I
106TH CONGRESS
1ST SESSION
H. R. 448
To provide new patient protections under group health plans.
IN THE HOUSE OF REPRESENTATIVES
FEBRUARY 2, 1999
Mr. BILIRAKIS (for himself, Mr. HASTERT, Mr. UPTON, Mr. TALENT, Mr.
GOODLING, Mr. GILLMOR, Mr. CUNNINGHAM, Mr. ENGLISH, Mr. GOSS,
Ms. PRYCE of Ohio, Mr. HILL of Montana, Mr. ARMEY, and Mr. OXLEY)
introduced the following bill; which was referred to the Committee on
Commerce, and in addition to the Committees on Education and the
Workforce, Ways and Means, and the Judiciary, for a period to be subse-
quently determined by the Speaker, in each case for consideration of such
provisions as fall within the jurisdiction of the committee concerned
A BILL
To provide new patient protections under group health plans.
Be it enacted by the Senate and House of Representa-
tives of the United States of America in Congress assembled,
SECTION 1. SHORT TITLE AND TABLE OF CONTENTS.
(a) SHORT TITLE.—This Act may be cited as the
‘‘Patient Protection Act of 1999’’.
(b) TABLE OF CONTENTS.—The table of contents is
as follows:
Sec. 1. Short title and table of contents.
TITLE I—AMENDMENTS TO THE EMPLOYEE RETIREMENT
INCOME SECURITY ACT OF 1974
Subtitle A—Patient Protections
Sec. 1001. Patient access to unrestricted medical advice, emergency medical
care, obstetric and gynecological care, and pediatric care.
Sec. 1002. Effective date and related rules.
Subtitle B—Patient Access to Information
Sec. 1101. Patient access to information regarding plan coverage, managed
care procedures, health care providers, and quality of medical
care.
Sec. 1102. Effective date.
Subtitle C—New Procedures and Access to Courts for Grievances Arising
under Group Health Plans
Sec. 1201. Special rules for group health plans.
Sec. 1202. Effective date.
Subtitle D—Affordable Health Coverage for Employees of Small Businesses
Sec. 1301. Short title of subtitle.
Sec. 1302. Rules governing association health plans.
Sec. 1303. Clarification of treatment of single employer arrangements.
Sec. 1304. Clarification of treatment of certain collectively bargained arrange-
ments.
Sec. 1305. Enforcement provisions relating to association health plans.
Sec. 1306. Cooperation between Federal and State authorities.
Sec. 1307. Effective date and transitional and other rules.
TITLE II—AMENDMENTS TO PUBLIC HEALTH SERVICE ACT
Subtitle A—Patient Protections and Point of Service Coverage Requirements
Sec. 2001. Patient access to unrestricted medical advice, emergency medical
care, obstetric and gynecological care, pediatric care.
Sec. 2002. Requiring health maintenance organizations to offer option of point-
of-service coverage.
Subtitle B—Patient Access to Information
Sec. 2101. Patient access to information regarding plan coverage, managed
care procedures, health care providers, and quality of medical
care.
Sec. 2102. Effective date.
Subtitle C—HealthMarts
Sec. 2201. Short title of subtitle.
Sec. 2202. Expansion of consumer choice through HealthMarts.
Subtitle D—Community Health Organizations
Sec. 2301. Promotion of provision of insurance by community health organiza-
tions.
TITLE III—AMENDMENTS TO THE INTERNAL REVENUE CODE OF
1986
Subtitle A—Patient Protections
Sec. 3001. Patient access to unrestricted medical advice, emergency medical
care, obstetric and gynecological care, and pediatric care.
Sec. 3002. Effective date and related rules.
Subtitle B—Patient Access to Information
Sec. 3101. Patient access to information regarding plan coverage, managed
care procedures, health care providers, and quality of medical
care.
Sec. 3102. Effective date.
Subtitle C—Medical Savings Accounts
Sec. 3201. Expansion of availability of medical savings accounts.
Sec. 3202. Exception from insurance limitation in case of medical savings ac-
counts.
Sec. 3203. Sense of the House of Representatives.
TITLE IV—HEALTH CARE LAWSUIT REFORM
Subtitle A—General Provisions
Sec. 4001. Federal reform of health care liability actions.
Sec. 4002. Definitions.
Sec. 4003. Effective date.
Subtitle B—Uniform Standards for Health Care Liability Actions
Sec. 4011. Statute of limitations.
Sec. 4012. Calculation and payment of damages.
Sec. 4013. Alternative dispute resolution.
Sec. 4014. Reporting on fraud and abuse enforcement activities.
TITLE V—CONFIDENTIALITY OF HEALTH INFORMATION
Sec. 5001. Confidentiality of protected health information.
