(i) by a nonparticipating health care
provider with or without prior authoriza-
tion, or
(ii) by a participating health care pro-
vider without prior authorization,
the participant, beneficiary, or enrollee is not
liable for amounts that exceed the amounts of
liability that would be incurred if the services
were provided by a participating health care
provider with prior authorization; and
(D) without regard to any other term or
condition of such coverage (other than exclusion
or coordination of benefits, or an affiliation or
waiting period, permitted under section 2701 of
the Public Health Service Act, section 701 of
the Employee Retirement Income Security Act
of 1974, or section 9801 of the Internal Rev-
enue Code of 1986, and other than applicable
cost-sharing).
(2) DEFINITIONS.—In this section:
(A) EMERGENCY
MEDICAL
CONDITION
BASED ON PRUDENT LAYPERSON STANDARD.—
The term ‘‘emergency medical condition’’ means
a medical condition manifesting itself by acute
symptoms of sufficient severity (including se-
vere pain) such that a prudent layperson, who
possesses an average knowledge of health and
medicine, could reasonably expect the absence
of immediate medical attention to result in a
condition described in clause (i), (ii), or (iii) of
section 1867(e)(1)(A) of the Social Security
Act.
(B) EMERGENCY
SERVICES.—The term
‘‘emergency services’’ means—
(i) a medical screening examination
(as required under section 1867 of the So-
cial Security Act) that is within the capa-
bility of the emergency department of a
hospital, including ancillary services rou-
tinely available to the emergency depart-
ment to evaluate an emergency medical
condition (as defined in subparagraph
(A)), and
(ii) within the capabilities of the staff
and facilities available at the hospital, such
further medical examination and treatment
as are required under section 1867 of such
Act to stabilize the patient.
(C) STABILIZE.—The term ‘‘to stabilize’’
means, with respect to an emergency medical
condition, to provide such medical treatment of
the condition as may be necessary to assure,
within reasonable medical probability, that no
material deterioration of the condition is likely
to result from or occur during the transfer of
the individual from a facility.
(b) REIMBURSEMENT FOR MAINTENANCE CARE AND
POST-STABILIZATION CARE.—If benefits are available
under a group health plan, or under health insurance cov-
erage offered by a health insurance issuer, with respect
to maintenance care or post-stabilization care covered
under the guidelines established under section 1852(d)(2)
of the Social Security Act, the plan or issuer shall provide
for reimbursement with respect to such services provided
to a participant, beneficiary, or enrollee other than
through a participating health care provider in a manner
consistent with subsection (a)(1)(C) (and shall otherwise
comply with such guidelines).
SEC. 114. ACCESS TO SPECIALTY CARE.
(a) SPECIALTY CARE FOR COVERED SERVICES.—
(1) IN GENERAL.—If—
(A) an individual is a participant or bene-
ficiary under a group health plan or an enrollee
who is covered under health insurance coverage
offered by a health insurance issuer,
(B) the individual has a condition or dis-
ease of sufficient seriousness and complexity to
require treatment by a specialist, and
(C) benefits for such treatment are pro-
vided under the plan or coverage,
the plan or issuer shall make or provide for a refer-
ral to a specialist 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
respect to a condition, a health care practitioner, fa-
cility, or center that has adequate expertise through
appropriate training and experience (including, in
the case of a child, appropriate pediatric expertise)
to provide high quality care in treating the condi-
tion.
(3) CARE UNDER REFERRAL.—A group health
plan or health insurance issuer may require that the
care provided to an individual pursuant to such re-
ferral under paragraph (1) be—
(A) pursuant to a treatment plan, only if
the treatment plan is developed by the specialist
and approved by the plan or issuer, in consulta-
tion with the designated primary care provider
or specialist and the individual (or the individ-
ual’s designee), and
(B) in accordance with applicable quality
assurance and utilization review standards of
the plan or issuer.
Nothing in this subsection shall be construed as pre-
venting such a treatment plan for an individual 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
PRO-
VIDERS.—A group health plan or health insurance
issuer is not required under paragraph (1) to pro-
vide for a referral to a specialist that is not a par-
ticipating provider, unless the plan or issuer does
not have an appropriate specialist that is available
and accessible to treat the individual’s condition and
that is a participating provider with respect to such
treatment.
(5) TREATMENT
OF
NONPARTICIPATING
PRO-
VIDERS.—If a plan or issuer refers an individual to
a nonparticipating specialist pursuant to paragraph
(1), services provided pursuant to the approved
treatment plan (if any) shall be provided at no addi-
tional cost to the individual beyond what the indi-
vidual would otherwise pay for services received by
such a specialist that is a participating provider.
