I
106TH CONGRESS
1ST SESSION
H. R. 2095
To amend title I of the Employee Retirement Income Security Act of 1974
to make needed reforms relating to group health plans.
IN THE HOUSE OF REPRESENTATIVES
JUNE 9, 1999
Mr. BOEHNER introduced the following bill; which was referred to the
Committee on Education and the Workforce
A BILL
To amend title I of the Employee Retirement Income Secu-
rity Act of 1974 to make needed reforms relating to
group health plans.
Be it enacted by the Senate and House of Representa-
tives of the United States of America in Congress assembled,
SECTION 1. SHORT TITLE AND TABLE OF CONTENTS.
(a) SHORT TITLE.—This Act may be cited as the
‘‘Health Care Quality and Access Act of 1999’’.
(b) TABLE OF CONTENTS.—The table of contents is
as follows:
Sec. 1. Short title and table of contents.
TITLE I—PATIENT RIGHT TO UNRESTRICTED MEDICAL ADVICE
Sec. 101. Patient access to unrestricted professional health care advice.
Sec. 102. Effective date and related rules.
TITLE II—PATIENT RIGHT TO EMERGENCY MEDICAL CARE
Sec. 201. Patient access to emergency medical care.
Sec. 202. Effective date and related rules.
TITLE III—PATIENT RIGHT TO OBSTETRIC AND GYNECOLOGICAL
CARE
Sec. 301. Patient access to obstetric and gynecological care.
Sec. 302. Effective date and related rules.
TITLE IV—PATIENT RIGHT TO PEDIATRIC CARE
Sec. 401. Patient access to pediatric care.
Sec. 402. Effective date and related rules.
TITLE V—PATIENT ACCESS TO INFORMATION
Sec. 501. Patient access to information regarding plan coverage, managed care
procedures, health care providers, and quality of medical care.
Sec. 502. Effective date and related rules.
TITLE VI—GROUP HEALTH PLAN REVIEW STANDARDS
Sec. 601. Special rules for group health plans.
Sec. 602. Clarification of ERISA preemption rules.
Sec. 603. Effective date.
TITLE VII—SMALL BUSINESS ACCESS AND CHOICE FOR
ENTREPRENEURS
Sec. 701. Rules governing association health plans.
‘‘PART 8—RULES GOVERNING ASSOCIATION HEALTH PLANS
‘‘Sec. 801. Association health plans.
‘‘Sec. 802. Certification of association health plans.
‘‘Sec. 803. Requirements relating to sponsors and boards of trustees.
‘‘Sec. 804. Participation and coverage requirements.
‘‘Sec. 805. Other requirements relating to plan documents, contribution
rates, and benefit options.
‘‘Sec. 806. Maintenance of reserves and provisions for solvency for plans
providing health benefits in addition to health insurance
coverage.
‘‘Sec. 807. Requirements for application and related requirements.
‘‘Sec. 808. Notice requirements for voluntary termination.
‘‘Sec. 809. Corrective actions and mandatory termination.
‘‘Sec. 810. Trusteeship by the Secretary of insolvent association health
plans providing health benefits in addition to health insur-
ance coverage.
‘‘Sec. 811. State assessment authority.
‘‘Sec. 812. Definitions and rules of construction.
Sec. 702. Clarification of treatment of single employer arrangements.
Sec. 703. Clarification of treatment of certain collectively bargained arrange-
ments.
Sec. 704. Enforcement provisions relating to association health plans.
Sec. 705. Cooperation between Federal and State authorities.
Sec. 706. Effective date and transitional and other rules.
TITLE VIII—HEALTH CARE ACCESS, AFFORDABILITY, AND
QUALITY COMMISSION
Sec. 801. Establishment of commission.
Sec. 802. Effective date.
TITLE I—PATIENT RIGHT TO UN-
RESTRICTED 
MEDICAL 
AD-
VICE
SEC. 101. PATIENT ACCESS TO UNRESTRICTED PROFES-
SIONAL HEALTH CARE ADVICE.
(a) IN GENERAL.—Subpart B of part 7 of subtitle
B of title I of the Employee Retirement Income Security
Act of 1974 is amended by adding at the end the following
new section:
‘‘SEC. 714. PATIENT ACCESS TO UNRESTRICTED PROFES-
SIONAL HEALTH CARE ADVICE.
‘‘(a) IN GENERAL.—A group health plan, or a health
insurance issuer offering health insurance coverage in con-
nection with a group health plan, shall not prohibit or oth-
erwise restrict a health care professional from advising a
participant or beneficiary under the plan who is a patient
of the professional about the health status of the partici-
pant or beneficiary or the medical care or treatment for
the condition or disease of the participant or beneficiary,
regardless of whether benefits for such care or treatment
are provided under the plan or coverage, if the professional
is acting within the lawful scope of practice of the profes-
sional.
