In the Senate of the United States,
October 14, 1999.
Resolved, That the bill from the House of Representa-
tives (H.R. 2990) entitled ‘‘An Act to amend the Internal
Revenue Code of 1986 to allow individuals greater access to
health insurance through a health care tax deduction, a long-
term care deduction, and other health-related tax incentives,
to amend the Employee Retirement Income Security Act of
1974 to provide access to and choice in health care through
association health plans, to amend the Public Health Service
Act to create new pooling opportunities for small employers
to obtain greater access to health coverage through
HealthMarts; to amend title I of the Employee Retirement
Income Security Act of 1974, title XXVII of the Public
Health Service Act, and the Internal Revenue Code of 1986
to protect consumers in managed care plans and other health
coverage; and for other purposes.’’, do pass with the following
AMENDMENT:
Strike out all after the enacting clause and insert:
SECTION 1. SHORT TITLE; TABLE OF CONTENTS.
(a) SHORT TITLE.—This Act may be cited as the ‘‘Pa-
tients’ Bill of Rights Plus Act’’.
(b) TABLE OF CONTENTS.—The table of contents for
this Act is as follows:
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Sec. 1. Short title; table of contents.
TITLE I—PATIENTS’ BILL OF RIGHTS
Subtitle A—Right to Advice and Care
Sec. 101. Patient right to medical advice and care.
‘‘SUBPART C—PATIENT RIGHT TO MEDICAL ADVICE AND CARE
‘‘Sec. 721. Patient access to emergency medical care.
‘‘Sec. 722. Offering of choice of coverage options.
‘‘Sec. 723. Patient access to obstetric and gynecological care.
‘‘Sec. 724. Patient access to pediatric care.
‘‘Sec. 725. Timely access to specialists.
‘‘Sec. 726. Continuity of care.
‘‘Sec. 727. Protection of patient-provider communications.
‘‘Sec. 728. Patient’s right to prescription drugs.
‘‘Sec. 729. Self-payment for behavioral health care services.
‘‘Sec. 730. Coverage for individuals participating in approved cancer clin-
ical trials.
‘‘Sec. 730A. Prohibiting discrimination against providers.
‘‘Sec. 730B. Generally applicable provision.’’.
Sec. 102. Conforming amendment to the Internal Revenue Code of 1986.
‘‘SUBCHAPTER C—PATIENT RIGHT TO MEDICAL ADVICE AND CARE
‘‘Sec. 9821. Patient access to emergency medical care.
‘‘Sec. 9822. Offering of choice of coverage options.
‘‘Sec. 9823. Patient access to obstetric and gynecological care.
‘‘Sec. 9824. Patient access to pediatric care.
‘‘Sec. 9825. Timely access to specialists.
‘‘Sec. 9826. Continuity of care.
‘‘Sec. 9827. Protection of patient-provider communications.
‘‘Sec. 9828. Patient’s right to prescription drugs.
‘‘Sec. 9829. Self-payment for behavioral health care services.
‘‘Sec. 9830. Coverage for individuals participating in approved cancer clin-
ical trials.
‘‘Sec. 9830A. Prohibiting discrimination against providers.
‘‘Sec. 9830B. Generally applicable provision.’’.
Sec. 103. Effective date and related rules.
Subtitle B—Right to Information About Plans and Providers
Sec. 111. Information about plans.
Sec. 112. Information about providers.
Subtitle C—Right to Hold Health Plans Accountable
Sec. 121. Amendment to Employee Retirement Income Security Act of 1974.
TITLE II—WOMEN’S HEALTH AND CANCER RIGHTS
Sec. 201. Women’s health and cancer rights.
TITLE III—GENETIC INFORMATION AND SERVICES
Sec. 301. Short title.
Sec. 302. Amendments to Employee Retirement Income Security Act of 1974.
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Sec. 303. Amendments to the Public Health Service Act.
Sec. 304. Amendments to the Internal Revenue Code of 1986.
TITLE IV—HEALTHCARE RESEARCH AND QUALITY
Sec. 401. Short title.
Sec. 402. Amendment to the Public Health Service Act.
