[Congressional Bills 106th Congress]
[From the U.S. Government Publishing Office]
[H.R. 2089 Introduced in House (IH)]







106th CONGRESS
  1st Session
                                H. R. 2089

To amend title I of the Employee Retirement Income Security Act of 1974 
 to provide new procedures and access to review for grievances arising 
                       under group health plans.


_______________________________________________________________________


                    IN THE HOUSE OF REPRESENTATIVES

                              June 9, 1999

 Mr. Boehner introduced the following bill; which was referred to the 
                Committee on Education and the Workforce

_______________________________________________________________________

                                 A BILL


 
To amend title I of the Employee Retirement Income Security Act of 1974 
 to provide new procedures and access to review for grievances arising 
                       under group health plans.

    Be it enacted by the Senate and House of Representatives of the 
United States of America in Congress assembled,

SECTION 1. SHORT TITLE.

    This Act may be cited as the ``Group Health Plan Review Standards 
Act of 1999''.

SEC. 2. SPECIAL RULES FOR GROUP HEALTH PLANS.

    (a) In General.--Section 503 of the Employee Retirement Income 
Security Act of 1974 (29 U.S.C. 1133) is amended--
            (1) by inserting ``(a) In General.--'' after ``Sec. 503.'';
            (2) by inserting ``(other than a group health plan)'' after 
        ``employee benefit plan''; and
            (3) by adding at the end the following new subsection:
    ``(b) Special Rules for Group Health Plans.--
            ``(1) Coverage determinations.--Every group health plan 
        shall--
                    ``(A) provide adequate notice in writing in 
                accordance with this subsection to any participant or 
                beneficiary of any adverse coverage decision with 
                respect to benefits of such participant or beneficiary 
                under the plan, setting forth the specific reasons for 
                such coverage decision and any rights of review 
                provided under the plan, written in a manner calculated 
                to be understood by the average participant;
                    ``(B) provide such notice in writing also to any 
                treating medical care provider of such participant or 
                beneficiary, if such provider has claimed reimbursement 
                for any item or service involved in such coverage 
                decision, or if a claim submitted by the provider 
                initiated the proceedings leading to such decision;
                    ``(C) afford a reasonable opportunity to any 
                participant or beneficiary who is in receipt of the 
                notice of such adverse coverage decision, and who files 
                a written request for review of the initial coverage 
                decision within 90 days after receipt of the notice of 
                the initial decision, for a full and fair review of the 
                decision by an appropriate named fiduciary who did not 
                make the initial decision; and
                    ``(D) meet the additional requirements of this 
                subsection.
            ``(2) Time limits for making initial coverage decisions for 
        benefits and completing internal appeals.--
                    ``(A) Time limits for deciding requests for benefit 
                payments, requests for advance determination of 
                coverage, and requests for required determination of 
                medical necessity.--Except as provided in subparagraph 
                (B)--
                            ``(i) Initial decisions.--If a request for 
                        benefit payments, a request for advance 
                        determination of coverage, or a request for 
                        required determination of medical necessity is 
                        submitted to a group health plan in such 
                        reasonable form as may be required under the 
                        plan, the plan shall issue in writing an 
                        initial coverage decision on the request before 
                        the end of the initial decision period under 
                        paragraph (10)(I) following the filing 
                        completion date. Failure to issue a coverage 
                        decision on such a request before the end of 
                        the period required under this clause shall be 
                        treated as an adverse coverage decision for 
                        purposes of internal review under clause (ii).
                            ``(ii) Internal reviews of initial 
                        denials.--Upon the written request of a 
                        participant or beneficiary for review of an 
                        initial adverse coverage decision under clause 
                        (i), a review by an appropriate named fiduciary 
                        (subject to paragraph (3)) of the initial 
                        coverage decision shall be completed, including 
                        issuance by the plan of a written decision 
                        affirming, reversing, or modifying the initial 
                        coverage decision, setting forth the grounds 
                        for such decision, before the end of the 
internal review period following the review filing date. Such decision 
shall be treated as the final decision of the plan, subject to any 
applicable reconsideration under paragraph (4). Failure to issue before 
the end of such period such a written decision requested under this 
clause shall be treated as a final decision affirming the initial 
coverage decision.
                    ``(B) Time limits for making coverage decisions 
                relating to accelerated need medical care and for 
                completing internal appeals.--
                            ``(i) Initial decisions.--A group health 
                        plan shall issue in writing an initial coverage 
                        decision on any request for expedited advance 
                        determination of coverage or for expedited 
                        required determination of medical necessity 
                        submitted, in such reasonable form as may be 
                        required under the plan before the end of the 