Sec. 5002. Study and report on effect of State law on health-related research.
Sec. 5003. Study and report on State law on protected health information.
Sec. 5004. Protection for certain information developed to reduce mortality or
morbidity or for improving patient care and safety.
TITLE I—AMENDMENTS TO THE
EMPLOYEE RETIREMENT IN-
COME SECURITY ACT OF 1974
Subtitle A—Patient Protections
SEC. 1001. PATIENT ACCESS TO UNRESTRICTED MEDICAL
ADVICE, EMERGENCY MEDICAL CARE, OB-
STETRIC AND GYNECOLOGICAL CARE, AND
PEDIATRIC CARE.
(a) IN GENERAL.—Subpart B of part 7 of subtitle
B of title I of the Employee Retirement Income Security
Act of 1974 is amended by adding at the end the following
new section:
‘‘SEC. 714. PATIENT ACCESS TO UNRESTRICTED MEDICAL
ADVICE, EMERGENCY MEDICAL CARE, OB-
STETRIC AND GYNECOLOGICAL CARE, PEDI-
ATRIC CARE.
‘‘(a) PATIENT ACCESS TO UNRESTRICTED MEDICAL
ADVICE.—
‘‘(1) IN GENERAL.—In the case of any health
care professional acting within the lawful scope of
practice in the course of carrying out a contractual
employment arrangement or other direct contractual
arrangement between such professional and a group
health plan or a health insurance issuer offering
health insurance coverage in connection with a group
health plan, the plan or issuer with which such con-
tractual employment arrangement or other direct
contractual arrangement is maintained by the pro-
fessional may not impose on such professional under
such arrangement any prohibition or restriction with
respect to advice, provided to a participant or bene-
ficiary under the plan who is a patient, about the
health status of the participant or beneficiary or the
medical care or treatment for the condition or dis-
ease of the participant or beneficiary, regardless of
whether benefits for such care or treatment are pro-
vided under the plan or health insurance coverage
offered in connection with the plan.
‘‘(2) HEALTH CARE PROFESSIONAL DEFINED.—
For purposes of this subsection, the term ‘health
care professional’ means a physician (as defined in
section 1861(r) of the Social Security Act) or other
health care professional if coverage for the profes-
sional’s services is provided under the group health
plan for the services of the professional. Such term
includes a podiatrist, optometrist, chiropractor, psy-
chologist, dentist, physician assistant, physical or oc-
cupational therapist and therapy assistant, speech-
language pathologist, audiologist, registered or li-
censed practical nurse (including nurse practitioner,
clinical nurse specialist, certified registered nurse
anesthetist, and certified nurse-midwife), licensed
certified social worker, registered respiratory thera-
pist, and certified respiratory therapy technician.
‘‘(b) PATIENT ACCESS
TO EMERGENCY MEDICAL
CARE.—
‘‘(1) IN
GENERAL.—To the extent that the
group health plan (or health insurance issuer offer-
ing health insurance coverage in connection with the
plan) provides for any benefits consisting of emer-
gency 
medical 
care 
(as 
defined 
in 
section
503(b)(9)(I)), except for items or services specifi-
cally excluded—
‘‘(A) the plan or issuer shall provide bene-
fits, without requiring preauthorization and
without regard to otherwise applicable network
limitations, for appropriate emergency medical
screening examinations (within the capability of
the emergency facility, including ancillary serv-
ices routinely available to the emergency facil-
ity) to the extent that a prudent layperson, who
possesses an average knowledge of health and
medicine, would determine such examinations to
be necessary in order to determine whether
emergency medical care (as so defined) is re-
quired; and
‘‘(B) the plan or issuer shall provide bene-
fits for additional emergency medical services
following an emergency medical screening exam-
ination (if determined necessary under subpara-
graph (A)) to the extent that a prudent emer-
gency medical professional would determine
such additional emergency services to be nec-
essary to avoid the consequences described in
section 503(b)(9)(I).
‘‘(2) UNIFORM
COST-SHARING
REQUIRED.—
Nothing in this subsection shall be construed as pre-
venting a group health plan or issuer from imposing
any form of cost-sharing applicable to any partici-
pant or beneficiary (including coinsurance, copay-
ments, deductibles, and any other charges) in rela-
tion to benefits described in paragraph (1), if such
form of cost-sharing is uniformly applied under such
plan, with respect to similarly situated participants
and beneficiaries, to all benefits consisting of emer-
gency 
medical 
care 
(as 
defined 
in 
section
503(b)(9)(I)) provided to such similarly situated
participants and beneficiaries under the plan.
