(III) does not otherwise have a 
conflict of interest with such a party 
(as determined under regulations). 
(ii) EXCEPTION
FOR
REASONABLE 
COMPENSATION.—Nothing in clause (i) 
shall be construed to prohibit receipt by a 
qualified external review entity of com-
pensation from a plan or issuer for the
conduct of external review activities under 
this section if the compensation is provided 
consistent with clause (iii). 
(iii) LIMITATIONS
ON
ENTITY
COM-
PENSATION.—Compensation provided by a 
plan or issuer to a qualified external review 
entity in connection with reviews under 
this section shall—
(I) not exceed a reasonable level; 
and 
(II) not be contingent on any de-
cision rendered by the entity or by 
any independent medical review panel. 
(C) CERTIFICATION AND RECERTIFICATION 
PROCESS.—
(i) IN GENERAL.—The initial certifi-
cation and recertification of a qualified ex-
ternal review entity shall be made—
(I) under a process that is recog-
nized or approved by the appropriate 
Secretary; or 
(II) by a qualified private stand-
ard-setting organization that is ap-
proved by the appropriate Secretary 
under clause (iii). 
In taking action under subclause (I), the 
appropriate Secretary shall give deference 
to entities that are under contract with the 
Federal Government or with an applicable 
State authority to perform functions of the 
type performed by qualified external review 
entities. 
(ii) PROCESS.—The appropriate Sec-
retary shall not recognize or approve a 
process under clause (i)(I) unless the proc-
ess applies standards (as promulgated in 
regulations) that ensure that a qualified 
external review entity—
(I) will carry out (and has car-
ried out, in the case of recertification)
the responsibilities of such an entity 
in accordance with this section, in-
cluding meeting applicable deadlines; 
(II) will meet (and has met, in 
the case of recertification) appropriate 
indicators of fiscal integrity; 
(III) will maintain (and has 
maintained, in the case of recertifi-
cation) 
appropriate 
confidentiality 
with respect to individually identifi-
able health information obtained in 
the course of conducting external re-
view activities; and 
(IV) in the case of recertification, 
shall review the matters described in 
clause (iv). 
(iii) APPROVAL
OF
QUALIFIED
PRI-
VATE
STANDARD-SETTING
ORGANIZA-
TIONS.—For purposes of clause (i)(II), the 
appropriate Secretary may approve a quali-
fied private standard-setting organization 
if such Secretary finds that the organiza-
tion only certifies (or recertifies) external 
review entities that meet at least the 
standards required for the certification (or
recertification) of external review entities 
under clause (ii). 
(iv) CONSIDERATIONS IN RECERTIFI-
CATIONS.—In conducting recertifications of 
a qualified external review entity under 
this paragraph, the appropriate Secretary 
or organization conducting the recertifi-
cation shall review compliance of the entity 
with the requirements for conducting ex-
ternal review activities under this section, 
including the following: 
(I) 
Provision 
of 
information 
under subparagraph (D). 
(II) 
Adherence 
to 
applicable 
deadlines (both by the entity and by 
independent medical review panels it 
refers cases to). 
(III) Compliance with limitations 
on compensation (with respect to both 
the entity and independent medical re-
view panels it refers cases to). 
(IV) Compliance with applicable 
independence requirements. 
(V) Compliance with the require-
ment of subsection (d)(1) that only
medically reviewable decisions shall be 
the subject of independent medical re-
view and with the requirement of sub-
section (d)(3) that independent med-
ical review panels may not require 
coverage for specifically excluded ben-
efits. 
(v) PERIOD OF CERTIFICATION OR RE-
CERTIFICATION.—A certification or recer-
tification provided under this paragraph 
shall extend for a period not to exceed 2 
years. 
(vi) REVOCATION.—A certification or 
recertification under this paragraph may 
be revoked by the appropriate Secretary or 
by the organization providing such certifi-
cation upon a showing of cause. The Sec-
retary, or organization, shall revoke a cer-
tification or deny a recertification with re-
spect to an entity if there is a showing that 
the entity has a pattern or practice of or-
dering coverage for benefits that are spe-
cifically excluded under the plan or cov-
erage.
(vii) PETITION FOR DENIAL OR WITH-
DRAWAL.—An individual may petition the 
Secretary, or an organization providing the 
certification involves, for a denial of recer-
tification or a withdrawal of a certification 
with respect to an entity under this sub-
paragraph if there is a pattern or practice 
of such entity failing to meet a require-
ment of this section. 
(viii) SUFFICIENT NUMBER OF ENTI-
TIES.—The appropriate Secretary shall 
certify and recertify a number of external 
review entities which is sufficient to ensure 
the timely and efficient provision of review 
services. 
(D) PROVISION OF INFORMATION.—
(i) IN GENERAL.—A qualified external 
review entity shall provide to the appro-
priate Secretary, in such manner and at 
such times as such Secretary may require, 
such information (relating to the denials 
which have been referred to the entity for 
the conduct of external review under this 
section) as such Secretary determines ap-
propriate to assure compliance with the
independence and other requirements of 
this section to monitor and assess the qual-
ity of its external review activities and lack 
of bias in making determinations. Such in-
formation shall include information de-
scribed in clause (ii) but shall not include 
individually identifiable medical informa-
tion. 
(ii) 
INFORMATION
TO
BE
IN-
CLUDED.—The information described in 
this subclause with respect to an entity is 
as follows: 
(I) The number and types of de-
nials for which a request for review 
has been received by the entity. 
(II) The disposition by the entity 
of such denials, including the number 
referred to an independent medical re-
view panel and the reasons for such 
dispositions (including the application 
of exclusions), on a plan or issuer-spe-
cific basis and on a health care spe-
cialty-specific basis.
(III) The length of time in mak-
ing determinations with respect to 
such denials. 
(IV) Updated information on the 
information required to be submitted 
as a condition of certification with re-
spect to the entity’s performance of 
external review activities. 
