[Congressional Bills 106th Congress]
[From the U.S. Government Publishing Office]
[H.R. 216 Introduced in House (IH)]







106th CONGRESS
  1st Session
                                H. R. 216

  To amend the Public Health Service Act and the Employee Retirement 
Income Security Act of 1974 to protect consumers in managed care plans 
    and preserve against preemption certain State causes of action.


_______________________________________________________________________


                    IN THE HOUSE OF REPRESENTATIVES

                            January 6, 1999

 Mr. Norwood introduced the following bill; which was referred to the 
 Committee on Commerce, and in addition to the Committee on Education 
 and the Workforce, for a period to be subsequently determined by the 
  Speaker, in each case for consideration of such provisions as fall 
           within the jurisdiction of the committee concerned

_______________________________________________________________________

                                 A BILL


 
  To amend the Public Health Service Act and the Employee Retirement 
Income Security Act of 1974 to protect consumers in managed care plans 
    and preserve against preemption certain State causes of action.

    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 ``Access to Quality 
Care Act of 1999''.
    (b) Table of Contents.--The table of contents of this Act is as 
follows:

Sec. 1. Short title; table of contents.
                    TITLE I--ACCESS TO QUALITY CARE

 Subtitle A--Promoting Quality Care by Ensuring Access to Health Care 
                             Professionals

Sec. 101. Consumer choice option.
Sec. 102. Choice of health professionals and providers.
Sec. 103. Access to care.
Sec. 104. Exclusions.
 Subtitle B--Promoting Quality Care by Ensuring Access to Health Care 
                               Services.

Sec. 111. Access to specialists.
Sec. 112. Continuity of care.
Sec. 113. Access to emergency room care.
Sec. 114. Patient access to obstetric and gynecological care.
Sec. 115. Patient access to pediatric care.
Sec. 116. Exclusions.
   Subtitle C--Promoting Quality Care by Ensuring Fair Resolution of 
                              Grievances.

Sec. 121. Utilization review standards.
Sec. 122. Internal and external review procedures.
       Subtitle D--Promoting Quality Care by Ensuring Fair Plan 
                            Administration.

Sec. 131. Restrictions on incentive plans.
Sec. 132. Development of issuer policies.
Sec. 133. Patient access to information.
Sec. 134. Protection of patient confidentiality.
Sec. 135. Due process for health professionals and providers.
Sec. 136. Prohibition of interference with certain medical 
                            communications.
Sec. 137. Plan solvency.
Sec. 138. Quality assessment program.
                        Subtitle E--Definitions

Sec. 151. Definitions.
Sec. 152. Preemption; State flexibility; construction.
Sec. 153. Regulations.
 TITLE II--APPLICATION OF QUALITY CARE STANDARDS TO GROUP HEALTH PLANS 
     AND HEALTH INSURANCE COVERAGE UNDER PUBLIC HEALTH SERVICE ACT

Sec. 201. Application to group health plans and group health insurance 
                            coverage.
Sec. 202. Application to individual health insurance coverage.
TITLE III--AMENDMENTS TO THE EMPLOYEE RETIREMENT INCOME SECURITY ACT OF 
                                  1974

Sec. 301. Application of patient protection standards to group health 
                            plans and group health insurance coverage 
                            under the Employee Retirement Income 
                            Security Act of 1974.
Sec. 302. ERISA preemption not to apply to certain actions involving 
                            health insurance policyholders.
       TITLE IV--EFFECTIVE DATES; COORDINATION IN IMPLEMENTATION

Sec. 401. Effective dates.
Sec. 402. Coordination in implementation.

                    TITLE I--ACCESS TO QUALITY CARE

 Subtitle A--Promoting Quality Care by Ensuring Access to Health Care 
                             Professionals

SEC. 101. CONSUMER CHOICE OPTION.

    (a) In General.--If a health insurance issuer offers to enrollees 
health insurance coverage which provides for coverage of services only 
if such services are furnished through health professionals and 
providers who are members of a network of health professionals and 
providers who have entered into a contract with the issuer to provide 
such services, the issuer shall also offer to such enrollees (at the 
time of enrollment) the option of health insurance coverage which 
provides for coverage of such services which are not furnished through 
health professionals and providers who are members of such a network 
unless enrollees are offered such non-network coverage through another 
health insurance issuer.
    (b) Fair Premiums.--The amount of any additional premium required 
for the additional cost of the option described in subsection (a) may 
not exceed an amount that is fair and reasonable, as established by the 
applicable State authority, in consultation with the National 
Association of Insurance Commissioners, based on the nature of the 
additional coverage provided.
    (c) Additional Costs.--The amount of any additional premium charged 
by the health insurance issuer for the additional cost of the creation 
and maintenance of the option described in subsection (a) shall be 
borne by the enrollee unless it is paid by the health plan sponsor 
through agreement with the health insurance issuer.
    (d) Open Season.--An enrollee may only change to the offering 
provided under this section only during a time period determined by the 
health insurance issuer. Such time period shall occur at least 
annually.
    (e) Cost Sharing.--Under the option described in subsection (a), 
the health insurance coverage shall provide for reimbursement rates for 
covered services offered by health professionals and providers who are 
not participating health professionals or providers that are not less 
than the reimbursement rates for covered services offered by 
participating health professionals and providers. Nothing in this 
section shall be construed as protecting an enrollee against balance 
billing by a health professional or provider that is not a 
participating health professional or provider.

SEC. 102. CHOICE OF HEALTH PROFESSIONALS AND PROVIDERS.

    (a) Choice of Personal Health Professional.--A group health plan, 
and a health insurance issuer that offers health insurance coverage, 
shall permit each participant, beneficiary, and enrollee to--
            (1) select a personal health professional from among the 
        participating health professionals of the issuer, and
            (2) change such selection--
                    (A) in the event of a disciplinary complaint 
                against the provider; or
                    (B) at least once every 4 months.

SEC. 103. ACCESS TO CARE.

    (a) In General.--A group health plan, and a health insurance issuer 
that offers health insurance coverage shall establish and maintain 
adequate arrangements, as defined by the applicable State authority, 
with a sufficient number, mix, and distribution of health professionals 
and providers to assure that covered items and services are available 
and accessible to each participant, beneficiary, and enrollee under 
health insurance coverage--
            (1) in the service area of the issuer;
            (2) in a variety of sites of service;
            (3) with reasonable promptness (including reasonable hours 
        of operation and after hours services);
            (4) with reasonable proximity to the residences or 
        workplaces of enrollees; and
            (5) in a manner that--
                    (A) takes into account the diverse needs of 
                enrollees, and
                    (B) reasonably assures continuity of care.
        A group health plan, and a health insurance issuer that offers 
        health insurance coverage that serves a rural or medically 
        underserved area shall be treated as meeting the requirement of 
        this subsection if the plan or issuer has arrangements with a 
        sufficient number, mix, and distribution of health 
        professionals and providers having a history of serving such 
        areas. The use of telemedicine and other innovative means to 
        provide covered items and services by a group health plan, and 
        a health insurance issuer that offers health insurance coverage 
        that serves a rural or medically under served area shall also 
        be considered in determining whether the requirement of this 
        subsection is met.
    (b) Rule of Construction.--Nothing in this subsection shall be 
construed as requiring a group health plan, and a health insurance 
issuer that offers health insurance coverage--
            (1) to have arrangements that conflict with its 
        responsibilities to establish measures designed to maintain 
        quality and control costs; or
            (2) to build or establish health care facilities to meet 
        the requirements of this sub section.
    (c) Definitions.--For purposes of this section:
            (1) Medically underserved area.--The term medically 
        underserved area means an area that is designated as a health 
        professional shortage area under section 332 of the Public 
        Health Service Act or as a medically underserved area for 
        purposes of section 330 or 1302(7) of such Act.
            (2) Rural area.--The term rural area means an area that is 
        not within a Standard Metropolitan Statistical Area or a New 
        England County Metropolitan Area (as defined by the Office of 
        Management and Budget).
    (d) Implementation.--The Secretary shall submit to Congress not 
later than January 1, 2000, a report detailing regulations and a plan 
for implementation of the details of this section. Such regulations and 
plan for implementation shall not proceed without the concurrence by 
joint resolution or Act of the Congress.

SEC. 104. EXCLUSIONS.

    Nothing in this subtitle shall be construed--
            (1) to require a group health plan, and a health insurance 
        issuer offering health insurance coverage--
                    (A) to provide particular benefits other than those 
                provided under the terms of such coverage; or
                    (B) to comply with this subtitle with respect to 
                abortion services or euthanasia services, even if the 
                issuer covers such services;
            (2) as forbidding a plan or issuer from offering (or 
        requiring a plan or issuer to offer) abortion or euthanasia 
        services; or
            (3) as applying to a fee-for-service plan.