‘‘TITLE IX—AGENCY FOR HEALTHCARE RESEARCH AND QUALITY
‘‘PART A—ESTABLISHMENT AND GENERAL DUTIES
‘‘Sec. 901. Mission and duties.
‘‘Sec. 902. General authorities.
‘‘PART B—HEALTHCARE IMPROVEMENT RESEARCH
‘‘Sec. 911. Healthcare outcome improvement research.
‘‘Sec. 912. Private-public partnerships to improve organization and delivery.
‘‘Sec. 913. Information on quality and cost of care.
‘‘Sec. 914. Information systems for healthcare improvement.
‘‘Sec. 915. Research supporting primary care and access in underserved
areas.
‘‘Sec. 916. Clinical practice and technology innovation.
‘‘Sec. 917. Coordination of Federal government quality improvement efforts.
‘‘PART C—GENERAL PROVISIONS
‘‘Sec. 921. Advisory Council for Healthcare Research and Quality.
‘‘Sec. 922. Peer review with respect to grants and contracts.
‘‘Sec. 923. Certain provisions with respect to development, collection, and
dissemination of data.
‘‘Sec. 924. Dissemination of information.
‘‘Sec. 925. Additional provisions with respect to grants and contracts.
‘‘Sec. 926. Certain administrative authorities.
‘‘Sec. 927. Funding.
‘‘Sec. 928. Definitions.’’.
Sec. 403. References.
TITLE V—ENHANCED ACCESS TO HEALTH INSURANCE COVERAGE
Sec. 501. Full deduction of health insurance costs for self-employed individuals.
Sec. 502. Full availability of medical savings accounts.
Sec. 503. Permitting contribution towards medical savings account through Fed-
eral employees health benefits program (FEHBP).
Sec. 504. Carryover of unused benefits from cafeteria plans, flexible spending ar-
rangements, and health flexible spending accounts.
TITLE VI—PROVISIONS RELATING TO LONG-TERM CARE
INSURANCE
Sec. 601. Inclusion of qualified long-term care insurance contracts in cafeteria
plans, flexible spending arrangements, and health flexible spend-
ing accounts.
Sec. 602. Deduction for premiums for long-term care insurance.
Sec. 603. Study of long-term care needs in the 21st century.
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TITLE VII—INDIVIDUAL RETIREMENT PLANS
Sec. 701. Modification of income limits on contributions and rollovers to Roth
IRAs.
TITLE VIII—REVENUE PROVISIONS
Sec. 801. Modification to foreign tax credit carryback and carryover periods.
Sec. 802. Limitation on use of non-accrual experience method of accounting.
Sec. 803. Returns relating to cancellations of indebtedness by organizations lend-
ing money.
Sec. 804. Extension of Internal Revenue Service user fees.
Sec. 805. Property subject to a liability treated in same manner as assumption
of liability.
Sec. 806. Charitable split-dollar life insurance, annuity, and endowment con-
tracts.
Sec. 807. Transfer of excess defined benefit plan assets for retiree health benefits.
Sec. 808. Limitations on welfare benefit funds of 10 or more employer plans.
Sec. 809. Modification of installment method and repeal of installment method for
accrual method taxpayers.
Sec. 810. Inclusion of certain vaccines against streptococcus pneumoniae to list
of taxable vaccines.
TITLE IX—MISCELLANEOUS PROVISIONS
Sec. 901. Medicare competitive pricing demonstration project.
TITLE I—PATIENTS’ BILL OF
RIGHTS
Subtitle A—Right to Advice and
Care
SEC. 101. PATIENT RIGHT TO MEDICAL ADVICE AND CARE.
(a) IN GENERAL.—Part 7 of subtitle B of title I of
the Employee Retirement Income Security Act of 1974 (29
U.S.C. 1181 et seq.) is amended—
(1) by redesignating subpart C as subpart D;
and
(2) by inserting after subpart B the following:
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‘‘Subpart C—Patient Right to Medical Advice and
Care
‘‘SEC. 721. PATIENT ACCESS TO EMERGENCY MEDICAL
CARE.
