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tion (as defined in paragraph (3)(A)) at the time of
such termination, the plan or issuer shall—
(A) notify the individual on a timely basis
of such termination and of the right to elect
continuation of coverage of treatment by the
provider under this section; and
(B) subject to subsection (c), permit the
individual to elect to continue to be covered
with respect to treatment by the provider of
such condition during a transitional period
(provided under subsection (b)).
(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.
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(3) DEFINITIONS.—For purposes of this sec-
tion:
(A) ONGOING
SPECIAL
CONDITION.—The
term ‘‘ongoing special condition’’ has the mean-
ing given such term in section 1114(b)(3), and
also includes pregnancy.
(B) TERMINATION.—The term ‘‘termi-
nated’’ includes, with respect to a contract, the
expiration or nonrenewal of the contract, but
does not include a termination of the contract
by the plan or issuer for failure to meet applica-
ble quality standards or for fraud.
(b) TRANSITIONAL PERIOD.—
(1) IN GENERAL.—Except as provided in para-
graphs (2) through (4), the transitional period under
this subsection shall extend up to 90 days (as deter-
mined by the treating health care professional) after
the date of the notice described in subsection
(a)(1)(A) of the provider’s termination.
(2) SCHEDULED SURGERY AND ORGAN TRANS-
PLANTATION.—If surgery or organ transplantation
was scheduled for an individual before the date of
the announcement of the termination of the provider
status under subsection (a)(1)(A) or if the individual
on such date was on an established waiting list or
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otherwise scheduled to have such surgery or trans-
plantation, the transitional period under this sub-
section with respect to the surgery or transplan-
tation shall extend beyond the period under para-
graph (1) and until the date of discharge of the indi-
vidual after completion of the surgery or transplan-
tation.
(3) PREGNANCY.—If—
(A) a participant, beneficiary, or enrollee
was determined to be pregnant at the time of
a provider’s termination of participation; and
(B) the provider was treating the preg-
nancy before date of the termination,
the transitional period under this subsection with re-
spect to provider’s treatment of the pregnancy shall
extend through the provision of post-partum care di-
rectly related to the delivery.
(4) TERMINAL ILLNESS.—If—
(A) a participant, beneficiary, or enrollee
was determined to be terminally ill (as deter-
mined under section 1861(dd)(3)(A) of the So-
cial Security Act) at the time of a provider’s
termination of participation; and
(B) the provider was treating the terminal
illness before the date of termination,
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the transitional period under this subsection shall
extend for the remainder of the individual’s life for
care 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
subsection (a)(1)(B) upon the individual notifying the plan
of the election of continued coverage and upon the pro-
vider agreeing to the following terms and conditions:
(1) The provider agrees to accept reimburse-
ment from the plan or issuer and individual involved
(with respect to cost-sharing) at the rates applicable
prior to the start of the transitional period as pay-
ment in full (or, in the case described in subsection
(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
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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.
SEC. 1118. 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 1121(c)(5) to participants, bene-
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ficiaries, and enrollees, the nature of the formulary
restrictions; and
(3) consistent with the standards for a utiliza-
tion review program under section 1101, provide for
exceptions from the formulary limitation when a
non-formulary alternative is medically indicated.
SEC. 1119. 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—
(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.
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(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.
(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.
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(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
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.
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(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:
(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
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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.
Subtitle C—Access to Information
SEC. 1121. 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;
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(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.
(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
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(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.
(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;
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(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.
(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
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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 1112(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,
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
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(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-
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
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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.
(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 1101, including under any drug formulary
program under section 1118.
(2) GRIEVANCE AND APPEALS INFORMATION.—
Information on the number of grievances and ap-
peals and on the disposition in the aggregate of such
matters.
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(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.
(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.
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Subtitle D—Protecting the Doctor-
Patient Relationship
SEC. 1131. 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-
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.
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SEC. 1132. PROHIBITION OF DISCRIMINATION AGAINST
PROVIDERS 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
construed—
(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
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.
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SEC. 1133. 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,
and a participant, beneficiary, or enrollee with the plan
or organization, respectively.
(c) CONSTRUCTION.—Nothing in this section shall be
construed as prohibiting all capitation and similar ar-
rangements or all provider discount arrangements.
SEC. 1134. PAYMENT OF CLAIMS.
A group health plan, and a health insurance issuer
offering group health insurance coverage, shall provide for
prompt payment of claims submitted for health care serv-
ices or supplies furnished to a participant, beneficiary, or
enrollee with respect to benefits covered by the plan or
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issuer, in a manner consistent with the provisions of sec-
tions 1816(c)(2) and 1842(c)(2) of the Social Security Act
(42 U.S.C. 1395h(c)(2) and 42 U.S.C. 1395u(c)(2)), ex-
cept that for purposes of this section, subparagraph (C)
of section 1816(c)(2) of the Social Security Act shall be
treated as applying to claims received from a participant,
beneficiary, or enrollee as well as claims referred to in
such subparagraph.
SEC. 1135. PROTECTION FOR PATIENT ADVOCACY.
