[Congressional Record Volume 147, Number 7 (Monday, January 22, 2001)]
[Senate]
[Pages S101-S113]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]

      By Mr. DASCHLE (for himself, Mr. Kennedy, Mr. Dodd, Mr. Bingaman, 
        Mrs. Murray, Mr. Wellstone, Mr. Dorgan, Ms. Mikulski, Mr. 
        Levin, Mrs. Clinton, Mr. Schumer, Mr. Rockefeller, Mr. Johnson, 
        Mr. Corzine, Mr. Biden, Mr. Kerry, and Mr. Reed):
  S. 6. A bill to amend the Public Health Service Act, the Employee 
Retirement Income Security Act of 1974, and the Internal Revenue Code 
of 1986 to protect consumers in managed care plans and other health 
coverage; to the Committee on Health, Education, Labor, and Pensions.


                      patients' bill of rights act

  Mr. DASCHLE. Mr. President, I ask unanimous consent that the text of 
the bill be printed in the Record.
  There being no objection, the bill was ordered to be printed in the 
Record, as follows:

                                  S. 6

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

     SECTION 1. SHORT TITLE; TABLE OF CONTENTS.

       (a) Short Title.--This Act may be cited as the ``Patients' 
     Bill of Rights Act''.
       (b) Table of Contents.--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.

[[Page S102]]

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.
Sec. 303. Limitations on actions.

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--MISCELLANEOUS PROVISIONS

Sec. 601. Health care paperwork simplification.
Sec. 602. No impact on social security trust fund.

                    TITLE I--IMPROVING MANAGED CARE

                   Subtitle A--Grievance and Appeals

     SEC. 101. UTILIZATION REVIEW ACTIVITIES.

       (a) Compliance With Requirements.--
       (1) In general.--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.
       (2) Use of outside agents.--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.
       (3) Utilization review defined.--For purposes of this 
     section, the terms ``utilization review'' and ``utilization 
     review activities'' 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.
       (b) Written Policies and Criteria.--
       (1) Written policies.--A utilization review program shall 
     be conducted consistent with written policies and procedures 
     that govern all aspects of the program.
       (2) Use of written criteria.--
       (A) In general.--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.
       (B) Continuing use of standards in retrospective review.--
     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.
       (C) Review of sample of claims denials.--Such a program 
     shall provide for an evaluation of the clinical 
     appropriateness of at least a sample of denials of claims for 
     benefits.
       (c) Conduct of Program Activities.--
       (1) Administration by health care professionals.--A 
     utilization review program shall be administered by qualified 
     health care professionals who shall oversee review decisions.
       (2) Use of qualified, independent personnel.--
       (A) In general.--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.
       (B) Prohibition of contingent compensation arrangements.--
     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.
       (C) Prohibition of conflicts.--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.
       (3) Accessibility of review.--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.
       (4) Limits on frequency.--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.
       (d) Deadline for Determinations.--
       (1) Prior authorization services.--
       (A) In general.--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).
       (B) Deadline.--
       (i) In general.--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.
       (ii) Extension permitted where notice of additional 
     information required.--If a utilization review program--

       (I) receives a request for a prior authorization;
       (II) determines that additional information is necessary to 
     complete the review and make the determination on the 
     request; and
       (III) notifies the requester, not later than five business 
     days after the date of receiving the request, of the need for 
     such specified additional information,

     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).
       (iii) Expedited cases.--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.
       (2) Ongoing care.--
       (A) Concurrent review.--
       (i) In general.--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.
       (ii) Contents of notice.--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.
       (B) Exception.--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.
       (3) Previously provided services.--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.
       (4) Failure to meet deadline.--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.
       (5) Reference to special rules for emergency services, 
     maintenance care, and post-stabilization care.--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.

[[Page S103]]

       (e) Notice of Denials of Claims for Benefits.--
       (1) In general.--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--
       (A) the reasons for the denial (including the clinical 
     rationale);
       (B) instructions on how to initiate an appeal under section 
     102; and
       (C) 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.
       (2) Specification of any additional information.--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.
       (f) Claim for Benefits and Denial of Claim for Benefits 
     Defined.--For purposes of this subtitle:
       (1) Claim for benefits.--The term ``claim for benefits'' 
     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.
       (2) Denial of claim for benefits.--The term ``denial'' 
     means, with respect to a claim for benefits, 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.

     SEC. 102. INTERNAL APPEALS PROCEDURES.

       (a) Right of Review.--
       (1) In general.--Each group health plan, and each health 
     insurance issuer offering health insurance coverage--
       (A) 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
       (B) 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.
       (2) Treatment of oral requests.--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.
       (b) Internal Review Process.--
       (1) Conduct of review.--
       (A) In general.--A review of a denial of claim under this 
     section shall be made by an individual who--
       (i) 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;
       (ii) has been selected by the plan or issuer; and
       (iii) did not make the initial denial in the internally 
     appealable decision.
       (B) Limited scope coverage defined.--For purposes of 
     subparagraph (A), the term ``limited scope coverage'' 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 Public Health Service Act (42 U.S.C. 
     300gg-91(c)(2)).
       (2) Time limits for internal reviews.--
       (A) In general.--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.
       (B) Deadline.--
       (i) In general.--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.
       (ii) Extension permitted where notice of additional 
     information required.--If a group health plan or health 
     insurance issuer--

       (I) receives a request for internal review;
       (II) determines that additional information is necessary to 
     complete the review and make the determination on the 
     request; and
       (III) notifies the requester, not later than five business 
     days after the date of receiving the request, of the need for 
     such specified additional information,

     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).
       (iii) Expedited cases.--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.
       (c) Expedited Review Process.--
       (1) In general.--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--
       (A) in which 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
       (B) described in section 101(d)(2) (relating to requests 
     for continuation of ongoing care which would otherwise be 
     reduced or terminated).
       (2) Process.--Under such procedures--
       (A) 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;
       (B) 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
       (C) 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).
       (3) Deadline for decision.--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.
       (d) Waiver of Process.--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.

     SEC. 103. EXTERNAL APPEALS PROCEDURES.