‘‘(a) COVERAGE OF EMERGENCY CARE.—
‘‘(1) IN GENERAL.—To the extent that the group
health plan (other than a fully insured group health
plan) provides coverage for benefits consisting of
emergency medical care (as defined in subsection (c))
or emergency ambulance services, except for items or
services specifically excluded—
‘‘(A) the plan shall provide coverage for
benefits, without requiring preauthorization, for
emergency medical screening examinations or
emergency ambulance services, to the extent that
a prudent layperson, who possesses an average
knowledge of health and medicine, would deter-
mine such examinations or emergency ambu-
lance services to be necessary to determine wheth-
er emergency medical care (as so defined) is nec-
essary; and
‘‘(B) the plan shall provide coverage for
benefits, without requiring preauthorization, for
additional emergency medical care to stabilize
an emergency medical condition following an
emergency medical screening examination (if de-
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termined necessary under subparagraph (A)),
pursuant to the definition of stabilize under sec-
tion 1867(e)(3) of the Social Security Act (42
U.S.C. 1395dd(e)(3)).
‘‘(2) REIMBURSEMENT FOR CARE TO MAINTAIN
MEDICAL STABILITY.—
‘‘(A) IN GENERAL.—In the case of services
provided to a participant or beneficiary by a
nonparticipating provider in order to maintain
the medical stability of the participant or bene-
ficiary, the group health plan involved shall pro-
vide for reimbursement with respect to such serv-
ices if—
‘‘(i) coverage for services of the type
furnished is available under the group
health plan;
‘‘(ii) the services were provided for care
related to an emergency medical condition
and in an emergency department in order
to maintain the medical stability of the
participant or beneficiary; and
‘‘(iii) the nonparticipating provider
contacted the plan regarding approval for
such services.
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‘‘(B) FAILURE TO RESPOND.—If a group
health plan fails to respond within 1 hours of
being contacted in accordance with subpara-
graph (A)(iii), then the plan shall be liable for
the cost of services provided by the nonpartici-
pating provider in order to maintain the sta-
bility of the participant or beneficiary.
‘‘(C) LIMITATION.—The liability of a group
health plan to provide reimbursement under sub-
paragraph (A) shall terminate when the plan
has contacted the nonparticipating provider to
arrange for discharge or transfer.
‘‘(D) LIABILITY OF PARTICIPANT.—A par-
ticipant or beneficiary shall not be liable for the
costs of services to which subparagraph (A) in an
amount that exceeds the amount of liability that
would be incurred if the services were provided
by a participating health care provider with
prior authorization by the plan.
‘‘(b) IN-NETWORK UNIFORM COSTS-SHARING
AND
OUT-OF-NETWORK CARE.—
‘‘(1) IN-NETWORK
UNIFORM
COST-SHARING.—
Nothing in this section shall be construed as pre-
venting a group health plan (other than a fully in-
sured group health plan) from imposing any form of
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cost-sharing applicable to any participant or bene-
ficiary 
(including 
coinsurance, 
copayments,
deductibles, and any other charges) in relation to cov-
erage for benefits described in subsection (a), if such
form of cost-sharing is uniformly applied under such
plan, with respect to similarly situated participants
and beneficiaries, to all benefits consisting of emer-
gency medical care (as defined in subsection (c)) pro-
vided to such similarly situated participants and
beneficiaries under the plan, and such cost-sharing is
disclosed in accordance with section 714.
‘‘(2) OUT-OF-NETWORK CARE.—If a group health
plan (other than a fully insured group health plan)
provides any benefits with respect to emergency med-
ical care (as defined in subsection (c)), the plan shall
cover emergency medical care under the plan in a
manner so that, if such care is provided to a partici-
pant or beneficiary by a nonparticipating health care
provider, the participant or beneficiary is not liable
for amounts that exceed any form of cost-sharing (in-
cluding co-insurance, co-payments, deductibles, and
any other charges) that would be incurred if the serv-
ices were provided by a participating provider.
