I
106TH CONGRESS
1ST SESSION
H. R. 216
To amend the Public Health Service Act and the Employee Retirement
Income Security Act of 1974 to protect consumers in managed care
plans and preserve against preemption certain State causes of action.
IN THE HOUSE OF REPRESENTATIVES
JANUARY 6, 1999
Mr. NORWOOD introduced the following bill; which was referred to the Com-
mittee on Commerce, and in addition to the Committee on Education and
the Workforce, for a period to be subsequently determined by the Speak-
er, in each case for consideration of such provisions as fall within the ju-
risdiction of the committee concerned
A BILL
To amend the Public Health Service Act and the Employee
Retirement Income Security Act of 1974 to protect con-
sumers in managed care plans and preserve against pre-
emption certain State causes of action.
Be it enacted by the Senate and House of Representa-
tives of the United States of America in Congress assembled,
SECTION 1. SHORT TITLE; TABLE OF CONTENTS.
(a) SHORT TITLE.—This Act may be cited as the
‘‘Access to Quality Care Act of 1999’’.
(b) TABLE OF CONTENTS.—The table of contents of
this Act is as follows:
Sec. 1. Short title; table of contents.
TITLE I—ACCESS TO QUALITY CARE
Subtitle A—Promoting Quality Care by Ensuring Access to Health Care
Professionals
Sec. 101. Consumer choice option.
Sec. 102. Choice of health professionals and providers.
Sec. 103. Access to care.
Sec. 104. Exclusions.
Subtitle B—Promoting Quality Care by Ensuring Access to Health Care
Services.
Sec. 111. Access to specialists.
Sec. 112. Continuity of care.
Sec. 113. Access to emergency room care.
Sec. 114. Patient access to obstetric and gynecological care.
Sec. 115. Patient access to pediatric care.
Sec. 116. Exclusions.
Subtitle C—Promoting Quality Care by Ensuring Fair Resolution of
Grievances.
Sec. 121. Utilization review standards.
Sec. 122. Internal and external review procedures.
Subtitle D—Promoting Quality Care by Ensuring Fair Plan Administration.
Sec. 131. Restrictions on incentive plans.
Sec. 132. Development of issuer policies.
Sec. 133. Patient access to information.
Sec. 134. Protection of patient confidentiality.
Sec. 135. Due process for health professionals and providers.
Sec. 136. Prohibition of interference with certain medical communications.
Sec. 137. Plan solvency.
Sec. 138. Quality assessment program.
Subtitle E—Definitions
Sec. 151. Definitions.
Sec. 152. Preemption; State flexibility; construction.
Sec. 153. Regulations.
TITLE II—APPLICATION OF QUALITY CARE STANDARDS TO
GROUP HEALTH PLANS AND HEALTH INSURANCE COVERAGE
UNDER PUBLIC HEALTH SERVICE ACT
Sec. 201. Application to group health plans and group health insurance cov-
erage.
Sec. 202. Application to individual health insurance coverage.
TITLE III—AMENDMENTS TO THE EMPLOYEE RETIREMENT
INCOME SECURITY ACT OF 1974
Sec. 301. Application of patient protection standards to group health plans and
group health insurance coverage under the Employee Retire-
ment Income Security Act of 1974.
Sec. 302. ERISA preemption not to apply to certain actions involving health in-
surance policyholders.
TITLE IV—EFFECTIVE DATES; COORDINATION IN
IMPLEMENTATION
Sec. 401. Effective dates.
Sec. 402. Coordination in implementation.
TITLE I—ACCESS TO QUALITY
CARE
Subtitle 
A—Promoting 
Quality
Care by Ensuring Access to
Health Care Professionals
SEC. 101. CONSUMER CHOICE OPTION.
(a) IN GENERAL.—If a health insurance issuer offers
to enrollees health insurance coverage which provides for
coverage of services only if such services are furnished
through health professionals and providers who are mem-
bers of a network of health professionals and providers
who have entered into a contract with the issuer to provide
such services, the issuer shall also offer to such enrollees
(at the time of enrollment) the option of health insurance
coverage which provides for coverage of such services
which are not furnished through health professionals and
providers who are members of such a network unless en-
rollees are offered such non-network coverage through an-
other health insurance issuer.
(b) FAIR PREMIUMS.—The amount of any additional
premium required for the additional cost of the option de-
scribed in subsection (a) may not exceed an amount that
is fair and reasonable, as established by the applicable
State authority, in consultation with the National Associa-
tion of Insurance Commissioners, based on the nature of
the additional coverage provided.
(c) 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) shall be borne by the
enrollee unless it is paid by the health plan sponsor
through agreement with the health insurance issuer.
(d) OPEN SEASON.—An enrollee may only change to
the offering provided under this section only during a time
period determined by the health insurance issuer. Such
time period shall occur at least annually.
(e) COST SHARING.—Under the option described in
subsection (a), the health insurance coverage shall provide
for reimbursement rates for covered services offered by
health professionals and providers who are not participat-
ing health professionals or providers that are not less than
the reimbursement rates for covered services offered by
participating health professionals and providers. Nothing
in this section shall be construed as protecting an enrollee
against balance billing by a health professional or provider
that is not a participating health professional or provider.
SEC. 102. CHOICE OF HEALTH PROFESSIONALS AND PRO-
VIDERS.
(a) CHOICE
OF
PERSONAL
HEALTH
PROFES-
SIONAL.—A group health plan, and a health insurance
issuer that offers health insurance coverage, shall permit
each participant, beneficiary, and enrollee to—
(1) select a personal health professional from
among the participating health professionals of the
issuer, and
(2) change such selection—
(A) in the event of a disciplinary complaint
against the provider; or
(B) at least once every 4 months.
SEC. 103. ACCESS TO CARE.
(a) IN GENERAL.—A group health plan, and a health
insurance issuer that offers health insurance coverage
shall establish and maintain adequate arrangements, as
defined by the applicable State authority, with a sufficient
number, mix, and distribution of health professionals and
providers to assure that covered items and services are
available and accessible to each participant, beneficiary,
and enrollee under health insurance coverage—
(1) in the service area of the issuer;
(2) in a variety of sites of service;
(3) with reasonable promptness (including rea-
sonable hours of operation and after hours services);
(4) with reasonable proximity to the residences
or workplaces of enrollees; and
(5) in a manner that—
(A) takes into account the diverse needs of
enrollees, and
(B) reasonably assures continuity of care.
A group health plan, and a health insurance issuer
that offers health insurance coverage that serves a
rural or medically underserved area shall be treated
as meeting the requirement of this subsection if the
plan or issuer has arrangements with a sufficient
number, mix, and distribution of health professionals
and providers having a history of serving such areas.
The use of telemedicine and other innovative means
to provide covered items and services by a group
health plan, and a health insurance issuer that of-
fers health insurance coverage that serves a rural or
medically under served area shall also be considered
in determining whether the requirement of this sub-
section is met.
(b) RULE OF CONSTRUCTION.—Nothing in this sub-
section shall be construed as requiring a group health
plan, and a health insurance issuer that offers health in-
surance coverage—
(1) to require a group health plan, and a health
insurance 
issuer 
offering 
health 
insurance
coverage—
(A) to provide particular benefits other
than those provided under the terms of such
coverage; or
(B) to comply with this subtitle with re-
spect to abortion services or euthanasia serv-
ices, even if the issuer covers such services;
(2) as forbidding a plan or issuer from offering
(or requiring a plan or issuer to offer) abortion or
euthanasia services; or
(3) as applying to a fee-for-service plan.
