110 HR 979 IH: To amend title I of the Employee Retirement Income
U.S. House of Representatives
2007-02-12
text/xml
EN
Pursuant to Title 17 Section 105 of the United States Code, this file is not subject to copyright protection and is in the public domain.
1.Short title; table of
contents
(a)This Act may be cited as the Bipartisan Consensus
Managed Care Improvement Act of 2007
.
(b)The table of contents of this Act is as follows:
Sec. 1. Short title; table of contents.
Title I—IMPROVING MANAGED CARE
Subtitle A—Grievance and Appeals
Sec. 101. Utilization review activities.
Sec. 102. Internal appeals procedures.
Sec. 103. External appeals procedures.
Sec. 104. Establishment of a grievance process.
Subtitle B—Access to Care
Sec. 111. Consumer choice option.
Sec. 112. Choice of health care professional.
Sec. 113. Access to emergency care.
Sec. 114. Access to specialty care.
Sec. 115. Access to obstetrical and gynecological
care.
Sec. 116. Access to pediatric care.
Sec. 117. Continuity of care.
Sec. 118. Access to needed prescription drugs.
Sec. 119. Coverage for individuals participating in approved
clinical trials.
Subtitle C—Access to Information
Sec. 121. Patient access to information.
Subtitle D—Protecting the Doctor-Patient
Relationship
Sec. 131. Prohibition of interference with certain medical
communications.
Sec. 132. Prohibition of discrimination against providers based
on licensure.
Sec. 133. Prohibition against improper incentive
arrangements.
Sec. 134. Payment of claims.
Sec. 135. Protection for patient advocacy.
Subtitle E—Definitions
Sec. 151. Definitions.
Sec. 152. Preemption; State flexibility;
construction.
Sec. 153. Exclusions.
Sec. 154. Coverage of limited scope plans.
Sec. 155. Regulations.
Title II—APPLICATION OF QUALITY CARE STANDARDS TO GROUP HEALTH
PLANS AND HEALTH INSURANCE COVERAGE UNDER THE 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—APPLICATION TO GROUP HEALTH PLANS UNDER THE INTERNAL
REVENUE CODE OF 1986
Sec. 401. Amendments to the Internal Revenue Code of
1986.
Title V—EFFECTIVE DATES; COORDINATION IN
IMPLEMENTATION
Sec. 501. Effective dates.
Sec. 502. Coordination in implementation.
Title VI—HEALTH CARE PAPERWORK SIMPLIFICATION
Sec. 601. Health care paperwork simplification.
<enum>I</enum><header>IMPROVING MANAGED
CARE</header>
<subtitle id="HD4FAF7361D0C48068CD01E55DA575C9C"><enum>A</enum><header>Grievance and
Appeals</header>
<section id="H7907A77797594968AED16DFAF91D0939"><enum>101.</enum><header>Utilization
review activities</header>
<subsection id="H70CE82D998884E579D208800FCFA545C"><enum>(a)</enum><header>Compliance With
Requirements</header>
<paragraph id="HDD25B30B16434E1892FC00FB97823592"><enum>(1)</enum><header>In
general</header><text>A group health plan, and a health insurance issuer that
provides health insurance coverage, shall conduct utilization review activities
in connection with the provision of benefits under such plan or coverage only
in accordance with a utilization review program that meets the requirements of
this section.</text>
</paragraph><paragraph id="H1BB6094DE60340A197BDB300F588CAEB"><enum>(2)</enum><header>Use of outside
agents</header><text>Nothing in this section shall be construed as preventing a
group health plan or health insurance issuer from arranging through a contract
or otherwise for persons or entities to conduct utilization review activities
on behalf of the plan or issuer, so long as such activities are conducted in
accordance with a utilization review program that meets the requirements of
this section.</text>
</paragraph><paragraph id="H4C28D67725644CE7A4D1D9B8C496DBB2"><enum>(3)</enum><header>Utilization
review defined</header><text>For purposes of this section, the terms
<term>utilization review</term> and <term>utilization review activities</term>
mean procedures used to monitor or evaluate the use or coverage, clinical
necessity, appropriateness, efficacy, or efficiency of health care services,
procedures or settings, and includes prospective review, concurrent review,
second opinions, case management, discharge planning, or retrospective
review.</text>
</paragraph></subsection><subsection id="H718F9647A2D040C1A3DE35FF8D8789F"><enum>(b)</enum><header>Written Policies
and Criteria</header>
<paragraph id="HE9ADBC0A04934472A75BA6AAABEBEC42"><enum>(1)</enum><header>Written
policies</header><text>A utilization review program shall be conducted
consistent with written policies and procedures that govern all aspects of the
program.</text>
</paragraph><paragraph id="H9EC65B4757E54E06BEA2D43BE725E344"><enum>(2)</enum><header>Use of written
criteria</header>
<subparagraph id="H8450E5537E12491094F51822BA8CF7B1"><enum>(A)</enum><header>In
general</header><text>Such a program shall utilize written clinical review
criteria developed with input from a range of appropriate actively practicing
health care professionals, as determined by the plan, pursuant to the program.
Such criteria shall include written clinical review criteria that are based on
valid clinical evidence where available and that are directed specifically at
meeting the needs of at-risk populations and covered individuals with chronic
conditions or severe illnesses, including gender-specific criteria and
pediatric-specific criteria where available and appropriate.</text>
</subparagraph><subparagraph id="HF164E6947EA8437A9BB487ED14CCB491"><enum>(B)</enum><header>Continuing use
of standards in retrospective review</header><text>If a health care service has
been specifically pre-authorized or approved for an enrollee under such a
program, the program shall not, pursuant to retrospective review, revise or
modify the specific standards, criteria, or procedures used for the utilization
review for procedures, treatment, and services delivered to the enrollee during
the same course of treatment.</text>
</subparagraph><subparagraph id="HC74B9B9468244C7DABE9791732101580"><enum>(C)</enum><header>Review of sample
of claims denials</header><text>Such a program shall provide for an evaluation
of the clinical appropriateness of at least a sample of denials of claims for
benefits.</text>
</subparagraph></paragraph></subsection><subsection id="H700125BEF62E4C0DA12400F6272132A"><enum>(c)</enum><header>Conduct of
Program Activities</header>
<paragraph id="H26369F339E8D46A3BBF77387E0E2D88"><enum>(1)</enum><header>Administration by
health care professionals</header><text>A utilization review program shall be
administered by qualified health care professionals who shall oversee review
decisions.</text>
</paragraph><paragraph id="HEB8E5E2B26724428A009D781EFE169B9"><enum>(2)</enum><header>Use of
qualified, independent personnel</header>
<subparagraph id="H6F173DF1EF3043369BEE04A5148BF43F"><enum>(A)</enum><header>In
general</header><text>A utilization review program shall provide for the
conduct of utilization review activities only through personnel who are
qualified and have received appropriate training in the conduct of such
activities under the program.</text>
</subparagraph><subparagraph id="H6E2D11F726194A418D3351EA810D1E4"><enum>(B)</enum><header>Prohibition of
contingent compensation arrangements</header><text>Such a program shall not,
with respect to utilization review activities, permit or provide compensation
or anything of value to its employees, agents, or contractors in a manner that
encourages denials of claims for benefits.</text>
</subparagraph><subparagraph id="HADD15579035641E48C6ED8706B29487C"><enum>(C)</enum><header>Prohibition of
conflicts</header><text>Such a program shall not permit a health care
professional who is providing health care services to an individual to perform
utilization review activities in connection with the health care services being
provided to the individual.</text>
</subparagraph></paragraph><paragraph id="HA7A34D68FA724C4CBB5988281CFF1CED"><enum>(3)</enum><header>Accessibility of
review</header><text>Such a program shall provide that appropriate personnel
performing utilization review activities under the program, including the
utilization review administrator, are reasonably accessible by toll-free
telephone during normal business hours to discuss patient care and allow
response to telephone requests, and that appropriate provision is made to
receive and respond promptly to calls received during other hours.</text>
</paragraph><paragraph id="H80582A5CCE6E442993C0AF9D128C72D5"><enum>(4)</enum><header>Limits on
frequency</header><text>Such a program shall not provide for the performance of
utilization review activities with respect to a class of services furnished to
an individual more frequently than is reasonably required to assess whether the
services under review are medically necessary or appropriate.</text>
</paragraph></subsection><subsection id="HE20E2F708AA44F4FBC1DEF89D805CA2B"><enum>(d)</enum><header>Deadline for
Determinations</header>
<paragraph id="H818C6AED0AA34439A900F8D788ACCFBB"><enum>(1)</enum><header>Prior
authorization services</header>
<subparagraph id="H1E7367CB5509443286787F1DC0593629"><enum>(A)</enum><header>In
general</header><text>Except as provided in paragraph (2), in the case of a
utilization review activity involving the prior authorization of health care
items and services for an individual, the utilization review program shall make
a determination concerning such authorization, and provide notice of the
determination to the individual or the individual’s designee and the
individual’s health care provider by telephone and in printed form, as soon as
possible in accordance with the medical exigencies of the case, and in no event
later than the deadline specified in subparagraph (B).</text>
</subparagraph><subparagraph id="H4B905A32C8524D38AB9E88E59BB59886"><enum>(B)</enum><header>Deadline</header>
<clause id="H5CA2E70B0B5949A98E1B3E2E53C2BBC2"><enum>(i)</enum><header>In
general</header><text>Subject to clauses (ii) and (iii), the deadline specified
in this subparagraph is 14 days after the date of receipt of the request for
prior authorization.</text>
</clause><clause id="H8DA34A6C52764163B9A5EEDF6CC29DE"><enum>(ii)</enum><header>Extension
permitted where notice of additional information required</header><text>If a
utilization review program—</text>
<subclause id="H548FF9A9C1724F66B692A6953DFD6896"><enum>(I)</enum><text>receives a request
for a prior authorization,</text>
</subclause><subclause id="HA12C12CB12EA4E5197584E79657FFBF6"><enum>(II)</enum><text>determines that
additional information is necessary to complete the review and make the
determination on the request, and</text>
</subclause><subclause id="H0FABBE01A3554956BEAD3787D9BCF00"><enum>(III)</enum><text>notifies the
requester, not later than 5 business days after the date of receiving the
request, of the need for such specified additional information,</text>
</subclause><continuation-text continuation-text-level="clause">the deadline
specified in this subparagraph is 14 days after the date the program receives
the specified additional information, but in no case later than 28 days after
the date of receipt of the request for the prior authorization. This clause
shall not apply if the deadline is specified in clause (iii).</continuation-text></clause><clause id="H84663D6D082945FBA0E7573318755FB5"><enum>(iii)</enum><header>Expedited
cases</header><text>In the case of a situation described in section
102(c)(1)(A), the deadline specified in this subparagraph is 72 hours after the
time of the request for prior authorization.</text>
</clause></subparagraph></paragraph><paragraph id="HEFA92B9A52974339A78608772E78A9BB"><enum>(2)</enum><header>Ongoing
care</header>
<subparagraph id="HC1270E57F5A34616AD004D33E945327F"><enum>(A)</enum><header>Concurrent
review</header>
<clause id="HBAE08495D1A449E19EA0A100001EB354"><enum>(i)</enum><header>In
general</header><text>Subject to subparagraph (B), in the case of a concurrent
review of ongoing care (including hospitalization), which results in a
termination or reduction of such care, the plan must provide by telephone and
in printed form notice of the concurrent review determination to the individual
or the individual’s designee and the individual’s health care provider as soon
as possible in accordance with the medical exigencies of the case, with
sufficient time prior to the termination or reduction to allow for an appeal
under section 102(c)(1)(A) to be completed before the termination or reduction
takes effect.</text>
</clause><clause id="H6CAAC45380EB4004006916A0C1F265A2"><enum>(ii)</enum><header>Contents of
notice</header><text>Such notice shall include, with respect to ongoing health
care items and services, the number of ongoing services approved, the new total
of approved services, the date of onset of services, and the next review date,
if any, as well as a statement of the individual’s rights to further
appeal.</text>
</clause></subparagraph><subparagraph id="HD54CEE1BFCB64D65A6B0D2C17DD64BA5"><enum>(B)</enum><header>Exception</header><text>Subparagraph
(A) shall not be interpreted as requiring plans or issuers to provide coverage
of care that would exceed the coverage limitations for such care.</text>
</subparagraph></paragraph><paragraph id="H225FD594019C410EA2003428DF790012"><enum>(3)</enum><header>Previously
provided services</header><text>In the case of a utilization review activity
involving retrospective review of health care services previously provided for
an individual, the utilization review program shall make a determination
concerning such services, and provide notice of the determination to the
individual or the individual’s designee and the individual’s health care
provider by telephone and in printed form, within 30 days of the date of
receipt of information that is reasonably necessary to make such determination,
but in no case later than 60 days after the date of receipt of the claim for
benefits.</text>
</paragraph><paragraph id="H4E588289B3E948C28013887069008D60"><enum>(4)</enum><header>Failure to meet
deadline</header><text>In a case in which a group health plan or health
insurance issuer fails to make a determination on a claim for benefit under
paragraph (1), (2)(A), or (3) by the applicable deadline established under the
respective paragraph, the failure shall be treated under this subtitle as a
denial of the claim as of the date of the deadline.</text>
</paragraph><paragraph id="H71F1AC2684564FDFAAE630397745E3C0"><enum>(5)</enum><header>Reference to
special rules for emergency services, maintenance care, and post-stabilization
care</header><text>For waiver of prior authorization requirements in certain
cases involving emergency services and maintenance care and post-stabilization
care, see subsections (a)(1) and (b) of section 113, respectively.</text>
</paragraph></subsection><subsection id="H018C93FBB2674AD486F5E19DB4D7D7A7"><enum>(e)</enum><header>Notice of
Denials of Claims for Benefits</header>
<paragraph id="H730F65E5B3BF447E98B25E9568007599"><enum>(1)</enum><header>In
general</header><text>Notice of a denial of claims for benefits under a
utilization review program shall be provided in printed form and written in a
manner calculated to be understood by the participant, beneficiary, or enrollee
and shall include—</text>
<subparagraph id="H2E6A12964A96411FA17212ADBDEBE93"><enum>(A)</enum><text>the reasons for the
denial (including the clinical rationale);</text>
</subparagraph><subparagraph id="HEED8F8BE11C44FD0ACE7BFA855A28B49"><enum>(B)</enum><text>instructions on
how to initiate an appeal under section 102; and</text>
</subparagraph><subparagraph id="H7BA15E6E65A1419A8F00236889F8399B"><enum>(C)</enum><text>notice of the
availability, upon request of the individual (or the individual’s designee) of
the clinical review criteria relied upon to make such denial.</text>
</subparagraph></paragraph><paragraph id="HDC9A19CF9DF145659471B69632480030"><enum>(2)</enum><header>Specification of
any additional information</header><text>Such a notice shall also specify what
(if any) additional necessary information must be provided to, or obtained by,
the person making the denial in order to make a decision on such an
appeal.</text>
</paragraph></subsection><subsection id="H24C806E7A7404961B6376F7D75768360"><enum>(f)</enum><header>Claim for
Benefits and Denial of Claim for Benefits Defined</header><text>For purposes of
this subtitle:</text>
<paragraph id="HB6D0C56ACA00497487451B183052F375"><enum>(1)</enum><header>Claim for
benefits</header><text>The term <term>claim for benefits</term> means any
request for coverage (including authorization of coverage), for eligibility, or
for payment in whole or in part, for an item or service under a group health
plan or health insurance coverage.</text>
</paragraph><paragraph id="HC4BF3AE77A654716BF4FB92D9E0040E6"><enum>(2)</enum><header>Denial of claim
for benefits</header><text>The term <term>denial</term> means, with respect to
a claim for benefits, means a denial, or a failure to act on a timely basis
upon, in whole or in part, the claim for benefits and includes a failure to
provide benefits (including items and services) required to be provided under
this title.</text>
</paragraph></subsection></section><section id="H4B2FC99774804F9A8861963F5CE2BD25"><enum>102.</enum><header>Internal
appeals procedures</header>
<subsection id="H848681EA423A45EEB8FCBFC7501C4400"><enum>(a)</enum><header>Right of
Review</header>
<paragraph id="H89DD468899254EC3B3A1E9D5CD5E962F"><enum>(1)</enum><header>In
general</header><text>Each group health plan, and each health insurance issuer
offering health insurance coverage—</text>
<subparagraph id="H29205F8DEDFE497E9E7B8BA300DF76B8"><enum>(A)</enum><text>shall provide
adequate notice in writing to any participant or beneficiary under such plan,
or enrollee under such coverage, whose claim for benefits under the plan or
coverage has been denied (within the meaning of section 101(f)(2)), setting
forth the specific reasons for such denial of claim for benefits and rights to
any further review or appeal, written in a manner calculated to be understood
by the participant, beneficiary, or enrollee; and</text>
</subparagraph><subparagraph id="H986AACFBB8A54E05B8B300CFA4BC339C"><enum>(B)</enum><text>shall afford such
a participant, beneficiary, or enrollee (and any provider or other person
acting on behalf of such an individual with the individual’s consent or without
such consent if the individual is medically unable to provide such consent) who
is dissatisfied with such a denial of claim for benefits a reasonable
opportunity (of not less than 180 days) to request and obtain a full and fair
review by a named fiduciary (with respect to such plan) or named appropriate
individual (with respect to such coverage) of the decision denying the
claim.</text>
</subparagraph></paragraph><paragraph id="HE5B7E2A5152F44429C192D71E9CD8841"><enum>(2)</enum><header>Treatment of
oral requests</header><text>The request for review under paragraph (1)(B) may
be made orally, but, in the case of an oral request, shall be followed by a
request in writing.</text>
</paragraph></subsection><subsection id="H561BB8B9FDD94AB2B73292216900D5F"><enum>(b)</enum><header>Internal Review
Process</header>
<paragraph id="H9229852F31564C8E82CB61113B007DB0"><enum>(1)</enum><header>Conduct of
review</header>
<subparagraph id="H132AB43533DD4292A3043B234EEDEA5"><enum>(A)</enum><header>In
general</header><text>A review of a denial of claim under this section shall be
made by an individual who—</text>
<clause id="H5EFCFBB298964C3CA97F2F574C3793A7"><enum>(i)</enum><text>in a
case involving medical judgment, shall be a physician or, in the case of
limited scope coverage (as defined in subparagraph (B), shall be an appropriate
specialist;</text>
</clause><clause id="HC186AA1666E44D6C0042ABE322D65852"><enum>(ii)</enum><text>has
been selected by the plan or issuer; and</text>
</clause><clause id="H36E3986A96DA4357892CD1B460C00192"><enum>(iii)</enum><text>did not make the
initial denial in the internally appealable decision.</text>
</clause></subparagraph><subparagraph id="H75B6C0B9D7494F719466C1987156B34E"><enum>(B)</enum><header>Limited scope
coverage defined</header><text>For purposes of subparagraph (A), the term
<term>limited scope coverage</term> means a group health plan or health
insurance coverage the only benefits under which are for benefits described in
section 2791(c)(2)(A) of the <act-name parsable-cite="PHSA">Public Health
Service Act</act-name> (<external-xref legal-doc="usc" parsable-cite="usc/42/300gg-91">42 U.S.C. 300gg–91(c)(2)</external-xref>).</text>
</subparagraph></paragraph><paragraph id="HD1FB8FE11AFF4824A85885DED600932E"><enum>(2)</enum><header>Time limits for
internal reviews</header>
<subparagraph id="H44EC8682F7434B29BD7555B9799CC546"><enum>(A)</enum><header>In
general</header><text>Having received such a request for review of a denial of
claim, the plan or issuer shall, in accordance with the medical exigencies of
the case but not later than the deadline specified in subparagraph (B),
complete the review on the denial and transmit to the participant, beneficiary,
enrollee, or other person involved a decision that affirms, reverses, or
modifies the denial. If the decision does not reverse the denial, the plan or
issuer shall transmit, in printed form, a notice that sets forth the grounds
for such decision and that includes a description of rights to any further
appeal. Such decision shall be treated as the final decision of the plan.