(a) PROTECTION FOR USE OF UTILIZATION REVIEW
AND GRIEVANCE PROCESS.—A group health plan, and a
health insurance issuer with respect to the provision of
health insurance coverage, may not retaliate against a par-
ticipant, beneficiary, enrollee, or health care provider
based on the participant’s, beneficiary’s, enrollee’s or pro-
vider’s use of, or participation in, a utilization review proc-
ess or a grievance process of the plan or issuer (including
an internal or external review or appeal process) under
this title.
(b) PROTECTION
FOR
QUALITY
ADVOCACY
BY
HEALTH CARE PROFESSIONALS.—
(1) IN
GENERAL.—A group health plan or
health insurance issuer may not retaliate or dis-
criminate against a protected health care profes-
sional because the professional in good faith—
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(A) discloses information relating to the
care, services, or conditions affecting one or
more participants, beneficiaries, or enrollees of
the plan or issuer to an appropriate public reg-
ulatory agency, an appropriate private accredi-
tation body, or appropriate management per-
sonnel of the plan or issuer; or
(B) initiates, cooperates, or otherwise par-
ticipates in an investigation or proceeding by
such an agency with respect to such care, serv-
ices, or conditions.
If an institutional health care provider is a partici-
pating provider with such a plan or issuer or other-
wise receives payments for benefits provided by such
a plan or issuer, the provisions of the previous sen-
tence shall apply to the provider in relation to care,
services, or conditions affecting one or more patients
within an institutional health care provider in the
same manner as they apply to the plan or issuer in
relation to care, services, or conditions provided to
one or more participants, beneficiaries, or enrollees;
and for purposes of applying this sentence, any ref-
erence to a plan or issuer is deemed a reference to
the institutional health care provider.
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(2) GOOD
FAITH
ACTION.—For purposes of
paragraph (1), a protected health care professional
is considered to be acting in good faith with respect
to disclosure of information or participation if, with
respect to the information disclosed as part of the
action—
(A) the disclosure is made on the basis of
personal knowledge and is consistent with that
degree of learning and skill ordinarily possessed
by health care professionals with the same li-
censure or certification and the same experi-
ence;
(B) the professional reasonably believes the
information to be true;
(C) the information evidences either a vio-
lation of a law, rule, or regulation, of an appli-
cable accreditation standard, or of a generally
recognized professional or clinical standard or
that a patient is in imminent hazard of loss of
life or serious injury; and
(D) subject to subparagraphs (B) and (C)
of paragraph (3), the professional has followed
reasonable internal procedures of the plan,
issuer, or institutional health care provider es-
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tablished for the purpose of addressing quality
concerns before making the disclosure.
(3) EXCEPTION AND SPECIAL RULE.—
(A) GENERAL EXCEPTION.—Paragraph (1)
does not protect disclosures that would violate
Federal or State law or diminish or impair the
rights of any person to the continued protection
of confidentiality of communications provided
by such law.
(B) NOTICE OF INTERNAL PROCEDURES.—
Subparagraph (D) of paragraph (2) shall not
apply unless the internal procedures involved
are reasonably expected to be known to the
health care professional involved. For purposes
of this subparagraph, a health care professional
is reasonably expected to know of internal pro-
cedures if those procedures have been made
available to the professional through distribu-
tion or posting.
(C) INTERNAL PROCEDURE EXCEPTION.—
Subparagraph (D) of paragraph (2) also shall
not apply if—
(i) the disclosure relates to an immi-
nent hazard of loss of life or serious injury
to a patient;
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(ii) the disclosure is made to an ap-
propriate private accreditation body pursu-
ant to disclosure procedures established by
the body; or
(iii) the disclosure is in response to an
inquiry made in an investigation or pro-
ceeding of an appropriate public regulatory
agency and the information disclosed is
limited to the scope of the investigation or
proceeding.
(4) ADDITIONAL
CONSIDERATIONS.—It shall
not be a violation of paragraph (1) to take an ad-
verse action against a protected health care profes-
sional if the plan, issuer, or provider taking the ad-
verse action involved demonstrates that it would
have taken the same adverse action even in the ab-
sence of the activities protected under such para-
graph.
(5) NOTICE.—A group health plan, health in-
surance issuer, and institutional health care provider
shall post a notice, to be provided or approved by
the Secretary of Labor, setting forth excerpts from,
or summaries of, the pertinent provisions of this
subsection and information pertaining to enforce-
ment of such provisions.
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(6) CONSTRUCTIONS.—
(A) DETERMINATIONS
OF
COVERAGE.—
Nothing in this subsection shall be construed to
prohibit a plan or issuer from making a deter-
mination not to pay for a particular medical
treatment or service or the services of a type of
health care professional.
(B) ENFORCEMENT OF PEER REVIEW PRO-
TOCOLS AND INTERNAL PROCEDURES.—Noth-
ing in this subsection shall be construed to pro-
hibit a plan, issuer, or provider from estab-
lishing and enforcing reasonable peer review or
utilization review protocols or determining
whether a protected health care professional has
complied with those protocols or from estab-
lishing and enforcing internal procedures for
the purpose of addressing quality concerns.
