I
105TH CONGRESS
1ST SESSION
H. R. 820
To amend title XXVII of the Public Health Service Act to establish standards
for protection of consumers in managed care plans and other health
insurance coverage.
IN THE HOUSE OF REPRESENTATIVES
FEBRUARY 25, 1997
Mr. DINGELL introduced the following bill; which was referred to the
Committee on Commerce
A BILL
To amend title XXVII of the Public Health Service Act
to establish standards for protection of consumers in
managed care plans and other health insurance coverage.
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
‘‘Health Insurance Bill of Rights Act of 1997’’.
(b) TABLE OF CONTENTS.—The table of contents of
this Act is as follows:
Sec. 1. Short title; table of contents.
Sec. 2. Amendments to the Public Health Service Act.
‘‘PART C—PATIENT PROTECTION STANDARDS
‘‘Sec. 2770. Notice; additional definitions.
‘‘SUBPART 1—ACCESS TO CARE
‘‘Sec. 2771. Access to emergency care.
‘‘Sec. 2772. Access to specialty care.
‘‘Sec. 2773. Continuity of care.
‘‘Sec. 2774. Choice of provider.
‘‘Sec. 2775. Coverage for individuals participating in approved clinical
trials.
‘‘Sec. 2776. Access to needed prescription drugs.
‘‘SUBPART 2—QUALITY ASSURANCE
‘‘Sec. 2777. Internal quality assurance program.
‘‘Sec. 2778. Collection of standardized data.
‘‘Sec. 2779. Process for selection of providers.
‘‘Sec. 2780. Drug utilization program.
‘‘Sec. 2781. Standards for utilization review activities.
‘‘SUBPART 3—PATIENT INFORMATION
‘‘Sec. 2782. Patient information.
‘‘Sec. 2783. Protection of patient confidentiality.
‘‘SUBPART 4—GRIEVANCE PROCEDURES
‘‘Sec. 2784. Establishment of complaint and appeals process.
‘‘Sec. 2785. Provisions relating to appeals of utilization review determina-
tions and similar determinations.
‘‘Sec. 2786. State health insurance ombudsmen.
‘‘SUBPART 5—PROTECTION OF PROVIDERS AGAINST INTERFERENCE WITH
MEDICAL COMMUNICATIONS AND IMPROPER INCENTIVE ARRANGEMENTS
‘‘Sec. 2787. Prohibition of interference with certain medical communica-
tions.
‘‘Sec. 2788. Prohibition against transfer of indemnification or improper in-
centive arrangements.
‘‘SUBPART 6—PROMOTING GOOD MEDICAL PRACTICE AND PROTECTING THE
DOCTOR-PATIENT RELATIONSHIP
‘‘Sec. 2789. Promoting good medical practice.
SEC. 2. AMENDMENTS TO THE PUBLIC HEALTH SERVICE
ACT.
(a) 
PATIENT
PROTECTION
STANDARDS.—Title
XXVII of the Public Health Service Act is amended—
(1) by redesignating part C as part D, and
(2) by inserting after part B the following new
part:
‘‘PART C—PATIENT PROTECTION STANDARDS
‘‘SEC. 2770. NOTICE; ADDITIONAL DEFINITIONS.
‘‘(a) NOTICE.—A health insurance issuer under this
part shall comply with the notice requirement under sec-
tion 711(d) of the Employee Retirement Income Security
Act of 1974 with respect to the requirements of this part
as if such section applied to such issuer and such issuer
were a group health plan.
‘‘(b) ADDITIONAL DEFINITIONS.—For purposes of
this part:
‘‘(1) NONPARTICIPATING
PHYSICIAN
OR
PRO-
VIDER.—The term ‘nonparticipating physician or
provider’ means, with respect to health care items
and services furnished to an enrollee under health
insurance coverage, a physician or provider that is
not a participating physician or provider for such
services.
‘‘(2) 
PARTICIPATING
PHYSICIAN
OR
PRO-
VIDER.—The term ‘participating physician or pro-
vider’ means, with respect to health care items and
services furnished to an enrollee under health insur-
ance coverage, a physician or provider that furnishes
such items and services under a contract or other
arrangement with the health insurance issuer offer-
ing such coverage.
‘‘SUBPART 1—ACCESS TO CARE
‘‘SEC. 2771. ACCESS TO EMERGENCY CARE.
‘‘(a) PROHIBITION OF CERTAIN RESTRICTIONS ON
COVERAGE OF EMERGENCY SERVICES.
‘‘(1) IN
GENERAL.—If health insurance cov-
erage provides any benefits with respect to emer-
gency services (as defined in paragraph (2)(B)), the
health insurance issuer offering such coverage shall
cover emergency services furnished to an enrollee—
‘‘(A) without the need for any prior au-
thorization determination,
‘‘(B) subject to paragraph (3), whether or
not the physician or provider furnishing such
services is a participating physician or provider
with respect to such services, and
‘‘(C) subject to paragraph (3), without re-
gard to any other term or condition of such cov-
erage (other than an exclusion of benefits, or an
affiliation or waiting period, permitted under
section 2701).
‘‘(2) EMERGENCY SERVICES; EMERGENCY MEDI-
CAL CONDITION.—For purposes of this section—
‘‘(A) EMERGENCY
MEDICAL
CONDITION
BASED
ON
PRUDENT
LAYPERSON.—The term
‘emergency medical condition’ means a medical
condition manifesting itself by acute symptoms
of sufficient severity (including severe pain)
such that a prudent layperson, who possesses
an average knowledge of health and medicine,
could reasonably expect the absence of imme-
diate medical attention to result in—
‘‘(i) placing the health of the individ-
ual (or, with respect to a pregnant woman,
the health of the woman or her unborn
child) in serious jeopardy,
‘‘(ii) serious impairment to bodily
functions, or
‘‘(iii) serious dysfunction of any bodily
organ or part.
‘‘(B) EMERGENCY
SERVICES.—The term
‘emergency services’ means—
‘‘(i) a medical screening examination
(as required under section 1867 of the So-
cial Security Act) that is within the capa-
bility of the emergency department of a
hospital, including ancillary services rou-
tinely available to the emergency depart-
ment, to evaluate an emergency medical
condition (as defined in subparagraph
(A)), and
‘‘(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 the Social Security Act to stabilize
the patient.
‘‘(C) TRAUMA AND BURN CENTERS.—The
provisions of clause (ii) of subparagraph (B)
apply to a trauma or burn center, in a hospital,
that—
‘‘(i) is designated by the State, a re-
gional authority of the State, or by the
designee of the State, or
‘‘(ii) is in a State that has not made
such designations and meets medically rec-
ognized national standards.