Failure to issue such a decision by such deadline shall be treated as a final
decision affirming the denial of claim.</text>
</subparagraph><subparagraph id="H17E0A0ABB4694950860403CF41DDA475"><enum>(B)</enum><header>Deadline</header>
<clause id="HDED6F5C45F8149D595A2758748F23833"><enum>(i)</enum><header>In
general</header><text>Subject to clauses (ii) and (iii), the deadline specified
in this subparagraph is 14 days after the date of receipt of the request for
internal review.</text>
</clause><clause id="HACDE1223E6D54C468119DFAFB800E122"><enum>(ii)</enum><header>Extension
permitted where notice of additional information required</header><text>If a
group health plan or health insurance issuer—</text>
<subclause id="HD8348F787C9740459DFE2C59FD79003E"><enum>(I)</enum><text>receives a request
for internal review,</text>
</subclause><subclause id="HA99133E981ED424E9C1EA0D5F178A68D"><enum>(II)</enum><text>determines that
additional information is necessary to complete the review and make the
determination on the request, and</text>
</subclause><subclause id="H1DE5FF09EEA64B87A1D8E0A921471856"><enum>(III)</enum><text>notifies the
requester, not later than 5 business days after the date of receiving the
request, of the need for such specified additional information,</text>
</subclause><continuation-text continuation-text-level="clause">the deadline
specified in this subparagraph is 14 days after the date the plan or issuer
receives the specified additional information, but in no case later than 28
days after the date of receipt of the request for the internal review. This
clause shall not apply if the deadline is specified in clause (iii).</continuation-text></clause><clause id="H52CDDC2D00B1455EA783003E37F40733"><enum>(iii)</enum><header>Expedited
cases</header><text>In the case of a situation described in subsection
(c)(1)(A), the deadline specified in this subparagraph is 72 hours after the
time of the request for review.</text>
</clause></subparagraph></paragraph></subsection><subsection id="HA2CB57B103A04A5BA7BE39BD2B8B066"><enum>(c)</enum><header>Expedited Review
Process</header>
<paragraph id="HC786D00348204ABF881C78D6D509FFE4"><enum>(1)</enum><header>In
general</header><text>A group health plan, and a health insurance issuer, shall
establish procedures in writing for the expedited consideration of requests for
review under subsection (b) in situations—</text>
<subparagraph id="H76564C9DF9CC4C51A675201ED1B1895"><enum>(A)</enum><text>in which, as
determined by the plan or issuer or as certified in writing by a treating
health care professional, the application of the normal timeframe for making a
determination could seriously jeopardize the life or health of the participant,
beneficiary, or enrollee or such an individual’s ability to regain maximum
function; or</text>
</subparagraph><subparagraph id="H4E0498B2C04A441EB59365282DD4ACFC"><enum>(B)</enum><text>described in
section 101(d)(2) (relating to requests for continuation of ongoing care which
would otherwise be reduced or terminated).</text>
</subparagraph></paragraph><paragraph id="HBB991CFFD9D5417188C83B288BC1EAB9"><enum>(2)</enum><header>Process</header><text>Under
such procedures—</text>
<subparagraph id="H7165752B98DE4690A07D4D2EA6B2D9CB"><enum>(A)</enum><text>the request for
expedited review may be submitted orally or in writing by an individual or
provider who is otherwise entitled to request the review;</text>
</subparagraph><subparagraph id="H9397ABF6878E4D8885B27719191CBEB"><enum>(B)</enum><text>all necessary
information, including the plan’s or issuer’s decision, shall be transmitted
between the plan or issuer and the requester by telephone, facsimile, or other
similarly expeditious available method; and</text>
</subparagraph><subparagraph id="H8EA4A931024B407EA2153B228B133919"><enum>(C)</enum><text>the plan or issuer
shall expedite the review in the case of any of the situations described in
subparagraph (A) or (B) of paragraph (1).</text>
</subparagraph></paragraph><paragraph id="H6F3A3F30745848BE8128167255F866FC"><enum>(3)</enum><header>Deadline for
decision</header><text>The decision on the expedited review must be made and
communicated to the parties as soon as possible in accordance with the medical
exigencies of the case, and in no event later than 72 hours after the time of
receipt of the request for expedited review, except that in a case described in
paragraph (1)(B), the decision must be made before the end of the approved
period of care.</text>
</paragraph></subsection><subsection id="H58C1F64B36D64819A65CE2305081E551"><enum>(d)</enum><header>Waiver of
Process</header><text>A plan or issuer may waive its rights for an internal
review under subsection (b). In such case the participant, beneficiary, or
enrollee involved (and any designee or provider involved) shall be relieved of
any obligation to complete the review involved and may, at the option of such
participant, beneficiary, enrollee, designee, or provider, proceed directly to
seek further appeal through any applicable external appeals process.</text>
</subsection></section><section id="H58ED61AB118E4793A11FAE227D30644E"><enum>103.</enum><header>External
appeals procedures</header>
<subsection id="HAD535917CB9E4C439EFDBD8CD54E87BF"><enum>(a)</enum><header>Right to
External Appeal</header>
<paragraph id="H20395C1ADB3348E6B57C99360229FD9F"><enum>(1)</enum><header>In
general</header><text>A group health plan, and a health insurance issuer
offering health insurance coverage, shall provide for an external appeals
process that meets the requirements of this section in the case of an
externally appealable decision described in paragraph (2), for which a timely
appeal is made either by the plan or issuer or by the participant, beneficiary,
or enrollee (and any provider or other person acting on behalf of such an
individual with the individual’s consent or without such consent if such an
individual is medically unable to provide such consent). The appropriate
Secretary shall establish standards to carry out such requirements.</text>
</paragraph><paragraph id="H676B21D047A449AF8547CF13DDCF6337"><enum>(2)</enum><header>Externally
appealable decision defined</header>
<subparagraph id="H25C38953E6234929AC00D54752BD864B"><enum>(A)</enum><header>In
general</header><text>For purposes of this section, the term <term>externally
appealable decision</term> means a denial of claim for benefits (as defined in
section 101(f)(2))—</text>
<clause id="H71A7D830BDB9496CA1AD0AE7B9CF2CD"><enum>(i)</enum><text>that
is based in whole or in part on a decision that the item or service is not
medically necessary or appropriate or is investigational or experimental;
or</text>
</clause><clause id="HB0ECB521D13B406FABBD4EA97C64C093"><enum>(ii)</enum><text>in
which the decision as to whether a benefit is covered involves a medical
judgment.</text>
</clause></subparagraph><subparagraph id="H1FB02B9586AE4EBB9544EA961FE84C5"><enum>(B)</enum><header>Inclusion</header><text>Such
term also includes a failure to meet an applicable deadline for internal review
under section 102.</text>
</subparagraph><subparagraph id="HE3C55AD8670B47E0A17569A984741731"><enum>(C)</enum><header>Exclusions</header><text>Such
term does not include—</text>
<clause id="H00F7CB700344447D803F63B33EF07290"><enum>(i)</enum><text>specific
exclusions or express limitations on the amount, duration, or scope of coverage
that do not involve medical judgment; or</text>
</clause><clause id="H85E0AEC5E440489F9D7C9E9F39C6AA25"><enum>(ii)</enum><text>a
decision regarding whether an individual is a participant, beneficiary, or
enrollee under the plan or coverage.</text>
</clause></subparagraph></paragraph><paragraph id="H7B171B34451142AE8B9B2BAFFBD6D1E0"><enum>(3)</enum><header>Exhaustion of
internal review process</header><text>Except as provided under section 102(d),
a plan or issuer may condition the use of an external appeal process in the
case of an externally appealable decision upon a final decision in an internal
review under section 102, but only if the decision is made in a timely basis
consistent with the deadlines provided under this subtitle.</text>
</paragraph><paragraph id="HBA287FE82F544C10AAEC172095193815"><enum>(4)</enum><header>Filing fee
requirement</header>
<subparagraph id="H477B527A28104A4481CA2DDBD221F8D"><enum>(A)</enum><header>In
general</header><text>Subject to subparagraph (B), a plan or issuer may
condition the use of an external appeal process upon payment to the plan or
issuer of a filing fee that does not exceed $25.</text>
</subparagraph><subparagraph id="HB4077B0FB5884F10AB3E66F0117F2CE8"><enum>(B)</enum><header>Exception for
indigency</header><text>The plan or issuer may not require payment of the
filing fee in the case of an individual participant, beneficiary, or enrollee
who certifies (in a form and manner specified in guidelines established by the
Secretary of Health and Human Services) that the individual is indigent (as
defined in such guidelines).</text>
</subparagraph><subparagraph id="H31B1BAB3F80B4FC9A5E0FAEA6056941D"><enum>(C)</enum><header>Refunding fee in
case of successful appeals</header><text>The plan or issuer shall refund
payment of the filing fee under this paragraph if the recommendation of the
external appeal entity is to reverse or modify the denial of a claim for
benefits which is the subject of the appeal.</text>
</subparagraph></paragraph></subsection><subsection id="H25A0F0ADDCE845D588C860BC1C0559F6"><enum>(b)</enum><header>General Elements
of External Appeals Process</header>
<paragraph id="H0A7C6D542183445EA7736235BCB8CC66"><enum>(1)</enum><header>Contract with
qualified external appeal entity</header>
<subparagraph id="H20CDD251EBFC44DC82177415F591D976"><enum>(A)</enum><header>Contract
requirement</header><text>Except as provided in subparagraph (D), the external
appeal process under this section of a plan or issuer shall be conducted under
a contract between the plan or issuer and one or more qualified external appeal
entities (as defined in subsection (c)).</text>
</subparagraph><subparagraph id="HD9D2BC588B7E45F8A35B8126DE5E5507"><enum>(B)</enum><header>Limitation on
plan or issuer selection</header><text>The applicable authority shall implement
procedures—</text>
<clause id="H1D7FD885648545B9A5A9FD1C4CA67915"><enum>(i)</enum><text>to
assure that the selection process among qualified external appeal entities will
not create any incentives for external appeal entities to make a decision in a
biased manner, and</text>
</clause><clause id="H848DFD20DF7549B48E95FB56BACCD637"><enum>(ii)</enum><text>for
auditing a sample of decisions by such entities to assure that no such
decisions are made in a biased manner.</text>
</clause></subparagraph><subparagraph id="HF2CDFDAD28494F67BF51A661BF83EAE"><enum>(C)</enum><header>Other terms and
conditions</header><text>The terms and conditions of a contract under this
paragraph shall be consistent with the standards the appropriate Secretary
shall establish to assure there is no real or apparent conflict of interest in
the conduct of external appeal activities. Such contract shall provide that all
costs of the process (except those incurred by the participant, beneficiary,
enrollee, or treating professional in support of the appeal) shall be paid by
the plan or issuer, and not by the participant, beneficiary, or enrollee. The
previous sentence shall not be construed as applying to the imposition of a
filing fee under subsection (a)(4).</text>
</subparagraph><subparagraph id="HDCCFFB34A9D54D719580B6A29D989047"><enum>(D)</enum><header>State authority
with respect qualified external appeal entity for health insurance
issuers</header><text>With respect to health insurance issuers offering health
insurance coverage in a State, the State may provide for external review
activities to be conducted by a qualified external appeal entity that is
designated by the State or that is selected by the State in a manner determined
by the State to assure an unbiased determination.</text>
</subparagraph></paragraph><paragraph id="H0E51F8FCD3BD47C296FA9059D328C64F"><enum>(2)</enum><header>Elements of
process</header><text>An external appeal process shall be conducted consistent
with standards established by the appropriate Secretary that include at least
the following:</text>
<subparagraph id="H9E0B3EFA4F8E47E4B5A935D7311F5E1D"><enum>(A)</enum><header>Fair and de novo
determination</header><text>The process shall provide for a fair, de novo
determination. However, nothing in this paragraph shall be construed as
providing for coverage of items and services for which benefits are
specifically excluded under the plan or coverage.</text>
</subparagraph><subparagraph id="H60C429CC7ACD457EA21C1FE86689EFC0"><enum>(B)</enum><header>Standard of
review</header><text>An external appeal entity shall determine whether the
plan’s or issuer’s decision is in accordance with the medical needs of the
patient involved (as determined by the entity) taking into account, as of the
time of the entity’s determination, the patient’s medical condition and any
relevant and reliable evidence the entity obtains under subparagraph (D). If
the entity determines the decision is in accordance with such needs, the entity
shall affirm the decision and to the extent that the entity determines the
decision is not in accordance with such needs, the entity shall reverse or
modify the decision.</text>
</subparagraph><subparagraph id="H9B4778A6B29B4D8C87E643CFF56BAC00"><enum>(C)</enum><header>Consideration of
plan or coverage definitions</header><text>In making such determination, the
external appeal entity shall consider (but not be bound by) any language in the
plan or coverage document relating to the definitions of the terms medical
necessity, medically necessary or appropriate, or experimental,
investigational, or related terms.</text>
</subparagraph><subparagraph id="H8C20F4FBFEEB415EBDD20427079FE0DF"><enum>(D)</enum><header>Evidence</header>
<clause id="H0C621047FBBF4EF58393B7B896F33FBF"><enum>(i)</enum><header>In
general</header><text>An external appeal entity shall include, among the
evidence taken into consideration—</text>
<subclause id="H31467C011332404B9900BD56700F64E"><enum>(I)</enum><text>the decision made
by the plan or issuer upon internal review under section 102 and any guidelines
or standards used by the plan or issuer in reaching such decision;</text>
</subclause><subclause id="H966A124356BF42B59D151E398175ECE"><enum>(II)</enum><text>any personal
health and medical information supplied with respect to the individual whose
denial of claim for benefits has been appealed; and</text>
</subclause><subclause id="H87223E7C434A4352986242612349F1F3"><enum>(III)</enum><text>the opinion of
the individual’s treating physician or health care professional.</text>
</subclause></clause><clause id="H8B005BBD633E4FBA914D5301747803A6"><enum>(ii)</enum><header>Additional
evidence</header><text>Such entity may also take into consideration but not be
limited to the following evidence (to the extent available):</text>
<subclause id="HD3C30B66F37049C6A703152461F3A64"><enum>(I)</enum><text>The results of
studies that meet professionally recognized standards of validity and
replicability or that have been published in peer-reviewed journals.</text>
</subclause><subclause id="H7AC4BE5201404527B3E1806D72086E3D"><enum>(II)</enum><text>The results of
professional consensus conferences conducted or financed in whole or in part by
one or more government agencies.</text>
</subclause><subclause id="HD3BF6D83032B40CD8B8DBFC23CE0008"><enum>(III)</enum><text>Practice and
treatment guidelines prepared or financed in whole or in part by government
agencies.</text>
</subclause><subclause id="H67B2E1F496554B3E96883BE08E00445F"><enum>(IV)</enum><text>Government-issued
coverage and treatment policies.</text>
</subclause><subclause id="H92D0C9BFA2564C44839FB8FC00E1327D"><enum>(V)</enum><text>Community standard
of care and generally accepted principles of professional medical
practice.</text>
</subclause><subclause id="HB9EEF6F0DD2A4726ADDC1D7E2DD533D2"><enum>(VI)</enum><text>To the extent
that the entity determines it to be free of any conflict of interest, the
opinions of individuals who are qualified as experts in one or more fields of
health care which are directly related to the matters under appeal.</text>
</subclause><subclause id="H1B82A4B5024E4258AB2C419B409D6BEB"><enum>(VII)</enum><text>To the extent
that the entity determines it to be free of any conflict of interest, the
results of peer reviews conducted by the plan or issuer involved.</text>
</subclause></clause></subparagraph><subparagraph id="H3C7891912ECE46DCAEABF6F98400D500"><enum>(E)</enum><header>Determination
concerning externally appealable decisions</header><text>A qualified external
appeal entity shall determine—</text>
<clause id="HF7851191594D40E3A8A1062503A57086"><enum>(i)</enum><text>whether a denial
of claim for benefits is an externally appealable decision (within the meaning
of subsection (a)(2));</text>
</clause><clause id="HBE2967C8CEC14344A16DAE4562549CA4"><enum>(ii)</enum><text>whether an
externally appealable decision involves an expedited appeal; and</text>
</clause><clause id="H0B6E4121AD7E493FBFF7AF6329C900BB"><enum>(iii)</enum><text>for purposes of
initiating an external review, whether the internal review process has been
completed.</text>
</clause></subparagraph><subparagraph id="H042F204C011D4DDE9381A88279F86DF"><enum>(F)</enum><header>Opportunity to
submit evidence</header><text>Each party to an externally appealable decision
may submit evidence related to the issues in dispute.</text>
</subparagraph><subparagraph id="HB3344BEDCF5E4D72A07E644004055866"><enum>(G)</enum><header>Provision of
information</header><text>The plan or issuer involved shall provide timely
access to the external appeal entity to information and to provisions of the
plan or health insurance coverage relating to the matter of the externally
appealable decision, as determined by the entity.</text>
</subparagraph><subparagraph id="H1274F811880C4F6580C138B71B06058"><enum>(H)</enum><header>Timely
decisions</header><text>A determination by the external appeal entity on the
decision shall—</text>
<clause id="H966818745B7F46FBACE462EECDFD15A8"><enum>(i)</enum><text>be
made orally or in writing and, if it is made orally, shall be supplied to the
parties in writing as soon as possible;</text>
</clause><clause id="HF1C3D2C108A64D0E92AFD74DDFC398BE"><enum>(ii)</enum><text>be
made in accordance with the medical exigencies of the case involved, but in no
event later than 21 days after the date (or, in the case of an expedited
appeal, 72 hours after the time) of requesting an external appeal of the
decision;</text>
</clause><clause id="H2E4D7CA63D39440E009B1826026243CA"><enum>(iii)</enum><text>state, in
layperson’s language, the basis for the determination, including, if relevant,
any basis in the terms or conditions of the plan or coverage; and</text>
</clause><clause id="HEDF8453EEC4D4E1B95C5B9C882369395"><enum>(iv)</enum><text>inform the
participant, beneficiary, or enrollee of the individual’s rights (including any
limitation on such rights) to seek further review by the courts (or other
process) of the external appeal determination.</text>
<subclause id="H44ECC1E9D5DE42FA931584CCE9BEF350" indent="up2"><enum>(I)</enum><header>Compliance with
determination</header><text>If the external appeal entity reverses or modifies
the denial of a claim for benefits, the plan or issuer shall—</text>
</subclause></clause><clause id="HF4FE787F675347E9B8400035179B65DF"><enum>(i)</enum><text>upon
the receipt of the determination, authorize benefits in accordance with such
determination;</text>
</clause><clause id="HB493EAB559EA40A18450CD92DB327630"><enum>(ii)</enum><text>take such actions
as may be necessary to provide benefits (including items or services) in a
timely manner consistent with such determination; and</text>
</clause><clause id="HA814865ADC7B42ACB2D983006E05EC6D"><enum>(iii)</enum><text>submit
information to the entity documenting compliance with the entity’s
determination and this subparagraph.</text>
</clause></subparagraph></paragraph></subsection><subsection id="H0272FCCC40924C18B5EB2D631BF2842B"><enum>(c)</enum><header>Qualifications