       (a) Right to External Appeal.--
       (1) In general.--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.
       (2) Externally appealable decision defined.--
       (A) In general.--For purposes of this section, the term 
     ``externally appealable decision'' means a denial of claim 
     for benefits (as defined in section 101(f)(2))--
       (i) 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
       (ii) in which the decision as to whether a benefit is 
     covered involves a medical judgment.
       (B) Inclusion.--Such term also includes a failure to meet 
     an applicable deadline for internal review under section 102.
       (C) Exclusions.--Such term does not include--
       (i) specific exclusions or express limitations on the 
     amount, duration, or scope of coverage that do not involve 
     medical judgment; or
       (ii) a decision regarding whether an individual is a 
     participant, beneficiary, or enrollee under the plan or 
     coverage.
       (3) Exhaustion of internal review process.--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.
       (4) Filing fee requirement.--
       (A) In general.--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.
       (B) Exception for indigency.--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).
       (C) Refunding fee in case of successful appeals.--The plan 
     or issuer shall refund payment of the filing fee under this 
     paragraph if the recommendation of the external

[[Page S104]]

     appeal entity is to reverse or modify the denial of a claim 
     for benefits which is the subject of the appeal.
       (b) General Elements of External Appeals Process.--
       (1) Contract with qualified external appeal entity.--
       (A) Contract requirement.--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)).
       (B) Limitation on plan or issuer selection.--
       (i) In general.--The applicable authority shall implement 
     procedures--

       (I) 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
       (II) for auditing a sample of decisions by such entities to 
     assure that no such decisions are made in a biased manner.

       (ii) Limitation on ability to influence selection.--No 
     selection process established by the applicable authority 
     under this subsection shall provide the participant, 
     beneficiary, or enrollee or the plan or issuer with the 
     ability to determine or influence the selection of a 
     qualified external appeal entity to review the appeal of the 
     participant, beneficiary, or enrollee.
       (C) Other terms and conditions.--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).
       (D) State authority with respect qualified external appeal 
     entity for health insurance issuers.--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.
       (2) Elements of process.--An external appeal process shall 
     be conducted consistent with standards established by the 
     appropriate Secretary that include at least the following:
       (A) Fair and de novo determination.--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.
       (B) Standard of review.--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.
       (C) Consideration of plan or coverage definitions.--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.
       (D) Evidence.--
       (i) In general.--An external appeal entity shall include, 
     among the evidence taken into consideration--

       (I) 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;
       (II) any personal health and medical information supplied 
     with respect to the individual whose denial of claim for 
     benefits has been appealed; and
       (III) the opinion of the individual's treating physician or 
     health care professional.

       (ii) Additional evidence.--Such entity may also take into 
     consideration but not be limited to the following evidence 
     (to the extent available):

       (I) The results of studies that meet professionally 
     recognized standards of validity and replicability or that 
     have been published in peer-reviewed journals.
       (II) The results of professional consensus conferences 
     conducted or financed in whole or in part by one or more 
     Government agencies.
       (III) Practice and treatment guidelines prepared or 
     financed in whole or in part by Government agencies.
       (IV) Government-issued coverage and treatment policies.
       (V) Community standard of care and generally accepted 
     principles of professional medical practice.
       (VI) 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.
       (VII) 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.

       (E) Determination concerning externally appealable 
     decisions.--A qualified external appeal entity shall 
     determine--
       (i) whether a denial of claim for benefits is an externally 
     appealable decision (within the meaning of subsection 
     (a)(2));
       (ii) whether an externally appealable decision involves an 
     expedited appeal; and
       (iii) for purposes of initiating an external review, 
     whether the internal review process has been completed.
       (F) Opportunity to submit evidence.--Each party to an 
     externally appealable decision may submit evidence related to 
     the issues in dispute.
       (G) Provision of information.--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.
       (H) Timely decisions.--A determination by the external 
     appeal entity on the decision shall--
       (i) be made orally or in writing and, if it is made orally, 
     shall be supplied to the parties in writing as soon as 
     possible;
       (ii) 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;
       (iii) 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
       (iv) 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.
       (I) Compliance with determination.--If the external appeal 
     entity reverses or modifies the denial of a claim for 
     benefits, the plan or issuer shall--
       (i) upon the receipt of the determination, authorize 
     benefits in accordance with such determination;
       (ii) take such actions as may be necessary to provide 
     benefits (including items or services) in a timely manner 
     consistent with such determination; and
       (iii) submit information to the entity documenting 
     compliance with the entity's determination and this 
     subparagraph.
       (c) Qualifications of External Appeal Entities.--
       (1) In general.--For purposes of this section, the term 
     ``qualified external appeal entity'' means, in relation to a 
     plan or issuer, an entity that is certified under paragraph 
     (2) as meeting the following requirements:
       (A) The entity meets the independence requirements of 
     paragraph (3).
       (B) The entity conducts external appeal activities through 
     a panel of not fewer than three clinical peers.
       (C) 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).
       (D) The entity meets such other requirements as the 
     appropriate Secretary may impose.
       (2) Initial certification of external appeal entities.--
       (A) In general.--In order to be treated as a qualified 
     external appeal entity with respect to--
       (i) a group health plan, the entity must be certified (and, 
     in accordance with subparagraph (B), periodically 
     recertified) as meeting the requirements of paragraph (1)--

       (I) by the Secretary of Labor;
       (II) under a process recognized or approved by the 
     Secretary of Labor; or

       (III) to the extent provided in subparagraph (C)(i), by a 
     qualified private standard-setting organization (certified 
     under such subparagraph); or

       (ii) 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--

       (I) by the applicable State authority (or under a process 
     recognized or approved by such authority); or
       (II) 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).

       (B) Recertification process.--The appropriate Secretary 
     shall develop standards for the recertification of external 
     appeal entities. Such standards shall include a review of--
       (i) the number of cases reviewed;
       (ii) a summary of the disposition of those cases;
       (iii) the length of time in making determinations on those 
     cases;

[[Page S105]]

       (iv) updated information of what was required to be 
     submitted as a condition of certification for the entity's 
     performance of external appeal activities; and
       (v) 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.
       (C) Certification of qualified private standard-setting 
     organizations.--
       (i) For external reviews under group health plans.--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).
       (ii) For external reviews of health insurance issuers.--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).
       (D) Requirement of sufficient number of certified 
     entities.--The appropriate Secretary shall certify and 
     recertify a sufficient number of external appeal entities 
     under this paragraph to ensure the timely and efficient 
     provision of external review services.
       (3) Independence requirements.--
       (A) In general.--A clinical peer or other entity meets the 
     independence requirements of this paragraph if--
       (i) the peer or entity does not have a familial, financial, 
     or professional relationship with any related party;
       (ii) 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;
       (iii) 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
       (iv) 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.
       (B) Related party.--For purposes of this paragraph, the 
     term ``related party'' means--
       (i) with respect to--