Subtitle 
B—Promoting 
Quality
Care by Ensuring Access to
Health Care Services
SEC. 111. ACCESS TO SPECIALISTS.
(a) IN GENERAL.—A group health plan, and a health
insurance issuer that offers health insurance coverage that
provides benefits, in whole or in part, through participat-
ing health care providers shall demonstrate that partici-
pants, beneficiaries, and enrollees have access to a special-
ist when treatment by such specialist is medically or clini-
cally indicated in the professional judgment of the treating
health professional, in consultation with the participant,
beneficiary, or enrollee.
(b) DEFINITION.—For purposes of subsection (a),
the term ‘‘specialist’’ means a health professional or pro-
vider (including a specialty institution) that, through
training or experience, has developed the expertise nec-
essary to treat individuals with special health care needs
or a chronic condition or disease.
SEC. 112. CONTINUITY OF CARE.
A group health plan, and a health insurance issuer
offer health insurance coverage that provides benefits, in
whole or in part, through participating health care profes-
sionals shall—
(1) ensure that any process established by the
issuer to coordinate care and control costs does not
create an undue burden, as defined by the applicable
State authority, for participants, beneficiaries, and
enrollees with special health care needs or chronic
conditions;
(2) ensure direct access to relevant specialists
for the continued care of participants, beneficiaries,
and enrollees when medically or clinically indicated
in the judgment of the treating health professional,
in consultation with the participant, beneficiary, or
enrollee;
(3) in the case of a participant, beneficiary, or
enrollee with special health care needs or a chronic
condition, determine whether, based on the judgment
of the treating health professional, in consultation
with the participant, beneficiary, or enrollee, it is
medically or clinically necessary to use a specialist or
a care coordinator from an interdisciplinary team to
ensure continuity of care; and
(4) in circumstances under which a change of
health professional or provider might disrupt the
continuity of care for a participant, beneficiary, or
enrollee, provide for continued coverage of items and
services furnished by the health professional or pro-
vider that was treating the participant, beneficiary,
or enrollee before such change for a reasonable pe-
riod of time.
A change of health professional or provider may be due
to changes in the membership of an issuer’s health profes-
sional and provider network, changes in the health cov-
erage made available by an employer, or other similar cir-
cumstances.
SEC. 113. ACCESS TO EMERGENCY ROOM CARE.
(a) EMERGENCY CARE.—
(1) IN GENERAL.—If a group health plan, or a
health insurance issuer offering health insurance
coverage provides any benefits with respect to emer-
gency services (as defined in subsection (b)(2)), the
plan or issuer shall cover emergency services fur-
nished under the plan or coverage—
(A) without the need for any prior author-
ization determination;
(B) whether or not the health care profes-
sional or provider furnishing such services is a
participating professional or provider with re-
spect to such services;
(C) in a manner so that, if such services
are provided to a participant, beneficiary, or en-
rollee by a non-participating health care profes-
sional or provider, the participant, beneficiary,
or enrollee is not liable for an amount that ex-
ceeds the amount of financial liability that
would be incurred if the services were provided
by a participating health care professional or
provider; and
(D) without regard to any other term or
condition of such plan or coverage (other than
exclusion or coordination of benefits, or an af-
filiation or waiting period, permitted under sec-
tion 2701 of the Public Health Service Act, sec-
tion 701 of the Employee Retirement Income
Security Act of 1974, and other than applicable
through cost-sharing).
(b) DEFINITIONS.—For purposes of this section:
(1) EMERGENCY
MEDICAL
CONDITION.—The
term ‘‘emergency medical condition’’ means a medi-
cal condition (including emergency labor and deliv-
ery) manifesting itself by acute symptoms of suffi-
cient severity (including, but not limited to, severe
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.
(2) EMERGENCY SERVICES.—The term ‘‘emer-
gency services’’ means—
(A) a medical screening examination (as
required under section 1867 of the Social Secu-
rity Act) that is within the capabilities of the
emergency department of a hospital, including
ancillary services routinely available to the
emergency department to evaluate an emer-
gency medical condition (as defined in para-
graph (1)), and
(B) within the capabilities of the staff and
facilities available at the hospital, such further
medical examination and treatment as required
under section 1867 of such Act to stabilize the
patient.
(3) 
STABILIZE.—The 
term 
‘‘to 
stabilize’’
means, with respect to an emergency medical condi-
tion, to provide such medical treatment of the condi-
tion as may be necessary to assure, within reason-
able medical probability, that no material deteriora-
tion of the condition is likely to result from or occur
during the transfer of the individual from a facility.
(c) 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 health insurance
issuer offering health insurance coverage, the plan or
issuer shall provide for reimbursement with respect to
such services provided to a participant, beneficiary, or en-
rollee other than through a participating health care pro-
fessional or provider in a manner consistent with sub-
section (a)(1)(C) if the services are maintenance care or
post-stabilization care covered under the guidelines estab-
lished under section 1852(d)(2) of the Social Security Act
(relating to promoting efficient and timely coordination of
appropriate maintenance and post-stabilization care of an
enrollee after an enrollee has been determined to be sta-
ble), in accordance with regulations established to carry
out such section.
SEC. 114. PATIENT ACCESS TO OBSTETRIC AND GYNECO-
LOGICAL CARE.
(a) IN GENERAL.—In any case in which a group
health plan or a health insurance issuer in connection with
the provision of health insurance coverage, requires or pro-
vides for designation by a participant, beneficiary, or en-
rollee of a participating primary care provider, and pro-
vides benefits under the terms of the plan consisting of—
(1) routine gynecological care (such as preven-
tive women’s health examinations), or
(2) routine obstetric care (such as routine preg-
nancy-related services), provided by a participating
professional who specializes in such care (or provides
benefits consisting of payment for such care),
if the primary care provider designated by such a partici-
pant, beneficiary, or enrollee is not such a professional,
then the plan or issuer shall meet the requirements of sub-
section (b).
(b) REQUIREMENTS.—A group health plan, or a
health insurance issuer in connection with the provision
of health insurance coverage, meets the requirements of
ent or guardian of any beneficiary under the plan who is
under 18 years of age, as the primary care provider with
respect to any such benefits.
(b) CONSTRUCTION.—Nothing in subsection (a) shall
waive any exclusions of coverage under the terms of the
plan with respect to coverage of pediatric care.
SEC. 116. EXCLUSIONS.
Nothing in this subtitle shall be construed—
(1) to require a group health plan, and a health
insurance 
issuer 
offering 
health 
insurance
coverage—
(A) to provide particular benefits other
than those provided under the terms of such
coverage; or
(B) to comply with this subtitle with re-
spect to abortion services or euthanasia serv-
ices, even if the issuer covers such services;
(2) as forbidding a plan or issuer from offering
(or requiring a plan or issuer to offer) abortion or
euthanasia services; or
(3) as applying to a fee-for-service plan.
Subtitle 
C—Promoting 
Quality
Care by Ensuring Fair Resolu-
tion of Grievances
SEC. 121. UTILIZATION REVIEW STANDARDS.
