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HealthMart or as an employee of the HealthMart, if
the individual is employed by, represents in any ca-
pacity, owns, or controls any ownership interest in
a organization from whom the HealthMart receives
contributions, grants, or other funds not connected
with 
a 
contract 
for 
coverage 
through 
the
HealthMart.
‘‘(3) 
EMPLOYMENT
AND
EMPLOYEE
REP-
RESENTATIVES.—
‘‘(A) IN GENERAL.—An individual who is
serving on a board of directors of a HealthMart
as a representative described in subparagraph
(A) or (B) of section 2801(a)(1) shall not be
employed by or affiliated with a health insur-
ance issuer or be licensed as or employed by or
affiliated with a health care provider.
‘‘(B) CONSTRUCTION.—For purposes of
subparagraph (A), the term ‘‘affiliated’’ does
not include membership in a health benefits
plan or the obtaining of health benefits cov-
erage offered by a health insurance issuer.
‘‘(e) CONSTRUCTION.—
‘‘(1) 
NETWORK
OF
AFFILIATED
HEALTHMARTS.—Nothing in this section shall be
construed as preventing one or more HealthMarts
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serving different areas (whether or not contiguous)
from providing for some or all of the following
(through a single administrative organization or oth-
erwise):
‘‘(A) Coordinating the offering of the same
or similar health benefits coverage in different
areas served by the different HealthMarts.
‘‘(B) Providing for crediting of deductibles
and other cost-sharing for individuals who are
provided health benefits coverage through the
HealthMarts 
(or 
affiliated 
HealthMarts)
after—
‘‘(i) a change of employers through
which the coverage is provided; or
‘‘(ii) a change in place of employment
to an area not served by the previous
HealthMart.
‘‘(2) PERMITTING
HEALTHMARTS
TO
ADJUST
DISTRIBUTIONS AMONG ISSUERS TO REFLECT REL-
ATIVE RISK OF ENROLLEES.—Nothing in this sec-
tion shall be construed as precluding a HealthMart
from providing for adjustments in amounts distrib-
uted among the health insurance issuers offering
health benefits coverage through the HealthMart
based on factors such as the relative health care risk
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of members enrolled under the coverage offered by
the different issuers.
‘‘(3) APPLICATION OF UNIFORM MINIMUM PAR-
TICIPATION
AND
CONTRIBUTION
RULES.—Nothing
in this section shall be construed as precluding a
HealthMart from establishing minimum participa-
tion and contribution rules (described in section
2711(e)(1)) for small employers that apply to be-
come purchasers in the HealthMart, so long as such
rules are applied uniformly for all health insurance
issuers.
‘‘SEC. 2802. APPLICATION OF CERTAIN LAWS AND REQUIRE-
MENTS.
‘‘(a) AUTHORITY OF STATES.—Nothing in this sec-
tion shall be construed as preempting State laws relating
to the following:
‘‘(1) The regulation of underwriters of health
coverage, including licensure and solvency require-
ments.
‘‘(2) The application of premium taxes and re-
quired payments for guaranty funds or for contribu-
tions to high-risk pools.
‘‘(3) The application of fair marketing require-
ments and other consumer protections (other than
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those specifically relating to an item described in
subsection (b)).
‘‘(4) The application of requirements relating to
the adjustment of rates for health insurance cov-
erage.
‘‘(b) TREATMENT OF BENEFIT AND GROUPING RE-
QUIREMENTS.—State laws insofar as they relate to any
of the following are superseded and shall not apply to
health benefits coverage made available through a
HealthMart:
‘‘(1) Benefit requirements for health benefits
coverage offered through a HealthMart, including
(but not limited to) requirements relating to cov-
erage of specific providers, specific services or condi-
tions, or the amount, duration, or scope of benefits,
but not including requirements to the extent re-
quired to implement title XXVII or other Federal
law and to the extent the requirement prohibits an
exclusion of a specific disease from such coverage.
‘‘(2) Requirements (commonly referred to as
fictitious group laws) relating to grouping and simi-
lar requirements for such coverage to the extent
such requirements impede the establishment and op-
eration of HealthMarts pursuant to this title.
