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is amended by adding at the end the fol-
lowing 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 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 pro

a

vide 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 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 transi

tional 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.-1f

“(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.

“(iv) volume of research subjects available not apply to a group health plan if the “(i) IN GENERAL.-For purposes of this in different sites of service;

health insurance coverage under the plan is paragraph, the term 'routine patient care (v) access to research sites and clinical made available through a HealthMart (as decosts' shall include the costs associated with trials by cancer patients;

fined in section 2801) and if any health insurthe provision of items and services that

"(vi) patient cost sharing or copayment ance coverage made available through the “(I) would otherwise be covered under the costs realized in different sites of service; HealthMart provides for coverage of the group health plan if such items and services “(vii) health outcomes experienced in dif services of any class of health care profeswere not provided in connection with an ap ferent sites of service;

sionals other than through a closed panel of proved clinical trial program; and

“(viii) long term health care services and professionals. "(II) are furnished according to the pro costs experienced in different sites of serv “(3) RELICENSURE EXEMPTION.-Subsections tocol of an approved clinical trial program. ice;

(a) and (b) shall not apply to a health main“(ii) EXCLUSION.-For purposes of this “(ix) morbidity and mortality experienced tenance organization in a State in any case paragraph, 'routine patient care costs' shall in different sites of service; and

in whichnot include the costs associated with the "(x) patient satisfaction and preference of "!(A) the organization demonstrates to the provision ofsites of service.

applicable authority that the organization “(I) an investigational drug or device, un “(B) REPORT TO CONGRESS.—Not later than has made a good faith effort to obtain (but less the Secretary has authorized the manu

January 1, 2005, the Secretary shall submit a has failed to obtain) a contract between the facturer of such drug or device to charge for report to Congress that contains

organization and any other health insurance such drug or device; or

“(i) an assessment of any incremental cost issuer providing for the coverage option or “(II) any item or service supplied without to group health plans resulting from the pro supplemental coverage described in subcharge by the sponsor of the approved clin visions of this section;

section (a) or (b), as the case may be, within ical trial program.

“(ii) a projection of expenditures to such the applicable service area of the organiza“(C) PAYMENT RATE.-For purposes of this plans resulting from this section:

tion; and subsection

“(iii) an assessment of any impact on pre “(B) the State requires the organization to “(i) PARTICIPATING PROVIDERS.—In the case miums resulting from this section, and

receive or qualify for a separate license, as of covered items and services provided by a “(iv) recommendations regarding action on an indemnity insurer or otherwise, in order participating provider, the payment rate other diseases.”.

to offer such coverage option or suppleshall be at the agreed upon rate. SEC. 202. REQUIRING HEALTH MAINTENANCE OR

mental coverage, respectively. “(ii) NONPARTICIPATING PROVIDERS.-In the

GANIZATIONS TO OFFER OPTION OF

The applicable authority may require that case of covered items and services provided

POINT-OF-SERVICE COVERAGE.

the organization demonstrate that it meets by a nonparticipating provider, the payment

Title XXVII of the Public Health Service

the requirements of the previous sentence no rate shall be at the rate the plan would norAct is amended by inserting after section

more frequently that once every 2 years. mally pay for comparable items or services 2713 the following new section:

“(4) COLLECTIVE BARGAINING AGREEMENTS.under clause (i). "SEC. 2714. REQUIRING OFFERING OF OPTION OF

Subsections (a) and (b) shall not apply in “(4) APPROVED CLINICAL TRIAL DEFINED.

POINT-OF-SERVICE COVERAGE.

connection with a group health plan if the “(A) IN GENERAL.–For purposes of this sub

“(a) REQUIREMENT TO OFFER COVERAGE OP

plan is established or maintained pursuant section, the term 'approved clinical trial' TION TO CERTAIN EMPLOYERS.-Except as pro

to one or more collective bargaining agreemeans a cancer clinical research study or vided in subsection (c), any health insurance ments. cancer clinical investigation approved by an issuer which

“(5) SMALL ISSUERS.-Subsections (a) and Institutional Review Board.