The utilization review program of a group health
plan, and a health insurance issuer that provides health
insurance coverage, shall—
(1) be developed (including any screening cri-
teria used by such program) with the involvement of
participating health professionals and providers;
(2) to the extent consistent with the protection
of proprietary business information (as defined for
purposes of section 552 of title 5, United States
Code) release, upon request, to affected health pro-
fessionals, providers, and enrollees the screening cri-
teria, weighting elements, and computer algorithms
used in reviews and a description of the method by
which they were developed;
(3) uniformly apply review criteria;
(4) subject to reasonable safeguards, disclose to
health professionals and providers and enrollees,
upon request, the names and credentials of individ-
uals conducting utilization review;
(5) not compensate individuals conducting utili-
zation review under a system that provides financial
or other incentives or bonuses for denials of payment
or coverage of benefits;
(6) comply with the requirement of section 113
that prior authorization not be required for emer-
gency and related services furnished in a hospital
emergency department; and
(7) provide timely access, as defined by the ap-
plicable State authority, to utilization review person-
nel and, if such personnel are not available, waives
any prior authorization that would otherwise be re-
quired.
SEC. 122. INTERNAL AND EXTERNAL REVIEW PROCEDURES.
(a) COVERAGE DETERMINATIONS.—A group health
plan and a health insurance issuer offering health insur-
ance coverage shall—
(1) provide notice in writing in accordance with
this section to any participant or beneficiary in a
group health plan, or any enrollee in health insur-
ance coverage offered by a health insurance issuer,
of any adverse coverage decision with respect to ben-
efits of such participant, beneficiary, or enrollee, set-
ting forth the specific reasons for such coverage de-
cision and any rights of review, written in a manner
calculated to be understood by the participant, bene-
ficiary, or enrollee;
(2) provide written notice to any treating health
care professional of such participant, beneficiary, or
enrollee if such professional has claimed reimburse-
ment for any item or service involved in such cov-
erage decision, or if a claim submitted by the profes-
sional initiated the proceedings leading to such deci-
sion;
(3) afford an opportunity to any participant,
beneficiary, or enrollee who is in receipt of the notice
of such adverse coverage decision and who files a
written request for review of the initial coverage de-
cision within 180 days after receipt of the notice of
the initial decision, for a full and fair de novo review
of the decision by a person who did not make the
initial decision; and
(4) meet the additional requirements of this
section.
(b) TIME LIMITS FOR MAKING INITIAL COVERAGE
DECISIONS FOR BENEFITS AND COMPLETING INTERNAL
APPEALS.—
(1) TIME LIMITS FOR DECIDING REQUESTS FOR
BENEFIT PAYMENTS AND REQUESTS FOR ADVANCE
DETERMINATION
OF
COVERAGE.—Except as pro-
vided in paragraph (2)—
(A) INITIAL DECISIONS.—If a request for
benefit payments, or a request for advance de-
termination of coverage is submitted to a group
health plan or a health insurance issuer offering
health insurance coverage in such form as may
be required under the plan or coverage, the
plan or issuer shall issue in writing an initial
coverage decision on the request not later than
7 days (or such longer period as may be pre-
scribed in regulations of the Secretary) after
the date as of which the plan or issuer is in re-
ceipt of all information required (in writing or
in such other form as may be specified under
the plan or coverage) to make an initial cov-
erage decision. Failure to issue a coverage deci-
sion on such a request by such deadline shall be
treated as an adverse coverage decision for pur-
poses of internal review under subparagraph
(B).
(B) INTERNAL REVIEWS OF INITIAL DENI-
ALS.—Upon the written request of a partici-
pant, beneficiary, or enrollee for review of an
initial adverse coverage decision under subpara-
graph (A), a review by an internal appeals en-
tity of the initial coverage decision shall be com-
pleted, including issuance by the plan or issuer
of a written decision affirming, reversing, or
modifying the initial coverage decision, setting
forth the grounds for such decision, not later
than 14 days (or such longer period as may be
prescribed in regulations of the Secretary) after
the date as of which the entity is in receipt of
all information required (in writing or in such
other form as may be specified under the plan
or coverage) to make a decision to affirm, mod-
ify, or reverse the coverage decision. Such deci-
sion shall be treated as the final decision of the
plan, subject to any applicable reconsideration.
Failure to issue by such deadline such a written
decision requested under this subparagraph
shall be treated as a final decision affirming the
initial coverage decision, subject to any applica-
ble reconsideration.
(2) TIME LIMITS FOR MAKING COVERAGE DECI-
SIONS RELATING TO URGENT HEALTH CARE AND
FOR COMPLETING INTERNAL APPEALS.—
(A) INITIAL DECISIONS.—A group health
plan and a health insurance issuer offering
health insurance coverage shall issue in writing
an initial coverage decision on any request for
expedited advance determination of coverage, in
such form as may be required under the plan
or coverage, not later than 2 days (or such
longer period as may be prescribed in regula-
tions of the Secretary) after the date as of
which the plan or issuer is in receipt of all in-
formation required (in writing or in such other
form as may be specified under the plan or cov-
erage) to make an initial coverage decision.
Such decision shall be treated as the final deci-
sion of the plan or issuer, subject to any appli-
cable reconsideration. Failure to issue before
the end of the applicable decision period such a
written decision requested under this subpara-
graph shall be treated as a final decision af-
firming the initial coverage decision, subject to
any applicable reconsideration.
(B) INTERNAL REVIEWS OF INITIAL DENI-
ALS.—Upon the written request of a partici-
pant, beneficiary, or enrollee for review of an
initial adverse coverage decision under subpara-
graph (A), if the case involves urgent health
care, a review by an internal review entity of
the initial coverage decision shall be completed,
including issuance by the plan or issuer of a
written decision affirming, reversing, or modify-
ing the initial coverage decision, setting forth
the grounds for the decision, not later than 2
days (or such longer period as may be pre-
scribed in regulations of the Secretary) after
the date as of which the entity is in receipt of
all information required (in writing or in such
other form as may be specified under the plan
or coverage) to make a decision to affirm, mod-
ify, or reverse the coverage decision. Such deci-
sion shall be treated as the final decision of the
plan or issuer, subject to any applicable recon-
sideration. Failure to issue before such deadline
such a written decision requested under this
subparagraph shall be treated as a final deci-
sion affirming the initial coverage decision, sub-
ject to any applicable reconsideration.
(c) REQUIREMENT FOR REVIEW OF INITIAL COV-
ERAGE DECISIONS BY A PHYSICIAN.—If an initial cov-
erage decision is based on a determination other than that
provision of a particular item or service is excluded from
coverage under the terms of the plan or coverage, the re-
view shall be conducted by a physician who is selected to
serve as an internal appeals entity under the plan or cov-
erage and who did not make the initial denial.
(d) EXTERNAL REVIEW BY INDEPENDENT MEDICAL
EXPERTS AND RECONSIDERATION OF INITIAL REVIEW
DECISION.—
(1) IN GENERAL.—The requirements of para-
graphs (2), (3), and (4) shall apply—
(A) in the case of any failure to timely
issue a coverage decision upon internal review
which is deemed to be an adverse coverage deci-
sion (thereby failing to constitute a coverage de-
cision for which specific reasons have been set
forth as required), and
(B) in the case of any adverse coverage de-
cision not based on a determination that provi-
sion of a particular item or service is excluded
from coverage under the terms of the plan or
coverage because the provision of such item or
service is specifically excluded as a benefit of
the plan or coverage.