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‘‘(3) Any other requirements (including limita-
tions on compensation arrangements) that, directly
or indirectly, preclude (or have the effect of preclud-
ing) the offering of such coverage through a
HealthMart, if the HealthMart meets the require-
ments of this title.
Any State law or regulation relating to the composition
or organization of a HealthMart is preempted to the ex-
tent the law or regulation is inconsistent with the provi-
sions of this title.
‘‘(c) APPLICATION OF ERISA FIDUCIARY AND DIS-
CLOSURE REQUIREMENTS.—The board of directors of a
HealthMart is deemed to be a plan administrator of an
employee welfare benefit plan which is a group health plan
for purposes of applying parts 1 and 4 of subtitle B of
title I of the Employee Retirement Income Security Act
of 1974 and those provisions of part 5 of such subtitle
which are applicable to enforcement of such parts 1 and
4, and the HealthMart shall be treated as such a plan
and the enrollees shall be treated as participants and bene-
ficiaries for purposes of applying such provisions pursuant
to this subsection.
‘‘(d) APPLICATION OF ERISA RENEWABILITY PRO-
TECTION.—A HealthMart is deemed to be group health
plan that is a multiple employer welfare arrangement for
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purposes of applying section 703 of the Employee Retire-
ment Income Security Act of 1974.
‘‘(e) APPLICATION OF RULES FOR NETWORK PLANS
AND
FINANCIAL
CAPACITY.—The provisions of sub-
sections (c) and (d) of section 2711 apply to health bene-
fits coverage offered by a health insurance issuer through
a HealthMart.
‘‘(f) CONSTRUCTION RELATING TO OFFERING RE-
QUIREMENT.—Nothing in section 2711(a) of this Act or
703 of the Employee Retirement Income Security Act of
1974 shall be construed as permitting the offering outside
the HealthMart of health benefits coverage that is only
made available through a HealthMart under this section
because of the application of subsection (b).
‘‘(g) APPLICATION TO GUARANTEED RENEWABILITY
REQUIREMENTS IN CASE OF DISCONTINUATION OF AN
ISSUER.—For purposes of applying section 2712 in the
case of health insurance coverage offered by a health in-
surance issuer through a HealthMart, if the contract be-
tween the HealthMart and the issuer is terminated and
the HealthMart continues to make available any health in-
surance coverage after the date of such termination, the
following rules apply:
‘‘(1) RENEWABILITY.—The HealthMart shall
fulfill the obligation under such section of the issuer
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renewing and continuing in force coverage by offer-
ing purchasers (and members and their dependents)
all available health benefits coverage that would oth-
erwise be available to similarly-situated purchasers
and members from the remaining participating
health insurance issuers in the same manner as
would be required of issuers under section 2712(c).
‘‘(2) APPLICATION OF ASSOCIATION RULES.—
The HealthMart shall be considered an association
for purposes of applying section 2712(e).
‘‘(h) CONSTRUCTION
IN RELATION
TO CERTAIN
OTHER LAWS.—Nothing in this title shall be construed
as modifying or affecting the applicability to HealthMarts
or health benefits coverage offered by a health insurance
issuer through a HealthMart of parts 6 and 7 of subtitle
B of title I of the Employee Retirement Income Security
Act of 1974 or titles XXII and XXVII of this Act.
‘‘SEC. 2803. ADMINISTRATION.
‘‘(a) IN GENERAL.—The applicable Federal authority
shall administer this title through the division established
under subsection (b) and is authorized to issue such regu-
lations as may be required to carry out this title. Such
regulations shall be subject to Congressional review under
the provisions of chapter 8 of title 5, United States Code.
The applicable Federal authority shall incorporate the
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process of ‘deemed file and use’ with respect to the infor-
mation filed under section 2801(a)(6)(A) and shall deter-
mine whether information filed by a HealthMart dem-
onstrates compliance with the applicable requirements of
this title. Such authority shall exercise its authority under
this title in a manner that fosters and promotes the devel-
opment of HealthMarts in order to improve access to
health care coverage and services.
