(g) COVERAGE
OF CONSULTATION
FOR SECOND
OPINIONS.—A managed care organization shall provide
enrollees with access to a consultation for a second opinion
regarding treatment options.
SEC. 6. ASSURING UNBIASED MEDICAL DETERMINATIONS
BY HEALTH CARE PROFESSIONALS AND PRO-
VIDERS.
(a) REQUIRING
MEDICAL
DETERMINATIONS
BY
TREATING PROFESSIONAL.—A managed care organiza-
tion may not deny payment for services covered under a
managed care plan based upon the fact that the services
are not medically necessary or appropriate with respect
to an enrollee unless the determination is made solely by
the health care professional treating the enrollee.
(b) PROHIBITION OF CERTAIN INCENTIVE ARRANGE-
MENTS.—
(1) IN GENERAL.—No managed care organiza-
tion shall offer monetary rewards, penalties, or in-
ducements (including varying the amount of com-
pensation) to a health care professional or provider,
or condition the initial or continued participation of
such a professional or provider in a managed care
plan offered by the organization, on the basis of the
professional’s or provider’s decision (or decisions) to
reduce or limit the availability of appropriate medi-
cal tests, services, or treatment, on the basis of any
utilization review decisions relating to the profes-
sional or provider, or the number of referrals, tests,
or other procedures ordered or performed by the
professional or provider.
(2) PENALTY.—Any managed care organiza-
tion, or executive of such an organization, that
knowingly offers a reward, penalty, or inducement in
violation of paragraph (1) shall be fined in accord-
ance with title 18, United States Code, imprisoned
for not more than 2 years, or both.
(c) PROHIBITION OF INTERFERENCE WITH CERTAIN
MEDICAL COMMUNICATIONS.—
(1) IN GENERAL.—The provisions of any con-
tract or agreement, or the operation of any contract
or agreement, between a managed care organization
and a health care professional shall not prohibit or
restrict the health care professional from engaging
in medical communications with a patient of the pro-
fessional.
(2) MEDICAL COMMUNICATION DEFINED.—For
purposes of this subsection, the term ‘‘medical com-
munication’’ means a communication made by a
health care professional with a patient of the health
care professional (or the guardian or legal represent-
ative of the patient) with respect to—
(A) the patient’s health status, medical
care, or treatment options;
(B) any utilization review requirements
that may affect treatment options for the pa-
tient; or
(C) any financial incentives that may af-
fect the treatment of the patient.
(d) WHISTLEBLOWER PROTECTION.—
(1) IN GENERAL.—No managed care organiza-
tion may discharge or otherwise discriminate against
any employee with respect to compensation, terms,
conditions, or privileges of employment because the
employee (or any person acting pursuant to the re-
quest of the employee) provided information to a
Federal or State official with any enforcement re-
sponsibility or authority concerning the provisions of
this Act regarding a possible violation of any provi-
sion of this Act, or any regulation under any such
provision, by the organization or any director, offi-
cer, or employee of the organization.
(2) ENFORCEMENT.—Any employee or former
employee who believes that such employee has been
discharged or discriminated against in violation of
paragraph (1) may file a civil action in the appro-
priate United States District Court before the end of
the 2-year period beginning on the date of such dis-
charge or discrimination.
(3) REMEDIES.—If the District Court deter-
mines that a violation has occurred, the court may
order the organization which committed the viola-
tion—
(A) to reinstate the employee to the em-
ployee’s former position;
(B) to pay compensatory damages; or
(C) to take other appropriate actions to
remedy any past discrimination.
(4) LIMITATION.—The protections of this sub-
section shall not apply to any employee who—
(A) deliberately causes or participates in
the alleged violation of law or regulation; or
(B) knowingly or recklessly provides sub-
stantially false information to the Federal or
State official involved.
(e) PROTECTION
OF ADVOCACY FUNCTIONS.—No
managed care organization shall terminate, vary the com-
pensation or working conditions, or refuse to renew a con-
tract for participation with a health care professional be-
cause the professional has—
(1) advocated on behalf of an enrollee,
(2) filed a complaint against the organization,
(3) appealed a decision of the organization,
(4) provided information or filed a report with
an appropriate Federal or State official, or
(5) requested a hearing or review pursuant to
this Act.
SEC. 7. NONDISCRIMINATION AGAINST ENROLLEES AND IN
THE SELECTION OF PARTICIPATING PROVID-
ERS; EQUITABLE ACCESS TO NETWORKS.
(a) NONDISCRIMINATION AGAINST ENROLLEES.—No
managed care organization may discriminate (directly or
through contractual arrangements) against any enrollee
on the basis of age, gender, disability, health status, ge-
netic information, or anticipated need for health services.
(b) NONDISCRIMINATION IN SELECTION OF PARTICI-
PATING HEALTH CARE PROFESSIONALS.—A managed
care organization shall not discriminate in selecting par-
ticipating health care professionals (or in establishing the
terms and conditions for such participation) on the basis
of—
(1) the race, national origin, gender, age, or
disability (other than a disability that impairs the
ability of an individual to provide health care serv-
ices or that may threaten the health of enrollees) of
the professional; or
(2) the professional’s lack of affiliation with, or
admitting privileges at, a hospital (unless such lack
of affiliation is a result of infractions of quality
standards and is not due to a professional’s type of
license).
