I 
109TH CONGRESS 
1ST SESSION H. R. 2650 
To amend the Public Health Service Act, the Employee Retirement Income 
Security Act of 1974, and the Internal Revenue Code of 1986 to protect 
consumers in managed care plans and other health coverage. 
IN THE HOUSE OF REPRESENTATIVES 
MAY 26, 2005 
Mr. NORWOOD introduced the following bill; which was referred to the Com-
mittee on Energy and Commerce, and in addition to the Committees on 
Education and the Workforce and Ways and Means, for a period to be 
subsequently determined by the Speaker, in each case for consideration 
of such provisions as fall within the jurisdiction of the committee con-
cerned 
A BILL 
To amend the Public Health Service Act, the Employee Re-
tirement Income Security Act of 1974, and the Internal 
Revenue Code of 1986 to protect consumers in managed 
care plans and other health coverage. 
Be it enacted by the Senate and House of Representa-
tives of the United States of America in Congress assembled, 
SECTION 1. SHORT TITLE; TABLE OF CONTENTS. 
(a) SHORT TITLE.—This Act may be cited as the 
‘‘Patient Protection Act of 2005’’.
(b) TABLE OF CONTENTS.—The table of contents of 
this Act is as follows: 
Sec. 1. Short title; table of contents. 
TITLE I—IMPROVING MANAGED CARE 
Subtitle A—Utilization review; claims; and internal and external appeals 
Sec. 101. Utilization review activities. 
Sec. 102. Procedures for initial claims for benefits and prior authorization de-
terminations. 
Sec. 103. Internal appeals of claims denials. 
Sec. 104. Independent external appeals procedures. 
Sec. 105. Health care consumer assistance fund. 
Subtitle B—Access to care 
Sec. 111. Consumer choice option. 
Sec. 112. Choice of health care professional. 
Sec. 113. Access to emergency care. 
Sec. 114. Timely access to specialists. 
Sec. 115. Patient access to obstetrical and gynecological care. 
Sec. 116. Access to pediatric care. 
Sec. 117. Continuity of care. 
Sec. 118. Access to needed prescription drugs. 
Sec. 119. Coverage for individuals participating in approved clinical trials. 
Sec. 120. Required coverage for minimum hospital stay for mastectomies and 
lymph node dissections for the treatment of breast cancer and 
coverage for secondary consultations. 
Subtitle C—Access to information 
Sec. 121. Patient access to information. 
Subtitle D—Protecting the doctor-patient relationship 
Sec. 131. Prohibition of interference with certain medical communications. 
Sec. 132. Prohibition of discrimination against providers based on licensure. 
Sec. 133. Prohibition against improper incentive arrangements. 
Sec. 134. Payment of claims. 
Sec. 135. Protection for patient advocacy. 
Subtitle E—Definitions 
Sec. 151. Definitions. 
Sec. 152. Preemption; State flexibility; construction. 
Sec. 153. Exclusions. 
Sec. 154. Treatment of excepted benefits. 
Sec. 155. Regulations. 
Sec. 156. Incorporation into plan or coverage documents.
Sec. 157. Preservation of protections. 
TITLE II—APPLICATION OF QUALITY CARE STANDARDS TO 
GROUP HEALTH PLANS AND HEALTH INSURANCE COVERAGE 
UNDER THE PUBLIC HEALTH SERVICE ACT 
Sec. 201. Application to group health plans and group health insurance cov-
erage. 
Sec. 202. Application to individual health insurance coverage. 
Sec. 203. Cooperation between Federal and State authorities. 
TITLE III—APPLICATION OF PATIENT PROTECTION STANDARDS 
TO FEDERAL HEALTH INSURANCE PROGRAMS 
Sec. 301. Application of patient protection standards to Federal health insur-
ance programs. 
TITLE IV—AMENDMENTS TO THE EMPLOYEE RETIREMENT 
INCOME SECURITY ACT OF 1974 
Sec. 401. Application of patient protection standards to group health plans and 
group health insurance coverage under the Employee Retire-
ment Income Security Act of 1974. 
Sec. 402. Cooperation between Federal and State authorities. 