(C) RELATION TO OTHER RIGHTS.—Noth-
ing in this subsection shall be construed to
abridge rights of participants, beneficiaries, en-
rollees, and protected health care professionals
under other applicable Federal or State laws.
(7) PROTECTED HEALTH CARE PROFESSIONAL
DEFINED.—For purposes of this subsection, the
term ‘‘protected health care professional’’ means an
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individual who is a licensed or certified health care
professional and who—
(A) with respect to a group health plan or
health insurance issuer, is an employee of the
plan or issuer or has a contract with the plan
or issuer for provision of services for which ben-
efits are available under the plan or issuer; or
(B) with respect to an institutional health
care provider, is an employee of the provider or
has a contract or other arrangement with the
provider respecting the provision of health care
services.
Subtitle E—Definitions
SEC. 1151. DEFINITIONS.
(a) INCORPORATION OF GENERAL DEFINITIONS.—
Except as otherwise provided, the provisions of section
2791 of the Public Health Service Act shall apply for pur-
poses of this title in the same manner as they apply for
purposes of title XXVII of such Act.
(b) SECRETARY.—Except as otherwise provided, the
term ‘‘Secretary’’ means the Secretary of Health and
Human Services, in consultation with the Secretary of
Labor and the term ‘‘appropriate Secretary’’ means the
Secretary of Health and Human Services in relation to
carrying out this title under sections 2706 and 2751 of
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the Public Health Service Act and the Secretary of Labor
in relation to carrying out this title under section 713 of
the Employee Retirement Income Security Act of 1974.
(c) ADDITIONAL DEFINITIONS.—For purposes of this
title:
(1) ACTIVELY PRACTICING.—The term ‘‘actively
practicing’’ means, with respect to a physician or
other health care professional, such a physician or
professional who provides professional services to in-
dividual patients on average at least two full days
per week.
(2) APPLICABLE AUTHORITY.—The term ‘‘ap-
plicable authority’’ means—
(A) in the case of a group health plan, the
Secretary of Health and Human Services and
the Secretary of Labor; and
(B) in the case of a health insurance issuer
with respect to a specific provision of this title,
the applicable State authority (as defined in
section 2791(d) of the Public Health Service
Act), or the Secretary of Health and Human
Services, if such Secretary is enforcing such
provision 
under 
section 
2722(a)(2) 
or
2761(a)(2) of the Public Health Service Act.
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(3) CLINICAL PEER.—The term ‘‘clinical peer’’
means, with respect to a review or appeal, an ac-
tively practicing physician (allopathic or osteopathic)
or other actively practicing health care professional
who holds a nonrestricted license, and who is appro-
priately credentialed in the same or similar specialty
or subspecialty (as appropriate) as typically handles
the medical condition, procedure, or treatment under
review or appeal and includes a pediatric specialist
where appropriate; except that only a physician
(allopathic or osteopathic) may be a clinical peer
with respect to the review or appeal of treatment
recommended or rendered by a physician.
(4) ENROLLEE.—The term ‘‘enrollee’’ means,
with respect to health insurance coverage offered by
a health insurance issuer, an individual enrolled with
the issuer to receive such coverage.
(5) GROUP HEALTH PLAN.—The term ‘‘group
health plan’’ has the meaning given such term in
section 733(a) of the Employee Retirement Income
Security Act of 1974 and in section 2791(a)(1) of
the Public Health Service Act.
(6) HEALTH CARE PROFESSIONAL.—The term
‘‘health care professional’’ means an individual who
is licensed, accredited, or certified under State law
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to provide specified health care services and who is
operating within the scope of such licensure, accredi-
tation, or certification.
(7) HEALTH
CARE
PROVIDER.—The term
‘‘health care provider’’ includes a physician or other
health care professional, as well as an institutional
or other facility or agency that provides health care
services and that is licensed, accredited, or certified
to provide health care items and services under ap-
plicable State law.
(8) NETWORK.—The term ‘‘network’’ means,
with respect to a group health plan or health insur-
ance issuer offering health insurance coverage, the
participating health care professionals and providers
through whom the plan or issuer provides health
care items and services to participants, beneficiaries,
or enrollees.
(9) 
NONPARTICIPATING.—The 
term 
‘‘non-
participating’’ means, with respect to a health care
provider that provides health care items and services
to a participant, beneficiary, or enrollee under group
health plan or health insurance coverage, a health
care provider that is not a participating health care
provider with respect to such items and services.
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(10) 
PARTICIPATING.—The 
term 
‘‘partici-
pating’’ means, with respect to a health care pro-
vider that provides health care items and services to
a participant, beneficiary, or enrollee under group
health plan or health insurance coverage offered by
a health insurance issuer, a health care provider that
furnishes such items and services under a contract
or other arrangement with the plan or issuer.
(11) PRIOR AUTHORIZATION.—The term ‘‘prior
authorization’’ means the process of obtaining prior
approval from a health insurance issuer or group
health plan for the provision or coverage of medical
services.
SEC. 1152. PREEMPTION; STATE FLEXIBILITY; CONSTRUC-
TION.