       (I) a group health plan or health insurance coverage 
     offered in connection with such a plan, the plan or the 
     health insurance issuer offering such coverage; or
       (II) individual health insurance coverage, the health 
     insurance issuer offering such coverage,

     or any plan sponsor, fiduciary, officer, director, or 
     management employee of such plan or issuer;
       (ii) the health care professional that provided the health 
     care involved in the coverage decision;
       (iii) the institution at which the health care involved in 
     the coverage decision is provided;
       (iv) the manufacturer of any drug or other item that was 
     included in the health care involved in the coverage 
     decision; or
       (v) any other party determined under any regulations which 
     the Secretary may prescribe to have a substantial interest in 
     the coverage decision.
       (4) Limitation on liability of reviewers.--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.
       (d) External Appeal Determination Binding on Plan.--The 
     determination by an external appeal entity under this section 
     is binding on the plan and issuer involved in the 
     determination.
       (e) Penalties Against Authorized Officials for Refusing to 
     Authorize the Determination of an External Review Entity.--
       (1) Monetary penalties.--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.
       (2) Cease and desist order and order of attorney's fees.--
     In any action described in paragraph (1) brought by a 
     participant, beneficiary, or enrollee with respect to a group 
     health plan, or a health insurance issuer offering health 
     insurance coverage, in which 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--
       (A) to cease and desist from the alleged action or failure 
     to act; and
       (B) to pay to the plaintiff a reasonable attorney's fee and 
     other reasonable costs relating to the prosecution of the 
     action on the charges on which the plaintiff prevails.
       (3) Additional civil penalties.--
       (A) In general.--In addition to any penalty imposed under 
     paragraph (1) or (2), the appropriate Secretary may assess a 
     civil penalty against a person acting in the capacity of 
     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--
       (i) 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
       (ii) any pattern or practice of repeated violations of the 
     requirements of this section with respect to such plan or 
     plans or coverage.
       (B) Standard of proof and amount of penalty.--Such penalty 
     shall be payable only upon proof by clear and convincing 
     evidence of such pattern or practice and shall be in an 
     amount not to exceed the lesser of--
       (i) 25 percent of the aggregate value of benefits shown by 
     the appropriate Secretary to have not been provided, or 
     unlawfully delayed, in violation of this section under such 
     pattern or practice; or
       (ii) $500,000.
       (4) Removal and disqualification.--Any person acting in the 
     capacity of 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.
       (f) Protection of Legal Rights.--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 Employee 
     Retirement Income Security Act of 1974), including the right 
     to file judicial actions to enforce rights.

     SEC. 104. ESTABLISHMENT OF A GRIEVANCE PROCESS.

       (a) Establishment of Grievance System.--
       (1) In general.--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.
       (2) Grievance defined.--In this section, the term 
     ``grievance'' 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)).
       (b) Grievance System.--Such system shall include the 
     following components with respect to individuals who are 
     participants, beneficiaries, or enrollees:
       (1) 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.
       (2) A system to record and document, over a period of at 
     least three previous years, all grievances and appeals made 
     and their status.
       (3) A process providing for timely processing and 
     resolution of grievances.
       (4) Procedures for follow-up action, including the methods 
     to inform the person making the grievance of the resolution 
     of the grievance.
     Grievances are not subject to appeal under the previous 
     provisions of this subtitle.

                       Subtitle B--Access to Care

     SEC. 111. CONSUMER CHOICE OPTION.

       (a) In General.--If--
       (1) a health insurance issuer providing health insurance 
     coverage in connection with a group health plan offers to 
     enrollees health insurance coverage 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, or
       (2) a group health plan offers to participants or 
     beneficiaries health benefits which

[[Page S106]]

     provide 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 plan to 
     provide such services,

     then the issuer or plan shall also offer or arrange to be 
     offered to such enrollees, participants, or beneficiaries (at 
     the time of enrollment and during an annual open season as 
     provided under subsection (c)) the option of health insurance 
     coverage or health benefits which provide for coverage of 
     such services which are not furnished through health care 
     professionals and providers who are members of such a network 
     unless such enrollees, participants, or beneficiaries are 
     offered such non-network coverage through another group 
     health plan or through another health insurance issuer in the 
     group market.
       (b) Additional Costs.--The amount of any additional premium 
     charged by the health insurance issuer or group health plan 
     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, participant, or beneficiary unless it 
     is paid by the health plan sponsor or group health plan 
     through agreement with the health insurance issuer.
       (c) Open Season.--An enrollee, participant, or beneficiary, 
     may change to the offering provided under this section only 
     during a time period determined by the health insurance 
     issuer or group health plan. Such time period shall occur at 
     least annually.

     SEC. 112. CHOICE OF HEALTH CARE PROFESSIONAL.

       (a) Primary Care.--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.
       (b) Specialists.--
       (1) In general.--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.
       (2) Limitation.--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.
       (3) Construction.--Nothing in this subsection shall be 
     construed as affecting the application of section 114 
     (relating to access to specialty care).

     SEC. 113. ACCESS TO EMERGENCY CARE.

       (a) Coverage of Emergency Services.--
       (1) In general.--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))--
       (A) without the need for any prior authorization 
     determination;
       (B) whether or not the health care provider furnishing such 
     services is a participating provider with respect to such 
     services;
       (C) in a manner so that, if such services are provided to a 
     participant, beneficiary, or enrollee--
       (i) by a nonparticipating health care provider with or 
     without prior authorization; or
       (ii) by a participating health care provider without prior 
     authorization,
     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
       (D) 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 Public Health Service Act, section 701 of the 
     Employee Retirement Income Security Act of 1974, or section 
     9801 of the Internal Revenue Code of 1986, and other than 
     applicable cost-sharing).
       (2) Definitions.--In this section:
       (A) Emergency medical condition based on prudent layperson 
     standard.--The term ``emergency medical condition'' means a 
     medical condition manifesting itself by acute symptoms of 
     sufficient severity (including severe pain) such that a 
     prudent layperson, who possesses an average knowledge of 
     health and medicine, could reasonably expect the absence of 
     immediate medical attention to result in a condition 
     described in clause (i), (ii), or (iii) of section 
     1867(e)(1)(A) of the Social Security Act.
       (B) Emergency services.--The term ``emergency services'' 
     means--
       (i) a medical screening examination (as required under 
     section 1867 of the Social Security Act) 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
       (ii) 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.
       (C) Stabilize.--The term ``to stabilize'' means, with 
     respect to an emergency medical condition, to provide such 
     medical treatment of the condition as may be necessary to 
     assure, within reasonable medical probability, that no 
     material deterioration of the condition is likely to result 
     from or occur during the transfer of the individual from a 
     facility.
       (b) Reimbursement for Maintenance Care and Post-
     Stabilization Care.--In the case of services (other than 
     emergency services) for which benefits are available under a 
     group health plan, or under health insurance coverage offered 
     by a health insurance issuer, 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 the guidelines established under section 
     1852(d)(2) of the Social Security Act), if the services are 
     maintenance care or post-stabilization care covered under 
     such guidelines.

     SEC. 114. ACCESS TO SPECIALTY CARE.