‘‘(b) ADMINISTRATION THROUGH HEALTH CARE
MARKETPLACE DIVISION.—
‘‘(1) IN GENERAL.—The applicable Federal au-
thority shall carry out its duties under this title
through a separate Health Care Marketplace Divi-
sion, the sole duty of which (including the staff of
which) shall be to administer this title.
‘‘(2) ADDITIONAL
DUTIES.—In addition to
other responsibilities provided under this title, such
Division is responsible for—
‘‘(A) 
oversight 
of 
the 
operations 
of
HealthMarts under this title; and
‘‘(B) the periodic submittal to Congress of
reports on the performance of HealthMarts
under this title under subsection (c).
‘‘(c) PERIODIC REPORTS.—The applicable Federal
authority shall submit to Congress a report every 30
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months, during the 10-year period beginning on the effec-
tive date of the rules promulgated by the applicable Fed-
eral authority to carry out this title, on the effectiveness
of this title in promoting coverage of uninsured individ-
uals. Such authority may provide for the production of
such reports through one or more contracts with appro-
priate private entities.
‘‘SEC. 2804. DEFINITIONS.
‘‘For purposes of this title:
‘‘(1) APPLICABLE FEDERAL AUTHORITY.—The
term ‘applicable Federal authority’ means the Sec-
retary of Health and Human Services.
‘‘(2) ELIGIBLE
EMPLOYEE
OR
INDIVIDUAL.—
The term ‘eligible’ means, with respect to an em-
ployee or other individual and a HealthMart, an em-
ployee or individual who is eligible under section
2801(c)(2) to enroll or be enrolled in health benefits
coverage offered through the HealthMart.
‘‘(3) EMPLOYER; EMPLOYEE; DEPENDENT.—
Except as the applicable Federal authority may oth-
erwise provide, the terms ‘employer’, ‘employee’, and
‘dependent’, as applied to health insurance coverage
offered by a health insurance issuer licensed (or oth-
erwise regulated) in a State, shall have the meanings
applied to such terms with respect to such coverage
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under the laws of the State relating to such coverage
and such an issuer.
‘‘(4) HEALTH BENEFITS COVERAGE.—The term
‘health benefits coverage’ has the meaning given the
term group health insurance coverage in section
2791(b)(4).
‘‘(5) HEALTH INSURANCE ISSUER.—The term
‘health insurance issuer’ has the meaning given such
term in section 2791(b)(2) and includes a commu-
nity health organization that is offering coverage
pursuant to section 330B(a).
‘‘(6) HEALTH STATUS-RELATED FACTOR.—The
term ‘health status-related factor’ has the meaning
given such term in section 2791(d)(9).
‘‘(7) HEALTHMART.—The term ‘HealthMart’ is
defined in section 2801(a).
‘‘(8) MEMBER.—The term ‘member’ means,
with respect to a HealthMart, an individual enrolled
for health benefits coverage through the HealthMart
under section 2801(c)(2).
‘‘(9) 
PURCHASER.—The 
term 
‘purchaser’
means, with respect to a HealthMart, a small em-
ployer 
that 
has 
contracted 
under 
section
2801(c)(1)(A) with the HealthMart for the purchase
of health benefits coverage.
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‘‘(10) SMALL EMPLOYER.—The term ‘small em-
ployer’ has the meaning given such term for pur-
poses of title XXVII.’’.
(b) EFFECTIVE DATE.—The amendment made by
subsection (a) shall take effect on January 1, 2000. The
Secretary of Health and Human Services shall first issue
all regulations necessary to carry out such amendment be-
fore such date.
Subtitle D—Community Health
Organizations
SEC. 2301. PROMOTION OF PROVISION OF INSURANCE BY
COMMUNITY HEALTH ORGANIZATIONS.
