receipt of emergency services (as defined in sub-
section (a)(2)(B)) in a case in which the emergency 
services are covered under the plan or coverage pur-
suant to subsection (a)(1) and a prudent layperson, 
with an average knowledge of health and medicine, 
could reasonably expect that the absence of such 
transport would result in placing the health of the 
individual in serious jeopardy, serious impairment of 
bodily function, or serious dysfunction of any bodily 
organ or part. 
SEC. 114. TIMELY ACCESS TO SPECIALISTS. 
(a) TIMELY ACCESS.— 
(1) IN GENERAL.—A group health plan and a 
health insurance issuer offering health insurance 
coverage shall ensure that participants, beneficiaries, 
and enrollees receive timely access to specialists who 
are appropriate to the condition of, and accessible 
to, the participant, beneficiary, or enrollee, when 
such specialty care is a covered benefit under the 
plan or coverage. 
(2) RULE
OF
CONSTRUCTION.—Nothing in 
paragraph (1) shall be construed— 
(A) to require the coverage under a group 
health plan or health insurance coverage of ben-
efits or services;
(B) to prohibit a plan or issuer from in-
cluding providers in the network only to the ex-
tent necessary to meet the needs of the plan’s 
or issuer’s participants, beneficiaries, or enroll-
ees; or 
(C) to override any State licensure or 
scope-of-practice law. 
(3) ACCESS TO CERTAIN PROVIDERS.— 
(A) IN
GENERAL.—With respect to spe-
cialty care under this section, if a participating 
specialist is not available and qualified to pro-
vide such care to the participant, beneficiary, or 
enrollee, the plan or issuer shall provide for cov-
erage of such care by a nonparticipating spe-
cialist. 
(B) TREATMENT
OF
NONPARTICIPATING 
PROVIDERS.—If a participant, beneficiary, or 
enrollee receives care from a nonparticipating 
specialist pursuant to subparagraph (A), such 
specialty care shall be provided at no additional 
cost to the participant, beneficiary, or enrollee 
beyond what the participant, beneficiary, or en-
rollee would otherwise pay for such specialty 
care if provided by a participating specialist. 
(b) REFERRALS.—
(1) AUTHORIZATION.—Subject to subsection 
(a)(1), a group health plan or health insurance 
issuer may require an authorization in order to ob-
tain coverage for specialty services under this sec-
tion. Any such authorization— 
(A) shall be for an appropriate duration of 
time or number of referrals, including an au-
thorization for a standing referral where appro-
priate; and 
(B) may not be refused solely because the 
authorization involves services of a nonpartici-
pating 
specialist 
(described 
in 
subsection 
(a)(3)). 
(2) REFERRALS FOR ONGOING SPECIAL CONDI-
TIONS.— 
(A) IN GENERAL.—Subject to subsection 
(a)(1), a group health plan and a health insur-
ance issuer shall permit a participant, bene-
ficiary, or enrollee who has an ongoing special 
condition (as defined in subparagraph (B)) to 
receive a referral to a specialist for the treat-
ment of such condition and such specialist may 
authorize such referrals, procedures, tests, and 
other medical services with respect to such con-
dition, or coordinate the care for such condi-
tion, subject to the terms of a treatment plan 
(if any) referred to in subsection (c) with re-
spect to the condition. 
(B) ONGOING
SPECIAL
CONDITION
DE-
FINED.—In this subsection, the term ‘‘ongoing 
special condition’’ means a condition or disease 
that— 
(i) is life-threatening, degenerative, 
potentially disabling, or congenital; and 
(ii) requires specialized medical care 
over a prolonged period of time. 
(c) TREATMENT PLANS.— 
(1) IN
GENERAL.—A group health plan or 
health insurance issuer may require that the spe-
cialty care be provided— 
(A) pursuant to a treatment plan, but only 
if the treatment plan— 
(i) is developed by the specialist, in 
consultation with the case manager or pri-
mary care provider, and the participant, 
beneficiary, or enrollee, and 
(ii) is approved by the plan or issuer 
in a timely manner, if the plan or issuer 
requires such approval; and
(B) in accordance with applicable quality 
assurance and utilization review standards of 
the plan or issuer. 
