under the internal review procedure under 
section 103; 
(iv) except as provided in subpara-
graph (B)(ii), require payment of a filing 
fee to the plan or issuer of a sum that does 
not exceed $25; and 
(v) require that a request for review 
include the consent of the participant, ben-
eficiary, or enrollee (or authorized rep-
resentative) for the release of necessary 
medical information or records of the par-
ticipant, beneficiary, or enrollee to the 
qualified external review entity only for 
purposes of conducting external review ac-
tivities. 
(B) REQUIREMENTS AND EXCEPTION RE-
LATING TO GENERAL RULE.— 
(i) ORAL
REQUESTS
PERMITTED
IN 
EXPEDITED OR CONCURRENT CASES.—In 
the case of an expedited or concurrent ex-
ternal review as provided for under sub-
section (e), the request for such review 
may be made orally. A group health plan, 
or health insurance issuer offering health 
insurance coverage, may require that the
participant, beneficiary, or enrollee (or au-
thorized representative) provide written 
confirmation of such request in a timely 
manner on a form provided by the plan or 
issuer. Such written confirmation shall be 
treated as a consent for purposes of sub-
paragraph (A)(v). In the case of such an 
oral request for such a review, the making 
of the request (and the timing of such re-
quest) shall be treated as the making at 
that time of a request for such a review 
without regard to whether and when a 
written confirmation of such request is 
made. 
(ii) EXCEPTION TO FILING FEE RE-
QUIREMENT.— 
(I) INDIGENCY.—Payment of a 
filing fee shall not be required under 
subparagraph (A)(iv) where there is a 
certification (in a form and manner 
specified in guidelines established by 
the appropriate Secretary) that the 
participant, beneficiary, or enrollee is 
indigent (as defined in such guide-
lines).
(II) FEE NOT REQUIRED.—Pay-
ment of a filing fee shall not be re-
quired under subparagraph (A)(iv) if 
the plan or issuer waives the internal 
appeals 
process 
under 
section 
103(a)(4). 
(III) REFUNDING OF FEE.—The 
filing fee paid under subparagraph 
(A)(iv) shall be refunded if the deter-
mination under the independent exter-
nal review is to reverse the denial 
which is the subject of the review. 
(IV) COLLECTION
OF
FILING 
FEE.—The failure to pay such a filing 
fee shall not prevent the consideration 
of a request for review but, subject to 
the preceding provisions of this clause, 
shall constitute a legal liability to pay. 
(c) REFERRAL TO QUALIFIED EXTERNAL REVIEW 
ENTITY UPON REQUEST.— 
(1) IN GENERAL.—Upon the filing of a request 
for independent external review with the group 
health plan, or health insurance issuer offering 
health insurance coverage, the plan or issuer shall 
immediately refer such request, and forward the
plan or issuer’s initial decision (including the infor-
mation described in section 103(d)(3)(A)), to a 
qualified external review entity selected in accord-
ance with this section. 
(2) ACCESS TO PLAN OR ISSUER AND HEALTH 
PROFESSIONAL INFORMATION.—With respect to an 
independent external review conducted under this 
section, the participant, beneficiary, or enrollee (or 
authorized representative), the plan or issuer, and 
the treating health care professional (if any) shall 
provide the external review entity with information 
that is necessary to conduct a review under this sec-
tion, as determined and requested by the entity. 
Such information shall be provided not later than 5 
days after the date on which the request for infor-
mation is received, or, in a case described in clause 
(ii) or (iii) of subsection (e)(1)(A), by such earlier 
time as may be necessary to comply with the appli-
cable timeline under such clause. 
(3) SCREENING OF REQUESTS BY QUALIFIED 
EXTERNAL REVIEW ENTITIES.— 
(A) IN GENERAL.—With respect to a re-
quest referred to a qualified external review en-
tity under paragraph (1) relating to a denial of 
a claim for benefits, the entity shall refer such
request for the conduct of an independent med-
ical review unless the entity determines that— 
(i) any of the conditions described in 
clauses (ii) or (iii) of subsection (b)(2)(A) 
have not been met; 
(ii) the denial of the claim for benefits 
does not involve a medically reviewable de-
cision under subsection (d)(2); 
(iii) the denial of the claim for bene-
fits relates to a decision regarding whether 
an individual is a participant, beneficiary, 
or enrollee who is enrolled under the terms 
and conditions of the plan or coverage (in-
cluding the applicability of any waiting pe-
riod under the plan or coverage); or 
(iv) the denial of the claim for bene-
fits is a decision as to the application of 
cost-sharing requirements or the applica-
tion of a specific exclusion or express limi-
tation on the amount, duration, or scope of 
coverage of items or services under the 
terms and conditions of the plan or cov-
erage unless the decision is a denial de-
scribed in subsection (d)(2).
Upon making a determination that any of 
clauses (i) through (iv) applies with respect to 
the request, the entity shall determine that the 
denial of a claim for benefits involved is not eli-
gible for independent medical review under sub-
section (d), and shall provide notice in accord-
ance with subparagraph (C). 
(B) PROCESS
FOR
MAKING
DETERMINA-
TIONS.— 
(i) NO DEFERENCE TO PRIOR DETER-
MINATIONS.—In 
making 
determinations 
under subparagraph (A), there shall be no 
deference given to determinations made by 
the plan or issuer or the recommendation 
of a treating health care professional (if 
any). 
(ii) 
USE
OF
APPROPRIATE
PER-
SONNEL.—A qualified external review enti-
ty shall use appropriately qualified per-
sonnel to make determinations under this 
section. 
(C) NOTICES
AND
GENERAL
TIMELINES 
FOR DETERMINATION.— 
(i) NOTICE IN CASE OF DENIAL OF 
REFERRAL.—If the entity under this para-
graph does not make a referral to an inde-
pendent medical review panel, the entity 
shall provide notice to the plan or issuer, 
the participant, beneficiary, or enrollee (or 
authorized representative) filing the re-
quest, and the treating health care profes-
sional (if any) that the denial is not sub-
ject to independent medical review. Such 
notice— 
(I) shall be written (and, in addi-
tion, may be provided orally) in a 
manner calculated to be understood 
by a participant or enrollee; 
(II) shall include the reasons for 
the determination; 
(III) include any relevant terms 
and conditions of the plan or cov-
erage; and 
(IV) include a description of any 
further recourse available to the indi-
vidual. 