‘‘(c) DEFINITION OF EMERGENCY MEDICAL CARE.—In
this section:
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‘‘(1) IN GENERAL.—The term ‘emergency medical
care’ means, with respect to a participant or bene-
ficiary under a group health plan (other than a fully
insured group health plan), covered inpatient and
outpatient services that—
‘‘(A) are furnished by any provider, includ-
ing a nonparticipating provider, that is quali-
fied to furnish such services; and
‘‘(B) are needed to evaluate or stabilize (as
such term is defined in section 1867(e)(3) of the
Social Security Act (42 U.S.C. 1395dd)(e)(3))
an emergency medical condition (as defined in
paragraph (2)).
‘‘(2) EMERGENCY
MEDICAL
CONDITION.—The
term ‘emergency medical condition’ means a medical
condition manifesting itself by acute symptoms of suf-
ficient severity (including severe pain) such that a
prudent layperson, who possesses an average knowl-
edge of health and medicine, could reasonably expect
the absence of immediate medical attention to result
in—
‘‘(A) placing the health of the participant or
beneficiary (or, with respect to a pregnant
woman, the health of the woman or her unborn
child) in serious jeopardy,
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‘‘(B) serious impairment to bodily func-
tions, or
‘‘(C) serious dysfunction of any bodily
organ or part.
‘‘SEC. 722. OFFERING OF CHOICE OF COVERAGE OPTIONS.
‘‘(a) REQUIREMENT.—
‘‘(1) OFFERING OF POINT-OF-SERVICE COVERAGE
OPTION.—Except as provided in paragraph (2), if a
group health plan (other than a fully insured group
health plan) provides coverage for benefits only
through a defined set of participating health care pro-
fessionals, the plan shall offer the participant the op-
tion to purchase point-of-service coverage (as defined
in subsection (b)) for all such benefits for which cov-
erage is otherwise so limited. Such option shall be
made available to the participant at the time of en-
rollment under the plan and at such other times as
the plan offers the participant a choice of coverage op-
tions.
‘‘(2) EXCEPTION IN CASE OF LACK OF AVAIL-
ABILITY.—Paragraph (1) shall not apply with respect
to a group health plan (other than a fully insured
group health plan) if care relating to the point-of-
service coverage would not be available and accessible
to the participant with reasonable promptness (con-
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sistent with section 1301(b)(4) of the Public Health
Service Act (42 U.S.C. 300e(b)(4))).
‘‘(b) POINT-OF-SERVICE
COVERAGE
DEFINED.—In
this section, the term ‘point-of-service coverage’ means, with
respect to benefits covered under a group health plan (other
than a fully insured group health plan), coverage of such
benefits when provided by a nonparticipating health care
professional.
‘‘(c) SMALL EMPLOYER EXEMPTION.—
‘‘(1) IN GENERAL.—This section shall not apply
to any group health plan (other than a fully insured
group health plan) of a small employer.
‘‘(2) SMALL EMPLOYER.—For purposes of para-
graph (1), the term ‘small employer’ means, in con-
nection with a group health plan (other than a fully
insured group health plan) with respect to a calendar
year and a plan year, an employer who employed an
average of at least 2 but not more than 50 employees
on business days during the preceding calendar year
and who employs at least 2 employees on the first day
of the plan year. For purposes of this paragraph, the
provisions of subparagraph (C) of section 712(c)(1)
shall apply in determining employer size.
‘‘(d) RULE OF CONSTRUCTION.—Nothing in this sec-
tion shall be construed—
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‘‘(1) as requiring coverage for benefits for a par-
ticular type of health care professional;
‘‘(2) as requiring an employer to pay any costs
as a result of this section or to make equal contribu-
tions with respect to different health coverage options;
‘‘(3) as preventing a group health plan (other
than a fully insured group health plan) from impos-
ing higher premiums or cost-sharing on a participant
for the exercise of a point-of-service coverage option;
or
‘‘(4) to require that a group health plan (other
than a fully insured group health plan) include cov-
erage of health care professionals that the plan ex-
cludes because of fraud, quality of care, or other simi-
lar reasons with respect to such professionals.
‘‘SEC. 723. PATIENT ACCESS TO OBSTETRIC AND GYNECO-
LOGICAL CARE.