‘‘(b) RULES OF CONSTRUCTION.—Nothing in this
section shall be construed—
‘‘(1) to prohibit the enforcement, as part of a
contract or agreement to which a health care profes-
sional is a party, of any mutually agreed upon terms
and conditions, including terms and conditions re-
quiring a health care professional to participate in,
and cooperate with, all programs, policies, and pro-
cedures developed or operated by a group health
plan or health insurance issuer to assure, review, or
improve the quality and effective utilization of health
care services (if such utilization is according to
guidelines or protocols that are based on clinical or
scientific evidence and the professional judgment of
the professional) but only if the guidelines or proto-
cols under such utilization do not prohibit or restrict
advice described in subsection (a) between health
care professionals and their patients; or
‘‘(2) to permit a health care professional to
misrepresent the scope of benefits covered under the
group health plan or health insurance coverage or to
otherwise require a group health plan or health in-
surance issuer to reimburse health care professionals
for benefits (including services and advice) not cov-
ered under the plan or coverage.
‘‘(c) HEALTH CARE PROFESSIONAL DEFINED.—For
purposes of this section, the term ‘health care professional’
means a physician (as defined in section 1861(r) of the
Social Security Act) or other health care professional if
coverage for the professional’s services is provided under
the group health plan for the services of the professional.
Such term includes a podiatrist, optometrist, chiropractor,
psychologist, dentist, physician assistant, physical or occu-
pational therapist and therapy assistant, speech-language
pathologist, audiologist, registered or licensed practical
nurse (including nurse practitioner, clinical nurse spe-
cialist, certified registered nurse anesthetist, and certified
nurse-midwife), licensed certified social worker, registered
respiratory therapist, and certified respiratory therapy
technician.’’.
(b) CONFORMING AMENDMENT.—Section 732(a) of
such Act (29 U.S.C. 1191a(a)) is amended by striking
‘‘section 711’’ and inserting ‘‘sections 711 and 714’’.
(c) CLERICAL AMENDMENT.—The table of contents
in section 1 of such Act is amended by adding at the end
of the items relating to subpart B of part 7 of subtitle
B of title I of such Act the following new item:
‘‘Sec. 714. Patient access to unrestricted professional health care advice.’’.
SEC. 102. EFFECTIVE DATE AND RELATED RULES.
(a) EFFECTIVE DATE.—
(1) IN GENERAL.—Subject to paragraph (2),
the amendments made by this title apply with re-
spect to group health plans for plan years beginning
on or after the first day of the first month that be-
gins more than 1 year after the date of the enact-
ment of this Act.
(2) COLLECTIVE BARGAINING EXCEPTION.—In
the case of a group health plan maintained pursuant
to 1 or more collective bargaining agreements be-
tween employee representatives and 1 or more em-
ployers ratified before the date of enactment of this
Act, the amendments made by this title shall not
apply to plan years beginning before the later of—
(A) the date on which the last collective
bargaining agreements relating to the plan ter-
minates (determined without regard to any ex-
tension thereof agreed to after the date of en-
actment of this Act), or
(B) the first day described in paragraph
(1).
For purposes of subparagraph (A), any plan amend-
ment made pursuant to a collective bargaining
agreement relating to the plan which amends the
plan solely to conform to any requirement added by
this title shall not be treated as a termination of
such collective bargaining agreement.
(c) LIMITATION ON ENFORCEMENT ACTIONS.—No
enforcement action shall be taken, pursuant to the amend-
ments made by this title, against a group health plan or
health insurance issuer with respect to a violation of a re-
quirement imposed by such amendments, and no penalty
shall be imposed on any failure by such plan to comply
with any requirement imposed by such amendments, to the
extent that violation or failure occurs before the date of
issuance of final regulations issued in connection with
such requirement, if the plan or issuer has sought to com-
ply in good faith with such requirement.
TITLE II—PATIENT RIGHT TO
EMERGENCY MEDICAL CARE
SEC. 201. PATIENT ACCESS TO EMERGENCY MEDICAL
CARE.
(a) IN GENERAL.—Subpart B of part 7 of subtitle
B of title I of the Employee Retirement Income Security
Act of 1974 (as amended by the preceding provisions of
this Act) is amended further by adding at the end the fol-
lowing new section:
‘‘SEC. 715. PATIENT ACCESS TO EMERGENCY MEDICAL
CARE.
‘‘(a) IN GENERAL.—To the extent that a group
health plan (or a health insurance issuer offering health
insurance coverage in connection with the plan) provides
for any benefits consisting of emergency medical care, ex-
cept for items or services specifically excluded—
‘‘(1) the plan or issuer shall provide benefits,
without requiring preauthorization and without re-
gard to otherwise applicable network limitations, for
appropriate emergency medical screening examina-
tions (within the capability of the emergency facility,
including ancillary services routinely available to the
emergency facility) to the extent that a prudent
layperson, who possesses an average knowledge of
health and medicine, would determine such examina-
tions to be necessary in order to determine whether
emergency medical care is required; and
‘‘(2) the plan or issuer shall provide benefits for
additional emergency medical services following an
emergency medical screening examination (if deter-
mined necessary under paragraph (1)) to the extent
that a prudent emergency medical professional
would determine such additional emergency services
to be necessary to avoid the consequences described
in subsection (c).
‘‘(b) UNIFORM COST-SHARING REQUIRED.—Nothing
in this section shall be construed as preventing a group
health plan or issuer from imposing any form of cost-shar-
ing applicable to any participant or beneficiary (including
coinsurance, copayments, deductibles, and any other
charges) in relation to benefits described in subsection (a),
if such form of cost-sharing is uniformly applied under
such plan, with respect to similarly situated participants
and beneficiaries, to all benefits consisting of emergency
medical care provided to such similarly situated partici-
pants and beneficiaries under the plan.
