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[Congressional Bills 106th Congress]
[From the U.S. Government Publishing Office]
[S. 3057 Placed on Calendar Senate (PCS)]

                                                       Calendar No. 808
106th CONGRESS
  2d Session
                                S. 3057

To amend the Public Health Service Act, the Employee Retirement Income 
Security Act of 1974, and the Internal Revenue Code of 1986 to protect 
       consumers in managed care plans and other health coverage.

_______________________________________________________________________

                   IN THE SENATE OF THE UNITED STATES

                           September 15, 2000

  Mr. Kennedy (for himself and Mr. Daschle) introduced the following 
                  bill; which was read the first time

                           September 18, 2000

            Read the second time and placed on the calendar

_______________________________________________________________________

                                 A BILL

 
To amend the Public Health Service Act, the Employee Retirement Income 
Security Act of 1974, and the Internal Revenue Code of 1986 to protect 
       consumers in managed care plans and other health coverage.

    Be it enacted by the Senate and House of Representatives of the 
United States of America in Congress assembled,

SECTION 1. SHORT TITLE; TABLE OF CONTENTS.

    (a) Short Title.--This Act may be cited as the ``Patients' Bill of 
Rights Act''.
    (b) Table of Contents.--The table of contents of this Act is as 
follows:

Sec. 1. Short title; table of contents.
                    TITLE I--IMPROVING MANAGED CARE

                   Subtitle A--Grievance and Appeals

Sec. 101. Utilization review activities.
Sec. 102. Internal appeals procedures.
Sec. 103. External appeals procedures.
Sec. 104. Establishment of a grievance process.
                       Subtitle B--Access to Care

Sec. 111. Consumer choice option.
Sec. 112. Choice of health care professional.
Sec. 113. Access to emergency care.
Sec. 114. Access to specialty care.
Sec. 115. Access to obstetrical and gynecological care.
Sec. 116. Access to pediatric care.
Sec. 117. Continuity of care.
Sec. 118. Access to needed prescription drugs.
Sec. 119. Coverage for individuals participating in approved clinical 
                            trials.
                   Subtitle C--Access to Information

Sec. 121. Patient access to information.
         Subtitle D--Protecting the Doctor-Patient Relationship

Sec. 131. Prohibition of interference with certain medical 
                            communications.
Sec. 132. Prohibition of discrimination against providers based on 
                            licensure.
Sec. 133. Prohibition against improper incentive arrangements.
Sec. 134. Payment of claims.
Sec. 135. Protection for patient advocacy.
                        Subtitle E--Definitions

Sec. 151. Definitions.
Sec. 152. Preemption; State flexibility; construction.
Sec. 153. Exclusions.
Sec. 154. Coverage of limited scope plans.
Sec. 155. Regulations.
 TITLE II--APPLICATION OF QUALITY CARE STANDARDS TO GROUP HEALTH PLANS 
   AND HEALTH INSURANCE COVERAGE UNDER THE PUBLIC HEALTH SERVICE ACT

Sec. 201. Application to group health plans and group health insurance 
                            coverage.
Sec. 202. Application to individual health insurance coverage.
TITLE III--AMENDMENTS TO THE EMPLOYEE RETIREMENT INCOME SECURITY ACT OF 
                                  1974

Sec. 301. Application of patient protection standards to group health 
                            plans and group health insurance coverage 
                            under the Employee Retirement Income 
                            Security Act of 1974.
Sec. 302. ERISA preemption not to apply to certain actions involving 
                            health insurance policyholders.
Sec. 303. Limitations on actions.
TITLE IV--APPLICATION TO GROUP HEALTH PLANS UNDER THE INTERNAL REVENUE 
                              CODE OF 1986

Sec. 401. Amendments to the Internal Revenue Code of 1986.
        TITLE V--EFFECTIVE DATES; COORDINATION IN IMPLEMENTATION

Sec. 501. Effective dates.
Sec. 502. Coordination in implementation.
                   TITLE VI--MISCELLANEOUS PROVISIONS

Sec. 601. Health care paperwork simplification.
Sec. 602. No impact on social security trust fund.
Sec. 603. FMAP reduction for other than substantial noncompliance with 
                            medicaid State plan requirements.
Sec. 604. Customs user fees.

                    TITLE I--IMPROVING MANAGED CARE

                   Subtitle A--Grievance and Appeals

SEC. 101. UTILIZATION REVIEW ACTIVITIES.

    (a) Compliance With Requirements.--
            (1) In general.--A group health plan, and a health 
        insurance issuer that provides health insurance coverage, shall 
        conduct utilization review activities in connection with the 
        provision of benefits under such plan or coverage only in 
        accordance with a utilization review program that meets the 
        requirements of this section.
            (2) Use of outside agents.--Nothing in this section shall 
        be construed as preventing a group health plan or health 
        insurance issuer from arranging through a contract or otherwise 
        for persons or entities to conduct utilization review 
        activities on behalf of the plan or issuer, so long as such 
        activities are conducted in accordance with a utilization 
        review program that meets the requirements of this section.
            (3) Utilization review defined.--For purposes of this 
        section, the terms ``utilization review'' and ``utilization 
        review activities'' mean procedures used to monitor or evaluate 
        the use or coverage, clinical necessity, appropriateness, 
        efficacy, or efficiency of health care services, procedures or 
        settings, and includes prospective review, concurrent review, 
        second opinions, case management, discharge planning, or 
        retrospective review.
    (b) Written Policies and Criteria.--
            (1) Written policies.--A utilization review program shall 
        be conducted consistent with written policies and procedures 
        that govern all aspects of the program.
            (2) Use of written criteria.--
                    (A) In general.--Such a program shall utilize 
                written clinical review criteria developed with input 
                from a range of appropriate actively practicing health 
                care professionals, as determined by the plan, pursuant 
                to the program. Such criteria shall include written 
                clinical review criteria that are based on valid 
                clinical evidence where available and that are directed 
                specifically at meeting the needs of at-risk 
                populations and covered individuals with chronic 
                conditions or severe illnesses, including gender-
                specific criteria and pediatric-specific criteria where 
                available and appropriate.
                    (B) Continuing use of standards in retrospective 
                review.--If a health care service has been specifically 
                pre-authorized or approved for an enrollee under such a 
                program, the program shall not, pursuant to 
                retrospective review, revise or modify the specific 
                standards, criteria, or procedures used for the 
                utilization review for procedures, treatment, and 
                services delivered to the enrollee during the same 
                course of treatment.
                    (C) Review of sample of claims denials.--Such a 
                program shall provide for an evaluation of the clinical 
                appropriateness of at least a sample of denials of 
                claims for benefits.
    (c) Conduct of Program Activities.--
            (1) Administration by health care professionals.--A 
        utilization review program shall be administered by qualified 
        health care professionals who shall oversee review decisions.
            (2) Use of qualified, independent personnel.--
                    (A) In general.--A utilization review program shall 
                provide for the conduct of utilization review 
                activities only through personnel who are qualified and 
                have received appropriate training in the conduct of 
                such activities under the program.
                    (B) Prohibition of contingent compensation 
                arrangements.--Such a program shall not, with respect 
                to utilization review activities, permit or provide 
                compensation or anything of value to its employees, 
                agents, or contractors in a manner that encourages 
                denials of claims for benefits.
                    (C) Prohibition of conflicts.--Such a program shall 
                not permit a health care professional who is providing 
                health care services to an individual to perform 
                utilization review activities in connection with the 
                health care services being provided to the individual.
            (3) Accessibility of review.--Such a program shall provide 
        that appropriate personnel performing utilization review 
        activities under the program, including the utilization review 
        administrator, are reasonably accessible by toll-free telephone 
        during normal business hours to discuss patient care and allow 
        response to telephone requests, and that appropriate provision 
        is made to receive and respond promptly to calls received 
        during other hours.
            (4) Limits on frequency.--Such a program shall not provide 
        for the performance of utilization review activities with 
        respect to a class of services furnished to an individual more 
        frequently than is reasonably required to assess whether the 
        services under review are medically necessary or appropriate.
    (d) Deadline for Determinations.--
            (1) Prior authorization services.--
                    (A) In general.--Except as provided in paragraph 
                (2), in the case of a utilization review activity 
                involving the prior authorization of health care items 
                and services for an individual, the utilization review 
                program shall make a determination concerning such 
                authorization, and provide notice of the determination 
                to the individual or the individual's designee and the 
                individual's health care provider by telephone and in 
                printed form, as soon as possible in accordance with 
                the medical exigencies of the case, and in no event 
later than the deadline specified in subparagraph (B).
                    (B) Deadline.--
                            (i) In general.--Subject to clauses (ii) 
                        and (iii), the deadline specified in this 
                        subparagraph is 14 days after the date of 
                        receipt of the request for prior authorization.
                            (ii) Extension permitted where notice of 
                        additional information required.--If a 
                        utilization review program--
                                    (I) receives a request for a prior 
                                authorization;
                                    (II) determines that additional 
                                information is necessary to complete 
                                the review and make the determination 
                                on the request; and
                                    (III) notifies the requester, not 
                                later than five business days after the 
                                date of receiving the request, of the 
                                need for such specified additional 
                                information,
                        the deadline specified in this subparagraph is 
                        14 days after the date the program receives the 
                        specified additional information, but in no 
                        case later than 28 days after the date of 
                        receipt of the request for the prior 
                        authorization. This clause shall not apply if 
                        the deadline is specified in clause (iii).
                            (iii) Expedited cases.--In the case of a 
                        situation described in section 102(c)(1)(A), 
                        the deadline specified in this subparagraph is 
                        72 hours after the time of the request for 
                        prior authorization.
            (2) Ongoing care.--
                    (A) Concurrent review.--
                            (i) In general.--Subject to subparagraph 
                        (B), in the case of a concurrent review of 
                        ongoing care (including hospitalization), which 
                        results in a termination or reduction of such 
                        care, the plan must provide by telephone and in 
                        printed form notice of the concurrent review 
                        determination to the individual or the 
                        individual's designee and the individual's 
                        health care provider as soon as possible in 
                        accordance with the medical exigencies of the 
                        case, with sufficient time prior to the 
                        termination or reduction to allow for an appeal 
                        under section 102(c)(1)(A) to be completed 
                        before the termination or reduction takes 
                        effect.
                            (ii) Contents of notice.--Such notice shall 
                        include, with respect to ongoing health care 
                        items and services, the number of ongoing 
                        services approved, the new total of approved 
                        services, the date of onset of services, and 
                        the next review date, if any, as well as a 
                        statement of the individual's rights to further 
                        appeal.
                    (B) Exception.--Subparagraph (A) shall not be 
                interpreted as requiring plans or issuers to provide 
                coverage of care that would exceed the coverage 
                limitations for such care.
            (3) Previously provided services.--In the case of a 
        utilization review activity involving retrospective review of 
        health care services previously provided for an individual, the 
        utilization review program shall make a determination 
        concerning such services, and provide notice of the 
        determination to the individual or the individual's designee 
        and the individual's health care provider by telephone and in 
        printed form, within 30 days of the date of receipt of 
        information that is reasonably necessary to make such 
        determination, but in no case later than 60 days after the date 
        of receipt of the claim for benefits.
            (4) Failure to meet deadline.--In a case in which a group 
        health plan or health insurance issuer fails to make a 
        determination on a claim for benefit under paragraph (1), 
        (2)(A), or (3) by the applicable deadline established under the 
        respective paragraph, the failure shall be treated under this 
        subtitle as a denial of the claim as of the date of the 
        deadline.
            (5) Reference to special rules for emergency services, 
        maintenance care, and post-stabilization care.--For waiver of 
        prior authorization requirements in certain cases involving 
        emergency services and maintenance care and post-stabilization 
        care, see subsections (a)(1) and (b) of section 113, 
        respectively.
    (e) Notice of Denials of Claims for Benefits.--
            (1) In general.--Notice of a denial of claims for benefits 
        under a utilization review program shall be provided in printed 
        form and written in a manner calculated to be understood by the 
        participant, beneficiary, or enrollee and shall include--
                    (A) the reasons for the denial (including the 
                clinical rationale);
                    (B) instructions on how to initiate an appeal under 
                section 102; and
                    (C) notice of the availability, upon request of the 
                individual (or the individual's designee) of the 
                clinical review criteria relied upon to make such 
                denial.
            (2) Specification of any additional information.--Such a 
        notice shall also specify what (if any) additional necessary 
        information must be provided to, or obtained by, the person 
        making the denial in order to make a decision on such an 
        appeal.
    (f) Claim for Benefits and Denial of Claim for Benefits Defined.--
For purposes of this subtitle:
            (1) Claim for benefits.--The term ``claim for benefits'' 
        means any request for coverage (including authorization of 
        coverage), for eligibility, or for payment in whole or in part, 
        for an item or service under a group health plan or health 
        insurance coverage.
            (2) Denial of claim for benefits.--The term ``denial'' 
        means, with respect to a claim for benefits, means a denial, or 
        a failure to act on a timely basis upon, in whole or in part, 
        the claim for benefits and includes a failure to provide 
        benefits (including items and services) required to be provided 
        under this title.

SEC. 102. INTERNAL APPEALS PROCEDURES.

