[Congressional Bills 105th Congress]
[From the U.S. Government Publishing Office]
[S. 1712 Introduced in Senate (IS)]







105th CONGRESS
  2d Session
                                S. 1712

  To amend title XXVII of the Public Health Service Act and part 7 of 
subtitle B of title I of the Employee Retirement Income Security Act of 
1974 to improve the quality of health plans and provide protections for 
                   consumers enrolled in such plans.


_______________________________________________________________________


                   IN THE SENATE OF THE UNITED STATES

                             March 5, 1998

 Mr. Jeffords (for himself and Mr. Lieberman) introduced the following 
 bill; which was read twice and referred to the Committee on Labor and 
                            Human Resources

_______________________________________________________________________

                                 A BILL


 
  To amend title XXVII of the Public Health Service Act and part 7 of 
subtitle B of title I of the Employee Retirement Income Security Act of 
1974 to improve the quality of health plans and provide protections for 
                   consumers enrolled in such plans.

    Be it enacted by the Senate and House of Representatives 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 Care 
Quality, Education, Security, and Trust Act'' or the ``Health Care 
QUEST Act''.
    (b) Table of Contents.--The table of contents of this Act is as 
follows:

Sec. 1. Short title; table of contents.
Sec. 2. Findings and purpose.
Sec. 3. Definitions.
Sec. 4. Effect on other laws.
                   TITLE I--HEALTH QUALITY OVERSIGHT

Sec. 101. Health Quality Council.
Sec. 102. Members of the Council.
Sec. 103. Personnel matters.
Sec. 104. Powers.
Sec. 105. General duties.
Sec. 106. National benchmarks of quality.
Sec. 107. National report cards.
Sec. 108. Evaluating provider quality in fee-for-service.
Sec. 109. Studies.
Sec. 110. Authorization of appropriations.
                     TITLE II--QUALITY IMPROVEMENT

Sec. 201. Investment in quality measurement.
        ``Sec. 915. National health care quality information.
                   TITLE III--HEALTH CARE INFORMATION

               Subtitle A--Plan Sponsor Responsibilities

Sec. 301. Employee Retirement Income Security Act of 1974.
      Subtitle B--Health Plan Requirements And Consumer Protection

Sec. 311. Amendment to Public Health Service Act.
                   ``Part C--Protection for Consumers

        ``Sec. 2770. Exemption.
                   ``Subpart 1--Consumer Information

        ``Sec. 2771. Health plan comparative information.
          ``Subpart 2--Consumer Protection and Plan Standards

        ``Sec. 2775. Emergency services.
        ``Sec. 2776. Advance directives and organ donation.
        ``Sec. 2777. Coverage determination, grievances and appeals.
        ``Sec. 2778. Confidentiality and accuracy of enrollees records.
           ``Subpart 3--Health Care Professional Protections

        ``Sec. 2781. Health care professional communications.
Sec. 312. Amendments to the Employee Retirement Income Security Act of 
                            1974.
                 ``Subpart B--Protection for Consumers

        ``Sec. 720. Exemption.
                   ``Chapter 1--Consumer Information

        ``Sec. 721. Health plan comparative information.
          ``Chapter 2--Consumer Protection and Plan Standards

        ``Sec. 725. Emergency services.
        ``Sec. 726. Advance directives and organ donation.
        ``Sec. 727. Coverage determination, grievances and appeals.
        ``Sec. 728. Confidentiality and accuracy of participants and 
                            beneficiaries records.
           ``Chapter 3--Health Care Professional Protections

        ``Sec. 730. Health care professional communications.

SEC. 2. FINDINGS AND PURPOSE.

    (a) Findings.--Congress makes the following findings:
            (1) While the health care delivered in the United States is 
        of high quality, the variations in quality are large.
            (2) The problems arising from the delivery of poor health 
        care quality are serious and raise the cost of health care for 
        all Americans.
            (3) Health care quality can be defined and measured, but 
        additional resources are needed to fully develop and implement 
        the necessary tools.
            (4) Inadequate information currently exists in the health 
        care marketplace to guide and inform purchasing decisions.
            (5) Health care professionals should act as advocates for 
        their patients.
            (6) Coverage determinations should be made in a timely 
        manner.
            (7) Procedures should be available to consumers of health 
        care for dispute resolution.
            (8) Consumers of health care should be able to access 
        emergency services for those conditions when a ``prudent 
        layperson'' would be concerned that lack of such services would 
        result in serious consequences.
            (9) Currently, there is no unified strategy for obtaining 
        quality indicators for health care in the fee-for-service 
        market.
    (b) Purpose.--It is the purpose of this Act to--
            (1) provide for the continuous quality improvement of the 
        health care delivered in the United States;
            (2) provide for the development and implementation of the 
        tools necessary to measure health care quality;
            (3) provide consumers with the information necessary to 
        guide and inform consumers regarding health care purchasing 
        decisions;
            (4) ensure that health care professionals can act as 
        advocates for their patients;
            (5) provide consumers with timely coverage decisions and 
        defined procedures for appealing adverse determinations; and
            (6) provide a ``prudent layperson'' standard for emergency 
        care throughout the United States.

SEC. 3. DEFINITIONS.

    (a) Application of Certain Definitions.--Except as otherwise 
provided in subsection (b), the definitions in section 2791 of the 
Public Health Service Act (42 U.S.C. 300gg-91) shall apply to this Act.
    (b) Other Definitions.--In this Act:
            (1) Council.--The term ``Council'' means the Health Quality 
        Council established under section 101.
            (2) Plan administrator.--The term ``plan administrator'' 
        has the meaning given the term ``administrator'' by section 
        3(16)(A) of the Employee Retirement Income Security Act of 1974 
        (42 U.S.C. 1002(16)(A)).
            (3) Plan fiduciary.--The term ``plan fiduciary'' means a 
        person named as a fiduciary in accordance with section 402(a) 
        of the Employee Retirement Income Security Act of 1974 (42 
        U.S.C. 1102(a)).
            (4) Plan sponsor.--The term ``plan sponsor'' has the 
        meaning given that term by section 2791(d)(13) of the Public 
        Health Service Act (42 U.S.C. 300gg-91(d)(13)).

SEC. 4. EFFECT ON OTHER LAWS.

    (a) ERISA.--Nothing in this Act (or an amendment made by this Act) 
shall be construed as affecting or modifying section 514 of the 
Employee Retirement Income Security Act of 1974 (29 U.S.C. 1144) with 
respect to a group health plan.
    (b) PHSA.--Nothing in this Act (or an amendment made by this Act) 
shall be construed to prohibit a State from establishing, implementing 
or continuing in effect requirements relating to the regulation of 
insurance as permitted under section 514(b)(2)(A) of the Employee 
Income Security Act of 1974 (29 U.S.C. 1144(b)(2)(A)).

                   TITLE I--HEALTH QUALITY OVERSIGHT

SEC. 101. HEALTH QUALITY COUNCIL.

    There is established a council to be known as the ``Health Quality 
Council'' to provide advice to the President and the Congress 
concerning health care quality and to otherwise carry out the duties 
described in this title.

SEC. 102. MEMBERS OF THE COUNCIL.

    (a) Appointment.--
            (1) In general.--The Council shall be composed of 9 members 
        to be appointed by the Comptroller General from among 
        individuals having expertise relating to--
                    (A) the measurement and improvement of the quality 
                of health care;
                    (B) the purchase of health care in the private 
                sector;
                    (C) the purchase of health care in the public 
                sector (Federal and State);
                    (D) the delivery and provision of health care;
                    (E) health economics;
                    (F) medical ethics; and
                    (G) the needs of participants and beneficiaries in 
                health care plans (including children and individuals 
                with disabilities).
            (2) Terms and vacancies.--
                    (A) Terms.--A member of the Council (other than the 
                Chairperson) shall be appointed for a term of 4 years, 
                except that of the members initially appointed to the 
                Council--
                            (i) 3 members shall be appointed for a term 
                        of 1 year;
                            (ii) 3 members shall be appointed for a 
                        term of 2 years; and
                            (iii) 3 members shall be appointed for a 
                        term of 3 years.
                    (B) Limitation.--At the expiration of the term of 
                office of a member of the Council appointed under 
                subsection (a), that member shall continue to hold 
                office until a successor for such member is appointed, 
                except that such member shall not continue to serve 
                beyond the expiration of the next session of Congress 
                subsequent to the expiration of the fixed term of 
                office.
                    (C) Vacancies.--A vacancy in the membership of the 
                Council shall not affect the powers of the Council and 
                shall be filled in the same manner as the original 
                appointment, except that any member appointed to fill a 
                vacancy that occurs prior to the expiration of the term 
                for which the predecessor of the member was appointed 
                shall be appointed for the remainder of such term.
    (b) Chairperson.--The Comptroller General shall select a 
Chairperson from among the members of the Council appointed under 
section (a)(1). A member may not serve as Chairperson for longer than 8 
years.
    (c) Executive Director.--The Chairperson of the Council shall 
appoint an individual to serve as the Executive Director of the 
Council. The Executive Director shall serve at the discretion of the 
Chairperson.
    (d) Meetings.--
            (1) Initial meeting.--Not later than 90 days after the date 
        on which all members of the Council have been appointed, the 
        Council shall hold its first meeting.
            (2) Meetings.--The Council shall meet at the call of the 
        Chairperson but in no case less than quarterly.
            (3) Quorum.--A majority of the members of the Council shall 
        constitute a quorum, but a lesser number of members may hold 
        hearings.
    (e) Compensation of Members.--
            (1) Full-time members.--The Chairperson and Executive 
        Director of the Council shall be compensated as provided for in 
        title 5, United States Code.
            (2) Other members.--Each member of the Council not 
        described in paragraph (1) who is not an officer or employee of 
        the Federal Government shall be compensated at a rate equal to 
        the daily equivalent of the annual rate of basic pay prescribed 
        for level IV of the Executive Schedule under section 5315 of 
        title 5, United States Code, for each day (including travel 
        time) during which such member is engaged in the performance of 
        the duties of the Council. All such members of the Council who 
        are officers or employees of the United States shall serve 
        without compensation in addition to that received for their 
        services as officers or employees of the United States.
            (3) Travel expenses.--The members of the Council shall be 
        allowed travel expenses, including per diem in lieu of 
        subsistence, at rates authorized for employees of agencies 
        under subchapter I of chapter 57 of title 5, United States 
        Code, while away from their homes or regular places of business 
        in the performance of services for the Council.
    (f) Conflict of Interest.--The Chairperson and the Executive 
Director of the Council shall not engage in any other business, 
vocation, or employment than that of serving as the Chairperson or 
Executive Director of the Council.

SEC. 103. PERSONNEL MATTERS.

    (a) General Support.--Administrative and scientific support for the 
Council shall be provided by the Agency for Health Care Policy and 
Research.
    (b) Staff.--If determined necessary by the Council, the Council may 
appoint and fix the compensation of such officers and other experts and 
employees as may be necessary for carrying out the functions of the 
Council under this title and shall fix the salaries of such officers, 
experts, and employees in accordance with chapter 51 and subchapter III 
of chapter 53 of title 5, United States Code.
    (c) Detail of Government Employees.--Any Federal Government 
employee may be detailed to the Council without reimbursement (other 
than the regular compensation of the employee), and such detail shall 
be without interruption or loss of civil service status or privilege.
    (d) Procurement of Temporary and Intermittent Services.--The 
Chairperson of the Council may procure temporary and intermittent 
services under section 3109(b) of title 5, United States Code, at rates 
for individuals which do not exceed the daily equivalent of the annual 
rate of basic pay prescribed for level V of the Executive Schedule 
under section 5316 of such title.
    (e) Leasing Authority.--Notwithstanding any other provision of law, 
the Council may enter directly into leases for real property for 
office, meeting, storage, and such other space as may be necessary to 
carry out the functions of the Council under this title, and shall be 
exempt from any General Services Administration space management 
regulations or directives.
    (f) Contracting Authority.--Notwithstanding any other provision of 
law, the Council may enter directly into contracts with entities as the 
Council determines necessary to carry out the duties of the Council 
under this title.
    (g) Acceptance of Payments.--
            (1) In general.--Notwithstanding any other provision of 
        law, in accordance with regulations which the Council shall 
        prescribe to prevent conflicts of interest, the Council may 
        accept payment and reimbursement, in cash or in kind, from non-
        Federal agencies, organizations, and individuals for travel, 
        subsistence, and other necessary expenses incurred by members 
        of the Council in attending meetings and conferences concerning 
        the functions or activities of the Council.
            (2) Credit of account.--Any payment or reimbursement 
        accepted shall be credited to the appropriated funds of the 
        Council.

