‘‘SEC. 2706. ADDITIONAL ENROLLEE PROTECTIONS.
‘‘(a) ASSURING ADEQUATE IN-NETWORK ACCESS.—
‘‘(1) TIMELY
ACCESS.—A group health plan,
and a health insurance issuer offering group health
insurance coverage, that restricts the health care
professionals from whom benefits may be obtained
shall guarantee to enrollees timely access to primary
and specialty health care professionals who are ap-
propriate to the enrollee’s condition.
‘‘(2) ACCESS TO SPECIALIZED CARE.—A group
health plan, and a health insurance issuer offering
group health insurance coverage, shall assure that
enrollees have access to specialized treatment when
medically necessary. This access may be satisfied
through contractual arrangements with specialized
providers outside of the network.
‘‘(3) CONTINUITY OF CARE.—A group health
plan, and a health insurance issuer offering group
health insurance coverage, shall assure that the
plan’s or issuer’s use of case management may not
create an undue burden for enrollees under this sec-
tion. The plan and issuer shall ensure direct access
to specialists for ongoing care as so determined by
the case manager in consultation with the specialty
care professional. This continuity of care may be
satisfied for enrollees with chronic conditions
through the use of a specialist serving as case man-
ager.
‘‘(b) GRIEVANCE PROCESS.—
‘‘(1) IN GENERAL.—A group health plan, and a
health insurance issuer offering group health insur-
ance coverage, shall provide a meaningful and expe-
dited procedure, which includes notice and hearing
requirements, for resolving grievances between the
plan or issuer (including any entity or individual
through which the plan or issuer provides health
care services) and enrollees. Under the procedure
any such enrollee may at any time file a complaint
to resolve grievances between the enrollee and the
plan or issuer before a board of appeals established
under paragraph (3).
‘‘(2) NOTICE REQUIREMENTS.—
‘‘(A) IN GENERAL.—Such a plan or issuer
shall provide, in a timely manner, an enrollee a
notice of any denial of services in-network or
denial of payment for out-of-network care.
‘‘(B) INFORMATION REQUIRED.—Such no-
tice shall include the following:
‘‘(i) A clear statement of the reason
for the denial.
‘‘(ii) An explanation of the complaint
process under paragraph (3) which is
available to the enrollee upon request.
‘‘(iii) An explanation of all other ap-
peal rights available to all enrollees.
‘‘(iv) A description of how to obtain
supporting evidence for the hearing de-
scribed in paragraph (3), including the pa-
tient’s medical records from the plan or
issuer, as well as supporting affidavits
from the attending health care profes-
sionals.
‘‘(3) HEARING BOARD.—
‘‘(A) IN
GENERAL.—Each group health
plan, and each health insurance issuer offering
group health insurance coverage, shall establish
a board of appeals to hear and make determina-
tions on complaints by enrollees concerning de-
nials of coverage or payment for services
(whether in-network or out-of-network) and the
medical necessity and appropriateness of cov-
ered items and services.
‘‘(B) COMPOSITION.—A board of appeals
of a plan or issuer shall consist of—
‘‘(i) representatives of the plan or
issuer, including physicians, nonphysicians,
administrators, and enrollees;
‘‘(ii) consumers who are not enrollees
and who have no financial interest in the
plan or issuer; and
‘‘(iii) health care professionals who
are not under contract with and have no fi-
nancial interest in the plan or issuer and
who are experts in the field of medicine
which necessitates treatment.
‘‘(C) DEADLINE FOR DECISION.—
‘‘(i) IN
GENERAL.—Except as pro-
vided in clause (ii), a board of appeals
shall hear and resolve complaints within 30
days after the date the complaint is filed
with the board.
‘‘(ii) 
EXPEDITED
PROCEDURE.—A
board of appeals shall have an expedited
procedure in order to hear and resolve
complaints regarding urgent care.
‘‘(c) NOTICE OF ENROLLEE RIGHTS AND ENROLLEE
INFORMATION CHECKLIST.—
‘‘(1) IN
GENERAL.—Each group health plan,
and each health insurance issuer offering group
health insurance coverage, shall provide each en-
rollee, at the time of enrollment and not less fre-
quently than annually thereafter, an explanation of
the enrollee’s rights under this section and a copy of
the most recent enrollee information checklist for the
plan or issuer (as described in paragraph (3)).
