I 
110TH CONGRESS 
1ST SESSION 
H. R. 282 
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 
JANUARY 5, 2007 
Mrs. DAVIS of California introduced the following bill; which was referred to 
the Committee on Energy and Commerce, and in addition to the Commit-
tees on Education and Labor 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 con-
cerned 
A BILL 
To amend the Public Health Service Act, the Employee Re-
tirement Income Security Act of 1974, and the Internal 
Revenue Code of 1986 to require that group and indi-
vidual health insurance coverage and group health plans 
provide coverage for second opinions. 
Be it enacted by the Senate and House of Representa-
tives of the United States of America in Congress assembled, 
SECTION 1. SHORT TITLE. 
This Act may be cited as the ‘‘Second Opinion Cov-
erage Act of 2007’’. 
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SEC. 2. COVERAGE OF SECOND OPINIONS. 
(a) GROUP HEALTH PLANS.— 
(1) PUBLIC
HEALTH
SERVICE
ACT
AMEND-
MENTS.—(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 partici-
pant, 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 rec-
ommended 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 seri-
ous chronic condition. 
‘‘(3) If the clinical indications are not clear or 
are complex and confusing, a diagnosis is in doubt 
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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 sec-
ond 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, re-
lated to the particular illness, disease, condition or condi-
tions associated with the request for a second opinion. 
‘‘(c) TIMELY RENDERING OF OPINIONS.—If a partic-
ipant, beneficiary, or enrollee or participating health care 
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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 expedi-
tious manner. When the condition of the participant, bene-
ficiary, or enrollee is such that the individual faces an im-
minent and serious threat to health, including the poten-
tial loss of life, limb, or other major bodily function, or 
lack of timeliness that would be detrimental to the individ-
ual’s ability to regain maximum function, the second opin-
ion 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 
group health insurance in connection with such a plan, 
approves a request by a participant, beneficiary, or en-
rollee for a second opinion, the participant, beneficiary, 
or enrollee shall be responsible only for the costs of appli-
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cable copayments that the group health plan or issuer re-
quires 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 en-
rollee. If not authorized by the plan or issuer, additional 
medical opinions not within the original physician organi-
zation shall be the responsibility of the enrollee. 
‘‘(g) USE
OF OUTSIDE PLAN CONSULTANTS.—If 
there is no participating provider under the plan or cov-
erage within the network who meets the standard specified 
in subsection (b), then the plan or issuer shall authorize 
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a second opinion by an appropriately qualified health pro-
fessional 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, bene-
ficiary, 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 pro-
vide the participant, beneficiary, or enrollee and the initial 
health professional with a consultation report, including 
any recommended procedures or test that the second opin-
ion 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 condi-
tion 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 opin-
ion, 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 serv-
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