‘‘(3) APPLICATION OF NETWORK RESTRICTION
PERMITTED IN CERTAIN CASES.—
‘‘(A) IN GENERAL.—Except as provided in
subparagraph (B), if a health insurance issuer
of health and medicine could reasonably
believe that, under the circumstances and
consistent with guidelines, the time re-
quired to go to a participating hospital for
such services could result in any of the ad-
verse health consequences described in a
clause of subsection (a)(2)(A).
‘‘(iii) PHYSICIAN REFERRAL.—A par-
ticipating physician or other person au-
thorized by the plan refers the enrollee to
an emergency department of a hospital and
does not specify an emergency department
of a hospital that is a participating hos-
pital with respect to such services.
‘‘(C) APPLICATION OF ‘BEYOND CONTROL’
STANDARDS.—For purposes of applying sub-
paragraph (B)(i), receipt of emergency services
from a nonparticipating hospital shall be treat-
ed under the guidelines as being ‘due to cir-
cumstances beyond the control of the enrollee’
if any of the following conditions are met:
‘‘(i) UNCONSCIOUS.—The enrollee was
unconscious or in an otherwise altered
mental state at the time of initiation of the
services.
‘‘(ii) AMBULANCE
DELIVERY.—The
enrollee was transported by an ambulance
or other emergency vehicle directed by a
person other than the enrollee to the non-
participating hospital in which the services
were provided.
‘‘(iii) NATURAL DISASTER.—A natural
disaster or civil disturbance prevented the
enrollee from presenting to a participating
hospital for the provision of such services.
‘‘(iv) NO GOOD FAITH EFFORT TO IN-
FORM OF CHANGE IN PARTICIPATION DUR-
ING A CONTRACT YEAR.—The status of the
hospital changed from a participating hos-
pital to a nonparticipating hospital with re-
spect to emergency services during a con-
tract year and the plan or issuer failed to
make a good faith effort to notify the en-
rollee involved of such change.
‘‘(v) 
OTHER
CONDITIONS.—There
were other factors (such as those identified
in guidelines) that prevented the enrollee
from controlling selection of the hospital in
which the services were provided.
‘‘(b) ASSURING COORDINATED COVERAGE OF MAIN-
TENANCE CARE AND POST-STABILIZATION CARE.—
‘‘(1) IN GENERAL.—In the case of an enrollee
who is covered under health insurance coverage is-
sued by a health insurance issuer and who has re-
ceived emergency services pursuant to a screening
evaluation conducted (or supervised) by a treating
physician at a hospital that is a nonparticipating
provider with respect to emergency services, if—
‘‘(A) pursuant to such evaluation, the phy-
sician identifies post-stabilization care (as de-
fined in paragraph (3)(B)) that is required by
the enrollee,
‘‘(B) the coverage provides benefits with
respect to the care so identified and the cov-
erage requires (but for this subsection) an af-
firmative prior authorization determination as a
condition of coverage of such care, and
‘‘(C) the treating physician (or another in-
dividual acting on behalf of such physician) ini-
tiates, not later than 30 minutes after the time
the treating physician determines that the con-
dition of the enrollee is stabilized, a good faith
effort to contact a physician or other person au-
thorized by the issuer (by telephone or other
means) to obtain an affirmative prior authoriza-
tion determination with respect to the care,
then, without regard to terms and conditions speci-
fied in paragraph (2) the issuer shall cover mainte-
nance care (as defined in paragraph (3)(A)) fur-
nished to the enrollee during the period specified in
paragraph (4) and shall cover post-stabilization care
furnished to the enrollee during the period beginning
under paragraph (5) and ending under paragraph
(6).
‘‘(2) TERMS
AND
CONDITIONS
WAIVED.—The
terms and conditions (of coverage) described in this
paragraph that are waived under paragraph (1) are
as follows:
‘‘(A) The need for any prior authorization
determination.
‘‘(B) Any limitation on coverage based on
whether or not the physician or provider fur-
nishing the care is a participating physician or
provider with respect to such care.
‘‘(C) Any other term or condition of the
coverage (other than an exclusion of benefits, or
an affiliation or waiting period, permitted under
section 2701 and other than a requirement re-
lating to medical necessity for coverage of bene-
fits).
‘‘(3) MAINTENANCE
CARE
AND
POST-STA-
BILIZATION CARE DEFINED.—In this subsection:
‘‘(A) MAINTENANCE
CARE.—The term
‘maintenance care’ means, with respect to an
individual who is stabilized after provision of
emergency services, medically necessary items
and services (other than emergency services)
that are required by the individual to ensure
that the individual remains stabilized during
the period described in paragraph (4).
‘‘(B) 
POST-STABILIZATION
CARE.—The
term ‘post-stabilization care’ means, with re-
spect to an individual who is determined to be
stable pursuant to a medical screening examina-
tion or who is stabilized after provision of emer-
gency services, medically necessary items and
services (other than emergency services and
other than maintenance care) that are required
by the individual.
‘‘(4) PERIOD
OF
REQUIRED
COVERAGE
OF
MAINTENANCE CARE.—The period of required cov-
erage of maintenance care of an individual under
this subsection begins at the time of the request (or
the initiation of the good faith effort to make the re-
quest) under paragraph (1)(C) and ends when—
‘‘(A) the individual is discharged from the
hospital;
‘‘(B) a physician (designated by the issuer
involved) and with privileges at the hospital in-
volved arrives at the emergency department of
the hospital and assumes responsibility with re-
spect to the treatment of the individual; or
‘‘(C) the treating physician and the issuer
agree to another arrangement with respect to
the care of the individual.
‘‘(5) WHEN
POST-STABILIZATION
CARE
RE-
QUIRED TO BE COVERED.—
‘‘(A) WHEN TREATING PHYSICIAN UNABLE
TO
COMMUNICATE
REQUEST.—If the treating
physician or other individual makes the good
faith effort to request authorization under para-
graph (1)(C) but is unable to communicate the
request directly with an authorized person re-
ferred to in such paragraph within 30 minutes
after the time of initiating such effort, then
post-stabilization care is required to be covered
under this subsection beginning at the end of
such 30-minute period.
‘‘(B) WHEN ABLE TO COMMUNICATE RE-
QUEST, AND NO TIMELY RESPONSE.—
‘‘(i) IN
GENERAL.—If the treating
physician or other individual under para-
graph (1)(C) is able to communicate the
request within the 30-minute period de-
scribed in subparagraph (A), the post-sta-
bilization care requested is required to be
covered under this subsection beginning 30
minutes after the time when the issuer re-
ceives the request unless a person author-
ized by the plan or issuer involved commu-
nicates (or makes a good faith effort to
communicate) a denial of the request for
the prior authorization determination with-
in 30 minutes of the time when the issuer
receives the request and the treating physi-
cian does not request under clause (ii) to
communicate directly with an authorized
physician concerning the denial.
