entity from the plans or issuers for which 
external appeal activities are being con-
ducted. 
(C) CERTIFICATION
OF
QUALIFIED
PRI-
VATE STANDARD-SETTING ORGANIZATIONS.— 
(i) FOR EXTERNAL REVIEWS UNDER 
GROUP HEALTH PLANS.—For purposes of 
subparagraph (A)(i)(III), the Secretary of 
Labor may provide for a process for certifi-
cation (and periodic recertification) of 
qualified private standard-setting organiza-
tions which provide for certification of ex-
ternal review entities. Such an organization 
shall only be certified if the organization 
does not certify an external review entity 
unless it meets standards required for cer-
tification of such an entity by such Sec-
retary under subparagraph (A)(i)(I). 
(ii) FOR
EXTERNAL
REVIEWS
OF 
HEALTH
INSURANCE
ISSUERS.—For pur-
poses of subparagraph (A)(ii)(II), the Sec-
retary of Health and Human Services may 
provide for a process for certification (and 
periodic recertification) of qualified private 
standard-setting organizations which pro-
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vide for certification of external review en-
tities. Such an organization shall only be 
certified if the organization does not certify 
an external review entity unless it meets 
standards required for certification of such 
an entity by such Secretary under subpara-
graph (A)(ii)(II). 
(3) INDEPENDENCE REQUIREMENTS.— 
(A) IN GENERAL.—A clinical peer or other 
entity meets the independence requirements of 
this paragraph if— 
(i) the peer or entity does not have a 
familial, financial, or professional relation-
ship with any related party; 
(ii) any compensation received by such 
peer or entity in connection with the exter-
nal review is reasonable and not contingent 
on any decision rendered by the peer or en-
tity; 
(iii) except as provided in paragraph 
(4), the plan and the issuer have no re-
course against the peer or entity in connec-
tion with the external review; and 
(iv) the peer or entity does not other-
wise have a conflict of interest with a re-
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lated party as determined under any regu-
lations which the Secretary may prescribe. 
(B) 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 plan sponsor, fiduciary, officer, di-
rector, 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; 
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(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. 
(4) LIMITATION
ON
LIABILITY
OF
REVIEW-
ERS.—No qualified external appeal entity having a 
contract with a plan or issuer under this part and 
no person who is employed by any such entity or 
who furnishes professional services to such entity, 
shall be held by reason of the performance of any 
duty, function, or activity required or authorized 
pursuant to this section, to have violated any crimi-
nal law, or to be civilly liable under any law of the 
United States or of any State (or political subdivi-
sion thereof) if due care was exercised in the per-
formance of such duty, function, or activity and 
there was no actual malice or gross misconduct in 
the performance of such duty, function, or activity. 
(d) EXTERNAL APPEAL DETERMINATION BINDING 
ON PLAN.—The determination by an external appeal enti-
ty under this section is binding on the plan and issuer 
involved in the determination. 
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(e) PENALTIES AGAINST AUTHORIZED OFFICIALS 
FOR REFUSING TO AUTHORIZE THE DETERMINATION OF 
AN EXTERNAL REVIEW ENTITY.— 
(1) MONETARY
PENALTIES.—In any case in 
which the determination of an external review entity 
is not followed by a group health plan, or by a 
health insurance issuer offering health insurance 
coverage, any person who, acting in the capacity of 
authorizing the benefit, causes such refusal may, in 
the discretion in a court of competent jurisdiction, 
be liable to an aggrieved participant, beneficiary, or 
enrollee for a civil penalty in an amount of up to 
$1,000 a day from the date on which the determina-
tion was transmitted to the plan or issuer by the ex-
ternal review entity until the date the refusal to pro-
vide the benefit is corrected. 