‘‘(c) PATIENT ACCESS TO OBSTETRIC AND GYNECO-
LOGICAL CARE.—
‘‘(1) IN
GENERAL.—In any case in which a
group health plan (or a health insurance issuer of-
fering health insurance coverage in connection with
the plan)—
‘‘(A) provides benefits under the terms of
the plan consisting of—
‘‘(i) routine gynecological care (such
as preventive women’s health examina-
tions); or
‘‘(ii) routine obstetric care (such as
routine pregnancy-related services),
provided by a participating physician who spe-
cializes in such care (or provides benefits con-
sisting of payment for such care); and
‘‘(B) the plan requires or provides for des-
ignation by a participant or beneficiary of a
participating primary care provider,
if the primary care provider designated by such a
participant or beneficiary is not such a physician,
then the plan (or issuer) shall meet the requirements
of paragraph (2).
‘‘(2) REQUIREMENTS.—A group health plan (or
a health insurance issuer offering health insurance
diatric care provided by a participating physician
who specializes in pediatrics (or consisting of pay-
ment for such care) and the plan requires or pro-
vides for designation by a participant or beneficiary
of a participating primary care provider, the plan (or
issuer) shall provide that such a participating physi-
cian may be designated, if available, by a parent or
guardian of any beneficiary under the plan who is
under 18 years of age, as the primary care provider
with respect to any such benefits.
‘‘(2) CONSTRUCTION.—Nothing in paragraph
(1) shall waive any requirements of coverage relating
to medical necessity or appropriateness with respect
to coverage of pediatric care.
‘‘(e) TREATMENT
OF MULTIPLE COVERAGE OP-
TIONS.—In the case of a plan providing benefits under two
or more coverage options, the requirements of subsections
(c) and (d) shall apply separately with respect to each cov-
erage option.’’.
(b) CONFORMING AMENDMENT.—The table of con-
tents in section 1 of such Act is amended by adding at
the end of the items relating to subpart B of part 7 of
subtitle B of title I of such Act the following new item:
‘‘Sec. 714. Patient access to unrestricted medical advice, emergency medical
care, obstetric and gynecological care, and pediatric care.’’.
SEC. 1002. EFFECTIVE DATE AND RELATED RULES.
(a) IN GENERAL.—The amendments made by this
subtitle shall apply with respect to plan years beginning
on or after January 1 of the second calendar year follow-
ing the date of the enactment of this Act, except that the
Secretary of Labor may issue regulations before such date
under such amendments. The Secretary shall first issue
regulations necessary to carry out the amendments made
by this section before the effective date thereof.
(b) LIMITATION ON ENFORCEMENT ACTIONS.—No
enforcement action shall be taken, pursuant to the amend-
ments made by this subtitle, 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 regulations issued in connection with
such requirement, if the plan or issuer has sought to com-
ply in good faith with such requirement.
(c) SPECIAL RULE FOR COLLECTIVE BARGAINING
AGREEMENTS.—In the case of a group health plan main-
tained pursuant to one or more collective bargaining
agreements between employee representatives and one or
more employers ratified before the date of the enactment
of this Act, the provisions of subsections (b), (c), and (d)
of section 714 of the Employee Retirement Income Secu-
rity Act of 1974 (as added by this subtitle) shall not apply
with respect to plan years beginning before the later of—
(1) the date on which the last of the collective
bargaining agreements relating to the plan termi-
nates (determined without regard to any extension
thereof agreed to after the date of the enactment of
this Act); or
(2) January 1, 2002.
For purposes of this subsection, any plan amendment
made pursuant to a collective bargaining agreement relat-
ing to the plan which amends the plan solely to conform
to any requirement added by this subtitle shall not be
treated as a termination of such collective bargaining
agreement.
(d) ASSURING COORDINATION.—The Secretary of
Labor, the Secretary of the Treasury, and the Secretary
of Health and Human Services shall ensure, through the
execution of an interagency memorandum of understand-
ing among such Secretaries, that—
(1) regulations, rulings, and interpretations
issued by such Secretaries relating to the same mat-
ter over which two or more such Secretaries have re-
sponsibility under the provisions of this subtitle, sec-
tion 2101, and subtitle A of title III (and the
amendments made thereby) are administered so as
to have the same effect at all times; and
(2) coordination of policies relating to enforcing
the same requirements through such Secretaries in
order to have a coordinated enforcement strategy
that avoids duplication of enforcement efforts and
assigns priorities in enforcement.
