‘‘(B) The enrollee’s physician certifies
that—
‘‘(i) there is no standard, medically
appropriate therapy for successfully treat-
ing such terminal condition, but
‘‘(ii) based on medical and scientific
evidence, there is a drug, device, proce-
dure, or therapy (in this section referred to
as the ‘experimental therapy’) that is more
beneficial than any available standard ther-
apy.
‘‘(C) The issuer has denied coverage of the
experimental therapy on the basis that it is ex-
perimental or investigational.
‘‘(3) DESCRIPTION
OF
PROCESS
AND
DECI-
SION.—The process under this subsection shall pro-
vide for a determination on a timely basis, by a
panel of independent, impartial physicians appointed
by a State authority or by an independent review or-
ganization certified by the State, of the medical ap-
propriateness of the experimental therapy. The deci-
sion of the panel shall be in writing and shall be ac-
companied by an explanation of the basis for the de-
cision. A decision of the panel that is favorable to
the enrollee may not be appealed by the issuer ex-
cept in the case of misrepresentation of a material
fact by the enrollee or a provider. A decision of the
panel that is not favorable to the enrollee may be
appealed by the enrollee.
‘‘(4) ISSUER COVERING PROCESS COSTS.—Di-
rect costs of the process under this subsection shall
be borne by the issuer, and not by the enrollee.
‘‘(g) OTHER INDEPENDENT
OR EXTERNAL RE-
VIEW.—
‘‘(1) IN GENERAL.—In the case of appealable
decision described in paragraph (2), the health in-
surance issuer shall provide for—
‘‘(A) an external review process for such
decisions consistent with the requirements of
paragraph (3), or
‘‘(B) an internal independent review proc-
ess for such decisions consistent with the re-
quirements of paragraph (4).
‘‘(2) APPEALABLE DECISION DESCRIBED.—An
appealable decision described in this paragraph is a
decision that does not involve a decision a described
in subsection (f)(1) but involves—
‘‘(A) a claim for benefits involving costs
over a significant threshold, or
‘‘(B) assuring access to care for a serious
condition.
‘‘(3) EXTERNAL
REVIEW
PROCESS.—The re-
quirements of this subsection for an external review
process are as follows:
‘‘(A) The process is established under
State law and provides for review of decisions
on stage 2 appeals by an independent review or-
ganization certified by the State.
‘‘(B) If the process provides that decisions
in such process are not binding on issuers, the
process must provide for public methods of dis-
closing frequency of noncompliance with such
decisions and for sanctioning issuers that con-
sistently refuse to take appropriate actions in
response to such decisions.
‘‘(C) Results of all such reviews under the
process are disclosed to the public, along with
at least annual disclosure of information on is-
suer compliance.
‘‘(D) All decisions under the process shall
be in writing and shall be accompanied by an
explanation of the basis for the decision.
‘‘(E) Direct costs of the process shall be
borne by the issuer, and not by the enrollee.
‘‘(F) The issuer shall provide for publica-
tion at least annually of information on the
numbers of appeals and decisions considered
under the process.
‘‘(4) INTERNAL, INDEPENDENT REVIEW PROC-
ESS.—The requirements of this subsection for an in-
ternal, independent review process are as follows:
‘‘(A)(i) The process must provide for the
participation of persons who are independent of
the issuer in conducting reviews and (ii) the
Secretary must have found (through reviews
conducted no less often than biannually) the
process to be fair and impartial.
‘‘(B) If the process provides that decisions
in such process are not binding on issuers, the
process must provide for public methods of dis-
closing frequency of noncompliance with such
decisions and for sanctioning issuers that con-
sistently refuse to take appropriate actions in
response to such decisions.
‘‘(C) Results of all such reviews under the
process are disclosed to the public, along with
at least annual disclosure of information on is-
suer compliance.
‘‘(D) All decisions under the process shall
be in writing and shall be accompanied by an
explanation of the basis for the decision.
‘‘(E) Direct costs of the process shall be
borne by the issuer, and not by the enrollee.
‘‘(F) The issuer shall provide for publica-
tion at least annually of information on the
numbers of appeals and decisions considered
under the process.
The Secretary may delegate the authority under sub-
paragraph (A)(ii) to applicable State authorities.