(a) CONTINUED APPLICABILITY
OF STATE LAW
WITH RESPECT TO HEALTH INSURANCE ISSUERS.—
(1) IN GENERAL.—Subject to paragraph (2),
this title shall not be construed to supersede any
provision of State law which establishes, implements,
or continues in effect any standard or requirement
solely relating to health insurance issuers (in connec-
tion with group health insurance coverage or other-
wise) except to the extent that such standard or re-
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quirement prevents the application of a requirement
of this title.
(2) CONTINUED
PREEMPTION
WITH
RESPECT
TO GROUP HEALTH PLANS.—Nothing in this title
shall be construed to affect or modify the provisions
of section 514 of the Employee Retirement Income
Security Act of 1974 with respect to group health
plans.
(b) DEFINITIONS.—For purposes of this section:
(1) STATE
LAW.—The term ‘‘State law’’ in-
cludes all laws, decisions, rules, regulations, or other
State action having the effect of law, of any State.
A law of the United States applicable only to the
District of Columbia shall be treated as a State law
rather than a law of the United States.
(2) STATE.—The term ‘‘State’’ includes a
State, the District of Columbia, Puerto Rico, the
Virgin Islands, Guam, American Samoa, the North-
ern Mariana Islands, any political subdivisions of
such, or any agency or instrumentality of such.
SEC. 1153. EXCLUSIONS.
(a) NO BENEFIT REQUIREMENTS.—Nothing in this
title shall be construed to require a group health plan or
a health insurance issuer offering health insurance cov-
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erage to provide items and services (including abortions)
that are specifically excluded under the plan or coverage.
(b) EXCLUSION FROM ACCESS TO CARE MANAGED
CARE PROVISIONS FOR FEE-FOR-SERVICE COVERAGE.—
(1) IN GENERAL.—The provisions of sections
1111 through 1117 shall not apply to a group health
plan or health insurance coverage if the only cov-
erage offered under the plan or coverage is fee-for-
service coverage (as defined in paragraph (2)).
(2) FEE-FOR-SERVICE
COVERAGE
DEFINED.—
For purposes of this subsection, the term ‘‘fee-for-
service coverage’’ means coverage under a group
health plan or health insurance coverage that—
(A) reimburses hospitals, health profes-
sionals, and other providers on the basis of a
rate determined by the plan or issuer on a fee-
for-service basis without placing the provider at
financial risk;
(B) does not vary reimbursement for such
a provider based on an agreement to contract
terms and conditions or the utilization of health
care items or services relating to such provider;
(C) does not restrict the selection of pro-
viders among those who are lawfully authorized
to provide the covered services and agree to ac-
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cept the terms and conditions of payment estab-
lished under the plan or by the issuer; and
(D) for which the plan or issuer does not
require prior authorization before providing cov-
erage for any services.
SEC. 1154. COVERAGE OF LIMITED SCOPE PLANS.
Only for purposes of applying the requirements of
this title under sections 2707 and 2753 of the Public
Health Service Act and section 714 of the Employee Re-
tirement 
Income 
Security 
Act 
of 
1974, 
section
2791(c)(2)(A), and section 733(c)(2)(A) of the Employee
Retirement Income Security Act of 1974 shall be deemed
not to apply.
SEC. 1155. REGULATIONS.
The Secretaries of Health and Human Services and
Labor shall issue such regulations as may be necessary
or appropriate to carry out this title. Such regulations
shall be issued consistent with section 104 of Health In-
surance Portability and Accountability Act of 1996. Such
Secretaries may promulgate any interim final rules as the
Secretaries determine are appropriate to carry out this
title.
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TITLE 
XII—APPLICATION 
OF
QUALITY CARE STANDARDS
TO GROUP HEALTH PLANS
AND 
HEALTH 
INSURANCE
COVERAGE UNDER THE PUB-
LIC HEALTH SERVICE ACT
SEC. 1201. APPLICATION TO GROUP HEALTH PLANS AND
GROUP HEALTH INSURANCE COVERAGE.
(a) IN GENERAL.—Subpart 2 of part A of title
XXVII of the Public Health Service Act is amended by
adding at the end the following new section:
‘‘SEC. 2707. PATIENT PROTECTION STANDARDS.
‘‘(a) IN GENERAL.—Each group health plan shall
comply with patient protection requirements under title XI
of the Bipartisan Consensus Managed Care Improvement
Act of 1999, and each health insurance issuer shall comply
with patient protection requirements under such title with
respect to group health insurance coverage it offers, and
such requirements shall be deemed to be incorporated into
this subsection.
‘‘(b) NOTICE.—A group health plan shall comply with
the notice requirement under section 711(d) of the Em-
ployee Retirement Income Security Act of 1974 with re-
spect to the requirements referred to in subsection (a) and
a health insurance issuer shall comply with such notice
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requirement as if such section applied to such issuer and
such issuer were a group health plan.’’.
(b) 
CONFORMING
AMENDMENT.—Section
2721(b)(2)(A) of such Act (42 U.S.C. 300gg–21(b)(2)(A))
is amended by inserting ‘‘(other than section 2707)’’ after
‘‘requirements of such subparts’’.