       (a) Specialty Care for Covered Services.--
       (1) In general.--If--
       (A) 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;
       (B) the individual has a condition or disease of sufficient 
     seriousness and complexity to require treatment by a 
     specialist; and
       (C) benefits for such treatment are provided under the plan 
     or coverage,
     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.
       (2) Specialist defined.--For purposes of this subsection, 
     the term ``specialist'' 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.
       (3) Care under referral.--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--
       (A) 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
       (B) in accordance with applicable quality assurance and 
     utilization review standards of the plan or issuer.
     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.
       (4) Referrals to participating providers.--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.
       (5) Treatment of nonparticipating providers.--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.
       (b) Specialists as Gatekeeper for Treatment of Ongoing 
     Special Conditions.--
       (1) In general.--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.
       (2) Treatment for related referrals.--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.
       (3) Ongoing special condition defined.--In this subsection, 
     the term ``ongoing special condition'' means a condition or 
     disease that--
       (A) is life-threatening, degenerative, or disabling; and

[[Page S107]]

       (B) requires specialized medical care over a prolonged 
     period of time.
       (4) Terms of referral.--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).
       (c) Standing Referrals.--
       (1) In general.--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.
       (2) Terms of referral.--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).

     SEC. 115. ACCESS TO OBSTETRICAL AND GYNECOLOGICAL CARE.

       (a) In General.--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--
       (1) 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
       (2) 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.
       (b) Construction.--Nothing in subsection (a) shall be 
     construed to--
       (1) 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
       (2) 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.

     SEC. 116. ACCESS TO PEDIATRIC CARE.

       (a) Pediatric Care.--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.
       (b) Construction.--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.

     SEC. 117. CONTINUITY OF CARE.

       (a) In General.--
       (1) Termination of provider.--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--
       (A) 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
       (B) 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)).
       (2) Treatment of termination of contract with health 
     insurance issuer.--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.
       (3) Definitions.--For purposes of this section:
       (A) Ongoing special condition.--The term ``ongoing special 
     condition'' has the meaning given such term in section 
     114(b)(3), and also includes pregnancy.
       (B) Termination.--The term ``terminated'' 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.
       (b) Transitional Period.--
       (1) In general.--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.
       (2) Scheduled surgery and organ transplantation.--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.
       (3) Pregnancy.--If--
       (A) a participant, beneficiary, or enrollee was determined 
     to be pregnant at the time of a provider's termination of 
     participation; and
       (B) the provider was treating the pregnancy before date of 
     the termination,
     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.
       (4) Terminal illness.--If--
       (A) a participant, beneficiary, or enrollee was determined 
     to be terminally ill (as determined under section 
     1861(dd)(3)(A) of the Social Security Act) at the time of a 
     provider's termination of participation; and
       (B) the provider was treating the terminal illness before 
     the date of termination,
     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.
       (c) Permissible Terms and Conditions.--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:
       (1) 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.
       (2) 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.
       (3) 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.
       (d) Construction.--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.

     SEC. 118. ACCESS TO NEEDED PRESCRIPTION DRUGS.

       (a) In General.--To the extent that a group health plan, or 
     health insurance coverage offered by a health insurance 
     issuer, provides coverage for benefits with respect to 
     prescription drugs, and limits such coverage to drugs 
     included in a formulary, the plan or issuer shall--
       (1) ensure the participation of physicians and pharmacists 
     in developing and reviewing such formulary;
       (2) provide for disclosure of the formulary to providers; 
     and
       (3) in accordance with the applicable quality assurance and 
     utilization review standards of the plan or issuer, provide 
     for exceptions from the formulary limitation when a non-
     formulary alternative is medically necessary and appropriate 
     and, in the case of such an exception, apply the same cost-
     sharing requirements that would have applied in the case of a 
     drug covered under the formulary.
       (b) Coverage of Approved Drugs and Medical Devices.--
       (1) In general.--A group health plan (or health insurance 
     coverage offered in connection with such a plan) that 
     provides any coverage of prescription drugs or medical 
     devices shall not deny coverage of such a drug or device on 
     the basis that the use is investigational, if the use--
       (A) in the case of a prescription drug--
       (i) is included in the labeling authorized by the 
     application in effect for the drug pursuant to subsection (b) 
     or (j) of section 505 of the Federal Food, Drug, and Cosmetic 
     Act,

[[Page S108]]

     without regard to any postmarketing requirements that may 
     apply under such Act; or
       (ii) is included in the labeling authorized by the 
     application in effect for the drug under section 351 of the 
     Public Health Service Act, without regard to any 
     postmarketing requirements that may apply pursuant to such 
     section; or
       (B) in the case of a medical device, is included in the 
     labeling authorized by a regulation under subsection (d) or 
     (3) of section 513 of the Federal Food, Drug, and Cosmetic 
     Act, an order under subsection (f) of such section, or an 
     application approved under section 515 of such Act, without 
     regard to any postmarketing requirements that may apply under 
     such Act.
       (2) Construction.--Nothing in this subsection shall be 
     construed as requiring a group health plan (or health 
     insurance coverage offered in connection with such a plan) to 
     provide any coverage of prescription drugs or medical 
     devices.

     SEC. 119. COVERAGE FOR INDIVIDUALS PARTICIPATING IN APPROVED 
                   CLINICAL TRIALS.

       (a) Coverage.--
       (1) In general.--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--
       (A) may not deny the individual participation in the 
     clinical trial referred to in subsection (b)(2);
       (B) 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
       (C) may not discriminate against the individual on the 
     basis of the enrollee's participation in such trial.
       (2) Exclusion of certain costs.--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.
       (3) Use of in-network providers.--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.
       (b) Qualified Individual Defined.--For purposes of 
     subsection (a), the term ``qualified individual'' 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:
       (1)(A) The individual has a life-threatening or serious 
     illness for which no standard treatment is effective.
       (B) The individual is eligible to participate in an 
     approved clinical trial according to the trial protocol with 
     respect to treatment of such illness.
       (C) The individual's participation in the trial offers 
     meaningful potential for significant clinical benefit for the 
     individual.
       (2) Either--
       (A) 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
       (B) 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).
       (c) Payment.--
       (1) In general.--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.
       (2) Payment rate.--In the case of covered items and 
     services provided by--
       (A) a participating provider, the payment rate shall be at 
     the agreed upon rate; or
       (B) a nonparticipating provider, the payment rate shall be 
     at the rate the plan or issuer would normally pay for 
     comparable services under subparagraph (A).
       (d) Approved Clinical Trial Defined.--
       (1) In general.--In this section, the term ``approved 
     clinical trial'' 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:
       (A) The National Institutes of Health.
       (B) A cooperative group or center of the National 
     Institutes of Health.
       (C) Either of the following if the conditions described in 
     paragraph (2) are met:
       (i) The Department of Veterans Affairs.
       (ii) The Department of Defense.
       (2) Conditions for departments.--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--
       (A) to be comparable to the system of peer review of 
     studies and investigations used by the National Institutes of 
     Health; and
       (B) assures unbiased review of the highest scientific 
     standards by qualified individuals who have no interest in 
     the outcome of the review.
       (e) Construction.--Nothing in this section shall be 
     construed to limit a plan's or issuer's coverage with respect 
     to clinical trials.