(iii) INFORMATION TO BE PROVIDED 
TO CERTIFYING ORGANIZATION.—
(I) IN GENERAL.—In the case of 
a qualified external review entity 
which is certified (or recertified) 
under this subsection by a qualified
private standard-setting organization, 
at the request of the organization, the 
entity shall provide the organization 
with the information provided to the 
appropriate Secretary under clause 
(i). 
(II) 
ADDITIONAL
INFORMA-
TION.—Nothing in this subparagraph 
shall be construed as preventing such 
an organization from requiring addi-
tional information as a condition of
certification or recertification of an 
entity. 
(iv) USE OF INFORMATION.—Informa-
tion provided under this subparagraph may 
be used by the appropriate Secretary and 
qualified private standard-setting organiza-
tions to conduct oversight of qualified ex-
ternal review entities, including recertifi-
cation of such entities, and shall be made 
available to the public in an appropriate 
manner. 
(E) LIMITATION ON LIABILITY.—No quali-
fied external review entity having a contract 
with a plan or issuer, and no person who is em-
ployed by any such entity or who furnishes pro-
fessional services to such entity (including as an 
independent medical review panel), shall be held 
by reason of the performance of any duty, func-
tion, or activity required or authorized pursuant 
to this section, to be civilly liable under any law 
of the United States or of any State (or polit-
ical subdivision thereof) if there was no actual 
malice or gross misconduct in the performance 
of such duty, function, or activity.
(5) REPORT.—Not later than 12 months after 
the general effective date referred to in section 601, 
the General Accounting Office shall prepare and 
submit to the appropriate committees of Congress a 
report concerning—
(A) the information that is provided under 
paragraph (3)(D); 
(B) the number of denials that have been 
upheld by independent medical review panels 
and the number of denials that have been re-
versed by such panels; and 
(C) the extent to which independent med-
ical review panels are requiring coverage for 
benefits that are specifically excluded under the 
plan or coverage. 
SEC. 105. HEALTH CARE CONSUMER ASSISTANCE FUND. 
(a) GRANTS.—
(1) IN GENERAL.—The Secretary of Health and 
Human Services (referred to in this section as the 
‘‘Secretary’’) shall establish a fund, to be known as 
the ‘‘Health Care Consumer Assistance Fund’’, to be 
used to award grants to eligible States to carry out 
consumer assistance activities (including programs 
established by States prior to the enactment of this
Act) designed to provide information, assistance, and 
referrals to consumers of health insurance products. 
(2) STATE ELIGIBILITY.—To be eligible to re-
ceive a grant under this subsection a State shall pre-
pare and submit to the Secretary an application at 
such time, in such manner, and containing such in-
formation as the Secretary may require, including a 
State plan that describes—
(A) the manner in which the State will en-
sure that the health care consumer assistance 
office (established under paragraph (4)) will 
educate and assist health care consumers in ac-
cessing needed care; 
(B) the manner in which the State will co-
ordinate and distinguish the services provided 
by the health care consumer assistance office 
with the services provided by Federal, State and 
local health-related ombudsman, information, 
protection and advocacy, insurance, and fraud 
and abuse programs; 
(C) the manner in which the State will 
provide information, outreach, and services to 
underserved, minority populations with limited 
English proficiency and populations residing in 
rural areas;
(D) the manner in which the State will 
oversee the health care consumer assistance of-
fice, its activities, product materials and evalu-
ate program effectiveness; 
(E) the manner in which the State will en-
sure that funds made available under this sec-
tion will be used to supplement, and not sup-
plant, any other Federal, State, or local funds 
expended to provide services for programs de-
scribed under this section and those described 
in subparagraphs (C) and (D); 
(F) the manner in which the State will en-
sure that health care consumer office personnel 
have the professional background and training 
to carry out the activities of the office; and 
(G) the manner in which the State will en-
sure that consumers have direct access to con-
sumer assistance personnel during regular busi-
ness hours. 
(3) AMOUNT OF GRANT.—
(A) IN GENERAL.—From amounts appro-
priated under subsection (b) for a fiscal year, 
the Secretary shall award a grant to a State in 
an amount that bears the same ratio to such 
amounts as the number of individuals within
the State covered under a group health plan or 
under health insurance coverage offered by a 
health insurance issuer bears to the total num-
ber of individuals so covered in all States (as 
determined by the Secretary). Any amounts 
provided to a State under this subsection that 
are not used by the State shall be remitted to 
the Secretary and reallocated in accordance 
with this subparagraph. 
(B) MINIMUM AMOUNT.—In no case shall 
the amount provided to a State under a grant 
under this subsection for a fiscal year be less 
than an amount equal to 0.5 percent of the 
amount appropriated for such fiscal year to 
carry out this section. 
(C) NON-FEDERAL
CONTRIBUTIONS.—A 
State will provide for the collection of non-Fed-
eral contributions for the operation of the office 
in an amount that is not less than 25 percent 
of the amount of Federal funds provided to the 
State under this section. 
(4) PROVISION OF FUNDS FOR ESTABLISHMENT 
OF OFFICE.—
(A) IN
GENERAL.—From amounts pro-
vided under a grant under this subsection, a
State shall, directly or through a contract with 
an independent, nonprofit entity with dem-
onstrated experience in serving the needs of 
health care consumers, provide for the estab-
lishment and operation of a State health care 
consumer assistance office. 
(B) ELIGIBILITY OF ENTITY.—To be eligi-
ble to enter into a contract under subparagraph 
(A), an entity shall demonstrate that it has the 
technical, organizational, and professional ca-
pacity to deliver the services described in sub-
section (b) to all public and private health in-
surance participants, beneficiaries, enrollees, or 
prospective enrollees. 
(C) EXISTING STATE ENTITY.—Nothing in 
this section shall prevent the funding of an ex-
isting health care consumer assistance program 
that otherwise meets the requirements of this 
section. 