(2) RECONSIDERATION OF INITIAL REVIEW DE-
CISION.—In any case in which a participant, bene-
ficiary, or enrollee who has received an adverse deci-
sion of the plan or issuer upon review of the initial
coverage decision and who has not commenced re-
view of the initial coverage decision makes a request
in writing, within 30 days after the date of such re-
view decision, for reconsideration of such review de-
cision, the terms of the plan or coverage shall pro-
vide for a procedure for such reconsideration paid
for by the plan or issuer under which—
(A) one or more independent medical ex-
perts will be selected to review the coverage de-
cision described;
(B) the record for review (including a spec-
ification of the terms of the plan or coverage
and other criteria serving as the basis for the
initial review decision) shall be presented to
such expert or experts and maintained in a
manner which shall ensure confidentiality of
such record;
(C) such expert or experts will make and
report in writing to the plan or issuer a deter-
mination as to whether such coverage decision
should be affirmed, modified, or reversed, set-
ting forth the grounds (including the clinical
basis) for the determination; and
(D) the determination of such expert or ex-
perts pursuant to subparagraph (C) shall be
considered binding on the plan or issuer.
(3) TIME LIMITS FOR RECONSIDERATION.—Any
review under this subsection shall be completed not
later than 14 days (or, in the case of a decision in-
volving urgent health care, 2 days, or such longer
period as may be prescribed in regulations of the
Secretary) after the date as of which the independ-
ent medical expert or experts involved is in receipt
of all information required (in writing or in such
other form as may be specified under the plan or
coverage) to make a decision to affirm, modify, or
reverse the coverage decision. Failure to issue a
written decision before such deadline in any recon-
sideration requested under this subsection shall be
treated as a final decision affirming the initial re-
view decision of the plan or issuer.
(4) INDEPENDENT MEDICAL EXPERTS.—
(A) IN GENERAL.—For purposes of this
section, the term ‘‘independent medical expert’’
means, in connection with any coverage decision
by a group health plan or health insurance
issuer, a health care professional who—
(i) is a physician or, if appropriate,
another health care professional;
(ii) has appropriate credentials and
has attained recognized expertise in the
applicable health care field;
(iii) was not involved in the initial de-
cision or any earlier review thereof; and
(iv) is selected in accordance with sub-
paragraph (B).
(B) SELECTION OF MEDICAL EXPERTS.—
An independent medical expert is selected in ac-
cordance with this subparagraph if—
(i) the expert is selected by an inter-
mediary which itself meets the require-
ments of subparagraph (C), by means of a
method which ensures that the identity of
the expert is not disclosed to the plan or
issuer, any health insurance issuer offering
health insurance coverage to the aggrieved
participant, beneficiary, or enrollee in con-
nection with the plan, and the aggrieved
participant, beneficiary, or enrollee under
the plan, and the identities of the plan, the
issuer, and the aggrieved participant, bene-
ficiary, or enrollee are not disclosed to the
expert;
(ii) the expert is selected, by an ap-
propriately credentialed panel of health
care professionals meeting the require-
ments of subparagraph (C) established by
a fully accredited teaching hospital meeting
such requirements;
(iii) the expert is selected by an orga-
nization described in section 1152(1)(A) of
the Social Security Act which meets the re-
quirements of subparagraph (C);
(iv) the expert is selected by an exter-
nal review organization which meets the re-
quirements of subparagraph (C) and is ac-
credited by a private standard-setting or-
ganization meeting such requirements and
recognized as such by the Secretary; or
(v) the expert is selected under regu-
lations issued pursuant to negotiated rule-
making, sufficient to ensure the expert’s
independence, and the method of selection
is devised to reasonably ensure that the ex-
pert selected meets the independence re-
quirements of subparagraph (C).
(C) INDEPENDENCE REQUIREMENTS.—An
independent medical expert or another entity
described in subparagraph (B) meets the inde-
pendence requirements of this subparagraph
if—
(i) the expert or entity is not affiliated
with any related party;
(ii) any compensation received by such
expert or entity in connection with the ex-
ternal review is reasonable and not contin-
gent on any decision rendered by the ex-
pert or entity;
(iii) under the terms of the plan and
any health insurance coverage involved, the
plan and the issuer (if any) have no re-
course against the expert or entity in con-
nection with the external review; and
(iv) the expert or entity does not oth-
erwise have a conflict of interest with a re-
lated party as determined under any regu-
lations which the Secretary may prescribe.
(D) RELATED
PARTY.—For purposes of
this paragraph, the term ‘‘related party’’
means—
(i) with respect to—
(I) a group health plan or health
insurance coverage offered in connec-
tion with such a plan, the plan or the
health insurance issuer offering such
coverage, or
(II) individual health insurance
coverage, the health insurance issuer
offering such coverage,
or any officer, director, or management
employee of such plan or issuer;
(ii) the health care professional that
provided the health care involved in the
coverage decision;
(iii) the institution at which the health
care involved in the coverage decision is
provided;
(iv) the manufacturer of any drug or
other item that was included in the health
care involved in the coverage decision; or
(v) any other party determined under
any regulations which the Secretary may
prescribe to have a substantial interest in
the coverage decision.
(E) AFFILIATED.—For purposes of this
paragraph, the term ‘‘affiliated’’ means, in con-
nection with any entity, having a familial, fi-
nancial, or professional relationship with, or in-
terest in, such entity.
(F) LIMITATION ON LIABILITY.—An indi-
vidual serving on as an independent medical ex-
pert or an entity acting as such under this
paragraph shall not be held liable for any deci-
sion made except in cases of gross negligence,
recklessness, or intentional misconduct by such
individual or entity.
(5) INAPPLICABILITY WITH RESPECT TO ITEMS
AND SERVICES SPECIFICALLY EXCLUDED FROM COV-
ERAGE.—An adverse coverage decision based on a
determination that an item or service is excluded
from coverage under the terms of a plan or health
insurance coverage shall not be subject to review
under this section.
(e) PENALTIES AGAINST AUTHORIZED OFFICIALS
FOR DENIAL OF EXTERNAL REVIEW.—
(1) MONETARY
PENALTIES.—In any case in
which review by an independent medical expert or
experts of a benefit is denied by a group health plan,
or by a health insurance issuer offering health insur-
ance coverage, any person who, acting in the capac-
ity of determining the necessity of such a review,
causes such denial may, in the court’s discretion, be
liable to the aggrieved participant, beneficiary, or
enrollee for a civil penalty in an amount of up to
$750 a day from the date on which the rec-
ommendation was made to the plan or issuer until
the date the failure to provide review is corrected, up
to a total amount not to exceed $250,000.
(2) CEASE AND DESIST ORDER AND ORDER OF
ATTORNEY’S
FEES.—In any action described in
paragraph (1) brought by a participant, beneficiary,
or enrollee with respect to a group health plan, or
a health insurance issuer offering health insurance
coverage, in which the plaintiff alleges that a person
referred to in such paragraph has taken an action
resulting in a denial of review by independent medi-
cal expert or experts in violation of such terms of
the plan, coverage, or this title, or has failed to take
an action for which such person is responsible under
the plan, coverage, or this title and which is nec-
essary under the plan or coverage for allowing such
review, the court shall cause to be served on the de-
fendant an order requiring the defendant—
(i) to cease and desist from the alleged ac-
tion or failure to act; and
(ii) to pay to the plaintiff a reasonable at-
torney’s fee and other reasonable costs relating
to the prosecution of the action on the charges
on which the plaintiff prevails.