of External Appeal Entities</header>
<paragraph id="HF1B773292EA04EABA5502F1437344430"><enum>(1)</enum><header>In
general</header><text>For purposes of this section, the term <term>qualified
external appeal entity</term> means, in relation to a plan or issuer, an entity
that is certified under paragraph (2) as meeting the following
requirements:</text>
<subparagraph id="H1508BA48DE324FB4B0D5C864AFC29966"><enum>(A)</enum><text>The entity meets
the independence requirements of paragraph (3).</text>
</subparagraph><subparagraph id="HD292AEA907F14CA9B685755750672051"><enum>(B)</enum><text>The entity
conducts external appeal activities through a panel of not fewer than 3
clinical peers.</text>
</subparagraph><subparagraph id="H25B0A81C9A4449F3AC00565D1589F425"><enum>(C)</enum><text>The entity has
sufficient medical, legal, and other expertise and sufficient staffing to
conduct external appeal activities for the plan or issuer on a timely basis
consistent with subsection (b)(2)(G).</text>
</subparagraph><subparagraph id="HBA269548F2174485AE4D79ACA5A770CD"><enum>(D)</enum><text>The entity meets
such other requirements as the appropriate Secretary may impose.</text>
</subparagraph></paragraph><paragraph id="HA53101EA1F904559A36850E9B8A626D"><enum>(2)</enum><header>Initial
certification of external appeal entities</header>
<subparagraph id="HBEFBF15F12E949C6BCC2F62B3C4935D7"><enum>(A)</enum><header>In
general</header><text>In order to be treated as a qualified external appeal
entity with respect to—</text>
<clause id="H93386768B80A4DF0B31917B7A7BC8C3F"><enum>(i)</enum><text>a
group health plan, the entity must be certified (and, in accordance with
subparagraph (B), periodically recertified) as meeting the requirements of
paragraph (1)—</text>
<subclause id="H571D429D19534C8C96FE5BDAA43908A7"><enum>(I)</enum><text>by the Secretary
of Labor;</text>
</subclause><subclause id="HAF0789C29BE648D7952E4F837907FB7"><enum>(II)</enum><text>under a process
recognized or approved by the Secretary of Labor; or</text>
</subclause><subclause id="H611DBA72F76248F5BF92B885724BD6C3"><enum>(III)</enum><text>to the extent
provided in subparagraph (C)(i), by a qualified private standard-setting
organization (certified under such subparagraph); or</text>
</subclause></clause><clause id="H1EE4850B322844488C98A7815A811F5"><enum>(ii)</enum><text>a
health insurance issuer operating in a State, the entity must be certified
(and, in accordance with subparagraph (B), periodically recertified) as meeting
such requirements—</text>
<subclause id="H022EF29F7AD146528221244D0205C1F"><enum>(I)</enum><text>by
the applicable State authority (or under a process recognized or approved by
such authority); or</text>
</subclause><subclause id="HF553D0F77F6D4FD28710C14AE827F00"><enum>(II)</enum><text>if the State has
not established a certification and recertification process for such entities,
by the Secretary of Health and Human Services, under a process recognized or
approved by such Secretary, or to the extent provided in subparagraph (C)(ii),
by a qualified private standard-setting organization (certified under such
subparagraph).</text>
</subclause></clause></subparagraph><subparagraph id="H1037C4C578F44D64B5ADA69543610E7"><enum>(B)</enum><header>Recertification
process</header><text>The appropriate Secretary shall develop standards for the
recertification of external appeal entities. Such standards shall include a
review of—</text>
<clause id="H41B9C4AE43AC4E08A4DA18E2540001B6"><enum>(i)</enum><text>the
number of cases reviewed;</text>
</clause><clause id="H7CB70075B44F4514884CD9BEDB24002F"><enum>(ii)</enum><text>a
summary of the disposition of those cases;</text>
</clause><clause id="H59B1146CD06F48F600D3F4605B7D3167"><enum>(iii)</enum><text>the length of
time in making determinations on those cases;</text>
</clause><clause id="H0BA3729A5BE94C97AB002EAA9B003804"><enum>(iv)</enum><text>updated
information of what was required to be submitted as a condition of
certification for the entity’s performance of external appeal activities;
and</text>
</clause><clause id="HC891FE0688B94105AAB987D54DE13437"><enum>(v)</enum><text>such
information as may be necessary to assure the independence of the entity from
the plans or issuers for which external appeal activities are being
conducted.</text>
</clause></subparagraph><subparagraph id="HCB9A3C425B124CC08219385182A3EF30"><enum>(C)</enum><header>Certification of
qualified private standard-setting organizations</header>
<clause id="H052EE524DAA846BA89553FDE91A900BA"><enum>(i)</enum><header>For external
reviews under group health plans</header><text>For purposes of subparagraph
(A)(i)(III), the Secretary of Labor may provide for a process for certification
(and periodic recertification) of qualified private standard-setting
organizations which provide for certification of external review entities. Such
an organization shall only be certified if the organization does not certify an
external review entity unless it meets standards required for certification of
such an entity by such Secretary under subparagraph (A)(i)(I).</text>
</clause><clause id="H1978FF51AC4A49428F467E029DB90843"><enum>(ii)</enum><header>For external
reviews of health insurance issuers</header><text>For purposes of subparagraph
(A)(ii)(II), the Secretary of Health and Human Services may provide for a
process for certification (and periodic recertification) of qualified private
standard-setting organizations which provide for certification of external
review entities. Such an organization shall only be certified if the
organization does not certify an external review entity unless it meets
standards required for certification of such an entity by such Secretary under
subparagraph (A)(ii)(II).</text>
</clause></subparagraph></paragraph><paragraph id="HC90732E0157B43B89C4B7536623BD76E"><enum>(3)</enum><header>Independence
requirements</header>
<subparagraph id="HD71B9D0E38A74FE4BD7EB0CBCFC1BC9"><enum>(A)</enum><header>In
general</header><text>A clinical peer or other entity meets the independence
requirements of this paragraph if—</text>
<clause id="H39CC2F5AD86A4D3B8028E074AB701F87"><enum>(i)</enum><text>the
peer or entity does not have a familial, financial, or professional
relationship with any related party;</text>
</clause><clause id="HB368BB4B39B74AF58F9D5C19AF12D188"><enum>(ii)</enum><text>any
compensation received by such peer or entity in connection with the external
review is reasonable and not contingent on any decision rendered by the peer or
entity;</text>
</clause><clause id="H686EFDB68E4C4C15B33094F9AE569B67"><enum>(iii)</enum><text>except as
provided in paragraph (4), the plan and the issuer have no recourse against the
peer or entity in connection with the external review; and</text>
</clause><clause id="HF2EC34F0C7EC4602A183C76EF75E65EB"><enum>(iv)</enum><text>the
peer or entity does not otherwise have a conflict of interest with a related
party as determined under any regulations which the Secretary may
prescribe.</text>
</clause></subparagraph><subparagraph id="HF8460671866242508F5F4E00B6EEDB25"><enum>(B)</enum><header>Related
party</header><text>For purposes of this paragraph, the term <term>related
party</term> means—</text>
<clause id="HBF838132A882458382B2032118012C39"><enum>(i)</enum><text>with
respect to—</text>
<subclause id="HBB1B261734F74C16AF66070076005098"><enum>(I)</enum><text>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</text>
</subclause><subclause id="H7D52EE3BB0044F11ABC9127B5B37C9B4"><enum>(II)</enum><text>individual health
insurance coverage, the health insurance issuer offering such coverage,</text>
</subclause><continuation-text continuation-text-level="clause">or any plan
sponsor, fiduciary, officer, director, or management employee of such plan or
issuer;</continuation-text></clause><clause id="H288270406EFC45BAB922D22C9BCECE5F"><enum>(ii)</enum><text>the
health care professional that provided the health care involved in the coverage
decision;</text>
</clause><clause id="H502620F5AC6849A9AF634935A6D9C83C"><enum>(iii)</enum><text>the institution
at which the health care involved in the coverage decision is provided;</text>
</clause><clause id="HB25E8F54625544409FD1F277633FF8A"><enum>(iv)</enum><text>the
manufacturer of any drug or other item that was included in the health care
involved in the coverage decision; or</text>
</clause><clause id="H1211C32711644296962BB40017F435A3"><enum>(v)</enum><text>any
other party determined under any regulations which the Secretary may prescribe
to have a substantial interest in the coverage decision.</text>
</clause></subparagraph></paragraph><paragraph id="H44A98E6918AA468BA6A5AA2813716957"><enum>(4)</enum><header>Limitation on
liability of reviewers</header><text>No qualified external appeal entity having
a contract with a plan or issuer under this part and no person who is employed
by any such entity or who furnishes professional services to such entity, shall
be held by reason of the performance of any duty, function, or activity
required or authorized pursuant to this section, to have violated any criminal
law, or to be civilly liable under any law of the United States or of any State
(or political subdivision thereof) if due care was exercised in the performance
of such duty, function, or activity and there was no actual malice or gross
misconduct in the performance of such duty, function, or activity.</text>
</paragraph></subsection><subsection id="H6F97684F743F4A73AB5B89228E0779AE"><enum>(d)</enum><header>External Appeal
Determination Binding on Plan</header><text>The determination by an external
appeal entity under this section is binding on the plan and issuer involved in
the determination.</text>
</subsection><subsection id="H3C5B840888C54C8A909ECFBF3359046"><enum>(e)</enum><header>Penalties Against
Authorized Officials for Refusing to Authorize the Determination of an External
Review Entity</header>
<paragraph id="H23783384F90943AFAB00E763DDF82613"><enum>(1)</enum><header>Monetary
penalties</header><text>In any case in which the determination of an external
review entity is not followed by a group health plan, or by a health insurance
issuer offering health insurance coverage, any person who, acting in the
capacity of authorizing the benefit, causes such refusal may, in the discretion
in a court of competent jurisdiction, be liable to an aggrieved participant,
beneficiary, or enrollee for a civil penalty in an amount of up to $1,000 a day
from the date on which the determination was transmitted to the plan or issuer
by the external review entity until the date the refusal to provide the benefit
is corrected.</text>
</paragraph><paragraph id="HC933FF2C9FE742A9965C354F86858CC"><enum>(2)</enum><header>Cease and desist
order and order of attorney’s fees</header><text>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 a plaintiff alleges that a person referred to in such
paragraph has taken an action resulting in a refusal of a benefit determined by
an external appeal entity in violation of such terms of the plan, coverage, or
this subtitle, 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 authorizing a benefit, the court shall cause to
be served on the defendant an order requiring the defendant—</text>
<subparagraph id="H8701D6ED669640DE9B44C0EBD7321236"><enum>(A)</enum><text>to cease and
desist from the alleged action or failure to act; and</text>
</subparagraph><subparagraph id="H2BDEE379D6DD49FF8F44BB39D0BF92B6"><enum>(B)</enum><text>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.</text>
</subparagraph></paragraph><paragraph id="HE7D7EA90B00946C5BFA62DD46986CC00"><enum>(3)</enum><header>Additional civil
penalties</header>
<subparagraph id="HE0E6CCA6A3784816924245209EE22021"><enum>(A)</enum><header>In
general</header><text>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 authorizing a benefit determined by an external
review entity for one or more group health plans, or health insurance issuers
offering health insurance coverage, for—</text>
<clause id="H46E0C057CF8C49DFA83FE9C52F90DA8E"><enum>(i)</enum><text>any
pattern or practice of repeated refusal to authorize a benefit determined by an
external appeal entity in violation of the terms of such a plan, coverage, or
this title; or</text>
</clause><clause id="H1545E41531B84D7E868EFF6AF4D83F6"><enum>(ii)</enum><text>any
pattern or practice of repeated violations of the requirements of this section
with respect to such plan or plans or coverage.</text>
</clause></subparagraph><subparagraph id="H54E95F72641745F788E9F12B2F5DCF00"><enum>(B)</enum><header>Standard of
proof and amount of penalty</header><text>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—</text>
<clause id="HB67191B872C44C24B26E00CB13753719"><enum>(i)</enum><text>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</text>
</clause><clause id="HD4BF10E9597444D9A000FB08B36500C0"><enum>(ii)</enum><text>$500,000.</text>
</clause></subparagraph></paragraph><paragraph id="H433598EBC01740DEA0ADCBDEF330E5BC"><enum>(4)</enum><header>Removal and
disqualification</header><text>Any person acting in the capacity of authorizing
benefits 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 such 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.</text>
</paragraph></subsection><subsection id="H1A798846F32949ACA6AD18190835C5C1"><enum>(f)</enum><header>Protection of
Legal Rights</header><text>Nothing in this subtitle shall be construed as
altering or eliminating any cause of action or legal rights or remedies of
participants, beneficiaries, enrollees, and others under State or Federal law
(including sections 502 and 503 of the <act-name parsable-cite="ERISA">Employee
Retirement Income Security Act of 1974</act-name>), including the right to file
judicial actions to enforce actions.</text>
</subsection></section><section id="H69327213EC04454A931165F9C44EC98E"><enum>104.</enum><header>Establishment
of a grievance process</header>
<subsection id="HE0B0499342DB41B6A0236E97D105890"><enum>(a)</enum><header>Establishment of
Grievance System</header>
<paragraph id="H1E7FECD2626241199E0094C219BA942E"><enum>(1)</enum><header>In
general</header><text>A group health plan, and a health insurance issuer in
connection with the provision of health insurance coverage, shall establish and
maintain a system to provide for the presentation and resolution of oral and
written grievances brought by individuals who are participants, beneficiaries,
or enrollees, or health care providers or other individuals acting on behalf of
an individual and with the individual’s consent or without such consent if the
individual is medically unable to provide such consent, regarding any aspect of
the plan’s or issuer’s services.</text>
</paragraph><paragraph id="HA11DDE09BF43472A91D5F54A6E74280"><enum>(2)</enum><header>Grievance
defined</header><text>In this section, the term <term>grievance</term> means
any question, complaint, or concern brought by a participant, beneficiary or
enrollee that is not a claim for benefits (as defined in section
101(f)(1)).</text>
</paragraph></subsection><subsection id="H55C9D42DFCB1447E98DF2D5F18E1DAB3"><enum>(b)</enum><header>Grievance
System</header><text>Such system shall include the following components with
respect to individuals who are participants, beneficiaries, or
enrollees:</text>
<paragraph id="H8B2F7DE3AB5D4760A249B426DBED6533"><enum>(1)</enum><text>Written
notification to all such individuals and providers of the telephone numbers and
business addresses of the plan or issuer personnel responsible for resolution
of grievances and appeals.</text>
</paragraph><paragraph id="H519ADAFFA4104C26A7D4C992F0944098"><enum>(2)</enum><text>A
system to record and document, over a period of at least 3 previous years, all
grievances and appeals made and their status.</text>
</paragraph><paragraph id="H72881CF079634FE2AFFA6B4FFF6B3169"><enum>(3)</enum><text>A
process providing for timely processing and resolution of grievances.</text>
</paragraph><paragraph id="HD0A0276026BD44DDBBAF259D8BCC153B"><enum>(4)</enum><text>Procedures for
follow-up action, including the methods to inform the person making the
grievance of the resolution of the grievance.</text>
</paragraph><continuation-text continuation-text-level="subsection">Grievances
are not subject to appeal under the previous provisions of this
subtitle.</continuation-text></subsection></section></subtitle><subtitle id="HE527757A27954B2D003157F3E89A200"><enum>B</enum><header>Access to
Care</header>
<section id="HC0F8C87136974CECB5406662B7619EBD"><enum>111.</enum><header>Consumer choice
option</header>
<subsection id="H06D3BBE7FE614191A8D74FBA9134BDE4"><enum>(a)</enum><header>In
General</header><text>If a health insurance issuer offers to enrollees health
insurance coverage in connection with a group health plan which provides for
coverage of services only if such services are furnished through health care
professionals and providers who are members of a network of health care
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 and during an annual open season as provided under
subsection (c)) the option of health insurance coverage which provides for
coverage of such services which are not furnished through health care
professionals and providers who are members of such a network unless enrollees
are offered such non-network coverage through another group health plan or
through another health insurance issuer in the group market.</text>
</subsection><subsection id="HC33F8198A14442259E407DA08C5E2CC7"><enum>(b)</enum><header>Additional
Costs</header><text>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) and the amount of any additional cost
sharing imposed under such option shall be borne by the enrollee unless it is
paid by the health plan sponsor through agreement with the health insurance
issuer.</text>
</subsection><subsection id="HC32499FFDEA8430C9871E421F3136FDC"><enum>(c)</enum><header>Open
Season</header><text>An enrollee may 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.</text>
</subsection></section><section id="H1391F89190364AAFBF44ABF2130077FE"><enum>112.</enum><header>Choice of
health care professional</header>
<subsection id="HA42AC064C87D4E608EB19CE72CA8D4BE"><enum>(a)</enum><header>Primary
Care</header><text>If a group health plan, or a health insurance issuer that
offers health insurance coverage, requires or provides for designation by a
participant, beneficiary, or enrollee of a participating primary care provider,
then the plan or issuer shall permit each participant, beneficiary, and
enrollee to designate any participating primary care provider who is available
to accept such individual.</text>
</subsection><subsection id="H9602EE808D5F4298A63248B3BFF0A079"><enum>(b)</enum><header>Specialists</header>
<paragraph id="HE6D0E58E01AE4A76823F28A663139D1E"><enum>(1)</enum><header>In
general</header><text>Subject to paragraph (2), a group health plan and a
health insurance issuer that offers health insurance coverage shall permit each
participant, beneficiary, or enrollee to receive medically necessary or
appropriate specialty care, pursuant to appropriate referral procedures, from
any qualified participating health care professional who is available to accept
such individual for such care.</text>
</paragraph><paragraph id="HA9F34C00CD6B49CA998421CCFEEF008"><enum>(2)</enum><header>Limitation</header><text>Paragraph
(1) shall not apply to specialty care if the plan or issuer clearly informs
participants, beneficiaries, and enrollees of the limitations on choice of
participating health care professionals with respect to such care.</text>
</paragraph></subsection></section><section id="HC851DBA218FE4A38B0F27FE449AD2F4E"><enum>113.</enum><header>Access to
emergency care</header>
<subsection id="HD2AE554470734FB5B8443E7E7EC9D08D"><enum>(a)</enum><header>Coverage of
Emergency Services</header>
<paragraph id="HD3116EA1DFF94C33882F26DEAF310327"><enum>(1)</enum><header>In
general</header><text>If a group health plan, or health insurance coverage
offered by a health insurance issuer, provides any benefits with respect to
services in an emergency department of a hospital, the plan or issuer shall
cover emergency services (as defined in paragraph (2)(B))—</text>
<subparagraph id="H9E8A2B1C67B04AACB5A84EE4EE00004"><enum>(A)</enum><text>without the need
