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ficiaries, or enrollees, or health care providers or
other individuals acting on behalf of an individual
and with the individual’s consent or without such
consent if the individual is medically unable to pro-
vide such consent, regarding any aspect of the plan’s
or issuer’s services.
(2) GRIEVANCE DEFINED.—In this section, the
term ‘‘grievance’’ means any question, complaint, or
concern brought by a participant, beneficiary or en-
rollee that is not a claim for benefits (as defined in
section 1101(f)(1)).
(b) GRIEVANCE SYSTEM.—Such system shall include
the following components with respect to individuals who
are participants, beneficiaries, or enrollees:
(1) Written notification to all such individuals
and providers of the telephone numbers and business
addresses of the plan or issuer personnel responsible
for resolution of grievances and appeals.
(2) A system to record and document, over a
period of at least three previous years, all grievances
and appeals made and their status.
(3) A process providing for timely processing
and resolution of grievances.
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(4) Procedures for follow-up action, including
the methods to inform the person making the griev-
ance of the resolution of the grievance.
Grievances are not subject to appeal under the previous
provisions of this subtitle.
Subtitle B—Access to Care
SEC. 1111. CONSUMER CHOICE OPTION.
(a) IN GENERAL.—If a health insurance issuer offers
to enrollees health insurance coverage in connection with
a group health plan which provides for coverage of 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 en-
tered into a contract with the issuer to provide such serv-
ices, the issuer shall also offer or arrange to be offered
to such enrollees (at the time of enrollment and during
an annual open season as provided under subsection (c))
the option of health insurance coverage which provides for
coverage of such services which are not furnished through
health care professionals and providers who are members
of such a network unless enrollees are offered such non-
network coverage through another group health plan or
through another health insurance issuer in the group mar-
ket.
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(b) ADDITIONAL COSTS.—The amount of any addi-
tional premium charged by the health insurance issuer 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 unless it is paid by the health
plan sponsor through agreement with the health insurance
issuer.
(c) OPEN SEASON.—An enrollee may change to the
offering provided under this section only during a time pe-
riod determined by the health insurance issuer. Such time
period shall occur at least annually.
SEC. 1112. 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
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participant, beneficiary, or enrollee to receive medi-
cally necessary or appropriate specialty care, pursu-
ant 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 1114 (relating to access to specialty
care).
SEC. 1113. 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 any benefits with respect 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;
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(B) whether or not the health care pro-
vider furnishing 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
enrollee—
(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).
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(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
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(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.—In the case of services
(other than emergency services) for which benefits are
available under a group health plan, or under health insur-
ance coverage offered by a health insurance issuer, the
plan or issuer shall provide for reimbursement with re-
spect to such services provided to a participant, bene-
ficiary, or enrollee other than through a participating
health care provider in a manner consistent with sub-
section (a)(1)(C) (and shall otherwise comply with the
guidelines established under section 1852(d)(2) of the So-
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cial Security Act), if the services are maintenance care or
post-stabilization care covered under such guidelines.
SEC. 1114. 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.
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(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
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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
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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.—
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(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. 1115. 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—
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(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.
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SEC. 1116. 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. 1117. 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-