(a)(2), at the rates applicable under the replacement 
plan or issuer after the date of the termination of 
the contract with the health insurance issuer) and 
not to impose cost-sharing with respect to the indi-
vidual in an amount that would exceed the cost-shar-
ing that could have been imposed if the contract re-
ferred to in subsection (a)(1) had not been termi-
nated. 
(2) The provider agrees to adhere to the quality 
assurance standards of the plan or issuer responsible 
for payment under paragraph (1) and to provide to 
such plan or issuer necessary medical information 
related to the care provided. 
(3) The provider agrees otherwise to adhere to 
such plan’s or issuer’s policies and procedures, in-
cluding procedures regarding referrals and obtaining 
prior authorization and providing services pursuant 
to a treatment plan (if any) approved by the plan or 
issuer. 
(d) CONSTRUCTION.—Nothing in this section shall be 
construed to require the coverage of benefits which would 
not have been covered if the provider involved remained 
a participating provider. 
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SEC. 118. ACCESS TO NEEDED PRESCRIPTION DRUGS. 
If a group health plan, or health insurance issuer that 
offers health insurance coverage, provides benefits with re-
spect to prescription drugs but the coverage limits such 
benefits to drugs included in a formulary, the plan or 
issuer shall— 
(1) ensure participation of participating physi-
cians and pharmacists in the development of the for-
mulary; 
(2) disclose to providers and, disclose upon re-
quest under section 121(c)(5) to participants, bene-
ficiaries, and enrollees, the nature of the formulary 
restrictions; and 
(3) consistent with the standards for a utiliza-
tion review program under section 101, provide for 
exceptions from the formulary limitation when a 
non-formulary alternative is medically indicated. 
SEC. 119. COVERAGE FOR INDIVIDUALS PARTICIPATING IN 
APPROVED CLINICAL TRIALS. 
(a) COVERAGE.— 
(1) IN GENERAL.—If a group health plan, or 
health insurance issuer that is providing health in-
surance coverage, provides coverage to a qualified in-
dividual (as defined in subsection (b)), the plan or 
issuer— 
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(A) may not deny the individual participa-
tion in the clinical trial referred to in subsection 
(b)(2); 
(B) subject to subsection (c), may not deny 
(or limit or impose additional conditions on) the 
coverage of routine patient costs for items and 
services furnished in connection with participa-
tion in the trial; and 
(C) may not discriminate against the indi-
vidual on the basis of the enrollee’s participa-
tion in such trial. 
(2) EXCLUSION OF CERTAIN COSTS.—For pur-
poses of paragraph (1)(B), routine patient costs do 
not include the cost of the tests or measurements 
conducted primarily for the purpose of the clinical 
trial involved. 
(3) USE OF IN-NETWORK PROVIDERS.—If one 
or more participating providers is participating in a 
clinical trial, nothing in paragraph (1) shall be con-
strued as preventing a plan or issuer from requiring 
that a qualified individual participate in the trial 
through such a participating provider if the provider 
will accept the individual as a participant in the 
trial. 
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(b) QUALIFIED INDIVIDUAL DEFINED.—For pur-
poses of subsection (a), the term ‘‘qualified individual’’ 
means an individual who is a participant or beneficiary 
in a group health plan, or who is an enrollee under health 
insurance coverage, and who meets the following condi-
tions: 
(1)(A) The individual has a life-threatening or 
serious illness for which no standard treatment is ef-
fective. 
(B) The individual is eligible to participate in 
an approved clinical trial according to the trial pro-
tocol with respect to treatment of such illness. 
(C) The individual’s participation in the trial 
offers meaningful potential for significant clinical 
benefit for the individual. 
(2) Either— 
(A) the referring physician is a partici-
pating health care professional and has con-
cluded that the individual’s participation in 
such trial would be appropriate based upon the 
individual meeting the conditions described in 
paragraph (1); or 
(B) the participant, beneficiary, or enrollee 
provides medical and scientific information es-
tablishing that the individual’s participation in 
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such trial would be appropriate based upon the 
individual meeting the conditions described in 
paragraph (1). 
(c) PAYMENT.— 
(1) IN GENERAL.—Under this section a group 
health plan or health insurance issuer shall provide 
for payment for routine patient costs described in 
subsection (a)(2) but is not required to pay for costs 
of items and services that are reasonably expected 
(as determined by the Secretary) to be paid for by 
the sponsors of an approved clinical trial. 