‘‘(a) GENERAL RIGHTS.—
‘‘(1) WAIVER
OF
PLAN
REFERRAL
REQUIRE-
MENT.—If a group health plan described in subsection
(b) requires a referral to obtain coverage for specialty
care, the plan shall waive the referral requirement in
the case of a female participant or beneficiary who
seeks coverage for obstetrical care and related follow-
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up obstetrical care or routine gynecological care (such
as preventive gynecological care).
‘‘(2) RELATED ROUTINE CARE.—With respect to
a participant or beneficiary described in paragraph
(1), a group health plan described in subsection (b)
shall treat the ordering of other routine care that is
related to routine gynecologic care, by a physician
who specializes in obstetrics and gynecology as the
authorization of the primary care provider for such
other care.
‘‘(b) APPLICATION OF SECTION.—A group health plan
described in this subsection is a group health plan (other
than a fully insured group health plan), that—
‘‘(1) provides coverage for obstetric care (such as
pregnancy-related services) or routine gynecologic
care (such as preventive women’s health examina-
tions); and
‘‘(2) requires the designation by a participant or
beneficiary of a participating primary care provider
who is not a physician who specializes in obstetrics
or gynecology.
‘‘(c) RULES OF CONSTRUCTION.—Nothing in this sec-
tion shall be construed—
‘‘(1) as waiving any coverage requirement relat-
ing to medical necessity or appropriateness with re-
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spect to the coverage of obstetric or gynecologic care
described in subsection (a);
‘‘(2) to preclude the plan from requiring that the
physician who specializes in obstetrics or gynecology
notify the designated primary care provider or the
plan of treatment decisions;
‘‘(3) to preclude a group health plan from allow-
ing health care professionals other than physicians to
provide routine obstetric or routine gynecologic care;
or
‘‘(4) to preclude a group health plan from per-
mitting a physician who specializes in obstetrics and
gynecology from being a primary care provider under
the plan.
‘‘SEC. 724. PATIENT ACCESS TO PEDIATRIC CARE.
‘‘(a) IN GENERAL.—In the case of a group health plan
(other than a fully insured group health plan) that provides
coverage for routine pediatric care and that requires the
designation by a participant or beneficiary of a partici-
pating primary care provider, if the designated primary
care provider is not a physician who specializes in
pediatrics—
‘‘(1) the plan may not require authorization or
referral by the primary care provider in order for a
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participant or beneficiary to obtain coverage for rou-
tine pediatric care; and
‘‘(2) the plan shall treat the ordering of other
routine care related to routine pediatric care by such
a specialist as having been authorized by the des-
ignated primary care provider.
‘‘(b) RULES
OF CONSTRUCTION.—Nothing in sub-
section (a) shall be construed—
‘‘(1) as waiving any coverage requirement relat-
ing to medical necessity or appropriateness with re-
spect to the coverage of any pediatric care provided
to, or ordered for, a participant or beneficiary;
‘‘(2) to preclude a group health plan from re-
quiring that a specialist described in subsection (a)
notify the designated primary care provider or the
plan of treatment decisions; or
‘‘(3) to preclude a group health plan from allow-
ing health care professionals other than physicians to
provide routine pediatric care.
‘‘SEC. 725. TIMELY ACCESS TO SPECIALISTS.
‘‘(a) TIMELY ACCESS.—
‘‘(1) IN GENERAL.—A group health plan (other
than a fully insured group health plan) shall ensure
that participants and beneficiaries have timely, in
accordance with the medical exigencies of the case, ac-
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cess to primary and specialty health care profes-
sionals who are appropriate to the condition of the
participant or beneficiary, when such care is covered
under the plan. Such access may be provided through
contractual arrangements with specialized providers
outside of the network of the plan.
‘‘(2) RULE
OF
CONSTRUCTION.—Nothing in
paragraph (1) shall be construed—
‘‘(A) to require the coverage under a group
health plan of particular benefits or services or
to prohibit a plan from including providers only
to the extent necessary to meet the needs of the
plan’s participants or beneficiaries or from es-
tablishing any measure designed to maintain
quality and control costs consistent with the re-
sponsibilities of the plan; or
‘‘(B) to override any State licensure or
scope-of-practice law.