(a) WAIVER OF STATE LICENSURE REQUIREMENT
FOR COMMUNITY HEALTH ORGANIZATIONS IN CERTAIN
CASES.—Subpart I of part D of title III of the Public
Health Service Act is amended by adding at the end the
following new section:
‘‘WAIVER OF STATE LICENSURE REQUIREMENT FOR
COMMUNITY HEALTH ORGANIZATIONS IN CERTAIN CASES
‘‘SEC. 330B. (a) WAIVER AUTHORIZED.—
‘‘(1) IN GENERAL.—A community health orga-
nization may offer health insurance coverage in a
State notwithstanding that it is not licensed in such
a State to offer such coverage if—
‘‘(A) the organization files an application
for waiver of the licensure requirement with the
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Secretary of Health and Human Services (in
this section referred to as the ‘Secretary’) by
not later than November 1, 2003; and
‘‘(B) the Secretary determines, based on
the application and other evidence presented to
the Secretary, that any of the grounds for ap-
proval of the application described in subpara-
graph (A), (B), or (C) of paragraph (2) has
been met.
‘‘(2) GROUNDS FOR APPROVAL OF WAIVER.—
‘‘(A) FAILURE TO ACT ON LICENSURE AP-
PLICATION ON A TIMELY BASIS.—The ground
for approval of such a waiver application de-
scribed in this subparagraph is that the State
has failed to complete action on a licensing ap-
plication of the organization within 90 days of
the date of the State’s receipt of a substantially
complete application. No period before the date
of the enactment of this section shall be in-
cluded in determining such 90-day period.
‘‘(B) DENIAL OF APPLICATION BASED ON
DISCRIMINATORY TREATMENT.—The ground for
approval of such a waiver application described
in this subparagraph is that the State has de-
nied such a licensing application and the stand-
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ards or review process imposed by the State as
a condition of approval of the license or as the
basis for such denial by the State imposes any
material requirements, procedures, or standards
(other than solvency requirements) to such or-
ganizations that are not generally applicable to
other entities engaged in a substantially similar
business.
‘‘(C) DENIAL OF APPLICATION BASED ON
APPLICATION OF SOLVENCY REQUIREMENTS.—
With respect to waiver applications filed on or
after the date of publication of solvency stand-
ards established by the Secretary under sub-
section (d), the ground for approval of such a
waiver application described in this subpara-
graph is that the State has denied such a li-
censing application based (in whole or in part)
on the organization’s failure to meet applicable
State solvency requirements and such require-
ments are not the same as the solvency stand-
ards established by the Secretary. For purposes
of this subparagraph, the term solvency require-
ments means requirements relating to solvency
and other matters covered under the standards
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established by the Secretary under subsection
(d).
‘‘(3) TREATMENT OF WAIVER.—In the case of
a waiver granted under this subsection for a commu-
nity health organization with respect to a State—
‘‘(A) LIMITATION TO STATE.—The waiver
shall be effective only with respect to that State
and does not apply to any other State.
‘‘(B) LIMITATION TO 36-MONTH PERIOD.—
The waiver shall be effective only for a 36-
month period but may be renewed for up to 36
additional months if the Secretary determines
that such an extension is appropriate.
‘‘(C) CONDITIONED ON COMPLIANCE WITH
CONSUMER PROTECTION AND QUALITY STAND-
ARDS.—The continuation of the waiver is condi-
tioned upon the organization’s compliance with
the requirements described in paragraph (5).
‘‘(D) PREEMPTION OF STATE LAW.—Any
provisions of law of that State which relate to
the licensing of the organization and which pro-
hibit the organization from providing health in-
surance coverage shall be superseded.
‘‘(4) PROMPT ACTION ON APPLICATION.—The
Secretary shall grant or deny such a waiver applica-
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tion within 60 days after the date the Secretary de-
termines that a substantially complete waiver appli-
cation has been filed. Nothing in this section shall
be construed as preventing an organization which
has had such a waiver application denied from sub-
mitting a subsequent waiver application.
‘‘(5) APPLICATION
AND
ENFORCEMENT
OF
STATE
CONSUMER
PROTECTION
AND
QUALITY
STANDARDS.—A waiver granted under this sub-
section to an organization with respect to licensing
under State law is conditioned upon the organiza-
tion’s compliance with all consumer protection and
quality standards insofar as such standards—
‘‘(A) would apply in the State to the com-
munity health organization if it were licensed as
an entity offering health insurance coverage
under State law; and
‘‘(B) are generally applicable to other risk-
bearing managed care organizations and plans
in the State.