(2) NOTIFICATION.—Nothing in paragraph (1) 
shall be construed as prohibiting a plan or issuer 
from requiring the specialist to provide the plan or 
issuer with regular updates on the specialty care 
provided, as well as all other reasonably necessary 
medical information. 
(d) SPECIALIST DEFINED.—For purposes of this sec-
tion, the term ‘‘specialist’’ means, with respect to the con-
dition of the participant, beneficiary, or enrollee, a health 
care professional, facility, or center that has adequate ex-
pertise through appropriate training and experience (in-
cluding, in the case of a child, appropriate pediatric exper-
tise) to provide high quality care in treating the condition. 
SEC. 115. PATIENT ACCESS TO OBSTETRICAL AND GYNECO-
LOGICAL CARE. 
(a) GENERAL RIGHTS.— 
(1) DIRECT ACCESS.—A group health plan, and 
a health insurance issuer offering health insurance 
coverage, described in subsection (b) may not re-
quire authorization or referral by the plan, issuer, or 
any person (including a primary care provider de-
scribed in subsection (b)(2)) in the case of a female
participant, beneficiary, or enrollee who seeks cov-
erage for obstetrical or gynecological care provided 
by a participating health care professional who spe-
cializes in obstetrics or gynecology. 
(2) 
OBSTETRICAL
AND
GYNECOLOGICAL 
CARE.—A group health plan and a health insurance 
issuer described in subsection (b) shall treat the pro-
vision of obstetrical and gynecological care, and the 
ordering of related obstetrical and gynecological 
items and services, pursuant to the direct access de-
scribed under paragraph (1), by a participating 
health care professional who specializes in obstetrics 
or gynecology as the authorization of the primary 
care provider. 
(b) APPLICATION OF SECTION.—A group health plan, 
or health insurance issuer offering health insurance cov-
erage, described in this subsection is a group health plan 
or coverage that— 
(1) 
provides 
coverage 
for 
obstetric 
or 
gynecologic care; and 
(2) requires the designation by a participant, 
beneficiary, or enrollee of a participating primary 
care provider. 
(c) CONSTRUCTION.—Nothing in subsection (a) shall 
be construed to—
(1) waive any exclusions of coverage under the 
terms and conditions of the plan or health insurance 
coverage with respect to coverage of obstetrical or 
gynecological care; or 
(2) preclude the group health plan or health in-
surance issuer involved from requiring that the ob-
stetrical or gynecological provider notify the primary 
care health care professional or the plan or issuer of 
treatment decisions. 
SEC. 116. ACCESS TO PEDIATRIC CARE. 
(a) PEDIATRIC CARE.—In the case of a person who 
has a child who is a participant, beneficiary, or enrollee 
under a group health plan, or health insurance coverage 
offered by a health insurance issuer, if the plan or issuer 
requires or provides for the designation of a participating 
primary care provider for the child, the plan or issuer shall 
permit such person to designate a physician (allopathic or 
osteopathic) who specializes in pediatrics as the child’s pri-
mary care provider if such provider participates in the net-
work of the plan or issuer. 
(b) CONSTRUCTION.—Nothing in subsection (a) shall 
be construed to waive any exclusions of coverage under 
the terms and conditions of the plan or health insurance 
coverage with respect to coverage of pediatric care.
SEC. 117. CONTINUITY OF CARE. 
(a) TERMINATION OF PROVIDER.— 
(1) IN GENERAL.—If— 
(A) a contract between a group health 
plan, or a health insurance issuer offering 
health insurance coverage, and a treating health 
care provider is terminated (as defined in para-
graph (e)(4)), or 
(B) benefits or coverage provided by a 
health care provider are terminated because of 
a change in the terms of provider participation 
in such plan or coverage, 
the plan or issuer shall meet the requirements of 
paragraph (3) with respect to each continuing care 
patient. 
(2) TREATMENT
OF
TERMINATION
OF
CON-
TRACT
WITH
HEALTH
INSURANCE
ISSUER.—If a 
contract for the provision of health insurance cov-
erage between a group health plan and a health in-
surance issuer is terminated and, as a result of such 
termination, coverage of services of a health care 
provider is terminated with respect to an individual, 
the provisions of paragraph (1) (and the succeeding 
provisions of this section) shall apply under the plan 
in the same manner as if there had been a contract 
between the plan and the provider that had been ter-
minated, but only with respect to benefits that are 
covered under the plan after the contract termi-
nation. 