(e) TREATMENT OF RELIGIOUS NONMEDICAL PRO-
VIDERS.—
(1) IN GENERAL.—Nothing in this Act (or the
amendments made thereby) shall be construed to—
(A) restrict or limit the right of group
health plans, and of health insurance issuers of-
fering health insurance coverage in connection
with group health plans, to include as providers
religious nonmedical providers;
(B) require such plans or issuers to—
(i) utilize medically based eligibility
standards or criteria in deciding provider
status of religious nonmedical providers;
(ii) use medical professionals or cri-
teria to decide patient access to religious
nonmedical providers;
(iii) utilize medical professionals or
criteria in making decisions in internal or
external appeals from decisions denying or
limiting coverage for care by religious non-
medical providers; or
(iv) compel a participant or bene-
ficiary to undergo a medical examination
or test as a condition of receiving health
insurance coverage for treatment by a reli-
gious nonmedical provider; or
(C) require such plans or issuers to ex-
clude religious nonmedical providers because
they do not provide medical or other data other-
wise required, if such data is inconsistent with
the religious nonmedical treatment or nursing
care provided by the provider.
(2) RELIGIOUS NONMEDICAL PROVIDER.—For
purposes of this subsection, the term ‘‘religious non-
medical provider’’ means a provider who provides no
medical care but who provides only religious non-
medical treatment or religious nonmedical nursing
care.
Subtitle B—Patient Access to
Information
SEC. 1101. PATIENT ACCESS TO INFORMATION REGARDING
PLAN COVERAGE, MANAGED CARE PROCE-
DURES, 
HEALTH 
CARE 
PROVIDERS, 
AND
QUALITY OF MEDICAL CARE.
(a) IN GENERAL.—Part 1 of subtitle B of title I of
the Employee Retirement Income Security Act of 1974 is
amended—
(1) by redesignating section 111 as section 112;
and
(2) by inserting after section 110 the following
new section:
‘‘DISCLOSURE BY GROUP HEALTH PLANS
‘‘SEC. 111. (a) DISCLOSURE REQUIREMENT.—
‘‘(1) GROUP
HEALTH
PLANS.—The adminis-
trator of each group health plan shall take such ac-
tions as are necessary to ensure that the summary
plan description of the plan required under section
102 (or each summary plan description in any case
in which different summary plan descriptions are ap-
propriate under part 1 for different options of cov-
erage) contains, among any information otherwise
required under this part, the information required
under subsections (b), (c), (d), and (e)(2)(A).
‘‘(2) 
HEALTH
INSURANCE
ISSUERS.—Each
health insurance issuer offering health insurance
coverage in connection with a group health plan
shall provide the administrator on a timely basis
with the information necessary to enable the admin-
istrator to comply with the requirements of para-
graph (1). To the extent that any such issuer pro-
vides on a timely basis to plan participants and
beneficiaries information otherwise required under
this part to be included in the summary plan de-
scription, the requirements of sections 101(a)(1) and
104(b) shall be deemed satisfied in the case of such
plan with respect to such information.
‘‘(b) PLAN BENEFITS.—The information required
under subsection (a) includes the following:
‘‘(1) COVERED ITEMS AND SERVICES.—
‘‘(A) CATEGORIZATION OF INCLUDED BEN-
EFITS.—A description of covered benefits, cat-
egorized by—
‘‘(i) types of items and services (in-
cluding any special disease management
program); and
‘‘(ii) types of health care professionals
providing such items and services.
‘‘(B) EMERGENCY MEDICAL CARE.—A de-
scription of the extent to which the plan covers
emergency medical care (including the extent to
which the plan provides for access to urgent
care centers), and any definitions provided
under the plan for the relevant plan terminol-
ogy referring to such care.
‘‘(C) PREVENTATIVE
SERVICES.—A de-
scription of the extent to which the plan pro-
vides benefits for preventative services.
‘‘(D) DRUG FORMULARIES.—A description
of the extent to which covered benefits are de-
termined by the use or application of a drug
formulary and a summary of the process for de-
termining what is included in such formulary.
‘‘(E) 
COBRA 
CONTINUATION
COV-
ERAGE.—A description of the benefits available
under the plan pursuant to part 6.
‘‘(2) LIMITATIONS, EXCLUSIONS, AND RESTRIC-
TIONS ON COVERED BENEFITS.—
‘‘(A) 
CATEGORIZATION
OF
EXCLUDED
BENEFITS.—A description of benefits specifi-
cally excluded from coverage, categorized by
types of items and services.
‘‘(B) 
UTILIZATION
REVIEW
AND
PREAUTHORIZATION REQUIREMENTS.—Whether
coverage for medical care is limited or excluded
on 
the 
basis 
of 
utilization 
review 
or
preauthorization requirements.
‘‘(C) LIFETIME, ANNUAL, OR OTHER PE-
RIOD LIMITATIONS.—A description of the cir-
cumstances under which, and the extent to
which, coverage is subject to lifetime, annual, or
other period limitations, categorized by types of
benefits.
