I 

109TH CONGRESS 

1ST SESSION H. R. 2936 

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 

JUNE 16, 2005 

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 the Workforce 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. 

1 Be it enacted by the Senate and House of Representa2 tives of the United States of America in Congress assembled, 

3 SECTION 1. SHORT TITLE. 

4 This Act may be cited as the ‘‘Second Opinion Cov5 erage Act of 2005’’. 
2 

•HR 2936 IH 

1 SEC. 2. COVERAGE OF SECOND OPINIONS. 

2 (a) GROUP HEALTH PLANS.— 

3 (1) PUBLIC HEALTH SERVICE ACT AMEND4 MENTS.—(A) Subpart 2 of part A of title XXVII of 

5 the Public Health Service Act is amended by adding 

6 at the end the following new section: 

7 ‘‘SEC. 2707. COVERAGE OF SECOND OPINIONS. 

8 ‘‘(a) IN GENERAL.—A group health plan, and a 

9 health insurance issuer offering group health insurance 

10 coverage, shall provide that when requested by a partici11 pant, beneficiary, or enrollee or participating health care 

12 professional who is treating the participant, beneficiary, 

13 or enrollee, the plan or issuer shall provide or authorize 

14 a second opinion by an appropriately qualified health care 

15 professional. Reasons for a second opinion to be provided 

16 or authorized include the following: 

17 ‘‘(1) If the participant, beneficiary, or enrollee 

18 questions the reasonableness or necessity of rec19 ommended surgical procedures. 

20 ‘‘(2) If the participant, beneficiary, or enrollee 

21 questions a diagnosis or plan of care for a condition 

22 that threatens loss of life, loss of limb, loss of bodily 

23 function, or substantial impairment, including a seri24 ous chronic condition. 

25 ‘‘(3) If the clinical indications are not clear or 

26 are complex and confusing, a diagnosis is in doubt 
3 

•HR 2936 IH 

1 due to conflicting test results, or the treating health 

2 care professional is unable to diagnose the condition, 

3 and the participant, beneficiary, or enrollee requests 

4 an additional diagnosis. 

5 ‘‘(4) If the treatment plan in progress is not 

6 improving the medical condition of the participant, 

7 beneficiary, or enrollee within an appropriate period 

8 of time given the diagnosis and plan of care and the 

9 participant, beneficiary, or enrollee requests a sec10 ond opinion regarding the diagnosis or continuance 

11 of the treatment. 

12 ‘‘(5) If the participant, beneficiary, or enrollee 

13 has attempted to follow the plan of care or consulted 

14 with the initial provider concerning serious concerns 

15 about the diagnosis or plan of care. 

16 ‘‘(b) APPROPRIATELY QUALIFIED HEALTH CARE

17 PROFESSIONAL DEFINED.—For purposes of this section, 

18 an ‘appropriately qualified health care professional’ is a 

19 primary care physician or a specialist who is acting within 

20 the professional’s scope of practice and who possesses a 

21 clinical background, including training and expertise, re22 lated to the particular illness, disease, condition or condi23 tions associated with the request for a second opinion. 

24 ‘‘(c) TIMELY RENDERING OF OPINIONS.—If a partic25 ipant, beneficiary, or enrollee or participating health care 
4 

•HR 2936 IH 

1 professional who is treating a participant, beneficiary, or 

2 enrollee requests a second opinion pursuant to this section, 

3 an authorization or denial shall be provided in an expedi4 tious manner. When the condition of the participant, bene5 ficiary, or enrollee is such that the individual faces an im6 minent and serious threat to health, including the poten7 tial loss of life, limb, or other major bodily function, or 

8 lack of timeliness that would be detrimental to the individ9 ual’s ability to regarding maximum function, the second 

10 opinion shall be rendered in a timely fashion appropriate 

11 for the nature of the condition involved, but not to exceed 

12 72 hours after the time of the plan’s receipt of the request, 

13 whenever possible. Each plan or issuer shall file with the 

14 Secretary timelines for responding to requests for second 

15 opinions for cases involving emergency needs, urgent care, 

16 and other requests by not later than 90 days after the 

17 date of the enactment of this section, and within 30 days 

18 of any amendment to the timelines. The timelines shall 

19 be made available to the public upon request. 

20 ‘‘(d) LIMITATION ON LIABILITY FOR COSTS.—If a 

21 group health plan, or health insurance issuer offering a 

22 group health insurance in connection with such a plan, 

23 approves a request by a participant, beneficiary, or en24 rollee for a second opinion, the participant, beneficiary, 

25 or enrollee shall be responsible only for the costs of appli-
5 

•HR 2936 IH 

1 cable copayments that the group health plan or issuer re2 quires for similar referrals. 

3 ‘‘(e) PRIMARY CARE REQUESTS.—If the participant, 

4 beneficiary, or enrollee is requesting a second opinion 

5 about care from the individual’s primary care physician, 

6 the second opinion shall be provided by an appropriately 

7 qualified health care professional of the individual’s choice 

8 within the same physician organization. 