(b) USE OF FUNDS.—
(1) BY STATE.—A State shall use amounts pro-
vided under a grant awarded under this section to 
carry out consumer assistance activities directly or 
by contract with an independent, non-profit organi-
zation. An eligible entity may use some reasonable
amount of such grant to ensure the adequate train-
ing of personnel carrying out such activities. To re-
ceive amounts under this subsection, an eligible enti-
ty shall provide consumer assistance services, includ-
ing—
(A) the operation of a toll-free telephone 
hotline to respond to consumer requests; 
(B) the dissemination of appropriate edu-
cational materials on available health insurance 
products and on how best to access health care 
and the rights and responsibilities of health 
care consumers;
(C) the provision of education on effective 
methods to promptly and efficiently resolve 
questions, problems, and grievances; 
(D) the coordination of educational and 
outreach efforts with health plans, health care 
providers, payers, and governmental agencies; 
(E) referrals to appropriate private and 
public entities to resolve questions, problems 
and grievances; and 
(F) the provision of information and as-
sistance, including acting as an authorized rep-
resentative, regarding internal, external, or ad-
ministrative grievances or appeals procedures in
nonlitigative settings to appeal the denial, ter-
mination, or reduction of health care services, 
or the refusal to pay for such services, under a 
group health plan or health insurance coverage 
offered by a health insurance issuer. 
(2) CONFIDENTIALITY AND ACCESS TO INFOR-
MATION.—
(A) STATE
ENTITY.—With respect to a 
State that directly establishes a health care con-
sumer assistance office, such office shall estab-
lish and implement procedures and protocols in 
accordance with applicable Federal and State 
laws. 
(B) CONTRACT ENTITY.—With respect to a 
State that, through contract, establishes a 
health care consumer assistance office, such of-
fice shall establish and implement procedures 
and protocols, consistent with applicable Fed-
eral and State laws, to ensure the confiden-
tiality of all information shared by a partici-
pant, beneficiary, enrollee, or their personal 
representative and their health care providers, 
group health plans, or health insurance insurers 
with the office and to ensure that no such infor-
mation is used by the office, or released or dis-
closed to State agencies or outside persons or 
entities without the prior written authorization 
(in accordance with section 164.508 of title 45, 
Code of Federal Regulations) of the individual 
or personal representative. The office may, con-
sistent with applicable Federal and State con-
fidentiality laws, collect, use or disclose aggre-
gate information that is not individually identi-
fiable (as defined in section 164.501 of title 45, 
Code of Federal Regulations). The office shall 
provide a written description of the policies and 
procedures of the office with respect to the 
manner in which health information may be 
used or disclosed to carry out consumer assist-
ance activities. The office shall provide health 
care providers, group health plans, or health in-
surance issuers with a written authorization (in 
accordance with section 164.508 of title 45, 
Code of Federal Regulations) to allow the office 
to obtain medical information relevant to the 
matter before the office. 
(3) AVAILABILITY
OF
SERVICES.—The health 
care consumer assistance office of a State shall not 
discriminate in the provision of information, refer-
rals, and services regardless of the source of the in-
dividual’s health insurance coverage or prospective 
coverage, including individuals covered under a 
group health plan or health insurance coverage of-
fered by a health insurance issuer, the medicare or 
medicaid programs under title XVIII or XIX of the 
Social Security Act (42 U.S.C. 1395 and 1396 et 
seq.), or under any other Federal or State health 
care program. 
(4) DESIGNATION OF RESPONSIBILITIES.—
(A) WITHIN EXISTING STATE ENTITY.—If 
the health care consumer assistance office of a 
State is located within an existing State regu-
latory agency or office of an elected State offi-
cial, the State shall ensure that—
(i) there is a separate delineation of 
the funding, activities, and responsibilities 
of the office as compared to the other 
funding, activities, and responsibilities of 
the agency; and 
(ii) the office establishes and imple-
ments procedures and protocols to ensure 
the 
confidentiality 
of 
all 
information 
shared by a participant, beneficiary, or en-
rollee or their personal representative and 
their health care providers, group health
plans, or health insurance issuers with the 
office and to ensure that no information is 
disclosed to the State agency or office 
without the written authorization of the in-
dividual or their personal representative in 
accordance with paragraph (2). 
(B) CONTRACT ENTITY.—In the case of an 
entity that enters into a contract with a State 
under subsection (a)(3), the entity shall provide 
assurances that the entity has no conflict of in-
terest in carrying out the activities of the office 
and that the entity is independent of group 
health plans, health insurance issuers, pro-
viders, payers, and regulators of health care. 
(5) SUBCONTRACTS.—The health care con-
sumer assistance office of a State may carry out ac-
tivities and provide services through contracts en-
tered into with 1 or more nonprofit entities so long 
as the office can demonstrate that all of the require-
ments of this section are complied with by the office. 
(6) TERM.—A contract entered into under this 
subsection shall be for a term of 3 years. 
(c) REPORT.—Not later than 1 year after the Sec-
retary first awards grants under this section, and annually 
thereafter, the Secretary shall prepare and submit to the
appropriate committees of Congress a report concerning 
the activities funded under this section and the effective-
ness of such activities in resolving health care-related 
problems and grievances. 
(d) AUTHORIZATION
OF APPROPRIATIONS.—There 
are authorized to be appropriated such sums as may be 
necessary to carry out this section. 
Subtitle B—Access to Care 
SEC. 111. CONSUMER CHOICE OPTION. 
