‘‘(B) RURAL AREA.—The term ‘rural area’
means an area that is not within a Standard
Metropolitan Statistical Area or a New England
County Metropolitan Area (as defined by the
Office of Management and Budget).
‘‘(b) EMERGENCY AND URGENT CARE.—
‘‘(1) IN GENERAL.—A health insurance issuer
shall—
‘‘(A) assure the availability and accessibil-
ity of medically or clinically necessary emer-
gency services and urgent care services within
the service area of the issuer 24 hours a day,
7 days a week;
‘‘(B) require no prior authorization for
items and services furnished in a hospital emer-
gency department to an enrollee (without re-
gard to whether the health professional or hos-
pital has a contractual or other arrangement
with the issuer) with symptoms that would rea-
sonably suggest to a prudent layperson an
emergency medical condition (including items
and 
services 
described 
in 
subparagraph
(C)(iii));
‘‘(C) cover (and make reasonable payments
for)—
‘‘(i) emergency services,
‘‘(ii) services that are not emergency
services but are described in subparagraph
(B),
‘‘(iii) medical screening examinations
and other ancillary services necessary to
diagnose, treat, and stabilize an emergency
medical condition, and
‘‘(iv) urgent care services, without re-
gard to whether the health professional or
provider furnishing such services has a
contractual (or other) arrangement with
the issuer; and
‘‘(D) make prior authorization determina-
tions for—
‘‘(i) services that are furnished in a
hospital emergency department (other than
services described in clauses (i) and (iii) of
subparagraph (C)), and
‘‘(ii) urgent care services, within the
time periods specified in (or pursuant to)
section 2781(a)(8).
‘‘(2) DEFINITIONS.—For purposes of this sub-
section:
‘‘(A) EMERGENCY MEDICAL CONDITION.—
The term ‘emergency medical condition’ means
a medical condition (including emergency labor
and delivery) manifesting itself by acute symp-
toms of sufficient severity (including severe
pain) such that a prudent layperson, who pos-
sesses an average knowledge of health and med-
icine, could reasonably expect the absence of
immediate medical attention could reasonably
be expected to result in—
‘‘(i) placing the patient’s health in se-
rious jeopardy,
‘‘(ii) serious impairment to bodily
functions, or
‘‘(iii) serious dysfunction of any bodily
organ or part.
‘‘(B) EMERGENCY
SERVICES.—The term
‘emergency services’ means health care items
and services that are necessary for the diag-
nosis, treatment, and stabilization of an emer-
gency medical condition.
‘‘(C) URGENT CARE SERVICES.—The term
‘urgent care services’ means health care items
and services that are necessary for the treat-
ment of a condition that—
‘‘(i) is not an emergency medical con-
dition,
‘‘(ii) requires prompt medical or clini-
cal treatment, and
‘‘(iii) poses a danger to the patient if
not treated in a timely manner, as defined
by the applicable State authority in con-
sultation with relevant treating health pro-
fessionals or providers.
‘‘(c) OBSTETRICAL AND GYNECOLOGICAL CARE.—
‘‘(1) IN GENERAL.—If a health insurance is-
suer, in connection with the provision of health in-
surance coverage, requires or provides for an en-
rollee to designate a participating primary care pro-
vider—
‘‘(A) the issuer shall permit a female en-
rollee to designate a physician who specializes
in obstetrics and gynecology as the enrollee’s
primary care provider; and
‘‘(B) if such an enrollee has not designated
such a provider as a primary care provider, the
issuer—
‘‘(i) may not require prior authoriza-
tion by the enrollee’s primary care provider
or otherwise for coverage of routine gyne-
cological care (such as preventive women’s
health examinations) and pregnancy-relat-
ed services provided by a participating phy-
sician who specializes in obstetrics and
gynecology to the extent such care is other-
wise covered, and
‘‘(ii) may treat the ordering of other
gynecological care by such a participating
physician as the prior authorization of the
primary care provider with respect to such
care under the coverage.
‘‘(2) CONSTRUCTION.—Nothing in paragraph
(1)(B)(ii) shall waive any requirements of coverage
relating to medical necessity or appropriateness with
respect to coverage of gynecological care so ordered.
