106(b)) be includible in the

16 taxpayer’s gross income for such taxable year.’’.

17 (e) REDUCTION OF PERMITTED DEDUCTIBLES

18 UNDER HIGH DEDUCTIBLE HEALTH PLANS.—

19 (1) IN GENERAL.—Subparagraph (A) of section

20 220(c)(2) of such Code (defining high deductible

21 health plan) is amended—

22 (A) by striking ‘‘$1,500’’ in clause (i) and

23 inserting ‘‘$1,000’’; and

24 (B) by striking ‘‘$3,000’’ in clause (ii) and

25 inserting ‘‘$2,000’’.
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1 (2) CONFORMING AMENDMENT.—Subsection (g)

2 of section 220 of such Code is amended to read as

3 follows:

4 ‘‘(g) COST-OF-LIVING ADJUSTMENT.—

5 ‘‘(1) IN GENERAL.—In the case of any taxable

6 year beginning in a calendar year after 1998, each

7 dollar amount in subsection (c)(2) shall be increased

8 by an amount equal to—

9 ‘‘(A) such dollar amount, multiplied by

10 ‘‘(B) the cost-of-living adjustment deter11 mined under section 1(f)(3) for the calendar

12 year in which such taxable year begins by sub13 stituting ‘calendar year 1997’ for ‘calendar year

14 1992’ in subparagraph (B) thereof.

15 ‘‘(2) SPECIAL RULES.—In the case of the

16 $1,000 amount in subsection (c)(2)(A)(i) and the

17 $2,000 amount in subsection (c)(2)(A)(ii), para18 graph (1)(B) shall be applied by substituting ‘cal19 endar year 1999’ for ‘calendar year 1997’.

20 ‘‘(3) ROUNDING.—If any increase under para21 graph (1) or (2) is not a multiple of $50, such in22 crease shall be rounded to the nearest multiple of

23 $50.’’.
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1 (f) MEDICAL SAVINGS ACCOUNTS MAY BE OFFERED

2 UNDER CAFETERIA PLANS.—Subsection (f) of section

3 125 of such Code is amended by striking ‘‘106(b),’’.

4 (g) EFFECTIVE DATE.—The amendments made by

5 this section shall apply to taxable years beginning after

6 December 31, 2000.

7 (h) GAO STUDY.—Not later than 1 year after the

8 date of the enactment of this Act, the Comptroller General

9 of the United States shall prepare and submit a report

10 to the Committee on Ways and Means of the House of

11 Representatives and the Committee on Finance of the

12 Senate on the impact of medical savings accounts on the

13 cost of conventional insurance (especially in those areas

14 where there are higher numbers of such accounts) and on

15 adverse selection and health care costs.

16 SEC. 302. DEDUCTION FOR 100 PERCENT OF HEALTH IN17 SURANCE COSTS OF SELF-EMPLOYED INDI18 VIDUALS.

19 (a) IN GENERAL.—Paragraph (1) of section 162(l)

20 of the Internal Revenue Code of 1986 is amended to read

21 as follows:

22 ‘‘(1) ALLOWANCE OF DEDUCTION.—In the case

23 of an individual who is an employee within the

24 meaning of section 401(c)(1), there shall be allowed

25 as a deduction under this section an amount equal
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1 to 100 percent of the amount paid during the tax2 able year for insurance which constitutes medical

3 care for the taxpayer and the taxpayer’s spouse and

4 dependents.’’.

5 (b) EFFECTIVE DATE.—The amendment made by

6 this section shall apply to taxable years beginning after

7 December 31, 2000.

8 TITLE IV—HEALTH CARE

9 PAPERWORK

10 SEC. 401. HEALTH CARE PAPERWORK SIMPLIFICATION.

11 (a) ESTABLISHMENT OF PANEL.—

12 (1) ESTABLISHMENT.—There is established a

13 panel to be known as the Health Care Panel to De14 vise a Uniform Explanation of Benefits (in this sec15 tion referred to as the ‘‘Panel’’).

16 (2) DUTIES OF PANEL.—

17 (A) IN GENERAL.—The Panel shall devise

18 a single form for use by third-party health care

19 payers for the remittance of claims to providers.

20 (B) DEFINITION.—For purposes of this

21 section, the term ‘‘third-party health care

22 payer’’ means any entity that contractually

23 pays health care bills for an individual.

24 (3) MEMBERSHIP.—
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1 (A) SIZE AND COMPOSITION.—The Sec2 retary of Health and Human Services, in con3 sultation with the Majority Leader of the Sen4 ate and the Speaker of the House of Represent5 atives, shall determine the number of members

6 and the composition of the Panel. Such Panel

7 shall include equal numbers of representatives

8 of private insurance organizations, consumer

9 groups, State insurance commissioners, State

10 medical societies, State hospital associations,

11 and State medical specialty societies.

12 (B) TERMS OF APPOINTMENT.—The mem13 bers of the Panel shall serve for the life of the

14 Panel.

15 (C) VACANCIES.—A vacancy in the Panel

16 shall not affect the power of the remaining

17 members to execute the duties of the Panel, but

18 any such vacancy shall be filled in the same

19 manner in which the original appointment was

20 made.

21 (4) PROCEDURES.—

22 (A) MEETINGS.—The Panel shall meet at

23 the call of a majority of its members.
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1 (B) FIRST MEETING.—The Panel shall

2 convene not later than 60 days after the date

3 of the enactment of this Act.

4 (C) QUORUM.—A quorum shall consist of

5 a majority of the members of the Panel.

6 (D) HEARINGS.—For the purpose of car7 rying out its duties, the Panel may hold such

8 hearings and undertake such other activities as

9 the Panel determines to be necessary to carry

10 out its duties.

11 (5) ADMINISTRATION.—

12 (A) COMPENSATION.—Except as provided

13 in subparagraph (B), members of the Panel

14 shall receive no additional pay, allowances, or

15 benefits by reason of their service on the Panel.

16 (B) TRAVEL EXPENSES AND PER DIEM.—

17 Each member of the Panel who is not an officer

18 or employee of the Federal Government shall

19 receive travel expenses and per diem in lieu of

20 subsistence in accordance with sections 5702

21 and 5703 of title 5, United States Code.

22 (C) CONTRACT AUTHORITY.—The Panel

23 may contract with and compensate government

24 and private agencies or persons for items and
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1 services, without regard to section 3709 of the

2 Revised Statutes (41 U.S.C. 5).

3 (D) USE OF MAILS.—The Panel may use

4 the United States mails in the same manner

5 and under the same conditions as Federal agen6 cies and shall, for purposes of the frank, be

7 considered a commission of Congress as de8 scribed in section 3215 of title 39, United

9 States Code.

10 (E) ADMINISTRATIVE SUPPORT SERV11 ICES.—Upon the request of the Panel, the Sec12 retary of Health and Human Services shall pro13 vide to the Panel on a reimbursable basis such

14 administrative support services as the Panel

15 may request.

16 (6) SUBMISSION OF FORM.—Not later than 2

17 years after the first meeting, the Panel shall submit

18 a form to the Secretary of Health and Human Serv19 ices for use by third-party health care payers.

20 (7) TERMINATION.—The Panel shall terminate

21 on the day after submitting its the form under para22 graph (6).

23 (b) REQUIREMENT FOR USE OF FORM BY THIRD24 PARTY CARE PAYERS.—A third-party health care payer

25 shall be required to use the form devised under subsection
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1 (a) for plan years beginning on or after 5 years following

2 the date of the enactment of this Act.

Æ