‘‘(6) REPORT.—By not later than December 31,
2002, the Secretary shall submit to the Committee
on Commerce of the House of Representatives and
the Committee on Labor and Human Resources of
the Senate a report regarding whether the waiver
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process under this subsection should be continued
after December 31, 2003.
‘‘(b) ASSUMPTION OF FULL FINANCIAL RISK.—To
qualify for a waiver under subsection (a), the community
health organization shall assume full financial risk on a
prospective basis for the provision of covered health care
services, except that the organization—
‘‘(1) may obtain insurance or make other ar-
rangements for the cost of providing to any enrolled
member such services the aggregate value of which
exceeds such aggregate level as the Secretary speci-
fies from time to time;
‘‘(2) may obtain insurance or make other ar-
rangements for the cost of such services provided to
its enrolled members other than through the organi-
zation because medical necessity required their pro-
vision before they could be secured through the orga-
nization;
‘‘(3) may obtain insurance or make other ar-
rangements for not more than 90 percent of the
amount by which its costs for any of its fiscal years
exceed 105 percent of its income for such fiscal year;
and
‘‘(4) may make arrangements with physicians
or other health care professionals, health care insti-
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tutions, or any combination of such individuals or
institutions to assume all or part of the financial
risk on a prospective basis for the provision of
health services by the physicians or other health pro-
fessionals or through the institutions.
‘‘(c) CERTIFICATION OF PROVISION AGAINST RISK OF
INSOLVENCY FOR UNLICENSED CHOS.—
‘‘(1) IN GENERAL.—Each community health or-
ganization that is not licensed by a State and for
which a waiver application has been approved under
subsection (a)(1), shall meet standards established
by the Secretary under subsection (d) relating to the
financial solvency and capital adequacy of the orga-
nization.
‘‘(2) CERTIFICATION PROCESS FOR SOLVENCY
STANDARDS FOR CHOS.—The Secretary shall estab-
lish a process for the receipt and approval of appli-
cations of a community health organization de-
scribed in paragraph (1) for certification (and peri-
odic recertification) of the organization as meeting
such solvency standards. Under such process, the
Secretary shall act upon such a certification applica-
tion not later than 60 days after the date the appli-
cation has been received.
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‘‘(d) ESTABLISHMENT
OF SOLVENCY STANDARDS
FOR COMMUNITY HEALTH ORGANIZATIONS.—
‘‘(1) IN GENERAL.—The Secretary shall estab-
lish, on an expedited basis and by rule pursuant to
section 553 of title 5, United States Code and
through the Health Resources and Services Adminis-
tration, standards described in subsection (c)(1) (re-
lating to financial solvency and capital adequacy)
that entities must meet to obtain a waiver under
subsection (a)(2)(C). In establishing such standards,
the Secretary shall consult with interested organiza-
tions, including the National Association of Insur-
ance Commissioners, the Academy of Actuaries, and
organizations representing Federally qualified health
centers.
‘‘(2) FACTORS
TO
CONSIDER
FOR
SOLVENCY
STANDARDS.—In establishing solvency standards for
community health organizations under paragraph
(1), the Secretary shall take into account—
‘‘(A) the delivery system assets of such an
organization and ability of such an organization
to provide services to enrollees;
‘‘(B) alternative means of protecting
against insolvency, including reinsurance, unre-
stricted surplus, letters of credit, guarantees,
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organizational insurance coverage, partnerships
with other licensed entities, and valuation at-
tributable to the ability of such an organization
to meet its service obligations through direct
delivery of care; and
‘‘(C) any standards developed by the Na-
tional Association of Insurance Commissioners
specifically for risk-based health care delivery
organizations.
‘‘(3) ENROLLEE PROTECTION AGAINST INSOL-
VENCY.—Such standards shall include provisions to
prevent enrollees from being held liable to any per-
son or entity for the organization’s debts in the
event of the organization’s insolvency.
‘‘(4) DEADLINE.—Such standards shall be pro-
mulgated in a manner so they are first effective by
not later than April 1, 1999.