(3) REQUIREMENTS.—The requirements of this 
paragraph are that the plan or issuer— 
(A) notify the continuing care patient in-
volved, or arrange to have the patient notified 
pursuant to subsection (d)(2), on a timely basis 
of the termination described in paragraph (1) 
(or paragraph (2), if applicable) and the right 
to elect continued transitional care from the 
provider under this section; 
(B) provide the patient with an oppor-
tunity to notify the plan or issuer of the pa-
tient’s need for transitional care; and 
(C) subject to subsection (c), permit the 
patient to elect to continue to be covered with 
respect to the course of treatment by such pro-
vider with the provider’s consent during a tran-
sitional period (as provided for under subsection 
(b)). 
(4) CONTINUING CARE PATIENT.—For purposes 
of this section, the term ‘‘continuing care patient’’ 
means a participant, beneficiary, or enrollee who—
(A) is undergoing a course of treatment 
for a serious and complex condition from the 
provider at the time the plan or issuer receives 
or provides notice of provider, benefit, or cov-
erage termination described in paragraph (1) 
(or paragraph (2), if applicable); 
(B) is undergoing a course of institutional 
or inpatient care from the provider at the time 
of such notice; 
(C) is scheduled to undergo non-elective 
surgery from the provider at the time of such 
notice; 
(D) is pregnant and undergoing a course 
of treatment for the pregnancy from the pro-
vider at the time of such notice; or 
(E) is or was determined to be terminally 
ill (as determined under section 1861(dd)(3)(A) 
of the Social Security Act) at the time of such 
notice, but only with respect to a provider that 
was treating the terminal illness before the date 
of such notice. 
(b) TRANSITIONAL PERIODS.— 
(1) SERIOUS AND COMPLEX CONDITIONS.—The 
transitional period under this subsection with re-
spect to a continuing care patient described in sub-
section (a)(4)(A) shall extend for up to 90 days (as 
determined by the treating health care professional) 
from the date of the notice described in subsection 
(a)(3)(A). 
(2) INSTITUTIONAL OR INPATIENT CARE.—The 
transitional period under this subsection for a con-
tinuing 
care 
patient 
described 
in 
subsection 
(a)(4)(B) shall extend until the earlier of— 
(A) the expiration of the 90-day period be-
ginning on the date on which the notice under 
subsection (a)(3)(A) is provided; or 
(B) the date of discharge of the patient 
from such care or the termination of the period 
of institutionalization, or, if later, the date of 
completion of reasonable follow-up care. 
(3) SCHEDULED
NON-ELECTIVE
SURGERY.— 
The transitional period under this subsection for a 
continuing care patient described in subsection 
(a)(4)(C) shall extend until the completion of the 
surgery involved and post-surgical follow-up care re-
lating to the surgery and occurring within 90 days 
after the date of the surgery. 
(4) 
PREGNANCY.—The 
transitional 
period 
under this subsection for a continuing care patient 
described in subsection (a)(4)(D) shall extend
through the provision of post-partum care directly 
related to the delivery. 
(5) TERMINAL ILLNESS.—The transitional pe-
riod under this subsection for a continuing care pa-
tient described in subsection (a)(4)(E) shall extend 
for the remainder of the patient’s life for care that 
is directly related to the treatment of the terminal 
illness or its medical manifestations. 
(c) PERMISSIBLE
TERMS
AND
CONDITIONS.—A 
group health plan or health insurance issuer may condi-
tion coverage of continued treatment by a provider under 
this section upon the provider agreeing to the following 
terms and conditions: 
(1) The treating health care provider agrees to 
accept reimbursement from the plan or issuer and 
continuing care patient involved (with respect to 
cost-sharing) at the rates applicable prior to the 
start of the transitional period as payment in full 
(or, in the case described in subsection (a)(2), at the 
rates applicable under the replacement plan or cov-
erage after the date of the termination of the con-
tract with the group health plan or health insurance 
issuer) and not to impose cost-sharing with respect 
to the patient in an amount that would exceed the 
cost-sharing that could have been imposed if the
contract referred to in subsection (a)(1) had not 
been terminated. 