                        accelerated need decision period under 
                        paragraph (10)(K), in cases involving 
                        accelerated need medical care, following the 
                        filing completion date. Failure to approve or 
                        deny such a request before the end of the 
                        applicable decision period shall be treated as 
                        a denial of the request for purposes of 
                        internal review under clause (ii).
                            ``(ii) Internal reviews of initial 
                        denials.--Upon the written request of a 
                        participant or beneficiary for review of an 
                        initial adverse coverage decision under clause 
                        (i), a review by an appropriate named fiduciary 
                        (subject to paragraph (3)) of the initial 
                        coverage decision shall be completed, including 
                        issuance by the plan of a written decision 
                        affirming, reversing, or modifying the initial 
                        converge decision, setting forth the grounds 
                        for the decision before the end of the 
                        accelerated need decision period under 
                        paragraph (10)(K) following the review filing 
                        date. Such decision shall be treated as the 
                        final decision of the plan, subject to any 
                        applicable reconsideration under paragraph (4). 
                        Failure to issue before the end of the 
                        applicable decision period such a written 
                        decision requested under this clause shall be 
                        treated as a final decision affirming the 
                        initial coverage decision.
            ``(3) Medical professionals must review initial coverage 
        decisions involving medical appropriateness or necessity or 
        investigational items or experimental treatment or 
        technology.--If an initial coverage decision under paragraph 
        (2)(A)(i) or (2)(B)(i) is based on a determination that 
        provision of a particular item or service is excluded from 
        coverage under the terms of the plan because the provision of 
        such item or service does not meet the plan's requirements for 
        medical appropriateness or necessity or would constitute 
        investigational items or experimental treatment or technology, 
        the review under paragraph (2)(A)(ii) or (2)(B)(ii), to the 
        extent that it relates to medical appropriateness or necessity 
        or to investigational items or experimental treatment or 
        technology, shall be conducted by a physician or, if 
        appropriate, another medical professional, who is selected by 
        the plan and who did not make the initial denial.
            ``(4) Elective external review by independent medical 
        expert and reconsideration of initial review decision.--
                    ``(A) In general.--In any case in which a 
                participant or beneficiary, who has received an adverse 
                coverage decision which is not reversed upon review 
                conducted pursuant to paragraph (1)(C) (including 
                review under paragraph (2)(A)(ii) or (2)(B)(ii)) and 
                who has not commenced review of the coverage decision 
                under section 502, makes a request in writing, within 
                30 days after the date of such review decision, for 
                reconsideration of such review decision, the 
                requirements of subparagraphs (B), (C), (D) and (E) 
                shall apply in the case of such adverse coverage 
                decision, if the requirements of clause (i), (ii), or 
                (iii) are met.
                            ``(i) Medical appropriateness or 
                        investigational item or experimental treatment 
                        or technology.--The requirements of this clause 
                        are met if such coverage decision is based on a 
                        determination that provision of a particular 
                        item or service that would otherwise be covered 
                        under the terms of the plan is excluded from 
                        coverage under the terms of the plan because 
                        the provision of such item or service--
                                    ``(I) does not meet the plan's 
                                requirements for medical 
                                appropriateness or necessity; or
                                    ``(II) would constitute an 
                                investigational item or experimental 
                                treatment or technology.
                            ``(ii) Categorical exclusion of item or 
                        service requiring evaluation of medical facts 
                        or evidence.--The requirements of this clause 
                        are met if--
                                    ``(I) such coverage decision is 
                                based on a determination that a 
                                particular item or service is not 
                                covered under the terms of the plan 
                                because provision of such item or 
                                service is categorically excluded from 
                                coverage under the terms of the plan, 
                                and
                                    ``(II) an independent contract 
                                expert finds under subparagraph (C), in 
                                advance of any review of the decision 
                                under subparagraph (D), that such 
                                determination primarily requires the 
                                evaluation of medical facts or medical 
                                evidence by a health professional.
                            ``(iii) Specific exclusion of item or 
                        service requiring evaluation of medical facts 
                        or evidence.--The requirements of this clause 
                        are met if--
                                    ``(I) such coverage decision is 
                                based on a determination that a 