(b) SPECIALISTS AS GATEKEEPER FOR TREATMENT
OF ONGOING SPECIAL CONDITIONS.—
(1) IN GENERAL.—A group health plan, or a
health insurance issuer, in connection with the provi-
sion of health insurance coverage, shall have a proce-
dure by which an individual who is a participant,
beneficiary, or enrollee and who has an ongoing spe-
cial condition (as defined in paragraph (3)) may re-
quest and receive a referral to a specialist for such
condition who shall be responsible for and capable of
providing and coordinating the individual’s care with
respect to the condition. Under such procedures if
such an individual’s care would most appropriately
be coordinated by such a specialist, such plan or
issuer shall refer the individual to such specialist.
(2) TREATMENT FOR RELATED REFERRALS.—
Such specialists shall be permitted to treat the indi-
vidual without a referral from the individual’s pri-
mary care provider and may authorize such refer-
rals, procedures, tests, and other medical services as
the individual’s primary care provider would other-
wise be permitted to provide or authorize, subject to
the terms of the treatment (referred to in subsection
(a)(3)(A)) with respect to the ongoing special condi-
tion.
(3) ONGOING SPECIAL CONDITION DEFINED.—
In this subsection, the term ‘‘ongoing special condi-
tion’’ means a condition or disease that—
(A) is life-threatening, degenerative, or dis-
abling, and
(B) requires specialized medical care over
a prolonged period of time.
(4) TERMS OF REFERRAL.—The provisions of
paragraphs (3) through (5) of subsection (a) apply
with respect to referrals under paragraph (1) of this
subsection in the same manner as they apply to re-
ferrals under subsection (a)(1).
(c) STANDING REFERRALS.—
(1) IN GENERAL.—A group health plan, and a
health insurance issuer in connection with the provi-
sion of health insurance coverage, shall have a proce-
dure by which an individual who is a participant,
beneficiary, or enrollee and who has a condition that
requires ongoing care from a specialist may receive
a standing referral to such specialist for treatment
of such condition. If the plan or issuer, or if the pri-
mary care provider in consultation with the medical
director of the plan or issuer and the specialist (if
any), determines that such a standing referral is ap-
propriate, the plan or issuer shall make such a refer-
ral to such a specialist if the individual so desires.
(2) TERMS OF REFERRAL.—The provisions of
paragraphs (3) through (5) of subsection (a) apply
with respect to referrals under paragraph (1) of this
subsection in the same manner as they apply to re-
ferrals under subsection (a)(1).
SEC. 115. ACCESS TO OBSTETRICAL AND GYNECOLOGICAL
CARE.
(a) IN GENERAL.—If a group health plan, or a health
insurance issuer in connection with the provision of health
insurance coverage, requires or provides for a participant,
beneficiary, or enrollee to designate a participating pri-
mary care health care professional, the plan or issuer—
(1) may not require authorization or a referral
by the individual’s primary care health care profes-
sional or otherwise for coverage of gynecological care
(including preventive women’s health examinations)
and pregnancy-related services provided by a partici-
pating health care professional, including a physi-
cian, who specializes in obstetrics and gynecology to
the extent such care is otherwise covered, and
(2) shall treat the ordering of other obstetrical
or gynecological care by such a participating profes-
sional as the authorization of the primary care
health care professional with respect to such care
under the plan or coverage.
(b) CONSTRUCTION.—Nothing in subsection (a) shall
be construed to—
(1) waive any exclusions of coverage under the
terms of the plan or health insurance coverage with
respect to coverage of obstetrical or gynecological
care; or
(2) preclude the group health plan or health in-
surance issuer involved from requiring that the ob-
stetrical or gynecological provider notify the primary
care health care professional or the plan or issuer of
treatment decisions.
SEC. 116. ACCESS TO PEDIATRIC CARE.
(a) PEDIATRIC CARE.—If a group health plan, or a
health insurance issuer in connection with the provision
of health insurance coverage, requires or provides for an
enrollee to designate a participating primary care provider
for a child of such enrollee, the plan or issuer shall permit
the enrollee to designate a physician who specializes in pe-
diatrics as the child’s primary care provider.
(b) CONSTRUCTION.—Nothing in subsection (a) shall
be construed to waive any exclusions of coverage under
the terms of the plan or health insurance coverage with
respect to coverage of pediatric care.
SEC. 117. CONTINUITY OF CARE.