"(1) is a health maintenance organization

(b) shall not apply in the case of a health in“(B) CONDITIONS FOR DEPARTMENTS.—The (as defined in section 2791(b)(3)); and

surance issuer with 25,000 or fewer covered conditions described in this paragraph, for a “(2) which provides for coverage of services

lives. study or investigation conducted by a De of one or more classes of health care profes "(d) APPLICABILITY.-The requirements of partment, are that the study or investiga

sionals under health insurance coverage of this section shall apply only in connection tion has been reviewed and approved through fered in connection with a group health plan with included group health plan benefits. a system of peer review that the Secretary only if such services are furnished exclu

“(e) DEFINITIONS.-For purposes of this secdetermines

sively through health

health care professionals tion: “(i) to be comparable to the system of peer

within such class or classes who are mem “(1) COVERAGE THROUGH CLOSED PANEL.— review of studies and investigations used by bers of a closed panel of health care profes Health insurance coverage for a class of the National Institutes of Health, and sionals,

health care professionals shall be treated as “(ii) assures unbiased review of the highest the issuer shall make available to the plan provided through a closed panel of such proscientific standards by qualified individuals sponsor in connection with such a plan a fessionals only if such coverage consists of who have no interest in the outcome of the coverage option which provides for coverage coverage of items or services consisting of review.

of such services which are furnished through professionals services which are reimbursed "(5) CONSTRUCTION.-Nothing in this sub such class (or classes) of health care profes for or provided only within a limited netsection shall be construed to limit a plan's sionals regardless of whether or not the pro work of such professionals. coverage with respect to clinical trials. fessionals are members of such panel.

“(2) HEALTH CARE PROFESSIONAL.-The “(6) PLAN SATISFACTION OF CERTAIN RE “(b) REQUIREMENT TO OFFER SUPPLEMENTAL term 'health care professional' has the meanQUIREMENTS; RESPONSIBILITIES OF FIDU COVERAGE TO PARTICIPANTS

IN

CERTAIN ing given such term in section 2707(a)(2). CIARIES.

CASES.—Except as provided in subsection (c), “(3) INCLUDED GROUP HEALTH PLAN BEN“(A) IN GENERAL.-For purposes of this sub if a health insurance issuer makes available EFIT.—The term 'included group health plan section, insofar as a group health plan pro a coverage option under and described in benefit' means a benefit which is not an exvides benefits in the form of health insur subsection (a) to a plan sponsor of a group cepted benefit

(as defined in section ance coverage through a health insurance health plan and the sponsor declines to con 2791(c)).". issuer, the plan shall be treated as meeting tract for such coverage option, then the SEC. 203. EFFECTIVE DATE AND RELATED RULES. the requirements of this subsection with re issuer shall make available in the individual (a) IN GENERAL.—The amendments made by spect to such benefits and not be considered insurance market to each participant in the this title shall apply with respect to plan as failing to meet such requirements because group health plan optional separate supple years beginning on or after January 1 of the of a failure of the issuer to meet such re mental health insurance coverage in the in second calendar year following the date of quirements so long as the plan sponsor or its dividual health insurance market which con the enactment of this Act, except that the representatives did not cause such failure by sists of services identical to those provided Secretary of Health and Human Services the issuer.

under such coverage provided through the may issue regulations before such date under “(B) CONSTRUCTION.-Nothing in this sub closed panel under the group health plan but such amendments. The Secretary shall first section shall be construed to affect or modify are furnished exclusively by health care pro issue regulations necessary to carry out the the responsibilities of the fiduciaries of a fessionals who are not members of such a amendments made by this title before the efgroup health plan under part 4 of subtitle B closed panel.

fective date thereof. of title I of the Employee Retirement In “(C) EXCEPTIONS.

(b) LIMITATION ON ENFORCEMENT ACTIONS.— come Security Act of 1974.

“(1) OFFERING OF NON-PANEL OPTION.–Sub No enforcement action shall be taken, pursu(7) STUDY AND REPORT.

sections (a) and (b) shall not apply with re ant to the amendments made by this title, “(A) STUDY.—The Secretary shall analyze spect to a group health plan if the plan offers against a group health plan or health insurcancer clinical research and its cost implica a coverage option that provides coverage for ance issuer with respect to a violation of a tions for managed care, including differen services that may be furnished by a class or requirement imposed by such amendments tiation in

classes of health care professionals who are before the date of issuance of regulations “(i) the cost of patient care in trials versus not in a closed panel. This paragraph shall be issued in connection with such requirement, standard care;

applied separately to distinguishable groups if the plan or issuer has sought to comply in "(ii) the cost effectiveness achieved in dif of employees under the plan.

good faith with such requirement. ferent sites of service;

(2) AVAILABILITY OF COVERAGE THROUGH (c) SPECIAL RULE FOR COLLECTIVE BAR“(iii) research outcomes;

HEALTHMART.-Subsections (a) and (b) shall GAINING 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 RE

GARDING PLAN COVERAGE, MAN-
AGED CARE PROCEDURES, HEALTH
CARE PROVIDERS, AND QUALITY OF

MEDICAL CARE. (a) IN GENERAL.-Subpart 2 of part 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 uch 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