 Subtitle B--Promoting Quality Care by Ensuring Access to Health Care 
                                Services

SEC. 111. ACCESS TO SPECIALISTS.

    (a) In General.--A group health plan, and a health insurance issuer 
that offers health insurance coverage that provides benefits, in whole 
or in part, through participating health care providers shall 
demonstrate that participants, beneficiaries, and enrollees have access 
to a specialist when treatment by such specialist is medically or 
clinically indicated in the professional judgment of the treating 
health professional, in consultation with the participant, beneficiary, 
or enrollee.
    (b) Definition.--For purposes of subsection (a), the term 
``specialist'' means a health professional or provider (including a 
specialty institution) that, through training or experience, has 
developed the expertise necessary to treat individuals with special 
health care needs or a chronic condition or disease.

SEC. 112. CONTINUITY OF CARE.

    A group health plan, and a health insurance issuer offer health 
insurance coverage that provides benefits, in whole or in part, through 
participating health care professionals shall--
            (1) ensure that any process established by the issuer to 
        coordinate care and control costs does not create an undue 
        burden, as defined by the applicable State authority, for 
        participants, beneficiaries, and enrollees with special health 
        care needs or chronic conditions;
            (2) ensure direct access to relevant specialists for the 
        continued care of participants, beneficiaries, and enrollees 
        when medically or clinically indicated in the judgment of the 
        treating health professional, in consultation with the 
        participant, beneficiary, or enrollee;
            (3) in the case of a participant, beneficiary, or enrollee 
        with special health care needs or a chronic condition, 
        determine whether, based on the judgment of the treating health 
        professional, in consultation with the participant, 
        beneficiary, or enrollee, it is medically or clinically 
        necessary to use a specialist or a care coordinator from an 
        interdisciplinary team to ensure continuity of care; and
            (4) in circumstances under which a change of health 
        professional or provider might disrupt the continuity of care 
        for a participant, beneficiary, or enrollee, provide for 
        continued coverage of items and services furnished by the 
        health professional or provider that was treating the 
        participant, beneficiary, or enrollee before such change for a 
        reasonable period of time.
A change of health professional or provider may be due to changes in 
the membership of an issuer's health professional and provider network, 
changes in the health coverage made available by an employer, or other 
similar circumstances.

SEC. 113. ACCESS TO EMERGENCY ROOM CARE.

    (a) Emergency Care.--
            (1) In general.--If a group health plan, or a health 
        insurance issuer offering health insurance coverage provides 
        any benefits with respect to emergency services (as defined in 
        subsection (b)(2)), the plan or issuer shall cover emergency 
        services furnished under the plan or coverage--
                    (A) without the need for any prior authorization 
                determination;
                    (B) whether or not the health care professional or 
                provider furnishing such services is a participating 
                professional or provider with respect to such services;
                    (C) in a manner so that, if such services are 
                provided to a participant, beneficiary, or enrollee by 
                a non-participating health care professional or 
                provider, the participant, beneficiary, or enrollee is 
                not liable for an amount that exceeds the amount of 
                financial liability that would be incurred if the 
                services were provided by a participating health care 
                professional or provider; and
                    (D) 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 of the Public 
                Health Service Act, section 701 of the Employee 
                Retirement Income Security Act of 1974, and other than 
                applicable through cost-sharing).
    (b) Definitions.--For purposes of this section:
            (1) Emergency medical condition.--The term ``emergency 
        medical condition'' means a medical condition (including 
        emergency labor and delivery) manifesting itself by acute 
        symptoms of sufficient severity (including, but not limited to, 
        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 condition described in clause (i), (ii), or (iii) of section 
        1867(e)(1)(A) of the Social Security Act.
            (2) Emergency services.--The term ``emergency services'' 
        means--
                    (A) a medical screening examination (as required 
                under section 1867 of the Social Security Act) that is 
                within the capabilities of the emergency department of 
                a hospital, including ancillary services routinely 
                available to the emergency department to evaluate an 
                emergency medical condition (as defined in paragraph 
                (1)), and
                    (B) within the capabilities of the staff and 
                facilities available at the hospital, such further 
                medical examination and treatment as required under 
                section 1867 of such Act to stabilize the patient.
            (3) Stabilize.--The term ``to stabilize'' means, with 
        respect to an emergency medical condition, to provide such 
        medical treatment of the condition as may be necessary to 
        assure, within reasonable medical probability, that no material 
        deterioration of the condition is likely to result from or 
        occur during the transfer of the individual from a facility.
    (c) Reimbursement for Maintenance Care and Post-Stabilization 
Care.--In the case of services (other than emergency services) for 
which benefits are available under a group health plan or health 
insurance issuer offering health insurance coverage, the plan or issuer 
shall provide for reimbursement with respect to such services provided 
to a participant, beneficiary, or enrollee other than through a 
participating health care professional or provider in a manner 
consistent with subsection (a)(1)(C) if the services are maintenance 
care or post-stabilization care covered under the guidelines 
established under section 1852(d)(2) of the Social Security Act 
(relating to promoting efficient and timely coordination of appropriate 
maintenance and post-stabilization care of an enrollee after an 
enrollee has been determined to be stable), in accordance with 
regulations established to carry out such section.

SEC. 114. PATIENT ACCESS TO OBSTETRIC AND GYNECOLOGICAL CARE.

    (a) In General.--In any case in which a group health plan or a 
health insurance issuer in connection with the provision of health 
insurance coverage, requires or provides for designation by a 
participant, beneficiary, or enrollee of a participating primary care 
provider, and provides benefits under the terms of the plan consisting 
of--
            (1) routine gynecological care (such as preventive women's 
        health examinations), or
            (2) routine obstetric care (such as routine pregnancy-
        related services), provided by a participating professional who 
        specializes in such care (or provides benefits consisting of 
        payment for such care),
if the primary care provider designated by such a participant, 
beneficiary, or enrollee is not such a professional, then the plan or 
issuer shall meet the requirements of subsection (b).
    (b) Requirements.--A group health plan, or a health insurance 
issuer in connection with the provision of health insurance coverage, 
meets the requirements of this paragraph, in connection with benefits 
described in subsection (a), if the plan or issuer--
            (1) does not require authorization or a referral by the 
        primary care provider in order to obtain such benefits, and
            (2) treats the ordering of other routine care of the same 
        type, by the participating professional providing the care 
        described in subsection (a) as the authorization of the primary 
        care provider with respect to such care.
    (c) Construction.--Nothing in subsection (b) shall waive any 
exclusions of coverage under the terms of the plan with respect to 
coverage of gynecological or obstetric care so ordered.

SEC. 115. PATIENT ACCESS TO PEDIATRIC CARE.

    (a) In General.--In any case in which a group health plan, or a 
health insurance issuer in connection with the provision of health 
insurance coverage, provides benefits consisting of routine pediatric 
care provided by a participating physician who specializes in 
pediatrics (or consisting of payment for such care) and the plan or 
issuer requires or provides for designation by a participant, 
beneficiary, or enrollee of a participating primary care provider, the 
plan or issuer shall provide that such a participating physician may be 
designated, if available, by a parent or guardian of any beneficiary 
under the plan who is under 18 years of age, as the primary care 
provider with respect to any such benefits.
    (b) Construction.--Nothing in subsection (a) shall waive any 
exclusions of coverage under the terms of the plan with respect to 
coverage of pediatric care.

SEC. 116. EXCLUSIONS.

    Nothing in this subtitle shall be construed--
            (1) to require a group health plan, and a health insurance 
        issuer offering health insurance coverage--
                    (A) to provide particular benefits other than those 
                provided under the terms of such coverage; or
                    (B) to comply with this subtitle with respect to 
                abortion services or euthanasia services, even if the 
                issuer covers such services;
            (2) as forbidding a plan or issuer from offering (or 
        requiring a plan or issuer to offer) abortion or euthanasia 
        services; or
            (3) as applying to a fee-for-service plan.

   Subtitle C--Promoting Quality Care by Ensuring Fair Resolution of 
                               Grievances

SEC. 121. UTILIZATION REVIEW STANDARDS.

