[House Report 106-366]
[From the U.S. Government Publishing Office]



106th Congress                                                   Report
                        HOUSE OF REPRESENTATIVES
 1st Session                                                    106-366

======================================================================


 
PROVIDING FOR THE CONSIDERATION OF H.R. 2990, THE QUALITY CARE FOR THE 
  UNINSURED ACT OF 1999, AND H.R. 2723, THE BIPARTISAN CONSENSUS MANAGED 
  CARE IMPROVEMENT ACT OF 1999

                                _______
                                

  October 5, 1999.--Referred to the House Calendar and ordered to be 
                                printed

                                _______


     Mr. Goss, from the Committee on Rules, submitted the following

                              R E P O R T

                       [To accompany H. Res. 323]

    The Committee on Rules, having had under consideration 
House Resolution 323, by a record vote of 9 to 3, report the 
same to the House with the recommendation that the resolution 
be adopted.

                  summary of provisions of resolution

    The resolution provides for the consideration of H.R. 2990, 
the Quality Care for the Uninsured Act of 1999, and H.R. 2723, 
Bipartisan Consensus Managed Care Improvement Act of 1999, 
under a structured rule.
    The rule provides two hours of debate in the House on H.R. 
2990, equally divided among and controlled by the chairmen and 
ranking minority members of the Committee on Commerce, the 
Committee on Education and the Workforce, and the Committee on 
Ways and Means. The rule waives all points of order against 
consideration of the bill. The rule provides one motion to 
recommit H.R. 2990.
    The rule further provides three hours of general debate on 
H.R. 2723, equally divided among and controlled by the chairmen 
and ranking minority members of the Committee on Commerce, the 
Committee on Education and the Workforce, and the Committee on 
Ways and Means. All points of order against consideration of 
the bill are waived. The rule also provides that the amendments 
printed in part A of this report shall be considered as adopted 
upon adoption of the rule.
    The rule provides for consideration of only the amendments 
printed in part B of this report. The amendments printed in 
part B shall be considered only in the order specified in this 
report, may be offered only by a Member designated in this 
report, shall be considered as read, shall be debatable for the 
time specified in this report equally divided and controlled by 
the proponent and an opponent, and shall not be subject to 
amendment. The rule also waives all points of order against the 
amendments printed in part B of this report except that the 
adoption of an amendment in the nature of a substitute shall 
constitute the conclusion of consideration of the bill for 
amendment. The rule provides one motion to recommit H.R. 2723, 
with or without instructions.
    Finally, the rule provides that in the engrossment of H.R. 
2990, the clerk shall add the text of H.R. 2723, as passed by 
the House, as a new matter at the end of H.R. 2990, and then 
lay H.R. 2723 on the table.

                            committee votes

    Pursuant to clause 3(b) of House rule XIII the results of 
each record vote on an amendment or motion to report, together 
with the names of those voting for and against, and printed 
below:

Rules Committee record vote No. 63

    Date: October 5, 1999.
    Measure: H.R. 2990, the Quality Care for the Uninsured Act 
of 1999 and H.R. 2723, the Bipartisan Consensus Managed Care 
Improvement Act of 1999.
    Motion by: Mr. Frost.
    Summary of motion: To make in order amendment No. 27 to 
H.R. 2990 offered by Reps. Norwood, Dingell, Ganske, and Berry 
which would provide for revenue provisions designed to offset 
revenue losses from the bill. (Revenue losses are estimated to 
result from increased deductions for higher medical premiums.) 
The offsets would raise approximately $7 billion over the 
period 2000-2004. Half of the offsets totaling $3.5 billion 
were included in the tax bill that passed the Congress in this 
session. The remaining offsets consist of the elimination of 
corporate tax shelters. The provision codifies a court-
developed doctrine that requires transactions to have economic 
substance in order to be respected for tax purposes. The 
provision would require that the transaction have a potential 
profit (and risk of loss) and that potential profit must be 
significant in relationship to the claimed tax benefits.
    Results: Defeated 3 to 9.
    Vote by Members: Goss--Nay; Linder--Nay; Pryce--Nay; Diaz-
Balart--Nay; Hastings--Nay; Myrick--Nay; Sessions--Nay; 
Reynolds--Nay; Frost--Yea; Hall--Yea; Slaughter--Yea; Dreier--
Nay.

Rules Committee record vote No. 64

    Date: October 5, 1999.
    Measure: H.R. 2990, the Quality Care for the Uninsured Act 
of 1999 and H.R. 2723, the Bipartisan Consensus Managed Care 
Improvement Act of 1999.
    Motion by: Mr. Hall.
    Summary of motion: To strike the provisions in the rule 
providing that H.R. 2990 and H.R. 2723 be engrossed together.
    Results: Defeated 3 to 9.
    Vote by Members: Goss--Nay; Linder--Nay; Pryce--Nay; Diaz-
Balart--Nay; Hastings--Nay; Myrick--Nay; Sessions--Nay; 
Reynolds--Nay; Frost--Yea; Hall--Yea; Slaughter--Yea; Dreier--
Nay.

Rules Committee record vote No. 65

    Date: October 5, 1999.
    Measure: H.R. 2990, the quality Care for the Uninsured Act 
of 1999 and H.R. 2723, the Bipartisan Consensus Managed Care 
Improvement Act of 1999.
    Motion by: Mr. Goss.
    Summary of motion: To report the rule.
    Results: Adopted 9 to 3.
    Vote by Members: Goss--Yea; Linder--Yea; Pryce--Yea; Diaz-
Balart--Yea; Hastings--Yea; Myrick--Yea; Sessions--Yea; 
Reynolds--Yea; Frost--Nay; Hall--Nay; Slaughter--Nay; Dreier--
Yea.

                                 PART A


       summary of amendments considered as adopted under the rule

    Amendments consisting of a variety of technical changes to 
H.R. 2723. Clarifies provisions in the bill to ensure that 
employers cannot be held liable unless they are making medical 
decisions.

      text of the amendments considered as adopted under the rule

  Page 17, beginning on line 24, strike ``, as determined by 
the plan or issuer or as certified in writing by a treating 
health care professional,''.
  Page 40, line 17, strike ``enforce actions'' and insert 
``enforce rights''.
  Page 42, line 15, insert ``or arrange to be offered'' after 
``shall offer''.
  Page 44, after line 8, insert the following:
          (3) Construction.--Nothing in this subsection shall 
        be construed as affecting the application of section 
        114 (relating to access to specialty care).
  Page 47, amend lines 7 through 18 to read as follows:
  (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.
  Page 86, amend lines 10 through 16 to read as follows:
  (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 provide items and 
services (including abortions) that are specifically excluded 
under the plan or coverage.
  Page 102, line 25, strike ``January 1, 2000'' and insert 
``January 1, 2001''.
  Page 96, strike line 20 and all that follows through line 15 
on page 101 and insert the following (and conform the table of 
contents accordingly):

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

  (a) In General.--Section 514 of the Employee Retirement 
Income Security Act of 1974 (29 U.S.C. 1144) is amended by 
adding at the end the following subsections:
  ``(e) 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 
                                Bipartisan Consensus Managed 
                                Care Improvement Act of 1999);
                                  ``(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 Bipartisan Consensus Managed Care Improvement Act 
        of 1999, 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).
  ``(f) 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 the 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 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 Bipartisan Consensus Managed Care 
Improvement Act of 1999 (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 Bipartisan Consensus Managed 
Care Improvement Act of 1999 (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.''.
  Page 102, line 20, and page 103, line 10, insert ``303,'' 
after ``301,''.
                              ----------                              


                                 PART B


           summary of amendments made in order under the rule

    1. Boehner No. 23: Amendment in the nature of a substitute. 
Provisions include: a prohibition on gag rules; access to 
emergency medical care; direct access to an OB/GYN; access to a 
pediatrician as a primary care provider; continuity of care for 
patients even if a provider leaves the plan; expanded plan 
information; a shortened group health plan review standard; a 
Health Care Access, Affordability, and Quality Commission; 
health care lawsuit reform, including a limitation on 
``noneconomic damages''; and a patient choice of medical 
provider option. 60 minutes.
    2. Goss/Coburn/Shadegg/Thomas/Greenwood No. 54: Amendment 
in the nature of a Substitute. Protects patients in managed 
care plans by: establishing utilization review procedures; 
requiring an internal appeals process within specified time 
lines; requiring independent external review of benefit 
disputes within specified time lines; allowing patients to sue 
health plans for benefit denials that cause harm; includes 
strong protection for employers; requires patients to exhaust 
the internal and external appeal prior to court action; 
includes caps on damages; allowing choice of medical 
professionals; establishing a prudent layperson standard for 
emergencies; allowing access to speciality care; allowing 
access to OB/GYNs without referral; allowing parents to 
designate a pediatrician as their primary care provider; 
prohibiting gag clauses; expanding access to cancer clinical 
trials; ensuring prompt payment of claims; simplifying 
paperwork requirements. 60 minutes.
    3. Houghton/Graham/Hilleary/Gibbons No. 59: Amendment in 
the nature of a substitute. The amendment: gives people a way 
to get fair compensation when they are hurt by a bad decision 
and limit it to that; lets people sue only the final decision-
maker who fails to exercise ordinary care; provides that 
patients would go to external review to get the benefits first, 
then go to court to seek compensation for any harm; and lets 
people sue the employer if the employer directly participates 
in the final decision. 60 minutes.

          text of the amendments made in order under the rule

 1. An Amendment To Be Offered by Representative Boehner of Ohio, or a 
                   Designee, Debatable for 60 Minutes

  Strike all after the enacting clause and insert the 
following:

SECTION 1. SHORT TITLE AND TABLE OF CONTENTS.

  (a) Short Title.--This Act may be cited as the 
``Comprehensive Access and Responsibility in Health Care Act of 
1999''.
  (b) Table of Contents.--The table of contents is as follows:

Sec. 1. Short title and table of contents.

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

                     Subtitle A--Patient Protections

Sec. 101. Patient access to unrestricted medical advice, emergency 
          medical care, obstetric and gynecological care, pediatric 
          care, and continuity of care.
Sec. 102. Required disclosure to network providers.
Sec. 103. Effective date and related rules.

                Subtitle B--Patient Access to Information

Sec. 111. Patient access to information regarding plan coverage, managed 
          care procedures, health care providers, and quality of medical 
          care.
Sec. 112. Effective date and related rules.

             Subtitle C--Group Health Plan Review Standards

Sec. 121. Special rules for group health plans.
Sec. 122. Special rule for access to specialty care.
Sec. 123. Protection for certain information developed to reduce 
          mortality or morbidity or for improving patient care and 
          safety.
Sec. 124. Effective date.

  Subtitle E--Health Care Access, Affordability, and Quality Commission

Sec. 131. Establishment of commission.
Sec. 132. Effective date.

          TITLE II--AMENDMENTS TO THE PUBLIC HEALTH SERVICE ACT

Sec. 201. Patient access to unrestricted medical advice, emergency 
          medical care, obstetric and gynecological care, pediatric 
          care, and continuity of care.
Sec. 202. Requiring health maintenance organizations to offer option of 
          point-of-service coverage.
Sec. 203. Effective date and related rules.

                Subtitle B--Patient Access to Information

Sec. 211. Patient access to information regarding plan coverage, managed 
          care procedures, health care providers, and quality of medical 
          care.
Sec. 212. Effective date and related rules.

       TITLE III--AMENDMENTS TO THE INTERNAL REVENUE CODE OF 1986

Sec. 301. Patient access to unrestricted medical advice, emergency 
          medical care, obstetric and gynecological care, pediatric 
          care, and continuity of care.

                  TITLE IV--HEALTH CARE LAWSUIT REFORM

                     Subtitle A--General Provisions

Sec. 401. Federal reform of health care liability actions.
Sec. 402. Definitions.
Sec. 403. Effective date.

     Subtitle B--Uniform Standards for Health Care Liability Actions

Sec. 411. Statute of limitations.
Sec. 412. Calculation and payment of damages.
Sec. 413. Alternative dispute resolution.
Sec. 414. Reporting on fraud and abuse enforcement activities.

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

                    Subtitle A--Patient Protections

SEC. 101. PATIENT ACCESS TO UNRESTRICTED MEDICAL ADVICE, EMERGENCY 
                    MEDICAL CARE, OBSTETRIC AND GYNECOLOGICAL CARE, 
                    PEDIATRIC CARE, AND CONTINUITY OF CARE.

  (a) In General.--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 ACCESS TO UNRESTRICTED MEDICAL ADVICE, EMERGENCY 
                    MEDICAL CARE, OBSTETRIC AND GYNECOLOGICAL CARE, 
                    PEDIATRIC CARE, AND CONTINUITY OF CARE.

  ``(a) Patient Access to Unrestricted Medical Advice.--
          ``(1) In general.--In the case of any health care 
        professional acting within the lawful scope of practice 
        in the course of carrying out a contractual employment 
        arrangement or other direct contractual arrangement 
        between such professional and a group health plan or a 
        health insurance issuer offering health insurance 
        coverage in connection with a group health plan, the 
        plan or issuer with which such contractual employment 
        arrangement or other direct contractual arrangement is 
        maintained by the professional may not impose on such 
        professional under such arrangement any prohibition or 
        restriction with respect to advice, provided to a 
        participant or beneficiary under the plan who is a 
        patient, about the health status of the participant or 
        beneficiary or the medical care or treatment for the 
        condition or disease of the participant or beneficiary, 
        regardless of whether benefits for such care or 
        treatment are provided under the plan or health 
        insurance coverage offered in connection with the plan.
          ``(2) Health care professional defined.--For purposes 
        of this paragraph, the term `health care professional' 
        means a physician (as defined in section 1861(r) of the 
        Social Security Act) or other health care professional 
        if coverage for the professional's services is provided 
        under the group health plan for the services of the 
        professional. Such term includes a podiatrist, 
        optometrist, chiropractor, psychologist, dentist, 
        physician assistant, physical or occupational therapist 
        and therapy assistant, speech-language pathologist, 
        audiologist, registered or licensed practical nurse 
        (including nurse practitioner, clinical nurse 
        specialist, certified registered nurse anesthetist, and 
        certified nurse-midwife), licensed certified social 
        worker, registered respiratory therapist, and certified 
        respiratory therapy technician.
          ``(3) Rule of construction.--Nothing in this 
        subsection shall be construed to require the sponsor of 
        a group health plan or a health insurance issuer 
        offering health insurance coverage in connection with 
        the group health plan to engage in any practice that 
        would violate its religious beliefs or moral 
        convictions.
  ``(b) Patient Access to Emergency Medical Care.--
          ``(1) Coverage of emergency services.--
                  ``(A) In general.--If a group health plan, or 
                health insurance coverage offered by a health 
                insurance issuer, provides any benefits with 
                respect to emergency services (as defined in 
                subparagraph (B)(ii)), or ambulance services, 
                the plan or issuer shall cover emergency 
                services (including emergency ambulance 
                services as defined in subparagraph (B)(iii)) 
                furnished under the plan or coverage--
                          ``(i) without the need for any prior 
                        authorization determination;
                          ``(ii) whether or not the health care 
                        provider furnishing such services is a 
                        participating provider with respect to 
                        such services;
                          ``(iii) in a manner so that, if such 
                        services are provided to a participant 
                        or beneficiary by a nonparticipating 
                        health care provider, the participant 
                        or beneficiary is not liable for 
                        amounts that exceed the amounts of 
                        liability that would be incurred if the 
                        services were provided by a 
                        participating provider; and
                          ``(iv) without regard to any other 
                        term or condition of such plan or 
                        coverage (other than exclusion or 
                        coordination of benefits, or an 
                        affiliation or waiting period, 
                        permitted under section 701 and other 
                        than applicable cost sharing).
                  ``(B) Definitions.--In this subsection:
                          ``(i) Emergency medical condition.--
                        The term `emergency medical condition' 
                        means--
                                  ``(I) 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 (42 U.S.C. 
                                1395dd(e)(1)(A)); and
                                  ``(II) a medical condition 
                                manifesting itself in a neonate 
                                by acute symptoms of sufficient 
                                severity (including severe 
                                pain) such that a prudent 
                                health care professional 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.
                          ``(ii) Emergency services.--The term 
                        `emergency services' means--
                                  ``(I) with respect to an 
                                emergency medical condition 
                                described in clause (i)(I), a 
                                medical screening examination 
                                (as required under section 1867 
                                of the Social Security Act, 42 
                                U.S.C. 1395dd)) 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 clause 
                                (i)) and also, within the 
                                capabilities of the staff and 
                                facilities at the hospital, 
                                such further medical 
                                examination and treatment as 
                                are required under section 1867 
                                of such Act to stabilize the 
                                patient; or
                                  ``(II) with respect to an 
                                emergency medical condition 
                                described in clause (i)(II), 
                                medical treatment for such 
                                condition rendered by a health 
                                care provider in a hospital to 
                                a neonate, including available 
                                hospital ancillary services in 
                                response to an urgent request 
                                of a health care professional 
                                and to the extent necessary to 
                                stabilize the neonate.
                          ``(iii) Emergency ambulance 
                        services.--The term `emergency 
                        ambulance services' means ambulance 
                        services (as defined for purposes of 
                        section 1861(s)(7) of the Social 
                        Security Act) furnished to transport an 
                        individual who has an emergency medical 
                        condition (as defined in clause (i)) to 
                        a hospital for the receipt of emergency 
                        services (as defined in clause (ii)) in 
                        a case in which appropriate emergency 
                        medical screening examinations are 
                        covered under the plan or coverage 
                        pursuant to paragraph (1)(A) and a 
                        prudent layperson, with an average 
                        knowledge of health and medicine, could 
                        reasonably expect that the absence of 
                        such transport would result in placing 
                        the health of the individual in serious 
                        jeopardy, serious impairment of bodily 
                        function, or serious dysfunction of any 
                        bodily organ or part.
                          ``(iv) 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.
                          ``(v) Nonparticipating.--The term 
                        `nonparticipating' means, with respect 
                        to a health care provider that provides 
                        health care items and services to a 
                        participant or beneficiary under group 
                        health plan or under group health 
                        insurance coverage, a health care 
                        provider that is not a participating 
                        health care provider with respect to 
                        such items and services.
                          ``(vi) Participating.--The term 
                        `participating' means, with respect to 
                        a health care provider that provides 
                        health care items and services to a 
                        participant or beneficiary under group 
                        health plan or health insurance 
                        coverage offered by a health insurance 
                        issuer in connection with such a plan, 
                        a health care provider that furnishes 
                        such items and services under a 
                        contract or other arrangement with the 
                        plan or issuer.
  ``(c) Patient Right to Obstetric and Gynecological Care.--
          ``(1) In general.--In any case in which a group 
        health plan (or a health insurance issuer offering 
        health insurance coverage in connection with the 
        plan)--
                  ``(A) provides benefits under the terms of 
                the plan consisting of--
                          ``(i) gynecological care (such as 
                        preventive women's health 
                        examinations); or
                          ``(ii) obstetric care (such as 
                        pregnancy-related services),
                provided by a participating health care 
                professional who specializes in such care (or 
                provides benefits consisting of payment for 
                such care); and
                  ``(B) requires or provides for designation by 
                a participant or beneficiary of a participating 
                primary care provider,
        if the primary care provider designated by such a 
        participant or beneficiary is not such a health care 
        professional, then the plan (or issuer) shall meet the 
        requirements of paragraph (2).
          ``(2) Requirements.--A group health plan (or a health 
        insurance issuer offering health insurance coverage in 
        connection with the plan) meets the requirements of 
        this paragraph, in connection with benefits described 
        in paragraph (1) consisting of care described in clause 
        (i) or (ii) of paragraph (1)(A) (or consisting of 
        payment therefor), if the plan (or issuer)--
                  ``(A) does not require authorization or a 
                referral by the primary care provider in order 
                to obtain such benefits; and
                  ``(B) treats the ordering of other care of 
                the same type, by the participating health care 
                professional providing the care described in 
                clause (i) or (ii) of paragraph (1)(A), as the 
                authorization of the primary care provider with 
                respect to such care.
          ``(3) Health care professional defined.--For purposes 
        of this subsection, the term `health care professional' 
        means an individual (including, but not limited to, a 
        nurse midwife or nurse practitioner) who is licensed, 
        accredited, or certified under State law to provide 
        obstetric and gynecological health care services and 
        who is operating within the scope of such licensure, 
        accreditation, or certification.
          ``(4) Construction.--Nothing in paragraph (1) shall 
        be construed as preventing a plan from offering (but 
        not requiring a participant or beneficiary to accept) a 
        health care professional trained, credentialed, and 
        operating within the scope of their licensure to 
        perform obstetric and gynecological health care 
        services. Nothing in paragraph (2)(B) shall waive any 
        requirements of coverage relating to medical necessity 
        or appropriateness with respect to coverage of 
        gynecological or obstetric care so ordered.
          ``(5) Treatment of multiple coverage options.--In the 
        case of a plan providing benefits under two or more 
        coverage options, the requirements of this subsection 
        shall apply separately with respect to each coverage 
        option.
  ``(d) Patient Right to Pediatric Care.--
          ``(1) In general.--In any case in which a group 
        health plan (or a health insurance issuer offering 
        health insurance coverage in connection with the plan) 
        provides benefits consisting of routine pediatric care 
        provided by a participating health care professional 
        who specializes in pediatrics (or consisting of payment 
        for such care) and the plan requires or provides for 
        designation by a participant or beneficiary of a 
        participating primary care provider, the plan (or 
        issuer) shall provide that such a participating health 
        care professional may be designated, if available, by a 
        parent or guardian of any beneficiary under the plan is 
        who under 18 years of age, as the primary care provider 
        with respect to any such benefits.
          ``(2) Health care professional defined.--For purposes 
        of this subsection, the term `health care professional' 
        means an individual (including, but not limited to, a 
        nurse practitioner) who is licensed, accredited, or 
        certified under State law to provide pediatric health 
        care services and who is operating within the scope of 
        such licensure, accreditation, or certification.
          ``(3) Construction.--Nothing in paragraph (1) shall 
        be construed as preventing a plan from offering (but 
        not requiring a participant or beneficiary to accept) a 
        health care professional trained, credentialed, and 
        operating within the scope of their licensure to 
        perform pediatric health care services. Nothing in 
        paragraph (1) shall waive any requirements of coverage 
        relating to medical necessity or appropriateness with 
        respect to coverage of pediatric care so ordered.
          ``(4) Treatment of multiple coverage options.--In the 
        case of a plan providing benefits under two or more 
        coverage options, the requirements of this subsection 
        shall apply separately with respect to each coverage 
        option.
  ``(e) Continuity of Care.--
          ``(1) In general.--
                  ``(A) Termination of provider.--If a contract 
                between a group health plan, or a health 
                insurance issuer offering health insurance 
                coverage in connection with a group health 
                plan, and a health care provider is terminated 
                (as defined in subparagraph (D)(ii)), 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, at the time 
                of such termination, is a participant or 
                beneficiary in the plan and is scheduled to 
                undergo surgery (including an organ 
                transplantation), is undergoing treatment for 
                pregnancy, or is determined to be terminally 
                ill (as defined in section 1861(dd)(3)(A) of 
                the Social Security Act) and is undergoing 
                treatment for the terminal illness, the plan or 
                issuer shall--
                          ``(i) 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 subsection; and
                          ``(ii) subject to paragraph (3), 
                        permit the individual to elect to 
                        continue to be covered with respect to 
                        treatment by the provider for such 
                        surgery, pregnancy, or illness during a 
                        transitional period (provided under 
                        paragraph (2)).
                  ``(B) 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 
                subparagraph (A) (and the succeeding provisions 
                of this subsection) 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.
                  ``(C) Termination defined.--For purposes of 
                this subsection, 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.
          ``(2) Transitional period.--
                  ``(A) In general.--Except as provided in 
                subparagraphs (B) through (D), the transitional 
                period under this paragraph shall extend up to 
                90 days (as determined by the treating health 
                care professional) after the date of the notice 
                described in paragraph (1)(A)(i) of the 
                provider's termination.
                  ``(B) Scheduled surgery.--If surgery was 
                scheduled for an individual before the date of 
                the announcement of the termination of the 
                provider status under paragraph (1)(A)(i), the 
                transitional period under this paragraph with 
                respect to the surgery shall extend beyond the 
                period under subparagraph (A) and until the 
                date of discharge of the individual after 
                completion of the surgery.
                  ``(C) Pregnancy.--If--
                          ``(i) a participant or beneficiary 
                        was determined to be pregnant at the 
                        time of a provider's termination of 
                        participation, and
                          ``(ii) the provider was treating the 
                        pregnancy before date of the 
                        termination,
                the transitional period under this paragraph 
                with respect to provider's treatment of the 
                pregnancy shall extend through the provision of 
                post-partum care directly related to the 
                delivery.
                  ``(D) Terminal illness.--If--
                          ``(i) a participant or beneficiary 
                        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
                          ``(ii) the provider was treating the 
                        terminal illness before the date of 
                        termination,
                the transitional period under this paragraph 
                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.
          ``(3) Permissible terms and conditions.--A group 
        health plan or health insurance issuer may condition 
        coverage of continued treatment by a provider under 
        paragraph (1)(A)(i) upon the individual notifying the 
        plan of the election of continued coverage and upon the 
        provider agreeing to the following terms and 
        conditions:
                  ``(A) 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 paragraph 
                (1)(B), 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 paragraph (1)(A) had not been 
                terminated.
                  ``(B) The provider agrees to adhere to the 
                quality assurance standards of the plan or 
                issuer responsible for payment under 
                subparagraph (A) and to provide to such plan or 
                issuer necessary medical information related to 
                the care provided.
                  ``(C) 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) The provider agrees to provide 
                transitional care to all participants and 
                beneficiaries who are eligible for and elect to 
                have coverage of such care from such provider.
                  ``(E) If the provider initiates the 
                termination, the provider has notified the plan 
                within 30 days prior to the effective date of 
                the termination of--
                          ``(i) whether the provider agrees to 
                        permissible terms and conditions (as 
                        set forth in this paragraph) required 
                        by the plan, and
                          ``(ii) if the provider agrees to the 
                        terms and conditions, the specific plan 
                        beneficiaries and participants 
                        undergoing a course of treatment from 
                        the provider who the provider believes, 
                        at the time of the notification, would 
                        be eligible for transitional care under 
                        this subsection.
          ``(4) Construction.--Nothing in this subsection shall 
        be construed to--
                  ``(A) require the coverage of benefits which 
                would not have been covered if the provider 
                involved remained a participating provider, or
                  ``(B) prohibit a group health plan from 
                conditioning a provider's participation on the 
                provider's agreement to provide transitional 
                care to all participants and beneficiaries 
                eligible to obtain coverage of such care 
                furnished by the provider as set forth under 
                this subsection.
  ``(f) Coverage for Individuals Participating in Approved 
Cancer Clinical Trials.--
          ``(1) Coverage.--
                  ``(A) In general.--If a group health plan (or 
                a health insurance issuer offering health 
                insurance coverage in connection with the plan) 
                provides coverage to a qualified individual (as 
                defined in paragraph (2)), the plan or issuer--
                          ``(i) may not deny the individual 
                        participation in the clinical trial 
                        referred to in paragraph (2)(B);
                          ``(ii) subject to paragraphs (2), 
                        (3), and (4), 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
                          ``(iii) may not discriminate against 
                        the individual on the basis of the 
                        participation of the participant or 
                        beneficiary in such trial.
                  ``(B) Exclusion of certain costs.--For 
                purposes of subparagraph (A)(ii), routine 
                patient costs do not include the cost of the 
                tests or measurements conducted primarily for 
                the purpose of the clinical trial involved.
                  ``(C) Use of in-network providers.--If one or 
                more participating providers is participating 
                in a clinical trial, nothing in subparagraph 
                (A) shall be construed as preventing a plan 
                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.
          ``(2) Qualified individual defined.--For purposes of 
        paragraph (1), the term `qualified individual' means an 
        individual who is a participant or beneficiary in a 
        group health plan and who meets the following 
        conditions:
                  ``(A)(i) The individual has been diagnosed 
                with cancer.
                  ``(ii) The individual is eligible to 
                participate in an approved clinical trial 
                according to the trial protocol with respect to 
                treatment of cancer.
                  ``(iii) The individual's participation in the 
                trial offers meaningful potential for 
                significant clinical benefit for the 
                individual.
                  ``(B) Either--
                          ``(i) 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 satisfaction by 
                        the individual of the conditions 
                        described in subparagraph (A); or
                          ``(ii) the individual provides 
                        medical and scientific information 
                        establishing that the individual's 
                        participation in such trial would be 
                        appropriate based upon the satisfaction 
                        by the individual of the conditions 
                        described in subparagraph (A).
          ``(3) Payment.--
                  ``(A) In general.--A group health plan (or a 
                health insurance issuer offering health 
                insurance coverage in connection with the plan) 
                shall provide for payment for routine patient 
                costs described in paragraph (1)(B) but is not 
                required to pay for costs of items and services 
                that are reasonably expected to be paid for by 
                the sponsors of an approved clinical trial.
                  ``(B) Routine patient care costs.--
                          ``(i) In general.--For purposes of 
                        this paragraph, the term `routine 
                        patient care costs' shall include the 
                        costs associated with the provision of 
                        items and services that--
                                  ``(I) would otherwise be 
                                covered under the group health 
                                plan if such items and services 
                                were not provided in connection 
                                with an approved clinical trial 
                                program; and
                                  ``(II) are furnished 
                                according to the protocol of an 
                                approved clinical trial 
                                program.
                          ``(ii) Exclusion.--For purposes of 
                        this paragraph, `routine patient care 
                        costs' shall not include the costs 
                        associated with the provision of--
                                  ``(I) an investigational drug 
                                or device, unless the Secretary 
                                has authorized the manufacturer 
                                of such drug or device to 
                                charge for such drug or device; 
                                or
                                  ``(II) any item or service 
                                supplied without charge by the 
                                sponsor of the approved 
                                clinical trial program.
                  ``(C) Payment rate.--For purposes of this 
                subsection--
                          ``(i) Participating providers.--In 
                        the case of covered items and services 
                        provided by a participating provider, 
                        the payment rate shall be at the agreed 
                        upon rate.
                          ``(ii) Nonparticipating providers.--
                        In the case of covered items and 
                        services provided by a nonparticipating 
                        provider, the payment rate shall be at 
                        the rate the plan would normally pay 
                        for comparable items or services under 
                        clause (i).
          ``(4) Approved clinical trial defined.--
                  ``(A) In general.--For purposes of this 
                subsection, the term `approved clinical trial' 
                means a cancer clinical research study or 
                cancer clinical investigation approved by an 
                Institutional Review Board.
                  ``(B) 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--
                          ``(i) to be comparable to the system 
                        of peer review of studies and 
                        investigations used by the National 
                        Institutes of Health, and
                          ``(ii) assures unbiased review of the 
                        highest scientific standards by 
                        qualified individuals who have no 
                        interest in the outcome of the review.
          ``(5) Construction.--Nothing in this subsection shall 
        be construed to limit a plan's coverage with respect to 
        clinical trials.
          ``(6) Plan satisfaction of certain requirements; 
        responsibilities of fiduciaries.--
                  ``(A) In general.--For purposes of this 
                subsection, 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 requirements of this subsection 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.
                  ``(B) 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.
          ``(7) Study and report.--
                  ``(A) Study.--The Secretary shall analyze 
                cancer clinical research and its cost 
                implications for managed care, including 
                differentiation in--
                          ``(i) the cost of patient care in 
                        trials versus standard care;
                          ``(ii) the cost effectiveness 
                        achieved in different sites of service;
                          ``(iii) research outcomes;
                          ``(iv) volume of research subjects 
                        available in different sites of 
                        service;
                          ``(v) access to research sites and 
                        clinical trials by cancer patients;
                          ``(vi) patient cost sharing or 
                        copayment costs realized in different 
                        sites of service;
                          ``(vii) health outcomes experienced 
                        in different sites of service;
                          ``(viii) long term health care 
                        services and costs experienced in 
                        different sites of service;
                          ``(ix) morbidity and mortality 
                        experienced in different sites of 
                        service; and
                          ``(x) patient satisfaction and 
                        preference of sites of service.
                  ``(B) Report to congress.--Not later than 
                January 1, 2005, the Secretary shall submit a 
                report to Congress that contains--
                          ``(i) an assessment of any 
                        incremental cost to group health plans 
                        resulting from the provisions of this 
                        section;
                          ``(ii) a projection of expenditures 
                        to such plans resulting from this 
                        section;
                          ``(iii) an assessment of any impact 
                        on premiums resulting from this 
                        section; and
                          ``(iv) recommendations regarding 
                        action on other diseases.''.
  (b) Conforming Amendment.--The table of contents in section 1 
of such Act is amended by adding at the end of the items 
relating to subpart B of part 7 of subtitle B of title I of 
such Act the following new item:

``Sec. 714. Patient access to unrestricted medical advice, emergency 
          medical care, obstetric and gynecological care, pediatric 
          care, and continuity of care.''.

SEC. 102. REQUIRED DISCLOSURE TO NETWORK PROVIDERS.

  (a) In General.--Subpart B of part 7 of subtitle B of title I 
of the Employee Retirement Income Security Act of 1974 (as 
amended by section 101) is amended further by adding at the end 
the following new section:

``SEC. 715. REQUIRED DISCLOSURE TO NETWORK PROVIDERS.

  ``(a) In General.--If a group health plan reimburses, through 
a contract or other arrangement, a health care provider at a 
discounted payment rate because the provider participates in a 
provider network, the plan shall disclose to the provider the 
following information before the provider furnishes covered 
items or services under the plan:
          ``(1) The identity of the plan sponsor or other 
        entity that is to utilize the discounted payment rates 
        in reimbursing network providers in that network.
          ``(2) The existence of any substantial benefit 
        differentials established for the purpose of actively 
        encouraging participants or beneficiaries under the 
        plan to utilize the providers in that network.
          ``(3) The methods and materials by which providers in 
        the network are identified to such participants or 
        beneficiaries as part of the network.
  ``(b) Permitted Means of Disclosure.--Disclosure required 
under subsection (a) by a plan may be made--
          ``(1) by another entity under a contract or other 
        arrangement between the plan and the entity; and
          ``(2) by making such information available in written 
        format, in an electronic format, on the Internet, or on 
        a proprietary computer network which is readily 
        accessible to the network providers.
  ``(c) Construction.--Nothing in this section shall be 
construed to require, directly or indirectly, disclosure of 
specific fee arrangements or other reimbursement arrangements--
          ``(1) between (i) group health plans or provider 
        networks and (ii) health care providers, or
          ``(2) among health care providers.
  ``(d) Definitions.--For purposes of this subsection:
          ``(1) Benefit differential.--The term `benefit 
        differential' means, with respect to a group health 
        plan, differences in the case of any participant or 
        beneficiary, in the financial responsibility for 
        payment of coinsurance, copayments, deductibles, 
        balance billing requirements, or any other charge, 
        based upon whether a health care provider from whom 
        covered items or services are obtained is a network 
        provider.
          ``(2) Discounted payment rate.--The term `discounted 
        payment rate' means, with respect to a provider, a 
        payment rate that is below the charge imposed by the 
        provider.
          ``(3) Network provider.--The term `network provider' 
        means, with respect to a group health plan, a health 
        care provider that furnishes health care items and 
        services to participants or beneficiaries under the 
        plan pursuant to a contract or other arrangement with a 
        provider network in which the provider is 
        participating.
          ``(4) Provider network.--The term `provider network' 
        means, with respect to a group health plan offering 
        health insurance coverage, an association of network 
        providers through whom the plan provides, through 
        contract or other arrangement, health care items and 
        services to participants and beneficiaries.''.
  (b) Conforming Amendment.--The table of contents in section 1 
of such Act is amended by adding at the end of the items 
relating to subpart B of part 7 of subtitle B of title I of 
such Act the following new item:

``Sec. 715. Required disclosure to network providers.''.

SEC. 103. EFFECTIVE DATE AND RELATED RULES.

  (a) In General.--The amendments made by this subtitle shall 
apply with respect to plan years beginning on or after January 
1 of the second calendar year following the date of the 
enactment of this Act, except that the Secretary of Labor may 
issue regulations before such date under such amendments. The 
Secretary shall first issue regulations necessary to carry out 
the amendments made by this subtitle before the effective date 
thereof.
  (b) Limitation on Enforcement Actions.--No enforcement action 
shall be taken, pursuant to the amendments made by this 
subtitle, against a group health plan or health insurance 
issuer with respect to a violation of a requirement imposed by 
such amendments before the date of issuance of regulations 
issued in connection with such requirement, if the plan or 
issuer has sought to comply in good faith with such 
requirement.
  (c) Special Rule for 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 this 
subtitle shall not apply with respect to plan years beginning 
before the later of--
          (1) the date on which the last of the 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
          (2) January 1, 2002.
For purposes of this subsection, 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 subtitle shall not be treated as a termination of 
such collective bargaining agreement.

               Subtitle B--Patient Access to Information

SEC. 111. PATIENT ACCESS TO INFORMATION REGARDING PLAN COVERAGE, 
                    MANAGED CARE PROCEDURES, HEALTH CARE PROVIDERS, AND 
                    QUALITY OF MEDICAL CARE.