                                particular item or service is not 
                                covered under the terms of the plan 
                                because provision of such item or 
                                service is specifically excluded from 
                                coverage under the terms of the plan, 
                                and
                                    ``(II) an independent contract 
                                expert finds under subparagraph (C), in 
                                advance of any review of the decision 
                                under subparagraph (D), that such 
                                determination primarily requires the 
                                evaluation of medical facts or medical 
                                evidence by a health professional.
                            ``(iv) Matters specifically not subject to 
                        review.--The requirements of subparagraphs (B), 
                        (C), (D), and (E) shall not apply in the case 
                        of any adverse coverage decision if such 
                        decision is based on--
                                    ``(I) a determination of 
                                eligibility for benefits,
                                    ``(II) the application of explicit 
                                plan limits on the number, cost, or 
                                duration of any benefit, or
                                    ``(III) a limitation on the amount 
                                of any benefit payment or a requirement 
                                to make copayments under the terms of 
                                the plan.
                Review under this paragraph shall not be available for 
                any coverage decision that has previously undergone 
                review under this paragraph.
                    ``(B) Limits on allowable advance payments.--The 
                review under this paragraph in connection with an 
                adverse coverage decision shall be available subject to 
                any requirement of the plan (unless waived by the plan 
                for financial or other reasons) for payment in advance 
                to the plan by the participant or beneficiary seeking 
                review of an amount not to exceed the greater of (i) 
                the lesser of $100 or 10 percent of the cost of the 
                medical care involved in the decision, or (ii) $25, 
                with such dollar amount subject to compounded annual 
                adjustments in the same manner and to the same extent 
                as apply under section 215(i) of the Social Security 
                Act, except that, for any calendar year, such amount as 
                so adjusted shall be deemed, solely for such calendar 
                year, to be equal to such amount rounded to the nearest 
                $10. No such payment may be required in the case of any 
                participant or beneficiary whose enrollment under the 
                plan is paid for, in whole or in part, under a State 
                plan under title XIX or XXI of the Social Security Act. 
                Any such advance payment shall be subject to 
                reimbursement if the recommendation of the independent 
                medical expert or experts under subparagraph (D)(iii) 
                is to reverse or modify the coverage decision.
                    ``(C) Request to independent contract experts for 
                determination of whether coverage decision required 
                evaluation of medical facts or evidence.--
                            ``(i) In general.--In the case of a request 
                        for review made by a participant or beneficiary 
                        as described in subparagraph (A), if the 
                        requirements of clause (ii) or (iii) of 
                        subparagraph (A) are met (and review is not 
                        otherwise precluded under subparagraph 
                        (A)(iv)), the terms of the plan shall provide 
                        for a procedure for initial review by an 
                        independent contract expert selected by the 
                        plan under which the expert will determine 
                        whether the coverage decision requires the 
                        evaluation of medical facts or evidence by a 
                        health professional. If the expert determines 
                        that the coverage decision requires such 
                        evaluation, reconsideration of such adverse 
                        decision shall proceed under this paragraph. If 
                        the expert determines that the coverage 
                        decision does not require such evaluation, the 
                        adverse decision shall remain the final 
                        decision of the plan.
                            ``(ii) Independent contract experts.--For 
                        purposes of this subparagraph, the term 
                        `independent contract expert' means a 
                        professional--
                                    ``(I) who has appropriate 
                                credentials and has attained recognized 
                                expertise in the applicable area of 
                                contract interpretation;
                                    ``(II) who was not involved in the 
                                initial decision or any earlier review 
                                thereof; and
                                    ``(III) who is selected in 
                                accordance with subparagraph (G)(i) and 
                                meets the requirements of subparagraph 
                                (G)(ii).
                    ``(D) Reconsideration of initial review decision.--
                            ``(i) In general.--In the case of a request 
                        for review made by a participant or beneficiary 
                        as described in subparagraph (A), if the 
                        requirements of subparagraph (A)(i) are met or 
                        reconsideration proceeds under this paragraph 
                        pursuant to subparagraph (C), the terms of the 
                        plan shall provide for a procedure for such 
                        reconsideration in accordance with clause (ii).