    (a) Right of Review.--
            (1) In general.--Each group health plan, and each health 
        insurance issuer offering health insurance coverage--
                    (A) shall provide adequate notice in writing to any 
                participant or beneficiary under such plan, or enrollee 
                under such coverage, whose claim for benefits under the 
                plan or coverage has been denied (within the meaning of 
                section 101(f)(2)), setting forth the specific reasons 
                for such denial of claim for benefits and rights to any 
                further review or appeal, written in a manner 
                calculated to be understood by the participant, 
                beneficiary, or enrollee; and
                    (B) shall afford such a participant, beneficiary, 
                or enrollee (and any provider or other person acting on 
                behalf of such an individual with the individual's 
                consent or without such consent if the individual is 
                medically unable to provide such consent) who is 
                dissatisfied with such a denial of claim for benefits a 
                reasonable opportunity (of not less than 180 days) to 
                request and obtain a full and fair review by a named 
                fiduciary (with respect to such plan) or named 
                appropriate individual (with respect to such coverage) 
                of the decision denying the claim.
            (2) Treatment of oral requests.--The request for review 
        under paragraph (1)(B) may be made orally, but, in the case of 
        an oral request, shall be followed by a request in writing.
    (b) Internal Review Process.--
            (1) Conduct of review.--
                    (A) In general.--A review of a denial of claim 
                under this section shall be made by an individual who--
                            (i) in a case involving medical judgment, 
                        shall be a physician or, in the case of limited 
                        scope coverage (as defined in subparagraph (B), 
                        shall be an appropriate specialist;
                            (ii) has been selected by the plan or 
                        issuer; and
                            (iii) did not make the initial denial in 
                        the internally appealable decision.
                    (B) Limited scope coverage defined.--For purposes 
                of subparagraph (A), the term ``limited scope 
                coverage'' means a group health plan or health 
                insurance coverage the only benefits under which are 
                for benefits described in section 2791(c)(2)(A) of the 
                Public Health Service Act (42 U.S.C. 300gg-91(c)(2)).
            (2) Time limits for internal reviews.--
                    (A) In general.--Having received such a request for 
                review of a denial of claim, the plan or issuer shall, 
                in accordance with the medical exigencies of the case 
                but not later than the deadline specified in 
                subparagraph (B), complete the review on the denial and 
                transmit to the participant, beneficiary, enrollee, or 
                other person involved a decision that affirms, 
                reverses, or modifies the denial. If the decision does 
                not reverse the denial, the plan or issuer shall 
                transmit, in printed form, a notice that sets forth the 
                grounds for such decision and that includes a 
                description of rights to any further appeal. Such 
                decision shall be treated as the final decision of the 
                plan. Failure to issue such a decision by such deadline 
                shall be treated as a final decision affirming the 
                denial of claim.
                    (B) Deadline.--
                            (i) In general.--Subject to clauses (ii) 
                        and (iii), the deadline specified in this 
                        subparagraph is 14 days after the date of 
                        receipt of the request for internal review.
                            (ii) Extension permitted where notice of 
                        additional information required.--If a group 
                        health plan or health insurance issuer--
                                    (I) receives a request for internal 
                                review;
                                    (II) determines that additional 
                                information is necessary to complete 
                                the review and make the determination 
                                on the request; and
                                    (III) notifies the requester, not 
                                later than five business days after the 
                                date of receiving the request, of the 
                                need for such specified additional 
                                information,
                        the deadline specified in this subparagraph is 
                        14 days after the date the plan or issuer 
                        receives the specified additional information, 
                        but in no case later than 28 days after the 
                        date of receipt of the request for the internal 
                        review. This clause shall not apply if the 
                        deadline is specified in clause (iii).
                            (iii) Expedited cases.--In the case of a 
                        situation described in subsection (c)(1)(A), 
                        the deadline specified in this subparagraph is 
                        72 hours after the time of the request for 
                        review.
    (c) Expedited Review Process.--
            (1) In general.--A group health plan, and a health 
        insurance issuer, shall establish procedures in writing for the 
        expedited consideration of requests for review under subsection 
        (b) in situations--
                    (A) in which the application of the normal 
                timeframe for making a determination could seriously 
                jeopardize the life or health of the participant, 
                beneficiary, or enrollee or such an individual's 
                ability to regain maximum function; or
                    (B) described in section 101(d)(2) (relating to 
                requests for continuation of ongoing care which would 
                otherwise be reduced or terminated).
            (2) Process.--Under such procedures--
                    (A) the request for expedited review may be 
                submitted orally or in writing by an individual or 
                provider who is otherwise entitled to request the 
                review;
                    (B) all necessary information, including the plan's 
                or issuer's decision, shall be transmitted between the 
                plan or issuer and the requester by telephone, 
                facsimile, or other similarly expeditious available 
                method; and
                    (C) the plan or issuer shall expedite the review in 
                the case of any of the situations described in 
                subparagraph (A) or (B) of paragraph (1).
            (3) Deadline for decision.--The decision on the expedited 
        review must be made and communicated to the parties as soon as 
        possible in accordance with the medical exigencies of the case, 
        and in no event later than 72 hours after the time of receipt 
        of the request for expedited review, except that in a case 
        described in paragraph (1)(B), the decision must be made before 
        the end of the approved period of care.
    (d) Waiver of Process.--A plan or issuer may waive its rights for 
an internal review under subsection (b). In such case the participant, 
beneficiary, or enrollee involved (and any designee or provider 
involved) shall be relieved of any obligation to complete the review 
involved and may, at the option of such participant, beneficiary, 
enrollee, designee, or provider, proceed directly to seek further 
appeal through any applicable external appeals process.

SEC. 103. EXTERNAL APPEALS PROCEDURES.

