I

106TH CONGRESS

1ST SESSION H. R. 1806

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 adequate access to providers of obstetric and gynecological

services.

IN THE HOUSE OF REPRESENTATIVES

MAY 13, 1999

Mrs. LOWEY (for herself and Mr. LAZIO) introduced the following bill; which

was referred to the Committee on 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 adequate access to providers of obstetric and

gynecological services.

1 Be it enacted by the Senate and House of Representa2 tives of the United States of America in Congress assembled,
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1 SECTION 1. SHORT TITLE; FINDINGS.

2 (a) SHORT TITLE.—This Act may be cited as the

3 ‘‘Access to Women’s Health Care Act of 1999’’.

4 (b) FINDINGS.—Congress finds the following:

5 (1) Women’s health historically has received lit6 tle attention.

7 (2) Women have a different set of primary care

8 needs than men and providing direct access to pro9 viders of obstetric and gynecological services is an

10 important way to address some of these differences.

11 (3) A majority of women view their provider of

12 obstetric and gynecological services as their primary

13 or sole care provider.

14 (4) 78 percent of women think direct access to

15 providers of obstetric and gynecological services is

16 very important.

17 (5) Access to obstetric and gynecological serv18 ices improves the health of a woman by providing

19 primary and preventive health care throughout the

20 woman’s lifetime, encompassing care of the whole

21 patient in addition to focusing on the processes of

22 the female reproductive system.

23 (6) More than 60 percent of all office visits to

24 providers of obstetric and gynecological services are

25 for preventive care.
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1 (7) President Clinton’s Advisory Commission on

2 Consumer Protection and Quality in the Health

3 Care Industry recommended that women should be

4 able to choose a qualified provider, including obste5 trician-gynecologists, certified nurse midwives, and

6 other qualified care providers offered by a plan, for

7 the provision of routine and preventive women’s

8 health care services.

9 (8) Providers of obstetric and gynecological

10 services refer their patients to other health care pro11 fessionals less frequently than other primary care

12 providers, thus avoiding costly and time-consuming

13 referrals.

14 (9) Providers of obstetric and gynecological

15 services manage the health of women beyond the re16 productive system, and are uniquely qualified on the

17 basis of education and experience to provide basic

18 health care services to women.

19 (10) While more than 37 States have acted to

20 promote residents’ access to providers of obstetric

21 and gynecological services, patients in other States

22 or in Federally-governed health plans are not pro23 tected from access restrictions or limitations.
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1 SEC. 2. PATIENT ACCESS TO UNRESTRICTED OBSTETRIC

2 AND GYNECOLOGICAL SERVICES..

3 (a) PUBLIC HEALTH SERVICE ACT AMENDMENTS.—

4 (1) GROUP HEALTH INSURANCE COVERAGE.—

5 Subpart 2 of part A of title XXVII of the Public

6 Health Service Act is amended by adding at the end

7 the following new section:

8 ‘‘SEC. 2707. STANDARDS RELATING TO ACCESS TO UNRE9 STRICTED OBSTETRIC AND GYNECOLOGICAL

10 SERVICES.

11 ‘‘(a) IN GENERAL.—In a case in which a group

12 health plan or health insurance issuer offering health in13 surance coverage in connection with a group health plan

14 provides benefits under the terms of the plan consisting

15 of obstetric or gynecological services, including appro16 priate follow-up services and referrals for related obstetric

17 or gynecological services, the plan or issuer shall provide

18 for a female participant or beneficiary to designate a pro19 vider of obstetric and gynecological services who has

20 agreed to be designated as such, as the participant or

21 beneficiary’s primary care provider. If such participant or

22 beneficiary has not designated such a provider as a pri23 mary care provider, the plan or issuer—

24 ‘‘(1) may not require prior authorization by the

25 participant or beneficiary’s primary care provider or

26 otherwise for coverage of obstetric or gynecological
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1 services provided by a participating health care pro2 fessional practicing in accordance with State law, to

3 the extent such care is otherwise covered; and

4 ‘‘(2) shall treat the ordering of other gyneco5 logical services by such a participating health care

6 professional as the prior authorization of the pri7 mary care provider with respect to such care under

8 the coverage.