                            ``(ii) Procedure for reconsideration.--The 
                        procedure required under clause (i) shall 
                        include the following--
                                    ``(I) One or more independent 
                                medical experts will be selected in 
                                accordance with subparagraph (F) to 
                                reconsider any coverage decision 
                                described in subparagraph (A) to 
                                determine whether such decision was in 
                                accordance with the terms of the plan 
                                and this title.
                                    ``(II) The record for review 
                                (including a specification of the terms 
                                of the plan and other criteria serving 
                                as the basis for the initial review 
                                decision) will be presented to such 
                                expert or experts and maintained in a 
                                manner which will ensure 
                                confidentiality of such record.
                                    ``(III) Such expert or experts will 
                                reconsider the initial review decision 
                                to determine whether such decision was 
                                in accordance with the terms of the 
                                plan and this title. Such 
                                reconsideration shall include the 
                                initial decision of the plan, the 
                                medical condition of the patient, and 
                                the recommendations of the treating 
                                physician. The experts shall take into 
                                account in the course of such 
                                reconsideration any guidelines adopted 
                                by the plan through a process involving 
                                medical practitioners and peer-reviewed 
                                medical literature identified as such 
                                under criteria established by the Food 
                                and Drug Administration.
                                    ``(IV) Such expert or experts will 
                                issue a written decision affirming, 
                                modifying, or reversing the initial 
                                review decision, setting forth the 
                                grounds for the decision.
                    ``(E) Time limits for reconsideration.--Any review 
                under this paragraph (including any review under 
                subparagraph (C)) shall be completed before the end of 
                the reconsideration period (as defined in paragraph 
                (10)(L)) following the review filing date in connection 
                with such review. The decision under this paragraph 
                affirming, reversing, or modifying the initial review 
                decision of the plan shall be the final decision of the 
                plan. Failure to issue a written decision before the 
                end of the reconsideration period in any 
                reconsideration requested under this paragraph shall be 
                treated as a final decision affirming the initial 
                review decision of the plan.
                    ``(F) Independent medical experts.--
                            ``(i) In general.--For purposes of this 
                        paragraph, the term `independent medical 
                        expert' means, in connection with any coverage 
                        decision by a group health plan, a 
                        professional--
                                    ``(I) who is a physician or, if 
                                appropriate, another medical 
                                professional;
                                    ``(II) who has appropriate 
                                credentials and has attained recognized 
                                expertise in the applicable medical 
                                field;
                                    ``(III) who was not involved in the 
                                initial decision or any earlier review 
                                thereof;
                                    ``(IV) who has not history of 
                                disciplinary action or sanctions 
                                (including, but not limited to, loss of 
                                staff privileges or participation 
                                restriction) taken or pending by any 
                                hospital, health carrier, government, 
                                or regulatory body; and
                                    ``(V) who is selected in accordance 
                                with subparagraph (G)(i) and meets the 
                                requirements of subparagraph (G)(ii).
                    ``(G) Selection of experts.--
                            ``(i) In general.--An independent contract 
                        expert or independent medical expert is 
                        selected in accordance with this clause if--
                                    ``(I) the expert is selected by an 
                                intermediary which itself meets the 
                                requirements of clause (ii), by means 
                                of a method which ensures that the 
                                identity of the expert is not disclosed 
                                to the plan, any health insurance 
                                issuer offering health insurance 
                                coverage to the aggrieved participant 
                                or beneficiary in connection with the 
                                plan, and the aggrieved participant or 
                                beneficiary under the plan, and the 
                                identities of the plan, the issuer, and 
                                the aggrieved participant or 
                                beneficiary are not disclosed to the 
                                expert; or
                                    ``(II) the expert is selected, by 
