110th CONGRESS
1st Session
H. R. 282
To amend the Public Health Service Act, the Employee Retirement
Income Security Act of 1974, and the Internal Revenue Code of 1986 to require
that group and individual health insurance coverage and group health plans
provide coverage for second opinions.
IN THE HOUSE OF REPRESENTATIVES
January 5, 2007
Mrs. DAVIS of California introduced the following bill; which was referred
to the Committee on Energy and Commerce, and in addition to the Committees
on Education and Labor and Ways and Means, for a period to be subsequently
determined by the Speaker, in each case for consideration of such provisions
as fall within the jurisdiction of the committee concerned
A BILL
To amend the Public Health Service Act, the Employee Retirement
Income Security Act of 1974, and the Internal Revenue Code of 1986 to require
that group and individual health insurance coverage and group health plans
provide coverage for second opinions.
Be it enacted by the Senate and House of Representatives of the United
States of America in Congress assembled,
SECTION 1. SHORT TITLE.
This Act may be cited as the `Second Opinion Coverage Act of 2007'.
SEC. 2. COVERAGE OF SECOND OPINIONS.
(1) PUBLIC HEALTH SERVICE ACT AMENDMENTS- (A) 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. COVERAGE OF SECOND OPINIONS.
`(a) In General- A group health plan, and a health insurance issuer offering
group health insurance coverage, shall provide that when requested by a
participant, beneficiary, or enrollee or participating health care professional
who is treating the participant, beneficiary, or enrollee, the plan or issuer
shall provide or authorize a second opinion by an appropriately qualified
health care professional. Reasons for a second opinion to be provided or
authorized include the following:
`(1) If the participant, beneficiary, or enrollee questions the reasonableness
or necessity of recommended surgical procedures.
`(2) If the participant, beneficiary, or enrollee questions a diagnosis
or plan of care for a condition that threatens loss of life, loss of limb,
loss of bodily function, or substantial impairment, including a serious
chronic condition.
`(3) If the clinical indications are not clear or are complex and confusing,
a diagnosis is in doubt due to conflicting test results, or the treating
health care professional is unable to diagnose the condition, and the
participant, beneficiary, or enrollee requests an additional diagnosis.
`(4) If the treatment plan in progress is not improving the medical condition
of the participant, beneficiary, or enrollee within an appropriate period
of time given the diagnosis and plan of care and the participant, beneficiary,
or enrollee requests a second opinion regarding the diagnosis or continuance
of the treatment.
`(5) If the participant, beneficiary, or enrollee has attempted to follow
the plan of care or consulted with the initial provider concerning serious
concerns about the diagnosis or plan of care.
`(b) Appropriately Qualified Health Care Professional Defined- For purposes
of this section, an `appropriately qualified health care professional' is
a primary care physician or a specialist who is acting within the professional's
scope of practice and who possesses a clinical background, including training
and expertise, related to the particular illness, disease, condition or
conditions associated with the request for a second opinion.
`(c) Timely Rendering of Opinions- If a participant, beneficiary, or enrollee
or participating health care professional who is treating a participant,
beneficiary, or enrollee requests a second opinion pursuant to this section,
an authorization or denial shall be provided in an expeditious manner. When
the condition of the participant, beneficiary, or enrollee is such that
the individual faces an imminent and serious threat to health, including
the potential loss of life, limb, or other major bodily function, or lack
of timeliness that would be detrimental to the individual's ability to regain
maximum function, the second opinion shall be rendered in a timely fashion
appropriate for the nature of the condition involved, but not to exceed
72 hours after the time of the plan's receipt of the request, whenever possible.
Each plan or issuer shall file with the Secretary timelines for responding
to requests for second opinions for cases involving emergency needs, urgent
care, and other requests by not later than 90 days after the date of the
enactment of this section, and within 30 days of any amendment to the timelines.
The timelines shall be made available to the public upon request.
`(d) Limitation on Liability for Costs- If a group health plan, or health
insurance issuer offering group health insurance in connection with such
a plan, approves a request by a participant, beneficiary, or enrollee for
a second opinion, the participant, beneficiary, or enrollee shall be responsible
only for the costs of applicable copayments that the group health plan or
issuer requires for similar referrals.
`(e) Primary Care Requests- If the participant, beneficiary, or enrollee
is requesting a second opinion about care from the individual's primary
care physician, the second opinion shall be provided by an appropriately
qualified health care professional of the individual's choice within the
same physician organization.
`(f) Specialists- If the participant, beneficiary, or enrollee is requesting
a second opinion about care from a specialist, the second opinion shall
be provided by any provider of that individual's choice from any independent
practice association or medical group within the network of the same or
equivalent specialty. If the specialist is not within the same physician
organization, the plan or issuer shall incur the cost or negotiate the fee
arrangements of that second opinion, beyond the applicable copayments which
shall be paid by the participant, beneficiary, or enrollee. If not authorized
by the plan or issuer, additional medical opinions not within the original
physician organization shall be the responsibility of the enrollee.
`(g) Use of Outside Plan Consultants- If there is no participating provider
under the plan or coverage within the network who meets the standard specified
in subsection (b), then the plan or issuer shall authorize a second opinion
by an appropriately qualified health professional outside of the plan's
or issuer's provider network. In approving a second opinion either inside
or outside of the plan's or issuer's provider network, the plan or issuer
shall take into account the ability of the participant, beneficiary, or
enrollee to travel to the provider, but the plan or issuer is not liable
for costs relating to such travel.