‘‘(d) REFERRAL TO SPECIALTY CARE FOR ENROLL-
EES REQUIRING TREATMENT BY SPECIALISTS.—
‘‘(1) IN GENERAL.—In the case of an enrollee
who is covered under health insurance coverage of-
fered by a health insurance issuer and who has a
condition or disease of sufficient seriousness and
complexity to require treatment by a specialist, the
issuer shall make or provide for a referral to a spe-
cialist who is available and accessible to provide the
treatment for such condition or disease.
‘‘(2) SPECIALIST
DEFINED.—For purposes of
this subsection, the term ‘specialist’ means, with re-
spect to a condition, a health care practitioner, facil-
ity, or center (such as a center of excellence) that
has adequate expertise through appropriate training
and experience (including, in the case of a child, ap-
propriate pediatric expertise) to provide high quality
care in treating the condition.
‘‘(3) CARE UNDER REFERRAL.—Care provided
pursuant to such referral under paragraph (1) shall
be—
‘‘(A) pursuant to a treatment plan (if any)
developed by the specialist and approved by the
issuer, in consultation with the designated pri-
mary care provider or specialist and the enrollee
(or the enrollee’s designee), and
‘‘(B) in accordance with applicable quality
assurance and utilization review standards of
the issuer.
Nothing in this subsection shall be construed as pre-
venting such a treatment plan for an enrollee from
requiring a specialist to provide the primary care
provider with regular updates on the specialty care
provided, as well as all necessary medical informa-
tion.
‘‘(4) REFERRALS
TO
PARTICIPATING
PROVID-
ERS.—An issuer is not required under paragraph (1)
to provide for a referral to a specialist that is not
a participating provider, unless the issuer does not
have an appropriate specialist that is available and
accessible to treat the enrollee’s condition and that
is a participating provider with respect to such treat-
ment.
‘‘(5) TREATMENT OF NONPARTICIPATING PRO-
VIDERS.—If an issuer refers an enrollee to a non-
participating specialist, services provided pursuant
to the approved treatment plan shall be provided at
no additional cost to the enrollee beyond what the
enrollee would otherwise pay for services received by
such a specialist that is a participating provider.
‘‘(e) CONTINUITY OF CARE.—
‘‘(1) IN GENERAL.—A health insurance issuer
offering network coverage shall—
‘‘(A) ensure that any process established
by the issuer to coordinate care and control
costs does not create an undue burden, as de-
fined by the applicable State authority, for en-
rollees with special health care needs or chronic
conditions;
‘‘(B) ensure direct access to relevant spe-
cialists for the continued care of such enrollees
when medically or clinically indicated in the
judgment of the treating health professional, in
consultation with the enrollee;
‘‘(C) in the case of an enrollee with special
health care needs or a chronic condition, deter-
mine whether, based on the judgment of the
treating health professional, in consultation
with the enrollee, it is medically or clinically
necessary to use a specialist or a care coordina-
tor from an interdisciplinary team to ensure
continuity of care; and
‘‘(D) in circumstances under which a
change of health professional or provider might
disrupt the continuity of care for an enrollee,
such as—
‘‘(i) hospitalization, or
‘‘(ii) dependency on high-technology
home medical equipment,
provide for continued coverage of items and
services furnished by the health professional or
provider that was treating the enrollee before
such change for a reasonable period of time.
For purposes of subparagraph (D), a change of
health professional or provider may be due to
changes in the membership of an issuer’s health pro-
fessional and provider network, changes in the
health coverage made available by an employer, or
other similar circumstances.
‘‘(2) CONTINUED COURSE OF TREATMENT.—
‘‘(A) IN GENERAL.—If a contract between
a health insurance issuer, in connection with
the provision of health insurance coverage, and
a health care provider is terminated (other than
by the issuer for failure to meet applicable qual-
ity standards or for fraud) and an enrollee is
described in subparagraph (B)(i), (B)(ii), or
(B)(iii) and is undergoing a course of treatment
from the provider at the time of such termi-
nation, the issuer shall—
‘‘(i) notify the enrollee of such termi-
nation, and
‘‘(ii) subject to subparagraph (C), per-
mit the enrollee to continue the course of
treatment with the provider during a tran-
sitional period (provided under subpara-
graph (B)).