‘‘(c) EMERGENCY MEDICAL CARE.—For purposes of
this section, the term ‘emergency medical care’ means
medical care in any case in which an appropriate physician
has certified in writing (or as otherwise provided in regula-
tions of the Secretary)—
‘‘(1) that failure to immediately provide the
care to the participant or beneficiary could reason-
ably be expected to result in—
‘‘(A) placing the health of such participant
or beneficiary (or, with respect to such a partic-
ipant or beneficiary who is a pregnant woman,
the health of the woman or her unborn child)
in serious jeopardy;
‘‘(B) serious impairment to bodily func-
tions; or
‘‘(C) serious dysfunction of any bodily
organ or part; or
‘‘(2) that immediate provision of the care is
necessary because the participant or beneficiary has
made or is at serious risk of making an attempt to
harm himself or herself or another individual.’’.
(b) CONFORMING AMENDMENT.—The table of con-
tents in section 1 of such Act (as amended by the pre-
ceding provisions of this Act) is amended further by add-
ing at the end of the items relating to subpart B of part
7 of subtitle B of title I of such Act the following new
item:
‘‘Sec. 715. Patient access to emergency medical care.’’.
SEC. 202. EFFECTIVE DATE AND RELATED RULES.
(a) IN GENERAL.—The amendments made by this
title shall apply with respect to plan years beginning on
or after January 1 of the second calendar year following
the date of the enactment of this Act, except that the Sec-
retary of Labor may issue regulations before such date
under such amendments. The Secretary shall first issue
regulations necessary to carry out the amendments made
by this title before the effective date thereof.
(b) LIMITATION ON ENFORCEMENT ACTIONS.—No
enforcement action shall be taken, pursuant to the amend-
ments made by this title, against a group health plan or
health insurance issuer with respect to a violation of a re-
quirement imposed by such amendments before the date
of issuance of regulations issued in connection with such
requirement, if the plan or issuer has sought to comply
in good faith with such requirement.
(c) SPECIAL RULE FOR COLLECTIVE BARGAINING
AGREEMENTS.—In the case of a group health plan main-
tained pursuant to one or more collective bargaining
agreements between employee representatives and one or
more employers ratified before the date of the enactment
of this Act, the amendments made by this title shall not
apply with respect to plan years beginning before the later
of—
(1) the date on which the last of the collective
bargaining agreements relating to the plan termi-
nates (determined without regard to any extension
thereof agreed to after the date of the enactment of
this Act); or
(2) January 1, 2002.
For purposes of this subsection, any plan amendment
made pursuant to a collective bargaining agreement relat-
ing to the plan which amends the plan solely to conform
to any requirement added by this title shall not be treated
as a termination of such collective bargaining agreement.
TITLE III—PATIENT RIGHT TO
OBSTETRIC 
AND 
GYNECO-
LOGICAL CARE
SEC. 301. PATIENT ACCESS TO OBSTETRIC AND GYNECO-
LOGICAL CARE.
(a) IN GENERAL.—Subpart B of part 7 of subtitle
B of title I of the Employee Retirement Income Security
Act of 1974 (as amended by the preceding provisions of
this Act) is amended further by adding at the end the fol-
lowing new section:
‘‘SEC. 716. PATIENT ACCESS TO OBSTETRIC AND GYNECO-
LOGICAL CARE
‘‘(a) IN GENERAL.—In any case in which a group
health plan (or a health insurance issuer offering health
insurance coverage in connection with the plan)—
‘‘(1) provides benefits under the terms of the
plan consisting of—
‘‘(A) routine gynecological care (such as
preventive women’s health examinations); or
‘‘(B) routine obstetric care (such as rou-
tine pregnancy-related services),
provided by a participating physician who specializes
in such care (or provides benefits consisting of pay-
ment for such care); and
‘‘(2) requires or provides for designation by a
participant or beneficiary of a participating primary
care provider,
if the primary care provider designated by such a partici-
pant or beneficiary is not such a physician, then the plan
(or issuer) shall meet the requirements of subsection (b).
‘‘(b) REQUIREMENTS.—A group health plan (or a
health insurance issuer offering health insurance coverage
in connection with the plan) meets the requirements of
this subsection, in connection with benefits described in
subsection (a) consisting of care described in subpara-
graph (A) or (B) of subsection (a)(1) (or consisting of
payment therefor), if the plan (or issuer)—
‘‘(1) does not require authorization or a referral
by the primary care provider in order to obtain such
benefits; and
‘‘(2) treats the ordering of other routine care of
the same type, by the participating physician pro-
viding the care described in subparagraph (A) or (B)
of subsection (a)(1), as the authorization of the pri-
mary care provider with respect to such care.
‘‘(c) CONSTRUCTION.—Nothing in subsection (b)(2)
shall waive any requirements of coverage relating to med-
ical necessity or appropriateness with respect to coverage
of gynecological or obstetric care so ordered.
‘‘(d) TREATMENT
OF MULTIPLE COVERAGE OP-
TIONS.—In the case of a plan providing benefits under two
or more coverage options, the requirements of this section
shall apply separately with respect to each coverage op-
tion.’’.