‘‘(ii) REQUEST
FOR
DIRECT
PHYSI-
CIAN-TO-PHYSICIAN COMMUNICATION CON-
CERNING DENIAL.—If a denial of a request
is communicated under clause (i), the
treating physician may request to commu-
nicate respecting the denial directly with a
physician who is authorized by the issuer
to deny or affirm such a denial.
‘‘(C) WHEN NO TIMELY RESPONSE TO RE-
QUEST
FOR
PHYSICIAN-TO-PHYSICIAN
COMMU-
NICATION.—If a request for physician-to-physi-
cian communication is made under subpara-
graph (B)(ii), the post-stabilization care re-
quested is required to be covered under this
subsection beginning 30 minutes after the time
when the issuer receives the request from a
treating physician unless a physician, who is
authorized by the issuer to reverse or affirm the
initial denial of the care, communicates (or
makes a good faith effort to communicate) di-
rectly with the treating physician within such
30-minute period.
‘‘(D) DISAGREEMENTS
OVER
POST-STA-
BILIZATION CARE.—If, after a direct physician-
to-physician communication under subpara-
graph (C), the denial of the request for the
post-stabilization care is not reversed and the
treating physician communicates to the issuer
involved a disagreement with such decision, the
post-stabilization care requested is required to
be covered under this subsection beginning as
follows:
‘‘(i) DELAY TO ALLOW FOR PROMPT
ARRIVAL
OF
PHYSICIAN
ASSUMING
RE-
SPONSIBILITY.—If 
the 
issuer 
commu-
nicates that a physician (designated by the
plan or issuer) with privileges at the hos-
pital involved will arrive promptly (as de-
termined under guidelines) at the emer-
gency department of the hospital in order
to assume responsibility with respect to the
treatment of the enrollee involved, the re-
quired coverage of the post-stabilization
care begins after the passage of such time
period as would allow the prompt arrival of
such a physician.
‘‘(ii) OTHER
CASES.—If the issuer
does not so communicate, the required cov-
erage of the post-stabilization care begins
immediately.
‘‘(6) NO REQUIREMENT OF COVERAGE OF POST-
STABILIZATION
CARE
IF
ALTERNATE
PLAN
OF
TREATMENT.—
‘‘(A) IN GENERAL.—Coverage of post-sta-
bilization care is not required under this sub-
section with respect to an individual when—
‘‘(i) subject to subparagraph (B), a
physician (designated by the plan or issuer
involved) and with privileges at the hos-
pital involved arrives at the emergency de-
partment of the hospital and assumes re-
sponsibility with respect to the treatment
of the individual; or
‘‘(ii) the treating physician and the is-
suer agree to another arrangement with re-
spect to the post-stabilization care (such as
an appropriate transfer of the individual
involved to another facility or an appoint-
ment for timely followup treatment for the
individual).
‘‘(B) SPECIAL RULE WHERE ONCE CARE
INITIATED.—Required coverage of requested
post-stabilization care shall not end by reason
of subparagraph (A)(i) during an episode of
care (as determined by guidelines) if the treat-
ing physician initiated such care (consistent
with a previous paragraph) before the arrival of
a physician described in such subparagraph.
‘‘(7) CONSTRUCTION.—Nothing in this sub-
section shall be construed as—
‘‘(A) preventing an issuer from authorizing
coverage of maintenance care or post-stabiliza-
tion care in advance or at any time; or
‘‘(B) preventing a treating physician or
other individual described in paragraph (1)(C)
and an issuer from agreeing to modify any of
the time periods specified in paragraphs (5) as
it relates to cases involving such persons.
‘‘(c) LIMITS ON COST-SHARING FOR SERVICES FUR-
NISHED IN EMERGENCY DEPARTMENTS.—If health insur-
ance coverage provides any benefits with respect to emer-
gency services, the health insurance issuer offering such
coverage may impose cost sharing with respect to such
services only if the following conditions are met:
‘‘(1) LIMITATIONS
ON
COST-SHARING
DIF-
FERENTIAL FOR NONPARTICIPATING PROVIDERS.—
‘‘(A) NO
DIFFERENTIAL
FOR
CERTAIN
SERVICES.—In the case of services furnished
under the circumstances described in clause (i),
(ii), or (iii) of subsection (a)(3)(B) (relating to
circumstances beyond the control of the en-
rollee, the likelihood of an adverse health con-
sequence based on layperson’s judgment, and
physician referral), the cost-sharing for such
services provided by a nonparticipating provider
or physician does not exceed the cost-sharing
for such services provided by a participating
provider or physician.
‘‘(B) ONLY
REASONABLE
DIFFERENTIAL
FOR OTHER SERVICES.—In the case of other
emergency services, any differential by which
the cost-sharing for such services provided by a
nonparticipating provider or physician exceeds
the cost-sharing for such services provided by a
participating provider or physician is reasonable
(as determined under guidelines).
‘‘(2) ONLY
REASONABLE
DIFFERENTIAL
BE-
TWEEN EMERGENCY SERVICES AND OTHER SERV-
ICES.—Any differential by which the cost-sharing for
services furnished in an emergency department ex-
ceeds the cost-sharing for such services furnished in
another setting is reasonable (as determined under
guidelines).
‘‘(3) CONSTRUCTION.—Nothing in paragraph
(1)(B) or (2) shall be construed as authorizing
guidelines other than guidelines that establish maxi-
mum cost-sharing differentials.
‘‘(d) INFORMATION
ON ACCESS
TO EMERGENCY
SERVICES.—A health insurance issuer, to the extent a
health insurance issuer offers health insurance coverage,
shall provide education to enrollees on—
‘‘(1) coverage of emergency services (as defined
in subsection (a)(2)(B)) by the issuer in accordance
with the provisions of this section,
‘‘(2) the appropriate use of emergency services,
including use of the 911 telephone system or its
local equivalent,
‘‘(3) any cost sharing applicable to emergency
services,
‘‘(4) the process and procedures of the plan for
obtaining emergency services, and
‘‘(5) the locations of—
‘‘(A) emergency departments, and
‘‘(B) other settings,
in which participating physicians and hospitals pro-
vide emergency services and post-stabilization care.
‘‘(e) GENERAL DEFINITIONS.—For purposes of this
section:
‘‘(1) COST SHARING.—The term ‘cost sharing’
means any deductible, coinsurance amount, copay-
ment or other out-of-pocket payment (other than
premiums or enrollment fees) that a health insur-
ance offering health insurance issuer imposes on en-
rollees with respect to the coverage of benefits.
‘‘(2) GOOD FAITH EFFORT.—The term ‘good
faith effort’ has the meaning given such term in
guidelines and requires such appropriate documenta-
tion as is specified under such guidelines.
‘‘(3) 
GUIDELINES.—The 
term 
‘guidelines’
means guidelines established by the Secretary after
consultation with an advisory panel that includes in-
dividuals representing emergency physicians, health
insurance issuers, including at least one health
maintenance organization, hospitals, employers, the
States, and consumers.