‘‘(D) CUSTODIAL CARE.—A description of
the circumstances under which, and the extent
to which, the coverage of benefits for custodial
care is limited or excluded, and a statement of
the definition used by the plan for custodial
care.
‘‘(E) 
EXPERIMENTAL
TREATMENTS.—
Whether coverage for any medical care is lim-
ited or excluded because it constitutes experi-
mental treatment or technology, and any defini-
tions provided under the plan for the relevant
plan terminology referring to such limited or
excluded care.
‘‘(F) MEDICAL APPROPRIATENESS OR NE-
CESSITY.—Whether coverage for medical care
may be limited or excluded by reason of a fail-
ure to meet the plan’s requirements for medical
appropriateness or necessity, and any defini-
tions provided under the plan for the relevant
plan terminology referring to such limited or
excluded care.
‘‘(G) SECOND
OR
SUBSEQUENT
OPIN-
IONS.—A description of the circumstances
under which, and the extent to which, coverage
for second or subsequent opinions is limited or
excluded.
‘‘(H) SPECIALTY CARE.—A description of
the circumstances under which, and the extent
to which, coverage of benefits for specialty care
is conditioned on referral from a primary care
provider.
‘‘(I) CONTINUITY OF CARE.—A description
of the circumstances under which, and the ex-
tent to which, coverage of items and services
provided by any health care professional is lim-
ited or excluded by reason of the departure by
the professional from any defined set of provid-
ers.
‘‘(J) RESTRICTIONS
ON
COVERAGE
OF
EMERGENCY
SERVICES.—A description of the
circumstances under which, and the extent to
which, the plan, in covering emergency medical
care furnished to a participant or beneficiary of
the plan imposes any financial responsibility de-
scribed in subsection (c) on participants or
beneficiaries or limits or conditions benefits for
such care subject to any other term or condition
of such plan.
‘‘(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 respon-
sibility described in paragraph (1) may vary, includ-
ing any distinctions based on whether a health care
provider from whom covered benefits are obtained is
included in a defined set of providers.
‘‘(d) DISPUTE RESOLUTION PROCEDURES.—The in-
formation required under subsection (a) includes a de-
scription of the processes adopted by the plan pursuant
to section 503(b), including—
‘‘(1) descriptions thereof relating specifically
to—
‘‘(A) coverage decisions;
‘‘(B) internal review of coverage decisions;
and
‘‘(C) any external review of coverage deci-
sions; and
‘‘(2) the procedures and time frames applicable
to each step of the processes referred to in subpara-
graphs (A), (B), and (C) of paragraph (1).
‘‘(e) INFORMATION AVAILABLE ON REQUEST.—
‘‘(1) ACCESS TO PLAN BENEFIT INFORMATION
IN ELECTRONIC FORM.—
‘‘(A) IN GENERAL.—In addition to the in-
formation required to be provided under section
104(b)(4), a group health plan (and a health
insurance issuer offering health insurance cov-
erage in connection with a group health plan)
shall, upon written request (made not more fre-
quently than annually), make available to par-
ticipants and beneficiaries, in a generally recog-
nized electronic format, the following informa-
tion:
‘‘(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.
‘‘(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
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
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
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.
‘‘(ix) INFORMATION RELATING TO EX-
TERNAL REVIEWS.—The number of exter-
nal reviews under section 503(b)(4) that
have been completed during the prior plan
year and the number of such reviews in
which the recommendation reported under
section 503(b)(4)(C)(iii) includes a rec-
ommendation for modification or reversal
of an internal review decision 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
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
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.
‘‘(h) DEFINITIONS.—For purposes of this section—
‘‘(1) GROUP HEALTH PLAN.—The term ‘group
health plan’ has the meaning provided such term
under section 503(b)(8).
‘‘(2) MEDICAL CARE.—The term ‘medical care’
has the meaning provided such term under section
733(a)(2).
‘‘(3) HEALTH
INSURANCE
COVERAGE.—The
term ‘health insurance coverage’ has the meaning
provided such term under section 733(b)(1).
‘‘(4) HEALTH INSURANCE ISSUER.—The term
‘health insurance issuer’ has the meaning provided
such term under section 733(b)(2).’’.
(b) CONFORMING AMENDMENTS.—
(1) Section 102(b) of such Act (29 U.S.C.
1022(b)) is amended—
(A) by striking ‘‘section 733(a)(1)’’ each
place 
it 
appears 
and 
inserting 
‘‘section
503(b)(6)’’; and
(B) by inserting before the period at the
end the following: ‘‘; and, in the case of a group
health plan (as defined in section 111(h)(1)),
the information required to be included under
section 111(a)’’.
(2) The table of contents in section 1 of such
Act is amended by striking the item relating to sec-
tion 111 and inserting the following new items:
‘‘Sec. 111. Disclosure by group health plans.