(ii) GENERAL TIMELINE FOR DETER-
MINATIONS.—Upon receipt of information 
under paragraph (2), the qualified external 
review entity, and if required the inde-
pendent medical review panel, shall make a 
determination within the overall timeline 
that is applicable to the case under review 
as described in subsection (e), except that 
if the entity determines that a referral to 
an independent medical review panel is not 
required, the entity shall provide notice of 
such determination to the participant, ben-
eficiary, or enrollee (or authorized rep-
resentative) within such timeline and with-
in 2 days of the date of such determina-
tion. 
(d) INDEPENDENT MEDICAL REVIEW.— 
(1) IN GENERAL.—If a qualified external review 
entity determines under subsection (c) that a denial 
of a claim for benefits is eligible for independent 
medical review, the entity shall refer the denial in-
volved to an independent medical reviewer for the 
conduct of an independent medical review under this 
subsection. 
(2) MEDICALLY
REVIEWABLE
DECISIONS.—A 
denial of a claim for benefits is eligible for inde-
pendent medical review if the benefit for the item or 
service for which the claim is made would be a cov-
ered benefit under the terms and conditions of the
plan or coverage but for one (or more) of the fol-
lowing determinations: 
(A) DENIALS BASED ON MEDICAL NECES-
SITY AND APPROPRIATENESS.—A determination 
that the item or service is not covered because 
it is not medically necessary and appropriate or 
based on the application of substantially equiva-
lent terms. 
(B) DENIALS
BASED
ON
EXPERIMENTAL 
OR
INVESTIGATIONAL
TREATMENT.—A deter-
mination that the item or service is not covered 
because it is experimental or investigational or 
based on the application of substantially equiva-
lent terms. 
(C) DENIALS OTHERWISE BASED ON AN 
EVALUATION
OF
MEDICAL
FACTS.—A deter-
mination that the item or service or condition 
is not covered based on grounds that require an 
evaluation of the medical facts by a health care 
professional in the specific case involved to de-
termine the coverage and extent of coverage of 
the item or service or condition. 
(3) INDEPENDENT
MEDICAL
REVIEW
DETER-
MINATION.—
(A) IN GENERAL.—An independent med-
ical review panel under this section shall make 
a new independent determination with respect 
to whether or not the denial of a claim for a 
benefit that is the subject of the review should 
be upheld or reversed. 
(B) STANDARD
FOR
DETERMINATION.— 
The independent medical review panel’s deter-
mination relating to the medical necessity and 
appropriateness, or the experimental or inves-
tigational nature, or the evaluation of the med-
ical facts, of the item, service, or condition in-
volved shall be based on the medical condition 
of the participant, beneficiary, or enrollee (in-
cluding the medical records of the participant, 
beneficiary, or enrollee) and valid, relevant sci-
entific evidence and clinical evidence, including 
peer-reviewed medical literature or findings and 
including expert opinion. 
(C) NO COVERAGE FOR EXCLUDED BENE-
FITS.—Nothing in this subsection shall be con-
strued to permit an independent medical review 
panel to require that a group health plan, or 
health insurance issuer offering health insur-
ance coverage, provide coverage for items or
services for which benefits are specifically ex-
cluded or expressly limited under the plan or 
coverage in the plain language of the plan docu-
ment (and which are disclosed under section 
121(b)(1)(C)). Notwithstanding any other pro-
vision of this Act, any exclusion of an exact 
medical procedure, any exact time limit on the 
duration or frequency of coverage, and any 
exact dollar limit on the amount of coverage 
that is specifically enumerated and defined (in 
the plain language of the plan or coverage docu-
ments) under the plan or coverage offered by a 
group health plan or health insurance issuer of-
fering health insurance coverage and that is 
disclosed under section 121(b)(1) shall be con-
sidered to govern the scope of the benefits that 
may be required: Provided, That the terms and 
conditions of the plan or coverage relating to 
such an exclusion or limit are in compliance 
with the requirements of law. 
(D) EVIDENCE AND INFORMATION TO BE 
USED IN MEDICAL REVIEWS.—In making a de-
termination under this subsection, the inde-
pendent medical review panel shall also consider
appropriate and available evidence and informa-
tion, including the following: 
(i) The determination made by the 
plan or issuer with respect to the claim 
upon internal review and the evidence, 
guidelines, or rationale used by the plan or 
issuer in reaching such determination. 
(ii) The recommendation of the treat-
ing health care professional and the evi-
dence, guidelines, and rationale used by 
the treating health care professional in 
reaching such recommendation. 
(iii) Additional relevant evidence or 
information obtained by the review panel 
or submitted by the plan, issuer, partici-
pant, beneficiary, or enrollee (or an au-
thorized representative), or treating health 
care professional. 
(iv) The plan or coverage document. 
(E) INDEPENDENT
DETERMINATION.—In 
making determinations under this section, a 
qualified external review entity and an inde-
pendent medical review panel shall— 
(i) consider the claim under review 
without deference to the determinations
made by the plan or issuer or the rec-
ommendation of the treating health care 
professional (if any); and 
(ii) consider, but not be bound by, the 
definition used by the plan or issuer of 
‘‘medically necessary and appropriate’’, or 
‘‘experimental or investigational’’, or other 
substantially equivalent terms that are 
used by the plan or issuer to describe med-
ical necessity and appropriateness or ex-
perimental or investigational nature of the 
treatment. 
(F) DETERMINATION
OF
INDEPENDENT 
MEDICAL
REVIEW
PANEL.—An independent 
medical review panel shall, in accordance with 
the deadlines described in subsection (e), pre-
pare a written determination to uphold or re-
verse the denial under review. Such written de-
termination shall include— 
(i) the determination of the review 
panel; 
(ii) the specific reasons of the review 
panel for such determination, including a 
summary of the clinical or scientific evi-
dence used in making the determination; 
and 
(iii) with respect to a determination to 
reverse the denial under review, a time-
frame within which the plan or issuer must 
comply with such determination. 
(G) NONBINDING NATURE OF ADDITIONAL 
RECOMMENDATIONS.—In addition to the deter-
mination under subparagraph (F), the review 
panel may provide the plan or issuer and the 
treating health care professional with additional 
recommendations in connection with such a de-
termination, but any such recommendations 
shall not affect (or be treated as part of) the 
determination and shall not be binding on the 
plan or issuer. 