  (a) In General.--Part 1 of subtitle B of title I of the 
Employee Retirement Income Security Act of 1974 is amended--
          (1) by redesignating section 111 as section 112; and
          (2) by inserting after section 110 the following new 
        section:

                   ``disclosure by group health plans

  ``Sec. 111. (a) Disclosure Requirement.--The administrator of 
each group health plan shall take such actions as are necessary 
to ensure that the summary plan description of the plan 
required under section 102 (or each summary plan description in 
any case in which different summary plan descriptions are 
appropriate under part 1 for different options of coverage) 
contains, among any information otherwise required under this 
part, the information required under subsections (b), (c), (d), 
and (e)(2)(A).
  ``(b) Plan Benefits.--The information required under 
subsection (a) includes the following:
          ``(1) Covered items and services.--
                  ``(A) Categorization of included benefits.--A 
                description of covered benefits, categorized 
                by--
                          ``(i) types of items and services 
                        (including any special disease 
                        management program); and
                          ``(ii) types of health care 
                        professionals providing such items and 
                        services.
                  ``(B) Emergency medical care.--A description 
                of the extent to which the plan covers 
                emergency medical care (including the extent to 
                which the plan provides for access to urgent 
                care centers), and any definitions provided 
                under the plan for the relevant plan 
                terminology referring to such care.
                  ``(C) Preventative services.--A description 
                of the extent to which the plan provides 
                benefits for preventative services.
                  ``(D) Drug formularies.--A description of the 
                extent to which covered benefits are determined 
                by the use or application of a drug formulary 
                and a summary of the process for determining 
                what is included in such formulary.
                  ``(E) COBRA continuation coverage.--A 
                description of the benefits available under the 
                plan pursuant to part 6.
          ``(2) Limitations, exclusions, and restrictions on 
        covered benefits.--
                  ``(A) Categorization of excluded benefits.--A 
                description of benefits specifically excluded 
                from coverage, categorized by types of items 
                and services.
                  ``(B) Utilization review and preauthorization 
                requirements.--Whether coverage for medical 
                care is limited or excluded on the basis of 
                utilization review or preauthorization 
                requirements.
                  ``(C) Lifetime, annual, or other period 
                limitations.--A description of the 
                circumstances under which, and the extent to 
                which, coverage is subject to lifetime, annual, 
                or other period limitations, categorized by 
                types of benefits.
                  ``(D) Custodial care.--A description of the 
                circumstances under which, and the extent to 
                which, the coverage of benefits for custodial 
                care is limited or excluded, and a statement of 
                the definition used by the plan for custodial 
                care.
                  ``(E) Experimental treatments.--Whether 
                coverage for any medical care is limited or 
                excluded because it constitutes an 
                investigational item or experimental treatment 
                or technology, and any definitions provided 
                under the plan for the relevant plan 
                terminology referring to such limited or 
                excluded care.
                  ``(F) Medical appropriateness or necessity.--
                Whether coverage for medical care may be 
                limited or excluded by reason of a failure to 
                meet the plan's requirements for medical 
                appropriateness or necessity, and any 
                definitions provided under the plan for the 
                relevant plan terminology referring to such 
                limited or excluded care.
                  ``(G) Second or subsequent opinions.--A 
                description of the circumstances under which, 
                and the extent to which, coverage for second or 
                subsequent opinions is limited or excluded.
                  ``(H) Specialty care.--A description of the 
                circumstances under which, and the extent to 
                which, coverage of benefits for specialty care 
                is conditioned on referral from a primary care 
                provider.
                  ``(I) Continuity of care.--A description of 
                the circumstances under which, and the extent 
                to which, coverage of items and services 
                provided by any health care professional is 
                limited or excluded by reason of the departure 
                by the professional from any defined set of 
                providers.
                  ``(J) Restrictions on coverage of emergency 
                services.--A description of the circumstances 
                under which, and the extent to which, the plan, 
                in covering emergency medical care furnished to 
                a participant or beneficiary of the plan 
                imposes any financial responsibility described 
                in subsection (c) on participants or 
                beneficiaries or limits or conditions benefits 
                for such care subject to any other term or 
                condition of such plan.
          ``(3) Network characteristics.--If the plan (or 
        health insurance issuer offering health insurance 
        coverage in connection with the plan) utilizes a 
        defined set of providers under contract with the plan 
        (or issuer), a detailed list of the names of such 
        providers and their geographic location, set forth 
        separately with respect to primary care providers and 
        with respect to specialists.
  ``(c) Participant's Financial Responsibilities.--The 
information required under subsection (a) includes an 
explanation of--
          ``(1) a participant's financial responsibility for 
        payment of premiums, coinsurance, copayments, 
        deductibles, and any other charges; and
          ``(2) the circumstances under which, and the extent 
        to which, the participant's financial responsibility 
        described in paragraph (1) may vary, including any 
        distinctions based on whether a health care provider 
        from whom covered benefits are obtained is included in 
        a defined set of providers.
  ``(d) Dispute Resolution Procedures.--The information 
required under subsection (a) includes a description of the 
processes adopted by the plan pursuant to section 503, 
including--
          ``(1) descriptions thereof relating specifically to--
                  ``(A) coverage decisions;
                  ``(B) internal review of coverage decisions; 
                and
                  ``(C) any external review of coverage 
                decisions; and
          ``(2) the procedures and time frames applicable to 
        each step of the processes referred to in subparagraphs 
        (A), (B), and (C) of paragraph (1).
  ``(e) Information on Plan Performance.--Any information 
required under subsection (a) shall include information 
concerning the number of external reviews under section 503 
that have been completed during the prior plan year and the 
number of such reviews in which a recommendation is made for 
modification or reversal of an internal review decision under 
the plan.
  ``(f) Information Included with Adverse Coverage Decisions.--
A group health plan shall provide to each participant and 
beneficiary, together with any notification of the participant 
or beneficiary of an adverse coverage decision, the following 
information:
          ``(1) Preauthorization and utilization review 
        procedures.--A description of the basis on which any 
        preauthorization requirement or any utilization review 
        requirement has resulted in the adverse coverage 
        decision.
          ``(2) Procedures for determining exclusions based on 
        medical necessity or on investigational items or 
        experimental treatments.--If the adverse coverage 
        decision is based on a determination relating to 
        medical necessity or to an investigational item or an 
        experimental treatment or technology, a description of 
        the procedures and medically-based criteria used in 
        such decision.
  ``(g) Information Available on Request.--
          ``(1) Access to plan benefit information in 
        electronic form.--
                  ``(A) In general.--In addition to the 
                information required to be provided under 
                section 104(b)(4), a group health plan may, 
                upon written request (made not more frequently 
                than annually), make available to participants 
                and beneficiaries, in a generally recognized 
                electronic format--
                          ``(i) the latest summary plan 
                        description, including the latest 
                        summary of material modifications, and
                          ``(ii) the actual plan provisions 
                        setting forth the benefits available 
                        under the plan,
                to the extent such information relates to the 
                coverage options under the plan available to 
                the participant or beneficiary. A reasonable 
                charge may be made to cover the cost of 
                providing such information in such generally 
                recognized electronic format. The Secretary may 
                by regulation prescribe a maximum amount which 
                will constitute a reasonable charge under the 
                preceding sentence.
                  ``(B) Alternative access.--The requirements 
                of this paragraph may be met by making such 
                information generally available (rather than 
                upon request) on the Internet or on a 
                proprietary computer network in a format which 
                is readily accessible to participants and 
                beneficiaries.
          ``(2) Additional information to be provided on 
        request.--
                  ``(A) Inclusion in summary plan description 
                of summary of additional information.--The 
                information required under subsection (a) 
                includes a summary description of the types of 
                information required by this subsection to be 
                made available to participants and 
                beneficiaries on request.
                  ``(B) Information required from plans and 
                issuers on request.--In addition to information 
                required to be included in summary plan 
                descriptions under this subsection, a group 
                health plan shall provide the following 
                information to a participant or beneficiary on 
                request:
                          ``(i) Care management information.--A 
                        description of the circumstances under 
                        which, and the extent to which, the 
                        plan has special disease management 
                        programs or programs for persons with 
                        disabilities, indicating whether these 
                        programs are voluntary or mandatory and 
                        whether a significant benefit 
                        differential results from participation 
                        in such programs.
                          ``(ii) Inclusion of drugs and 
                        biologicals in formularies.--A 
                        statement of whether a specific drug or 
                        biological is included in a formulary 
                        used to determine benefits under the 
                        plan and a description of the 
                        procedures for considering requests for 
                        any patient-specific waivers.
                          ``(iii) Accreditation status of 
                        health insurance issuers and service 
                        providers.--A description of the 
                        accreditation and licensing status (if 
                        any) of each health insurance issuer 
                        offering health insurance coverage in 
                        connection with the plan and of any 
                        utilization review organization 
                        utilized by the issuer or the plan, 
                        together with the name and address of 
                        the accrediting or licensing authority.
                          ``(iv) Quality performance 
                        measures.--The latest information (if 
                        any) maintained by the plan relating to 
                        quality of performance of the delivery 
                        of medical care with respect to 
                        coverage options offered under the plan 
                        and of health care professionals and 
                        facilities providing medical care under 
                        the plan.
                  ``(C) Information required from health care 
                professionals.--
                          ``(i) Qualifications, privileges, and 
                        method of compensation.--Any health 
                        care professional treating a 
                        participant or beneficiary under a 
                        group health plan shall provide to the 
                        participant or beneficiary, on request, 
                        a description of his or her 
                        professional qualifications (including 
                        board certification status, licensing 
                        status, and accreditation status, if 
                        any), privileges, and experience and a 
                        general description by category 
                        (including salary, fee-for-service, 
                        capitation, and such other categories 
                        as may be specified in regulations of 
                        the Secretary) of the applicable method 
                        by which such professional is 
                        compensated in connection with the 
                        provision of such medical care.
                          ``(ii) Cost of procedures.--Any 
                        health care professional who recommends 
                        an elective procedure or treatment 
                        while treating a participant or 
                        beneficiary under a group health plan 
                        that requires a participant or 
                        beneficiary to share in the cost of 
                        treatment shall inform such participant 
                        or beneficiary of each cost associated 
                        with the procedure or treatment and an 
                        estimate of the magnitude of such 
                        costs.
                  ``(D) Information required from health care 
                facilities on request.--Any health care 
                facility from which a participant or 
                beneficiary has sought treatment under a group 
                health plan shall provide to the participant or 
                beneficiary, on request, a description of the 
                facility's corporate form or other 
                organizational form and all forms of licensing 
                and accreditation status (if any) assigned to 
                the facility by standard-setting organizations.
  ``(h) Access to Information Relevant to the Coverage Options 
under which the Participant or Beneficiary is Eligible to 
Enroll.--In addition to information otherwise required to be 
made available under this section, a group health plan shall, 
upon written request (made not more frequently than annually), 
make available to a participant (and an employee who, under the 
terms of the plan, is eligible for coverage but not enrolled) 
in connection with a period of enrollment the summary plan 
description for any coverage option under the plan under which 
the participant is eligible to enroll and any information 
described in clauses (i), (ii), (iii), (vi), (vii), and (viii) 
of subsection (e)(2)(B).
  ``(i) Advance Notice of Changes in Drug Formularies.--Not 
later than 30 days before the effective of date of any 
exclusion of a specific drug or biological from any drug 
formulary under the plan that is used in the treatment of a 
chronic illness or disease, the plan shall take such actions as 
are necessary to reasonably ensure that plan participants are 
informed of such exclusion. The requirements of this subsection 
may be satisfied--
          ``(1) by inclusion of information in publications 
        broadly distributed by plan sponsors, employers, or 
        employee organizations;
          ``(2) by electronic means of communication (including 
        the Internet or proprietary computer networks in a 
        format which is readily accessible to participants);
          ``(3) by timely informing participants who, under an 
        ongoing program maintained under the plan, have 
        submitted their names for such notification; or
          ``(4) by any other reasonable means of timely 
        informing plan participants.
  ``(j) Definitions and Related Rules.--
          ``(1) In general.--For purposes of this section--
                  ``(A) Group health plan.--The term `group 
                health plan' has the meaning provided such term 
                under section 733(a)(1).
                  ``(B) Medical care.--The term `medical care' 
                has the meaning provided such term under 
                section 733(a)(2).
                  ``(C) Health insurance coverage.--The term 
                `health insurance coverage' has the meaning 
                provided such term under section 733(b)(1).
                  ``(D) Health insurance issuer.--The term 
                `health insurance issuer' has the meaning 
                provided such term under section 733(b)(2).
          ``(2) Applicability only in connection with included 
        group health plan benefits.--
                  ``(A) In general.--The requirements of this 
                section shall apply only in connection with 
                included group health plan benefits.
                  ``(B) Included group health plan benefit.--
                For purposes of subparagraph (A), the term 
                `included group health plan benefit' means a 
                benefit which is not an excepted benefit (as 
                defined in section 733(c)).''.
  (b) Conforming Amendments.--
          (1) Section 102(b) of such Act (29 U.S.C. 1022(b)) is 
        amended by inserting before the period at the end the 
        following: ``; and, in the case of a group health plan 
        (as defined in section 112(j)(1)(A)) providing included 
        group health plan benefits (as defined in section 
        111(j)(2)(B)), the information required to be included 
        under section 111(a)''.
          (2) The table of contents in section 1 of such Act is 
        amended by striking the item relating to section 111 
        and inserting the following new items:

``Sec. 111. Disclosure by group health plans.
``Sec. 112. Repeal and effective date.''.

SEC. 112. EFFECTIVE DATE AND RELATED RULES.

  (a) In General.--The amendments made by this subtitle shall 
apply with respect to plan years beginning on or after January 
1 of the second calendar year following the date of the 
enactment of this Act. The Secretary of Labor shall first issue 
all regulations necessary to carry out the amendments made by 
this subtitle before such date.
  (b) Limitation on Enforcement Actions.--No enforcement action 
shall be taken, pursuant to the amendments made by this 
subtitle, against a group health plan or health insurance 
issuer with respect to a violation of a requirement imposed by 
such amendments before the date of issuance of final 
regulations issued in connection with such requirement, if the 
plan or issuer has sought to comply in good faith with such 
requirement.

             Subtitle C--Group Health Plan Review Standards

SEC. 121. SPECIAL RULES FOR GROUP HEALTH PLANS.

  (a) In General.--Section 503 of the Employee Retirement 
Income Security Act of 1974 (29 U.S.C. 1133) is amended--
          (1) by inserting ``(a) In General.--'' after ``Sec. 
        503.'';
          (2) by inserting (after and below paragraph (2)) the 
        following new flush-left sentence:
``This subsection does not apply in the case of included group 
health plan benefits (as defined in subsection (b)(10)(S)).''; 
and
          (3) by adding at the end the following new 
        subsection:
  ``(b) Special Rules for Group Health Plans.--
          ``(1) Coverage determinations.--Every group health 
        plan shall, in the case of included group health plan 
        benefits--
                  ``(A) provide adequate notice in writing in 
                accordance with this subsection to any 
                participant or beneficiary of any adverse 
                coverage decision with respect to such benefits 
                of such participant or beneficiary under the 
                plan, setting forth the specific reasons for 
                such coverage decision and any rights of review 
                provided under the plan, written in a manner 
                calculated to be understood by the average 
                participant;
                  ``(B) provide such notice in writing also to 
                any treating medical care provider of such 
                participant or beneficiary, if such provider 
                has claimed reimbursement for any item or 
                service involved in such coverage decision, or 
                if a claim submitted by the provider initiated 
                the proceedings leading to such decision;
                  ``(C) afford a reasonable opportunity to any 
                participant or beneficiary who is in receipt of 
                the notice of such adverse coverage decision, 
                and who files a written request for review of 
                the initial coverage decision within 90 days 
                after receipt of the notice of the initial 
                decision, for a full and fair review of the 
                decision by an appropriate named fiduciary who 
                did not make the initial decision; and
                  ``(D) meet the additional requirements of 
                this subsection, which shall apply solely with 
                respect to such benefits.
          ``(2) Time limits for making initial coverage 
        decisions for benefits and completing internal 
        appeals.--
                  ``(A) Time limits for deciding requests for 
                benefit payments, requests for advance 
                determination of coverage, and requests for 
                required determination of medical necessity.--
                Except as provided in subparagraph (B)--
                          ``(i) Initial decisions.--If a 
                        request for benefit payments, a request 
                        for advance determination of coverage, 
                        or a request for required determination 
                        of medical necessity is submitted to a 
                        group health plan in such reasonable 
                        form as may be required under the plan, 
                        the plan shall issue in writing an 
                        initial coverage decision on the 
                        request before the end of the initial 
                        decision period under paragraph (10)(I) 
                        following the filing completion date. 
                        Failure to issue a coverage decision on 
                        such a request before the end of the 
                        period required under this clause shall 
                        be treated as an adverse coverage 
                        decision for purposes of internal 
                        review under clause (ii).
                          ``(ii) Internal reviews of initial 
                        denials.--Upon the written request of a 
                        participant or beneficiary for review 
                        of an initial adverse coverage decision 
                        under clause (i), a review by an 
                        appropriate named fiduciary (subject to 
                        paragraph (3)) of the initial coverage 
                        decision shall be completed, including 
                        issuance by the plan of a written 
                        decision affirming, reversing, or 
                        modifying the initial coverage 
                        decision, setting forth the grounds for 
                        such decision, before the end of the 
                        internal review period following the 
                        review filing date. Such decision shall 
                        be treated as the final decision of the 
                        plan, subject to any applicable 
                        reconsideration under paragraph (4). 
                        Failure to issue before the end of such 
                        period such a written decision 
                        requested under this clause shall be 
                        treated as a final decision affirming 
                        the initial coverage decision.
                  ``(B) Time limits for making coverage 
                decisions relating to accelerated need medical 
                care and for completing internal appeals.--
                          ``(i) Initial decisions.--A group 
                        health plan shall issue in writing an 
                        initial coverage decision on any 
                        request for expedited advance 
                        determination of coverage or for 
                        expedited required determination of 
                        medical necessity submitted, in such 
                        reasonable form as may be required 
                        under the plan before the end of the 
                        accelerated need decision period under 
                        paragraph (10)(K), in cases involving 
                        accelerated need medical care, 
                        following the filing completion date. 
                        Failure to approve or deny such a 
                        request before the end of the 
                        applicable decision period shall be 
                        treated as a denial of the request for 
                        purposes of internal review under 
                        clause (ii).
                          ``(ii) Internal reviews of initial 
                        denials.--Upon the written request of a 
                        participant or beneficiary for review 
                        of an initial adverse coverage decision 
                        under clause (i), a review by an 
                        appropriate named fiduciary (subject to 
                        paragraph (3)) of the initial coverage 
                        decision shall be completed, including 
                        issuance by the plan of a written 
                        decision affirming, reversing, or 
                        modifying the initial converge 
                        decision, setting forth the grounds for 
                        the decision before the end of the 
                        accelerated need decision period under 
                        paragraph (10)(K) following the review 
                        filing date. Such decision shall be 
                        treated as the final decision of the 
                        plan, subject to any applicable 
                        reconsideration under paragraph (4). 
                        Failure to issue before the end of the 
                        applicable decision period such a 
                        written decision requested under this 
                        clause shall be treated as a final 
                        decision affirming the initial coverage 
                        decision.
          ``(3) Physicians must review initial coverage 
        decisions involving medical appropriateness or 
        necessity or investigational items or experimental 
        treatment.--If an initial coverage decision under 
        paragraph (2)(A)(i) or (2)(B)(i) is based on a 
        determination that provision of a particular item or 
        service is excluded from coverage under the terms of 
        the plan because the provision of such item or service 
        does not meet the requirements for medical 
        appropriateness or necessity or would constitute 
        provision of investigational items or experimental 
        treatment or technology, the review under paragraph 
        (2)(A)(ii) or (2)(B)(ii), to the extent that it relates 
        to medical appropriateness or necessity or to 
        investigational items or experimental treatment or 
        technology, shall be conducted by a physician who is 
        selected by the plan and who did not make the initial 
        denial.
          ``(4) Elective external review by independent medical 
        expert and reconsideration of initial review 
        decision.--
                  ``(A) In general.--In any case in which a 
                participant or beneficiary, who has received an 
                adverse coverage decision which is not reversed 
                upon review conducted pursuant to paragraph 
                (1)(C) (including review under paragraph 
                (2)(A)(ii) or (2)(B)(ii)) and who has not 
                commenced review of the coverage decision under 
                section 502, makes a request in writing, within 
                30 days after the date of such review decision, 
                for reconsideration of such review decision, 
                the requirements of subparagraphs (B), (C), (D) 
                and (E) shall apply in the case of such adverse 
                coverage decision, if the requirements of 
                clause (i) or (ii) are met, subject to clause 
                (iii).
                          ``(i) Medical appropriateness or 
                        investigational item or experimental 
                        treatment or technology.--The 
                        requirements of this clause are met if 
                        such coverage decision is based on a 
                        determination that provision of a 
                        particular item or service that would 
                        otherwise be covered is excluded from 
                        coverage because the provision of such 
                        item or service--
                                  ``(I) is not medically 
                                appropriate or necessary; or
                                  ``(II) would constitute 
                                provision of an investigational 
                                item or experimental treatment 
                                or technology.
                          ``(ii) Exclusion of item or service 
                        requiring evaluation of medical facts 
                        or evidence.--The requirements of this 
                        clause are met if--
                                  ``(I) such coverage decision 
                                is based on a determination 
                                that a particular item or 
                                service is not covered under 
                                the terms of the plan because 
                                provision of such item or 
                                service is specifically or 
                                categorically excluded from 
                                coverage under the terms of the 
                                plan, and
                                  ``(II) an independent 
                                contract expert finds under 
                                subparagraph (C), in advance of 
                                any review of the decision 
                                under subparagraph (D), that 
                                such determination primarily 
                                requires the evaluation of 
                                medical facts or medical 
                                evidence by a health 
                                professional.
                          ``(iii) Matters specifically not 
                        subject to review.--The requirements of 
                        subparagraphs (B), (C), (D), and (E) 
                        shall not apply in the case of any 
                        adverse coverage decision if such 
                        decision is based on--
                                  ``(I) a determination of 
                                eligibility for benefits,
                                  ``(II) the application of 
                                explicit plan limits on the 
                                number, cost, or duration of 
                                any benefit, or
                                  ``(III) a limitation on the 
                                amount of any benefit payment 
                                or a requirement to make 
                                copayments under the terms of 
                                the plan.
                Review under this paragraph shall not be 
                available for any coverage decision that has 
                previously undergone review under this 
                paragraph.
                  ``(B) Limits on allowable advance payments.--
                The review under this paragraph in connection 
                with an adverse coverage decision shall be 
                available subject to any requirement of the 
                plan (unless waived by the plan for financial 
                or other reasons) for payment in advance to the 
                plan by the participant or beneficiary seeking 
                review of an amount not to exceed the greater 
                of--
                          ``(i) the lesser of $100 or 10 
                        percent of the cost of the medical care 
                        involved in the decision, or
                          ``(ii) $25,
                with such dollar amount subject to compounded 
                annual adjustments in the same manner and to 
                the same extent as apply under section 215(i) 
                of the Social Security Act, except that, for 
                any calendar year, such amount as so adjusted 
                shall be deemed, solely for such calendar year, 
                to be equal to such amount rounded to the 
                nearest $10. No such payment may be required in 
                the case of any participant or beneficiary 
                whose enrollment under the plan is paid for, in 
                whole or in part, under a State plan under 
                title XIX or XXI of the Social Security Act. 
                Any such advance payment shall be subject to 
                reimbursement if the recommendation of the 
                independent medical expert (or panel of such 
                experts) under subparagraph (D)(ii)(IV) is to 
                reverse or modify the coverage decision.
                  ``(C) Request to independent contract expert 
                for determination of whether coverage decision 
                required evaluation of medical facts or 
                evidence.--
                          ``(i) In general.--In the case of a 
                        request for review made by a 
                        participant or beneficiary as described 
                        in subparagraph (A), if the 
                        requirements of subparagraph (A)(ii) 
                        are met (and review is not otherwise 
                        precluded under subparagraph (A)(iii)), 
                        the terms of the plan shall provide for 
                        a procedure for initial review by an 
                        independent contract expert selected in 
                        accordance with subparagraph (H) under 
                        which the expert will determine whether 
                        the coverage decision requires the 
                        evaluation of medical facts or evidence 
                        by a health professional. If the expert 
                        determines that the coverage decision 
                        requires such evaluation, 
                        reconsideration of such adverse 
                        decision shall proceed under this 
                        paragraph. If the expert determines 
                        that the coverage decision does not 
                        require such evaluation, the adverse 
                        decision shall remain the final 
                        decision of the plan.
                          ``(ii) Independent contract 
                        experts.--For purposes of this 
                        subparagraph, the term `independent 
                        contract expert' means a professional--
                                  ``(I) who has appropriate 
                                credentials and has attained 
                                recognized expertise in the 
                                applicable area of contract 
                                interpretation;
                                  ``(II) who was not involved 
                                in the initial decision or any 
                                earlier review thereof; and
                                  ``(III) who is selected in 
                                accordance with subparagraph 
                                (H)(i) and meets the 
                                requirements of subparagraph 
                                (H)(iii).
                  ``(D) Reconsideration of initial review 
                decision.--
                          ``(i) In general.--In the case of a 
                        request for review made by a 
                        participant or beneficiary as described 
                        in subparagraph (A), if the 
                        requirements of subparagraph (A)(i) are 
                        met or reconsideration proceeds under 
                        this paragraph pursuant to subparagraph 
                        (C), the terms of the plan shall 
                        provide for a procedure for such 
                        reconsideration in accordance with 
                        clause (ii).
                          ``(ii) Procedure for 
                        reconsideration.--The procedure 
                        required under clause (i) shall include 
                        the following--
                                  ``(I) An independent medical 
                                expert (or a panel of such 
                                experts, as determined 
                                necessary) will be selected in 
                                accordance with subparagraph 
                                (H) to reconsider any coverage 
                                decision described in 
                                subparagraph (A) to determine 
                                whether such decision was in 
                                accordance with the terms of 
                                the plan and this title.
                                  ``(II) The record for review 
                                (including a specification of 
                                the terms of the plan and other 
                                criteria serving as the basis 
                                for the initial review 
                                decision) will be presented to 
                                such expert (or panel) and 
                                maintained in a manner which 
                                will ensure confidentiality of 
                                such record.
                                  ``(III) Such expert (or 
                                panel) will reconsider the 
                                initial review decision to 
                                determine whether such decision 
                                was in accordance with the 
                                terms of the plan and this 
                                title. The expert (or panel) in 
                                its reconsideration will take 
                                into account the medical 
                                condition of the patient, the 
                                recommendation of the treating 
                                physician, the initial coverage 
                                decision (including the reasons 
                                for such decision) and the 
                                decision upon review conducted 
                                pursuant to paragraph (1)(C) 
                                (including review under 
                                paragraph (2)(A)(ii) or 
                                (2)(B)(ii)) , any guidelines 
                                adopted by the plan through a 
                                process involving medical 
                                practitioners and peer-reviewed 
                                medical literature identified 
                                as such under criteria 
                                established by the Food and 
                                Drug Administration, and any 
                                other valid, relevant, 
                                scientific or clinical evidence 
                                the expert (or panel) 
                                determines appropriate for its 
                                review. The expert (or panel) 
                                may consult the participant or 
                                beneficiary, the treating 
                                physician, the medical director 
                                of the plan, or any other party 
                                who, in the opinion of the 
                                expert (or panel), may have 
                                relevant information for 
                                consideration.
                  ``(E) Issuance of binding final decision.--
                Upon completion of the procedure for review 
                under subparagraph (D), the independent medical 
                expert (or panel of such experts) shall issue a 
                written decision affirming, modifying, or 
                reversing the initial review decision, setting 
                forth the grounds for the decision. Such 
                decision shall be the final decision of the 
                plan and shall be binding on the plan. Such 
                decision shall set forth specifically the 
                determination of the expert (or panel) of the 
                appropriate period for timely compliance by the 
                plan with the decision. Such decision shall be 
                issued concurrently to the participant or 
                beneficiary, to the treating physician, and to 
                the plan, shall constitute conclusive, written 
                authorization for the provision of benefits 
                under the plan in accordance with the decision, 
                and shall be treated as terms of the plan for 
                purposes of any action by the participant or 
                beneficiary under section 502.
                  ``(F) Time limits for reconsideration.--Any 
                review under this paragraph (including any 
                review under subparagraph (C)) shall be 
                completed before the end of the reconsideration 
                period (as defined in paragraph (10)(L)) 
                following the review filing date in connection 
                with such review. Failure to issue a written 
                decision before the end of the reconsideration 
                period in any reconsideration requested under 
                this paragraph shall be treated as a final 
                decision affirming the initial review decision 
                of the plan.
                  ``(G) Independent medical experts.--
                          ``(i) In general.--For purposes of 
                        this paragraph, the term `independent 
                        medical expert' means, in connection 
                        with any coverage decision by a group 
                        health plan, a professional--
                                  ``(I) who is a physician or, 
                                if appropriate, another medical 
                                professional,
                                  ``(II) who has appropriate 
                                credentials and has attained 
                                recognized expertise in the 
                                applicable medical field,
                                  ``(III) who was not involved 
                                in the initial decision or any 
                                earlier review thereof,
                                  ``(IV) who has no history of 
                                disciplinary action or 
                                sanctions (including, but not 
                                limited to, loss of staff 
                                privileges or participation 
                                restriction) taken or pending 
                                by any hospital, health 
                                carrier, government, or 
                                regulatory body, and
                                  ``(V) who is selected in 
                                accordance with subparagraph 
                                (H)(i) and meets the 
                                requirements of subparagraph 
                                (H)(iii).
                  ``(H) Selection of experts.--
                          ``(i) In general.--An independent 
                        contract expert or independent medical 
                        expert (or each member of any panel of 
                        independent medical experts selected 
                        under subparagraph (D)(ii)) is selected 
                        in accordance with this clause if--
                                  ``(I) the expert is selected 
                                by an intermediary which itself 
                                meets the requirements of 
                                clauses (ii) and (iii), by 
                                means of a method which ensures 
                                that the identity of the expert 
                                is not disclosed to the plan, 
                                any health insurance issuer 
                                offering health insurance 
                                coverage to the aggrieved 
                                participant or beneficiary in 
                                connection with the plan, and 
                                the aggrieved participant or 
                                beneficiary under the plan, and 
                                the identities of the plan, the 
                                issuer, and the aggrieved 
                                participant or beneficiary are 
                                not disclosed to the expert;
                                  ``(II) the expert is selected 
                                by an appropriately 
                                credentialed panel of 
                                physicians meeting the 
                                requirements of clauses (ii) 
                                and (iii) established by a 
                                fully accredited teaching 
                                hospital meeting such 
                                requirements;
                                  ``(III) the expert is 
                                selected by an organization 
                                described in section 1152(1)(A) 
                                of the Social Security Act 
                                which meets the requirements of 
                                clauses (ii) and (iii);
                                  ``(IV) the expert is selected 
                                by an external review 
                                organization which meets the 
                                requirements of clauses (ii) 
                                and (iii) and is accredited by 
                                a private standard-setting 
                                organization meeting such 
                                requirements;
                                  ``(V) the expert is selected 
                                by a State agency which is 
                                established for the purpose of 
                                conducting independent external 
                                reviews and which meets the 
                                requirements of clauses (ii) 
                                and (iii); or
                                  ``(VI) the expert is 
                                selected, by an intermediary or 
                                otherwise, in a manner that is, 
                                under regulations issued 
                                pursuant to negotiated 
                                rulemaking, sufficient to 
                                ensure the expert's 
                                independence, and the method of 
                                selection is devised to 
                                reasonably ensure that the 
                                expert selected meets the 
                                requirements of clauses (ii) 
                                and (iii).
                          ``(ii) Standards of performance for 
                        intermediaries.--The Secretary shall 
                        prescribe by regulation standards (in 
                        addition to the requirements of clause 
                        (iii)) which entities making selections 
                        under subclause (I), (II), (III), (IV), 
                        (V), or (VI) of clause (ii) must meet 
                        in order to be eligible for making such 
                        selections. Such standards shall 
                        include (but are not limited to)--
                                  ``(I) assurance that the 
                                entity will carry out specified 
                                duties in the course of 
                                exercising the entity's 
                                responsibilities under clause 
                                (i)(I),
                                  ``(II) assurance that 
                                applicable deadlines will be 
                                met in the exercise of such 
                                responsibilities, and
                                  ``(III) assurance that the 
                                entity meets appropriate 
                                indicators of solvency and 
                                fiscal integrity.
                        Each such entity shall provide to the 
                        Secretary, in such manner and at such 
                        times as the Secretary may prescribe, 
                        information relating the volume of 
                        claims with respect to which the entity 
                        has served under this subparagraph, the 
                        types of such claims, and such other 
                        information regarding such claims as 
                        the Secretary may determine 
                        appropriate.
                          ``(iii) Independence requirements.--
                        An independent contract expert or 
                        independent medical expert or another 
                        entity described in clause (i) meets 
                        the independence requirements of this 
                        clause if--
                                  ``(I) the expert or entity is 
                                not affiliated with any related 
                                party;
                                  ``(II) any compensation 
                                received by such expert or 
                                entity in connection with the 
                                external review is reasonable 
                                and not contingent on any 
                                decision rendered by the expert 
                                or entity;
                                  ``(III) under the terms of 
                                the plan and any health 
                                insurance coverage offered in 
                                connection with the plan, the 
                                plan and the issuer (if any) 
                                have no recourse against the 
                                expert or entity in connection 
                                with the external review; and
                                  ``(IV) the expert or entity 
                                does not otherwise have a 
                                conflict of interest with a 
                                related party as determined 
                                under any regulations which the 
                                Secretary may prescribe.
                          ``(iv) Related party.--For purposes 
                        of clause (i)(I), the term `related 
                        party' means--
                                  ``(I) the plan or any health 
                                insurance issuer offering 
                                health insurance coverage in 
                                connection with the plan (or 
                                any officer, director, or 
                                management employee of such 
                                plan or issuer);
                                  ``(II) the physician or other 
                                medical care provider that 
                                provided the medical care 
                                involved in the coverage 
                                decision;
                                  ``(III) the institution at 
                                which the medical care involved 
                                in the coverage decision is 
                                provided;
                                  ``(IV) the manufacturer of 
                                any drug or other item that was 
                                included in the medical care 
                                involved in the coverage 
                                decision; or
                                  ``(V) any other party 
                                determined under any 
                                regulations which the Secretary 
                                may prescribe to have a 
                                substantial interest in the 
                                coverage decision.
                          ``(v) Affiliated.--For purposes of 
                        clause (ii)(I), the term `affiliated' 
                        means, in connection with any entity, 
                        having a familial, financial, or 
                        professional relationship with, or 
                        interest in, such entity.
                  ``(I) Misbehavior by experts.--Any action by 
                the expert or experts in applying for their 
                selection under this paragraph or in the course 
                of carrying out their duties under this 
                paragraph which constitutes--
                          ``(i) fraud or intentional 
                        misrepresentation by such expert or 
                        experts, or
                          ``(ii) demonstrates failure to adhere 
                        to the standards for selection set 
                        forth in subparagraph (H)(iii),
                shall be treated as a failure to meet the 
                requirements of this paragraph and therefore as 
                a cause of action which may be brought by a 
                fiduciary under section 502(a)(3).
                  ``(J) Benefit exclusions maintained.--Nothing 
                in this paragraph shall be construed as 
                providing for or requiring the coverage of 
                items or services for which benefits are 
                specifically excluded under the group health 
                plan or any health insurance coverage offered 
                in connection with the plan.
          ``(5) Permitted alternatives to required forms of 
        review.--
                  ``(A) In general.--In accordance with such 
                regulations (if any) as may be prescribed by 
                the Secretary for purposes of this paragraph, 
                in the case of any initial coverage decision or 
                any decision upon review thereof under 
                paragraph (2)(A)(ii) or (2)(B)(ii), a group 
                health plan may provide an alternative dispute 
                resolution procedure meeting the requirements 
                of subparagraph (B) for use in lieu of the 
                procedures set forth under the preceding 
                provisions of this subsection relating review 
                of such decision. Such procedure may be 
                provided in one form for all participants and 
                beneficiaries or in a different form for each 
                group of similarly situated participants and 
                beneficiaries. Upon voluntary election of such 
                procedure by the plan and by the aggrieved 
                participant or beneficiary in connection with 
                the decision, the plan may provide under such 
                procedure (in a manner consistent with such 
                regulations as the Secretary may prescribe to 
                ensure equitable procedures) for waiver of the 
                review of the decision under paragraph (3) or 
                waiver of further review of the decision under 
                paragraph (4) or section 502 or for election by 
                such parties of an alternative means of 
                external review (other than review under 
                paragraph (4)).
                  ``(B) Requirements.--An alternative dispute 
                resolution procedure meets the requirements of 
                this subparagraph, in connection with any 
                decision, if--
                          ``(i) such procedure is utilized 
                        solely--
                                  ``(I) in accordance with the 
                                applicable terms of a bona fide 
                                collective bargaining agreement 
                                pursuant to which the plan (or 
                                the applicable portion thereof 
                                governed by the agreement) is 
                                established or maintained, or
                                  ``(II) upon election by both 
                                the aggrieved participant or 
                                beneficiary and the plan,
                          ``(ii) the procedure incorporates any 
                        otherwise applicable requirement for 
                        review by a physician under paragraph 
                        (3), unless waived by the participant 
                        or beneficiary (in a manner consistent 
                        with such regulations as the Secretary 
                        may prescribe to ensure equitable 
                        procedures); and
                          ``(iii) the means of resolution of 
                        dispute allow for adequate presentation 
                        by each party of scientific and medical 
                        evidence supporting the position of 
                        such party.
          ``(6) Review requirements.--In any review of a 
        decision issued under this subsection--
                  ``(A) the record shall be maintained for 
                purposes of any further review in accordance 
                with standards which shall be prescribed in 
                regulations of the Secretary designed to 
                facilitate such further review, and
                  ``(B) any decision upon review which modifies 
                or reverses a decision below shall specifically 
                set forth a determination that the record upon 
                review is sufficient to rebut a presumption in 
                favor of the decision below.
          ``(7) Compliance with fiduciary standards.--The 
        issuance of a decision under a plan upon review in good 
        faith compliance with the requirements of this 
        subsection shall not be treated as a violation of part 
        4 of subtitle B of title I of the Employee Retirement 
        Income Security Act of 1974.
          ``(8) Limitation on applicability of special rules.--
        The provisions of this subsection shall not apply with 
        respect to employee benefit plans that are not group 
        health plans or with respect to benefits that are not 
        included group health plan benefits (as defined in 
        paragraph (10)(S)).
          ``(9) Group health plan defined.--For purposes of 
        this section--
                  ``(A) In general.--The term `group health 
                plan' shall have the meaning provided in 
                section 733(a).
                  ``(B) Treatment of partnerships.--The 
                provisions of paragraphs (1), (2), and (3) of 
                section 732(d) shall apply.
          ``(10) Other definitions.--For purposes of this 
        subsection--
                  ``(A) Request for benefit payments.--The term 
                `request for benefit payments' means a request, 
                for payment of benefits by a group health plan 
                for medical care, which is made by, or (if 
                expressly authorized) on behalf of, a 
                participant or beneficiary after such medical 
                care has been provided.
                  ``(B) Required determination of medical 
                necessity.--The term `required determination of 
                medical necessity' means a determination 
                required under a group health plan solely that 
                proposed medical care meets, under the facts 
                and circumstances at the time of the 
                determination, the requirements for medical 
                appropriateness or necessity (which may be 
                subject to exceptions under the plan for fraud 
                or misrepresentation), irrespective of whether 
                the proposed medical care otherwise meets other 
                terms and conditions of coverage, but only if 
                such determination does not constitute an 
                advance determination of coverage (as defined 
                in subparagraph (C)).
                  ``(C) Advance determination of coverage.--The 
                term `advance determination of coverage' means 
                a determination under a group health plan that 
                proposed medical care meets, under the facts 
                and circumstances at the time of the 
                determination, the plan's terms and conditions 
                of coverage (which may be subject to exceptions 
                under the plan for fraud or misrepresentation).
                  ``(D) Request for advance determination of 
                coverage.--The term `request for advance 
                determination of coverage' means a request for 
                an advance determination of coverage of medical 
                care which is made by, or (if expressly 
                authorized) on behalf of, a participant or 
                beneficiary before such medical care is 
                provided.
                  ``(E) Request for expedited advance 
                determination of coverage.--The term `request 
                for expedited advance determination of 
                coverage' means a request for advance 
                determination of coverage, in any case in which 
                the proposed medical care constitutes 
                accelerated need medical care.
                  ``(F) Request for required determination of 
                medical necessity.--The term `request for 
                required determination of medical necessity' 
                means a request for a required determination of 
                medical necessity for medical care which is 
                made by or on behalf of a participant or 
                beneficiary before the medical care is 
                provided.
                  ``(G) Request for expedited required 
                determination of medical necessity.--The term 
                `request for expedited required determination 
                of medical necessity' means a request for 
                required determination of medical necessity in 
                any case in which the proposed medical care 
                constitutes accelerated need medical care.
                  ``(H) Accelerated need medical care.--The 
                term `accelerated need medical care' means 
                medical care in any case in which an 
                appropriate physician has certified in writing 
                (or as otherwise provided in regulations of the 
                Secretary) that the participant or beneficiary 
                is stabilized and--
                          ``(i) that failure to immediately 
                        provide the care to the participant or 
                        beneficiary could reasonably be 
                        expected to result in--
                                  ``(I) placing the health of 
                                such participant or beneficiary 
                                (or, with respect to such a 
                                participant or beneficiary who 
                                is a pregnant woman, the health 
                                of the woman or her unborn 
                                child) in serious jeopardy;
                                  ``(II) serious impairment to 
                                bodily functions; or
                                  ``(III) serious dysfunction 
                                of any bodily organ or part; or
                          ``(ii) that immediate provision of 
                        the care is necessary because the 
                        participant or beneficiary has made or 
                        is at serious risk of making an attempt 
                        to harm himself or herself or another 
                        individual.
                  ``(I) Initial decision period.--The term 
                `initial decision period' means a period of 30 
                days, or such period as may be prescribed in 
                regulations of the Secretary.
                  ``(J) Internal review period.--The term 
                `internal review period' means a period of 30 
                days, or such period as may be prescribed in 
                regulations of the Secretary.
                  ``(K) Accelerated need decision period.--The 
                term `accelerated need decision period' means a 
                period of 3 days, or such period as may be 
                prescribed in regulations of the Secretary.
                  ``(L) Reconsideration period.--The term 
                `reconsideration period' means a period of 25 
                days, or such period as may be prescribed in 
                regulations of the Secretary, except that, in 
                the case of a decision involving accelerated 
                need medical care, such term means the 
                accelerated need decision period.
                  ``(M) Filing completion date.--The term 
                `filing completion date' means, in connection 
                with a group health plan, the date as of which 
                the plan is in receipt of all information 
                reasonably required (in writing or in such 
                other reasonable form as may be specified by 
                the plan) to make an initial coverage decision.
                  ``(N) Review filing date.--The term `review 
                filing date' means, in connection with a group 
                health plan, the date as of which the 
                appropriate named fiduciary (or the independent 
                medical expert or panel of such experts in the 
                case of a review under paragraph (4)) is in 
                receipt of all information reasonably required 
                (in writing or in such other reasonable form as 
                may be specified by the plan) to make a 
                decision to affirm, modify, or reverse a 
                coverage decision.
                  ``(O) Medical care.--The term `medical care' 
                has the meaning provided such term by section 
                733(a)(2).
                  ``(P) Health insurance coverage.--The term 
                `health insurance coverage' has the meaning 
                provided such term by section 733(b)(1).
                  ``(Q) Health insurance issuer.--The term 
                `health insurance issuer' has the meaning 
                provided such term by section 733(b)(2).
                  ``(R) Written or in writing.--
                          ``(i) In general.--A request or 
                        decision shall be deemed to be 
                        `written' or `in writing' if such 
                        request or decision is presented in a 
                        generally recognized printable or 
                        electronic format. The Secretary may by 
                        regulation provide for presentation of 
                        information otherwise required to be in 
                        written form in such other forms as may 
                        be appropriate under the circumstances.
                          ``(ii) Medical appropriateness or 
                        investigational items or experimental 
                        treatment determinations.--For purposes 
                        of this subparagraph, in the case of a 
                        request for advance determination of 
                        coverage, a request for expedited 
                        advance determination of coverage, a 
                        request for required determination of 
                        medical necessity, or a request for 
                        expedited required determination of 
                        medical necessity, if the decision on 
                        such request is conveyed to the 
                        provider of medical care or to the 
                        participant or beneficiary by means of 
                        telephonic or other electronic 
                        communications, such decision shall be 
                        treated as a written decision.
                  ``(S) Included group health plan benefit.--
                The term `included group health plan benefit'' 
                means a benefit under a group health plan which 
                is not an excepted benefit (as defined in 
                section 733(c)).''.
  (b) Civil Penalties.--
          (1) In general.--Section 502(c) of such Act (29 
        U.S.C. 1132(c)) is amended by redesignating paragraphs 
        (6) and (7) as paragraphs (7) and (8), respectively, 
        and by inserting after paragraph (5) the following new 
        paragraph:
  ``(6)(A)(i) In the case of any failure to timely provide an 
included group health plan benefit (as defined in section 
503(b)(10)(S)) to a participant or beneficiary, which occurs 
after the issuance of, and in violation of, a final decision 
rendered upon completion of external review (under section 
503(b)(4)) of an adverse coverage decision by the plan relating 
to such benefit, any person acting in the capacity of a 
fiduciary of the plan so as to cause such failure may, in the 
court's discretion, be liable to the aggrieved participant or 
beneficiary for a civil penalty.
  ``(ii) Except as provided in clause (iii), such civil penalty 
shall be in an amount of up to $1,000 a day from the date that 
occurs on or after the date of the issuance of the decision 
under section 503(b)(4) and upon which the plan otherwise could 
have been reasonably expected to commence compliance with the 
decision until the date the failure to provide the benefit is 
corrected.
  ``(iii) In any case in which it is proven by clear and 
convincing evidence that the person referred to in clause (i) 
acted willfully and in bad faith, the daily penalty under 
clause (ii) shall be increased to an amount of up to $5,000 a 
day.
  ``(iv) In any case in which it is further proven by clear and 
convincing evidence that--
          ``(I) the plan is not in full compliance with the 
        decision of the independent medical expert (or panel of 
        such experts) under section 503(b)(4)(E)) within the 
        appropriate period specified in such decision, and
          ``(II) the failure to be in full compliance was 
        caused by the plan or by a health insurance issuer 
        offering health insurance coverage in connection with 
        the plan,
the plan shall pay the cost of all medical care which was not 
provided by reason of such failure to fully comply and which is 
otherwise obtained by the participant or beneficiary from any 
provider.
  ``(B) For purposes of subparagraph (A), the plan, and any 
health insurance issuer offering health insurance coverage in 
connection with the plan, shall be deemed to be in compliance 
with any decision of an independent medical expert (or panel of 
such experts) under section 503(b)(4) with respect to any 
participant or beneficiary upon transmission to such entity (or 
panel) and to such participant or beneficiary by the plan or 
issuer of timely notice of an authorization of coverage by the 
plan or issuer which is consistent with such decision.
  ``(C) In any action commenced under subsection (a) by a 
participant or beneficiary with respect to an included group 
health plan benefit in which the plaintiff alleges that a 
person, in the capacity of a fiduciary and in violation of the 
terms of the plan or this title, has taken an action resulting 
in an adverse coverage decision in violation of the terms of 
the plan, or has failed to take an action for which such person 
is responsible under the plan and which is necessary under the 
plan for a favorable coverage decision, upon finding in favor 
of the plaintiff, if such action was commenced after a final 
decision of the plan upon review which included a review under 
section 503(b)(4) or such action was commenced under subsection 
(b)(4) of this section, the court shall cause to be served on 
the defendant an order requiring the defendant--
          ``(i) to cease and desist from the alleged action or 
        failure to act; and
          ``(ii) to pay to the plaintiff a reasonable 
        attorney's fee and other reasonable costs relating to 
        the prosecution of the action on the charges on which 
        the plaintiff prevails.
The remedies provided under this subparagraph shall be in 
addition to remedies otherwise provided under this section.
  ``(D)(i) The Secretary may assess a civil penalty against a 
person acting in the capacity of a fiduciary of one or more 
group health plans (as defined in section 503(b)(9)) for--
          ``(I) any pattern or practice of repeated adverse 
        coverage decisions in connection with included group 
        health plan benefits in violation of the terms of the 
        plan or plans or this title; or
          ``(II) any pattern or practice of repeated violations 
        of the requirements of section 503 in connection with 
        such benefits.
Such penalty shall be payable only upon proof by clear and 
convincing evidence of such pattern or practice.
  ``(ii) Such penalty shall be in an amount not to exceed the 
lesser of--
          ``(I) 5 percent of the aggregate value of benefits 
        shown by the Secretary to have not been provided, or 
        unlawfully delayed in violation of section 503, under 
        such pattern or practice; or
          ``(II) $100,000.
  ``(iii) Any person acting in the capacity of a fiduciary of a 
group health plan or plans who has engaged in any such pattern 
or practice in connection with included group health plan 
benefits, upon the petition of the Secretary, may be removed by 
the court from that position, and from any other involvement, 
with respect to such plan or plans, and may be precluded from 
returning to any such position or involvement for a period 
determined by the court.
  ``(E) For purposes of this paragraph, the term `included 
group health plan benefit' has the meaning provided in section 
503(b)(10)(S).
  ``(F) The preceding provisions of this paragraph shall not 
apply with respect to employee benefit plans that are not group 
health plans or with respect to benefits that are not included 
group health plan benefits (as defined in paragraph 
(10)(S)).''.
          (2) Conforming amendment.--Section 502(a)(6) of such 
        Act (29 U.S.C. 1132(a)(6)) is amended by striking ``, 
        or (6)'' and inserting ``, (6), or (7)''.
  (c) Expedited Court Review.--Section 502 of such Act (29 
U.S.C. 1132) is amended--
          (1) in subsection (a)(8), by striking ``or'' at the 
        end;
          (2) in subsection (a)(9), by striking the period and 
        inserting ``; or'';
          (3) by adding at the end of subsection (a) the 
        following new paragraph:
  ``(10) by a participant or beneficiary for appropriate relief 
under subsection (b)(4).''.
          (4) by adding at the end of subsection (b) the 
        following new paragraph:
  ``(4) In the case of a group health plan, if exhaustion of 
administrative remedies in accordance with paragraph (2)(A)(ii) 
or (2)(B)(ii) of section 503(b) otherwise necessary for an 
action for relief under paragraph (1)(B) or (3) of subsection 
(a) has not been obtained and it is demonstrated to the court 
by means of certification by an appropriate physician that such 
exhaustion is not reasonably attainable under the facts and 
circumstances without undue risk of irreparable harm to the 
health of the participant or beneficiary, a civil action may be 
brought by the participant or beneficiary to obtain appropriate 
equitable relief. Any determinations made under paragraph 
(2)(A)(ii) or (2)(B)(ii) of section 503(b) made while an action 
under this paragraph is pending shall be given due 
consideration by the court in any such action. This paragraph 
shall not apply with respect to benefits that are not included 
group health plan benefits (as defined in section 
503(b)(10)(S)).''.
  (d) Attorney's Fees.--Section 502(g) of such Act (29 U.S.C. 
1132(g)) is amended--
          (1) in paragraph (1), by striking ``paragraph (2)'' 
        and inserting ``paragraph (2) or (3))''; and
          (2) by adding at the end the following new paragraph:
  ``(3) In any action under this title by a participant or 
beneficiary in connection with an included group health plan 
benefit (as defined in section 503(b)(10)(S)) in which judgment 
in favor of the participant or beneficiary is awarded, the 
court shall allow a reasonable attorney's fee and costs of 
action to the participant or beneficiary.''.
  (e) Standard of Review Unaffected.--The standard of review 
under section 502 of the Employee Retirement Income Security 
Act of 1974 (as amended by this section) shall continue on and 
after the date of the enactment of this Act to be the standard 
of review which was applicable under such section as of 
immediately before such date.
  (f) Concurrent Jurisdiction.--Section 502(e)(1) of such Act 
(29 U.S.C. 1132(e)(1)) is amended--
          (1) in the first sentence, by striking ``under 
        subsection (a)(1)(B) of this section'' and inserting 
        ``under subsection (a)(1)(A) for relief under 
        subsection (c)(6), under subsection (a)(1)(B), and 
        under subsection (b)(4)''; and
          (2) in the last sentence, by striking ``of actions 
        under paragraphs (1)(B) and (7) of subsection (a) of 
        this section'' and inserting ``of actions under 
        paragraph (1)(A) of subsection (a) for relief under 
        subsection (c)(6) and of actions under paragraphs 
        (1)(B) and (7) of subsection (a) and paragraph (4) of 
        subsection (b)''.