for any prior authorization determination;</text>
</subparagraph><subparagraph id="H5D3AC6C083C747A685451F4325CA6BEB"><enum>(B)</enum><text>whether or not the
health care provider furnishing such services is a participating provider with
respect to such services;</text>
</subparagraph><subparagraph id="H62F47A12A94D4A8AB500681DA5F57108"><enum>(C)</enum><text>in a manner so
that, if such services are provided to a participant, beneficiary, or
enrollee—</text>
<clause id="H0492E02F16EA434FBBCCEEF23C30D0AC"><enum>(i)</enum><text>by a
nonparticipating health care provider with or without prior authorization,
or</text>
</clause><clause id="H8C39E31E121544D1B2D60300EA682C0"><enum>(ii)</enum><text>by a
participating health care provider without prior authorization,</text>
</clause><continuation-text continuation-text-level="subparagraph">the
participant, beneficiary, or enrollee is not liable for amounts that exceed the
amounts of liability that would be incurred if the services were provided by a
participating health care provider with prior authorization; and</continuation-text></subparagraph><subparagraph id="H697C8DBB00A640068C2E19202C73C66F"><enum>(D)</enum><text>without regard to
any other term or condition of such coverage (other than exclusion or
coordination of benefits, or an affiliation or waiting period, permitted under
section 2701 of the <act-name parsable-cite="PHSA">Public Health Service
Act</act-name>, section 701 of the <act-name parsable-cite="ERISA">Employee
Retirement Income Security Act of 1974</act-name>, or section 9801 of the
Internal Revenue Code of 1986, and other than applicable cost-sharing).</text>
</subparagraph></paragraph><paragraph id="H70B2D06D48B246728C20CCD37E00AE10"><enum>(2)</enum><header>Definitions</header><text>In
this section:</text>
<subparagraph id="HB9F4E9A8303C447F873CE884856BEF2"><enum>(A)</enum><header>Emergency medical
condition based on prudent layperson standard</header><text>The term
<term>emergency medical condition</term> means a medical condition manifesting
itself by acute symptoms of sufficient severity (including severe pain) such
that a prudent layperson, who possesses an average knowledge of health and
medicine, could reasonably expect the absence of immediate medical attention to
result in a condition described in clause (i), (ii), or (iii) of section
1867(e)(1)(A) of the <act-name parsable-cite="SSA">Social Security
Act</act-name>.</text>
</subparagraph><subparagraph id="H87455C39083F4162ABDB5CFAF64F7392"><enum>(B)</enum><header>Emergency
services</header><text>The term <term>emergency services</term> means—</text>
<clause id="HC44F62E885A34762996FA1B89F284327"><enum>(i)</enum><text>a
medical screening examination (as required under section 1867 of the
<act-name parsable-cite="SSA">Social Security Act</act-name>) that is within
the capability 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 subparagraph (A)), and</text>
</clause><clause id="HC10B523612A8448F00D9D0A8C8AB5E1E"><enum>(ii)</enum><text>within the
capabilities of the staff and facilities available at the hospital, such
further medical examination and treatment as are required under section 1867 of
such Act to stabilize the patient.</text>
</clause></subparagraph><subparagraph id="H5C1566A084F74DCB809125261EB9B34"><enum>(C)</enum><header>Stabilize</header><text>The
term <term>to stabilize</term> 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.</text>
</subparagraph></paragraph></subsection><subsection id="H83B6D43E8D624C41A259008D722FC348"><enum>(b)</enum><header>Reimbursement
for Maintenance Care and Post-Stabilization Care</header><text>If benefits are
available under a group health plan, or under health insurance coverage offered
by a health insurance issuer, with respect to maintenance care or
post-stabilization care covered under the guidelines established under section
1852(d)(2) of the <act-name parsable-cite="SSA">Social Security Act</act-name>,
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 provider in a manner consistent with subsection
(a)(1)(C) (and shall otherwise comply with such guidelines).</text>
</subsection></section><section id="H197CC2D819CE4066842171835B9F0952"><enum>114.</enum><header>Access to
specialty care</header>
<subsection id="H14D96E22DB7B44A1849EFFA16346B54"><enum>(a)</enum><header>Specialty Care
for Covered Services</header>
<paragraph id="HADCFE709814D48FEA31C7070B9402567"><enum>(1)</enum><header>In
general</header><text>If—</text>
<subparagraph id="HA387EB9467204FCF9D3841E7315577C0"><enum>(A)</enum><text>an individual is a
participant or beneficiary under a group health plan or an enrollee who is
covered under health insurance coverage offered by a health insurance
issuer,</text>
</subparagraph><subparagraph id="H8668B651D38F44BD8F321200F43541EE"><enum>(B)</enum><text>the individual has
a condition or disease of sufficient seriousness and complexity to require
treatment by a specialist, and</text>
</subparagraph><subparagraph id="HCE7B6595B64B471AADC587B94FD995AA"><enum>(C)</enum><text>benefits for such
treatment are provided under the plan or coverage,</text>
</subparagraph><continuation-text continuation-text-level="paragraph">the plan or
issuer shall make or provide for a referral to a specialist who is available
and accessible to provide the treatment for such condition or disease.</continuation-text></paragraph><paragraph id="H95DA28C853754040B3B9BF62CB5E9FDE"><enum>(2)</enum><header>Specialist
defined</header><text>For purposes of this subsection, the term
<term>specialist</term> means, with respect to a condition, a health care
practitioner, facility, or center that has adequate expertise through
appropriate training and experience (including, in the case of a child,
appropriate pediatric expertise) to provide high quality care in treating the
condition.</text>
</paragraph><paragraph id="H9CB9765341C845DC9FE3AE935E6F9D05"><enum>(3)</enum><header>Care under
referral</header><text>A group health plan or health insurance issuer may
require that the care provided to an individual pursuant to such referral under
paragraph (1) be—</text>
<subparagraph id="H39732C4E183F4B56BC709108618C14E1"><enum>(A)</enum><text>pursuant to a
treatment plan, only if the treatment plan is developed by the specialist and
approved by the plan or issuer, in consultation with the designated primary
care provider or specialist and the individual (or the individual’s designee),
and</text>
</subparagraph><subparagraph id="HB5F72F89D42242F8AE81B7D02343E77E"><enum>(B)</enum><text>in accordance with
applicable quality assurance and utilization review standards of the plan or
issuer.</text>
</subparagraph><continuation-text continuation-text-level="paragraph">Nothing in
this subsection shall be construed as preventing such a treatment plan for an
individual from requiring a specialist to provide the primary care provider
with regular updates on the specialty care provided, as well as all necessary
medical information.</continuation-text></paragraph><paragraph id="H6CD5FAD6E67A4EE6A1E24DA5300096EC"><enum>(4)</enum><header>Referrals to
participating providers</header><text>A group health plan or health insurance
issuer is not required under paragraph (1) to provide for a referral to a
specialist that is not a participating provider, unless the plan or issuer does
not have an appropriate specialist that is available and accessible to treat
the individual’s condition and that is a participating provider with respect to
such treatment.</text>
</paragraph><paragraph id="H964849B945084D199FFD4DB057501170"><enum>(5)</enum><header>Treatment of
nonparticipating providers</header><text>If a plan or issuer refers an
individual to a nonparticipating specialist pursuant to paragraph (1), services
provided pursuant to the approved treatment plan (if any) shall be provided at
no additional cost to the individual beyond what the individual would otherwise
pay for services received by such a specialist that is a participating
provider.</text>
</paragraph></subsection><subsection id="HB33F240009DC4A39B299AA762C1F4CEA"><enum>(b)</enum><header>Specialists as
Gatekeeper for Treatment of Ongoing Special Conditions</header>
<paragraph id="HB44E937467834EEAB4C0D6B44D7886AF"><enum>(1)</enum><header>In
general</header><text>A group health plan, or a health insurance issuer, in
connection with the provision of health insurance coverage, shall have a
procedure by which an individual who is a participant, beneficiary, or enrollee
and who has an ongoing special condition (as defined in paragraph (3)) may
request and receive a referral to a specialist for such condition who shall be
responsible for and capable of providing and coordinating the individual’s care
with respect to the condition. Under such procedures if such an individual’s
care would most appropriately be coordinated by such a specialist, such plan or
issuer shall refer the individual to such specialist.</text>
</paragraph><paragraph id="H8A0593638C7E4F72B4F902BD789C3E40"><enum>(2)</enum><header>Treatment for
related referrals</header><text>Such specialists shall be permitted to treat
the individual without a referral from the individual’s primary care provider
and may authorize such referrals, procedures, tests, and other medical services
as the individual’s primary care provider would otherwise be permitted to
provide or authorize, subject to the terms of the treatment (referred to in
subsection (a)(3)(A)) with respect to the ongoing special condition.</text>
</paragraph><paragraph id="H1F431B3AD878457E8B2DB540B19D5987"><enum>(3)</enum><header>Ongoing special
condition defined</header><text>In this subsection, the term <term>ongoing
special condition</term> means a condition or disease that—</text>
<subparagraph id="H2BE980099703402BBD705994B1FCBD67"><enum>(A)</enum><text>is
life-threatening, degenerative, or disabling, and</text>
</subparagraph><subparagraph id="H7A348D06D96A43CCB8A83400BC83F6AE"><enum>(B)</enum><text>requires
specialized medical care over a prolonged period of time.</text>
</subparagraph></paragraph><paragraph id="H6C088A9501174FD1A024BE3DFBA9D0A7"><enum>(4)</enum><header>Terms of
referral</header><text>The provisions of paragraphs (3) through (5) of
subsection (a) apply with respect to referrals under paragraph (1) of this
subsection in the same manner as they apply to referrals under subsection
(a)(1).</text>
</paragraph></subsection><subsection id="HC4BE0D797E9A4472B0DF6B250268670"><enum>(c)</enum><header>Standing
Referrals</header>
<paragraph id="H7889003ADB4E432D90BE8D65C654969B"><enum>(1)</enum><header>In
general</header><text>A group health plan, and a health insurance issuer in
connection with the provision of health insurance coverage, shall have a
procedure by which an individual who is a participant, beneficiary, or enrollee
and who has a condition that requires ongoing care from a specialist may
receive a standing referral to such specialist for treatment of such condition.
If the plan or issuer, or if the primary care provider in consultation with the
medical director of the plan or issuer and the specialist (if any), determines
that such a standing referral is appropriate, the plan or issuer shall make
such a referral to such a specialist if the individual so desires.</text>
</paragraph><paragraph id="H694B18ACC348461A0072DCB26344B4A4"><enum>(2)</enum><header>Terms of
referral</header><text>The provisions of paragraphs (3) through (5) of
subsection (a) apply with respect to referrals under paragraph (1) of this
subsection in the same manner as they apply to referrals under subsection
(a)(1).</text>
</paragraph></subsection></section><section id="H3CA25906ABEA45C5B534E3ADDDD953C8"><enum>115.</enum><header>Access to
obstetrical and gynecological care</header>
<subsection id="H8FB11433000B4E3F8D278EA362A13707"><enum>(a)</enum><header>In
General</header><text>If a group health plan, or a health insurance issuer in
connection with the provision of health insurance coverage, requires or
provides for a participant, beneficiary, or enrollee to designate a
participating primary care health care professional, the plan or issuer—</text>
<paragraph id="H152D61F044594781ACBC86561E767099"><enum>(1)</enum><text>may not require
authorization or a referral by the individual’s primary care health care
professional or otherwise for coverage of gynecological care (including
preventive women’s health examinations) and pregnancy-related services provided
by a participating health care professional, including a physician, who
specializes in obstetrics and gynecology to the extent such care is otherwise
covered, and</text>
</paragraph><paragraph id="HFA1FAD7CA8C84818AE4E19ECC6CB5491"><enum>(2)</enum><text>shall treat the
ordering of other obstetrical or gynecological care by such a participating
professional as the authorization of the primary care health care professional
with respect to such care under the plan or coverage.</text>
</paragraph></subsection><subsection id="H3220974CF70941C5977F61E5EEC3A06B"><enum>(b)</enum><header>Construction</header><text>Nothing
in subsection (a) shall be construed to—</text>
<paragraph id="H8C676866B2CF4AE3B064561028662466"><enum>(1)</enum><text>waive any
exclusions of coverage under the terms of the plan or health insurance coverage
with respect to coverage of obstetrical or gynecological care; or</text>
</paragraph><paragraph id="HB7C3D96CBF9E43ED9348464175D49CFF"><enum>(2)</enum><text>preclude the group
health plan or health insurance issuer involved from requiring that the
obstetrical or gynecological provider notify the primary care health care
professional or the plan or issuer of treatment decisions.</text>
</paragraph></subsection></section><section id="H9BAED2225D5E4623906D436C5EB28B27"><enum>116.</enum><header>Access to
pediatric care</header>
<subsection id="H81DC18FF44C245B9A2E5D361688F8972"><enum>(a)</enum><header>Pediatric
Care</header><text>If a group health plan, or a health insurance issuer in
connection with the provision of health insurance coverage, requires or
provides for an enrollee to designate a participating primary care provider for
a child of such enrollee, the plan or issuer shall permit the enrollee to
designate a physician who specializes in pediatrics as the child’s primary care
provider.</text>
</subsection><subsection id="H57F975CEA9BC4497009F5C7850E2D36E"><enum>(b)</enum><header>Construction</header><text>Nothing
in subsection (a) shall be construed to waive any exclusions of coverage under
the terms of the plan or health insurance coverage with respect to coverage of
pediatric care.</text>
</subsection></section><section id="HC5CB1E3545434989BCD98321A149CD28"><enum>117.</enum><header>Continuity of
care</header>
<subsection id="H37CCD7DF473D43B6A6C17AD51C496A1"><enum>(a)</enum><header>In
General</header>
<paragraph id="H58FE423103EC4C978839A2A055F8C748"><enum>(1)</enum><header>Termination of
provider</header><text>If a contract between a group health plan, or a health
insurance issuer in connection with the provision of health insurance coverage,
and a health care provider is terminated (as defined in paragraph (3)(B)), or
benefits or coverage provided by a health care provider are terminated because
of a change in the terms of provider participation in a group health plan, and
an individual who is a participant, beneficiary, or enrollee in the plan or
coverage is undergoing treatment from the provider for an ongoing special
condition (as defined in paragraph (3)(A)) at the time of such termination, the
plan or issuer shall—</text>
<subparagraph id="HC544DF3B6F4F4282B6D5B0C6C2976EA2"><enum>(A)</enum><text>notify the
individual on a timely basis of such termination and of the right to elect
continuation of coverage of treatment by the provider under this section;
and</text>
</subparagraph><subparagraph id="H7731525267924820AB2FA2D0B988928E"><enum>(B)</enum><text>subject to
subsection (c), permit the individual to elect to continue to be covered with
respect to treatment by the provider of such condition during a transitional
period (provided under subsection (b)).</text>
</subparagraph></paragraph><paragraph id="H279B59F3D1874C5699E4EAEC8BC53E6"><enum>(2)</enum><header>Treatment of
termination of contract with health insurance issuer</header><text>If a
contract for the provision of health insurance coverage between a group health
plan and a health insurance issuer is terminated and, as a result of such
termination, coverage of services of a health care provider is terminated with
respect to an individual, the provisions of paragraph (1) (and the succeeding
provisions of this section) shall apply under the plan in the same manner as if
there had been a contract between the plan and the provider that had been
terminated, but only with respect to benefits that are covered under the plan
after the contract termination.</text>
</paragraph><paragraph id="HBA976696683F480589B22777F400FB29"><enum>(3)</enum><header>Definitions</header><text>For
purposes of this section:</text>
<subparagraph id="HAE918041A8B441C19BAE53B73F49C3F5"><enum>(A)</enum><header>Ongoing special
condition</header><text>The term <term>ongoing special condition</term> has the
meaning given such term in section 114(b)(3), and also includes
pregnancy.</text>
</subparagraph><subparagraph id="H34DEE60A8962411DA762003401005592"><enum>(B)</enum><header>Termination</header><text>The
term <term>terminated</term> includes, with respect to a contract, the
expiration or nonrenewal of the contract, but does not include a termination of
the contract by the plan or issuer for failure to meet applicable quality
standards or for fraud.</text>
</subparagraph></paragraph></subsection><subsection id="HF6AD44B4897A4BA78336D6C345C41E64"><enum>(b)</enum><header>Transitional
Period</header>
<paragraph id="H062E1AB45FEE43E69291CC127454F1E9"><enum>(1)</enum><header>In
general</header><text>Except as provided in paragraphs (2) through (4), the
transitional period under this subsection shall extend up to 90 days (as
determined by the treating health care professional) after the date of the
notice described in subsection (a)(1)(A) of the provider’s termination.</text>
</paragraph><paragraph id="HFC5DF59A26E34A53001033F26608BEA2"><enum>(2)</enum><header>Scheduled
surgery and organ transplantation</header><text>If surgery or organ
transplantation was scheduled for an individual before the date of the
announcement of the termination of the provider status under subsection
(a)(1)(A) or if the individual on such date was on an established waiting list
or otherwise scheduled to have such surgery or transplantation, the
transitional period under this subsection with respect to the surgery or
transplantation shall extend beyond the period under paragraph (1) and until
the date of discharge of the individual after completion of the surgery or
transplantation.</text>
</paragraph><paragraph id="HB3A928B438864C490045064C06C98566"><enum>(3)</enum><header>Pregnancy</header><text>If—</text>
<subparagraph id="H4919F50665FB46A795DACCB00024E75"><enum>(A)</enum><text>a participant,
beneficiary, or enrollee was determined to be pregnant at the time of a
provider’s termination of participation, and</text>
</subparagraph><subparagraph id="HCA096FEE167940AF902BC15C5D382D8D"><enum>(B)</enum><text>the provider was
treating the pregnancy before date of the termination,</text>
</subparagraph><continuation-text continuation-text-level="paragraph">the
transitional period under this subsection with respect to provider’s treatment
of the pregnancy shall extend through the provision of post-partum care
directly related to the delivery.</continuation-text></paragraph><paragraph id="H7A98698D411346F08DF424C189DA96F"><enum>(4)</enum><header>Terminal
illness</header><text>If—</text>
<subparagraph id="HF574E0553841484C90961746F42CD86F"><enum>(A)</enum><text>a participant,
beneficiary, or enrollee was determined to be terminally ill (as determined
under section 1861(dd)(3)(A) of the <act-name parsable-cite="SSA">Social
Security Act</act-name>) at the time of a provider’s termination of
participation, and</text>
</subparagraph><subparagraph id="H43B56B1A54A74B5BBEC95DA13C793B63"><enum>(B)</enum><text>the provider was
treating the terminal illness before the date of termination,</text>