[blocks in formation]

provide the following information to a par coverage option under the plan under which “Sec. 9813. Patient access to unrestricted ticipant or beneficiary on request: the participant is eligible to enroll and any

medical advice, emergency “(i) CARE MANAGEMENT INFORMATION.—A information described in clauses (i), (ii), (iii),

medical care, obstetric and description of the circumstances under (vi), (vii), and (viii) of subsection (e)(2)(B).

gynecological care, pediatric which, and the extent to which, the plan has “(i) ADVANCE NOTICE OF CHANGES IN DRUG

care, and continuity of care."'; special disease management programs or FORMULARIES.-Not later than 30 days before

and programs for persons with disabilities, indi the effective of date of any exclusion of a

(2) by inserting after section 9812 the folcating whether these programs are voluntary specific drug or biological from any drug for

lowing: or mandatory and whether a significant ben mulary under health insurance coverage of

“SEC. 9813. PATIENT ACCESS TO UNRESTRICTED efit differential results from participation in fered by a health insurance issuer in connec

MEDICAL ADVICE, EMERGENCY such programs. tion with a group health plan that is used in

MEDICAL CARE, OBSTETRIC AND "(ii) INCLUSION OF DRUGS AND BIOLOGICALS the treatment of a chronic illness or disease,

GYNECOLOGICAL CARE, PEDIATRIC IN FORMULARIES.-A statement of whether a the issuer shall take such actions as are nec

CARE, AND CONTINUITY OF CARE. specific drug or biological is included in a essary to reasonably ensure that plan par “(a) PATIENT ACCESS TO UNRESTRICTED formulary used to determine benefits under ticipants are informed of such exclusion. The MEDICAL ADVICE.the plan and a description of the procedures requirements of this subsection may be “(1) IN GENERAL.-In the case of any health for considering requests for any patient-spe satisfied

care professional acting within the lawful cific waivers.

“(1) by inclusion of information in publica scope of practice in the course of carrying “(iii) ACCREDITATION STATUS OF HEALTH IN tions broadly distributed by plan sponsors, out a contractual employment arrangement SURANCE ISSUERS AND SERVICE PROVIDERS.-A employers, or employee organizations;

or other direct contractual arrangement bedescription of the accreditation and licens

“(2) by electronic means of communication tween such professional and a group health ing status (if any) of each health insurance

(including the Internet or proprietary com plan, the plan with which such contractual issuer offering health insurance coverage in puter networks in a format which is readily

employment arrangement or other direct connection with the plan and of any utiliza accessible to participants);

contractual arrangement is maintained by tion review organization utilized by the

"(3) by timely informing participants who, the professional may not impose on such proissuer or the plan, together with the name

under an ongoing program maintained under fessional under such arrangement any prohiand address of the accrediting or licensing

the plan, have submitted their names for bition or restriction with respect to advice, authority. such notification; or

provided to a participant or beneficiary “(iv) QUALITY PERFORMANCE MEASURES.

“(4) by any other reasonable means of under the plan who is a patient, about the The latest information (if any) maintained timely informing plan participants.

health status of the participant or beneby the health insurance issuer relating to

“(j) DEFINITIONS AND RELATED RULES.

ficiary or the medical care or treatment for quality of performance of the delivery of

“(1) IN GENERAL.–For purposes of this the condition or disease of the participant or medical care with respect to coverage op section

beneficiary, regardless of whether benefits tions offered under the plan and of health

(A) GROUP HEALTH PLAN.—The term care professionals and facilities providing

for such care or treatment are provided 'group health plan' has the meaning provided under the plan. medical care under the plan. such term under section 733(a)(1).

“(2) HEALTH CARE PROFESSIONAL DEFINED.“(C) INFORMATION REQUIRED FROM HEALTH

“(B) MEDICAL CARE.-The term 'medical For purposes of this paragraph, the term CARE PROFESSIONALS.

care' has the meaning provided such term “(i) QUALIFICATIONS, PRIVILEGES, AND METH

‘health care professional' means a physician under section 733(a)(2).