‘‘(2) RIGHTS DESCRIBED.—The explanation of
rights under paragraph (1) shall include an expla-
nation of—
‘‘(A) the enrollee’s rights to benefits from
the plan or issuer;
‘‘(B) the restrictions on payments (if any)
under the plan or coverage for services fur-
nished other than by or through the plan or
issuer;
‘‘(C) out-of-area coverage provided under
the plan or coverage;
‘‘(D) the plan’s or issuer’s coverage of
emergency services and urgently needed care;
‘‘(E) the plan’s or issuer’s coverage of out-
of-network services; and
‘‘(F) appeal rights of enrollees.
‘‘(3) ENROLLEE
INFORMATION
CHECKLIST.—
For purposes of paragraph (1), the term ‘enrollee in-
formation checklist’ means, with respect to a plan or
issuer for a year, a list containing the following in-
formation (provided in a manner that permits con-
sumers to compare plans and issuers with respect to
the information):
‘‘(A) For each plan or coverage offered, in-
formation on the following:
‘‘(i) The premium for the plan or cov-
erage.
‘‘(ii) The benefits offered under the
plan or coverage.
‘‘(iii) the amount of any deductibles,
coinsurance, or any monetary limits on
benefits.
‘‘(iv) The identity, location, qualifica-
tions, and availability of health care pro-
fessionals in any networks of the plan or
issuer.
‘‘(v) The procedures used by the plan
or issuer to control utilization of services
and expenditures, including any financial
incentives.
‘‘(vi) The procedures used by the plan
or issuer to ensure quality of care.
‘‘(vii) The rights and responsibilities
of enrollees.
‘‘(viii) The number of applications
during the previous plan year requesting
that the plan or issuer cover certain medi-
cal services that were denied by the plan or
issuer (and the number of such denials
that were subsequently reversed by the
plan or issuer), stated as a percentage of
the total number of applications during
such period requesting that the plan or
issuer cover such services.
‘‘(ix) The number of times during the
previous plan year that a court of law
upheld or reversed a denial of a request
that the plan or issuer cover certain medi-
cal services.
‘‘(x) The restrictions (if any) on pay-
ment for services provided outside the
plan’s or issuer’s health care professional
network.
‘‘(xi) The process by which services
may be obtained through the plan’s or
issuer’s health care professional network.
‘‘(xii) Coverage for out-of-area serv-
ices.
‘‘(xiii) Any exclusions in the types of
health care professionals participating in
the plan’s or issuer’s health care profes-
sional network.
‘‘(d) RESTRICTIONS
ON HEALTH CARE PROFES-
SIONAL INCENTIVE PLANS.—A group health plan, and a
health insurance issuer offering group health insurance
coverage, may not operate any health care professional in-
centive plan under which a specific payment is made di-
rectly or indirectly under the plan to a health care profes-
sional or professional group as an inducement to reduce
or limit medically necessary services provided with respect
to enrollees.
‘‘(e) PROHIBITION OF INTERFERENCE WITH CER-
TAIN MEDICAL COMMUNICATIONS.—
‘‘(1) IN GENERAL.—
‘‘(A) PROHIBITION
OF
CERTAIN
PROVI-
SIONS.—Subject to paragraph (3), a group
health plan, and a health insurance issuer offer-
ing group health insurance coverage, may not
include under the plan or coverage any provi-
sion that prohibits or restricts any medical com-
munication (as defined in paragraph (2)) as
part of—
‘‘(i) a written contract or agreement
with a health care professional,
‘‘(ii) a written statement to such a
professional, or
‘‘(iii) an oral communication to such a
professional.
‘‘(B) NULLIFICATION.—Any provision de-
scribed in clause (i) is null and void.
‘‘(2) MEDICAL COMMUNICATION DEFINED.—In
this paragraph, the term ‘medical communication’
means a communication made by a health care pro-
fessional with a patient of the professional (or the
guardian or legal representative of such patient)
with respect to any of the following:
‘‘(A) How participating physicians and
health care professionals are paid.
