143 
‘‘(J) RESTRICTIONS
ON
COVERAGE
OF 
EMERGENCY
SERVICES.—A description of the 
circumstances under which, and the extent to 
which, the coverage, in including emergency 
medical care furnished to a participant or bene-
ficiary of the plan imposes any financial respon-
sibility described in subsection (c) on partici-
pants or beneficiaries or limits or conditions 
benefits for such care subject to any other term 
or condition of such coverage. 
‘‘(c) 
PARTICIPANT’S
FINANCIAL
RESPONSIBIL-
ITIES.—The information required under subsection (a) in-
cludes an explanation of— 
‘‘(1) a participant’s financial responsibility for 
payment of premiums, coinsurance, copayments, 
deductibles, and any other charges; and 
‘‘(2) the circumstances under which, and the 
extent to which, the participant’s financial responsi-
bility described in paragraph (1) may vary, including 
any distinctions based on whether a health care pro-
vider from whom covered benefits are obtained is in-
cluded in a defined set of providers. 
‘‘(d) ACCOUNTABILITY.—The information required 
under subsection (a) includes a description of the legal re-
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144 
course options available for participants and beneficiaries 
under the plan including— 
‘‘(1) the preemption that applies under section 
514 of the Employee Retirement Income Security 
Act of 1974 (29 U.S.C. 1144) to certain actions 
arising out of the provision of health benefits; 
‘‘(2) the ability of a participant or beneficiary 
(or the estate of the participant or beneficiary) 
under State law to recover damages resulting from 
personal injury or for wrongful death against any 
person in connection with the provision of insurance, 
administrative services, or medical services by such 
person to or for a group health plan; and 
‘‘(3) the extent to which coverage decisions 
made by the plan are subject to internal review or 
any external review and the proper time frames 
under which such reviews may be requested and con-
ducted. 
‘‘(e) INFORMATION AVAILABLE ON REQUEST.— 
‘‘(1) ACCESS TO PLAN BENEFIT INFORMATION 
IN ELECTRONIC FORM.— 
‘‘(A) IN GENERAL.—A group health plan 
(and a health insurance issuer offering health 
insurance coverage in connection with a group 
health plan) shall, upon written request (made 
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145 
not more frequently than annually), make avail-
able to participants and beneficiaries, in a gen-
erally recognized electronic format, the fol-
lowing information: 
‘‘(i) the latest summary plan descrip-
tion, including the latest summary of ma-
terial modifications; and 
‘‘(ii) the actual plan provisions setting 
forth the benefits available under the plan, 
to the extent such information relates to the 
coverage options under the plan available to the 
participant or beneficiary. A reasonable charge 
may be made to cover the cost of providing 
such information in such generally recognized 
electronic format. The Secretary may by regula-
tion prescribe a maximum amount which will 
constitute a reasonable charge under the pre-
ceding sentence. 
‘‘(B) ALTERNATIVE ACCESS.—The require-
ments of this paragraph may be met by making 
such information generally available (rather 
than upon request) on the Internet or on a pro-
prietary computer network in a format which is 
readily accessible to participants and bene-
ficiaries. 
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146 
‘‘(2) ADDITIONAL
INFORMATION
TO
BE
PRO-
VIDED ON REQUEST.— 
‘‘(A) INCLUSION IN SUMMARY PLAN DE-
SCRIPTION
OF
SUMMARY
OF
ADDITIONAL
IN-
FORMATION.—The information required under 
subsection (a) includes a summary description 
of the types of information required by this 
subsection to be made available to participants 
and beneficiaries on request. 
‘‘(B) 
INFORMATION
REQUIRED
FROM 
PLANS AND ISSUERS ON REQUEST.—In addition 
to information required to be included in sum-
mary plan descriptions under this subsection, a 
group health plan (and a health insurance 
issuer offering health insurance coverage in 
connection with a group health plan) shall pro-
vide the following information to a participant 
or beneficiary on request: 
‘‘(i) NETWORK CHARACTERISTICS.—If 
the plan (or issuer) utilizes a defined set of 
providers under contract with the plan (or 
issuer), a detailed list of the names of such 
providers and their geographic location, set 
forth separately with respect to primary 
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147 
care providers and with respect to special-
ists. 
‘‘(ii) CARE
MANAGEMENT
INFORMA-
TION.—A description of the circumstances 
under which, and the extent to which, the 
plan has special disease management pro-
grams or programs for persons with dis-
abilities, indicating whether these pro-
grams are voluntary or mandatory and 
whether a significant benefit differential 
results from participation in such pro-
grams. 
‘‘(iii) INCLUSION
OF
DRUGS
AND 
BIOLOGICALS IN FORMULARIES.—A state-
ment of whether a specific drug or biologi-
cal is included in a formulary used to de-
termine benefits under the plan and a de-
scription of the procedures for considering 
requests for any patient-specific waivers. 