SEC. 1202. APPLICATION TO INDIVIDUAL HEALTH INSUR-
ANCE COVERAGE.
Part B of title XXVII of the Public Health Service
Act is amended by inserting after section 2752 the fol-
lowing new section:
‘‘SEC. 2753. PATIENT PROTECTION STANDARDS.
‘‘(a) IN GENERAL.—Each health insurance issuer
shall comply with patient protection requirements under
title XI of the Bipartisan Consensus Managed Care Im-
provement Act of 1999 with respect to individual health
insurance coverage it offers, and such requirements shall
be deemed to be incorporated into this subsection.
‘‘(b) NOTICE.—A health insurance issuer under this
part shall comply with the notice requirement under sec-
tion 711(d) of the Employee Retirement Income Security
Act of 1974 with respect to the requirements of such title
as if such section applied to such issuer and such issuer
were a group health plan.’’.
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TITLE 
XIII—AMENDMENTS 
TO
THE EMPLOYEE RETIREMENT
INCOME SECURITY ACT OF
1974
SEC. 1301. APPLICATION OF PATIENT PROTECTION STAND-
ARDS TO GROUP HEALTH PLANS AND GROUP
HEALTH INSURANCE COVERAGE UNDER THE
EMPLOYEE RETIREMENT INCOME SECURITY
ACT OF 1974.
Subpart B of part 7 of subtitle B of title I of the
Employee Retirement Income Security Act of 1974 is
amended by adding at the end the following new section:
‘‘SEC. 714. PATIENT PROTECTION STANDARDS.
‘‘(a) IN GENERAL.—Subject to subsection (b), a
group health plan (and a health insurance issuer offering
group health insurance coverage in connection with such
a plan) shall comply with the requirements of title XI of
the Bipartisan Consensus Managed Care Improvement
Act of 1999 (as in effect as of the date of the enactment
of such Act), and such requirements shall be deemed to
be incorporated into this subsection.
‘‘(b) PLAN SATISFACTION OF CERTAIN REQUIRE-
MENTS.—
‘‘(1) SATISFACTION
OF
CERTAIN
REQUIRE-
MENTS
THROUGH
INSURANCE.—For purposes of
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subsection (a), insofar as a group health plan pro-
vides benefits in the form of health insurance cov-
erage through a health insurance issuer, the plan
shall be treated as meeting the following require-
ments of title XI of the Bipartisan Consensus Man-
aged Care Improvement Act of 1999 with respect to
such benefits and not be considered as failing to
meet such requirements because of a failure of the
issuer to meet such requirements so long as the plan
sponsor or its representatives did not cause such
failure by the issuer:
‘‘(A) Section 1112 (relating to choice of
providers).
‘‘(B) Section 1113 (relating to access to
emergency care).
‘‘(C) Section 1114 (relating to access to
specialty care).
‘‘(D) Section 1115 (relating to access to
obstetrical and gynecological care).
‘‘(E) Section 1116 (relating to access to
pediatric care).
‘‘(F) Section 1117(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-
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tract), but only insofar as a replacement issuer
assumes the obligation for continuity of care.
‘‘(G) Section 1118 (relating to access to
needed prescription drugs).
‘‘(H) Section 1119 (relating to coverage
for individuals participating in approved clinical
trials.)
‘‘(I) Section 1134 (relating to payment of
claims).
‘‘(2) INFORMATION.—With respect to informa-
tion required to be provided or made available under
section 1121, 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
which the plan is not required to provide or make
available the information (and is not liable for the
issuer’s failure to provide or make available the in-
formation), if the issuer is obligated to provide and
make available (or provides and makes available)
such information.
‘‘(3) GRIEVANCE
AND
INTERNAL
APPEALS.—
With respect to the internal appeals process and the
grievance system required to be established under
sections 1102 and 1104, in the case of a group
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health plan that provides benefits in the form of
health insurance coverage through a health insur-
ance issuer, the Secretary shall determine the cir-
cumstances under which the plan is not required to
provide for such process and system (and is not lia-
ble for the issuer’s failure to provide for such proc-
ess and system), if the issuer is obligated to provide
for (and provides for) such process and system.
‘‘(4) EXTERNAL APPEALS.—Pursuant to rules
of the Secretary, insofar as a group health plan en-
ters into a contract with a qualified external appeal
entity for the conduct of external appeal activities in
accordance with section 1103, the plan shall be
treated as meeting the requirement of such section
and is not liable for the entity’s failure to meet any
requirements under such section.
‘‘(5) APPLICATION TO PROHIBITIONS.—Pursu-
ant to rules of the Secretary, if a health insurance
issuer offers health insurance coverage in connection
with a group health plan and takes an action in vio-
lation of any of the following sections, the group
health plan shall not be liable for such violation un-
less the plan caused such violation:
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‘‘(A) Section 1131 (relating to prohibition
of interference with certain medical communica-
tions).
‘‘(B) Section 1132 (relating to prohibition
of discrimination against providers based on li-
censure).
‘‘(C) Section 1133 (relating to prohibition
against improper incentive arrangements).