                   Subtitle C--Access to Information

     SEC. 121. PATIENT ACCESS TO INFORMATION.

       (a) Disclosure Requirement.--
       (1) Group health plans.--A group health plan shall--
       (A) 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;
       (B) 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
       (C) 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.
       (2) Health insurance issuers.--A health insurance issuer in 
     connection with the provision of health insurance coverage 
     shall--
       (A) 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;
       (B) 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
       (C) 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.
       (b) Information Provided.--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:
       (1) Service area.--The service area of the plan or issuer.
       (2) Benefits.--Benefits offered under the plan or coverage, 
     including--
       (A) covered benefits, including benefit limits and coverage 
     exclusions;
       (B) 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;
       (C) the extent to which benefits may be obtained from 
     nonparticipating providers;
       (D) 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;
       (E) process for determining experimental coverage; and
       (F) use of a prescription drug formulary.
       (3) Access.--A description of the following:
       (A) The number, mix, and distribution of providers under 
     the plan or coverage.
       (B) Out-of-network coverage (if any) provided by the plan 
     or coverage.
       (C) Any point-of-service option (including any supplemental 
     premium or cost-sharing for such option).
       (D) The procedures for participants, beneficiaries, and 
     enrollees to select, access, and change participating primary 
     and specialty providers.
       (E) The rights and procedures for obtaining referrals 
     (including standing referrals) to participating and 
     nonparticipating providers.
       (F) 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.
       (G) Any limitations imposed on the selection of qualifying 
     participating health care providers, including any 
     limitations imposed under section 112(b)(2).
       (H) 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.
       (4) Out-of-area coverage.--Out-of-area coverage provided by 
     the plan or issuer.
       (5) Emergency coverage.--Coverage of emergency services, 
     including--
       (A) 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;
       (B) the process and procedures of the plan or issuer for 
     obtaining emergency services; and
       (C) the locations of (i) emergency departments, and (ii) 
     other settings, in which plan physicians and hospitals 
     provide emergency services and post-stabilization care.
       (6) Percentage of premiums used for benefits (loss-
     ratios).--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

[[Page S109]]

     with rules established or recognized by the Secretary of 
     Health and Human Services).
       (7) Prior authorization rules.--Rules regarding prior 
     authorization or other review requirements that could result 
     in noncoverage or nonpayment.
       (8) Grievance and appeals procedures.--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.
       (9) Quality assurance.--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.
       (10) Information on issuer.--Notice of appropriate mailing 
     addresses and telephone numbers to be used by participants, 
     beneficiaries, and enrollees in seeking information or 
     authorization for treatment.
       (11) Notice of requirements.--Notice of the requirements of 
     this title.
       (12) Availability of information on request.--Notice that 
     the information described in subsection (c) is available upon 
     request.
       (c) Information Made Available Upon Request.--The 
     information described in this subsection is the following:
       (1) Utilization review activities.--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.
       (2) Grievance and appeals information.--Information on the 
     number of grievances and appeals and on the disposition in 
     the aggregate of such matters.
       (3) Method of physician compensation.--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.
       (4) Specific information on credentials of participating 
     providers.--In the case of each participating provider, a 
     description of the credentials of the provider.
       (5) Formulary restrictions.--A description of the nature of 
     any drug formula restrictions.
       (6) Participating provider list.--A list of current 
     participating health care providers.
       (d) Construction.--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.

         Subtitle D--Protecting the Doctor-Patient Relationship

     SEC. 131. PROHIBITION OF INTERFERENCE WITH CERTAIN MEDICAL 
                   COMMUNICATIONS.

       (a) General Rule.--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.
       (b) Nullification.--Any contract provision or agreement 
     that restricts or prohibits medical communications in 
     violation of subsection (a) shall be null and void.

     SEC. 132. PROHIBITION OF DISCRIMINATION AGAINST PROVIDERS 
                   BASED ON LICENSURE.

       (a) In General.--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.
       (b) Construction.--Subsection (a) shall not be construed--
       (1) 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;
       (2) to override any State licensure or scope-of-practice 
     law; or
       (3) 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.

     SEC. 133. PROHIBITION AGAINST IMPROPER INCENTIVE 
                   ARRANGEMENTS.

       (a) In General.--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 Social Security Act) 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.
       (b) Application.--For purposes of carrying out paragraph 
     (1), any reference in section 1876(i)(8) of the Social 
     Security Act 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.
       (c) Construction.--Nothing in this section shall be 
     construed as prohibiting all capitation and similar 
     arrangements or all provider discount arrangements.

     SEC. 134. PAYMENT OF CLAIMS.

       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 Social Security Act (42 U.S.C. 
     1395h(c)(2) and 42 U.S.C. 1395u(c)(2)), except that for 
     purposes of this section, subparagraph (C) of section 
     1816(c)(2) of the Social Security Act shall be treated as 
     applying to claims received from a participant, beneficiary, 
     or enrollee as well as claims referred to in such 
     subparagraph.

     SEC. 135. PROTECTION FOR PATIENT ADVOCACY.

       (a) Protection for Use of Utilization Review and Grievance 
     Process.--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.
       (b) Protection for Quality Advocacy by Health Care 
     Professionals.--
       (1) In general.--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--
       (A) 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
       (B) initiates, cooperates, or otherwise participates in an 
     investigation or proceeding by such an agency with respect to 
     such care, services, or conditions.

     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.
       (2) Good faith action.--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--
       (A) 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;
       (B) the professional reasonably believes the information to 
     be true;
       (C) 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
       (D) 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.
       (3) Exception and special rule.--
       (A) General exception.--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.
       (B) Notice of internal procedures.--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.
       (C) Internal procedure exception.--Subparagraph (D) of 
     paragraph (2) also shall not apply if--

[[Page S110]]

       (i) the disclosure relates to an imminent hazard of loss of 
     life or serious injury to a patient;
       (ii) the disclosure is made to an appropriate private 
     accreditation body pursuant to disclosure procedures 
     established by the body; or
       (iii) 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.
       (4) Additional considerations.--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.
       (5) Notice.--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.
       (6) Constructions.--
       (A) Determinations of coverage.--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.
       (B) Enforcement of peer review protocols and internal 
     procedures.--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.
       (C) Relation to other rights.--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.
       (7) Protected health care professional defined.--For 
     purposes of this subsection, the term ``protected health care 
     professional'' means an individual who is a licensed or 
     certified health care professional and who--
       (A) 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
       (B) 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.

