(B) Section 731(c) of such Act (29 U.S.C.
1191(c)), as amended by section 603(b)(1) of Public
Law 104–204, is amended by striking ‘‘section 711’’
and inserting ‘‘sections 711 and 713’’.
(C) Section 732(a) of such Act (29 U.S.C.
1191a(a)), as amended by section 603(b)(2) of Pub-
lic Law 104–204, 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. Managed care consumer protections.’’.
(b) PHSA AMENDMENTS.—(1) Subpart 2 of part A
of title XXVII of the Public Health Service Act, as amend-
ed by section 703(a) of Public Law 104–204, is amended
by adding at the end the following new section:
‘‘SEC. 2706. QUALITY HEALTH CARE AND CONSUMER PRO-
TECTION ACT.
‘‘(a) ACCESS TO PERSONNEL AND FACILITIES.—
‘‘(1) IN
GENERAL.—A managed care group
health plan (and a health insurance issuer offering
managed care group health insurance) shall—
‘‘(A) include a sufficient number and type
of primary care practitioners and specialists,
throughout the service area, to meet the needs
of enrollees and to provide meaningful choice;
and
‘‘(B) demonstrate that it offers the follow-
ing:
‘‘(i) An adequate number of accessible
acute care hospital services, within a rea-
sonable distance and travel time for enroll-
ees.
‘‘(ii) An adequate number of acces-
sible primary care practitioners, within a
reasonable distance and travel time for en-
rollees.
‘‘(iii) An adequate number of acces-
sible specialists and subspecialists, within a
reasonable distance and travel time for en-
rollees.
‘‘(iv) The availability of specialty med-
ical services, including physical therapy,
occupational therapy, and rehabilitation
services.
‘‘(v) The availability of specialists who
are not participating providers or profes-
sionals, when a patient’s unique medical
circumstances warrant it.
Clause (iii) shall be construed as requiring ac-
cess to nonparticipating health care profes-
sionals who are specialists for treatment of a
specific condition if and when there are not suf-
ficient number of such specialists who are par-
ticipating health care professionals.
‘‘(2) CONTINUITY OF CARE.—A managed care
group health plan (and a health insurance issuer of-
fering managed care group health insurance) shall—
‘‘(A) provide for continuity of care with es-
tablished primary care practitioners, when the
health care professional’s contract is termi-
nated, and
‘‘(B) allow enrollees, at no additional out-
of-pocket cost, to continue receiving services
from a primary care practitioner whose contract
with the plan or issuer is terminated without
cause for a period of at least 60 days if the en-
rollee requests such continuation.
‘‘(3) TELEPHONE
ACCESS.—A managed care
group health plan (and a health insurance issuer of-
fering managed care group health insurance) shall
provide telephone access to the plan or issuer for
sufficient time during business and evening hours to
ensure enrollee access for routine care, and 24 hour
telephone access to either the plan, issuer, or a par-
ticipating provider or professional, for emergency
care or authorization for such care.
‘‘(4) STANDARDS
FOR
WAITING
TIMES.—A
managed care group health plan (and a health insur-
ance issuer offering managed care group health in-
surance) shall establish reasonable standards for
waiting times for enrollees to obtain appointments,
subject to special rules for emergency services under
paragraph (5). Such standards shall include appoint-
ment scheduling guidelines based on the type of
health care service, including prenatal care appoint-
ments, well-child visits and immunizations, routine
physicals, follow-up appointments for chronic condi-
tions, and urgent care.
‘‘(5) COVERAGE OF EMERGENCY SERVICES.—
‘‘(A) IN
GENERAL.—A managed care
group health plan (and a health insurance is-
suer offering managed care group health insur-
ance) shall cover and reimburse expenses for
treatment of an emergency medical condition if
the treatment is obtained, without prior author-
ization.
‘‘(B) EMERGENCY
MEDICAL
CONDITION
DEFINED.—The term ‘emergency medical con-
dition’ means a medical condition, the onset of
which is sudden and unexpected, that manifests
itself by symptoms of sufficient severity, that a
prudent layperson, who possesses an average
knowledge of health and medicine, could reason-
ably assume that the condition requires imme-
diate medical treatment, and could expect the
absence of medical attention to result in serious
impairment to bodily functions or place the per-
son’s health in serious jeopardy.
‘‘(C) PRUDENT LAYPERSON DEFINED.—In
this paragraph, the term ‘prudent layperson’
means a person without specific medical train-
ing for the illness or condition in question who
acts as a reasonable person would under similar
circumstances.
‘‘(b) ASSURING ADEQUATE CHOICE
OF HEALTH
CARE PROFESSIONALS.—
‘‘(1) IN
GENERAL.—A managed care group
health plan (and a health insurance issuer offering
managed care group health insurance) shall provide
that each enrollee shall have adequate choice among
participating health care professionals who are ac-
cessible and qualified.
‘‘(2) CHOICE.—A managed care group health
plan (and a health insurance issuer offering man-
aged care group health insurance) shall permit en-
rollees to choose their own primary care practitioner
from a list of health care professionals within the
plan or coverage. Such list shall be updated as
health care professionals are added or removed and
shall include—
‘‘(A) a sufficient number of primary care
practitioners who are accepting new enrollees;
and
‘‘(B) a sufficient mix of primary care prac-
titioners that reflects a diversity that is ade-
quate to meet the needs of the enrollees’ varied
characteristics, including age, gender, race, and
health status.
‘‘(3) MEDICAL SPECIALISTS.—A managed care
group health plan (and a health insurance issuer of-
fering managed care group health insurance) shall
develop a system to permit enrollees to use a medical
specialist primary care practitioner, when the enroll-
ee’s medical conditions (including suffering from a
chronic disease or medical condition) warrant it.
‘‘(4) CONTINUITY OF CARE.—A managed care
group health plan (and a health insurance issuer of-