‘‘(e) DEFINITIONS.—In this section:
‘‘(1) COMMUNITY
HEALTH
ORGANIZATION.—
The term ‘community health organization ’ means
an organization that is a Federally-qualified health
center or is controlled by one or more Federally-
qualified health centers.
‘‘(2) FEDERALLY-QUALIFIED
HEALTH
CEN-
TER.—The term ‘Federally-qualified health center’
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has the meaning given such term in section
1905(l)(2)(B) of the Social Security Act.
‘‘(3) HEALTH
INSURANCE
COVERAGE.—The
term ‘health insurance coverage’ has the meaning
given such term in section 2791(b)(1).
‘‘(4) CONTROL.—The term ‘control’ means the
possession, whether direct or indirect, of the power
to direct or cause the direction of the management
and policies of the organization through member-
ship, board representation, or an ownership interest
equal to or greater than 50.1 percent.’’.
TITLE 
III—AMENDMENTS 
TO
THE 
INTERNAL 
REVENUE
CODE OF 1986
Subtitle A—Patient Protections
SEC. 3001. PATIENT ACCESS TO UNRESTRICTED MEDICAL
ADVICE, EMERGENCY MEDICAL CARE, OB-
STETRIC AND GYNECOLOGICAL CARE, PEDI-
ATRIC CARE.
(a) IN GENERAL.—Subchapter B of chapter 100 of
the Internal Revenue Code of 1986 (relating to other re-
quirements) is amended by adding at the end the following
new section:
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‘‘SEC. 9813. PATIENT ACCESS TO UNRESTRICTED MEDICAL
ADVICE, EMERGENCY MEDICAL CARE, OB-
STETRIC AND GYNECOLOGICAL CARE, PEDI-
ATRIC CARE.
‘‘(a) PATIENT ACCESS TO UNRESTRICTED MEDICAL
ADVICE.—
‘‘(1) IN GENERAL.—In the case of any health
care professional acting within the lawful scope of
practice in the course of carrying out a contractual
employment arrangement or other direct contractual
arrangement between such professional and a group
health plan, the plan with which such contractual
employment arrangement or other direct contractual
arrangement is maintained by the professional may
not impose on such professional under such arrange-
ment any prohibition or restriction with respect to
advice, provided to a participant or beneficiary
under the plan who is a patient, about the health
status of the participant or beneficiary or the medi-
cal care or treatment for the condition or disease of
the participant or beneficiary, regardless of whether
benefits for such care or treatment are provided
under the plan.
‘‘(2) HEALTH CARE PROFESSIONAL DEFINED.—
For purposes of this subsection, the term ‘health
care professional’ means a physician (as defined in
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section 1861(r) of the Social Security Act) or other
health care professional if coverage for the profes-
sional’s services is provided under the group health
plan for the services of the professional. Such term
includes a podiatrist, optometrist, chiropractor, psy-
chologist, dentist, physician assistant, physical or oc-
cupational therapist and therapy assistant, speech–
language pathologist, audiologist, registered or li-
censed practical nurse (including nurse practitioner,
clinical nurse specialist, certified registered nurse
anesthetist, and certified nurse–midwife), licensed
certified social worker, registered respiratory thera-
pist, and certified respiratory therapy technician.
‘‘(b) PATIENT ACCESS
TO EMERGENCY MEDICAL
CARE.—
‘‘(1) IN
GENERAL.—To the extent that the
group health plan provides for any benefits consist-
ing of emergency medical care (as defined in section
503(b)(9)(I) of the Employee Retirement Income Se-
curity Act of 1974), except for items or services spe-
cifically excluded—
‘‘(A) the plan shall provide benefits, with-
out requiring preauthorization and without re-
gard to otherwise applicable network limita-
tions, 
for 
appropriate 
emergency 
medical
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screening examinations (within the capability of
the emergency facility, including ancillary serv-
ices routinely available to the emergency facil-
ity) to the extent that a prudent layperson, who
possesses an average knowledge of health and
medicine, would determine such examinations to
be necessary in order to determine whether
emergency medical care (as so defined) is re-
quired; and
‘‘(B) the plan shall provide benefits for ad-
ditional emergency medical services following an
emergency medical screening examination (if
determined necessary under subparagraph (A))
to the extent that a prudent emergency medical
professional would determine such additional
emergency services to be necessary to avoid the
consequences described in clause (i) of section
503(b)(9)(I) of such Act.
