113 
(1) BENEFITS.—A description of the covered 
benefits, including— 
(A) any in- and out-of-network benefits; 
(B) specific preventive services covered 
under the plan or coverage if such services are 
covered; 
(C) any specific exclusions or express limi-
tations 
of 
benefits 
described 
in 
section 
104(d)(3)(C); 
(D) any other benefit limitations, including 
any annual or lifetime benefit limits and any 
monetary limits or limits on the number of vis-
its, days, or services, and any specific coverage 
exclusions; and 
(E) any definition of medical necessity 
used in making coverage determinations by the 
plan, issuer, or claims administrator. 
(2) COST SHARING.—A description of any cost- 
sharing requirements, including— 
(A) any premiums, deductibles, coinsur-
ance, copayment amounts, and liability for bal-
ance billing, for which the participant, bene-
ficiary, or enrollee will be responsible under 
each option available under the plan;
114 
(B) any maximum out-of-pocket expense 
for which the participant, beneficiary, or en-
rollee may be liable; 
(C) any cost-sharing requirements for out- 
of-network benefits or services received from 
nonparticipating providers; and 
(D) any additional cost-sharing or charges 
for benefits and services that are furnished 
without meeting applicable plan or coverage re-
quirements, such as prior authorization or 
precertification. 
(3) DISENROLLMENT.—Information relating to 
the disenrollment of a participant, beneficiary, or en-
rollee. 
(4) SERVICE AREA.—A description of the plan 
or issuer’s service area, including the provision of 
any out-of-area coverage. 
(5) PARTICIPATING PROVIDERS.—A directory of 
participating providers (to the extent a plan or 
issuer provides coverage through a network of pro-
viders) that includes, at a minimum, the name, ad-
dress, and telephone number of each participating 
provider, and information about how to inquire 
whether a participating provider is currently accept-
ing new patients.
115 
(6) CHOICE OF PRIMARY CARE PROVIDER.—A 
description of any requirements and procedures to 
be used by participants, beneficiaries, and enrollees 
in selecting, accessing, or changing their primary 
care provider, including providers both within and 
outside of the network (if the plan or issuer permits 
out-of-network services), and the right to select a pe-
diatrician as a primary care provider under section 
116 for a participant, beneficiary, or enrollee who is 
a child if such section applies. 
(7) PREAUTHORIZATION
REQUIREMENTS.—A 
description of the requirements and procedures to be 
used to obtain preauthorization for health services, 
if such preauthorization is required. 
(8) EXPERIMENTAL
AND
INVESTIGATIONAL 
TREATMENTS.—A description of the process for de-
termining whether a particular item, service, or 
treatment is considered experimental or investiga-
tional, and the circumstances under which such 
treatments are covered by the plan or issuer. 
(9) SPECIALTY CARE.—A description of the re-
quirements and procedures to be used by partici-
pants, beneficiaries, and enrollees in accessing spe-
cialty care and obtaining referrals to participating 
and nonparticipating specialists, including any limi-
116 
tations on choice of health care professionals re-
ferred to in section 112(b)(2) and the right to timely 
access to specialists care under section 114 if such 
section applies. 
(10) CLINICAL TRIALS.—A description of the 
circumstances and conditions under which participa-
tion in clinical trials is covered under the terms and 
conditions of the plan or coverage, and the right to 
obtain coverage for approved clinical trials under 
section 119 if such section applies. 
(11) PRESCRIPTION DRUGS.—To the extent the 
plan or issuer provides coverage for prescription 
drugs, a statement of whether such coverage is lim-
ited to drugs included in a formulary, a description 
of any provisions and cost-sharing required for ob-
taining on- and off-formulary medications, and a de-
scription of the rights of participants, beneficiaries, 
and enrollees in obtaining access to prescription 
drugs under section 118 if such section applies. 
(12) EMERGENCY
SERVICES.—A summary of 
the rules and procedures for accessing emergency 
services, including the right of a participant, bene-
ficiary, or enrollee to obtain emergency services 
under the prudent layperson standard under section 
113, if such section applies, and any educational in-
117 
formation that the plan or issuer may provide re-
garding the appropriate use of emergency services. 
(13) CLAIMS AND APPEALS.—A description of 
the plan or issuer’s rules and procedures pertaining 
to claims and appeals, a description of the rights 
(including deadlines for exercising rights) of partici-
pants, beneficiaries, and enrollees under subtitle A 
in obtaining covered benefits, filing a claim for bene-
fits, and appealing coverage decisions internally and 
externally (including telephone numbers and mailing 
addresses of the appropriate authority), and a de-
scription of any additional legal rights and remedies 
available under section 502 of the Employee Retire-
ment Income Security Act of 1974 and applicable 
State law. 
(14) ADVANCE DIRECTIVES AND ORGAN DONA-
TION.—A description of procedures for advance di-
rectives and organ donation decisions if the plan or 
issuer maintains such procedures. 