                                an intermediary or otherwise, in a 
                                manner that is, under regulations 
                                issued pursuant to negotiated 
                                rulemaking, sufficient to ensure the 
expert's independence, including selection by the plan in cases where 
it is determined that a suitable intermediary is not reasonably 
available,
                        and the method of selection is devised to 
                        reasonably ensure that the expert selected 
                        meets the independence requirements of clause 
                        (ii).
                            ``(ii) Independence requirements.--An 
                        independent contract expert or independent 
                        medical expert or another entity described in 
                        clause (i) meets the independence requirements 
                        of this clause if--
                                    ``(I) the expert or entity is not 
                                affiliated with any related party;
                                    ``(II) any compensation received by 
                                such expert or entity in connection 
                                with the external review is reasonable 
                                and not contingent on any decision 
                                rendered by the expert or entity;
                                    ``(III) under the terms of the plan 
                                and any health insurance coverage 
                                offered in connection with the plan, 
                                the plan and the issuer (if any) have 
                                no recourse against the expert or 
                                entity in connection with the external 
                                review; and
                                    ``(IV) the expert or entity does 
                                not otherwise have a conflict of 
                                interest with a related party as 
                                determined under any regulations which 
                                the Secretary may prescribe.
                            ``(iii) Related party.--For purposes of 
                        clause (i)(I), the term `related party' means--
                                    ``(I) the plan or any health 
                                insurance issuer offering health 
                                insurance coverage in connection with 
                                the plan (or any officer, director, or 
                                management employee of such plan or 
                                issuer);
                                    ``(II) the physician or other 
                                medical care provider that provided the 
                                medical care involved in the coverage 
                                decision;
                                    ``(III) the institution at which 
                                the medical care involved in the 
                                coverage decision is provided;
                                    ``(IV) the manufacturer of any drug 
                                or other item that was included in the 
                                medical care involved in the coverage 
                                decision; or
                                    ``(V) any other party determined 
                                under any regulations which the 
                                Secretary may prescribe to have a 
                                substantial interest in the coverage 
                                decision.
                            ``(iv) Affiliated.--For purposes of clause 
                        (ii)(I), the term `affiliated' means, in 
                        connection with any entity, having a familial, 
                        financial, or professional relationship with, 
                        or interest in, such entity.
                    ``(H) Misbehavior by experts.--Any action by the 
                expert or experts in applying for their selection under 
                this paragraph or in the course of carrying out their 
                duties under this paragraph which constitutes--
                            ``(i) fraud or intentional 
                        misrepresentation by such expert or experts, or
                            ``(ii) demonstrates failure to adhere to 
                        the standards for selection set forth in 
                        subparagraph (G)(ii),
                shall be treated as a failure to meet the requirements 
                of this paragraph and therefore as a cause of action 
                which may be brought by a fiduciary under section 
                502(a)(3).
            ``(5) Permitted alternatives to required internal review.--
                    ``(A) In general.--In accordance with such 
                regulations (if any) as may be prescribed by the 
                Secretary for purposes of this paragraph, in the case 
                of any initial coverage decision for benefits under 
                paragraph (2)(A)(ii) or (2)(B)(ii), a group health plan 
                may provide an alternative dispute resolution procedure 
                meeting the requirements of subparagraph (B) for use in 
                lieu of the procedures set forth under the preceding 
                provisions of this subsection relating review of such 
                decision. Such procedure may be provided in one form 
                for all participants and beneficiaries or in a 
                different form each group of similarly situated 
                participants and beneficiaries.
                    ``(B) Requirements.--An alternative dispute 
                resolution procedure meets the requirements of this 
                subparagraph, in connection with any initial coverage 
                decision, if--
                            ``(i) such procedure is utilized solely--
                                    ``(I) accordance with the 
                                applicable terms of a bona fide 
                                collective bargaining agreement 
                                pursuant to which the plan (or the 
                                applicable portion thereof governed by 
                                the agreement) is established or 
                                maintained, or