(a) IN GENERAL.—If—
(1) a health insurance issuer providing health 
insurance coverage in connection with a group health 
plan offers to enrollees health insurance coverage 
which provides for coverage of services (including 
physician pathology services) only if such services 
are furnished through health care professionals and 
providers who are members of a network of health 
care professionals and providers who have entered 
into a contract with the issuer to provide such serv-
ices, or 
(2) a group health plan offers to participants or 
beneficiaries health benefits which provide for cov-
erage of services only if such services are furnished 
through health care professionals and providers who 
are members of a network of health care profes-
sionals and providers who have entered into a con-
tract with the plan to provide such services, 
then the issuer or plan shall also offer or arrange to be 
offered to such enrollees, participants, or beneficiaries (at 
the time of enrollment and during an annual open season 
as provided under subsection (c)) the option of health in-
surance coverage or health benefits which provide for cov-
erage of such services which are not furnished through 
health care professionals and providers who are members 
of such a network unless such enrollees, participants, or 
beneficiaries are offered such non-network coverage 
through another group health plan or through another 
health insurance issuer in the group market. 
(b) ADDITIONAL COSTS.—The amount of any addi-
tional premium charged by the health insurance issuer or 
group health plan for the additional cost of the creation 
and maintenance of the option described in subsection (a) 
and the amount of any additional cost sharing imposed 
under such option shall be borne by the enrollee, partici-
pant, or beneficiary unless it is paid by the health plan 
sponsor or group health plan through agreement with the 
health insurance issuer. 
(c) OPEN SEASON.—An enrollee, participant, or ben-
eficiary, may change to the offering provided under this 
section only during a time period determined by the health
insurance issuer or group health plan. Such time period 
shall occur at least annually. 
SEC. 112. CHOICE OF HEALTH CARE PROFESSIONAL. 
(a) PRIMARY CARE.—If a group health plan, or a 
health insurance issuer that offers health insurance cov-
erage, requires or provides for designation by a partici-
pant, beneficiary, or enrollee of a participating primary 
care provider, then the plan or issuer shall permit each 
participant, beneficiary, and enrollee to designate any par-
ticipating primary care provider who is available to accept 
such individual. 
(b) SPECIALISTS.—
(1) IN GENERAL.—Subject to paragraph (2), a 
group health plan and a health insurance issuer that 
offers health insurance coverage shall permit each 
participant, beneficiary, or enrollee to receive medi-
cally necessary and appropriate specialty care, pur-
suant to appropriate referral procedures, from any 
qualified participating health care professional who 
is available to accept such individual for such care. 
(2) LIMITATION.—Paragraph (1) shall not 
apply to specialty care if the plan or issuer clearly 
informs participants, beneficiaries, and enrollees of 
the limitations on choice of participating health care 
professionals with respect to such care.
(3) CONSTRUCTION.—Nothing in this sub-
section shall be construed as affecting the applica-
tion of section 114 (relating to access to specialists). 
SEC. 113. ACCESS TO EMERGENCY CARE. 
(a) COVERAGE OF EMERGENCY SERVICES.—
(1) IN GENERAL.—If a group health plan, or 
health insurance coverage offered by a health insur-
ance issuer, provides or covers any benefits with re-
spect to services in an emergency department of a 
hospital, the plan or issuer shall cover emergency 
services (as defined in paragraph (2)(B))—
(A) without the need for any prior author-
ization determination; 
(B) whether the health care provider fur-
nishing such services is a participating provider 
with respect to such services; 
(C) in a manner so that, if such services 
are provided to a participant, beneficiary, or en-
rollee—
(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.—
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, with respect to an 
emergency medical condition—
(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 such emergency medical 
condition, 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’’, 
with respect to an emergency medical condition 
(as defined in subparagraph (A)), has the 
meaning given in section 1867(e)(3) of the So-
cial Security Act (42 U.S.C. 1395dd(e)(3)). 
(b) REIMBURSEMENT FOR MAINTENANCE CARE AND 
POST-STABILIZATION CARE.—A group health plan, and
health insurance coverage offered by a health insurance 
issuer, must provide reimbursement for maintenance care 
and post-stabilization care in accordance with the require-
ments of section 1852(d)(2) of the Social Security Act (42 
U.S.C. 1395w–22(d)(2)). Such reimbursement shall be 
provided in a manner consistent with subsection (a)(1)(C). 
(c) COVERAGE OF EMERGENCY AMBULANCE SERV-
ICES.—
(1) IN GENERAL.—If a group health plan, or 
health insurance coverage provided by a health in-
surance issuer, provides any benefits with respect to 
ambulance services and emergency services, the plan 
or issuer shall cover emergency ambulance services 
(as defined in paragraph (2)) furnished under the 
plan or coverage under the same terms and condi-
tions under subparagraphs (A) through (D) of sub-
section (a)(1) under which coverage is provided for 
emergency services. 
(2) EMERGENCY AMBULANCE SERVICES.—For 
purposes of this subsection, the term ‘‘emergency 
ambulance services’’ means ambulance services (as 
defined for purposes of section 1861(s)(7) of the So-
cial Security Act) furnished to transport an indi-
vidual who has an emergency medical condition (as 
defined in subsection (a)(2)(A)) to a hospital for the
receipt of emergency services (as defined in sub-
section (a)(2)(B)) in a case in which the emergency 
services are covered under the plan or coverage pur-
suant to subsection (a)(1) and a prudent layperson, 
with an average knowledge of health and medicine, 
could reasonably expect that the absence of such 
transport would result in placing the health of the 
individual in serious jeopardy, serious impairment of 
bodily function, or serious dysfunction of any bodily 
organ or part. 
SEC. 114. TIMELY ACCESS TO SPECIALISTS. 
(a) TIMELY ACCESS.—
(1) IN GENERAL.—A group health plan and a 
health insurance issuer offering health insurance 
coverage shall ensure that participants, beneficiaries, 
and enrollees receive timely access to specialists who 
are appropriate to the condition of, and accessible 
to, the participant, beneficiary, or enrollee, when 
such specialty care is a covered benefit under the 
plan or coverage. 