(e) TIMELINES AND NOTIFICATIONS.— 
(1) TIMELINES
FOR
INDEPENDENT
MEDICAL 
REVIEW.— 
(A) PRIOR
AUTHORIZATION
DETERMINA-
TION.— 
(i) IN
GENERAL.—The independent 
medical review panel shall make a deter-
mination on a denial of a claim for benefits 
that is referred to the review panel under
subsection (c)(3) in accordance with the 
medical exigencies of the case and as soon 
as possible, but in no case later than 14 
days after the date of receipt of informa-
tion under subsection (c)(2) if the review 
involves a prior authorization of items or 
services and in no case later than 21 days 
after the date the request for external re-
view is received. 
(ii) EXPEDITED
DETERMINATION.— 
Notwithstanding clause (i) and subject to 
clause (iii), the independent medical review 
panel shall make an expedited determina-
tion on a denial of a claim for benefits de-
scribed in clause (i), when a request for 
such an expedited determination is made 
by a participant, beneficiary, or enrollee 
(or authorized representative) at any time 
during the process for making a deter-
mination, and a health care professional 
certifies, with the request, that a deter-
mination under the timeline described in 
clause (i) would seriously jeopardize the 
life or health of the participant, bene-
ficiary, or enrollee or the ability of the par-
ticipant, beneficiary, or enrollee to main-
tain or regain maximum function. Such de-
termination shall be made in accordance 
with the medical exigencies of the case and 
as soon as possible, but in no case later 
than 72 hours after the time the request 
for external review is received by the quali-
fied external review entity. 
(iii) 
ONGOING
CARE
DETERMINA-
TION.—Notwithstanding clause (i), in the 
case of a review described in such clause 
that involves a termination or reduction of 
care, the notice of the determination shall 
be completed not later than 24 hours after 
the time the request for external review is 
received by the qualified external review 
entity and before the end of the approved 
period of care. 
(B) RETROSPECTIVE
DETERMINATION.— 
The independent medical review panel shall 
complete a review in the case of a retrospective 
determination on an appeal of a denial of a 
claim for benefits that is referred to the review 
panel under subsection (c)(3) in no case later 
than 30 days after the date of receipt of infor-
mation under subsection (c)(2) and in no case 
later than 60 days after the date the request 
for external review is received by the qualified 
external review entity. 
(2) NOTIFICATION
OF
DETERMINATION.—The 
external review entity shall ensure that the plan or 
issuer, the participant, beneficiary, or enrollee (or 
authorized representative) and the treating health 
care professional (if any) receives a copy of the writ-
ten determination of the independent medical review 
panel prepared under subsection (d)(3)(F). Nothing 
in this paragraph shall be construed as preventing 
an entity or review panel from providing an initial 
oral notice of the review panel’s determination. 
(3) FORM
OF
NOTICES.—Determinations and 
notices under this subsection shall be written in a 
manner calculated to be understood by a participant. 
(f) COMPLIANCE.— 
(1) APPLICATION OF DETERMINATIONS.— 
(A) EXTERNAL REVIEW DETERMINATIONS 
BINDING ON PLAN.—The determinations of an 
external review entity and an independent med-
ical review panel under this section shall be 
binding upon the plan or issuer involved.
(B) 
COMPLIANCE
WITH
DETERMINA-
TION.—If the determination of an independent 
medical review panel is to reverse the denial, 
the plan or issuer, upon the receipt of such de-
termination, shall authorize coverage to comply 
with the medical reviewer’s determination in ac-
cordance with the timeframe established by the 
medical review panel. 
(2) FAILURE TO COMPLY.— 
(A) IN GENERAL.—If a plan or issuer fails 
to comply with the timeframe established under 
paragraph (1)(B) with respect to a participant, 
beneficiary, or enrollee, where such failure to 
comply is caused by the plan or issuer, the par-
ticipant, beneficiary, or enrollee may obtain the 
items or services involved (in a manner con-
sistent with the determination of the inde-
pendent external review panel) from any pro-
vider regardless of whether such provider is a 
participating provider under the plan or cov-
erage. 
(B) REIMBURSEMENT.— 
(i) IN
GENERAL.—Where a partici-
pant, beneficiary, or enrollee obtains items 
or services in accordance with subpara-
graph (A), the plan or issuer involved shall 
provide for reimbursement of the costs of 
such items or services. Such reimburse-
ment shall be made to the treating health 
care professional or to the participant, ben-
eficiary, or enrollee (in the case of a partic-
ipant, beneficiary, or enrollee who pays for 
the costs of such items or services). 
(ii) AMOUNT.—The plan or issuer 
shall fully reimburse a professional, partici-
pant, beneficiary, or enrollee under clause 
(i) for the total costs of the items or serv-
ices provided (regardless of any plan limi-
tations that may apply to the coverage of 
such items or services) so long as the items 
or services were provided in a manner con-
sistent with the determination of the inde-
pendent medical review panel. 
(C) FAILURE
TO
REIMBURSE.—Where a 
plan or issuer fails to provide reimbursement to 
a professional, participant, beneficiary, or en-
rollee in accordance with this paragraph, the 
professional, participant, beneficiary, or enrollee 
may commence a civil action (or utilize other 
remedies available under law) to recover only
the amount of any such reimbursement that is 
owed by the plan or issuer and any necessary 
legal costs or expenses (including attorney’s 
fees) incurred in recovering such reimburse-
ment. 
(D) AVAILABLE REMEDIES.—The remedies 
provided under this paragraph are in addition 
to any other available remedies. 
(3) PENALTIES
AGAINST
AUTHORIZED
OFFI-
CIALS FOR REFUSING TO AUTHORIZE THE DETER-
MINATION OF AN EXTERNAL REVIEW ENTITY.— 
(A) MONETARY PENALTIES.— 
(i) IN
GENERAL.—In any case in 
which the determination of an external re-
view 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 au-
thorizing the benefit, causes such refusal 
may, in the discretion of a court of com-
petent jurisdiction, be liable to an ag-
grieved 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. 