‘‘(2) UNIFORM
COST-SHARING
REQUIRED.—
Nothing in this subsection shall be construed as pre-
venting a group health plan from imposing any form
of cost-sharing applicable to any participant or bene-
ficiary 
(including 
coinsurance, 
copayments,
deductibles, and any other charges) in relation to
benefits described in paragraph (1), if such form of
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cost-sharing is uniformly applied under such plan,
with respect to similarly situated participants and
beneficiaries, to all benefits consisting of emergency
medical care (as defined in section 503(b)(9)(I) of
the Employee Retirement Income Security Act of
1974) provided to such similarly situated partici-
pants and beneficiaries under the plan.
‘‘(c) PATIENT ACCESS TO OBSTETRIC AND GYNECO-
LOGICAL CARE.—
‘‘(1) IN
GENERAL.—In any case in which a
group health plan—
‘‘(A) provides benefits under the terms of
the plan consisting of—
‘‘(i) routine gynecological care (such
as preventive women’s health examina-
tions); or
‘‘(ii) routine obstetric care (such as
routine pregnancy-related services),
provided by a participating physician who spe-
cializes in such care (or provides benefits con-
sisting of payment for such care); and
‘‘(B) the plan requires or provides for des-
ignation by a participant or beneficiary of a
participating primary care provider,
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if the primary care provider designated by such a
participant or beneficiary is not such a physician,
then the plan shall meet the requirements of para-
graph (2).
‘‘(2) REQUIREMENTS.—A group health plan
meets the requirements of this paragraph, in connec-
tion with benefits described in paragraph (1) con-
sisting of care described in clause (i) or (ii) of para-
graph (1)(A) (or consisting of payment therefor), if
the plan—
‘‘(A) does not require authorization or a
referral by the primary care provider in order
to obtain such benefits; and
‘‘(B) treats the ordering of other routine
care of the same type, by the participating phy-
sician providing the care described in clause (i)
or (ii) of paragraph (1)(A), as the authorization
of the primary care provider with respect to
such care.
‘‘(3) CONSTRUCTION.—Nothing in paragraph
(2)(B) shall waive any requirements of coverage re-
lating to medical necessity or appropriateness with
respect to coverage of gynecological or obstetric care
so ordered.
‘‘(d) PATIENT ACCESS TO PEDIATRIC CARE.—
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‘‘(1) IN
GENERAL.—In any case in which a
group health plan (or a health insurance issuer of-
fering health insurance coverage in connection with
the plan) provides benefits consisting of routine pe-
diatric care provided by a participating physician
who specializes in pediatrics (or consisting of pay-
ment for such care) and the plan requires or pro-
vides for designation by a participant or beneficiary
of a participating primary care provider, the plan (or
issuer) shall provide that such a participating physi-
cian may be designated, if available, by a parent or
guardian of any beneficiary under the plan is who
under 18 years of age, as the primary care provider
with respect to any such benefits.
‘‘(2) CONSTRUCTION.—Nothing in paragraph
(1) shall waive any requirements of coverage relating
to medical necessity or appropriateness with respect
to coverage of pediatric care.
‘‘(e) TREATMENT
OF MULTIPLE COVERAGE OP-
TIONS.—In the case of a plan providing benefits under two
or more coverage options, the requirements of subsections
(c) and (d) shall apply separately with respect to each cov-
erage option.’’.
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(b) CLERICAL AMENDMENT.—The table of sections
of such subchapter of such chapter is amended by adding
at the end the following new item:
‘‘Sec. 9813. Patient access to unrestricted medical advice, emer-
gency medical care, obstetric and gynecological
care, pediatric care.’’.
SEC. 3002. EFFECTIVE DATE AND RELATED RULES.