SEC. 122. SPECIAL RULE FOR ACCESS TO SPECIALTY CARE.

  Section 503(b) of such Act (as added by the preceding 
provisions of this subtitle) is amended by adding at the end 
the following new paragraph:
          ``(11) Special rule for access to specialty care.--
                  ``(A) In general.--In the case of a request 
                for advance determination of coverage 
                consisting of a request by a physician for a 
                determination of coverage of the services of a 
                specialist with respect to any condition, if 
                coverage of the services of such specialist for 
                such condition is otherwise provided under the 
                plan, the initial coverage decision referred to 
                in subparagraph (A)(i) or (B)(i) of paragraph 
                (2) shall be issued within the accelerated need 
                decision period.
                  ``(B) Specialist.--For purposes of this 
                paragraph, the term `specialist' means, with 
                respect to a condition, a physician who has a 
                high level of expertise through appropriate 
                training and experience (including, in the case 
                of a patient who is a child, appropriate 
                pediatric expertise) to treat the condition.''.

SEC. 123. PROTECTION FOR CERTAIN INFORMATION DEVELOPED TO REDUCE 
                    MORTALITY OR MORBIDITY OR FOR IMPROVING PATIENT 
                    CARE AND SAFETY.

  (a) Protection of Certain Information.--Notwithstanding any 
other provision of Federal or State law, health care response 
information shall be exempt from any disclosure requirement 
(regardless of whether the requirement relates to subpoenas, 
discovery, introduction of evidence, testimony, or any other 
form of disclosure), in connection with a civil or 
administrative proceeding under Federal or State law, to the 
same extent as information developed by a health care provider 
with respect to any of the following:
          (1) Peer review.
          (2) Utilization review.
          (3) Quality management or improvement.
          (4) Quality control.
          (5) Risk management.
          (6) Internal review for purposes of reducing 
        mortality, morbidity, or for improving patient care or 
        safety.
  (b) No Waiver of Protection Through Interaction with 
Accrediting Body.--Notwithstanding any other provision of 
Federal or State law, the protection of health care response 
information from disclosure provided under subsection (a) shall 
not be deemed to be modified or in any way waived by--
          (1) the development of such information in connection 
        with a request or requirement of an accrediting body; 
        or
          (2) the transfer of such information to an 
        accrediting body.
  (c) Definitions.--For purposes of this section:
          (1) The term ``accrediting body'' means a national, 
        not-for-profit organization that--
                  (A) accredits health care providers; and
                  (B) is recognized as an accrediting body by 
                statute or by a Federal or State agency that 
                regulates health care providers.
          (2) The term ``health care provider'' has the meaning 
        given such term in section 1188 of the Social Security 
        Act (as added by section 5001 of this Act).
          (3) The term ``health care response information'' 
        means information (including any data, report, record, 
        memorandum, analysis, statement, or other 
        communication) developed by, or on behalf of, a health 
        care provider in response to a serious, adverse, 
        patient-related event--
                  (A) during the course of analyzing or 
                studying the event and its causes; and
                  (B) for purposes of--
                          (i) reducing mortality or morbidity; 
                        or
                          (ii) improving patient care or safety 
                        (including the provider's notification 
                        to an accrediting body and the 
                        provider's plans of action in response 
                        to such event).
          (5) The term ``State'' includes the District of 
        Columbia, Puerto Rico, the Virgin Islands, Guam, 
        American Samoa, and the Northern Mariana Islands.

SEC. 124. EFFECTIVE DATE.

  (a) In General.--The amendments made by sections 801 and 802 
shall apply with respect to grievances arising in plan years 
beginning on or after January 1 of the second calendar year 
following 12 months after the date the Secretary of Labor 
issues all regulations necessary to carry out amendments made 
by this title. The amendments made by section 803 shall take 
effect on such January 1.
  (b) Limitation on Enforcement Actions.--No enforcement action 
shall be taken, pursuant to the amendments made by this title, 
against a group health plan or health insurance issuer with 
respect to a violation of a requirement imposed by such 
amendments before the date of issuance of final regulations 
issued in connection with such requirement, if the plan or 
issuer has sought to comply in good faith with such 
requirement.
  (c) Collective Bargaining Agreements.--Any plan amendment 
made pursuant to a collective bargaining agreement relating to 
the plan which amends the plan solely to conform to any 
requirement added by this title shall not be treated as a 
termination of such collective bargaining agreement.

 Subtitle D--Health Care Access, Affordability, and Quality Commission

SEC. 131. ESTABLISHMENT OF COMMISSION.

  Part 5 of the Employee Retirement Income Security Act of 1974 
is amended by adding at the end the following new section:

                 ``SEC. 518. HEALTH POLICY COMMISSION.

  ``(a) Establishment.--There is hereby established a 
commission to be known as the Health Care Access, 
Affordability, and Quality Commission (hereinafter in this Act 
referred to as the ``Commission'').
  ``(b) Duties of Commission.--The duties of the Commission 
shall be as follows:
          ``(1) Studies of critical areas.--Based on 
        information gathered by appropriate Federal agencies, 
        advisory groups, and other appropriate sources for 
        health care information, studies, and data, the 
        Commission shall study and report on in each of the 
        following areas:
                  ``(A) Independent expert external review 
                programs.
                  ``(B) Consumer friendly information programs.
                  ``(C) The extent to which the following 
                affect patient quality and satisfaction:
                          ``(i) health plan enrollees' 
                        attitudes based on surveys;
                          ``(ii) outcomes measurements; and
                          ``(iii) accreditation by private 
                        organizations.
                  ``(D) Available systems to ensure the timely 
                processing of claims.
          ``(2) Establishment of form for remittance of claims 
        to providers.--Not later than 2 years after the date of 
        the first meeting of the Commission, the Commission 
        shall develop and transmit to the Secretary a proposed 
        form for use by health insurance issuers (as defined in 
        section 733(b)(2)) for the remittance of claims to 
        health care providers. Effective for plan years 
        beginning after 5 years after the date of the 
        Comprehensive Access and Responsibility in Health Care 
        Act of 1999, a health insurance issuer offering health 
        insurance coverage in connection with a group health 
        plan shall use such form for the remittance of all 
        claims to providers.
          ``(3) Evaluation of health benefits mandates.--At the 
        request of the chairmen or ranking minority members of 
        the appropriate committees of Congress, the Commission 
        shall evaluate, taking into consideration the overall 
        cost effect, availability of treatment, and the effect 
        on the health of the general population, existing and 
        proposed benefit requirements for group health plans.
          ``(4) Comments on certain secretarial reports.--If 
        the Secretary submits to Congress (or a committee of 
        Congress) a report that is required by law and that 
        relates to policies under this section, the Secretary 
        shall transmit a copy of the report to the Commission. 
        The Commission shall review the report and, not later 
        than 6 months after the date of submittal of the 
        Secretary's report to Congress, shall submit to the 
        appropriate committees of Congress written comments on 
        such report. Such comments may include such 
        recommendations as the Commission deems appropriate.
          ``(5) Agenda and additional review.--The Commission 
        shall consult periodically with the chairmen and 
        ranking minority members of the appropriate committees 
        of Congress regarding the Commission's agenda and 
        progress toward achieving the agenda. The Commission 
        may conduct additional reviews, and submit additional 
        reports to the appropriate committees of Congress, from 
        time to time on such topics as may be requested by such 
        chairmen and members and as the Commission deems 
        appropriate.
          ``(6) Availability of reports.--The Commission shall 
        transmit to the Secretary a copy of each report 
        submitted under this subsection and shall make such 
        reports available to the public.
  ``(c) Membership.--
          ``(1) Number and appointment.--The Commission shall 
        be composed of 11 members appointed by the Comptroller 
        General.
          ``(2) Qualifications.--
                  ``(A) In general.--The membership of the 
                Commission shall include--
                          ``(i) physicians and other health 
                        professionals;
                          ``(ii) representatives of employers, 
                        including multiemployer plans;
                          ``(ii) representatives of insured 
                        employees;
                          ``(iv) third-party payers; and
                          ``(v) health services and health 
                        economics researchers with expertise in 
                        outcomes and effectiveness research and 
                        technology assessment.
                  ``(B) Ethical disclosure.--The Comptroller 
                General shall establish a system for public 
                disclosure by members of the Commission of 
                financial and other potential conflicts of 
                interest relating to such members.
          ``(3) Terms.--
                  ``(A) In general.--Each member shall be 
                appointed for a term of 3 years, except that 
                the Comptroller shall designate staggered terms 
                for the members first appointed.
                  ``(B) Vacancies.--Any member appointed to 
                fill a vacancy occurring before the expiration 
                of the term for which the member's predecessor 
                was appointed shall be appointed only for the 
                remainder of that term. A member may serve 
                after the expiration of that member's term 
                until a successor has taken office. A vacancy 
                in the Commission shall be filled in the manner 
                in which the original appointment was made.
          ``(4) Basic pay.--
                  ``(A) Rates of pay.--Except as provided in 
                subparagraph (B), members shall each be paid at 
                a rate equal to the rate of basic pay payable 
                for level IV of the Executive Schedule for each 
                day (including travel time) during which they 
                are engaged in the actual performance of duties 
                vested in the Commission.
                  ``(B) Prohibition of compensation of federal 
                employees.--Members of the Commission who are 
                full-time officers or employees of the United 
                States (or Members of Congress) may not receive 
                additional pay, allowances, or benefits by 
                reason of their service on the Commission.
          ``(5) Travel expenses.--Each member shall receive 
        travel expenses, including per diem in lieu of 
        subsistence, in accordance with sections 5702 and 5703 
        of title 5, United States Code.
          ``(6) Chairperson.--The Chairperson of the Commission 
        shall be designated by the Comptroller at the time of 
        the appointment. The term of office of the Chairperson 
        shall be 3 years.
          ``(7) Meetings.--The Commission shall meet 4 times 
        each year.
  ``(d) Director and Staff of Commission.--
          ``(1) Director.--The Commission shall have a Director 
        who shall be appointed by the Chairperson. The Director 
        shall be paid at a rate not to exceed the maximum rate 
        of basic pay payable for GS-13 of the General Schedule.
          ``(2) Staff.--The Director may appoint 2 additional 
        staff members.
          ``(3) Applicability of certain civil service laws.--
        The Director and staff of the Commission shall be 
        appointed subject to the provisions of title 5, United 
        States Code, governing appointments in the competitive 
        service, and shall be paid in accordance with the 
        provisions of chapter 51 and subchapter III of chapter 
        53 of that title relating to classification and General 
        Schedule pay rates.
  ``(e) Powers of Commission.--
          ``(1) Hearings and sessions.--The Commission may, for 
        the purpose of carrying out this Act, hold hearings, 
        sit and act at times and places, take testimony, and 
        receive evidence as the Commission considers 
        appropriate. The Commission may administer oaths or 
        affirmations to witnesses appearing before it.
          ``(2) Powers of members and agents.--Any member or 
        agent of the Commission may, if authorized by the 
        Commission, take any action which the Commission is 
        authorized to take by this section.
          ``(3) Obtaining official data.--The Commission may 
        secure directly from any department or agency of the 
        United States information necessary to enable it to 
        carry out this Act. Upon request of the Chairperson of 
        the Commission, the head of that department or agency 
        shall furnish that information to the Commission.
          ``(4) Mails.--The Commission may use the United 
        States mails in the same manner and under the same 
        conditions as other departments and agencies of the 
        United States.
          ``(5) Administrative support services.--Upon the 
        request of the Commission, the Administrator of General 
        Services shall provide to the Commission, on a 
        reimbursable basis, the administrative support services 
        necessary for the Commission to carry out its 
        responsibilities under this Act.
          ``(6) Contract authority.--The Commission may 
        contract with and compensate government and private 
        agencies or persons for services, without regard to 
        section 3709 of the Revised Statutes (41 U.S.C. 5).
  ``(f) Reports.--Beginning December 31, 2000, and each year 
thereafter, the Commission shall submit to the Congress an 
annual report detailing the following information:
          ``(1) Access to care, affordability to employers and 
        employees, and quality of care under employer-sponsored 
        health plans and recommendations for improving such 
        access, affordability, and quality.
          ``(2) Any issues the Commission deems appropriate or 
        any issues (such as the appropriateness and 
        availability of particular medical treatment) that the 
        chairmen or ranking members of the appropriate 
        committees of Congress requested the Commission to 
        evaluate.
  ``(g) Definition of Appropriate Committees of Congress.--For 
purposes of this section the term `appropriate committees of 
Congress' means any committee in the Senate or House of 
Representatives having jurisdiction over the Employee 
Retirement Income Security Act of 1974.
  ``(h) Termination.--Section 14(a)(2)(B) of the Federal 
Advisory Committee Act (5 U.S.C. App.; relating to the 
termination of advisory committees) shall not apply to the 
Commission.
  ``(i) Authorization of Appropriations.--There is authorized 
to be appropriated for fiscal years 2000 through 2004 such sums 
as may be necessary to carry out this section.''.

SEC. 132. EFFECTIVE DATE.

  This subtitle shall be effective 6 months after the date of 
the enactment of this Act.

         TITLE II--AMENDMENTS TO THE PUBLIC HEALTH SERVICE ACT

     Subtitle A--Patient Protections and Point of Service Coverage 
                              Requirements

SEC. 201. PATIENT ACCESS TO UNRESTRICTED MEDICAL ADVICE, EMERGENCY 
                    MEDICAL CARE, OBSTETRIC AND GYNECOLOGICAL CARE, 
                    PEDIATRIC CARE, AND CONTINUITY OF CARE.

  (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 ACCESS TO UNRESTRICTED MEDICAL ADVICE, EMERGENCY 
                    MEDICAL CARE, OBSTETRIC AND GYNECOLOGICAL CARE, 
                    PEDIATRIC CARE, AND CONTINUITY OF CARE.

  ``(a) Patient Access to Unrestricted Medical Advice.--
          ``(1) In general.--In the case of any health care 
        professional acting within the lawful scope of practice 
        in the course of carrying out a contractual employment 
        arrangement or other direct contractual arrangement 
        between such professional and a group health plan or a 
        health insurance issuer offering health insurance 
        coverage in connection with a group health plan, the 
        plan or issuer with which such contractual employment 
        arrangement or other direct contractual arrangement is 
        maintained by the professional may not impose on such 
        professional under such arrangement any prohibition or 
        restriction with respect to advice, provided to a 
        participant or beneficiary under the plan who is a 
        patient, about the health status of the participant or 
        beneficiary or the medical care or treatment for the 
        condition or disease of the participant or beneficiary, 
        regardless of whether benefits for such care or 
        treatment are provided under the plan or health 
        insurance coverage offered in connection with the plan.
          ``(2) Health care professional defined.--For purposes 
        of this paragraph, the term `health care professional' 
        means a physician (as defined in section 1861(r) of the 
        Social Security Act) or other health care professional 
        if coverage for the professional's services is provided 
        under the group health plan for the services of the 
        professional. Such term includes a podiatrist, 
        optometrist, chiropractor, psychologist, dentist, 
        physician assistant, physical or occupational therapist 
        and therapy assistant, speech-language pathologist, 
        audiologist, registered or licensed practical nurse 
        (including nurse practitioner, clinical nurse 
        specialist, certified registered nurse anesthetist, and 
        certified nurse-midwife), licensed certified social 
        worker, registered respiratory therapist, and certified 
        respiratory therapy technician.
          ``(3) Rule of construction.--Nothing in this 
        subsection shall be construed to require the sponsor of 
        a group health plan or a health insurance issuer 
        offering health insurance coverage in connection with 
        the group health plan to engage in any practice that 
        would violate its religious beliefs or moral 
        convictions.
  ``(b) Patient Access to Emergency Medical Care.--
          ``(1) Coverage of emergency services.--
                  ``(A) In general.--If a group health plan, or 
                health insurance coverage offered by a health 
                insurance issuer, provides any benefits with 
                respect to emergency services (as defined in 
                subparagraph (B)(ii)), or ambulance services, 
                the plan or issuer shall cover emergency 
                services (including emergency ambulance 
                services as defined in subparagraph (B)(iii)) 
                furnished under the plan or coverage--
                          ``(i) without the need for any prior 
                        authorization determination;
                          ``(ii) whether or not the health care 
                        provider furnishing such services is a 
                        participating provider with respect to 
                        such services;
                          ``(iii) in a manner so that, if such 
                        services are provided to a participant, 
                        beneficiary, or enrollee by a 
                        nonparticipating health care provider, 
                        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 provider; 
                        and
                          ``(iv) without regard to any other 
                        term or condition of such plan or 
                        coverage (other than exclusion or 
                        coordination of benefits, or an 
                        affiliation or waiting period, 
                        permitted under section 2701 and other 
                        than applicable cost sharing).
                  ``(B) Definitions.--In this subsection:
                          ``(i) Emergency medical condition.--
                        The term `emergency medical condition' 
                        means--
                                  ``(I) 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 (42 U.S.C. 
                                1395dd(e)(1)(A)); and
                                  ``(II) a medical condition 
                                manifesting itself in a neonate 
                                by acute symptoms of sufficient 
                                severity (including severe 
                                pain) such that a prudent 
                                health care professional 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.
                          ``(ii) Emergency services.--The term 
                        `emergency services' means--
                                  ``(I) with respect to an 
                                emergency medical condition 
                                described in clause (i)(I), a 
                                medical screening examination 
                                (as required under section 1867 
                                of the Social Security Act, 42 
                                U.S.C. 1395dd)) 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 clause 
                                (i)) and also, within the 
                                capabilities of the staff and 
                                facilities at the hospital, 
                                such further medical 
                                examination and treatment as 
                                are required under section 1867 
                                of such Act to stabilize the 
                                patient; or
                                  ``(II) with respect to an 
                                emergency medical condition 
                                described in clause (i)(II), 
                                medical treatment for such 
                                condition rendered by a health 
                                care provider in a hospital to 
                                a neonate, including available 
                                hospital ancillary services in 
                                response to an urgent request 
                                of a health care professional 
                                and to the extent necessary to 
                                stabilize the neonate.
                          ``(iii) Emergency ambulance 
                        services.--The term `emergency 
                        ambulance services' means ambulance 
                        services (as defined for purposes of 
                        section 1861(s)(7) of the Social 
                        Security Act) furnished to transport an 
                        individual who has an emergency medical 
                        condition (as defined in clause (i)) to 
                        a hospital for the receipt of emergency 
                        services (as defined in clause (ii)) in 
                        a case in which appropriate emergency 
                        medical screening examinations are 
                        covered under the plan or coverage 
                        pursuant to paragraph (1)(A) and a 
                        prudent layperson, with an average 
                        knowledge of health and medicine, could 
                        reasonably expect that the absence of 
                        such transport would result in placing 
                        the health of the individual in serious 
                        jeopardy, serious impairment of bodily 
                        function, or serious dysfunction of any 
                        bodily organ or part.
                          ``(iv) 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.
                          ``(v) Nonparticipating.--The term 
                        `nonparticipating' means, with respect 
                        to a health care provider that provides 
                        health care items and services to a 
                        participant or beneficiary under group 
                        health plan or under group health 
                        insurance coverage, a health care 
                        provider that is not a participating 
                        health care provider with respect to 
                        such items and services.
                          ``(vi) Participating.--The term 
                        `participating' means, with respect to 
                        a health care provider that provides 
                        health care items and services to a 
                        participant or beneficiary under group 
                        health plan or health insurance 
                        coverage offered by a health insurance 
                        issuer in connection with such a plan, 
                        a health care provider that furnishes 
                        such items and services under a 
                        contract or other arrangement with the 
                        plan or issuer.
  ``(c) Patient Right to Obstetric and Gynecological Care.--
          ``(1) In general.--In any case in which a group 
        health plan (or a health insurance issuer offering 
        health insurance coverage in connection with the 
        plan)--
                  ``(A) provides benefits under the terms of 
                the plan consisting of--
                          ``(i) gynecological care (such as 
                        preventive women's health 
                        examinations); or
                          ``(ii) obstetric care (such as 
                        pregnancy-related services),
                provided by a participating health care 
                professional who specializes in such care (or 
                provides benefits consisting of payment for 
                such care); and
                  ``(B) requires or provides for designation by 
                a participant or beneficiary of a participating 
                primary care provider,
        if the primary care provider designated by such a 
        participant or beneficiary is not such a health care 
        professional, then the plan (or issuer) shall meet the 
        requirements of paragraph (2).
          ``(1) Requirements.--A group health plan (or a health 
        insurance issuer offering health insurance coverage in 
        connection with the plan) meets the requirements of 
        this paragraph, in connection with benefits described 
        in paragraph (1) consisting of care described in clause 
        (i) or (ii) of paragraph (1)(A) (or consisting of 
        payment therefor), if the plan (or issuer)--
                  ``(A) does not require authorization or a 
                referral by the primary care provider in order 
                to obtain such benefits; and
                  ``(B) treats the ordering of other care of 
                the same type, by the participating health care 
                professional providing the care described in 
                clause (i) or (ii) of paragraph (1)(A), as the 
                authorization of the primary care provider with 
                respect to such care.
          ``(3) Health care professional defined.--For purposes 
        of this subsection, the term `health care professional' 
        means an individual (including, but not limited to, a 
        nurse midwife or nurse practitioner) who is licensed, 
        accredited, or certified under State law to provide 
        obstetric and gynecological health care services and 
        who is operating within the scope of such licensure, 
        accreditation, or certification.
          ``(4) Construction.--Nothing in paragraph (1) shall 
        be construed as preventing a plan from offering (but 
        not requiring a participant or beneficiary to accept) a 
        health care professional trained, credentialed, and 
        operating within the scope of their licensure to 
        perform obstetric and gynecological health care 
        services. Nothing in paragraph (2)(B) shall waive any 
        requirements of coverage relating to medical necessity 
        or appropriateness with respect to coverage of 
        gynecological or obstetric care so ordered.
          ``(5) Treatment of multiple coverage options.--In the 
        case of a plan providing benefits under two or more 
        coverage options, the requirements of this subsection 
        shall apply separately with respect to each coverage 
        option.
  ``(d) Patient Right to Pediatric Care.--
          ``(1) In general.--In any case in which a group 
        health plan (or a health insurance issuer offering 
        health insurance coverage in connection with the plan) 
        provides benefits consisting of routine pediatric care 
        provided by a participating health care professional 
        who specializes in pediatrics (or consisting of payment 
        for such care) and the plan requires or provides for 
        designation by a participant or beneficiary of a 
        participating primary care provider, the plan (or 
        issuer) shall provide that such a participating health 
        care professional may be designated, if available, by a 
        parent or guardian of any beneficiary under the plan is 
        who under 18 years of age, as the primary care provider 
        with respect to any such benefits.
          ``(2) Health care professional defined.--For purposes 
        of this subsection, the term `health care professional' 
        means an individual (including, but not limited to, a 
        nurse practitioner) who is licensed, accredited, or 
        certified under State law to provide pediatric health 
        care services and who is operating within the scope of 
        such licensure, accreditation, or certification.
          ``(3) Construction.--Nothing in paragraph (1) shall 
        be construed as preventing a plan from offering (but 
        not requiring a participant or beneficiary to accept) a 
        health care professional trained, credentialed, and 
        operating within the scope of their licensure to 
        perform pediatric health care services. Nothing in 
        paragraph (1) shall waive any requirements of coverage 
        relating to medical necessity or appropriateness with 
        respect to coverage of pediatric care so ordered.
          ``(4) Treatment of multiple coverage options.--In the 
        case of a plan providing benefits under two or more 
        coverage options, the requirements of this subsection 
        shall apply separately with respect to each coverage 
        option.
  ``(e) Continuity of Care.--
          ``(1) In general.--
                  ``(A) Termination of provider.--If a contract 
                between a group health plan, or a health 
                insurance issuer offering health insurance 
                coverage in connection with a group health 
                plan, and a health care provider is terminated 
                (as defined in subparagraph (D)(ii)), 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, at the time 
                of such termination, is a participant or 
                beneficiary in the plan and is scheduled to 
                undergo surgery (including an organ 
                transplantation), is undergoing treatment for 
                pregnancy, or is determined to be terminally 
                ill (as defined in section 1861(dd)(3)(A) of 
                the Social Security Act) and is undergoing 
                treatment for the terminal illness, the plan or 
                issuer shall--
                          ``(i) 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 subsection; and
                          ``(ii) subject to paragraph (3), 
                        permit the individual to elect to 
                        continue to be covered with respect to 
                        treatment by the provider for such 
                        surgery, pregnancy, or illness during a 
                        transitional period (provided under 
                        paragraph (2)).
                  ``(B) 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 
                subparagraph (A) (and the succeeding provisions 
                of this subsection) 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.
                  ``(C) Termination defined.--For purposes of 
                this subsection, 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.
          ``(2) Transitional period.--
                  ``(A) In general.--Except as provided in 
                subparagraphs (B) through (D), the transitional 
                period under this paragraph shall extend up to 
                90 days (as determined by the treating health 
                care professional) after the date of the notice 
                described in paragraph (1)(A)(i) of the 
                provider's termination.
                  ``(B) Scheduled surgery.--If surgery was 
                scheduled for an individual before the date of 
                the announcement of the termination of the 
                provider status under paragraph (1)(A)(i), the 
                transitional period under this paragraph with 
                respect to the surgery shall extend beyond the 
                period under subparagraph (A) and until the 
                date of discharge of the individual after 
                completion of the surgery.
                  ``(C) Pregnancy.--If--
                          ``(i) a participant or beneficiary 
                        was determined to be pregnant at the 
                        time of a provider's termination of 
                        participation, and
                          ``(ii) the provider was treating the 
                        pregnancy before date of the 
                        termination,
                the transitional period under this paragraph 
                with respect to provider's treatment of the 
                pregnancy shall extend through the provision of 
                post-partum care directly related to the 
                delivery.
                  ``(D) Terminal illness.--If--
                          ``(i) a participant or beneficiary 
                        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
                          ``(ii) the provider was treating the 
                        terminal illness before the date of 
                        termination,
                the transitional period under this paragraph 
                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.
          ``(3) Permissible terms and conditions.--A group 
        health plan or health insurance issuer may condition 
        coverage of continued treatment by a provider under 
        paragraph (1)(A)(i) upon the individual notifying the 
        plan of the election of continued coverage and upon the 
        provider agreeing to the following terms and 
        conditions:
                  ``(A) 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 paragraph 
                (1)(B), 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 paragraph (1)(A) had not been 
                terminated.
                  ``(B) The provider agrees to adhere to the 
                quality assurance standards of the plan or 
                issuer responsible for payment under 
                subparagraph (A) and to provide to such plan or 
                issuer necessary medical information related to 
                the care provided.
                  ``(C) 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) The provider agrees to provide 
                transitional care to all participants and 
                beneficiaries who are eligible for and elect to 
                have coverage of such care from such provider.
                  ``(E) If the provider initiates the 
                termination, the provider has notified the plan 
                within 30 days prior to the effective date of 
                the termination of--
                          ``(i) whether the provider agrees to 
                        permissible terms and conditions (as 
                        set forth in this paragraph) required 
                        by the plan, and
                          ``(ii) if the provider agrees to the 
                        terms and conditions, the specific plan 
                        beneficiaries and participants 
                        undergoing a course of treatment from 
                        the provider who the provider believes, 
                        at the time of the notification, would 
                        be eligible for transitional care under 
                        this subsection.
          ``(4) Construction.--Nothing in this subsection shall 
        be construed to--
                  ``(A) require the coverage of benefits which 
                would not have been covered if the provider 
                involved remained a participating provider, or
                  ``(B) prohibit a group health plan from 
                conditioning a provider's participation on the 
                provider's agreement to provide transitional 
                care to all participants and beneficiaries 
                eligible to obtain coverage of such care 
                furnished by the provider as set forth under 
                this subsection.
  ``(f) Coverage for Individuals Participating in Approved 
Cancer Clinical Trials.--
          ``(1) Coverage.--
                  ``(A) In general.--If a group health plan (or 
                a health insurance issuer offering health 
                insurance coverage) provides coverage to a 
                qualified individual (as defined in paragraph 
                (2)), the plan or issuer--
                          ``(i) may not deny the individual 
                        participation in the clinical trial 
                        referred to in paragraph (2)(B);
                          ``(ii) subject to paragraphs (2), 
                        (3), and (4), 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
                          ``(iii) may not discriminate against 
                        the individual on the basis of the 
                        participation of the participant or 
                        beneficiary in such trial.
                  ``(B) Exclusion of certain costs.--For 
                purposes of subparagraph (A)(ii), routine 
                patient costs do not include the cost of the 
                tests or measurements conducted primarily for 
                the purpose of the clinical trial involved.
                  ``(C) Use of in-network providers.--If one or 
                more participating providers is participating 
                in a clinical trial, nothing in subparagraph 
                (A) shall be construed as preventing a plan 
                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.
          ``(2) Qualified individual defined.--For purposes of 
        paragraph (1), the term `qualified individual' means an 
        individual who is a participant or beneficiary in a 
        group health plan and who meets the following 
        conditions:
                  ``(A)(i) The individual has been diagnosed 
                with cancer.
                  ``(ii) The individual is eligible to 
                participate in an approved clinical trial 
                according to the trial protocol with respect to 
                treatment of cancer.
                  ``(iii) The individual's participation in the 
                trial offers meaningful potential for 
                significant clinical benefit for the 
                individual.
                  ``(B) Either--
                          ``(i) 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 satisfaction by 
                        the individual of the conditions 
                        described in subparagraph (A); or
                          ``(ii) the individual provides 
                        medical and scientific information 
                        establishing that the individual's 
                        participation in such trial would be 
                        appropriate based upon the satisfaction 
                        by the individual of the conditions 
                        described in subparagraph (A).
          ``(3) Payment.--
                  ``(A) In general.--A group health plan (or a 
                health insurance issuer offering health 
                insurance coverage) shall provide for payment 
                for routine patient costs described in 
                paragraph (1)(B) but is not required to pay for 
                costs of items and services that are reasonably 
                expected to be paid for by the sponsors of an 
                approved clinical trial.
                  ``(B) Routine patient care costs.--
                          ``(i) In general.--For purposes of 
                        this paragraph, the term `routine 
                        patient care costs' shall include the 
                        costs associated with the provision of 
                        items and services that--
                                  ``(I) would otherwise be 
                                covered under the group health 
                                plan if such items and services 
                                were not provided in connection 
                                with an approved clinical trial 
                                program; and
                                  ``(II) are furnished 
                                according to the protocol of an 
                                approved clinical trial 
                                program.
                          ``(ii) Exclusion.--For purposes of 
                        this paragraph, `routine patient care 
                        costs' shall not include the costs 
                        associated with the provision of--
                                  ``(I) an investigational drug 
                                or device, unless the Secretary 
                                has authorized the manufacturer 
                                of such drug or device to 
                                charge for such drug or device; 
                                or
                                  ``(II) any item or service 
                                supplied without charge by the 
                                sponsor of the approved 
                                clinical trial program.
                  ``(C) Payment rate.--For purposes of this 
                subsection--
                          ``(i) Participating providers.--In 
                        the case of covered items and services 
                        provided by a participating provider, 
                        the payment rate shall be at the agreed 
                        upon rate.
                          ``(ii) Nonparticipating providers.--
                        In the case of covered items and 
                        services provided by a nonparticipating 
                        provider, the payment rate shall be at 
                        the rate the plan would normally pay 
                        for comparable items or services under 
                        clause (i).
          ``(4) Approved clinical trial defined.--
                  ``(A) In general.--For purposes of this 
                subsection, the term `approved clinical trial' 
                means a cancer clinical research study or 
                cancer clinical investigation approved by an 
                Institutional Review Board.
                  ``(B) 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--
                          ``(i) to be comparable to the system 
                        of peer review of studies and 
                        investigations used by the National 
                        Institutes of Health, and
                          ``(ii) assures unbiased review of the 
                        highest scientific standards by 
                        qualified individuals who have no 
                        interest in the outcome of the review.
          ``(5) Construction.--Nothing in this subsection shall 
        be construed to limit a plan's coverage with respect to 
        clinical trials.
          ``(6) Plan satisfaction of certain requirements; 
        responsibilities of fiduciaries.--
                  ``(A) In general.--For purposes of this 
                subsection, 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 requirements of this subsection 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.
                  ``(B) 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 of title I of the Employee Retirement Income 
                Security Act of 1974.
          ``(7) Study and report.--
                  ``(A) Study.--The Secretary shall analyze 
                cancer clinical research and its cost 
                implications for managed care, including 
                differentiation in--
                          ``(i) the cost of patient care in 
                        trials versus standard care;
                          ``(ii) the cost effectiveness 
                        achieved in different sites of service;
                          ``(iii) research outcomes;
                          ``(iv) volume of research subjects 
                        available in different sites of 
                        service;
                          ``(v) access to research sites and 
                        clinical trials by cancer patients;
                          ``(vi) patient cost sharing or 
                        copayment costs realized in different 
                        sites of service;
                          ``(vii) health outcomes experienced 
                        in different sites of service;
                          ``(viii) long term health care 
                        services and costs experienced in 
                        different sites of service;
                          ``(ix) morbidity and mortality 
                        experienced in different sites of 
                        service; and
                          ``(x) patient satisfaction and 
                        preference of sites of service.
                  ``(B) Report to congress.--Not later than 
                January 1, 2005, the Secretary shall submit a 
                report to Congress that contains--
                          ``(i) an assessment of any 
                        incremental cost to group health plans 
                        resulting from the provisions of this 
                        section;
                          ``(ii) a projection of expenditures 
                        to such plans resulting from this 
                        section;
                          ``(iii) an assessment of any impact 
                        on premiums resulting from this 
                        section; and
                          ``(iv) recommendations regarding 
                        action on other diseases.''.

SEC. 202. REQUIRING HEALTH MAINTENANCE ORGANIZATIONS TO OFFER OPTION OF 
                    POINT-OF-SERVICE COVERAGE.

  Title XXVII of the Public Health Service Act is amended by 
inserting after section 2713 the following new section:

``SEC. 2714. REQUIRING OFFERING OF OPTION OF POINT-OF-SERVICE COVERAGE.

  ``(a) Requirement to Offer Coverage Option to Certain 
Employers.--Except as provided in subsection (c), any health 
insurance issuer which--
          ``(1) is a health maintenance organization (as 
        defined in section 2791(b)(3)); and
          ``(2) which provides for coverage of services of one 
        or more classes of health care professionals under 
        health insurance coverage offered in connection with a 
        group health plan only if such services are furnished 
        exclusively through health care professionals within 
        such class or classes who are members of a closed panel 
        of health care professionals, the issuer shall make available 
        to the plan sponsor in connection with such a plan a coverage 
        option which provides for coverage of such services which are 
        furnished through such class (or classes) of health care 
        professionals regardless of whether or not the professionals 
        are members of such panel.
  ``(b) Requirement to Offer Supplemental Coverage to 
Participants in Certain Cases.--Except as provided in 
subsection (c), if a health insurance issuer makes available a 
coverage option under and described in subsection (a) to a plan 
sponsor of a group health plan and the sponsor declines to 
contract for such coverage option, then the issuer shall make 
available in the individual insurance market to each 
participant in the group health plan optional separate 
supplemental health insurance coverage in the individual health 
insurance market which consists of services identical to those 
provided under such coverage provided through the closed panel 
under the group health plan but are furnished exclusively by 
health care professionals who are not members of such a closed 
panel.
  ``(c) Exceptions.--
          ``(1) Offering of non-panel option.--Subsections (a) 
        and (b) shall not apply with respect to a group health 
        plan if the plan offers a coverage option that provides 
        coverage for services that may be furnished by a class 
        or classes of health care professionals who are not in 
        a closed panel. This paragraph shall be applied 
        separately to distinguishable groups of employees under 
        the plan.
          ``(2) Availability of coverage through healthmart.--
        Subsections (a) and (b) shall not apply to a group 
        health plan if the health insurance coverage under the 
        plan is made available through a HealthMart (as defined 
        in section 2801) and if any health insurance coverage 
        made available through the HealthMart provides for 
        coverage of the services of any class of health care 
        professionals other than through a closed panel of 
        professionals.
          ``(3) Relicensure exemption.--Subsections (a) and (b) 
        shall not apply to a health maintenance organization in 
        a State in any case in which--
                  ``(A) the organization demonstrates to the 
                applicable authority that the organization has 
                made a good faith effort to obtain (but has 
                failed to obtain) a contract between the 
                organization and any other health insurance 
                issuer providing for the coverage option or 
                supplemental coverage described in subsection 
                (a) or (b), as the case may be, within the 
                applicable service area of the organization; 
                and
                  ``(B) the State requires the organization to 
                receive or qualify for a separate license, as 
                an indemnity insurer or otherwise, in order to 
                offer such coverage option or supplemental 
                coverage, respectively.
        The applicable authority may require that the 
        organization demonstrate that it meets the requirements 
        of the previous sentence no more frequently that once 
        every 2 years.
          ``(4) Collective bargaining agreements.--Subsections 
        (a) and (b) shall not apply in connection with a group 
        health plan if the plan is established or maintained 
        pursuant to one or more collective bargaining 
        agreements.
          ``(5) Small issuers.--Subsections (a) and (b) shall 
        not apply in the case of a health insurance issuer with 
        25,000 or fewer covered lives.
  ``(d) Applicability.--The requirements of this section shall 
apply only in connection with included group health plan 
benefits.
  ``(e) Definitions.--For purposes of this section:
          ``(1) Coverage through closed panel.--Health 
        insurance coverage for a class of health care 
        professionals shall be treated as provided through a 
        closed panel of such professionals only if such 
        coverage consists of coverage of items or services 
        consisting of professionals services which are 
        reimbursed for or provided only within a limited 
        network of such professionals.
          ``(2) Health care professional.--The term `health 
        care professional' has the meaning given such term in 
        section 2707(a)(2).
          ``(3) Included group health plan benefit.--The term 
        `included group health plan benefit' means a benefit 
        which is not an excepted benefit (as defined in section 
        2791(c)).''.

SEC. 203. EFFECTIVE DATE AND RELATED RULES.

  (a) In General.--The amendments made by this title shall 
apply with respect to plan years beginning on or after January 
1 of the second calendar year following the date of the 
enactment of this Act, except that the Secretary of Health and 
Human Services may issue regulations before such date under 
such amendments. The Secretary shall first issue regulations 
necessary to carry out the amendments made by this title before 
the effective date thereof.
  (b) Limitation on Enforcement Actions.--No enforcement action 
shall be taken, pursuant to the amendments made by this title, 
against a group health plan or health insurance issuer with 
respect to a violation of a requirement imposed by such 
amendments before the date of issuance of regulations issued in 
connection with such requirement, if the plan or issuer has 
sought to comply in good faith with such requirement.
  (c) Special Rule for 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 this 
title shall not apply with respect to plan years beginning 
before the later of--
          (1) the date on which the last of the 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
          (2) January 1, 2002.
For purposes of this subsection, 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 title shall not be treated as a termination of 
such collective bargaining agreement.