    (a) Right to External Appeal.--
            (1) In general.--A group health plan, and a health 
        insurance issuer offering health insurance coverage, shall 
        provide for an external appeals process that meets the 
        requirements of this section in the case of an externally 
        appealable decision described in paragraph (2), for which a 
        timely appeal is made either by the plan or issuer or by the 
        participant, beneficiary, or enrollee (and any provider or 
        other person acting on behalf of such an individual with the 
        individual's consent or without such consent if such an 
        individual is medically unable to provide such consent). The 
        appropriate Secretary shall establish standards to carry out 
        such requirements.
            (2) Externally appealable decision defined.--
                    (A) In general.--For purposes of this section, the 
                term ``externally appealable decision'' means a denial 
                of claim for benefits (as defined in section 
                101(f)(2))--
                            (i) that is based in whole or in part on a 
                        decision that the item or service is not 
                        medically necessary or appropriate or is 
                        investigational or experimental; or
                            (ii) in which the decision as to whether a 
                        benefit is covered involves a medical judgment.
                    (B) Inclusion.--Such term also includes a failure 
                to meet an applicable deadline for internal review 
                under section 102.
                    (C) Exclusions.--Such term does not include--
                            (i) specific exclusions or express 
                        limitations on the amount, duration, or scope 
                        of coverage that do not involve medical 
                        judgment; or
                            (ii) a decision regarding whether an 
                        individual is a participant, beneficiary, or 
                        enrollee under the plan or coverage.
            (3) Exhaustion of internal review process.--Except as 
        provided under section 102(d), a plan or issuer may condition 
        the use of an external appeal process in the case of an 
        externally appealable decision upon a final decision in an 
        internal review under section 102, but only if the decision is 
        made in a timely basis consistent with the deadlines provided 
        under this subtitle.
            (4) Filing fee requirement.--
                    (A) In general.--Subject to subparagraph (B), a 
                plan or issuer may condition the use of an external 
                appeal process upon payment to the plan or issuer of a 
                filing fee that does not exceed $25.
                    (B) Exception for indigency.--The plan or issuer 
                may not require payment of the filing fee in the case 
                of an individual participant, beneficiary, or enrollee 
                who certifies (in a form and manner specified in 
                guidelines established by the Secretary of Health and 
                Human Services) that the individual is indigent (as 
                defined in such guidelines).
                    (C) Refunding fee in case of successful appeals.--
                The plan or issuer shall refund payment of the filing 
                fee under this paragraph if the recommendation of the 
                external appeal entity is to reverse or modify the 
                denial of a claim for benefits which is the subject of 
                the appeal.
    (b) General Elements of External Appeals Process.--
            (1) Contract with qualified external appeal entity.--
                    (A) Contract requirement.--Except as provided in 
                subparagraph (D), the external appeal process under 
                this section of a plan or issuer shall be conducted 
                under a contract between the plan or issuer and one or 
                more qualified external appeal entities (as defined in 
                subsection (c)).
                    (B) Limitation on plan or issuer selection.--The 
                applicable authority shall implement procedures--
                            (i) to assure that the selection process 
                        among qualified external appeal entities will 
                        not create any incentives for external appeal 
                        entities to make a decision in a biased manner; 
                        and
                            (ii) for auditing a sample of decisions by 
                        such entities to assure that no such decisions 
                        are made in a biased manner.
                    (C) Other terms and conditions.--The terms and 
                conditions of a contract under this paragraph shall be 
                consistent with the standards the appropriate Secretary 
                shall establish to assure there is no real or apparent 
                conflict of interest in the conduct of external appeal 
                activities. Such contract shall provide that all costs 
                of the process (except those incurred by the 
                participant, beneficiary, enrollee, or treating 
                professional in support of the appeal) shall be paid by 
                the plan or issuer, and not by the participant, 
                beneficiary, or enrollee. The previous sentence shall 
                not be construed as applying to the imposition of a 
                filing fee under subsection (a)(4).
                    (D) State authority with respect qualified external 
                appeal entity for health insurance issuers.--With 
                respect to health insurance issuers offering health 
                insurance coverage in a State, the State may provide 
                for external review activities to be conducted by a 
                qualified external appeal entity that is designated by 
                the State or that is selected by the State in a manner 
                determined by the State to assure an unbiased 
                determination.
            (2) Elements of process.--An external appeal process shall 
        be conducted consistent with standards established by the 
        appropriate Secretary that include at least the following:
                    (A) Fair and de novo determination.--The process 
                shall provide for a fair, de novo determination. 
                However, nothing in this paragraph shall be construed 
                as providing for coverage of items and services for 
                which benefits are specifically excluded under the plan 
                or coverage.
                    (B) Standard of review.--An external appeal entity 
                shall determine whether the plan's or issuer's decision 
                is in accordance with the medical needs of the patient 
                involved (as determined by the entity) taking into 
                account, as of the time of the entity's determination, 
                the patient's medical condition and any relevant and 
                reliable evidence the entity obtains under subparagraph 
                (D). If the entity determines the decision is in 
                accordance with such needs, the entity shall affirm the 
                decision and to the extent that the entity determines 
                the decision is not in accordance with such needs, the 
                entity shall reverse or modify the decision.
                    (C) Consideration of plan or coverage 
                definitions.--In making such determination, the 
                external appeal entity shall consider (but not be bound 
                by) any language in the plan or coverage document 
                relating to the definitions of the terms medical 
                necessity, medically necessary or appropriate, or 
                experimental, investigational, or related terms.
                    (D) Evidence.--
                            (i) In general.--An external appeal entity 
                        shall include, among the evidence taken into 
                        consideration--
                                    (I) the decision made by the plan 
                                or issuer upon internal review under 
                                section 102 and any guidelines or 
                                standards used by the plan or issuer in 
                                reaching such decision;
                                    (II) any personal health and 
                                medical information supplied with 
                                respect to the individual whose denial 
                                of claim for benefits has been 
                                appealed; and
                                    (III) the opinion of the 
                                individual's treating physician or 
                                health care professional.
                            (ii) Additional evidence.--Such entity may 
                        also take into consideration but not be limited 
                        to the following evidence (to the extent 
                        available):
                                    (I) The results of studies that 
                                meet professionally recognized 
                                standards of validity and replicability 
                                or that have been published in peer-
                                reviewed journals.
                                    (II) The results of professional 
                                consensus conferences conducted or 
                                financed in whole or in part by one or 
                                more Government agencies.
                                    (III) Practice and treatment 
                                guidelines prepared or financed in 
                                whole or in part by Government 
                                agencies.
                                    (IV) Government-issued coverage and 
                                treatment policies.
                                    (V) Community standard of care and 
                                generally accepted principles of 
                                professional medical practice.
                                    (VI) To the extent that the entity 
                                determines it to be free of any 
                                conflict of interest, the opinions of 
                                individuals who are qualified as 
                                experts in one or more fields of health 
                                care which are directly related to the 
matters under appeal.
                                    (VII) To the extent that the entity 
                                determines it to be free of any 
                                conflict of interest, the results of 
                                peer reviews conducted by the plan or 
                                issuer involved.
                    (E) Determination concerning externally appealable 
                decisions.--A qualified external appeal entity shall 
                determine--
                            (i) whether a denial of claim for benefits 
                        is an externally appealable decision (within 
                        the meaning of subsection (a)(2));
                            (ii) whether an externally appealable 
                        decision involves an expedited appeal; and
                            (iii) for purposes of initiating an 
                        external review, whether the internal review 
                        process has been completed.
                    (F) Opportunity to submit evidence.--Each party to 
                an externally appealable decision may submit evidence 
                related to the issues in dispute.
                    (G) Provision of information.--The plan or issuer 
                involved shall provide timely access to the external 
                appeal entity to information and to provisions of the 
                plan or health insurance coverage relating to the 
                matter of the externally appealable decision, as 
                determined by the entity.
                    (H) Timely decisions.--A determination by the 
                external appeal entity on the decision shall--
                            (i) be made orally or in writing and, if it 
                        is made orally, shall be supplied to the 
                        parties in writing as soon as possible;
                            (ii) be made in accordance with the medical 
                        exigencies of the case involved, but in no 
                        event later than 21 days after the date (or, in 
                        the case of an expedited appeal, 72 hours after 
                        the time) of requesting an external appeal of 
                        the decision;
                            (iii) state, in layperson's language, the 
                        basis for the determination, including, if 
                        relevant, any basis in the terms or conditions 
                        of the plan or coverage; and
                            (iv) inform the participant, beneficiary, 
                        or enrollee of the individual's rights 
                        (including any limitation on such rights) to 
                        seek further review by the courts (or other 
                        process) of the external appeal determination.
                    (I) Compliance with determination.--If the external 
                appeal entity reverses or modifies the denial of a 
                claim for benefits, the plan or issuer shall--
                            (i) upon the receipt of the determination, 
                        authorize benefits in accordance with such 
                        determination;
                            (ii) take such actions as may be necessary 
                        to provide benefits (including items or 
                        services) in a timely manner consistent with 
                        such determination; and
                            (iii) submit information to the entity 
                        documenting compliance with the entity's 
                        determination and this subparagraph.
    (c) Qualifications of External Appeal Entities.--
            (1) In general.--For purposes of this section, the term 
        ``qualified external appeal entity'' means, in relation to a 
        plan or issuer, an entity that is certified under paragraph (2) 
        as meeting the following requirements:
                    (A) The entity meets the independence requirements 
                of paragraph (3).
                    (B) The entity conducts external appeal activities 
                through a panel of not fewer than three clinical peers.
                    (C) The entity has sufficient medical, legal, and 
                other expertise and sufficient staffing to conduct 
                external appeal activities for the plan or issuer on a 
                timely basis consistent with subsection (b)(2)(G).
                    (D) The entity meets such other requirements as the 
                appropriate Secretary may impose.
            (2) Initial certification of external appeal entities.--
                    (A) In general.--In order to be treated as a 
                qualified external appeal entity with respect to--
                            (i) a group health plan, the entity must be 
                        certified (and, in accordance with subparagraph 
                        (B), periodically recertified) as meeting the 
                        requirements of paragraph (1)--
                                    (I) by the Secretary of Labor;
                                    (II) under a process recognized or 
                                approved by the Secretary of Labor; or
                                    (III) to the extent provided in 
                                subparagraph (C)(i), by a qualified 
                                private standard-setting organization 
                                (certified under such subparagraph); or
                            (ii) a health insurance issuer operating in 
                        a State, the entity must be certified (and, in 
                        accordance with subparagraph (B), periodically 
                        recertified) as meeting such requirements--
                                    (I) by the applicable State 
                                authority (or under a process 
                                recognized or approved by such 
                                authority); or
                                    (II) if the State has not 
                                established a certification and 
                                recertification process for such 
                                entities, by the Secretary of Health 
                                and Human Services, under a process 
                                recognized or approved by such 
                                Secretary, or to the extent provided in 
                                subparagraph (C)(ii), by a qualified 
                                private standard-setting organization 
                                (certified under such subparagraph).
                    (B) Recertification process.--The appropriate 
                Secretary shall develop standards for the 
                recertification of external appeal entities. Such 
                standards shall include a review of--
                            (i) the number of cases reviewed;
                            (ii) a summary of the disposition of those 
                        cases;
                            (iii) the length of time in making 
                        determinations on those cases;
                            (iv) updated information of what was 
                        required to be submitted as a condition of 
                        certification for the entity's performance of 
                        external appeal activities; and
                            (v) such information as may be necessary to 
                        assure the independence of the entity from the 
                        plans or issuers for which external appeal 
                        activities are being conducted.
                    (C) Certification of qualified private standard-
                setting organizations.--
                            (i) For external reviews under group health 
                        plans.--For purposes of subparagraph 
                        (A)(i)(III), the Secretary of Labor may provide 
                        for a process for certification (and periodic 
                        recertification) of qualified private standard-
                        setting organizations which provide for 
                        certification of external review entities. Such 
                        an organization shall only be certified if the 
                        organization does not certify an external 
                        review entity unless it meets standards 
                        required for certification of such an entity by 
                        such Secretary under subparagraph (A)(i)(I).
                            (ii) For external reviews of health 
                        insurance issuers.--For purposes of 
                        subparagraph (A)(ii)(II), the Secretary of 
                        Health and Human Services may provide for a 
                        process for certification (and periodic 
                        recertification) of qualified private standard-
                        setting organizations which provide for 
                        certification of external review entities. Such 
                        an organization shall only be certified if the 
                        organization does not certify an external 
                        review entity unless it meets standards 
                        required for certification of such an entity by 
                        such Secretary under subparagraph (A)(ii)(II).
            (3) Independence requirements.--
                    (A) In general.--A clinical peer or other entity 
                meets the independence requirements of this paragraph 
                if--
                            (i) the peer or entity does not have a 
                        familial, financial, or professional 
                        relationship with any related party;
                            (ii) any compensation received by such peer 
                        or entity in connection with the external 
                        review is reasonable and not contingent on any 
                        decision rendered by the peer or entity;
                            (iii) except as provided in paragraph (4), 
                        the plan and the issuer have no recourse 
                        against the peer or entity in connection with 
                        the external review; and
                            (iv) the peer or entity does not otherwise 
                        have a conflict of interest with a related 
                        party as determined under any regulations which 
                        the Secretary may prescribe.
                    (B) Related party.--For purposes of this paragraph, 
                the term ``related party'' means--
                            (i) with respect to--
                                    (I) a group health plan or health 
                                insurance coverage offered in 
                                connection with such a plan, the plan 
                                or the health insurance issuer offering 
                                such coverage; or
                                    (II) individual health insurance 
                                coverage, the health insurance issuer 
                                offering such coverage,
                        or any plan sponsor, fiduciary, officer, 
                        director, or management employee of such plan 
                        or issuer;
                            (ii) the health care professional that 
                        provided the health care involved in the 
                        coverage decision;
                            (iii) the institution at which the health 
                        care involved in the coverage decision is 
                        provided;
                            (iv) the manufacturer of any drug or other 
                        item that was included in the health care 
                        involved in the coverage decision; or
                            (v) any other party determined under any 
                        regulations which the Secretary may prescribe 
                        to have a substantial interest in the coverage 
                        decision.
            (4) Limitation on liability of reviewers.--No qualified 
        external appeal entity having a contract with a plan or issuer 
        under this part and no person who is employed by any such 
        entity or who furnishes professional services to such entity, 
        shall be held by reason of the performance of any duty, 
        function, or activity required or authorized pursuant to this 
        section, to have violated any criminal law, or to be civilly 
        liable under any law of the United States or of any State (or 
        political subdivision thereof) if due care was exercised in the 
        performance of such duty, function, or activity and there was 
        no actual malice or gross misconduct in the performance of such 
        duty, function, or activity.
    (d) External Appeal Determination Binding on Plan.--The 
determination by an external appeal entity under this section is 
binding on the plan and issuer involved in the determination.
    (e) Penalties Against Authorized Officials for Refusing to 
Authorize the Determination of an External Review Entity.--
            (1) Monetary penalties.--In any case in which the 
        determination of an external review entity is not followed by a 
        group health plan, or by a health insurance issuer offering 
        health insurance coverage, any person who, acting in the 
        capacity of authorizing the benefit, causes such refusal may, 
        in the discretion in a court of competent jurisdiction, be 
        liable to an aggrieved participant, beneficiary, or enrollee 
        for a civil penalty in an amount of up to $1,000 a day from the 
        date on which the determination was transmitted to the plan or 
        issuer by the external review entity until the date the refusal 
        to provide the benefit is corrected.
            (2) Cease and desist order and order of attorney's fees.--
        In any action described in paragraph (1) brought by a 
        participant, beneficiary, or enrollee with respect to a group 
        health plan, or a health insurance issuer offering health 
        insurance coverage, in which a plaintiff alleges that a person 
        referred to in such paragraph has taken an action resulting in 
        a refusal of a benefit determined by an external appeal entity 
        in violation of such terms of the plan, coverage, or this 
        subtitle, or has failed to take an action for which such person 
        is responsible under the plan, coverage, or this title and 
        which is necessary under the plan or coverage for authorizing a 
        benefit, the court shall cause to be served on the defendant an 
        order requiring the defendant--
                    (A) to cease and desist from the alleged action or 
                failure to act; and
                    (B) to pay to the plaintiff a reasonable attorney's 
                fee and other reasonable costs relating to the 
                prosecution of the action on the charges on which the 
                plaintiff prevails.
            (3) Additional civil penalties.--
                    (A) In general.--In addition to any penalty imposed 
                under paragraph (1) or (2), the appropriate Secretary 
                may assess a civil penalty against a person acting in 
                the capacity of authorizing a benefit determined by an 
                external review entity for one or more group health 
                plans, or health insurance issuers offering health 
                insurance coverage, for--
                            (i) any pattern or practice of repeated 
                        refusal to authorize a benefit determined by an 
                        external appeal entity in violation of the 
                        terms of such a plan, coverage, or this title; 
                        or
                            (ii) any pattern or practice of repeated 
                        violations of the requirements of this section 
                        with respect to such plan or plans or coverage.
                    (B) Standard of proof and amount of penalty.--Such 
                penalty shall be payable only upon proof by clear and 
                convincing evidence of such pattern or practice and 
                shall be in an amount not to exceed the lesser of--
                            (i) 25 percent of the aggregate value of 
                        benefits shown by the appropriate Secretary to 
                        have not been provided, or unlawfully delayed, 
                        in violation of this section under such pattern 
                        or practice; or
                            (ii) $500,000.
            (4) Removal and disqualification.--Any person acting in the 
        capacity of authorizing benefits who has engaged in any such 
        pattern or practice described in paragraph (3)(A) with respect 
        to a plan or coverage, upon the petition of the appropriate 
        Secretary, may be removed by the court from such position, and 
        from any other involvement, with respect to such a plan or 
        coverage, and may be precluded from returning to any such 
        position or involvement for a period determined by the court.
    (f) Protection of Legal Rights.--Nothing in this subtitle shall be 
construed as altering or eliminating any cause of action or legal 
rights or remedies of participants, beneficiaries, enrollees, and 
others under State or Federal law (including sections 502 and 503 of 
the Employee Retirement Income Security Act of 1974), including the 
right to file judicial actions to enforce rights.

SEC. 104. ESTABLISHMENT OF A GRIEVANCE PROCESS.

    (a) Establishment of Grievance System.--
            (1) In general.--A group health plan, and a health 
        insurance issuer in connection with the provision of health 
        insurance coverage, shall establish and maintain a system to 
        provide for the presentation and resolution of oral and written 
        grievances brought by individuals who are participants, 
        beneficiaries, or enrollees, or health care providers or other 
        individuals acting on behalf of an individual and with the 
        individual's consent or without such consent if the individual 
        is medically unable to provide such consent, regarding any 
        aspect of the plan's or issuer's services.
            (2) Grievance defined.--In this section, the term 
        ``grievance'' means any question, complaint, or concern brought 
        by a participant, beneficiary or enrollee that is not a claim 
        for benefits (as defined in section 101(f)(1)).
    (b) Grievance System.--Such system shall include the following 
components with respect to individuals who are participants, 
beneficiaries, or enrollees:
            (1) Written notification to all such individuals and 
        providers of the telephone numbers and business addresses of 
        the plan or issuer personnel responsible for resolution of 
        grievances and appeals.
            (2) A system to record and document, over a period of at 
        least three previous years, all grievances and appeals made and 
        their status.
            (3) A process providing for timely processing and 
        resolution of grievances.
            (4) Procedures for follow-up action, including the methods 
        to inform the person making the grievance of the resolution of 
        the grievance.
Grievances are not subject to appeal under the previous provisions of 
this subtitle.

                       Subtitle B--Access to Care

SEC. 111. CONSUMER CHOICE OPTION.

    (a) In General.--If--
            (1) a health insurance issuer providing health insurance 
        coverage in connection with a group health plan offers to 
        enrollees health insurance coverage which provides for coverage 
        of services only if such services are furnished through health 
        care professionals and providers who are members of a network 
        of health care professionals and providers who have entered 
        into a contract with the issuer to provide such services, or
            (2) a group health plan offers to participants or 
        beneficiaries health benefits which provide for coverage of 
        services only if such services are furnished through health 
        care professionals and providers who are members of a network 
        of health care professionals and providers who have entered 
        into a contract with the plan to provide such services,
then the issuer or plan shall also offer or arrange to be offered to 
such enrollees, participants, or beneficiaries (at the time of 
enrollment and during an annual open season as provided under 
subsection (c)) the option of health insurance coverage or health 
benefits which provide for coverage of such services which are not 
furnished through health care professionals and providers who are 
members of such a network unless such enrollees, participants, or 
beneficiaries are offered such non-network coverage through another 
group health plan or through another health insurance issuer in the 
group market.
    (b) Additional Costs.--The amount of any additional premium charged 
by the health insurance issuer or group health plan for the additional 
cost of the creation and maintenance of the option described in 
subsection (a) and the amount of any additional cost sharing imposed 
under such option shall be borne by the enrollee, participant, or 
beneficiary unless it is paid by the health plan sponsor or group 
health plan through agreement with the health insurance issuer.
    (c) Open Season.--An enrollee, participant, or beneficiary, may 
change to the offering provided under this section only during a time 
period determined by the health insurance issuer or group health plan. 
Such time period shall occur at least annually.

SEC. 112. CHOICE OF HEALTH CARE PROFESSIONAL.

    (a) Primary Care.--If a group health plan, or a health insurance 
issuer that offers health insurance coverage, requires or provides for 
designation by a participant, beneficiary, or enrollee of a 
participating primary care provider, then the plan or issuer shall 
permit each participant, beneficiary, and enrollee to designate any 
participating primary care provider who is available to accept such 
individual.
    (b) Specialists.--
            (1) In general.--Subject to paragraph (2), a group health 
        plan and a health insurance issuer that offers health insurance 
        coverage shall permit each participant, beneficiary, or 
        enrollee to receive medically necessary or appropriate 
        specialty care, pursuant to appropriate referral procedures, 
        from any qualified participating health care professional who 
        is available to accept such individual for such care.
            (2) Limitation.--Paragraph (1) shall not apply to specialty 
        care if the plan or issuer clearly informs participants, 
        beneficiaries, and enrollees of the limitations on choice of 
        participating health care professionals with respect to such 
        care.
            (3) Construction.--Nothing in this subsection shall be 
        construed as affecting the application of section 114 (relating 
        to access to specialty care).