</subparagraph><continuation-text continuation-text-level="paragraph">the
transitional period under this subsection shall extend for the remainder of the
individual’s life for care directly related to the treatment of the terminal
illness or its medical manifestations.</continuation-text></paragraph></subsection><subsection id="H92F761E1FC8D4D8BBF3CA4A649BC88BC"><enum>(c)</enum><header>Permissible
Terms and Conditions</header><text>A group health plan or health insurance
issuer may condition coverage of continued treatment by a provider under
subsection (a)(1)(B) upon the individual notifying the plan of the election of
continued coverage and upon the provider agreeing to the following terms and
conditions:</text>
<paragraph id="HD99CC89ADEF44657BEDCCCCF4293D13"><enum>(1)</enum><text>The provider agrees
to accept reimbursement from the plan or issuer and individual involved (with
respect to cost-sharing) at the rates applicable prior to the start of the
transitional period as payment in full (or, in the case described in subsection
(a)(2), at the rates applicable under the replacement plan or issuer after the
date of the termination of the contract with the health insurance issuer) and
not to impose cost-sharing with respect to the individual in an amount that
would exceed the cost-sharing that could have been imposed if the contract
referred to in subsection (a)(1) had not been terminated.</text>
</paragraph><paragraph id="HE0A5E50CF5F14C3FB952C2FF868F2358"><enum>(2)</enum><text>The provider
agrees to adhere to the quality assurance standards of the plan or issuer
responsible for payment under paragraph (1) and to provide to such plan or
issuer necessary medical information related to the care provided.</text>
</paragraph><paragraph id="H9E9E90B7766C41F3BCFCA32756EEB2F"><enum>(3)</enum><text>The provider agrees
otherwise to adhere to such plan’s or issuer’s policies and procedures,
including procedures regarding referrals and obtaining prior authorization and
providing services pursuant to a treatment plan (if any) approved by the plan
or issuer.</text>
</paragraph></subsection><subsection id="H09624FD54BBA4F9896FDE74255F383C"><enum>(d)</enum><header>Construction</header><text>Nothing
in this section shall be construed to require the coverage of benefits which
would not have been covered if the provider involved remained a participating
provider.</text>
</subsection></section><section id="H05DF4F5919EE4CE6B3883C26466F0346"><enum>118.</enum><header>Access to
needed prescription drugs</header><text display-inline="no-display-inline">If a
group health plan, or health insurance issuer that offers health insurance
coverage, provides benefits with respect to prescription drugs but the coverage
limits such benefits to drugs included in a formulary, the plan or issuer
shall—</text>
<paragraph id="H51230694D1CF48E7870255E82300E568"><enum>(1)</enum><text>ensure
participation of participating physicians and pharmacists in the development of
the formulary;</text>
</paragraph><paragraph id="HBDBA38F8444042F298BFBA57B83F06FF"><enum>(2)</enum><text>disclose to
providers and, disclose upon request under section 121(c)(5) to participants,
beneficiaries, and enrollees, the nature of the formulary restrictions;
and</text>
</paragraph><paragraph id="H3E18D44945BC40EAB2E1FD913DEE9B36"><enum>(3)</enum><text>consistent with
the standards for a utilization review program under section 101, provide for
exceptions from the formulary limitation when a non-formulary alternative is
medically indicated.</text>
</paragraph></section><section id="H5B624447838B418FB9E66A7436CB805"><enum>119.</enum><header>Coverage for
individuals participating in approved clinical trials</header>
<subsection id="H9FBC3671802D405FBD75A12DCBD703CA"><enum>(a)</enum><header>Coverage</header>
<paragraph id="HFB29C278A3DD429C859653D6673E70E"><enum>(1)</enum><header>In
general</header><text>If a group health plan, or health insurance issuer that
is providing health insurance coverage, provides coverage to a qualified
individual (as defined in subsection (b)), the plan or issuer—</text>
<subparagraph id="H74B6A804AEEC4F39939F8CE140B51649"><enum>(A)</enum><text>may not deny the
individual participation in the clinical trial referred to in subsection
(b)(2);</text>
</subparagraph><subparagraph id="HB6351B654BDF459AA98159491C7F632C"><enum>(B)</enum><text>subject to
subsection (c), may not deny (or limit or impose additional conditions on) the
coverage of routine patient costs for items and services furnished in
connection with participation in the trial; and</text>
</subparagraph><subparagraph id="H9B9D710A198947C48DFE1CE4376B0069"><enum>(C)</enum><text>may not
discriminate against the individual on the basis of the enrollee’s
participation in such trial.</text>
</subparagraph></paragraph><paragraph id="H6F7FD049794A4DE1920020C76D57D28E"><enum>(2)</enum><header>Exclusion of
certain costs</header><text>For purposes of paragraph (1)(B), routine patient
costs do not include the cost of the tests or measurements conducted primarily
for the purpose of the clinical trial involved.</text>
</paragraph><paragraph id="HCDFBEE6461DA4EA69B5325005115FDCF"><enum>(3)</enum><header>Use of
in-network providers</header><text>If one or more participating providers is
participating in a clinical trial, nothing in paragraph (1) shall be construed
as preventing a plan or issuer from requiring that a qualified individual
participate in the trial through such a participating provider if the provider
will accept the individual as a participant in the trial.</text>
</paragraph></subsection><subsection id="H839C058E0A284974B356816B728158FB"><enum>(b)</enum><header>Qualified
Individual Defined</header><text>For purposes of subsection (a), the term
<term>qualified individual</term> means an individual who is a participant or
beneficiary in a group health plan, or who is an enrollee under health
insurance coverage, and who meets the following conditions:</text>
<paragraph id="H13E6B67DB56A47B2AE45C2EC5D357CD8"><enum>(1)</enum><subparagraph commented="no" display-inline="yes-display-inline" id="HC2B19B14B4B44B46B72EC8493F12AFB6"><enum>(A)</enum><text>The individual has a
life-threatening or serious illness for which no standard treatment is
effective.</text>
</subparagraph><subparagraph id="HAC567A23A87E45D6872E007C00FFA152" indent="up1"><enum>(B)</enum><text>The individual is eligible to
participate in an approved clinical trial according to the trial protocol with
respect to treatment of such illness.</text>
</subparagraph><subparagraph id="H1078FBF505C34EE4A3EEE6C86FD4AEBC" indent="up1"><enum>(C)</enum><text>The individual’s participation in the
trial offers meaningful potential for significant clinical benefit for the
individual.</text>
</subparagraph></paragraph><paragraph id="H0AF5D9952E18445FA7B3CD05C540B788"><enum>(2)</enum><text>Either—</text>
<subparagraph id="H0E8364B682E54C608305CC157457DD6D"><enum>(A)</enum><text>the referring
physician is a participating health care professional and has concluded that
the individual’s participation in such trial would be appropriate based upon
the individual meeting the conditions described in paragraph (1); or</text>
</subparagraph><subparagraph id="H97896406D1C04509AD61E5476F24B7F0"><enum>(B)</enum><text>the participant,
beneficiary, or enrollee provides medical and scientific information
establishing that the individual’s participation in such trial would be
appropriate based upon the individual meeting the conditions described in
paragraph (1).</text>
</subparagraph></paragraph></subsection><subsection id="HE319738FE62341D90038694C21005064"><enum>(c)</enum><header>Payment</header>
<paragraph id="HB33807C18328469CA656EAB502B3BF10"><enum>(1)</enum><header>In
general</header><text>Under this section a group health plan or health
insurance issuer shall provide for payment for routine patient costs described
in subsection (a)(2) but is not required to pay for costs of items and services
that are reasonably expected (as determined by the Secretary) to be paid for by
the sponsors of an approved clinical trial.</text>
</paragraph><paragraph id="HE3862B04552B4164A4A321EE7FA0586F"><enum>(2)</enum><header>Payment
rate</header><text>In the case of covered items and services provided
by—</text>
<subparagraph id="HE7236F44C5374B6A853D5B7CA6B1057F"><enum>(A)</enum><text>a participating
provider, the payment rate shall be at the agreed upon rate, or</text>
</subparagraph><subparagraph id="HBE19685491B1450684BACEDEEC56794B"><enum>(B)</enum><text>a nonparticipating
provider, the payment rate shall be at the rate the plan or issuer would
normally pay for comparable services under subparagraph (A).</text>
</subparagraph></paragraph></subsection><subsection id="H2C0491643C9248B583D48E1BE480A399"><enum>(d)</enum><header>Approved
Clinical Trial Defined</header>
<paragraph id="HC8544173E1DA423DBC003BA9001D9F86"><enum>(1)</enum><header>In
general</header><text>In this section, the term <term>approved clinical
trial</term> means a clinical research study or clinical investigation approved
and funded (which may include funding through in-kind contributions) by one or
more of the following:</text>
<subparagraph id="H66F0FD4AD0B746AB976073884B6533FA"><enum>(A)</enum><text>The National
Institutes of Health.</text>
</subparagraph><subparagraph id="H33291DD23ADD4870889DB60410496D05"><enum>(B)</enum><text>A cooperative
group or center of the National Institutes of Health.</text>
</subparagraph><subparagraph id="H5A098E5AD47945829FFB76DAB399FDB1"><enum>(C)</enum><text>Either of the
following if the conditions described in paragraph (2) are met:</text>
<clause id="HE2B3210BEAA944AEA7195CC11F88E11B"><enum>(i)</enum><text>The
Department of Veterans Affairs.</text>
</clause><clause id="HB7495250613441FC98BBFA931236E38C"><enum>(ii)</enum><text>The
Department of Defense.</text>
</clause></subparagraph></paragraph><paragraph id="HECF4D6A466E742660002F3CFAD719B81"><enum>(2)</enum><header>Conditions for
departments</header><text>The conditions described in this paragraph, for a
study or investigation conducted by a Department, are that the study or
investigation has been reviewed and approved through a system of peer review
that the Secretary determines—</text>
<subparagraph id="HC977DCB264574CF3B4C1A08175BDD174"><enum>(A)</enum><text>to be comparable
to the system of peer review of studies and investigations used by the National
Institutes of Health, and</text>
</subparagraph><subparagraph id="H4B177EF2235943028F1207C2FBCCBAC"><enum>(B)</enum><text>assures unbiased
review of the highest scientific standards by qualified individuals who have no
interest in the outcome of the review.</text>
</subparagraph></paragraph></subsection><subsection id="H574D79C435EA4A619F2E16809BBE5816"><enum>(e)</enum><header>Construction</header><text>Nothing
in this section shall be construed to limit a plan’s or issuer’s coverage with
respect to clinical trials.</text>
</subsection></section></subtitle><subtitle id="H6421FAC42B984C11A6E15C553F526BB6"><enum>C</enum><header>Access to
Information</header>
<section id="H04BBDDE24A274001B6E4188075E03351"><enum>121.</enum><header>Patient access
to information</header>
<subsection id="H17245A8F161D45949C43803EDA608C85"><enum>(a)</enum><header>Disclosure
Requirement</header>
<paragraph id="HF7435C38AFBA4FD3BAEC9EE5AF2B7B30"><enum>(1)</enum><header>Group health
plans</header><text>A group health plan shall—</text>
<subparagraph id="H1CCB62D3AD7A421F931C446CE22C3E99"><enum>(A)</enum><text>provide to
participants and beneficiaries at the time of initial coverage under the plan
(or the effective date of this section, in the case of individuals who are
participants or beneficiaries as of such date), and at least annually
thereafter, the information described in subsection (b) in printed form;</text>
</subparagraph><subparagraph id="H506FA3E44B594CA09213397FC7C1AE93"><enum>(B)</enum><text>provide to
participants and beneficiaries, within a reasonable period (as specified by the
appropriate Secretary) before or after the date of significant changes in the
information described in subsection (b), information in printed form on such
significant changes; and</text>
</subparagraph><subparagraph id="H5627FC89273D4D328BB32FC2EA6699F0"><enum>(C)</enum><text>upon request, make
available to participants and beneficiaries, the applicable authority, and
prospective participants and beneficiaries, the information described in
subsection (b) or (c) in printed form.</text>
</subparagraph></paragraph><paragraph id="H0BFBE5E1F66A42B789361B5B86430039"><enum>(2)</enum><header>Health insurance
issuers</header><text>A health insurance issuer in connection with the
provision of health insurance coverage shall—</text>
<subparagraph id="H8FCF89C008A6427C85471289E2D344F"><enum>(A)</enum><text>provide to
individuals enrolled under such coverage at the time of enrollment, and at
least annually thereafter, the information described in subsection (b) in
printed form;</text>
</subparagraph><subparagraph id="H91AF6216071346039E04A59480B8387"><enum>(B)</enum><text>provide to
enrollees, within a reasonable period (as specified by the appropriate
Secretary) before or after the date of significant changes in the information
described in subsection (b), information in printed form on such significant
changes; and</text>
</subparagraph><subparagraph id="H66E30A722EC24D9594C11DCD5111514E"><enum>(C)</enum><text>upon request, make
available to the applicable authority, to individuals who are prospective
enrollees, and to the public the information described in subsection (b) or (c)
in printed form.</text>
</subparagraph></paragraph></subsection><subsection id="H00DF20FD0D904F98B7324C27970253ED"><enum>(b)</enum><header>Information
Provided</header><text>The information described in this subsection with
respect to a group health plan or health insurance coverage offered by a health
insurance issuer includes the following:</text>
<paragraph id="H2862D33F09D64DB383A0C0725EE1AF92"><enum>(1)</enum><header>Service
area</header><text>The service area of the plan or issuer.</text>
</paragraph><paragraph id="H83064046410B4EE9BFD41164E4BDAF8C"><enum>(2)</enum><header>Benefits</header><text>Benefits
offered under the plan or coverage, including—</text>
<subparagraph id="H925B51DD060C4201AC393DAF64CD14C4"><enum>(A)</enum><text>covered benefits,
including benefit limits and coverage exclusions;</text>
</subparagraph><subparagraph id="H1E3F72A3A7514EADA58EE02D84E2CB5D"><enum>(B)</enum><text>cost sharing, such
as deductibles, coinsurance, and copayment amounts, including any liability for
balance billing, any maximum limitations on out of pocket expenses, and the
maximum out of pocket costs for services that are provided by nonparticipating
providers or that are furnished without meeting the applicable utilization
review requirements;</text>
</subparagraph><subparagraph id="HD42E730D608B441090CDB9F3901E406B"><enum>(C)</enum><text>the extent to
which benefits may be obtained from nonparticipating providers;</text>
</subparagraph><subparagraph id="HD895613F79884F80BAA8004D5FB3E001"><enum>(D)</enum><text>the extent to
which a participant, beneficiary, or enrollee may select from among
participating providers and the types of providers participating in the plan or
issuer network;</text>
</subparagraph><subparagraph id="H42BCA928F7794BE58C3977D545D2A031"><enum>(E)</enum><text>process for
determining experimental coverage; and</text>
</subparagraph><subparagraph id="HA7EA481C44F147BC90AA64CB0300761E"><enum>(F)</enum><text>use of a
prescription drug formulary.</text>
</subparagraph></paragraph><paragraph id="H95947DE4D96B433696F5C70076FA1827"><enum>(3)</enum><header>Access</header><text>A
description of the following:</text>
<subparagraph id="HC83F975931F94524A70094BF3ECD1B8"><enum>(A)</enum><text>The number, mix,
and distribution of providers under the plan or coverage.</text>
</subparagraph><subparagraph id="HEA2AF404A47E4529A6199C004625ED28"><enum>(B)</enum><text>Out-of-network
coverage (if any) provided by the plan or coverage.</text>
</subparagraph><subparagraph id="H2DF4F0B43F614CAD91F4294200955C5F"><enum>(C)</enum><text>Any
point-of-service option (including any supplemental premium or cost-sharing for
such option).</text>
</subparagraph><subparagraph id="HDBD959F34356422BA73BAA5FBCD37225"><enum>(D)</enum><text>The procedures for
participants, beneficiaries, and enrollees to select, access, and change
participating primary and specialty providers.</text>
</subparagraph><subparagraph id="HC007CEFCA3C2496FA734E29803F7CC3"><enum>(E)</enum><text>The rights and
procedures for obtaining referrals (including standing referrals) to
participating and nonparticipating providers.</text>
</subparagraph><subparagraph id="HA77A1152B1EC486F97ADFBB289F8EF8"><enum>(F)</enum><text>The name, address,
and telephone number of participating health care providers and an indication
of whether each such provider is available to accept new patients.</text>
</subparagraph><subparagraph id="H9FB4A0438DE44A618E78B71CBE70A793"><enum>(G)</enum><text>Any limitations
imposed on the selection of qualifying participating health care providers,
including any limitations imposed under section 112(b)(2).</text>
</subparagraph><subparagraph id="H977A762A31DE4ED795E8405B4CCBE5C4"><enum>(H)</enum><text>How the plan or
issuer addresses the needs of participants, beneficiaries, and enrollees and
others who do not speak English or who have other special communications needs
in accessing providers under the plan or coverage, including the provision of
information described in this subsection and subsection (c) to such
individuals.</text>
</subparagraph></paragraph><paragraph id="H3197E50C5FA146A1BF00432F683ED357"><enum>(4)</enum><header>Out-of-area
coverage</header><text>Out-of-area coverage provided by the plan or
issuer.</text>
</paragraph><paragraph id="HB6A3ADC9429B43DCB0EC9EE7F4941C"><enum>(5)</enum><header>Emergency
coverage</header><text>Coverage of emergency services, including—</text>
<subparagraph id="H8509302D62234DDFB19D795BBB520000"><enum>(A)</enum><text>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;</text>
</subparagraph><subparagraph id="HD3452A78992746449BA8DBC9C7946496"><enum>(B)</enum><text>the process and
procedures of the plan or issuer for obtaining emergency services; and</text>
</subparagraph><subparagraph id="HB97DD141144444AF8DE919CC1FC53024"><enum>(C)</enum><text>the locations of
(i) emergency departments, and (ii) other settings, in which plan physicians
and hospitals provide emergency services and post-stabilization care.</text>
</subparagraph></paragraph><paragraph id="H0FF6AF34B8A74176B62E4DB26BFB85AA"><enum>(6)</enum><header>Percentage of
premiums used for benefits (loss-ratios)</header><text>In the case of health
insurance coverage only (and not with respect to group health plans that do not
provide coverage through health insurance coverage), a description of the
overall loss-ratio for the coverage (as defined in accordance with rules
established or recognized by the Secretary of Health and Human
Services).</text>
</paragraph><paragraph id="H1BCC5BD95A99488490E9284FE0394003"><enum>(7)</enum><header>Prior
authorization rules</header><text>Rules regarding prior authorization or other
review requirements that could result in noncoverage or nonpayment.</text>
</paragraph><paragraph id="H1559DEE2C76440D886C744E5BC216E5E"><enum>(8)</enum><header>Grievance and
appeals procedures</header><text>All appeal or grievance rights and procedures
under the plan or coverage, including the method for filing grievances and the
time frames and circumstances for acting on grievances and appeals, who is the
applicable authority with respect to the plan or issuer.</text>
</paragraph><paragraph id="H2C3B0A418AC54501A290E0A61B26BFED"><enum>(9)</enum><header>Quality
assurance</header><text>Any information made public by an accrediting
organization in the process of accreditation of the plan or issuer or any
additional quality indicators the plan or issuer makes available.</text>
</paragraph><paragraph id="HB1D1B6C5066A456384C63781DD281779"><enum>(10)</enum><header>Information on
issuer</header><text>Notice of appropriate mailing addresses and telephone
numbers to be used by participants, beneficiaries, and enrollees in seeking