‘‘(B) TRANSITIONAL PERIODS.—
‘‘(ii) TRANSITIONAL PERIOD FOR IN-
STITUTIONAL CARE.—The transitional pe-
riod under this clause for institutional or
inpatient care from a provider shall extend
until the discharge or termination of the
period of institutionalization and shall in-
clude reasonable follow-up care related to
the institutionalization and shall also in-
clude institutional care scheduled prior to
the date of termination of the provider sta-
tus.
‘‘(iii) PREGNANCY.—If—
‘‘(I) an enrollee has entered the
second trimester of pregnancy at the
time of a provider’s termination of
participation, and
‘‘(II) the provider was treating
the pregnancy before date of the ter-
mination,
the transitional period under this clause
with respect to provider’s treatment of the
pregnancy shall extend through the provi-
sion of post-partum care directly related to
the delivery.
‘‘(iv) TERMINAL ILLNESS.—If—
‘‘(I) an enrollee was determined
to be terminally ill at the time of a
provider’s termination of participa-
tion, and
‘‘(II) the provider was treating
the terminal illness before the date of
termination,
the transitional period under this clause
shall extend for the remainder of the en-
rollee’s life for care directly related to the
treatment of the terminal illness. In sub-
clause (I), an enrollee is considered to be
‘terminally ill’ if the enrollee has a medical
prognosis that the enrollee’s life expectancy
is 6 months or less.
‘‘(C) PERMISSIBLE
TERMS
AND
CONDI-
TIONS.—An issuer may condition coverage of
continued treatment by a provider under sub-
paragraph (A)(ii) upon the provider agreeing to
the following terms and conditions:
‘‘(i) The provider agrees to continue
to accept reimbursement from the issuer at
the rates applicable prior to the start of
the transitional period as payment in full.
‘‘(ii) The provider agrees to adhere to
the issuer’s quality assurance standards
and to provide to the issuer necessary med-
ical information related to the care pro-
vided.
‘‘(iii) The provider agrees otherwise to
adhere to the issuer’s policies and proce-
dures, including procedures regarding re-
ferrals and obtaining prior authorization
and providing services pursuant to a treat-
ment plan approved by the issuer.
‘‘(e) NONDISCRIMINATION AGAINST ENROLLEES.—
No health insurance issuer may discriminate (directly or
through contractual arrangements) in any activity that
has the effect of discriminating against an individual on
the basis of race, national origin, genetic makeup, gender,
language, socioeconomic status, sexual orientation, age,
disability, health status, or anticipated need for health
services.
SEC. 103. QUALITY OF CARE.
(a) QUALITY IMPROVEMENT PROGRAM.—Such part
is further amended by adding at the end the following:
‘‘SEC. 2772. QUALITY IMPROVEMENT PROGRAM.
‘‘(a) IN GENERAL.—A health insurance issuer shall
establish a quality improvement program (consistent with
subsection (b)) that systematically and continuously as-
sesses and improves—
‘‘(1) enrollee health status, patient outcomes,
processes of care, and enrollee satisfaction associ-
ated with health care provided by the issuer; and
‘‘(2) the administrative and funding capacity of
the issuer to support and emphasize preventive care,
utilization, access and availability, cost effectiveness,
acceptable treatment modalities, specialists referrals,
the peer review process, and the efficiency of the ad-
ministrative process.
‘‘(b) FUNCTIONS.—A quality improvement program
established pursuant to subsection (a) shall—
‘‘(1) assess the performance of the issuer and
its participating health professionals and providers
and report the results of such assessment to pur-
chasers, participating health professionals and pro-
viders, and administrative personnel;
‘‘(2) demonstrate measurable improvements in
clinical outcomes and plan performance measured by
identified criteria, including those specified in sub-
section (a)(1); and
‘‘(3) analyze quality assessment data to deter-
mine specific interactions in the delivery system
(both the design and funding of the health insurance
coverage and the clinical provision of care) that have
an adverse impact on the quality of care.’’.
‘‘(c) INCENTIVE PLANS.—
‘‘(1) IN GENERAL.—In the case of a health in-
surance issuer that offers network coverage, any
health professional or provider incentive plan oper-
ated by the issuer with respect to such coverage
shall meet the following requirements:
‘‘(A) No specific payment is made directly
or indirectly under the plan to a professional or
provider or group of professionals or providers
as an inducement to reduce or limit medically
necessary services provided with respect to a
specific enrollee.