‘‘(5) OVERSIGHT.—The Secretary (and applica-
ble State authorities in the case of delegation of Sec-
retarial authority under paragraph (4)) shall con-
duct reviews not less often than biannually of the
fairness and impartiality issuers who desired to use
an internal, independent review process described in
paragraph (4) to satisfy the requirement of para-
graph (1).
‘‘(6) REPORT.—The Secretary shall provide for
periodic reports on the effectiveness of this sub-
section in assuring fair and impartial reviews of
stage 2 appeals. Such reports shall include informa-
tion on the number of stage 2 appeals (and deci-
sions), for each of the types of review processes de-
scribed in paragraph (2), by health insurance cov-
erage.
‘‘(h) CONSTRUCTION.—Nothing in this part shall be
construed as removing any legal rights of enrollees under
State or Federal law, including the right to file judicial
actions to enforce rights.’’.
TITLE VI—ADDITIONAL AMEND-
MENTS; EFFECTIVE DATES.
SEC. 601. APPLICATION TO GROUP AND INDIVIDUAL
HEALTH INSURANCE COVERAGE.
(a) GROUP HEALTH INSURANCE COVERAGE.—(1)
Subpart 2 of part A of title XXVII of the Public Health
Service Act is amended by adding at the end the following
new section:
‘‘SEC. 2706. CONSUMER PROTECTION STANDARDS.
‘‘(a) IN GENERAL.—Each health insurance issuer
shall comply with consumer protection requirements under
part C with respect to group health insurance coverage
it offers.
‘‘(b) ASSURING COORDINATION.—The Secretary of
Health and Human Services and the Secretary of Labor
shall ensure, through the execution of an interagency
memorandum of understanding between such Secretaries,
that—
‘‘(1) regulations, rulings, and interpretations is-
sued by such Secretaries relating to the same matter
over which such Secretaries have responsibility
under part C (and this section) and section 713 of
the Employee Retirement Income Security Act of
1974 are administered so as to have the same effect
at all times; and
‘‘(2) coordination of policies relating to enforc-
ing the same requirements through such Secretaries
in order to have a coordinated enforcement strategy
that avoids duplication of enforcement efforts and
assigns priorities in enforcement.’’.
(2) Section 2792 of such Act (42 U.S.C.
300gg–92) is amended by inserting ‘‘and section
2706(b)’’ after ‘‘of 1996’’.
(b) APPLICATION TO INDIVIDUAL HEALTH INSUR-
ANCE COVERAGE.—Part B of title XXVII of the Public
Health Service Act is amended by inserting after section
2751 the following new section:
‘‘SEC. 2752. CONSUMER PROTECTION STANDARDS.
‘‘Each health insurance issuer shall comply with
consumer protection requirements under part C with re-
spect to individual health insurance coverage it offers.’’.
(c) APPLICATION UNDER MEDICARE AND MEDICAID
PROGRAMS.—
(1) MEDICARE PROGRAM.—Section 1852 of the
Social Security Act (42 U.S.C. 1395w–22), as in-
serted by section 4001 of the Balanced Budget Act
of 1997 (Public Law 105–33) is amended by adding
at the end the following new subsection:
‘‘(l) ADDITIONAL BENEFICIARY PROTECTIONS.—
‘‘(1) IN
GENERAL.—Each Medicare+Choice
plan shall comply with consumer protection require-
ments under part C of title XXVII of the Public
Health Service Act.
‘‘(2) CONSTRUCTION.—Paragraph (1) shall not
be construed as superseding any requirements of
this part to the extent such requirements are more
stringent than the requirements under part C of title
XXVII of the Public Health Service Act.’’,
(2) MEDICAID PROGRAM.—Section 1932(b) of
the Social Security Act (42 U.S.C. 1396u–2(b)), as
added by section 4704(a) of the Balanced Budget
Act of 1997 (Public Law 105–33) is amended by
adding at the end the following new paragraph:
‘‘(9) ADDITIONAL ENROLLEE PROTECTIONS.—
‘‘(A) IN GENERAL.—A medicaid managed
care organization shall comply with consumer
protection requirements under part C of title
XXVII of the Public Health Service Act with
respect to individuals enrolled with the organi-
zation under a contract under section 1903(m)
or 1905(t)(3).