                        Subtitle E--Definitions

     SEC. 151. DEFINITIONS.

       (a) Incorporation of General Definitions.--Except as 
     otherwise provided, the provisions of section 2791 of the 
     Public Health Service Act shall apply for purposes of this 
     title in the same manner as they apply for purposes of title 
     XXVII of such Act.
       (b) Secretary.--Except as otherwise provided, the term 
     ``Secretary'' means the Secretary of Health and Human 
     Services, in consultation with the Secretary of Labor and the 
     term ``appropriate Secretary'' means the Secretary of Health 
     and Human Services in relation to carrying out this title 
     under sections 2706 and 2751 of the Public Health Service Act 
     and the Secretary of Labor in relation to carrying out this 
     title under section 713 of the Employee Retirement Income 
     Security Act of 1974.
       (c) Additional Definitions.--For purposes of this title:
       (1) Actively practicing.--The term ``actively practicing'' 
     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.
       (2) Applicable authority.--The term ``applicable 
     authority'' means--
       (A) in the case of a group health plan, the Secretary of 
     Health and Human Services and the Secretary of Labor; and
       (B) in the case of a health insurance issuer with respect 
     to a specific provision of this title, the applicable State 
     authority (as defined in section 2791(d) of the Public Health 
     Service Act), or the Secretary of Health and Human Services, 
     if such Secretary is enforcing such provision under section 
     2722(a)(2) or 2761(a)(2) of the Public Health Service Act.
       (3) Clinical peer.--The term ``clinical peer'' 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.
       (4) Enrollee.--The term ``enrollee'' means, with respect to 
     health insurance coverage offered by a health insurance 
     issuer, an individual enrolled with the issuer to receive 
     such coverage.
       (5) Group health plan.--The term ``group health plan'' has 
     the meaning given such term in section 733(a) of the Employee 
     Retirement Income Security Act of 1974 and in section 
     2791(a)(1) of the Public Health Service Act.
       (6) Health care professional.--The term ``health care 
     professional'' means an individual who is licensed, 
     accredited, or certified under State law to provide specified 
     health care services and who is operating within the scope of 
     such licensure, accreditation, or certification.
       (7) Health care provider.--The term ``health care 
     provider'' 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.
       (8) Network.--The term ``network'' 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.
       (9) Nonparticipating.--The term ``nonparticipating'' means, 
     with respect to a health care provider that provides health 
     care items and services to a participant, beneficiary, or 
     enrollee under group health plan or health insurance 
     coverage, a health care provider that is not a participating 
     health care provider with respect to such items and services.
       (10) Participating.--The term ``participating'' means, with 
     respect to a health care provider that provides health care 
     items and services to a participant, beneficiary, or enrollee 
     under group health plan or health insurance coverage offered 
     by a health insurance issuer, a health care provider that 
     furnishes such items and services under a contract or other 
     arrangement with the plan or issuer.
       (11) Prior authorization.--The term ``prior authorization'' 
     means the process of obtaining prior approval from a health 
     insurance issuer or group health plan for the provision or 
     coverage of medical services.

     SEC. 152. PREEMPTION; STATE FLEXIBILITY; CONSTRUCTION.

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

     SEC. 153. EXCLUSIONS.

       (a) No Benefit Requirements.--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 under the terms of such a 
     plan or coverage, other than those that are provided for 
     under the terms of such plan or coverage.
       (b) Exclusion From Access to Care Managed Care Provisions 
     for Fee-for-Service Coverage.--
       (1) In general.--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)).
       (2) Fee-for-service coverage defined.--For purposes of this 
     subsection, the term ``fee-for-service coverage'' means 
     coverage under a group health plan or health insurance 
     coverage that--
       (A) 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;
       (B) 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;
       (C) does not restrict the selection of providers among 
     those who are lawfully authorized to provide the covered 
     services and agree to accept the terms and conditions of 
     payment established under the plan or by the issuer; and

[[Page S111]]

       (D) for which the plan or issuer does not require prior 
     authorization before providing coverage for any services.

     SEC. 154. COVERAGE OF LIMITED SCOPE PLANS.

       Only for purposes of applying the requirements of this 
     title under sections 2707 and 2753 of the Public Health 
     Service Act and section 714 of the Employee Retirement Income 
     Security Act of 1974, section 2791(c)(2)(A), and section 
     733(c)(2)(A) of the Employee Retirement Income Security Act 
     of 1974 shall be deemed not to apply.

     SEC. 155. REGULATIONS.

       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 Health Insurance 
     Portability and Accountability Act of 1996. Such Secretaries 
     may promulgate any interim final rules as the Secretaries 
     determine are appropriate to carry out this title.

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

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

       (a) In General.--Subpart 2 of part A of title XXVII of the 
     Public Health Service Act is amended by adding at the end the 
     following new section:

     ``SEC. 2707. PATIENT PROTECTION STANDARDS.

       ``(a) In General.--Each group health plan shall comply with 
     patient protection requirements under title I of the 
     Patients' Bill of Rights Act, and each health insurance 
     issuer shall comply with patient protection requirements 
     under such title with respect to group health insurance 
     coverage it offers, and such requirements shall be deemed to 
     be incorporated into this subsection.
       ``(b) Notice.--A group health plan shall comply with the 
     notice requirement under section 711(d) of the Employee 
     Retirement Income Security Act of 1974 with respect to the 
     requirements referred to in subsection (a) and a health 
     insurance issuer shall comply with such notice requirement as 
     if such section applied to such issuer and such issuer were a 
     group health plan.''.
       (b) Conforming Amendment.--Section 2721(b)(2)(A) of such 
     Act (42 U.S.C. 300gg-21(b)(2)(A)) is amended by inserting 
     ``(other than section 2707)'' after ``requirements of such 
     subparts''.

     SEC. 202. APPLICATION TO INDIVIDUAL HEALTH INSURANCE 
                   COVERAGE.

       Part B of title XXVII of the Public Health Service Act is 
     amended by inserting after section 2752 the following new 
     section:

     ``SEC. 2753. PATIENT PROTECTION STANDARDS.

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

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

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

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

     ``SEC. 714. PATIENT PROTECTION STANDARDS.