SEC. 113. ACCESS TO EMERGENCY CARE.

    (a) Coverage of Emergency Services.--
            (1) In general.--If a group health plan, or health 
        insurance coverage offered by a health insurance issuer, 
        provides any benefits with respect to services in an emergency 
        department of a hospital, the plan or issuer shall cover 
        emergency services (as defined in paragraph (2)(B))--
                    (A) without the need for any prior authorization 
                determination;
                    (B) whether or not the health care provider 
                furnishing such services is a participating provider 
                with respect to such services;
                    (C) in a manner so that, if such services are 
                provided to a participant, beneficiary, or enrollee--
                            (i) by a nonparticipating health care 
                        provider with or without prior authorization; 
                        or
                            (ii) by a participating health care 
                        provider without prior authorization,
                the participant, beneficiary, or enrollee is not liable 
                for amounts that exceed the amounts of liability that 
                would be incurred if the services were provided by a 
                participating health care provider with prior 
                authorization; and
                    (D) without regard to any other term or condition 
                of such coverage (other than exclusion or coordination 
                of benefits, or an affiliation or waiting period, 
                permitted under section 2701 of the Public Health 
                Service Act, section 701 of the Employee Retirement 
                Income Security Act of 1974, or section 9801 of the 
                Internal Revenue Code of 1986, and other than 
                applicable cost-sharing).
            (2) Definitions.--In this section:
                    (A) Emergency medical condition based on prudent 
                layperson standard.--The term ``emergency medical 
                condition'' means a medical condition manifesting 
                itself by acute symptoms of sufficient severity 
                (including severe pain) such that a prudent layperson, 
                who possesses an average knowledge of health and 
                medicine, could reasonably expect the absence of 
                immediate medical attention to result in a condition 
                described in clause (i), (ii), or (iii) of section 
                1867(e)(1)(A) of the Social Security Act.
                    (B) Emergency services.--The term ``emergency 
                services'' means--
                            (i) a medical screening examination (as 
                        required under section 1867 of the Social 
                        Security Act) that is within the capability of 
                        the emergency department of a hospital, 
                        including ancillary services routinely 
                        available to the emergency department to 
                        evaluate an emergency medical condition (as 
                        defined in subparagraph (A)); and
                            (ii) within the capabilities of the staff 
                        and facilities available at the hospital, such 
                        further medical examination and treatment as 
                        are required under section 1867 of such Act to 
                        stabilize the patient.
                    (C) Stabilize.--The term ``to stabilize'' means, 
                with respect to an emergency medical condition, to 
                provide such medical treatment of the condition as may 
                be necessary to assure, within reasonable medical 
                probability, that no material deterioration of the 
                condition is likely to result from or occur during the 
                transfer of the individual from a facility.
    (b) Reimbursement for Maintenance Care and Post-Stabilization 
Care.--In the case of services (other than emergency services) for 
which benefits are available under a group health plan, or under health 
insurance coverage offered by a health insurance issuer, the plan or 
issuer shall provide for reimbursement with respect to such services 
provided to a participant, beneficiary, or enrollee other than through 
a participating health care provider in a manner consistent with 
subsection (a)(1)(C) (and shall otherwise comply with the guidelines 
established under section 1852(d)(2) of the Social Security Act), if 
the services are maintenance care or post-stabilization care covered 
under such guidelines.

SEC. 114. ACCESS TO SPECIALTY CARE.

    (a) Specialty Care for Covered Services.--
            (1) In general.--If--
                    (A) an individual is a participant or beneficiary 
                under a group health plan or an enrollee who is covered 
                under health insurance coverage offered by a health 
                insurance issuer;
                    (B) the individual has a condition or disease of 
                sufficient seriousness and complexity to require 
                treatment by a specialist; and
                    (C) benefits for such treatment are provided under 
                the plan or coverage,
        the plan or issuer shall make or provide for a referral to a 
        specialist who is available and accessible to provide the 
        treatment for such condition or disease.
            (2) Specialist defined.--For purposes of this subsection, 
        the term ``specialist'' means, with respect to a condition, a 
        health care practitioner, facility, or center that has adequate 
        expertise through appropriate training and experience 
        (including, in the case of a child, appropriate pediatric 
        expertise) to provide high quality care in treating the 
        condition.
            (3) Care under referral.--A group health plan or health 
        insurance issuer may require that the care provided to an 
        individual pursuant to such referral under paragraph (1) be--
                    (A) pursuant to a treatment plan, only if the 
                treatment plan is developed by the specialist and 
                approved by the plan or issuer, in consultation with 
                the designated primary care provider or specialist and 
                the individual (or the individual's designee); and
                    (B) in accordance with applicable quality assurance 
                and utilization review standards of the plan or issuer.
        Nothing in this subsection shall be construed as preventing 
        such a treatment plan for an individual from requiring a 
        specialist to provide the primary care provider with regular 
        updates on the specialty care provided, as well as all 
        necessary medical information.
            (4) Referrals to participating providers.--A group health 
        plan or health insurance issuer is not required under paragraph 
        (1) to provide for a referral to a specialist that is not a 
        participating provider, unless the plan or issuer does not have 
        an appropriate specialist that is available and accessible to 
        treat the individual's condition and that is a participating 
        provider with respect to such treatment.
            (5) Treatment of nonparticipating providers.--If a plan or 
        issuer refers an individual to a nonparticipating specialist 
        pursuant to paragraph (1), services provided pursuant to the 
        approved treatment plan (if any) shall be provided at no 
        additional cost to the individual beyond what the individual 
        would otherwise pay for services received by such a specialist 
        that is a participating provider.
    (b) Specialists as Gatekeeper for Treatment of Ongoing Special 
Conditions.--
            (1) In general.--A group health plan, or a health insurance 
        issuer, in connection with the provision of health insurance 
        coverage, shall have a procedure by which an individual who is 
        a participant, beneficiary, or enrollee and who has an ongoing 
        special condition (as defined in paragraph (3)) may request and 
        receive a referral to a specialist for such condition who shall 
        be responsible for and capable of providing and coordinating 
        the individual's care with respect to the condition. Under such 
        procedures if such an individual's care would most 
        appropriately be coordinated by such a specialist, such plan or 
        issuer shall refer the individual to such specialist.
            (2) Treatment for related referrals.--Such specialists 
        shall be permitted to treat the individual without a referral 
        from the individual's primary care provider and may authorize 
        such referrals, procedures, tests, and other medical services 
        as the individual's primary care provider would otherwise be 
        permitted to provide or authorize, subject to the terms of the 
        treatment (referred to in subsection (a)(3)(A)) with respect to 
        the ongoing special condition.
            (3) Ongoing special condition defined.--In this subsection, 
        the term ``ongoing special condition'' means a condition or 
        disease that--
                    (A) is life-threatening, degenerative, or 
                disabling; and
                    (B) requires specialized medical care over a 
                prolonged period of time.
            (4) Terms of referral.--The provisions of paragraphs (3) 
        through (5) of subsection (a) apply with respect to referrals 
        under paragraph (1) of this subsection in the same manner as 
        they apply to referrals under subsection (a)(1).
    (c) Standing Referrals.--
            (1) In general.--A group health plan, and a health 
        insurance issuer in connection with the provision of health 
        insurance coverage, shall have a procedure by which an 
        individual who is a participant, beneficiary, or enrollee and 
        who has a condition that requires ongoing care from a 
        specialist may receive a standing referral to such specialist 
        for treatment of such condition. If the plan or issuer, or if 
        the primary care provider in consultation with the medical 
        director of the plan or issuer and the specialist (if any), 
        determines that such a standing referral is appropriate, the 
        plan or issuer shall make such a referral to such a specialist 
        if the individual so desires.
            (2) Terms of referral.--The provisions of paragraphs (3) 
        through (5) of subsection (a) apply with respect to referrals 
        under paragraph (1) of this subsection in the same manner as 
        they apply to referrals under subsection (a)(1).

SEC. 115. ACCESS TO OBSTETRICAL AND GYNECOLOGICAL CARE.

    (a) In General.--If a group health plan, or a health insurance 
issuer in connection with the provision of health insurance coverage, 
requires or provides for a participant, beneficiary, or enrollee to 
designate a participating primary care health care professional, the 
plan or issuer--
            (1) may not require authorization or a referral by the 
        individual's primary care health care professional or otherwise 
        for coverage of gynecological care (including preventive 
        women's health examinations) and pregnancy-related services 
        provided by a participating health care professional, including 
        a physician, who specializes in obstetrics and gynecology to 
        the extent such care is otherwise covered; and
            (2) shall treat the ordering of other obstetrical or 
        gynecological care by such a participating professional as the 
        authorization of the primary care health care professional with 
        respect to such care under the plan or coverage.
    (b) Construction.--Nothing in subsection (a) shall be construed 
to--
            (1) waive any exclusions of coverage under the terms of the 
        plan or health insurance coverage with respect to coverage of 
        obstetrical or gynecological care; or
            (2) preclude the group health plan or health insurance 
        issuer involved from requiring that the obstetrical or 
        gynecological provider notify the primary care health care 
        professional or the plan or issuer of treatment decisions.

SEC. 116. ACCESS TO PEDIATRIC CARE.

    (a) Pediatric Care.--If a group health plan, or a health insurance 
issuer in connection with the provision of health insurance coverage, 
requires or provides for an enrollee to designate a participating 
primary care provider for a child of such enrollee, the plan or issuer 
shall permit the enrollee to designate a physician who specializes in 
pediatrics as the child's primary care provider.
    (b) Construction.--Nothing in subsection (a) shall be construed to 
waive any exclusions of coverage under the terms of the plan or health 
insurance coverage with respect to coverage of pediatric care.

SEC. 117. CONTINUITY OF CARE.

    (a) In General.--
            (1) Termination of provider.--If a contract between a group 
        health plan, or a health insurance issuer in connection with 
        the provision of health insurance coverage, and a health care 
        provider is terminated (as defined in paragraph (3)(B)), or 
        benefits or coverage provided by a health care provider are 
        terminated because of a change in the terms of provider 
        participation in a group health plan, and an individual who is 
        a participant, beneficiary, or enrollee in the plan or coverage 
        is undergoing treatment from the provider for an ongoing 
        special condition (as defined in paragraph (3)(A)) at the time 
        of such termination, the plan or issuer shall--
                    (A) notify the individual on a timely basis of such 
                termination and of the right to elect continuation of 
                coverage of treatment by the provider under this 
                section; and
                    (B) subject to subsection (c), permit the 
                individual to elect to continue to be covered with 
                respect to treatment by the provider of such condition 
                during a transitional period (provided under subsection 
                (b)).
            (2) Treatment of termination of contract with health 
        insurance issuer.--If a contract for the provision of health 
        insurance coverage between a group health plan and a health 
        insurance issuer is terminated and, as a result of such 
        termination, coverage of services of a health care provider is 
        terminated with respect to an individual, the provisions of 
        paragraph (1) (and the succeeding provisions of this section) 
        shall apply under the plan in the same manner as if there had 
        been a contract between the plan and the provider that had been 
        terminated, but only with respect to benefits that are covered 
        under the plan after the contract termination.
            (3) Definitions.--For purposes of this section:
                    (A) Ongoing special condition.--The term ``ongoing 
                special condition'' has the meaning given such term in 
                section 114(b)(3), and also includes pregnancy.
                    (B) Termination.--The term ``terminated'' includes, 
                with respect to a contract, the expiration or 
                nonrenewal of the contract, but does not include a 
                termination of the contract by the plan or issuer for 
                failure to meet applicable quality standards or for 
                fraud.
    (b) Transitional Period.--
            (1) In general.--Except as provided in paragraphs (2) 
        through (4), the transitional period under this subsection 
        shall extend up to 90 days (as determined by the treating 
        health care professional) after the date of the notice 
        described in subsection (a)(1)(A) of the provider's 
        termination.
            (2) Scheduled surgery and organ transplantation.--If 
        surgery or organ transplantation was scheduled for an 
        individual before the date of the announcement of the 
        termination of the provider status under subsection (a)(1)(A) 
        or if the individual on such date was on an established waiting 
        list or otherwise scheduled to have such surgery or 
        transplantation, the transitional period under this subsection 
        with respect to the surgery or transplantation shall extend 
        beyond the period under paragraph (1) and until the date of 
        discharge of the individual after completion of the surgery or 
        transplantation.
            (3) Pregnancy.--If--
                    (A) a participant, beneficiary, or enrollee was 
                determined to be pregnant at the time of a provider's 
                termination of participation; and
                    (B) the provider was treating the pregnancy before 
                date of the termination,
        the transitional period under this subsection with respect to 
        provider's treatment of the pregnancy shall extend through the 
        provision of post-partum care directly related to the delivery.
            (4) Terminal illness.--If--
                    (A) a participant, beneficiary, or enrollee was 
                determined to be terminally ill (as determined under 
                section 1861(dd)(3)(A) of the Social Security Act) at 
                the time of a provider's termination of participation; 
                and
                    (B) the provider was treating the terminal illness 
                before the date of termination,
        the transitional period under this subsection shall extend for 
        the remainder of the individual's life for care directly 
        related to the treatment of the terminal illness or its medical 
        manifestations.
    (c) Permissible Terms and Conditions.--A group health plan or 
health insurance issuer may condition coverage of continued treatment 
by a provider under subsection (a)(1)(B) upon the individual notifying 
the plan of the election of continued coverage and upon the provider 
agreeing to the following terms and conditions:
            (1) The provider agrees to accept reimbursement from the 
        plan or issuer and individual involved (with respect to cost-
        sharing) at the rates applicable prior to the start of the 
        transitional period as payment in full (or, in the case 
        described in subsection (a)(2), at the rates applicable under 
        the replacement plan or issuer after the date of the 
        termination of the contract with the health insurance issuer) 
        and not to impose cost-sharing with respect to the individual 
        in an amount that would exceed the cost-sharing that could have 
        been imposed if the contract referred to in subsection (a)(1) 
        had not been terminated.
            (2) The provider agrees to adhere to the quality assurance 
        standards of the plan or issuer responsible for payment under 
        paragraph (1) and to provide to such plan or issuer necessary 
        medical information related to the care provided.
            (3) The provider agrees otherwise to adhere to such plan's 
        or issuer's policies and procedures, including procedures 
        regarding referrals and obtaining prior authorization and 
        providing services pursuant to a treatment plan (if any) 
        approved by the plan or issuer.
    (d) Construction.--Nothing in this section shall be construed to 
require the coverage of benefits which would not have been covered if 
the provider involved remained a participating provider.