9 ‘‘(f) SPECIALISTS.—If the participant, beneficiary, or 

10 enrollee is requesting a second opinion about care from 

11 a specialist, the second opinion shall be provided by any 

12 provider of that individual’s choice from any independent 

13 practice association or medical group within the network 

14 of the same or equivalent specialty. If the specialist is not 

15 within the same physician organization, the plan or issuer 

16 shall incur the cost or negotiate the fee arrangements of 

17 that second opinion, beyond the applicable copayments 

18 which shall be paid by the participant, beneficiary, or en19 rollee. If not authorized by the plan or issuer, additional 

20 medical opinions not within the original physician organi21 zation shall be the responsibility of the enrollee. 

22 ‘‘(g) USE OF OUTSIDE PLAN CONSULTANTS.—If 

23 there is no participating provider under the plan or cov24 erage within the network who meets the standard specified 

25 in subsection (b), then the plan or issuer shall authorize 
6 

•HR 2936 IH 

1 a second opinion by an appropriately qualified health pro2 fessional outside of the plan’s or issuer’s provider network. 

3 In approving a second opinion either inside or outside of 

4 the plan’s or issuer’s provider network, the plan or issuer 

5 shall take into account the ability of the participant, bene6 ficiary, or enrollee to travel to the provider, but the plan 

7 or issuer is not liable for costs relating to such travel. 

8 ‘‘(h) CONSULTATION REPORTS.—The plan or issuer 

9 shall require the second opinion health professional to pro10 vide the participant, beneficiary, or enrollee and the initial 

11 health professional with a consultation report, including 

12 any recommended procedures or test that the second opin13 ion health professional believes appropriate. Nothing in 

14 this section shall be construed to prevent the plan or issuer 

15 from authorizing, based on its independent determination, 

16 additional medical opinions concerning the medical condi17 tion of a participant, beneficiary, or enrollee. 

18 ‘‘(i) NOTICE.—If the plan or issuer denies a request 

19 by a participant, beneficiary, or enrollee for a second opin20 ion, it shall notify the participant, beneficiary, or enrollee 

21 in writing of the reasons for the denial and shall inform 

22 the participant, beneficiary, or enrollee of the rights to file 

23 a grievance with the plan. 

24 ‘‘(j) LIMITATION TO PARTICIPATING PROVIDERS.— 

25 Unless authorized by the plan or issuer, in order for serv-
7 

•HR 2936 IH 

1 ices to be covered the participant, beneficiary, or enrollee 

2 shall obtain services only from a provider who is partici3 pating in, or under contract with, the plan or issuer pursu4 ant to the specific contract under which the participant, 

5 beneficiary, or enrollee is entitled to health care services. 

6 The plan or issuer may limit referrals to its network of 

7 providers if there is a participating plan provider who 

8 meets the standard specified in subsection (b). 

9 ‘‘(k) EXEMPTION.—This section shall not apply to 

10 health care service plan contracts that provide benefits to 

11 enrollees through preferred provider contracting arrange12 ments if, subject to all other terms and conditions of the 

13 contract that apply generally to all other benefits, access 

14 to and coverage for second opinions are not limited. 

15 ‘‘(l) NOTICE.—A group health plan under this part 

16 shall comply with the notice requirement under section 

17 714(b) of the Employee Retirement Income Security Act 

18 of 1974 with respect to the requirements of this section 

19 as if such section applied to such plan.’’. 

20 (B) Section 2723(c) of such Act (42 U.S.C. 

21 300gg–23(c)) is amended by striking ‘‘section 2704’’ 

22 and inserting ‘‘sections 2704 and 2707’’. 

23 (2) ERISA AMENDMENTS.—(A) Subpart B of 

24 part 7 of subtitle B of title I of the Employee Re-
8 

•HR 2936 IH 

1 tirement Income Security Act of 1974 is amended by 

2 adding at the end the following new section: 

3 ‘‘SEC. 714. COVERAGE OF SECOND OPINIONS. 

4 ‘‘(a) REQUIREMENT.—The provisions of section 2707 

5 shall apply under this subtitle to group health plans, and 

6 to group health insurance coverage offered by a health in7 surance issuer, in the same manner as they apply if such 

8 provisions were included in this subsection. 

9 ‘‘(b) NOTICE UNDER GROUP HEALTH PLAN.—The 

10 imposition of the requirement of this section shall be treat11 ed as a material modification in the terms of the plan de12 scribed in section 102(a)(1), for purposes of assuring no13 tice of such requirements under the plan; except that the 

14 summary description required to be provided under the 

15 last sentence of section 104(b)(1) with respect to such 

16 modification shall be provided by not later than 60 days 

17 after the first day of the first plan year in which such 

18 requirement apply.’’. 

19 (B) Section 731(c) of such Act (29 U.S.C. 