(2) PAYMENT RATE.—In the case of covered 
items and services provided by— 
(A) a participating provider, the payment 
rate shall be at the agreed upon rate, or 
(B) a nonparticipating provider, the pay-
ment rate shall be at the rate the plan or issuer 
would normally pay for comparable services 
under subparagraph (A). 
(d) APPROVED CLINICAL TRIAL DEFINED.— 
(1) IN
GENERAL.—In this section, the term 
‘‘approved clinical trial’’ means a clinical research 
study or clinical investigation approved and funded 
(which may include funding through in-kind con-
tributions) by one or more of the following: 
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(A) The National Institutes of Health. 
(B) A cooperative group or center of the 
National Institutes of Health. 
(C) Either of the following if the condi-
tions described in paragraph (2) are met: 
(i) The Department of Veterans Af-
fairs. 
(ii) The Department of Defense. 
(2) CONDITIONS
FOR
DEPARTMENTS.—The 
conditions described in this paragraph, for a study 
or investigation conducted by a Department, are 
that the study or investigation has been reviewed 
and approved through a system of peer review that 
the Secretary determines— 
(A) to be comparable to the system of peer 
review of studies and investigations used by the 
National Institutes of Health, and 
(B) assures unbiased review of the highest 
scientific standards by qualified individuals who 
have no interest in the outcome of the review. 
(e) CONSTRUCTION.—Nothing in this section shall be 
construed to limit a plan’s or issuer’s coverage with re-
spect to clinical trials. 
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Subtitle C—Access to Information 
SEC. 121. PATIENT ACCESS TO INFORMATION. 
(a) DISCLOSURE REQUIREMENT.— 
(1) GROUP HEALTH PLANS.—A group health 
plan shall— 
(A) provide to participants and bene-
ficiaries at the time of initial coverage under 
the plan (or the effective date of this section, in 
the case of individuals who are participants or 
beneficiaries as of such date), and at least an-
nually thereafter, the information described in 
subsection (b) in printed form; 
(B) provide to participants and bene-
ficiaries, within a reasonable period (as speci-
fied by the appropriate Secretary) before or 
after the date of significant changes in the in-
formation described in subsection (b), informa-
tion in printed form on such significant 
changes; and 
(C) upon request, make available to par-
ticipants and beneficiaries, the applicable au-
thority, and prospective participants and bene-
ficiaries, the information described in sub-
section (b) or (c) in printed form. 
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(2) HEALTH
INSURANCE
ISSUERS.—A health 
insurance issuer in connection with the provision of 
health insurance coverage shall— 
(A) provide to individuals enrolled under 
such coverage at the time of enrollment, and at 
least annually thereafter, the information de-
scribed in subsection (b) in printed form; 
(B) provide to enrollees, within a reason-
able period (as specified by the appropriate Sec-
retary) before or after the date of significant 
changes in the information described in sub-
section (b), information in printed form on such 
significant changes; and 
(C) upon request, make available to the 
applicable authority, to individuals who are pro-
spective enrollees, and to the public the infor-
mation described in subsection (b) or (c) in 
printed form. 
(b) INFORMATION PROVIDED.—The information de-
scribed in this subsection with respect to a group health 
plan or health insurance coverage offered by a health in-
surance issuer includes the following: 
(1) SERVICE AREA.—The service area of the 
plan or issuer. 
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(2) BENEFITS.—Benefits offered under the 
plan or coverage, including— 
(A) covered benefits, including benefit lim-
its and coverage exclusions; 
(B) cost sharing, such as deductibles, coin-
surance, and copayment amounts, including any 
liability for balance billing, any maximum limi-
tations on out of pocket expenses, and the max-
imum out of pocket costs for services that are 
provided by nonparticipating providers or that 
are furnished without meeting the applicable 
utilization review requirements; 
(C) the extent to which benefits may be ob-
tained from nonparticipating providers; 
(D) the extent to which a participant, ben-
eficiary, or enrollee may select from among par-
ticipating providers and the types of providers 
participating in the plan or issuer network; 
(E) process for determining experimental 
coverage; and 
(F) use of a prescription drug formulary. 