‘‘(b) TREATMENT PLANS.—
‘‘(1) IN GENERAL.—Nothing in this section shall
be construed to prohibit a group health plan (other
than a fully insured group health plan) from requir-
ing that specialty care be provided pursuant to a
treatment plan so long as the treatment plan is—
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‘‘(A) developed by the specialist, in con-
sultation with the case manager or primary care
provider, and the participant or beneficiary;
‘‘(B) approved by the plan in a timely
manner in accordance with the medical exigen-
cies of the case; and
‘‘(C) in accordance with the applicable
quality assurance and utilization review stand-
ards of the plan.
‘‘(2) NOTIFICATION.—Nothing in paragraph (1)
shall be construed as prohibiting a plan from requir-
ing the specialist to provide the case manager or pri-
mary care provider with regular updates on the spe-
cialty care provided, as well as all other necessary
medical information.
‘‘(c) REFERRALS.—Nothing in this section shall be
construed to prohibit a plan from requiring an authoriza-
tion by the case manager or primary care provider of the
participant or beneficiary in order to obtain coverage for
specialty services so long as such authorization is for an
adequate number of referrals.
‘‘(d) SPECIALTY CARE DEFINED.—For purposes of this
subsection, the term ‘specialty care’ means, with respect to
a condition, care and treatment provided by a health care
practitioner, facility, or center (such as a center of excel-
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lence) that has adequate expertise (including age-appro-
priate expertise) through appropriate training and experi-
ence.
‘‘SEC. 726. CONTINUITY OF CARE.
‘‘(a) IN GENERAL.—
‘‘(1) TERMINATION OF PROVIDER.—If a contract
between a group health plan (other than a fully in-
sured group health plan) and a health care provider
is terminated (as defined in paragraph (2)), or bene-
fits or coverage provided by a health care provider are
terminated because of a change in the terms of pro-
vider participation in such group health plan, and
an individual who is a participant or beneficiary in
the plan is undergoing a course of treatment from the
provider at the time of such termination, the plan
shall—
‘‘(A) notify the individual on a timely basis
of such termination;
‘‘(B) provide the individual with an oppor-
tunity to notify the plan of a need for transi-
tional care; and
‘‘(C) in the case of termination described in
paragraph (2), (3), or (4) of subsection (b), and
subject to subsection (c), permit the individual to
continue or be covered with respect to the course
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of treatment with the provider’s consent during
a transitional period (as provided under sub-
section (b)).
‘‘(2) TERMINATED.—In this section, the term
‘terminated’ includes, with respect to a contract, the
expiration or nonrenewal of the contract by the group
health plan, but does not include a termination of the
contract by the plan for failure to meet applicable
quality standards or for fraud.
‘‘(3) CONTRACTS.—For purposes of this section,
the term ‘contract between a group health plan (other
than a fully insured group health plan) and a health
care provider’ shall include a contract between such
a plan and an organized network of providers.
‘‘(b) TRANSITIONAL PERIOD.—
‘‘(1) GENERAL
RULE.—Except as provided in
paragraph (3), the transitional period under this sub-
section shall permit the participant or beneficiary to
extend the coverage involved for up to 90 days from
the date of the notice described in subsection (a)(1)(A)
of the provider’s termination.
‘‘(2) INSTITUTIONAL
CARE.—Subject to para-
graph (1), the transitional period under this sub-
section for institutional or inpatient care from a pro-
vider shall extend until the discharge or termination
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of the period of institutionalization and also shall in-
clude institutional care provided within a reasonable
time of the date of termination of the provider status
if the care was scheduled before the date of the an-
nouncement 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 other-
wise scheduled to have such care.
‘‘(3) PREGNANCY.—Notwithstanding paragraph
(1), if—
‘‘(A) a participant or beneficiary has en-
tered the second trimester of pregnancy at the
time of a provider’s termination of participa-
tion; and
‘‘(B) the provider was treating the preg-
nancy before the date of the termination;
the transitional period under this subsection with re-
spect to provider’s treatment of the pregnancy shall
extend through the provision of post-partum care di-
rectly related to the delivery.