SEC. 104. POWERS.

    (a) Hearings.--The Council may hold such hearings, sit and act at 
such times and places, take such testimony, and receive such evidence 
as the Council considers advisable to carry out the purposes of this 
title.
    (b) Advisory Committees.--The Council may establish such advisory 
committees as the Council determines necessary to carry out its duties 
under this title.
    (c) Information From Federal Agencies.--The Council may secure 
directly from any Federal department or agency such information as the 
Council considers necessary to carry out the provisions of this title. 
Upon request of the Chairperson of the Council, the head of such 
department or agency shall furnish such information to the Council. Any 
information furnished to the Council under this subsection shall, upon 
the request of the department or agency, be kept confidential and be 
used only for the purpose for which such information was provided.
    (d) Postal Services.--The Council may use the United States mails 
in the same manner and under the same conditions as other departments 
and agencies of the Federal Government.
    (e) Gifts.--The Council may accept, use, and dispose of gifts or 
donations of services or property.

SEC. 105. GENERAL DUTIES.

    The Council shall--
            (1) serve as a resource for the appropriate committees of 
        Congress and the President in providing information and 
        scientific evidence with respect to health care quality and 
        consumer protection legislation;
            (2) at the request of the appropriate committees of 
        Congress or the President, develop financial and socioeconomic 
        impact statements for health care quality and consumer 
        protection legislation;
            (3) develop, using the process recommended by the National 
        Academy of Sciences (Institute of Medicine) and the studies 
        carried out under section 109, update, and disseminate 
        population-based benchmarks and indicators of health care 
        quality;
            (4) in accordance with section 107, provide the appropriate 
        committees of Congress and the President with an annual report 
        on the State of the Nation's health care quality or related 
        topics;
            (5) in accordance with section 108, develop recommendations 
        for measuring and reporting quality indicators for use in the 
        fee-for-service market;
            (6) develop, in consultation with the Agency for Health 
        Care Policy and Research and appropriate experts, the data 
        sampling methods to be used in data reporting for monitoring 
        quality indicators and health outcomes measures as required 
        under section 915(c) of the Public Health Service Act (as added 
        by this Act); and
            (7) carry out such other activities as the Council 
        determines appropriate to carry out its duties under this Act.

SEC. 106. NATIONAL BENCHMARKS OF QUALITY.

    (a) Development.--
            (1) In general.--The Council shall develop population-based 
        benchmarks of health care quality.
            (2) Revisions and dissemination.--The population-based 
        benchmarks developed under paragraph (1) shall be revised, 
        updated and disseminated biennially.
            (3) Process for development.--The development of the 
        population-based benchmarks under paragraph (1) shall follow 
        the process recommended by the National Academy of Sciences 
        (Institute of Medicine) under section 109, be consistent with 
        advice and testimony received under subsection (b).
    (b) Experts.--
            (1) Contracts.--The Council may enter into a contract with 
        such experts as the Council determines are necessary to carry 
        out its duties under this Act.
            (2) Experts.--Consistent with sections 103 and 104, the 
        Council shall have the authority to convene expert panels, 
        conduct hearings, and contract for services to obtain 
information as necessary to carry out its duties under this Act.
    (c) Model Standard Format.--The Council, in conjunction with the 
Agency for Health Care Policy and Research, shall develop model 
standard formats for providing health plan information to consumers 
that may be used by employers or health insurance issuers. In 
developing such model formats, the Council shall take into 
consideration the recommendations of the National Academy of Sciences 
(Institute of Medicine) following the study authorized under paragraph 
(4) of section 109(a).
    (d) Quality Indicators and Outcomes Measures.--
            (1) In general.--The Council shall recommend to the 
        Secretary of Health and Human Services and the Secretary of 
        Labor, a set of quality indicators (including health services 
        delivery and processes) and health outcomes measures to be used 
        for the reporting of information under this Act (or an 
        amendment made by this Act) by health care providers and health 
        plans. Such measures shall take into consideration the 
        different populations served (such as children and the 
        disabled) and where appropriate shall be consistent with 
        requirements applicable to Medicare+Choice plans under title 
        XVIII of the Social Security Act (42 U.S.C. 1395 et seq.).
            (2) Different indicators and outcomes measures.--The 
        Secretary of Health and Human Services and the Secretary of 
        Labor may adopt quality indicators or health outcomes measures 
        that are in a different form than the indicators or outcomes 
        measures recommended by the Council under paragraph (1) if--
                    (A) the Secretary of Health and Human Services or 
                the Secretary of Labor finds that different indicators 
                or outcomes measures will substantially reduce 
                administrative costs to health care providers and 
                health plans as compared to the alternatives, or that 
                such indicators or measures are demonstrated or proven 
                to be more appropriate for the populations served; and
                    (B) the indicators or outcomes measures are adopted 
                in accordance with the rulemaking procedures of 
                subchapter III of chapter 5 of title 5, United States 
                Code.

SEC. 107. NATIONAL REPORT CARDS.

    (a) Report on National Goals.--Not later than 18 months after the 
date of enactment of this Act, and every 2 years thereafter, the 
Council shall prepare and submit to the appropriate committees of 
Congress and the President a report that--
            (1) establishes national goals for the improvement of the 
        quality of health care; and
            (2) contains the recommendations of the Council for 
        achieving the national goals.
    (b) Report on Health Related Topics.--Not later than 30 months 
after the date of enactment of this Act and every 2 years thereafter, 
the Council shall prepare and submit to the Congress and the President 
a report that addresses at least 1 of the following (or a related 
matter):
            (1) The availability, applicability and appropriateness of 
        information to consumers regarding the quality of their health 
        care.
            (2) The state of information systems and data collecting 
        capabilities for measuring and reporting on quality indicators.
            (3) The impact of quality measurement on access to and the 
        cost of medical care.
            (4) Barriers to continuous quality improvement in medical 
        care.
            (5) The state of health care quality measurement research 
        and development.

SEC. 108. EVALUATING PROVIDER QUALITY IN FEE-FOR-SERVICE.

    (a) Development.--The Council shall develop recommendations for 
measuring and reporting provider health care quality indicators in the 
fee-for-service market.
    (b) Report.--Not later than 24 months after the date of enactment 
of this Act, the Council shall prepare and submit to the Congress and 
the President a report concerning the strategy developed under this 
section.

SEC. 109. STUDIES.

    (a) National Academy of Science.--The Secretary of Health and Human 
Services shall enter into a contract with the Institute of Medicine of 
the National Academy of Sciences to conduct studies to--
            (1) determine what standards should be used in the 
        development of population-based benchmarks against which health 
        care quality can be compared and measured;
            (2) determine the optimal process for establishing such 
        population-based benchmarks;
            (3) validate the process determined most appropriate under 
        paragraph (2);
            (4) assess the optimal application of population-based 
        benchmarks and how information concerning health care quality 
        should be presented to users, including consumers, providers, 
        and purchasers;
            (5) analyze the next steps necessary for a national 
        continuous health care quality improvement process;
            (6) develop recommendations for linking payment for health 
        services to health outcomes measures in order to recognize and 
        reimburse health plans and health care providers that provide 
        quality health care, particularly with respect to individuals 
        with special needs or chronic health problems; and
            (7) consider the relationship between the need for public 
        information to help consumers make informed health care choices 
        and the processes necessary to create an environment that will 
        promote the use of continuous quality improvement techniques.
    (b) Report.--During the period beginning 24 months after the date 
of enactment of this Act, but not later than 36 months after such date 
of enactment, the Institute of Medicine shall prepare and submit to the 
Congress and the President a report concerning each study conducted 
under subsection (a).
    (c) Review by GAO.--The General Accounting Office shall conduct a 
periodic review of the conduct of the Council and report its findings 
to the appropriate committees of Congress and the President.

SEC. 110. AUTHORIZATION OF APPROPRIATIONS.

    (a) In General.--There are authorized to be appropriated to the 
Council such sums as may be necessary to carry out this title.
    (b) Availability.--Any amounts appropriated under subsection (a) 
shall remain available, without fiscal year limitation, until expended.

                     TITLE II--QUALITY IMPROVEMENT

SEC. 201. INVESTMENT IN QUALITY MEASUREMENT.

    Part B of title IX of the Public Health Service Act (42 U.S.C. 299b 
et seq.) is amended by adding at the end the following:

``SEC. 915. NATIONAL HEALTH CARE QUALITY INFORMATION.

    ``(a) Purpose.--It is the purpose of this section to expand the 
duties and responsibilities of the Agency to include the collection, 
analysis, and dissemination of health care quality information.
    ``(b) Duties.--In carrying out this section, the Agency shall--
            ``(1) provide administrative and scientific support to the 
        Health Quality Council established under section 101 of the 
        Health Care Quality, Education, Security and Trust Act;
            ``(2) develop risk and case mix adjustment methodology for 
        use in comparing health outcomes data;
            ``(3) compile and publicly disseminate aggregate data 
        regarding health care quality indicators and outcomes;
            ``(4) develop a model standard format that may be used by 
        health insurance issuers in reporting the information required 
        under part C of title XXVII;
            ``(5) provide assistance in the development of improved 
        information systems, including computerized formats that may be 
        used by health plans in providing the information required 
        under title XXVII;
            ``(6) collect, maintain and publicly distribute health care 
        quality population-based benchmarks established by the Health 
        Quality Council;
            ``(7) coordinate its activities with respect to health care 
        quality with health plan accrediting bodies, the National 
        Committee on Vital and Health Statistics, the National Center 
        for Health Statistics, and State and local governments.
            ``(8) develop survey tools to measure participant and 
        beneficiary satisfaction as required under section 101(j)(4) of 
        the Employee Retirement Income Security Act of 1974.
    ``(c) Submission of Data.--
            ``(1) In general.--Health insurance issuers, group health 
        plans, and health insurance issuers of group health plans shall 
        submit aggregate data, without patient identifiers, obtained in 
        the process of reporting quality indicators and health outcomes 
        measures to the Agency for the purpose of the Health Quality 
        Council's report as required in section 107(a) of the Health 
        Care Quality, Education, Security and Trust Act.
            ``(2) Data sampling methods.--The Secretary of Health and 
        Human Services and the Secretary of Labor shall develop data 
        sampling methods for the submission of aggregate data under 
        this section. Such methods shall be based on the recommendation 
        of the Health Quality Council established under section 101 of 
        the Health Care Quality, Education, Security, and Trust Act.
            ``(3) Different methods.--The Secretary of Health and Human 
        Services and the Secretary of Labor may adopt data sampling 
        methods that are in a different form than the methods 
        recommended by the Council under paragraph (2) if--
                    ``(A) the Secretary of Health and Human Services or 
                the Secretary of Labor finds that different methods 
                will substantially reduce administrative costs to 
                health care providers and health plans as compared to 
                the alternatives, or that such methods are demonstrated 
                or proven to be more appropriate; and
                    ``(B) the methods are adopted in accordance with 
                the rulemaking procedures of subchapter III of chapter 
                5 of title 5, United States Code.''.

                   TITLE III--HEALTH CARE INFORMATION

               Subtitle A--Plan Sponsor Responsibilities

SEC. 301. EMPLOYEE RETIREMENT INCOME SECURITY ACT OF 1974.