(ii) ADDITIONAL PENALTY FOR FAIL-
ING TO FOLLOW TIMELINE.—In any case 
in which treatment was not commenced by 
the plan in accordance with the determina-
tion of an independent external review 
panel, the Secretary shall assess a civil 
penalty of $10,000 against the plan and 
the plan shall pay such penalty to the par-
ticipant, beneficiary, or enrollee involved. 
(B) CEASE
AND
DESIST
ORDER
AND 
ORDER OF ATTORNEY’S FEES.—In any action 
described in subparagraph (A) 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 subparagraph has taken an action re-
sulting in a refusal of a benefit determined by 
an external appeal entity to be covered, or has 
failed to take an action for which such person 
is responsible under the terms and conditions of 
the plan or coverage 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 defend-
ant— 
(i) to cease and desist from the al-
leged action or failure to act; and 
(ii) 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. 
(C) ADDITIONAL CIVIL PENALTIES.— 
(i) IN GENERAL.—In addition to any 
penalty imposed under subparagraph (A) 
or (B), the appropriate Secretary may as-
sess a civil penalty against a person acting 
in the capacity of authorizing a benefit de-
termined 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 re-
peated refusal to authorize a benefit 
determined by an external appeal enti-
ty to be covered; or
(II) any pattern or practice of re-
peated violations of the requirements 
of this section with respect to such 
plan or coverage. 
(ii) 
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 appro-
priate Secretary to have not been pro-
vided, or unlawfully delayed, in viola-
tion of this section under such pattern 
or practice; or 
(II) $500,000. 
(D) REMOVAL AND DISQUALIFICATION.— 
Any person acting in the capacity of author-
izing benefits who has engaged in any such pat-
tern or practice described in subparagraph 
(C)(i) 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 involve-
ment for a period determined by the court. 
(4) PROTECTION OF LEGAL RIGHTS.—Nothing 
in this subsection or subtitle shall be construed as 
altering or eliminating any cause of action or legal 
rights or remedies of participants, beneficiaries, en-
rollees, and others under State or Federal law (in-
cluding sections 502 and 503 of the Employee Re-
tirement Income Security Act of 1974), including 
the right to file judicial actions to enforce rights. 
(g) QUALIFICATIONS
OF INDEPENDENT MEDICAL 
REVIEWERS.— 
(1) IN GENERAL.—In referring a denial to an 
independent medical review panel to conduct inde-
pendent medical review under subsection (c), the 
qualified external review entity shall ensure that— 
(A) each independent medical reviewer 
meets the qualifications described in paragraphs 
(2) and (3); 
(B) with respect to each review, the review 
panel meets the requirements of paragraph (4) 
and at least 1 reviewer on the panel meets the 
requirements described in paragraph (5); and
(C) compensation provided by the entity to 
each reviewer is consistent with paragraph (6). 
(2) LICENSURE AND EXPERTISE.—Each inde-
pendent medical reviewer shall be a physician 
(allopathic or osteopathic) or health care profes-
sional who— 
(A) is appropriately credentialed or li-
censed in 1 or more States to deliver health 
care services; and 
(B) typically treats the condition, makes 
the diagnosis, or provides the type of treatment 
under review. 
(3) INDEPENDENCE.— 
(A) IN
GENERAL.—Subject to subpara-
graph (B), each independent medical reviewer 
in a case shall— 
(i) not be a related party (as defined 
in paragraph (7)); 
(ii) not have a material familial, fi-
nancial, or professional relationship with 
such a party; and 
(iii) not otherwise have a conflict of 
interest with such a party (as determined 
under regulations).
(B) EXCEPTION.—Nothing in subpara-
graph (A) shall be construed to— 
(i) prohibit an individual, solely on the 
basis of affiliation with the plan or issuer, 
from serving as an independent medical re-
viewer if— 
(I) a non-affiliated individual is 
not reasonably available; 
(II) the affiliated individual is 
not involved in the provision of items 
or services in the case under review; 
(III) the fact of such an affili-
ation is disclosed to the plan or issuer 
and the participant, beneficiary, or 
enrollee (or authorized representative) 
and neither party objects; and 
(IV) the affiliated individual is 
not an employee of the plan or issuer 
and does not provide services exclu-
sively or primarily to or on behalf of 
the plan or issuer; 
(ii) prohibit an individual who has 
staff privileges at the institution where the 
treatment involved takes place from serv-
ing as an independent medical reviewer
merely on the basis of such affiliation if 
the affiliation is disclosed to the plan or 
issuer and the participant, beneficiary, or 
enrollee (or authorized representative), and 
neither party objects; or 
(iii) prohibit receipt of compensation 
by an independent medical reviewer from 
an entity if the compensation is provided 
consistent with paragraph (6). 
(4) PRACTICING HEALTH CARE PROFESSIONAL 
IN SAME FIELD.— 
(A) IN
GENERAL.—In a case involving 
treatment, or the provision of items or serv-
ices— 
(i) by a physician, a reviewer shall be 
a practicing physician (allopathic or osteo-
pathic) of the same or similar specialty, as 
a physician who, acting within the appro-
priate scope of practice within the State in 
which the service is provided or rendered, 
typically treats the condition, makes the 
diagnosis, or provides the type of treat-
ment under review; or 
(ii) by a non-physician health care 
professional, the independent medical re-
view panel shall include at least one prac-
ticing non-physician health care profes-
sional of the same or similar specialty as 
the non-physician health care professional 
who, acting within the appropriate scope of 
practice within the State in which the serv-
ice is provided or rendered, typically treats 
the condition, makes the diagnosis, or pro-
vides the type of treatment under review. 
(B) PRACTICING DEFINED.—For purposes 
of this paragraph, the term ‘‘practicing’’ means, 
with respect to an individual who is a physician 
or other health care professional that the indi-
vidual provides health care services to individual 
patients on average at least 2 days per week. 
(5) PEDIATRIC EXPERTISE.—In the case of an 
external review relating to a child, a reviewer shall 
have expertise under paragraph (2) in pediatrics. 
(6) LIMITATIONS
ON
REVIEWER
COMPENSA-
TION.—Compensation provided by a qualified exter-
nal review entity to an independent medical reviewer 
in connection with a review under this section 
shall— 
(A) not exceed a reasonable level; and
(B) not be contingent on the decision ren-
dered by the reviewer. 