SEC. 118. ACCESS TO NEEDED PRESCRIPTION DRUGS.

    If a group health plan, or health insurance issuer that offers 
health insurance coverage, provides benefits with respect to 
prescription drugs but the coverage limits such benefits to drugs 
included in a formulary, the plan or issuer shall--
            (1) ensure participation of participating physicians and 
        pharmacists in the development of the formulary;
            (2) disclose to providers and, disclose upon request under 
        section 121(c)(5) to participants, beneficiaries, and 
        enrollees, the nature of the formulary restrictions; and
            (3) consistent with the standards for a utilization review 
        program under section 101, provide for exceptions from the 
        formulary limitation when a non-formulary alternative is 
        medically indicated.

SEC. 119. COVERAGE FOR INDIVIDUALS PARTICIPATING IN APPROVED CLINICAL 
              TRIALS.

    (a) Coverage.--
            (1) In general.--If a group health plan, or health 
        insurance issuer that is providing health insurance coverage, 
        provides coverage to a qualified individual (as defined in 
        subsection (b)), the plan or issuer--
                    (A) may not deny the individual participation in 
                the clinical trial referred to in subsection (b)(2);
                    (B) subject to subsection (c), may not deny (or 
                limit or impose additional conditions on) the coverage 
                of routine patient costs for items and services 
                furnished in connection with participation in the 
                trial; and
                    (C) may not discriminate against the individual on 
                the basis of the enrollee's participation in such 
                trial.
            (2) Exclusion of certain costs.--For purposes of paragraph 
        (1)(B), routine patient costs do not include the cost of the 
        tests or measurements conducted primarily for the purpose of 
        the clinical trial involved.
            (3) Use of in-network providers.--If one or more 
        participating providers is participating in a clinical trial, 
        nothing in paragraph (1) shall be construed as preventing a 
        plan or issuer from requiring that a qualified individual 
        participate in the trial through such a participating provider 
        if the provider will accept the individual as a participant in 
        the trial.
    (b) Qualified Individual Defined.--For purposes of subsection (a), 
the term ``qualified individual'' means an individual who is a 
participant or beneficiary in a group health plan, or who is an 
enrollee under health insurance coverage, and who meets the following 
conditions:
            (1)(A) The individual has a life-threatening or serious 
        illness for which no standard treatment is effective.
            (B) The individual is eligible to participate in an 
        approved clinical trial according to the trial protocol with 
        respect to treatment of such illness.
            (C) The individual's participation in the trial offers 
        meaningful potential for significant clinical benefit for the 
        individual.
            (2) Either--
                    (A) the referring physician is a participating 
                health care professional and has concluded that the 
                individual's participation in such trial would be 
                appropriate based upon the individual meeting the 
                conditions described in paragraph (1); or
                    (B) the participant, beneficiary, or enrollee 
                provides medical and scientific information 
                establishing that the individual's participation in 
                such trial would be appropriate based upon the 
                individual meeting the conditions described in 
                paragraph (1).
    (c) Payment.--
            (1) In general.--Under this section a group health plan or 
        health insurance issuer shall provide for payment for routine 
        patient costs described in subsection (a)(2) but is not 
        required to pay for costs of items and services that are 
        reasonably expected (as determined by the Secretary) to be paid 
        for by the sponsors of an approved clinical trial.
            (2) Payment rate.--In the case of covered items and 
        services provided by--
                    (A) a participating provider, the payment rate 
                shall be at the agreed upon rate; or
                    (B) a nonparticipating provider, the payment rate 
                shall be at the rate the plan or issuer would normally 
                pay for comparable services under subparagraph (A).
    (d) Approved Clinical Trial Defined.--
            (1) In general.--In this section, the term ``approved 
        clinical trial'' means a clinical research study or clinical 
        investigation approved and funded (which may include funding 
        through in-kind contributions) by one or more of the following:
                    (A) The National Institutes of Health.
                    (B) A cooperative group or center of the National 
                Institutes of Health.
                    (C) Either of the following if the conditions 
                described in paragraph (2) are met:
                            (i) The Department of Veterans Affairs.
                            (ii) The Department of Defense.
            (2) Conditions for departments.--The conditions described 
        in this paragraph, for a study or investigation conducted by a 
        Department, are that the study or investigation has been 
        reviewed and approved through a system of peer review that the 
        Secretary determines--
                    (A) to be comparable to the system of peer review 
                of studies and investigations used by the National 
                Institutes of Health; and
                    (B) assures unbiased review of the highest 
                scientific standards by qualified individuals who have 
                no interest in the outcome of the review.
    (e) Construction.--Nothing in this section shall be construed to 
limit a plan's or issuer's coverage with respect to clinical trials.

                   Subtitle C--Access to Information

SEC. 121. PATIENT ACCESS TO INFORMATION.

    (a) Disclosure Requirement.--
            (1) Group health plans.--A group health plan shall--
                    (A) provide to participants and beneficiaries at 
                the time of initial coverage under the plan (or the 
                effective date of this section, in the case of 
                individuals who are participants or beneficiaries as of 
                such date), and at least annually thereafter, the 
                information described in subsection (b) in printed 
                form;
                    (B) provide to participants and beneficiaries, 
                within a reasonable period (as specified by the 
                appropriate Secretary) before or after the date of 
                significant changes in the information described in 
                subsection (b), information in printed form on such 
                significant changes; and
                    (C) upon request, make available to participants 
                and beneficiaries, the applicable authority, and 
                prospective participants and beneficiaries, the 
                information described in subsection (b) or (c) in 
                printed form.
            (2) Health insurance issuers.--A health insurance issuer in 
        connection with the provision of health insurance coverage 
        shall--
                    (A) provide to individuals enrolled under such 
                coverage at the time of enrollment, and at least 
                annually thereafter, the information described in 
                subsection (b) in printed form;
                    (B) provide to enrollees, within a reasonable 
                period (as specified by the appropriate Secretary) 
                before or after the date of significant changes in the 
                information described in subsection (b), information in 
                printed form on such significant changes; and
                    (C) upon request, make available to the applicable 
                authority, to individuals who are prospective 
                enrollees, and to the public the information described 
                in subsection (b) or (c) in printed form.
    (b) Information Provided.--The information described in this 
subsection with respect to a group health plan or health insurance 
coverage offered by a health insurance issuer includes the following:
            (1) Service area.--The service area of the plan or issuer.
            (2) Benefits.--Benefits offered under the plan or coverage, 
        including--
                    (A) covered benefits, including benefit limits and 
                coverage exclusions;
                    (B) cost sharing, such as deductibles, coinsurance, 
                and copayment amounts, including any liability for 
                balance billing, any maximum limitations on out of 
                pocket expenses, and the maximum out of pocket costs 
                for services that are provided by nonparticipating 
                providers or that are furnished without meeting the 
                applicable utilization review requirements;
                    (C) the extent to which benefits may be obtained 
                from nonparticipating providers;
                    (D) the extent to which a participant, beneficiary, 
                or enrollee may select from among participating 
                providers and the types of providers participating in 
                the plan or issuer network;
                    (E) process for determining experimental coverage; 
                and
                    (F) use of a prescription drug formulary.
            (3) Access.--A description of the following:
                    (A) The number, mix, and distribution of providers 
                under the plan or coverage.
                    (B) Out-of-network coverage (if any) provided by 
                the plan or coverage.
                    (C) Any point-of-service option (including any 
                supplemental premium or cost-sharing for such option).
                    (D) The procedures for participants, beneficiaries, 
                and enrollees to select, access, and change 
                participating primary and specialty providers.
                    (E) The rights and procedures for obtaining 
                referrals (including standing referrals) to 
                participating and nonparticipating providers.
                    (F) The name, address, and telephone number of 
                participating health care providers and an indication 
                of whether each such provider is available to accept 
                new patients.
                    (G) Any limitations imposed on the selection of 
                qualifying participating health care providers, 
                including any limitations imposed under section 
                112(b)(2).
                    (H) How the plan or issuer addresses the needs of 
                participants, beneficiaries, and enrollees and others 
                who do not speak English or who have other special 
                communications needs in accessing providers under the 
                plan or coverage, including the provision of 
                information described in this subsection and subsection 
                (c) to such individuals.
            (4) Out-of-area coverage.--Out-of-area coverage provided by 
        the plan or issuer.
            (5) Emergency coverage.--Coverage of emergency services, 
        including--
                    (A) the appropriate use of emergency services, 
                including use of the 911 telephone system or its local 
                equivalent in emergency situations and an explanation 
                of what constitutes an emergency situation;
                    (B) the process and procedures of the plan or 
                issuer for obtaining emergency services; and
                    (C) the locations of (i) emergency departments, and 
                (ii) other settings, in which plan physicians and 
                hospitals provide emergency services and post-
                stabilization care.
            (6) Percentage of premiums used for benefits (loss-
        ratios).--In the case of health insurance coverage only (and 
        not with respect to group health plans that do not provide 
        coverage through health insurance coverage), a description of 
        the overall loss-ratio for the coverage (as defined in 
        accordance with rules established or recognized by the 
        Secretary of Health and Human Services).
            (7) Prior authorization rules.--Rules regarding prior 
        authorization or other review requirements that could result in 
        noncoverage or nonpayment.
            (8) Grievance and appeals procedures.--All appeal or 
        grievance rights and procedures under the plan or coverage, 
        including the method for filing grievances and the time frames 
        and circumstances for acting on grievances and appeals, who is 
        the applicable authority with respect to the plan or issuer.
            (9) Quality assurance.--Any information made public by an 
        accrediting organization in the process of accreditation of the 
        plan or issuer or any additional quality indicators the plan or 
        issuer makes available.
            (10) Information on issuer.--Notice of appropriate mailing 
        addresses and telephone numbers to be used by participants, 
        beneficiaries, and enrollees in seeking information or 
        authorization for treatment.
            (11) Notice of requirements.--Notice of the requirements of 
        this title.
            (12) Availability of information on request.--Notice that 
        the information described in subsection (c) is available upon 
        request.
    (c) Information Made Available Upon Request.--The information 
described in this subsection is the following:
            (1) Utilization review activities.--A description of 
        procedures used and requirements (including circumstances, time 
        frames, and appeal rights) under any utilization review program 
        under section 101, including under any drug formulary program 
        under section 118.
            (2) Grievance and appeals information.--Information on the 
        number of grievances and appeals and on the disposition in the 
        aggregate of such matters.
            (3) Method of physician compensation.--A general 
        description by category (including salary, fee-for-service, 
        capitation, and such other categories as may be specified in 
        regulations of the Secretary) of the applicable method by which 
        a specified prospective or treating health care professional is 
        (or would be) compensated in connection with the provision of 
        health care under the plan or coverage.
            (4) Specific information on credentials of participating 
        providers.--In the case of each participating provider, a 
        description of the credentials of the provider.
            (5) Formulary restrictions.--A description of the nature of 
        any drug formula restrictions.
            (6) Participating provider list.--A list of current 
        participating health care providers.
    (d) Construction.--Nothing in this section shall be construed as 
requiring public disclosure of individual contracts or financial 
arrangements between a group health plan or health insurance issuer and 
any provider.

         Subtitle D--Protecting the Doctor-Patient Relationship

SEC. 131. PROHIBITION OF INTERFERENCE WITH CERTAIN MEDICAL 
              COMMUNICATIONS.

    (a) General Rule.--The provisions of any contract or agreement, or 
the operation of any contract or agreement, between a group health plan 
or health insurance issuer in relation to health insurance coverage 
(including any partnership, association, or other organization that 
enters into or administers such a contract or agreement) and a health 
care provider (or group of health care providers) shall not prohibit or 
otherwise restrict a health care professional from advising such a 
participant, beneficiary, or enrollee who is a patient of the 
professional about the health status of the individual or medical care 
or treatment for the individual's condition or disease, regardless of 
whether benefits for such care or treatment are provided under the plan 
or coverage, if the professional is acting within the lawful scope of 
practice.
    (b) Nullification.--Any contract provision or agreement that 
restricts or prohibits medical communications in violation of 
subsection (a) shall be null and void.

SEC. 132. PROHIBITION OF DISCRIMINATION AGAINST PROVIDERS BASED ON 
              LICENSURE.