    (a) In General.--Section 101 of the Employee Retirement Income 
Security Act of 1974 (29 U.S.C. 1021) is amended--
            (1) by redesignating the second subsection (h) (relating to 
        cross reference) as subsection (i); and
            (2) by adding at the end the following:
    ``(j) Group Health Plan Distribution of Information.--
            ``(1) Summary plan description.--
                    ``(A) In general.--Notwithstanding section 102, or 
                any other provision of this Act, with respect to a 
                group health plan (as defined in section 733(a)(1)), 
                the plan administrator of such plan shall furnish to 
                each participant under the group health plan, a copy of 
                the most recent summary plan description for each plan 
                option under which the participant or beneficiary may 
                elect to receive benefits--
                            ``(i) upon the employment of the 
                        participant or at the time the group health 
                        plan first becomes subject to this title, 
                        whichever is later; and
                            ``(ii) at the beginning of an open 
                        enrollment period, if the plan sponsor provides 
                        such a period.
                Plan sponsors that provide such information in an 
                accessible centralized location and notify participants 
                of that location shall be deemed to meet the 
                requirements of clause (ii).
                    ``(B) Additional requirements.--
                            ``(i) In general.--The plan administrator 
                        shall ensure that the most recent summary plan 
                        description for a group health plan is provided 
                        to participants and beneficiaries--
                                    ``(I) at least annually if the plan 
                                has been materially modified or 
                                amended; and
                                    ``(II) upon the request of a 
                                participant or beneficiary.
                            ``(ii) Required information.--A summary 
                        plan description shall inform participants and 
                        beneficiaries of the availability of technical 
                        support and information concerning the rights 
                        of such participants and beneficiaries under 
                        this Act from the Department of Labor, 
                        including the phone numbers and location of the 
                        Department's regional offices, and Internet 
                        access to information.
            ``(2) Required annual information.--
                    ``(A) In general.--Notwithstanding any other 
                provision of this Act, with respect to a group health 
                plan (as defined in section 733(a)(1)), the plan 
                administrator of such plan shall ensure that the 
                information described in subparagraph (B) with respect 
                to material modifications, will be provided not later 
                than 30 days after the date on which the change 
                involved becomes effective, to participants and 
                beneficiaries.
                    ``(B) Information.--The information required under 
                this subparagraph includes information with respect 
                to--
                            ``(i) any material changes in benefit 
                        coverage including any new exclusions from 
                        coverage or new optional supplemental coverage 
                        (including the associated premiums, 
                        deductibles, coinsurance, copayments for which 
                        the enrollee will be responsible, and any 
                        annual or lifetime limits on benefits);
                            ``(ii) any material changes in the health 
                        insurance issuer's service area, including any 
                        changes in the number, mix, and geographic 
                        distribution of participating providers, 
                        including specialists;
                            ``(iii) any material changes in out-of-area 
                        coverage or out-of-network services (if 
                        previously provided) or changes in additional 
                        payments required for these services;
                            ``(iv) any material changes in prior 
                        authorization rules; and
                            ``(v) any material changes in plan 
                        grievance and appeals procedures.
                    ``(C) Permissible provision of information.--A 
                group health plan shall be considered to have complied 
                with the provisions of subparagraph (B)(ii) if the plan 
                administrator distributes a directory or listing of 
                participating providers to participants and 
                beneficiaries and such directory of list is updated to 
                reflect any material changes in participating 
                providers.
                    ``(D) Participant satisfaction.--
                            ``(i) In general.--With respect to a plan 
                        sponsor described in clause (ii) that provides 
                        a group health plan, the plan sponsor shall 
                        annually provide to participants and 
                        beneficiaries a summary report of participant 
                        satisfaction and disenrollment rates (if 
                        applicable) regarding each enrollment option 
                        offered to participants and beneficiaries.
                            ``(ii) Plan sponsor described.--A plan 
                        sponsor described in this clause is a plan 
                        sponsor--
                                    ``(I) with 100 or more participants 
                                enrolled in a group health plan during 
                                a plan year; and
                                    ``(II) with a contracting 
                                relationship with the health insurance 
                                issuer involved for at least 2 years.
            ``(3) Notifications by plan administrator.--With respect to 
        a group health plan, a plan administrator shall notify 
        participants and beneficiaries under the plan that the plan 
        sponsor involved--
                    ``(A) has stopped paying plan premiums or has 
                terminated reimbursement for services covered under the 
                plan not later than 30 days after the date of the first 
                nonpayment by the plan sponsor; or
                    ``(B) in the case of a plan sponsor involved in a 
                sale or merger, has made changes in the group health 
                plan involved not later than the date on which the 
                assets of the plan sponsor are transferred following 
                such sale or merger.
            ``(4) Use of certain information.--In order to meet the 
        requirements of paragraph (2)(D), a group health plan sponsor 
        may use satisfaction survey measurement tools that have been 
        developed and made available by the Agency for Health Care 
        Policy and Research.
            ``(5) Establishment of internet site.--The Secretary shall 
        provide for the establishment of a site on the Internet to 
        provide technical support and information concerning the rights 
        of participants and beneficiaries under this Act.
            ``(6) No limitation.--Nothing in this subsection shall be 
        construed to prohibit a plan sponsor from distributing any 
        additional information that such plan sponsor considers 
        important or necessary in assisting participants and 
        beneficiaries with changes to the group health plan.
            ``(7) Rule of construction.--For purposes of this 
        subsection, a plan administrator, in reliance on records 
        maintained by the administrator, shall be deemed to have met 
        the requirements of this subsection if the administrator 
        provides the information requested under this subsection to 
        participants and beneficiaries at the address contained in such 
        records with respect to such participants and beneficiaries.''.

      Subtitle B--Health Plan Requirements And Consumer Protection

SEC. 311. AMENDMENT TO PUBLIC HEALTH SERVICE ACT.

    (a) Consumer 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:

                   ``Part C--Protection for Consumers

``SEC. 2770. EXEMPTION.

    ``(a) In General.--Upon the application of a group health plan or a 
health insurance issuer, the Secretary may exempt such plan or issuer 
from compliance with 1 or more of the requirements of this part.
    ``(b) Requirements.--The Secretary may grant an exemption under 
this section if--
            ``(1) the Secretary--
                    ``(A) publishes a notice of the pendency of such 
                exemption in the Federal Register; and
                    ``(B) provides notice, and an opportunity for 
                comment, of the pendency of such exemption to 
                interested individuals; and
            ``(2) the Secretary determines that the exemption--
                    ``(A) is administratively feasible;
                    ``(B) is in the interests of the group health plan 
                and the participants and beneficiaries under such plan, 
                or in the interests of the health insurance issuer and 
                the enrollees involved; and
                    ``(C) is protective of the rights of participants 
                and beneficiaries or enrollees, as the case may be.
    ``(c) Scope of Exemption.--An exemption provided under this 
section--
            ``(1) shall apply only to those requirements identified by 
        the Secretary in approving the exemption;
            ``(2) may be conditional; and
            ``(3) may be provided to a class of plans or issuers.
    ``(d) Procedures.--The Secretary shall develop procedures to 
provide exemptions under this section.

                   ``Subpart 1--Consumer Information

``SEC. 2771. HEALTH PLAN COMPARATIVE INFORMATION.

    ``(a) Requirement.--A health insurance issuer in connection with 
the provision of health insurance coverage, shall, not later than 12 
months after the date of enactment of this part, provide for the 
disclosure, in a clear and accurate form to each plan sponsor, with 
which the issuer has contracted, each enrollee, or upon request to a 
potential enrollee or plan sponsor, of the information described in 
subsection (b).
    ``(b) Required Information.--The informational materials to be 
distributed under this section shall include for each plan the 
following:
            ``(1) A description of the covered items and services under 
        each such plan and the in- and out-of-network features of each 
        such plan.
            ``(2) A description of any cost sharing, including 
        premiums, deductibles, coinsurance, and copayment amounts, for 
        which the enrollee will be responsible, including any annual or 
        lifetime limits on benefits, for each such plan.
            ``(3) A description of any optional supplemental benefits 
        offered by each such plan and the terms and conditions 
        (including premiums or cost-sharing) for such supplemental 
        coverage.
            ``(4) A description of any restrictions on payments for 
        services furnished to an enrollee by a health care professional 
        that is not a participating professional and the liability of 
        the enrollee for additional payments for these services.
            ``(5) A description of the service area of each such plan, 
        including the provision of any out-of-area coverage.
            ``(6) A description of the extent to which enrollees may 
        select the primary care provider of their choice, including 
        providers both within the network and outside the network of 
        each such plan (if the plan permits out-of-network services) as 
        well as procedures for obtaining specialist referral.
            ``(7) A summary of data concerning enrollee satisfaction 
        with the plan, including disenrollment rates for the previous 2 
        plan years (excluding disenrollments due to the death of an 
        enrollee or the enrollee moving outside of the service area of 
        the plan), based on the health plan's `book-of-business'. 
        Health plans may elect to provide specific information 
        regarding disenrollment rates.
            ``(8) A description of the procedures for advance 
        directives and organ donation decisions.
            ``(9) A description of the requirements and procedures to 
        be used to obtain preauthorization for health services 
        (including telephone numbers and mailing addresses), including 
        referrals for specialty care.
            ``(10) A summary of the rules and methods for appealing 
        coverage decisions and filing grievances (including telephone 
        numbers and mailing addresses), as well as other available 
        remedies.
            ``(11) A summary of the rules for access to emergency room 
        care, including educational material regarding proper use of 
        emergency services.
            ``(12) A description of licensure, certification or 
        accreditation status of the health plan and the name and 
        address of the State or Federal regulatory agency with 
        oversight responsibilities.
            ``(13) A description of whether or not access is provided 
        to experimental treatments, investigational treatments, or 
        clinical trials and the circumstances under which access to 
        such treatments or trials is made available.
            ``(14) A description of whether or not access is provided 
        to specialists without referral and the circumstances under 
        which access to such specialists is provided.
            ``(15) A description of the quality indicators and health 
        outcomes measures of the plan in accordance with subsection 
        (c).
            ``(16) A statement that the following information, and 
        instructions on obtaining such information (including telephone 
        numbers and Internet websites), shall be made available upon 
        request:
                    ``(A) Additional information on the quality of care 
                and health outcomes under the plan.
                    ``(B) The names, credentials, addresses, and 
                telephone numbers and the availability (such as whether 
                professionals accept patients), speciality focus, 
                affiliation arrangements, number and mix of the health 
                care professionals in the network of the plan, and any 
                measures of consumer satisfaction if such satisfaction 
                measures are available.
                    ``(C) The names and locations of participating 
                health care facilities, the accreditation status, the 
                for-profit or not-for-profit status of such facilities, 
                and any measures of consumer satisfaction if such 
                satisfaction measures are available.
                    ``(D) A summary description of the methods used for 
                compensating participating health care professionals 
                (including capitation, financial incentives or bonuses, 
                fee-for-service, group practice, salary and 
                withholdings), including the proportions of 
                participating health care professionals who are 
                compensated under each type of arrangement under the 
                plan.
                    ``(E) A summary description of the procedures used 
                for utilization review, including the process by which 
                specific determinations are made.
                    ``(F) The list of the specific prescription 
                medications included in the formulary of the plan, if 
                the plan uses a defined formulary.
                    ``(G) A description of the specific exclusions from 
                coverage under the plan.
                    ``(H) A description of the specific preventative 
                services covered under the plan.
                    ``(I) A description of the availability of 
                translation or interpretation services for non-English 
                speakers and people with communication disabilities, 
                including the availability of audio tapes or 
                information in Braille.
                    ``(J) A description of the number of external 
                review requests that have been filed with an external 
                review panel designated in accordance with section 
                2777(e) and the outcome of such requests by an external 
                review panel in the preceding calendar year.
    ``(c) Determination of Indicators and Measures.--
            ``(1) In general.--The Secretary of Health and Human 
        Services, in consultation with the Secretary of Labor, shall 
        develop quality indicators and health outcomes measures for use 
        by health insurance issuers in providing the information 
        required under section (b), taking into consideration the 
        recommendations of the Health Quality Council. Such quality 
        indicators and health outcomes measures shall, while taking 
        into consideration the different populations served (such as 
        children and individuals with disabilities), be consistent 
        where appropriate with requirements applicable to 
        Medicare+Choice health plans under title XVIII of the Social 
        Security Act (42 U.S.C. 1395 et seq.).
            ``(2) Different indicators and outcomes measures.--The 
        Secretary of Health and Human Services and the Secretary of 
        Labor may adopt quality indicators or health outcomes measures 
        that are in a different form than the indicators or outcomes 
        measures recommended by the Council under paragraph (1) if--
                    ``(A) the Secretary of Health and Human Services or 
                the Secretary of Labor finds that different indicators 
                or outcomes measures will substantially reduce 
                administrative costs to health care providers and 
                health plans as compared to the alternatives, or that 
                such indicators or measures are demonstrated or proven 
                to be more appropriate for the populations served; and
                    ``(B) the indicators or outcomes measures are 
                adopted in accordance with the rulemaking procedures of 
                subchapter III of chapter 5 of title 5, United States 
                Code.
    ``(d) Manner of Distribution.--
            ``(1) In general.--The information described in this 
        section shall--
                    ``(A) be distributed in an accessible format that 
                is understandable to an average plan enrollee; and
                    ``(B) with respect to populations of individuals 
                whose primary language is other than English, be 
                provided in the primary language of such population if 
                that population comprises not less than 20 percent of 
                the total population of the geographic area served by 
                the health plan involved.
            ``(2) Rule of construction.--For purposes of this section, 
        a health insurance issuer, in reliance on records maintained by 
        the issuer, in reliance on records maintained by the issuer, 
        shall be deemed to have met the requirements of this section if 
        the issuer provides the information requested under 
this section to enrollees at the address contained in such records with 
respect to such enrollees.
    ``(e) Rule of Construction.--Nothing in this section may be 
construed to prohibit a health insurance issuer from distributing any 
other information determined to be important or necessary in assisting 
enrollees or upon request potential enrollees in the selection of a 
health plan.