    The utilization review program of a group health plan, and a health 
insurance issuer that provides health insurance coverage, shall--
            (1) be developed (including any screening criteria used by 
        such program) with the involvement of participating health 
        professionals and providers;
            (2) to the extent consistent with the protection of 
        proprietary business information (as defined for purposes of 
        section 552 of title 5, United States Code) release, upon 
        request, to affected health professionals, providers, and 
        enrollees the screening criteria, weighting elements, and 
        computer algorithms used in reviews and a description of the 
        method by which they were developed;
            (3) uniformly apply review criteria;
            (4) subject to reasonable safeguards, disclose to health 
        professionals and providers and enrollees, upon request, the 
        names and credentials of individuals conducting utilization 
        review;
            (5) not compensate individuals conducting utilization 
        review under a system that provides financial or other 
        incentives or bonuses for denials of payment or coverage of 
        benefits;
            (6) comply with the requirement of section 113 that prior 
        authorization not be required for emergency and related 
        services furnished in a hospital emergency department; and
            (7) provide timely access, as defined by the applicable 
        State authority, to utilization review personnel and, if such 
        personnel are not available, waives any prior authorization 
        that would otherwise be required.

SEC. 122. INTERNAL AND EXTERNAL REVIEW PROCEDURES.

    (a) Coverage Determinations.--A group health plan and a health 
insurance issuer offering health insurance coverage shall--
            (1) provide notice in writing in accordance with this 
        section to any participant or beneficiary in a group health 
        plan, or any enrollee in health insurance coverage offered by a 
        health insurance issuer, of any adverse coverage decision with 
        respect to benefits of such participant, beneficiary, or 
        enrollee, setting forth the specific reasons for such coverage 
        decision and any rights of review, written in a manner 
        calculated to be understood by the participant, beneficiary, or 
        enrollee;
            (2) provide written notice to any treating health care 
        professional of such participant, beneficiary, or enrollee if 
        such professional has claimed reimbursement for any item or 
        service involved in such coverage decision, or if a claim 
        submitted by the professional initiated the proceedings leading 
        to such decision;
            (3) afford an opportunity to any participant, beneficiary, 
        or enrollee who is in receipt of the notice of such adverse 
        coverage decision and who files a written request for review of 
        the initial coverage decision within 180 days after receipt of 
        the notice of the initial decision, for a full and fair de novo 
        review of the decision by a person who did not make the initial 
        decision; and
            (4) meet the additional requirements of this section.
    (b) Time Limits for Making Initial Coverage Decisions for Benefits 
and Completing Internal Appeals.--
            (1) Time limits for deciding requests for benefit payments 
        and requests for advance determination of coverage.--Except as 
        provided in paragraph (2)--
                    (A) Initial decisions.--If a request for benefit 
                payments, or a request for advance determination of 
                coverage is submitted to a group health plan or a 
                health insurance issuer offering health insurance 
                coverage in such form as may be required under the plan 
                or coverage, the plan or issuer shall issue in writing 
                an initial coverage decision on the request not later 
                than 7 days (or such longer period as may be prescribed 
                in regulations of the Secretary) after the date as of 
                which the plan or issuer is in receipt of all 
                information required (in writing or in such other form 
                as may be specified under the plan or coverage) to make 
                an initial coverage decision. Failure to issue a 
                coverage decision on such a request by such deadline 
                shall be treated as an adverse coverage decision for 
                purposes of internal review under subparagraph (B).
                    (B) Internal reviews of initial denials.--Upon the 
                written request of a participant, beneficiary, or 
                enrollee for review of an initial adverse coverage 
                decision under subparagraph (A), a review by an 
                internal appeals entity of the initial coverage 
                decision shall be completed, including issuance by the 
                plan or issuer of a written decision affirming, 
                reversing, or modifying the initial coverage decision, 
                setting forth the grounds for such decision, not later 
                than 14 days (or such longer period as may be 
                prescribed in regulations of the Secretary) after the 
                date as of which the entity is in receipt of all 
                information required (in writing or in such other form 
                as may be specified under the plan or coverage) to make 
                a decision to affirm, modify, or reverse the coverage 
                decision. Such decision shall be treated as the final 
                decision of the plan, subject to any applicable 
                reconsideration. Failure to issue by such deadline such 
                a written decision requested under this subparagraph 
                shall be treated as a final decision affirming the 
                initial coverage decision, subject to any applicable 
                reconsideration.
            (2) Time limits for making coverage decisions relating to 
        urgent health care and for completing internal appeals.--
                    (A) Initial decisions.--A group health plan and a 
                health insurance issuer offering health insurance 
                coverage shall issue in writing an initial coverage 
                decision on any request for expedited advance 
                determination of coverage, in such form as may be 
                required under the plan or coverage, not later than 2 
                days (or such longer period as may be prescribed in 
                regulations of the Secretary) after the date as of 
                which the plan or issuer is in receipt of all 
                information required (in writing or in such other form 
                as may be specified under the plan or coverage) to make 
                an initial coverage decision. Such decision shall be 
                treated as the final decision of the plan or issuer, 
                subject to any applicable reconsideration. Failure to 
                issue before the end of the applicable decision period 
                such a written decision requested under this 
                subparagraph shall be treated as a final decision 
                affirming the initial coverage decision, subject to any 
                applicable reconsideration.
                    (B) Internal reviews of initial denials.--Upon the 
                written request of a participant, beneficiary, or 
                enrollee for review of an initial adverse coverage 
                decision under subparagraph (A), if the case involves 
                urgent health care, a review by an internal review 
                entity of the initial coverage decision shall be 
                completed, including issuance by the plan or issuer of 
                a written decision affirming, reversing, or modifying 
                the initial coverage decision, setting forth the 
                grounds for the decision, not later than 2 days (or 
                such longer period as may be prescribed in regulations 
                of the Secretary) after the date as of which the entity 
                is in receipt of all information required (in writing 
                or in such other form as may be specified under the 
                plan or coverage) to make a decision to affirm, modify, 
                or reverse the coverage decision. Such decision shall 
                be treated as the final decision of the plan or issuer, 
                subject to any applicable reconsideration. Failure to 
                issue before such deadline such a written decision 
                requested under this subparagraph shall be treated as a 
                final decision affirming the initial coverage decision, 
                subject to any applicable reconsideration.
    (c) Requirement for Review of Initial Coverage Decisions by a 
Physician.--If an initial coverage decision is based on a determination 
other than that provision of a particular item or service is excluded 
from coverage under the terms of the plan or coverage, the review shall 
be conducted by a physician who is selected to serve as an internal 
appeals entity under the plan or coverage and who did not make the 
initial denial.
    (d) External Review by Independent Medical Experts and 
Reconsideration of Initial Review Decision.--
            (1) In general.--The requirements of paragraphs (2), (3), 
        and (4) shall apply--
                    (A) in the case of any failure to timely issue a 
                coverage decision upon internal review which is deemed 
                to be an adverse coverage decision (thereby failing to 
                constitute a coverage decision for which specific 
                reasons have been set forth as required), and
                    (B) in the case of any adverse coverage decision 
                not based on a determination that provision of a 
                particular item or service is excluded from coverage 
                under the terms of the plan or coverage because the 
                provision of such item or service is specifically 
                excluded as a benefit of the plan or coverage.
            (2) Reconsideration of initial review decision.--In any 
        case in which a participant, beneficiary, or enrollee who has 
        received an adverse decision of the plan or issuer upon review 
        of the initial coverage decision and who has not commenced 
        review of the initial coverage decision makes a request in 
        writing, within 30 days after the date of such review decision, 
        for reconsideration of such review decision, the terms of the 
        plan or coverage shall provide for a procedure for such 
        reconsideration paid for by the plan or issuer under which--
                    (A) one or more independent medical experts will be 
                selected to review the coverage decision described;
                    (B) the record for review (including a 
                specification of the terms of the plan or coverage and 
                other criteria serving as the basis for the initial 
                review decision) shall be presented to such expert or 
                experts and maintained in a manner which shall ensure 
                confidentiality of such record;
                    (C) such expert or experts will make and report in 
                writing to the plan or issuer a determination as to 
                whether such coverage decision should be affirmed, 
                modified, or reversed, setting forth the grounds 
                (including the clinical basis) for the determination; 
                and
                    (D) the determination of such expert or experts 
                pursuant to subparagraph (C) shall be considered 
                binding on the plan or issuer.
            (3) Time limits for reconsideration.--Any review under this 
        subsection shall be completed not later than 14 days (or, in 
        the case of a decision involving urgent health care, 2 days, or 
        such longer period as may be prescribed in regulations of the 
        Secretary) after the date as of which the independent medical 
        expert or experts involved is in receipt of all information 
        required (in writing or in such other form as may be specified 
        under the plan or coverage) to make a decision to affirm, 
        modify, or reverse the coverage decision. Failure to issue a 
        written decision before such deadline in any reconsideration 
        requested under this subsection shall be treated as a final 
        decision affirming the initial review decision of the plan or 
        issuer.
            (4) Independent medical experts.--
                    (A) In general.--For purposes of this section, the 
                term ``independent medical expert'' means, in 
                connection with any coverage decision by a group health 
                plan or health insurance issuer, a health care 