‘‘(iv) PROCEDURES FOR DETERMINING 
EXCLUSIONS BASED ON MEDICAL NECES-
SITY OR EXPERIMENTAL TREATMENTS.— 
Upon receipt by the participant or bene-
ficiary of any notification of an adverse 
coverage decision based on a determination 
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148 
relating to medical necessity or an experi-
mental treatment or technology, a descrip-
tion of the procedures and medically based 
criteria used in such decision. 
‘‘(v) PREAUTHORIZATION AND UTILI-
ZATION REVIEW PROCEDURES.—Upon re-
ceipt by the participant or beneficiary of 
any notification of an adverse coverage de-
cision, a description of the basis on which 
any preauthorization requirement or any 
utilization review requirement has resulted 
in such decision. 
‘‘(vi) ACCREDITATION
STATUS
OF 
HEALTH INSURANCE ISSUERS AND SERV-
ICE PROVIDERS.—A description of the ac-
creditation and licensing status (if any) of 
each health insurance issuer offering 
health insurance coverage in connection 
with the plan and of any utilization review 
organization utilized by the issuer or the 
plan, together with the name and address 
of the accrediting or licensing authority. 
‘‘(vii) MEASURES OF ENROLLEE SAT-
ISFACTION.—The latest information (if 
any) maintained by the plan, or by any 
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149 
health insurance issuer offering health in-
surance coverage in connection with the 
plan, relating to enrollee satisfaction. 
‘‘(viii) QUALITY PERFORMANCE MEAS-
URES.—The latest information (if any) 
maintained by the plan, or by any health 
insurance issuer offering health insurance 
coverage in connection with the plan, relat-
ing to quality of performance of the deliv-
ery of medical care with respect to cov-
erage options offered under the plan and 
of health care professionals and facilities 
providing medical care under the plan. 
‘‘(C) 
INFORMATION
REQUIRED
FROM 
HEALTH CARE PROFESSIONALS ON REQUEST.— 
Any health care professional treating a partici-
pant or beneficiary under a group health plan 
shall provide to the participant or beneficiary, 
on request, a description of his or her profes-
sional qualifications (including board certifi-
cation status, licensing status, and accreditation 
status, if any), privileges, and experience and a 
general description by category (including sal-
ary, fee-for-service, capitation, and such other 
categories as may be specified in regulations of 
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smartinez on PROD1PC64 with BILLS
150 
the Secretary) of the applicable method by 
which such professional is compensated in con-
nection with the provision of such medical care. 
‘‘(D) 
INFORMATION
REQUIRED
FROM 
HEALTH CARE FACILITIES ON REQUEST.—Any 
health care facility from which a participant or 
beneficiary has sought treatment under a group 
health plan shall provide to the participant or 
beneficiary, on request, a description of the fa-
cility’s corporate form or other organizational 
form and all forms of licensing and accredita-
tion status (if any) assigned to the facility by 
standard-setting organizations. 
‘‘(f) ACCESS TO INFORMATION RELEVANT TO THE 
COVERAGE OPTIONS UNDER WHICH THE PARTICIPANT 
OR BENEFICIARY IS ELIGIBLE TO ENROLL.—In addition 
to information otherwise required to be made available 
under this section, a group health plan (and a health in-
surance issuer offering health insurance coverage in con-
nection with a group health plan) shall, upon written re-
quest (made not more frequently than annually), make 
available to a participant (and an employee who, under 
the terms of the plan, is eligible for coverage but not en-
rolled) in connection with a period of enrollment the sum-
mary plan description for any coverage option under the 
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151 
plan under which the participant is eligible to enroll and 
any information described in clauses (i), (ii), (iii), (vi), 
(vii), and (viii) of subsection (e)(2)(B). 
‘‘(g) 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 plan that is used in 
the treatment of a chronic illness or disease, the plan shall 
take such actions as are necessary to reasonably ensure 
that plan participants are informed of such exclusion. The 
requirements of this subsection may be satisfied— 
‘‘(1) by inclusion of information in publications 
broadly distributed by plan sponsors, employers, or 
employee organizations; 
‘‘(2) by electronic means of communication (in-
cluding the Internet or proprietary computer net-
works in a format which is readily accessible to par-
ticipants); 
‘‘(3) by timely informing participants who, 
under an ongoing program maintained under the 
plan, have submitted their names for such notifica-
tion; or 
‘‘(4) by any other reasonable means of timely 
informing plan participants.’’. 
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SEC. 602. EFFECTIVE DATE. 
(a) IN GENERAL.—The amendments made by section 
601 shall apply with respect to plan years beginning on 
or after January 1 of the second calendar year following 
the date of the enactment of this Act. The Secretary shall 
first issue all regulations necessary to carry out the 
amendments made by section 601 before such date. 
(b) LIMITATION ON ENFORCEMENT ACTIONS.—No 
enforcement action shall be taken, pursuant to the amend-
ments made by section 601, against a group health plan 
or health insurance issuer with respect to a violation of 
a requirement imposed by such amendments before the 
date of issuance of final regulations issued in connection 
with such requirement, if the plan or issuer has sought 
to comply in good faith with such requirement. 
Æ 
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