          ``Subpart 2--Consumer Protection and Plan Standards

``SEC. 2775. EMERGENCY SERVICES.

    ``(a) Access to Services.--A group health plan, health insurance 
issuer offering group health insurance, or a health insurance issuer 
who provides coverage for emergency service shall ensure that emergency 
services are available and accessible 24 hours a day and 7 days a week.
    ``(b) Payment for Services.--A group health plan, health insurance 
issuer offering group health insurance, or a health insurance issuer 
described in subsection (a), shall cover emergency services furnished 
under the plan or coverage--
            ``(1) in a manner so that, if such services are provided to 
        an enrollee by a non-participating health care provider--
                    ``(A) the enrollee shall not be liable for amounts 
                paid for such services in excess of the amount that 
                would have been paid if the services were provided by a 
                participating health care provider; and
                    ``(B) the plan or issuer shall pay an amount for 
                such services that is not less than the amount that 
                would be paid to a participating health care provider 
                for the same services; and
            ``(2) without regard to any other term or condition of such 
        plan or coverage (other than exclusion or coordination of 
        benefits, or an affiliation or waiting period permitted under 
        section 2701, and other than applicable cost-sharing 
        requirements).
    ``(c) Prior Authorization.--A group health plan, health insurance 
issuer offering group health insurance, or a health insurance issuer 
described in subsection (a) shall provide coverage for emergency 
services without regard to prior authorization or the emergency care 
provider's contractual relationship with the plan involved.
    ``(d) Guidelines Respecting Coordination of Post-Stabilization 
Care.--
            ``(1) In general.--A group health plan, a health insurance 
        issuer offering group health insurance, or a health insurance 
        issuer shall comply with guidelines established by the 
        Secretary of Health and Human Services (with respect to health 
        insurance issuers) and the Secretary of Labor (with respect to 
        group health plans) relating to promoting efficient and timely 
        coordination of appropriate maintenance and post-stabilization 
        care of an enrollee after the enrollee has been determined to 
        be stable (as defined for purposes of section 1867 of the 
        Social Security Act).
            ``(2) Guidelines.--The guidelines established by the 
        Secretary of Health and Human Services and the Secretary of 
        Labor under paragraph (1) shall be the guidelines adopted with 
        respect to appropriate maintenance and post-stabilization care 
        for Medicare+Choice plans under part C of title XVIII of the 
        Social Security Act.
    ``(e) Definitions.--In this section:
            ``(1) Emergency services.--The term `emergency services' 
        means, with respect to an enrollee in a health plan, covered 
        inpatient and outpatient services that are needed to evaluate 
        or stabilize an emergency medical condition (as defined in 
        paragraph (2)).
            ``(2) Emergency medical condition.--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 immediate medical attention to result in--
                            ``(i) placing the health of the individual 
                        (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.
            ``(2) Post-stabilization care.--The term `post-
        stabilization care' means, with respect to an individual who is 
        determined to be stable under section 1867 of the Social 
        Security Act pursuant to a medical screening examination or who 
        is stabilized after provision of emergency services, medically 
        necessary items and services (other than emergency services and 
        other than maintenance care) that are required by the 
        individual.

``SEC. 2776. ADVANCE DIRECTIVES AND ORGAN DONATION.

    ``A group health plan or health insurance issuer shall maintain 
written policies and procedures with respect to advance directives (as 
such term is defined in section 1866(f)(3) of the Social Security Act 
(42 U.S.C. 1395cc(f)(3))) and organ donation decisions on the part of 
an enrollee. Nothing in the preceding sentence shall be construed to 
require the provision of information regarding assisted suicide, 
euthanasia, or mercy killing.

``SEC. 2777. COVERAGE DETERMINATION, GRIEVANCES AND APPEALS.