(7) RELATED PARTY DEFINED.—For purposes 
of this section, the term ‘‘related party’’ means, with 
respect to a denial of a claim under a plan or cov-
erage relating to a participant, beneficiary, or en-
rollee, any of the following: 
(A) The plan, plan sponsor, or issuer in-
volved, or any fiduciary, officer, director, or em-
ployee of such plan, plan sponsor, or issuer. 
(B) The participant, beneficiary, or en-
rollee (or authorized representative). 
(C) The health care professional that pro-
vides the items or services involved in the de-
nial. 
(D) The institution at which the items or 
services (or treatment) involved in the denial 
are provided. 
(E) The manufacturer of any drug or 
other item that is included in the items or serv-
ices involved in the denial. 
(F) Any other party determined under any 
regulations to have a substantial interest in the 
denial involved. 
(h) QUALIFIED EXTERNAL REVIEW ENTITIES.—
(1) SELECTION OF QUALIFIED EXTERNAL RE-
VIEW ENTITIES.— 
(A) LIMITATION ON PLAN OR ISSUER SE-
LECTION.—The appropriate Secretary shall im-
plement procedures— 
(i) to assure that the selection process 
among qualified external review entities 
will not create any incentives for external 
review entities to make a decision in a bi-
ased manner; and 
(ii) for auditing a sample of decisions 
by such entities to assure that no such de-
cisions are made in a biased manner. 
No such selection process under the procedures 
implemented by the appropriate Secretary may 
give either the patient or the plan or issuer any 
ability to determine or influence the selection of 
a qualified external review entity to review the 
case of any participant, beneficiary, or enrollee. 
(B) STATE AUTHORITY WITH RESPECT TO 
QUALIFIED EXTERNAL REVIEW ENTITIES FOR 
HEALTH INSURANCE ISSUERS.—With respect to 
health insurance issuers offering health insur-
ance coverage in a State, the State may provide 
for external review activities to be conducted by
a qualified external appeal entity that is des-
ignated by the State or that is selected by the 
State in a manner determined by the State to 
assure an unbiased determination. 
(2) CONTRACT WITH QUALIFIED EXTERNAL RE-
VIEW
ENTITY.—Except as provided in paragraph 
(1)(B), the external review process of a plan or 
issuer under this section shall be conducted under a 
contract between the plan or issuer and 1 or more 
qualified external review entities (as defined in para-
graph (4)(A)). 
(3) TERMS AND CONDITIONS OF CONTRACT.— 
The terms and conditions of a contract under para-
graph (2) shall— 
(A) 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 review activities; and 
(B) provide that the costs of the external 
review process shall be borne by the plan or 
issuer. 
Subparagraph (B) shall not be construed as apply-
ing to the imposition of a filing fee under subsection 
(b)(2)(A)(iv) or costs incurred by the participant, 
beneficiary, or enrollee (or authorized representative)
or treating health care professional (if any) in sup-
port of the review, including the provision of addi-
tional evidence or information. 
(4) QUALIFICATIONS.— 
(A) IN
GENERAL.—In this section, the 
term ‘‘qualified external review entity’’ means, 
in relation to a plan or issuer, an entity that is 
initially certified (and periodically recertified) 
under subparagraph (C) as meeting the fol-
lowing requirements: 
(i) The entity has (directly or through 
contracts or other arrangements) sufficient 
medical, legal, and other expertise and suf-
ficient staffing to carry out duties of a 
qualified external review entity under this 
section on a timely basis, including making 
determinations under subsection (b)(2)(A) 
and providing for independent medical re-
views under subsection (d). 
(ii) The entity is not a plan or issuer 
or an affiliate or a subsidiary of a plan or 
issuer, and is not an affiliate or subsidiary 
of a professional or trade association of 
plans or issuers or of health care providers.
(iii) The entity has provided assur-
ances that it will conduct external review 
activities consistent with the applicable re-
quirements of this section and standards 
specified in subparagraph (C), including 
that it will not conduct any external review 
activities in a case unless the independence 
requirements of subparagraph (B) are met 
with respect to the case. 
(iv) The entity has provided assur-
ances that it will provide information in a 
timely manner under subparagraph (D). 
(v) The entity meets such other re-
quirements as the appropriate Secretary 
provides by regulation. 
(B) INDEPENDENCE REQUIREMENTS.— 
(i) IN
GENERAL.—Subject to clause 
(ii), an entity meets the independence re-
quirements of this subparagraph with re-
spect to any case if the entity— 
(I) is not a related party (as de-
fined in subsection (g)(7)); 
(II) does not have a material fa-
milial, financial, or professional rela-
tionship with such a party; and
(III) does not otherwise have a 
conflict of interest with such a party 
(as determined under regulations). 
(ii) EXCEPTION
FOR
REASONABLE 
COMPENSATION.—Nothing in clause (i) 
shall be construed to prohibit receipt by a 
qualified external review entity of com-
pensation from a plan or issuer for the 
conduct of external review activities under 
this section if the compensation is provided 
consistent with clause (iii). 
(iii) LIMITATIONS
ON
ENTITY
COM-
PENSATION.—Compensation provided by a 
plan or issuer to a qualified external review 
entity in connection with reviews under 
this section shall— 
(I) not exceed a reasonable level; 
and 
(II) not be contingent on any de-
cision rendered by the entity or by 
any independent medical review panel. 
(C) CERTIFICATION AND RECERTIFICATION 
PROCESS.—
(i) IN GENERAL.—The initial certifi-
cation and recertification of a qualified ex-
ternal review entity shall be made— 
(I) under a process that is recog-
nized or approved by the appropriate 
Secretary; or 
(II) by a qualified private stand-
ard-setting organization that is ap-
proved by the appropriate Secretary 
under clause (iii). 
In taking action under subclause (I), the 
appropriate Secretary shall give deference 
to entities that are under contract with the 
Federal Government or with an applicable 
State authority to perform functions of the 
type performed by qualified external review 
entities. 