               Subtitle B--Patient Access to Information

SEC. 111. PATIENT ACCESS TO INFORMATION REGARDING PLAN COVERAGE, 
                    MANAGED CARE PROCEDURES, HEALTH CARE PROVIDERS, AND 
                    QUALITY OF MEDICAL CARE.

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

``SEC. 2708. DISCLOSURE BY GROUP HEALTH PLANS.

  ``(a) Disclosure Requirement.--Each health insurance issuer 
offering health insurance coverage in connection with a group 
health plan shall provide the plan administrator on a timely 
basis with the information necessary to enable the 
administrator to provide participants and beneficiaries with 
information in a manner and to an extent consistent with the 
requirements of section 111 of the Employee Retirement Income 
Security Act of 1974. To the extent that any such issuer 
provides such information on a timely basis to plan 
participants and beneficiaries, the requirements of this 
subsection shall be deemed satisfied in the case of such plan 
with respect to such information.
  ``(b) Plan Benefits.--The information required under 
subsection (a) includes the following:
          ``(1) Covered items and services.--
                  ``(A) Categorization of included benefits.--A 
                description of covered benefits, categorized 
                by--
                          ``(i) types of items and services 
                        (including any special disease 
                        management program); and
                          ``(ii) types of health care 
                        professionals providing such items and 
                        services.
                  ``(B) Emergency medical care.--A description 
                of the extent to which the plan covers 
                emergency medical care (including the extent to 
                which the plan provides for access to urgent 
                care centers), and any definitions provided 
                under the plan for the relevant plan 
                terminology referring to such care.
                  ``(C) Preventative services.--A description 
                of the extent to which the plan provides 
                benefits for preventative services.
                  ``(D) Drug formularies.--A description of the 
                extent to which covered benefits are determined 
                by the use or application of a drug formulary 
                and a summary of the process for determining 
                what is included in such formulary.
                  ``(E) COBRA continuation coverage.--A 
                description of the benefits available under the 
                plan pursuant to part 6.
          ``(2) Limitations, exclusions, and restrictions on 
        covered benefits.--
                  ``(A) Categorization of excluded benefits.--A 
                description of benefits specifically excluded 
                from coverage, categorized by types of items 
                and services.
                  ``(B) Utilization review and preauthorization 
                requirements.--Whether coverage for medical 
                care is limited or excluded on the basis of 
                utilization review or preauthorization 
                requirements.
                  ``(C) Lifetime, annual, or other period 
                limitations.--A description of the 
                circumstances under which, and the extent to 
                which, coverage is subject to lifetime, annual, 
                or other period limitations, categorized by 
                types of benefits.
                  ``(D) Custodial care.--A description of the 
                circumstances under which, and the extent to 
                which, the coverage of benefits for custodial 
                care is limited or excluded, and a statement of 
                the definition used by the plan for custodial 
                care.
                  ``(E) Experimental treatments.--Whether 
                coverage for any medical care is limited or 
                excluded because it constitutes an 
                investigational item or experimental treatment 
                or technology, and any definitions provided 
                under the plan for the relevant plan 
                terminology referring to such limited or 
                excluded care.
                  ``(F) Medical appropriateness or necessity.--
                Whether coverage for medical care may be 
                limited or excluded by reason of a failure to 
                meet the plan's requirements for medical 
                appropriateness or necessity, and any 
                definitions provided under the plan for the 
                relevant plan terminology referring to such 
                limited or excluded care.
                  ``(G) Second or subsequent opinions.--A 
                description of the circumstances under which, 
                and the extent to which, coverage for second or 
                subsequent opinions is limited or excluded.
                  ``(H) Specialty care.--A description of the 
                circumstances under which, and the extent to 
                which, coverage of benefits for specialty care 
                is conditioned on referral from a primary care 
                provider.
                  ``(I) Continuity of care.--A description of 
                the circumstances under which, and the extent 
                to which, coverage of items and services 
                provided by any health care professional is 
                limited or excluded by reason of the departure 
                by the professional from any defined set of 
                providers.
                  ``(J) Restrictions on coverage of emergency 
                services.--A description of the circumstances 
                under which, and the extent to which, the plan, 
                in covering emergency medical care furnished to 
                a participant or beneficiary of the plan 
                imposes any financial responsibility described 
                in subsection (c) on participants or 
                beneficiaries or limits or conditions benefits 
                for such care subject to any other term or 
                condition of such plan.
          ``(3) Network characteristics.--If the plan (or 
        issuer) utilizes a defined set of providers under 
        contract with the plan (or issuer), a detailed list of 
        the names of such providers and their geographic 
        location, set forth separately with respect to primary 
        care providers and with respect to specialists.
  ``(c) Participant's Financial Responsibilities.--The 
information required under subsection (a) includes an 
explanation of--
          ``(1) a participant's financial responsibility for 
        payment of premiums, coinsurance, copayments, 
        deductibles, and any other charges; and
          ``(2) the circumstances under which, and the extent 
        to which, the participant's financial responsibility 
        described in paragraph (1) may vary, including any 
        distinctions based on whether a health care provider 
        from whom covered benefits are obtained is included in 
        a defined set of providers.
  ``(d) Dispute Resolution Procedures.--The information 
required under subsection (a) includes a description of the 
processes adopted by the plan of the type described in section 
503 of the Employee Retirement Income Security Act of 1974, 
including--
          ``(1) descriptions thereof relating specifically to--
                  ``(A) coverage decisions;
                  ``(B) internal review of coverage decisions; 
                and
                  ``(C) any external review of coverage 
                decisions; and
          ``(2) the procedures and time frames applicable to 
        each step of the processes referred to in subparagraphs 
        (A), (B), and (C) of paragraph (1).
  ``(e) Information on Plan Performance.--Any information 
required under subsection (a) shall include information 
concerning the number of external reviews of the type described 
in section 503 of the Employee Retirement Income Security Act 
of 1974 that have been completed during the prior plan year and 
the number of such reviews in which a recommendation is made 
for modification or reversal of an internal review decision 
under the plan.
  ``(f) Information Included with Adverse Coverage Decisions.--
A health insurance issuer offering health insurance coverage in 
connection with a group health plan shall provide to each 
participant and beneficiary, together with any notification of 
the participant or beneficiary of an adverse coverage decision, 
the following information:
          ``(1) Preauthorization and utilization review 
        procedures.--A description of the basis on which any 
        preauthorization requirement or any utilization review 
        requirement has resulted in the adverse coverage 
        decision.
          ``(2) Procedures for determining exclusions based on 
        medical necessity or on investigational items or 
        experimental treatments.--If the adverse coverage 
        decision is based on a determination relating to 
        medical necessity or to an investigational item or an 
        experimental treatment or technology, a description of 
        the procedures and medically-based criteria used in 
        such decision.
  ``(g) Information Available on Request.--
          ``(1) Access to plan benefit information in 
        electronic form.--
                  ``(A) In general.--A health insurance issuer 
                offering health insurance coverage in 
                connection with a group health plan may, upon 
                written request (made not more frequently than 
                annually), make available to participants and 
                beneficiaries, in a generally recognized 
                electronic format--
                          ``(i) the latest summary plan 
                        description, including the latest 
                        summary of material modifications, and
                          ``(ii) the actual plan provisions 
                        setting forth the benefits available 
                        under the plan,
                to the extent such information relates to the 
                coverage options under the plan available to 
                the participant or beneficiary. A reasonable 
                charge may be made to cover the cost of 
                providing such information in such generally 
                recognized electronic format. The Secretary may 
                by regulation prescribe a maximum amount which 
                will constitute a reasonable charge under the 
                preceding sentence.
                  ``(B) Alternative access.--The requirements 
                of this paragraph may be met by making such 
                information generally available (rather than 
                upon request) on the Internet or on a 
                proprietary computer network in a format which 
                is readily accessible to participants and 
                beneficiaries.
          ``(2) Additional information to be provided on 
        request.--
                  ``(A) Inclusion in summary plan description 
                of summary of additional information.--The 
                information required under subsection (a) 
                includes a summary description of the types of 
                information required by this subsection to be 
                made available to participants and 
                beneficiaries on request.
                  ``(B) Information required from plans and 
                issuers on request.--In addition to information 
                otherwise required to be provided under this 
                subsection, a health insurance issuer offering 
                health insurance coverage in connection with a 
                group health plan shall provide the following 
                information to a participant or beneficiary on 
                request:
                          ``(i) Care management information.--A 
                        description of the circumstances under 
                        which, and the extent to which, the 
                        plan has special disease management 
                        programs or programs for persons with 
                        disabilities, indicating whether these 
                        programs are voluntary or mandatory and 
                        whether a significant benefit 
                        differential results from participation 
                        in such programs.
                          ``(ii) Inclusion of drugs and 
                        biologicals in formularies.--A 
                        statement of whether a specific drug or 
                        biological is included in a formulary 
                        used to determine benefits under the 
                        plan and a description of the 
                        procedures for considering requests for 
                        any patient-specific waivers.
                          ``(iii) Accreditation status of 
                        health insurance issuers and service 
                        providers.--A description of the 
                        accreditation and licensing status (if 
                        any) of each health insurance issuer 
                        offering health insurance coverage in 
                        connection with the plan and of any 
                        utilization review organization 
                        utilized by the issuer or the plan, 
                        together with the name and address of 
                        the accrediting or licensing authority.
                          ``(iv) Quality performance 
                        measures.--The latest information (if 
                        any) maintained by the health insurance 
                        issuer relating to quality of 
                        performance of the delivery of medical 
                        care with respect to coverage options 
                        offered under the plan and of health 
                        care professionals and facilities 
                        providing medical care under the plan.
                  ``(C) Information required from health care 
                professionals.--
                          ``(i) Qualifications, privileges, and 
                        method of compensation.--Any health 
                        care professional treating a 
                        participant or beneficiary under a 
                        group health plan shall provide to the 
                        participant or beneficiary, on request, 
                        a description of his or her 
                        professional qualifications (including 
                        board certification status, licensing 
                        status, and accreditation status, if 
                        any), privileges, and experience and a 
                        general description by category 
                        (including salary, fee-for-service, 
                        capitation, and such other categories 
                        as may be specified in regulations of 
                        the Secretary) of the applicable method 
                        by which such professional is 
                        compensated in connection with the 
                        provision of such medical care.
                          ``(ii) Cost of procedures.--Any 
                        health care professional who recommends 
                        an elective procedure or treatment 
                        while treating a participant or 
                        beneficiary under a group health plan 
                        that requires a participant or 
                        beneficiary to share in the cost of 
                        treatment shall inform such participant 
                        or beneficiary of each cost associated 
                        with the procedure or treatment and an 
                        estimate of the magnitude of such 
                        costs.
                  ``(D) Information required from health care 
                facilities on request.--Any health care 
                facility from which a participant or 
                beneficiary has sought treatment under a group 
                health plan shall provide to the participant or 
                beneficiary, on request, a description of the 
                facility's corporate form or other 
                organizational form and all forms of licensing 
                and accreditation status (if any) assigned to 
                the facility by standard-setting organizations.
  ``(h) Access to Information Relevant to the Coverage Options 
under which the Participant or Beneficiary is Eligible to 
Enroll.--In addition to information otherwise required to be 
made available under this section, a health insurance issuer 
offering health insurance coverage in connection with a group 
health plan shall, upon written request (made not more 
frequently than annually), make available to a participant (and 
an employee who, under the terms of the plan, is eligible for 
coverage but not enrolled) in connection with a period of 
enrollment the summary plan description for any coverage option 
under the plan under which the participant is eligible to 
enroll and any information described in clauses (i), (ii), 
(iii), (vi), (vii), and (viii) of subsection (e)(2)(B).
  ``(i) Advance Notice of Changes in Drug Formularies.--Not 
later than 30 days before the effective of date of any 
exclusion of a specific drug or biological from any drug 
formulary under health insurance coverage offered by a health 
insurance issuer in connection with a group health plan that is 
used in the treatment of a chronic illness or disease, the 
issuer shall take such actions as are necessary to reasonably 
ensure that plan participants are informed of such exclusion. 
The requirements of this subsection may be satisfied--
          ``(1) by inclusion of information in publications 
        broadly distributed by plan sponsors, employers, or 
        employee organizations;
          ``(2) by electronic means of communication (including 
        the Internet or proprietary computer networks in a 
        format which is readily accessible to participants);
          ``(3) by timely informing participants who, under an 
        ongoing program maintained under the plan, have 
        submitted their names for such notification; or
          ``(4) by any other reasonable means of timely 
        informing plan participants.
  ``(j) Definitions and Related Rules.--
          ``(1) In general.--For purposes of this section--
                  ``(A) Group health plan.--The term `group 
                health plan' has the meaning provided such term 
                under section 733(a)(1).
                  ``(B) Medical care.--The term `medical care' 
                has the meaning provided such term under 
                section 733(a)(2).
                  ``(C) Health insurance coverage.--The term 
                `health insurance coverage' has the meaning 
                provided such term under section 733(b)(1).
                  ``(D) Health insurance issuer.--The term 
                `health insurance issuer' has the meaning 
                provided such term under section 733(b)(2).
          ``(2) Applicability only in connection with included 
        group health plan benefits.--
                  ``(A) In general.--The requirements of this 
                section shall apply only in connection with 
                included group health plan benefits.
                  ``(B) Included group health plan benefit.--
                For purposes of subparagraph (A), the term 
                `included group health plan benefit' means a 
                benefit which is not an excepted benefit (as 
                defined in section 2791(c)).''.

SEC. 212. EFFECTIVE DATE AND RELATED RULES.

  (a) In General.--The amendments made by section 211 shall 
apply with respect to plan years beginning on or after January 
1 of the second calendar year following the date of the 
enactment of this Act. The Secretary of Labor shall first issue 
all regulations necessary to carry out the amendments made by 
this title before such date.
  (b) Limitation on Enforcement Actions.--No enforcement action 
shall be taken, pursuant to the amendments made by this title, 
against a health insurance issuer with respect to a violation 
of a requirement imposed by such amendments before the date of 
issuance of final regulations issued in connection with such 
requirement, if the issuer has sought to comply in good faith 
with such requirement.

       TITLE III--AMENDMENTS TO THE INTERNAL REVENUE CODE OF 1986

SEC. 301. PATIENT ACCESS TO UNRESTRICTED MEDICAL ADVICE, EMERGENCY 
                    MEDICAL CARE, OBSTETRIC AND GYNECOLOGICAL CARE, 
                    PEDIATRIC CARE, AND CONTINUITY OF CARE.

  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. Patient access to unrestricted medical advice, 
                  emergency medical care, obstetric and gynecological 
                  care, pediatric care, and continuity of care.''; and

          (2) by inserting after section 9812 the following:

``SEC. 9813. PATIENT ACCESS TO UNRESTRICTED MEDICAL ADVICE, EMERGENCY 
                    MEDICAL CARE, OBSTETRIC AND GYNECOLOGICAL CARE, 
                    PEDIATRIC CARE, AND CONTINUITY OF CARE.

  ``(a) Patient Access to Unrestricted Medical Advice.--
          ``(1) In general.--In the case of any health care 
        professional acting within the lawful scope of practice 
        in the course of carrying out a contractual employment 
        arrangement or other direct contractual arrangement 
        between such professional and a group health plan, the 
        plan with which such contractual employment arrangement 
        or other direct contractual arrangement is maintained 
        by the professional may not impose on such professional 
        under such arrangement any prohibition or restriction 
        with respect to advice, provided to a participant or 
        beneficiary under the plan who is a patient, about the 
        health status of the participant or beneficiary or the 
        medical care or treatment for the condition or disease 
        of the participant or beneficiary, regardless of 
        whether benefits for such care or treatment are 
        provided under the plan.
          ``(2) Health care professional defined.--For purposes 
        of this paragraph, the term `health care professional' 
        means a physician (as defined in section 1861(r) of the 
        Social Security Act) or other health care professional 
        if coverage for the professional's services is provided 
        under the group health plan for the services of the 
        professional. Such term includes a podiatrist, 
        optometrist, chiropractor, psychologist, dentist, 
        physician assistant, physical or occupational therapist 
        and therapy assistant, speech-language pathologist, 
        audiologist, registered or licensed practical nurse 
        (including nurse practitioner, clinical nurse 
        specialist, certified registered nurse anesthetist, and 
        certified nurse-midwife), licensed certified social 
        worker, registered respiratory therapist, and certified 
        respiratory therapy technician.
          ``(3) Rule of construction.--Nothing in this 
        subsection shall be construed to require the sponsor of 
        a group health plan to engage in any practice that 
        would violate its religious beliefs or moral 
        convictions.
  ``(b) Patient Access to Emergency Medical Care.--
          ``(1) Coverage of emergency services.--
                  ``(A) In general.--If a group health plan 
                provides any benefits with respect to emergency 
                services (as defined in subparagraph (B)(ii)), 
                or ambulance services, the plan shall cover 
                emergency services (including emergency 
                ambulance services as defined in subparagraph 
                (B)(iii)) furnished under the plan--
                          ``(i) without the need for any prior 
                        authorization determination;
                          ``(ii) whether or not the health care 
                        provider furnishing such services is a 
                        participating provider with respect to 
                        such services;
                          ``(iii) in a manner so that, if such 
                        services are provided to a participant 
                        or beneficiary by a nonparticipating 
                        health care provider, the participant 
                        or beneficiary is not liable for 
                        amounts that exceed the amounts of 
                        liability that would be incurred if the 
                        services were provided by a 
                        participating provider; and
                          ``(iv) without regard to any other 
                        term or condition of such plan (other 
                        than exclusion or coordination of 
                        benefits, or an affiliation or waiting 
                        period, permitted under section 701 and 
                        other than applicable cost sharing).
                  ``(B) Definitions.--In this subsection:
                          ``(i) Emergency medical condition.--
                        The term `emergency medical condition' 
                        means--
                                  ``(I) 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 (42 U.S.C. 
                                1395dd(e)(1)(A)); and
                                  ``(II) a medical condition 
                                manifesting itself in a neonate 
                                by acute symptoms of sufficient 
                                severity (including severe 
                                pain) such that a prudent 
                                health care professional 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.
                          ``(ii) Emergency services.--The term 
                        `emergency services' means--
                                  ``(I) with respect to an 
                                emergency medical condition 
                                described in clause (i)(I), a 
                                medical screening examination 
                                (as required under section 1867 
                                of the Social Security Act, 42 
                                U.S.C. 1395dd)) 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 clause 
                                (i)) and also, within the 
                                capabilities of the staff and 
                                facilities at the hospital, 
                                such further medical 
                                examination and treatment as 
                                are required under section 1867 
                                of such Act to stabilize the 
                                patient; or
                                  ``(II) with respect to an 
                                emergency medical condition 
                                described in clause (i)(II), 
                                medical treatment for such 
                                condition rendered by a health 
                                care provider in a hospital to 
                                a neonate, including available 
                                hospital ancillary services in 
                                response to an urgent request 
                                of a health care professional 
                                and to the extent necessary to 
                                stabilize the neonate.
                          ``(iii) Emergency ambulance 
                        services.--The term `emergency 
                        ambulance services' means ambulance 
                        services (as defined for purposes of 
                        section 1861(s)(7) of the Social 
                        Security Act) furnished to transport an 
                        individual who has an emergency medical 
                        condition (as defined in clause (i)) to 
                        a hospital for the receipt of emergency 
                        services (as defined in clause (ii)) in 
                        a case in which appropriate emergency 
                        medical screening examinations are 
                        covered under the plan pursuant to 
                        paragraph (1)(A) and a prudent 
                        layperson, with an average knowledge of 
                        health and medicine, could reasonably 
                        expect that the absence of such 
                        transport would result in placing the 
                        health of the individual in serious 
                        jeopardy, serious impairment of bodily 
                        function, or serious dysfunction of any 
                        bodily organ or part.
                          ``(iv) 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.
                          ``(v) Nonparticipating.--The term 
                        `nonparticipating' means, with respect 
                        to a health care provider that provides 
                        health care items and services to a 
                        participant or beneficiary under group 
                        health plan, a health care provider 
                        that is not a participating health care 
                        provider with respect to such items and 
                        services.
                          ``(vi) Participating.--The term 
                        `participating' means, with respect to 
                        a health care provider that provides 
                        health care items and services to a 
                        participant or beneficiary under group 
                        health plan, a health care provider 
                        that furnishes such items and services 
                        under a contract or other arrangement 
                        with the plan.
  ``(c) Patient Right to Obstetric and Gynecological Care.--
          ``(1) In general.--In any case in which a group 
        health plan--
                  ``(A) provides benefits under the terms of 
                the plan consisting of--
                          ``(i) gynecological care (such as 
                        preventive women's health 
                        examinations); or
                          ``(ii) obstetric care (such as 
                        pregnancy-related services),
                provided by a participating health care 
                professional who specializes in such care (or 
                provides benefits consisting of payment for 
                such care); and
                  ``(B) requires or provides for designation by 
                a participant or beneficiary of a participating 
                primary care provider,
        if the primary care provider designated by such a 
        participant or beneficiary is not such a health care 
        professional, then the plan shall meet the requirements 
        of paragraph (2).
          ``(2) Requirements.--A group health plan meets the 
        requirements of this paragraph, in connection with 
        benefits described in paragraph (1) consisting of care 
        described in clause (i) or (ii) of paragraph (1)(A) (or 
        consisting of payment therefor), if the plan--
                  ``(A) does not require authorization or a 
                referral by the primary care provider in order 
                to obtain such benefits; and
                  ``(B) treats the ordering of other care of 
                the same type, by the participating health care 
                professional providing the care described in 
                clause (i) or (ii) of paragraph (1)(A), as the 
                authorization of the primary care provider with 
                respect to such care.
          ``(3) Health care professional defined.--For purposes 
        of this subsection, the term `health care professional' 
        means an individual (including, but not limited to, a 
        nurse midwife or nurse practitioner) who is licensed, 
        accredited, or certified under State law to provide 
        obstetric and gynecological health care services and 
        who is operating within the scope of such licensure, 
        accreditation, or certification.
          ``(4) Construction.--Nothing in paragraph (1) shall 
        be construed as preventing a plan from offering (but 
        not requiring a participant or beneficiary to accept) a 
        health care professional trained, credentialed, and 
        operating within the scope of their licensure to 
        perform obstetric and gynecological health care 
        services. Nothing in paragraph (2)(B) shall waive any 
        requirements of coverage relating to medical necessity 
        or appropriateness with respect to coverage of 
        gynecological or obstetric care so ordered.
          ``(5) Treatment of multiple coverage options.--In the 
        case of a plan providing benefits under two or more 
        coverage options, the requirements of this subsection 
        shall apply separately with respect to each coverage 
        option.
  ``(d) Patient Right to Pediatric Care.--
          ``(1) In general.--In any case in which a group 
        health plan provides benefits consisting of routine 
        pediatric care provided by a participating health care 
        professional who specializes in pediatrics (or 
        consisting of payment for such care) and the plan 
        requires or provides for designation by a participant 
        or beneficiary of a participating primary care 
        provider, the plan shall provide that such a 
        participating health care professional may be 
        designated, if available, by a parent or guardian of 
        any beneficiary under the plan is who under 18 years of 
        age, as the primary care provider with respect to any 
        such benefits.
          ``(2) Health care professional defined.--For purposes 
        of this subsection, the term `health care professional' 
        means an individual (including, but not limited to, a 
        nurse practitioner) who is licensed, accredited, or 
        certified under State law to provide pediatric health 
        care services and who is operating within the scope of 
        such licensure, accreditation, or certification.
          ``(3) Construction.--Nothing in paragraph (1) shall 
        be construed as preventing a plan from offering (but 
        not requiring a participant or beneficiary to accept) a 
        health care professional trained, credentialed, and 
        operating within the scope of their licensure to 
        perform pediatric health care services. Nothing in 
        paragraph (1) shall waive any requirements of coverage 
        relating to medical necessity or appropriateness with 
        respect to coverage of pediatric care so ordered.
          ``(4) Treatment of multiple coverage options.--In the 
        case of a plan providing benefits under two or more 
        coverage options, the requirements of this subsection 
        shall apply separately with respect to each coverage 
        option.
  ``(e) Continuity of Care.--
          ``(1) In general.--
                  ``(A) Termination of provider.--If a contract 
                between a group health plan and a health care 
                provider is terminated (as defined in 
                subparagraph (D)(ii)), or benefits 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, at the time of such 
                termination, is a participant or beneficiary in 
                the plan and is scheduled to undergo surgery 
                (including an organ transplantation), is 
                undergoing treatment for pregnancy, or is 
                determined to be terminally ill (as defined in 
                section 1861(dd)(3)(A) of the Social Security 
                Act) and is undergoing treatment for the 
                terminal illness, the plan shall--
                          ``(i) 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 subsection; and
                          ``(ii) subject to paragraph (3), 
                        permit the individual to elect to 
                        continue to be covered with respect to 
                        treatment by the provider for such 
                        surgery, pregnancy, or illness during a 
                        transitional period (provided under 
                        paragraph (2)).
                  ``(B) 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 
                subparagraph (A) (and the succeeding provisions 
                of this subsection) 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.
                  ``(C) Termination defined.--For purposes of 
                this subsection, 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 for failure to meet applicable 
                quality standards or for fraud.
          ``(2) Transitional period.--
                  ``(A) In general.--Except as provided in 
                subparagraphs (B) through (D), the transitional 
                period under this paragraph shall extend up to 
                90 days (as determined by the treating health 
                care professional) after the date of the notice 
                described in paragraph (1)(A)(i) of the 
                provider's termination.
                  ``(B) Scheduled surgery.--If surgery was 
                scheduled for an individual before the date of 
                the announcement of the termination of the 
                provider status under paragraph (1)(A)(i), the 
                transitional period under this paragraph with 
                respect to the surgery or transplantation.
                  ``(C) Pregnancy.--If--
                          ``(i) a participant or beneficiary 
                        was determined to be pregnant at the 
                        time of a provider's termination of 
                        participation, and
                          ``(ii) the provider was treating the 
                        pregnancy before date of the 
                        termination,
                the transitional period under this paragraph 
                with respect to provider's treatment of the 
                pregnancy shall extend through the provision of 
                post-partum care directly related to the 
                delivery.
                  ``(D) Terminal illness.--If--
                          ``(i) a participant or beneficiary 
                        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
                          ``(ii) the provider was treating the 
                        terminal illness before the date of 
                        termination,
                the transitional period under this paragraph 
                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.
          ``(3) Permissible terms and conditions.--A group 
        health plan may condition coverage of continued 
        treatment by a provider under paragraph (1)(A)(i) upon 
        the individual notifying the plan of the election of 
        continued coverage and upon the provider agreeing to 
        the following terms and conditions:
                  ``(A) The provider agrees to accept 
                reimbursement from the plan 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 paragraph (1)(B), at the 
                rates applicable under the replacement plan 
                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 paragraph (1)(A) 
                had not been terminated.
                  ``(B) The provider agrees to adhere to the 
                quality assurance standards of the plan 
                responsible for payment under subparagraph (A) 
                and to provide to such plan necessary medical 
                information related to the care provided.
                  ``(C) The provider agrees otherwise to adhere 
                to such plan'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.
                  ``(D) The provider agrees to provide 
                transitional care to all participants and 
                beneficiaries who are eligible for and elect to 
                have coverage of such care from such provider.
                  ``(E) If the provider initiates the 
                termination, the provider has notified the plan 
                within 30 days prior to the effective date of 
                the termination of--
                          ``(i) whether the provider agrees to 
                        permissible terms and conditions (as 
                        set forth in this paragraph) required 
                        by the plan, and
                          ``(ii) if the provider agrees to the 
                        terms and conditions, the specific plan 
                        beneficiaries and participants 
                        undergoing a course of treatment from 
                        the provider who the provider believes, 
                        at the time of the notification, would 
                        be eligible for transitional care under 
                        this subsection.
          ``(4) Construction.--Nothing in this subsection shall 
        be construed to--
                  ``(A) require the coverage of benefits which 
                would not have been covered if the provider 
                involved remained a participating provider, or
                  ``(B) prohibit a group health plan from 
                conditioning a provider's participation on the 
                provider's agreement to provide transitional 
                care to all participants and beneficiaries 
                eligible to obtain coverage of such care 
                furnished by the provider as set forth under 
                this subsection.
  ``(f) Coverage for Individuals Participating in Approved 
Cancer Clinical Trials.--
          ``(1) Coverage.--
                  ``(A) In general.--If a group health plan 
                provides coverage to a qualified individual (as 
                defined in paragraph (2)), the plan--
                          ``(i) may not deny the individual 
                        participation in the clinical trial 
                        referred to in paragraph (2)(B);
                          ``(ii) subject to paragraphs (2), 
                        (3), and (4), 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
                          ``(iii) may not discriminate against 
                        the individual on the basis of the 
                        participation of the participant or 
                        beneficiary in such trial.
                  ``(B) Exclusion of certain costs.--For 
                purposes of subparagraph (A)(ii), routine 
                patient costs do not include the cost of the 
                tests or measurements conducted primarily for 
                the purpose of the clinical trial involved.
                  ``(C) Use of in-network providers.--If one or 
                more participating providers is participating 
                in a clinical trial, nothing in subparagraph 
                (A) shall be construed as preventing a plan 
                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.
          ``(2) Qualified individual defined.--For purposes of 
        paragraph (1), the term `qualified individual' means an 
        individual who is a participant or beneficiary in a 
        group health plan and who meets the following 
        conditions:
                  ``(A)(i) The individual has been diagnosed 
                with cancer.
                  ``(ii) The individual is eligible to 
                participate in an approved clinical trial 
                according to the trial protocol with respect to 
                treatment of cancer.
                  ``(iii) The individual's participation in the 
                trial offers meaningful potential for 
                significant clinical benefit for the 
                individual.
                  ``(B) Either--
                          ``(i) 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 satisfaction by 
                        the individual of the conditions 
                        described in subparagraph (A); or
                          ``(ii) the individual provides 
                        medical and scientific information 
                        establishing that the individual's 
                        participation in such trial would be 
                        appropriate based upon the satisfaction 
                        by the individual of the conditions 
                        described in subparagraph (A).
          ``(3) Payment.--
                  ``(A) In general.--A group health plan shall 
                provide for payment for routine patient costs 
                described in paragraph (1)(B) but is not 
                required to pay for costs of items and services 
                that are reasonably expected to be paid for by 
                the sponsors of an approved clinical trial.
                  ``(B) Routine patient care costs.--
                          ``(i) In general.--For purposes of 
                        this paragraph, the term `routine 
                        patient care costs' shall include the 
                        costs associated with the provision of 
                        items and services that--
                                  ``(I) would otherwise be 
                                covered under the group health 
                                plan if such items and services 
                                were not provided in connection 
                                with an approved clinical trial 
                                program; and
                                  ``(II) are furnished 
                                according to the protocol of an 
                                approved clinical trial 
                                program.
                          ``(ii) Exclusion.--For purposes of 
                        this paragraph, `routine patient care 
                        costs' shall not include the costs 
                        associated with the provision of--
                                  ``(I) an investigational drug 
                                or device, unless the Secretary 
                                has authorized the manufacturer 
                                of such drug or device to 
                                charge for such drug or device; 
                                or
                                  ``(II) any item or service 
                                supplied without charge by the 
                                sponsor of the approved 
                                clinical trial program.
                  ``(C) Payment rate.--For purposes of this 
                subsection--
                          ``(i) Participating providers.--In 
                        the case of covered items and services 
                        provided by a participating provider, 
                        the payment rate shall be at the agreed 
                        upon rate.
                          ``(ii) Nonparticipating providers.--
                        In the case of covered items and 
                        servicesprovided by a nonparticipating 
                        provider, the payment rate shall be at 
                        the rate the plan would normally pay 
                        for comparable items or services under 
                        clause (i).
          ``(4) Approved clinical trial defined.--
                  ``(A) In general.--For purposes of this 
                subsection, the term `approved clinical trial' 
                means a cancer clinical research study or 
                cancer clinical investigation approved by an 
                Institutional Review Board.
                  ``(B) 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--
                          ``(i) to be comparable to the system 
                        of peer review of studies and 
                        investigations used by the National 
                        Institutes of Health, and
                          ``(ii) assures unbiased review of the 
                        highest scientific standards by 
                        qualified individuals who have no 
                        interest in the outcome of the review.
          ``(5) Construction.--Nothing in this subsection shall 
        be construed to limit a plan's coverage with respect to 
        clinical trials.
          ``(6) Plan satisfaction of certain requirements; 
        responsibilities of fiduciaries.--
                  ``(A) In general.--For purposes of this 
                subsection, 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 requirements of this subsection 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.
                  ``(B) 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 of title I of the Employee Retirement Income 
                Security Act of 1974.
          ``(7) Study and report.--
                  ``(A) Study.--The Secretary shall analyze 
                cancer clinical research and its cost 
                implications for managed care, including 
                differentiation in--
                          ``(i) the cost of patient care in 
                        trials versus standard care;
                          ``(ii) the cost effectiveness 
                        achieved in different sites of service;
                          ``(iii) research outcomes;
                          ``(iv) volume of research subjects 
                        available in different sites of 
                        service;
                          ``(v) access to research sites and 
                        clinical trials by cancer patients;
                          ``(vi) patient cost sharing or 
                        copyament costs realized in different 
                        sites of service;
                          ``(vii) health outcomes experienced 
                        in different sites of service;
                          ``(viii) long term health care 
                        services and costs experienced in 
                        different sites of service;
                          ``(ix) morbidity and mortality 
                        experienced in different sites of 
                        service; and
                          ``(x) patient satisfaction and 
                        preference of sites of service.
                  ``(B) Report to congress.--Not later than 
                January 1, 2005, the Secretary shall submit a 
                report to Congress that contains--
                          ``(i) an assessment of any 
                        incremental cost to group health plans 
                        resulting from the provisions of this 
                        section;
                          ``(ii) a projection of expenditures 
                        to such plans resulting from this 
                        section;
                          ``(iii) an assessment of any impact 
                        on premiums resulting from this 
                        section; and
                          ``(iv) recommendations regarding 
                        action on other diseases.''.

SEC. 302. EFFECTIVE DATE AND RELATED RULES.

  (a) In General.--The amendments made by this title shall 
apply with respect to plan years beginning on or after January 
1 of the second calendar year following the date of the 
enactment of this Act, except that the Secretary of the 
Treasury may issue regulations before such date under such 
amendments. The Secretary shall first issue regulations 
necessary to carry out the amendments made by this title before 
the effective date thereof.
  (b) Limitation on Enforcement Actions.--No enforcement action 
shall be taken, pursuant to the amendments made by this title, 
against a group health plan with respect to a violation of a 
requirement imposed by such amendments before the date of 
issuance of regulations issued in connection with such 
requirement, if the plan has sought to comply in good faith 
with such requirement.
  (c) Special Rule for 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 this 
title shall not apply with respect to plan years beginning 
before the later of--
          (1) the date on which the last of the 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
          (2) January 1, 2002.
For purposes of this subsection, 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 title shall not be treated as a termination of 
such collective bargaining agreement.

                  TITLE IV--HEALTH CARE LAWSUIT REFORM

                     Subtitle A--General Provisions

SEC. 401. FEDERAL REFORM OF HEALTH CARE LIABILITY ACTIONS.

  (a) Applicability.--This title shall apply with respect to 
any health care liability action brought in any State or 
Federal court, except that this title shall not apply to--
          (1) an action for damages arising from a vaccine-
        related injury or death to the extent that title XXI of 
        the Public Health Service Act applies to the action;
          (2) an action under the Employee Retirement Income 
        Security Act of 1974 (29 U.S.C. 1001 et seq.); or
          (3) an action in connection with benefits which are 
        not included group health plan benefits (as defined in 
        section 402(14)).
  (b) Preemption.--This title shall preempt any State law to 
the extent such law is inconsistent with the limitations 
contained in this title. This title shall not preempt any State 
law that provides for defenses or places limitations on a 
person's liability in addition to those contained in this title 
or otherwise imposes greater restrictions than those provided 
in this title.
  (c) Effect on Sovereign Immunity and Choice of Law or 
Venue.--Nothing in subsection (b) shall be construed to--
          (1) waive or affect any defense of sovereign immunity 
        asserted by any State under any provision of law;
          (2) waive or affect any defense of sovereign immunity 
        asserted by the United States;
          (3) affect the applicability of any provision of the 
        Foreign Sovereign Immunities Act of 1976;
          (4) preempt State choice-of-law rules with respect to 
        claims brought by a foreign nation or a citizen of a 
        foreign nation; or
          (5) affect the right of any court to transfer venue 
        or to apply the law of a foreign nation or to dismiss a 
        claim of a foreign nation or of a citizen of a foreign 
        nation on the ground of inconvenient forum.
  (d) Amount in Controversy.--In an action to which this title 
applies and which is brought under section 1332 of title 28, 
United States Code, the amount of non-economic damages or 
punitive damages, and attorneys' fees or costs, shall not be 
included in determining whether the matter in controversy 
exceeds the sum or value of $50,000.
  (e) Federal Court Jurisdiction Not Established on Federal 
Question Grounds.--Nothing in this title shall be construed to 
establish any jurisdiction in the district courts of the United 
States over health care liability actions on the basis of 
section 1331 or 1337 of title 28, United States Code.

SEC. 402. DEFINITIONS.

  As used in this title:
          (1) Actual damages.--The term ``actual damages'' 
        means damages awarded to pay for economic loss.
          (2) Alternative dispute resolution system; adr.--The 
        term ``alternative dispute resolution system'' or 
        ``ADR'' means a system established under Federal or 
        State law that provides for the resolution of health 
        care liability claims in a manner other than through 
        health care liability actions.
          (3) Claimant.--The term ``claimant'' means any person 
        who brings a health care liability action and any 
        person on whose behalf such an action is brought. If 
        such action is brought through or on behalf of an 
        estate, the term includes the claimant's decedent. If 
        such action is brought through or on behalf of a minor 
        or incompetent, the term includes the claimant's legal 
        guardian.
          (4) Clear and convincing evidence.--The term ``clear 
        and convincing evidence'' is that measure or degree of 
        proof that will produce in the mind of the trier of 
        fact a firm belief or conviction as to the truth of the 
        allegations sought to be established. Such measure or 
        degree of proof is more than that required under 
        preponderance of the evidence but less than that 
        required for proof beyond a reasonable doubt.
          (5) Collateral source payments.--The term 
        ``collateral source payments'' means any amount paid or 
        reasonably likely to be paid in the future to or on 
        behalf of a claimant, or any service, product, or other 
        benefit provided or reasonably likely to be provided in 
        the future to or on behalf of a claimant, as a result 
        of an injury or wrongful death, pursuant to--
                  (A) any State or Federal health, sickness, 
                income-disability, accident or workers' 
                compensation Act;
                  (B) any health, sickness, income-disability, 
                or accident insurance that provides health 
                benefits or income-disability coverage;
                  (C) any contract or agreement of any group, 
                organization, partnership, or corporation to 
                provide, pay for, or reimburse the cost of 
                medical, hospital, dental, or income disability 
                benefits; and
                  (D) any other publicly or privately funded 
                program.
          (6) Drug.--The term ``drug'' has the meaning given 
        such term in section 201(g)(1) of the Federal Food, 
        Drug, and Cosmetic Act (21 U.S.C. 321(g)(1)).
          (7) Economic loss.--The term ``economic loss'' means 
        any pecuniary loss resulting from injury (including the 
        loss of earnings or other benefits related to 
        employment, medical expense loss, replacement services 
        loss, loss due to death, burial costs, and loss of 
        business or employment opportunities), to the extent 
        recovery for such loss is allowed under applicable 
        State law.
          (8) Harm.--The term ``harm'' means any legally 
        cognizable wrong or injury for which punitive damages 
        may be imposed.
          (9) Health benefit plan.--The term ``health benefit 
        plan'' means--
                  (A) a hospital or medical expense incurred 
                policy or certificate;
                  (B) a hospital or medical service plan 
                contract;
                  (C) a health maintenance subscriber contract; 
                or
                  (D) a Medicare+Choice plan (offered under 
                part C of title XVIII of the Social Security 
                Act),
        that provides benefits with respect to health care 
        services.
          (10) Health care liability action.--The term ``health 
        care liability action'' means a civil action brought in 
        a State or Federal court against--
                  (A) a health care provider;
                  (B) an entity which is obligated to provide 
                or pay for health benefits under any health 
                benefit plan (including any person or entity 
                acting under a contract or arrangement to 
                provide or administer any health benefit); or
                  (C) the manufacturer, distributor, supplier, 
                marketer, promoter, or seller of a medical 
                product, in which the claimant alleges a claim 
                (including third party claims, cross claims, counter 
                claims, or contribution claims) based upon the 
                provision of (or the failure to provide or pay for) 
                health care services or the use of a medical product, 
                regardless of the theory of liability on which the 
                claim is based or the number of plaintiffs, defendants, 
                or causes of action.
          (11) Health care liability claim.--The term ``health 
        care liability claim'' means a claim in which the 
        claimant alleges that injury was caused by the 
        provision of (or the failure to provide) health care 
        services.
          (12) Health care provider.--The term ``health care 
        provider'' means any person that is engaged in the 
        delivery of health care services in a State and that is 
        required by the laws or regulations of the State to be 
        licensed or certified by the State to engage in the 
        delivery of such services in the State.
          (13) Health care service.--The term ``health care 
        service'' means any service eligible for payment under 
        a health benefit plan, including services related to 
        the delivery or administration of such service.
          (14) Included group health plan benefit.--The term 
        `included group health plan benefit' means a benefit 
        under a group health plan which is not an excepted 
        benefit (as defined in section 733(c) of the Employee 
        Retirement Income Security Act of 1974).
          (15) Medical device.--The term ``medical device'' has 
        the meaning given such term in section 201(h) of the 
        Federal Food, Drug, and Cosmetic Act (21 U.S.C. 
        321(h)).
          (16) Non-economic damages.--The term ``non-economic 
        damages'' means damages paid to an individual for pain 
        and suffering, inconvenience, emotional distress, 
        mental anguish, loss of consortium, injury to 
        reputation, humiliation, and other nonpecuniary losses.
          (17) Person.--The term ``person'' means any 
        individual, corporation, company, association, firm, 
        partnership, society, joint stock company, or any other 
        entity, including any governmental entity.
          (18) Product seller.--
                  (A) In general.--Subject to subparagraph (B), 
                the term ``product seller'' means a person who, 
                in the course of a business conducted for that 
                purpose--
                          (i) sells, distributes, rents, 
                        leases, prepares, blends, packages, 
                        labels, or is otherwise involved in 
                        placing, a product in the stream of 
                        commerce; or
                          (ii) installs, repairs, or maintains 
                        the harm-causing aspect of a product.
                  (B) Exclusion.--Such term does not include--
                          (i) a seller or lessor of real 
                        property;
                          (ii) a provider of professional 
                        services in any case in which the sale 
                        or use of a product is incidental to 
                        the transaction and the essence of the 
                        transaction is the furnishing of 
                        judgment, skill, or services; or
                          (iii) any person who--
                                  (I) acts in only a financial 
                                capacity with respect to the 
                                sale of a product; or
                                  (II) leases a product under a 
                                lease arrangement in which the 
                                selection, possession, 
                                maintenance, and operation of 
                                the product are controlled by a 
                                person other than the lessor.
          (19) Punitive damages.--The term ``punitive damages'' 
        means damages awarded against any person not to 
        compensate for actual injury suffered, but to punish or 
        deter such person or others from engaging in similar 
        behavior in the future.
          (20) State.--The term ``State'' means each of the 
        several States, the District of Columbia, Puerto Rico, 
        the Virgin Islands, Guam, American Samoa, the Northern 
        Mariana Islands, and any other territory or possession 
        of the United States.