(b) CONFORMING AMENDMENT.—The table of con-
tents in section 1 of such Act (as amended by the pre-
ceding provisions of this Act) is amended further by add-
ing at the end of the items relating to subpart B of part
7 of subtitle B of title I of such Act the following new
item:
‘‘Sec. 716. Patient access to obstetric and gynecological care.’’.
SEC. 302. EFFECTIVE DATE AND RELATED RULES.
(a) IN GENERAL.—The amendments made by this
title shall apply with respect to plan years beginning on
or after January 1 of the second calendar year following
the date of the enactment of this Act, except that the Sec-
retary of Labor may issue regulations before such date
under such amendments. The Secretary shall first issue
regulations necessary to carry out the amendments made
by this title before the effective date thereof.
(b) LIMITATION ON ENFORCEMENT ACTIONS.—No
enforcement action shall be taken, pursuant to the amend-
ments made by this title, against a group health plan or
health insurance issuer with respect to a violation of a re-
quirement imposed by such amendments before the date
of issuance of regulations issued in connection with such
requirement, if the plan or issuer has sought to comply
in good faith with such requirement.
(c) SPECIAL RULE FOR COLLECTIVE BARGAINING
AGREEMENTS.—In the case of a group health plan main-
tained pursuant to one or more collective bargaining
agreements between employee representatives and one or
more employers ratified before the date of the enactment
of this Act, the amendments made by this title shall not
apply with respect to plan years beginning before the later
of—
(1) the date on which the last of the collective
bargaining agreements relating to the plan termi-
nates (determined without regard to any extension
thereof agreed to after the date of the enactment of
this Act); or
(2) January 1, 2002.
For purposes of this subsection, any plan amendment
made pursuant to a collective bargaining agreement relat-
ing to the plan which amends the plan solely to conform
to any requirement added by this title shall not be treated
as a termination of such collective bargaining agreement.
TITLE IV—PATIENT RIGHT TO
PEDIATRIC CARE
SEC. 401. PATIENT ACCESS TO PEDIATRIC CARE.
(a) IN GENERAL.—Subpart B of part 7 of subtitle
B of title I of the Employee Retirement Income Security
Act of 1974 (as amended by the preceding provisions of
this Act) is amended further by adding at the end the fol-
lowing new section:
‘‘SEC. 717. PATIENT ACCESS TO PEDIATRIC CARE.
‘‘(a) IN GENERAL.—In any case in which a group
health plan (or a health insurance issuer offering health
insurance coverage in connection with the plan) provides
benefits consisting of routine pediatric care provided by
a participating physician who specializes in pediatrics (or
consisting of payment for such care) and the plan requires
or provides for designation by a participant or beneficiary
of a participating primary care provider, the plan (or
issuer) shall provide that such a participating physician
may be designated, if available, by a parent or guardian
of any beneficiary under the plan is who under 18 years
of age, as the primary care provider with respect to any
such benefits.
‘‘(b) CONSTRUCTION.—Nothing in subsection (a)
shall waive any requirements of coverage relating to med-
ical necessity or appropriateness with respect to coverage
of pediatric care.
‘‘(c) TREATMENT
OF MULTIPLE COVERAGE OP-
TIONS.—In the case of a plan providing benefits under two
or more coverage options, the requirements of this section
shall apply separately with respect to each coverage op-
tion.’’.
(b) CONFORMING AMENDMENT.—The table of con-
tents in section 1 of such Act (as amended by the pre-
ceding provisions of this Act) is amended further by add-
ing at the end of the items relating to subpart B of part
7 of subtitle B of title I of such Act the following new
item:
‘‘Sec. 717. Patient access to pediatric care.’’.
SEC. 402. EFFECTIVE DATE AND RELATED RULES.
(a) IN GENERAL.—The amendments made by this
title shall apply with respect to plan years beginning on
or after January 1 of the second calendar year following
the date of the enactment of this Act, except that the Sec-
retary of Labor may issue regulations before such date
under such amendments. The Secretary shall first issue
regulations necessary to carry out the amendments made
by this title before the effective date thereof.
(b) LIMITATION ON ENFORCEMENT ACTIONS.—No
enforcement action shall be taken, pursuant to the amend-
ments made by this title, against a group health plan or
health insurance issuer with respect to a violation of a re-
quirement imposed by such amendments before the date
of issuance of regulations issued in connection with such
requirement, if the plan or issuer has sought to comply
in good faith with such requirement.
(c) SPECIAL RULE FOR COLLECTIVE BARGAINING
AGREEMENTS.—In the case of a group health plan main-
tained pursuant to one or more collective bargaining
agreements between employee representatives and one or
more employers ratified before the date of the enactment
of this Act, the amendments made by this title shall not
apply with respect to plan years beginning before the later
of—
(1) the date on which the last of the collective
bargaining agreements relating to the plan termi-
nates (determined without regard to any extension
thereof agreed to after the date of the enactment of
this Act); or
(2) January 1, 2002.
For purposes of this subsection, any plan amendment
made pursuant to a collective bargaining agreement relat-
ing to the plan which amends the plan solely to conform
to any requirement added by this title shall not be treated
as a termination of such collective bargaining agreement.