(ii) PROCESS.—The appropriate Sec-
retary shall not recognize or approve a 
process under clause (i)(I) unless the proc-
ess applies standards (as promulgated in 
regulations) that ensure that a qualified 
external review entity— 
(I) will carry out (and has car-
ried out, in the case of recertification)
the responsibilities of such an entity 
in accordance with this section, in-
cluding meeting applicable deadlines; 
(II) will meet (and has met, in 
the case of recertification) appropriate 
indicators of fiscal integrity; 
(III) will maintain (and has 
maintained, in the case of recertifi-
cation) 
appropriate 
confidentiality 
with respect to individually identifi-
able health information obtained in 
the course of conducting external re-
view activities; and 
(IV) in the case of recertification, 
shall review the matters described in 
clause (iv). 
(iii) APPROVAL
OF
QUALIFIED
PRI-
VATE
STANDARD-SETTING
ORGANIZA-
TIONS.—For purposes of clause (i)(II), the 
appropriate Secretary may approve a quali-
fied private standard-setting organization 
if such Secretary finds that the organiza-
tion only certifies (or recertifies) external 
review entities that meet at least the 
standards required for the certification (or
recertification) of external review entities 
under clause (ii). 
(iv) CONSIDERATIONS IN RECERTIFI-
CATIONS.—In conducting recertifications of 
a qualified external review entity under 
this paragraph, the appropriate Secretary 
or organization conducting the recertifi-
cation shall review compliance of the entity 
with the requirements for conducting ex-
ternal review activities under this section, 
including the following: 
(I) 
Provision 
of 
information 
under subparagraph (D). 
(II) 
Adherence 
to 
applicable 
deadlines (both by the entity and by 
independent medical review panels it 
refers cases to). 
(III) Compliance with limitations 
on compensation (with respect to both 
the entity and independent medical re-
view panels it refers cases to). 
(IV) Compliance with applicable 
independence requirements. 
(V) Compliance with the require-
ment of subsection (d)(1) that only
medically reviewable decisions shall be 
the subject of independent medical re-
view and with the requirement of sub-
section (d)(3) that independent med-
ical review panels may not require 
coverage for specifically excluded ben-
efits. 
(v) PERIOD OF CERTIFICATION OR RE-
CERTIFICATION.—A certification or recer-
tification provided under this paragraph 
shall extend for a period not to exceed 2 
years. 
(vi) REVOCATION.—A certification or 
recertification under this paragraph may 
be revoked by the appropriate Secretary or 
by the organization providing such certifi-
cation upon a showing of cause. The Sec-
retary, or organization, shall revoke a cer-
tification or deny a recertification with re-
spect to an entity if there is a showing that 
the entity has a pattern or practice of or-
dering coverage for benefits that are spe-
cifically excluded under the plan or cov-
erage.
(vii) PETITION FOR DENIAL OR WITH-
DRAWAL.—An individual may petition the 
Secretary, or an organization providing the 
certification involves, for a denial of recer-
tification or a withdrawal of a certification 
with respect to an entity under this sub-
paragraph if there is a pattern or practice 
of such entity failing to meet a require-
ment of this section. 
(viii) SUFFICIENT NUMBER OF ENTI-
TIES.—The appropriate Secretary shall 
certify and recertify a number of external 
review entities which is sufficient to ensure 
the timely and efficient provision of review 
services. 
(D) PROVISION OF INFORMATION.— 
(i) IN GENERAL.—A qualified external 
review entity shall provide to the appro-
priate Secretary, in such manner and at 
such times as such Secretary may require, 
such information (relating to the denials 
which have been referred to the entity for 
the conduct of external review under this 
section) as such Secretary determines ap-
propriate to assure compliance with the
independence and other requirements of 
this section to monitor and assess the qual-
ity of its external review activities and lack 
of bias in making determinations. Such in-
formation shall include information de-
scribed in clause (ii) but shall not include 
individually identifiable medical informa-
tion. 
(ii) 
INFORMATION
TO
BE
IN-
CLUDED.—The information described in 
this subclause with respect to an entity is 
as follows: 
(I) The number and types of de-
nials for which a request for review 
has been received by the entity. 
(II) The disposition by the entity 
of such denials, including the number 
referred to an independent medical re-
view panel and the reasons for such 
dispositions (including the application 
of exclusions), on a plan or issuer-spe-
cific basis and on a health care spe-
cialty-specific basis.
(III) The length of time in mak-
ing determinations with respect to 
such denials. 
(IV) Updated information on the 
information required to be submitted 
as a condition of certification with re-
spect to the entity’s performance of 
external review activities. 
(iii) INFORMATION TO BE PROVIDED 
TO CERTIFYING ORGANIZATION.— 
(I) IN GENERAL.—In the case of 
a qualified external review entity 
which is certified (or recertified) 
under this subsection by a qualified 
private standard-setting organization, 
at the request of the organization, the 
entity shall provide the organization 
with the information provided to the 
appropriate Secretary under clause 
(i). 
(II) 
ADDITIONAL
INFORMA-
TION.—Nothing in this subparagraph 
shall be construed as preventing such 
an organization from requiring addi-
tional information as a condition of
certification or recertification of an 
entity. 
(iv) USE OF INFORMATION.—Informa-
tion provided under this subparagraph may 
be used by the appropriate Secretary and 
qualified private standard-setting organiza-
tions to conduct oversight of qualified ex-
ternal review entities, including recertifi-
cation of such entities, and shall be made 
available to the public in an appropriate 
manner. 
(E) LIMITATION ON LIABILITY.—No quali-
fied external review entity having a contract 
with a plan or issuer, and no person who is em-
ployed by any such entity or who furnishes pro-
fessional services to such entity (including as an 
independent medical review panel), shall be held 
by reason of the performance of any duty, func-
tion, or activity required or authorized pursuant 
to this section, to be civilly liable under any law 
of the United States or of any State (or polit-
ical subdivision thereof) if there was no actual 
malice or gross misconduct in the performance 
of such duty, function, or activity.
(5) REPORT.—Not later than 12 months after 
the general effective date referred to in section 601, 
the General Accounting Office shall prepare and 
submit to the appropriate committees of Congress a 
report concerning— 
(A) the information that is provided under 
paragraph (3)(D); 
(B) the number of denials that have been 
upheld by independent medical review panels 
and the number of denials that have been re-
versed by such panels; and 
(C) the extent to which independent med-
ical review panels are requiring coverage for 
benefits that are specifically excluded under the 
plan or coverage. 
SEC. 105. HEALTH CARE CONSUMER ASSISTANCE FUND. 