                professional who--
                            (i) is a physician or, if appropriate, 
                        another health care professional;
                            (ii) has appropriate credentials and has 
                        attained recognized expertise in the applicable 
                        health care field;
                            (iii) was not involved in the initial 
                        decision or any earlier review thereof; and
                            (iv) is selected in accordance with 
                        subparagraph (B).
                    (B) Selection of medical experts.--An independent 
                medical expert is selected in accordance with this 
                subparagraph if--
                            (i) the expert is selected by an 
                        intermediary which itself meets the 
                        requirements of subparagraph (C), by means of a 
                        method which ensures that the identity of the 
                        expert is not disclosed to the plan or issuer, 
                        any health insurance issuer offering health 
                        insurance coverage to the aggrieved 
                        participant, beneficiary, or enrollee in 
                        connection with the plan, and the aggrieved 
                        participant, beneficiary, or enrollee under the 
                        plan, and the identities of the plan, the 
                        issuer, and the aggrieved participant, 
                        beneficiary, or enrollee are not disclosed to 
                        the expert;
                            (ii) the expert is selected, by an 
                        appropriately credentialed panel of health care 
                        professionals meeting the requirements of 
                        subparagraph (C) established by a fully 
                        accredited teaching hospital meeting such 
                        requirements;
                            (iii) the expert is selected by an 
                        organization described in section 1152(1)(A) of 
                        the Social Security Act which meets the 
                        requirements of subparagraph (C);
                            (iv) the expert is selected by an external 
                        review organization which meets the 
                        requirements of subparagraph (C) and is 
                        accredited by a private standard-setting 
                        organization meeting such requirements and 
                        recognized as such by the Secretary; or
                            (v) the expert is selected under 
                        regulations issued pursuant to negotiated 
                        rulemaking, sufficient to ensure the expert's 
                        independence, and the method of selection is 
                        devised to reasonably ensure that the expert 
                        selected meets the independence requirements of 
                        subparagraph (C).
                    (C) Independence requirements.--An independent 
                medical expert or another entity described in 
                subparagraph (B) meets the independence requirements of 
                this subparagraph 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 involved, 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.
                    (D) Related party.--For purposes of this paragraph, 
                the term ``related party'' means--
                            (i) with respect to--
                                    (I) a group health plan or health 
                                insurance coverage offered in 
                                connection with such a plan, the plan 
                                or the health insurance issuer offering 
                                such coverage, or
                                    (II) individual health insurance 
                                coverage, the health insurance issuer 
                                offering such coverage,
                        or any officer, director, or management 
                        employee of such plan or issuer;
                            (ii) the health care professional that 
                        provided the health care involved in the 
                        coverage decision;
                            (iii) the institution at which the health 
                        care involved in the coverage decision is 
                        provided;
                            (iv) the manufacturer of any drug or other 
                        item that was included in the health care 
                        involved in the coverage decision; or
                            (v) any other party determined under any 
                        regulations which the Secretary may prescribe 
                        to have a substantial interest in the coverage 
                        decision.
                    (E) Affiliated.--For purposes of this paragraph, 
                the term ``affiliated'' means, in connection with any 
                entity, having a familial, financial, or professional 
                relationship with, or interest in, such entity.
                    (F) Limitation on liability.--An individual serving 
                on as an independent medical expert or an entity acting 
                as such under this paragraph shall not be held liable 
                for any decision made except in cases of gross 
                negligence, recklessness, or intentional misconduct by 
                such individual or entity.
            (5) Inapplicability with respect to items and services 
        specifically excluded from coverage.--An adverse coverage 
        decision based on a determination that an item or service is 
        excluded from coverage under the terms of a plan or health 
        insurance coverage shall not be subject to review under this 
        section.
    (e) Penalties Against Authorized Officials for Denial of External 
Review.--
            (1) Monetary penalties.--In any case in which review by an 
        independent medical expert or experts of a benefit is denied by 
        a group health plan, or by a health insurance issuer offering 
        health insurance coverage, any person who, acting in the 
        capacity of determining the necessity of such a review, causes 
        such denial may, in the court's discretion, be liable to the 
        aggrieved participant, beneficiary, or enrollee for a civil 
        penalty in an amount of up to $750 a day from the date on which 
        the recommendation was made to the plan or issuer until the 
        date the failure to provide review is corrected, up to a total 
        amount not to exceed $250,000.
            (2) Cease and desist order and order of attorney's fees.--
        In any action described in paragraph (1) brought by a 
        participant, beneficiary, or enrollee with respect to a group 
        health plan, or a health insurance issuer offering health 
        insurance coverage, in which the plaintiff alleges that a 
        person referred to in such paragraph has taken an action 
        resulting in a denial of review by independent medical expert 
        or experts in violation of such terms of the plan, coverage, or 
        this title, or has failed to take an action for which such 
        person is responsible under the plan, coverage, or this title 
        and which is necessary under the plan or coverage for allowing 
        such review, the court shall cause to be served on the 
        defendant an order requiring the defendant--
                    (i) to cease and desist from the alleged action or 
                failure to act; and
                    (ii) to pay to the plaintiff a reasonable 
                attorney's fee and other reasonable costs relating to 
                the prosecution of the action on the charges on which 
                the plaintiff prevails.
            (3) Additional civil penalties.--
                    (A) In general.--In addition to any penalty imposed 
                under paragraph (1) or (2), the appropriate Secretary 
                may assess a civil penalty against a person acting in 
                the capacity of determining the necessity of external 
                review for one or more group health plans, or health 
                insurance issuers offering health insurance coverage, 
                for--
                            (i) any pattern or practice of repeated 
                        denial of review by independent medical expert 
                        or experts in violation of the terms of such a 
                        plan, coverage, or this title; or
                            (ii) any pattern or practice of repeated 
                        violations of the requirements of this section 
                        with respect to such plan or plans or coverage.
                    (B) Standard of proof and amount of penalty.--Such 
                penalty shall be payable only upon proof by clear and 
                convincing evidence of such pattern or practice and 
                shall be in an amount not to exceed the lesser of--
                            (i) 25 percent of the aggregate value of 
                        benefits shown by the appropriate Secretary to 
                        have not been provided, or unlawfully delayed, 
                        in violation of this section under such pattern 
                        or practice, or
                            (ii) $500,000.
            (4) Removal and disqualification.--Any person acting in the 
        capacity of determining the necessity of external review who 
        has engaged in any such pattern or practice described in 
        paragraph (3)(A) with respect to a plan or coverage, upon the 
        petition of the appropriate Secretary, may be removed by the 
        court from that position, and from any other involvement, with 
        respect to such a plan or coverage, and may be precluded from 
        returning to any such position or involvement for a period 
        determined by the court.
    (f) Definitions.--For purposes of this section:
            (1) Advance determination of coverage.--The term ``advance 
        determination of coverage'' means a determination under a group 
        health plan, and a health insurance issuer offering health 
        insurance coverage that proposed health care meets, under the 
        facts and circumstances at the time of the determination, the 
        plan or issuer's terms and conditions of coverage (which may be 
        subject to exceptions under the plan for fraud or 
        misrepresentation).
            (2) Adverse coverage decision.--The term ``adverse coverage 
        decision'' means any request for payment of benefits, 
        determination of coverage, advance determination of coverage, 
        or expedited advance determination of coverage made by a group 
        health plan, or a health insurance issuer offering health 
        insurance coverage, that does not affirm the treatment decision 
        of the treating health care professional.
            (3) Request for advance determination of coverage.--The 
        term ``request for advance determination of coverage'' means a 
        request for an advance determination of coverage of health care 
        which is made by or on behalf of a participant, beneficiary, or 
        enrollee before such health care is provided.
            (4) Request for benefit payments.--The term ``request for 
        benefit payments'' means a request, for payment of benefits by 
        a group health plan, or health insurance issuer offering health 
        insurance coverage for health care, which is made by or on 
        behalf of a participant, beneficiary, or enrollee after such 
        health care has been provided.
            (5) 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 
        health care constitutes urgent health care.
            (6) Urgent health care.--The term ``urgent health care'' 
        means health care in any case in which a physician has 
        certified in writing (or as otherwise provided in regulations 
        of the Secretary) that failure to provide the participant, 
        beneficiary, or enrollee with such health care within 7 days 
        can reasonably be expected to result in either--
                    (A) the imminent death of the participant, 
                beneficiary, or enrollee; or
                    (B) the immediate, serious, and irreversible 
                deterioration of the health of the participant or 
                beneficiary which will significantly increase the 
                likelihood of death of, or irreparable harm to, the 
                participant, beneficiary, or enrollee.
            (7) Written or in writing.--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 appropriate 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.

Subtitle D--Promoting Quality Care by Ensuring Fair Plan Administration

SEC. 131. RESTRICTIONS ON INCENTIVE PLANS.