TITLE V—PATIENT ACCESS TO
INFORMATION
SEC. 501. PATIENT ACCESS TO INFORMATION REGARDING
PLAN COVERAGE, MANAGED CARE PROCE-
DURES, 
HEALTH 
CARE 
PROVIDERS, 
AND
QUALITY OF MEDICAL CARE.
(a) IN GENERAL.—Part 1 of subtitle B of title I of
the Employee Retirement Income Security Act of 1974 is
amended—
(1) by redesignating section 111 as section 112;
and
(2) by inserting after section 110 the following
new section:
‘‘DISCLOSURE BY GROUP HEALTH PLANS
‘‘SEC. 111. (a) DISCLOSURE REQUIREMENT.—
‘‘(1) GROUP
HEALTH
PLANS.—The adminis-
trator of each group health plan shall take such ac-
tions as are necessary to ensure that the summary
plan description of the plan required under section
102 (or each summary plan description in any case
in which different summary plan descriptions are ap-
propriate under part 1 for different options of cov-
erage) contains, among any information otherwise
required under this part, the information required
under subsections (b), (c), (d), and (e)(2)(A).
‘‘(2) 
HEALTH
INSURANCE
ISSUERS.—Each
health insurance issuer offering health insurance
coverage in connection with a group health plan
shall provide the administrator on a timely basis
with the information necessary to enable the admin-
istrator to comply with the requirements of para-
graph (1). To the extent that any such issuer pro-
vides on a timely basis to plan participants and
beneficiaries information otherwise required under
this part to be included in the summary plan de-
scription, the requirements of sections 101(a)(1) and
104(b) shall be deemed satisfied in the case of such
plan with respect to such information.
‘‘(b) PLAN BENEFITS.—The information required
under subsection (a) includes the following:
‘‘(1) COVERED ITEMS AND SERVICES.—
‘‘(A) CATEGORIZATION OF INCLUDED BEN-
EFITS.—A description of covered benefits, cat-
egorized by—
‘‘(i) types of items and services (in-
cluding any special disease management
program); and
‘‘(ii) types of health care professionals
providing such items and services.
‘‘(B) EMERGENCY MEDICAL CARE.—A de-
scription of the extent to which the plan covers
emergency medical care (including the extent to
which the plan provides for access to urgent
care centers), and any definitions provided
under the plan for the relevant plan termi-
nology referring to such care.
‘‘(C) PREVENTATIVE
SERVICES.—A de-
scription of the extent to which the plan pro-
vides benefits for preventative services.
‘‘(D) DRUG FORMULARIES.—A description
of the extent to which covered benefits are de-
termined by the use or application of a drug
formulary and a summary of the process for de-
termining what is included in such formulary.
‘‘(E) 
COBRA 
CONTINUATION
COV-
ERAGE.—A description of the benefits available
under the plan pursuant to part 6.
‘‘(2) LIMITATIONS, EXCLUSIONS, AND RESTRIC-
TIONS ON COVERED BENEFITS.—
‘‘(A) 
CATEGORIZATION
OF
EXCLUDED
BENEFITS.—A description of benefits specifi-
cally excluded from coverage, categorized by
types of items and services.
‘‘(B) 
UTILIZATION
REVIEW
AND
PREAUTHORIZATION REQUIREMENTS.—Whether
coverage for medical care is limited or excluded
on 
the 
basis 
of 
utilization 
review 
or
preauthorization requirements.
‘‘(C) LIFETIME, ANNUAL, OR OTHER PE-
RIOD LIMITATIONS.—A description of the cir-
cumstances under which, and the extent to
which, coverage is subject to lifetime, annual, or
other period limitations, categorized by types of
benefits.
‘‘(D) CUSTODIAL CARE.—A description of
the circumstances under which, and the extent
to which, the coverage of benefits for custodial
care is limited or excluded, and a statement of
the definition used by the plan for custodial
care.
‘‘(E) 
EXPERIMENTAL
TREATMENTS.—
Whether coverage for any medical care is lim-
ited or excluded because it constitutes experi-
mental treatment or technology, and any defini-
tions provided under the plan for the relevant
plan terminology referring to such limited or
excluded care.
‘‘(F) MEDICAL APPROPRIATENESS OR NE-
CESSITY.—Whether coverage for medical care
may be limited or excluded by reason of a fail-
ure to meet the plan’s requirements for medical
appropriateness or necessity, and any defini-
tions provided under the plan for the relevant
plan terminology referring to such limited or
excluded care.
‘‘(G) SECOND
OR
SUBSEQUENT
OPIN-
IONS.—A description of the circumstances
under which, and the extent to which, coverage
for second or subsequent opinions is limited or
excluded.
‘‘(H) SPECIALTY CARE.—A description of
the circumstances under which, and the extent
to which, coverage of benefits for specialty care
is conditioned on referral from a primary care
provider.
‘‘(I) CONTINUITY OF CARE.—A description
of the circumstances under which, and the ex-
tent to which, coverage of items and services
provided by any health care professional is lim-
ited or excluded by reason of the departure by
the professional from any defined set of pro-
viders.
‘‘(J) RESTRICTIONS
ON
COVERAGE
OF
EMERGENCY
SERVICES.—A description of the
circumstances under which, and the extent to
which, the plan, in covering emergency medical
care furnished to a participant or beneficiary of
the plan imposes any financial responsibility de-
scribed in subsection (c) on participants or
beneficiaries or limits or conditions benefits for
such care subject to any other term or condition
of such plan.