(a) GRANTS.— 
(1) IN GENERAL.—The Secretary of Health and 
Human Services (referred to in this section as the 
‘‘Secretary’’) shall establish a fund, to be known as 
the ‘‘Health Care Consumer Assistance Fund’’, to be 
used to award grants to eligible States to carry out 
consumer assistance activities (including programs 
established by States prior to the enactment of this
Act) designed to provide information, assistance, and 
referrals to consumers of health insurance products. 
(2) STATE ELIGIBILITY.—To be eligible to re-
ceive a grant under this subsection a State shall pre-
pare and submit to the Secretary an application at 
such time, in such manner, and containing such in-
formation as the Secretary may require, including a 
State plan that describes— 
(A) the manner in which the State will en-
sure that the health care consumer assistance 
office (established under paragraph (4)) will 
educate and assist health care consumers in ac-
cessing needed care; 
(B) the manner in which the State will co-
ordinate and distinguish the services provided 
by the health care consumer assistance office 
with the services provided by Federal, State and 
local health-related ombudsman, information, 
protection and advocacy, insurance, and fraud 
and abuse programs; 
(C) the manner in which the State will 
provide information, outreach, and services to 
underserved, minority populations with limited 
English proficiency and populations residing in 
rural areas;
(D) the manner in which the State will 
oversee the health care consumer assistance of-
fice, its activities, product materials and evalu-
ate program effectiveness; 
(E) the manner in which the State will en-
sure that funds made available under this sec-
tion will be used to supplement, and not sup-
plant, any other Federal, State, or local funds 
expended to provide services for programs de-
scribed under this section and those described 
in subparagraphs (C) and (D); 
(F) the manner in which the State will en-
sure that health care consumer office personnel 
have the professional background and training 
to carry out the activities of the office; and 
(G) the manner in which the State will en-
sure that consumers have direct access to con-
sumer assistance personnel during regular busi-
ness hours. 
(3) AMOUNT OF GRANT.— 
(A) IN GENERAL.—From amounts appro-
priated under subsection (b) for a fiscal year, 
the Secretary shall award a grant to a State in 
an amount that bears the same ratio to such 
amounts as the number of individuals within
the State covered under a group health plan or 
under health insurance coverage offered by a 
health insurance issuer bears to the total num-
ber of individuals so covered in all States (as 
determined by the Secretary). Any amounts 
provided to a State under this subsection that 
are not used by the State shall be remitted to 
the Secretary and reallocated in accordance 
with this subparagraph. 
(B) MINIMUM AMOUNT.—In no case shall 
the amount provided to a State under a grant 
under this subsection for a fiscal year be less 
than an amount equal to 0.5 percent of the 
amount appropriated for such fiscal year to 
carry out this section. 
(C) NON-FEDERAL
CONTRIBUTIONS.—A 
State will provide for the collection of non-Fed-
eral contributions for the operation of the office 
in an amount that is not less than 25 percent 
of the amount of Federal funds provided to the 
State under this section. 
(4) PROVISION OF FUNDS FOR ESTABLISHMENT 
OF OFFICE.— 
(A) IN
GENERAL.—From amounts pro-
vided under a grant under this subsection, a
State shall, directly or through a contract with 
an independent, nonprofit entity with dem-
onstrated experience in serving the needs of 
health care consumers, provide for the estab-
lishment and operation of a State health care 
consumer assistance office. 
(B) ELIGIBILITY OF ENTITY.—To be eligi-
ble to enter into a contract under subparagraph 
(A), an entity shall demonstrate that it has the 
technical, organizational, and professional ca-
pacity to deliver the services described in sub-
section (b) to all public and private health in-
surance participants, beneficiaries, enrollees, or 
prospective enrollees. 
(C) EXISTING STATE ENTITY.—Nothing in 
this section shall prevent the funding of an ex-
isting health care consumer assistance program 
that otherwise meets the requirements of this 
section. 
(b) USE OF FUNDS.— 
(1) BY STATE.—A State shall use amounts pro-
vided under a grant awarded under this section to 
carry out consumer assistance activities directly or 
by contract with an independent, non-profit organi-
zation. An eligible entity may use some reasonable
amount of such grant to ensure the adequate train-
ing of personnel carrying out such activities. To re-
ceive amounts under this subsection, an eligible enti-
ty shall provide consumer assistance services, includ-
ing— 
(A) the operation of a toll-free telephone 
hotline to respond to consumer requests; 
(B) the dissemination of appropriate edu-
cational materials on available health insurance 
products and on how best to access health care 
and the rights and responsibilities of health 
care consumers; 
(C) the provision of education on effective 
methods to promptly and efficiently resolve 
questions, problems, and grievances; 
(D) the coordination of educational and 
outreach efforts with health plans, health care 
providers, payers, and governmental agencies; 
(E) referrals to appropriate private and 
public entities to resolve questions, problems 
and grievances; and 
(F) the provision of information and as-
sistance, including acting as an authorized rep-
resentative, regarding internal, external, or ad-
ministrative grievances or appeals procedures in
nonlitigative settings to appeal the denial, ter-
mination, or reduction of health care services, 
or the refusal to pay for such services, under a 
group health plan or health insurance coverage 
offered by a health insurance issuer. 
(2) CONFIDENTIALITY AND ACCESS TO INFOR-
MATION.— 
(A) STATE
ENTITY.—With respect to a 
State that directly establishes a health care con-
sumer assistance office, such office shall estab-
lish and implement procedures and protocols in 
accordance with applicable Federal and State 
laws. 
(B) CONTRACT ENTITY.—With respect to a 
State that, through contract, establishes a 
health care consumer assistance office, such of-
fice shall establish and implement procedures 
and protocols, consistent with applicable Fed-
eral and State laws, to ensure the confiden-
tiality of all information shared by a partici-
pant, beneficiary, enrollee, or their personal 
representative and their health care providers, 
group health plans, or health insurance insurers 
with the office and to ensure that no such infor-
mation is used by the office, or released or dis-
closed to State agencies or outside persons or 
entities without the prior written authorization 
(in accordance with section 164.508 of title 45, 
Code of Federal Regulations) of the individual 
or personal representative. The office may, con-
sistent with applicable Federal and State con-
fidentiality laws, collect, use or disclose aggre-
gate information that is not individually identi-
fiable (as defined in section 164.501 of title 45, 
Code of Federal Regulations). The office shall 
provide a written description of the policies and 
procedures of the office with respect to the 
manner in which health information may be 
used or disclosed to carry out consumer assist-
ance activities. The office shall provide health 
care providers, group health plans, or health in-
surance issuers with a written authorization (in 
accordance with section 164.508 of title 45, 
Code of Federal Regulations) to allow the office 
to obtain medical information relevant to the 
matter before the office. 