information or authorization for treatment.</text>
</paragraph><paragraph id="H4D3DCEE3704540B3963E6300E31AD99"><enum>(11)</enum><header>Notice of
requirements</header><text>Notice of the requirements of this title.</text>
</paragraph><paragraph id="HCB49BFEA669742D78B5F8E32A86CACCB"><enum>(12)</enum><header>Availability of
information on request</header><text>Notice that the information described in
subsection (c) is available upon request.</text>
</paragraph></subsection><subsection id="H1FCC01DEB33743A085BEDBCBE00B21"><enum>(c)</enum><header>Information Made
Available Upon Request</header><text>The information described in this
subsection is the following:</text>
<paragraph id="HB34C5F62C9EF4BA7B9BE9800B0734744"><enum>(1)</enum><header>Utilization
review activities</header><text>A description of procedures used and
requirements (including circumstances, time frames, and appeal rights) under
any utilization review program under section 101, including under any drug
formulary program under section 118.</text>
</paragraph><paragraph id="HB5410229D6144E22B8A0ED6D5FDDD8C"><enum>(2)</enum><header>Grievance and
appeals information</header><text>Information on the number of grievances and
appeals and on the disposition in the aggregate of such matters.</text>
</paragraph><paragraph id="HFE8953E28F9641BBA1E6B579FC58B006"><enum>(3)</enum><header>Method of
physician compensation</header><text>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 a specified prospective or treating health care professional is (or would
be) compensated in connection with the provision of health care under the plan
or coverage.</text>
</paragraph><paragraph id="H790C8DE53968409AA40700A147931ED9"><enum>(4)</enum><header>Specific
information on credentials of participating providers</header><text>In the case
of each participating provider, a description of the credentials of the
provider.</text>
</paragraph><paragraph id="HB910D8361B8E455897A33E6D4007C400"><enum>(5)</enum><header>Formulary
restrictions</header><text>A description of the nature of any drug formula
restrictions.</text>
</paragraph><paragraph id="HD896A7438E71426B93E43B3DF2000000"><enum>(6)</enum><header>Participating
provider list</header><text>A list of current participating health care
providers.</text>
</paragraph></subsection><subsection id="HEADC088EDFF844608C4BF3AACC074B43"><enum>(d)</enum><header>Construction</header><text>Nothing
in this section shall be construed as requiring public disclosure of individual
contracts or financial arrangements between a group health plan or health
insurance issuer and any provider.</text>
</subsection></section></subtitle><subtitle id="HE3FEB2387D1247EAA53F45D2E0A728A7"><enum>D</enum><header>Protecting the
Doctor-Patient Relationship</header>
<section id="H0352567BB8364B1B80E6D5BC3B8DD69F"><enum>131.</enum><header>Prohibition of
interference with certain medical communications</header>
<subsection id="H3613C367D1C947A49DA800997961007B"><enum>(a)</enum><header>General
Rule</header><text>The provisions of any contract or agreement, or the
operation of any contract or agreement, between a group health plan or health
insurance issuer in relation to health insurance coverage (including any
partnership, association, or other organization that enters into or administers
such a contract or agreement) and a health care provider (or group of health
care providers) shall not prohibit or otherwise restrict a health care
professional from advising such a participant, beneficiary, or enrollee who is
a patient of the professional about the health status of the individual or
medical care or treatment for the individual’s condition or disease, regardless
of whether benefits for such care or treatment are provided under the plan or
coverage, if the professional is acting within the lawful scope of
practice.</text>
</subsection><subsection id="HE1EC80B246CC4185A14361DDC1F94561"><enum>(b)</enum><header>Nullification</header><text>Any
contract provision or agreement that restricts or prohibits medical
communications in violation of subsection (a) shall be null and void.</text>
</subsection></section><section id="HFE5B5201C31746AC00AE692973D19B23"><enum>132.</enum><header>Prohibition of
discrimination against providers based on licensure</header>
<subsection id="H4FA381FB028448EF85C734E86DE98C47"><enum>(a)</enum><header>In
General</header><text>A group health plan and a health insurance issuer
offering health insurance coverage shall not discriminate with respect to
participation or indemnification as to any provider who is acting within the
scope of the provider’s license or certification under applicable State law,
solely on the basis of such license or certification.</text>
</subsection><subsection id="H7F1A4F895D8E49BC8DDE805ED2BB31D"><enum>(b)</enum><header>Construction</header><text>Subsection
(a) shall not be construed—</text>
<paragraph id="HA76C4EB2B3FB42AF98E072420078B55F"><enum>(1)</enum><text>as requiring the
coverage under a group health plan or health insurance coverage of particular
benefits or services or to prohibit a plan or issuer from including providers
only to the extent necessary to meet the needs of the plan’s or issuer’s
participants, beneficiaries, or enrollees or from establishing any measure
designed to maintain quality and control costs consistent with the
responsibilities of the plan or issuer;</text>
</paragraph><paragraph id="H9E32B29BCA9944F8B6EAD29D02E0696"><enum>(2)</enum><text>to
override any State licensure or scope-of-practice law; or</text>
</paragraph><paragraph id="HDC3B77B773F042F8B99B91A73B00EFF1"><enum>(3)</enum><text>as requiring a
plan or issuer that offers network coverage to include for participation every
willing provider who meets the terms and conditions of the plan or
issuer.</text>
</paragraph></subsection></section><section id="H708F93E3CE724E7F84401368327C5003"><enum>133.</enum><header>Prohibition
against improper incentive arrangements</header>
<subsection id="HA1948D283B4341FBA7B2A762B4AFD1D4"><enum>(a)</enum><header>In
General</header><text>A group health plan and a health insurance issuer
offering health insurance coverage may not operate any physician incentive plan
(as defined in subparagraph (B) of section 1876(i)(8) of the
<act-name parsable-cite="SSA">Social Security Act</act-name>) unless the
requirements described in clauses (i), (ii)(I), and (iii) of subparagraph (A)
of such section are met with respect to such a plan.</text>
</subsection><subsection id="H7C672DBF092B4998844733AAD4B447C5"><enum>(b)</enum><header>Application</header><text>For
purposes of carrying out paragraph (1), any reference in section 1876(i)(8) of
the <act-name parsable-cite="SSA">Social Security Act</act-name> to the
Secretary, an eligible organization, or an individual enrolled with the
organization shall be treated as a reference to the applicable authority, a
group health plan or health insurance issuer, respectively, and a participant,
beneficiary, or enrollee with the plan or organization, respectively.</text>
</subsection><subsection id="HD496729D355A4169B8CCFC1B58FAFCDD"><enum>(c)</enum><header>Construction</header><text>Nothing
in this section shall be construed as prohibiting all capitation and similar
arrangements or all provider discount arrangements.</text>
</subsection></section><section id="H5A208B799A464A56B928B801D7E096BD"><enum>134.</enum><header>Payment of
claims</header><text display-inline="no-display-inline">A group health plan,
and a health insurance issuer offering group health insurance coverage, shall
provide for prompt payment of claims submitted for health care services or
supplies furnished to a participant, beneficiary, or enrollee with respect to
benefits covered by the plan or issuer, in a manner consistent with the
provisions of sections 1816(c)(2) and 1842(c)(2) of the
<act-name parsable-cite="SSA">Social Security Act</act-name> (42 U.S.C.
1395h(c)(2) and <external-xref legal-doc="usc" parsable-cite="usc/42/1395u">42 U.S.C. 1395u(c)(2)</external-xref>), except that for purposes of this
section, subparagraph (C) of section 1816(c)(2) of the
<act-name parsable-cite="SSA">Social Security Act</act-name> shall be treated
as applying to claims received from a participant, beneficiary, or enrollee as
well as claims referred to in such subparagraph.</text>
</section><section id="HC3A9456959A8443B992447764642B1A"><enum>135.</enum><header>Protection for
patient advocacy</header>
<subsection id="H6A9C19EA36154862B2BF1F5491ED7176"><enum>(a)</enum><header>Protection for
Use of Utilization Review and Grievance Process</header><text>A group health
plan, and a health insurance issuer with respect to the provision of health
insurance coverage, may not retaliate against a participant, beneficiary,
enrollee, or health care provider based on the participant’s, beneficiary’s,
enrollee’s or provider’s use of, or participation in, a utilization review
process or a grievance process of the plan or issuer (including an internal or
external review or appeal process) under this title.</text>
</subsection><subsection id="H0764058FDB6C452BB09D5E20E08FCCE"><enum>(b)</enum><header>Protection for
Quality Advocacy by Health Care Professionals</header>
<paragraph id="H4E5EAC70F5D640A7BF8387F2B6BB0A4"><enum>(1)</enum><header>In
general</header><text>A group health plan or health insurance issuer may not
retaliate or discriminate against a protected health care professional because
the professional in good faith—</text>
<subparagraph id="H99B69B64EDA548B4AECC93652F9E81B4"><enum>(A)</enum><text>discloses
information relating to the care, services, or conditions affecting one or more
participants, beneficiaries, or enrollees of the plan or issuer to an
appropriate public regulatory agency, an appropriate private accreditation
body, or appropriate management personnel of the plan or issuer; or</text>
</subparagraph><subparagraph id="H093E5B4E45924B538539D5E83CD09600"><enum>(B)</enum><text>initiates,
cooperates, or otherwise participates in an investigation or proceeding by such
an agency with respect to such care, services, or conditions.</text>
</subparagraph><continuation-text continuation-text-level="paragraph">If an
institutional health care provider is a participating provider with such a plan
or issuer or otherwise receives payments for benefits provided by such a plan
or issuer, the provisions of the previous sentence shall apply to the provider
in relation to care, services, or conditions affecting one or more patients
within an institutional health care provider in the same manner as they apply
to the plan or issuer in relation to care, services, or conditions provided to
one or more participants, beneficiaries, or enrollees; and for purposes of
applying this sentence, any reference to a plan or issuer is deemed a reference
to the institutional health care provider.</continuation-text></paragraph><paragraph id="HE6D26CDDBB494D73B3005CE784F0EA9"><enum>(2)</enum><header>Good faith
action</header><text>For purposes of paragraph (1), a protected health care
professional is considered to be acting in good faith with respect to
disclosure of information or participation if, with respect to the information
disclosed as part of the action—</text>
<subparagraph id="H334A7F948748411D92FBABF1C8EF27EB"><enum>(A)</enum><text>the disclosure is
made on the basis of personal knowledge and is consistent with that degree of
learning and skill ordinarily possessed by health care professionals with the
same licensure or certification and the same experience;</text>
</subparagraph><subparagraph id="HD41CF1B3A30345D0BF74BBCB00184B03"><enum>(B)</enum><text>the professional
reasonably believes the information to be true;</text>
</subparagraph><subparagraph id="HD8776CE091BA4D5AA2C3EBF81F878D85"><enum>(C)</enum><text>the information
evidences either a violation of a law, rule, or regulation, of an applicable
accreditation standard, or of a generally recognized professional or clinical
standard or that a patient is in imminent hazard of loss of life or serious
injury; and</text>
</subparagraph><subparagraph id="HC383E2C765984902951FE7A3A2E9024E"><enum>(D)</enum><text>subject to
subparagraphs (B) and (C) of paragraph (3), the professional has followed
reasonable internal procedures of the plan, issuer, or institutional health
care provider established for the purpose of addressing quality concerns before
making the disclosure.</text>
</subparagraph></paragraph><paragraph id="H43C7FCCB725641D9B3EDA4709F800041"><enum>(3)</enum><header>Exception and
special rule</header>
<subparagraph id="H710A3EE9B53742048CEA6EB248AA77C4"><enum>(A)</enum><header>General
exception</header><text>Paragraph (1) does not protect disclosures that would
violate Federal or State law or diminish or impair the rights of any person to
the continued protection of confidentiality of communications provided by such
law.</text>
</subparagraph><subparagraph id="H28D11486942D482A974444AC5DBDB6A9"><enum>(B)</enum><header>Notice of
internal procedures</header><text>Subparagraph (D) of paragraph (2) shall not
apply unless the internal procedures involved are reasonably expected to be
known to the health care professional involved. For purposes of this
subparagraph, a health care professional is reasonably expected to know of
internal procedures if those procedures have been made available to the
professional through distribution or posting.</text>
</subparagraph><subparagraph id="H14B6390FC95C4A0DB4083D212E2F15B9"><enum>(C)</enum><header>Internal
procedure exception</header><text>Subparagraph (D) of paragraph (2) also shall
not apply if—</text>
<clause id="H24F8BAFAB95A443E81E7244BBA1E2227"><enum>(i)</enum><text>the
disclosure relates to an imminent hazard of loss of life or serious injury to a
patient;</text>
</clause><clause id="HFD9706FBC0074134A6D68243FC69B407"><enum>(ii)</enum><text>the
disclosure is made to an appropriate private accreditation body pursuant to
disclosure procedures established by the body; or</text>
</clause><clause id="H2506E1B00D1F44C7A3336DD0088055B"><enum>(iii)</enum><text>the
disclosure is in response to an inquiry made in an investigation or proceeding
of an appropriate public regulatory agency and the information disclosed is
limited to the scope of the investigation or proceeding.</text>
</clause></subparagraph></paragraph><paragraph id="HB5C7B62BD71049F6B7B848A8C06FD472"><enum>(4)</enum><header>Additional
considerations</header><text>It shall not be a violation of paragraph (1) to
take an adverse action against a protected health care professional if the
plan, issuer, or provider taking the adverse action involved demonstrates that
it would have taken the same adverse action even in the absence of the
activities protected under such paragraph.</text>
</paragraph><paragraph id="H96621EDDF3374A70824DB664D58F9004"><enum>(5)</enum><header>Notice</header><text>A
group health plan, health insurance issuer, and institutional health care
provider shall post a notice, to be provided or approved by the Secretary of
Labor, setting forth excerpts from, or summaries of, the pertinent provisions
of this subsection and information pertaining to enforcement of such
provisions.</text>
</paragraph><paragraph id="HF840BBABC7A2413E80D343BB47D943AD"><enum>(6)</enum><header>Constructions</header>
<subparagraph id="H7887AF64EB47480387FF36D0427F008B"><enum>(A)</enum><header>Determinations
of coverage</header><text>Nothing in this subsection shall be construed to
prohibit a plan or issuer from making a determination not to pay for a
particular medical treatment or service or the services of a type of health
care professional.</text>
</subparagraph><subparagraph id="H4EBECB9BB73F49C09035C0B732D59CAA"><enum>(B)</enum><header>Enforcement of
peer review protocols and internal procedures</header><text>Nothing in this
subsection shall be construed to prohibit a plan, issuer, or provider from
establishing and enforcing reasonable peer review or utilization review
protocols or determining whether a protected health care professional has
complied with those protocols or from establishing and enforcing internal
procedures for the purpose of addressing quality concerns.</text>
</subparagraph><subparagraph id="HE005B518CB7140DE95637693EEB02B94"><enum>(C)</enum><header>Relation to
other rights</header><text>Nothing in this subsection shall be construed to
abridge rights of participants, beneficiaries, enrollees, and protected health
care professionals under other applicable Federal or State laws.</text>
</subparagraph></paragraph><paragraph id="H5B45AAC54682443BB7D3B407C700464E"><enum>(7)</enum><header>Protected health
care professional defined</header><text>For purposes of this subsection, the
term <term>protected health care professional</term> means an individual who is
a licensed or certified health care professional and who—</text>
<subparagraph id="H9317B42DB05A4258886EB2AB88A77E11"><enum>(A)</enum><text>with respect to a
group health plan or health insurance issuer, is an employee of the plan or
issuer or has a contract with the plan or issuer for provision of services for
which benefits are available under the plan or issuer; or</text>
</subparagraph><subparagraph id="H80383A61ECD94BE09035A76689A4085F"><enum>(B)</enum><text>with respect to an
institutional health care provider, is an employee of the provider or has a
contract or other arrangement with the provider respecting the provision of
health care services.</text>
</subparagraph></paragraph></subsection></section></subtitle><subtitle id="H8218F0EFC1354CFF93925F00690600E1"><enum>E</enum><header>Definitions</header>
<section id="HBE5346409F2D4BCFAE998C02C5E599E7"><enum>151.</enum><header>Definitions</header>
<subsection id="HAD5CE051A10442B4893859868EBADE93"><enum>(a)</enum><header>Incorporation of
General Definitions</header><text>Except as otherwise provided, the provisions
of section 2791 of the <act-name parsable-cite="PHSA">Public Health Service
Act</act-name> shall apply for purposes of this title in the same manner as
they apply for purposes of title XXVII of such Act.</text>
</subsection><subsection id="H49F3B74F34104CC39103D0D0A00F412"><enum>(b)</enum><header>Secretary</header><text>Except
as otherwise provided, the term <term>Secretary</term> means the Secretary of
Health and Human Services, in consultation with the Secretary of Labor and the
term <term>appropriate Secretary</term> means the Secretary of Health and Human
Services in relation to carrying out this title under sections 2706 and 2751 of
the <act-name parsable-cite="PHSA">Public Health Service Act</act-name> and the
Secretary of Labor in relation to carrying out this title under section 713 of
the <act-name parsable-cite="ERISA">Employee Retirement Income Security Act of
1974</act-name>.</text>
</subsection><subsection id="HADD8050E55D043CFBB33D95210EAE07F"><enum>(c)</enum><header>Additional
Definitions</header><text>For purposes of this title:</text>
<paragraph id="H61BEE5C486584A46849C47CF9E0000DD"><enum>(1)</enum><header>Actively
practicing</header><text>The term <term>actively practicing</term> means, with
respect to a physician or other health care professional, such a physician or
professional who provides professional services to individual patients on
average at least two full days per week.</text>
</paragraph><paragraph id="H167C95A00D8A4187B157BD0089576BD8"><enum>(2)</enum><header>Applicable
authority</header><text>The term <term>applicable authority</term>
means—</text>
<subparagraph id="HA4FDC08C3E46466D9E00A628256647F9"><enum>(A)</enum><text>in the case of a
group health plan, the Secretary of Health and Human Services and the Secretary
of Labor; and</text>
</subparagraph><subparagraph id="H4FAB68C7320543A9B62133C1EDC5A14D"><enum>(B)</enum><text>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
<act-name parsable-cite="PHSA">Public Health Service Act</act-name>), 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
<act-name parsable-cite="PHSA">Public Health Service Act</act-name>.</text>
</subparagraph></paragraph><paragraph id="H886EAA42C0FD4E9080E139431380365"><enum>(3)</enum><header>Clinical
peer</header><text>The term <term>clinical peer</term> means, with respect to a
review or appeal, an actively practicing physician (allopathic or osteopathic)
or other actively practicing health care professional who holds a nonrestricted