(3) ACCESS.—A description of the following: 
(A) The number, mix, and distribution of 
providers under the plan or coverage. 
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(B) Out-of-network coverage (if any) pro-
vided by the plan or coverage. 
(C) Any point-of-service option (including 
any supplemental premium or cost-sharing for 
such option). 
(D) The procedures for participants, bene-
ficiaries, and enrollees to select, access, and 
change participating primary and specialty pro-
viders. 
(E) The rights and procedures for obtain-
ing referrals (including standing referrals) to 
participating and nonparticipating providers. 
(F) The name, address, and telephone 
number of participating health care providers 
and an indication of whether each such provider 
is available to accept new patients. 
(G) Any limitations imposed on the selec-
tion of qualifying participating health care pro-
viders, including any limitations imposed under 
section 112(b)(2). 
(H) How the plan or issuer addresses the 
needs of participants, beneficiaries, and enroll-
ees and others who do not speak English or 
who have other special communications needs in 
accessing providers under the plan or coverage, 
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including the provision of information described 
in this subsection and subsection (c) to such in-
dividuals. 
(4) OUT-OF-AREA COVERAGE.—Out-of-area cov-
erage provided by the plan or issuer. 
(5) 
EMERGENCY
COVERAGE.—Coverage 
of 
emergency services, including— 
(A) the appropriate use of emergency serv-
ices, including use of the 911 telephone system 
or its local equivalent in emergency situations 
and an explanation of what constitutes an 
emergency situation; 
(B) the process and procedures of the plan 
or issuer for obtaining emergency services; and 
(C) the locations of (i) emergency depart-
ments, and (ii) other settings, in which plan 
physicians and hospitals provide emergency 
services and post-stabilization care. 
(6) PERCENTAGE
OF
PREMIUMS
USED
FOR 
BENEFITS (LOSS-RATIOS).—In the case of health in-
surance coverage only (and not with respect to group 
health plans that do not provide coverage through 
health insurance coverage), a description of the over-
all loss-ratio for the coverage (as defined in accord-
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ance with rules established or recognized by the Sec-
retary of Health and Human Services). 
(7) PRIOR AUTHORIZATION RULES.—Rules re-
garding prior authorization or other review require-
ments that could result in noncoverage or non-
payment. 
(8) GRIEVANCE AND APPEALS PROCEDURES.— 
All appeal or grievance rights and procedures under 
the plan or coverage, including the method for filing 
grievances and the time frames and circumstances 
for acting on grievances and appeals, who is the ap-
plicable authority with respect to the plan or issuer. 
(9) QUALITY
ASSURANCE.—Any information 
made public by an accrediting organization in the 
process of accreditation of the plan or issuer or any 
additional quality indicators the plan or issuer 
makes available. 
(10) INFORMATION ON ISSUER.—Notice of ap-
propriate mailing addresses and telephone numbers 
to be used by participants, beneficiaries, and enroll-
ees in seeking information or authorization for treat-
ment. 
(11) NOTICE
OF
REQUIREMENTS.—Notice of 
the requirements of this title. 
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(12) AVAILABILITY OF INFORMATION ON RE-
QUEST.—Notice that the information described in 
subsection (c) is available upon request. 
(c) INFORMATION MADE AVAILABLE UPON RE-
QUEST.—The information described in this subsection is 
the following: 
(1) UTILIZATION REVIEW ACTIVITIES.—A de-
scription of procedures used and requirements (in-
cluding circumstances, time frames, and appeal 
rights) under any utilization review program under 
section 101, including under any drug formulary 
program under section 118. 
(2) GRIEVANCE AND APPEALS INFORMATION.— 
Information on the number of grievances and ap-
peals and on the disposition in the aggregate of such 
matters. 
(3) METHOD OF PHYSICIAN COMPENSATION.— 
A general description by category (including salary, 
fee-for-service, capitation, and such other categories 
as may be specified in regulations of the Secretary) 
of the applicable method by which a specified pro-
spective or treating health care professional is (or 
would be) compensated in connection with the provi-
sion of health care under the plan or coverage. 
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(4) SPECIFIC INFORMATION ON CREDENTIALS 
OF PARTICIPATING PROVIDERS.—In the case of each 
participating provider, a description of the creden-
tials of the provider. 