(3) AVAILABILITY
OF
SERVICES.—The health 
care consumer assistance office of a State shall not 
discriminate in the provision of information, refer-
rals, and services regardless of the source of the in-
dividual’s health insurance coverage or prospective 
coverage, including individuals covered under a 
group health plan or health insurance coverage of-
fered by a health insurance issuer, the medicare or 
medicaid programs under title XVIII or XIX of the 
Social Security Act (42 U.S.C. 1395 and 1396 et 
seq.), or under any other Federal or State health 
care program. 
(4) DESIGNATION OF RESPONSIBILITIES.— 
(A) WITHIN EXISTING STATE ENTITY.—If 
the health care consumer assistance office of a 
State is located within an existing State regu-
latory agency or office of an elected State offi-
cial, the State shall ensure that— 
(i) there is a separate delineation of 
the funding, activities, and responsibilities 
of the office as compared to the other 
funding, activities, and responsibilities of 
the agency; and 
(ii) the office establishes and imple-
ments procedures and protocols to ensure 
the 
confidentiality 
of 
all 
information 
shared by a participant, beneficiary, or en-
rollee or their personal representative and 
their health care providers, group health
plans, or health insurance issuers with the 
office and to ensure that no information is 
disclosed to the State agency or office 
without the written authorization of the in-
dividual or their personal representative in 
accordance with paragraph (2). 
(B) CONTRACT ENTITY.—In the case of an 
entity that enters into a contract with a State 
under subsection (a)(3), the entity shall provide 
assurances that the entity has no conflict of in-
terest in carrying out the activities of the office 
and that the entity is independent of group 
health plans, health insurance issuers, pro-
viders, payers, and regulators of health care. 
(5) SUBCONTRACTS.—The health care con-
sumer assistance office of a State may carry out ac-
tivities and provide services through contracts en-
tered into with 1 or more nonprofit entities so long 
as the office can demonstrate that all of the require-
ments of this section are complied with by the office. 
(6) TERM.—A contract entered into under this 
subsection shall be for a term of 3 years. 
(c) REPORT.—Not later than 1 year after the Sec-
retary first awards grants under this section, and annually 
thereafter, the Secretary shall prepare and submit to the
appropriate committees of Congress a report concerning 
the activities funded under this section and the effective-
ness of such activities in resolving health care-related 
problems and grievances. 
(d) AUTHORIZATION
OF APPROPRIATIONS.—There 
are authorized to be appropriated such sums as may be 
necessary to carry out this section. 
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 (including 
physician pathology 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 serv-
ices, or 
(2) a group health plan offers to participants or 
beneficiaries health benefits which provide for cov-
erage of services only if such services are furnished 
through health care professionals and providers who 
are members of a network of health care profes-
sionals and providers who have entered into a con-
tract 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 in-
surance coverage or health benefits which provide for cov-
erage 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 addi-
tional 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, partici-
pant, 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 ben-
eficiary, 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 cov-
erage, requires or provides for designation by a partici-
pant, beneficiary, or enrollee of a participating primary 
care provider, then the plan or issuer shall permit each 
participant, beneficiary, and enrollee to designate any par-
ticipating 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 medi-
cally necessary and appropriate specialty care, pur-
suant 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 sub-
section shall be construed as affecting the applica-
tion of section 114 (relating to access to specialists). 
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 insur-
ance issuer, provides or covers any benefits with re-
spect 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 author-
ization determination; 
(B) whether the health care provider fur-
nishing 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 en-
rollee— 
(i) by a nonparticipating health care 
provider with or without prior authoriza-
tion, or 
(ii) by a participating health care pro-
vider 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 Rev-
enue Code of 1986, and other than applicable 
cost-sharing). 
(2) DEFINITIONS.—In this section: 
(A) EMERGENCY
MEDICAL
CONDITION.— 
The term ‘‘emergency medical condition’’ means 
a medical condition manifesting itself by acute 
symptoms of sufficient severity (including se-
vere 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, with respect to an 
emergency medical condition— 
(i) a medical screening examination 
(as required under section 1867 of the So-
cial Security Act) that is within the capa-
bility of the emergency department of a 
hospital, including ancillary services rou-
tinely available to the emergency depart-
ment to evaluate such emergency medical 
condition, 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’’, 
with respect to an emergency medical condition 
(as defined in subparagraph (A)), has the 
meaning given in section 1867(e)(3) of the So-
cial Security Act (42 U.S.C. 1395dd(e)(3)). 
(b) REIMBURSEMENT FOR MAINTENANCE CARE AND 
POST-STABILIZATION CARE.—A group health plan, and
health insurance coverage offered by a health insurance 
issuer, must provide reimbursement for maintenance care 
and post-stabilization care in accordance with the require-
ments of section 1852(d)(2) of the Social Security Act (42 
U.S.C. 1395w–22(d)(2)). Such reimbursement shall be 
provided in a manner consistent with subsection (a)(1)(C). 
(c) COVERAGE OF EMERGENCY AMBULANCE SERV-
ICES.— 
(1) IN GENERAL.—If a group health plan, or 
health insurance coverage provided by a health in-
surance issuer, provides any benefits with respect to 
ambulance services and emergency services, the plan 
or issuer shall cover emergency ambulance services 
(as defined in paragraph (2)) furnished under the 
plan or coverage under the same terms and condi-
tions under subparagraphs (A) through (D) of sub-
section (a)(1) under which coverage is provided for 
emergency services. 
(2) EMERGENCY AMBULANCE SERVICES.—For 
purposes of this subsection, the term ‘‘emergency 
ambulance services’’ means ambulance services (as 
defined for purposes of section 1861(s)(7) of the So-
cial Security Act) furnished to transport an indi-
vidual who has an emergency medical condition (as 
defined in subsection (a)(2)(A)) to a hospital for the