(a) IN GENERAL.—The amendments made by this
subtitle shall apply with respect to plan years beginning
on or after January 1 of the second calendar year follow-
ing the date of the enactment of this Act, except that the
Secretary of the Treasury may issue regulations before
such date under such amendments. The Secretary shall
first issue regulations necessary to carry out the amend-
ments made by this section before the effective date there-
of.
(b) LIMITATION ON PENALTY FOR CERTAIN FAIL-
URES.—No penalty shall be imposed on any failure to
comply with any requirement imposed by the amendments
made by section 3101 to the extent such failure occurs
before the date of issuance of regulations issued in connec-
tion with such requirement if the plan has sought to com-
ply in good faith with such requirement.
(c) SPECIAL RULE FOR COLLECTIVE BARGAINING
AGREEMENTS.—In the case of a group health plan main-
tained pursuant to one or more collective bargaining
agreements between employee representatives and one or
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more employers ratified before the date of the enactment
of this Act, the provisions of subsections (b), (c), and (d)
of section 9813 of the Internal Revenue Code of 1986 (as
added by this subtitle) shall not apply with respect to plan
years beginning before the later of—
(1) the date on which the last of the collective
bargaining agreements relating to the plan termi-
nates (determined without regard to any extension
thereof agreed to after the date of the enactment of
this Act); or
(2) January 1, 2001.
For purposes of this subsection, 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 subtitle shall not be treated as a termination of
such collective bargaining agreement.
Subtitle B—Patient Access to
Information
SEC. 3101. PATIENT ACCESS TO INFORMATION REGARDING
PLAN COVERAGE, MANAGED CARE PROCE-
DURES, 
HEALTH 
CARE 
PROVIDERS, 
AND
QUALITY OF MEDICAL CARE.
(a) IN GENERAL.—Subchapter B of chapter 100 of
the Internal Revenue Code of 1986 (relating to other re-
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quirements) is amended by adding at the end the following
new section:
‘‘SEC. 9814. DISCLOSURE BY GROUP HEALTH PLANS.
‘‘(a) DISCLOSURE
REQUIREMENT.—The adminis-
trator of each group health plan shall take such actions
as are necessary to ensure that the summary plan descrip-
tion of the plan required under section 102 of Employee
Retirement Income Security Act of 1974 (or each sum-
mary plan description in any case in which different sum-
mary plan descriptions are appropriate under part 1 of
subtitle B of title I of such Act for different options of
coverage) contains the information required under sub-
sections (b), (c), (d), and (e)(2)(A). To the extent that
any health insurance issuer offering health insurance cov-
erage in connection with such plan provides such informa-
tion on a timely basis to plan participants and bene-
ficiaries, the requirements of this subsection shall be
deemed satisfied in the case of such plan with respect to
such information.
‘‘(b) PLAN BENEFITS.—The information required
under subsection (a) includes the following:
‘‘(1) COVERED ITEMS AND SERVICES.—
‘‘(A) CATEGORIZATION OF INCLUDED BEN-
EFITS.—A description of covered benefits, cat-
egorized by—
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TITLE V—CONFIDENTIALITY OF
HEALTH INFORMATION
SEC. 5001. CONFIDENTIALITY OF PROTECTED HEALTH IN-
FORMATION.
(a) IN GENERAL.—Title XI of the Social Security Act
(42 U.S.C. 1301 et seq.) is amended by adding at the end
the following:
‘‘PART D—CONFIDENTIALITY OF PROTECTED HEALTH
INFORMATION
‘‘INSPECTION AND COPYING OF PROTECTED HEALTH
INFORMATION
‘‘SEC. 1181. (a) IN GENERAL.—Subject to the suc-
ceeding provisions of this section, upon the request of an
individual who is the subject of protected health informa-
tion, a person who is a health care provider, health plan,
employer, health or life insurer, or educational institution
shall make available to the individual (or, in the discretion
of the person, to a health care provider designated by the
individual), for inspection and copying, protected health
information concerning the individual that the person
maintains, including records created under section 1182.
‘‘(b) ACCESS THROUGH ORIGINATING PROVIDER.—
Protected health information that is created by an origi-
nating provider, and subsequently received by another
health care provider or a health plan as part of treatment