‘‘(4) 
PRIOR
AUTHORIZATION
DETERMINA-
TION.—The term ‘prior authorization determination’
means, with respect to items and services for which
coverage may be provided under health insurance
coverage, a determination (before the provision of
the items and services and as a condition of coverage
of the items and services under the coverage) of
whether or not such items and services will be cov-
ered under the coverage.
‘‘(5) 
STABILIZE.—The 
term 
‘to 
stabilize’
means, with respect to an emergency medical condi-
tion, to provide (in complying with section 1867 of
the Social Security Act) such medical treatment of
the condition as may be necessary to assure, within
reasonable medical probability, that no material de-
terioration of the condition is likely to result from or
occur during the transfer of the individual from the
facility.
‘‘(6) 
STABILIZED.—The 
term 
‘stabilized’
means, with respect to an emergency medical condi-
tion, that no material deterioration of the condition
is likely, within reasonable medical probability, to re-
sult from or occur before an individual can be trans-
ferred from the facility, in compliance with the re-
quirements of section 1867 of the Social Security
Act.
‘‘(7) TREATING PHYSICIAN.—The term ‘treat-
ing physician’ includes a treating health care profes-
sional who is licensed under State law to provide
emergency services other than under the supervision
of a physician.
‘‘SEC. 2772. ACCESS TO SPECIALTY CARE.
‘‘(a) OBSTETRICAL AND GYNECOLOGICAL CARE.—
‘‘(1) IN GENERAL.—If a health insurance is-
suer, in connection with the provision of health in-
surance coverage, requires or provides for an en-
rollee to designate a participating primary care pro-
vider—
‘‘(A) the issuer shall permit a female en-
rollee to designate a physician who specializes
in obstetrics and gynecology as the enrollee’s
primary care provider; and
‘‘(B) if such an enrollee has not designated
such a provider as a primary care provider, the
issuer—
‘‘(i) may not require prior authoriza-
tion by the enrollee’s primary care provider
or otherwise for coverage of routine gyne-
cological care (such as preventive women’s
health examinations) and pregnancy-relat-
ed services provided by a participating phy-
sician who specializes in obstetrics and
gynecology to the extent such care is other-
wise covered, and
‘‘(ii) may treat the ordering of other
gynecological care by such a participating
physician as the prior authorization of the
primary care provider with respect to such
care under the coverage.
‘‘(2) CONSTRUCTION.—Nothing in paragraph
(1)(B)(ii) shall waive any requirements of coverage
relating to medical necessity or appropriateness with
respect to coverage of gynecological care so ordered.
‘‘(b) SPECIALTY CARE.—
‘‘(1) REFERRAL TO SPECIALTY CARE FOR EN-
ROLLEES
REQUIRING
TREATMENT
BY
SPECIAL-
ISTS.—
‘‘(A) IN GENERAL.—In the case of an en-
rollee who is covered under health insurance
coverage offered by a health insurance issuer
and who has a condition or disease of sufficient
seriousness and complexity to require treatment
by a specialist, the issuer shall make or provide
for a referral to a specialist who is available
and accessible to provide the treatment for such
condition or disease.
‘‘(B) SPECIALIST DEFINED.—For purposes
of this subsection, the term ‘specialist’ means,
with respect to a condition, a health care practi-
tioner, facility, or center (such as a center of
excellence) that has adequate expertise through
appropriate training and experience (including,
in the case of a child, appropriate pediatric ex-
pertise) to provide high quality care in treating
the condition.
‘‘(C) CARE UNDER REFERRAL.—Care pro-
vided pursuant to such referral under subpara-
graph (A) shall be—
‘‘(i) pursuant to a treatment plan (if
any) developed by the specialist and ap-
proved by the issuer, in consultation with
the designated primary care provider or
specialist and the enrollee (or the enrollee’s
designee), and
‘‘(ii) in accordance with applicable
quality assurance and utilization review
standards of the issuer.
Nothing in this subsection shall be construed as
preventing such a treatment plan for an en-
rollee from requiring a specialist to provide the
primary care provider with regular updates on
the specialty care provided, as well as all nec-
essary medical information.
‘‘(D) REFERRALS TO PARTICIPATING PRO-
VIDERS.—An issuer is not required under sub-
paragraph (A) to provide for a referral to a spe-
cialist that is not a participating provider, un-
less the issuer does not have an appropriate
specialist that is available and accessible to
treat the enrollee’s condition and that is a par-
ticipating provider with respect to such treat-
ment.
‘‘(E) TREATMENT OF NONPARTICIPATING
PROVIDERS.—If an issuer refers an enrollee to
a nonparticipating specialist, services provided
pursuant to the approved treatment plan shall
be provided at no additional cost to the enrollee
beyond what the enrollee would otherwise pay
for services received by such a specialist that is
a participating provider.
‘‘(2) SPECIALISTS AS PRIMARY CARE PROVID-
ERS.—
‘‘(A) IN GENERAL.—A health insurance is-
suer, in connection with the provision of health
insurance coverage, shall have a procedure by
which a new enrollee upon enrollment, or an en-
rollee upon diagnosis, with an ongoing special
condition (as defined in subparagraph (C)) may
receive a referral to a specialist for such condi-
tion who shall be responsible for and capable of
providing and coordinating the enrollee’s pri-
mary and specialty care. If such an enrollee’s
care would most appropriately be coordinated
by such a specialist, the issuer shall refer the
enrollee to such specialist.
‘‘(B) TREATMENT AS PRIMARY CARE PRO-
VIDER.—Such specialist shall be permitted to
treat the enrollee without a referral from the
enrollee’s primary care provider and may au-
thorize such referrals, procedures, tests, and
other medical services as the enrollee’s primary
care provider would otherwise be permitted to
provide or authorize, subject to the terms of the
treatment plan (referred to in paragraph
(1)(C)(i)).
‘‘(C) ONGOING
SPECIAL
CONDITION
DE-
FINED.—In this paragraph, the term ‘special
condition’ means a condition or disease that—
‘‘(i) is life-threatening, degenerative,
or disabling, and
‘‘(ii) requires specialized medical care
over a prolonged period of time.
‘‘(D) TERMS OF REFERRAL.—The provi-
sions of subparagraphs (C) through (E) of
paragraph (1) shall apply with respect to refer-
rals under subparagraph (A) of this paragraph
in the same manner as they apply to referrals
under paragraph (1)(A).
‘‘(3) STANDING REFERRALS.—
‘‘(A) IN GENERAL.—A health insurance is-
suer, in connection with the provision of health
insurance coverage, shall have a procedure by
which an enrollee who has a condition that re-
quires ongoing care from a specialist may re-
ceive a standing referral to such specialist for
treatment of such condition. If the issuer, or
the primary care provider in consultation with
the medical director of the issuer and the spe-
cialist (if any), determines that such a standing
referral is appropriate, the issuer shall make
such a referral to such a specialist.