       ``(a) In General.--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 
     Patients' Bill of Rights Act (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.
       ``(b) Plan Satisfaction of Certain Requirements.--
       ``(1) Satisfaction of certain requirements through 
     insurance.--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 Patients' Bill of Rights Act 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:
       ``(A) Section 112 (relating to choice of providers).
       ``(B) Section 113 (relating to access to emergency care).
       ``(C) Section 114 (relating to access to specialty care).
       ``(D) Section 115 (relating to access to obstetrical and 
     gynecological care).
       ``(E) Section 116 (relating to access to pediatric care).
       ``(F) 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.
       ``(G) Section 118 (relating to access to needed 
     prescription drugs).
       ``(H) Section 119 (relating to coverage for individuals 
     participating in approved clinical trials.)
       ``(I) Section 134 (relating to payment of claims).
       ``(2) Information.--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.
       ``(3) Grievance and internal appeals.--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.
       ``(4) External appeals.--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.
       ``(5) Application to prohibitions.--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:
       ``(A) Section 131 (relating to prohibition of interference 
     with certain medical communications).
       ``(B) Section 132 (relating to prohibition of 
     discrimination against providers based on licensure).
       ``(C) Section 133 (relating to prohibition against improper 
     incentive arrangements).
       ``(D) Section 135 (relating to protection for patient 
     advocacy).
       ``(6) Construction.--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.
       ``(7) Application to certain prohibitions against 
     retaliation.--With respect to compliance with the 
     requirements of section 135(b)(1) of the Patients' Bill of 
     Rights Act, for purposes of this subtitle the term `group 
     health plan' is deemed to include a reference to an 
     institutional health care provider.
       ``(c) Enforcement of Certain Requirements.--
       ``(1) Complaints.--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 Patients' Bill of Rights Act may file with the Secretary 
     a complaint within 180 days of the date of the alleged 
     retaliation or discrimination.
       ``(2) Investigation.--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.
       ``(d) Conforming Regulations.--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.''.
       (b) Satisfaction of ERISA Claims Procedure Requirement.--
     Section 503 of such Act (29 U.S.C. 1133) is amended by 
     inserting ``(a)'' after ``Sec. 503.'' and by adding at the 
     end the following new subsection:
       ``(b) 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 Patients Bill of Rights Act in the case of 
     a claims denial shall be deemed compliance with subsection 
     (a) with respect to such claims denial.''.
       (c) Conforming Amendments.--(1) Section 732(a) of such Act 
     (29 U.S.C. 1185(a)) is amended by striking ``section 711'' 
     and inserting ``sections 711 and 714''.
       (2) 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:

``Sec. 714. Patient protection standards.''.


[[Page S112]]


       (3) Section 502(b)(3) of such Act (29 U.S.C. 1132(b)(3)) is 
     amended by inserting ``(other than section 135(b))'' after 
     ``part 7''.

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

       (a) In General.--Section 514 of the Employee Retirement 
     Income Security Act of 1974 (29 U.S.C. 1144) (as amended by 
     section 301(b)) is amended further by adding at the end the 
     following subsections:
       ``(f) Preemption Not To Apply to Certain Actions Arising 
     Out of Provision of Health Benefits.--
       ``(1) Non-preemption of certain causes of action.--
       ``(A) In general.--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--
       ``(i) 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
       ``(ii) that arises out of the arrangement by such person 
     for the provision of such insurance, administrative services, 
     or medical services by other persons.
       ``(B) Limitation on punitive damages.--
       ``(i) In general.--No person shall be liable for any 
     punitive, exemplary, or similar damages in the case of a 
     cause of action brought under subparagraph (A) if--

       ``(I) it relates to an externally appealable decision (as 
     defined in subsection (a)(2) of section 103 of the Patients' 
     Bill of Rights Act);
       ``(II) an external appeal with respect to such decision was 
     completed under such section 103;
       ``(III) 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
       ``(IV) the plan or issuer complied with the determination 
     of the external appeal entity upon receipt of the 
     determination of the external appeal entity.

     The provisions of this clause supersede any State law or 
     common law to the contrary.
       ``(ii) Exception.--Clause (i) shall not apply with respect 
     to damages in the case of a cause of action for wrongful 
     death if the applicable State law provides (or has been 
     construed to provide) for damages in such a cause of action 
     which are only punitive or exemplary in nature.
       ``(C) Personal injury defined.--For purposes of this 
     subsection, the term `personal injury' means a physical 
     injury and includes an injury arising out of the treatment 
     (or failure to treat) a mental illness or disease.
       ``(2) Exception for group health plans, employers, and 
     other plan sponsors.--
       ``(A) In general.--Subject to subparagraph (B), paragraph 
     (1) does not authorize--
       ``(i) any cause of action against a group health plan or an 
     employer or other plan sponsor maintaining the plan (or 
     against an employee of such a plan, employer, or sponsor 
     acting within the scope of employment), or
       ``(ii) a right of recovery, indemnity, or contribution by a 
     person against a group health plan or 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).
       ``(B) Special rule.--Subparagraph (A) shall not preclude 
     any cause of action described in paragraph (1) against group 
     health plan or an employer or other plan sponsor (or against 
     an employee of such a plan, employer, or sponsor acting 
     within the scope of employment) if--
       ``(i) such action is based on the exercise by the plan, 
     employer, or sponsor (or employee) of discretionary authority 
     to make a decision on a claim for benefits covered under the 
     plan or health insurance coverage in the case at issue; and
       ``(ii) the exercise by the plan, employer, or sponsor (or 
     employee) of such authority resulted in personal injury or 
     wrongful death.
       ``(C) Exception.--The exercise of discretionary authority 
     described in subparagraph (B)(i) shall not be construed to 
     include--
       ``(i) the decision to include or exclude from the plan any 
     specific benefit;
       ``(ii) any decision to provide extra-contractual benefits; 
     or
       ``(iii) any decision not to consider the provision of a 
     benefit while internal or external review is being conducted.
       ``(3) Futility of exhaustion.--An individual bringing an 
     action under this subsection is required to exhaust 
     administrative processes under sections 102 and 103 of the 
     Patients' Bill of Rights Act, unless the injury to or death 
     of such individual has occurred before the completion of such 
     processes.
       ``(4) Construction.--Nothing in this subsection shall be 
     construed as--
       ``(A) 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;
       ``(B) as preempting a State law which requires an affidavit 
     or certificate of merit in a civil action; or
       ``(C) permitting a cause of action or remedy under State 
     law in connection with the provision or arrangement of 
     excepted benefits (as defined in section 733(c)), other than 
     those described in section 733(c)(2)(A).
       ``(g) Rules of Construction Relating to Health Care.--
     Nothing in this title shall be construed as--
       ``(1) permitting the application of State laws that are 
     otherwise superseded by this title and that mandate the 
     provision of specific benefits by a group health plan (as 
     defined in section 733(a)) or a multiple employer welfare 
     arrangement (as defined in section 3(40)), or
       ``(2) affecting any State law which regulates the practice 
     of medicine or provision of medical care, or affecting any 
     action based upon such a State law.''.
       (b) Effective Date.--The amendment made by subsection (a) 
     shall apply to acts and omissions occurring on or after the 
     date of enactment of this Act, from which a cause of action 
     arises.

     SEC. 303. LIMITATIONS ON ACTIONS.