(2) RULE
OF
CONSTRUCTION.—Nothing in 
paragraph (1) shall be construed—
(A) to require the coverage under a group 
health plan or health insurance coverage of ben-
efits or services;
(B) to prohibit a plan or issuer from in-
cluding providers in the network only to the ex-
tent necessary to meet the needs of the plan’s 
or issuer’s participants, beneficiaries, or enroll-
ees; or 
(C) to override any State licensure or 
scope-of-practice law. 
(3) ACCESS TO CERTAIN PROVIDERS.—
(A) IN
GENERAL.—With respect to spe-
cialty care under this section, if a participating 
specialist is not available and qualified to pro-
vide such care to the participant, beneficiary, or 
enrollee, the plan or issuer shall provide for cov-
erage of such care by a nonparticipating spe-
cialist. 
(B) TREATMENT
OF
NONPARTICIPATING 
PROVIDERS.—If a participant, beneficiary, or 
enrollee receives care from a nonparticipating 
specialist pursuant to subparagraph (A), such 
specialty care shall be provided at no additional 
cost to the participant, beneficiary, or enrollee 
beyond what the participant, beneficiary, or en-
rollee would otherwise pay for such specialty 
care if provided by a participating specialist. 
(b) REFERRALS.—
(1) AUTHORIZATION.—Subject to subsection 
(a)(1), a group health plan or health insurance 
issuer may require an authorization in order to ob-
tain coverage for specialty services under this sec-
tion. Any such authorization—
(A) shall be for an appropriate duration of 
time or number of referrals, including an au-
thorization for a standing referral where appro-
priate; and 
(B) may not be refused solely because the 
authorization involves services of a nonpartici-
pating 
specialist 
(described 
in 
subsection 
(a)(3)). 
(2) REFERRALS FOR ONGOING SPECIAL CONDI-
TIONS.—
(A) IN GENERAL.—Subject to subsection 
(a)(1), a group health plan and a health insur-
ance issuer shall permit a participant, bene-
ficiary, or enrollee who has an ongoing special 
condition (as defined in subparagraph (B)) to 
receive a referral to a specialist for the treat-
ment of such condition and such specialist may 
authorize such referrals, procedures, tests, and 
other medical services with respect to such con-
dition, or coordinate the care for such condi-
tion, subject to the terms of a treatment plan 
(if any) referred to in subsection (c) with re-
spect to the condition. 
(B) ONGOING
SPECIAL
CONDITION
DE-
FINED.—In this subsection, the term ‘‘ongoing 
special condition’’ means a condition or disease 
that—
(i) is life-threatening, degenerative, 
potentially disabling, or congenital; and 
(ii) requires specialized medical care 
over a prolonged period of time. 
(c) TREATMENT PLANS.—
(1) IN
GENERAL.—A group health plan or 
health insurance issuer may require that the spe-
cialty care be provided—
(A) pursuant to a treatment plan, but only 
if the treatment plan—
(i) is developed by the specialist, in 
consultation with the case manager or pri-
mary care provider, and the participant, 
beneficiary, or enrollee, and 
(ii) is approved by the plan or issuer 
in a timely manner, if the plan or issuer 
requires such approval; and
(B) in accordance with applicable quality 
assurance and utilization review standards of 
the plan or issuer. 
(2) NOTIFICATION.—Nothing in paragraph (1) 
shall be construed as prohibiting a plan or issuer 
from requiring the specialist to provide the plan or 
issuer with regular updates on the specialty care 
provided, as well as all other reasonably necessary 
medical information. 
(d) SPECIALIST DEFINED.—For purposes of this sec-
tion, the term ‘‘specialist’’ means, with respect to the con-
dition of the participant, beneficiary, or enrollee, a health 
care professional, facility, or center that has adequate ex-
pertise through appropriate training and experience (in-
cluding, in the case of a child, appropriate pediatric exper-
tise) to provide high quality care in treating the condition. 
SEC. 115. PATIENT ACCESS TO OBSTETRICAL AND GYNECO-
LOGICAL CARE. 
(a) GENERAL RIGHTS.—
(1) DIRECT ACCESS.—A group health plan, and 
a health insurance issuer offering health insurance 
coverage, described in subsection (b) may not re-
quire authorization or referral by the plan, issuer, or 
any person (including a primary care provider de-
scribed in subsection (b)(2)) in the case of a female
participant, beneficiary, or enrollee who seeks cov-
erage for obstetrical or gynecological care provided 
by a participating health care professional who spe-
cializes in obstetrics or gynecology. 
(2) 
OBSTETRICAL
AND
GYNECOLOGICAL 
CARE.—A group health plan and a health insurance 
issuer described in subsection (b) shall treat the pro-
vision of obstetrical and gynecological care, and the 
ordering of related obstetrical and gynecological 
items and services, pursuant to the direct access de-
scribed under paragraph (1), by a participating 
health care professional who specializes in obstetrics 
or gynecology as the authorization of the primary 
care provider. 
(b) APPLICATION OF SECTION.—A group health plan, 
or health insurance issuer offering health insurance cov-
erage, described in this subsection is a group health plan 
or coverage that—
(1) 
provides 
coverage 
for 
obstetric 
or 
gynecologic care; and 
(2) requires the designation by a participant, 
beneficiary, or enrollee of a participating primary 
care provider. 
(c) CONSTRUCTION.—Nothing in subsection (a) shall 
be construed to—
(1) waive any exclusions of coverage under the 
terms and conditions of the plan or health insurance 
coverage with respect to coverage of obstetrical or 
gynecological care; or 
(2) preclude the group health plan or health in-
surance issuer involved from requiring that the ob-
stetrical or gynecological provider notify the primary 
care health care professional or the plan or issuer of 
treatment decisions. 
SEC. 116. ACCESS TO PEDIATRIC CARE. 