‘‘(4) 
TERMINAL
ILLNESS.—Notwithstanding
paragraph (1), if—
‘‘(A) a participant or beneficiary was deter-
mined to be terminally ill (as determined under
section 1861(dd)(3)(A) of the Social Security
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Act) prior to a provider’s termination of partici-
pation; and
‘‘(B) the provider was treating the terminal
illness before the date of termination;
the transitional period under this subsection shall be
for care directly related to the treatment of the ter-
minal illness and shall extend for the remainder of
the individual’s life for such care.
‘‘(c) PERMISSIBLE TERMS AND CONDITIONS.—A group
health plan (other than a fully insured group health plan)
may condition coverage of continued treatment by a pro-
vider under subsection (a)(1)(C) upon the provider agreeing
to the following terms and conditions:
‘‘(1) The provider agrees to accept reimburse-
ment from the plan and individual involved (with re-
spect to cost-sharing) at the rates applicable prior to
the start of the transitional period as payment in full
(or at the rates applicable under the replacement plan
after the date of the termination of the contract with
the group health plan) and not to impose cost-sharing
with respect to the individual 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.
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‘‘(2) The provider agrees to adhere to the quality
assurance standards of the plan responsible for pay-
ment under paragraph (1) and to provide to such
plan necessary medical information related to the
care provided.
‘‘(3) The provider agrees otherwise to adhere to
such plan’s policies and procedures, including proce-
dures regarding referrals and obtaining prior author-
ization and providing services pursuant to a treat-
ment plan (if any) approved by the plan.
‘‘(d) RULE OF CONSTRUCTION.—Nothing in this sec-
tion shall be construed to require the coverage of benefits
which would not have been covered if the provider involved
remained a participating provider.
‘‘(e) DEFINITION.—In this section, the term ‘health
care provider’ or ‘provider’ means—
‘‘(1) any individual who is engaged in the deliv-
ery of health care services in a State and who is re-
quired 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
‘‘(2) any entity that is engaged in the delivery
of health care services in a State and that, if it is re-
quired by State law or regulation to be licensed or
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costs described in subsection (a)(2) but is not required
to pay for costs of items and services that are reason-
ably expected to be paid for by the sponsors of an ap-
proved clinical trial.
‘‘(2) STANDARDS
FOR
DETERMINING
ROUTINE
PATIENT
COSTS
ASSOCIATED
WITH
CLINICAL
TRIAL
PARTICIPATION.—
‘‘(A) IN GENERAL.—The Secretary shall es-
tablish, on an expedited basis and using a nego-
tiated rulemaking process under subchapter III
of chapter 5 of title 5, United States Code, stand-
ards relating to the coverage of routine patient
costs for individuals participating in clinical
trials that group health plans must meet under
this section.
‘‘(B) FACTORS.—In establishing routine pa-
tient cost standards under subparagraph (A), the
Secretary shall consult with interested parties
and take into account —
‘‘(i) quality of patient care;
‘‘(ii) routine patient care costs versus
costs associated with the conduct of clinical
trials, including unanticipated patient care
costs as a result of participation in clinical
trials; and
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‘‘(1) the plan may not require authorization or
referral by the primary care provider in order for a
participant or beneficiary to obtain coverage for rou-
tine pediatric care; and
‘‘(2) the plan shall treat the ordering of other
routine care related to routine pediatric care by such
a specialist as having been authorized by the des-
ignated primary care provider.
‘‘(b) RULES
OF CONSTRUCTION.—Nothing in sub-
section (a) shall be construed—
‘‘(1) as waiving any coverage requirement relat-
ing to medical necessity or appropriateness with re-
spect to the coverage of any pediatric care provided
to, or ordered for, a participant or beneficiary;
‘‘(2) to preclude a group health plan from re-
quiring that a specialist described in subsection (a)
notify the designated primary care provider or the
plan of treatment decisions; or
‘‘(3) to preclude a group health plan from allow-
ing health care professionals other than physicians to
provide routine pediatric care.
‘‘SEC. 9825. TIMELY ACCESS TO SPECIALISTS.
‘‘(a) TIMELY ACCESS.—
‘‘(1) IN GENERAL.—A group health plan (other
than a fully insured group health plan) shall ensure