SEC. 205. DUE PROCESS FOR ENROLLEES.
(a) IN GENERAL.—A health plan meets the require-
ments of this section if the plan meets—
(1) the requirements of subsection (b) relating
to utilization review and payment of claims;
(2) the requirements of subsection (c) relating
to external appeals; and
(3) the requirements of subsection (d) relating
to internal grievance procedures.
(b) UTILIZATION REVIEW.—The requirements of this
subsection are that the utilization review program of a
health plan—
(1) is developed (including any screening cri-
teria used by such program) with the involvement of
participating health professionals and providers;
(2) to the extent consistent with the protection
of proprietary business information (as defined for
purposes of section 552 of title 5, United States
Code), releases, upon request, to affected health pro-
fessionals, providers, and enrollees the screening cri-
teria, weighting elements, and computer algorithms
used in reviews and a description of the method by
which they were developed;
(3) uniformly applies review criteria that are
based on sound scientific principles and the most re-
cent medical evidence;
(4) uses licensed, certified, or otherwise
credentialed health professionals to make review de-
terminations (and for services requiring specialized
training for their delivery, uses a health professional
who is qualified through equivalent specialized train-
ing);
(5) subject to reasonable safeguards specified
by the Secretary, discloses to health professionals
and providers, upon request, the names and creden-
tials of individuals conducting utilization review;
(6) does not compensate individuals conducting
utilization review for denials of payment or coverage
of benefits;
(7) complies with the requirement of section
201(c)(2) that preauthorization not be required for
emergency and related services furnished in a hos-
pital emergency department;
(8) makes preauthorization determinations—
(A) in the case of services to be furnished
in a hospital emergency department that are
not services described in section 201(c)(2),
within 30 minutes of a request for such deter-
mination, and
(B) in the case of other services, within 24
hours after the time of a request for determina-
tion;
(9) includes in any notice of such determination
an explanation of the basis of the determination and
the right to an immediate appeal;
(10) treats a favorable preauthorization review
determination as a final determination for purposes
of making payment for a claim submitted for the
item or service involved unless such determination
was based on fraudulent information supplied by the
person requesting the determination;
(11) provides timely access to review personnel
and, if such personnel are not available, waives any
preauthorization that would otherwise be required;
and
(12) provides notice of an initial determination
on payment of a claim within 30 days after the date
the claim is submitted for such item or service, and
includes in such notice an explanation of the reasons
for such determination and of the right to an imme-
diate appeal.
For purposes of paragraph (10), failure of a plan to make
a determination described in paragraph (8)(A) within the
period of time specified in such paragraph shall be treated
as a favorable determination for the items and services
for which the determination was requested.
(c) APPEALS PROCESS.—A health plan meets the re-
quirements of this subsection if the plan establishes and
maintains an accessible appeals process that—
(1) reviews an adverse preauthorization deter-
mination—
(A) for services described in subsection
(b)(8)(A) and urgent care services, within 1
hour after the time of a request for such review,
and
(B) for other services, within 24 hours
after the time of a request for such review;
(2) reviews an initial determination on payment
of claims described in subsection (b)(12) within 30
days after the date of a request for such review;
(3) provides for review of determinations de-
scribed in paragraphs (1) and (2) by an appropriate
clinical peer professional who is in the same or simi-
lar specialty as would typically provide the item or
service involved (or another licensed, certified, or
otherwise credentialed health professional acceptable
to the plan and the person requesting such review);
and
(4) provides for review of—
(A) the determinations described in para-
graphs (1), (2), and (3), and
(B) enrollee complaints about inadequate
access to any category, class, or type of health
professional or provider in the network of the
plan and other matters specified by this Act,
by a person that is not involved in the operation of
the plan or in making the determination or policy
being appealed.
The procedures specified in this subsection shall not be
construed as preempting or superseding any other reviews
or appeals a plan is required by law to make available.
SEC. 206. DUE PROCESS FOR HEALTH PROFESSIONALS AND
PROVIDERS.
(a) IN GENERAL.—The requirements of this section
are that a network plan—
(1) allow all health professionals and providers
in its service area to apply to become a participating
health professional or provider during at least one
period in each calendar year;
(2) provide reasonable notice to such health
professionals and providers of the opportunity to
apply and of the period during which applications
are accepted;
(3) provide for review of each application by a
credentialing committee with appropriate representa-
tion of the category, class, or type of health profes-
sional or provider;
(4) select participating health professionals and
providers based on objective standards of quality de-
veloped with the suggestions and advice of profes-
sional associations, health professionals, and provid-
ers;
(5) make such standards available to—
(A) those applying to become a participat-
ing provider or health professional;
(B) health plan purchasers, and
(C) enrollees;
(6) when economic considerations are taken
into account in selecting participating health profes-
sionals and providers, uses objective criteria that are
available to those applying to become a participating
provider or health professional and enrollees;
(7) adjust any economic profiling to take into
account patient characteristics (such as severity of
illness) that may result in atypical utilization of
services;
(13) unless a health professional or provider
poses an imminent harm to enrollees or an adverse
action by a governmental agency effectively impairs
the ability to provide health care items and services,
provide—
(A) reasonable notice of any determination
to terminate a health professional or provider
‘‘for cause’’ (including an explanation of the
reasons for the determination),
(B) an opportunity to review and discuss
all of the information on which the determina-
tion is based, and
(C) an opportunity to enter into a correc-
tive action plan,
before the determination becomes subject to appeal
under the process referred to in paragraph (12).