‘‘(B) Utilization review procedures.
‘‘(C) The basis for specific utilization re-
view decisions.
‘‘(D) Whether a specific prescription drug
or biological is included in the formulary.
‘‘(E) How the plan or organization decides
whether a treatment or procedure is experi-
mental.
‘‘(F) The patient’s physical or mental con-
dition or treatment options.
‘‘(3) CONSTRUCTION.—Nothing in this sub-
section shall be construed as preventing an entity
from—
‘‘(A) acting on information relating to the
provision of (or failure to provide) treatment to
a patient, or
‘‘(B) restricting a medical communication
that recommends one health plan over another
if the sole purpose of the communication is to
secure financial gain for the health care profes-
sional.
‘‘(f) OUT-OF-NETWORK ACCESS.—
‘‘(1) IN GENERAL.—Subject to paragraph (2),
if a group health plan, or a health insurance issuer
offering group health insurance coverage, offers to
enrollees coverage for benefits for services only if
such services are furnished through professionals
and other persons who are members of a network of
professionals and other persons who have entered
into a contract with the plan or issuer to provide
such services, the plan or issuer shall also offer to
such enrollees (at the time of enrollment) the option
of coverage of such services which are not furnished
through professionals and other persons who are
members of such a network.
‘‘(2) EFFECTIVENESS.—Paragraph (1) shall
apply only in accordance with section 3(b)(2) of the
Patient Choice and Access to Quality Health Care
Act of 1998 (relating to a finding by the Secretary
that the other patient protections have not assured
quality of care).
‘‘(g) ADDITIONAL DEFINITIONS.—For purposes of
this section:
‘‘(1) HEALTH CARE PROFESSIONAL.—The term
‘health care professional’ means a physician or other
health care practitioner licensed, accredited, or cer-
tified to perform specified health services consistent
with State law.
‘‘(2) 
IN-NETWORK.—The 
term 
‘in-network’
means services provided by health care professionals
who have entered into a contract or agreement with
a group health plan, or health insurance issuer offer-
ing group health insurance coverage in connection
with such a plan, under which such professionals are
obligated to provide items, treatment, and services
under this section to individuals enrolled under the
plan.
(C) CONFORMING
AMENDMENT.—Section
2723(c) of such Act (42 U.S.C. 300gg–23(c)),
as amended by section 604(b)(2) of Public Law
104–204, is amended by striking ‘‘section
2704’’ and inserting ‘‘sections 2704 and 2706’’.
(2) ERISA AMENDMENTS.—
(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. ADDITIONAL ENROLLEE PROTECTIONS.
‘‘(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 section 2706
of the Public Health Service Act. For purposes of applying
this subsection, any reference in such section 2706 to an
enrollee with respect to health insurance coverage is
deemed to include a reference to a participant or bene-
ficiary with respect to a group health plan.
‘‘(b) NOTICE UNDER GROUP HEALTH PLAN.—The
imposition of the requirement of this section shall be treat-
ed as a material modification in the terms of the plan de-
scribed in section 102(a)(1), for purposes of assuring no-
tice of such requirements under the plan; except that the
summary description required to be provided under the
last sentence of section 104(b)(1) with respect to such
modification shall be provided by not later than 60 days
after the first day of the first plan year in which such
requirement apply.’’.
(B) REFERENCE
TO
NON-PREEMPTION
PROVISION.—Pursuant to section 731 of the
Employee Retirement Income Security Act of
1974, States may provide protections for indi-
viduals that are equivalent to or stricter than
the protections provided under the amendment
made by subparagraph (A).
(C) CONFORMING AMENDMENTS.—(i) Sec-
tion 731(c) of such Act (29 U.S.C. 1191(c)) is
amended by striking ‘‘section 711’’ and insert-
ing ‘‘sections 711 and 713’’.
(ii) Section 732(a) of such Act (29 U.S.C.
1191a(a)) is amended by striking ‘‘section 711’’
and inserting ‘‘sections 711 and 713’’.
(D) The table of contents in section 1 of
such Act is amended by inserting after the item
relating to section 712 the following new item:
‘‘Sec. 713. Additional enrollee protections.’’.