(a) PEDIATRIC CARE.—In the case of a person who 
has a child who is a participant, beneficiary, or enrollee 
under a group health plan, or health insurance coverage 
offered by a health insurance issuer, if the plan or issuer 
requires or provides for the designation of a participating 
primary care provider for the child, the plan or issuer shall 
permit such person to designate a physician (allopathic or 
osteopathic) who specializes in pediatrics as the child’s pri-
mary care provider if such provider participates in the net-
work of the plan or issuer. 
(b) CONSTRUCTION.—Nothing in subsection (a) shall 
be construed to waive any exclusions of coverage under 
the terms and conditions of the plan or health insurance 
coverage with respect to coverage of pediatric care.
SEC. 117. CONTINUITY OF CARE. 
(a) TERMINATION OF PROVIDER.—
(1) IN GENERAL.—If—
(A) a contract between a group health 
plan, or a health insurance issuer offering 
health insurance coverage, and a treating health 
care provider is terminated (as defined in para-
graph (e)(4)), or 
(B) benefits or coverage provided by a 
health care provider are terminated because of 
a change in the terms of provider participation 
in such plan or coverage, 
the plan or issuer shall meet the requirements of 
paragraph (3) with respect to each continuing care 
patient. 
(2) TREATMENT
OF
TERMINATION
OF
CON-
TRACT
WITH
HEALTH
INSURANCE
ISSUER.—If a 
contract for the provision of health insurance cov-
erage between a group health plan and a health in-
surance issuer is terminated and, as a result of such 
termination, coverage of services of a health care 
provider is terminated with respect to an individual, 
the provisions of paragraph (1) (and the succeeding 
provisions of this section) shall apply under the plan 
in the same manner as if there had been a contract 
between the plan and the provider that had been ter-
minated, but only with respect to benefits that are 
covered under the plan after the contract termi-
nation.
(3) REQUIREMENTS.—The requirements of this 
paragraph are that the plan or issuer—
(A) notify the continuing care patient in-
volved, or arrange to have the patient notified 
pursuant to subsection (d)(2), on a timely basis 
of the termination described in paragraph (1) 
(or paragraph (2), if applicable) and the right 
to elect continued transitional care from the 
provider under this section; 
(B) provide the patient with an oppor-
tunity to notify the plan or issuer of the pa-
tient’s need for transitional care; and 
(C) subject to subsection (c), permit the 
patient to elect to continue to be covered with 
respect to the course of treatment by such pro-
vider with the provider’s consent during a tran-
sitional period (as provided for under subsection 
(b)). 
(4) CONTINUING CARE PATIENT.—For purposes 
of this section, the term ‘‘continuing care patient’’ 
means a participant, beneficiary, or enrollee who—
(A) is undergoing a course of treatment 
for a serious and complex condition from the 
provider at the time the plan or issuer receives 
or provides notice of provider, benefit, or cov-
erage termination described in paragraph (1) 
(or paragraph (2), if applicable); 
(B) is undergoing a course of institutional 
or inpatient care from the provider at the time 
of such notice; 
(C) is scheduled to undergo non-elective 
surgery from the provider at the time of such 
notice; 
(D) is pregnant and undergoing a course 
of treatment for the pregnancy from the pro-
vider at the time of such notice; or 
(E) is or was determined to be terminally 
ill (as determined under section 1861(dd)(3)(A) 
of the Social Security Act) at the time of such 
notice, but only with respect to a provider that 
was treating the terminal illness before the date 
of such notice. 
(b) TRANSITIONAL PERIODS.—
(1) SERIOUS AND COMPLEX CONDITIONS.—The 
transitional period under this subsection with re-
spect to a continuing care patient described in sub-
section (a)(4)(A) shall extend for up to 90 days (as 
determined by the treating health care professional) 
from the date of the notice described in subsection 
(a)(3)(A). 
(2) INSTITUTIONAL OR INPATIENT CARE.—The 
transitional period under this subsection for a con-
tinuing 
care 
patient 
described 
in 
subsection 
(a)(4)(B) shall extend until the earlier of—
(A) the expiration of the 90-day period be-
ginning on the date on which the notice under 
subsection (a)(3)(A) is provided; or 
(B) the date of discharge of the patient 
from such care or the termination of the period 
of institutionalization, or, if later, the date of 
completion of reasonable follow-up care. 
(3) SCHEDULED
NON-ELECTIVE
SURGERY.—
The transitional period under this subsection for a 
continuing care patient described in subsection 
(a)(4)(C) shall extend until the completion of the 
surgery involved and post-surgical follow-up care re-
lating to the surgery and occurring within 90 days 
after the date of the surgery. 
(4) 
PREGNANCY.—The 
transitional 
period 
under this subsection for a continuing care patient 
described in subsection (a)(4)(D) shall extend
through the provision of post-partum care directly 
related to the delivery. 
(5) TERMINAL ILLNESS.—The transitional pe-
riod under this subsection for a continuing care pa-
tient described in subsection (a)(4)(E) shall extend 
for the remainder of the patient’s life for care that 
is directly related to the treatment of the terminal 
illness or its medical manifestations. 
(c) PERMISSIBLE
TERMS
AND
CONDITIONS.—A 
group health plan or health insurance issuer may condi-
tion coverage of continued treatment by a provider under 
this section upon the provider agreeing to the following 
terms and conditions: 
(1) The treating health care provider agrees to 
accept reimbursement from the plan or issuer and 
continuing care patient involved (with respect to 
cost-sharing) at the rates applicable prior to the 
start of the transitional period as payment in full 
(or, in the case described in subsection (a)(2), at the 
rates applicable under the replacement plan or cov-
erage after the date of the termination of the con-
tract with the group health plan or health insurance 
issuer) and not to impose cost-sharing with respect 
to the patient in an amount that would exceed the 
cost-sharing that could have been imposed if the
contract referred to in subsection (a)(1) had not 
been terminated. 