                                    ``(II) upon election by all parties 
                                to such decision,
                            ``(ii) the procedure incorporates time 
                        limits not exceeding the time limits otherwise 
                        applicable under paragraphs (2)(A)(ii) and 
                        (2)(B)(ii);
                            ``(iii) the procedure incorporates any 
                        otherwise applicable requirement for review by 
                        a physician under paragraph (3), unless waived 
                        by the participant or beneficiary (in a manner 
                        consistent with such regulations as the 
                        Secretary may prescribe to ensure equitable 
                        procedures); and
                            ``(iv) the means of resolution of dispute 
                        allow for adequate presentation by each party 
                        of scientific and medical evidence supporting 
                        the position of such party.
                    ``(C) Waivers.--In any case in which utilization of 
                the alternative dispute resolution procedure is 
                voluntarily elected by all parties in connection with a 
                coverage decision, the plan may require or allow under 
                such procedure (in a manner consistent with such 
                regulations as the Secretary may prescribe to ensure 
                equitable procedures) any party to waive review of the 
                coverage decision under paragraph (3), to waive further 
                review of the coverage decision under paragraph (4) or 
                section 502, and to elect an alternative means of 
                external review (other than review under paragraph 
                (4)).
            ``(6) Permitted alternatives to required external review.--
        A group health plan shall not be treated as failing to meet the 
        requirements of this subsection in connection with review of 
        coverage decisions under paragraph (4) if the aggrieved 
        participant or beneficiary elects to utilize a procedure in 
        connection with such review which is made generally available 
        under the plan (in a manner consistent with such regulations as 
        the Secretary may prescribe to ensure equitable procedures) 
        under which--
                    ``(A) the plan agrees in advance of the 
                recommendations of the independent medical expert or 
                experts under paragraph (4)(C)(iii) to render a final 
                decision in accordance with such recommendations; and
                    ``(B) the participant or beneficiary waives in 
                advance any right to review of the final decision under 
                section 502.
            ``(7) Review requirements.--In any review of a decision 
        issued under this subsection--
                    ``(A) the record below shall be maintained for 
                purposes of review in accordance with standards which 
                shall be prescribed in regulations of the Secretary 
                designed to facilitate such review, and
                    ``(B) any decision upon review which modifies or 
                reverses a decision below shall specifically set forth 
                a determination that the record upon review is 
                sufficient to rebut a presumption in favor of the 
                decision below.
            ``(8) Compliance with fiduciary standards.--The issuance of 
        a decision under a plan upon review in good faith compliance 
        with the requirements of this subsection shall not be treated 
        as a violation of part 4.
            ``(9) Group health plan defined.--For purposes of this 
        section--
                    ``(A) In general.--The term `group health plan' 
                shall have the meaning provided in section 733(a).
                    ``(B) Treatment of partnerships.--The provisions of 
                paragraphs (1), (2), and (3) of section 732(d) shall 
                apply.
            ``(10) Other definitions.--For purposes of this 
        subsection--
                    ``(A) Request for benefit payments.--The term 
                `request for benefit payments' means a request, for 
                payment of benefits by a group health plan for medical 
                care, which is made by, or (if expressly authorized) on 
                behalf of, a participant or beneficiary after such 
                medical care has been provided.
                    ``(B) Required determination of medical 
                necessity.--The term `required determination of medical 
                necessity' means a determination required under a group 
                health plan solely that proposed medical care meets, 
                under the facts and circumstances at the time of the 
                determination, the plan's requirements for medical 
                appropriateness or necessity (which may be subject to 
                exceptions under the plan for fraud or 
                misrepresentation), irrespective of whether the 
                proposed medical care otherwise meets other terms and 
                conditions of coverage, but only if such determination 
                does not constitute an advance determination of 
                coverage (as defined in subparagraph (C)).
                    ``(C) Advance determination of coverage.--The term 
                `advance determination of coverage' means a 
                determination under a group health plan that proposed 
                medical care meets, under the facts and circumstances 
                at the time of the determination, the plan's terms and 
                conditions of coverage (which may be subject to 
                exceptions under the plan for fraud or 
                misrepresentation).
                    ``(D) Request for advance determination of 
                coverage.--The term `request for advance determination 
                of coverage' means a request for an advance 
                determination of coverage of medical care which is made 
                by, or (if expressly authorized) on behalf of, a 
                participant or beneficiary before such medical care is 
                provided.
                    ``(E) Request for expedited advance determination 
                of coverage.--The term `request for expedited advance 