‘‘Sec. 112. Repeal and effective date.’’.
SEC. 1102. EFFECTIVE DATE AND RELATED RULES.
(a) IN GENERAL.—The amendments made by this
subtitle shall apply with respect to plan years beginning
on or after January 1 of the second calendar year follow-
ing the date of the enactment of this Act. The Secretary
shall first issue all regulations necessary to carry out the
amendments made by this subtitle before such date.
(b) LIMITATION ON ENFORCEMENT ACTIONS.—No
enforcement action shall be taken, pursuant to the amend-
ments made by this subtitle, 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.
(c) ASSURING COORDINATION.—The Secretary of
Labor, the Secretary of Health and Human Services, and
the Secretary of the Treasury shall ensure, through the
execution of an interagency memorandum of understand-
ing among such Secretaries, that—
(1) regulations, rulings, and interpretations
issued by such Secretaries relating to the same mat-
ter over which two or more such Secretaries have re-
sponsibility under the provisions of this subtitle, sub-
title B of title II, and subtitle B of title III (and the
amendments made thereby) are administered so as
to have the same effect at all times; and
(2) coordination of policies relating to enforcing
the same requirements through such Secretaries in
order to have a coordinated enforcement strategy
that avoids duplication of enforcement efforts and
assigns priorities in enforcement.
Subtitle C—New Procedures and
Access to Courts for Grievances
Arising Under Group Health
Plans
SEC. 1201. SPECIAL RULES FOR GROUP HEALTH PLANS.
(a) IN GENERAL.—Section 503 of the Employee Re-
tirement Income Security Act of 1974 (29 U.S.C. 1133)
is amended—
(1) by inserting ‘‘(a) IN GENERAL.—’’ after
‘‘SEC. 503.’’;
(2) by inserting ‘‘(other than a group health
plan)’’ after ‘‘employee benefit plan’’; and
(3) by adding at the end the following new sub-
section:
‘‘(b) SPECIAL RULES FOR GROUP HEALTH PLANS.—
‘‘(1) 
COVERAGE
DETERMINATIONS.—Every
group health plan shall—
‘‘(A) provide adequate notice in writing in
accordance with this subsection to any partici-
pant or beneficiary of any adverse coverage de-
cision with respect to benefits of such partici-
pant or beneficiary under the plan, setting forth
the specific reasons for such coverage decision
and any rights of review provided under the
plan, written in a manner calculated to be un-
derstood by the participant;
‘‘(B) provide such notice in writing also to
any treating medical care provider of such par-
ticipant or beneficiary, if such provider has
claimed reimbursement for any item or service
involved in such coverage decision, or if a claim
submitted by the provider initiated the proceed-
ings leading to such decision;
‘‘(C) afford a reasonable opportunity to
any participant or beneficiary who is in receipt
of the notice of such adverse coverage decision,
and who files a written request for review of the
initial coverage decision within 180 days after
receipt of the notice of the initial decision, for
a full and fair de novo review of the decision by
an appropriate named fiduciary who did not
make the initial decision; and
‘‘(D) meet the additional requirements of
this subsection.
‘‘(2) TIME LIMITS FOR MAKING INITIAL COV-
ERAGE DECISIONS FOR BENEFITS AND COMPLETING
INTERNAL APPEALS.—
‘‘(A) TIME
LIMITS
FOR
DECIDING
RE-
QUESTS
FOR
BENEFIT
PAYMENTS, REQUESTS
FOR ADVANCE DETERMINATION OF COVERAGE,
AND
REQUESTS
FOR
REQUIRED
DETERMINA-
TION OF MEDICAL NECESSITY.—Except as pro-
vided in subparagraph (B)—
‘‘(i) INITIAL DECISIONS.—If a request
for benefit payments, a request for advance
determination of coverage, or a request for
required determination of medical necessity
is submitted to a group health plan in such
reasonable form as may be required under
the plan, the plan shall issue in writing an
initial coverage decision on the request be-
fore the end of the initial decision period
under paragraph (9)(J) following the filing
completion date. Failure to issue a cov-
erage decision on such a request before the
end of the period required under this
clause shall be treated as an adverse cov-
erage decision for purposes of internal re-
view under clause (ii).
‘‘(ii) INTERNAL REVIEWS OF INITIAL
DENIALS.—Upon the written request of a
participant or beneficiary for review of an
initial adverse coverage decision under
clause (i), a review by an appropriate
named fiduciary (subject to paragraph (3))
of the initial coverage decision shall be
completed, including issuance by the plan
of a written decision affirming, reversing,
or modifying the initial coverage decision,
setting forth the grounds for such decision,
before the end of the internal review period
following the review filing date. Such deci-
sion shall be treated as the final decision
of the plan, subject to any applicable re-
consideration under paragraph (4). Failure
to issue before the end of such period such
a written decision requested under this
clause shall be treated as a final decision
affirming the initial coverage decision, sub-
ject to any applicable reconsideration
under paragraph (4).