‘‘(c) 
PARTICIPANT’S
FINANCIAL
RESPONSIBIL-
ITIES.—The information required under subsection (a) in-
cludes an explanation of—
‘‘(1) a participant’s financial responsibility for
payment of premiums, coinsurance, copayments,
deductibles, and any other charges; and
‘‘(2) the circumstances under which, and the
extent to which, the participant’s financial responsi-
bility described in paragraph (1) may vary, including
any distinctions based on whether a health care pro-
vider from whom covered benefits are obtained is in-
cluded in a defined set of providers.
‘‘(d) DISPUTE RESOLUTION PROCEDURES.—The in-
formation required under subsection (a) includes a de-
scription of the processes adopted by the plan pursuant
to section 503, including—
‘‘(1) descriptions thereof relating specifically
to—
‘‘(A) coverage decisions;
‘‘(B) internal review of coverage decisions;
and
‘‘(C) any external review of coverage deci-
sions; and
‘‘(2) the procedures and time frames applicable
to each step of the processes referred to in subpara-
graphs (A), (B), and (C) of paragraph (1).
‘‘(e) INFORMATION AVAILABLE ON REQUEST.—
‘‘(1) ACCESS TO PLAN BENEFIT INFORMATION
IN ELECTRONIC FORM.—
‘‘(A) IN GENERAL.—In addition to the in-
formation required to be provided under section
104(b)(4), a group health plan (and a health
insurance issuer offering health insurance cov-
erage in connection with a group health plan)
shall, upon written request (made not more fre-
quently than annually), make available to par-
ticipants and beneficiaries, in a generally recog-
nized electronic format, the following informa-
tion:
‘‘(i) the latest summary plan descrip-
tion, including the latest summary of ma-
terial modifications; and
‘‘(ii) the actual plan provisions setting
forth the benefits available under the plan
to the extent such information relates to the
coverage options under the plan available to the
participant or beneficiary. A reasonable charge
may be made to cover the cost of providing
such information in such generally recognized
electronic format. The Secretary may by regula-
tion prescribe a maximum amount which will
constitute a reasonable charge under the pre-
ceding sentence.
‘‘(B) ALTERNATIVE ACCESS.—The require-
ments of this paragraph may be met by making
such information generally available (rather
than upon request) on the Internet or on a pro-
prietary computer network in a format which is
readily accessible to participants and bene-
ficiaries.
‘‘(2) ADDITIONAL
INFORMATION
TO
BE
PRO-
VIDED ON REQUEST.—
‘‘(A) INCLUSION IN SUMMARY PLAN DE-
SCRIPTION
OF
SUMMARY
OF
ADDITIONAL
IN-
FORMATION.—The information required under
subsection (a) includes a summary description
of the types of information required by this
subsection to be made available to participants
and beneficiaries on request.
‘‘(B) 
INFORMATION
REQUIRED
FROM
PLANS AND ISSUERS ON REQUEST.—In addition
to information required to be included in sum-
mary plan descriptions under this subsection, a
group health plan (and a health insurance
issuer offering health insurance coverage in
connection with a group health plan) shall pro-
vide the following information to a participant
or beneficiary on request:
‘‘(i) NETWORK CHARACTERISTICS.—If
the plan (or issuer) utilizes a defined set of
providers under contract with the plan (or
issuer), a detailed list of the names of such
providers and their geographic location, set
forth separately with respect to primary
care providers and with respect to special-
ists.
‘‘(ii) CARE
MANAGEMENT
INFORMA-
TION.—A description of the circumstances
under which, and the extent to which, the
plan has special disease management pro-
grams or programs for persons with dis-
abilities, indicating whether these pro-
grams are voluntary or mandatory and
whether a significant benefit differential
results from participation in such pro-
grams.
‘‘(iii) INCLUSION
OF
DRUGS
AND
BIOLOGICALS IN FORMULARIES.—A state-
ment of whether a specific drug or biologi-
cal is included in a formulary used to de-
termine benefits under the plan and a de-
scription of the procedures for considering
requests for any patient-specific waivers.
‘‘(iv) PROCEDURES FOR DETERMINING
EXCLUSIONS BASED ON MEDICAL NECES-
SITY OR EXPERIMENTAL TREATMENTS.—
Upon receipt by the participant or bene-
ficiary of any notification of an adverse
coverage decision based on a determination
relating to medical necessity or an experi-
mental treatment or technology, a descrip-
tion of the procedures and medically-based
criteria used in such decision.
‘‘(v) PREAUTHORIZATION AND UTILI-
ZATION REVIEW PROCEDURES.—Upon re-
ceipt by the participant or beneficiary of
any notification of an adverse coverage de-
cision, a description of the basis on which
any preauthorization requirement or any
utilization review requirement has resulted
in such decision.
‘‘(vi) ACCREDITATION
STATUS
OF
HEALTH INSURANCE ISSUERS AND SERV-
ICE PROVIDERS.—A description of the ac-
creditation and licencing status (if any) of
each health insurance issuer offering
health insurance coverage in connection
with the plan and of any utilization review
organization utilized by the issuer or the
plan, together with the name and address
of the accrediting or licencing authority.