    (a) In General.--A group health plan and a health insurance issuer 
offering health insurance coverage shall not discriminate with respect 
to participation or indemnification as to any provider who is acting 
within the scope of the provider's license or certification under 
applicable State law, solely on the basis of such license or 
certification.
    (b) Construction.--Subsection (a) shall not be construed--
            (1) as requiring the coverage under a group health plan or 
        health insurance coverage of particular benefits or services or 
        to prohibit a plan or issuer from including providers only to 
        the extent necessary to meet the needs of the plan's or 
        issuer's participants, beneficiaries, or enrollees or from 
        establishing any measure designed to maintain quality and 
        control costs consistent with the responsibilities of the plan 
        or issuer;
            (2) to override any State licensure or scope-of-practice 
        law; or
            (3) as requiring a plan or issuer that offers network 
        coverage to include for participation every willing provider 
        who meets the terms and conditions of the plan or issuer.

SEC. 133. PROHIBITION AGAINST IMPROPER INCENTIVE ARRANGEMENTS.

    (a) In General.--A group health plan and a health insurance issuer 
offering health insurance coverage may not operate any physician 
incentive plan (as defined in subparagraph (B) of section 1876(i)(8) of 
the Social Security Act) unless the requirements described in clauses 
(i), (ii)(I), and (iii) of subparagraph (A) of such section are met 
with respect to such a plan.
    (b) Application.--For purposes of carrying out paragraph (1), any 
reference in section 1876(i)(8) of the Social Security Act to the 
Secretary, an eligible organization, or an individual enrolled with the 
organization shall be treated as a reference to the applicable 
authority, a group health plan or health insurance issuer, 
respectively, and a participant, beneficiary, or enrollee with the plan 
or organization, respectively.
    (c) Construction.--Nothing in this section shall be construed as 
prohibiting all capitation and similar arrangements or all provider 
discount arrangements.

SEC. 134. PAYMENT OF CLAIMS.

    A group health plan, and a health insurance issuer offering group 
health insurance coverage, shall provide for prompt payment of claims 
submitted for health care services or supplies furnished to a 
participant, beneficiary, or enrollee with respect to benefits covered 
by the plan or issuer, in a manner consistent with the provisions of 
sections 1816(c)(2) and 1842(c)(2) of the Social Security Act (42 
U.S.C. 1395h(c)(2) and 42 U.S.C. 1395u(c)(2)), except that for purposes 
of this section, subparagraph (C) of section 1816(c)(2) of the Social 
Security Act shall be treated as applying to claims received from a 
participant, beneficiary, or enrollee as well as claims referred to in 
such subparagraph.

SEC. 135. PROTECTION FOR PATIENT ADVOCACY.

    (a) Protection for Use of Utilization Review and Grievance 
Process.--A group health plan, and a health insurance issuer with 
respect to the provision of health insurance coverage, may not 
retaliate against a participant, beneficiary, enrollee, or health care 
provider based on the participant's, beneficiary's, enrollee's or 
provider's use of, or participation in, a utilization review process or 
a grievance process of the plan or issuer (including an internal or 
external review or appeal process) under this title.
    (b) Protection for Quality Advocacy by Health Care Professionals.--
            (1) In general.--A group health plan or health insurance 
        issuer may not retaliate or discriminate against a protected 
        health care professional because the professional in good 
        faith--
                    (A) discloses information relating to the care, 
                services, or conditions affecting one or more 
                participants, beneficiaries, or enrollees of the plan 
                or issuer to an appropriate public regulatory agency, 
                an appropriate private accreditation body, or 
                appropriate management personnel of the plan or issuer; 
                or
                    (B) initiates, cooperates, or otherwise 
                participates in an investigation or proceeding by such 
                an agency with respect to such care, services, or 
                conditions.
        If an institutional health care provider is a participating 
        provider with such a plan or issuer or otherwise receives 
        payments for benefits provided by such a plan or issuer, the 
        provisions of the previous sentence shall apply to the provider 
        in relation to care, services, or conditions affecting one or 
        more patients within an institutional health care provider in 
        the same manner as they apply to the plan or issuer in relation 
        to care, services, or conditions provided to one or more 
        participants, beneficiaries, or enrollees; and for purposes of 
        applying this sentence, any reference to a plan or issuer is 
        deemed a reference to the institutional health care provider.
            (2) Good faith action.--For purposes of paragraph (1), a 
        protected health care professional is considered to be acting 
        in good faith with respect to disclosure of information or 
        participation if, with respect to the information disclosed as 
        part of the action--
                    (A) the disclosure is made on the basis of personal 
                knowledge and is consistent with that degree of 
                learning and skill ordinarily possessed by health care 
                professionals with the same licensure or certification 
                and the same experience;
                    (B) the professional reasonably believes the 
                information to be true;
                    (C) the information evidences either a violation of 
                a law, rule, or regulation, of an applicable 
                accreditation standard, or of a generally recognized 
                professional or clinical standard or that a patient is 
                in imminent hazard of loss of life or serious injury; 
                and
                    (D) subject to subparagraphs (B) and (C) of 
                paragraph (3), the professional has followed reasonable 
                internal procedures of the plan, issuer, or 
                institutional health care provider established for the 
                purpose of addressing quality concerns before making 
                the disclosure.
            (3) Exception and special rule.--
                    (A) General exception.--Paragraph (1) does not 
                protect disclosures that would violate Federal or State 
                law or diminish or impair the rights of any person to 
                the continued protection of confidentiality of 
                communications provided by such law.
                    (B) Notice of internal procedures.--Subparagraph 
                (D) of paragraph (2) shall not apply unless the 
                internal procedures involved are reasonably expected to 
                be known to the health care professional involved. For 
                purposes of this subparagraph, a health care 
                professional is reasonably expected to know of internal 
                procedures if those procedures have been made available 
                to the professional through distribution or posting.
                    (C) Internal procedure exception.--Subparagraph (D) 
                of paragraph (2) also shall not apply if--
                            (i) the disclosure relates to an imminent 
                        hazard of loss of life or serious injury to a 
                        patient;
                            (ii) the disclosure is made to an 
                        appropriate private accreditation body pursuant 
                        to disclosure procedures established by the 
                        body; or
                            (iii) the disclosure is in response to an 
                        inquiry made in an investigation or proceeding 
                        of an appropriate public regulatory agency and 
                        the information disclosed is limited to the 
                        scope of the investigation or proceeding.
            (4) Additional considerations.--It shall not be a violation 
        of paragraph (1) to take an adverse action against a protected 
        health care professional if the plan, issuer, or provider 
        taking the adverse action involved demonstrates that it would 
        have taken the same adverse action even in the absence of the 
        activities protected under such paragraph.
            (5) Notice.--A group health plan, health insurance issuer, 
        and institutional health care provider shall post a notice, to 
        be provided or approved by the Secretary of Labor, setting 
        forth excerpts from, or summaries of, the pertinent provisions 
        of this subsection and information pertaining to enforcement of 
        such provisions.
            (6) Constructions.--
                    (A) Determinations of coverage.--Nothing in this 
                subsection shall be construed to prohibit a plan or 
                issuer from making a determination not to pay for a 
                particular medical treatment or service or the services 
                of a type of health care professional.
                    (B) Enforcement of peer review protocols and 
                internal procedures.--Nothing in this subsection shall 
                be construed to prohibit a plan, issuer, or provider 
                from establishing and enforcing reasonable peer review 
                or utilization review protocols or determining whether 
                a protected health care professional has complied with 
                those protocols or from establishing and enforcing 
                internal procedures for the purpose of addressing 
                quality concerns.
                    (C) Relation to other rights.--Nothing in this 
                subsection shall be construed to abridge rights of 
                participants, beneficiaries, enrollees, and protected 
                health care professionals under other applicable 
                Federal or State laws.
            (7) Protected health care professional defined.--For 
        purposes of this subsection, the term ``protected health care 
        professional'' means an individual who is a licensed or 
        certified health care professional and who--
                    (A) with respect to a group health plan or health 
                insurance issuer, is an employee of the plan or issuer 
                or has a contract with the plan or issuer for provision 
                of services for which benefits are available under the 
                plan or issuer; or
                    (B) with respect to an institutional health care 
                provider, is an employee of the provider or has a 
                contract or other arrangement with the provider 
                respecting the provision of health care services.

                        Subtitle E--Definitions

SEC. 151. DEFINITIONS.

    (a) Incorporation of General Definitions.--Except as otherwise 
provided, the provisions of section 2791 of the Public Health Service 
Act shall apply for purposes of this title in the same manner as they 
apply for purposes of title XXVII of such Act.
    (b) Secretary.--Except as otherwise provided, the term 
``Secretary'' means the Secretary of Health and Human Services, in 
consultation with the Secretary of Labor and the term ``appropriate 
Secretary'' means the Secretary of Health and Human Services in 
relation to carrying out this title under sections 2706 and 2751 of the 
Public Health Service Act and the Secretary of Labor in relation to 
carrying out this title under section 713 of the Employee Retirement 
Income Security Act of 1974.
    (c) Additional Definitions.--For purposes of this title:
            (1) Actively practicing.--The term ``actively practicing'' 
        means, with respect to a physician or other health care 
        professional, such a physician or professional who provides 
        professional services to individual patients on average at 
        least two full days per week.
            (2) Applicable authority.--The term ``applicable 
        authority'' means--
                    (A) in the case of a group health plan, the 
                Secretary of Health and Human Services and the 
                Secretary of Labor; and
                    (B) in the case of a health insurance issuer with 
                respect to a specific provision of this title, the 
                applicable State authority (as defined in section 
                2791(d) of the Public Health Service Act), or the 
                Secretary of Health and Human Services, if such 
                Secretary is enforcing such provision under section 
                2722(a)(2) or 2761(a)(2) of the Public Health Service 
                Act.
            (3) Clinical peer.--The term ``clinical peer'' means, with 
        respect to a review or appeal, an actively practicing physician 
        (allopathic or osteopathic) or other actively practicing health 
        care professional who holds a nonrestricted license, and who is 
        appropriately credentialed in the same or similar specialty or 
        subspecialty (as appropriate) as typically handles the medical 
        condition, procedure, or treatment under review or appeal and 
        includes a pediatric specialist where appropriate; except that 
        only a physician (allopathic or osteopathic) may be a clinical 
        peer with respect to the review or appeal of treatment 
        recommended or rendered by a physician.
            (4) Enrollee.--The term ``enrollee'' means, with respect to 
        health insurance coverage offered by a health insurance issuer, 
        an individual enrolled with the issuer to receive such 
        coverage.
            (5) Group health plan.--The term ``group health plan'' has 
        the meaning given such term in section 733(a) of the Employee 
        Retirement Income Security Act of 1974 and in section 
        2791(a)(1) of the Public Health Service Act.
            (6) Health care professional.--The term ``health care 
        professional'' means an individual who is licensed, accredited, 
        or certified under State law to provide specified health care 
        services and who is operating within the scope of such 
        licensure, accreditation, or certification.
            (7) Health care provider.--The term ``health care 
        provider'' includes a physician or other health care 
        professional, as well as an institutional or other facility or 
        agency that provides health care services and that is licensed, 
        accredited, or certified to provide health care items and 
        services under applicable State law.
            (8) Network.--The term ``network'' means, with respect to a 
        group health plan or health insurance issuer offering health 
        insurance coverage, the participating health care professionals 
        and providers through whom the plan or issuer provides health 
        care items and services to participants, beneficiaries, or 
        enrollees.
            (9) Nonparticipating.--The term ``nonparticipating'' means, 
        with respect to a health care provider that provides health 
        care items and services to a participant, beneficiary, or 
        enrollee under group health plan or health insurance coverage, 
        a health care provider that is not a participating health care 
        provider with respect to such items and services.
            (10) Participating.--The term ``participating'' means, with 
        respect to a health care provider that provides health care 
        items and services to a participant, beneficiary, or enrollee 
        under group health plan or health insurance coverage offered by 
        a health insurance issuer, a health care provider that 
        furnishes such items and services under a contract or other 
        arrangement with the plan or issuer.
            (11) Prior authorization.--The term ``prior authorization'' 
        means the process of obtaining prior approval from a health 
        insurance issuer or group health plan for the provision or 
        coverage of medical services.

SEC. 152. PREEMPTION; STATE FLEXIBILITY; CONSTRUCTION.

    (a) Continued Applicability of State Law With Respect to Health 
Insurance Issuers.--
            (1) In general.--Subject to paragraph (2), this title shall 
        not be construed to supersede any provision of State law which 
        establishes, implements, or continues in effect any standard or 
        requirement solely relating to health insurance issuers (in 
        connection with group health insurance coverage or otherwise) 
        except to the extent that such standard or requirement prevents 
        the application of a requirement of this title.
            (2) Continued preemption with respect to group health 
        plans.--Nothing in this title shall be construed to affect or 
        modify the provisions of section 514 of the Employee Retirement 
        Income Security Act of 1974 with respect to group health plans.
    (b) Definitions.--For purposes of this section:
            (1) State law.--The term ``State law'' includes all laws, 
        decisions, rules, regulations, or other State action having the 
        effect of law, of any State. A law of the United States 
applicable only to the District of Columbia shall be treated as a State 
law rather than a law of the United States.
            (2) State.--The term ``State'' includes a State, the 
        District of Columbia, Puerto Rico, the Virgin Islands, Guam, 
        American Samoa, the Northern Mariana Islands, any political 
        subdivisions of such, or any agency or instrumentality of such.

SEC. 153. EXCLUSIONS.

