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107TH CONGRESS

1ST SESSION H. R. 1440

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 permit enrollees direct access to services of obstetrical and gynecological physician services directly and without a referral.

IN THE HOUSE OF REPRESENTATIVES

APRIL 4, 2001

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

permit enrollees direct access to services of obstetrical

and gynecological physician services directly and without

a referral.

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.

2 This Act may be cited as the ‘‘Women’s Obstetrician

3 and Gynecologist Medical Access Now Act’’.

4 SEC. 2. WOMEN’S ACCESS TO OBSTETRICAL AND GYNECO5 LOGICAL SERVICES.

6 (a) GROUP HEALTH PLANS.—

7 (1) PUBLIC HEALTH SERVICE ACT AMEND8 MENTS.—(A) Subpart 2 of part A of title XXVII of

9 the Public Health Service Act is amended by adding

10 at the end the following new section:

11 ‘‘SEC. 2707. STANDARD RELATING TO WOMEN’S ACCESS TO

12 OBSTETRICAL AND GYNECOLOGICAL SERV13 ICES.

14 ‘‘(a) DIRECT ACCESS REQUIRED.—

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

16 health insurance issuer offering group health insur17 ance coverage, shall allow a participant or bene18 ficiary the option to seek obstetrical and gyneco19 logical physician services directly from a partici20 pating obstetrician and gynecologist or directly from

21 a participating family practice physician and sur22 geon designated by the plan or issuer as providing

23 obstetrical and gynecological services. A group

24 health plan or health insurance issuer, in connection

25 with the offering of group health insurance coverage,

26 shall not require a participant or beneficiary to ob-
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1 tain prior approval from another physician, another

2 provider, the plan or issuer, or any other person

3 prior to obtaining direct access to obstetrical and

4 gynecological physician services.

5 ‘‘(2) CONSTRUCTION.—Paragraph (1) shall not

6 be construed as preventing a plan or issuer—

7 ‘‘(A) from establishing reasonable require8 ments for the participating obstetrician and

9 gynecologist or family practice physician and

10 surgeon to communicate with the participant’s

11 or beneficiary’s primary care physician and sur12 geon regarding the participant’s or beneficiary’s

13 condition, treatment, and any need for followup

14 care; or

15 ‘‘(B) from establishing reasonable provi16 sions governing utilization protocols and the use

17 of obstetricians and gynecologists, or family

18 practice physicians and surgeons, participating

19 in the plan or issuer network, medical group, or

20 independent practice association, so long as

21 these provisions—

22 ‘‘(i) are consistent with the intent of

23 such paragraph;

24 ‘‘(ii) are those customarily applied to

25 other physicians and surgeons, such as pri-
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1 mary care physicians and surgeons, to

2 whom the participant or beneficiary has di3 rect access; and

4 ‘‘(iii) are not be more restrictive for

5 the provision of obstetrical and gyneco6 logical physician services.

7 ‘‘(b) NOTICE.—A group health plan under this part

8 shall comply with the notice requirement under section

9 714(b) of the Employee Retirement Income Security Act

10 of 1974 with respect to the requirements of this section

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

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

13 part 7 of subtitle B of title I of the Employee Re14 tirement Income Security Act of 1974 is amended by

15 adding at the end the following new section:

16 ‘‘SEC. 714. STANDARD RELATING TO WOMEN’S ACCESS TO

17 OBSTETRICAL AND GYNECOLOGICAL SERV18 ICES.

19 ‘‘(a) DIRECT ACCESS REQUIRED.—

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

21 health insurance issuer offering group health insur22 ance coverage, shall allow a participant or bene23 ficiary the option to seek obstetrical and gyneco24 logical physician services directly from a partici25 pating obstetrician and gynecologist or directly from
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1 a participating family practice physician and sur2 geon designated by the plan or issuer as providing

3 obstetrical and gynecological services. A group

4 health plan or health insurance issuer, in connection

5 with the offering of group health insurance coverage,

6 shall not require a participant or beneficiary to ob7 tain prior approval from another physician, another

8 provider, the plan or issuer, or any other person

9 prior to obtaining direct access to obstetrical and

10 gynecological physician services.

11 ‘‘(2) CONSTRUCTION.—Paragraph (1) shall not

12 be construed as preventing a plan or issuer—

13 ‘‘(A) from establishing reasonable require14 ments for the participating obstetrician and

15 gynecologist or family practice physician and

16 surgeon to communicate with the participant’s

17 or beneficiary’s primary care physician and sur18 geon regarding the participant’s or beneficiary’s

19 condition, treatment, and any need for followup

20 care; or

21 ‘‘(B) from establishing reasonable provi22 sions governing utilization protocols and the use

23 of obstetricians and gynecologists, or family

24 practice physicians and surgeons, participating

25 in the plan or issuer network, medical group, or
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1 independent practice association, so long as

2 these provisions—

3 ‘‘(i) are consistent with the intent of

4 such paragraph;

5 ‘‘(ii) are those customarily applied to

6 other physicians and surgeons, such as pri7 mary care physicians and surgeons, to

8 whom the participant or beneficiary has di9 rect access; and

10 ‘‘(iii) are not be more restrictive for

11 the provision of obstetrical and gyneco12 logical physician services.

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

14 imposition of the requirement of this section shall be treat15 ed as a material modification in the terms of the plan de16 scribed in section 102(a)(1), for purposes of assuring no17 tice of such requirements under the plan; except that the

18 summary description required to be provided under the

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

20 modification shall be provided by not later than 60 days

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

22 requirement apply.’’.

