I

106TH CONGRESS

1ST SESSION H. R. 2275

To amend title I of the Employee Retirement Income Security Act to ensure

choice of physicians.

IN THE HOUSE OF REPRESENTATIVES

JUNE 17, 1999

Mr. FLETCHER (for himself, Mr. NORWOOD, and Mr. MCKEON) introduced

the following bill; which was referred to the Committee on Education and

the Workforce

A BILL

To amend title I of the Employee Retirement Income

Security Act to ensure choice of physicians.

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 ‘‘Ensuring Physician

5 Choice Act of 1999’’.

6 SEC. 2. CHOICE OF PHYSICIANS.

7 (a) IN GENERAL.—Subpart B of part 7 of subtitle

8 B of title I of the Employee Retirement Income Security

9 Act of 1974 is amended by adding at the end the following

10 new section:
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1 ‘‘SEC. 715. CHOICE OF PHYSICIANS.

2 ‘‘(a) REQUIREMENT TO OFFER COVERAGE OPTION

3 TO CERTAIN EMPLOYEES.—Except as provided in sub4 section (b), if a group health plan provides, directly or

5 through insurance, for coverage of services in connection

6 with the group health plan only if such services are fur7 nished exclusively through health care professionals who

8 are members of a closed panel of health care professionals,

9 such plan shall make available a coverage option which

10 provides for coverage of such services regardless of wheth11 er or not the professionals are members of such a panel.

12 ‘‘(b) EXCEPTIONS.—

13 ‘‘(1) ALTERNATIVE GROUP HEALTH PLAN.—

14 Subsection (a) shall not apply in the case of any

15 group health plan with respect to coverage provided

16 to any participant or beneficiary of such plan if any

17 other group health plan maintained by the same

18 plan sponsor offers to the same participant or bene19 ficiary a coverage option that provides coverage for

20 services that may be furnished by professionals

21 whether or not they are members of such a panel.

22 ‘‘(2) SMALL EMPLOYER.—

23 ‘‘(A) IN GENERAL.—Subsection (a) shall

24 not apply to any group health plan (other than

25 a plan under which all benefits consist of health

26 insurance coverage) of a small employer, as de-
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1 fined, for purposes of this paragraph, with re2 spect to a calendar year and a plan year, as an

3 employer who employed an average of at least

4 2 but not more than 25 employees on business

5 days during the preceding calendar year and

6 who employs at least 2 employees on the first

7 day of the plan year.

8 ‘‘(B) APPLICATION OF CERTAIN RULES IN

9 DETERMINATION OF EMPLOYER SIZE.—For

10 purposes of this paragraph—

11 ‘‘(i) APPLICATION OF AGGREGATION

12 RULE FOR EMPLOYERS.—Rules similar to

13 the rules under subsections (b), (c), (m),

14 and (o) of section 414 of the Internal Rev15 enue Code of 1986 shall apply for purposes

16 of treating persons as a single employer.

17 ‘‘(ii) EMPLOYERS NOT IN EXISTENCE

18 IN PRECEDING YEAR.—In the case of an

19 employer which was not in existence

20 throughout the preceding calendar year,

21 the determination of whether such em22 ployer is a small employer shall be based

23 on the average number of employees that

24 it is reasonably expected such employer
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1 will employ on business days in the current

2 calendar year.

3 ‘‘(iii) PREDECESSORS.—Any reference

4 in this paragraph to an employer shall in5 clude a reference to any predecessor of

6 such employer.

7 ‘‘(c) CONSTRUCTION.—Nothing in this section shall

8 be construed—

9 ‘‘(1) as requiring coverage for benefits for a

10 particular type of health care provider;

11 ‘‘(2) as requiring an employer to pay any costs

12 as a result of this section or to make equal contribu13 tions with respect to different health coverage op14 tions;

15 ‘‘(3) as preventing a group health plan or

16 health insurance issuer from imposing higher pre17 miums or cost-sharing on a participant for the exer18 cise of a coverage option that provides coverage for

19 services that may be furnished by professionals

20 whether or not they are members of a closed panel;

21 or

22 ‘‘(4) as applying to any excepted benefits as de23 fined in section 733(c).

24 ‘‘(d) DEFINITIONS.—For purposes of this section:
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1 ‘‘(1) COVERAGE THROUGH A CLOSED PANEL OF

2 HEALTH CARE PROFESSIONALS.—The term ‘cov3 erage through a closed panel of health care profes4 sionals’ means coverage of items or services which

5 are reimbursed for or provided only within a limited

6 network of such professionals.

7 ‘‘(2) HEALTH CARE PROFESSIONAL.—The term

8 ‘health care professional’ means a physician (as de9 fined in section 1861(r) of the Social Security Act)

10 or other health care professional if coverage for the

11 professional’s services is provided under the group

12 health plan for the services of the professional. Such

13 term includes a podiatrist, optometrist, chiropractor,

14 psychologist, dentist, physician assistant, physical or

15 occupational therapist and therapy assistant, speech16 language pathologist, audiologist, registered or li17 censed practical nurse (including nurse practitioner,

18 clinical nurse specialist, certified registered nurse

19 anesthetist, and certified nurse-midwife), licensed

20 certified social worker, registered respiratory thera21 pist, and certified respiratory therapy technician.’’.

22 (b) CONFORMING AMENDMENT.—The table of con23 tents in section 1 of such Act is amended by adding at

24 the end of the items relating to subpart B of part 7 of

25 subtitle B of title I of such Act the following new item:

‘‘Sec. 715. Ensuring choice of physicians.’’.
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1 SEC. 3. EFFECTIVE DATE AND RELATED RULES.

2 (a) IN GENERAL.—The amendments made by this

3 Act shall apply with respect to plan years beginning on

4 or after January 1 of the second calendar year following

5 the date of the enactment of this Act, except that the Sec6 retary of Labor may issue regulations before such date

7 under such amendments. The Secretary shall first issue

8 regulations necessary to carry out the amendments made

9 by this Act before the effective date thereof.

10 (b) LIMITATION ON ENFORCEMENT ACTIONS.—No

11 enforcement action shall be taken, pursuant to the amend12 ments made by this Act, against a group health plan or

13 health insurance issuer with respect to a violation of a re14 quirement imposed by such amendments before the date

15 of issuance of regulations issued in connection with such

16 requirement, if the plan or issuer has sought to comply

17 in good faith with such requirement.

18 (c) SPECIAL RULE FOR COLLECTIVE BARGAINING

19 AGREEMENTS.—In the case of a group health plan main20 tained pursuant to one or more collective bargaining

21 agreements between employee representatives and one or

22 more employers ratified before the date of the enactment

23 of this Act, the amendments made by this Act shall not

24 apply with respect to plan years beginning before the later

25 of—
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1 (1) the date on which the last of the collective

2 bargaining agreements relating to the plan termi3 nates (determined without regard to any extension

4 thereof agreed to after the date of the enactment of

5 this Act); or

6 (2) January 1, 2002.

7 For purposes of this subsection, any plan amendment

8 made pursuant to a collective bargaining agreement relat9 ing to the plan which amends the plan solely to conform

10 to any requirement added by this Act shall not be treated

11 as a termination of such collective bargaining agreement.

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