    (a) No Benefit Requirements.--Nothing in this title shall be 
construed to require a group health plan or a health insurance issuer 
offering health insurance coverage to include specific items and 
services under the terms of such a plan or coverage, other than those 
that are provided for under the terms of such plan or coverage.
    (b) Exclusion from Access to Care Managed Care Provisions for Fee-
for-Service Coverage.--
            (1) In general.--The provisions of sections 111 through 117 
        shall not apply to a group health plan or health insurance 
        coverage if the only coverage offered under the plan or 
        coverage is fee-for-service coverage (as defined in paragraph 
        (2)).
            (2) Fee-for-service coverage defined.--For purposes of this 
        subsection, the term ``fee-for-service coverage'' means 
        coverage under a group health plan or health insurance coverage 
        that--
                    (A) reimburses hospitals, health professionals, and 
                other providers on the basis of a rate determined by 
                the plan or issuer on a fee-for-service basis without 
                placing the provider at financial risk;
                    (B) does not vary reimbursement for such a provider 
                based on an agreement to contract terms and conditions 
                or the utilization of health care items or services 
                relating to such provider;
                    (C) does not restrict the selection of providers 
                among those who are lawfully authorized to provide the 
                covered services and agree to accept the terms and 
                conditions of payment established under the plan or by 
                the issuer; and
                    (D) for which the plan or issuer does not require 
                prior authorization before providing coverage for any 
                services.

SEC. 154. COVERAGE OF LIMITED SCOPE PLANS.

    Only for purposes of applying the requirements of this title under 
sections 2707 and 2753 of the Public Health Service Act and section 714 
of the Employee Retirement Income Security Act of 1974, section 
2791(c)(2)(A), and section 733(c)(2)(A) of the Employee Retirement 
Income Security Act of 1974 shall be deemed not to apply.

SEC. 155. REGULATIONS.

    The Secretaries of Health and Human Services and Labor shall issue 
such regulations as may be necessary or appropriate to carry out this 
title. Such regulations shall be issued consistent with section 104 of 
Health Insurance Portability and Accountability Act of 1996. Such 
Secretaries may promulgate any interim final rules as the Secretaries 
determine are appropriate to carry out this title.

 TITLE II--APPLICATION OF QUALITY CARE STANDARDS TO GROUP HEALTH PLANS 
   AND HEALTH INSURANCE COVERAGE UNDER THE PUBLIC HEALTH SERVICE ACT

SEC. 201. APPLICATION TO GROUP HEALTH PLANS AND GROUP HEALTH INSURANCE 
              COVERAGE.

    (a) In General.--Subpart 2 of part A of title XXVII of the Public 
Health Service Act is amended by adding at the end the following new 
section:

``SEC. 2707. PATIENT PROTECTION STANDARDS.

    ``(a) In General.--Each group health plan shall comply with patient 
protection requirements under title I of the Patients' Bill of Rights 
Act, and each health insurance issuer shall comply with patient 
protection requirements under such title with respect to group health 
insurance coverage it offers, and such requirements shall be deemed to 
be incorporated into this subsection.
    ``(b) Notice.--A group health plan shall comply with the notice 
requirement under section 711(d) of the Employee Retirement Income 
Security Act of 1974 with respect to the requirements referred to in 
subsection (a) and a health insurance issuer shall comply with such 
notice requirement as if such section applied to such issuer and such 
issuer were a group health plan.''.
    (b) Conforming Amendment.--Section 2721(b)(2)(A) of such Act (42 
U.S.C. 300gg-21(b)(2)(A)) is amended by inserting ``(other than section 
2707)'' after ``requirements of such subparts''.

SEC. 202. APPLICATION TO INDIVIDUAL HEALTH INSURANCE COVERAGE.

    Part B of title XXVII of the Public Health Service Act is amended 
by inserting after section 2752 the following new section:

``SEC. 2753. PATIENT PROTECTION STANDARDS.

    ``(a) In General.--Each health insurance issuer shall comply with 
patient protection requirements under title I of the Patients' Bill of 
Rights Act with respect to individual health insurance coverage it 
offers, and such requirements shall be deemed to be incorporated into 
this subsection.
    ``(b) Notice.--A health insurance issuer under this part shall 
comply with the notice requirement under section 711(d) of the Employee 
Retirement Income Security Act of 1974 with respect to the requirements 
of such title as if such section applied to such issuer and such issuer 
were a group health plan.''.

TITLE III--AMENDMENTS TO THE EMPLOYEE RETIREMENT INCOME SECURITY ACT OF 
                                  1974

SEC. 301. APPLICATION OF PATIENT PROTECTION STANDARDS TO GROUP HEALTH 
              PLANS AND GROUP HEALTH INSURANCE COVERAGE UNDER THE 
              EMPLOYEE RETIREMENT INCOME SECURITY ACT OF 1974.

    Subpart B of part 7 of subtitle B of title I of the Employee 
Retirement Income Security Act of 1974 is amended by adding at the end 
the following new section:

``SEC. 714. PATIENT PROTECTION STANDARDS.

    ``(a) In General.--Subject to subsection (b), a group health plan 
(and a health insurance issuer offering group health insurance coverage 
in connection with such a plan) shall comply with the requirements of 
title I of the Patients' Bill of Rights Act (as in effect as of the 
date of the enactment of such Act), and such requirements shall be 
deemed to be incorporated into this subsection.
    ``(b) Plan Satisfaction of Certain Requirements.--
            ``(1) Satisfaction of certain requirements through 
        insurance.--For purposes of subsection (a), insofar as a group 
        health plan provides benefits in the form of health insurance 
        coverage through a health insurance issuer, the plan shall be 
        treated as meeting the following requirements of title I of the 
        Patients' Bill of Rights Act with respect to such benefits and 
        not be considered as failing to meet such requirements because 
        of a failure of the issuer to meet such requirements so long as 
        the plan sponsor or its representatives did not cause such 
        failure by the issuer:
                    ``(A) Section 112 (relating to choice of 
                providers).
                    ``(B) Section 113 (relating to access to emergency 
                care).
                    ``(C) Section 114 (relating to access to specialty 
                care).
                    ``(D) Section 115 (relating to access to 
                obstetrical and gynecological care).
                    ``(E) Section 116 (relating to access to pediatric 
                care).
                    ``(F) Section 117(a)(1) (relating to continuity in 
                case of termination of provider contract) and section 
                117(a)(2) (relating to continuity in case of 
                termination of issuer contract), but only insofar as a 
                replacement issuer assumes the obligation for 
                continuity of care.
                    ``(G) Section 118 (relating to access to needed 
                prescription drugs).
                    ``(H) Section 119 (relating to coverage for 
                individuals participating in approved clinical trials.)
                    ``(I) Section 134 (relating to payment of claims).
            ``(2) Information.--With respect to information required to 
        be provided or made available under section 121, in the case of 
        a group health plan that provides benefits in the form of 
        health insurance coverage through a health insurance issuer, 
        the Secretary shall determine the circumstances under which the 
        plan is not required to provide or make available the 
        information (and is not liable for the issuer's failure to 
        provide or make available the information), if the issuer is 
        obligated to provide and make available (or provides and makes 
        available) such information.
            ``(3) Grievance and internal appeals.--With respect to the 
        internal appeals process and the grievance system required to 
        be established under sections 102 and 104, in the case of a 
        group health plan that provides benefits in the form of health 
        insurance coverage through a health insurance issuer, the 
        Secretary shall determine the circumstances under which the 
        plan is not required to provide for such process and system 
        (and is not liable for the issuer's failure to provide for such 
        process and system), if the issuer is obligated to provide for 
        (and provides for) such process and system.
            ``(4) External appeals.--Pursuant to rules of the 
        Secretary, insofar as a group health plan enters into a 
        contract with a qualified external appeal entity for the 
        conduct of external appeal activities in accordance with 
        section 103, the plan shall be treated as meeting the 
        requirement of such section and is not liable for the entity's 
        failure to meet any requirements under such section.
            ``(5) Application to prohibitions.--Pursuant to rules of 
        the Secretary, if a health insurance issuer offers health 
        insurance coverage in connection with a group health plan and 
        takes an action in violation of any of the following sections, 
        the group health plan shall not be liable for such violation 
        unless the plan caused such violation:
                    ``(A) Section 131 (relating to prohibition of 
                interference with certain medical communications).
                    ``(B) Section 132 (relating to prohibition of 
                discrimination against providers based on licensure).
                    ``(C) Section 133 (relating to prohibition against 
                improper incentive arrangements).
                    ``(D) Section 135 (relating to protection for 
                patient advocacy).
            ``(6) Construction.--Nothing in this subsection shall be 
        construed to affect or modify the responsibilities of the 
        fiduciaries of a group health plan under part 4 of subtitle B.
            ``(7) Application to certain prohibitions against 
        retaliation.--With respect to compliance with the requirements 
        of section 135(b)(1) of the Patients' Bill of Rights Act, for 
        purposes of this subtitle the term `group health plan' is 
        deemed to include a reference to an institutional health care 
        provider.
    ``(c) Enforcement of Certain Requirements.--
            ``(1) Complaints.--Any protected health care professional 
        who believes that the professional has been retaliated or 
        discriminated against in violation of section 135(b)(1) of the 
        Patients' Bill of Rights Act may file with the Secretary a 
        complaint within 180 days of the date of the alleged 
        retaliation or discrimination.
            ``(2) Investigation.--The Secretary shall investigate such 
        complaints and shall determine if a violation of such section 
        has occurred and, if so, shall issue an order to ensure that 
        the protected health care professional does not suffer any loss 
        of position, pay, or benefits in relation to the plan, issuer, 
        or provider involved, as a result of the violation found by the 
        Secretary.
    ``(d) Conforming Regulations.--The Secretary may issue regulations 
to coordinate the requirements on group health plans under this section 
with the requirements imposed under the other provisions of this 
title.''.
    (b) Satisfaction of ERISA Claims Procedure Requirement.--Section 
503 of such Act (29 U.S.C. 1133) is amended by inserting ``(a)'' after 
``Sec. 503.'' and by adding at the end the following new subsection:
    ``(b) In the case of a group health plan (as defined in section 
733) compliance with the requirements of subtitle A of title I of the 
Patients Bill of Rights Act in the case of a claims denial shall be 
deemed compliance with subsection (a) with respect to such claims 
denial.''.
    (c) Conforming Amendments.--(1) Section 732(a) of such Act (29 
U.S.C. 1185(a)) is amended by striking ``section 711'' and inserting 
``sections 711 and 714''.
    (2) The table of contents in section 1 of such Act is amended by 
inserting after the item relating to section 713 the following new 
item:

``Sec. 714. Patient protection standards.''.
    (3) Section 502(b)(3) of such Act (29 U.S.C. 1132(b)(3)) is amended 
by inserting ``(other than section 135(b))'' after ``part 7''.

SEC. 302. ERISA PREEMPTION NOT TO APPLY TO CERTAIN ACTIONS INVOLVING 
              HEALTH INSURANCE POLICYHOLDERS.

    (a) In General.--Section 514 of the Employee Retirement Income 
Security Act of 1974 (29 U.S.C. 1144) (as amended by section 301(b)) is 
amended further by adding at the end the following subsections:
    ``(f) Preemption Not To Apply to Certain Actions Arising Out of 
Provision of Health Benefits.--
            ``(1) Non-preemption of certain causes of action.--
                    ``(A) In general.--Except as provided in this 
                subsection, nothing in this title shall be construed to 
                invalidate, impair, or supersede any cause of action by 
                a participant or beneficiary (or the estate of a 
                participant or beneficiary) under State law to recover 
                damages resulting from personal injury or for wrongful 
                death against any person--
                            ``(i) in connection with the provision of 
                        insurance, administrative services, or medical 
                        services by such person to or for a group 
                        health plan as defined in section 733), or
                            ``(ii) that arises out of the arrangement 
                        by such person for the provision of such 
                        insurance, administrative services, or medical 
                        services by other persons.
                    ``(B) Limitation on punitive damages.--
                            ``(i) In general.--No person shall be 
                        liable for any punitive, exemplary, or similar 
                        damages in the case of a cause of action 
                        brought under subparagraph (A) if--
                                    ``(I) it relates to an externally 
                                appealable decision (as defined in 
                                subsection (a)(2) of section 103 of the 
                                Patients' Bill of Rights Act);
                                    ``(II) an external appeal with 
                                respect to such decision was completed 
                                under such section 103;
                                    ``(III) in the case such external 
                                appeal was initiated by the plan or 
                                issuer filing the request for the 
                                external appeal, the request was filed 
                                on a timely basis before the date the 
                                action was brought or, if later, within 
                                30 days after the date the externally 
                                appealable decision was made; and
                                    ``(IV) the plan or issuer complied 
                                with the determination of the external 
                                appeal entity upon receipt of the 
                                determination of the external appeal 
                                entity.
                        The provisions of this clause supersede any 
                        State law or common law to the contrary.
                            ``(ii) Exception.--Clause (i) shall not 
                        apply with respect to damages in the case of a 
                        cause of action for wrongful death if the 
                        applicable State law provides (or has been 
                        construed to provide) for damages in such a 
                        cause of action which are only punitive or 
                        exemplary in nature.
                    ``(C) Personal injury defined.--For purposes of 
                this subsection, the term `personal injury' means a 
                physical injury and includes an injury arising out of 
                the treatment (or failure to treat) a mental illness or 
                disease.
            ``(2) Exception for group health plans, employers, and 
        other plan sponsors.--
                    ``(A) In general.--Subject to subparagraph (B), 
                paragraph (1) does not authorize--
                            ``(i) any cause of action against a group 
                        health plan or an employer or other plan 
                        sponsor maintaining the plan (or against an 
                        employee of such a plan, employer, or sponsor 
                        acting within the scope of employment), or
                            ``(ii) a right of recovery, indemnity, or 
                        contribution by a person against a group health 
                        plan or an employer or other plan sponsor (or 
                        such an employee) for damages assessed against 
                        the person pursuant to a cause of action under 
                        paragraph (1).
                    ``(B) Special rule.--Subparagraph (A) shall not 
                preclude any cause of action described in paragraph (1) 
                against group health plan or an employer or other plan 
                sponsor (or against an employee of such a plan, 
                employer, or sponsor acting within the scope of 
                employment) if--
                            ``(i) such action is based on the exercise 
                        by the plan, employer, or sponsor (or employee) 
                        of discretionary authority to make a decision 
                        on a claim for benefits covered under the plan 
                        or health insurance coverage in the case at 
                        issue; and
                            ``(ii) the exercise by the plan, employer, 
                        or sponsor (or employee) of such authority 
                        resulted in personal injury or wrongful death.
                    ``(C) Exception.--The exercise of discretionary 
                authority described in subparagraph (B)(i) shall not be 
                construed to include--
                            ``(i) the decision to include or exclude 
                        from the plan any specific benefit;
                            ``(ii) any decision to provide extra-
                        contractual benefits; or
                            ``(iii) any decision not to consider the 
                        provision of a benefit while internal or 
                        external review is being conducted.
            ``(3) Futility of exhaustion.--An individual bringing an 
        action under this subsection is required to exhaust 
        administrative processes under sections 102 and 103 of the 
        Patients' Bill of Rights Act, unless the injury to or death of 
        such individual has occurred before the completion of such 
        processes.
            ``(4) Construction.--Nothing in this subsection shall be 
        construed as--
                    ``(A) permitting a cause of action under State law 
                for the failure to provide an item or service which is 
                specifically excluded under the group health plan 
                involved;
                    ``(B) as preempting a State law which requires an 
                affidavit or certificate of merit in a civil action; or
                    ``(C) permitting a cause of action or remedy under 
                State law in connection with the provision or 
                arrangement of excepted benefits (as defined in section 
                733(c)), other than those described in section 
                733(c)(2)(A).
    ``(g) Rules of Construction Relating to Health Care.--Nothing in 
this title shall be construed as--
            ``(1) permitting the application of State laws that are 
        otherwise superseded by this title and that mandate the 
        provision of specific benefits by a group health plan (as 
        defined in section 733(a)) or a multiple employer welfare 
        arrangement (as defined in section 3(40)), or
            ``(2) affecting any State law which regulates the practice 
        of medicine or provision of medical care, or affecting any 
        action based upon such a State law.''.
    (b) Effective Date.--The amendment made by subsection (a) shall 
apply to acts and omissions occurring on or after the date of enactment 
of this Act, from which a cause of action arises.