‘‘(C) TERMS
OF
REFERRAL.—The provi-
sions of subparagraphs (C) through (E) of
paragraph (1) shall apply with respect to refer-
rals under subparagraph (A) of this paragraph
in the same manner as they apply to referrals
under paragraph (1)(A).
‘‘SEC. 2773. CONTINUITY OF CARE.
‘‘(a) IN GENERAL.—If a contract between a health
insurance issuer, in connection with the provision of health
insurance coverage, and a health care provider is termi-
nated (other than by the issuer for failure to meet applica-
ble quality standards or for fraud) and an enrollee is un-
dergoing a course of treatment from the provider at the
time of such termination, the issuer shall—
‘‘(1) notify the enrollee of such termination,
and
‘‘(2) subject to subsection (c), permit the en-
rollee to continue the course of treatment with the
provider during a transitional period (provided under
subsection (b)).
‘‘(b) TRANSITIONAL PERIOD.—
‘‘(1) IN GENERAL.—Except as provided in para-
graphs (2) through (4), the transitional period under
this subsection shall extend for at least—
‘‘(A) 60 days from the date of the notice
to the enrollee of the provider’s termination in
the case of a primary care provider, or
‘‘(B) 120 days from such date in the case
of another provider.
‘‘(2) INSTITUTIONAL
CARE.—The transitional
period under this subsection for institutional or in-
patient care from a provider shall extend until the
discharge or termination of the period of institu-
tionalization and shall include reasonable follow-up
care related to the institutionalization and shall also
include institutional care scheduled prior to the date
of termination of the provider status.
‘‘(3) PREGNANCY.—If—
‘‘(A) an enrollee has entered the second
trimester of pregnancy at the time of a provid-
er’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
extend through the provision of post-partum care di-
rectly related to the delivery.
‘‘(4) TERMINAL ILLNESS.—
‘‘(A) IN GENERAL.—If—
‘‘(i) an enrollee was determined to be
terminally ill (as defined in subparagraph
(B)) at the time of a provider’s termi-
nation of participation, and
‘‘(ii) the provider was treating the ter-
minal illness before the date of termi-
nation,
the transitional period under this subsection
shall extend for the remainder of the enrollee’s
life for care directly related to the treatment of
the terminal illness.
‘‘(B) DEFINITION.—In subparagraph (A),
an enrollee is considered to be ‘terminally ill’ if
the enrollee has a medical prognosis that the
enrollee’s life expectancy is 6 months or less.
‘‘(c) PERMISSIBLE TERMS AND CONDITIONS.—An is-
suer may condition coverage of continued treatment by a
provider under subsection (a)(2) upon the provider agree-
ing to the following terms and conditions:
‘‘(1) The provider agrees to continue to accept
reimbursement from the issuer at the rates applica-
ble prior to the start of the transitional period as
payment in full.
‘‘(2) The provider agrees to adhere to the issu-
er’s quality assurance standards and to provide to
the issuer necessary medical information related to
the care provided.
‘‘(3) The provider agrees otherwise to adhere to
the issuer’s policies and procedures, including proce-
dures regarding referrals and obtaining prior au-
thorization and providing services pursuant to a
treatment plan approved by the issuer.
‘‘SEC. 2774. CHOICE OF PROVIDER.
‘‘(a) PRIMARY CARE.—A health insurance issuer that
offers health insurance coverage shall permit each enrollee
to receive primary care from any participating primary
care provider who is available to accept such enrollee.
‘‘(b) SPECIALISTS.—
‘‘(1) IN GENERAL.—Subject to paragraph (2), a
health insurance issuer that offers health insurance
coverage shall permit each enrollee to receive medi-
cally necessary specialty care, pursuant to appro-
priate referral procedures, from any qualified par-
ticipating health care provider who is available to ac-
cept such enrollee for such care.
‘‘(2) LIMITATION.—Paragraph (1) shall not
apply to speciality care if the issuer clearly informs
enrollees of the limitations on choice of participating
providers with respect to such care.
‘‘(c) LIST OF PARTICIPATING PROVIDERS.—For dis-
closure of information about participating primary care
and specialty care providers, see section 2782(b)(3).
‘‘SEC. 2775. COVERAGE FOR INDIVIDUALS PARTICIPATING
IN APPROVED CLINICAL TRIALS.
‘‘(a) IN GENERAL.—If a health insurance issuer of-
fers health insurance coverage to a qualified enrollee (as
defined in subsection (b)), the issuer—
‘‘(1) may not deny the enrollee participation in
the clinical trial referred to in subsection (b)(2);
‘‘(2) subject to subsection (c), may not deny (or
limit or impose additional conditions on) the cov-
erage of routine patient costs for items and services
furnished in connection with participation in the
trial; and
‘‘(3) may not discriminate against the enrollee
on the basis of the enrollee’s participation in such
trial.
‘‘(b) QUALIFIED ENROLLEE DEFINED.—For pur-
poses of subsection (a), the term ‘qualified enrollee’ means
an enrollee under health insurance coverage who meets the
following conditions:
‘‘(1) The enrollee has a life-threatening or seri-
ous illness for which no standard treatment is effec-
tive.
‘‘(2) The enrollee is eligible to participate in an
approved clinical trial with respect to treatment of
such illness.
‘‘(3) The enrollee and the referring physician
conclude that the enrollee’s participation in such
trial would be appropriate.
‘‘(4) The enrollee’s participation in the trial of-
fers potential for significant clinical benefit for the
enrollee.
‘‘(c) PAYMENT.—
‘‘(1) IN GENERAL.—Under this section an is-
suer shall provide for payment for routine patient
costs described in subsection (a)(2) but is not re-
quired to pay for costs of items and services that are
reasonably expected (as determined by the Sec-
retary) to be paid for by the sponsors of an ap-
proved clinical trial.
‘‘(2) PAYMENT RATE.—In the case of covered
items and services provided by—
‘‘(A) a participating provider, the payment
rate shall be at the agreed upon rate, or
‘‘(B) a nonparticipating provider, the pay-
ment rate shall be at the rate the issuer would
normally pay for comparable services under
subparagraph (A).
‘‘(d) APPROVED CLINICAL TRIAL DEFINED.—In this
section, the term ‘approved clinical trial’ means a clinical
research study or clinical investigation approved and fund-
ed by one or more of the following:
‘‘(1) The National Institutes of Health.
‘‘(2) A cooperative group or center of the Na-
tional Institutes of Health.
‘‘(3) The Department of Veterans Affairs.
‘‘(4) The Department of Defense.
‘‘SEC. 2776. ACCESS TO NEEDED PRESCRIPTION DRUGS.