(3) ADDITIONAL CIVIL PENALTIES.—
(A) IN GENERAL.—In addition to any pen-
alty imposed under paragraph (1) or (2), the
appropriate Secretary may assess a civil penalty
against a person acting in the capacity of deter-
mining the necessity of external review for one
or more group health plans, or health insurance
issuers offering health insurance coverage,
for—
(i) any pattern or practice of repeated
denial of review by independent medical ex-
pert or experts in violation of the terms of
such a plan, coverage, or this title; or
(ii) any pattern or practice of re-
peated violations of the requirements of
this section with respect to such plan or
plans or coverage.
(B) STANDARD OF PROOF AND AMOUNT OF
PENALTY.—Such penalty shall be payable only
upon proof by clear and convincing evidence of
such pattern or practice and shall be in an
amount not to exceed the lesser of—
(i) 25 percent of the aggregate value
of benefits shown by the appropriate Sec-
retary to have not been provided, or unlaw-
fully delayed, in violation of this section
under such pattern or practice, or
(ii) $500,000.
(4) REMOVAL
AND
DISQUALIFICATION.—Any
person acting in the capacity of determining the ne-
cessity of external review who has engaged in any
such pattern or practice described in paragraph
(3)(A) with respect to a plan or coverage, upon the
petition of the appropriate Secretary, may be re-
moved by the court from that position, and from any
other involvement, with respect to such a plan or
coverage, and may be precluded from returning to
any such position or involvement for a period deter-
mined by the court.
(f) DEFINITIONS.—For purposes of this section:
(1) 
ADVANCE
DETERMINATION
OF
COV-
ERAGE.—The term ‘‘advance determination of cov-
erage’’ means a determination under a group health
plan, and a health insurance issuer offering health
insurance coverage that proposed health care meets,
under the facts and circumstances at the time of the
determination, the plan or issuer’s terms and condi-
tions of coverage (which may be subject to excep-
tions under the plan for fraud or misrepresentation).
(2) ADVERSE COVERAGE DECISION.—The term
‘‘adverse coverage decision’’ means any request for
payment of benefits, determination of coverage, ad-
vance determination of coverage, or expedited ad-
vance determination of coverage made by a group
health plan, or a health insurance issuer offering
health insurance coverage, that does not affirm the
treatment decision of the treating health care profes-
sional.
(3) REQUEST FOR ADVANCE DETERMINATION
OF COVERAGE.—The term ‘‘request for advance de-
termination of coverage’’ means a request for an ad-
vance determination of coverage of health care which
is made by or on behalf of a participant, beneficiary,
or enrollee before such health care is provided.
(4) REQUEST FOR BENEFIT PAYMENTS.—The
term ‘‘request for benefit payments’’ means a re-
quest, for payment of benefits by a group health
plan, or health insurance issuer offering health in-
surance coverage for health care, which is made by
or on behalf of a participant, beneficiary, or enrollee
after such health care has been provided.
(5) REQUEST FOR EXPEDITED ADVANCE DE-
TERMINATION
OF
COVERAGE.—The term ‘‘request
for expedited advance determination of coverage’’
means a request for advance determination of cov-
erage, in any case in which the proposed health care
constitutes urgent health care.
(6) URGENT HEALTH CARE.—The term ‘‘urgent
health care’’ means health care in any case in which
a physician has certified in writing (or as otherwise
provided in regulations of the Secretary) that failure
to provide the participant, beneficiary, or enrollee
with such health care within 7 days can reasonably
be expected to result in either—
(A) the imminent death of the participant,
beneficiary, or enrollee; or
(B) the immediate, serious, and irrevers-
ible deterioration of the health of the partici-
pant or beneficiary which will significantly in-
crease the likelihood of death of, or irreparable
harm to, the participant, beneficiary, or en-
rollee.
(7) WRITTEN OR IN WRITING.—A request or
decision shall be deemed to be ‘‘written’’ or ‘‘in writ-
ing’’ if such request or decision is presented in a
generally recognized printable or electronic format.
The appropriate Secretary may by regulation provide
for presentation of information otherwise required to
be in written form in such other forms as may be
appropriate under the circumstances.
Subtitle 
D—Promoting 
Quality
Care by Ensuring Fair Plan Ad-
ministration
SEC. 131. RESTRICTIONS ON INCENTIVE PLANS.
(a) INCENTIVE PLANS.—
(1) IN
GENERAL.—In the case of a group
health plan, and a health insurance issuer that of-
fers network coverage, any health professional or
provider incentive plan operated by the plan or
issuer with respect to such coverage shall meet the
following requirements:
(A) No specific payment shall be made di-
rectly or indirectly under the plan to a profes-
sional or provider or group of professionals or
providers as an inducement to reduce or limit
medically necessary services provided with re-
spect to a specific participant, beneficiary, or
enrollee.
(B) If a plan or issuer places such a pro-
fessional, provider, or group at substantial fi-
nancial risk (as determined by the Secretary)
for services not provided by the professional,
provider, or group, the plan issuer shall provide
stop-loss protection for the professional, pro-
vider, or group that is adequate and appro-
priate, based on standards developed by the
Secretary that take into account the number of
professionals or providers placed at such sub-
stantial financial risk in the group or under the
coverage and the number of individuals enrolled
with the plan or issuer who receive services
from the professional, provider, or group.
(2) NOTIFICATION.—The plan or issuer shall
provide the Secretary with descriptive information
regarding the plan, sufficient to permit the Sec-
retary to determine whether the plan is in compli-
ance with the requirements of this section.
(b) HEALTH PROFESSIONAL OR PROVIDER INCEN-
TIVE PLAN DEFINED.—In this subsection, the term health
professional or provider incentive plan means any com-
pensation arrangement between a health insurance issuer
and a health professional or provider or professional or
provider group that has the effect of reducing or limiting
services provided with respect to individuals enrolled with
the plan or issuer.
(c) CONSTRUCTION.—Nothing in this section shall be
construed as prohibiting all capitation and similar ar-
rangements or all provider discount arrangements.
(d) IMPLEMENTATION.—The Secretary shall submit
to Congress not later than January 1, 2000 a report de-
tailing regulations and a plan for implementation of the
details of this section. Such regulations and plan for im-
plementation shall not proceed without the concurrence by
joint resolution or Act of the Congress.
SEC. 132. DEVELOPMENT OF PLAN AND ISSUER POLICIES.
A group health plan, and a health insurance issuer
that offers network coverage shall establish mechanisms
to consider the recommendations, suggestions, and views
of participants, beneficiaries, enrollees and participating
health professionals and providers regarding—
(1) the medical policies of the plan or issuer
(including policies relating to coverage of new tech-
nologies, treatments, and procedures);
(2) the utilization review criteria and proce-
dures of the plan or issuer;
(3) the quality and credentialing criteria of the
plan or issuer; and
(4) the medical management procedures of the
plan or issuer.
SEC. 133. PATIENT ACCESS TO INFORMATION.
(a) DISCLOSURE REQUIREMENTS.—
(1) IN
GENERAL.—A group health plan or
health insurance issuer providing health insurance
coverage shall take such actions as necessary to en-
sure that—
(A) information required under subsections
(b) through (k) is provided at the time of en-
rollment, at least annually thereafter, and upon
written request; and
(B) the information described in subsection
(l) is provided upon written request,
to plan participants and beneficiaries and to enroll-
ees, respectively.