(a) IN GENERAL.—
(1) TERMINATION OF PROVIDER.—If a contract
between a group health plan, or a health insurance
issuer in connection with the provision of health in-
surance coverage, and a health care provider is ter-
minated (as defined in paragraph (3)(B)), or bene-
fits or coverage provided by a health care provider
are terminated because of a change in the terms of
provider participation in a group health plan, and an
individual who is a participant, beneficiary, or en-
rollee in the plan or coverage is undergoing treat-
ment from the provider for an ongoing special condi-
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.
(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 114(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
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—
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. 118. ACCESS TO NEEDED PRESCRIPTION DRUGS.
If a group health plan, or health insurance issuer that
offers health insurance coverage, provides benefits with re-
spect to prescription drugs but the coverage limits such
benefits to drugs included in a formulary, the plan or
issuer shall—
(1) ensure participation of participating physi-
cians and pharmacists in the development of the for-
mulary;
(2) disclose to providers and, disclose upon re-
quest under section 121(c)(5) to participants, bene-
ficiaries, and enrollees, the nature of the formulary
restrictions; and
(3) consistent with the standards for a utiliza-
tion review program under section 101, provide for
exceptions from the formulary limitation when a
non-formulary alternative is medically indicated.
SEC. 119. COVERAGE FOR INDIVIDUALS PARTICIPATING IN
APPROVED CLINICAL TRIALS.
(a) COVERAGE.—
(1) IN GENERAL.—If a group health plan, or
health insurance issuer that is providing health in-
surance coverage, provides coverage to a qualified in-
dividual (as defined in subsection (b)), the plan or
issuer—
(A) may not deny the individual participa-
tion in the clinical trial referred to in subsection
(b)(2);
(B) subject to subsection (c), may not deny
(or limit or impose additional conditions on) the
coverage of routine patient costs for items and
services furnished in connection with participa-
tion in the trial; and
(C) may not discriminate against the indi-
vidual on the basis of the enrollee’s participa-
tion in such trial.
(2) EXCLUSION OF CERTAIN COSTS.—For pur-
poses of paragraph (1)(B), routine patient costs do
not include the cost of the tests or measurements
conducted primarily for the purpose of the clinical
trial involved.
(3) USE OF IN-NETWORK PROVIDERS.—If one
or more participating providers is participating in a
clinical trial, nothing in paragraph (1) shall be con-
strued as preventing a plan or issuer from requiring
that a qualified individual participate in the trial
through such a participating provider if the provider
will accept the individual as a participant in the
trial.
(b) QUALIFIED INDIVIDUAL DEFINED.—For pur-
poses of subsection (a), the term ‘‘qualified individual’’
means an individual who is a participant or beneficiary
in a group health plan, or who is an enrollee under health
insurance coverage, and who meets the following condi-
tions:
(1)(A) The individual has a life-threatening or
serious illness for which no standard treatment is ef-
fective.
(B) The individual is eligible to participate in
an approved clinical trial according to the trial pro-
tocol with respect to treatment of such illness.
(C) The individual’s participation in the trial
offers meaningful potential for significant clinical
benefit for the individual.
(2) Either—
(A) the referring physician is a partici-
pating health care professional and has con-
cluded that the individual’s participation in
such trial would be appropriate based upon the
individual meeting the conditions described in
paragraph (1); or
(B) the participant, beneficiary, or enrollee
provides medical and scientific information es-
tablishing that the individual’s participation in
such trial would be appropriate based upon the
individual meeting the conditions described in
paragraph (1).
(c) PAYMENT.—
(1) IN GENERAL.—Under this section a group
health plan or health insurance issuer shall provide
for payment for routine patient costs described in
subsection (a)(2) but is not required to pay for costs
of items and services that are reasonably expected
(as determined by the Secretary) to be paid for by
the sponsors of an approved clinical trial.
(2) PAYMENT RATE.—In the case of covered
items and services provided by—
(A) a participating provider, the payment
rate shall be at the agreed upon rate, or
(B) a nonparticipating provider, the pay-
ment rate shall be at the rate the plan or issuer
would normally pay for comparable services
under subparagraph (A).
(d) APPROVED CLINICAL TRIAL DEFINED.—
(1) IN
GENERAL.—In this section, the term
‘‘approved clinical trial’’ means a clinical research
study or clinical investigation approved and funded
(which may include funding through in-kind con-
tributions) by one or more of the following:
(A) The National Institutes of Health.
(B) A cooperative group or center of the
National Institutes of Health.
(C) Either of the following if the condi-
tions described in paragraph (2) are met:
(i) The Department of Veterans Af-
fairs.