(15) INFORMATION ON PLANS AND ISSUERS.— 
The name, mailing address, and telephone number 
or numbers of the plan administrator and the issuer 
to be used by participants, beneficiaries, and enroll-
ees seeking information about plan or coverage bene-
fits and services, payment of a claim, or authoriza-
118 
tion for services and treatment. Notice of whether 
the benefits under the plan or coverage are provided 
under a contract or policy of insurance issued by an 
issuer, or whether benefits are provided directly by 
the plan sponsor who bears the insurance risk. 
(16) TRANSLATION SERVICES.—A summary de-
scription of any translation or interpretation services 
(including the availability of printed information in 
languages other than English, audio tapes, or infor-
mation in Braille) that are available for non-English 
speakers and participants, beneficiaries, and enroll-
ees with communication disabilities and a description 
of how to access these items or services. 
(17) ACCREDITATION INFORMATION.—Any in-
formation that is made public by accrediting organi-
zations in the process of accreditation if the plan or 
issuer is accredited, or any additional quality indica-
tors (such as the results of enrollee satisfaction sur-
veys) that the plan or issuer makes public or makes 
available to participants, beneficiaries, and enrollees. 
(18) NOTICE OF REQUIREMENTS.—A descrip-
tion of any rights of participants, beneficiaries, and 
enrollees that are established by the provisions of 
this Act (excluding those described in paragraphs 
(1) through (17)) if such provisions apply. The de-
119 
scription required under this paragraph may be com-
bined with the notices of the type described in sec-
tions 711(d), 713(b), or 606(a)(1) of the Employee 
Retirement Income Security Act of 1974 and with 
any other notice provision that the appropriate Sec-
retary determines may be combined, so long as such 
combination does not result in any reduction in the 
information that would otherwise be provided to the 
recipient. 
(19) AVAILABILITY OF ADDITIONAL INFORMA-
TION.—A statement that the information described 
in subsection (c), and instructions on obtaining such 
information (including telephone numbers and, if 
available, Internet websites), shall be made available 
upon request. 
(20) DESIGNATED
DECISIONMAKERS.—A de-
scription of the participants and beneficiaries with 
respect to whom each designated decisionmaker 
under the plan has assumed liability under section 
502(o) of the Employee Retirement Income Security 
Act of 1974 and the name and address of each such 
decisionmaker. 
(c) ADDITIONAL INFORMATION.—The informational 
materials to be provided upon the request of a participant, 
beneficiary, or enrollee shall include for each option avail-
120 
able under a group health plan or health insurance cov-
erage the following: 
(1) STATUS OF PROVIDERS.—The State licen-
sure status of the plan or issuer’s participating 
health care professionals and participating health 
care facilities, and, if available, the education, train-
ing, specialty qualifications or certifications of such 
professionals. 
(2) COMPENSATION
METHODS.—A summary 
description by category of the applicable methods 
(such as capitation, fee-for-service, salary, bundled 
payments, per diem, or a combination thereof) used 
for compensating prospective or treating health care 
professionals (including primary care providers and 
specialists) and facilities in connection with the pro-
vision of health care under the plan or coverage. 
(3) PRESCRIPTION DRUGS.—Information about 
whether a specific prescription medication is in-
cluded in the formulary of the plan or issuer, if the 
plan or issuer uses a defined formulary. 
(4) UTILIZATION REVIEW ACTIVITIES.—A de-
scription of procedures used and requirements (in-
cluding circumstances, timeframes, and appeals 
rights) under any utilization review program under
121 
sections 101 and 102, including any drug formulary 
program under section 118. 
(5) EXTERNAL
APPEALS
INFORMATION.—Ag-
gregate information on the number and outcomes of 
external medical reviews, relative to the sample size 
(such as the number of covered lives) under the plan 
or under the coverage of the issuer. 
(d) MANNER OF DISCLOSURE.—The information de-
scribed in this section shall be disclosed in an accessible 
medium and format that is calculated to be understood 
by a participant or enrollee. 
(e) RULES OF CONSTRUCTION.—Nothing in this sec-
tion shall be construed to prohibit a group health plan, 
or a health insurance issuer in connection with health in-
surance coverage, from— 
(1) distributing any other additional informa-
tion determined by the plan or issuer to be impor-
tant or necessary in assisting participants, bene-
ficiaries, and enrollees in the selection of a health 
plan or health insurance coverage; and 
(2) complying with the provisions of this section 
by providing information in brochures, through the 
Internet or other electronic media, or through other 
similar means, so long as—
122 
(A) the disclosure of such information in 
such form is in accordance with requirements 
as the appropriate Secretary may impose, and 
(B) in connection with any such disclosure 
of information through the Internet or other 
electronic media— 
(i) the recipient has affirmatively con-
sented to the disclosure of such informa-
tion in such form, 
(ii) the recipient is capable of access-
ing the information so disclosed on the re-
cipient’s individual workstation or at the 
recipient’s home, 
(iii) the recipient retains an ongoing 
right to receive paper disclosure of such in-
formation and receives, in advance of any 
attempt at disclosure of such information 
to him or her through the Internet or 
other electronic media, notice in printed 
form of such ongoing right and of the 
proper software required to view informa-
tion so disclosed, and 
(iv) the plan administrator appro-
priately ensures that the intended recipient 
is receiving the information so disclosed
123 
and provides the information in printed 
form if the information is not received. 