9 ‘‘(b) ADEQUATE NUMBER OF PROVIDERS OF OB10 STETRIC AND GYNECOLOGICAL SERVICES.—Each group

11 health plan and health insurance issuer offering health in12 surance coverage in connection with a group health plan

13 shall have an adequate number of providers of obstetric

14 and gynecological services on its roster to satisfy the

15 health care needs of all female participants and bene16 ficiaries who choose to have such a provider as a primary

17 care provider, or who otherwise need the services of a pro18 vider of obstetric and gynecological services.

19 ‘‘(c) DEFINITION OF ‘‘PROVIDER OF OBSTETRIC AND

20 GYNECOLOGICAL SERVICES’’.—For purposes of this sec21 tion the term ‘‘provider of obstetric and gynecological serv22 ices means—

23 ‘‘(1) an obstetrician-gynecologist;

24 ‘‘(2) a nurse practitioner as defined in section

25 1861(aa)(5)(A); or
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1 ‘‘(3) a certified nurse-midwife as defined in sec2 tion 1861(gg)(2).

3 ‘‘(d) CONSTRUCTION.—Nothing in subsection (a)(2)

4 shall waive any requirements of coverage relating to med5 ical necessity or appropriateness with respect to coverage

6 of obstetric or gynecological services so ordered.

7 ‘‘(e) PROHIBITIONS.—A group health plan, and a

8 health insurance issuer offering group health insurance

9 coverage in connection with a group health plan, may

10 not—

11 ‘‘(1) deny to a woman eligibility, or continued

12 eligibility, to enroll or to renew coverage under the

13 terms of the plan, solely for the purpose of avoiding

14 the requirements of this section;

15 ‘‘(2) provide monetary payments or rebates to

16 women to encourage such women to accept less than

17 the minimum protections available under this sec18 tion; or

19 ‘‘(3) penalize or otherwise reduce or limit the

20 reimbursement of a provider because such provider

21 provided care to an individual participant or bene22 ficiary in accordance with this section.

23 ‘‘(f) LEVEL AND TYPE OF REIMBURSEMENTS.—

24 Nothing in this section shall be construed to prevent a

25 group health plan or a health insurance issuer offering
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1 group health insurance coverage from negotiating the level

2 and type of reimbursement with a provider for care pro3 vided in accordance with this section.

4 ‘‘(g) NON-PREEMPTION OF MORE PROTECTIVE

5 STATE LAW WITH RESPECT TO HEALTH INSURANCE

6 ISSUERS.—This section shall not be construed to super7 sede any provision of State law which establishes, imple8 ments, or continues in effect any standard or requirement

9 solely relating to health insurance issuers in connection

10 with group health insurance coverage that provides great11 er protections to participant and beneficiaries than the

12 protections provided under this section.’’.

13 ‘‘(h) NOTICE.—A group health plan under this part

14 shall comply with the notice requirement under section

15 714(b) of the Employee Retirement Income Security Act

16 of 1974 with respect to the requirements of this section

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

18 (2) INDIVIDUAL HEALTH INSURANCE COV19 ERAGE.—Part B of title XXVII of such Act is

20 amended by inserting after section 2752 the fol21 lowing new section:
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1 ‘‘SEC. 2753. STANDARDS RELATING TO ACCESS TO UNRE2 STRICTED OBSTETRIC AND GYNECOLOGICAL

3 SERVICES.

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

5 shall apply to health insurance coverage offered by a

6 health insurance issuer in the individual market in the

7 same manner as it applies to health insurance coverage

8 offered by a health insurance issuer in connection with a

9 group health plan in the small or large group market.

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

11 part shall comply with the notice requirement under sec12 tion 714(b) of the Employee Retirement Income Security

13 Act of 1974 with respect to the requirements referred to

14 in this section as if such section applied to such issuer

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

16 (b) ERISA AMENDMENTS.—

17 (1) IN GENERAL.—Subpart B of part 7 of sub18 title B of title I of the Employee Retirement Income

19 Security Act of 1974 is amended by adding at the

20 end the following new section:

21 ‘‘SEC. 714. STANDARDS RELATING TO ACCESS TO UNRE22 STRICTED OBSTETRIC AND GYNECOLOGICAL

23 SERVICES.

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

25 health insurance issuer offering group health insurance

26 coverage in connection with such a plan) shall comply with
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1 the requirements of section 2707 of the Public Health

2 Service Act.

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

4 imposition of the requirement of this section shall be treat5 ed as a material modification in the terms of the plan de6 scribed in section 102(a)(1), for purposes of assuring no7 tice of such requirements under the plan; except that the

8 summary description required to be provided under the

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

10 modification shall be provided by not later than 60 days

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

12 requirement apply.’’.