(ii) The Department of Defense.
(2) CONDITIONS
FOR
DEPARTMENTS.—The
conditions described in this paragraph, for a study
or investigation conducted by a Department, are
that the study or investigation has been reviewed
and approved through a system of peer review that
the Secretary determines—
(A) to be comparable to the system of peer
review of studies and investigations used by the
National Institutes of Health, and
(B) assures unbiased review of the highest
scientific standards by qualified individuals who
have no interest in the outcome of the review.
(e) CONSTRUCTION.—Nothing in this section shall be
construed to limit a plan’s or issuer’s coverage with re-
spect to clinical trials.
Subtitle C—Access to Information
SEC. 121. PATIENT ACCESS TO INFORMATION.
(a) DISCLOSURE REQUIREMENT.—
(1) GROUP HEALTH PLANS.—A group health
plan shall—
(A) provide to participants and bene-
ficiaries at the time of initial coverage under
the plan (or the effective date of this section, in
the case of individuals who are participants or
beneficiaries as of such date), and at least an-
nually thereafter, the information described in
subsection (b) in printed form;
(B) provide to participants and bene-
ficiaries, within a reasonable period (as speci-
fied by the appropriate Secretary) before or
after the date of significant changes in the in-
formation described in subsection (b), informa-
tion in printed form on such significant
changes; and
(C) upon request, make available to par-
ticipants and beneficiaries, the applicable au-
thority, and prospective participants and bene-
ficiaries, the information described in sub-
section (b) or (c) in printed form.
(2) HEALTH
INSURANCE
ISSUERS.—A health
insurance issuer in connection with the provision of
health insurance coverage shall—
(A) provide to individuals enrolled under
such coverage at the time of enrollment, and at
least annually thereafter, the information de-
scribed in subsection (b) in printed form;
(B) provide to enrollees, within a reason-
able period (as specified by the appropriate Sec-
retary) before or after the date of significant
changes in the information described in sub-
section (b), information in printed form on such
significant changes; and
(C) upon request, make available to the
applicable authority, to individuals who are pro-
spective enrollees, and to the public the infor-
mation described in subsection (b) or (c) in
printed form.
(b) INFORMATION PROVIDED.—The information de-
scribed in this subsection with respect to a group health
plan or health insurance coverage offered by a health in-
surance issuer includes the following:
(1) SERVICE AREA.—The service area of the
plan or issuer.
(2) BENEFITS.—Benefits offered under the
plan or coverage, including—
(A) covered benefits, including benefit lim-
its and coverage exclusions;
(B) cost sharing, such as deductibles, coin-
surance, and copayment amounts, including any
liability for balance billing, any maximum limi-
tations on out of pocket expenses, and the max-
imum out of pocket costs for services that are
provided by nonparticipating providers or that
are furnished without meeting the applicable
utilization review requirements;
(C) the extent to which benefits may be ob-
tained from nonparticipating providers;
(D) the extent to which a participant, ben-
eficiary, or enrollee may select from among par-
ticipating providers and the types of providers
participating in the plan or issuer network;
(E) process for determining experimental
coverage; and
(F) use of a prescription drug formulary.
(3) ACCESS.—A description of the following:
(A) The number, mix, and distribution of
providers under the plan or coverage.
(B) Out-of-network coverage (if any) pro-
vided by the plan or coverage.
(C) Any point-of-service option (including
any supplemental premium or cost-sharing for
such option).
(D) The procedures for participants, bene-
ficiaries, and enrollees to select, access, and
change participating primary and specialty pro-
viders.
(E) The rights and procedures for obtain-
ing referrals (including standing referrals) to
participating and nonparticipating providers.
(F) The name, address, and telephone
number of participating health care providers
and an indication of whether each such provider
is available to accept new patients.
(G) Any limitations imposed on the selec-
tion of qualifying participating health care pro-
viders, including any limitations imposed under
section 112(b)(2).
(H) How the plan or issuer addresses the
needs of participants, beneficiaries, and enroll-
ees and others who do not speak English or
who have other special communications needs in
accessing providers under the plan or coverage,
including the provision of information described
in this subsection and subsection (c) to such in-
dividuals.
(4) OUT-OF-AREA COVERAGE.—Out-of-area cov-
erage provided by the plan or issuer.