(2) The treating health care provider agrees to 
adhere to the quality assurance standards of the 
plan or issuer responsible for payment under para-
graph (1) and to provide to such plan or issuer nec-
essary medical information related to the care pro-
vided. 
(3) The treating health care provider agrees 
otherwise to adhere to such plan’s or issuer’s policies 
and procedures, including procedures regarding re-
ferrals and obtaining prior authorization and pro-
viding services pursuant to a treatment plan (if any) 
approved by the plan or issuer. 
(d) RULES OF CONSTRUCTION.—Nothing in this sec-
tion shall be construed—
(1) to require the coverage of benefits which 
would not have been covered if the provider involved 
remained a participating provider; or 
(2) with respect to the termination of a con-
tract under subsection (a) to prevent a group health 
plan or health insurance issuer from requiring that 
the health care provider—
(A) notify participants, beneficiaries, or en-
rollees of their rights under this section; or
(B) provide the plan or issuer with the 
name of each participant, beneficiary, or en-
rollee who the provider believes is a continuing 
care patient. 
(e) DEFINITIONS.—In this section: 
(1) CONTRACT.—The term ‘‘contract’’ includes, 
with respect to a plan or issuer and a treating 
health care provider, a contract between such plan 
or issuer and an organized network of providers that 
includes the treating health care provider, and (in 
the case of such a contract) the contract between the 
treating health care provider and the organized net-
work. 
(2) HEALTH
CARE
PROVIDER.—The term 
‘‘health care provider’’ or ‘‘provider’’ means—
(A) any individual who is engaged in the 
delivery of health care services in a State and 
who is required by State law or regulation to be 
licensed or certified by the State to engage in 
the delivery of such services in the State; and 
(B) any entity that is engaged in the deliv-
ery of health care services in a State and that, 
if it is required by State law or regulation to be 
licensed or certified by the State to engage in
100
the delivery of such services in the State, is so 
licensed. 
(3) SERIOUS AND COMPLEX CONDITION.—The 
term ‘‘serious and complex condition’’ means, with 
respect to a participant, beneficiary, or enrollee 
under the plan or coverage—
(A) in the case of an acute illness, a condi-
tion that is serious enough to require special-
ized medical treatment to avoid the reasonable 
possibility of death or permanent harm; or 
(B) in the case of a chronic illness or con-
dition, is an ongoing special condition (as de-
fined in section 114(b)(2)(B)). 
(4) TERMINATED.—The term ‘‘terminated’’ in-
cludes, with respect to a contract, the expiration or 
nonrenewal of the contract, but does not include a 
termination of the contract for failure to meet appli-
cable quality standards or for fraud.
SEC. 118. ACCESS TO NEEDED PRESCRIPTION DRUGS. 
(a) IN GENERAL.—To the extent that a group health 
plan, or health insurance coverage offered by a health in-
surance issuer, provides coverage for benefits with respect 
to prescription drugs, and limits such coverage to drugs 
included in a formulary, the plan or issuer shall—
101
(1) ensure the participation of physicians and 
pharmacists in developing and reviewing such for-
mulary; 
(2) provide for disclosure of the formulary to 
providers; and 
(3) in accordance with the applicable quality as-
surance and utilization review standards of the plan 
or issuer, provide for exceptions from the formulary 
limitation when a non-formulary alternative is medi-
cally necessary and appropriate and, in the case of 
such an exception, apply the same cost-sharing re-
quirements that would have applied in the case of a 
drug covered under the formulary. 
(b) COVERAGE OF APPROVED DRUGS AND MEDICAL 
DEVICES.—
(1) IN GENERAL.—A group health plan (and 
health insurance coverage offered in connection with 
such a plan) that provides any coverage of prescrip-
tion drugs or medical devices shall not deny coverage 
of such a drug or device on the basis that the use 
is investigational, if the use—
(A) in the case of a prescription drug—
(i) is included in the labeling author-
ized by the application in effect for the 
drug pursuant to subsection (b) or (j) of
102
section 505 of the Federal Food, Drug, 
and Cosmetic Act, without regard to any 
postmarketing 
requirements 
that 
may 
apply under such Act; or 
(ii) is included in the labeling author-
ized by the application in effect for the 
drug under section 351 of the Public 
Health Service Act, without regard to any 
postmarketing 
requirements 
that 
may 
apply pursuant to such section; or 
(B) in the case of a medical device, is in-
cluded in the labeling authorized by a regula-
tion under subsection (d) or (e) of section 513 
of the Federal Food, Drug, and Cosmetic Act, 
an order under subsection (f) of such section, or 
an application approved under section 515 of 
such Act, without regard to any postmarketing 
requirements that may apply under such Act. 
(2) CONSTRUCTION.—Nothing in this sub-
section shall be construed as requiring a group 
health plan (or health insurance coverage offered in 
connection with such a plan) to provide any coverage 
of prescription drugs or medical devices.
103
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
104
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
105
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 and a health insurance issuer shall pro-
vide 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 ex-
pected (as determined by the appropriate Secretary) 
to be paid for by the sponsors of an approved clin-
ical 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
106
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—
(A) approved and funded (which may in-
clude funding through in-kind contributions) by 
one or more of the following: 
(i) the National Institutes of Health; 
(ii) a cooperative group or center of 
the National Institutes of Health, includ-
ing a qualified nongovernmental research 
entity to which the National Cancer Insti-
tute has awarded a center support grant; 
(iii) either of the following if the con-
ditions described in paragraph (2) are 
met—
(I) the Department of Veterans 
Affairs; 
(II) the Department of Defense; 
or 
(B) approved by the Food and Drug Ad-
ministration.
107
(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 appropriate 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 
ethical 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. 
SEC. 120. REQUIRED COVERAGE FOR MINIMUM HOSPITAL 
STAY FOR MASTECTOMIES AND LYMPH NODE 
DISSECTIONS 
FOR 
THE 
TREATMENT 
OF 
BREAST CANCER AND COVERAGE FOR SEC-
ONDARY CONSULTATIONS. 