                determination of coverage' means a request for advance 
                determination of coverage, in any case in which the 
                proposed medical care constitutes accelerated need 
                medical care.
                    ``(F) Request for required determination of medical 
                necessity.--The term `request for required 
                determination of medical necessity' means a request for 
                a required determination of medical necessity for 
                medical care which is made by or on behalf of a 
                participant or beneficiary before the medical care is 
                provided.
                    ``(G) Request for expedited required determination 
                of medical necessity.--The term `request for expedited 
                required determination of medical necessity' means a 
                request for required determination of medical necessity 
                in any case in which the proposed medical care 
                constitutes accelerated need medical care.
                    ``(H) Accelerated need medical care.--The term 
                `accelerated need medical care' means medical care in 
                any case in which an appropriate physician has 
                certified in writing (or as otherwise provided in 
                regulations of the Secretary) that the participant or 
beneficiary is stabilized and--
                            ``(i) that failure to immediately provide 
                        the care to the participant or beneficiary 
                        could reasonably be expected to result in--
                                    ``(I) placing the health of such 
                                participant or beneficiary (or, with 
                                respect to such a participant or 
                                beneficiary who is 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; or
                            ``(ii) that immediate provision of the care 
                        is necessary because the participant or 
                        beneficiary has made or is at serious risk of 
                        making an attempt to harm himself or herself or 
                        another individual.
                    ``(I) Initial decision period.--The term `initial 
                decision period' means a period of 30 days, or such 
                longer period as may be prescribed in regulations of 
                the Secretary.
                    ``(J) Internal review period.--The term `internal 
                review period' means a period of 30 days, or such 
                longer period as may be prescribed in regulations of 
                the Secretary.
                    ``(K) Accelerated need decision period.--The term 
                `accelerated need decision period' means a period of 5 
                days, or such longer period as may be prescribed in 
                regulations of the Secretary.
                    ``(L) Reconsideration period.--The term 
                `reconsideration period' means a period of 25 days, or 
                such longer period as may be prescribed in regulations 
                of the Secretary, except that--
                            ``(i) in the case of a decision involving 
                        urgent medical care, such term means the urgent 
                        decision period; and
                            ``(ii) in the case of a decision involving 
                        accelerated need medical care, such term means 
                        the accelerated need decision period.
                    ``(M) Filing completion date.--The term `filing 
                completion date' means, in connection with a group 
                health plan, the date as of which the plan is in 
                receipt of all information reasonably required (in 
                writing or in such other reasonable form as may be 
                specified by the plan) to make an initial coverage 
                decision.
                    ``(N) Review filing date.--The term `review filing 
                date' means, in connection with a group health plan, 
                the date as of which the appropriate named fiduciary 
                (or the independent medical expert or experts in the 
                case of a review under paragraph (4)) is in receipt of 
                all information reasonably required (in writing or in 
                such other reasonable form as may be specified by the 
                plan) to make a decision to affirm, modify, or reverse 
                a coverage decision.
                    ``(O) Medical care.--The term `medical care' has 
                the meaning provided such term by section 733(a)(2).
                    ``(P) Health insurance coverage.--The term `health 
                insurance coverage' has the meaning provided such term 
                by section 733(b)(1).
                    ``(Q) Health insurance issuer.--The term `health 
                insurance issuer' has the meaning provided such term by 
                section 733(b)(2).
                    ``(R) Written or in writing.--
                            ``(i) In general.--A request or decision 
                        shall be deemed to be `written' or `in writing' 
if such request or decision is presented in a generally recognized 
printable or electronic format. The Secretary may by regulation provide 
for presentation of information otherwise required to be in written 
form in such other forms as may be appropriate under the circumstances.
                            ``(ii) Medical appropriateness or 
                        investigational items or experimental treatment 
                        determinations.--For purposes of this 
                        subparagraph, in the case of a request for 
                        advance determination of coverage, a request 
                        for expedited advance determination of 
                        coverage, a request for required determination 
                        of medical necessity, or a request for 
                        expedited required determination of medical 
                        necessity, if the decision on such request is 
                        conveyed to the provider of medical care or to 
                        the participant or beneficiary by means of 
                        telephonic or other electronic communications, 
                        such decision shall be treated as a written 
                        decision.''.