(b) RULE OF CONSTRUCTION.—The requirements of
subsection (a) shall not be construed as preempting or su-
perseding any other reviews and appeals a plan is required
by law to make available.
SEC. 207. INFORMATION REPORTING AND DISCLOSURE BY
NETWORK PLANS.
(a) IN GENERAL.—The requirement of this section
is that a network plan provide enrollees and prospective
enrollees with truthful, accurate, and easily understand-
able marketing materials and information about—
(1) coverage provisions, benefits, and any exclu-
sions—
(A) by category of service,
(B) by category, class, or type of health
professional or provider, and
(C) if applicable, by specific service, includ-
ing experimental treatments;
(2) the specific amount of the premium charged
by the plan that is set aside for administration and
marketing of the plan;
(3) the specific amount of such premium that
is expended directly for patient care;
(4) the number, mix, and distribution of partici-
pating health professionals and providers;
(5) the ratio of enrollees to participating health
professionals and providers by category, class, and
type of health professional and provider,
(6) the expenditures and utilization per enrollee
by category, class, and type of health professional
and provider;
(7) the financial obligations of the enrollee and
the 
plan, 
including 
premiums, 
copayments,
deductibles, and established aggregate maximums on
out-of-pocket costs, for all items and services, includ-
ing—
(A) those furnished by health professionals
and providers that are not participating health
professionals and providers, and
(B) those furnished to an enrollee who is
outside the service area of the plan;
(8) utilization review requirements of the plan
(including preauthorization review, concurrent re-
view, post-service review, post-payment review, and
any other procedures that may lead to denial of cov-
erage or payment for a service);
(9) financial arrangements and incentives that
may—
(A) limit the items and services furnished
to an enrollee,
(B) restrict referral or treatment options,
or
(C) negatively affect the fiduciary respon-
sibility of a health professional or provider to
an enrollee;
(10) other incentives for health professionals
and providers to control costs;
(11) the loss ratio of the plan;
(12) enrollee satisfaction statistics (that include
data for enrollees receiving services from health pro-
fessionals and providers that are not participating
health professionals and providers), including—
(A) the percentage of enrollees reenrolling
with the plan, and
(B) the percentage of enrollees disenrolling
from the plan;
(13) quality indicators for the plan and partici-
pating health professionals and providers, includ-
ing—
(A) population-based statistics such as im-
munization rates, and
(B) performance measures, such as—
(i) survival after surgery (adjusted for
case mix),
(ii) hospital readmissions, and
(iii) appropriate referrals and preven-
tion of secondary complications following
treatment;
(14) grievance procedures and appeals rights
under the plan, and summary information about the
number and disposition of grievances and appeals in
the most recent period for which complete and accu-
rate information is available; and
(15) the percentage of utilization review deter-
minations made by the plan that disagree with the
judgment of the treating health professional or pro-
vider and the percentage of such determinations that
are reversed on appeal.
(b) UNIFORM FORMAT.—The information required to
be provided pursuant to this section shall be displayed in
a uniform format specified by the State that includes the
service area of a plan. If a State fails to establish such
a format, such information shall be displayed in a uniform
format specified by the Secretary.
SEC. 208. OTHER HEALTH PLAN REQUIREMENTS.
(a) IN GENERAL.—A health plan meets the require-
ments of this section if the plan meets—
(1) the requirement of subsection (b) for pre-
serving confidentiality of records; and
(2) the requirements established pursuant to
subsection (c) to ensure the continued operation of
the plan.
(b) CONFIDENTIALITY.—The requirement of this
subsection is that a health plan establish mechanisms and
procedures to ensure compliance with applicable Federal
and State laws to protect the confidentiality of individually
identifiable information held by the plan with respect to
an enrollee, health professional, or provider.
(c) FINANCIAL RESERVES; SOLVENCY.—A health
plan meets the requirements of this subsection if the
plan—
(1) meets such financial reserve or other sol-
vency-related requirements as the Secretary may es-
tablish to assure the continued availability of (and
appropriate payment for) covered items and services
for enrollees; and
(2) establishes mechanisms specified by the
Secretary to protect enrollees, health professionals,
and providers in the event of plan failure.
Such requirements shall not unduly impede the establish-
ment of health plans owned and operated by health care
professionals or providers or by non-profit community-
based organizations.
SEC. 209. QUALITY ASSURANCE PROGRAM; CASE REVIEW.
(a) QUALITY ASSURANCE PROGRAM.—
(1) IN GENERAL.—A health plan meets the re-
quirements of this section if the plan establishes a
quality improvement program (consistent with sub-
section (b)) that systematically and continuously as-
sesses and improves—
(A) enrollee health status, patient out-
comes, processes of care, and enrollee satisfac-