    ``(a) Coverage Determinations.--
            ``(1) In general.--A group health plan or a health 
        insurance issuer shall ensure that procedures are in place 
        for--
                    ``(A) making determinations regarding whether an 
                enrollee is eligible to receive a payment or coverage 
                for health service under the plan or coverage involved 
                and the amount (if any) that the enrollee is required 
                to pay with respect to such service;
                    ``(B) notifying covered enrollees (or individuals 
                acting on behalf of such enrollees) and health care 
                professionals providing the service involved regarding 
                determinations made by the plan or issuer and any 
                additional payments that the enrollee may be required 
                to make with respect to such service; and
                    ``(C) responding to either written or oral requests 
                for coverage determinations from an enrollee (or an 
                individual acting on behalf of an enrollee) or a 
                treating health care professional.
            ``(2) Routine determination.--
                    ``(A) In general.--A group health plan or a health 
                insurance issuer shall ensure that prior authorization 
                determinations concerning the provision of non-
                emergency items or services are made within 15 days of 
                the date on which the plan or issuer receives a request 
                for such a determination.
                    ``(B) Incomplete information.--If a determination 
                cannot be made under subparagraph (A) within the 15 day 
                period referred to in such subparagraph, because of the 
                incomplete nature of the medical or coverage 
                information involved, the plan or issuer shall provide 
                a written notification of such fact to the enrollee (or 
                individual acting on behalf of the enrollee) and the 
                treating health care professional.
                    ``(C) Submission of additional information.--Upon 
                receipt of a notification under subparagraph (B), an 
                enrollee (or individual acting on behalf of an 
                enrollee) or the treating health care professional 
                shall submit the additional information required within 
                the 30-day period beginning on the date on which such 
                notification is received.
                    ``(D) Determination.--A group health plan or health 
                insurance issuer shall make a determination under this 
                paragraph within 2 working days of the date on which 
                complete information is obtained.
            ``(3) Expedited determination.--
                    ``(A) In general.--A prior authorization 
                determination under this subsection shall be made 
                within 72 hours after a request is received by the plan 
                or issuer if the request indicates that the treating 
                health care professional (regardless of whether the 
                professional is affiliated with the plan or issuer 
                involved) certifies that a determination under the 
                procedures described in paragraph (2) could seriously 
                jeopardize the life or health of the enrollee or the 
                ability of the enrollee to regain maximum function.
                    ``(B) Information.--In an expedited review under 
                this paragraph, all necessary information shall be 
                transmitted between the plan or issuer and the enrollee 
                (or individual acting on behalf of the enrollee) and 
                the treating health care professional by the most 
                expeditious method available.
                    ``(C) Notice.--Notice of a determination under an 
                expedited review shall be provided to the enrollee (or 
                individual acting on behalf of the enrollee) and the 
                treating health care professional within the 72-hour 
                period referred to in subparagraph (A) by the most 
                expedient method available. Written confirmation of 
                such determination shall be provided to the enrollee 
                (or individual) or treating health care professional 
                within 2 working days of the initial notice.
            ``(4) Notice of determinations.--
                    ``(A) Approval.--With respect to the routine 
                determination of a plan or issuer under paragraph (2) 
                to certify an admission, procedure or service, with 
                respect to an enrollee, the plan or issuer shall 
                provide notice of such determination to the treating 
                health care professional involved within 24 hours of 
                making such determination. A written or electronic 
                confirmation of such determination shall be made 
to such professional and enrollee (or individual acting on behalf of 
the enrollee) within 2 working days of the date on which the initial 
notice was provided.
                    ``(B) Adverse determinations.--With respect to a 
                routine adverse determination by a plan or issuer under 
                paragraph (2), the plan or issuer shall provide notice 
                of such determination to the treating health care 
                professional within 24 hours of making the 
                determination. A written or electronic confirmation of 
                such determination shall be made to such professional, 
                and a written notice of such determination shall be 
                made to the enrollee involved (or individual acting on 
                behalf of an individual), within 1 working day of the 
                date on which the initial notice was provided.
                    ``(C) Concurrent reviews.--With respect to the 
                determination of a plan or issuer under paragraph (1) 
                to certify or deny an extended stay or additional 
                services, the plan or issuer shall provide notice of 
                such determination to the health care provider 
                rendering the service involved within 1 working day of 
                making such determination. A written or electronic 
                confirmation of such determination shall be made to 
                such professional and to the enrollee involved (or 
                individual acting on behalf of the enrollee) within 1 
                working day of the date on which the initial notice was 
                provided.
                    ``(D) Retrospective reviews.--With respect to the 
                retrospective review by a plan or issuer of a 
                determination made under paragraph (1), a determination 
                shall be made within 30 working days of the date on 
                which the plan or issuer receives all necessary 
                information. The plan or issuer shall provide written 
                notice of an approval or disapproval of a determination 
                under this subparagraph to the enrollee (or individual 
                acting on behalf of the enrollee) and health care 
                provider involved within 5 working days of the date on 
                which such determination is made.
                    ``(E) Requirement of notice.--A written or 
                electronic notice of an adverse determination under 
                subparagraph (B), (C) or (D), or of an expedited 
                adverse determination under paragraph (3), shall be 
                provided to the enrollee (or individual acting on 
                behalf of the enrollee) and health care provider (if 
                any) involved and shall include--
                            ``(i) the reasons for the determination 
                        (including the clinical rationale) written in a 
                        manner to be understandable (to the extent 
                        possible) to the average enrollee;
                            ``(ii) the procedures for obtaining 
                        additional information concerning the 
                        determination; and
                            ``(iii) notification of the right to appeal 
                        the determination and instructions on how to 
                        initiate an appeal in accordance with 
                        subsection (d)(2).
            ``(5) Definition.--As used in this section, the term 
        `adverse determination' with respect to a group health plan or 
        health insurance coverage means a determination to deny, reduce 
        or terminate services, deny payment for services, or any 
        decision to deny coverage based on a lack of medical necessity, 
        under the terms and conditions of such plan or coverage.
    ``(b) Notice for Other Determinations.--A group health plan or a 
health insurance issuer shall provide written notice to an enrollee (or 
individual acting on behalf of an enrollee) and a health care 
professional involved of a determination by the plan or issuer to deny, 
reduce or terminate services or deny payment for services. Such 
notification shall include a brief explanation (written in a manner to 
be understood by an average enrollee) of the reasons for the 
determination, procedures for obtaining additional information, and 
procedures for appealing the determination.
    ``(c) Grievances.--A group health plan or a health insurance issuer 
shall have written procedures for addressing grievances between the 
plan and enrollees, including grievances relating to waiting periods, 
operating hours, the demeanor of personnel, and the adequacy of 
facilities. Determinations under such procedures shall be non-
appealable.
    ``(d) Internal Appeal of Coverage Determinations.--
            ``(1) In general.--An enrollee (or an individual acting on 
        behalf of an enrollee) and the treating health care 
        professional with the consent of the enrollee (or an individual 
        acting on behalf of the enrollee), may appeal (orally or in 
        writing) any adverse determination under subsection (a) or (b) 
        under the procedures described in this subsection.
            ``(2) Appeal.--A group health plan and a health insurance 
        issuer shall establish and maintain an internal appeal process 
        under which any enrollee (or an individual acting on behalf of 
an enrollee) or the treating health care professional with the consent 
of the enrollee (or an individual acting on behalf of the enrollee), 
who is dissatisfied with any adverse determination has the opportunity 
to discuss and appeal (either orally or in writing) that decision.
            ``(3) Records.--A group health plan and a health insurance 
        issuer shall maintain written records with respect to any 
        appeal under this subsection for purposes of internal quality 
        assurance and improvement.
            ``(4) Written request.--With respect to an oral request 
        under paragraph (1), a group health plan or a health insurance 
        issuer may require that the requesting individual provide 
        written evidence of such request for record keeping purposes. A 
        request for written evidence under the preceding sentence shall 
        not be used by a group health plan or health insurance issuer 
        to delay the initiation of the appeals process under this 
        subsection pending the receipt of such evidence.
            ``(5) Routine determinations.--Except as provided for in 
        paragraph (6), a group health plan or a health insurance issuer 
        shall provide for the consideration of an appeal of an adverse 
        determination under this subsection not later than 30 days 
        after the date on which a request for such appeal is received.
            ``(6) Expedited determination.--A determination with 
        respect to an appeal under this subsection shall, upon the 
        written or oral request of an enrollee (or an individual acting 
        on behalf of the enrollee) or the treating health care 
        professional, be made within 72 hours after the request for 
        such appeal is received by the plan or issuer if the request 
        indicates that the treating health care professional 
        (regardless of whether the professional is affiliated with the 
        plan or issuer involved) certifies that a determination under 
        the procedures described in paragraph (5) could seriously 
        jeopardize the life or health of the enrollee or the ability of 
        the enrollee to regain maximum function.
            ``(7) Conduct of review.--A review of a determination under 
        this subsection shall be conducted by health care professionals 
        who are knowledgeable about the enrollee's condition and the 
        treatment or service involved, including physicians and other 
        trained health care professionals. Such review shall not be 
        conducted by an individual who was involved in the initial 
        decision.
            ``(8) Lack of medical necessity.--An appeal under this 
        subsection relating to a determination to deny coverage based 
        on a lack of medical necessity or appropriateness shall be made 
        only by a physician with appropriate expertise in the field of 
        medicine involved who is not involved in the initial 
        determination.
            ``(9) Notice.--
                    ``(A) In general.--Written notice--
                            ``(i) of a determination made under 
                        paragraph (6) shall be provided to the enrollee 
                        (or individual acting on behalf of the 
                        enrollee) and the treating health care 
                        professional within the 72-hour period referred 
                        to in such paragraph in the most expeditious 
                        manner possible; and
                            ``(ii) of a determination under paragraph 
                        (5), shall be provided in writing to the 
                        enrollee (or individual acting on behalf of the 
                        enrollee) and the treating health care 
                        professional within 2 working days after the 
                        completion of the review referred to in such 
                        paragraph.
                    ``(B) Adverse determinations.--With respect to an 
                adverse determination made under paragraph (5) or (6), 
                the notice described in subparagraph (A) shall include 
                written information on how the determination may be 
                appealed to an external entity under subsection (e).
    ``(e) External Review.--
            ``(1) In general.--A group health plan or a health 
        insurance issuer shall have written procedures to permit an 
        enrollee (or an individual acting on behalf of an enrollee) or 
        the treating health care professional with the consent of the 
        enrollee (or individual), the right to an external appeal of an 
        adverse determination if such determination involves treatments 
        or services covered by the terms and condition of the plan that 
        cost at least $1,000.
            ``(2) Eligibility for designation as external review 
        panel.--
                    ``(A) Designation.--The appropriate State agent 
                shall designate individuals who are eligible to serve 
                on, or entities eligible to act as, an external review 
                panel to review external appeals brought under this 
                subsection.
                    ``(B) Requirements.--In designating individuals or 
                entities under subparagraph (A), the State agent shall 
                ensure that the individual or entity is licensed or 
certified to conduct external reviews by--
                            ``(i) the State agent, in accordance with 
                        licensing and certification procedures to be 
                        developed by the State in consultation with the 
                        National Association of Insurance 
                        Commissioners; or
                            ``(ii) in the case of a State that--
                                    ``(I) has not established such 
                                licensing and certification procedures 
                                within 24 months of the date of 
                                enactment of this subpart, the State in 
                                accordance with procedures to be 
                                developed by the Secretary; or
                                    ``(II) refuses to designate such 
                                panels, the Secretary.
                    ``(C) Liability.--An individual designated to an 
                external review panel under this subsection shall not 
                be held liable for any decision made by such panel.
            ``(3) Initiation of the external review process.--
                    ``(A) Filing of request.--An enrollee (or 
                individual acting on behalf of an enrollee) or the 
                treating health care professional with the consent of 
                the enrollee (or individual) who desires to have an 
                external review conducted under this subsection shall 
                file a written request for such a review with the plan 
                or issuer involved and the appropriate State agent not 
                later than 30 days after the receipt of a final denial 
                of a claim under subsection (d). Any such request shall 
                include the consent of the enrollee (or individual) for 
                the release of confidential medical information 
                regarding the enrollee (or individual) if such 
                information is necessary for the proper conduct of the 
                external review.
                    ``(B) Information and notice.--Not later than 5 
                working days after the receipt of a request under 
                subparagraph (A), the plan or issuer involved shall--
                            ``(i) forward all necessary information 
                        (including medical records, any relevant review 
                        criteria, the clinical rationale for the 
                        denial, and evidence of the enrollee's 
                        coverage) to the appropriate State agent (or 
                        the designee of such agent); and
                            ``(ii) send a written notification to the 
                        enrollee (or individual acting on behalf of the 
                        enrollee), the treating health care 
                        professional, and the plan administrator, 
                        indicating that an external review has been 
                        initiated.
                    ``(C) Appointment of panel.--Not later than 30 days 
                after the information and notification are provided 
                under subsection (b)--
                            ``(i) the State agent, in the case of a 
                        plan or issuer involved that is fully insured, 
                        shall appoint an external review panel from 
                        among the individuals and entities eligible 
                        under paragraph (2);
                            ``(ii) the plan fiduciary, in the case of a 
                        plan or issuer involved that is self-insured, 
                        shall appoint an external review panel from 
                        among the individuals and entities eligible 
                        under paragraph (2); or
                            ``(iii) the State agent, in the case of a 
                        group health plan where the plan sponsor 
                        directly provided health care under such plan.
                    ``(D) Requirements.--A review panel appointed under 
                subparagraph (C) shall--
                            ``(i) consist of at least 3 physicians or 
                        other health care professionals who are experts 
                        in the treatment of the enrollee's condition 
                        and knowledgeable about the recommended 
                        treatment; or
                            ``(ii) be an impartial review entity 
                        including a medical peer review organization or 
                        an independent utilization review company.
                    ``(E) Approval of enrollee.--Not later than 15 days 
                after the date on which an external review panel is 
                designated under this paragraph, the enrollee involved 
                shall, in writing--
                            ``(i) approve such panel; or
                            ``(ii) object to such panel and select 
                        alternative individuals or entities who are 
                        eligible under paragraph (2) to serve on such 
                        panel.
                Individuals or entities approved or selected under this 
                subparagraph shall serve as the external review panel 
                under this subsection with respect to the enrollee 
                involved.
                    ``(F) Conflict of interest.--An external review 
                panel designated under this paragraph shall not have 
                any material, professional, familial, or financial 
                affiliation with the health plan, health insurance 
                issuer or the enrollee involved, or any officer, 
                director, or management employee of the plan, issuer, 
physician, medical group, or association recommending the treatment, 
the institution where the treatment would take place, or the 
manufacturer of any drug, device, procedure, or other therapy proposed 
for the enrollee whose treatment is under review.
            ``(4) Standard of review.--An external review panel 
        designated under paragraph (3) shall--
                    ``(A) complete a review of an adverse determination 
                not later than 30 days after the later of--
                            ``(i) the date on which such panel is 
                        approved under paragraph (4)(E); or
                            ``(ii) the date on which all information 
                        necessary to completing such review is 
                        received;
                    ``(B) take into consideration the benefits and 
                coverage provided under the terms and conditions of the 
                plan involved;
                    ``(C) follow a standard of review that promotes 
                evidence-based decision making; and
                    ``(D) submit a report on the final determinations 
                of the panel to--
                            ``(i) the plan or issuer involved;
                            ``(ii) the enrollee involved (or individual 
                        acting on behalf of the enrollee);
                            ``(iii) the health care professional 
                        involved; and
                            ``(iv) the State agent responsible for 
                        designating review panels under paragraph (2).
            ``(5) Filing fee.--A State may impose a filing fee to be 
        applied to an enrollee initiating an external review under this 
        subsection. If a State elects to impose such a filing fee, the 
        State must include a procedure to provide for a fee reduction 
        if the enrollee demonstrates financial hardship through status 
        or evidence of participation in a State or Federal cash 
        assistance program.
            ``(6) Payment for external review.--A health plan, or 
        health insurance issuer shall be financially responsible for 
        any reasonable costs associated with the conduct of an external 
        review under this subsection.
            ``(7) Annual reporting.--The appropriate State agent shall 
        conduct annual reviews of the number of external reviews 
        requested under this subsection and the outcomes of such 
        reviews. A report concerning such annual reviews shall be made 
        public and forwarded to the Secretary of Health and Human 
        Services (with respect to health insurance issuers) and the 
        Secretary of Labor (with respect to reports on group health 
        plans). Such reports shall breakdown the results by relevance 
        to group health plans and health insurance issuers.
            ``(8) Audits.--Not later than 2 years after the date of 
        enactment of this subpart, the General Accounting Office shall 
        conduct a review of all licensed, certified, or appointed 
        review panels under paragraph (3). Such review shall include an 
        assessment of the process involved during an external review 
        and the basis of decisionmaking by the board or panel.
            ``(9) Rule of construction.--The determination of an 
        external review panel shall be binding on the plan or issuer 
        involved, except that nothing in this subsection shall be 
        construed to preclude the right of a group health plan, health 
        insurance issuer, or an enrollee from commencing a civil action 
        based on the plan or coverage involved.
    ``(f) Prior Authorization Determination.--For purposes of this 
section, the term `prior authorization determination' means, with 
respect to items and services for which coverage may be provided under 
a health plan, 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 covered 
under the coverage.

``SEC. 2778. CONFIDENTIALITY AND ACCURACY OF ENROLLEES RECORDS.

    ``A group health plan or a health insurance issuer shall establish 
procedures with respect to medical records or other health information 
maintained regarding enrollees to safeguard the privacy of any 
individually identifiable enrollee information.

           ``Subpart 3--Health Care Professional Protections

``SEC. 2781. HEALTH CARE PROFESSIONAL COMMUNICATIONS.

    ``(a) Provision of Information to Professionals.--
            ``(1) Health insurance issuers.--A health insurance issuer 
        shall establish procedures concerning the participation of 
        health care professionals under coverage provided by the issuer 
        under which such professionals will be provided with written 
        notice of--
                    ``(A) the rules of the issuer concerning 
                participation;
                    ``(B) any participation decisions that are adverse 
                to health care professionals; and
                    ``(C) the process of the issuer for appealing such 
                adverse decisions, including the presentation of 
                information and the views of the health care 
                professional regarding such decision.
            ``(2) Group health plans.--A group health plan shall ensure 
        that the organization that is responsible for maintaining the 
        provider network involved under the plan provides health care 
        professionals with the information described in paragraph (1).
            ``(3) Rule of construction.--Nothing in this subsection 
        shall be construed to in any way effect a provision in a 
        contract between a plan or issuer and a health care 
        professional that permits either party to the contract to 
        terminate the employment or participation of the professional 
        under the plan or issuer without cause.
    ``(b) Communications.--
            ``(1) In general.--An organization on behalf of a group 
        health plan (as described in subsection (a)(2)) or a health 
        insurance issuer shall not penalize (financially or otherwise) 
        a health care professional for advocating on behalf of his or 
        her patient or for providing information or referral for 
        medical care (as defined in section 2791(a)(2)) consistent with 
        the health care needs of the patient and with the code of 
        ethical conduct, professional responsibility, conscience, 
        medical knowledge, and license of the health care professional.
            ``(2) Construction.--Nothing in paragraph (1) shall be 
        construed as requiring a health insurance issuer or a group 
        health plan to pay for medical care not otherwise paid for or 
        covered by the plan provided by nonparticipating health care 
        professionals, except in those instances and to the extent that 
        the issuer or plan would normally pay for such medical care.
            ``(3) Assistance and support.--A group health plan or a 
        health insurance issuer shall not prohibit or otherwise 
        restrict a health care professional from providing letters of 
        support to, or in any way assisting, enrollees who are 
        appealing a denial, termination, or reduction of service in 
        accordance with the procedures under section 2777.''.
    (b) Application to Group Health Insurance Coverage.--
            (1) In general.--Subpart 2 of part A of title XXVII of the 
        Public Health Service Act is amended by adding at the end the 
        following new section:

``SEC. 2706. PROTECTION FOR CONSUMERS.