(2) INCLUSION
IN
SUMMARY
PLAN
DESCRIP-
TION.—In the case of a group health plan, the infor-
mation described in paragraph (1)(A) shall be made
available as part of the summary plan description of
the plan.
(3) CHARGING FOR INFORMATION MADE AVAIL-
ABLE UPON REQUEST.—In cases in which the infor-
mation is made available upon written request under
paragraph (1), the plan or issuer may impose a rea-
sonable charge to cover the cost of making the infor-
mation so available. The Secretary may by regula-
tion prescribe a maximum amount which will con-
stitute a reasonable charge under this paragraph.
(b) PLAN BENEFITS.—The information required
under subsection (a) includes the following:
(1) COVERED ITEMS AND SERVICES.—
(A) CATEGORIZATION OF INCLUDED BENE-
FITS.—A description of covered benefits, cat-
egorized by—
(i) types of items and services (includ-
ing any special disease management pro-
gram); and
(ii) types of health care professionals
providing such items and services.
(B) EMERGENCY MEDICAL CARE.—A de-
scription of—
(i) the extent to which the plan or
health insurance coverage covers emer-
gency medical care;
(ii) the locations of hospital emer-
gency departments, urgent care centers,
and other sites or settings in which the
plan or health insurance coverage makes
available emergency medical care or post-
stabilization care; and
(iii) the appropriate use of emergency
services, including use of the 911 telephone
system or its local equivalent in emergency
situations, and an explanation of what con-
stitutes an emergency situation.
(C) PREVENTATIVE SERVICES.—A descrip-
tion of the extent to which the plan or health
insurance coverage provides benefits for pre-
ventative services.
(D) DRUG
FORMULARIES.—A description
of the extent to which covered benefits are de-
termined by the use or application of a drug
formulary and a summary of the process for de-
termining what is included in such formulary.
(E) COBRA CONTINUATION COVERAGE.—
In the case of a group health plan, a descrip-
tion of the benefits available under the plan
pursuant to part 6 of the Employee Retirement
Income Security Act.
(2) LIMITATIONS, EXCLUSIONS, AND RESTRIC-
TIONS ON COVERED BENEFITS.—
(A) CATEGORIZATION OF EXCLUDED BEN-
EFITS.—A description of benefits specifically
excluded from coverage, categorized by types of
items and services.
(B) 
UTILIZATION
REVIEW
AND
PREAUTHORIZATION REQUIREMENTS.—Whether
coverage for health care is limited or excluded
on 
the 
basis 
of 
utilization 
review 
or
preauthorization requirements.
(C) LIFETIME, ANNUAL, OR
OTHER
PE-
RIOD LIMITATIONS.—A description of the cir-
cumstances under which, and the extent to
which, coverage is subject to lifetime, annual, or
other period limitations, categorized by types of
benefits.
(D) CUSTODIAL
CARE.—A description of
the circumstances under which, and the extent
to which, the coverage of benefits for custodial
care is limited or excluded, and a statement of
the definition used by the plan for custodial
care.
(E) 
EXPERIMENTAL
TREATMENTS.—
Whether coverage for any health care is limited
or excluded because it constitutes experimental
treatment or technology, and any definitions
provided under the plan or coverage for the rel-
evant terminology referring to such limited or
excluded care.
(F) SECOND OR SUBSEQUENT OPINIONS.—
A description of the circumstances under which,
and the extent to which, coverage for second or
subsequent opinions is limited or excluded.
(G) SPECIALTY
CARE.—A description of
the circumstances under which, and the extent
to which, coverage of benefits for specialty care
is conditioned on referral from a primary care
provider.
(H) CONTINUITY OF CARE.—A description
of the circumstances under which, and the ex-
tent to which, coverage of items and services
provided by any health care professional is lim-
ited or excluded by reason of the departure by
the professional from any defined set of provid-
ers.
(I) 
RESTRICTIONS
ON
COVERAGE
OF
EMERGENCY
SERVICES.—A description of the
circumstances under which, and the extent to
which, the plan or health insurance coverage, in
covering emergency medical care furnished to a
participant or beneficiary of the plan or enrollee
imposes any financial responsibility described in
subsection (c) on participants or beneficiaries or
enrollees or limits or conditions benefits for
such care subject to any other term or condition
of such plan or coverage.
(c) PARTICIPANT’S FINANCIAL RESPONSIBILITIES.—
The information required under subsection (a) includes an
explanation of—
(1) a participant’s or enrollee’s financial re-
sponsibility for payment of premiums, coinsurance,
copayments, deductibles, and any other charges; and
(2) the circumstances under which, and the ex-
tent to which, the participant’s or enrollee’s financial
responsibility described in paragraph (1) may vary,
including any distinctions based on whether a health
care provider from whom covered benefits are ob-
tained is included in a defined set of providers.
(d) DISPUTE RESOLUTION PROCEDURES.—The in-
formation required under subsection (a) includes a de-
scription of the processes adopted by the plan pursuant
to section 122, including—
(1) descriptions relating specifically to—
(A) coverage decisions;
(B) internal review of coverage decisions;
and
(C) any external review of coverage deci-
sions;
(2) the procedures and time frames applicable
to each step of the processes referred to in subpara-
graphs (A), (B), and (C) of paragraph (1); and
(3) the number of external review cases con-
ducted annually and, of such number, the number of
such cases where the decision of the plan or issuer
is upheld and the number of such cases where the
decision of the plan or issuer is modified or over-
turned.
(e) NETWORK CHARACTERISTICS.—If the plan or
health insurance issuer utilizes a defined set of providers
under contract with the plan or issuer, the information
required under subsection (a) includes a detailed list of
the names of such providers and their geographic location,
set forth separately with respect to primary care providers
and with respect to specialists.
(f) CARE MANAGEMENT INFORMATION.—The infor-
mation required under subsection (a) includes a descrip-
tion of the circumstances under which, and the extent to
which, the plan or health insurance issuer has special dis-
ease management programs or programs for persons with
disabilities, indicating whether these programs are vol-
untary or mandatory and whether a significant benefit dif-
ferential results from participation in such programs.
(g) INCLUSION
OF DRUGS
AND BIOLOGICALS
IN
FORMULARIES.—The information required under sub-
section (a) includes a statement of whether a specific drug
or biological is included in a formulary used to determine
benefits under the plan or health insurance coverage and
a description of the procedures for considering requests
for any patient-specific waivers.
(h) PREAUTHORIZATION AND UTILIZATION REVIEW
PROCEDURES.—The information required under sub-
section (a) includes, upon receipt by the participant or
beneficiary or enrollee of any notification of an adverse
coverage decision, a description of the basis on which any
preauthorization requirement or any utilization review re-
quirement has resulted in such decision.
(i) ACCREDITATION STATUS OF HEALTH INSURANCE
ISSUERS AND SERVICE PROVIDERS.—The information re-
quired under subsection (a) includes a description of the
accreditation and licensing status (if any) of each health
insurance issuer (or each such issuer offering health insur-
ance coverage in connection with the plan) and of any uti-
lization review organization utilized by the issuer or the
plan, together with the name and address of the accredit-
ing or licensing authority.
(j) MEASURES OF ENROLLEE SATISFACTION.—The
information required under subsection (a) includes the lat-
est information (if any) maintained by the plan (or by any
health insurance issuer offering health insurance coverage
in connection with the plan) or by the health insurance
issuer relating to enrollee satisfaction.