‘‘(D) Section 1135 (relating to protection
for patient advocacy).
‘‘(6) CONSTRUCTION.—Nothing in this sub-
section shall be construed to affect or modify the re-
sponsibilities of the fiduciaries of a group health
plan under part 4 of subtitle B.
‘‘(7) APPLICATION TO CERTAIN PROHIBITIONS
AGAINST RETALIATION.—With respect to compliance
with the requirements of section 1135(b)(1) of the
Bipartisan Consensus Managed Care Improvement
Act of 1999, for purposes of this subtitle the term
‘group health plan’ is deemed to include a reference
to an institutional health care provider.
‘‘(c) ENFORCEMENT OF CERTAIN REQUIREMENTS.—
‘‘(1) COMPLAINTS.—Any protected health care
professional who believes that the professional has
been retaliated or discriminated against in violation
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of section 1135(b)(1) of the Bipartisan Consensus
Managed Care Improvement Act of 1999 may file
with the Secretary a complaint within 180 days of
the date of the alleged retaliation or discrimination.
‘‘(2) INVESTIGATION.—The Secretary shall in-
vestigate such complaints and shall determine if a
violation of such section has occurred and, if so,
shall issue an order to ensure that the protected
health care professional does not suffer any loss of
position, pay, or benefits in relation to the plan,
issuer, or provider involved, as a result of the viola-
tion found by the Secretary.
‘‘(d) CONFORMING REGULATIONS.—The Secretary
may issue regulations to coordinate the requirements on
group health plans under this section with the require-
ments imposed under the other provisions of this title.’’.
(b) SATISFACTION OF ERISA CLAIMS PROCEDURE
REQUIREMENT.—Section 503 of such Act (29 U.S.C.
1133) is amended by inserting ‘‘(a)’’ after ‘‘SEC. 503.’’
and by adding at the end the following new subsection:
‘‘(b) In the case of a group health plan (as defined
in section 733) compliance with the requirements of sub-
title A of title XI of the Bipartisan Consensus Managed
Care Improvement Act of 1999 in the case of a claims
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denial shall be deemed compliance with subsection (a) with
respect to such claims denial.’’.
(c) CONFORMING AMENDMENTS.—(1) Section 732(a)
of such Act (29 U.S.C. 1185(a)) is amended by striking
‘‘section 711’’ and inserting ‘‘sections 711 and 714’’.
(2) The table of contents in section 1 of such Act
is amended by inserting after the item relating to section
713 the following new item:
‘‘Sec. 714. Patient protection standards.’’.
(3) Section 502(b)(3) of such Act (29 U.S.C.
1132(b)(3)) is amended by inserting ‘‘(other than section
135(b))’’ after ‘‘part 7’’.
SEC. 1302. ERISA PREEMPTION NOT TO APPLY TO CERTAIN
ACTIONS INVOLVING HEALTH INSURANCE
POLICYHOLDERS.
(a) IN GENERAL.—Section 514 of the Employee Re-
tirement Income Security Act of 1974 (29 U.S.C. 1144)
(as amended by section 301(b)) is amended further by
adding at the end the following subsections:
‘‘(f) PREEMPTION NOT TO APPLY TO CERTAIN AC-
TIONS ARISING OUT OF PROVISION OF HEALTH BENE-
FITS.—
‘‘(1) NON-PREEMPTION OF CERTAIN CAUSES OF
ACTION.—
‘‘(A) IN GENERAL.—Except as provided in
this subsection, nothing in this title shall be
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construed to invalidate, impair, or supersede
any cause of action by a participant or bene-
ficiary (or the estate of a participant or bene-
ficiary) under State law to recover damages re-
sulting from personal injury or for wrongful
death against any person—
‘‘(i) in connection with the provision
of insurance, administrative services, or
medical services by such person to or for
a group health plan (as defined in section
733), or
‘‘(ii) that arises out of the arrange-
ment by such person for the provision of
such insurance, administrative services, or
medical services by other persons.
‘‘(B) LIMITATION
ON
PUNITIVE
DAM-
AGES.—
‘‘(i) IN GENERAL.—No person shall be
liable for any punitive, exemplary, or simi-
lar damages in the case of a cause of ac-
tion brought under subparagraph (A) if—
‘‘(I) it relates to an externally
appealable decision (as defined in sub-
section (a)(2) of section 1103 of the
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Bipartisan Consensus Managed Care
Improvement Act of 1999);
‘‘(II) an external appeal with re-
spect to such decision was completed
under such section 1103;
‘‘(III) in the case such external
appeal was initiated by the plan or
issuer filing the request for the exter-
nal appeal, the request was filed on a
timely basis before the date the action
was brought or, if later, within 30
days after the date the externally ap-
pealable decision was made; and
‘‘(IV) the plan or issuer complied
with the determination of the external
appeal entity upon receipt of the de-
termination of the external appeal en-
tity.
The provisions of this clause supersede any
State law or common law to the contrary.
‘‘(ii) EXCEPTION.—Clause (i) shall
not apply with respect to damages in the
case of a cause of action for wrongful
death if the applicable State law provides
(or has been construed to provide) for
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damages in such a cause of action which
are only punitive or exemplary in nature.