(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 a plaintiff alleges that a person 
referred to in such paragraph has taken an action 
resulting in a refusal of a benefit determined by an 
external appeal entity in violation of such terms of 
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the plan, coverage, or this subtitle, or has failed to 
take an action for which such person is responsible 
under the plan, coverage, or this title and which is 
necessary under the plan or coverage for authorizing 
a benefit, the court shall cause to be served on the 
defendant an order requiring the defendant— 
(A) to cease and desist from the alleged 
action or failure to act; and 
(B) 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 au-
thorizing a benefit determined by an external 
review entity for one or more group health 
plans, or health insurance issuers offering 
health insurance coverage, for— 
(i) any pattern or practice of repeated 
refusal to authorize a benefit determined 
by an external appeal entity in violation of 
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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 authorizing benefits 
who has engaged in any such pattern or practice de-
scribed in paragraph (3)(A) with respect to a plan 
or coverage, upon the petition of the appropriate 
Secretary, may be removed by the court from such 
position, and from any other involvement, with re-
spect to such a plan or coverage, and may be pre-
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cluded from returning to any such position or in-
volvement for a period determined by the court. 
(f) PROTECTION
OF LEGAL RIGHTS.—Nothing in 
this subtitle shall be construed as altering or eliminating 
any cause of action or legal rights or remedies of partici-
pants, beneficiaries, enrollees, and others under State or 
Federal law (including sections 502 and 503 of the Em-
ployee Retirement Income Security Act of 1974), includ-
ing the right to file judicial actions to enforce actions. 
SEC. 104. ESTABLISHMENT OF A GRIEVANCE PROCESS. 
(a) ESTABLISHMENT OF GRIEVANCE SYSTEM.— 
(1) IN GENERAL.—A group health plan, and a 
health insurance issuer in connection with the provi-
sion of health insurance coverage, shall establish and 
maintain a system to provide for the presentation 
and resolution of oral and written grievances 
brought by individuals who are participants, bene-
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 
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concern brought by a participant, beneficiary or en-
rollee that is not a claim for benefits (as defined in 
section 101(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 3 previous years, all grievances 
and appeals made and their status. 
(3) A process providing for timely processing 
and resolution of grievances. 
(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. 111. 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 
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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 to such enrollees (at the 
time of enrollment and during an annual open season as 
provided under subsection (c)) the option of health insur-
ance 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 in-
surance issuer in the group market. 
(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. 
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SEC. 112. CHOICE OF HEALTH CARE PROFESSIONAL. 
(a) PRIMARY CARE.—If a group health plan, or a 
health insurance issuer that offers health insurance cov-
erage, requires or provides for designation by a partici-
pant, beneficiary, or enrollee of a participating primary 
care provider, then the plan or issuer shall permit each 
participant, beneficiary, and enrollee to designate any par-
ticipating primary care provider who is available to accept 
such individual. 
(b) SPECIALISTS.— 
(1) IN GENERAL.—Subject to paragraph (2), a 
group health plan and a health insurance issuer that 
offers health insurance coverage shall permit each 
participant, beneficiary, or enrollee to receive medi-
cally necessary 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. 
SEC. 113. ACCESS TO EMERGENCY CARE. 
(a) COVERAGE OF EMERGENCY SERVICES.— 
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(D) without regard to any other term or 
condition of such coverage (other than exclusion 
or coordination of benefits, or an affiliation or 
waiting period, permitted under section 2701 of 
the Public Health Service Act, section 701 of 
the Employee Retirement Income Security Act 
of 1974, or section 9801 of the Internal Rev-
enue Code of 1986, and other than applicable 
cost-sharing). 
(2) DEFINITIONS.—In this section: 
(A) EMERGENCY
MEDICAL
CONDITION 
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— 
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(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 
(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.—If benefits are available 
under a group health plan, or under health insurance cov-
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erage offered by a health insurance issuer, with respect 
to maintenance care or post-stabilization care covered 
under the guidelines established under section 1852(d)(2) 
of the Social Security Act, the plan or issuer shall provide 
for reimbursement with respect to such services provided 
to a participant, beneficiary, or enrollee other than 
through a participating health care provider in a manner 
consistent with subsection (a)(1)(C) (and shall otherwise 
comply with such guidelines). 
SEC. 114. 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. 
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(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. 
(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 
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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 
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, 
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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 
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 
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(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.— 
(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 
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subsection in the same manner as they apply to re-
ferrals under subsection (a)(1). 