‘‘If a health insurance issuer offers health insurance
coverage that provides benefits with respect to prescription
drugs but the coverage limits such benefits to drugs in-
cluded in a formulary, the issuer shall—
‘‘(1) ensure participation of participating physi-
cians in the development of the formulary;
‘‘(2) disclose the nature of the formulary re-
strictions; and
‘‘(3) provide for exceptions from the formulary
limitation when medical necessity, as determined by
the enrollee’s physician subject to reasonable review
by the issuer, dictates that a non-formulary alter-
native is indicated.
‘‘SUBPART 2—QUALITY ASSURANCE
‘‘SEC. 2777. INTERNAL QUALITY ASSURANCE PROGRAM.
‘‘(a) REQUIREMENT.—A health insurance issuer that
offers health insurance coverage shall establish and main-
tain an ongoing, internal quality assurance and continuous
quality improvement program that meets the requirements
of subsection (b).
‘‘(b) PROGRAM REQUIREMENTS.—The requirements
of this subsection for a quality improvement program of
an issuer are as follows:
‘‘(1) ADMINISTRATION.—The issuer has a sepa-
rate identifiable unit with responsibility for adminis-
tration of the program.
‘‘(2) WRITTEN PLAN.—The issuer has a written
plan for the program that is updated annually and
that specifies at least the following:
‘‘(A) The activities to be conducted.
‘‘(B) The organizational structure.
‘‘(C) The duties of the medical director.
‘‘(D) Criteria and procedures for the as-
sessment of quality.
‘‘(E) Systems for ongoing and focussed
evaluation activities.
‘‘(3) SYSTEMATIC REVIEW.—The program pro-
vides for systematic review of the type of health
services provided, consistency of services provided
with good medical practice, and patient outcomes.
‘‘(4) QUALITY CRITERIA.—The program—
‘‘(A) uses criteria that are based on per-
formance and clinical outcomes where feasible
and appropriate, and
‘‘(B) includes criteria that are directed
specifically at meeting the needs of at-risk pop-
ulations and enrollees with chronic or severe ill-
nesses.
‘‘(5) SYSTEM FOR REPORTING.—The program
has procedures for reporting of possible quality con-
cerns by providers and enrollees and for remedial ac-
tions to correct quality problems, including written
procedures for responding to concerns and taking
appropriate corrective action.
‘‘(6) DATA
COLLECTION.—The program pro-
vides for the collection of systematic, scientifically
based data to be used in the measure of quality.
‘‘(c) DEEMING.—For purposes of subsection (a), the
requirements of subsection (b) are deemed to be met with
respect to a health insurance issuer if the issuer—
‘‘(1) is a qualified health maintenance organiza-
tion (as defined in section 1310(d)), or
‘‘(2) is accredited by a national accreditation
organization that is certified by the Secretary.
‘‘SEC. 2778. COLLECTION OF STANDARDIZED DATA.
‘‘(a) IN GENERAL.—A health insurance issuer that
offers health insurance coverage shall collect uniform qual-
ity data that include—
‘‘(1) a minimum uniform data set described in
subsection (b), and
‘‘(2) additional data that are consistent with
the requirements of a nationally recognized body
identified by the Secretary.
‘‘(b) MINIMUM UNIFORM DATA SET.—The Secretary
shall specify the data required to be included in the mini-
mum uniform data set under subsection (a)(1) and the
standard format for such data. Such data shall include
at least—
‘‘(1) aggregate utilization data;
‘‘(2) data on the demographic characteristics of
enrollees;
‘‘(3) data on disease-specific and age-specific
mortality rates of enrollees;
‘‘(4) data on enrollee satisfaction, including
data on enrollee disenrollment and grievances; and
‘‘(5) data on quality indicators.
‘‘(c) AVAILABILITY.—A summary of the data col-
lected under subsection (a) shall be disclosed under section
2782(b)(4).
‘‘SEC. 2779. PROCESS FOR SELECTION OF PROVIDERS.
‘‘(a) IN GENERAL.—A health insurance issuer that
offers health insurance coverage shall have a written proc-
ess for the selection of participating health care profes-
sionals, including minimum professional requirements.
‘‘(b) VERIFICATION OF BACKGROUND.—Such process
shall include verification of a health care provider’s li-
cense, a history of suspension or revocation, and liability
claim history.
‘‘(c) RESTRICTION.—Such process shall not use a
high-risk patient base or location of a provider in an area
with residents with poorer health status as a basis for ex-
cluding providers from participation.
‘‘SEC. 2780. DRUG UTILIZATION PROGRAM.
‘‘A health insurance issuer that provides health insur-
ance coverage that includes benefits for prescription drugs
shall establish and maintain a drug utilization program
which—
‘‘(1) encourages appropriate use of prescription
drugs by enrollees and providers,
‘‘(2) monitors illnesses arising from improper
drug use or from adverse drug reactions or inter-
actions, and
‘‘(3) takes appropriate action to reduce the inci-
dence of improper drug use and adverse drug reac-
tions and interactions.
‘‘SEC. 2781. STANDARDS FOR UTILIZATION REVIEW ACTIVI-
TIES.
‘‘(a) COMPLIANCE WITH REQUIREMENTS.—
‘‘(1) IN GENERAL.—A health insurance issuer
shall conduct utilization review activities in connec-
tion with the provision of health insurance coverage
only in accordance with a utilization review program
that meets the requirements of this section.
‘‘(2) USE
OF
OUTSIDE
AGENTS.—Nothing in
this section shall be construed as preventing a health
insurance issuer from arranging through a contract
or otherwise for persons or entities to conduct utili-
zation review activities on behalf of the issuer, so
long as such activities are conducted in accordance
with a utilization review program that meets the re-
quirements of this section.
‘‘(3) UTILIZATION REVIEW DEFINED.—For pur-
poses of this section, the terms ‘utilization review’
and ‘utilization review activities’ mean procedures
used to monitor or evaluate the clinical necessity,
appropriateness, efficacy, or efficiency of health care
services, procedures or settings, and includes ambu-
latory review, prospective review, concurrent review,
second opinions, case management, discharge plan-
ning, or retrospective review.
‘‘(b) WRITTEN POLICIES AND CRITERIA.—
‘‘(1) WRITTEN POLICIES.—A utilization review
program shall be conducted consistent with written
policies and procedures that govern all aspects of the
program.
‘‘(2) USE OF WRITTEN CRITERIA.—
‘‘(A) IN GENERAL.—Such a program shall
utilize written clinical review criteria developed
pursuant to the program with the input of ap-
propriate physicians.
‘‘(B) CONTINUING USE OF STANDARDS IN
RETROSPECTIVE
REVIEW.—If a health care
service has been specifically pre-authorized or
approved for an enrollee under such a program,
the program shall not, pursuant to retrospective
review, revise or modify the specific standards,
criteria, or procedures used for the utilization
review for procedures, treatment, and services
delivered to the enrollee during the same course
of treatment.