‘‘(B) TIME LIMITS FOR MAKING COVERAGE
DECISIONS RELATING TO URGENT AND EMER-
GENCY MEDICAL CARE AND FOR COMPLETING
INTERNAL APPEALS.—
‘‘(i) INITIAL
DECISIONS.—A group
health plan shall issue in writing an initial
coverage decision on any request for expe-
dited advance determination of coverage or
for expedited required determination of
medical necessity submitted, in such rea-
sonable form as may be required under the
plan—
‘‘(I) before the end of the urgent
decision 
period 
under 
paragraph
(9)(L), in cases involving urgent med-
ical care but not involving emergency
medical care; or
‘‘(II) before the end of the emer-
gency decision period under para-
graph (9)(M), in cases involving emer-
gency medical care,
following the filing completion date. Fail-
ure to approve or deny such a request be-
fore the end of the applicable decision pe-
riod shall be treated as a denial of the re-
quest for purposes of internal review under
clause (ii).
‘‘(ii) INTERNAL REVIEWS OF INITIAL
DENIALS.—Upon the written request of a
participant or beneficiary for review of an
initial adverse coverage decision under
clause (i), a review by an appropriate
named fiduciary (subject to paragraph (3))
of the initial coverage decision shall be
completed, including issuance by the plan
of a written decision affirming, reversing,
or modifying the initial converge decision,
setting 
forth 
the 
grounds 
for 
the
decision—
‘‘(I) before the end of the urgent
decision 
period 
under 
paragraph
(9)(L), in cases involving urgent med-
ical care but not involving emergency
medical care; or
‘‘(II) before the end of the emer-
gency decision period under para-
graph (9)(M), in cases involving emer-
gency medical care,
following the review filing date. Such deci-
sion shall be treated as the final decision
of the plan, subject to any applicable re-
consideration under paragraph (4). Failure
to issue before the end of the applicable
decision period such a written decision re-
quested under this clause shall be treated
as a final decision affirming the initial cov-
erage decision, subject to any applicable re-
consideration under paragraph (4).
‘‘(3) PHYSICIANS MUST REVIEW INITIAL COV-
ERAGE
DECISIONS
INVOLVING
MEDICAL
APPRO-
PRIATENESS
OR
NECESSITY
OR
EXPERIMENTAL
TREATMENT.—If an initial coverage decision under
paragraph (2)(A)(i) or (2)(B)(i) is based on a deter-
mination that provision of a particular item or serv-
ice is excluded from coverage under the terms of the
plan because the provision of such item or service
does not meet the plan’s requirements for medical
appropriateness or necessity or would constitute ex-
perimental treatment or technology, the review
under paragraph (2)(A)(ii) or (2)(B)(ii), to the ex-
tent that it relates to medical appropriateness or ne-
cessity or to experimental treatment or technology,
shall be conducted by a physician who is selected to
serve as an appropriate named fiduciary under the
plan and who did not make the initial denial.
‘‘(4) ELECTIVE EXTERNAL REVIEW BY INDE-
PENDENT MEDICAL EXPERT AND RECONSIDERATION
OF INITIAL REVIEW DECISION.—
‘‘(A) IN GENERAL.—The requirements of
subparagraphs (B), (C) and (D) shall apply—
‘‘(i) in the case of any failure to time-
ly issue a coverage decision upon internal
review which is deemed to be an adverse
coverage 
decision 
under 
paragraph
(2)(A)(ii) or (2)(B)(ii) (thereby failing to
constitute a coverage decision for which
specific reasons have been set forth as re-
quired under paragraph (1)(A)); and
‘‘(ii) in the case of any adverse cov-
erage decision which is not reversed upon
a review conducted pursuant to paragraph
(1)(C) (including any review pursuant to
paragraph (2)(A)(ii) or (2)(B)(ii)), if such
coverage decision is based on a determina-
tion that provision of a particular item or
service is excluded from coverage under the
terms of the plan because the provision of
such item or service—
‘‘(I) does not meet the plan’s re-
quirements for medical appropriate-
ness or necessity; or
‘‘(II) would constitute experi-
mental treatment or technology.