20 1191(c)) is amended by striking ‘‘section 711’’ and 

21 inserting ‘‘sections 711 and 714’’. 

22 (C) Section 732(a) of such Act (29 U.S.C. 

23 1191a(a)) is amended by striking ‘‘section 711’’ and 

24 inserting ‘‘sections 711 and 714’’. 
9 

•HR 2936 IH 

1 (D) The table of contents in section 1 of such 

2 Act is amended by inserting after the item relating 

3 to section 713 the following new item: 

‘‘714. Coverage of second opinions.’’. 

4 (3) INTERNAL REVENUE CODE AMEND5 MENTS.— 

6 (A) IN GENERAL.—Subchapter B of chap7 ter 100 of the Internal Revenue Code of 1986 

8 is amended— 

9 (i) in the table of sections, by insert10 ing after the item relating to section 9812 

11 the following new item: 

‘‘9813. Coverage of second opinions.’’; 

12 and 

13 (ii) by inserting after section 9812 the 

14 following: 

15 ‘‘SEC. 9813. COVERAGE OF SECOND OPINIONS. 

16 ‘‘The requirements of section 2707 of the Public 

17 Health Service Act shall apply under this section as if such 

18 section were included herein.’’. 

19 (B) CONFORMING AMENDMENT.—Section 

20 4980D(d)(1) of such Code is amended by strik21 ing ‘‘section 9811’’ and inserting ‘‘sections 

22 9811 and 9813’’. 

23 (b) INDIVIDUAL HEALTH INSURANCE.—(1) Part B 

24 of title XXVII of the Public Health Service Act is amend-
10 

•HR 2936 IH 

1 ed by inserting after section 2752 the following new sec2 tion: 

3 ‘‘SEC. 2753. COVERAGE OF SECOND OPINIONS. 

4 ‘‘(a) IN GENERAL.—The provisions of section 2707 

5 (other than subsection (l)) shall apply to health insurance 

6 coverage offered by a health insurance issuer in the indi7 vidual market in the same manner as they apply to health 

8 insurance coverage offered by a health insurance issuer 

9 in connection with a group health plan in the small or 

10 large group market. 

11 ‘‘(b) NOTICE.—A health insurance issuer under this 

12 part shall comply with the notice requirement under sec13 tion 714(b) of the Employee Retirement Income Security 

14 Act of 1974 with respect to the requirements referred to 

15 in subsection (a) as if such section applied to such issuer 

16 and such issuer were a group health plan.’’. 

17 (2) Section 2762(b)(2) of such Act (42 U.S.C. 

18 300gg–62(b)(2)) is amended by striking ‘‘section 2751’’ 

19 and inserting ‘‘sections 2751 and 2753’’. 

20 (c) EFFECTIVE DATES.— 

21 (1) GROUP HEALTH PLANS AND GROUP

22 HEALTH INSURANCE COVERAGE.—Subject to para23 graph (3), the amendments made by subsection (a) 

24 apply with respect to group health plans for plan 

25 years beginning on or after January 1, 2006. 
11 

•HR 2936 IH 

1 (2) INDIVIDUAL HEALTH INSURANCE COV2 ERAGE.—The amendments made by subsection (b) 

3 apply with respect to health insurance coverage of4 fered, sold, issued, renewed, in effect, or operated in 

5 the individual market on or after such date. 

6 (3) COLLECTIVE BARGAINING EXCEPTION.—In 

7 the case of a group health plan maintained pursuant 

8 to 1 or more collective bargaining agreements be9 tween employee representatives and 1 or more em10 ployers ratified before the date of enactment of this 

11 Act, the amendments made subsection (a) shall not 

12 apply to plan years beginning before the later of— 

13 (A) the date on which the last collective 

14 bargaining agreements relating to the plan ter15 minates (determined without regard to any ex16 tension thereof agreed to after the date of en17 actment of this Act), or 

18 (B) January 1, 2006. 

19 For purposes of subparagraph (A), any plan amend20 ment made pursuant to a collective bargaining 

21 agreement relating to the plan which amends the 

22 plan solely to conform to any requirement added by 

23 subsection (a) shall not be treated as a termination 

24 of such collective bargaining agreement. 
12 

•HR 2936 IH 

1 (d) COORDINATION OF ADMINISTRATION.—The Sec2 retary of Labor, the Secretary of the Treasury, and the 

3 Secretary of Health and Human Services shall ensure, 

4 through the execution of an interagency memorandum of 

5 understanding among such Secretaries, that— 

6 (1) regulations, rulings, and interpretations 

7 issued by such Secretaries relating to the same mat8 ter over which two or more such Secretaries have re9 sponsibility under the provisions of this Act (and the 

10 amendments made thereby) are administered so as 

11 to have the same effect at all times; and 

12 (2) coordination of policies relating to enforcing 

13 the same requirements through such Secretaries in 

14 order to have a coordinated enforcement strategy 

15 that avoids duplication of enforcement efforts and 

16 assigns priorities in enforcement. 

Æ