(c) NONDISCRIMINATION
IN ACCESS
TO HEALTH
PLANS.—
(1) IN GENERAL.—Subject to paragraph (2), a
managed care organization shall not discriminate in
participation, reimbursement, or indemnification
against a health care professional, who is acting
within the scope of the professional’s license or cer-
tification under applicable State law, solely on the
basis of such license or certification.
(2) CONSTRUCTION.—Nothing in this sub-
section shall be construed as a requirement to in-
clude for participation every willing health care pro-
fessional who meets the terms and conditions of a
managed care organization.
SEC. 8. DISCLOSURE OF INFORMATION.
(a) PROVISION
OF INFORMATION
AND ORIENTA-
TION.—
(1) GENERAL REQUIREMENT.—A managed care
organization offering a managed care plan shall pro-
vide enrollees and, upon request, prospective enroll-
ees with written information concerning the terms
and conditions of the plan, including the information
described in subsection (c).
(2) INFORMATION UPON REQUEST.—In addition
to the information provided under subsection (c), a
managed care organization offering a managed care
plan shall provide, upon request of an enrollee or
prospective enrollee, the information described in
subsection (d).
(3) REQUIREMENT FOR INITIAL INFORMATION
SESSION.—
(A) IN GENERAL.—Within 30 days of en-
rolling an individual under a managed care
plan, the managed care organization shall pro-
vide for an in-person information session with
the enrollee for the purpose of outlining the in-
formation described in this section.
(B) PAYMENT.—Such a session shall be
held with an enrollee before the enrollee is re-
quired to pay for services. This subparagraph
shall not affect the coverage of items and serv-
ices under the plan immediately upon the effec-
tive date of enrollment.
(4) COMPARATIVE
FORM.—The information
provided under this section shall be in a form, speci-
fied by the Secretary, so that prospective enrollees
may compare the attributes of all such plans offered
within a coverage area.
(b) UNDERSTANDABILITY.—Information provided
under this section, whether written or oral shall be easily
understandable, truthful, linguistically appropriate and
objective with respect to the terms used.
(c) REQUIRED INFORMATION.—Information required
under subsection (a)(1) shall include information concern-
ing each of the following:
(1) COVERAGE AND BENEFITS.—Coverage pro-
visions, benefits, and any exclusions by category of
service or product, including 24-hour coverage of
emergency services without a requirement for prior
approval.
(2) PRIOR AUTHORIZATION REQUIREMENTS.—
Prior authorization requirements for coverage of
benefits.
(3) UTILIZATION
REVIEW
POLICIES.—Utiliza-
tion review procedures and policies (including
preauthorization review, concurrent review, post-
service review, post-payment review procedures that
may lead an enrollee to be denied coverage for or not
be provided a particular service or product), includ-
ing time frames for review decisions and enrollee
rights relating to notice, reconsideration, and appeal
of utilization review decisions, and including infor-
mation on the percentage of utilization review deter-
minations that disagree with the judgment of the
initial treating health care professional and the per-
centage of such determinations which are reversed
(whether internally or externally) on appeal.
(4) PAYMENT METHODS.—Types of methodolo-
gies used by the organization to reimburse types of
providers or for types of services.
(5) 
ENROLLEE
FINANCIAL
RESPONSIBIL-
ITIES.—Enrollees’ financial responsibility for serv-
ices, including any variation in the responsibility
based on whether the provider is a participating pro-
vider.
(6) GRIEVANCE PROCEDURES.—Grievance pro-
cedures.
(7) PROVIDER SELECTION PROCEDURES.—Pro-
cedures used by enrollees to select and change pri-
mary and specialty providers and to be referred to
nonparticipating providers and appropriate special-
ists, consistent with the requirements of this Act.
(8) ENROLLEE PARTICIPATION IN POLICY DE-
VELOPMENT.—Procedures which enrollees may use
to participate in development of policy of the organi-
zation.
(9) PROCEDURES
FOR
NON-ENGLISH
PRO-
FICIENT ENROLLEES.—Procedures which the organi-
zation has established to meet the needs of enrollees
who are not proficient in English.
(10) INFORMATION.—An address and phone
number at which enrollees and prospective enrollees
can obtain information about the organization and
managed care plans offered by the organization.
(11) LIST OF CONTRACT FACILITIES.—A list,
annually updated, of the facilities and providers, by
specialty, through which the organization provides
its benefits. For each such facility or provider the
list shall include the name, address, phone number,
and (in the case of a physician) board certification.
(12) NON-HEALTH
CARE
EXPENDITURES.—A
statement of the percentage of health-care related
revenues of the organization used for administration,
the percentage of such revenues used for marketing,
and the percentage of such revenues attributable to
profit.
(13) ENROLLEE SATISFACTION.—Statistics on
enrollee satisfaction, stated separately for those who
continue enrollment and those who discontinue en-
rollment, and on the proportion of enrollees who
disenroll.
(14) AVAILABILITY OF PROVIDERS; PROVIDER
INCENTIVES.—The characteristics and availability of
participating health care providers and professionals,
including a description of any financial or contrac-
tual arrangements with hospitals, utilization review
organizations, physicians, or other health care pro-
viders or professionals that would affect the services
offered, referral or treatment options, or providers’
fiduciary responsibility to patients, including any fi-
nancial or other incentives regarding the provision,
denial, or limitation of needed services.
(15) QUALITY
INDICATORS.—Indicators that
measure the quality of services provided by the orga-
nization and by participating health providers with
the organization, including population-based statis-
tics such as immunization rates and performance
measures such as survival after surgery, adjusted for
case mix.