    ``(a) In General.--Each health insurance issuer shall comply with 
the protections and requirements under part C with respect to group 
health insurance coverage it offers.
    ``(b) Assuring Coordination.--The Secretary of Health and Human 
Services and the Secretary of Labor shall ensure, through the execution 
of an interagency memorandum of understanding between such Secretaries, 
that--
            ``(1) regulations, rulings, and interpretations issued by 
        such Secretaries relating to the same matter over which such 
        Secretaries have responsibility under part C (and this section) 
        and section 713 of the Employee Retirement Income Security Act 
        of 1974 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.''.
            (2) Conforming amendment.--Section 2792 of such Act (42 
        U.S.C. 300gg-92) is amended by inserting ``and section 
        2706(b)'' after ``of 1996''.
    (c) Application to Individual Health Insurance Coverage.--Part B of 
title XXVII of the Public Health Service Act is amended by inserting 
after section 2751 the following new section:

``SEC. 2752. PROTECTION FOR CONSUMERS.

    ``Each health insurance issuer shall comply with the protections 
and requirements under part C with respect to individual health 
insurance coverage it offers.''.
    (d) Definitions.--Section 2791(d) of the Public Health Service Act 
(42 U.S.C. 300gg-91(d)) is amended--
            (1) by redesignating paragraphs (9) through (14) as 
        paragraphs (10) through (15), respectively; and
            (2) by inserting after paragraph (8), the following:
            ``(9) Health care professional.--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 professional's services is provided under 
        the health plan involved for the services of the professional. 
        Such term includes a podiatrist, optometrist, chiropractor, 
        psychologist, dentist, physician assistant, physical or 
        occupational therapist and therapy assistant, speech-language 
        pathologist, audiologist, registered or licensed practical 
        nurse (including nurse practitioner, clinical nurse specialist, 
        certified registered nurse anesthetist, and certified nurse-
        midwife), licensed certified social worker, registered 
        respiratory therapist, and certified respiratory therapy 
        technician.''.

SEC. 312. AMENDMENTS TO THE EMPLOYEE RETIREMENT INCOME SECURITY ACT OF 
              1974.

    (a) In General.--The Employee Retirement Income Security Act of 
1974 (29 U.S.C. 1001 et seq.) is amended--
            (1) by redesignating subpart C as subpart D; and
            (2) by inserting after subpart B, the following:

                 ``Subpart B--Protection for Consumers

``SEC. 720. EXEMPTION.

    ``(a) In General.--Upon the application of a group health plan or a 
health insurance issuer offering health insurance coverage, the 
Secretary may exempt such plan or issuer from compliance with 1 or more 
of the requirements of this part.
    ``(b) Requirements.--The Secretary may grant an exemption under 
this section if--
            ``(1) the Secretary--
                    ``(A) publishes a notice of the pendency of such 
                exemption in the Federal Register; and
                    ``(B) provides notice, and an opportunity for 
                comment, of the pendency of such exemption to 
                interested individuals; and
            ``(2) the Secretary determines that the exemption--
                    ``(A) is administratively feasible;
                    ``(B) is in the interests of the group health plan 
                and the participants and beneficiaries under such plan, 
                or in the interests of the health insurance issuer and 
                the participants and beneficiaries involved; and
                    ``(C) is protective of the rights of participants 
                and beneficiaries, as the case may be.
    ``(c) Scope of Exemption.--An exemption provided under this 
section--
            ``(1) shall apply only to those requirements identified by 
        the Secretary in approving the exemption;
            ``(2) may be conditional; and
            ``(3) may be provided to a class of plans or issuers.
    ``(d) Procedures.--The Secretary shall develop procedures to 
provide exemptions under this section.

                   ``CHAPTER 1--CONSUMER INFORMATION

``SEC. 721. HEALTH PLAN COMPARATIVE INFORMATION.

    ``(a) Requirement.--A health insurance issuer in connection with 
group health insurance coverage, shall, not later than 12 months after 
the date of enactment of this part, provide for the disclosure, in a 
clear and accurate form to each plan sponsor, with which the issuer has 
contracted, each participant or beneficiary, or upon request to a 
potential participant or beneficiary or plan sponsor, of the 
information described in subsection (b).
    ``(b) Required Information.--The informational materials to be 
distributed under this section shall include for each plan the 
following:
            ``(1) A description of the covered items and services under 
        each such plan and the in- and out-of-network features of each 
        such plan.
            ``(2) A description of any cost sharing, including 
        premiums, deductibles, coinsurance, and copayment amounts, for 
        which the participant or beneficiary will be responsible, 
        including any annual or lifetime limits on benefits, for each 
        such plan.
            ``(3) A description of any optional supplemental benefits 
        offered by each such plan and the terms and conditions 
        (including premiums or cost-sharing) for such supplemental 
        coverage.
            ``(4) A description of any restrictions on payments for 
        services furnished to a participant or beneficiary by a health 
        care professional that is not a participating professional and 
        the liability of the participant or beneficiary for additional 
        payments for these services.
            ``(5) A description of the service area of each such plan, 
        including the provision of any out-of-area coverage.
            ``(6) A description of the extent to which participants or 
        beneficiaries may select the primary care provider of their 
        choice, including providers both within the network and outside 
        the network of each such plan (if the plan permits out-of-
        network services) as well as procedures for obtaining 
        specialist referral.
            ``(7) A summary of data concerning participant or 
        beneficiary satisfaction with the plan, including disenrollment 
        rates for the previous 2 plan years (excluding disenrollments 
        due to the death of a participant or beneficiary or the 
        participant or beneficiary moving outside of the service area 
        of the plan), based on the health plan's `book-of-business'. 
        Health plans may elect to provide specific information 
        regarding disenrollment rates.
            ``(8) A description of the procedures for advance 
        directives and organ donation decisions.
            ``(9) A description of the requirements and procedures to 
        be used to obtain preauthorization for health services 
        (including telephone numbers and mailing addresses), including 
        referrals for specialty care.
            ``(10) A summary of the rules and methods for appealing 
        coverage decisions and filing grievances (including telephone 
        numbers and mailing addresses), as well as other available 
        remedies.
            ``(11) A summary of the rules for access to emergency room 
        care, including educational material regarding proper use of 
        emergency services.
            ``(12) A description of licensure, certification or 
        accreditation status of the health plan and the name and 
        address of the State or Federal regulatory agency with 
        oversight responsibilities.
            ``(13) A description of whether or not access is provided 
        to experimental treatments, investigational treatments, or 
        clinical trials and the circumstances under which access to 
such treatments or trials is made available.
            ``(14) A description of whether or not access is provided 
        to specialists without referral and the circumstances under 
        which assess to such specialists is provided.
            ``(15) A description of the quality indicators and health 
        outcomes measures of the plan in accordance with subsection 
        (c).
            ``(16) A statement that the following information, and 
        instructions on obtaining such information (including telephone 
        numbers and Internet websites), shall be made available upon 
        request:
                    ``(A) Additional information on the quality of care 
                and health outcomes under the plan.
                    ``(B) The names, credentials, addresses, and 
                telephone numbers and the availability (such as whether 
                professionals accept patients), speciality focus, 
                affiliation arrangements, number and mix of the health 
                care professionals in the network of the plan, and any 
                measures of consumer satisfaction if such satisfaction 
                measures are available.
                    ``(C) The names and locations of participating 
                health care facilities, the accreditation status, the 
                for-profit or not-for-profit status of such facilities, 
                and any measures of consumer satisfaction if such 
                satisfaction measures are available.
                    ``(D) A summary description of the methods used for 
                compensating participating health care professionals 
                (including capitation, financial incentives or bonuses, 
                fee-for-service, group practice, salary and 
                withholdings), including the proportions of 
                participating health care professionals who are 
                compensated under each type of arrangement under the 
                plan.
                    ``(E) A summary description of the procedures used 
                for utilization review, including the process by which 
                specific determinations are made.
                    ``(F) The list of the specific prescription 
                medications included in the formulary of the plan, if 
                the plan uses a defined formulary.
                    ``(G) A description of the specific exclusions from 
                coverage under the plan.
                    ``(H) A description of the specific preventative 
                services covered under the plan.
                    ``(I) A description of the availability of 
                translation or interpretation services for non-English 
                speakers and people with communication disabilities, 
                including the availability of audio tapes or 
                information in Braille.
                    ``(J) A description of the number of external 
                review requests that have been filed with an external 
                review panel designated in accordance with section 
                727(e) and the outcome of such requests by an external 
                review panel in the preceding calendar year.
    ``(c) Determination of Indicators and Measures.--
            ``(1) In general.--The Secretary, in consultation with the 
        Secretary of Health and Human Services, shall develop quality 
        indicators and health outcomes measures for use by health 
        insurance issuers offering group health insurance coverage in 
        providing the information required under section (b), taking 
        into consideration the recommendations of the Health Quality 
        Council established under section 101 of the Health Care 
        Quality, Education, Security, and Trust Act (referred to in 
        this subpart as the `Council'). Such quality indicators and 
        health outcomes measures shall, while taking into consideration 
        the different populations served (such as children and 
        individuals with disabilities), be consistent where appropriate 
        with requirements applicable to Medicare+Choice health plans 
        under title XVIII of the Social Security Act (42 U.S.C. 1395 et 
        seq.).
            ``(2) Different indicators and outcomes measures.--The 
        Secretary of Health and Human Services and the Secretary of 
        Labor may adopt quality indicators or health outcomes measures 
        that are in a different form than the indicators or outcomes 
        measures recommended by the Council under paragraph (1) if--
                    ``(A) the Secretary of Health and Human Services or 
                the Secretary of Labor finds that different indicators 
                or outcomes measures will substantially reduce 
                administrative costs to health care providers and 
                health plans as compared to the alternatives, or that 
                such indicators or measures are demonstrated or proven 
                to be more appropriate for the populations served; and
                    ``(B) the indicators or outcomes measures are 
                adopted in accordance with the rulemaking procedures of 
                subchapter III of chapter 5 of title 5, United States 
                Code.
    ``(d) Manner of Distribution.--
            ``(1) In general.--The information described in this 
        section shall--
                    ``(A) be distributed in an accessible format that 
                is understandable to an average plan participant or 
                beneficiary; and
                    ``(B) with respect to populations of individuals 
                whose primary language is other than English, be 
                provided in the primary language of such population if 
                that population comprises not less than 20 percent of 
                the total population of the geographic area served by 
                the health plan involved.
            ``(2) Rule of construction.--For purposes of this section, 
        a health insurance issuer, in reliance on records maintained by 
        the issuer, shall be deemed to have met the requirements of 
        this section if the issuer provides the information requested 
        under this section to enrollees at the address contained in 
        such records with respect to such enrollees.
    ``(e) Rule of Construction.--Nothing in this section may be 
construed to prohibit a health insurnace issuer offering group health 
insurance coverage from distributing any other information determined 
to be important or necessary in assisting participants or beneficiaries 
or upon request potential participants or beneficiaries in the 
selection of a health plan.

          ``CHAPTER 2--CONSUMER PROTECTION AND PLAN STANDARDS

``SEC. 725. EMERGENCY SERVICES.