‘‘(vii) MEASURES OF ENROLLEE SAT-
ISFACTION.—The latest information (if
any) maintained by the plan, or by any
health insurance issuer offering health in-
surance coverage in connection with the
plan, relating to enrollee satisfaction.
‘‘(viii) QUALITY PERFORMANCE MEAS-
URES.—The latest information (if any)
maintained by the plan, or by any health
insurance issuer offering health insurance
coverage in connection with the plan, relat-
ing to quality of performance of the deliv-
ery of medical care with respect to cov-
erage options offered under the plan and
of health care professionals and facilities
providing medical care under the plan.
‘‘(ix) INFORMATION RELATING TO EX-
TERNAL
REVIEWS.—The number of any
external reviews under section 503 that
have been completed during the prior plan
year and the number of such reviews in
which a recommendation is made for modi-
fication or reversal of an internal review
decision under the plan.
‘‘(C) 
INFORMATION
REQUIRED
FROM
HEALTH CARE PROFESSIONALS ON REQUEST.—
Any health care professional treating a partici-
pant or beneficiary under a group health plan
shall provide to the participant or beneficiary,
on request, a description of his or her profes-
sional qualifications (including board certifi-
cation status, licensing status, and accreditation
status, if any), privileges, and experience and a
general description by category (including sal-
ary, fee-for-service, capitation, and such other
categories as may be specified in regulations of
the Secretary) of the applicable method by
which such professional is compensated in con-
nection with the provision of such medical care.
‘‘(D) 
INFORMATION
REQUIRED
FROM
HEALTH CARE FACILITIES ON REQUEST.—Any
health care facility from which a participant or
beneficiary has sought treatment under a group
health plan shall provide to the participant or
beneficiary, on request, a description of the fa-
cility’s corporate form or other organizational
form and all forms of licensing and accredita-
tion status (if any) assigned to the facility by
standard-setting organizations.
‘‘(f) ACCESS TO INFORMATION RELEVANT TO THE
COVERAGE OPTIONS UNDER WHICH THE PARTICIPANT
OR BENEFICIARY IS ELIGIBLE TO ENROLL.—In addition
to information otherwise required to be made available
under this section, a group health plan (and a health in-
surance issuer offering health insurance coverage in con-
nection with a group health plan) shall, upon written re-
quest (made not more frequently than annually), make
available to a participant (and an employee who, under
the terms of the plan, is eligible for coverage but not en-
rolled) in connection with a period of enrollment the sum-
mary plan description for any coverage option under the
plan under which the participant is eligible to enroll and
any information described in clauses (i), (ii), (iii), (vi),
(vii), and (viii) of subsection (e)(2)(B).
‘‘(g) ADVANCE NOTICE
OF CHANGES
IN DRUG
FORMULARIES.—Not later than 30 days before the effec-
tive of date of any exclusion of a specific drug or biological
from any drug formulary under the plan that is used in
the treatment of a chronic illness or disease, the plan shall
take such actions as are necessary to reasonably ensure
that plan participants are informed of such exclusion. The
requirements of this subsection may be satisfied—
‘‘(1) by inclusion of information in publications
broadly distributed by plan sponsors, employers, or
employee organizations;
‘‘(2) by electronic means of communication (in-
cluding the Internet or proprietary computer net-
works in a format which is readily accessible to par-
ticipants);
‘‘(3) by timely informing participants who,
under an ongoing program maintained under the
plan, have submitted their names for such notifica-
tion; or
‘‘(4) by any other reasonable means of timely
informing plan participants.
‘‘(h) DEFINITIONS.—For purposes of this section—
‘‘(1) GROUP HEALTH PLAN.—The term ‘group
health plan’ has the meaning provided such term
under section 733(a)(1).
‘‘(2) MEDICAL CARE.—The term ‘medical care’
has the meaning provided such term under section
733(a)(2).
‘‘(3) HEALTH
INSURANCE
COVERAGE.—The
term ‘health insurance coverage’ has the meaning
provided such term under section 733(b)(1).
‘‘(4) HEALTH INSURANCE ISSUER.—The term
‘health insurance issuer’ has the meaning provided
such term under section 733(b)(2).’’.
(b) CONFORMING AMENDMENTS.—
(1) Section 102(b) of such Act (29 U.S.C.
1022(b)) is amended by inserting before the period
at the end the following: ‘‘; and, in the case of a
group health plan (as defined in section 111(h)(1)),
the information required to be included under sec-
tion 111(a)’’.
(2) The table of contents in section 1 of such
Act is amended by striking the item relating to sec-
tion 111 and inserting the following new items:
‘‘Sec. 111. Disclosure by group health plans.
‘‘Sec. 112. Repeal and effective date.’’.
SEC. 502. EFFECTIVE DATE AND RELATED RULES.
(a) IN GENERAL.—The amendments made by this
title shall apply with respect to plan years beginning on
or after January 1 of the second calendar year following
the date of the enactment of this Act. The Secretary shall
first issue all regulations necessary to carry out the
amendments made by this title before such date.
(b) LIMITATION ON ENFORCEMENT ACTIONS.—No
enforcement action shall be taken, pursuant to the amend-
ments made by this title, against a group health plan or
health insurance issuer with respect to a violation of a re-
quirement imposed by such amendments before the date
of issuance of final regulations issued in connection with
such requirement, if the plan or issuer has sought to com-
ply in good faith with such requirement.