    (a) Incentive Plans.--
            (1) In general.--In the case of a group health plan, and a 
        health insurance issuer that offers network coverage, any 
        health professional or provider incentive plan operated by the 
        plan or issuer with respect to such coverage shall meet the 
        following requirements:
                    (A) No specific payment shall be made directly or 
                indirectly under the plan to a professional or provider 
                or group of professionals or providers as an inducement 
                to reduce or limit medically necessary services 
                provided with respect to a specific participant, 
                beneficiary, or enrollee.
                    (B) If a plan or issuer places such a professional, 
                provider, or group at substantial financial risk (as 
                determined by the Secretary) for services not provided 
                by the professional, provider, or group, the plan 
                issuer shall provide stop-loss protection for the 
                professional, provider, or group that is adequate and 
                appropriate, based on standards developed by the 
                Secretary that take into account the number of 
                professionals or providers placed at such substantial 
                financial risk in the group or under the coverage and 
                the number of individuals enrolled with the plan or 
                issuer who receive services from the professional, 
                provider, or group.
            (2) Notification.--The plan or issuer shall provide the 
        Secretary with descriptive information regarding the plan, 
        sufficient to permit the Secretary to determine whether the 
        plan is in compliance with the requirements of this section.
    (b) Health Professional or Provider Incentive Plan Defined.--In 
this subsection, the term health professional or provider incentive 
plan means any compensation arrangement between a health insurance 
issuer and a health professional or provider or professional or 
provider group that has the effect of reducing or limiting services 
provided with respect to individuals enrolled with the plan or issuer.
    (c) Construction.--Nothing in this section shall be construed as 
prohibiting all capitation and similar arrangements or all provider 
discount arrangements.
    (d) Implementation.--The Secretary shall submit to Congress not 
later than January 1, 2000 a report detailing regulations and a plan 
for implementation of the details of this section. Such regulations and 
plan for implementation shall not proceed without the concurrence by 
joint resolution or Act of the Congress.

 SEC. 132. DEVELOPMENT OF PLAN AND ISSUER POLICIES.

    A group health plan, and a health insurance issuer that offers 
network coverage shall establish mechanisms to consider the 
recommendations, suggestions, and views of participants, beneficiaries, 
enrollees and participating health professionals and providers 
regarding--
            (1) the medical policies of the plan or issuer (including 
        policies relating to coverage of new technologies, treatments, 
        and procedures);
            (2) the utilization review criteria and procedures of the 
        plan or issuer;
            (3) the quality and credentialing criteria of the plan or 
        issuer; and
            (4) the medical management procedures of the plan or 
        issuer.

 SEC. 133. PATIENT ACCESS TO INFORMATION.

    (a) Disclosure Requirements.--
            (1) In general.--A group health plan or health insurance 
        issuer providing health insurance coverage shall take such 
        actions as necessary to ensure that--
                    (A) information required under subsections (b) 
                through (k) is provided at the time of enrollment, at 
                least annually thereafter, and upon written request; 
                and
                    (B) the information described in subsection (l) is 
                provided upon written request,
        to plan participants and beneficiaries and to enrollees, 
        respectively.
            (2) Inclusion in summary plan description.--In the case of 
        a group health plan, the information described in paragraph 
        (1)(A) shall be made available as part of the summary plan 
        description of the plan.
            (3) Charging for information made available upon request.--
        In cases in which the information is made available upon 
        written request under paragraph (1), the plan or issuer may 
        impose a reasonable charge to cover the cost of making the 
        information so available. The Secretary may by regulation 
        prescribe a maximum amount which will constitute a reasonable 
        charge under this paragraph.
    (b) Plan Benefits.--The information required under subsection (a) 
includes the following:
            (1) Covered items and services.--
                    (A) Categorization of included benefits.--A 
                description of covered benefits, categorized by--
                            (i) types of items and services (including 
                        any special disease management program); and
                            (ii) types of health care professionals 
                        providing such items and services.
                    (B) Emergency medical care.--A description of--
                            (i) the extent to which the plan or health 
                        insurance coverage covers emergency medical 
                        care;
                            (ii) the locations of hospital emergency 
                        departments, urgent care centers, and other 
                        sites or settings in which the plan or health 
                        insurance coverage makes available emergency 
                        medical care or post-stabilization care; and
                            (iii) the appropriate use of emergency 
                        services, including use of the 911 telephone 
                        system or its local equivalent in emergency 
                        situations, and an explanation of what 
                        constitutes an emergency situation.
                    (C) Preventative services.--A description of the 
                extent to which the plan or health insurance coverage 
                provides benefits for preventative services.
                    (D) Drug formularies.--A description of the extent 
                to which covered benefits are determined by the use or 
                application of a drug formulary and a summary of the 
                process for determining what is included in such 
                formulary.
                    (E) COBRA continuation coverage.--In the case of a 
                group health plan, a description of the benefits 
                available under the plan pursuant to part 6 of the 
                Employee Retirement Income Security Act.
            (2) Limitations, exclusions, and restrictions on covered 
        benefits.--
                    (A) Categorization of excluded benefits.--A 
                description of benefits specifically excluded from 
                coverage, categorized by types of items and services.
                    (B) Utilization review and preauthorization 
                requirements.--Whether coverage for health care is 
                limited or excluded on the basis of utilization review 
                or preauthorization requirements.
                    (C) Lifetime, annual, or other period 
                limitations.--A description of the circumstances under 
                which, and the extent to which, coverage is subject to 
                lifetime, annual, or other period limitations, 
                categorized by types of benefits.
                    (D) Custodial care.--A description of the 
                circumstances under which, and the extent to which, the 
                coverage of benefits for custodial care is limited or 
                excluded, and a statement of the definition used by the 
                plan for custodial care.
                    (E) Experimental treatments.-- Whether coverage for 
                any health care is limited or excluded because it 
                constitutes experimental treatment or technology, and 
                any definitions provided under the plan or coverage for 
                the relevant terminology referring to such limited or 
                excluded care.
                    (F) Second or subsequent opinions.--A description 
                of the circumstances under which, and the extent to 
                which, coverage for second or subsequent opinions is 
                limited or excluded.
                    (G) Specialty care.--A description of the 
                circumstances under which, and the extent to which, 
                coverage of benefits for specialty care is conditioned 
                on referral from a primary care provider.
                    (H) Continuity of care.--A description of the 
                circumstances under which, and the extent to which, 
                coverage of items and services provided by any health 
                care professional is limited or excluded by reason of 
                the departure by the professional from any defined set 
                of providers.
                    (I) Restrictions on coverage of emergency 
                services.--A description of the circumstances under 
                which, and the extent to which, the plan or health 
                insurance coverage, in covering emergency medical care 
                furnished to a participant or beneficiary of the plan 
                or enrollee imposes any financial responsibility 
                described in subsection (c) on participants or 
                beneficiaries or enrollees or limits or conditions 
                benefits for such care subject to any other term or 
                condition of such plan or coverage.
    (c) Participant's Financial Responsibilities.--The information 
required under subsection (a) includes an explanation of--
            (1) a participant's or enrollee's financial responsibility 
        for payment of premiums, coinsurance, copayments, deductibles, 
        and any other charges; and
            (2) the circumstances under which, and the extent to which, 
        the participant's or enrollee's financial responsibility 
        described in paragraph (1) may vary, including any distinctions 
        based on whether a health care provider from whom covered 
        benefits are obtained is included in a defined set of 
        providers.
    (d) Dispute Resolution Procedures.--The information required under 
subsection (a) includes a description of the processes adopted by the 
plan pursuant to section 122, including--
            (1) descriptions relating specifically to--
                    (A) coverage decisions;
                    (B) internal review of coverage decisions; and
                    (C) any external review of coverage decisions;
            (2) the procedures and time frames applicable to each step 
        of the processes referred to in subparagraphs (A), (B), and (C) 
        of paragraph (1); and
            (3) the number of external review cases conducted annually 
        and, of such number, the number of such cases where the 
        decision of the plan or issuer is upheld and the number of such 
        cases where the decision of the plan or issuer is modified or 
        overturned.
    (e) Network Characteristics.--If the plan or health insurance 
issuer utilizes a defined set of providers under contract with the plan 
or issuer, the information required under subsection (a) includes a 
detailed list of the names of such providers and their geographic 
location, set forth separately with respect to primary care providers 
and with respect to specialists.
    (f) Care Management Information.--The information required under 
subsection (a) includes a description of the circumstances under which, 
and the extent to which, the plan or health insurance issuer has 
special disease management programs or programs for persons with 
disabilities, indicating whether these programs are voluntary or 
mandatory and whether a significant benefit differential results from 
participation in such programs.
    (g) Inclusion of Drugs and Biologicals in Formularies.--The 
information required under subsection (a) includes a statement of 
whether a specific drug or biological is included in a formulary used 
to determine benefits under the plan or health insurance coverage and a 
description of the procedures for considering requests for any patient-
specific waivers.
    (h) Preauthorization and Utilization Review Procedures.--The 
information required under subsection (a) includes, upon receipt by the 
participant or beneficiary or enrollee of any notification of an 
adverse coverage decision, a description of the basis on which any 
preauthorization requirement or any utilization review requirement has 
resulted in such decision.
    (i) Accreditation Status of Health Insurance Issuers and Service 
Providers.--The information required under subsection (a) includes a 
description of the accreditation and licensing status (if any) of each 
health insurance issuer (or each such issuer offering health insurance 
coverage in connection with the plan) and of any utilization review 
organization utilized by the issuer or the plan, together with the name 
and address of the accrediting or licensing authority.
    (j) Measures of Enrollee Satisfaction.--The information required 
under subsection (a) includes the latest information (if any) 
maintained by the plan (or by any health insurance issuer offering 
health insurance coverage in connection with the plan) or by the health 
insurance issuer relating to enrollee satisfaction.
    (k) Quality Performance Measures.--The information required under 
subsection (a) includes the latest information (if any) maintained by 
the plan (or by any health insurance issuer offering health insurance 
coverage in connection with the plan) or by the health insurance 
issuer, relating to quality of performance of the delivery of health 
care with respect to coverage options offered under the plan or health 
insurance coverage and of health care professionals and facilities 
providing health care under the plan or coverage.
    (l) Information Available on Request.--Pursuant to written request 
under subsection (a)(1)(B)--
            (1) Information required from individual health care 
        professionals on request.-- Any health care professional 
        treating a participant or beneficiary under a group health plan 
        or an enrollee under health insurance coverage shall provide to 
        the participant or beneficiary or enrollee, on request, a 
        description of his or her professional qualifications 
        (including board certification status, licensing status, and 
        accreditation status, if any), privileges, and experience and a 
        general description by category (including salary, fee-for-
        service, capitation, and such other categories as may be 
        specified in regulations of the Secretary) of the applicable 
        method by which such professional is compensated in connection 
        with the provision of such health care under the plan or 
        coverage.
            (2) Information required from individual health care 
        facilities on request.--Any health care facility from which a 
        participant, beneficiary, or enrollee has sought treatment 
        under a group health plan or health insurance coverage shall 
        provide to the participant, beneficiary, or enrollee, on 
        request, a description of the facility's corporate form or 
        other organizational form and all forms of licensing and 
        accreditation status (if any) assigned to the facility by 
        standard-setting organizations.
    (m) Advance Notice of Changes in Drug Formularies.--Not later than 
30 days before the effective date of any exclusion of a specific drug 
or biological from any drug formulary under the group health plan or 
health insurance coverage that is used in the treatment of a chronic 
illness or disease, the plan or issuer shall take such actions as are 
necessary to reasonably ensure that plan participants or enrollees are 
informed of such exclusion. The requirements of this subsection may be 
satisfied--
            (1) in the case of a group health plan, by inclusion of 
        information in publications broadly distributed by plan 
        sponsors, employers, or employee organizations;
            (2) by timely informing participants or enrollees who, 
        under an ongoing program maintained under the plan or health 
        insurance issuer, have submitted their names for such 
        notification; or
            (3) by any other reasonable means of timely informing 
        participants or enrollees.