(5) 
EMERGENCY
COVERAGE.—Coverage 
of
emergency services, including—
(A) the appropriate use of emergency serv-
ices, including use of the 911 telephone system
or its local equivalent in emergency situations
and an explanation of what constitutes an
emergency situation;
(B) the process and procedures of the plan
or issuer for obtaining emergency services; and
(C) the locations of (i) emergency depart-
ments, and (ii) other settings, in which plan
physicians and hospitals provide emergency
services and post-stabilization care.
(6) PERCENTAGE
OF
PREMIUMS
USED
FOR
BENEFITS (LOSS-RATIOS).—In the case of health in-
surance coverage only (and not with respect to group
health plans that do not provide coverage through
health insurance coverage), a description of the over-
all loss-ratio for the coverage (as defined in accord-
ance with rules established or recognized by the Sec-
retary of Health and Human Services).
(7) PRIOR AUTHORIZATION RULES.—Rules re-
garding prior authorization or other review require-
ments that could result in noncoverage or non-
payment.
(8) GRIEVANCE AND APPEALS PROCEDURES.—
All appeal or grievance rights and procedures under
the plan or coverage, including the method for filing
grievances and the time frames and circumstances
for acting on grievances and appeals, who is the ap-
plicable authority with respect to the plan or issuer.
(9) QUALITY
ASSURANCE.—Any information
made public by an accrediting organization in the
process of accreditation of the plan or issuer or any
additional quality indicators the plan or issuer
makes available.
(10) INFORMATION ON ISSUER.—Notice of ap-
propriate mailing addresses and telephone numbers
to be used by participants, beneficiaries, and enroll-
ees in seeking information or authorization for treat-
ment.
(11) NOTICE
OF
REQUIREMENTS.—Notice of
the requirements of this title.
(12) AVAILABILITY OF INFORMATION ON RE-
QUEST.—Notice that the information described in
subsection (c) is available upon request.
(c) INFORMATION MADE AVAILABLE UPON RE-
QUEST.—The information described in this subsection is
the following:
(1) UTILIZATION REVIEW ACTIVITIES.—A de-
scription of procedures used and requirements (in-
cluding circumstances, time frames, and appeal
rights) under any utilization review program under
section 101, including under any drug formulary
program under section 118.
(2) GRIEVANCE AND APPEALS INFORMATION.—
Information on the number of grievances and ap-
peals and on the disposition in the aggregate of such
matters.
(3) METHOD OF PHYSICIAN COMPENSATION.—
A general description by category (including salary,
fee-for-service, capitation, and such other categories
as may be specified in regulations of the Secretary)
of the applicable method by which a specified pro-
spective or treating health care professional is (or
would be) compensated in connection with the provi-
sion of health care under the plan or coverage.
(4) SPECIFIC INFORMATION ON CREDENTIALS
OF PARTICIPATING PROVIDERS.—In the case of each
participating provider, a description of the creden-
tials of the provider.
(5) FORMULARY RESTRICTIONS.—A description
of the nature of any drug formula restrictions.
(6) PARTICIPATING PROVIDER LIST.—A list of
current participating health care providers.
(d) CONSTRUCTION.—Nothing in this section shall be
construed as requiring public disclosure of individual con-
tracts or financial arrangements between a group health
plan or health insurance issuer and any provider.
Subtitle D—Protecting the Doctor-
Patient Relationship
SEC. 131. PROHIBITION OF INTERFERENCE WITH CERTAIN
MEDICAL COMMUNICATIONS.
(a) GENERAL RULE.—The provisions of any contract
or agreement, or the operation of any contract or agree-
ment, between a group health plan or health insurance
issuer in relation to health insurance coverage (including
any partnership, association, or other organization that
enters into or administers such a contract or agreement)
and a health care provider (or group of health care pro-
viders) shall not prohibit or otherwise restrict a health
care professional from advising such a participant, bene-
ficiary, or enrollee who is a patient of the professional
about the health status of the individual or medical care
or treatment for the individual’s condition or disease, re-
gardless of whether benefits for such care or treatment
are provided under the plan or coverage, if the professional
is acting within the lawful scope of practice.
(b) NULLIFICATION.—Any contract provision or
agreement that restricts or prohibits medical communica-
tions in violation of subsection (a) shall be null and void.
SEC. 132. PROHIBITION OF DISCRIMINATION AGAINST PRO-
VIDERS BASED ON LICENSURE.
(a) IN GENERAL.—A group health plan and a health
insurance issuer offering health insurance coverage shall
not discriminate with respect to participation or indem-
nification as to any provider who is acting within the scope
of the provider’s license or certification under applicable
State law, solely on the basis of such license or certifi-
cation.
(b) CONSTRUCTION.—Subsection (a) shall not be
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