SEC. 403. EFFECTIVE DATE.

  This title will apply to--
          (1) any health care liability action brought in a 
        Federal or State court; and
          (2) any health care liability claim subject to an 
        alternative dispute resolution system,
that is initiated on or after the date of enactment of this 
title, except that any health care liability claim or action 
arising from an injury occurring before the date of enactment 
of this title shall be governed by the applicable statute of 
limitations provisions in effect at the time the injury 
occurred.

    Subtitle B--Uniform Standards for Health Care Liability Actions

SEC. 411. STATUTE OF LIMITATIONS.

  A health care liability action may not be brought after the 
expiration of the 2-year period that begins on the date on 
which the alleged injury that is the subject of the action was 
discovered or should reasonably have been discovered, but in no 
case after the expiration of the 5-year period that begins on 
the date the alleged injury occurred.

SEC. 412. CALCULATION AND PAYMENT OF DAMAGES.

  (a) Treatment of Non-Economic Damages.--
          (1) Limitation on non-economic damages.--The total 
        amount of non-economic damages that may be awarded to a 
        claimant for losses resulting from the injury which is 
        the subject of a health care liability action may not 
        exceed $250,000, regardless of the number of parties 
        against whom the action is brought or the number of 
        actions brought with respect to the injury. The 
        limitation under this paragraph shall not apply to an 
        action for damages based solely on intentional denial 
        of medical treatment necessary to preserve a patient's 
        life that the patient is otherwise qualified to 
        receive, against the wishes of a patient, or if the 
        patient is incompetent, against the wishes of the 
        patient's guardian, on the basis of the patient's 
        present or predicated age, disability, degree of 
        medical dependency, or quality of life.
          (2) Limit.--If, after the date of the enactment of 
        this Act, a State enacts a law which prescribes the 
        amount of non-economic damages which may be awarded in 
        a health care liability action which is different from 
        the amount prescribed by section 412(a)(1), the State 
        amount shall apply in lieu of the amount prescribed by 
        such section. If, after the date of the enactment of 
        this Act, a State enacts a law which limits the amount 
        of recovery in a health care liability action without 
        delineating between economic and non-economic damages, 
        the State amount shall apply in lieu of the amount 
        prescribed by such section.
          (3) Joint and several liability.--In any health care 
        liability action brought in State or Federal court, a 
        defendant shall be liable only for the amount of non-
        economic damages attributable to such defendant in 
        direct proportion to such defendant's share of fault or 
        responsibility for the claimant's actual damages, as 
        determined by the trier of fact. In all such cases, the 
        liability of a defendant for non-economic damages shall 
        be several and not joint and a separate judgment shall 
        be rendered against each defendant for the amount 
        allocated to such defendant.
  (b) Treatment of Punitive Damages.--
          (1) General rule.--Punitive damages may, to the 
        extent permitted by applicable State law, be awarded in 
        any health care liability action for harm in any 
        Federal or State court against a defendant if the 
        claimant establishes by clear and convincing evidence 
        that the harm suffered was the result of conduct--
                  (A) specifically intended to cause harm; or
                  (B) conduct manifesting a conscious, flagrant 
                indifference to the rights or safety of others.
          (2) Applicability.--This subsection shall apply to 
        any health care liability action brought in any Federal 
        or State court on any theory where punitive damages are 
        sought. This subsection does not create a cause of 
        action for punitive damages.
          (3) Limitation on punitive damages.--The total amount 
        of punitive damages that may be awarded to a claimant 
        for losses resulting from the injury which is the 
        subject of a health care liability action may not 
        exceed the greater of--
                  (A) 2 times the amount of economic damages, 
                or
                  (B) $250,000,
        regardless of the number of parties against whom the 
        action is brought or the number of actions brought with 
        respect to the injury. This subsection does not preempt 
        or supersede any State or Federal law to the extent 
        that such law would further limit the award of punitive 
        damages.
          (4) Bifurcation.--At the request of any party, the 
        trier of fact shall consider in a separate proceeding 
        whether punitive damages are to be awarded and the 
        amount of such award. If a separate proceeding is 
        requested, evidence relevant only to the claim of 
        punitive damages, as determined by applicable State 
        law, shall be inadmissible in any proceeding to 
        determine whether actual damages are to be awarded.
          (4) Drugs and devices.--
                  (A) In general.--
                          (i) Punitive damages.--Punitive 
                        damages shall not be awarded against a 
                        manufacturer or product seller of a 
                        drug or medical device which caused the 
                        claimant's harm where--
                                  (I) such drug or device was 
                                subject to premarket approval 
                                by the Food and Drug 
                                Administration with respect to 
                                the safety of the formulation 
                                or performance of the aspect of 
                                such drug or device which 
                                caused the claimant's harm, or 
                                the adequacy of the packaging 
                                or labeling of such drug or 
                                device which caused the harm, 
                                and such drug, device, 
                                packaging, or labeling was 
                                approved by the Food and Drug 
                                Administration; or
                                  (II) the drug is generally 
                                recognized as safe and 
                                effective pursuant to 
                                conditions established by the 
                                Food and Drug Administration 
                                and applicable regulations, 
                                including packaging and 
                                labeling regulations.
                          (ii) Application.--Clause (i) shall 
                        not apply in any case in which the 
                        defendant, before or after premarket 
                        approval of a drug or device--
                                  (I) intentionally and 
                                wrongfully withheld from or 
                                misrepresented to the Food and 
                                Drug Administration information 
                                concerning such drug or device 
                                required to be submitted under 
                                the Federal Food, Drug, and 
                                Cosmetic Act (21 U.S.C. 301 et 
                                seq.) or section 351 of the 
                                Public Health Service Act (42 
                                U.S.C. 262) that is material 
                                and relevant to the harm 
                                suffered by the claimant; or
                                  (II) made an illegal payment 
                                to an official or employee of 
                                the Food and Drug 
                                Administration for the purpose 
                                of securing or maintaining 
                                approval of such drug or 
                                device.
                  (B) Packaging.--In a health care liability 
                action for harm which is alleged to relate to 
                the adequacy of the packaging or labeling of a 
                drug which is required to have tamper-resistant 
                packaging under regulations of the Secretary of 
                Health and Human Services (including labeling 
                regulations related to such packaging), the 
                manufacturer or product seller of the drug 
                shall not be held liable for punitive damages 
                unless such packaging or labeling is found by 
                the court by clear and convincing evidence to 
                be substantially out of compliance with such 
                regulations.
  (c) Periodic Payments for Future Losses.--
          (1) General rule.--In any health care liability 
        action in which the damages awarded for future economic 
        and non-economic loss exceeds $50,000, a person shall 
        not be required to pay such damages in a single, lump-
        sum payment, but shall be permitted to make such 
        payments periodically based on when the damages are 
        likely to occur, as such payments are determined by the 
        court.
          (2) Finality of judgment.--The judgment of the court 
        awarding periodic payments under this subsection may 
        not, in the absence of fraud, be reopened at any time 
        to contest, amend, or modify the schedule or amount of 
        the payments.
          (3) Lump-sum settlements.--This subsection shall not 
        be construed to preclude a settlement providing for a 
        single, lump-sum payment.
  (d) Treatment of Collateral Source Payments.--
          (1) Introduction into evidence.--In any health care 
        liability action, any defendant may introduce evidence 
        of collateral source payments. If any defendant elects 
        to introduce such evidence, the claimant may introduce 
        evidence of any amount paid or contributed or 
        reasonably likely to be paid or contributed in the 
        future by or on behalf of the claimant to secure the 
        right to such collateral source payments.
          (2) No subrogation.--No provider of collateral source 
        payments shall recover any amount against the claimant 
        or receive any lien or credit against the claimant's 
        recovery or be equitably or legally subrogated to the 
        right of the claimant in a health care liability 
        action.
          (3) Application to settlements.--This subsection 
        shall apply to an action that is settled as well as an 
        action that is resolved by a fact finder.

SEC. 413. ALTERNATIVE DISPUTE RESOLUTION.

  Any ADR used to resolve a health care liability action or 
claim shall contain provisions relating to statute of 
limitations, non-economic damages, joint and several liability, 
punitive damages, collateral source rule, and periodic payments 
which are consistent with the provisions relating to such 
matters in this title.

SEC. 414. REPORTING ON FRAUD AND ABUSE ENFORCEMENT ACTIVITIES.

  The General Accounting Office shall--
          (1) monitor--
                  (A) the compliance of the Department of 
                Justice and all United States Attorneys-with 
                the guideline entitled ``Guidance on the Use of 
                the False Claims Act in Civil Health Care 
                Matters'' issued by the Department on June 3, 
                1998, including any revisions to that 
                guideline; and
                  (B) the compliance of the Office of the 
                Inspector General of the Department of Health 
                and Human Services with the protocols and 
                guidelines entitled ``National Project 
                Protocols--Best Practice Guidelines'' issued by 
                the Inspector General on June 3, 1998, 
                including any revisions to such protocols and 
                guidelines; and
          (2) submit a report on such compliance to the 
        Committee on Commerce, the Committee on the Judiciary, 
        and the Committee on Ways and Means of the House of 
        Representatives and the Committee on the Judiciary and 
        the Committee on Finance of the Senate not later than 
        February 1, 2000, and every year thereafter for a 
        period of 4 years ending February 1, 2003.
                              ----------                              


  2. An Amendment To Be Offered by Representative Goss of Florida, or 
  Representative Coburn of Oklahoma, or a Designee, Debatable for 60 
                                Minutes

  Strike all after the enacting clause and insert the 
following:

SECTION 1. SHORT TITLE; TABLE OF CONTENTS.

  (a) Short Title.--This Act may be cited as the ``Health Care 
Quality and Choice Act of 1999''.
  (b) Table of Contents.--The table of contents of this Act is 
as follows:

Sec. 1. Short title; table of contents.

          TITLE I-- AMENDMENTS TO THE PUBLIC HEALTH SERVICE ACT

Sec. 101. Application to group health plans and group health insurance 
          coverage.
Sec. 102. Application to individual health insurance coverage.
Sec. 103. Improving managed care.

                 ``TITLE XXVIII--IMPROVING MANAGED CARE

                   ``Subtitle A--Grievance and Appeals

    ``Sec. 2801. Utilization review activities.
    ``Sec. 2802. Internal appeals procedures.
    ``Sec. 2803. External appeals procedures.
    ``Sec. 2804. Establishment of a grievance process.

                      ``Subtitle B--Access to Care

    ``Sec. 2811. Consumer choice option.
    ``Sec. 2812. Choice of health care professional.
    ``Sec. 2813. Access to emergency care.
    ``Sec. 2814. Access to specialty care.
    ``Sec. 2815. Access to obstetrical and gynecological care.
    ``Sec. 2816. Access to pediatric care.
    ``Sec. 2817. Continuity of care.
    ``Sec. 2818. Network adequacy.
    ``Sec. 2819. Access to experimental or investigational prescription 
              drugs.
    ``Sec. 2820. Coverage for individuals participating in approved 
              cancer clinical trials.

                   ``Subtitle C--Access to Information

    ``Sec. 2821. Patient access to information.

        ``Subtitle D--Protecting the Doctor-Patient Relationship

    ``Sec. 2831. Prohibition of interference with certain medical 
              communications.
    ``Sec. 2832. Prohibition of discrimination against providers based 
              on licensure.
    ``Sec. 2833. Prohibition against improper incentive arrangements.
    ``Sec. 2834. Payment of clean claims.

                        ``Subtitle E--Definitions

    ``Sec. 2841. Definitions.
    ``Sec. 2842. Rule of construction.
    ``Sec. 2843. Exclusions.
    ``Sec. 2844. Coverage of limited scope plans.
    ``Sec. 2845. Regulations.
    ``Sec. 2846. Limitation on application of provisions relating to 
              group health plans..

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

Sec. 201. Application of patient protection standards to group health 
          plans and group health insurance coverage under the Employee 
          Retirement Income Security Act of 1974.
Sec. 202. Improving managed care.

                    ``Part 8--Improving Managed Care

                   ``Subpart A--Grievance and Appeals

    ``Sec. 801. Utilization review activities.
    ``Sec. 802. Internal appeals procedures.
    ``Sec. 803. External appeals procedures.
    ``Sec. 804. Establishment of a grievance process.

                       ``Subpart B--Access to Care

    ``Sec. 812. Choice of health care professional.
    ``Sec. 813. Access to emergency care.
    ``Sec. 814. Access to specialty care.
    ``Sec. 815. Access to obstetrical and gynecological care.
    ``Sec. 816. Access to pediatric care.
    ``Sec. 817. Continuity of care.
    ``Sec. 818. Network adequacy.
    ``Sec. 819. Access to experimental or investigational prescription 
              drugs.
    ``Sec. 820. Coverage for individuals participating in approved 
              cancer clinical trials.

                   ``Subpart C--Access to Information

    ``Sec. 821. Patient access to information.

         ``Subpart D--Protecting the Doctor-Patient Relationship

    ``Sec. 831. Prohibition of interference with certain medical 
              communications.
    ``Sec. 832. Prohibition of discrimination against providers based on 
              licensure.
    ``Sec. 833. Prohibition against improper incentive arrangements.
    ``Sec. 834. Payment of clean claims.

                        ``Subpart E--Definitions

    ``Sec. 841. Definitions.
    ``Sec. 842. Rule of construction.
    ``Sec. 843. Exclusions.
    ``Sec. 844. Coverage of limited scope plans.
    ``Sec. 845. Regulations.
Sec. 203. Availability of court remedies.
Sec. 204. Availability of binding arbitration.

       TITLE III-- AMENDMENTS TO THE INTERNAL REVENUE CODE OF 1986

Sec. 301. Application to group health plans under the Internal Revenue 
          Code of 1986.
Sec. 302. Improving managed care.

                  ``Chapter 101--Improving Managed Care

                  ``SUBCHAPTER A--GRIEVANCE AND APPEALS.

    ``Sec. 9901. Utilization review activities.
    ``Sec. 9902. Internal appeals procedures.
    ``Sec. 9903. External appeals procedures.
    ``Sec. 9904. Establishment of a grievance process.

                      ``SUBCHAPTER B--ACCESS TO CARE

    ``Sec. 9912. Choice of health care professional.
    ``Sec. 9913. Access to emergency care.
    ``Sec. 9914. Access to specialty care.
    ``Sec. 9915. Access to obstetrical and gynecological care.
    ``Sec. 9916. Access to pediatric care.
    ``Sec. 9917. Continuity of care.
    ``Sec. 9918. Network adequacy.
    ``Sec. 9919. Access to experimental or investigational prescription 
              drugs.
    ``Sec. 9920. Coverage for individuals participating in approved 
              cancer clinical trials.

                   ``SUBCHAPTER C--ACCESS TO INFORMATION

    ``Sec. 9921. Patient access to information.

        ``SUBCHAPTER D--PROTECTING THE DOCTOR-PATIENT RELATIONSHIP

    ``Sec. 9931. Prohibition of interference with certain medical 
              communications.
    ``Sec. 9932. Prohibition of discrimination against providers based 
              on licensure.
    ``Sec. 9933. Prohibition against improper incentive arrangements.
    ``Sec. 9934. Payment of clean claims.

                        ``SUBCHAPTER E--DEFINITIONS

    ``Sec. 9941. Definitions.
    ``Sec. 9942. Exclusions.
    ``Sec. 9943. Coverage of limited scope plans.
    ``Sec. 9944. Regulations.

        TITLE IV--EFFECTIVE DATES; COORDINATION IN IMPLEMENTATION

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

                        TITLE V--OTHER PROVISIONS

                  Subtitle A--Protection of Information

Sec. 501. Protection for certain information.

                        Subtitle B--Other Matters

Sec. 511. Health care paperwork simplification.

         TITLE I-- AMENDMENTS TO THE PUBLIC HEALTH SERVICE ACT

SEC. 101. 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 XXVIII, 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 (as in effect on the 
date of the enactment of the Health Care Quality and Choice Act 
of 1999) 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. 102. 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 XXVIII 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.''.

SEC. 103. IMPROVING MANAGED CARE.

  The Public Health Service Act is amended by adding at the end 
the following new title:

                 ``TITLE XXVIII--IMPROVING MANAGED CARE

                  ``Subtitle A--Grievance and Appeals

``SEC. 2801. 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 practicing physicians, 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 periodic 
                evaluation at reasonable intervals of the 
                clinical appropriateness of 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 
        appropriate physician specialists who shall be selected 
        by the plan or issuer and 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. This subparagraph shall not 
                preclude any capitation arrangements between 
                plans and providers.
                  ``(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 or electronic form, no later than the 
                deadline specified in subparagraph (B). The 
                provider involved shall provide timely access 
                to information relevant to the matter of the 
                review decision.
                  ``(B) Deadline.--
                          ``(i) In general.--Subject to clauses 
                        (ii) and (iii), the deadline specified 
                        in this subparagraph is 14 days after 
                        the earliest date as of which the 
                        request for prior authorization has 
                        been received and all necessary 
                        information has been provided.
                          ``(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,
                                  ``(III) notifies the 
                                requester, not later than 5 
                                business days after the date of 
                                receiving the request, of the 
                                need for such specified 
                                additional information, and
                                  ``(IV) requires the requester 
                                to submit specified information 
                                not later than 2 business days 
                                after notification,
                        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 48 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 or electronic 
                        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 or 
        electronic 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, post-stabilization care, 
        and emergency ambulance services.--For waiver of prior 
        authorization requirements in certain cases involving 
        emergency services, maintenance care and post-
        stabilization care, and emergency ambulance services, 
        see subsections (a)(1), (b), and (c)(1) of section 113, 
        respectively.
  ``(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 or electronic 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), 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 or pay for benefits (including items 
        and services) required to be provided or paid for under 
        this title.

``SEC. 2802. 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 
                written or electronic form 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 2801(f)(2)), 
                setting forth the specific reasons for such 
                denial of claim for benefits and rights to any 
                further review or appeal, written in layman's 
                terms 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 written or electronic form.
  ``(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 shall be a physician in a case 
                involving medical judgment) who has been 
                selected by the plan or issuer and who did not 
                make the initial denial in the internally 
                appealable decision, except that in the case of 
                limited scope coverage (as defined in 
                subparagraph (B)) an appropriate specialist 
                shall review the 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 
                or electronic 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 earliest date as of which the 
                        request for prior authorization has 
                        been received and all necessary 
                        information has been provided. The 
                        provider involved shall provide timely 
                        access to information relevant to the 
                        matter of the review decision.
                          ``(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,
                                  ``(III) notifies the 
                                requester, not later than 5 
                                business days after the date of 
                                receiving the request, of the 
                                need for such specified 
                                additional information, and
                                  ``(IV) requires the requester 
                                to submit specified information 
                                not later than 48 hours after 
                                notification,
                        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 48 hours after the 
                        time of 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, as determined by the plan or 
                issuer or as certified in writing by a treating 
                physician, the application of the normal 
                timeframe for making the determination could 
                seriously jeopardize the life or health of the 
                participant, beneficiary, or enrollee or such 
                individual's ability to regain maximum 
                function; or
                  ``(B) described in section 2801(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 48 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. 2803. 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 
        (within a reasonable period not to exceed 365 days) 
        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).
          ``(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 2801(f)(2)), if--
                          ``(i) the item or service involved is 
                        covered under the plan or coverage,
                          ``(ii) the amount involved exceeds 
                        $100, increased or decreased, for each 
                        calendar year that ends after December 
                        31, 2001, by the same percentage as the 
                        percentage by which the medical care 
                        expenditure category of the Consumer 
                        Price Index for All Urban Consumers 
                        (United States city average), published 
                        by the Bureau of Labor Statistics, for 
                        September of the preceding calendar 
                        year has increased or decreased from 
                        such index for September 2000, and
                          ``(iii) the requirements of 
                        subparagraph (B) are met with respect 
                        to such denial.
                Such term also includes a failure to meet an 
                applicable deadline for internal review under 
                section 2802 or such standards as are 
                established pursuant to section 2818.
                  ``(B) Requirements.--For purposes of 
                subparagraph (A)(iii), the requirements of this 
                subparagraph are met with respect to a denial 
                of a claim for benefits if--
                          ``(i) the denial 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 such denial, the decision 
                        as to whether an item or service is 
                        covered involves a medical judgment.
                  ``(C) Exclusions.--The term `externally 
                appealable decision' does not include--
                          ``(i) specific exclusions or express 
                        limitations on the amount, duration, or 
                        scope of coverage; or
                          ``(ii) a decision regarding 
                        eligibility for any benefits.
          ``(3) Exhaustion of internal review process.--Except 
        as provided under section 2802(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 2802, 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.--A plan or issuer may 
                condition the use of an external appeal process 
                upon payment in advance to the plan or issuer 
                of a $25 filing fee.
                  ``(B) 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 appeal 
                entity is to reverse the denial of a claim for 
                benefits which is the subject of the appeal.
  ``(b) General Elements of External Appeals Process.--
          ``(1) Use of qualified external appeal entity.--
                  ``(A) In general.--The external appeal 
                process under this section of a plan or issuer 
                shall be conducted between the plan or issuer 
                and one or more qualified external appeal 
                entities (as defined in subsection (c)). 
                Nothing in this subsection shall be construed 
                as requiring that such procedures provide for 
                the selection for any plan of more than one 
                such entity.
                  ``(B) Limitation on plan or issuer 
                selection.--The Secretary shall implement 
                procedures 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.
                  ``(C) Other terms and conditions.--The terms 
                and conditions of this paragraph shall be 
                consistent with the standards the Secretary 
                shall establish to assure there is no real or 
                apparent conflict of interest in the conduct of 
                external appeal activities. 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).
          ``(2) Elements of process.--An external appeal 
        process shall be conducted consistent with standards 
        established by the Secretary that include at least the 
        following:
                  ``(A) Fair and de novo determination.--The 
                process shall provide for a fair, de novo 
                determination described in subparagraph (B) 
                based on evidence described in subparagraphs 
                (C) and (D).
                  ``(B) Standard of review.--An external appeal 
                entity shall determine whether the plan's or 
                issuer's decision is appropriate for the 
                medical condition 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 subparagraphs (C) and (D). If the 
                entity determines the decision is appropriate 
                for such condition, the entity shall affirm the 
                decision and to the extent that the entity 
                determines the decision is not appropriate for 
                such condition, the entity shall reverse the 
                decision. Nothing in this subparagraph shall be 
                construed as providing for coverage of items or 
                services not provided or covered by the plan or 
                issuer.
                  ``(C) Required consideration of certain 
                matters.--In making such determination, the 
                external appeal entity shall consider, but not 
                be bound by--
                          ``(i) 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;
                          ``(ii) the decision made by the plan 
                        or issuer upon internal review under 
                        section 2802 and any guidelines or 
                        standards used by the plan or issuer in 
                        reaching such decision; and
                          ``(iii) the opinion of the 
                        individual's treating physician or 
                        health care professional.
                The entity also shall consider any personal 
                health and medical information supplied with 
                respect to the individual whose denial of claim 
                for benefits has been appealed. The entity also 
                shall consider the results of studies that meet 
                professionally recognized standards of validity 
                and replicability or that have been published 
                in peer-reviewed journals.
                  ``(D) 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 professional 
                        consensus conferences.
                          ``(ii) Practice and treatment 
                        policies.
                          ``(iii) Community standard of care.
                          ``(iv) Generally accepted principles 
                        of professional medical practice 
                        consistent with the best practice of 
                        medicine.
                          ``(v) 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.
                          ``(vi) 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.--
                          ``(i) In general.--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;
                                  ``(III) for purposes of 
                                initiating an external review, 
                                whether the internal review 
                                process has been completed; and
                                  ``(IV) whether the item or 
                                services is covered under the 
                                plan or coverage.
                          ``(ii) Construction.--Nothing in a 
                        determination by a qualified external 
                        appeal entity under this section shall 
                        be construed as authorizing, or 
                        providing for, coverage of items and 
                        services for which benefits are not 
                        provided under the plan or coverage.
                  ``(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 to the external 
                appeal entity timely access 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. The provider involved shall 
                provide to the external appeal entity timely 
                access to information relevant 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 written or 
                        electronic form and, if it is made 
                        orally, shall be supplied to the 
                        parties in written or electronic form 
                        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, 48 hours after the 
                        time) of requesting an external appeal 
                        of the decision;
                          ``(iii) state, in layperson's 
                        language, the scientific rationale for 
                        such determination as well as the basis 
                        for such 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 
                        binding arbitration or further review 
                        by the courts (or other process) of the 
                        external appeal determination.
                  ``(I) Compliance with determination.--If the 
                external appeal entity determines that a denial 
                of a claim for benefits was not reasonable and 
                reverses the denial, the plan or issuer--
                          ``(i) shall (upon the receipt of the 
                        determination) authorize the provision 
                        or payment for benefits in accordance 
                        with such determination;
                          ``(ii) shall take such actions as may 
                        be necessary to provide or pay for 
                        benefits (including items or services) 
                        in a timely manner consistent with such 
                        determination; and
                          ``(iii) shall submit information to 
                        the entity documenting compliance with 
                        the entity's determination and this 
                        subparagraph.
                  ``(J) Construction.--Nothing in this 
                paragraph shall be construed as providing for 
                coverage of items and services for which 
                benefits are not provided under the plan or 
                coverage.
  ``(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 at least three clinical 
                peers who are practicing physicians.
                  ``(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).
          ``(2) Initial certification of external appeal 
        entities.--
                  ``(A) In general.--In order to be treated as 
                a qualified external appeal entity with respect 
                to a group health plan or 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, under a 
                        process recognized or approved by the 
                        Secretary, or to the extent provided in 
                        subparagraph (C)(ii), by a qualified 
                        private standard-setting organization 
                        (certified under such subparagraph), if 
                        elected by the entity.
                  ``(B) Recertification process.--The 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;
                          ``(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) information necessary to assure 
                        that the entity meets the independence 
                        requirements (described in paragraph 
                        (3)) with respect to plans and issuers 
                        for which it conducts external review 
                        activities.
                  ``(C) Certification of qualified private 
                standard-setting organizations.--For purposes 
                of subparagraph (A)(ii), the Secretary may 
                provide for a process for certification (and 
                periodic recertification) of qualified private 
                standard-setting organizations which provide 
                for certification of external appeal entities. 
                Such an organization shall only be certified if 
                the organization does not certify an external 
                appeal entity unless it meets standards as 
                least as stringent as the standards required 
                for certification of such an entity by the 
                Secretary under subparagraph (A)(ii).
          ``(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 is not 
                        affiliated 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) the plan and the issuer (if 
                        any) 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.
                  ``(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; or
                          ``(iv) the manufacturer of any drug 
                        or other item that was included in the 
                        health care involved in the coverage 
                        decision.
                  ``(C) Affiliated.--For purposes of this 
                paragraph, the term `affiliated' means, in 
                connection with any peer or entity, having a 
                familial, financial, or fiduciary relationship 
                with such peer or entity.
          ``(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.--
          ``(1) In general.--The determination by an external 
        appeal entity shall be binding on the plan (and issuer, 
        if any) involved in the determination.
          ``(2) Protection of legal rights.--Nothing in this 
        subtitle shall be construed as removing any legal 
        rights of participants, beneficiaries, enrollees, and 
        others under State or Federal law, including the right 
        to file judicial actions to enforce rights.
  ``(e) Penalties Against Authorized Officials for Refusing to 
Authorize the Determination of an External Appeal Entity.--
          ``(1) Monetary penalties.--In any case in which the 
        determination of an external appeal entity is not 
        followed in a timely fashion by a group health plan, or 
        by a health insurance issuer offering health insurance 
        coverage, any named fiduciary 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 appeal 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.
  ``(f) Protection of Legal Rights.--Nothing in this subtitle 
shall be construed as removing or limiting any legal rights of 
participants, beneficiaries, enrollees, and others under State 
or Federal law (including section 502 of the Employee 
Retirement Income Security Act of 1974), including the right to 
file judicial actions to enforce rights.

``SEC. 2804. 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.
  ``(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 3 previous years beginning two months after 
        the date of the enactment of this Act, all grievances 
        and appeals made and their status.
          ``(3) A process providing processing and resolution 
        of grievances within 60 days.
          ``(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. 2811. CONSUMER CHOICE OPTION.

  ``(a) In General.--If a health insurance issuer offers to 
enrollees health insurance coverage in connection with a group 
health plan which provides for coverage of services only if 
such services are furnished through health care professionals 
and providers who are members of a network of health care 
professionals and providers who have entered into a contract 
with the issuer to provide such services, the issuer shall also 
offer to such enrollees (at the time of enrollment and during 
an annual open season as provided under subsection (c)) the 
option of health insurance coverage which provides for coverage 
of such services which are not furnished through health care 
professionals and providers who are members of such a network 
unless enrollees are offered such non-network coverage through 
another health insurance issuer.
  ``(b) Additional Costs.--The amount of any additional premium 
charged by the health insurance issuer for the additional cost 
of the creation and maintenance of the option described in 
subsection (a) and the amount of any additional cost sharing 
imposed under such option shall be borne by the enrollee unless 
it is paid by the health plan sponsor through agreement with 
the health insurance issuer.
  ``(c) Open Season.--An enrollee may change to the offering 
provided under this section only during a time period 
determined by the health insurance issuer. Such time period 
shall occur at least annually.

``SEC. 2812. 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.--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.

``SEC. 2813. 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 or covers 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 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.--The term 
                `emergency medical condition' means--
                          ``(i) 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; and
                          ``(ii) a medical condition 
                        manifesting itself in a neonate by 
                        acute symptoms of sufficient severity 
                        (including severe pain) such that a 
                        prudent health care professional 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) with respect to an emergency 
                        medical condition described in 
                        subparagraph (A)(i)--
                                  ``(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 such emergency medical 
                                condition, 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; or
                          ``(ii) with respect to an emergency 
                        medical condition described in 
                        subparagraph (A)(ii), medical treatment 
                        for such condition rendered by a health 
                        care provider in a hospital to a 
                        neonate, including available hospital 
                        ancillary services in response to an 
                        urgent request of a health care 
                        professional and to the extent 
                        necessary to stabilize the neonate.
                  ``(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.--If benefits are available under a group 
health plan, or under health insurance coverage offered by a 
health insurance issuer, with respect to maintenance care or 
post-stabilization care covered under the guidelines 
established under section 1852(d)(2) of the Social Security 
Act, the plan or issuer shall provide for reimbursement with 
respect to such services provided to a participant, 
beneficiary, or enrollee other than through a participating 
health care provider in a manner consistent with subsection 
(a)(1)(C) (and shall otherwise comply with such guidelines).
  ``(c) Coverage of Emergency Ambulance Services.--
          ``(1) In general.--If a group health plan, or health 
        insurance coverage provided by a health insurance 
        issuer, provides any benefits with respect to ambulance 
        services and emergency services, the plan or issuer 
        shall cover emergency ambulance services (as defined in 
        paragraph (2)) furnished under the plan or coverage 
        under the same terms and conditions under subparagraphs 
        (A) through (D) of subsection (a)(1) under which 
        coverage is provided for emergency services.
          ``(2) Emergency ambulance services.--For purposes of 
        this subsection, the term `emergency ambulance 
        services' means ambulance services (as defined for 
        purposes of section 1861(s)(7) of the Social Security 
        Act) furnished to transport an individual who has an 
        emergency medical condition (as defined in subsection 
        (a)(2)(A)) to a hospital for the receipt of emergency 
        services (as defined in subsection (a)(2)(B)) in a case 
        in which the emergency services are covered under the 
        plan or coverage pursuant to subsection (a)(1) and a 
        prudent layperson, with an average knowledge of health 
        and medicine, could reasonably expect that the absence 
        of such transport would result in placing the health of 
        the individual in serious jeopardy, serious impairment 
        of bodily function, or serious dysfunction of any 
        bodily organ or part.

``SEC. 2814. 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 
                or the individual requires physician pathology 
                services, and
                  ``(C) benefits for such treatment or services 
                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 
        (consistent with standards developed under section 
        2818) to provide the treatment for such condition or 
        disease or to provide such services.
          ``(2) Specialist defined.--For purposes of this 
        subsection, the term `specialist' means, with respect 
        to a condition or services, a health care practitioner, 
        facility, or center or physician pathologist that has 
        adequate expertise through appropriate training and 
        experience (including, in the case of a child, 
        appropriate pediatric expertise and in the case of a 
        pregnant woman, appropriate obstetrical expertise) to 
        provide high quality care in treating the condition or 
        to provide physician pathology services.
          ``(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) with respect to treatment 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 a specialist that is 
        available and accessible to treat the individual's 
        condition or provide physician pathology services and 
        that is a participating provider with respect to such 
        treatment or services.
          ``(5) Referrals to nonparticipating providers.--In a 
        case in which a referral of an individual to a 
        nonparticipating specialist is required under paragraph 
        (1), the group health plan or health insurance issuer 
        shall provide the individual the option of at least 
        three nonparticipating specialists.
          ``(6) 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
                  ``(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).
          ``(5) Construction.--Nothing in this subsection shall 
        be construed as preventing an individual who is a 
        participant, beneficiary, or enrollee and who has an 
        ongoing special condition from having the individual's 
        primary care physician assume the responsibilities for 
        providing and coordinating care described in paragraph 
        (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. 2815. 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 covered gynecological care (including 
        preventive women's health examinations) or for covered 
        pregnancy-related services provided by a participating 
        physician (including a family practice physician) who 
        specializes or is trained and experienced in gynecology 
        or obstetrics, respectively, to the extent such care is 
        otherwise covered; and
          ``(2) shall treat the ordering of other gynecological 
        or obstetrical care by such a participating physician 
        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 with respect to coverage of 
        gynecological or obstetrical care;
          ``(2) preclude the group health plan or health 
        insurance issuer involved from requiring that the 
        gynecologist or obstetrician notify the primary care 
        health care professional or the plan of treatment 
        decisions; or
          ``(3) prevent a plan or issuer from offering, in 
        addition to physicians described in subsection (a)(1), 
        non-physician health care professionals who are trained 
        and experienced in gynecology or obstetrics.

``SEC. 2816. 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 (including a family practice physician) 
who specializes or is trained and experienced 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 with respect to coverage of pediatric care.

``SEC. 2817. 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 2814(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. 2818. NETWORK ADEQUACY.

  ``(a) Requirement.--A group health plan, and a health 
insurance issuer providing health insurance coverage, shall 
meet such standards for network adequacy as are established by 
law pursuant to this section.
  ``(b) Development of Standards.--
          ``(1) Establishment of panel.--There is established a 
        panel to be known as the Health Care Panel to Establish 
        Network Adequacy Standards (in this section referred to 
        as the `Panel').
          ``(2) Duties of panel.--The Panel shall devise 
        standards for group health plans and health insurance 
        issuers that offer health insurance coverage to ensure 
        that--
                  ``(A) participants, beneficiaries, and 
                enrollees have access to a sufficient number, 
                mix, and distribution of health care 
                professionals and providers; and
                  ``(B) covered items and services are 
                available and accessible to each participant, 
                beneficiary, and enrollee--
                          ``(i) in the service area of the plan 
                        or issuer;
                          ``(ii) at a variety of sites of 
                        service;
                          ``(iii) with reasonable promptness 
                        (including reasonable hours of 
                        operation and after hours services);
                          ``(iv) with reasonable proximity to 
                        the residences or workplaces of 
                        enrollees; and
                          ``(v) in a manner that takes into 
                        account the diverse needs of enrollees 
                        and reasonably assures continuity of 
                        care.
  ``(c) Membership.--
          ``(1) Size and composition.--The Panel shall be 
        composed of 15 members. The Secretary of Health and 
        Human Services, the Majority Leader of the Senate, and 
        the Speaker of House of Representatives shall each 
        appoint 1 member from representatives of private 
        insurance organizations, consumer groups, State 
        insurance commissioners, State medical societies, and 
        State medical specialty societies.
          ``(2) Terms of appointment.--The members of the Panel 
        shall serve for the life of the Panel.
          ``(3) 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.
  ``(d) Procedures.--
          ``(1) Meetings.--The Panel shall meet at the call of 
        a majority of its members.
          ``(2) First meeting.--The Panel shall convene not 
        later than 60 days after the date of the enactment of 
        the Health Care Quality and Choice Act of 1999.
          ``(3) Quorum.--A quorum shall consist of a majority 
        of the members of the Panel.
          ``(4) 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.
  ``(e) Administration.--
          ``(1) Compensation.--Except as provided in paragraph 
        (1), members of the Panel shall receive no additional 
        pay, allowances, or benefits by reason of their service 
        on the Panel.
          ``(2) 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.
          ``(3) 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).
          ``(4) 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.
          ``(5) 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.
  ``(f) Report and Establishment of Standards.--Not later than 
2 years after the first meeting, the Panel shall submit a 
report to Congress and the Secretary of Health and Human 
Services detailing the standards devised under subsection (b) 
and recommendations regarding the implementation of such 
standards. Such standards shall take effect to the extent 
provided by Federal law enacted after the date of the 
submission of such report.
  ``(g) Termination.--The Panel shall terminate on the day 
after submitting its report to the Secretary of Health and 
Human Services under subsection (f).

``SEC. 2819. ACCESS TO EXPERIMENTAL OR INVESTIGATIONAL PRESCRIPTION 
                    DRUGS.

  ``No use of a prescription drug or medical device shall be 
considered experimental or investigational under a group health 
plan or under health insurance coverage provided by a health 
insurance issuer if such use is included in the labeling 
authorized by the U.S. Food and Drug Administration under 
section 505, 513 or 515 of the Federal Food, Drug, and Cosmetic 
Act (21 U.S.C. 355) or under section 351 of the Public Health 
Service Act (42 U.S.C. 262), unless such use is demonstrated to 
be unsafe or ineffective.

``SEC. 2820. COVERAGE FOR INDIVIDUALS PARTICIPATING IN APPROVED CANCER 
                    CLINICAL TRIALS.

  ``(a) Coverage.--
          ``(1) In general.--If a group health plan (or a 
        health insurance issuer offering 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 subsections (b), (c), and 
                (d), 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 individual'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 an enrollee in health insurance coverage and who 
meets the following conditions:
          ``(1)(A) The individual has been diagnosed with 
        cancer.
          ``(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 individual 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 offering health 
        insurance) 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 to be paid for by the sponsors 
        of an approved clinical trial.
          ``(2) Routine patient care costs.--For purposes of 
        this section--
                  ``(A) In general.--The term `routine patient 
                care costs' includes the costs associated with 
                the provision of items and services that--
                          ``(i) would otherwise be covered 
                        under the group health plan or health 
                        insurance coverage if such items and 
                        services were not provided in 
                        connection with an approved clinical 
                        trial program; and
                          ``(ii) are furnished according to the 
                        protocol of an approved clinical trial 
                        program.
                  ``(B) Exclusion.--Such term does include the 
                costs associated with the provision of--
                          ``(i) an investigational drug or 
                        device, unless the Secretary has 
                        authorized the manufacturer of such 
                        drug or device to charge for such drug 
                        or device; or
                          ``(ii) any item or service supplied 
                        without charge by the sponsor of the 
                        approved clinical trial program.
          ``(3) 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 items 
                or services under subparagraph (A).
  ``(d) Approved Clinical Trial Defined.--In this section, the 
term `approved clinical trial' means a cancer clinical research 
study or cancer clinical investigation approved by an 
Institutional Review Board.
  ``(e) Construction.--Nothing in this section shall be 
construed to limit a plan's or issuer's coverage with respect 
to clinical trials.
  ``(f) Plan Satisfaction of Certain Requirements; 
Responsibilities of Fiduciaries.--
          ``(1) In general.--For purposes of this section, 
        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 requirements of this section 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.
          ``(2) Construction.--Nothing in this section shall be 
        construed to affect or modify the responsibilities of 
        the fiduciaries of a group health plan under part 4 of 
        subtitle B of the Employee Retirement Income Security 
        Act of 1974.
  ``(g) Study and Report.--
          ``(1) Study.--The Secretary of Health and Human 
        Services, in consultation with the Secretary and the 
        Secretary of the Treasury, shall analyze cancer 
        clinical research and its cost implications for managed 
        care, including differentiation in--
                  ``(A) the cost of patient care in trials 
                versus standard care;
                  ``(B) the cost effectiveness achieved in 
                different sites of service;
                  ``(C) research outcomes;
                  ``(D) volume of research subjects available 
                in different sites of service;
                  ``(E) access to research sites and clinical 
                trials by cancer patients;
                  ``(F) patient cost sharing or copayment costs 
                realized in different sites of service;
                  ``(G) health outcomes experienced in 
                different sites of service;
                  ``(H) long term health care services and 
                costs experienced in different sites of 
                service;
                  ``(I) morbidity and mortality experienced in 
                different sites of service; and
                  ``(J) patient satisfaction and preference of 
                sites of service.
          ``(2) Report to congress.--Not later than January 1, 
        2005, the Secretary of Health and Human Services shall 
        submit a report to Congress that contains--
                  ``(A) an assessment of any incremental cost 
                to group health plans and health insurance 
                issuers resulting from the provisions of this 
                section;
                  ``(B) a projection of expenditures to such 
                plans and issuers resulting from this section;
                  ``(C) an assessment of any impact on premiums 
                resulting from this section; and
                  ``(D) recommendations regarding action on 
                other diseases.