13 (2) CONFORMING AMENDMENT.—Section

14 732(a) of such Act (29 U.S.C. 1191a(a)) is amended

15 by striking ‘‘section 711’’ and inserting ‘‘sections

16 711 and 714’’.

17 (3) CLERICAL AMENDMENT.—The table of con18 tents in section 1 of such Act is amended by insert19 ing after the item relating to section 713 the fol20 lowing new item:

‘‘Sec. 714. Standards relating to access to unrestricted obstetric and gynecological services.’’.

21 (c) INTERNAL REVENUE CODE AMENDMENTS.—

22 (1) IN GENERAL.—Subchapter B of chapter

23 100 of the Internal Revenue Code of 1986 is amend-
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1 ed by inserting after section 9812 the following new

2 section:

3 ‘‘SEC. 9813. STANDARDS RELATING TO ACCESS TO UNRE4 STRICTED OBSTETRIC AND GYNECOLOGICAL

5 SERVICES.

6 ‘‘(a) IN GENERAL.—In a case in which a group

7 health plan provides benefits under the terms of the plan

8 consisting of obstetric or gynecological services, including

9 appropriate follow-up services and referrals for diagnostic

10 testing related to obstetric or gynecological services, the

11 plan shall provide for a female participant or beneficiary

12 to designate a provider of obstetric and gynecological serv13 ices who has agreed to be designated as such, as the par14 ticipant or beneficiary’s primary care provider. If such

15 participant or beneficiary has not designated such a pro16 vider as a primary care provider, the plan—

17 ‘‘(1) may not require prior authorization by the

18 participant or beneficiary’s primary care provider or

19 otherwise for coverage of obstetric or gynecological

20 services provided by a participating health care pro21 fessional practicing in accordance with State law, to

22 the extent such service is otherwise covered; and

23 ‘‘(2) shall treat the ordering of other gyneco24 logical services by such a participating health care

25 professional as the prior authorization of the pri-
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1 mary care provider with respect to such care under

2 the coverage.

3 ‘‘(b) ADEQUATE NUMBER OF PROVIDERS OF OB4 STETRIC AND GYNECOLOGICAL SERVICES.—Each group

5 health plan shall have an adequate number of providers

6 of obstetric and gynecological services on its roster to sat7 isfy the health care needs of all female participants and

8 beneficiaries who choose to have such a provider as a pri9 mary care provider, or who otherwise need the services of

10 a provider obstetric and gynecological services.

11 ‘‘(c) DEFINITION OF ‘‘PROVIDER OF OBSTETRIC AND

12 GYNECOLOGICAL SERVICES’’.—For purposes of this sec13 tion the term ‘‘provider of obstetric and gynecological serv14 ices means—

15 ‘‘(1) an obstetrician-gynecologist;

16 ‘‘(2) a nurse practitioner as defined in section

17 1861(aa)(5)(A) of the Social Security Act (42

18 U.S.C. 1395x(aa)(5(A)); or

19 ‘‘(3) a certified nurse-midwife as defined in sec20 tion 1861(gg)(2) of the Social Security Act (42

21 U.S.C. 1395x(gg)(2)).

22 ‘‘(d) CONSTRUCTION.—Nothing in subsection (a)(2)

23 shall waive any requirements of coverage relating to med24 ical necessity or appropriateness with respect to coverage

25 of obstetric or gynecological services so ordered.
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1 ‘‘(e) PROHIBITIONS.—A group health plan, and a

2 health insurance issuer offering group health insurance

3 coverage in connection with a group health plan, may

4 not—

5 ‘‘(1) deny to a woman eligibility, or continued

6 eligibility, to enroll or to renew coverage under the

7 terms of the plan, solely for the purpose of avoiding

8 the requirements of this section;

9 ‘‘(2) provide monetary payments or rebates to

10 women to encourage such women to accept less than

11 the minimum protections available under this sec12 tion; or

13 ‘‘(3) penalize or otherwise reduce or limit the

14 reimbursement of a provider because such provider

15 provided care to an individual participant or bene16 ficiary in accordance with this section.