    ``(a) Access to Services.--A group health plan or a health 
insurance issuer offering group health insurance coverage who provides 
coverage for emergency service shall ensure that emergency services are 
available and accessible 24 hours a day and 7 days a week.
    ``(b) Payment for Services.--A group health plan or a health 
insurance issuer offering group health insurance coverage described in 
subsection (a), shall cover emergency services furnished under the plan 
or coverage--
            ``(1) in a manner so that, if such services are provided to 
        a participant or beneficiary by a non-participating health care 
        provider--
                    ``(A) the participant or beneficiary shall not be 
                liable for amounts paid for such services in excess of 
                the amount that would have been paid if the services 
                were provided by a participating health care provider; 
                and
                    ``(B) the plan or issuer shall pay an amount for 
                such services that is not less than the amount that 
                would be paid to a participating health care provider 
                for the same services; and
            ``(2) without regard to any other term or condition of such 
        plan or coverage (other than exclusion or coordination of 
        benefits, or an affiliation or waiting period permitted under 
        section 701, and other than applicable cost-sharing 
        requirements).
    ``(c) Prior Authorization.--A group health plan or a health 
insurance issuer offering group health insurance coverage described in 
subsection (a) shall provide coverage for emergency services without 
regard to prior authorization or the emergency care provider's 
contractual relationship with the plan involved.
    ``(d) Guidelines Respecting Coordination of Post-Stabilization 
Care.--
            ``(1) In general.--A group health plan or a health 
        insurance issuer offering group health insurance coverage shall 
        comply with guidelines established by the Secretary of Health 
        and Human Services (with respect to health insurance issuers) 
        and the Secretary of Labor (with respect to group health plans) 
        relating to promoting efficient and timely coordination of 
        appropriate maintenance and post-stabilization care of a 
        participant or beneficiary after the participant or beneficiary 
        has been determined to be stable (as defined for purposes of 
        section 1867 of the Social Security Act).
            ``(2) Guidelines.--The guidelines established by the 
        Secretary of Health and Human Services and the Secretary of 
        Labor under paragraph (1) shall be the guidelines adopted with 
        respect to appropriate maintenance and post-stabilization care 
        for Medicare+Choice plans under part C of title XVIII of the 
        Social Security Act.
    ``(e) Definitions.--In this section:
            ``(1) Emergency services.--The term `emergency services' 
        means, with respect to a participant or beneficiary in a health 
        plan, covered inpatient and outpatient services that are needed 
        to evaluate or stabilize an emergency medical condition (as 
        defined in paragraph (2)).
            ``(2) Emergency medical condition.--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 immediate medical attention to result in--
                    ``(A) placing the health of the individual (or, 
                with respect to a pregnant woman, the health of the 
                woman or her unborn child) in serious jeopardy;
                    ``(B) serious impairment to bodily functions; or
                    ``(C) serious dysfunction of any bodily organ or 
                part.
            ``(2) Post-stabilization care.--The term `post-
        stabilization care' means, with respect to an individual who is 
        determined to be stable under section 1867 of the Social 
        Security Act pursuant to a medical screening examination or who 
        is stabilized after provision of emergency services, medically 
        necessary items and services (other than emergency services and 
        other than maintenance care) that are required by the 
        individual.

``SEC. 726. ADVANCE DIRECTIVES AND ORGAN DONATION.

    ``A group health plan or health insurance issuer offering group 
health insurance coverage shall maintain written policies and 
procedures with respect to advance directives (as such term is defined 
in section 1866(f)(3) of the Social Security Act (42 U.S.C. 
1395cc(f)(3))) and organ donation decisions on the part of a 
participant or beneficiary. Nothing in the preceding sentence shall be 
construed to require the provision of information regarding assisted 
suicide, euthanasia, or mercy killing.

``SEC. 727. COVERAGE DETERMINATION, GRIEVANCES AND APPEALS.

    ``(a) Coverage Determinations.--
            ``(1) In general.--A group health plan or a health 
        insurance issuer offering group health insurance coverage shall 
        ensure that procedures are in place for--
                    ``(A) making determinations regarding whether a 
                participant or beneficiary is eligible to receive a 
                payment or coverage for health service under the plan 
                or coverage involved and the amount (if any) that the 
                participant or beneficiary is required to pay with 
                respect to such service;
                    ``(B) notifying participant or beneficiary (or 
                individuals acting on behalf of such participants or 
                beneficiaries) and health care professionals providing 
                the service involved regarding determinations made by 
                the plan or issuer and any additional payments that the 
                participant or beneficiary may be required to make with 
                respect to such service; and
                    ``(C) responding to either written or oral requests 
                for coverage determinations from a participant or 
                beneficiary (or an individual acting on behalf of a 
                participant or beneficiary) or a treating health care 
                professional.
            ``(2) Routine determination.--
                    ``(A) In general.--A group health plan or a health 
                insurance issuer offering group health insurance 
                coverage shall ensure that prior authorization 
                determinations concerning the provision of non-
                emergency items or services are made within 15 days of 
                the date on which the plan or issuer receives a request 
                for such a determination.
                    ``(B) Incomplete information.--If a determination 
                cannot be made under subparagraph (A) within the 15 day 
                period referred to in such subparagraph, because of the 
                incomplete nature of the medical or coverage 
                information involved, the plan or issuer shall provide 
                a written notification of such fact to the participant 
                or beneficiary (or individual acting on behalf of the 
                participant or beneficiary) and the treating health 
                care professional.
                    ``(C) Submission of additional information.--Upon 
                receipt of a notification under subparagraph (B), a 
                participant or beneficiary (or individual acting on 
                behalf of a participant or beneficiary) or the treating 
                health care professional shall submit the additional 
                information required within the 30-day period beginning 
                on the date on which such notification is received.
                    ``(D) Determination.--A group health plan or health 
                insurance issuer offering group health insurance 
                coverage shall make a determination under this 
                paragraph within 2 working days of the date on which 
                complete information is obtained.
            ``(3) Expedited determination.--
                    ``(A) In general.--A prior authorization 
                determination under this subsection shall be made 
                within 72 hours after a request is received by the plan 
                or issuer if the request indicates that the treating 
                health care professional (regardless of whether the 
                professional is affiliated with the plan or issuer 
                involved) certifies that a determination under the 
                procedures described in paragraph (2) could seriously 
                jeopardize the life or health of the participant 
or beneficiary or the ability of the participant or beneficiary to 
regain maximum function.
                    ``(B) Information.--In an expedited review under 
                this paragraph, all necessary information shall be 
                transmitted between the plan or issuer and the 
                participant or beneficiary (or individual acting on 
                behalf of the participant or beneficiary) and the 
                treating health care professional by the most 
                expeditious method available.
                    ``(C) Notice.--Notice of a determination under an 
                expedited review shall be provided to the participant 
                or beneficiary (or individual acting on behalf of the 
                participant or beneficiary) and the treating health 
                care professional within the 72-hour period referred to 
                in subparagraph (A) by the most expedient method 
                available. Written confirmation of such determination 
                shall be provided to the participant or beneficiary (or 
                individual) or treating health care professional within 
                2 working days of the initial notice.
            ``(4) Notice of determinations.--
                    ``(A) Approval.--With respect to the routine 
                determination of a plan or issuer under paragraph (2) 
                to certify an admission, procedure or service, with 
                respect to a participant or beneficiary, the plan or 
                issuer shall provide notice of such determination to 
                the treating health care professional involved within 
                24 hours of making such determination. A written or 
                electronic confirmation of such determination shall be 
                made to such professional and participant or 
                beneficiary (or individual acting on behalf of the 
                participant or beneficiary) within 2 working days of 
                the date on which the initial notice was provided.
                    ``(B) Adverse determinations.--With respect to a 
                routine adverse determination by a plan or issuer under 
                paragraph (2), the plan or issuer shall provide notice 
                of such determination to the treating health care 
                professional within 24 hours of making the 
                determination. A written or electronic confirmation of 
                such determination shall be made to such professional, 
                and a written notice of such determination shall be 
                made to the participant or beneficiary involved (or 
                individual acting on behalf of an individual), within 1 
                working day of the date on which the initial notice was 
                provided.
                    ``(C) Concurrent reviews.--With respect to the 
                determination of a plan or issuer under paragraph (1) 
                to certify or deny an extended stay or additional 
                services, the plan or issuer shall provide notice of 
                such determination to the health care provider 
                rendering the service involved within 1 working day of 
                making such determination. A written or electronic 
                confirmation of such determination shall be made to 
                such professional and to the participant or beneficiary 
                involved (or individual acting on behalf of the 
                participant or beneficiary) within 1 working day of the 
                date on which the initial notice was provided.
                    ``(D) Retrospective reviews.--With respect to the 
                retrospective review by a plan or issuer of a 
                determination made under paragraph (1), a determination 
                shall be made within 30 working days of the date on 
                which the plan or issuer receives all necessary 
                information. The plan or issuer shall provide written 
                notice of an approval or disapproval of a determination 
                under this subparagraph to the participant or 
                beneficiary (or individual acting on behalf of the 
                participant or beneficiary) and health care provider 
                involved within 5 working days of the date on which 
                such determination is made.
                    ``(E) Requirement of notice.--A written or 
                electronic notice of an adverse determination under 
                subparagraph (B), (C) or (D), or of an expedited 
                adverse determination under paragraph (3), shall be 
                provided to the participant or beneficiary (or 
                individual acting on behalf of the participant or 
                beneficiary) and health care provider (if any) involved 
                and shall include--
                            ``(i) the reasons for the determination 
                        (including the clinical rationale) written in a 
                        manner to be understandable (to the extent 
                        possible) to the average participant or 
                        beneficiary;
                            ``(ii) the procedures for obtaining 
                        additional information concerning the 
                        determination; and
                            ``(iii) notification of the right to appeal 
                        the determination and instructions on how to 
                        initiate an appeal in accordance with 
                        subsection (d)(2).
            ``(5) Definition.--As used in this section, the term 
        `adverse determination' with respect to a group health plan or 
        health insurance coverage means a determination to deny, reduce 
        or terminate services, deny payment for services, or any 
        decision to deny coverage based on a lack of medical necessity, 
        under the terms and conditions of such plan or coverage.
    ``(b) Notice for Other Determinations.--A group health plan or a 
health insurance issuer offering group health insurance coverage shall 
provide written notice to a participant or beneficiary (or individual 
acting on behalf of a participant or beneficiary) and a health care 
professional involved of a determination by the plan or issuer to deny, 
reduce or terminate services or deny payment for services. Such 
notification shall include a brief explanation (written in a manner to 
be understood by an average participant or beneficiary) of the reasons 
for the determination, procedures for obtaining additional information, 
and procedures for appealing the determination.
    ``(c) Grievances.--A group health plan or a health insurance issuer 
offering group health insurance coverage shall have written procedures 
for addressing grievances between the plan and participants or 
beneficiaries, including grievances relating to waiting periods, 
operating hours, the demeanor of personnel, and the adequacy of 
facilities. Determinations under such procedures shall be non-
appealable.
    ``(d) Internal Appeal of Coverage Determinations.--
            ``(1) In general.--A participant or beneficiary (or an 
        individual acting on behalf of a participant or beneficiary) 
        and the treating health care professional with the consent of 
        the participant or beneficiary (or an individual acting on 
        behalf of an individual or beneficiary), may appeal (orally or 
        in writing) any adverse determination under subsection (a) or 
        (b) under the procedures described in this subsection.
            ``(2) Appeal.--A group health plan and a health insurance 
        issuer offering group health insurance coverage shall establish 
        and maintain an internal appeal process under which any 
        participant or beneficiary (or an individual acting on behalf 
        of any participant or beneficiary) or the treating health care 
        professional with the consent of the participant or beneficiary 
        (or an individual acting on behalf of the participant or 
        beneficiary), who is dissatisfied with any adverse 
        determination has the opportunity to discuss and appeal (either 
        orally or in writing) that decision.
            ``(3) Records.--A group health plan and a health insurance 
        issuer offering group health insurance coverage shall maintain 
        written records with respect to any appeal under this 
        subsection for purposes of internal quality assurance and 
        improvement.
            ``(4) Written request.--With respect to an oral request 
        under paragraph (1), a group health plan or a health insurance 
        issuer offering group health insurance coverage may require 
        that the requesting individual provide written evidence of such 
        request for record keeping purposes. A request for written 
        evidence under the preceding sentence shall not be used by a 
        group health plan or health insurance issuer to delay the 
        initiation of the appeals process under this subsection pending 
        the receipt of such evidence.
            ``(5) Routine determinations.--Except as provided for in 
        paragraph (6), a group health plan or a health insurance issuer 
        offering group health insurance coverage shall provide for the 
        consideration of an appeal of an adverse determination under 
        this subsection not later than 30 days after the date on which 
        a request for such appeal is received.
            ``(6) Expedited determination.--A determination with 
        respect to an appeal under this subsection shall, upon the 
        written or oral request of any participant or beneficiary (or 
        an individual acting on behalf of the participant or 
        beneficiary) or the treating health care professional, be made 
        within 72 hours after the request for such appeal is received 
        by the plan or issuer if the request indicates that the 
        treating health care professional (regardless of whether the 
        professional is affiliated with the plan or issuer involved) 
        certifies that a determination under the procedures described 
        in paragraph (5) could seriously jeopardize the life or health 
        of the participant or beneficiary or the ability of the 
        participant or beneficiary to regain maximum function.
            ``(7) Conduct of review.--A review of a determination under 
        this subsection shall be conducted by health care professionals 
        who are knowledgeable about the participant's or beneficiary's 
        condition and the treatment or service involved, including 
        physicians and other trained health care professionals. Such 
        review shall not be conducted by an individual who was involved 
        in the initial decision.
            ``(8) Lack of medical necessity.--An appeal under this 
        subsection relating to a determination to deny coverage based 
        on a lack of medical necessity or appropriateness shall be made 
        only by a physician with appropriate expertise in the field of 
        medicine involved who is not involved in the initial 
        determination.
            ``(9) Notice.--
                    ``(A) In general.--Written notice--
                            ``(i) of a determination made under 
                        paragraph (6) shall be provided to the 
                        participant or beneficiary (or individual 
                        acting on behalf of the participant or 
                        beneficiary) and the treating health care 
                        professional within the 72-hour period referred 
                        to in such paragraph in the most expeditious 
                        manner possible; and
                            ``(ii) of a determination under paragraph 
                        (5), shall be provided to the participant or 
                        beneficiary (or individual acting on behalf of 
                        the participant or beneficiary) and the 
                        treating health care professional in writing 
                        within 2 working days after the completion of 
                        the review referred to in such paragraph.
                    ``(B) Adverse determinations.--With respect to an 
                adverse determination made under paragraph (5) or (6), 
                the notice described in subparagraph (A) shall include 
                written information on how the determination may be 
                appealed to an external entity under subsection (e).
    ``(e) External Review.--
            ``(1) In general.--A group health plan or a health 
        insurance issuer offering group health insurance coverage shall 
        have written procedures to permit a participant or beneficiary 
        (or an individual acting on behalf of a participant or 
        beneficiary) or the treating health care professional with the 
        consent of the participant or beneficiary (or individual), the 
        right to an external appeal of an adverse determination if such 
        determination involves treatments or services covered by the 
        terms and condition of the plan that cost at least $1,000.
            ``(2) Eligibility for designation as external review 
        panel.--
                    ``(A) Designation.--The appropriate State agent 
                shall designate individuals who are eligible to serve 
                on, or entities eligible to act as, an external review 
                panel to review external appeals brought under this 
                subsection.
                    ``(B) Requirements.--In designating individuals or 
                entities under subparagraph (A), the State agent shall 
                ensure that the individual or entity is licensed or 
certified to conduct external reviews by--
                            ``(i) the State agent, in accordance with 
                        licensing and certification procedures to be 
                        developed by the State in consultation with the 
                        National Association of Insurance 
                        Commissioners; or
                            ``(ii) in the case of a State that--
                                    ``(I) has not established such 
                                licensing and certification procedures 
                                within 24 months of the date of 
                                enactment of this subpart, the State in 
                                accordance with procedures to be 
                                developed by the Secretary; or
                                    ``(II) refuses to designate such 
                                panels, the Secretary.
                    ``(C) Liability.--An individual designated to an 
                external review panel under this subsection shall not 
                be held liable for any decision made by such panel.
            ``(3) Initiation of the external review process.--
                    ``(A) Filing of request.--A participant or 
                beneficiary (or individual acting on behalf of a 
                participant or beneficiary) or the treating health care 
                professional with the consent of the participant or 
                beneficiary (or individual) who desires to have an 
                external review conducted under this subsection shall 
                file a written request for such a review with the plan 
                or issuer involved and the appropriate State agent not 
                later than 30 days after the receipt of a final denial 
                of a claim under subsection (d). Any such request shall 
                include the consent of the participant or beneficiary 
                for the release of confidential medical information 
                regarding the participant or beneficiary if such 
                information is necessary for the proper conduct of the 
                external review.
                    ``(B) Information and notice.--Not later than 5 
                working days after the receipt of a request under 
                subparagraph (A), the plan or issuer involved shall--
                            ``(i) forward all necessary information 
                        (including medical records, any relevant review 
                        criteria, the clinical rationale for the 
                        denial, and evidence of the participant's or 
                        beneficiary's coverage) to the appropriate 
                        State agent (or the designee of such agent); 
                        and
                            ``(ii) send a written notification to the 
                        participant or beneficiary (or individual 
                        acting on behalf of the participant or 
                        beneficiary), the treating health care 
                        professional, and the plan administrator, 
                        indicating that an external review has been 
                        initiated.
                    ``(C) Appointment of panel.--Not later than 30 days 
                after the information and notification are provided 
                under subsection (b)--
                            ``(i) the State agent, in the case of a 
                        plan or issuer involved that is fully insured, 
                        shall appoint an external review panel from 
                        among the individuals and entities eligible 
                        under paragraph (2);
                            ``(ii) the plan fiduciary, in the case of a 
                        plan or issuer involved that is self-insured, 
                        shall appoint an external review panel from 
                        among the individuals and entities eligible 
                        under paragraph (2); or
                            ``(iii) the State agent, in the case of a 
                        group health plan where the plan sponsor 
                        directly provided health care under such plan.
                    ``(D) Requirements.--A review panel appointed under 
                subparagraph (C) shall--
                            ``(i) consist of at least 3 physicians or 
                        other health care professionals who are experts 
                        in the treatment of the participant's or 
                        beneficiary's condition and knowledgeable about 
                        the recommended treatment; or
                            ``(ii) be an impartial review entity 
                        including a medical peer review organization or 
                        an independent utilization review company.
                    ``(E) Approval of participant or beneficiary.--Not 
                later than 15 days after the date on which an external 
                review panel is designated under this paragraph, the 
                participant or beneficiary involved shall, in writing--
                            ``(i) approve such panel; or
                            ``(ii) object to such panel and select 
                        alternative individuals or entities who are 
                        eligible under paragraph (2) to serve on such 
                        panel.
                Individuals or entities approved or selected under this 
                subparagraph shall serve as the external review panel 
                under this subsection with respect to the participant 
                or beneficiary involved.
                    ``(F) Conflict of interest.--An external review 
                panel designated under this paragraph shall not have 
                any material, professional, familial, or financial 
                affiliation with the health plan, health insurance 
                issuer or the participant or beneficiary involved, or 
                any officer, director, or management employee of the 
                plan, issuer, physician, medical group, or association 
                recommending the treatment, the institution where the 
                treatment would take place, or the manufacturer of any 
                drug, device, procedure, or other therapy proposed for 
                the participant or beneficiary whose treatment is under 
                review.
            ``(4) Standard of review.--An external review panel 
        designated under paragraph (3) shall--
                    ``(A) complete a review of an adverse determination 
                not later than 30 days after the later of--
                            ``(i) the date on which such panel is 
                        approved under paragraph (4)(E); or
                            ``(ii) the date on which all information 
                        necessary to completing such review is 
                        received;
                    ``(B) take into consideration the benefits and 
                coverage provided under the terms and conditions of the 
                plan involved;
                    ``(C) follow a standard of review that promotes 
                evidence-based decision making; and
                    ``(D) submit a report on the final determinations 
                of the panel to--
                            ``(i) the plan or issuer involved;
                            ``(ii) the participant or beneficiary 
                        involved (or individual acting on behalf of the 
                        participant or beneficiary);
                            ``(iii) the health care professional 
                        involved; and
                            ``(iv) the State agent responsible for 
                        designating review panels under paragraph (2).
            ``(5) Filing fee.--A State may impose a filing fee to be 
        applied to a participant or beneficiary initiating an external 
        review under this subsection. If a State elects to impose such 
        a filing fee, the State must include a procedure to provide for 
        a fee reduction if the participant or beneficiary demonstrates 
        financial hardship through status or evidence of participation 
        in a State or Federal cash assistance program.
            ``(6) Payment for external review.--A group health plan or 
        health insurance issuer offering group health insurance 
        coverage shall be financially responsible for any reasonable 
        costs associated with the conduct of an external review under 
        this subsection.
            ``(7) Annual reporting.--The appropriate State agent shall 
        conduct annual reviews of the number of external reviews 
        requested under this subsection and the outcomes of such 
        reviews. A report concerning such annual reviews shall be made 
        public and forwarded to the Secretary of Health and Human 
        Services (with respect to health insurance issuers) and the 
        Secretary of Labor (with respect to reports on group health 
        plans). Such reports shall breakdown the results by relevance 
        to group health plans and health insurance issuers.
            ``(8) Audits.--Not later than 2 years after the date of 
        enactment of this subpart, the General Accounting Office shall 
        conduct a review of all licensed, certified, or appointed 
        review panels under paragraph (3). Such review shall include an 
        assessment of the process involved during an external review 
        and the basis of decisionmaking by the board or panel.
            ``(9) Rule of construction.--The determination of an 
        external review panel shall be binding on the plan or issuer 
        involved, except that nothing in this subsection shall be 
        construed to preclude the right of a group health plan, health 
        insurance issuer, or a participant or beneficiary from 
        commencing a civil action based on the plan or coverage 
        involved.
    ``(f) Prior Authorization Determination.--For purposes of this 
section. the term `prior authorization determination' means, with 
respect to items and services for which coverage may be provided under 
a health plan, 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 covered 
under the coverage.