`(h) Consultation Reports- The plan or issuer shall require the second opinion
health professional to provide the participant, beneficiary, or enrollee
and the initial health professional with a consultation report, including
any recommended procedures or test that the second opinion health professional
believes appropriate. Nothing in this section shall be construed to prevent
the plan or issuer from authorizing, based on its independent determination,
additional medical opinions concerning the medical condition of a participant,
beneficiary, or enrollee.
`(i) Notice- If the plan or issuer denies a request by a participant, beneficiary,
or enrollee for a second opinion, it shall notify the participant, beneficiary,
or enrollee in writing of the reasons for the denial and shall inform the
participant, beneficiary, or enrollee of the rights to file a grievance
with the plan.
`(j) Limitation to Participating Providers- Unless authorized by the plan
or issuer, in order for services to be covered the participant, beneficiary,
or enrollee shall obtain services only from a provider who is participating
in, or under contract with, the plan or issuer pursuant to the specific
contract under which the participant, beneficiary, or enrollee is entitled
to health care services. The plan or issuer may limit referrals to its network
of providers if there is a participating plan provider who meets the standard
specified in subsection (b).
`(k) Exemption- This section shall not apply to health care service plan
contracts that provide benefits to enrollees through preferred provider
contracting arrangements if, subject to all other terms and conditions of
the contract that apply generally to all other benefits, access to and coverage
for second opinions are not limited.
`(l) Notice- A group health plan under this part shall comply with the notice
requirement under section 714(b) of the Employee Retirement Income Security
Act of 1974 with respect to the requirements of this section as if such
section applied to such plan.'.
(B) Section 2723(c) of such Act (42 U.S.C. 300gg-23(c)) is amended by
striking `section 2704' and inserting `sections 2704 and 2707'.
(2) ERISA AMENDMENTS- (A) 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. COVERAGE OF SECOND OPINIONS.
`(a) Requirement- The provisions of section 2707 shall apply under this
subtitle to group health plans, and to group health insurance coverage offered
by a health insurance issuer, in the same manner as they apply if such provisions
were included in this subsection.
`(b) Notice Under Group Health Plan- The imposition of the requirement of
this section shall be treated as a material modification in the terms of
the plan described in section 102(a)(1), for purposes of assuring notice
of such requirements under the plan; except that the summary description
required to be provided under the last sentence of section 104(b)(1) with
respect to such modification shall be provided by not later than 60 days
after the first day of the first plan year in which such requirements apply.'.
(B) Section 731(c) of such Act (29 U.S.C. 1191(c)) is amended by striking
`section 711' and inserting `sections 711 and 714'.
(C) Section 732(a) of such Act (29 U.S.C. 1191a(a)) is amended by striking
`section 711' and inserting `sections 711 and 714'.
(D) 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. Coverage of second opinions.'.
(3) INTERNAL REVENUE CODE AMENDMENTS-
(A) IN GENERAL- Subchapter B of chapter 100 of the Internal Revenue
Code of 1986 is amended--
(i) in the table of sections, by inserting after the item relating
to section 9812 the following new item:
`Sec. 9813. Coverage of second opinions.'; and
(ii) by inserting after section 9812 the following:
`SEC. 9813. COVERAGE OF SECOND OPINIONS.
`The requirements of section 2707 of the Public Health Service Act shall
apply under this section as if such section were included herein.'.
(B) CONFORMING AMENDMENT- Section 4980D(d)(1) of such Code is amended
by striking `section 9811' and inserting `sections 9811 and 9813'.
(b) Individual Health Insurance- (1) Part B of title XXVII of the Public
Health Service Act is amended by inserting after section 2752 the following
new section:
`SEC. 2753. COVERAGE OF SECOND OPINIONS.
`(a) In General- The provisions of section 2707 (other than subsection (l))
shall apply to health insurance coverage offered by a health insurance issuer
in the individual market in the same manner as they apply to health insurance
coverage offered by a health insurance issuer in connection with a group
health plan in the small or large group market.
`(b) Notice- A health insurance issuer under this part shall comply with
the notice requirement under section 714(b) of the Employee Retirement Income
Security Act of 1974 with respect to the requirements referred to in subsection
(a) as if such section applied to such issuer and such issuer were a group
health plan.'.
(2) Section 2762(b)(2) of such Act (42 U.S.C. 300gg-62(b)(2)) is amended
by striking `section 2751' and inserting `sections 2751 and 2753'.
(1) GROUP HEALTH PLANS AND GROUP HEALTH INSURANCE COVERAGE- Subject to
paragraph (3), the amendments made by subsection (a) apply with respect
to group health plans for plan years beginning on or after January 1,
2008.
(2) INDIVIDUAL HEALTH INSURANCE COVERAGE- The amendments made by subsection
(b) apply with respect to health insurance coverage offered, sold, issued,
renewed, in effect, or operated in the individual market on or after such
date.
(3) COLLECTIVE BARGAINING EXCEPTION- 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 to subsection (a) 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
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 subsection (a) shall
not be treated as a termination of such collective bargaining agreement.
(d) Coordination of Administration- The Secretary of Labor, the Secretary
of the Treasury, and the Secretary of Health and Human Services 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 two or more 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.
END