‘‘(B) 
CONSTRUCTION.—Paragraph 
(1)
shall not be construed as superseding any re-
quirements of this title to the extent such re-
quirements are more stringent than the require-
ments under part C of title XXVII of the Pub-
lic Health Service Act.’’,
(d) MODIFICATION OF PREEMPTION STANDARDS.—
(1) GROUP HEALTH INSURANCE COVERAGE.—
Section 2723 of such Act (42 U.S.C. 300gg–23) is
amended—
(A) in subsection (a)(1), by striking ‘‘sub-
section (b)’’ and inserting ‘‘subsections (b) and
(c)’’;
(B) by redesignating subsections (c) and
(d) as subsections (d) and (e), respectively; and
(C) by inserting after subsection (b) the
following new subsection:
‘‘(c) SPECIAL RULES IN CASE OF CONSUMER PRO-
TECTION REQUIREMENTS.—Subject to subsection (a)(2),
the provisions of section 2706 and part C, and part D
insofar as it applies to section 2706 or part C, shall not
be construed to preempt any State law, or the enactment
or implementation of such a State law, that provides pro-
tections for individuals that are equivalent to or stricter
than the protections provided under such provisions.’’.
(2) INDIVIDUAL
HEALTH
INSURANCE
COV-
ERAGE.—Section 2762 of such Act (42 U.S.C.
300gg–62), as added by section 605(b)(3)(B) of
Public Law 104–204, is amended—
(A) in subsection (a), by striking ‘‘sub-
section (b), nothing in this part’’ and inserting
‘‘subsections (b) and (c)’’, and
(B) by adding at the end the following new
subsection:
‘‘(c) SPECIAL RULES IN CASE OF CONSUMER PRO-
TECTION REQUIREMENTS.—Subject to subsection (b), the
provisions of section 2752 and part C, and part D insofar
as it applies to section 2752 or part C, shall not be con-
strued to preempt any State law, or the enactment or im-
plementation of such a State law, that provides protections
for individuals that are equivalent to or stricter than the
protections provided under such provisions.’’.
(e) ADDITIONAL CONFORMING AMENDMENTS.—
(1) Section 2723(a)(1) of such Act (42 U.S.C.
300gg–23(a)(1)) is amended by striking ‘‘part C’’
and inserting ‘‘parts C and D’’.
(2) Section 2762(b)(1) of such Act (42 U.S.C.
300gg–62(b)(1)) is amended by striking ‘‘part C’’
and inserting ‘‘part D’’.
(f) EFFECTIVE DATES.—(1)(A) Subject to subpara-
graph (B), the amendments made by this Act shall apply
with respect to group health insurance coverage for group
health plan years beginning on or after July 1, 1998 (in
this subsection referred to as the ‘‘general effective date’’)
and also shall apply to portions of plan years occurring
on and after January 1, 1999.
(B) In the case of group health insurance coverage
provided pursuant to a group health plan maintained pur-
suant to 1 or more collective bargaining agreements be-
tween employee representatives and 1 or more employers
ratified before the date of enactment of this Act, the
amendments made by this Act shall not apply to plan
years beginning before the later of—
(i) the date on which the last collective bargain-
ing agreements relating to the plan terminates (de-
termined without regard to any extension thereof
agreed to after the date of enactment of this Act),
or
(ii) the general effective date.
For purposes of clause (i), any plan amendment made pur-
suant to a collective bargaining agreement relating to the
plan which amends the plan solely to conform to any re-
quirement added by this Act shall not be treated as a ter-
mination of such collective bargaining agreement.
(2) The amendments made by this Act shall apply
with respect to individual health insurance coverage of-
fered, sold, issued, renewed, in effect, or operated in the
individual market on or after the general effective date.
(3) The amendments made by this Act shall apply
under the medicare and medicaid programs under titles
XVIII and XIX of the Social Security Act on and after
the general effective date.
SEC. 602. CONSUMER PROTECTION STANDARDS UNDER
THE EMPLOYEE RETIREMENT INCOME SECU-
RITY ACT OF 1974.
(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. 713. CONSUMER PROTECTION STANDARDS.
‘‘(a) IN GENERAL.—Subject to subsection (b), a
group health plan (and a health insurance issuer offering
group health insurance coverage in connection with such
a plan) shall comply with the requirements of part C of
title XXVII of the Public Health Service Act.