(b) INDIVIDUAL HEALTH INSURANCE.—
(1) IN GENERAL.—Part B of title XXVII of the
Public Health Service Act is amended by inserting
after section 2751 the following new section:
‘‘SEC. 2752. ADDITIONAL ENROLLEE PROTECTIONS.
‘‘(a) IN GENERAL.—The provisions of section 2706
(other than subsection (i)) shall apply to health insurance
coverage offered by a health insurance issuer in the indi-
vidual market in the same manner as they apply to health
insurance coverage offered by a health insurance issuer
in connection with a group health plan in the small or
large group market.
‘‘(b) NOTICE.—A health insurance issuer under this
part shall comply with the notice requirement under sec-
tion 713(b) of the Employee Retirement Income Security
Act of 1974 with respect to the requirements referred to
in subsection (a) as if such section applied to such issuer
and such issuer were a group health plan.’’.
(2) REFERENCE TO NON-PREEMPTION PROVI-
SION.—Pursuant to section 2762 of the Public
Health Service Act, States may provide protections
for individuals that are equivalent to or stricter than
the protections provided under the amendment made
by paragraph (1).
(3) 
CONFORMING
AMENDMENT.—Section
2762(b)(2) of such Act (42 U.S.C. 300gg–62(b)(2))
is amended by striking ‘‘section 2751’’ and inserting
‘‘sections 2751 and 2752’’.
(c) EFFECTIVE DATES.—
(1) GROUP HEALTH PLANS.—
(A) IN
GENERAL.—Subject to subpara-
graph (B), the amendments made by subsection
(a) shall apply with respect to group health
plans for plan years beginning on or after Jan-
uary 1, 1999.
(B) RULE FOR CERTAIN COLLECTIVE BARGAIN-
ING AGREEMENTS.—In the case of a group health
plan maintained pursuant to 1 or more collective
bargaining agreements between employee representa-
tives and 1 or more employers ratified before the
date of enactment of this Act, the amendments made
subsection (a) shall not apply to plan years begin-
ning before the later of—
(i) 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
(ii) January 1, 1999.
For purposes of clause (i), any plan amendment
made pursuant to a collective bargaining agreement
relating to the plan which amends the plan solely to
conform to any requirement added by subsection (a)
shall not be treated as a termination of such collec-
tive bargaining agreement.
(2) INDIVIDUAL
HEALTH
INSURANCE
COV-
ERAGE.—The amendment made by subsection (b)
shall apply with respect to health insurance coverage
offered, sold, issued, renewed, in effect, or operated
in the individual market on or after such date.
(d) COORDINATED REGULATIONS.—Section 104(1)
of Health Insurance Portability and Accountability Act of
1996 is amended by striking ‘‘this subtitle (and the
amendments made by this subtitle and section 401)’’ and
inserting ‘‘the provisions of part 7 of subtitle B of title
I of the Employee Retirement Income Security Act of
1974, the provisions of parts A and C of title XXVII of
the Public Health Service Act, and chapter 100 of the In-
ternal Revenue Code of 1986’’.
SEC. 4. REPORT ON EFFECTIVENESS OF PATIENT PROTEC-
TIONS.
(a) STUDY.—The Secretary of Health and Human
Services shall provide for a study on the effectiveness of
the amendments made by section 3 in assuring quality of
care for patients. Such study shall also examine any addi-
tional costs imposed as a result of the enactment of such
amendments.
(b) REPORT.—
(1) IN GENERAL.—The Secretary shall submit
to Congress a report on such study not later than
January 1, 2001.
(2) FINDING REGARDING QUALITY CARE.—The
Secretary shall include in the report a specific find-
ing as to whether, taking into account the patient
protections provided under such amendments, indi-
viduals covered under health plans are not being
provided quality care. If the Secretary makes such
a finding that individuals covered under health plans
are not being provided quality care and if Congress
concurs by joint resolution or Act with such a find-
ing, then subsection (f)(1) of section 2706 of the
Public Health Service Act shall become effective in
the same manner as amendments made by sub-
sections (a) and (b) of section 3 become effective
under section 3(c), except that (for purposes of this
paragraph) any reference in such section 3(c) to
January 1, 1999, shall be deemed a reference to
January 1, 2002.
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