(k) QUALITY PERFORMANCE MEASURES.—The infor-
mation required under subsection (a) includes the latest
information (if any) maintained by the plan (or by any
health insurance issuer offering health insurance coverage
in connection with the plan) or by the health insurance
issuer, relating to quality of performance of the delivery
of health care with respect to coverage options offered
under the plan or health insurance coverage and of health
care professionals and facilities providing health care
under the plan or coverage.
(l) INFORMATION AVAILABLE ON REQUEST.—Pursu-
ant to written request under subsection (a)(1)(B)—
(1) INFORMATION REQUIRED FROM INDIVIDUAL
HEALTH CARE PROFESSIONALS ON REQUEST.— Any
health care professional treating a participant or
beneficiary under a group health plan or an enrollee
under health insurance coverage shall provide to the
participant or beneficiary or enrollee, on request, a
description of his or her professional qualifications
(including board certification status, licensing sta-
tus, and accreditation status, if any), privileges, and
experience and a general description by category (in-
cluding salary, fee-for-service, capitation, and such
other categories as may be specified in regulations of
the Secretary) of the applicable method by which
such professional is compensated in connection with
the provision of such health care under the plan or
coverage.
(2) INFORMATION REQUIRED FROM INDIVIDUAL
HEALTH
CARE
FACILITIES
ON
REQUEST.—Any
health care facility from which a participant, bene-
ficiary, or enrollee has sought treatment under a
group health plan or health insurance coverage shall
provide to the participant, beneficiary, or enrollee,
on request, a description of the facility’s corporate
form or other organizational form and all forms of
licensing and accreditation status (if any) assigned
to the facility by standard-setting organizations.
(m) ADVANCE
NOTICE
OF
CHANGES
IN
DRUG
FORMULARIES.—Not later than 30 days before the effec-
tive date of any exclusion of a specific drug or biological
from any drug formulary under the group health plan or
health insurance coverage that is used in the treatment
of a chronic illness or disease, the plan or issuer shall take
such actions as are necessary to reasonably ensure that
plan participants or enrollees are informed of such exclu-
sion. The requirements of this subsection may be
satisfied—
(1) in the case of a group health plan, by inclu-
sion of information in publications broadly distrib-
uted by plan sponsors, employers, or employee orga-
nizations;
(2) by timely informing participants or enrollees
who, under an ongoing program maintained under
the plan or health insurance issuer, have submitted
their names for such notification; or
(3) by any other reasonable means of timely in-
forming participants or enrollees.
SEC. 134. PROTECTION OF CONFIDENTIALITY.
(a) IN GENERAL.—A group health plan, and a health
insurance issuer offering health insurance coverage, shall
establish mechanisms and procedures to ensure compli-
ance with applicable Federal and State laws to protect the
confidentiality of individually identifiable information held
by the plan issuer with respect to a participant, bene-
ficiary, enrollee, health professional, or provider.
(b) INDIVIDUALLY IDENTIFIABLE INFORMATION DE-
FINED.—For purposes of subsection (a), the term ‘‘indi-
vidually identifiable information’’ means, with respect to
a participant, beneficiary, enrollee, a health professional,
or a provider, any information, whether oral or recorded
in any medium or form, that identifies or can readily be
associated with the identity of the participant, beneficiary,
enrollee, the health professional, or the provider.
SEC. 135. DUE PROCESS FOR HEALTH PROFESSIONALS AND
PROVIDERS.
(a) IN GENERAL.—A group health plan, and a health
insurance issuer, with respect to its offering of network
coverage shall—
(1) allow all health professionals and providers
in its service area who are licensed, accredited, or
certified to perform specific health services consist-
ent with State law and those services covered under
the network coverage to apply to become a partici-
pating health professional or provider as openings in
a network become available during at least one pe-
riod in each calendar year;
(2) provide reasonable notice to such health
professionals and providers of the opportunity to
apply and of the period during which applications
are accepted;
(3) provide for review of each application by a
credentialing committee with representation of the
category or type of health professional or provider
being credentialed;
(4) select participating health professionals and
providers using objective standards of quality devel-
oped with the suggestions and advice of professional
associations, health professionals, and providers;
(5) make such selection standards available
to—
(A) those applying to become a participat-
ing provider or health professional;
(B) purchasers of health insurance cov-
erage; and
(C) participants, beneficiaries, or enrollees;
(6) when economic considerations are taken
into account in selecting participating health profes-
sionals and providers, use objective criteria that are
available to those applying to become a participating
provider or health professional and participants,
beneficiaries, or enrollees;
(7) adjust any economic profiling to take into
account patient characteristics (such as severity of
illness) that may result in atypical utilization of
services;
(8) make the results of such profiling available
to insurance purchasers, enrollees, and the health
professional or provider involved;
(9) notify any health professional or provider
being reviewed under the process referred to in para-
graph (3) of any information indicating that the
health professional or provider fails to meet the
standards of the issuer;
(10) offer a health professional or provider re-
ceiving notice pursuant to the requirement of para-
graph (9) with an opportunity to—
(A) review the information referred to in
such paragraph; and
(B) submit supplemental or corrected in
formation;
(11) not include in its contracts with participat-
ing health professionals and providers a provision
permitting the issuer to terminate the contract with-
out cause;
(12) provide a due process appeal that con-
forms to the process specified in section 412 of the
Health Care Quality Improvement Act of 1986 (42
U.S.C. 11112) for all determinations that are ad-
verse to a health professional or provider; and
(13) unless a health professional or provider
poses an imminent harm to enrollees or an adverse
action by a governmental agency effectively impairs
the ability to provide health care items and services,
provide—
(A) reasonable notice of any decision to
terminate a health professional or provider for
cause (including an explanation of the reasons
for the determination);
(B) an opportunity to review and discuss
all of the information on which the determina-
tion is based; and
(C) an opportunity to enter into a correc-
tive action plan, before the determination be
comes subject to appeal under the process re-
ferred to in paragraph (12).
(b) RULES OF CONSTRUCTION.—The requirements of
subsection (a) shall not be construed as preempting or su-
perseding any other reviews and appeals a group health
plan, or a health insurance issuer are required by law to
make available. Nothing in subsection (a) shall be con-
strued to require a group health plan or a health insurance
issuer to renew a contract with a participating provider.
SEC. 136. PROHIBITION OF INTERFERENCE WITH CERTAIN
MEDICAL COMMUNICATIONS.
(a) IN GENERAL.—Subject to subsections (b) and (c),
a group health plan, and a health insurance issuer (in rela-
tion to an individual enrolled under health insurance cov-
erage offered by the issuer) shall not prohibit or otherwise
restrict a covered health care professional (as defined in
subsection (d)) from advising such an individual who is
a patient of the professional about the health status of
the individual or health care or treatment for the individ-
uals condition or disease, regardless of whether benefits
for such care or treatment are provided under the cov-
erage, if the professional is acting within the lawful scope
of practice.
(b) CONSCIENCE PROTECTION.—Subsection (a) shall
not be construed as requiring a group health plan or a
health insurance issuer to provide, reimburse for, or pro-
vide coverage of a counseling or referral service if the
issuer—
(1) objects to the provision of such service on
moral or religious grounds; and
(2) in the manner and through the written in-
strumentalities such issuer deems appropriate,
makes available information on its policies regarding
such service to prospective enrollees before or during
enrollment and to enrollees within 90 days after the
date that the issuer adopts a change in policy re-
garding such a counseling or referral service.