17 ‘‘(f) LEVEL AND TYPE OF REIMBURSEMENTS.—

18 Nothing in this section shall be construed to prevent a

19 group health plan from negotiating the level and type of

20 reimbursement with a provider for care provided in ac21 cordance with this section.’’.

22 (2) CONFORMING AMENDMENT.—Section

23 4980D(d)(1) of such Code is amended by striking

24 ‘‘section 9811’’ and inserting ‘‘sections 9811 and

25 9813’’.
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1 (3) CLERICAL AMENDMENT.—The table of sec2 tions of subchapter B of chapter 100 of such Code

3 is amended by inserting after the item relating to

4 section 9812 the following new item:

‘‘Sec. 9813. Standards relating to access to unrestricted obstetric

and gynecological services.’’.

5 (d) EFFECTIVE DATES AND RELATED RULES.—

6 (1) GROUP HEALTH PLANS AND GROUP

7 HEALTH INSURANCE COVERAGE.—

8 (A) IN GENERAL.—Subject to subpara9 graph (B), the amendments made by sub10 sections (a)(1), (b), and (c) apply with respect

11 to group health plans for plan years beginning

12 on or after the first day of the first month that

13 begins more than 1 year after the date of the

14 enactment of this Act.

15 (B) COLLECTIVE BARGAINING EXCEP16 TION.—In the case of a group health plan

17 maintained pursuant to 1 or more collective

18 bargaining agreements between employee rep19 resentatives and 1 or more employers ratified

20 before the date of enactment of this Act, the

21 amendments made subsections (a)(1), (b), and

22 (c) shall not apply to plan years beginning be23 fore the later of—
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1 (i) the date on which the last collec2 tive bargaining agreements relating to the

3 plan terminates (determined without re4 gard to any extension thereof agreed to

5 after the date of enactment of this Act), or

6 (ii) the first day described in subpara7 graph (A).

8 For purposes of clause (i), any plan amendment

9 made pursuant to a collective bargaining agree10 ment relating to the plan which amends the

11 plan solely to conform to any requirement

12 added by subsection (a)(1), (b), or (c) shall not

13 be treated as a termination of such collective

14 bargaining agreement.

15 (2) INDIVIDUAL HEALTH INSURANCE COV16 ERAGE.—The amendment made by subsection (a)(2)

17 applies with respect to health insurance coverage of18 fered, sold, issued, renewed, in effect, or operated in

19 the individual market on or after the first day of the

20 first month that begins more than 1 year after the

21 date of the enactment of this Act.

22 (3) LIMITATION ON ENFORCEMENT ACTIONS.—

23 No enforcement action shall be taken, pursuant to

24 the amendments made by this section, against a

25 group health plan or health insurance issuer with re-
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1 spect to a violation of a requirement imposed by

2 such amendments, and no penalty shall be imposed

3 on any failure by such plan to comply with any re4 quirement imposed by such amendments, to the ex5 tent that violation or failure occurs before the date

6 of issuance of final regulations issued in connection

7 with such requirement, if the plan or issuer has

8 sought to comply in good faith with such require9 ment.

10 SEC. 3. COORDINATION OF ADMINISTRATION.

11 The Secretary of Labor, the Secretary of the Treas12 ury, and the Secretary of Health and Human Services

13 shall ensure, through the execution of an interagency

14 memorandum of understanding among such Secretaries,

15 that—

16 (1) regulations, rulings, and interpretations

17 issued by such Secretaries relating to the same mat18 ter over which two or more such Secretaries have re19 sponsibility under the provisions of this Act (and the

20 amendments made thereby) are administered so as

21 to have the same effect at all times; and

22 (2) coordination of policies relating to enforcing

23 the same requirements through such Secretaries in

24 order to have a coordinated enforcement strategy
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1 that avoids duplication of enforcement efforts and

2 assigns priorities in enforcement.

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