‘‘(C) NO ADVERSE DETERMINATION BASED
ON REFUSAL TO OBSERVE SERVICE.—Such a
program shall not base an adverse determina-
tion on—
‘‘(i) a refusal to consent to observing
any health care service, or
‘‘(ii) lack of reasonable access to a
health care provider’s medical or treatment
records, unless the program has provided
reasonable notice to the enrollee.
‘‘(c) CONDUCT OF PROGRAM ACTIVITIES.—
‘‘(1) ADMINISTRATION BY HEALTH CARE PRO-
FESSIONALS.—A utilization review program shall be
administered by qualified health care professionals
who shall oversee review decisions. In this sub-
section, the term ‘health care professional’ means a
physician or other health care practitioner licensed,
accredited, or certified to perform specified health
services consistent with State law.
‘‘(2) USE OF QUALIFIED, INDEPENDENT PER-
SONNEL.—
‘‘(A) IN
GENERAL.—A utilization review
program shall provide for the conduct of utiliza-
tion review activities only through personnel
who are qualified and, to the extent required,
who have received appropriate training in the
conduct of such activities under the program.
‘‘(B) PEER REVIEW OF ADVERSE CLINICAL
DETERMINATIONS.—Such a program shall pro-
vide that clinical peers shall evaluate the clinical
appropriateness of adverse clinical determina-
tions. In this subsection, the term ‘clinical peer’
means, with respect to a review, a physician or
other health care professional who holds a non-
restricted license in a State and in the same or
similar specialty as typically manages the medi-
cal condition, procedure, or treatment under re-
view.
‘‘(C) PROHIBITION OF CONTINGENT COM-
PENSATION ARRANGEMENTS.—Such a program
shall not, with respect to utilization review ac-
tivities, permit or provide compensation or any-
thing of value to its employees, agents, or con-
tractors in a manner that—
‘‘(i) provides incentives, direct or indi-
rect, for such persons to make inappropri-
ate review decisions, or
‘‘(ii) is based, directly or indirectly, on
the quantity or type of adverse determina-
tions rendered.
‘‘(D) PROHIBITION OF CONFLICTS.—Such
a program shall not permit a health care pro-
fessional who provides health care services to an
enrollee to perform utilization review activities
in connection with the health care services
being provided to the enrollee.
‘‘(3) TOLL-FREE TELEPHONE NUMBER.—Such
a program shall provide that—
‘‘(A) appropriate personnel performing uti-
lization review activities under the program are
reasonably accessible by toll-free telephone not
less than 40 hours per week during normal
business hours to discuss patient care and allow
response to telephone requests, and
‘‘(B) the program has a telephone system
capable of accepting, recording, or providing in-
struction to incoming telephone calls during
other than normal business hours and to ensure
response to accepted or recorded messages not
less than one business day after the date on
which the call was received.
‘‘(4) LIMITS ON FREQUENCY.—Such a program
shall not provide for the performance of utilization
review activities with respect to a class of services
furnished to an enrollee more frequently than is rea-
sonably required to assess whether the services
under review are medically necessary.
‘‘(5) 
LIMITATION
ON
INFORMATION
RE-
QUESTS.—Under such a program, information shall
be required to be provided by health care providers
only to the extent it is necessary to perform the uti-
lization review activity involved.
‘‘(d) DEADLINE FOR DETERMINATIONS.—
‘‘(1) PRIOR
AUTHORIZATION
SERVICES.—Ex-
cept as provided in paragraph (2), in the case of a
utilization review activity involving the prior author-
ization of health care items and services, the utiliza-
tion review program shall make a determination con-
cerning such authorization, and provide notice of the
determination to the enrollee or the enrollee’s des-
ignee and the enrollee’s health care provider by tele-
phone and in writing, as soon as possible in accord-
ance with the medical exigencies of the cases, and in
no event later than 3 business days after the date
of receipt of the necessary information respecting
such determination.
‘‘(2) CONTINUED CARE.—In the case of a utili-
zation review activity involving authorization for con-
tinued or extended health care services, or additional
services for an enrollee undergoing a course of con-
tinued treatment prescribed by a health care pro-
vider, the utilization review program shall make a
determination concerning such authorization, and
provide notice of the determination to the enrollee or
the enrollee’s designee and the enrollee’s health care
provider by telephone and in writing, within 1 busi-
ness day of the date of receipt of the necessary in-
formation respecting such determination. Such no-
tice shall include, with respect to continued or ex-
tended health care services, the number of extended
services approved, the new total of approved serv-
ices, the date of onset of services, and the next re-
view date.
‘‘(3) PREVIOUSLY PROVIDED SERVICES.—In the
case of a utilization review activity involving retro-
spective review of health care services previously pro-
vided, the utilization review program shall make a
the determination concerning such services, and pro-
vide notice of the determination to the enrollee or
the enrollee’s designee and the enrollee’s health care
provider by telephone and in writing, within 30 days
of the date of receipt of the necessary information
respecting such determination.
‘‘(4) REFERENCE
TO
SPECIAL
RULES
FOR
EMERGENCY
SERVICES, MAINTENANCE
CARE, AND
POST-STABILIZATION CARE.—For waiver of prior au-
thorization requirements in certain cases involving
emergency services and maintenance care and post-
stabilization care, see sections 2771(a)(1)(A) and
2771(a)(2)(A), respectively.
‘‘(e) NOTICE OF ADVERSE DETERMINATIONS.—
‘‘(1) IN GENERAL.—Notice of an adverse deter-
mination under a utilization review program (includ-
ing as a result of a reconsideration under subsection
(f)) shall be in writing and shall include—
‘‘(A) the reasons for the determination (in-
cluding the clinical rationale);
‘‘(B) instructions on how to initiate an ap-
peal under section 2785; and
‘‘(C) notice of the availability, upon re-
quest of the enrollee (or the enrollee’s designee)
of the clinical review criteria relied upon to
make such determination.
‘‘(2) SPECIFICATION OF ANY ADDITIONAL IN-
FORMATION.—Such a notice shall also specify what
(if any) additional necessary information must be
provided to, or obtained by, person making the de-
termination in order to make a decision on such an
appeal.
‘‘(f) RECONSIDERATION.—
‘‘(1) AT REQUEST OF PROVIDER.—In the event
that a utilization review program provides for an ad-
verse determination without attempting to discuss
such matter with the enrollee’s health care provider
who specifically recommended the health care serv-
ice, procedure, or treatment under review, such
health care provider shall have the opportunity to re-
quest a reconsideration of the adverse determination
under this subsection.