(5) FORMULARY RESTRICTIONS.—A description 
of the nature of any drug formula restrictions. 
(6) PARTICIPATING PROVIDER LIST.—A list of 
current participating health care providers. 
(d) CONSTRUCTION.—Nothing in this section shall be 
construed as requiring public disclosure of individual con-
tracts or financial arrangements between a group health 
plan or health insurance issuer and any provider. 
Subtitle D—Protecting the Doctor- 
Patient Relationship 
SEC. 131. PROHIBITION OF INTERFERENCE WITH CERTAIN 
MEDICAL COMMUNICATIONS. 
(a) GENERAL RULE.—The provisions of any contract 
or agreement, or the operation of any contract or agree-
ment, between a group health plan or health insurance 
issuer in relation to health insurance coverage (including 
any partnership, association, or other organization that 
enters into or administers such a contract or agreement) 
and a health care provider (or group of health care pro-
viders) shall not prohibit or otherwise restrict a health 
care professional from advising such a participant, bene-
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ficiary, or enrollee who is a patient of the professional 
about the health status of the individual or medical care 
or treatment for the individual’s condition or disease, re-
gardless of whether benefits for such care or treatment 
are provided under the plan or coverage, if the professional 
is acting within the lawful scope of practice. 
(b) NULLIFICATION.—Any contract provision or 
agreement that restricts or prohibits medical communica-
tions in violation of subsection (a) shall be null and void. 
SEC. 132. PROHIBITION OF DISCRIMINATION AGAINST PRO-
VIDERS BASED ON LICENSURE. 
(a) IN GENERAL.—A group health plan and a health 
insurance issuer offering health insurance coverage shall 
not discriminate with respect to participation or indem-
nification as to any provider who is acting within the scope 
of the provider’s license or certification under applicable 
State law, solely on the basis of such license or certifi-
cation. 
(b) CONSTRUCTION.—Subsection (a) shall not be con-
strued— 
(1) as requiring the coverage under a group 
health plan or health insurance coverage of par-
ticular benefits or services or to prohibit a plan or 
issuer from including providers only to the extent 
necessary to meet the needs of the plan’s or issuer’s 
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participants, beneficiaries, or enrollees or from es-
tablishing any measure designed to maintain quality 
and control costs consistent with the responsibilities 
of the plan or issuer; 
(2) to override any State licensure or scope-of- 
practice law; or 
(3) as requiring a plan or issuer that offers net-
work coverage to include for participation every will-
ing provider who meets the terms and conditions of 
the plan or issuer. 
SEC. 133. PROHIBITION AGAINST IMPROPER INCENTIVE 
ARRANGEMENTS. 
(a) IN GENERAL.—A group health plan and a health 
insurance issuer offering health insurance coverage may 
not operate any physician incentive plan (as defined in 
subparagraph (B) of section 1876(i)(8) of the Social Secu-
rity Act) unless the requirements described in clauses (i), 
(ii)(I), and (iii) of subparagraph (A) of such section are 
met with respect to such a plan. 
(b) APPLICATION.—For purposes of carrying out 
paragraph (1), any reference in section 1876(i)(8) of the 
Social Security Act to the Secretary, an eligible organiza-
tion, or an individual enrolled with the organization shall 
be treated as a reference to the applicable authority, a 
group health plan or health insurance issuer, respectively, 
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‘‘(C) Section 114 (relating to access to 
specialty care). 
‘‘(D) Section 115 (relating to access to ob-
stetrical and gynecological care). 
‘‘(E) Section 116 (relating to access to pe-
diatric care). 
‘‘(F) Section 117(a)(1) (relating to con-
tinuity in case of termination of provider con-
tract) and section 117(a)(2) (relating to con-
tinuity in case of termination of issuer con-
tract), but only insofar as a replacement issuer 
assumes the obligation for continuity of care. 
‘‘(G) Section 118 (relating to access to 
needed prescription drugs). 
‘‘(H) Section 119 (relating to coverage for 
individuals participating in approved clinical 
trials.) 
‘‘(I) Section 134 (relating to payment of 
claims). 
‘‘(2) INFORMATION.—With respect to informa-
tion required to be provided or made available under 
section 121, in the case of a group health plan that 
provides benefits in the form of health insurance 
coverage through a health insurance issuer, the Sec-
retary shall determine the circumstances under 
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