‘‘(B) LIMITS
ON
ALLOWABLE
ADVANCE
PAYMENTS.—The review under this paragraph
in connection with an adverse coverage decision
shall be available subject to any requirement of
the plan (unless waived by the plan for financial
or other reasons) for payment in advance to the
plan by the participant or beneficiary seeking
review of an amount not to exceed the greater
of—
‘‘(i) the lesser of $100 or 10 percent
of the cost of the medical care involved in
the decision; or
‘‘(ii) $25,
with each such dollar amount subject to com-
pounded annual adjustments in the same man-
ner and to the same extent as apply under sec-
tion 215(i) of the Social Security Act, except
that, for any calendar year, such amount as so
adjusted shall be deemed, solely for such cal-
endar year, to be equal to such amount rounded
to the nearest $10. No such payment may be
required in the case of any participant or bene-
ficiary whose enrollment under the plan is paid
for, in whole or in part, under a State plan
under title XIX or XXI of the Social Security
Act. Any such advance payment shall be subject
to reimbursement if the recommendation of the
independent medical expert or experts under
subparagraph (C)(iii) is to reverse or modify
the coverage decision.
‘‘(C) RECONSIDERATION
OF
INITIAL
RE-
VIEW DECISION.—In any case in which a partic-
ipant or beneficiary who has received an ad-
verse decision of the plan upon initial review of
the coverage decision and who has not com-
menced review of the initial coverage decision
under section 502 makes a request in writing,
within 30 days after the date of such review de-
cision, for reconsideration of such review deci-
sion, the terms of the plan shall provide for a
procedure 
for 
such 
reconsideration 
under
which—
‘‘(i) one or more independent medical
experts will be selected in accordance with
subparagraph (E) to review the coverage
decision described in subparagraph (A) to
determine whether such decision was in ac-
cordance with the terms of the plan and
this title;
‘‘(ii) the record for review (including a
specification of the terms of the plan and
other criteria serving as the basis for the
initial review decision) will be presented to
such expert or experts and maintained in
a manner which will ensure confidentiality
of such record;
‘‘(iii) such expert or experts will re-
port in writing to the plan their rec-
ommendation, based on the determination
made under clause (i), as to whether such
coverage decision should be affirmed, modi-
fied, or reversed, setting forth the grounds
(including the clinical basis) for the rec-
ommendation; and
‘‘(iv) a physician who did not make
the initial review decision will reconsider
the initial review decision to determine
whether such decision was in accordance
with the terms of the plan and this title
and will issue a written decision affirming,
modifying, or reversing the initial review
decision, taking into account any rec-
ommendations reported to the plan pursu-
ant to clause (iii), and setting forth the
grounds for the decision.
‘‘(D) TIME
LIMITS
FOR
RECONSIDER-
ATION.—Any review under this paragraph shall
be completed before the end of the reconsider-
ation period (as defined in paragraph (9)(O))
following the review filing date in connection
with such review. The decision under this para-
graph affirming, reversing, or modifying the ini-
tial review decision of the plan shall be the final
decision of the plan. Failure to issue a written
decision before the end of the reconsideration
period in any reconsideration requested under
this paragraph shall be treated as a final deci-
sion affirming the initial review decision of the
plan.
‘‘(E) INDEPENDENT MEDICAL EXPERTS.—
‘‘(i) IN
GENERAL.—For purposes of
this paragraph, the term ‘independent
medical expert’ means, in connection with
any coverage decision by a group health
plan, a professional—
‘‘(I) who is a physician or, if ap-
propriate, another medical profes-
sional;
‘‘(II) who has appropriate cre-
dentials and has attained recognized
expertise in the applicable medical
field;
‘‘(III) who was not involved in
the initial decision or any earlier re-
view thereof; and
‘‘(IV) who is selected in accord-
ance with clause (ii) and meets the re-
quirements of clause (iii).
‘‘(ii) SELECTION
OF
MEDICAL
EX-
PERTS.—An independent medical expert is
selected in accordance with this clause if—
‘‘(ii) The plan shall secure specific ex-
cess /stop loss insurance for the plan with
an attachment point which is at least equal
to an amount recommended by the plan’s
qualified actuary (but not more than
$200,000). The applicable authority may
by regulation provide for adjustments in
the amount of such insurance in specified
circumstances in which the plan specifically
provides for and maintains reserves in ex-
cess of the amounts required under sub-
paragraph (A).
‘‘(iii) The plan shall secure indem-
nification insurance for any claims which
the plan is unable to satisfy by reason of
a plan termination.
Any regulations prescribed by the applicable authority
pursuant to clause (i) or (ii) of subparagraph (B) may
allow for such adjustments in the required levels of excess /
stop loss insurance as the qualified actuary may rec-
ommend, taking into account the specific circumstances
of the plan.
‘‘(b) MINIMUM SURPLUS IN ADDITION TO CLAIMS
RESERVES.—The requirements of this subsection are met
if the plan establishes and maintains surplus in an amount