       Section 502 of the Employee Retirement Income Security Act 
     of 1974 (29 U.S.C. 1132) is amended further by adding at the 
     end the following new subsection:
       ``(n)(1) Except as provided in this subsection, no action 
     may be brought under subsection (a)(1)(B), (a)(2), or (a)(3) 
     by a participant or beneficiary seeking relief based on the 
     application of any provision in section 101, subtitle B, or 
     subtitle D of title I of the Patients' Bill of Rights Act (as 
     incorporated under section 714).
       ``(2) An action may be brought under subsection (a)(1)(B), 
     (a)(2), or (a)(3) by a participant or beneficiary seeking 
     relief based on the application of section 101, 113, 114, 
     115, 116, 117, 119, or 118(3) of the Patients' Bill of Rights 
     Act (as incorporated under section 714) to the individual 
     circumstances of that participant or beneficiary, except 
     that--
       ``(A) such an action may not be brought or maintained as a 
     class action; and
       ``(B) in such an action, relief may only provide for the 
     provision of (or payment of) benefits, items, or services 
     denied to the individual participant or beneficiary involved 
     (and for attorney's fees and the costs of the action, at the 
     discretion of the court) and shall not provide for any other 
     relief to the participant or beneficiary or for any relief to 
     any other person.
       ``(3) Nothing in this subsection shall be construed as 
     affecting any action brought by the Secretary.''.

TITLE IV--APPLICATION TO GROUP HEALTH PLANS UNDER THE INTERNAL REVENUE 
                              CODE OF 1986

     SEC. 401. AMENDMENTS TO THE INTERNAL REVENUE CODE OF 1986.

       Subchapter B of chapter 100 of the Internal Revenue Code of 
     1986 is amended--
       (1) in the table of sections, by inserting after the item 
     relating to section 9812 the following new item:

``Sec. 9813. Standard relating to patient freedom of choice.'';

     and
       (2) by inserting after section 9812 the following:

     ``SEC. 9813. STANDARD RELATING TO PATIENTS' BILL OF RIGHTS.

       ``A group health plan shall comply with the requirements of 
     title I of the Patients' Bill of Rights Act (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.''.

        TITLE V--EFFECTIVE DATES; COORDINATION IN IMPLEMENTATION

     SEC. 501. EFFECTIVE DATES.

       (a) Group Health Coverage.--
       (1) In general.--Subject to paragraph (2), the amendments 
     made by sections 201(a), 301, 303, 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, 2002 (in this section 
     referred to as the ``general effective date'') and also shall 
     apply to portions of plan years occurring on and after such 
     date.
       (2) Treatment of collective bargaining agreements.--In the 
     case of a group health plan maintained pursuant to one or 
     more collective bargaining agreements between employee 
     representatives and one or more employers ratified before the 
     date of the enactment of this Act, the amendments made by 
     sections 201(a), 301, 303, and 401 (and title I insofar as it 
     relates to such sections) shall not apply to plan years 
     beginning before the later of--
       (A) the date on which the last collective bargaining 
     agreements relating to the plan terminates (determined 
     without regard to any extension thereof agreed to after the 
     date of the enactment of this Act); or
       (B) the general effective date.
     For purposes of subparagraph (A), any plan amendment made 
     pursuant to a collective bargaining agreement relating to the 
     plan which amends the plan solely to conform to any 
     requirement added by this Act shall not be treated as a 
     termination of such collective bargaining agreement.
       (b) Individual Health Insurance Coverage.--The amendments 
     made by section 202 shall apply with respect to individual 
     health insurance coverage offered, sold, issued, renewed, in 
     effect, or operated in the individual market on or after the 
     general effective date.

     SEC. 502. COORDINATION IN IMPLEMENTATION.

       The Secretary of Labor, the Secretary of Health and Human 
     Services, and the Secretary of the Treasury shall ensure, 
     through

[[Page S113]]

     the execution of an interagency memorandum of understanding 
     among such Secretaries, that--
       (1) 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
       (2) coordination of policies relating to enforcing the same 
     requirements through such Secretaries in order to have a 
     coordinated enforcement strategy that avoids duplication of 
     enforcement efforts and assigns priorities in enforcement.

                   TITLE VI--MISCELLANEOUS PROVISIONS

     SEC. 601. HEALTH CARE PAPERWORK SIMPLIFICATION.

       (a) Establishment of Panel.--
       (1) Establishment.--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 
     ``Panel'').
       (2) Duties of panel.--
       (A) In general.--The Panel shall devise a single form for 
     use by third-party health care payers for the remittance of 
     claims to providers.
       (B) Definition.--For purposes of this section, the term 
     ``third-party health care payer'' means any entity that 
     contractually pays health care bills for an individual.
       (3) Membership.--
       (A) Size and composition.--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.
       (B) Terms of appointment.--The members of the Panel shall 
     serve for the life of the Panel.
       (C) Vacancies.--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.
       (4) Procedures.--
       (A) Meetings.--The Panel shall meet at the call of a 
     majority of its members.
       (B) First meeting.--The Panel shall convene not later than 
     60 days after the date of the enactment of the Patients' Bill 
     of Rights Act.
       (C) Quorum.--A quorum shall consist of a majority of the 
     members of the Panel.
       (D) Hearings.--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.
       (5) Administration.--
       (A) Compensation.--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.
       (B) Travel expenses and per diem.--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 5702 and 5703 of 
     title 5, United States Code.
       (C) Contract authority.--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 (41 U.S.C. 5).
       (D) Use of mails.--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 
     section 3215 of title 39, United States Code.
       (E) Administrative support services.--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.
       (6) Submission of form.--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.
       (7) Termination.--The Panel shall terminate on the day 
     after submitting the form under paragraph (6).
       (b) Requirement for Use of Form by Third-Party Care 
     Payers.--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.

     SEC. 602. NO IMPACT ON SOCIAL SECURITY TRUST FUND.

       (a) In General.--Nothing in this Act (or an amendment made 
     by this Act) shall be construed to alter or amend the Social 
     Security Act (or any regulation promulgated under that Act).
       (b) Transfers.--
       (1) Estimate of secretary.--The Secretary of the Treasury 
     shall annually estimate the impact that the enactment of this 
     Act has on the income and balances of the trust funds 
     established under section 201 of the Social Security Act (42 
     U.S.C. 401).
       (2) Transfer of funds.--If, under paragraph (1), the 
     Secretary of the Treasury estimates that the enactment of 
     this Act has a negative impact on the income and balances of 
     the trust funds established under section 201 of the Social 
     Security Act (42 U.S.C. 401), the Secretary shall transfer, 
     not less frequently than quarterly, from the general revenues 
     of the Federal Government an amount sufficient so as to 
     ensure that the income and balances of such trust funds are 
     not reduced as a result of the enactment of such Act.
                                 ______