‘‘(B) If the plan places such a professional,
provider, or group at substantial financial risk
(as determined by the Secretary) for services
not provided by the professional, provider, or
group, the issuer—
‘‘(i) provides stop-loss protection for
the professional, provider, or group that is
adequate and appropriate, based on stand-
ards developed by the Secretary that take
into account the number of professionals
or providers placed at such substantial fi-
nancial risk in the group or under the cov-
erage and the number of individuals en-
rolled with the issuer who receive services
from the professional, provider, or group,
and
‘‘(ii) conducts periodic surveys of both
individuals enrolled and individuals pre-
viously enrolled with the issuer to deter-
mine the degree of access of such individ-
uals to services provided by the issuer and
satisfaction with the quality of such serv-
ices.
‘‘(C) The issuer provides the Secretary
with descriptive information regarding the plan,
sufficient to permit the Secretary to determine
whether the plan is in compliance with the re-
quirements of this paragraph.
‘‘(2) In this subsection, the term ‘health profes-
sional or provider incentive plan’ means any com-
pensation arrangement between a health insurance
issuer and a health professional or provider or pro-
fessional or provide group that may directly or indi-
rectly have the effect of reducing or limiting services
provided with respect to individuals enrolled with the
issuer.’’.
(b) OFFICE OF MEDICARE ADVOCACY.—Title XVIII
of the Social Security Act is amended by inserting after
section 1804 the following new section:
‘‘OFFICE OF MEDICARE ADVOCACY
‘‘SEC. 1805. (a) ESTABLISHMENT.—The Secretary
shall establish, within the Health Care Financing Admin-
istration, an office of medicare advocacy (in this section
referred to as the ‘office’), to be headed by a director ap-
pointed by the Secretary.
‘‘(b) PURPOSE.—The office shall provide, in accord-
ance with this section, independent review of problems and
concerns of medicare beneficiaries in relation to the pro-
grams under this title, including, but not limited to, com-
plaints concerning plans offered under part C or section
1876.
‘‘(c) ACCESS.—In order to carry out its functions, the
office shall provide for a toll-free telephone number
through which medicare beneficiaries can obtain assist-
ance in the programs under this title, including providing
comparative information on plans offered under part C or
section 1876. The office also shall undertake such addi-
tional outreach activities, such as the use of town meetings
and development of an appropriate Internet site, as most
effectively and efficiently promotes dissemination of infor-
mation to medicare beneficiaries.
‘‘(d) RECEIPT AND DISPOSITION OF COMPLAINTS.—
The office shall provide for a record of the types of com-
plaints and problems received and shall submit to the Sec-
retary and publish an annual report on the nature of such
complaints and problems, the disposition with respect to
such complaints and problems, and such other additional
information as the Secretary may specify.
‘‘(e) EXPEDITED
REVIEW
PROCESS
FOR
COM-
PLAINTS UNDER EMERGENCY CIRCUMSTANCES.—
‘‘(1) IN GENERAL.—Under regulations of the
Secretary, the office shall have authority to provide
for an expedited review and resolution of complaints
under emergency circumstances, including those de-
scribed in paragraph (2). Such reviews and resolu-
tions shall be conducted to the greatest extent prac-
ticable through regional and local agencies.
‘‘(2) 
EMERGENCY
CIRCUMSTANCES
DE-
SCRIBED.—The emergency circumstances described
in this paragraph are cases in which—
‘‘(A) a delay in treatment resulting from
application of the usual hearing and appeals
process may endanger the life of the bene-
ficiary, result in a loss of function or a signifi-
cant worsening of a condition, or render treat-
ment ineffective; or
the names and credentials of individuals conducting
utilization review;
‘‘(6) not compensate individuals conducting uti-
lization review for denials of payment or coverage of
benefits;
‘‘(7) comply with the requirement of section
2771 that prior authorization not be required for
emergency and related services furnished in a hos-
pital emergency department;
‘‘(8) make prior authorization determinations—
‘‘(A) in the case of services that are urgent
care 
services 
described 
in 
section
2771(b)(2)(C), within 30 minutes of a request
for such determination, and
‘‘(B) in the case of other services, within
24 hours after the time of a request for deter-
mination;
‘‘(9) include in any notice of such determination
an explanation of the basis of the determination and
the right to an immediate appeal;
‘‘(10) treat a favorable prior authorization re-
view determination as a final determination for pur-
poses of making payment for a claim submitted for
the item or service involved unless such determina-