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 agree-
ment, 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 pro-
viders) shall not prohibit or otherwise restrict a health 
care professional from advising such a participant, bene-
ficiary, 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, re-
gardless 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 communica-
tions in violation of subsection (a) shall be null and void.
124 
SEC. 132. PROHIBITION OF DISCRIMINATION AGAINST PRO-
VIDERS BASED ON LICENSURE. 
(a) IN GENERAL.—A group health plan, and a health 
insurance issuer with respect to health insurance coverage, 
shall not discriminate with respect to participation or in-
demnification as to any provider who is acting within the 
scope of the provider’s license or certification under appli-
cable State law, solely on the basis of such license or cer-
tification. 
(b) CONSTRUCTION.—Subsection (a) shall not be con-
strued— 
(1) as requiring the coverage under a group 
health plan or health insurance coverage of a par-
ticular benefit or service 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 es-
tablishing 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 net-
work coverage to include for participation every will-
ing provider who meets the terms and conditions of 
the plan or issuer.
125 
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 1852(j)(4) of the Social Secu-
rity 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 1852(j)(4) of the 
Social Security Act to the Secretary, a Medicare+Choice 
or MedicareAdvantage organization, or an individual en-
rolled with such an organization shall be treated as a ref-
erence to the applicable authority, a group health plan or 
health insurance issuer, respectively, and a participant, 
beneficiary, or enrollee with the plan or organization, re-
spectively. 
(c) CONSTRUCTION.—Nothing in this section shall be 
construed as prohibiting all capitation and similar ar-
rangements or all provider discount arrangements. 
SEC. 134. PAYMENT OF CLAIMS. 
A group health plan, and a health insurance issuer 
offering health insurance coverage, shall provide for 
prompt payment of claims submitted for health care serv-
ices or supplies furnished to a participant, beneficiary, or
126 
enrollee with respect to benefits covered by the plan or 
issuer, in a manner that is no less protective than the pro-
visions of section 1842(c)(2) of the Social Security Act 
(42 U.S.C. 1395u(c)(2)). 
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 par-
ticipant, beneficiary, enrollee, or health care provider 
based on the participant’s, beneficiary’s, enrollee’s or pro-
vider’s use of, or participation in, a utilization review proc-
ess 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 and a 
health insurance issuer may not retaliate or dis-
criminate against a protected health care profes-
sional 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 reg-
127 
ulatory agency, an appropriate private accredi-
tation body, or appropriate management per-
sonnel of the plan or issuer; or 
(B) initiates, cooperates, or otherwise par-
ticipates in an investigation or proceeding by 
such an agency with respect to such care, serv-
ices, or conditions. 
If an institutional health care provider is a partici-
pating provider with such a plan or issuer or other-
wise receives payments for benefits provided by such 
a plan or issuer, the provisions of the previous sen-
tence 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 ref-
erence 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
128 
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 li-
censure or certification and the same experi-
ence; 
(B) the professional reasonably believes the 
information to be true; 
(C) the information evidences either a vio-
lation of a law, rule, or regulation, of an appli-
cable 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 es-
tablished 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
129 
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 pro-
cedures if those procedures have been made 
available to the professional through distribu-
tion or posting. 
(C) INTERNAL PROCEDURE EXCEPTION.— 
Subparagraph (D) of paragraph (2) also shall 
not apply if— 
(i) the disclosure relates to an immi-
nent hazard of loss of life or serious injury 
to a patient; 
(ii) the disclosure is made to an ap-
propriate private accreditation body pursu-
ant to disclosure procedures established by 
the body; or
130 
(iii) the disclosure is in response to an 
inquiry made in an investigation or pro-
ceeding 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 ad-
verse action against a protected health care profes-
sional if the plan, issuer, or provider taking the ad-
verse action involved demonstrates that it would 
have taken the same adverse action even in the ab-
sence of the activities protected under such para-
graph. 
(5) NOTICE.—A group health plan, health in-
surance 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 enforce-
ment 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 deter-
131 
mination 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 PRO-
TOCOLS AND INTERNAL PROCEDURES.—Noth-
ing in this subsection shall be construed to pro-
hibit a plan, issuer, or provider from estab-
lishing and enforcing reasonable peer review or 
utilization review protocols or determining 
whether a protected health care professional has 
complied with those protocols or from estab-
lishing and enforcing internal procedures for 
the purpose of addressing quality concerns. 
(C) RELATION TO OTHER RIGHTS.—Noth-
ing in this subsection shall be construed to 
abridge rights of participants, beneficiaries, en-
rollees, 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