‘‘(C) PERSONAL
INJURY
DEFINED.—For
purposes of this subsection, the term ‘personal
injury’ means a physical injury and includes an
injury arising out of the treatment (or failure
to treat) a mental illness or disease.
‘‘(2) EXCEPTION FOR GROUP HEALTH PLANS,
EMPLOYERS, AND OTHER PLAN SPONSORS.—
‘‘(A) IN
GENERAL.—Subject to subpara-
graph (B), paragraph (1) does not authorize—
‘‘(i) any cause of action against a
group health plan or an employer or other
plan sponsor maintaining the plan (or
against an employee of such a plan, em-
ployer, or sponsor acting within the scope
of employment), or
‘‘(ii) a right of recovery, indemnity, or
contribution by a person against a group
health plan or an employer or other plan
sponsor (or such an employee) for damages
assessed against the person pursuant to a
cause of action under paragraph (1).
‘‘(B) SPECIAL RULE.—Subparagraph (A)
shall not preclude any cause of action described
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in paragraph (1) against group health plan or
an employer or other plan sponsor (or against
an employee of such a plan, employer, or spon-
sor acting within the scope of employment) if—
‘‘(i) such action is based on the exer-
cise by the plan, employer, or sponsor (or
employee) of discretionary authority to
make a decision on a claim for benefits
covered under the plan or health insurance
coverage in the case at issue; and
‘‘(ii) the exercise by the plan, em-
ployer, or sponsor (or employee) of such
authority resulted in personal injury or
wrongful death.
‘‘(C) EXCEPTION.—The exercise of discre-
tionary authority described in subparagraph
(B)(i) shall not be construed to include—
‘‘(i) the decision to include or exclude
from the plan any specific benefit;
‘‘(ii) any decision to provide extra-con-
tractual benefits; or
‘‘(iii) any decision not to consider the
provision of a benefit while internal or ex-
ternal review is being conducted.
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‘‘(3) FUTILITY OF EXHAUSTION.—An individual
bringing an action under this subsection is required
to exhaust administrative processes under sections
1102 and 1103 of the Bipartisan Consensus Man-
aged Care Improvement Act of 1999, unless the in-
jury to or death of such individual has occurred be-
fore the completion of such processes.
‘‘(4) CONSTRUCTION.—Nothing in this sub-
section shall be construed as—
‘‘(A) permitting a cause of action under
State law for the failure to provide an item or
service which is specifically excluded under the
group health plan involved;
‘‘(B) as preempting a State law which re-
quires an affidavit or certificate of merit in a
civil action; or
‘‘(C) permitting a cause of action or rem-
edy under State law in connection with the pro-
vision or arrangement of excepted benefits (as
defined in section 733(c)), other than those de-
scribed in section 733(c)(2)(A).
‘‘(g) RULES
OF
CONSTRUCTION
RELATING
TO
HEALTH CARE.—Nothing in this title shall be construed
as—
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‘‘(1) permitting the application of State laws
that are otherwise superseded by this title and that
mandate the provision of specific benefits by a group
health plan (as defined in section 733(a)) or a mul-
tiple employer welfare arrangement (as defined in
section 3(40)), or
‘‘(2) affecting any State law which regulates the
practice of medicine or provision of medical care, or
affecting any action based upon such a State law.’’.
(b) EFFECTIVE DATE.—The amendment made by
subsection (a) shall apply to acts and omissions occurring
on or after the date of the enactment of this Act from
which a cause of action arises.
SEC. 1303. LIMITATIONS ON ACTIONS.
Section 502 of the Employee Retirement Income Se-
curity Act of 1974 (29 U.S.C. 1132) (as amended by sec-
tion 304(b)) is amended further by adding at the end the
following new subsection:
‘‘(o)(1) Except as provided in this subsection, no ac-
tion may be brought under subsection (a)(1)(B), (a)(2),
or (a)(3) by a participant or beneficiary seeking relief
based on the application of any provision in section 1101,
subtitle B, or subtitle D of title XI of the Bipartisan Con-
sensus Managed Care Improvement Act of 1999 (as incor-
porated under section 714).
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‘‘(2) An action may be brought under subsection
(a)(1)(B), (a)(2), or (a)(3) by a participant or beneficiary
seeking relief based on the application of section 1101,
1113, 1114, 1115, 1116, 1117, 1119, or 1118(3) of the
Bipartisan Consensus Managed Care Improvement Act of
1999 (as incorporated under section 714) to the individual
circumstances of that participant or beneficiary, except
that—
‘‘(A) such an action may not be brought or
maintained as a class action; and
‘‘(B) in such an action, relief may only provide
for the provision of (or payment of) benefits, items,
or services denied to the individual participant or
beneficiary involved (and for attorney’s fees and the
costs of the action, at the discretion of the court)
and shall not provide for any other relief to the par-
ticipant or beneficiary or for any relief to any other
person.
‘‘(3) Nothing in this subsection shall be construed as
affecting any action brought by the Secretary.’’.