license, and who is appropriately credentialed in the same or similar specialty
or subspecialty (as appropriate) as typically handles the medical condition,
procedure, or treatment under review or appeal and includes a pediatric
specialist where appropriate; except that only a physician (allopathic or
osteopathic) may be a clinical peer with respect to the review or appeal of
treatment recommended or rendered by a physician.</text>
</paragraph><paragraph id="HDE2FBEA799A3431683006F5B743F36A6"><enum>(4)</enum><header>Enrollee</header><text>The
term <term>enrollee</term> means, with respect to health insurance coverage
offered by a health insurance issuer, an individual enrolled with the issuer to
receive such coverage.</text>
</paragraph><paragraph id="HEE81C18D1CD14818BD5BEBE3548B95BD"><enum>(5)</enum><header>Group health
plan</header><text>The term <term>group health plan</term> has the meaning
given such term in section 733(a) of the <act-name parsable-cite="ERISA">Employee Retirement Income Security Act of
1974</act-name> and in section 2791(a)(1) of the <act-name parsable-cite="PHSA">Public Health Service Act</act-name>.</text>
</paragraph><paragraph id="HF86C3C7228CE42CE96AC92D34D9DF794"><enum>(6)</enum><header>Health care
professional</header><text>The term <term>health care professional</term> 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.</text>
</paragraph><paragraph id="HDE6956394F3C4E91A244620066B9F858"><enum>(7)</enum><header>Health care
provider</header><text>The term <term>health care provider</term> includes a
physician or other health care professional, as well as an institutional or
other facility or agency that provides health care services and that is
licensed, accredited, or certified to provide health care items and services
under applicable State law.</text>
</paragraph><paragraph id="H6D2DC3F272EB4FAA8C5BB8C2442C90D6"><enum>(8)</enum><header>Network</header><text>The
term <term>network</term> means, with respect to a group health plan or health
insurance issuer offering health insurance coverage, the participating health
care professionals and providers through whom the plan or issuer provides
health care items and services to participants, beneficiaries, or
enrollees.</text>
</paragraph><paragraph id="H2656422420E94ECE84D7DB52811E4925"><enum>(9)</enum><header>Nonparticipating</header><text>The
term <term>nonparticipating</term> 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.</text>
</paragraph><paragraph id="HF6FF8676290E43EF8D2C5269679F8242"><enum>(10)</enum><header>Participating</header><text>The
term <term>participating</term> 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.</text>
</paragraph><paragraph id="H51E77B51DE274C3E8205AAB9F44F2679"><enum>(11)</enum><header>Prior
authorization</header><text>The term <term>prior authorization</term> means the
process of obtaining prior approval from a health insurance issuer or group
health plan for the provision or coverage of medical services.</text>
</paragraph></subsection></section><section id="H31C741CD11A24AB491939209141CFA7"><enum>152.</enum><header>Preemption;
State flexibility; construction</header>
<subsection id="H9DF61AC368434EDB00FB05F84378D823"><enum>(a)</enum><header>Continued
Applicability of State Law With Respect to Health Insurance Issuers</header>
<paragraph id="H2BD587CE29CA40E89EC40B91560BC00"><enum>(1)</enum><header>In
general</header><text>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.</text>
</paragraph><paragraph id="H20534449303F4DD792E0A679E312604E"><enum>(2)</enum><header>Continued
preemption with respect to group health plans</header><text>Nothing in this
title shall be construed to affect or modify the provisions of section 514 of
the <act-name parsable-cite="ERISA">Employee Retirement Income Security Act of
1974</act-name> with respect to group health plans.</text>
</paragraph></subsection><subsection id="HDFCF0F49076E455495C66182CF883D59"><enum>(b)</enum><header>Definitions</header><text>For
purposes of this section:</text>
<paragraph id="HA8B2229D73834BBAA06D804DA8DBFBC7"><enum>(1)</enum><header>State
law</header><text>The term <term>State law</term> 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.</text>
</paragraph><paragraph id="H8DBE9226A873409ABAFC1035607DC4D"><enum>(2)</enum><header>State</header><text>The
term <term>State</term> includes a State, the District of Columbia, Puerto
Rico, the Virgin Islands, Guam, American Samoa, the Northern Mariana Islands,
any political subdivisions of such, or any agency or instrumentality of
such.</text>
</paragraph></subsection></section><section id="H3D5FD6F245B84AA090FE2CB7224B0069"><enum>153.</enum><header>Exclusions</header>
<subsection id="HC723D841F6404A9B0011B2467CD6DDE4"><enum>(a)</enum><header>No Benefit
Requirements</header><text>Nothing in this title shall be construed to require
a group health plan or a health insurance issuer offering health insurance
coverage to include specific items and services (including abortions) under the
terms of such plan or coverage, other than those provided under the terms of
such plan or coverage.</text>
</subsection><subsection id="H47E2058DB2964B1F91B039F436B499C7"><enum>(b)</enum><header>Exclusion from
Access to Care Managed Care Provisions for Fee-for-Service Coverage</header>
<paragraph id="H58BC99CA95284C7EB83D866D1332261F"><enum>(1)</enum><header>In
general</header><text>The provisions of sections 111 through 117 shall not
apply to a group health plan or health insurance coverage if the only coverage
offered under the plan or coverage is fee-for-service coverage (as defined in
paragraph (2)).</text>
</paragraph><paragraph id="H3AF6EBD03A96446BB4A6D0370296A137"><enum>(2)</enum><header>Fee-for-service
coverage defined</header><text>For purposes of this subsection, the term
<term>fee-for-service coverage</term> means coverage under a group health plan
or health insurance coverage that—</text>
<subparagraph id="H78DA538001EB4574B064A269B2C4BF9D"><enum>(A)</enum><text>reimburses
hospitals, health professionals, and other providers on the basis of a rate
determined by the plan or issuer on a fee-for-service basis without placing the
provider at financial risk;</text>
</subparagraph><subparagraph id="H8EB08170F8F54511B96C7FAF335F7C00"><enum>(B)</enum><text>does not vary
reimbursement 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;</text>
</subparagraph><subparagraph id="H2806F341E384432FA3DDB170699B8540"><enum>(C)</enum><text>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 under the plan or by the issuer; and</text>
</subparagraph><subparagraph id="H04FCC38AB6E440719C62C082D92BA597"><enum>(D)</enum><text>for which the plan
or issuer does not require prior authorization before providing coverage for
any services.</text>
</subparagraph></paragraph></subsection></section><section id="H0F4D26ED66AD4CE1ADB591B6B4CCB9E"><enum>154.</enum><header>Coverage of
limited scope plans</header><text display-inline="no-display-inline">Only for
purposes of applying the requirements of this title under sections 2707 and
2753 of the <act-name parsable-cite="PHSA">Public Health Service Act</act-name>
and section 714 of the <act-name parsable-cite="ERISA">Employee Retirement
Income Security Act of 1974</act-name>, section 2791(c)(2)(A), and section
733(c)(2)(A) of the <act-name parsable-cite="ERISA">Employee Retirement Income
Security Act of 1974</act-name> shall be deemed not to apply.</text>
</section><section id="H7A9FA6EB458346C59FE1F4A386333CA1"><enum>155.</enum><header>Regulations</header><text display-inline="no-display-inline">The Secretaries of Health and Human Services
and Labor 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 <act-name parsable-cite="HIPAA">Health Insurance Portability and
Accountability Act of 1996</act-name>. Such Secretaries may promulgate any
interim final rules as the Secretaries determine are appropriate to carry out
this title.</text>
</section></subtitle><enum>II</enum><header>APPLICATION OF
QUALITY CARE STANDARDS TO GROUP HEALTH PLANS AND HEALTH INSURANCE COVERAGE
UNDER THE PUBLIC HEALTH SERVICE ACT</header>
<section id="H07D837C698C44F10B2003D8E7E726366"><enum>201.</enum><header>Application to
group health plans and group health insurance coverage</header>
<subsection id="H9470D579EA9249DAB47B3FF1847736F"><enum>(a)</enum><header>In
General</header><text>Subpart 2 of part A of title XXVII of the
<act-name parsable-cite="PHSA">Public Health Service Act</act-name> is amended
by adding at the end the following new section:</text>
<quoted-block act-name="Public Health Service Act" id="HC2E79923E2E449E19D4C8C96F09B3822" style="OLC">
<section id="H96FD8C5B3FD94C5B8C4E5CB4F84D7020"><enum>2707.</enum><header>Patient
protection standards</header>
<subsection id="H2CFCEACDF19F4A3AAEC32DA3A6FAEAFA"><enum>(a)</enum><header>In
General</header><text>Each group health plan shall comply with patient
protection requirements under title I of the Bipartisan Consensus Managed Care
Improvement Act of 2007, 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.</text>
</subsection><subsection id="HAA854087CE564E329FA800D542004676"><enum>(b)</enum><header>Notice</header><text>A
group health plan shall comply with the notice requirement under section 711(d)
of the <act-name parsable-cite="ERISA">Employee Retirement Income Security Act
of 1974</act-name> 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.</text>
</subsection></section><after-quoted-block>.</after-quoted-block></quoted-block>
</subsection><subsection id="H5102F4DD0FEA43BE87D2AE73EC89D884"><enum>(b)</enum><header>Conforming
Amendment</header><text>Section 2721(b)(2)(A) of such Act (42 U.S.C.
300gg–21(b)(2)(A)) is amended by inserting <quote>(other than section
2707)</quote> after <quote>requirements of such subparts</quote>.</text>
</subsection></section><section id="H2C56AD20438F43A5A336C9BE10D10048"><enum>202.</enum><header>Application to
individual health insurance coverage</header><text display-inline="no-display-inline">Part B of title XXVII of the
<act-name parsable-cite="PHSA">Public Health Service Act</act-name> is amended
by inserting after section 2752 the following new section:</text>
<quoted-block act-name="Public Health Service Act" id="HB645DB2F7A20412DA6612F8C006FF186" style="OLC">
<section id="HF134FF69B7634E368740D352F206F153"><enum>2753.</enum><header>Patient
protection standards</header>
<subsection id="HBEBD96B5ED9E4192B5DEBF59B2532804"><enum>(a)</enum><header>In
General</header><text>Each health insurance issuer shall comply with patient
protection requirements under title I of the Bipartisan Consensus Managed Care
Improvement Act of 2007 with respect to individual health insurance coverage it
offers, and such requirements shall be deemed to be incorporated into this
subsection.</text>
</subsection><subsection id="H9C933605A6484F2C8E2EF3FC175165F2"><enum>(b)</enum><header>Notice</header><text>A
health insurance issuer under this part shall comply with the notice
requirement under section 711(d) of the <act-name parsable-cite="ERISA">Employee Retirement Income Security Act of
1974</act-name> with respect to the requirements of such title as if such
section applied to such issuer and such issuer were a group health
plan.</text>
</subsection></section><after-quoted-block>.</after-quoted-block></quoted-block>
</section><enum>III</enum><header>AMENDMENTS TO
THE EMPLOYEE RETIREMENT INCOME SECURITY ACT OF 1974</header>
<section id="H71C81BBE62C34048B4310017D77C96B4"><enum>301.</enum><header>Application of
patient protection standards to group health plans and group health insurance
coverage under the <act-name parsable-cite="ERISA">Employee Retirement Income
Security Act of 1974</act-name></header>
<subsection id="idAE333F2A8F7447B19B3ED455DEBBCCD6"><enum>(a)</enum><text display-inline="yes-display-inline">Subpart B of part 7 of subtitle B of title
I of the <act-name parsable-cite="ERISA">Employee Retirement Income Security
Act of 1974</act-name> is amended by adding at the end the following new
section:</text>
<quoted-block act-name="Employee Retirement Income Security Act of 1974" id="HFEAEA36F4A054715B96DD1D5FC561C2C" style="OLC">
<section id="H026822DAD2074B1690A600A0E8EA4B5D"><enum>714.</enum><header>Patient
protection standards</header>
<subsection id="H017CF30E727E43B90027004B7570F13F"><enum>(a)</enum><header>In
General</header><text>Subject to subsection (b), 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
Bipartisan Consensus Managed Care Improvement Act of 2007 (as in effect as of
the date of the enactment of such Act), and such requirements shall be deemed
to be incorporated into this subsection.</text>
</subsection><subsection id="H85AF26DF9EEA409E82183824ACC1FB2"><enum>(b)</enum><header>Plan Satisfaction
of Certain Requirements</header>
<paragraph id="H1AC63CADFF584342B2515F2B9266DE50"><enum>(1)</enum><header>Satisfaction of
certain requirements through insurance</header><text>For purposes of subsection
(a), insofar as a group health plan provides benefits in the form of health
insurance coverage through a health insurance issuer, the plan shall be treated
as meeting the following requirements of title I of the Bipartisan Consensus
Managed Care Improvement Act of 2007 with respect to such benefits and not be
considered as failing to meet such requirements because of a failure of the
issuer to meet such requirements so long as the plan sponsor or its
representatives did not cause such failure by the issuer:</text>
<subparagraph id="H358F14E1372B42599B793539E614C900"><enum>(A)</enum><text>Section 112
(relating to choice of providers).</text>
</subparagraph><subparagraph id="H959266B7654A44E8845BA8E92BCEE0CE"><enum>(B)</enum><text>Section 113
(relating to access to emergency care).</text>
</subparagraph><subparagraph id="H4AD3D6870CD64C03A30900DE31922EA"><enum>(C)</enum><text>Section 114
(relating to access to specialty care).</text>
</subparagraph><subparagraph id="HE5C12F5CE4E14DC08BA7D2FB27F542B"><enum>(D)</enum><text>Section 115
(relating to access to obstetrical and gynecological care).</text>
</subparagraph><subparagraph id="HDA0388CE22FE41F6897F44005D3035DD"><enum>(E)</enum><text>Section 116
(relating to access to pediatric care).</text>
</subparagraph><subparagraph id="H8DEEBB2E4EBA4B378E8EF475C2FFF126"><enum>(F)</enum><text>Section 117(a)(1)
(relating to continuity in case of termination of provider contract) and
section 117(a)(2) (relating to continuity in case of termination of issuer
contract), but only insofar as a replacement issuer assumes the obligation for
continuity of care.</text>
</subparagraph><subparagraph id="H269C8D8B08AD4B6BA3B5AF2B49B74DD6"><enum>(G)</enum><text>Section 118
(relating to access to needed prescription drugs).</text>
</subparagraph><subparagraph id="H1DD822AA7F2E4DA292A0D796D4FFF4B0"><enum>(H)</enum><text>Section 119
(relating to coverage for individuals participating in approved clinical
trials.)</text>
</subparagraph><subparagraph id="H5BED5225102E4BDE8410E18221C8193"><enum>(I)</enum><text>Section 134
(relating to payment of claims).</text>
</subparagraph></paragraph><paragraph id="HF50C99B867FF418D94844348ADF46C9C"><enum>(2)</enum><header>Information</header><text>With
respect to information required to be provided or made available under section
121, in the case of a group health plan that provides benefits in the form of
health insurance coverage through a health insurance issuer, the Secretary
shall determine the circumstances under which the plan is not required to
provide or make available the information (and is not liable for the issuer’s
failure to provide or make available the information), if the issuer is
obligated to provide and make available (or provides and makes available) such
information.</text>
</paragraph><paragraph id="H59BCFD72B84344C389D4A0623BDF6940"><enum>(3)</enum><header>Grievance and
internal appeals</header><text>With respect to the internal appeals process and
the grievance system required to be established under sections 102 and 104, in
the case of a group health plan that provides benefits in the form of health
insurance coverage through a health insurance issuer, the Secretary shall
determine the circumstances under which the plan is not required to provide for
such process and system (and is not liable for the issuer’s failure to provide
for such process and system), if the issuer is obligated to provide for (and
provides for) such process and system.</text>
</paragraph><paragraph id="H1EDCAEE13F044635861D066800C6D66D"><enum>(4)</enum><header>External
appeals</header><text>Pursuant to rules of the Secretary, insofar as a group
health plan enters into a contract with a qualified external appeal entity for
the conduct of external appeal activities in accordance with section 103, the
plan shall be treated as meeting the requirement of such section and is not
liable for the entity’s failure to meet any requirements under such
section.</text>
</paragraph><paragraph id="HE949933F1C244C6F869E4372E2BED747"><enum>(5)</enum><header>Application to
prohibitions</header><text>Pursuant to rules of the Secretary, if a health
insurance issuer offers health insurance coverage in connection with a group
health plan and takes an action in violation of any of the following sections,
the group health plan shall not be liable for such violation unless the plan
caused such violation:</text>
<subparagraph id="H78798C2FE3044BDD8BCA74E38B8D5603"><enum>(A)</enum><text>Section 131
(relating to prohibition of interference with certain medical
communications).</text>
</subparagraph><subparagraph id="H73ABDC0CF40C47B284A2836F6C6948AB"><enum>(B)</enum><text>Section 132
(relating to prohibition of discrimination against providers based on
licensure).</text>
</subparagraph><subparagraph id="HC45E5A11D1474B5EA2616CC69D0812DB"><enum>(C)</enum><text>Section 133
(relating to prohibition against improper incentive arrangements).</text>
</subparagraph><subparagraph id="H583B4974B4E045C498B74FE9194B5746"><enum>(D)</enum><text>Section 135
(relating to protection for patient advocacy).</text>
</subparagraph></paragraph><paragraph id="HB2CC1F97ECFF4555BE725456D465F6AE"><enum>(6)</enum><header>Construction</header><text>Nothing
in this subsection shall be construed to affect or modify the responsibilities
of the fiduciaries of a group health plan under part 4 of subtitle B.</text>
</paragraph><paragraph id="H38AA9D3EC7A24768BE11AA1E76995B13"><enum>(7)</enum><header>Application to
certain prohibitions against retaliation</header><text>With respect to
compliance with the requirements of section 135(b)(1) of the Bipartisan
Consensus Managed Care Improvement Act of 2007, for purposes of this subtitle
the term <term>group health plan</term> is deemed to include a reference to an
institutional health care provider.</text>
</paragraph></subsection><subsection id="H3E311D6EF0BA4C1BBC84FB5DD7406C3F"><enum>(c)</enum><header>Enforcement of
Certain Requirements</header>
<paragraph id="H0561F3DCBF794E4B885E59F6E6B800A3"><enum>(1)</enum><header>Complaints</header><text>Any
protected health care professional who believes that the professional has been
retaliated or discriminated against in violation of section 135(b)(1) of the
Bipartisan Consensus Managed Care Improvement Act of 2007 may file with the
Secretary a complaint within 180 days of the date of the alleged retaliation or
discrimination.</text>
</paragraph><paragraph id="HBDDFA1C21802475C83B0ABF56780013"><enum>(2)</enum><header>Investigation</header><text>The
Secretary shall investigate such complaints and shall determine if a violation
of such section has occurred and, if so, shall issue an order to ensure that
the protected health care professional does not suffer any loss of position,
pay, or benefits in relation to the plan, issuer, or provider involved, as a
result of the violation found by the Secretary.</text>
</paragraph></subsection><subsection id="H016B6DD0658E4DD0A934AE387498F213"><enum>(d)</enum><header>Conforming
Regulations</header><text>The Secretary may issue regulations to coordinate the
requirements on group health plans under this section with the requirements
imposed under the other provisions of this
title.</text>
</subsection></section><after-quoted-block>.</after-quoted-block></quoted-block>