SEC. 134. PROTECTION OF CONFIDENTIALITY.

    (a) In General.--A group health plan, and a health insurance issuer 
offering health insurance coverage, shall establish mechanisms and 
procedures to ensure compliance with applicable Federal and State laws 
to protect the confidentiality of individually identifiable information 
held by the plan issuer with respect to a participant, beneficiary, 
enrollee, health professional, or provider.
    (b) Individually Identifiable Information Defined.--For purposes of 
subsection (a), the term ``individually identifiable information'' 
means, with respect to a participant, beneficiary, enrollee, a health 
professional, or a provider, any information, whether oral or recorded 
in any medium or form, that identifies or can readily be associated 
with the identity of the participant, beneficiary, enrollee, the health 
professional, or the provider.

SEC. 135. DUE PROCESS FOR HEALTH PROFESSIONALS AND PROVIDERS.

    (a) In General.--A group health plan, and a health insurance 
issuer, with respect to its offering of network coverage shall--
            (1) allow all health professionals and providers in its 
        service area who are licensed, accredited, or certified to 
        perform specific health services consistent with State law and 
        those services covered under the network coverage to apply to 
        become a participating health professional or provider as 
        openings in a network become available during at least one 
        period in each calendar year;
            (2) provide reasonable notice to such health professionals 
        and providers of the opportunity to apply and of the period 
        during which applications are accepted;
            (3) provide for review of each application by a 
        credentialing committee with representation of the category or 
        type of health professional or provider being credentialed;
            (4) select participating health professionals and providers 
        using objective standards of quality developed with the 
        suggestions and advice of professional associations, health 
        professionals, and providers;
            (5) make such selection standards available to--
                    (A) those applying to become a participating 
                provider or health professional;
                    (B) purchasers of health insurance coverage; and
                    (C) participants, beneficiaries, or enrollees;
            (6) when economic considerations are taken into account in 
        selecting participating health professionals and providers, use 
        objective criteria that are available to those applying to 
        become a participating provider or health professional and 
        participants, beneficiaries, or enrollees;
            (7) adjust any economic profiling to take into account 
        patient characteristics (such as severity of illness) that may 
        result in atypical utilization of services;
            (8) make the results of such profiling available to 
        insurance purchasers, enrollees, and the health professional or 
        provider involved;
            (9) notify any health professional or provider being 
        reviewed under the process referred to in paragraph (3) of any 
        information indicating that the health professional or provider 
        fails to meet the standards of the issuer;
            (10) offer a health professional or provider receiving 
        notice pursuant to the requirement of paragraph (9) with an 
        opportunity to--
                    (A) review the information referred to in such 
                paragraph; and
                    (B) submit supplemental or corrected in formation;
            (11) not include in its contracts with participating health 
        professionals and providers a provision permitting the issuer 
        to terminate the contract without cause;
            (12) provide a due process appeal that conforms to the 
        process specified in section 412 of the Health Care Quality 
        Improvement Act of 1986 (42 U.S.C. 11112) for all 
        determinations that are adverse to a health professional or 
        provider; and
            (13) unless a health professional or provider poses an 
        imminent harm to enrollees or an adverse action by a 
        governmental agency effectively impairs the ability to provide 
        health care items and services, provide--
                    (A) reasonable notice of any decision to terminate 
                a health professional or provider for cause (including 
                an explanation of the reasons for the determination);
                    (B) an opportunity to review and discuss all of the 
                information on which the determination is based; and
                    (C) an opportunity to enter into a corrective 
                action plan, before the determination be comes subject 
                to appeal under the process referred to in paragraph 
                (12).
    (b) Rules of Construction.--The requirements of subsection (a) 
shall not be construed as preempting or superseding any other reviews 
and appeals a group health plan, or a health insurance issuer are 
required by law to make available. Nothing in subsection (a) shall be 
construed to require a group health plan or a health insurance issuer 
to renew a contract with a participating provider.

 SEC. 136. PROHIBITION OF INTERFERENCE WITH CERTAIN MEDICAL 
              COMMUNICATIONS.

    (a) In General.--Subject to subsections (b) and (c), a group health 
plan, and a health insurance issuer (in relation to an individual 
enrolled under health insurance coverage offered by the issuer) shall 
not prohibit or otherwise restrict a covered health care professional 
(as defined in subsection (d)) from advising such an individual who is 
a patient of the professional about the health status of the individual 
or health care or treatment for the individuals condition or disease, 
regardless of whether benefits for such care or treatment are provided 
under the coverage, if the professional is acting within the lawful 
scope of practice.
    (b) Conscience Protection.--Subsection (a) shall not be construed 
as requiring a group health plan or a health insurance issuer to 
provide, reimburse for, or provide coverage of a counseling or referral 
service if the issuer--
            (1) objects to the provision of such service on moral or 
        religious grounds; and
            (2) in the manner and through the written instrumentalities 
        such issuer deems appropriate, makes available information on 
        its policies regarding such service to prospective enrollees 
        before or during enrollment and to enrollees within 90 days 
        after the date that the issuer adopts a change in policy 
        regarding such a counseling or referral service.
    (c) Construction.--Nothing in subsection (b) shall be construed to 
affect disclosure requirements under State law or under the Employee 
Retirement Income Security Act of 1974.