SEC. 3. CLARIFICATION OF ERISA PREEMPTION RULES.

    (a) In General.--Section 514 of the Employee Retirement Income 
Security Act of 1974 (29 U.S.C. 1144) is amended--
            (1) by redesignating subsection (d) as subsection (e); and
            (2) by inserting after subsection (c) the following new 
        subsection:
    ``(d) The procedures and remedies required or provided under 
sections 502 and 503 in connection with--
            ``(1) review of claims for benefits under employee benefit 
        plans and for review of decisions denying such claims 
        (including review of coverage decisions referred to in section 
        503(b) and decisions upon review of such coverage decisions), 
        and
            ``(2) causes of action brought to recover plan benefits, to 
        enforce rights under the terms of the plan or this title, or to 
        clarify rights to future benefits under the terms of the plan 
        or this title,
are the exclusive procedures and remedies with respect to any such 
review or cause of action and supersede any provision of State law 
providing for any such review or cause of action.''.
    (b) Conforming Amendment.--Section 514(b)(2)(A) of such Act (42 
U.S.C. 1144(b)(2)(A)) is amended by inserting ``or subsection (d)'' 
after ``subparagraph (B)''.

SEC. 4. EFFECTIVE DATE.

    (a) In General.--The amendments made by this Act shall apply with 
respect to grievances arising in plan years beginning on or after 
January 1 of the second calendar year following 12 months after the 
date the Secretary of Labor issues all regulations necessary to carry 
out amendments made by this Act.
    (b) Limitation on Enforcement Actions.--No enforcement action shall 
be taken, pursuant to the amendments made by this Act, against a group 
health plan or health insurance issuer with respect to a violation of a 
requirement imposed by such amendments before the date of issuance of 
final regulations issued in connection with such requirement, if the 
plan or issuer has sought to comply in good faith with such 
requirement.
    (c) Collective Bargaining Agreements.--Any plan amendment made 
pursuant to a collective bargaining agreement relating to the plan 
which amends the plan solely to conform to any requirement added by 
this Act shall not be treated as a termination of such collective 
bargaining agreement.
                                 <all>