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TITLE 
XIV—APPLICATION 
TO
GROUP 
HEALTH 
PLANS
UNDER THE INTERNAL REV-
ENUE CODE OF 1986
SEC. 1401. AMENDMENTS TO THE INTERNAL REVENUE
CODE OF 1986.
Subchapter B of chapter 100 of the Internal Revenue
Code of 1986 is amended—
(1) in the table of sections, by inserting after
the item relating to section 9812 the following new
item:
‘‘Sec. 9813. Standard relating to patient freedom of choice.’’;
and
(2) by inserting after section 9812 the fol-
lowing:
‘‘SEC. 9813. STANDARD RELATING TO PATIENTS’ BILL OF
RIGHTS.
‘‘A group health plan shall comply with the require-
ments of title XI of the Bipartisan Consensus Managed
Care Improvement Act of 1999 (as in effect as of the date
of the enactment of such Act), and such requirements
shall be deemed to be incorporated into this section.’’.
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TITLE 
XV—EFFECTIVE 
DATES;
COORDINATION 
IN 
IMPLE-
MENTATION
SEC. 1501. EFFECTIVE DATES.
(a) GROUP HEALTH COVERAGE.—
(1) IN GENERAL.—Subject to paragraph (2),
the amendments made by sections 1201(a), 1301,
1303, and 1401 (and title XI insofar as it relates to
such sections) shall apply with respect to group
health plans, and health insurance coverage offered
in connection with group health plans, for plan years
beginning on or after January 1, 2001 (in this sec-
tion referred to as the ‘‘general effective date’’) and
also shall apply to portions of plan years occurring
on and after such date.
(2) TREATMENT OF COLLECTIVE BARGAINING
AGREEMENTS.—In the case of a group health plan
maintained pursuant to one or more collective bar-
gaining agreements between employee representa-
tives and one or more employers ratified before the
date of the enactment of this Act, the amendments
made by sections 1201(a), 1301, 1303, and 1401
(and title XI insofar as it relates to such sections)
shall not apply to plan years beginning before the
later of—
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(A) the date on which the last collective
bargaining agreements relating to the plan ter-
minates (determined without regard to any ex-
tension thereof agreed to after the date of the
enactment of this Act); or
(B) the general effective date.
For purposes of subparagraph (A), any plan amend-
ment made pursuant to a collective bargaining
agreement relating to the plan which amends the
plan solely to conform to any requirement added by
this division shall not be treated as a termination of
such collective bargaining agreement.
(b) INDIVIDUAL HEALTH INSURANCE COVERAGE.—
The amendments made by section 1202 shall apply with
respect to individual health insurance coverage offered,
sold, issued, renewed, in effect, or operated in the indi-
vidual market on or after the general effective date.
SEC. 1502. COORDINATION IN IMPLEMENTATION.
The Secretary of Labor, the Secretary of Health and
Human Services, and the Secretary of the Treasury shall
ensure, through the execution of an interagency memo-
randum of understanding among such Secretaries, that—
(1) regulations, rulings, and interpretations
issued by such Secretaries relating to the same mat-
ter over which such Secretaries have responsibility
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under the provisions of this division (and the amend-
ments made thereby) are administered so as to have
the same effect at all times; and
(2) coordination of policies relating to enforcing
the same requirements through such Secretaries in
order to have a coordinated enforcement strategy
that avoids duplication of enforcement efforts and
assigns priorities in enforcement.
TITLE XVI—HEALTH CARE
PAPERWORK SIMPLIFICATION
SEC. 1601. HEALTH CARE PAPERWORK SIMPLIFICATION.
(a) ESTABLISHMENT OF PANEL.—
(1) ESTABLISHMENT.—There is established a
panel to be known as the Health Care Panel to De-
vise a Uniform Explanation of Benefits (in this sec-
tion referred to as the ‘‘Panel’’).
(2) DUTIES OF PANEL.—
(A) IN GENERAL.—The Panel shall devise
a single form for use by third-party health care
payers for the remittance of claims to providers.
(B) DEFINITION.—For purposes of this
section, the term ‘‘third-party health care
payer’’ means any entity that contractually
pays health care bills for an individual.
(3) MEMBERSHIP.—
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(A) SIZE
AND
COMPOSITION.—The Sec-
retary of Health and Human Services shall de-
termine the number of members and the com-
position of the Panel. Such Panel shall include
equal numbers of representatives of private in-
surance organizations, consumer groups, State
insurance commissioners, State medical soci-
eties, State hospital associations, and State
medical specialty societies.
(B) TERMS OF APPOINTMENT.—The mem-
bers of the Panel shall serve for the life of the
Panel.
(C) VACANCIES.—A vacancy in the Panel
shall not affect the power of the remaining
members to execute the duties of the Panel, but
any such vacancy shall be filled in the same
manner in which the original appointment was
made.
(4) PROCEDURES.—
(A) MEETINGS.—The Panel shall meet at
the call of a majority of its members.
(B) FIRST
MEETING.—The Panel shall
convene not later than 60 days after the date
of the enactment of the Bipartisan Consensus
Managed Care Improvement Act of 1999.