 SEC. 137. PLAN SOLVENCY.

    A group health plan and a health insurance issuer offering health 
insurance coverage shall--
            (1) meet such financial reserve or other solvency-related 
        requirements as the applicable State authority may establish to 
        assure the continued availability of (and appropriate payment 
        for) covered items and services for enrollees; and
            (2) establish mechanisms specified by the applicable State 
        authority to protect enrollees, health professionals, and 
        providers in the event of failure of the issuer.
Such requirements shall not unduly impede the establishment of health 
insurance issuers owned and operated by health care professionals or 
providers or by nonprofit community-based organizations.

 SEC. 138. QUALITY ASSESSMENT PROGRAM.

    (a) In General.--A group health plan and a health insurance issuer 
offering health insurance coverage shall establish a quality assessment 
program (consistent with subsection (b)) that systematically and 
continuously assesses--
            (1) participant, beneficiary, or enrollee health status, 
        patient outcomes, processes of care, and participant, 
        beneficiary, or enrollee satisfaction associated with health 
        care provided by the plan or issuer; and
            (2) the administrative and funding capacity of the issuer 
        to support and emphasize preventive care, utilization, access 
        and availability, cost effectiveness, acceptable treatment 
        modalities, specialists referrals, the peer review process, and 
        the efficiency of the administrative process.
    (b) Functions.--A quality assessment program established pursuant 
to subsection (a) shall--
            (1) assess the performance of the plan or issuer and its 
        participating health professionals and providers and report the 
        results of such assessment to purchasers, participating health 
        professionals and providers, and administrative personnel; and
            (2) analyze quality assessment data to determine specific 
        interactions in the delivery system (both the design and 
        funding of the health insurance coverage and the clinical 
        provision of care) that have an adverse impact on the quality 
        of care.

                        Subtitle E--Definitions

SEC. 151. DEFINITIONS.

    (a) Incorporation of General Definitions.--Except as otherwise 
provided, the provisions of section 2971 of the Public Health Service 
Act shall apply for purposes of this title in the same manner as they 
apply for purposes of title XXVII of such Act.
    (b) Secretary.--Except as otherwise provided, the term 
``Secretary'' means the Secretary of Health and Human Services, in 
consultation with the Secretary of Labor and the Secretary of the 
Treasury and the term ``appropriate Secretary'' means the Secretary of 
Health and Human Services in relation to carrying out this title under 
sections 2706 and 2751 of the Public Health Service Act and the 
Secretary of Labor in relation to carrying out this title under section 
713 of the Employee Retirement Income Security Act of 1974.
    (c) Additional Definitions.--For purposes of this title:
            (1) Applicable authority.--The term ``applicable 
        authority'' means--
                    (A) in the case of a group health plan, the 
                Secretary of Health and Human Services and the 
                Secretary of Labor; and
                    (B) in the case of a health insurance issuer with 
                respect to a specific provision of this title, the 
                applicable State authority (as defined in section 
                2791(d) of the Public Health Service Act), or the 
                Secretary of Health and Human Services, if such 
                Secretary is enforcing such provision under section 
                2722(a)(2) or 2761(a)(2) of the Public Health Service 
                Act.
            (2) Enrollee.--The term ``enrollee'' means, with respect to 
        health insurance coverage offered by a health insurance issuer, 
        an individual enrolled with the issuer to receive such 
        coverage.
            (3) Fee-for-service coverage.--The term ``fee-for-service 
        coverage'' means coverage that--
                    (A) reimburses hospitals, health professionals, or 
                other providers, directly or by payment to enrollees 
                who are required to pay such parties, on the basis of a 
                rate determined by the issuer on a fee-for-service 
                basis without placing the provider at financial risk;
                    (B) does not vary reimbursement for the coverage 
                period for such a provider based on an agreement to 
                contract terms and conditions or the utilization of 
                health care items or services relating to such provider 
                or enrollees; and
                    (C) does not restrict the selection of providers 
                among those who are lawfully authorized to provide the 
                covered services and agree to accept the terms and 
                conditions of payment established by the issuer; and
                    (D) for which the issuer does not utilize 
                prospective or concurrent review.
            (4) Group health plan.--The term ``group health plan'' has 
        the meaning given such term in section 733(a) of the Employee 
        Retirement Income Security Act of 1974.
            (5) Health professional.--The term ``health professional'' 
        means an individual who is licensed, accredited, or certified 
        under State law to provide specified health care services and 
        who is operating within the scope of such licensure, 
        accreditation, or certification.
            (6) Network.--The term ``network'' means, with respect to a 
        group health plan or health insurance issuer offering health 
        insurance coverage, the participating health professionals and 
        providers through whom the plan or issuer provides health care 
        items and services to participants, beneficiaries, or 
        enrollees.
            (7) Network coverage.--The term ``network coverage'' means, 
        with respect to a group health plan or health insurance 
        coverage offered by a health insurance issuer, health benefits 
        coverage that provides or arranges for the provision of health 
        care items and services to participants, beneficiaries, or 
        enrollees through participating health professionals and 
        providers.
            (8) Nonparticipating.--The term ``nonparticipating'' means, 
        with respect to a health care provider that provides health 
        care items and services to a participant, beneficiary, or 
        enrollee under group health plan or health insurance coverage, 
        a health care provider that is not a participating health care 
        provider with respect to such items and services.
            (9) Participating.--The term ``participating'' means, with 
        respect to a health care provider that provides health care 
        items and services to a participant, beneficiary, or enrollee 
        under group health plan or health insurance coverage offered by 
        a health insurance issuer, a health care provider that 
        furnishes such items and services under a contract or other 
        arrangement with the plan or issuer.
            (10) Prior authorization.--The term ``prior authorization'' 
        means the process of obtaining prior approval from a health 
        insurance issuer for the treatment of a medical or clinical 
        condition.
            (11) Provider.--The term ``provider'' means a health 
        organization, health facility, or health agency that is 
        licensed, accredited, or certified to provide health care items 
        and services under applicable State law.
            (12) Service area.--The term ``service area'' means, with 
        respect to a health insurance issuer with respect to health 
        insurance coverage, the geographic area served by the issuer 
        with respect to the coverage.
            (13) Utilization review.--The term ``utilization review'' 
        means prospective, concurrent, or retrospective review of 
        health care items and services, and includes prior 
        authorization requirements for coverage of such items and 
        services.
    (d) Abortion and Euthanasia Services Defined.--For purposes of this 
sections 104 and 116:
            (1) Abortion services.--The term ``abortion services'' 
        means the performance of an abortion, the providing of drugs to 
        induce an abortion, and services related directly to the 
        performance of an abortion (such as the performance of 
        ultrasound and similar preparatory procedures and preparation 
        of post-abortion pathology reports), but does not include the 
        treatment of injuries or illnesses caused by an abortion.
            (2) Euthanasia services.--The term ``euthanasia services'' 
        means anything for which the use of funds appropriated by the 
        Congress is prohibited under the Assisted Suicide Funding 
        Restriction Act of 1997 (Public Law 105-12; 42 U.S.C. 14401 et 
        seq.), subject to sections 3(b) of such Act (42 U.S.C. 
        14402(b)).
    (e) Application to Partnerships.--The provisions of paragraphs (1), 
(2), and (3) of section 732(d) of the Employee Retirement Income 
Security Act of 1974 shall apply with respect to partnerships.

SEC. 152. PREEMPTION; STATE FLEXIBILITY; CONSTRUCTION.

    (a) Continued Applicability of State Law With Respect to Health 
Insurance Issuers.--
            (1) In general.--Subject to paragraph (2), this title shall 
        not be construed to supersede any provision of State law which 
        establishes, implements, or continues in effect any standard or 
        requirement solely relating to health insurance issuers (in 
        connection with group health insurance coverage or otherwise) 
        except to the extent that such standard or requirement prevents 
        the application of a requirement of this title.
            (2) Continued preemption with respect to group health 
        plans.--Nothing in this title shall be construed to affect or 
        modify the provisions of section 514 of the Employee Retirement 
        Income Security Act of 1974 with respect to group health plans.
    (b) Rules of Construction.--Nothing in this title shall be 
construed as requiring a group health plan or health insurance coverage 
to provide specific benefits under the terms of such plan or coverage.
    (c) Definitions.--For purposes of this section:
            (1) State law.--The term ``State law'' includes all laws, 
        decisions, rules, regulations, or other State action having the 
        effect of law, of any State. A law of the United States 
        applicable only to the District of Columbia shall be treated as 
        a State law rather than a law of the United States.
            (2) State.--The term ``State'' includes a State, the 
        Northern Mariana Islands, any political subdivisions of a State 
        or such Islands, or any agency or instrumentality of either.

SEC. 153. REGULATIONS.