``SEC. 728. CONFIDENTIALITY AND ACCURACY OF PARTICIPANTS AND 
              BENEFICIARIES RECORDS.

    ``A group health plan or a health insurance issuer offering group 
health insurance coverage shall establish procedures with respect to 
medical records or other health information maintained regarding 
participants or beneficiaries to safeguard the privacy of any 
individually identifiable participant or beneficiary information.

           ``CHAPTER 3--HEALTH CARE PROFESSIONAL PROTECTIONS

``SEC. 730. HEALTH CARE PROFESSIONAL COMMUNICATIONS.

    ``(a) Provision of Information to Professionals.--
            ``(1) Health insurance issuers.--A health insurance issuer 
        offering group health insurance coverage shall establish 
        procedures concerning the participation of health care 
        professionals under coverage provided by the issuer under which 
        such professionals will be provided with written notice of--
                    ``(A) the rules of the issuer concerning 
                participation;
                    ``(B) any participation decisions that are adverse 
                to health care professionals; and
                    ``(C) the process of the issuer for appealing such 
                adverse decisions, including the presentation of 
                information and the views of the health care 
                professional regarding such decision.
            ``(2) Group health plans.--A group health plan shall ensure 
        that the organization that is responsible for maintaining the 
        provider network involved under the plan provides health care 
        professionals with the information described in paragraph (1).
            ``(3) Rule of construction.--Nothing in this subsection 
        shall be construed to in any way effect a provision in a 
        contract between a plan or issuer and a health care 
        professional that permits either party to the contract to 
        terminate the employment or participation of the professional 
        under the plan or issuer without cause.
    ``(b) Communications.--
            ``(1) In general.--An organization on behalf of a group 
        health plan (as described in subsection (a)(2)) or a health 
        insurance issuer offering group health insurance coverage shall 
        not penalize (financially or otherwise) a health care 
        professional for advocating on behalf of his or her patient or 
        for providing information or referral for medical care (as 
        defined in section 733(a)(2)) consistent with the health care 
        needs of the patient and with the code of ethical conduct, 
        professional responsibility, conscience, medical knowledge, and 
        license of the health care professional.
            ``(2) Construction.--Nothing in paragraph (1) shall be 
        construed as requiring a health insurance issuer offering group 
        health insurance coverage or a group health plan to pay for 
        medical care not otherwise paid for or covered by the plan 
        provided by nonparticipating health care professionals, except 
        in those instances and to the extent that the issuer or plan 
        would normally pay for such medical care.
            ``(3) Assistance and support.--A group health plan or a 
        health insurance issuer offering group health insurance 
        coverage shall not prohibit or otherwise restrict a health care 
        professional from providing letters of support to, or in any 
        way assisting, participants or beneficiaries who are appealing 
        a denial, termination, or reduction of service in accordance 
        with the procedures under section 727.''.
    (b) Conforming Amendments.--
            (1) Section 732(a) of the Employee Retirement Income 
        Security Act of 1974 (29 U.S.C. 1185(a)) is amended by striking 
        ``section 711, and inserting ``section 711 and subpart C''.
            (2) The table of contents in section 1 of the Employee 
        Retirement Income Security Act of 1974 (29 U.S.C. 1001) is 
        amended--
                    (A) in the item relating to subpart C, by striking 
                ``Subpart C'' and inserting ``Subpart D''; and
                    (B) by inserting after the item relating to section 
                712, the following:

                 ``Subpart B--Protection for Consumers

        ``Sec. 720. Exemption.
                   ``Chapter 1--Consumer Information

        ``Sec. 721. Health plan comparative information.
          ``Chapter 2--Consumer Protection and Plan Standards

        ``Sec. 725. Emergency services.
        ``Sec. 726. Advance directives and organ donation.
        ``Sec. 727. Coverage determination, grievances and appeals.
        ``Sec. 728. Confidentiality and accuracy of participants and 
                            beneficiaries records.
           ``Chapter 3--Health Care Professional Protections

        ``Sec. 730. Health care professional communications.''.
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