TITLE VI—GROUP HEALTH PLAN
REVIEW STANDARDS
SEC. 601. SPECIAL RULES FOR GROUP HEALTH PLANS.
(a) IN GENERAL.—Section 503 of the Employee Re-
tirement Income Security Act of 1974 (29 U.S.C. 1133)
is amended—
(1) by inserting ‘‘(a) IN GENERAL.—’’ after
‘‘SEC. 503.’’;
(2) by inserting ‘‘(other than a group health
plan)’’ after ‘‘employee benefit plan’’; and
(3) by adding at the end the following new sub-
section:
‘‘(b) SPECIAL RULES FOR GROUP HEALTH PLANS.—
‘‘(1) 
COVERAGE
DETERMINATIONS.—Every
group health plan shall—
‘‘(A) provide adequate notice in writing in
accordance with this subsection to any partici-
pant or beneficiary of any adverse coverage de-
cision with respect to benefits of such partici-
pant or beneficiary under the plan, setting forth
the specific reasons for such coverage decision
and any rights of review provided under the
plan, written in a manner calculated to be un-
derstood by the average participant;
‘‘(B) provide such notice in writing also to
any treating medical care provider of such par-
ticipant or beneficiary, if such provider has
claimed reimbursement for any item or service
involved in such coverage decision, or if a claim
submitted by the provider initiated the pro-
ceedings leading to such decision;
‘‘(C) afford a reasonable opportunity to
any participant or beneficiary who is in receipt
of the notice of such adverse coverage decision,
and who files a written request for review of the
initial coverage decision within 90 days after re-
ceipt of the notice of the initial decision, for a
full and fair review of the decision by an appro-
priate named fiduciary who did not make the
initial decision; and
‘‘(D) meet the additional requirements of
this subsection.
‘‘(2) TIME LIMITS FOR MAKING INITIAL COV-
ERAGE DECISIONS FOR BENEFITS AND COMPLETING
INTERNAL APPEALS.—
‘‘(A) TIME
LIMITS
FOR
DECIDING
RE-
QUESTS
FOR
BENEFIT
PAYMENTS, REQUESTS
FOR ADVANCE DETERMINATION OF COVERAGE,
AND
REQUESTS
FOR
REQUIRED
DETERMINA-
TION OF MEDICAL NECESSITY.—Except as pro-
vided in subparagraph (B)—
‘‘(i) INITIAL DECISIONS.—If a request
for benefit payments, a request for advance
determination of coverage, or a request for
required determination of medical necessity
is submitted to a group health plan in such
reasonable form as may be required under
the plan, the plan shall issue in writing an
initial coverage decision on the request be-
fore the end of the initial decision period
under paragraph (10)(I) following the fil-
ing completion date. Failure to issue a cov-
erage decision on such a request before the
end of the period required under this
clause shall be treated as an adverse cov-
erage decision for purposes of internal re-
view under clause (ii).
‘‘(ii) INTERNAL REVIEWS OF INITIAL
DENIALS.—Upon the written request of a
participant or beneficiary for review of an
initial adverse coverage decision under
clause (i), a review by an appropriate
named fiduciary (subject to paragraph (3))
of the initial coverage decision shall be
completed, including issuance by the plan
of a written decision affirming, reversing,
or modifying the initial coverage decision,
setting forth the grounds for such decision,
before the end of the internal review period
following the review filing date. Such deci-
sion shall be treated as the final decision
of the plan, subject to any applicable re-
consideration under paragraph (4). Failure
to issue before the end of such period such
a written decision requested under this
clause shall be treated as a final decision
affirming the initial coverage decision.
‘‘(B) TIME LIMITS FOR MAKING COVERAGE
DECISIONS RELATING TO ACCELERATED NEED
MEDICAL CARE AND FOR COMPLETING INTER-
NAL APPEALS.—
‘‘(i) INITIAL
DECISIONS.—A group
health plan shall issue in writing an initial
coverage decision on any request for expe-
dited advance determination of coverage or
for expedited required determination of
medical necessity submitted, in such rea-
sonable form as may be required under the
plan before the end of the accelerated need
decision period under paragraph (10)(K),
in cases involving accelerated need medical
care, following the filing completion date.
Failure to approve or deny such a request
before the end of the applicable decision
period shall be treated as a denial of the
request for purposes of internal review
under clause (ii).
‘‘(ii) INTERNAL REVIEWS OF INITIAL
DENIALS.—Upon the written request of a
participant or beneficiary for review of an
initial adverse coverage decision under
clause (i), a review by an appropriate
named fiduciary (subject to paragraph (3))
of the initial coverage decision shall be
completed, including issuance by the plan
of a written decision affirming, reversing,
or modifying the initial converge decision,
setting forth the grounds for the decision
before the end of the accelerated need deci-
sion period under paragraph (10)(K) fol-
lowing the review filing date. Such decision
shall be treated as the final decision of the
plan, subject to any applicable reconsider-
ation under paragraph (4). Failure to issue
before the end of the applicable decision
period such a written decision requested
under this clause shall be treated as a final
decision affirming the initial coverage deci-
sion.