                  ``Subtitle C--Access to Information

``SEC. 2821. 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);
                  ``(B) provide to participants and 
                beneficiaries, within a reasonable period (as 
                specified by the Secretary) before or after the 
                date of significant changes in the information 
                described in subsection (b), information on 
                such significant changes; and
                  ``(C) upon request, make available to 
                participants and beneficiaries, the Secretary, 
                and prospective participants and beneficiaries, 
                the information described in subsection (b) or 
                (c).
        The plan may charge a reasonable fee for provision in 
        printed form of any of the information described in 
        subsection (b) or (c) more than once during any plan 
        year.
          ``(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);
                  ``(B) provide to enrollees, within a 
                reasonable period (as specified by the 
                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 
                Secretary, to individuals who are prospective 
                enrollees, and to the public the information 
                described in subsection (b) or (c).
  ``(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 shall 
be provided to a participant, beneficiary, or enrollee free of 
charge at least once a year and 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) those that are covered benefits ``(all 
                of which shall be referred to by such relevant 
                CPT and DRG codes as are available), limits and 
                conditions on such benefits, and those benefits 
                that are explicitly excluded from coverage (all 
                of which shall be referred to by such relevant 
                CPT and DRG codes as are available);
                  ``(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 2812(b)(2).
          ``(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) Prior authorization rules.--Rules regarding 
        prior authorization or other review requirements that 
        could result in noncoverage or nonpayment.
          ``(7) 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.
          ``(8) Accountability.--A description of the legal 
        recourse options available for participants and 
        beneficiaries under the plan including--
                  ``(A) the preemption that applies under 
                section 514 of the Employee Retirement Income 
                Security Act of 1974 (29 U.S.C. 1144) to 
                certain actions arising out of the provision of 
                health benefits; and
                  ``(B) the extent to which coverage decisions 
                made by the plan are subject to internal review 
                or any external review and the proper time 
                frames under
          ``(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) 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 2801.
          ``(2) Grievance and appeals information.--Information 
        on the number of grievances and appeals and on the 
        disposition in the aggregate of such matters.
          ``(3) Formulary restrictions.--A description of the 
        nature of any drug formula restrictions.
          ``(4) 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. 2831. 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. 2832. 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;
          ``(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; or
          ``(4) as prohibiting a family practice physician with 
        appropriate expertise from providing pediatric or 
        obstetrical or gynecological care.

``SEC. 2833. 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. 2834. PAYMENT OF CLEAN 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.

                       ``Subtitle E--Definitions

``SEC. 2841. DEFINITIONS.

  ``(a) Incorporation of General Definitions.--Except as 
otherwise provided, the provisions of section 2791 shall apply 
for purposes of this title in the same manner as they apply for 
purposes of title XXVII.
  ``(b) Additional Definitions.--For purposes of this title:
          ``(1) Applicable authority.--The term `applicable 
        authority' means--
                  ``(A) in the case of a group health plan, the 
                Secretary of Health and Human Services; and
                  ``(B) in the case of a health insurance 
                issuer with respect to a specific provision of 
                this title, the applicable State authority (as 
                defined in section 2791(d) of the Public Health 
                Service Act), or the Secretary of Health and 
                Human Services, if such Secretary is enforcing 
                such provision under section 2722(a)(2) or 
                2761(a)(2) of the Public Health Service Act.
          ``(2) Clinical peer.--The term `clinical peer' means, 
        with respect to a review or appeal, a practicing 
        physician or other health care professional who holds a 
        nonrestricted license and who is--
                  ``(A) appropriately certified by a nationally 
                recognized, peer reviewed accrediting body in 
                the same or similar specialty as typically 
                manages the medical condition, procedure, or 
                treatment under review or appeal, or
                  ``(B) is trained and experienced in managing 
                such condition, procedure, or treatment,
        and includes a pediatric specialist where appropriate; 
        except that only a physician may be a clinical peer 
        with respect to the review or appeal of treatment 
        recommended or rendered by a physician.
          ``(3) 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.
          ``(4) 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.
          ``(5) 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.
          ``(6) 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.
          ``(7) 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.
          ``(8) 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.
          ``(9) Physician.--The term `physician' means an 
        allopathic or osteopathic physician.
          ``(10) Practicing physician.--The term `practicing 
        physician' means a physician who is licensed in the 
        State in which the physician furnishes professional 
        services and who provides professional services to 
        individual patients on average at least two full days 
        per week.
          ``(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. 2842. RULE OF 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 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.
  ``(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, the Northern Mariana Islands, any 
        political subdivisions of a State or such Islands, or 
        any agency or instrumentality of either.

``SEC. 2843. 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 provide 
specific benefits under the terms of such plan or coverage, 
other than those provided under the terms of such plan or 
coverage.
  ``(b) Exclusion for Fee-for-Service Coverage.--
          ``(1) In general.--
                  ``(A) Group health plans.--The provisions of 
                sections 2811 through 2821 shall not apply to a 
                group health plan if the only coverage offered 
                under the plan is fee-for-service coverage (as 
                defined in paragraph (2)).
                  ``(B) Health insurance coverage.--The 
                provisions of sections 2801 through 2821 shall 
                not apply to health insurance coverage if the 
                only coverage offered under the 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 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) allows access to any provider that is 
                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
                  ``(D) for which the plan or issuer does not 
                require prior authorization before providing 
                for any health care services.

``SEC. 2844. COVERAGE OF LIMITED SCOPE PLANS.

  ``Only for purposes of applying the requirements of this 
title under sections 2707 and 2753, section 2791(c)(2)(A) shall 
be deemed not to apply.

``SEC. 2845. REGULATIONS.

  ``The Secretary of Health and Human Services shall issue such 
regulations as may be necessary or appropriate to carry out 
this title under sections 2707 and 2753. The Secretary may 
promulgate such regulations in the form of interim final rules 
as may be necessary to carry out this title in a timely manner.

``SEC. 2846. LIMITATION ON APPLICATION OF PROVISIONS RELATING TO GROUP 
                    HEALTH PLANS.

  ``The requirements of this title shall apply with respect to 
group health plans only--
          ``(1) in the case of a plan that is a non-Federal 
        governmental plan (as defined in section 
        2791(d)(8)(C)), and
          ``(2) with respect to health insurance coverage 
        offered in connection with a group health plan 
        (including such a plan that is a church plan or a 
        governmental plan), except that subtitle A shall apply 
        with respect to such coverage only to the extent it is 
        offered in connection with a non-Federal governmental 
        plan or a church plan.''.

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

SEC. 201. APPLICATION OF PATIENT PROTECTION STANDARDS TO GROUP HEALTH 
                    PLANS AND GROUP HEALTH INSURANCE COVERAGE UNDER THE 
                    EMPLOYEE RETIREMENT INCOME SECURITY ACT OF 1974.

  (a) In General.--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 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 part 8 and such 
requirements shall be deemed to be incorporated into this 
section.''.
  (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 subpart A of 
part 8 in the case of a claims denial shall be deemed 
compliance with subsection (a) with respect to such claims 
denial. For purposes of applying the previous sentence, the 
exceptions provided under section 732 shall be deemed to 
apply.''.
  (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.''.

SEC. 202. IMPROVING MANAGED CARE.

  (a) In General.--Subtitle B of title I of the Employee 
Retirement Income Security Act of 1974 is amended by adding at 
the end the following new part:

                    ``Part 8--Improving Managed Care


                   ``Subpart A--Grievance and Appeals


``SEC. 801. UTILIZATION REVIEW ACTIVITIES.

  ``(a) Compliance With Requirements.--
          ``(1) In general.--A group health plan, and a health 
        insurance issuer that provides health insurance 
        coverage in connection with such a plan, 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 practicing physicians, 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 a participant or beneficiary 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 
                individual during the same course of treatment.
                  ``(C) Review of sample of claims denials.--
                Such a program shall provide for periodic 
                evaluation at reasonable intervals of the 
                clinical appropriateness of 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 
        appropriate physician specialists who shall be selected 
        by the plan or issuer and 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. This subparagraph shall not 
                preclude any capitation arrangements between 
                plans and providers.
                  ``(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 or electronic form, no later than the 
                deadline specified in subparagraph (B). The 
                provider involved shall provide timely access 
                to information relevant to the matter of the 
                review decision.
                  ``(B) Deadline.--
                          ``(i) In general.--Subject to clauses 
                        (ii) and (iii), the deadline specified 
                        in this subparagraph is 14 days after 
                        the earliest date as of which the 
                        request for prior authorization has 
                        been received and all necessary 
                        information has been provided.
                          ``(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,
                                  ``(III) notifies the 
                                requester, not later than 5 
                                business days after the date of 
                                receiving the request, of the 
                                need for such specified 
                                additional information, and
                                  ``(IV) requires the requester 
                                to submit specified information 
                                not later than 2 business days 
                                after notification,
                        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 
                        802(c)(1)(A), the deadline specified in 
                        this subparagraph is 48 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 or electronic 
                        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 802(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 or 
        electronic 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 subpart as a 
        denial of the claim as of the date of the deadline.
          ``(5) Reference to special rules for emergency 
        services, maintenance care, post-stabilization care, 
        and emergency ambulance services.--For waiver of prior 
        authorization requirements in certain cases involving 
        emergency services, maintenance care and post-
        stabilization care, and emergency ambulance services, 
        see subsections (a)(1), (b), and (c)(1) of section 813, 
        respectively.
  ``(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 or electronic form and written in a 
        manner calculated to be understood by the participant 
        or beneficiary and shall include--
                  ``(A) the reasons for the denial (including 
                the clinical rationale);
                  ``(B) instructions on how to initiate an 
                appeal under section 802; 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 subpart:
          ``(1) Claim for benefits.--The term `claim for 
        benefits' means any request for coverage (including 
        authorization of coverage), or for payment in whole or 
        in part, for an item or service under a group health 
        plan or health insurance coverage offered in connection 
        with such a plan.
          ``(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 or pay for benefits (including items 
        and services) required to be provided or paid for under 
        this part.

``SEC. 802. INTERNAL APPEALS PROCEDURES.

  ``(a) Right of Review.--
          ``(1) In general.--Each group health plan, and each 
        health insurance issuer offering health insurance 
        coverage in connection with such a plan--
                  ``(A) shall provide adequate notice in 
                written or electronic form to any participant 
                or beneficiary under such plan whose claim for 
                benefits under the plan or coverage has been 
                denied (within the meaning of section 
                801(f)(2)), setting forth the specific reasons 
                for such denial of claim for benefits and 
                rights to any further review or appeal, written 
                in layman's terms to be understood by the 
                participant or beneficiary; and
                  ``(B) shall afford such a participant or 
                beneficiary (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 written or electronic form.
  ``(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 shall be a physician in a case 
                involving medical judgment) who has been 
                selected by the plan or issuer and who did not 
                make the initial denial in the internally 
                appealable decision, except that in the case of 
                limited scope coverage (as defined in 
                subparagraph (B)) an appropriate specialist 
                shall review the 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, 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 or 
                electronic 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 earliest date as of which the 
                        request for prior authorization has 
                        been received and all necessary 
                        information has been provided. The 
                        provider involved shall provide timely 
                        access to information relevant to the 
                        matter of the review decision.
                          ``(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,
                                  ``(III) notifies the 
                                requester, not later than 5 
                                business days after the date of 
                                receiving the request, of the 
                                need for such specified 
                                additional information, and
                                  ``(IV) requires the requester 
                                to submit specified information 
                                not later than 48 hours after 
                                notification,
                        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 48 hours after the 
                        time of 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, as determined by the plan or 
                issuer or as certified in writing by a treating 
                physician, the application of the normal 
                timeframe for making the determination could 
                seriously jeopardize the life or health of the 
                participant or beneficiary or such individual's 
                ability to regain maximum function; or
                  ``(B) described in section 801(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 48 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 or beneficiary 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, designee, or provider, proceed 
directly to seek further appeal through any applicable external 
appeals process.

``SEC. 803. EXTERNAL APPEALS PROCEDURES.

  ``(a) Right to External Appeal.--
          ``(1) In general.--A group health plan, and a health 
        insurance issuer offering health insurance coverage in 
        connection with such a plan, 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 (within a reasonable period not to 
        exceed 365 days) either by the plan or issuer or by the 
        participant or beneficiary (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).
          ``(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 801(f)(2)), if--
                          ``(i) the item or service involved is 
                        covered under the plan or coverage,
                          ``(ii) the amount involved exceeds 
                        $100, increased or decreased, for each 
                        calendar year that ends after December 
                        31, 2001, by the same percentage as the 
                        percentage by which the medical care 
                        expenditure category of the Consumer 
                        Price Index for All Urban Consumers 
                        (United States city average), published 
                        by the Bureau of Labor Statistics, for 
                        September of the preceding calendar 
                        year has increased or decreased from 
                        such index for September 2000, and
                          ``(iii) the requirements of 
                        subparagraph (B) are met with respect 
                        to such denial.
                Such term also includes a failure to meet an 
                applicable deadline for internal review under 
                section 802 or such standards as are 
                established pursuant to section 818.
                  ``(B) Requirements.--For purposes of 
                subparagraph (A)(iii), the requirements of this 
                subparagraph are met with respect to a denial 
                of a claim for benefits if--
                          ``(i) the denial 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 such denial, the decision 
                        as to whether an item or service is 
                        covered involves a medical judgment.
                  ``(C) Exclusions.--The term `externally 
                appealable decision' does not include--
                          ``(i) specific exclusions or express 
                        limitations on the amount, duration, or 
                        scope of coverage; or
                          ``(ii) a decision regarding 
                        eligibility for any benefits.
          ``(3) Exhaustion of internal review process.--Except 
        as provided under section 802(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 802, but 
        only if the decision is made in a timely basis 
        consistent with the deadlines provided under this 
        subpart.
          ``(4) Filing fee requirement.--
                  ``(A) In general.--A plan or issuer may 
                condition the use of an external appeal process 
                upon payment in advance to the plan or issuer 
                of a $25 filing fee.
                  ``(B) 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 appeal 
                entity is to reverse the denial of a claim for 
                benefits which is the subject of the appeal.
  ``(b) General Elements of External Appeals Process.--
          ``(1) Use of qualified external appeal entity.--
                  ``(A) In general.--The external appeal 
                process under this section of a plan or issuer 
                shall be conducted between the plan or issuer 
                and one or more qualified external appeal 
                entities (as defined in subsection (c)). 
                Nothing in this subsection shall be construed 
                as requiring that such procedures provide for 
                the selection for any plan of more than one 
                such entity.
                  ``(B) Limitation on plan or issuer 
                selection.--The Secretary shall implement 
                procedures 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.
                  ``(C) Other terms and conditions.--The terms 
                and conditions of this paragraph shall be 
                consistent with the standards the Secretary 
                shall establish to assure there is no real or 
                apparent conflict of interest in the conduct of 
                external appeal activities. All costs of the 
                process (except those incurred by the 
                participant, beneficiary, or treating 
                professional in support of the appeal) shall be 
                paid by the plan or issuer, and not by the 
                participant or beneficiary. The previous 
                sentence shall not be construed as applying to 
                the imposition of a filing fee under subsection 
                (a)(4).
          ``(2) Elements of process.--An external appeal 
        process shall be conducted consistent with standards 
        established by the Secretary that include at least the 
        following:
                  ``(A) Fair and de novo determination.--The 
                process shall provide for a fair, de novo 
                determination described in subparagraph (B) 
                based on evidence described in subparagraphs 
                (C) and (D).
                  ``(B) Standard of review.--An external appeal 
                entity shall determine whether the plan's or 
                issuer's decision is appropriate for the 
                medical condition 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 subparagraphs (C) and (D). If the 
                entity determines the decision is appropriate 
                for such condition, the entity shall affirm the 
                decision and to the extent that the entity 
                determines the decision is not appropriate for 
                such condition, the entity shall reverse the 
                decision. Nothing in this subparagraph shall be 
                construed as providing for coverage of items or 
                services not provided or covered by the plan or 
                issuer.
                  ``(C) Required consideration of certain 
                matters.--In making such determination, the 
                external appeal entity shall consider, but not 
                be bound by--
                          ``(i) 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;
                          ``(ii) the decision made by the plan 
                        or issuer upon internal review under 
                        section 802 and any guidelines or 
                        standards used by the plan or issuer in 
                        reaching such decision; and
                          ``(iii) the opinion of the 
                        individual's treating physician or 
                        health care professional.
                The entity also shall consider any personal 
                health and medical information supplied with 
                respect to the individual whose denial of claim 
                for benefits has been appealed. The entity also 
                shall consider the results of studies that meet 
                professionally recognized standards of validity 
                and replicability or that have been published 
                in peer-reviewed journals.
                  ``(D) 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 professional 
                        consensus conferences.
                          ``(ii) Practice and treatment 
                        policies.
                          ``(iii) Community standard of care.
                          ``(iv) Generally accepted principles 
                        of professional medical practice 
                        consistent with the best practice of 
                        medicine.
                          ``(v) 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.
                          ``(vi) 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.--
                          ``(i) In general.--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;
                                  ``(III) for purposes of 
                                initiating an external review, 
                                whether the internal review 
                                process has been completed; and
                                  ``(IV) whether the item or 
                                services is covered under the 
                                plan or coverage.
                          ``(ii) Construction.--Nothing in a 
                        determination by a qualified external 
                        appeal entity under this section shall 
                        be construed as authorizing, or 
                        providing for, coverage of items and 
                        services for which benefits are not 
                        provided under the plan or coverage.
                  ``(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 to the external 
                appeal entity timely access 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. The provider involved shall 
                provide to the external appeal entity timely 
                access to information relevant 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 written or 
                        electronic form and, if it is made 
                        orally, shall be supplied to the 
                        parties in written or electronic form 
                        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, 48 hours after the 
                        time) of requesting an external appeal 
                        of the decision;
                          ``(iii) state, in layperson's 
                        language, the scientific rationale for 
                        such determination as well as the basis 
                        for such determination, including, if 
                        relevant, any basis in the terms or 
                        conditions of the plan or coverage; and
                          ``(iv) inform the participant or 
                        beneficiary of the individual's rights 
                        (including any limitation on such 
                        rights) to seek binding arbitration or 
                        further review by the courts (or other 
                        process) of the external appeal 
                        determination.
                  ``(I) Compliance with determination.--If the 
                external appeal entity determines that a denial 
                of a claim for benefits was not reasonable and 
                reverses the denial, the plan or issuer--
                          ``(i) shall (upon the receipt of the 
                        determination) authorize benefits in 
                        accordance with such determination;
                          ``(ii) shall take such actions as may 
                        be necessary to provide benefits 
                        (including items or services) in a 
                        timely manner consistent with such 
                        determination; and
                          ``(iii) shall submit information to 
                        the entity documenting compliance with 
                        the entity's determination and this 
                        subparagraph.
                  ``(J) Construction.--Nothing in this 
                paragraph shall be construed as providing for 
                coverage of items and services for which 
                benefits are not provided under the plan or 
                coverage.
  ``(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 at least three clinical 
                peers who are practicing physicians.
                  ``(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).
          ``(2) Initial certification of external appeal 
        entities.--
                  ``(A) In general.--In order to be treated as 
                a qualified external appeal entity with respect 
                to a group health plan or a health insurance 
                issuer in connection with a group health plan, 
                the entity must be certified (and, in 
                accordance with subparagraph (B), periodically 
                recertified), under such standards as may be 
                prescribed by the Secretary, as meeting the 
                requirements of paragraph (1)--
                          ``(i) by the Secretary;
                          ``(ii) under a process recognized or 
                        approved by the Secretary; or
                          ``(iii) to the extent provided in 
                        subparagraph (C)(i), by a qualified 
                        private standard-setting organization 
                        (certified under such subparagraph), if 
                        elected by the entity.
                  ``(B) Recertification process.--The 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;
                          ``(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) information necessary to assure 
                        that the entity meets the independence 
                        requirements (described in paragraph 
                        (3)) with respect to plans and issuers 
                        for which it conducts external review 
                        activities.
                  ``(C) Certification of qualified private 
                standard-setting organizations.--For purposes 
                of subparagraph (A)(iii), the Secretary shall 
                provide for a process for certification (and 
                periodic recertification) of qualified private 
                standard-setting organizations which provide 
                for certification of external appeal entities. 
                Such an organization shall only be certified if 
                the organization does not certify an external 
                appeal entity unless it meets standards at 
                least as stringent as the standards required 
                for certification of such an entity by the 
                Secretary under subparagraph (A)(i).
                  ``(D) Construction.--Nothing in subparagraph 
                (A) shall be construed as permitting the 
                Secretary to delegate certification or 
                regulatory authority under clause (i) of such 
                subparagraph to any person outside the 
                Department of Labor.
          ``(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 is not 
                        affiliated 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) the plan and the issuer (if 
                        any) 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.
                  ``(B) Related party.--For purposes of this 
                paragraph, the term `related party' means--
                          ``(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 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; or
                          ``(iv) the manufacturer of any drug 
                        or other item that was included in the 
                        health care involved in the coverage 
                        decision.
                  ``(C) Affiliated.--For purposes of this 
                paragraph, the term `affiliated' means, in 
                connection with any peer or entity, having a 
                familial, financial, or fiduciary relationship 
                with such peer or entity.
          ``(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.--
          ``(1) In general.--The determination by an external 
        appeal entity shall be binding on the plan (and issuer, 
        if any) involved in the determination.
          ``(2) Protection of legal rights.--Nothing in this 
        subpart shall be construed as removing any legal rights 
        of participants, beneficiaries, and others under State 
        or Federal law, including the right to file judicial 
        actions to enforce rights.
  ``(e) Penalties Against Authorized Officials for Refusing to 
Authorize the Determination of an External Appeal Entity.--
          ``(1) Monetary penalties.--In any case in which the 
        determination of an external appeal entity is not 
        followed in a timely fashion by a group health plan, or 
        by a health insurance issuer offering health insurance 
        coverage in connection with such a plan, any named 
        fiduciary 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 or beneficiary 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 appeal 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 or beneficiary with respect to a group 
        health plan, or a health insurance issuer offering 
        health insurance coverage in connection with such a 
        plan, 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 subpart, or has failed to 
        take an action for which such person is responsible 
        under the plan, coverage, or this part 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.
  ``(f) Protection of Legal Rights.--Nothing in this subpart 
shall be construed as removing or limiting any legal rights of 
participants, beneficiaries, and others under State or Federal 
law (including section 502), including the right to file 
judicial actions to enforce rights.

``SEC. 804. 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 in connection with such a 
        plan, shall establish and maintain a system to provide 
        for the presentation and resolution of oral and written 
        grievances brought by individuals who are participants 
        or beneficiaries 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 or beneficiary that is not a 
        claim for benefits.
  ``(b) Grievance System.--Such system shall include the 
following components with respect to individuals who are 
participants or beneficiaries:
          ``(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 3 previous years beginning two months after 
        the date of the enactment of this Act, all grievances 
        and appeals made and their status.
          ``(3) A process providing processing and resolution 
        of grievances within 60 days.
          ``(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 subpart.

                      ``Subpart B--Access to Care


``SEC. 812. CHOICE OF HEALTH CARE PROFESSIONAL.

  ``(a) Primary Care.--If a group health plan, or a health 
insurance issuer that offers health insurance coverage in 
connection with such a plan, requires or provides for 
designation by a participant or beneficiary of a participating 
primary care provider, then the plan or issuer shall permit 
each participant and beneficiary to designate any participating 
primary care provider who is available to accept such 
individual.
  ``(b) Specialists.--A group health plan and a health 
insurance issuer that offers health insurance coverage in 
connection with such a plan shall permit each participant or 
beneficiary 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.

``SEC. 813. 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 
        in connection with such a plan, provides or covers 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 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 or beneficiary--
                          ``(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 or beneficiary 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, 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.--The term 
                `emergency medical condition' means--
                          ``(i) 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; and
                          ``(ii) a medical condition 
                        manifesting itself in a neonate by 
                        acute symptoms of sufficient severity 
                        (including severe pain) such that a 
                        prudent health care professional 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) with respect to an emergency 
                        medical condition described in 
                        subparagraph (A)(i)--
                                  ``(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 such emergency medical 
                                condition, 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; or
                          ``(ii) with respect to an emergency 
                        medical condition described in 
                        subparagraph (A)(ii), medical treatment 
                        for such condition rendered by a health 
                        care provider in a hospital to a 
                        neonate, including available hospital 
                        ancillary services in response to an 
                        urgent request of a health care 
                        professional and to the extent 
                        necessary to stabilize the neonate.
                  ``(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.--If benefits are available under a group 
health plan, or under health insurance coverage offered by a 
health insurance issuer in connection with such a plan, with 
respect to maintenance care or post-stabilization care covered 
under the guidelines established under section 1852(d)(2) of 
the Social Security Act, the plan or issuer shall provide for 
reimbursement with respect to such services provided to a 
participant or beneficiary other than through a participating 
health care provider in a manner consistent with subsection 
(a)(1)(C) (and shall otherwise comply with such guidelines).
  ``(c) Coverage of Emergency Ambulance Services.--
          ``(1) In general.--If a group health plan, or health 
        insurance coverage provided by a health insurance 
        issuer in connection with such a plan, provides any 
        benefits with respect to ambulance services and 
        emergency services, the plan or issuer shall cover 
        emergency ambulance services (as defined in paragraph 
        (2))) furnished under the plan or coverage under the 
        same terms and conditions under subparagraphs (A) 
        through (D) of subsection (a)(1) under which coverage 
        is provided for emergency services.
          ``(2) Emergency ambulance services.--For purposes of 
        this subsection, the term `emergency ambulance 
        services' means ambulance services (as defined for 
        purposes of section 1861(s)(7) of the Social Security 
        Act) furnished to transport an individual who has an 
        emergency medical condition (as defined in subsection 
        (a)(2)(A)) to a hospital for the receipt of emergency 
        services (as defined in subsection (a)(2)(B)) in a case 
        in which the emergency services are covered under the 
        plan or coverage pursuant to subsection (a)(1) and a 
        prudent layperson, with an average knowledge of health 
        and medicine, could reasonably expect that the absence 
        of such transport would result in placing the health of 
        the individual in serious jeopardy, serious impairment 
        of bodily function, or serious dysfunction of any 
        bodily organ or part.

``SEC. 814. 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 is 
                covered under health insurance coverage offered 
                by a health insurance issuer in connection with 
                such a plan,
                  ``(B) the individual has a condition or 
                disease of sufficient seriousness and 
                complexity to require treatment by a specialist 
                or the individual requires physician pathology 
                services, and
                  ``(C) benefits for such treatment or services 
                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 
        (consistent with standards developed under section 818) 
        to provide the treatment for such condition or disease 
        or to provide such services.
          ``(2) Specialist defined.--For purposes of this 
        subsection, the term `specialist' means, with respect 
        to a condition or services, a health care practitioner, 
        facility, or center or physician pathologist that has 
        adequate expertise through appropriate training and 
        experience (including, in the case of a child, 
        appropriate pediatric expertise and in the case of a 
        pregnant woman, appropriate obstetrical expertise) to 
        provide high quality care in treating the condition or 
        to provide physician pathology services.
          ``(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) with respect to treatment 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 a specialist that is 
        available and accessible to treat the individual's 
        condition or provide physician pathology services and 
        that is a participating provider with respect to such 
        treatment or services.
          ``(5) Referrals to nonparticipating providers.--In a 
        case in which a referral of an individual to a 
        nonparticipating specialist is required under paragraph 
        (1), the group health plan or health insurance issuer 
        shall provide the individual the option of at least 
        three nonparticipating specialists.
          ``(6) 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 in connection with such a 
        plan, shall have a procedure by which an individual who 
        is a participant or beneficiary 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
                  ``(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).
          ``(5) Construction.--Nothing in this subsection shall 
        be construed as preventing an individual who is a 
        participant or beneficiary and who has an ongoing 
        special condition from having the individual's primary 
        care physician assume the responsibilities for 
        providing and coordinating care described in paragraph 
        (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 in connection with such a 
        plan, shall have a procedure by which an individual who 
        is a participant or beneficiary 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. 815. 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 in connection with such a plan, requires or 
provides for a participant or beneficiary 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 covered gynecological care (including 
        preventive women's health examinations) or for covered 
        pregnancy-related services provided by a participating 
        physician (including a family practice physician) who 
        specializes or is trained and experienced in gynecology 
        or obstetrics, respectively, to the extent such care is 
        otherwise covered; and
          ``(2) shall treat the ordering of other gynecological 
        or obstetrical care by such a participating physician 
        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 with respect to coverage of 
        gynecological or obstetrical care;
          ``(2) preclude the group health plan or health 
        insurance issuer involved from requiring that the 
        gynecologist or obstetrician notify the primary care 
        health care professional or the plan of treatment 
        decisions; or
          ``(3) prevent a plan or issuer from offering, in 
        addition to physicians described in subsection (a)(1), 
        non-physician health care professionals who are trained 
        and experienced in gynecology or obstetrics.

``SEC. 816. 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 in connection with such a plan, requires or 
provides for a participant or beneficiary to designate a 
participating primary care provider for a child of such 
individual, the plan or issuer shall permit the participant or 
beneficiary to designate a physician (including a family 
practice physician) who specializes or is trained and 
experienced 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 with respect to coverage of pediatric care.

``SEC. 817. 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 in connection with such a plan, 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 or beneficiary 
        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 814(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 or beneficiary 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 or beneficiary 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. 818. NETWORK ADEQUACY.

  ``(a) Requirement.--A group health plan, and a health 
insurance issuer providing health insurance coverage in 
connection with such a plan, shall meet such standards for 
network adequacy as are established by law pursuant to this 
section.
  ``(b) Development of Standards.--
          ``(1) Establishment of panel.--There is established a 
        panel to be known as the Health Care Panel to Establish 
        Network Adequacy Standards (in this section referred to 
        as the `Panel').
          ``(2) Duties of panel.--The Panel shall devise 
        standards for group health plans and health insurance 
        issuers that offer health insurance coverage in 
        connection with such a plan to ensure that--
                  ``(A) participants and beneficiaries have 
                access to a sufficient number, mix, and 
                distribution of health care professionals and 
                providers; and
                  ``(B) covered items and services are 
                available and accessible to each participant 
                and beneficiary--
                          ``(i) in the service area of the plan 
                        or issuer;
                          ``(ii) at a variety of sites of 
                        service;
                          ``(iii) with reasonable promptness 
                        (including reasonable hours of 
                        operation and after hours services);
                          ``(iv) with reasonable proximity to 
                        the residences or workplaces of 
                        participants and beneficiaries; and
                          ``(v) in a manner that takes into 
                        account the diverse needs of such 
                        individuals and reasonably assures 
                        continuity of care.
  ``(c) Membership.--
          ``(1) Size and composition.--The Panel shall be 
        composed of 15 members. The Secretary of Health and 
        Human Services, the Majority Leader of the Senate, and 
        the Speaker of House of Representatives shall each 
        appoint 1 member from representatives of private 
        insurance organizations, consumer groups, State 
        insurance commissioners, State medical societies, and 
        State medical specialty societies.
          ``(2) Terms of appointment.--The members of the Panel 
        shall serve for the life of the Panel.
          ``(3) 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.
  ``(d) Procedures.--
          ``(1) Meetings.--The Panel shall meet at the call of 
        a majority of its members.
          ``(2) First meeting.--The Panel shall convene not 
        later than 60 days after the date of the enactment of 
        the Health Care Quality and Choice Act of 1999.
          ``(3) Quorum.--A quorum shall consist of a majority 
        of the members of the Panel.
          ``(4) 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.
  ``(e) Administration.--
          ``(1) Compensation.--Except as provided in paragraph 
        (1), members of the Panel shall receive no additional 
        pay, allowances, or benefits by reason of their service 
        on the Panel.
          ``(2) 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.
          ``(3) 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).
          ``(4) 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.
          ``(5) 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.
  ``(f) Report and Establishment of Standards.--Not later than 
2 years after the first meeting, the Panel shall submit a 
report to Congress and the Secretary of Health and Human 
Services detailing the standards devised under subsection (b) 
and recommendations regarding the implementation of such 
standards. Such standards shall take effect to the extent 
provided by Federal law enacted after the date of the 
submission of such report.
  ``(g) Termination.--The Panel shall terminate on the day 
after submitting its report to the Secretary of Health and 
Human Services under subsection (f).

``SEC. 819. ACCESS TO EXPERIMENTAL OR INVESTIGATIONAL PRESCRIPTION 
                    DRUGS.

  ``No use of a prescription drug or medical device shall be 
considered experimental or investigational under a group health 
plan or under health insurance coverage provided by a health 
insurance issuer in connection with such a plan if such use is 
included in the labeling authorized by the U.S. Food and Drug 
Administration under section 505, 513 or 515 of the Federal 
Food, Drug, and Cosmetic Act (21 U.S.C. 355) or under section 
351 of the Public Health Service Act (42 U.S.C. 262), unless 
such use is demonstrated to be unsafe or ineffective.

``SEC. 820. COVERAGE FOR INDIVIDUALS PARTICIPATING IN APPROVED CANCER 
                    CLINICAL TRIALS.

  ``(a) Coverage.--
          ``(1) In general.--If a group health plan (or a 
        health insurance issuer offering health insurance 
        coverage in connection with such a plan) 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 subsections (b), (c), and 
                (d), 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 individual'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 who meets the following conditions:
          ``(1)(A) The individual has been diagnosed with 
        cancer.
          ``(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 individual 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 offering health 
        insurance) 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 to be paid for by the sponsors 
        of an approved clinical trial.
          ``(2) Routine patient care costs.--For purposes of 
        this section--
                  ``(A) In general.--The term `routine patient 
                care costs' includes the costs associated with 
                the provision of items and services that--
                          ``(i) would otherwise be covered 
                        under the group health plan if such 
                        items and services were not provided in 
                        connection with an approved clinical 
                        trial program; and
                          ``(ii) are furnished according to the 
                        protocol of an approved clinical trial 
                        program.
                  ``(B) Exclusion.--Such term does include the 
                costs associated with the provision of--
                          ``(i) an investigational drug or 
                        device, unless the Secretary has 
                        authorized the manufacturer of such 
                        drug or device to charge for such drug 
                        or device; or
                          ``(ii) any item or service supplied 
                        without charge by the sponsor of the 
                        approved clinical trial program.
          ``(3) 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 items 
                or services under subparagraph (A).
  ``(d) Approved Clinical Trial Defined.--In this section, the 
term `approved clinical trial' means a cancer clinical research 
study or cancer clinical investigation approved by an 
Institutional Review Board.
  ``(e) Construction.--Nothing in this section shall be 
construed to limit a plan's or issuer's coverage with respect 
to clinical trials.
  ``(f) Plan Satisfaction of Certain Requirements; 
Responsibilities of Fiduciaries.--
          ``(1) In general.--For purposes of this section, 
        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 requirements of this section 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.
          ``(2) Construction.--Nothing in this section shall be 
        construed to affect or modify the responsibilities of 
        the fiduciaries of a group health plan under part 4 of 
        subtitle B.

                   ``Subpart C--Access to Information


``SEC. 821. 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);
                  ``(B) provide to participants and 
                beneficiaries, within a reasonable period (as 
                specified by the Secretary) before or after the 
                date of significant changes in the information 
                described in subsection (b), information on 
                such significant changes; and
                  ``(C) upon request, make available to 
                participants and beneficiaries, the Secretary, 
                and prospective participants and beneficiaries, 
                the information described in subsection (b) or 
                (c).
        The plan may charge a reasonable fee for provision in 
        printed form of any of the information described in 
        subsection (b) or (c) more than once during any plan 
        year.
          ``(2) Health insurance issuers.--A health insurance 
        issuer in connection with the provision of health 
        insurance coverage in connection with a group health 
        plan shall--
                  ``(A) provide to participants and 
                beneficiaries enrolled under such coverage at 
                the time of enrollment, and at least annually 
                thereafter, the information described in 
                subsection (b);
                  ``(B) provide to such participants and 
                beneficiaries, within a reasonable period (as 
                specified by the 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 
                Secretary, to individuals who are prospective 
                participants and beneficiaries, and to the 
                public the information described in subsection 
                (b) or (c).
          ``(3) Employers.--Effective 5 years after the date 
        this part first becomes effective, each employer (other 
        than an employer described in paragraph (1) of 
        subsection (d)) shall provide to each employee at least 
        annually information (consistent with such subsection) 
        on the amount that the employer contributes on behalf 
        of the employee (and any dependents of the employee) 
        for health benefits coverage.
  ``(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 shall 
be provided to a participant or beneficiary free of charge at 
least once a year and 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) those that are covered benefits ``(all 
                of which shall be referred to by such relevant 
                CPT and DRG codes as are available), limits and 
                conditions on such benefits, and those benefits 
                that are explicitly excluded from coverage (all 
                of which shall be referred to by such relevant 
                CPT and DRG codes as are available);
                  ``(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 or 
                beneficiary 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 and 
                beneficiaries 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 812(b)(2).
          ``(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) Prior authorization rules.--Rules regarding 
        prior authorization or other review requirements that 
        could result in noncoverage or nonpayment.
          ``(7) 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.
          ``(8) Accountability.--A description of the legal 
        recourse options available for participants and 
        beneficiaries under the plan including--
                  ``(A) the preemption that applies under 
                section 514 to certain actions arising out of 
                the provision of health benefits; and
                  ``(B) the extent to which coverage decisions 
                made by the plan are subject to internal review 
                or any external review and the proper time 
                frames under
          ``(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 and beneficiaries in seeking information 
        or authorization for treatment.
          ``(11) 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 801.
          ``(2) Grievance and appeals information.--Information 
        on the number of grievances and appeals and on the 
        disposition in the aggregate of such matters.
          ``(3) Formulary restrictions.--A description of the 
        nature of any drug formula restrictions.
          ``(4) Participating provider list.--A list of current 
        participating health care providers.
  ``(d) Employer Information.--
          ``(1) Small employer exemption.--Subsection (a)(3) 
        shall not apply to an employer that is a small employer 
        (as defined in section 712(c)(1)(B)) or would be such 
        an employer if `100' were substituted for `50' in such 
        section.
          ``(2) Computation.--The amount described in 
        subsection (a)(3) may be computed on an average, per 
        employee basis, and may be based on rules similar to 
        the rules applied in computing the applicable premium 
        under section 604.
          ``(3) Form of disclosure.--The information under 
        subsection (a)(3) may be provided in any reasonable 
        form, including as part of the summary plan 
        description, a letter, or information accompanying a W-
        2 form.
  ``(e) 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.

        ``Subpart D--Protecting the Doctor-Patient Relationship


``SEC. 831. 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 offered in connection 
with such a plan (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 or 
beneficiary 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. 832. PROHIBITION OF DISCRIMINATION AGAINST PROVIDERS BASED ON 
                    LICENSURE.

  ``(a) In General.--A group health plan and a health insurance 
issuer offering health insurance coverage in connection with 
such a plan 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 or beneficiaries 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;
          ``(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; or
          ``(4) as prohibiting a family practice physician with 
        appropriate expertise from providing pediatric or 
        obstetrical or gynecological care.

``SEC. 833. PROHIBITION AGAINST IMPROPER INCENTIVE ARRANGEMENTS.

  ``(a) In General.--A group health plan and a health insurance 
issuer offering health insurance coverage in connection with 
such a plan 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 or 
beneficiary 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. 834. PAYMENT OF CLEAN 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 or beneficiary 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 or beneficiary as well as claims referred to 
in such subparagraph.

                        ``Subpart E--Definitions


``SEC. 841. DEFINITIONS.

  ``(a) Incorporation of General Definitions.--Except as 
otherwise provided, the provisions of section 733 shall apply 
for purposes of this part in the same manner as they apply for 
purposes of part 7.
  ``(b) Additional Definitions.--For purposes of this part:
          ``(1) Applicable authority.--The term `applicable 
        authority' means--
                  ``(A) in the case of a group health plan, the 
                Secretary of Labor; and
                  ``(B) in the case of a health insurance 
                issuer with respect to a specific provision of 
                this part, the applicable State authority (as 
                defined in section 2791(d) of the Public Health 
                Service Act), or the Secretary of Health and 
                Human Services, if such Secretary is enforcing 
                such provision under section 2722(a)(2) or 
                2761(a)(2) of the Public Health Service Act.
          ``(2) Clinical peer.--The term `clinical peer' means, 
        with respect to a review or appeal, a practicing 
        physician or other health care professional who holds a 
        nonrestricted license and who is--
                  ``(A) appropriately certified by a nationally 
                recognized, peer reviewed accrediting body in 
                the same or similar specialty as typically 
                manages the medical condition, procedure, or 
                treatment under review or appeal, or
                  ``(B) is trained and experienced in managing 
                such condition, procedure, or treatment,
        and includes a pediatric specialist where appropriate; 
        except that only a physician may be a clinical peer 
        with respect to the review or appeal of treatment 
        recommended or rendered by a physician.
          ``(3) 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.
          ``(4) 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.
          ``(5) 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 or beneficiaries.
          ``(6) Nonparticipating.--The term `nonparticipating' 
        means, with respect to a health care provider that 
        provides health care items and services to a 
        participant or beneficiary 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.
          ``(7) Participating.--The term `participating' means, 
        with respect to a health care provider that provides 
        health care items and services to a participant or 
        beneficiary under group health plan or health insurance 
        coverage offered by a health insurance issuer in 
        connection with such a plan, a health care provider 
        that furnishes such items and services under a contract 
        or other arrangement with the plan or issuer.
          ``(8) Physician.--The term `physician' means an 
        allopathic or osteopathic physician.
          ``(9) Practicing physician.--The term `practicing 
        physician' means a physician who is licensed in the 
        State in which the physician furnishes professional 
        services and who provides professional services to 
        individual patients on average at least two full days 
        per week.
          ``(10) 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. 842. RULE OF CONSTRUCTION.

  ``Nothing in this part or section 714 shall be construed to 
affect or modify the provisions of section 514.

``SEC. 843. EXCLUSIONS.

  ``(a) No Benefit Requirements.--Nothing in this part shall be 
construed to require a group health plan or a health insurance 
issuer offering health insurance coverage in connection with 
such a plan to provide specific benefits under the terms of 
such plan or coverage, other than those provided under the 
terms of such plan or coverage.
  ``(b) Exclusion for Fee-for-Service Coverage.--
          ``(1) In general.--
                  ``(A) Group health plans.--The provisions of 
                sections 811 through 821 shall not apply to a 
                group health plan if the only coverage offered 
                under the plan is fee-for-service coverage (as 
                defined in paragraph (2)).
                  ``(B) Health insurance coverage.--The 
                provisions of sections 801 through 821 shall 
                not apply to health insurance coverage if the 
                only coverage offered under the 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 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) allows access to any provider that is 
                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
                  ``(D) for which the plan or issuer does not 
                require prior authorization before providing 
                for any health care services.

``SEC. 844. COVERAGE OF LIMITED SCOPE PLANS.

  ``Only for purposes of applying the requirements of this part 
under section 714, section 733(c)(2)(A) shall be deemed not to 
apply.

``SEC. 845. REGULATIONS.

  ``(a) Regulations.--The Secretary of Labor shall issue such 
regulations as may be necessary or appropriate to carry out 
this part under section 714. The Secretary may promulgate such 
regulations in the form of interim final rules as may be 
necessary to carry out this part in a timely manner.''.
  (b) Clerical Amendment.--The table of contents in section 1 
of the Employee Retirement Income Security Act of 1974 is 
amended by inserting after the item relating to section 734 the 
following new items:

                    ``Part 8--Improving Managed Care

                   ``Subpart A--Grievance and Appeals

``Sec. 801. Utilization review activities.
``Sec. 802. Internal appeals procedures.
``Sec. 803. External appeals procedures.
``Sec. 804. Establishment of a grievance process.