SEC. 303. LIMITATIONS ON ACTIONS.

    Section 502 of the Employee Retirement Income Security Act of 1974 
(29 U.S.C. 1132) (as amended by section 304(b)) is amended further by 
adding at the end the following new subsection:
    ``(o)(1) Except as provided in this subsection, no action may be 
brought under subsection (a)(1)(B), (a)(2), or (a)(3) by a participant 
or beneficiary seeking relief based on the application of any provision 
in section 101, subtitle B, or subtitle D of title I of the Patients' 
Bill of Rights Act (as incorporated under section 714).
    ``(2) An action may be brought under subsection (a)(1)(B), (a)(2), 
or (a)(3) by a participant or beneficiary seeking relief based on the 
application of section 101, 113, 114, 115, 116, 117, 119, or 118(3) of 
the Patients' Bill of Rights Act (as incorporated under section 714) to 
the individual circumstances of that participant or beneficiary, except 
that--
            ``(A) such an action may not be brought or maintained as a 
        class action; and
            ``(B) in such an action, relief may only provide for the 
        provision of (or payment of) benefits, items, or services 
        denied to the individual participant or beneficiary involved 
        (and for attorney's fees and the costs of the action, at the 
        discretion of the court) and shall not provide for any other 
        relief to the participant or beneficiary or for any relief to 
        any other person.
    ``(3) Nothing in this subsection shall be construed as affecting 
any action brought by the Secretary.''.

TITLE IV--APPLICATION TO GROUP HEALTH PLANS UNDER THE INTERNAL REVENUE 
                              CODE OF 1986

SEC. 401. AMENDMENTS TO THE INTERNAL REVENUE CODE OF 1986.

    Subchapter B of chapter 100 of the Internal Revenue Code of 1986 is 
amended--
            (1) in the table of sections, by inserting after the item 
        relating to section 9812 the following new item:

                              ``Sec. 9813. Standard relating to patient 
                                        freedom of choice.'';
        and
            (2) by inserting after section 9812 the following:

``SEC. 9813. STANDARD RELATING TO PATIENTS' BILL OF RIGHTS.

    ``A group health plan shall comply with the requirements of title I 
of the Patients' Bill of Rights Act (as in effect as of the date of the 
enactment of such Act), and such requirements shall be deemed to be 
incorporated into this section.''.

        TITLE V--EFFECTIVE DATES; COORDINATION IN IMPLEMENTATION

SEC. 501. EFFECTIVE DATES.

    (a) Group Health Coverage.--
            (1) In general.--Subject to paragraph (2), the amendments 
        made by sections 201(a), 301, 303, and 401 (and title I insofar 
        as it relates to such sections) shall apply with respect to 
        group health plans, and health insurance coverage offered in 
        connection with group health plans, for plan years beginning on 
        or after January 1, 2002 (in this section referred to as the 
        ``general effective date'') and also shall apply to portions of 
        plan years occurring on and after such date.
            (2) Treatment of collective bargaining agreements.--In the 
        case of a group health plan maintained pursuant to one or more 
        collective bargaining agreements between employee 
        representatives and one or more employers ratified before the 
        date of the enactment of this Act, the amendments made by 
        sections 201(a), 301, 303, and 401 (and title I insofar as it 
        relates to such sections) shall not apply to plan years 
        beginning before the later of--
                    (A) the date on which the last collective 
                bargaining agreements relating to the plan terminates 
                (determined without regard to any extension thereof 
                agreed to after the date of the enactment of this Act); 
                or
                    (B) the general effective date.
        For purposes of subparagraph (A), any plan amendment made 
        pursuant to a collective bargaining agreement relating to the 
        plan which amends the plan solely to conform to any requirement 
        added by this Act shall not be treated as a termination of such 
        collective bargaining agreement.
    (b) Individual Health Insurance Coverage.--The amendments made by 
section 202 shall apply with respect to individual health insurance 
coverage offered, sold, issued, renewed, in effect, or operated in the 
individual market on or after the general effective date.

SEC. 502. COORDINATION IN IMPLEMENTATION.

    The Secretary of Labor, the Secretary of Health and Human Services, 
and the Secretary of the Treasury shall ensure, through the execution 
of an interagency memorandum of understanding among such Secretaries, 
that--
            (1) regulations, rulings, and interpretations issued by 
        such Secretaries relating to the same matter over which such 
        Secretaries have responsibility under the provisions of this 
        Act (and the amendments made thereby) are administered so as to 
        have the same effect at all times; and
            (2) coordination of policies relating to enforcing the same 
        requirements through such Secretaries in order to have a 
        coordinated enforcement strategy that avoids duplication of 
        enforcement efforts and assigns priorities in enforcement.

                   TITLE VI--MISCELLANEOUS PROVISIONS

SEC. 601. HEALTH CARE PAPERWORK SIMPLIFICATION.

    (a) Establishment of Panel.--
            (1) Establishment.--There is established a panel to be 
        known as the Health Care Panel to Devise a Uniform Explanation 
        of Benefits (in this section referred to as the ``Panel'').
            (2) Duties of panel.--
                    (A) In general.--The Panel shall devise a single 
                form for use by third-party health care payers for the 
                remittance of claims to providers.
                    (B) Definition.--For purposes of this section, the 
                term ``third-party health care payer'' means any entity 
                that contractually pays health care bills for an 
                individual.
            (3) Membership.--
                    (A) Size and composition.--The Secretary of Health 
                and Human Services shall determine the number of 
                members and the composition of the Panel. Such Panel 
                shall include equal numbers of representatives of 
                private insurance organizations, consumer groups, State 
                insurance commissioners, State medical societies, State 
                hospital associations, and State medical specialty 
                societies.
                    (B) Terms of appointment.--The members of the Panel 
                shall serve for the life of the Panel.
                    (C) Vacancies.--A vacancy in the Panel shall not 
                affect the power of the remaining members to execute 
                the duties of the Panel, but any such vacancy shall be 
                filled in the same manner in which the original 
                appointment was made.
            (4) Procedures.--
                    (A) Meetings.--The Panel shall meet at the call of 
                a majority of its members.
                    (B) First meeting.--The Panel shall convene not 
                later than 60 days after the date of the enactment of 
                the Bipartisan Consensus Managed Care Improvement Act 
                of 1999.
                    (C) Quorum.--A quorum shall consist of a majority 
                of the members of the Panel.
                    (D) Hearings.--For the purpose of carrying out its 
                duties, the Panel may hold such hearings and undertake 
                such other activities as the Panel determines to be 
                necessary to carry out its duties.
            (5) Administration.--
                    (A) Compensation.--Except as provided in 
                subparagraph (B), members of the Panel shall receive no 
                additional pay, allowances, or benefits by reason of 
                their service on the Panel.
                    (B) Travel expenses and per diem.--Each member of 
                the Panel who is not an officer or employee of the 
                Federal Government shall receive travel expenses and 
                per diem in lieu of subsistence in accordance with 
                sections 5702 and 5703 of title 5, United States Code.
                    (C) Contract authority.--The Panel may contract 
                with and compensate Government and private agencies or 
                persons for items and services, without regard to 
                section 3709 of the Revised Statutes (41 U.S.C. 5).
                    (D) Use of mails.--The Panel may use the United 
                States mails in the same manner and under the same 
                conditions as Federal agencies and shall, for purposes 
                of the frank, be considered a commission of Congress as 
                described in section 3215 of title 39, United States 
                Code.
                    (E) Administrative support services.--Upon the 
                request of the Panel, the Secretary of Health and Human 
                Services shall provide to the Panel on a reimbursable 
                basis such administrative support services as the Panel 
                may request.
            (6) Submission of form.--Not later than 2 years after the 
        first meeting, the Panel shall submit a form to the Secretary 
        of Health and Human Services for use by third-party health care 
        payers.
            (7) Termination.--The Panel shall terminate on the day 
        after submitting the form under paragraph (6).
    (b) Requirement for Use of Form by Third-Party Care Payers.--A 
third-party health care payer shall be required to use the form devised 
under subsection (a) for plan years beginning on or after 5 years 
following the date of the enactment of this Act.

SEC. 602. NO IMPACT ON SOCIAL SECURITY TRUST FUND.

    (a) In General.--Nothing in this Act (or an amendment made by this 
Act) shall be construed to alter or amend the Social Security Act (or 
any regulation promulgated under that Act).
    (b) Transfers.--
            (1) Estimate of secretary.--The Secretary of the Treasury 
        shall annually estimate the impact that the enactment of this 
        Act has on the income and balances of the trust funds 
        established under section 201 of the Social Security Act (42 
        U.S.C. 401).
            (2) Transfer of funds.--If, under paragraph (1), the 
        Secretary of the Treasury estimates that the enactment of this 
        Act has a negative impact on the income and balances of the 
        trust funds established under section 201 of the Social 
        Security Act (42 U.S.C. 401), the Secretary shall transfer, not 
        less frequently than quarterly, from the general revenues of 
        the Federal Government an amount sufficient so as to ensure 
        that the income and balances of such trust funds are not 
        reduced as a result of the enactment of such Act.

SEC. 603. FMAP REDUCTION FOR OTHER THAN SUBSTANTIAL NONCOMPLIANCE WITH 
              MEDICAID STATE PLAN REQUIREMENTS.

    (a) In General.--Section 1904 of the Social Security Act (42 U.S.C. 
1396c) is amended--
            (1) by striking all (including the heading) that precedes 
        ``If the Secretary'' and inserting the following:

             ``sanctions for non-compliance of state plans

    Sec. 1904. (a) Sanctions for Substantial Non-Compliance.--''; and
            (2) by adding at the end the following new subsection:
    ``(b) Other Sanctions.--
            ``(1) In general.--If the Secertary, after affording the 
        State agency reasonable notice and opportunity for hearing, 
        finds a failure of the State plan to comply with section 1902, 
        or a failure of plan administration to comply with the plan, 
        other than a failure of the severity described in subsection 
        (a), the Secretary may reduce payments under section 1903(a)(1) 
        to that State by up to 0.5 percent for each instance of such 
        non-compliance.
            ``(2) Continuation of reductions.--Reductions under 
        paragraph (1) are authorized to continue until the Secretary is 
        satisfied that the instance of non-compliance has ceased and 
        will not recur.''.
    (b) Conforming Amendments.--
            (1) Section 1903(a)(1) of such Act (42 U.S.C. 1396b(a)(1)) 
        is amended by striking ``and subsection 1923(f)'' and inserting 
        ``sections 1904 and 1923(f)''.
            (2) Section 1905(b) of such Act (42 U.S.C. 1396d(b)) is 
        amended by striking ``section 1933(d)'' and inserting 
        ``sections 1904 and 1933(d)''.
    (c) Effective Date.--The amendments made by this section take 
effect on October 1, 2000.

SEC. 604. CUSTOMS USER FEES.

    Section 13031(j)(3) of the Consolidated Omnibus Budget 
Reconciliation Act of 1985 (19 U.S.C. 58c(j)(3)) is amended by striking 
``2003'' and inserting ``2010''.

                                                       Calendar No. 808

106th CONGRESS

  2d Session

                                S. 3057

_______________________________________________________________________

                                 A BILL

To amend the Public Health Service Act, the Employee Retirement Income 
Security Act of 1974, and the Internal Revenue Code of 1986 to protect 
       consumers in managed care plans and other health coverage.

_______________________________________________________________________

                           September 18, 2000

            Read the second time and placed on the calendar
```