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

24 1191a(a)) is amended by striking ‘‘section 711’’ and

25 inserting ‘‘sections 711 and 714’’.
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1 (C) 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:

‘‘Sec. 714. Standard relating to women’s access to obstetrical and gynecological

services.’’.

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:

‘‘Sec. 9813. Standard relating to women’s access to obstetrical

and gynecological services.’’; and

12 (ii) by inserting after section 9812 the

13 following:

14 ‘‘SEC. 9813. STANDARD RELATING TO WOMEN’S ACCESS TO

15 OBSTETRICAL AND GYNECOLOGICAL SERV16 ICES.

17 ‘‘(a) DIRECT ACCESS REQUIRED.—A group health

18 plan, and a health insurance issuer offering group health

19 insurance coverage, shall allow a participant or beneficiary

20 the option to seek obstetrical and gynecological physician

21 services directly from a participating obstetrician and gyn22 ecologist or directly from a participating family practice

23 physician and surgeon designated by the plan or issuer
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1 as providing obstetrical and gynecological services. A

2 group health plan or health insurance issuer, in connection

3 with the offering of group health insurance coverage, shall

4 not require a participant or beneficiary to obtain prior ap5 proval from another physician, another provider, the plan

6 or issuer, or any other person prior to obtaining direct

7 access to obstetrical and gynecological physician services.

8 ‘‘(b) CONSTRUCTION.—Subsection (a) shall not be

9 construed as preventing a plan or issuer—

10 ‘‘(1) from establishing reasonable requirements

11 for the participating obstetrician and gynecologist or

12 family practice physician and surgeon to commu13 nicate with the participant’s or beneficiary’s primary

14 care physician and surgeon regarding the partici15 pant’s or beneficiary’s condition, treatment, and any

16 need for followup care; or

17 ‘‘(2) from establishing reasonable provisions

18 governing utilization protocols and the use of obste19 tricians and gynecologists, or family practice physi20 cians and surgeons, participating in the plan or

21 issuer network, medical group, or independent prac22 tice association, so long as these provisions—

23 ‘‘(A) are consistent with the intent of such

24 subsection;
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1 ‘‘(B) are those customarily applied to other

2 physicians and surgeons, such as primary care

3 physicians and surgeons, to whom the partici4 pant or beneficiary has direct access; and

5 ‘‘(C) are not be more restrictive for the

6 provision of obstetrical and gynecological physi7 cian services.

8 (B) CONFORMING AMENDMENT.—Section

9 4980D(d)(1) of such Code is amended by strik10 ing ‘‘section 9811’’ and inserting ‘‘sections

11 9811 and 9813’’.

12 (b) INDIVIDUAL HEALTH INSURANCE.—Part B of

13 title XXVII of the Public Health Service Act is amended

14 by inserting after section 2752 the following new section:

15 ‘‘SEC. 2753. STANDARD RELATING TO WOMEN’S ACCESS TO

16 OBSTETRICAL AND GYNECOLOGICAL SERV17 ICES.

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

19 2707(a) shall apply to health insurance coverage offered

20 by a health insurance issuer in the individual market in

21 the same manner as they apply to health insurance cov22 erage offered by a health insurance issuer in connection

23 with a group health plan in the small or large group mar24 ket.
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1 ‘‘(b) NOTICE.—A health insurance issuer under this

2 part shall comply with the notice requirement under sec3 tion 714(b) of the Employee Retirement Income Security

4 Act of 1974 with respect to the requirements referred to

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

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

7 (c) EFFECTIVE DATES.—

8 (1) GROUP HEALTH PLANS AND GROUP

9 HEALTH INSURANCE COVERAGE.—Subject to para10 graph (3), the amendments made by subsection (a)

11 apply with respect to group health plans for plan

12 years beginning more than 180 days after the date

13 of the enactment of this Act.

14 (2) INDIVIDUAL HEALTH INSURANCE COV15 ERAGE.—The amendment made by subsection (b)

16 applies with respect to health insurance coverage of17 fered, sold, issued, renewed, in effect, or operated in

18 the individual market on or after such date.

19 (3) COLLECTIVE BARGAINING EXCEPTION.—In

20 the case of a group health plan maintained pursuant

21 to 1 or more collective bargaining agreements be22 tween employee representatives and 1 or more em23 ployers ratified before the date of enactment of this

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

25 apply to plan years beginning before the later of—
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1 (A) the date on which the last collective

2 bargaining agreements relating to the plan ter3 minates (determined without regard to any ex4 tension thereof agreed to after the date of en5 actment of this Act), or

6 (B) the date that is 180 days after the

7 date of the enactment of this Act.

8 For purposes of subparagraph (A), any plan amend9 ment made pursuant to a collective bargaining

10 agreement relating to the plan which amends the

11 plan solely to conform to any requirement added by

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

13 of such collective bargaining agreement.

14 (d) COORDINATION OF ADMINISTRATION.—The Sec15 retary of Labor, the Secretary of the Treasury, and the

16 Secretary of Health and Human Services shall ensure,

17 through the execution of an interagency memorandum of

18 understanding among such Secretaries, that—

19 (1) regulations, rulings, and interpretations

20 issued by such Secretaries relating to the same mat21 ter over which two or more such Secretaries have re22 sponsibility under the provisions of this Act (and the

23 amendments made thereby) are administered so as

24 to have the same effect at all times; and
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1 (2) coordination of policies relating to enforcing

2 the same requirements through such Secretaries in

3 order to have a coordinated enforcement strategy

4 that avoids duplication of enforcement efforts and

5 assigns priorities in enforcement.

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