SEC. 115. 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— 
(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— 
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(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. 
SEC. 116. 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. 117. CONTINUITY OF CARE. 
(a) IN GENERAL.— 
(1) TERMINATION OF PROVIDER.—If a contract 
between a group health plan, or a health insurance 
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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-
tion (as defined in paragraph (3)(A)) at the time of 
such termination, the plan or issuer shall— 
(A) notify the individual on a timely basis 
of such termination and of the right to elect 
continuation of coverage of treatment by the 
provider under this section; and 
(B) subject to subsection (c), permit the 
individual to elect to continue to be covered 
with respect to treatment by the provider of 
such condition during a transitional period 
(provided under subsection (b)). 
(2) TREATMENT
OF
TERMINATION
OF
CON-
TRACT
WITH
HEALTH
INSURANCE
ISSUER.—If a 
contract for the provision of health insurance cov-
erage between a group health plan and a health in-
surance issuer is terminated and, as a result of such 
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termination, coverage of services of a health care 
provider is terminated with respect to an individual, 
the provisions of paragraph (1) (and the succeeding 
provisions of this section) shall apply under the plan 
in the same manner as if there had been a contract 
between the plan and the provider that had been ter-
minated, but only with respect to benefits that are 
covered under the plan after the contract termi-
nation. 
(3) DEFINITIONS.—For purposes of this sec-
tion: 
(A) ONGOING
SPECIAL
CONDITION.—The 
term ‘‘ongoing special condition’’ has the mean-
ing given such term in section 114(b)(3), and 
also includes pregnancy. 
(B) TERMINATION.—The term ‘‘termi-
nated’’ includes, with respect to a contract, the 
expiration or nonrenewal of the contract, but 
does not include a termination of the contract 
by the plan or issuer for failure to meet applica-
ble quality standards or for fraud. 
(b) TRANSITIONAL PERIOD.— 
(1) IN GENERAL.—Except as provided in para-
graphs (2) through (4), the transitional period under 
this subsection shall extend up to 90 days (as deter-
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mined by the treating health care professional) after 
the date of the notice described in subsection 
(a)(1)(A) of the provider’s termination. 
(2) SCHEDULED SURGERY AND ORGAN TRANS-
PLANTATION.—If surgery or organ transplantation 
was scheduled for an individual before the date of 
the announcement of the termination of the provider 
status under subsection (a)(1)(A) or if the individual 
on such date was on an established waiting list or 
otherwise scheduled to have such surgery or trans-
plantation, the transitional period under this sub-
section with respect to the surgery or transplan-
tation shall extend beyond the period under para-
graph (1) and until the date of discharge of the indi-
vidual after completion of the surgery or transplan-
tation. 
(3) PREGNANCY.—If— 
(A) a participant, beneficiary, or enrollee 
was determined to be pregnant at the time of 
a provider’s termination of participation, and 
(B) the provider was treating the preg-
nancy before date of the termination, 
the transitional period under this subsection with re-
spect to provider’s treatment of the pregnancy shall 
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extend through the provision of post-partum care di-
rectly related to the delivery. 
(4) TERMINAL ILLNESS.—If— 
(A) a participant, beneficiary, or enrollee 
was determined to be terminally ill (as deter-
mined under section 1861(dd)(3)(A) of the So-
cial Security Act) at the time of a provider’s 
termination of participation, and 
(B) the provider was treating the terminal 
illness before the date of termination, 
the transitional period under this subsection shall 
extend for the remainder of the individual’s life for 
care directly related to the treatment of the terminal 
illness or its medical manifestations. 
(c) PERMISSIBLE
TERMS
AND
CONDITIONS.—A 
group health plan or health insurance issuer may condi-
tion coverage of continued treatment by a provider under 
subsection (a)(1)(B) upon the individual notifying the plan 
of the election of continued coverage and upon the pro-
vider agreeing to the following terms and conditions: 
(1) The provider agrees to accept reimburse-
ment from the plan or issuer and individual involved 
(with respect to cost-sharing) at the rates applicable 
prior to the start of the transitional period as pay-
ment in full (or, in the case described in subsection 
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