(c) CONSTRUCTION.—Nothing in subsection (b) shall
be construed to affect disclosure requirements under State
law or under the Employee Retirement Income Security
Act of 1974.
SEC. 137. PLAN SOLVENCY.
A group health plan and a health insurance issuer
offering health insurance coverage shall—
(1) meet such financial reserve or other sol-
vency-related requirements as the applicable State
authority may establish to assure the continued
availability of (and appropriate payment for) covered
items and services for enrollees; and
(2) establish mechanisms specified by the appli-
cable State authority to protect enrollees, health pro-
fessionals, and providers in the event of failure of
the issuer.
Such requirements shall not unduly impede the establish-
ment of health insurance issuers owned and operated by
health care professionals or providers or by nonprofit com-
munity-based organizations.
SEC. 138. QUALITY ASSESSMENT PROGRAM.
(a) IN GENERAL.—A group health plan and a health
insurance issuer offering health insurance coverage shall
establish a quality assessment program (consistent with
subsection (b)) that systematically and continuously
assesses—
(1) participant, beneficiary, or enrollee health
status, patient outcomes, processes of care, and par-
ticipant, beneficiary, or enrollee satisfaction associ-
ated with health care provided by the plan or issuer;
and
(2) the administrative and funding capacity of
the issuer to support and emphasize preventive care,
utilization, access and availability, cost effectiveness,
acceptable treatment modalities, specialists referrals,
the peer review process, and the efficiency of the ad-
ministrative process.
(b) FUNCTIONS.—A quality assessment program es-
tablished pursuant to subsection (a) shall—
(1) assess the performance of the plan or issuer
and its participating health professionals and provid-
ers and report the results of such assessment to pur-
chasers, participating health professionals and pro-
viders, and administrative personnel; and
(2) analyze quality assessment data to deter-
mine specific interactions in the delivery system
(both the design and funding of the health insurance
coverage and the clinical provision of care) that have
an adverse impact on the quality of care.
Subtitle E—Definitions
SEC. 151. DEFINITIONS.
(a) INCORPORATION OF GENERAL DEFINITIONS.—
Except as otherwise provided, the provisions of section
2971 of the Public Health Service Act shall apply for pur-
poses of this title in the same manner as they apply for
purposes of title XXVII of such Act.
(b) SECRETARY.—Except as otherwise provided, the
term ‘‘Secretary’’ means the Secretary of Health and
Human Services, in consultation with the Secretary of
Labor and the Secretary of the Treasury and the term
‘‘appropriate Secretary’’ means the Secretary of Health
and Human Services in relation to carrying out this title
under sections 2706 and 2751 of the Public Health Serv-
ice Act and the Secretary of Labor in relation to carrying
out this title under section 713 of the Employee Retire-
ment Income Security Act of 1974.
(c) ADDITIONAL DEFINITIONS.—For purposes of this
title:
(1) APPLICABLE AUTHORITY.—The term ‘‘ap-
plicable authority’’ means—
(A) in the case of a group health plan, the
Secretary of Health and Human Services and
the Secretary of Labor; and
(B) in the case of a health insurance issuer
with respect to a specific provision of this title,
the applicable State authority (as defined in
section 2791(d) of the Public Health Service
Act), or the Secretary of Health and Human
Services, if such Secretary is enforcing such
provision 
under 
section 
2722(a)(2) 
or
2761(a)(2) of the Public Health Service Act.
(2) ENROLLEE.—The term ‘‘enrollee’’ means,
with respect to health insurance coverage offered by
a health insurance issuer, an individual enrolled with
the issuer to receive such coverage.
(3) FEE-FOR-SERVICE
COVERAGE.—The term
‘‘fee-for-service coverage’’ means coverage that—
(A) reimburses hospitals, health profes-
sionals, or other providers, directly or by pay-
ment to enrollees who are required to pay such
parties, on the basis of a rate determined by
the issuer on a fee-for-service basis without
placing the provider at financial risk;
(B) does not vary reimbursement for the
coverage period for such a provider based on an
agreement to contract terms and conditions or
the utilization of health care items or services
relating to such provider or enrollees; and
(C) does not restrict the selection of pro-
viders among those who are lawfully authorized
to provide the covered services and agree to ac-
cept the terms and conditions of payment estab-
lished by the issuer; and
(D) for which the issuer does not utilize
prospective or concurrent review.
(4) GROUP HEALTH PLAN.—The term ‘‘group
health plan’’ has the meaning given such term in
section 733(a) of the Employee Retirement Income
Security Act of 1974.
(5) 
HEALTH
PROFESSIONAL.—The 
term
‘‘health professional’’ means an individual who is li-
censed, accredited, or certified under State law to
provide specified health care services and who is op-
erating within the scope of such licensure, accredita-
tion, or certification.
(6) NETWORK.—The term ‘‘network’’ means,
with respect to a group health plan or health insur-
ance issuer offering health insurance coverage, the
participating health professionals and providers
through whom the plan or issuer provides health
care items and services to participants, beneficiaries,
or enrollees.
(7) NETWORK COVERAGE.—The term ‘‘network
coverage’’ means, with respect to a group health
plan or health insurance coverage offered by a
health insurance issuer, health benefits coverage that
provides or arranges for the provision of health care
items and services to participants, beneficiaries, or
enrollees through participating health professionals
and providers.
shall apply with respect to group health plans, and
health insurance coverage offered in connection with
group health plans, for plan years beginning on or
after January 1, 2000 (in this section referred to as
the ‘‘general effective date’’) and also shall apply to
portions of plan years occurring on and after such
date.
(2) TREATMENT OF COLLECTIVE BARGAINING
AGREEMENTS.—In the case of a group health plan
maintained pursuant to 1 or more collective bargain-
ing agreements between employee representatives
and 1 or more employers ratified before the date of
enactment of this Act, the amendments made by sec-
tions 201(a) and 301 (and title I insofar as it re-
lates to such sections) shall not apply to plan years
beginning before the later of—
(A) the date on which the last collective
bargaining agreements relating to the plan ter-
minates (determined without regard to any ex-
tension thereof agreed to after the date of en-
actment of this Act), or
(B) the general effective date.
For purposes of subparagraph (A), any plan amend-
ment made pursuant to a collective bargaining
agreement relating to the plan which amends the
plan solely to conform to any requirement added by
this Act shall not be treated as a termination of
such collective bargaining agreement.
(b) INDIVIDUAL HEALTH INSURANCE COVERAGE.—
The amendments made by section 202 shall apply with
respect to individual health insurance coverage offered,
sold, issued, renewed, in effect, or operated in the individ-
ual market on or after the general effective date.
SEC. 402. COORDINATION IN IMPLEMENTATION.
Section 104(1) of Health Insurance Portability and
Accountability Act of 1996 is amended by striking ‘‘this
subtitle (and the amendments made by this subtitle and
section 401)’’ and inserting ‘‘the provisions of part 7 of
subtitle B of title I of the Employee Retirement Income
Security Act of 1974, the provisions of parts A and C of
title XXVII of the Public Health Service Act, chapter 100
of the Internal Revenue Code of 1986, and title I of the
Access to Quality Care Act of 1999’’.
Æ