(as defined in section 1861(r) of the Social SeOD OF COMPENSATION.–Any health care pro

"(C) HEALTH INSURANCE COVERAGE.—The fessional treating a participant or bene

curity Act) or other health care professional term 'health insurance coverage' has the ficiary under a group health plan shall pro

if coverage for the professional's services is meaning provided such term under section vide to the participant or beneficiary, on re

provided under the group health plan for the 733(b)(1). quest, a description of his or her professional

services of the professional. Such term in

“(D) HEALTH INSURANCE ISSUER.—The term qualifications (including board certification

cludes a podiatrist, optometrist, chiro'health insurance issuer' has the meaning status, licensing status, and accreditation

practor, psychologist, dentist, physician asstatus, if any), privileges, and experience and

provided such term under section 733(b)(2). sistant, physical or occupational therapist

“(2) APPLICABILITY ONLY IN CONNECTION a general description by category (including

and therapy assistant, speech-language paWITH INCLUDED GROUP HEALTH PLAN BENEsalary, fee-for-service, capitation, and such

thologist, audiologist, registered or licensed FITS.other categories as may be specified in regu

practical nurse (including nurse practilations of the Secretary) of the applicable

“(A) IN GENERAL.- The requirements of tioner, clinical nurse specialist, certified

this section shall apply only in connection method by which such professional is com

registered nurse anesthetist, and certified with included group health plan benefits. pensated in connection with the provision of

nurse-midwife), licensed certified social such medical care.

“(B) INCLUDED GROUP HEALTH PLAN BEN worker, registered respiratory therapist, and “(ii) COST OF PROCEDURES.-Any health

EFIT.-For purposes of subparagraph (A), the certified respiratory therapy technician. care professional who recommends an elec

term included group health plan benefit' “(3) RULE OF CONSTRUCTION.-Nothing in tive procedure or treatment while treating a

means a benefit which is not an excepted this subsection shall be construed to require participant or beneficiary under a group benefit (as defined in section 2791(c)).".

the sponsor of a group health plan to engage health plan that requires a participant or SEC. 212. EFFECTIVE DATE AND RELATED RULES.

in any practice that would violate its relibeneficiary to share in the cost of treatment

(a) IN GENERAL.-The amendments made by gious beliefs or moral convictions. shall inform such participant or beneficiary section 211 shall apply with respect to plan "(b) PATIENT ACCESS TO EMERGENCY MEDof each cost associated with the procedure or years beginning on or after January 1 of the ICAL CARE.treatment and an estimate of the magnitude second calendar year following the date of “(1) COVERAGE OF EMERGENCY SERVICES.of such costs.

the enactment of this Act. The Secretary of “(A) IN GENERAL.-If a group health plan (D) INFORMATION REQUIRED FROM HEALTH Labor shall first issue all regulations nec provides any benefits with respect to emerCARE FACILITIES ON REQUEST.-Any health essary to carry out the amendments made by gency services (as defined in subparagraph care facility from which a participant or this title before such date.

(B)(ii)), or ambulance services, the plan shall beneficiary has sought treatment under a (b) LIMITATION ON ENFORCEMENT ACTIONS. cover emergency services (including emergroup health plan shall provide to the partic

No enforcement action shall be taken, pursu gency ambulance services as defined in subipant or beneficiary, on request, a descrip

ant to the amendments made by this title, paragraph (B)(iii) furnished under the plantion of the facility's corporate form or other against a health insurance issuer with re “(i) without the need for any prior authororganizational form and all forms of licens spect to a violation of a requirement im ization determination; ing and accreditation status (if any) assigned posed by such amendments before the date of “(ii) whether or not the health care proto the facility by standard-setting organiza issuance of final regulations issued in con vider furnishing such services is a particitions.

nection with such requirement, if the issuer pating provider with respect to such serv“(h) ACCESS TO INFORMATION RELEVANT TO has sought to comply in good faith with such ices; THE COVERAGE OPTIONS UNDER WHICH THE requirement.

“(iii) in a manner so that, if such services PARTICIPANT OR BENEFICIARY IS ELIGIBLE TO

TITLE III—AMENDMENTS TO THE

are provided to a participant or beneficiary ENROLL.-In addition to information other

INTERNAL REVENUE CODE OF 1986 by a nonparticipating health care provider, wise required to be made available under SEC. 301. PATIENT ACCESS TO UNRESTRICTED

the participant or beneficiary is not liable this section, a health insurance issuer offer

MEDICAL ADVICE, EMERGENCY

for amounts that exceed the amounts of liing health insurance coverage in connection

MEDICAL CARE, OBSTETRIC AND ability that would be incurred if the services with a group health plan shall, upon written

GYNECOLOGICAL CARE, PEDIATRIC were provided by a participating provider; request (made not more frequently than an

CARE, AND CONTINUITY OF CARE. and nually), make available to a participant (and Subchapter B of chapter 100 of the Internal “(iv) without regard to any other term or an employee who, under the terms of the Revenue Code of 1986 is amended,

condition of such plan (other than exclusion plan, is eligible for coverage but not en (1) in the table of sections, by inserting or coordination of benefits, or an affiliation rolled) in connection with a period of enroll after the item relating to section 9812 the or waiting period, permitted under section ment the summary plan description for any following new item:

701 and other than applicable cost sharing).

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