                       ``Subpart B--Access to Care

``Sec. 812. Choice of health care professional.
``Sec. 813. Access to emergency care.
``Sec. 814. Access to specialty care.
``Sec. 815. Access to obstetrical and gynecological care.
``Sec. 816. Access to pediatric care.
``Sec. 817. Continuity of care.
``Sec. 818. Network adequacy.
``Sec. 819. Access to experimental or investigational prescription 
          drugs.
``Sec. 820. Coverage for individuals participating in approved cancer 
          clinical trials.

                   ``Subpart C--Access to Information

``Sec. 821. Patient access to information.

         ``Subpart D--Protecting the Doctor-Patient Relationship

``Sec. 831. Prohibition of interference with certain medical 
          communications.
``Sec. 832. Prohibition of discrimination against providers based on 
          licensure.
``Sec. 833. Prohibition against improper incentive arrangements.
``Sec. 834. Payment of clean claims.

                        ``Subpart E--Definitions

``Sec. 841. Definitions.
``Sec. 842. Preemption; State flexibility; construction.
``Sec. 843. Exclusions.
``Sec. 844. Coverage of limited scope plans.
``Sec. 845. Regulations.

SEC. 203. AVAILABILITY OF COURT REMEDIES.

  (a) In General.--Section 502 of the Employee Retirement 
Income Security Act of 1974 (29 U.S.C. 1132) is amended by 
adding at the end the following new subsection:
  ``(n) Cause of Action Relating to Provision of Health 
Benefits.--
          ``(1) In general.--In any case in which--
                  ``(A) a person who is a fiduciary of a group 
                health plan, a health insurance issuer offering 
                health insurance coverage in connection with 
                the plan, or an agent of the plan or plan 
                sponsor (not including a participating 
                physician, other than a physician who 
                participated in making the final decision under 
                section 802 pursuant to section 802(b)(1)(A)) 
                and who, under the plan, has authority to make 
                final decisions under 802--
                          ``(i) fails to exercise ordinary care 
                        in making an incorrect determination in 
                        the case of a participant or 
                        beneficiary that an item or service is 
                        excluded from coverage under the terms 
                        of the plan based on the fact that the 
                        item or service--
                                  ``(I) does not meet the 
                                requirements for medical 
                                appropriateness or necessity,
                                  ``(II) would constitute 
                                experimental treatment or 
                                technology (as defined under 
                                the plan), or
                                  ``(III) is not a covered 
                                benefit, or
                          ``(ii) fails to exercise ordinary 
                        care to ensure that--
                                  ``(I) any denial of claim for 
                                benefits (within the meaning of 
                                section 801(f)), or
                                  ``(II) any decision by the 
                                plan on a request, made by a 
                                participant or beneficiary 
                                under section 802 or 803, for a 
                                reversal of an earlier decision 
                                of the plan,
                        is made and issued to the participant 
                        or beneficiary (in such form and manner 
                        as may be prescribed in regulations of 
                        the Secretary) before the end of the 
                        applicable period specified in section 
                        801, 802, or 803, and
                  ``(B) such failure is the proximate cause of 
                substantial harm to, or wrongful death of, the 
                participant or beneficiary,
        such person shall be liable to the participant or 
        beneficiary (or the estate of such participant or 
        beneficiary) for economic and noneconomic damages in 
        connection with such failure and such injury or death 
        (subject to paragraph (10)). For purposes of this 
        subsection, the term `final decision' means, with 
        respect to a group health plan, the sole final decision 
        of the plan under section 802.
          ``(2) Ordinary care.--For purposes of this 
        subsection, the term `ordinary care' means the care, 
        skill, prudence, and diligence under the circumstances 
        then prevailing that a prudent individual acting in a 
        like capacity and familiar with such matters would use 
        in the conduct of an enterprise of a like character and 
        with like aims.
          ``(3) Substantial harm.--The term `substantial harm' 
        means loss of life, loss or significant impairment of 
        limb or bodily function, significant disfigurement, or 
        severe and chronic physical pain.
          ``(4) Exception for employers and other plan 
        sponsors.--
                  ``(A) In general.--Subject to subparagraph 
                (B), paragraph (1) does not authorize--
                          ``(i) any cause of action against an 
                        employer or other plan sponsor 
                        maintaining the group health plan (or 
                        against an employee of such an employer 
                        or sponsor acting within the scope of 
                        employment),
                          ``(ii) a right of recovery or 
                        indemnity by a person against an 
                        employer or other plan sponsor (or such 
                        an employee) for damages assessed 
                        against the person pursuant to a cause 
                        of action under paragraph (1), or
                          ``(iii) any cause of action in 
                        connection with the provision of 
                        excepted benefits described in section 
                        733(c), other than those described in 
                        section 733(c)(2).
                  ``(B) Special rule.--Subparagraph (A) shall 
                not preclude any cause of action described in 
                paragraph (1) commenced against an employer or 
                other plan sponsor (or against an employee of 
                such an employer or sponsor acting within the 
                scope of employment), but only if--
                          ``(i) such action is based on the 
                        direct participation of the employer or 
                        other plan sponsor (or employee of the 
                        employer or plan sponsor) in the final 
                        decision of the plan with respect to a 
                        specific participant or beneficiary on 
                        a claim for benefits covered under the 
                        plan or health insurance coverage in 
                        the case at issue; and
                          ``(ii) the decision on the claim 
                        resulted in substantial harm to, or the 
                        wrongful death of, such participant or 
                        beneficiary.
                  ``(C) Direct participation.--For purposes of 
                this subsection, the term `direct 
                participation' means, in connection with a 
                final decision under section 802, the actual 
                making of such final decision as a plan 
                fiduciary or the actual exercise of final 
                controlling authority in the approval of such 
                final decision. In determining whether an 
                employer or other plan sponsor (or employee of 
                an employer or other plan sponsor) is engaged 
                in direct participation in the final decision 
                of the plan on a claim, the employer or plan 
                sponsor (or employee) shall not be construed to 
                be engaged in such direct participation (and to 
                be liable for any damages whatsoever) because 
                of any form of decisionmaking or other conduct, 
                whether or not fiduciary in nature, that does 
                not involve a final decision with respect to a 
                specific claim for benefits by a specific 
                participant or beneficiary, including (but not 
                limited to)--
                          ``(i) any participation by the 
                        employer or other plan sponsor (or 
                        employee) in the selection of the group 
                        health plan or health insurance 
                        coverage involved or the third party 
                        administrator or other agent;
                          ``(ii) any engagement by the employer 
                        or other plan sponsor (or employee) in 
                        any cost-benefit analysis undertaken in 
                        connection with the selection of, or 
                        continued maintenance of, the plan or 
                        coverage involved;
                          ``(iii) any participation by the 
                        employer or other plan sponsor (or 
                        employee) in the creation, 
                        continuation, modification, or 
                        termination of the plan or of any 
                        coverage, benefit, or item or service 
                        covered by the plan;
                          ``(iv) any participation by the 
                        employer or other plan sponsor (or 
                        employee) in the design of any 
                        coverage, benefit, or item or service 
                        covered by the plan, including the 
                        amount of copayment and limits 
                        connected with such coverage, and the 
                        specification of any protocol, 
                        procedure, or policy for determining 
                        whether any such coverage, benefit, or 
                        item or service is medically necessary 
                        and appropriate or is experimental or 
                        investigational;
                          ``(v) any action by an agent of the 
                        employer or plan sponsor in making such 
                        a final decision on behalf of such 
                        employer or plan sponsor;
                          ``(vi) any decision by an employer or 
                        plan sponsor (or employee) or agent 
                        acting on behalf of an employer or plan 
                        sponsor either to authorize coverage 
                        for, or to intercede or not to 
                        intercede as an advocate for or on 
                        behalf of, any specific participant or 
                        beneficiary (or group of participants 
                        or beneficiaries) under the plan;
                          ``(vii) the approval of, or 
                        participation in the approval of, the 
                        plan provisions defining medical 
                        necessity or of policies or procedures 
                        that have a direct bearing on the 
                        outcome of the final decision; or
                          ``(viii) any other form of 
                        decisionmaking or other conduct 
                        performed by the employer or other plan 
                        sponsor (or employee) in connection 
                        with the plan or coverage involved 
                        unless it involves the making of a 
                        final decision of the plan consisting 
                        of a failure described in clause (i) or 
                        (ii) of paragraph (1)(A) as to specific 
                        participants or beneficiaries who 
                        suffer substantial harm or wrongful 
                        death as a proximate cause of such 
                        decision.
          ``(5) Required demonstration of direct 
        participation.--An action against an employer or plan 
        sponsor (or employee thereof) under this subsection 
        shall be immediately dismissed--
                  ``(A) in the absence of an allegation in the 
                complaint of direct participation by the 
                employer or plan sponsor in the final decision 
                of the plan with respect to a specific 
                participant or beneficiary who suffers 
                substantial harm or wrongful death, or
                  ``(B) upon a demonstration to the court that 
                such employer or plan sponsor (or employee) did 
                not directly participate in the final decision 
                of the plan.
          ``(6) Treatment of third-party providers of 
        nondiscretionary administrative services.--Paragraph 
        (1) does not authorize any action against any person 
        providing nondiscretionary administrative services to 
        employers or other plan sponsors.
          ``(7) Requirement of exhaustion of administrative 
        remedies.--
                  ``(A) In general.--Paragraph (1) applies in 
                the case of any cause of action only if all 
                remedies under section 503 (including remedies 
                under sections 802 and 803, made applicable 
                under section 714) with respect to such cause 
                of action have been exhausted.
                  ``(B) External review required.--For purposes 
                of subparagraph (A), administrative remedies 
                under section 503 shall not be deemed exhausted 
                until available remedies under section 803 have 
                been elected and are exhausted by issuance of a 
                final determination by an external appeal 
                entity under such section.
                  ``(C) Consideration of administrative 
                determinations.--Any determinations made under 
                section 802 or 803 made while an action under 
                this paragraph is pending shall be given due 
                consideration by the court in such action.
          ``(8) Use of external appeal entity in establishing 
        absence of substantial harm or causation in 
        litigation.--
                  ``(A) In general.--In any action under this 
                subsection by an individual in which damages 
                are sought on the basis of substantial harm to 
                the individual, the defendant may obtain (at 
                its own expense), under procedures similar to 
                procedures applicable under section 803, a 
                determination by a qualified external appeal 
                entity (as defined in section 803(c)(1)) that 
                has not been involved in any stage of the 
                grievance or appeals process which resulted in 
                such action as to--
                          ``(i) whether such substantial harm 
                        has been sustained, and
                          ``(ii) whether the proximate cause of 
                        such injury was the result of the 
                        failure of the defendant to exercise 
                        ordinary care, as described in 
                        paragraph (1)(A).
                  ``(B) Effect of finding in favor of 
                defendant.--If the external appeal entity 
                determines that such an injury has not been 
                sustained or was not proximately caused by such 
                a failure, such a finding shall be an 
                affirmative defense, and the action shall be 
                dismissed forthwith unless such finding is 
                overcome upon a showing of clear and convincing 
                evidence to the contrary. Notwithstanding 
                subsection (g), in any case in which the 
                plaintiff fails in any attempt to make such a 
                showing to the contrary, the court shall award 
                to the defendant reasonable attorney's fees and 
                the costs of the action incurred in connection 
                with such failed showing.
          ``(9) Rebuttable presumption.--In the case of any 
        action commenced pursuant to paragraph (1), there shall 
        be a rebuttable presumption in favor of the decision of 
        the external appeal entity rendered upon completion of 
        any review elected under section 803 and such 
        presumption may be overcome only upon a showing of 
        clear and convincing evidence to the contrary.
          ``(10) Maximum noneconomic damages.--Total liability 
        for noneconomic loss under this subsection in 
        connection with any failure with respect to any 
        participant or beneficiary may not exceed the lesser 
        of--
                  ``(A) $500,000, or
                  ``(B) 2 times the amount of economic loss.
        The dollar amount under subparagraph (A), shall be 
        increased or decreased, for each calendar year that 
        ends after December 31, 2001, by the same percentage as 
        the percentage by which the medical care expenditure 
        category of the Consumer Price Index for All Urban 
        Consumers (United States city average), published by 
        the Bureau of Labor Statistics, for September of the 
        preceding calendar year has increased or decreased from 
        such index for September 2000
          ``(11) Prohibition of award of punitive damages.--
                  ``(A) General rule.--Except as provided in 
                this paragraph, nothing in this subsection 
                shall be construed as authorizing a cause of 
                action for punitive, exemplary, or similar 
                damages.
                  ``(B) Exception.--Punitive damages are 
                authorized in any case described in paragraph 
                (1)(A)(ii)(II) in which the plaintiff 
                establishes by clear and convincing evidence 
                that conduct carried out by the defendant with 
                a conscious, flagrant indifference to the 
                rights or safety of others was the proximate 
                cause of the harm that is the subject of the 
                action and that such conduct was contrary to 
                the recommendations of an external appeal 
                entity issued in the determination in such case 
                rendered pursuant to section 803.
                  ``(C) Limitation on amount.--
                          ``(i) In general.--The amount of 
                        punitive damages that may be awarded in 
                        an action described in subparagraph (B) 
                        may not exceed the greater of--
                                  ``(I) 2 times the sum of the 
                                amount awarded to the claimant 
                                for economic loss; or
                                  ``(II) $250,000.
                          ``(ii) Special rule.--Notwithstanding 
                        clause (i), in any action described in 
                        subparagraph (B) against an individual 
                        whose net worth does not exceed 
                        $500,000 or against an owner of an 
                        unincorporated business, or any 
                        partnership, corporation, association, 
                        unit of local government, or 
                        organization which has fewer that 25 
                        employees, the punitive damages shall 
                        not exceed the lesser of--
                                  ``(I) 2 times the amount 
                                awarded to the claimant for 
                                economic loss; or
                                  ``(II) $250,000.
                          ``(iii) Controlled groups.--
                                  ``(I) In general.--For the 
                                purpose of determining the 
                                applicability of clause (ii) to 
                                any employer, in determining 
                                the number of employees of an 
                                employer who is a member of a 
                                controlled group, the employees 
                                of any person in such group 
                                shall be deemed to be employees 
                                of the employer.
                                  ``(II) Controlled group.--For 
                                purposes of subclause (I), the 
                                term `controlled group' means 
                                any group treated as a single 
                                employer under subsection (b), 
                                (c), (m), or (o) of section 414 
                                of the Internal Revenue Code of 
                                1986.
                  ``(D) Exception for insufficient award in 
                cases of egregious conduct.--
                          ``(i) Determination by court.--If the 
                        court makes a determination, based on 
                        clear and convincing evidence and after 
                        considering each of the factors in 
                        subparagraph (E), that the application 
                        of subparagraph (C) would result in an 
                        award of punitive damages that is 
                        insufficient to punish the egregious 
                        conduct of the defendant against whom 
                        the punitive damages are to be awarded 
                        or to deter such conduct in the future, 
                        the court shall determine the 
                        additional amount of punitive damages 
                        (referred to in this subparagraph as 
                        the `additional amount') in excess of 
                        the amount determined in accordance 
                        with subparagraph (C) to be awarded 
                        against the defendant in a separate 
                        proceeding in accordance with this 
                        subparagraph.
                          ``(ii) Absolute limit on punitives.--
                        Nothing in this subtitle shall be 
                        construed to authorize the court to 
                        award an additional amount greater than 
                        an amount equal to the maximum amount 
                        applicable under subparagraph (C).
                          ``(iii) Requirements for awarding 
                        additional amount.--If the court awards 
                        an additional amount pursuant to this 
                        subparagraph, the court shall state its 
                        reasons for setting the amount of the 
                        additional amount in findings of fact 
                        and conclusions of law.
                  ``(E) Factors for consideration in cases of 
                egregious conduct.--In any proceeding under 
                subparagraph (D), the matters to be considered 
                by the court shall include (but are not limited 
                to)--
                          ``(i) the extent to which the 
                        defendant acted with actual malice;
                          ``(ii) the likelihood that serious 
                        harm would arise from the conduct of 
                        the defendant;
                          ``(iii) the degree of the awareness 
                        of the defendant of that likelihood;
                          ``(iv) the profitability of the 
                        misconduct to the defendant;
                          ``(v) the duration of the misconduct 
                        and any concurrent or subsequent 
                        concealment of the conduct by the 
                        defendant;
                          ``(vi) the attitude and conduct of 
                        the defendant upon the discovery of the 
                        misconduct and whether the misconduct 
                        has terminated;
                          ``(vii) the financial condition of 
                        the defendant; and
                          ``(viii) the cumulative deterrent 
                        effect of other losses, damages, and 
                        punishment suffered by the defendant as 
                        a result of the misconduct, reducing 
                        the amount of punitive damages on the 
                        basis of the economic impact and 
                        severity of all measures to which the 
                        defendant has been or may be subjected, 
                        including--
                                  ``(I) compensatory and 
                                punitive damage awards to 
                                similarly situated claimants;
                                  ``(II) the adverse economic 
                                effect of stigma or loss of 
                                reputation;
                                  ``(III) civil fines and 
                                criminal and administrative 
                                penalties; and
                                  ``(IV) stop sale, cease and 
                                desist, and other remedial or 
                                enforcement orders.
                  ``(F) Application by court.--This paragraph 
                shall be applied by the court and, in the case 
                of a trial by jury, application of this 
                paragraph shall not be disclosed to the jury.
                  ``(G) Limitation on punitive damages.--No 
                person shall be liable for punitive, exemplary, 
                or similar damages in an action under this 
                subsection based on any failure described in 
                paragraph (1) if such failure was in compliance 
                with the recommendations of an external appeal 
                entity issued in a determination under section 
                803.
                  ``(H) Bifurcation at request of any party.--
                          ``(i) In general.--At the request of 
                        any party the trier of fact in any 
                        action that is subject to this 
                        paragraph shall consider in a separate 
                        proceeding, held subsequent to the 
                        determination of the amount of 
                        compensatory damages, whether punitive 
                        damages are to be awarded for the harm 
                        that is the subject of the action and 
                        the amount of the award.
                          ``(ii) Inadmissibility of evidence 
                        relative only to a claim of punitive 
                        damages in a proceeding concerning 
                        compensatory damages.--If any party 
                        requests a separate proceeding under 
                        clause (i), in a proceeding to 
                        determine whether the claimant may be 
                        awarded compensatory damages, any 
                        evidence, argument, or contention that 
                        is relevant only to the claim of 
                        punitive damages, as determined by 
                        applicable State law, shall be 
                        inadmissible.
          ``(12) Limitation of action.--Paragraph (1) shall not 
        apply in connection with any action commenced after the 
        later of--
                  ``(A) 1 year after (i) the date of the last 
                action which constituted a part of the failure, 
                or (ii) in the case of an omission, the latest 
                date on which the fiduciary could have cured 
                the failure, or
                  ``(B) 1 year after the earliest date on which 
                the plaintiff first knew, or reasonably should 
                have known, of the substantial harm resulting 
                from the failure.
          ``(13) Coordination with fiduciary requirements.--A 
        fiduciary shall not be treated as failing to meet any 
        requirement of part 4 solely by reason of any action 
        taken by a fiduciary which consists of full compliance 
        with the reversal under section 803 of a denial of 
        claim for benefits (within the meaning of section 
        801(f)).
          ``(14) Construction.--Nothing in this subsection 
        shall be construed as authorizing a cause of action for 
        the failure to provide an item or service which is not 
        covered under the group health plan involved.
          ``(15) Protection of medical malpractice and similar 
        actions under state law.--This subsection shall not be 
        construed to preclude any action under State law (as 
        defined in section 514(c)(1)) not otherwise preempted 
        under this title with respect to the duty (if any) 
        under such State law imposed on any person to exercise 
        a specified standard of care when making a health care 
        treatment decision in any case in which medical 
        services are provided by such person or in any case in 
        which such decision affects the quality of care or 
        treatment provided or received.
          ``(16) Coexisting actions in federal and state courts 
        disallowed.--
                  ``(A) Precedence of federal action.--An 
                action may be commenced under this subsection 
                only if no action for damages has been 
                commenced by the plaintiff under State law (as 
                defined in section 514(c)(1)) based on the same 
                substantial harm.
                  ``(B) Actions under state law superseded.--
                Upon the commencement of any action under this 
                subsection, this subsection supersedes any 
                action authorized under State law (as so 
                defined) against any person based on the same 
                substantial harm during the pendency of the 
                action commenced under this subsection.
                  ``(C) Double recovery of damages precluded.--
                This subsection supersedes any action under 
                State law (as so defined) for damages based on 
                any substantial harm to the extent that damages 
                for such substantial harm have been recovered 
                in an action under this subsection.
          ``(17) Limitation on relief where defendant's 
        position previously supported upon external review.--In 
        any case in which the court finds the defendant to be 
        liable in an action under this subsection, to the 
        extent that such liability is based on a finding by the 
        court of a particular failure described in paragraph 
        (1) and such finding is contrary to a determination by 
        an external review entity in a decision previously 
        rendered under section 803 with respect to such 
        defendant, no relief shall be available under this 
        subsection in addition to the relief otherwise 
        available under subsection (a)(1)(B).''.
  (b) Conforming Amendment.--Section 502(a)(1)(A) of such Act 
(29 U.S.C. 1132(a)(1)(A)) is amended by inserting ``or (n)'' 
after ``subsection (c)''.
  (c) Effective Date.--The amendments made by this section 
shall apply to acts and omissions (from which a cause of action 
arises) occurring on or after the date of the enactment of this 
Act.

SEC. 204. AVAILABILITY OF BINDING ARBITRATION.

  (a) In General.--Section 503 of the Employee Retirement 
Income Security Act of 1974 (as amended by the preceding 
provisions of this Act) is amended further--
          (1) in subsection (a), by inserting ``In General.--'' 
        after ``(a)'';
          (2) in subsection (b), by striking ``(b) In the 
        case'' and inserting the following:
  ``(b) Group Health Plans.--
          ``(1) In general.--In the case''; and
          (3) by adding at the end of subsection (b) the 
        following:
          ``(2) Binding arbitration permitted as alternative 
        means of dispute resolution.--
                  ``(A) In general.--A group health plan shall 
                not be treated as failing to meet the 
                requirements of the preceding provisions of 
                this section relating to review of any adverse 
                coverage decision rendered by or under the 
                plan, if--
                          ``(i) in lieu of the procedures 
                        otherwise provided under the plan in 
                        accordance with such provisions and in 
                        lieu of any subsequent review of the 
                        matter by a court under section 502--
                                  ``(I) the aggrieved 
                                participant or beneficiary 
                                elects in the request for the 
                                review a procedure by which the 
                                dispute is resolved by binding 
                                arbitration which is available 
                                under the plan with respect to 
                                similarly situated participants 
                                and beneficiaries and which 
                                meets the requirements of 
                                subparagraph (B); or
                                  ``(II) in the case of any 
                                such plan or portion thereof 
                                which is established and 
                                maintained pursuant to a bona 
                                fide collective bargaining 
                                agreement, the plan provides 
                                for a procedure by which such 
                                disputes are resolved by means 
                                of binding arbitration which 
                                meets the requirements of 
                                subparagraph (B); and
                          ``(ii) the additional requirements of 
                        subparagraph (B) are met.
                  ``(B) Additional requirements.--The Secretary 
                shall prescribe by regulation requirements for 
                arbitration procedures under this paragraph, 
                including at least the following requirements:
                          ``(i) Arbitration panel.--The 
                        arbitration shall be conducted by an 
                        arbitration panel meeting the 
                        requirements of subparagraph (C).
                          ``(ii) Fair process; de novo 
                        determination.--The procedure shall 
                        provide for a fair, de novo 
                        determination.
                          ``(iii) Opportunity to submit 
                        evidence, have representation, and make 
                        oral presentation.--Each party to the 
                        arbitration procedure--
                                  ``(I) may submit and review 
                                evidence related to the issues 
                                in dispute;
                                  ``(II) may use the assistance 
                                or representation of one or 
                                more individuals (any of whom 
                                may be an attorney); and
                                  ``(III) may make an oral 
                                presentation.
                          ``(iv) Provision of information.--The 
                        plan shall provide timely access to all 
                        its records relating to the matters 
                        under arbitration and to all provisions 
                        of the plan relating to such matters.
                          ``(v) Timely decisions.--A 
                        determination by the arbitration panel 
                        on the decision shall--
                                  ``(I) be made in writing;
                                  ``(II) be binding on the 
                                parties; and
                                  ``(III) be made in accordance 
                                with the medical exigencies of 
                                the case involved.
                          ``(vi) Exhaustion of external review 
                        required.--The arbitration procedures 
                        under this paragraph shall not be 
                        available to party unless the party has 
                        exhausted external review procedures 
                        under section 804.
                          ``(vii) Voluntary election.--A group 
                        health plan may not require, through 
                        the plan document, a contract, or 
                        otherwise, that a participant or 
                        beneficiary make the election described 
                        in subparagraph (A)(i)(I).
                  ``(C) Arbitration panel.--
                          ``(i) In general.--Arbitrations 
                        commenced pursuant to this paragraph 
                        shall be conducted by a panel of 
                        arbitrators selected by the parties 
                        made up of 3 individuals, including at 
                        least one practicing physician and one 
                        practicing attorney.
                          ``(ii) Qualifications.--Any 
                        individual who is a member of an 
                        arbitration panel shall meet the 
                        following requirements:
                                  ``(I) There is no real or 
                                apparent conflict of interest 
                                that would impede the 
                                individual conducting 
                                arbitration independent of the 
                                plan and meets the independence 
                                requirements of clause (iii).
                                  ``(II) The individual has 
                                sufficient medical or legal 
                                expertise to conduct the 
                                arbitration for the plan on a 
                                timely basis.
                                  ``(III) The individual has 
                                appropriate credentials and has 
                                attained recognized expertise 
                                in the applicable medical or 
                                legal field.
                                  ``(IV) The individual was not 
                                involved in the initial adverse 
                                coverage decision or any other 
                                review thereof.
                          ``(iii) Independence requirements.--
                        An individual described in clause (ii) 
                        meets the independence requirements of 
                        this clause if--
                                  ``(I) the individual is not 
                                affiliated with any related 
                                party,
                                  ``(II) any compensation 
                                received by such individual in 
                                connection with the binding 
                                arbitration procedure is 
                                reasonable and not contingent 
                                on any decision rendered by the 
                                individual,
                                  ``(III) under the terms of 
                                the plan, the plan has no 
                                recourse against the individual 
                                or entity in connection with 
                                the binding arbitration 
                                procedure, and
                                  ``(IV) the individual does 
                                not otherwise have a conflict 
                                of interest with a related 
                                party as determined under such 
                                regulations as the Secretary 
                                may prescribe.
                          ``(iv) Related party.--For purposes 
                        of clause (iii), the term `related 
                        party' means--
                                  ``(I) the plan or any health 
                                insurance issuer offering 
                                health insurance coverage in 
                                connection with the plan (or 
                                any officer, director, or 
                                management employee of such 
                                plan or issuer),
                                  ``(II) the physician or other 
                                medical care provider that 
                                provided the medical care 
                                involved in the coverage 
                                decision,
                                  ``(III) the institution at 
                                which the medical care involved 
                                in the coverage decision is 
                                provided,
                                  ``(IV) the manufacturer of 
                                any drug or other item that was 
                                included in the medical care 
                                involved in the coverage 
                                decision, or
                                  ``(V) any other party 
                                determined under such 
                                regulations as the Secretary 
                                may prescribe to have a 
                                substantial interest in the 
                                coverage decision .
                          ``(iv) Affiliated.--For purposes of 
                        clause (iii), the term `affiliated' 
                        means, in connection with any entity, 
                        having a familial, financial, or 
                        professional relationship with, or 
                        interest in, such entity.
                  ``(D) Decisions.--
                          ``(i) In general.--Decisions rendered 
                        by the arbitration panel shall be 
                        binding on all parties to the 
                        arbitration and shall be enforcible 
                        under section 502 as if the terms of 
                        the decision were the terms of the 
                        plan, except that the court may vacate 
                        any award made pursuant to the 
                        arbitration for any cause described in 
                        paragraph (1), (2), (3), (4), or (5) of 
                        section 10(a) of title 9, United States 
                        Code.
                          ``(ii) Allowable remedies.--The 
                        remedies which may be implemented by 
                        the arbitration panel shall consist of 
                        those remedies which would be available 
                        in an action timely commenced by a 
                        participant or beneficiary under 
                        section 502 after exhaustion of 
                        administrative remedies, except that a 
                        money award may be made in the 
                        arbitration proceedings in any amount 
                        not to exceed 3 times the maximum 
                        amount of damages that would be 
                        allowable in such case in an action 
                        described in section 502(n).''.
  (b) Effective Date.--The amendment made by this section shall 
apply to adverse coverage decisions initially rendered by group 
health plans on or after the date of the enactment of this Act.

      TITLE III-- AMENDMENTS TO THE INTERNAL REVENUE CODE OF 1986

SEC. 301. APPLICATION TO GROUP HEALTH PLANS UNDER 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 chapter 101.''; and
          (2) by inserting after section 9812 the following:

``SEC. 9813. STANDARD RELATING TO CHAPTER 101.

  ``A group health plan shall comply with the requirements of 
chapter 101 and such requirements shall be deemed to be 
incorporated into this section.''.

SEC. 302. IMPROVING MANAGED CARE.

  (a) In General.--The Internal Revenue Code of 1986 is amended 
by adding at the end the following new chapter:

                 ``CHAPTER 101--IMPROVING MANAGED CARE

        ``Subchapter A. Access to care.
        ``Subchapter B. Access to information.
        ``Subchapter C. Protecting the doctor-patient relationship.
        ``Subchapter D. Definitions.

                     ``Subchapter A--Access to Care

        ``Sec. 9901. Choice of health care professional.
        ``Sec. 9902. Access to emergency care.
        ``Sec. 9903. Access to specialty care.
        ``Sec. 9904. Access to obstetrical and gynecological care.
        ``Sec. 9905. Access to pediatric care.
        ``Sec. 9906. Continuity of care.
        ``Sec. 9907. Network adequacy.
        ``Sec. 9908. Access to experimental or investigational 
                  prescription drugs.
        ``Sec. 9909. Coverage for individuals participating in approved 
                  cancer clinical trials.

``SEC. 9901. CHOICE OF HEALTH CARE PROFESSIONAL.

  ``(a) Primary Care.--If a group health plan requires or 
provides for designation by a participant or beneficiary of a 
participating primary care provider, then the plan shall permit 
each participant and beneficiary to designate any participating 
primary care provider who is available to accept such 
individual.
  ``(b) Specialists.--A group health plan shall permit each 
participant or beneficiary 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.

``SEC. 9902. ACCESS TO EMERGENCY CARE.

  ``(a) Coverage of Emergency Services.--
          ``(1) In general.--If a group health plan provides or 
        covers any benefits with respect to services in an 
        emergency department of a hospital, the plan shall 
        cover emergency services (as defined in paragraph 
        (2)(B))--
                  ``(A) without the need for any prior 
                authorization determination;
                  ``(B) whether 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 or beneficiary--
                          ``(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 or beneficiary 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.--The term 
                `emergency medical condition' means--
                          ``(i) 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; and
                          ``(ii) a medical condition 
                        manifesting itself in a neonate by 
                        acute symptoms of sufficient severity 
                        (including severe pain) such that a 
                        prudent health care professional 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) with respect to an emergency 
                        medical condition described in 
                        subparagraph (A)(i)--
                                  ``(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 such emergency medical 
                                condition, 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; or
                          ``(ii) with respect to an emergency 
                        medical condition described in 
                        subparagraph (A)(ii), medical treatment 
                        for such condition rendered by a health 
                        care provider in a hospital to a 
                        neonate, including available hospital 
                        ancillary services in response to an 
                        urgent request of a health care 
                        professional and to the extent 
                        necessary to stabilize the neonate.
                  ``(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.--If benefits are available under a group 
health plan with respect to maintenance care or post-
stabilization care covered under the guidelines established 
under section 1852(d)(2) of the Social Security Act, the plan 
shall provide for reimbursement with respect to such services 
provided to a participant or beneficiary other than through a 
participating health care provider in a manner consistent with 
subsection (a)(1)(C) (and shall otherwise comply with such 
guidelines).
  ``(c) Coverage of Emergency Ambulance Services.--
          ``(1) In general.--If a group health plan provides 
        any benefits with respect to ambulance services and 
        emergency services, the plan shall cover emergency 
        ambulance services (as defined in paragraph (2))) 
        furnished under the plan under the same terms and 
        conditions under subparagraphs (A) through (D) of 
        subsection (a)(1) under which coverage is provided for 
        emergency services.
          ``(2) Emergency ambulance services.--For purposes of 
        this subsection, the term `emergency ambulance 
        services' means ambulance services (as defined for 
        purposes of section 1861(s)(7) of the Social Security 
        Act) furnished to transport an individual who has an 
        emergency medical condition (as defined in subsection 
        (a)(2)(A)) to a hospital for the receipt of emergency 
        services (as defined in subsection (a)(2)(B)) in a case 
        in which the emergency services are covered under the 
        plan pursuant to subsection (a)(1) and a prudent 
        layperson, with an average knowledge of health and 
        medicine, could reasonably expect that the absence of 
        such transport would result in placing the health of 
        the individual in serious jeopardy, serious impairment 
        of bodily function, or serious dysfunction of any 
        bodily organ or part.

``SEC. 9903. 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,
                  ``(B) the individual has a condition or 
                disease of sufficient seriousness and 
                complexity to require treatment by a specialist 
                or the individual requires physician pathology 
                services, and
                  ``(C) benefits for such treatment or services 
                are provided under the plan,
        the plan shall make or provide for a referral to a 
        specialist who is available and accessible (consistent 
        with standards developed under section 9907) to provide 
        the treatment for such condition or disease or to 
        provide such services.
          ``(2) Specialist defined.--For purposes of this 
        subsection, the term `specialist' means, with respect 
        to a condition or services, a health care practitioner, 
        facility, or center or physician pathologist that has 
        adequate expertise through appropriate training and 
        experience (including, in the case of a child, 
        appropriate pediatric expertise and in the case of a 
        pregnant woman, appropriate obstetrical expertise) to 
        provide high quality care in treating the condition or 
        to provide physician pathology services.
          ``(3) Care under referral.--A group health plan may 
        require that the care provided to an individual 
        pursuant to such referral under paragraph (1) with 
        respect to treatment be--
                  ``(A) pursuant to a treatment plan, only if 
                the treatment plan is developed by the 
                specialist and approved by the plan, 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.
        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 is not required under paragraph (1) to 
        provide for a referral to a specialist that is not a 
        participating provider, unless the plan does not have a 
        specialist that is available and accessible to treat 
        the individual's condition or provide physician 
        pathology services and that is a participating provider 
        with respect to such treatment or services.
          ``(5) Referrals to nonparticipating providers.--In a 
        case in which a referral of an individual to a 
        nonparticipating specialist is required under paragraph 
        (1), the group health plan shall provide the individual 
        the option of at least three nonparticipating 
        specialists.
          ``(6) Treatment of nonparticipating providers.--If a 
        plan 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 shall have a 
        procedure by which an individual who is a participant 
        or beneficiary 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 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
                  ``(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).
          ``(5) Construction.--Nothing in this subsection shall 
        be construed as preventing an individual who is a 
        participant or beneficiary and who has an ongoing 
        special condition from having the individual's primary 
        care physician assume the responsibilities for 
        providing and coordinating care described in paragraph 
        (1).
  ``(c) Standing Referrals.--
          ``(1) In general.--A group health plan shall have a 
        procedure by which an individual who is a participant 
        or beneficiary 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 if the primary care provider 
        in consultation with the medical director of the plan 
        and the specialist (if any), determines that such a 
        standing referral is appropriate, the plan 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. 9904. ACCESS TO OBSTETRICAL AND GYNECOLOGICAL CARE.

  ``(a) In General.--If a group health plan requires or 
provides for a participant or beneficiary to designate a 
participating primary care health care professional, the plan--
          ``(1) may not require authorization or a referral by 
        the individual's primary care health care professional 
        or otherwise for covered gynecological care (including 
        preventive women's health examinations) or for covered 
        pregnancy-related services provided by a participating 
        physician (including a family practice physician) who 
        specializes or is trained and experienced in gynecology 
        or obstetrics, respectively, to the extent such care is 
        otherwise covered; and
          ``(2) shall treat the ordering of other gynecological 
        or obstetrical care by such a participating physician 
        as the authorization of the primary care health care 
        professional with respect to such care under the plan.
  ``(b) Construction.--Nothing in subsection (a) shall be 
construed to--
          ``(1) waive any exclusions of coverage under the 
        terms of the plan with respect to coverage of 
        gynecological or obstetrical care;
          ``(2) preclude the group health plan involved from 
        requiring that the gynecologist or obstetrician notify 
        the primary care health care professional or the plan 
        of treatment decisions; or
          ``(3) prevent a plan from offering, in addition to 
        physicians described in subsection (a)(1), non-
        physician health care professionals who are trained and 
        experienced in gynecology or obstetrics.

``SEC. 9905. ACCESS TO PEDIATRIC CARE.

  ``(a) Pediatric Care.--If a group health plan requires or 
provides for a participant or beneficiary to designate a 
participating primary care provider for a child of such 
individual, the plan shall permit the individual to designate a 
physician (including a family practice physician) who 
specializes or is trained and experienced 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 with respect to coverage of pediatric care.

``SEC. 9906. CONTINUITY OF CARE.

  ``(a) In General.--
          ``(1) Termination of provider.--If a contract between 
        a group health plan 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 or beneficiary in the 
        plan 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 
        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 9903(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 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 or beneficiary 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 or beneficiary 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 
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 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 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 responsible for payment 
        under paragraph (1) and to provide to such plan 
        necessary medical information related to the care 
        provided.
          ``(3) The provider agrees otherwise to adhere to such 
        plan'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.
  ``(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. 9907. NETWORK ADEQUACY.

  ``(a) Requirement.--A group health plan shall meet such 
standards for network adequacy as are established by law 
pursuant to this section.
  ``(b) Development of Standards.--
          ``(1) Establishment of panel.--There is established a 
        panel to be known as the Health Care Panel to Establish 
        Network Adequacy Standards (in this section referred to 
        as the `Panel').
          ``(2) Duties of panel.--The Panel shall devise 
        standards for group health plans and to ensure that--
                  ``(A) participants and beneficiaries have 
                access to a sufficient number, mix, and 
                distribution of health care professionals and 
                providers; and
                  ``(B) covered items and services are 
                available and accessible to each participant 
                and beneficiary--
                          ``(i) in the service area of the 
                        plan;
                          ``(ii) at a variety of sites of 
                        service;
                          ``(iii) with reasonable promptness 
                        (including reasonable hours of 
                        operation and after hours services);
                          ``(iv) with reasonable proximity to 
                        the residences or workplaces of 
                        participants and beneficiaries; and
                          ``(v) in a manner that takes into 
                        account the diverse needs of such 
                        individuals and reasonably assures 
                        continuity of care.
  ``(c) Membership.--
          ``(1) Size and composition.--The Panel shall be 
        composed of 15 members. The Secretary of Health and 
        Human Services, the Majority Leader of the Senate, and 
        the Speaker of House of Representatives shall each 
        appoint 1 member from representatives of private 
        insurance organizations, consumer groups, State 
        insurance commissioners, State medical societies, and 
        State medical specialty societies.
          ``(2) Terms of appointment.--The members of the Panel 
        shall serve for the life of the Panel.
          ``(3) 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.
  ``(d) Procedures.--
          ``(1) Meetings.--The Panel shall meet at the call of 
        a majority of its members.
          ``(2) First meeting.--The Panel shall convene not 
        later than 60 days after the date of the enactment of 
        the Health Care Quality and Choice Act of 1999.
          ``(3) Quorum.--A quorum shall consist of a majority 
        of the members of the Panel.
          ``(4) 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.
  ``(e) Administration.--
          ``(1) Compensation.--Except as provided in paragraph 
        (1), members of the Panel shall receive no additional 
        pay, allowances, or benefits by reason of their service 
        on the Panel.
          ``(2) 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.
          ``(3) 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).
          ``(4) 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.
          ``(5) 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.
  ``(f) Report and Establishment of Standards.--Not later than 
2 years after the first meeting, the Panel shall submit a 
report to Congress and the Secretary of Health and Human 
Services detailing the standards devised under subsection (b) 
and recommendations regarding the implementation of such 
standards. Such standards shall take effect to the extent 
provided by Federal law enacted after the date of the 
submission of such report.
  ``(g) Termination.--The Panel shall terminate on the day 
after submitting its report to the Secretary of Health and 
Human Services under subsection (f).

``SEC. 9908. ACCESS TO EXPERIMENTAL OR INVESTIGATIONAL PRESCRIPTION 
                    DRUGS.

  ``No use of a prescription drug or medical device shall be 
considered experimental or investigational under a group health 
plan if such use is included in the labeling authorized by the 
U.S. Food and Drug Administration under section 505, 513 or 515 
of the Federal Food, Drug, and Cosmetic Act (21 U.S.C. 355) or 
under section 351 of the Public Health Service Act (42 U.S.C. 
262), unless such use is demonstrated to be unsafe or 
ineffective.

``SEC. 9909. COVERAGE FOR INDIVIDUALS PARTICIPATING IN APPROVED CANCER 
                    CLINICAL TRIALS.

  ``(a) Coverage.--
          ``(1) In general.--If a group health plan provides 
        coverage to a qualified individual (as defined in 
        subsection (b)), the plan--
                  ``(A) may not deny the individual 
                participation in the clinical trial referred to 
                in subsection (b)(2);
                  ``(B) subject to subsections (b), (c), and 
                (d), 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 individual'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 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 and who meets the following conditions:
          ``(1)(A) The individual has been diagnosed with 
        cancer.
          ``(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 individual 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 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 to be paid for by the sponsors 
        of an approved clinical trial.
          ``(2) Routine patient care costs.--For purposes of 
        this section--
                  ``(A) In general.--The term `routine patient 
                care costs' includes the costs associated with 
                the provision of items and services that--
                          ``(i) would otherwise be covered 
                        under the group health plan if such 
                        items and services were not provided in 
                        connection with an approved clinical 
                        trial program; and
                          ``(ii) are furnished according to the 
                        protocol of an approved clinical trial 
                        program.
                  ``(B) Exclusion.--Such term does include the 
                costs associated with the provision of--
                          ``(i) an investigational drug or 
                        device, unless the Secretary has 
                        authorized the manufacturer of such 
                        drug or device to charge for such drug 
                        or device; or
                          ``(ii) any item or service supplied 
                        without charge by the sponsor of the 
                        approved clinical trial program.
          ``(3) 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 
                would normally pay for comparable items or 
                services under subparagraph (A).
  ``(d) Approved Clinical Trial Defined.--In this section, the 
term `approved clinical trial' means a cancer clinical research 
study or cancer clinical investigation approved by an 
Institutional Review Board.
  ``(e) Construction.--Nothing in this section shall be 
construed to limit a plan's coverage with respect to clinical 
trials.
  ``(f) Plan Satisfaction of Certain Requirements; 
Responsibilities of Fiduciaries.--
          ``(1) In general.--For purposes of this section, 
        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 requirements of this section 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.
          ``(2) Construction.--Nothing in this section shall be 
        construed to affect or modify the responsibilities of 
        the fiduciaries of a group health plan under part 4 of 
        subtitle B of the Employee Retirement Income Security 
        Act of 1974.