(2) The treating health care provider agrees to 
adhere to the quality assurance standards of the 
plan or issuer responsible for payment under para-
graph (1) and to provide to such plan or issuer nec-
essary medical information related to the care pro-
vided. 
(3) The treating health care provider agrees 
otherwise to adhere to such plan’s or issuer’s policies 
and procedures, including procedures regarding re-
ferrals and obtaining prior authorization and pro-
viding services pursuant to a treatment plan (if any) 
approved by the plan or issuer. 
(d) RULES OF CONSTRUCTION.—Nothing in this sec-
tion shall be construed— 
(1) to require the coverage of benefits which 
would not have been covered if the provider involved 
remained a participating provider; or 
(2) with respect to the termination of a con-
tract under subsection (a) to prevent a group health 
plan or health insurance issuer from requiring that 
the health care provider— 
(A) notify participants, beneficiaries, or en-
rollees of their rights under this section; or
(B) provide the plan or issuer with the 
name of each participant, beneficiary, or en-
rollee who the provider believes is a continuing 
care patient. 
(e) DEFINITIONS.—In this section: 
(1) CONTRACT.—The term ‘‘contract’’ includes, 
with respect to a plan or issuer and a treating 
health care provider, a contract between such plan 
or issuer and an organized network of providers that 
includes the treating health care provider, and (in 
the case of such a contract) the contract between the 
treating health care provider and the organized net-
work. 
(2) HEALTH
CARE
PROVIDER.—The term 
‘‘health care provider’’ or ‘‘provider’’ means— 
(A) any individual who is engaged in the 
delivery of health care services in a State and 
who is required by State law or regulation to be 
licensed or certified by the State to engage in 
the delivery of such services in the State; and 
(B) any entity that is engaged in the deliv-
ery of health care services in a State and that, 
if it is required by State law or regulation to be 
licensed or certified by the State to engage in
100 
the delivery of such services in the State, is so 
licensed. 
(3) SERIOUS AND COMPLEX CONDITION.—The 
term ‘‘serious and complex condition’’ means, with 
respect to a participant, beneficiary, or enrollee 
under the plan or coverage— 
(A) in the case of an acute illness, a condi-
tion that is serious enough to require special-
ized medical treatment to avoid the reasonable 
possibility of death or permanent harm; or 
(B) in the case of a chronic illness or con-
dition, is an ongoing special condition (as de-
fined in section 114(b)(2)(B)). 
(4) TERMINATED.—The term ‘‘terminated’’ in-
cludes, with respect to a contract, the expiration or 
nonrenewal of the contract, but does not include a 
termination of the contract for failure to meet appli-
cable quality standards or for fraud. 
SEC. 118. ACCESS TO NEEDED PRESCRIPTION DRUGS. 
(a) IN GENERAL.—To the extent that a group health 
plan, or health insurance coverage offered by a health in-
surance issuer, provides coverage for benefits with respect 
to prescription drugs, and limits such coverage to drugs 
included in a formulary, the plan or issuer shall—
101 
(1) ensure the participation of physicians and 
pharmacists in developing and reviewing such for-
mulary; 
(2) provide for disclosure of the formulary to 
providers; and 
(3) in accordance with the applicable quality as-
surance and utilization review standards of the plan 
or issuer, provide for exceptions from the formulary 
limitation when a non-formulary alternative is medi-
cally necessary and appropriate and, in the case of 
such an exception, apply the same cost-sharing re-
quirements that would have applied in the case of a 
drug covered under the formulary. 
(b) COVERAGE OF APPROVED DRUGS AND MEDICAL 
DEVICES.— 
(1) IN GENERAL.—A group health plan (and 
health insurance coverage offered in connection with 
such a plan) that provides any coverage of prescrip-
tion drugs or medical devices shall not deny coverage 
of such a drug or device on the basis that the use 
is investigational, if the use— 
(A) in the case of a prescription drug— 
(i) is included in the labeling author-
ized by the application in effect for the 
drug pursuant to subsection (b) or (j) of