(a) INPATIENT CARE.—
(1) IN GENERAL.—A group health plan, and a 
health insurance issuer providing health insurance 
coverage, that provides medical and surgical benefits 
shall ensure that inpatient coverage with respect to
108
the treatment of breast cancer is provided for a pe-
riod of time as is determined by the attending physi-
cian, in consultation with the patient, to be medi-
cally necessary and appropriate following—
(A) a mastectomy; 
(B) a lumpectomy; or 
(C) a lymph node dissection for the treat-
ment of breast cancer. 
(2) EXCEPTION.—Nothing in this section shall 
be construed as requiring the provision of inpatient 
coverage if the attending physician and patient de-
termine that a shorter period of hospital stay is 
medically appropriate. 
(b) PROHIBITION ON CERTAIN MODIFICATIONS.—In 
implementing the requirements of this section, a group 
health plan, and a health insurance issuer providing health 
insurance coverage, may not modify the terms and condi-
tions of coverage based on the determination by a partici-
pant, beneficiary, or enrollee to request less than the min-
imum coverage required under subsection (a). 
(c) SECONDARY CONSULTATIONS.—
(1) IN GENERAL.—A group health plan, and a 
health insurance issuer providing health insurance 
coverage, that provides coverage with respect to 
medical and surgical services provided in relation to
109
the diagnosis and treatment of cancer shall ensure 
that full coverage is provided for secondary consulta-
tions by specialists in the appropriate medical fields 
(including pathology, radiology, and oncology) to 
confirm or refute such diagnosis. Such plan or issuer 
shall ensure that full coverage is provided for such 
secondary consultation whether such consultation is 
based on a positive or negative initial diagnosis. In 
any case in which the attending physician certifies in 
writing that services necessary for such a secondary 
consultation are not sufficiently available from spe-
cialists operating under the plan or coverage with re-
spect to whose services coverage is otherwise pro-
vided under such plan or by such issuer, such plan 
or issuer shall ensure that coverage is provided with 
respect to the services necessary for the secondary 
consultation with any other specialist selected by the 
attending physician for such purpose at no addi-
tional cost to the individual beyond that which the 
individual would have paid if the specialist was par-
ticipating in the network of the plan or issuer. 
(2) EXCEPTION.—Nothing in paragraph (1) 
shall be construed as requiring the provision of sec-
ondary consultations where the patient determines 
not to seek such a consultation.
110
(d) PROHIBITION ON PENALTIES OR INCENTIVES.—
A group health plan, and a health insurance issuer pro-
viding health insurance coverage, may not—
(1) penalize or otherwise reduce or limit the re-
imbursement of a provider or specialist because the 
provider or specialist provided care to a participant, 
beneficiary, or enrollee in accordance with this sec-
tion; 
(2) provide financial or other incentives to a 
physician or specialist to induce the physician or 
specialist to keep the length of inpatient stays of pa-
tients following a mastectomy, lumpectomy, or a 
lymph node dissection for the treatment of breast 
cancer below certain limits or to limit referrals for 
secondary consultations; or 
(3) provide financial or other incentives to a 
physician or specialist to induce the physician or 
specialist to refrain from referring a participant, 
beneficiary, or enrollee for a secondary consultation 
that would otherwise be covered by the plan or cov-
erage involved under subsection (c). 
Subtitle C—Access to Information 
SEC. 121. PATIENT ACCESS TO INFORMATION. 
(a) REQUIREMENT.—
(1) DISCLOSURE.—
117
formation that the plan or issuer may provide re-
garding the appropriate use of emergency services. 
(13) CLAIMS AND APPEALS.—A description of 
the plan or issuer’s rules and procedures pertaining 
to claims and appeals, a description of the rights 
(including deadlines for exercising rights) of partici-
pants, beneficiaries, and enrollees under subtitle A 
in obtaining covered benefits, filing a claim for bene-
fits, and appealing coverage decisions internally and 
externally (including telephone numbers and mailing 
addresses of the appropriate authority), and a de-
scription of any additional legal rights and remedies 
available under section 502 of the Employee Retire-
ment Income Security Act of 1974 and applicable 
State law. 
(14) ADVANCE DIRECTIVES AND ORGAN DONA-
TION.—A description of procedures for advance di-
rectives and organ donation decisions if the plan or 
issuer maintains such procedures. 
(15) INFORMATION ON PLANS AND ISSUERS.—
The name, mailing address, and telephone number 
or numbers of the plan administrator and the issuer 
to be used by participants, beneficiaries, and enroll-
ees seeking information about plan or coverage bene-
fits and services, payment of a claim, or authoriza-
118
tion for services and treatment. Notice of whether 
the benefits under the plan or coverage are provided 
under a contract or policy of insurance issued by an 
issuer, or whether benefits are provided directly by 
the plan sponsor who bears the insurance risk. 
(16) TRANSLATION SERVICES.—A summary de-
scription of any translation or interpretation services 
(including the availability of printed information in 
languages other than English, audio tapes, or infor-
mation in Braille) that are available for non-English 
speakers and participants, beneficiaries, and enroll-
ees with communication disabilities and a description 
of how to access these items or services. 
(17) ACCREDITATION INFORMATION.—Any in-
formation that is made public by accrediting organi-
zations in the process of accreditation if the plan or 
issuer is accredited, or any additional quality indica-
tors (such as the results of enrollee satisfaction sur-
veys) that the plan or issuer makes public or makes 
available to participants, beneficiaries, and enrollees. 
(18) NOTICE OF REQUIREMENTS.—A descrip-
tion of any rights of participants, beneficiaries, and 
enrollees that are established by the provisions of 
this Act (excluding those described in paragraphs 
(1) through (17)) if such provisions apply. The de-