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.

Summary: Second Opinion Coverage Act of 2005 - Amends the Public Health Service Act, the Employee Retirement Income Security Act of 1974 (ERISA), and the Internal Revenue Code to require a group health plan and an issuer offering group coverage to provide coverage for second opinions upon request under certain circumstances, including if: (1) the participant questions the reasonableness or necessity of recommended surgical procedures or of a diagnosis or plan of care for a condition that threatens loss or substantial impairment of life, limb, or bodily function; (2) the clinical indications are not clear or are complex or confusing, a diagnosis is in doubt due to conflicting test results, or the treating health care professional is unable to diagnose the condition; (3) the treatment plan in progress is not improving the medical condition of the participant; and (4) the participant has attempted to follow the plan of care or has consulted with the initial provider concerning serious concerns about the diagnosis or plan of care.

Applies such requirements to coverage offered in the individual market.

SECTION 1. SHORT TITLE.

    This Act may be cited as the ``Second Opinion Coverage Act of 
2005''.

SEC. 2. COVERAGE OF SECOND OPINIONS.

    (a) Group Health Plans.--
            (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 regarding 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 a 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 requirement 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:

``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:

``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''.
    (c) Effective Dates.--
            (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, 2006.
            (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 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
                    (B) January 1, 2006.
        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.