</subsection><subsection id="H2796354377CD4C99A2ACD5A5AB06B534"><enum>(b)</enum><header>Satisfaction of
ERISA Claims Procedure Requirement</header><text>Section 503 of such Act (29
U.S.C. 1133) is amended by inserting <quote>(a)</quote> after
<quote><header-in-text level="title" style="traditional">Sec.</header-in-text>
503.</quote> and by adding at the end the following new subsection:</text>
<quoted-block id="H19C6DA8E151F4125B6E797B620A76CA6" style="OLC">
<subsection id="HE79DFF7D39424DA8B415604DC3F8348"><enum>(b)</enum><text>In the case of a
group health plan (as defined in section 733) compliance with the requirements
of subtitle A of title I of the Bipartisan Consensus Managed Care Improvement
Act of 2007 in the case of a claims denial shall be deemed compliance with
subsection (a) with respect to such claims
denial.</text>
</subsection><after-quoted-block>.</after-quoted-block></quoted-block>
</subsection><subsection id="HDB39AE2120414E9589948CD06E2CF3FC"><enum>(c)</enum><header>Conforming
Amendments</header><paragraph commented="no" display-inline="yes-display-inline" id="H79D21B887A074AB0A15F8090FF63A107"><enum>(1)</enum><text>Section 732(a) of such
Act (<external-xref legal-doc="usc" parsable-cite="usc/29/1185">29 U.S.C. 1185(a)</external-xref>) is amended by striking <quote>section 711</quote> and
inserting <quote>sections 711 and 714</quote>.</text>
</paragraph><paragraph id="H6607118EDD8C45A3B22F372917631073" indent="up1"><enum>(2)</enum><text>The table of contents in section 1 of
such Act is amended by inserting after the item relating to section 713 the
following new item:</text>
<quoted-block id="H3F12B44511A946D195007400F2A20077" style="OLC">
<toc regeneration="no-regeneration">
<toc-entry level="section">Sec. 714. Patient protection
standards.</toc-entry>
</toc>
<after-quoted-block>.</after-quoted-block></quoted-block>
</paragraph><paragraph id="HDAADDFBEF51C450FAF96D5B615267D6C" indent="up1"><enum>(3)</enum><text>Section 502(b)(3) of such Act (29
U.S.C. 1132(b)(3)) is amended by inserting <quote>(other than section 135(b) of
the Bipartisan Consensus Managed Care Improvement Act of 2007, as incorporated
into this subsection under section 714 of this Act)</quote> after <quote>part
7</quote>.</text>
</paragraph></subsection></section><section id="H0A5A3E18210E434DA37D7B023B99D2FD"><enum>302.</enum><header>ERISA
preemption not to apply to certain actions involving health insurance
policyholders</header>
<subsection id="H7313A64A1841434E925E437659BFFBAD"><enum>(a)</enum><header>In
General</header><text>Section 514 of the <act-name parsable-cite="ERISA">Employee Retirement Income Security Act of
1974</act-name> (<external-xref legal-doc="usc" parsable-cite="usc/29/1144">29 U.S.C. 1144</external-xref>) is amended by adding at the end the following
subsection:</text>
<quoted-block act-name="Employee Retirement Income Security Act of 1974" id="H2080C1C2AA6948CF9F00986E021CC1CA" style="OLC">
<subsection id="H98FC6C380CFB4EFB8001FB6EEA746EA"><enum>(f)</enum><header>Preemption Not To
Apply to Certain Actions Arising Out of Provision of Health Benefits</header>
<paragraph id="H5EBAC0A9937F411FB4732B6592A0A4CC"><enum>(1)</enum><header>Non-preemption
of certain causes of action</header>
<subparagraph id="HF78578A0B0874F619C006B1EB6CC12F0"><enum>(A)</enum><header>In
general</header><text>Except as provided in this subsection, nothing in this
title shall be construed to invalidate, impair, or supersede any cause of
action by a participant or beneficiary (or the estate of a participant or
beneficiary) under State law to recover damages resulting from personal injury
or for wrongful death against any person—</text>
<clause id="HB084071ED2494E44BFBA4B00F8C497B9"><enum>(i)</enum><text>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</text>
</clause><clause id="H63B28F2C69064D92887B3D2E32A36F9E"><enum>(ii)</enum><text>that arises out
of the arrangement by such person for the provision of such insurance,
administrative services, or medical services by other persons.</text>
</clause></subparagraph><subparagraph id="H563263B6DC5840E29CAB496618F0B486"><enum>(B)</enum><header>Limitation on
punitive damages</header><text>The plan or issuer is not liable for any
punitive, exemplary, or similar damages in the case of a cause of action
brought under subparagraph (A) if—</text>
<clause id="H3A0B41CE31124124B03B4BFB30786D5F"><enum>(i)</enum><text>it
relates to an externally appealable decision (as defined in subsection (a)(2)
of section 103 of the Bipartisan Consensus Managed Care Improvement Act of
2007);</text>
</clause><clause id="H3F32A215D99F47CAAD275C80A8A793A5"><enum>(ii)</enum><text>an external
appeal with respect to such decision was completed under such section
103;</text>
</clause><clause id="H48EC5F9497184015B65DD827C0F47E62"><enum>(iii)</enum><text>in the case such
external appeal was initiated by the plan or issuer filing the request for the
external appeal, the request was filed on a timely basis before the date the
action was brought or, if later, within 30 days after the date the externally
appealable decision was made; and</text>
</clause><clause id="HB075BAB1E317499ABA94AD130823916"><enum>(iv)</enum><text>the plan or issuer
complied with the determination of the external appeal entity upon receipt of
the determination of the external appeal entity.</text>
</clause><continuation-text continuation-text-level="subparagraph">The
provisions of this subparagraph supersede any State law or common law to the
contrary.</continuation-text></subparagraph><subparagraph id="H4F02A8DA204240B8A800325796001EE8"><enum>(C)</enum><header>Personal injury
defined</header><text>For purposes of this subsection, the term <term>personal
injury</term> means a physical injury and includes an injury arising out of the
treatment (or failure to treat) a mental illness or disease.</text>
</subparagraph></paragraph><paragraph id="H473DF9483C0B454DA85570E16CF1C77B"><enum>(2)</enum><header>Exception for
employers and other plan sponsors</header>
<subparagraph id="H3187603F202A4A43956FD8772EF50058"><enum>(A)</enum><header>In
general</header><text>Subject to subparagraph (B), paragraph (1) does not
authorize—</text>
<clause id="HC5AA20E7FCE643D8ACD8553B5C76F83"><enum>(i)</enum><text>any
cause of action against an employer or other plan sponsor maintaining the group
health plan (or against an employee of such an employer or sponsor acting
within the scope of employment), or</text>
</clause><clause id="H5CDEA34A477747088B003FDC9FB19F74"><enum>(ii)</enum><text>a
right of recovery or indemnity by a person against an employer or other plan
sponsor (or such an employee) for damages assessed against the person pursuant
to a cause of action under paragraph (1).</text>
</clause></subparagraph><subparagraph id="HB82F266D70BB4ADEB409002CD3EDCBF"><enum>(B)</enum><header>Special
rule</header><text>Subparagraph (A) shall not preclude any cause of action
described in paragraph (1) against an employer or other plan sponsor (or
against an employee of such an employer or sponsor acting within the scope of
employment) if—</text>
<clause id="H524FDD77936D455BA1E9F3B89B7C2349"><enum>(i)</enum><text>such action is
based on the employer’s or other plan sponsor’s (or employee’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</text>
</clause><clause id="H0855EE543C05462DB452A78711EE453C"><enum>(ii)</enum><text>the exercise by
such employer or other plan sponsor (or employee) of such authority resulted in
personal injury or wrongful death.</text>
</clause></subparagraph><subparagraph id="H174F42C46EAD4ABA90C1144404A200C"><enum>(C)</enum><header>Exception</header><text>The
exercise of discretionary authority described in subparagraph (B)(i) shall not
be construed to include—</text>
<clause id="H79E795F824164465AB020236E94C0103"><enum>(i)</enum><text>the decision to
include or exclude from the plan any specific benefit;</text>
</clause><clause id="H479AB47F8EC748B7BDB316FB5D91BA44"><enum>(ii)</enum><text>any decision to
provide extra-contractual benefits; or</text>
</clause><clause id="H9162926F53C74A1FA5C902F29C404362"><enum>(iii)</enum><text>any decision not
to consider the provision of a benefit while internal or external review is
being conducted.</text>
</clause></subparagraph></paragraph><paragraph id="H30E3E0DB37BE4CF7AFA19248C11681E8"><enum>(3)</enum><header>Futility of
exhaustion</header><text>An individual bringing an action under this subsection
is not required to exhaust administrative processes under section 102 or 103 of
the Bipartisan Consensus Managed Care Improvement Act of 2007 where the injury
to or death of such individual has occurred before the completion of such
processes.</text>
</paragraph><paragraph id="H85496EF47C854AE2BF226857FBD9D7E7"><enum>(4)</enum><header>Construction</header><text>Nothing
in this subsection shall be construed as—</text>
<subparagraph id="H0A549DBD50E949BBBE15C8A458E7C8EB"><enum>(A)</enum><text>permitting a cause
of action under State law for the failure to provide an item or service which
is specifically excluded under the group health plan involved; or</text>
</subparagraph><subparagraph id="H63D3DEBF6B204EEEBEB3A84B4CFCF708"><enum>(B)</enum><text>as preempting a
State law which requires an affidavit or certificate of merit in a civil
action.</text>
</subparagraph></paragraph></subsection><after-quoted-block>.</after-quoted-block></quoted-block>
</subsection><subsection id="HF42A2E0F35534D5D9C54AE598CA8E133"><enum>(b)</enum><header>Effective
Date</header><text>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.</text>
</subsection></section><enum>IV</enum><header>APPLICATION TO
GROUP HEALTH PLANS UNDER THE INTERNAL REVENUE CODE OF 1986</header>
<section id="H703DC94877F641309CEC6C12775235B"><enum>401.</enum><header>Amendments to
the Internal Revenue Code of 1986</header>
<subsection id="H4427085DF98846D6A9CD8DD818351333"><enum>(a)</enum><header>In
general</header><text display-inline="yes-display-inline">Subchapter B of
<external-xref legal-doc="usc-chapter" parsable-cite="usc-chapter/26/100">chapter 100</external-xref> of the Internal Revenue Code of 1986 is amended by adding at the
end the following:</text>
<quoted-block display-inline="no-display-inline" id="HEDA942F38878447D8C10FCA1A7539EFC" style="OLC">
<section id="HB863E5DF60D84BBE875805856F29758B"><enum>9813.</enum><header>Standard
relating to patient freedom of choice</header><text display-inline="no-display-inline">A group health plan shall comply with the
requirements of title I of the Bipartisan Consensus Managed Care Improvement
Act of 2007 (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.</text>
</section><after-quoted-block>.</after-quoted-block></quoted-block>
</subsection><subsection id="H46ED78083480462B8C4624EA7945FA2F"><enum>(b)</enum><header>Conforming
amendment</header><text>The table of sections of such subchapter is amended by
adding at the end the following new item:</text>
<quoted-block display-inline="no-display-inline" id="HE85762191A894745ABB8FC55E069BD4" style="OLC">
<toc regeneration="no-regeneration">
<toc-entry level="section">Sec. 9813. Standard relating to patient
freedom of
choice.</toc-entry>
</toc>
<after-quoted-block>.</after-quoted-block></quoted-block>
</subsection></section><enum>V</enum><header>EFFECTIVE DATES;
COORDINATION IN IMPLEMENTATION</header>
<section id="H43CFB9E2A3EB4E33819DDA872D9E96F3"><enum>501.</enum><header>Effective
dates</header>
<subsection id="H446A93FF576F4AB9A8FA5FFC2750A0C0"><enum>(a)</enum><header>Group Health
Coverage</header>
<paragraph id="H8CE7C783B0F84026BF403908D62839E"><enum>(1)</enum><header>In
general</header><text>Subject to paragraph (2), the amendments made by sections
201(a), 301, and 401 (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, 2008 (in this section referred to as the <quote>general effective
date</quote>) and also shall apply to portions of plan years occurring on and
after such date.</text>
</paragraph><paragraph id="HF1042B37EF9F4EE18B9324614BF993C5"><enum>(2)</enum><header>Treatment of
collective bargaining agreements</header><text>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), 301, and 401
(and title I insofar as it relates to such sections) shall not apply to plan
years beginning before the later of—</text>
<subparagraph id="HA5257E0981AE4328B951BE60E1699CC8"><enum>(A)</enum><text>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</text>
</subparagraph><subparagraph id="H2E2E782ED3E240BCA913E9CCFD7C9EF3"><enum>(B)</enum><text>the general
effective date.</text>
</subparagraph><continuation-text continuation-text-level="paragraph">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.</continuation-text></paragraph></subsection><subsection id="H24D8220AC37A48C7A5ACDB00F4B20309"><enum>(b)</enum><header>Individual
Health Insurance Coverage</header><text>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.</text>
</subsection></section><section id="H4DA0F416053D459B9D3C2DD9F886683"><enum>502.</enum><header>Coordination in
implementation</header><text display-inline="no-display-inline">The Secretary
of Labor, the Secretary of Health and Human Services, and the Secretary of the
Treasury shall ensure, through the execution of an interagency memorandum of
understanding among such Secretaries, that—</text>
<paragraph id="HB0636371C7DC4BA38FA7FB54ED284437"><enum>(1)</enum><text>regulations,
rulings, and interpretations issued by such Secretaries relating to the same
matter over which such Secretaries have responsibility under the provisions of
this Act (and the amendments made thereby) are administered so as to have the
same effect at all times; and</text>
</paragraph><paragraph id="HD2DF0BECBE374DC4AFB68FE2B6C2BC30"><enum>(2)</enum><text>coordination of
policies relating to enforcing the same requirements through such Secretaries
in order to have a coordinated enforcement strategy that avoids duplication of
enforcement efforts and assigns priorities in enforcement.</text>
</paragraph></section><enum>VI</enum><header>HEALTH CARE
PAPERWORK SIMPLIFICATION</header>
<section id="HF558BF800FC04E0199CAA53D00CC28E"><enum>601.</enum><header>Health care
paperwork simplification</header>
<subsection id="HA372F0588EF743948EB6A62B15630000"><enum>(a)</enum><header>Establishment of
Panel</header>
<paragraph id="H89645A9ED2F049E900D432D3307FB90"><enum>(1)</enum><header>Establishment</header><text>There
is established a panel to be known as the Health Care Panel to Devise a Uniform
Explanation of Benefits (in this section referred to as the
<quote>Panel</quote>).</text>
</paragraph><paragraph id="H9A58E5EB6EEA4CA200DF3F29472B8587"><enum>(2)</enum><header>Duties of
panel</header>
<subparagraph id="H6CD2DF9C157F4D828BBDA3C708855BB5"><enum>(A)</enum><header>In
general</header><text>The Panel shall devise a single form for use by
third-party health care payers for the remittance of claims to
providers.</text>
</subparagraph><subparagraph id="H63C03F8A0CCC44C29B3F2F56B77C006E"><enum>(B)</enum><header>Definition</header><text>For
purposes of this section, the term <term>third-party health care payer</term>
means any entity that contractually pays health care bills for an
individual.</text>
</subparagraph></paragraph><paragraph id="H78A311617B5843DE913BE0DB796C3B6C"><enum>(3)</enum><header>Membership</header>
<subparagraph id="H614ED2B3ABE04C34B6FE002E630306B9"><enum>(A)</enum><header>Size and
composition</header><text>The Secretary of Health and Human Services shall
determine the number of members and the composition of the Panel. Such Panel
shall include equal numbers of representatives of private insurance
organizations, consumer groups, State insurance commissioners, State medical
societies, State hospital associations, and State medical specialty
societies.</text>
</subparagraph><subparagraph id="H77B36912D7594823911EE3E1B43796D6"><enum>(B)</enum><header>Terms of
appointment</header><text>The members of the Panel shall serve for the life of
the Panel.</text>
</subparagraph><subparagraph id="HF6ADA89CAE0649508B63DF9DCA7357CD"><enum>(C)</enum><header>Vacancies</header><text>A
vacancy in the Panel shall not affect the power of the remaining members to
execute the duties of the Panel, but any such vacancy shall be filled in the
same manner in which the original appointment was made.</text>
</subparagraph></paragraph><paragraph id="H819664D5C1A8434B8195BC811F095DF"><enum>(4)</enum><header>Procedures</header>
<subparagraph id="HD1AA715F8B5049ED97A1EC34C8FAEB14"><enum>(A)</enum><header>Meetings</header><text>The
Panel shall meet at the call of a majority of its members.</text>
</subparagraph><subparagraph id="HC4EEA3EAE6D64948B158FA6488FF6E8E"><enum>(B)</enum><header>First
meeting</header><text>The Panel shall convene not later than 60 days after the
date of the enactment of the Bipartisan Consensus Managed Care Improvement Act
of 2007.</text>
</subparagraph><subparagraph id="HB01D20D222DF45B095C124573873E305"><enum>(C)</enum><header>Quorum</header><text>A
quorum shall consist of a majority of the members of the Panel.</text>
</subparagraph><subparagraph id="H0B095045B99B4960871341525487C2B1"><enum>(D)</enum><header>Hearings</header><text>For
the purpose of carrying out its duties, the Panel may hold such hearings and
undertake such other activities as the Panel determines to be necessary to
carry out its duties.</text>
</subparagraph></paragraph><paragraph id="HAA62D73FF85B41B3AE9F3400ABBF7C25"><enum>(5)</enum><header>Administration</header>
<subparagraph id="H8E87AD5DEED24987B57D9211208604C8"><enum>(A)</enum><header>Compensation</header><text>Except
as provided in subparagraph (B), members of the Panel shall receive no
additional pay, allowances, or benefits by reason of their service on the
Panel.</text>
</subparagraph><subparagraph id="H4557784570EF4772B8139B53C819B631"><enum>(B)</enum><header>Travel expenses
and per diem</header><text>Each member of the Panel who is not an officer or
employee of the Federal Government shall receive travel expenses and per diem
in lieu of subsistence in accordance with sections <external-xref legal-doc="usc" parsable-cite="usc/5/5702">5702</external-xref> and <external-xref legal-doc="usc" parsable-cite="usc/5/5703">5703</external-xref> of title 5,
United States Code.</text>
</subparagraph><subparagraph id="HD4B5776004C94D899FA1A9002BE0B937"><enum>(C)</enum><header>Contract
authority</header><text>The Panel may contract with and compensate government
and private agencies or persons for items and services, without regard to
section 3709 of the Revised Statutes (<external-xref legal-doc="usc" parsable-cite="usc/41/5">41 U.S.C. 5</external-xref>).</text>
</subparagraph><subparagraph id="H7B5E3682837E400ABBE44B8F21A111F"><enum>(D)</enum><header>Use of
mails</header><text>The Panel may use the United States mails in the same
manner and under the same conditions as Federal agencies and shall, for
purposes of the frank, be considered a commission of Congress as described in
<external-xref legal-doc="usc" parsable-cite="usc/39/3215">section 3215</external-xref> of title 39, United States Code.</text>
</subparagraph><subparagraph id="H89A8C3F56CB9439D89FA05F515B15564"><enum>(E)</enum><header>Administrative
support services</header><text>Upon the request of the Panel, the Secretary of
Health and Human Services shall provide to the Panel on a reimbursable basis
such administrative support services as the Panel may request.</text>
</subparagraph></paragraph><paragraph id="HF267004E809D45BE91451B84AF14B6ED"><enum>(6)</enum><header>Submission of
form</header><text>Not later than 2 years after the first meeting, the Panel
shall submit a form to the Secretary of Health and Human Services for use by
third-party health care payers.</text>
</paragraph><paragraph id="H4B33ECC10F744D64AE81597E98C0D33D"><enum>(7)</enum><header>Termination</header><text>The
Panel shall terminate on the day after submitting the form under paragraph
(6).</text>
</paragraph></subsection><subsection id="HE3A435EC09544090ACE0876C12BF15F"><enum>(b)</enum><header>Requirement for
Use of Form by Third-Party Care Payers</header><text>A third-party health care
payer shall be required to use the form devised under subsection (a) for plan
years beginning on or after 5 years following the date of the enactment of this
Act.</text>
</subsection></section>