    The Secretaries of Health and Human Services, Labor, and the 
Treasury shall issue such regulations as may be necessary or 
appropriate to carry out this title. Such regulations shall be issued 
consistent with section 104 of Health Insurance Portability and 
Accountability Act of 1996. Such Secretaries may promulgate any interim 
final rules as the Secretaries determine are appropriate to carry out 
this title.

 TITLE II--APPLICATION OF QUALITY CARE STANDARDS TO GROUP HEALTH PLANS 
     AND HEALTH INSURANCE COVERAGE UNDER PUBLIC HEALTH SERVICE ACT

SEC. 201. APPLICATION TO GROUP HEALTH PLANS AND GROUP HEALTH INSURANCE 
              COVERAGE.

    (a) 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. PATIENT PROTECTION STANDARDS.

    ``(a) In General.--Each group health plan shall comply with patient 
protection requirements under title I of the Access to Quality Care Act 
of 1999, and each health insurance issuer shall comply with patient 
protection requirements under such title with respect to group health 
insurance coverage it offers, and such requirements shall be deemed to 
be incorporated into this subsection.
    ``(b) Notice.--A group health plan shall comply with the notice 
requirement under section 711(d) of the Employee Retirement Income 
Security Act of 1974 with respect to the requirements referred to in 
subsection (a) and a health insurance issuer shall comply with such 
notice requirement as if such section applied to such issuer and such 
issuer were a group health plan.''.
    (b) Conforming Amendment.--Section 2721(b)(1)(A) of such Act (42 
U.S.C. 300gg-21(b)(1)(A)) is amended by inserting ``(other than section 
2706)'' after ``requirements of such subparts''.

SEC. 202. 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. PATIENT PROTECTION STANDARDS.

    ``(a) In General.--Each health insurance issuer shall comply with 
patient protection requirements under title I of the Access to Quality 
Care Act of 1999 with respect to individual health insurance coverage 
it offers, and such requirements shall be deemed to be incorporated 
into this subsection.
    ``(b) Notice.--A health insurance issuer under this part shall 
comply with the notice requirement under section 711(d) of the Employee 
Retirement Income Security Act of 1974 with respect to the requirements 
of such title as if such section applied to such issuer and such issuer 
were a group health plan.''.

TITLE III--AMENDMENTS TO THE EMPLOYEE RETIREMENT INCOME SECURITY ACT OF 
                                  1974

SEC. 301. APPLICATION OF PATIENT PROTECTION STANDARDS TO GROUP HEALTH 
              PLANS AND GROUP HEALTH INSURANCE COVERAGE UNDER THE 
              EMPLOYEE RETIREMENT INCOME SECURITY ACT OF 1974.

    Subpart B of part 7 of subtitle B of title I of the Employee 
Retirement Income Security Act of 1974 is amended by adding at the end 
the following new section:

``SEC. 713. PATIENT PROTECTION STANDARDS.

    ``A group health plan (and a health insurance issuer offering group 
health insurance coverage in connection with such a plan) shall comply 
with the requirements of title I of the Access to Quality Care Act of 
1999 (as in effect as of the date of the enactment of such Act), and 
such requirements shall be deemed to be incorporated into this 
section.''.

SEC. 302. ERISA PREEMPTION NOT TO APPLY TO CERTAIN ACTIONS INVOLVING 
              HEALTH INSURANCE POLICYHOLDERS.

    (a) In General.--Section 514 of the Employee Retirement Income 
Security Act of 1974 (29 U.S.C. 1144) is amended by adding at the end 
the following subsection:
    ``(e) Preemption Not To Apply to Certain Actions Arising Out of 
Provision of Health Benefits.--
            ``(1) In general.--Except as provided in this subsection, 
        nothing in this title shall be construed to invalidate, impair, 
        or supersede any cause of action under State law to recover 
        damages resulting from personal injury or for wrongful death 
        against any person--
                    ``(A) in connection with the provision of 
                insurance, administrative services, or medical services 
                by such person to or for a group health plan (as 
                defined in section 733), or
                    ``(B) that arises out of the arrangement by such 
                person for the provision of such insurance, 
                administrative services, or medical services by other 
                persons.
            ``(2) Exception for employers and other plan sponsors.--
                    ``(A) In general.--Subject to subparagraph (B), 
                paragraph (1) does not authorize--
                            ``(i) any cause of action against an 
                        employer or other plan sponsor maintaining the 
                        group health plan, or
                            ``(ii) a right of recovery or indemnity by 
                        a person against an employer or other plan 
                        sponsor for damages assessed against the person 
                        pursuant to a cause of action under paragraph 
                        (1).
                    ``(B) Special rule.--Subparagraph (A) shall not 
                preclude any cause of action described in paragraph (1) 
                against an employer or other plan sponsor if--
                            ``(i) such action is based on the 
                        employer's or other plan sponsor's exercise of 
                        discretionary authority to make a decision on a 
                        claim for benefits covered under the plan or 
                        health insurance coverage in the case at issue; 
                        and
                            ``(ii) the exercise by such employer or 
                        other plan sponsor of such authority resulted 
                        in personal injury or wrongful death.
                    ``(C) Exception.--The exercise of discretionary 
                authority described in subparagraph (B)(i) shall not be 
                construed to include--
                            ``(i) the decision to include or exclude 
                        from the plan any specific benefit;
                            ``(ii) any decision affirming the decision 
                        of a treating health care professional; or
                            ``(iii) any decision to provide benefits 
                        beyond those specified in the plan at the 
                        request of a treating health care 
                        professional.''.
    (b) Effective Date.--The amendment made by subsection (a) shall 
apply to acts and omissions occurring on or after the date of the 
enactment of this Act from which a cause of action arises.

SEC. 303. DIRECT ACCESS TO COURTS.

    Section 502 of the Employee Retirement Income Security Act is 
amended--
            (1) in subsection (a)(8) by striking ``or'' at the end;
            (2) in subsection (a)(9) by striking the period at the end 
        and inserting ``; or'';
            (3) by adding at the end of subsection (a) the following 
        new paragraph:
            ``(10) by a participant or beneficiary for appropriate 
        relief under subsection (b)(4).''; and
            (4) by adding at the end of subsection (b) the following 
        new paragraph:
            ``(4) In any case in which exhaustion of administrative 
        remedies otherwise necessary for an action for relief has not 
        been obtained and it is demonstrated to the court by means of 
        certification by an appropriate physician that such exhaustion 
        is not reasonably attainable under the facts and circumstances 
        without undue risk of irreparable harm to the health of the 
        participant or beneficiary, a civil action may be brought by a 
        participant or beneficiary to obtain appropriate equitable 
        relief. Any determinations made while an action under this 
        paragraph is pending shall be given due consideration by the 
        court in any such action.''.

       TITLE IV--EFFECTIVE DATES; COORDINATION IN IMPLEMENTATION

SEC. 401. EFFECTIVE DATES.

    (a) Group Health Coverage.--
            (1) In general.--Subject to paragraph (2), the amendments 
        made by sections 201(a) and 301 (and title I insofar as it 
        relates to such sections) shall apply with respect to group 
        health plans, and health insurance coverage offered in 
        connection with group health plans, for plan years beginning on 
        or after January 1, 2000 (in this section referred to as the 
        ``general effective date'') and also shall apply to portions of 
        plan years occurring on and after such date.
            (2) Treatment of collective bargaining agreements.--In the 
        case of a group health plan maintained pursuant to 1 or more 
        collective bargaining agreements between employee 
        representatives and 1 or more employers ratified before the 
        date of enactment of this Act, the amendments made by sections 
        201(a) and 301 (and title I insofar as it relates to such 
        sections) shall not apply to plan years beginning before the 
        later of--
                    (A) the date on which the last collective 
                bargaining agreements relating to the plan terminates 
                (determined without regard to any extension thereof 
                agreed to after the date of enactment of this Act), or
                    (B) the general effective date.
        For purposes of subparagraph (A), 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.
    (b) Individual Health Insurance Coverage.--The amendments made by 
section 202 shall apply with respect to individual health insurance 
coverage offered, sold, issued, renewed, in effect, or operated in the 
individual market on or after the general effective date.

SEC. 402. COORDINATION IN IMPLEMENTATION.

    Section 104(1) of Health Insurance Portability and Accountability 
Act of 1996 is amended by striking ``this subtitle (and the amendments 
made by this subtitle and section 401)'' and inserting ``the provisions 
of part 7 of subtitle B of title I of the Employee Retirement Income 
Security Act of 1974, the provisions of parts A and C of title XXVII of 
the Public Health Service Act, chapter 100 of the Internal Revenue Code 
of 1986, and title I of the Access to Quality Care Act of 1999''.
                                 <all>