‘‘(2) TIMING AND CONDUCT.—Except in cases
of retrospective reviews, such reconsideration shall
occur as soon as possible in accordance with the
medical exigencies of the cases, and in no event later
than 1 business day after the date of receipt of the
request and shall be conducted by the enrollee’s
health care provider and the health care professional
making the initial determination or a designated
qualified health care professional if the original pro-
fessional cannot be available.
‘‘(3) NOTICE.—In the event that the adverse
determination is upheld after reconsideration, the
utilization review program shall provide notice as re-
quired under subsection (e).
‘‘(4) CONSTRUCTION.—Nothing in this sub-
section shall preclude the enrollee from initiating an
appeal from an adverse determination under section
2785.
‘‘SUBPART 3—PATIENT INFORMATION
‘‘SEC. 2782. PATIENT INFORMATION.
‘‘(a) DISCLOSURE REQUIREMENT.—A health insur-
ance issuer in connection with the provision of health in-
surance coverage shall submit to the applicable State au-
thority, provide to enrollees (and prospective enrollees),
and make available to the public, in writing the informa-
tion described in subsection (b).
‘‘(b) INFORMATION.—The information described in
this subsection includes the following:
‘‘(1) DESCRIPTION OF COVERAGE.—A descrip-
tion of coverage provisions, including health care
benefits, benefit limits, coverage exclusions, coverage
of emergency care, and the definition of medical ne-
cessity used in determining whether benefits will be
covered.
‘‘(2) ENROLLEE FINANCIAL RESPONSIBILITY.—
An explanation of an enrollee’s financial responsibil-
ity for payment of premiums, coinsurance, copay-
ments, deductibles, and any other charges, including
limits on such responsibility and responsibility for
health care services that are provided by nonpartici-
pating providers or are furnished without meeting
applicable utilization review requirements.
‘‘(3) INFORMATION ON PROVIDERS.—A descrip-
tion—
‘‘(A) of procedures for enrollees to select,
access, and change participating primary and
specialty providers,
‘‘(B) of the rights and procedures for ob-
taining referrals (including standing referrals)
to participating and nonparticipating providers,
and
‘‘(C) in the case of each participating pro-
vider, of the name, address, and telephone num-
ber of the provider, the credentials of the pro-
vider, and the provider’s availability to accept
new patients.
‘‘(4) UTILIZATION REVIEW ACTIVITIES.—A de-
scription of procedures used and requirements (in-
cluding circumstances, time frames, and rights to re-
consideration and appeal) under any utilization re-
view program under section 2781 or any drug utili-
zation program under section 2780, as well as a
summary of the minimum uniform data collected
under section 2778(a)(1).
‘‘(5) GRIEVANCE
PROCEDURES.—Information
on the grievance procedures under sections 2784 and
2785, including information describing—
‘‘(A) the grievance procedures used by the
issuer to process and resolve disputes between
the issuer and an enrollee (including method for
filing grievances and the time frames and cir-
cumstances for acting on grievances);
‘‘(B) written complaints and appeals, by
type of complaint or appeal, received by the is-
suer relating to its coverage; and
‘‘(C) the disposition of such complaints
and appeals.
‘‘(6) PAYMENT METHODOLOGY.—A description
of the types of methodologies the issuer uses to re-
imburse different classes of providers and, as speci-
fied by the Secretary, the financial arrangements or
contractual provisions with providers.
‘‘(7) INFORMATION ON ISSUER.—Notice of ap-
propriate mailing addresses and telephone numbers
to be used by enrollees in seeking information or au-
thorization for treatment.
‘‘(8) ASSURING
COMMUNICATIONS
WITH
EN-
ROLLEES.—A description of how the issuer address-
es the needs of non-English-speaking enrollees and
others with special communications needs, including
the provision of information described in this sub-
section to such enrollees.
‘‘(c) FORM OF DISCLOSURE.—
‘‘(1) UNIFORMITY.—Information required to be
disclosed under this section shall be provided in ac-
cordance with uniform, national reporting standards
specified by the Secretary, after consultation with
applicable State authorities, so that prospective en-
rollees may compare the attributes of different issu-
ers and coverage offered within an area.
‘‘(2) INFORMATION INTO HANDBOOK.—Nothing
in this section shall be construed as preventing an
issuer from making the information under sub-
section (b) available to enrollees through an enrollee
handbook or similar publication.
‘‘(3) UPDATING.—The information on partici-
pating providers described in subsection (a)(3)(C)
shall be updated not less frequently than monthly.
Nothing in this section shall prevent an issuer from
changing or updating other information made avail-
able under this section.
‘‘(4) CONSTRUCTION.—Nothing in subsection
(a)(6) shall be construed as requiring disclosure of
individual contracts or financial arrangements be-
tween an issuer and any provider. Nothing in this
subsection shall be construed as preventing the in-
formation described in subsection (a)(3)(C) from
being provided in a separate document.
‘‘SEC. 2783. PROTECTION OF PATIENT CONFIDENTIALITY.
‘‘A health insurance issuer that offers health insur-
ance coverage shall establish appropriate policies and pro-
cedures to ensure that all applicable State and Federal
laws to protect the confidentiality of individually identifi-
able medical information are followed.
‘‘SUBPART 4—GRIEVANCE PROCEDURES
‘‘SEC. 2784. ESTABLISHMENT OF COMPLAINT AND APPEALS
PROCESS.
‘‘(a) ESTABLISHMENT OF SYSTEM.—A health insur-
ance issuer in connection with the provision of health in-
surance coverage shall establish and maintain a system to
provide for the presentation and resolution of complaints
and appeals brought by enrollees, designees of enrollees,
or by health care providers acting on behalf of an enrollee
and with the enrollee’s consent, regarding any aspect of
the issuer’s health care services, including complaints re-
garding quality of care, choice and accessibility of provid-
ers, network adequacy, and compliance with the require-
ments of this part.
‘‘(b) COMPONENTS OF SYSTEM.—Such system shall
include the following components (which shall be consist-
ent with applicable requirements of section 2785):
‘‘(1) Written notification to all enrollees and
providers of the telephone numbers and business ad-
dresses of the issuer employees responsible for reso-
lution of complaints and appeals.
‘‘(2) A system to record and document, over a
period of at least 3 years, all complaints and appeals
made and their status.
‘‘(3) The availability of an enrollee services rep-
resentative to assist enrollees, as requested, with
complaint and appeal procedures.
‘‘(4) Establishment of a specified deadline (not
to exceed 30 days after the date of receipt of a com-
plaint or appeal) for the issuer to respond to com-
plaints or appeals.
‘‘(5) A process describing how complaints and
appeals are processed and resolved.
‘‘(6) Procedures for follow-up action, including
the methods to inform the complainant or appellant
of the resolution of a complaint or appeal.
‘‘(7) Notification to the continuous quality im-
provement program under section 2777(a) of all
complaints and appeals relating to quality of care.