                 ``Subchapter B--Access to Information

        ``Sec. 9911. Patient access to information.

``SEC. 9911. PATIENT ACCESS TO INFORMATION.

  ``(a) Disclosure Requirement.--A group health plan shall--
          ``(1) 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);
          ``(2) provide to participants and beneficiaries, 
        within a reasonable period (as specified by the 
        Secretary) before or after the date of significant 
        changes in the information described in subsection (b), 
        information on such significant changes; and
          ``(3) upon request, make available to participants 
        and beneficiaries, the Secretary, and prospective 
        participants and beneficiaries, the information 
        described in subsection (b) or (c).
The plan may charge a reasonable fee for provision in printed 
form of any of the information described in subsection (b) or 
(c) more than once during any plan year.
  ``(b) Information Provided.--The information described in 
this subsection with respect to a group health plan shall be 
provided to a participant or beneficiary free of charge at 
least once a year and includes the following:
          ``(1) Service area.--The service area of the plan.
          ``(2) Benefits.--Benefits offered under the plan, 
        including--
                  ``(A) those that are covered benefits ``(all 
                of which shall be referred to by such relevant 
                CPT and DRG codes as are available), limits and 
                conditions on such benefits, and those benefits 
                that are explicitly excluded from coverage (all 
                of which shall be referred to by such relevant 
                CPT and DRG codes as are available);
                  ``(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 or 
                beneficiary may select from among participating 
                providers and the types of providers 
                participating in the plan 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.
                  ``(B) Out-of-network coverage (if any) 
                provided by the plan.
                  ``(C) Any point-of-service option (including 
                any supplemental premium or cost-sharing for 
                such option).
                  ``(D) The procedures for participants and 
                beneficiaries 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 9901(b)(2).
          ``(4) Out-of-area coverage.--Out-of-area coverage 
        provided by the plan.
          ``(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 
                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) Prior authorization rules.--Rules regarding 
        prior authorization or other review requirements that 
        could result in noncoverage or nonpayment.
          ``(7) Grievance and appeals procedures.--All appeal 
        or grievance rights and procedures under the plan, 
        including the method for filing grievances and the time 
        frames and circumstances for acting on grievances and 
        appeals.
          ``(8) Accountability.--A description of the legal 
        recourse options available for participants and 
        beneficiaries under the plan including--
                  ``(A) the preemption that applies under 
                section 514 of the Employee Retirement Income 
                Security Act of 1974 (29 U.S.C. 1144) to 
                certain actions arising out of the provision of 
                health benefits; and
                  ``(B) the extent to which coverage decisions 
                made by the plan are subject to internal review 
                or any external review and the proper time 
                frames under
          ``(9) Quality assurance.--Any information made public 
        by an accrediting organization in the process of 
        accreditation of the plan or any additional quality 
        indicators the plan makes available.
          ``(10) Information on treatment authorization.--
        Notice of appropriate mailing addresses and telephone 
        numbers to be used by participants and beneficiaries in 
        seeking information or authorization for treatment.
          ``(11) 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 maintained by the plan.
          ``(2) Grievance and appeals information.--Information 
        on the number of grievances and appeals and on the 
        disposition in the aggregate of such matters.
          ``(3) Formulary restrictions.--A description of the 
        nature of any drug formula restrictions.
          ``(4) 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.

       ``Subchapter C--Protecting the Doctor-Patient Relationship

        ``Sec. 9921. Prohibition of interference with certain medical 
                  communications.
        ``Sec. 9922. Prohibition of discrimination against providers 
                  based on licensure.
        ``Sec. 9923. Prohibition against improper incentive 
                  arrangements.
        ``Sec. 9924. Payment of clean claims.

``SEC. 9921. 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 (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 or beneficiary 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, 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. 9922. PROHIBITION OF DISCRIMINATION AGAINST PROVIDERS BASED ON 
                    LICENSURE.

  ``(a) In General.--A group health plan 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 of particular benefits or services or to prohibit 
        a plan from including providers only to the extent 
        necessary to meet the needs of the plan's participants 
        or beneficiaries or from establishing any measure 
        designed to maintain quality and control costs 
        consistent with the responsibilities of the plan;
          ``(2) to override any State licensure or scope-of-
        practice law;
          ``(3) as requiring a plan that offers network 
        coverage to include for participation every willing 
        provider who meets the terms and conditions of the 
        plan; or
          ``(4) as prohibiting a family practice physician with 
        appropriate expertise from providing pediatric or 
        obstetrical or gynecological care.

``SEC. 9923. PROHIBITION AGAINST IMPROPER INCENTIVE ARRANGEMENTS.

  ``(a) In General.--A group health plan 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 Secretary of the Treasury, a group health 
plan, and a participant or beneficiary with the plan, 
respectively.
  ``(c) Construction.--Nothing in this section shall be 
construed as prohibiting all capitation and similar 
arrangements or all provider discount arrangements.

``SEC. 9924. PAYMENT OF CLEAN CLAIMS.

  ``A group health plan shall provide for prompt payment of 
claims submitted for health care services or supplies furnished 
to a participant or beneficiary with respect to benefits 
covered by the plan, 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 or beneficiary 
as well as claims referred to in such subparagraph.

                      ``Subchapter D--Definitions

        ``Sec. 9931. Definitions.
        ``Sec. 9933. Exclusions.
        ``Sec. 9933. Coverage of limited scope plans.
        ``Sec. 9934. Regulations; coordination; application under 
                  different laws.

``SEC. 9931. DEFINITIONS.

  For purposes of this chapter--
  ``(a) Incorporation of General Definitions.--Except as 
otherwise provided, the provisions of section 9831 shall apply 
for purposes of this chapter in the same manner as they apply 
for purposes of chapter 100.
  ``(b) Additional Definitions.--For purposes of this chapter:
          ``(1) Clinical peer.--The term `clinical peer' means, 
        with respect to a review or appeal, a practicing 
        physician or other health care professional who holds a 
        nonrestricted license and who is--
                  ``(A) appropriately certified by a nationally 
                recognized, peer reviewed accrediting body in 
                the same or similar specialty as typically 
                manages the medical condition, procedure, or 
                treatment under review or appeal, or
                  ``(B) is trained and experienced in managing 
                such condition, procedure, or treatment,
        and includes a pediatric specialist where appropriate; 
        except that only a physician may be a clinical peer 
        with respect to the review or appeal of treatment 
        recommended or rendered by a physician.
          ``(2) 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.
          ``(3) 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.
          ``(4) Network.--The term `network' means, with 
        respect to a group health plan, the participating 
        health care professionals and providers through whom 
        the plan provides health care items and services to 
        participants or beneficiaries.
          ``(5) Nonparticipating.--The term `nonparticipating' 
        means, with respect to a health care provider that 
        provides health care items and services to a 
        participant or beneficiary under group health plan, a 
        health care provider that is not a participating health 
        care provider with respect to such items and services.
          ``(6) Participating.--The term `participating' means, 
        with respect to a health care provider that provides 
        health care items and services to a participant or 
        beneficiary under group health plan, a health care 
        provider that furnishes such items and services under a 
        contract or other arrangement with the plan.
          ``(7) Physician.--The term `physician' means an 
        allopathic or osteopathic physician.
          ``(8) Practicing physician.--The term `practicing 
        physician' means a physician who is licensed in the 
        State in which the physician furnishes professional 
        services and who provides professional services to 
        individual patients on average at least two full days 
        per week.
          ``(9) Prior authorization.--The term `prior 
        authorization' means the process of obtaining prior 
        approval from a group health plan for the provision or 
        coverage of medical services.

``SEC. 9932. EXCLUSIONS.

  ``(a) No Benefit Requirements.--Nothing in this chapter shall 
be construed to require a group health plan to provide specific 
benefits under the terms of such plan, other than those 
provided under the terms of such plan.
  ``(b) Exclusion for Fee-for-Service Coverage.--
          ``(1) Group health plans.--The provisions of sections 
        9901 through 9911 shall not apply to a group health 
        plan if the only coverage offered under the plan 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 that--
                  ``(A) reimburses hospitals, health 
                professionals, and other providers 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) allows access to any provider that is 
                lawfully authorized to provide the covered 
                services and agree to accept the terms and 
                conditions of payment established under the 
                plan; and
                  ``(D) for which the plan does not require 
                prior authorization before providing for any 
                health care services.

``SEC. 9933. COVERAGE OF LIMITED SCOPE PLANS.

  ``Only for purposes of applying the requirements of this 
chapter under section 9813, section 9832(c)(2)(A) shall be 
deemed not to apply.

``SEC. 9934. REGULATIONS.

  ``The Secretary of the Treasury shall issue such regulations 
as may be necessary or appropriate to carry out this chapter 
under section 9813. The Secretary may promulgate such 
regulations in the form of interim final rules as may be 
necessary to carry out this chapter in a timely manner.''.
  (b) Clerical Amendment.--The table of chapters for subtitle K 
of the Internal Revenue Code of 1986 is amended by adding at 
the end the following new item:

        ``Chapter 101. Improving managed care.''

       TITLE IV--EFFECTIVE DATES; COORDINATION IN IMPLEMENTATION

SEC. 401. EFFECTIVE DATES.

  (a) Group Health Coverage.--
          (1) In general.--Subject to paragraph (2), the 
        amendments made by title I (other than section 102), 
        sections 201 and 202, and title III shall apply with 
        respect to group health plans, and health insurance 
        coverage offered in connection with group health plans, 
        for plan years beginning on or after January 1, 2000 
        (in this section referred to as the ``general effective 
        date'') and also shall apply to portions of plan years 
        occurring on and after such date.
          (2) Treatment of collective bargaining agreements.--
        In the case of a group health plan maintained pursuant 
        to 1 or more collective bargaining agreements between 
        employee representatives and 1 or more employers 
        ratified before the date of enactment of this Act, the 
        amendments made by title I (other than section 102), 
        sections 201 and 202, and title III shall not apply to 
        plan years beginning before the later of--
                  (A) the date on which the last collective 
                bargaining agreements relating to the plan 
                terminates (determined without regard to any 
                extension thereof agreed to after the date of 
                enactment of this Act), or
                  (B) the general effective date.
        For purposes of subparagraph (A), any plan amendment 
        made pursuant to a collective bargaining agreement 
        relating to the plan which amends the plan solely to 
        conform to any requirement added by this Act shall not 
        be treated as a termination of such collective 
        bargaining agreement.
  (b) Individual Health Insurance Coverage.--The amendments 
made by section 102 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.
  (c) Treatment of Religious Nonmedical Providers.--
          (1) In general.--Nothing in this Act (or the 
        amendments made thereby) shall be construed to--
                  (A) restrict or limit the right of group 
                health plans, and of health insurance issuers 
                offering health insurance coverage, to include 
                as providers religious nonmedical providers;
                  (B) require such plans or issuers to--
                          (i) utilize medically based 
                        eligibility standards or criteria in 
                        deciding provider status of religious 
                        nonmedical providers;
                          (ii) use medical professionals or 
                        criteria to decide patient access to 
                        religious nonmedical providers;
                          (iii) utilize medical professionals 
                        or criteria in making decisions in 
                        internal or external appeals regarding 
                        coverage for care by religious 
                        nonmedical providers; or
                          (iv) compel a participant or 
                        beneficiary to undergo a medical 
                        examination or test as a condition of 
                        receiving health insurance coverage for 
                        treatment by a religious nonmedical 
                        provider; or
                  (C) require such plans or issuers to exclude 
                religious nonmedical providers because they do 
                not provide medical or other required data, if 
                such data is inconsistent with the religious 
                nonmedical treatment or nursing care provided 
                by the provider.
          (2) Religious nonmedical provider.--For purposes of 
        this subsection, the term ``religious nonmedical 
        provider'' means a provider who provides no medical 
        care but who provides only religious nonmedical 
        treatment or religious nonmedical nursing care.

SEC. 402. COORDINATION IN IMPLEMENTATION.

  The Secretary of Labor, the Secretary of Health and Human 
Services, and the Secretary of the Treasury shall ensure, 
through the execution of an interagency memorandum of 
understanding among such Secretaries, that--
          (1) regulations, rulings, and interpretations issued 
        by such Secretaries relating to the same matter over 
        which both 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 V--OTHER PROVISIONS

                 Subtitle A--Protection of Information

SEC. 501. PROTECTION FOR CERTAIN INFORMATION.

  (a) Protection of Certain Information.--Notwithstanding any 
other provision of Federal or State law, health care response 
information shall be exempt from any disclosure requirement 
(regardless of whether the requirement relates to subpoenas, 
discover, introduction of evidence, testimony, or any other 
form of disclosure), in connection with a civil or 
administrative proceeding under Federal or State law, to the 
same extent as information developed by a health care provider 
with respect to any of the following:
          (1) Peer review.
          (2) Utilization review.
          (3) Quality management or improvement.
          (4) Quality control.
          (5) Risk management.
          (6) Internal review for purposes of reducing 
        mortality, morbidity, or for improving patient care or 
        safety.
  (b) No Waiver of Protection Through Interaction With 
Accrediting Body.--Notwithstanding any other provision of 
Federal or State law, the protection of health care response 
information from disclosure provided under subsection (a) shall 
not be deemed to be modified or in any way waived by--
          (1) the development of such information in connection 
        with a request or requirement of an accrediting body; 
        or
          (2) the transfer of such information to an 
        accrediting body.
  (c) Definitions.--For purposes of this section:
          (1) Accrediting body.--The term ``accrediting body'' 
        means a national, not-for-profit organization that--
                  (A) accredits health care providers; and
                  (B) is recognized as an accrediting body by 
                statute or by a Federal or State agency that 
                regulates health care providers.
          (2) Health care response information.--The term 
        ``health care response information'' means information 
        (including any data, report, record, memorandum, 
        analysis, statement, or other communication) developed 
        by, or on behalf of, a health care provider in response 
        to a serious, adverse, patient related event--
                  (A) during the course of analyzing or 
                studying the event and its causes; and
                  (B) for the purposes of--
                          (i) reducing mortality or morbidity; 
                        or
                          (ii) improving patient care or safety 
                        (including the provider's notification 
                        to an accrediting body and the 
                        provider's plans of action in response 
                        to such event).
          (3) Health care provider.--The term ``health care 
        provider'' means a person, who with respect to a 
        specific item of protected health information, 
        receives, creates, uses, maintains, or discloses the 
        information while acting in whole or in part in the 
        capacity of--
                  (A) a person who is licensed, certified, 
                registered, or otherwise authorized by Federal 
                or State law to provide an item or service that 
                constitutes health care in the ordinary course 
                of business, or practice of a profession;
                  (B) a Federal, State, or employer-sponsored 
                or any other privately-sponsored program that 
                directly provides items or services that 
                constitute health care to beneficiaries; or
                  (C) an officer or employee of a person 
                described in subparagraph (A) or (B).
          (4) State.--The term ``State'' includes a State, the 
        District of Columbia, the Northern Mariana Islands, any 
        political subdivisions of a State or such Islands, or 
        any agency or instrumentality of either.
  (d) Effective Date.--The provisions of this section are 
effective on the date of the enactment of this Act.

                       Subtitle B--Other Matters

SEC. 511. 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, in consultation with 
                the Majority Leader of the Senate and the 
                Speaker of the House of Representatives, 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 Health Care Quality and Choice 
                Act of 1999.
                  (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 its 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.
                              ----------                              


 3. An Amendment To Be Offered by Representative Houghton of New York, 
 or Representative Graham of South Carolina, or a Designee, Debatable 
                             for 60 Minutes

  Strike out all after the enacting clause and insert the 
following:

SECTION 1. SHORT TITLE; TABLE OF CONTENTS.

  (a) Short Title.--This Act may be cited as the ``Bipartisan 
Consensus Managed Care Improvement Act of 1999''.
  (b) Table of Contents.--The table of contents of this Act is 
as follows:

Sec. 1. Short title; table of contents.

                     TITLE I--IMPROVING MANAGED CARE

                   Subtitle A--Grievances and Appeals

Sec. 101. Utilization review activities.
Sec. 102. Internal appeals procedures.
Sec. 103. External appeals procedures.
Sec. 104. Establishment of a grievance process.

                       Subtitle B--Access to Care

Sec. 111. Consumer choice option.
Sec. 112. Choice of health care professional.
Sec. 113. Access to emergency care.
Sec. 114. Access to specialty care.
Sec. 115. Access to obstetrical and gynecological care.
Sec. 116. Access to pediatric care.
Sec. 117. Continuity of care.
Sec. 118. Access to needed prescription drugs.
Sec. 119. Coverage for individuals participating in approved clinical 
          trials.

                    Subtitle C--Access to Information

Sec. 121. Patient access to information.

         Subtitle D--Protecting the Doctor-Patient Relationship

Sec. 131. Prohibition of interference with certain medical 
          communications.
Sec. 132. Prohibition of discrimination against providers based on 
          licensure.
Sec. 133. Prohibition against improper incentive arrangements.
Sec. 134. Payment of claims.
Sec. 135. Protection for patient advocacy.

                         Subtitle E--Definitions

Sec. 151. Definitions.
Sec. 152. Preemption; State flexibility; construction.
Sec. 153. Exclusions.
Sec. 154. Coverage of limited scope plans.
Sec. 155. Regulations.

  TITLE II--APPLICATION OF QUALITY 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. Additional judicial remedies.
Sec. 303. Availability of binding arbitration.

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

Sec. 401. Amendments to the Internal Revenue Code of 1986.

        TITLE V--EFFECTIVE DATES; COORDINATION IN IMPLEMENTATION

Sec. 501. Effective dates.
Sec. 502. Coordination in implementation.

             TITLE VI--HEALTH CARE PAPERWORK SIMPLIFICATION

Sec. 601. Health care paperwork simplification.

                    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 5 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.
  (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, 
        means a denial, or a failure to act on a timely basis 
        upon, in whole or in part, the claim for benefits and 
        includes a failure to provide benefits (including items 
        and services) required to be provided under this title.

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 5 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, as determined by the plan or 
                issuer or as certified in writing by a treating 
                health care professional, the application of 
                the normal timeframe for making a determination 
                could seriously jeopardize the life or health 
                of the participant, beneficiary, or enrollee or 
                such an individual's ability to regain maximum 
                function; or
                  (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 an appeal is made, within 180 
        days after completion of the plan's internal appeals 
        process under section 102, 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 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.--
                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.
                  (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 3 
                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;
                          (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).
          (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 actions.

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 3 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 a health insurance issuer offers to 
enrollees health insurance coverage in connection with a group 
health plan which provides for coverage of services only if 
such services are furnished through health care professionals 
and providers who are members of a network of health care 
professionals and providers who have entered into a contract 
with the issuer to provide such services, the issuer shall also 
offer to such enrollees (at the time of enrollment and during 
an annual open season as provided under subsection (c)) the 
option of health insurance coverage which provides for coverage 
of such services which are not furnished through health care 
professionals and providers who are members of such a network 
unless enrollees are offered such non-network coverage through 
another group health plan or through another health insurance 
issuer in the group market.
  (b) Additional Costs.--The amount of any additional premium 
charged by the health insurance issuer for the additional cost 
of the creation and maintenance of the option described in 
subsection (a) and the amount of any additional cost sharing 
imposed under such option shall be borne by the enrollee unless 
it is paid by the health plan sponsor through agreement with 
the health insurance issuer.
  (c) Open Season.--An enrollee may change to the offering 
provided under this section only during a time period 
determined by the health insurance issuer. Such time period 
shall occur at least annually.

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.

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.--If benefits are available under a group health plan, or 
under health insurance coverage offered by a health insurance 
issuer, with respect to maintenance care or post-stabilization 
care covered under the guidelines established under section 
1852(d)(2) of the Social Security Act, the plan or issuer shall 
provide for reimbursement with respect to such services 
provided to a participant, beneficiary, or enrollee other than 
through a participating health care provider in a manner 
consistent with subsection (a)(1)(C) (and shall otherwise 
comply with such guidelines).

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
                  (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.

  If a group health plan, or health insurance issuer that 
offers health insurance coverage, provides benefits with 
respect to prescription drugs but the coverage limits such 
benefits to drugs included in a formulary, the plan or issuer 
shall--
          (1) ensure participation of participating physicians 
        and pharmacists in the development of the formulary;
          (2) disclose to providers and, disclose upon request 
        under section 121(c)(5) to participants, beneficiaries, 
        and enrollees, the nature of the formulary 
        restrictions; and
          (3) consistent with the standards for a utilization 
        review program under section 101, provide for 
        exceptions from the formulary limitation when a non-
        formulary alternative is medically indicated.

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 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--
                          (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 includespecific 
items and services (including abortions) under the terms of such plan 
or coverage, other than those provided under the terms of such plan or 
coverage.
  (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
                  (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 Bipartisan 
Consensus Managed Care Improvement Act of 1999, and each health 
insurance issuer shall comply with patient protection 
requirements under such title with respect to group health 
insurance coverage it offers, and such requirements shall be 
deemed to be incorporated into this subsection.
  ``(b) Notice.--A group health plan shall comply with the 
notice requirement under section 711(d) of the Employee 
Retirement Income Security Act of 1974 with respect to the 
requirements referred to in subsection (a) and a health 
insurance issuer shall comply with such notice requirement as 
if such section applied to such issuer and such issuer were a 
group health plan.''.
  (b) Conforming Amendment.--Section 2721(b)(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 
Bipartisan Consensus Managed Care Improvement Act of 1999 with 
respect to individual health insurance coverage it offers, and 
such requirements shall be deemed to be incorporated into this 
subsection.
  ``(b) Notice.--A health insurance issuer under this part 
shall comply with the notice requirement under section 711(d) 
of the Employee Retirement Income Security Act of 1974 with 
respect to the requirements of such title as if such section 
applied to such issuer and such issuer were a group health 
plan.''.

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

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

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

``SEC. 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 Bipartisan Consensus 
Managed Care Improvement Act of 1999 (as in effect as of the 
date of the enactment of such Act), and such requirements shall 
be deemed to be incorporated into this 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 Bipartisan 
        Consensus Managed Care Improvement Act of 1999 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 Bipartisan 
        Consensus Managed Care Improvement Act of 1999, 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 Bipartisan Consensus 
        Managed Care Improvement Act of 1999 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 Bipartisan Consensus Managed Care Improvement 
Act of 1999 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.''.

  (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. ADDITIONAL JUDICIAL REMEDIES.

  (a) Cause of Action Relating to Denial of Health Benefits.--
Section 502(a) of the Employee Retirement Income Security Act 
of 1974 (29 U.S.C. 1132(a)) is amended--
          (1) by striking ``or'' at the end of paragraph (8);
          (2) by striking ``amounts.'' at the end of paragraph 
        (9) and inserting ``amounts; or''; and
          (3) by adding at the end the following new paragraph:
          ``(10) by a participant or beneficiary of a group 
        health plan (or the estate of such a participant or 
        beneficiary), for relief described in subsection (n), 
        against a person who--
                  ``(A) is a fiduciary of such plan, a health 
                insurance issuer offering health insurance 
                coverage in connection with such plan, or an 
                agent of such plan or the plan sponsor,
                  ``(B) under such plan, has authority to make 
                the sole final decision described in subsection 
                (n)(2) regarding claims for benefits, and
                  ``(C) has exercised such authority in making 
                such final decision denying such a claim by 
                such participant or beneficiary in violation of 
                the terms of the plan or this title and, in 
                making such final decision, failed to exercise 
                ordinary care in making an incorrect 
                determination in the case of such participant 
                or beneficiary that an item or service is 
                excluded from coverage under the terms of the 
                plan,
        if the denial is the proximate cause of personal injury 
        to, or the wrongful death of, such participant or 
        beneficiary.''.
  (b) Judicial Remedies for Denial of Health Benefits.--Section 
502 of such Act (29 U.S.C. 1132) is amended by adding at the 
end the following new subsections:
  ``(n) Additional Remedies for Denial of Health Benefits.--
          ``(1) In general.--In an action commenced under 
        paragraph (10) of subsection (a) by a participant or 
        beneficiary of a group health plan (or by the estate of 
        such a participant or beneficiary) against a person 
        described in subparagraphs (A), (B), and (C) of such 
        paragraph, the court may award, in addition to other 
        appropriate equitable relief under this section, 
        monetary compensatory relief which may include both 
        economic and noneconomic damages (but which shall 
        exclude punitive damages). The amount of any such 
        noneconomic damages awarded as monetary compensatory 
        relief--
                  ``(A) in a case in which 2 times the amount 
                of the economic damages awarded as monetary 
                compensatory relief is less than or equal to 
                $250,000, may not exceed the greater of--
                          ``(i) 2 times the amount of such 
                        economic damages so awarded, or
                          ``(ii) $250,000; and
                  ``(B) in a case in which 2 times the amount 
                of the economic damages awarded as monetary 
                compensatory relief is greater than $250,000, 
                may not exceed $500,000.
          ``(2) Application to decisions involving medical 
        necessity and medical judgment.--This subsection and 
        subsection (a)(10) apply only with respect to final 
        decisions described in section 103(a)(2) of the 
        Bipartisan Consensus Managed Care Improvement Act of 
        1999.
          ``(3) Definitions.--For purposes of this subsection 
        and subsection (a)(10)--
                  ``(A) Group health plan; health insurance 
                issuer; health insurance coverage.--The terms 
                `group health plan', `health insurance issuer', 
                and `health insurance coverage' shall have the 
                meanings provided such terms under section 733, 
                respectively.
                  ``(B) Final decision.--The term `final 
                decision' means, with respect to a group health 
                plan, the final decision of the plan under 
                section 102 of the Bipartisan Consensus Managed 
                Care Improvement Act of 1999.
                  ``(C) Personal injury.--The term `personal 
                injury' means loss of life, loss or significant 
                impairment of limb or bodily function, 
                significant disfigurement, or severe and 
                chronic physical pain, and includes a physical 
                injury arising out of a failure to treat a 
                mental illness or disease.
                  ``(D) Claim for benefits.--The term `claim 
                for benefits' has the meaning provided in 
                section 101(f)(1) of the Bipartisan Consensus 
                Managed Care Improvement Act of 1999.
                  ``(E) Failure to exercise ordinary care.--The 
                term `failure to exercise ordinary care' means 
                a negligent failure to provide--
                          ``(i) the consideration of 
                        appropriate medical evidence, or
                          ``(ii) the regard for the health and 
                        safety of the participant or 
                        beneficiary,
                that a prudent individual acting in a like 
                capacity and familiar with such matters would 
                use in the conduct of an enterprise of a like 
                character and with same or similar 
                circumstances.
          ``(4) Exception for denials in accordance with 
        recommendation of external appeal entity.--No person 
        shall be liable under subsection (a)(10) for additional 
        monetary compensatory relief described in paragraph (1) 
        in any case in which the denial referred to in 
        subsection (a)(10) is upheld by the recommendation of 
        an external appeal entity issued with respect to such 
        denial under section 103 of the Bipartisan Consensus 
        Managed Care Improvement Act of 1999.
          ``(5) Exception for employers and other plan 
        sponsors.--
                  ``(A) In general.--Subject to subparagraph 
                (B), subsection (a)(10) does not authorize--
                          ``(i) any cause of action against an 
                        employer or other plan sponsor 
                        maintaining a group health plan (or 
                        against an employee of such an employer 
                        or sponsor acting within the scope of 
                        employment), or
                          ``(ii) a right of recovery or 
                        indemnity by a person against such an 
                        employer or sponsor (or such an 
                        employee) for relief assessed against 
                        the person pursuant to a cause of 
                        action under subsection (a)(10).
                  ``(B) Special rule.--Subparagraph (A) shall 
                not preclude any cause of action under 
                subsection (a)(10) commenced against an 
                employer or other plan sponsor (or against an 
                employee of such an employer or sponsor acting 
                within the scope of employment), if--
                          ``(i) such action is based on the 
                        direct participation of the employer or 
                        sponsor (or employee) in the sole final 
                        decision of the plan referred to in 
                        paragraph (2) with respect to a 
                        specific participant or beneficiary on 
                        a claim for benefits covered under the 
                        plan or health insurance coverage in 
                        the case at issue; and
                          ``(ii) the decision on the claim 
                        resulted in personal injury to, or the 
                        wrongful death of, such participant or 
                        beneficiary.
                  ``(C) Direct participation.--For purposes of 
                this subsection, in determining whether an 
                employer or other plan sponsor (or employee of 
                an employer or other plan sponsor) is engaged 
                in direct participation in the sole final 
                decision of the plan on a claim under section 
                102 of the Bipartisan Consensus Managed Care 
                Improvement Act of 1999, the employer or plan 
                sponsor (or employee) shall not be construed to 
                be engaged in such direct participation solely 
                because of any form of decisionmaking or 
                conduct, whether or not fiduciary in nature, 
                that does not involve the final decision with 
                respect to a specific claim for benefits by a 
                specific participant or beneficiary, including 
                (but not limited to) any participation in a 
                decision relating to:
                          ``(i) the selection or retention of 
                        the group health plan or health 
                        insurance coverage involved or the 
                        third party administrator or other 
                        agent, including any related cost-
                        benefit analysis undertaken in 
                        connection with the selection of, or 
                        continued maintenance of, the plan or 
                        coverage involved;
                          ``(ii) the creation, continuation, 
                        modification, or termination of the 
                        plan or of any coverage, benefit, or 
                        item or service covered by the plan 
                        affecting a cross-section of the plan 
                        participants and beneficiaries;
                          ``(iii) the design of any coverage, 
                        benefit, or item or service covered by 
                        the plan, including the amount of 
                        copayments and limits connected with 
                        such coverage, and the specification of 
                        protocols, procedures, or policies for 
                        determining whether any such coverage, 
                        benefit, or item or service is 
                        medically necessary and appropriate or 
                        is experimental or investigational;
                          ``(iv) any action by an agent of the 
                        employer or plan sponsor (other than an 
                        employee of the employer or plan 
                        sponsor) in making such a final 
                        decision on behalf of such employer or 
                        plan sponsor;
                          ``(v) any decision by an employer or 
                        plan sponsor (or employee) or agent 
                        acting on behalf of an employer or plan 
                        sponsor either to authorize coverage 
                        for, or to intercede or not to 
                        intercede as an advocate for or on 
                        behalf of, any specific participant or 
                        beneficiary (or group of participants 
                        or beneficiaries) under the plan; or
                          ``(vi) any other form of 
                        decisionmaking or other conduct 
                        performed by the employer or plan 
                        sponsor (or employee) in connection 
                        with the plan or coverage involved, 
                        unless the employer makes the sole 
                        final decision of the plan consisting 
                        of a failure described in paragraph 
                        (1)(A) as to specific participants or 
                        beneficiaries who suffer personal 
                        injury or wrongful death as a proximate 
                        cause of such decision.
          ``(6) Required demonstration of direct 
        participation.--An action under subsection (a)(10) 
        against an employer or plan sponsor (or employee 
        thereof) for remedies described in paragraph (1) shall 
        be immediately dismissed--
                  ``(A) in the absence of an evidentiary 
                demonstration in the complaint of direct 
                participation by the employer or plan sponsor 
                (or employee) in the sole final decision of the 
                plan with respect to a specific participant or 
                beneficiary who suffers personal injury or 
                wrongful death,
                  ``(B) upon a demonstration to the court that 
                such employer or plan sponsor (or employee) did 
                not directly participate in the final decision 
                of the plan, or
                  ``(C) in the absence of an evidentiary 
                demonstration that a personal injury to, or 
                wrongful death of, the participant or 
                beneficiary resulted.
          ``(7) Treatment of third-party providers of 
        nondiscretionary administrative services.--Subsection 
        (a)(10) does not authorize any action against any 
        person providing nondiscretionary administrative 
        services to employers or other plan sponsors.
          ``(8) Requirement of exhaustion of administrative 
        remedies.--
                  ``(A) In general.--Subsection (a)(10) applies 
                in the case of any cause of action only if all 
                remedies under section 503 (including remedies 
                under sections 102 and 103 of the Bipartisan 
                Consensus Managed Care Improvement Act of 1999 
                made applicable under section 714) with respect 
                to such cause of action have been exhausted.
                  ``(B) External review required.--For purposes 
                of subparagraph (A), administrative remedies 
                under section 503 shall not be deemed exhausted 
                until available remedies under section 103 of 
                the Bipartisan Consensus Managed Care 
                Improvement Act of 1999 have been elected and 
                are exhausted.
                  ``(C) Consideration of administrative 
                determinations.--Any determinations under 
                section 102 or 103 of the Bipartisan Consensus 
                Managed Care Improvement Act of 1999 made while 
                an action under subsection (a)(10) is pending 
                shall be given due consideration by the court 
                in such action.
          ``(9) Substantial weight given to external review 
        decisions.--In the case of any action under subsection 
        (a)(10) for remedies described in paragraph (1), the 
        external review decision under section 103 shall be 
        given substantial weight when considered along with 
        other available evidence.
          ``(10) Limitation of action.--Subsection (a)(10) 
        shall not apply in connection with any action commenced 
        after the later of--
                  ``(A) 1 year after (i) the date of the last 
                action which constituted a part of the failure, 
                or (ii) in the case of an omission, the latest 
                date on which the fiduciary could have cured 
                the failure, or
                  ``(B) 1 year after the earliest date on which 
                the plaintiff first knew, or reasonably should 
                have known, of the personal injury or wrongful 
                death resulting from the failure.
          ``(11) Coordination with fiduciary requirements.--A 
        fiduciary shall not be treated as failing to meet any 
        requirement of part 4 solely by reason of any action 
        taken by the fiduciary which consists of full 
        compliance with the reversal under section 103 of the 
        Bipartisan Consensus Managed Care Improvement Act of 
        1999 of a denial of a claim for benefits.
          ``(12) Construction.--Nothing in this subsection or 
        subsection (a)(10) shall be construed as authorizing an 
        action--
                  ``(A) for the failure to provide an item or 
                service which is not covered under the group 
                health plan involved, or
                  ``(B) for any action taken by a fiduciary 
                which consists of compliance with the reversal 
                or modification under section 103 of the 
                Bipartisan Consensus Managed Care Improvement 
                Act of 1999 of a final decision under section 
                102 of such Act.
          ``(13) Protection of medical malpractice under state 
        law.--This subsection and subsection (a)(10) shall not 
        be construed to preclude any action under State law not 
        otherwise preempted under this section or section 503 
        or 514 with respect to the exercise of a specified 
        professional standard of care in the provision of 
        medical services.
          ``(14) References to the bipartisan consensus managed 
        care improvement act of 1999.--Any reference in this 
        subsection to any provision of the Bipartisan Consensus 
        Managed Care Improvement Act of 1999 shall be deemed a 
        reference to such provision as in effect on the date of 
        the enactment of such Act.
  ``(o) Expedited Court Review.--In any case in which 
exhaustion of administrative remedies in accordance with 
section 102 or 103 of the Bipartisan Consensus Managed Care 
Improvement Act of 1999 otherwise necessary for an action for 
injunctive relief under paragraph (1)(B) or (3) of subsection 
(a) has not been obtained and it is demonstrated to the court 
by clear and convincing evidence that such exhaustion is not 
reasonably attainable under the facts and circumstances without 
any further undue risk of irreparable harm to the health of the 
participant or beneficiary, a civil action may be brought by a 
participant or beneficiary to obtain such relief. Any 
determinations which already have been made under section 102 
or 103 in such case, or which are made in such case while an 
action under this paragraph is pending, shall be given due 
consideration by the court in any action under this subsection 
in such case.''.
  (c) Effective Date.--The amendments made by this section 
shall apply to acts and omissions (from which a cause of action 
arises) occurring on or after the date of the enactment of this 
Act.

SEC. 304. AVAILABILITY OF BINDING ARBITRATION.

  (a) In General.--Section 502 of the Employee Retirement 
Income Security Act of 1974 (as amended by the preceding 
provisions of this Act) is amended further by adding at the end 
the following new subsection:
  ``(p) Binding Arbitration Permitted as Alternative Means of 
Dispute Resolution.--
          ``(1) In general.--This subsection shall apply with 
        respect to any adverse coverage decision rendered under 
        a group health plan under section 102 or 103, if--
                  ``(A) all administrative remedies under 
                section 503 required for an action in court 
                under this section have been exhausted,
                  ``(B) under the terms of the plan, the 
                aggrieved participant or beneficiary may elect 
                to resolve the dispute by means of a procedure 
                of binding arbitration which is available with 
                respect to all similarly situated participants 
                and beneficiaries (or which is available under 
                the plan pursuant to a bona fide collective 
                bargaining agreement pursuant to which the plan 
                is established and maintained), and which meets 
                the requirements of paragraph (3), and
                  ``(C) the participant or beneficiary has 
                elected such procedure in accordance with the 
                terms of the plan.
          ``(2) Effect of election.--In the case of an election 
        by a participant or beneficiary pursuant to paragraph 
        (1)--
                  ``(A) decisions rendered under the procedure 
                of binding arbitration shall be binding on all 
                parties to the procedure and shall be 
                enforceable under the preceding subsections of 
                this section as if the terms of the decision 
                were the terms of the plan, except that the 
                court in an action brought under this section 
                may vacate any award made pursuant to the 
                arbitration for any cause described in 
                paragraph (1), (2), (3), (4), or (5) of section 
                10(a) of title 9, United States Code, and
                  ``(B) subject to subparagraph (A), such 
                participant or beneficiary shall be treated as 
                having effectively waived any right to further 
                review of the decision by a court under the 
                preceding subsections of this section.
          ``(3) Additional requirements.--The requirements of 
        this paragraph consist of the following:
                  ``(A) Arbitration panel.--The arbitration 
                shall be conducted by an arbitration panel 
                meeting the requirements of paragraph (4).
                  ``(B) Fair process; de novo determination.--
                The procedure shall provide for a fair, de novo 
                determination.
                  ``(C) Opportunity to submit evidence, have 
                representation, and make oral presentation.--
                Each party to the arbitration procedure--
                          ``(i) may submit and review evidence 
                        related to the issues in dispute;
                          ``(ii) may use the assistance or 
                        representation of one or more 
                        individuals (any of whom may be an 
                        attorney); and
                          ``(iii) may make an oral 
                        presentation.
                  ``(D) Provision of information.--The plan 
                shall provide timely access to all its records 
                relating to the matters under arbitration and 
                to all provisions of the plan relating to such 
                matters.
                  ``(E) Timely decisions.--A determination by 
                the arbitration panel on the decision shall--
                          ``(i) be made in writing;
                          ``(ii) be binding on the parties; and
                          ``(iii) be made in accordance with 
                        the medical exigencies of the case 
                        involved.
          ``(4) Arbitration panel.--
                  ``(A) In general.--Arbitrations commenced 
                pursuant to this subsection shall be conducted 
                by a panel of arbitrators selected by the 
                parties made up of 3 individuals, including at 
                least one physician and one attorney.
                  ``(B) Qualifications.--Any individual who is 
                a member of an arbitration panel shall meet the 
                following requirements:
                          ``(i) There is no real or apparent 
                        conflict of interest that would impede 
                        the individual conducting arbitration 
                        independent of the plan and meets the 
                        independence requirements of 
                        subparagraph (C).
                          ``(ii) The individual has sufficient 
                        medical or legal expertise to conduct 
                        the arbitration for the plan on a 
                        timely basis.
                          ``(iii) The individual has 
                        appropriate credentials and has 
                        attained recognized expertise in the 
                        applicable medical or legal field.
                          ``(iv) The individual was not 
                        involved in the initial adverse 
                        coverage decision or any other review 
                        thereof.
                  ``(C) Independence requirements.--An 
                individual described in subparagraph (B) meets 
                the independence requirements of this 
                subparagraph if--
                          ``(i) the individual is not 
                        affiliated with any related party,
                          ``(ii) any compensation received by 
                        such individual in connection with the 
                        binding arbitration procedure is 
                        reasonable and not contingent on any 
                        decision rendered by the individual,
                          ``(iii) under the terms of the plan, 
                        the plan has no recourse against the 
                        individual or entity in connection with 
                        the binding arbitration procedure, and
                          ``(iv) the individual does not 
                        otherwise have a conflict of interest 
                        with a related party as determined 
                        under such regulations as the Secretary 
                        may prescribe.
                  ``(D) Related party.--For purposes of 
                subparagraph (C), the term `related party' 
                means--
                          ``(i) the plan or any health 
                        insurance issuer offering health 
                        insurance coverage in connection with 
                        the plan (or any officer, director, or 
                        management employee of such plan or 
                        issuer),
                          ``(ii) the physician or other medical 
                        care provider that provided the medical 
                        care involved in the coverage decision,
                          ``(iii) the institution at which the 
                        medical care involved in the coverage 
                        decision is provided,
                          ``(iv) the manufacturer of any drug 
                        or other item that was included in the 
                        medical care involved in the coverage 
                        decision, or
                          ``(v) any other party determined 
                        under such regulations as the Secretary 
                        may prescribe to have a substantial 
                        interest in the coverage decision .
                  ``(E) Affiliated.--For purposes of 
                subparagraph (C), the term `affiliated' means, 
                in connection with any entity, having a 
                familial, financial, or professional 
                relationship with, or interest in, such entity.
          ``(5) Allowable remedies.--The remedies which may be 
        implemented by the arbitration panel shall consist of 
        those remedies which would be available in an action 
        timely commenced by a participant or beneficiary under 
        section 502, taking into account the administrative 
        remedies exhausted by the participant or beneficiary 
        under section 503.''.
  (b) Effective Date.--The amendment made by this section shall 
apply to adverse coverage decisions initially rendered by group 
health plans on or after the date of the enactment of this Act.

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 Bipartisan Consensus Managed Care Improvement 
Act of 1999 (as in effect as of the date of the enactment of 
such Act), and such requirements shall be deemed to be 
incorporated into this section.''.

        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, 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, 2000 (in this section referred to as the 
        ``general effective date'') and also shall apply to 
        portions of plan years occurring on and after such 
        date.
          (2) Treatment of collective bargaining agreements.--
        In the case of a group health plan maintained pursuant 
        to 1 or more collective bargaining agreements between 
        employee representatives and 1 or more employers 
        ratified before the date of enactment of this Act, the 
        amendments made by sections 201(a), 301, 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 
                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 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--HEALTH CARE PAPERWORK SIMPLIFICATION

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 Bipartisan Consensus Managed 
                Care Improvement Act of 1999.
                  (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.

                                  
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