Sec. 403. Sense of the Congress concerning the importance of certain unpaid 
services. 
TITLE V—AMENDMENTS TO THE INTERNAL REVENUE CODE OF 
1986 
Sec. 501. Application of requirements to group health plans under the Internal 
Revenue Code of 1986. 
Sec. 502. Conforming enforcement for women’s health and cancer rights. 
TITLE VI—EFFECTIVE DATES; COORDINATION IN 
IMPLEMENTATION 
Sec. 601. Effective dates. 
Sec. 602. Coordination in implementation. 
Sec. 603. Severability. 
TITLE VII—MISCELLANEOUS PROVISIONS 
Sec. 701. No impact on Social Security Trust Fund. 
Sec. 702. Sense of Congress with respect to participation in clinical trials and 
access to specialty care. 
Sec. 703. Sense of the Congress regarding fair review process. 
Sec. 704. Annual review.
TITLE I—IMPROVING MANAGED 
CARE 
Subtitle 
A—Utilization 
Review; 
Claims; and Internal and Exter-
nal Appeals 
SEC. 101. UTILIZATION REVIEW ACTIVITIES. 
(a) COMPLIANCE WITH REQUIREMENTS.— 
(1) IN GENERAL.—A group health plan, and a 
health insurance issuer that provides health insur-
ance coverage, shall conduct utilization review activi-
ties in connection with the provision of benefits 
under such plan or coverage only in accordance with 
a utilization review program that meets the require-
ments of this section and section 102. 
(2) USE OF OUTSIDE AGENTS.—Nothing in this 
section shall be construed as preventing a group 
health plan or health insurance issuer from arrang-
ing through a contract or otherwise for persons or 
entities to conduct utilization review activities on be-
half of the plan or issuer, so long as such activities 
are conducted in accordance with a utilization review 
program that meets the requirements of this section. 
(3) UTILIZATION REVIEW DEFINED.—For pur-
poses of this section, the terms ‘‘utilization review’’ 
and ‘‘utilization review activities’’ mean procedures
used to monitor or evaluate the use or coverage, 
clinical necessity, appropriateness, efficacy, or effi-
ciency of health care services, procedures or settings, 
and includes prospective review, concurrent review, 
second opinions, case management, discharge plan-
ning, or retrospective review. 
(b) WRITTEN POLICIES AND CRITERIA.— 
(1) WRITTEN POLICIES.—A utilization review 
program shall be conducted consistent with written 
policies and procedures that govern all aspects of the 
program. 
(2) USE OF WRITTEN CRITERIA.— 
(A) IN GENERAL.—Such a program shall 
utilize written clinical review criteria developed 
with input from a range of appropriate actively 
practicing health care professionals, as deter-
mined by the plan, pursuant to the program. 
Such criteria shall include written clinical re-
view criteria that are based on valid clinical evi-
dence where available and that are directed spe-
cifically at meeting the needs of at-risk popu-
lations and covered individuals with chronic 
conditions or severe illnesses, including gender- 
specific criteria and pediatric-specific criteria 
where available and appropriate.
(B) CONTINUING USE OF STANDARDS IN 
RETROSPECTIVE
REVIEW.—If a health care 
service has been specifically pre-authorized or 
approved for a participant, beneficiary, or en-
rollee under such a program, the program shall 
not, pursuant to retrospective review, revise or 
modify the specific standards, criteria, or proce-
dures used for the utilization review for proce-
dures, treatment, and services delivered to the 
enrollee during the same course of treatment. 
(C) REVIEW OF SAMPLE OF CLAIMS DENI-
ALS.—Such a program shall provide for a peri-
odic evaluation of the clinical appropriateness of 
at least a sample of denials of claims for bene-
fits. 
(c) CONDUCT OF PROGRAM ACTIVITIES.— 
(1) ADMINISTRATION BY HEALTH CARE PRO-
FESSIONALS.—A utilization review program shall be 
administered by qualified health care professionals 
who shall oversee review decisions. 
(2) USE
OF
QUALIFIED, INDEPENDENT
PER-
SONNEL.— 
(A) IN
GENERAL.—A utilization review 
program shall provide for the conduct of utiliza-
tion review activities only through personnel