Ensuring Physician Choice Act of 1999

Summary: Ensuring Physician Choice Act of 1999 - Amends the Employee Retirement Income Security Act of 1974 (ERISA) to require group health plans, if they provide for coverage of services only if such services are furnished exclusively through health care professionals who are members of a closed panel of health care professionals, to make available an option which provides for coverage of services regardless of whether or not the professionals are members of such a panel. Exempts from such requirement: (1) plans that maintain an alternative group health plan which offers such a coverage option; and (2) plans (other than ones under which all benefits consist of health insurance coverage) of small employers who employ an average of two to 25 employees on business days.

SECTION 1. SHORT TITLE.

    This Act may be cited as the ``Ensuring Physician Choice Act of 
1999''.

SEC. 2. CHOICE OF PHYSICIANS.

    (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. 715. CHOICE OF PHYSICIANS.

    ``(a) Requirement To Offer Coverage Option to Certain Employees.--
Except as provided in subsection (b), if a group health plan provides, 
directly or through insurance, for coverage of services in connection 
with the group health plan only if such services are furnished 
exclusively through health care professionals who are members of a 
closed panel of health care professionals, such plan shall make 
available a coverage option which provides for coverage of such 
services regardless of whether or not the professionals are members of 
such a panel.
    ``(b) Exceptions.--
            ``(1) Alternative group health plan.--Subsection (a) shall 
        not apply in the case of any group health plan with respect to 
        coverage provided to any participant or beneficiary of such 
        plan if any other group health plan maintained by the same plan 
        sponsor offers to the same participant or beneficiary a 
        coverage option that provides coverage for services that may be 
        furnished by professionals whether or not they are members of 
        such a panel.
            ``(2) Small employer.--
                    ``(A) In general.--Subsection (a) shall not apply 
                to any group health plan (other than a plan under which 
                all benefits consist of health insurance coverage) of a 
                small employer, as defined, for purposes of this 
                paragraph, with respect to a calendar year and a plan 
                year, as an employer who employed an average of at 
                least 2 but not more than 25 employees on business days 
                during the preceding calendar year and who employs at 
                least 2 employees on the first day of the plan year.
                    ``(B) Application of certain rules in determination 
                of employer size.--For purposes of this paragraph--
                            ``(i) Application of aggregation rule for 
                        employers.--Rules similar to the rules under 
                        subsections (b), (c), (m), and (o) of section 
                        414 of the Internal Revenue Code of 1986 shall 
                        apply for purposes of treating persons as a 
                        single employer.
                            ``(ii) Employers not in existence in 
                        preceding year.--In the case of an employer 
                        which was not in existence throughout the 
                        preceding calendar year, the determination of 
                        whether such employer is a small employer shall 
                        be based on the average number of employees 
                        that it is reasonably expected such employer 
                        will employ on business days in the current 
                        calendar year.
                            ``(iii) Predecessors.--Any reference in 
                        this paragraph to an employer shall include a 
                        reference to any predecessor of such employer.
    ``(c) Construction.--Nothing in this section shall be construed--
            ``(1) as requiring coverage for benefits for a particular 
        type of health care provider;
            ``(2) as requiring an employer to pay any costs as a result 
        of this section or to make equal contributions with respect to 
        different health coverage options;
            ``(3) as preventing a group health plan or health insurance 
        issuer from imposing higher premiums or cost-sharing on a 
        participant for the exercise of a coverage option that provides 
        coverage for services that may be furnished by professionals 
        whether or not they are members of a closed panel; or
            ``(4) as applying to any excepted benefits as defined in 
        section 733(c).
    ``(d) Definitions.--For purposes of this section:
            ``(1) Coverage through a closed panel of health care 
        professionals.--The term `coverage through a closed panel of 
        health care professionals' means coverage of items or services 
        which are reimbursed for or provided only within a limited 
        network of such professionals.
            ``(2) Health care professional.--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.''.
    (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. Ensuring choice of physicians.''.

SEC. 3. EFFECTIVE DATE AND RELATED RULES.

    (a) In General.--The amendments made by this Act 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 Act before the 
effective date thereof.
    (b) Limitation on Enforcement Actions.--No enforcement action shall 
be taken, pursuant to the amendments made by this Act, 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 Act 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 Act shall not 
be treated as a termination of such collective bargaining agreement.