I
107TH CONGRESS
2D SESSION
H. R. 5325
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
SEPTEMBER 4, 2002
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 the Workforce and Ways and Means, for a period
to be subsequently determined by the Speaker, in each case for consider-
ation of such provisions as fall within the jurisdiction of the committee
concerned
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 2002’’.
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
due to conflicting test results, or the treating health
care professional is unable to diagnose the condition,
and the participant, beneficiary, or enrollee requests
and 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
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 regarding maximum function, the second
opinion 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 a
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-
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 halth care profession 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
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-
ices to be covered the participant, beneficiary, or enrollee
shall obtain services only from a provider who is partici-
pating in, or under contract with, the plan or issuer pursu-
ant to the specific contract under which the participant,
beneficiary, or enrollee is entitled to health care services.
The plan or issuer may limit referrals to its network of
providers if there is a participating plan provider who
meets the standard specified in subsection (b).
‘‘(k) EXEMPTION.—This section shall not apply to
health care service plan contracts that provide benefits to
enrollees through preferred provider contracting arrange-
ments if, subject to all other terms and conditions of the
contract that apply generally to all other benefits, access
to and coverage for second opinions are not limited.
‘‘(l) NOTICE.—A group health plan under this part
shall comply with the notice requirement under section
714(b) of the Employee Retirement Income Security Act
of 1974 with respect to the requirements of this section
as if such section applied to such plan.’’.
(B) Section 2723(c) of such Act (42 U.S.C.
300gg–23(c)) is amended by striking ‘‘section 2704’’
and inserting ‘‘sections 2704 and 2707’’.
(2) ERISA AMENDMENTS.—(A) Subpart B of
part 7 of subtitle B of title I of the Employee Re-
tirement Income Security Act of 1974 is amended by
adding at the end the following new section:
‘‘SEC. 714. COVERAGE OF SECOND OPINIONS.
‘‘(a) REQUIREMENT.—The provisions of section 2707
shall apply under this subtitle to group health plans, and
to group health insurance coverage offered by a health in-
surance issuer, in the same manner as they apply if such
provisions were included in this subsection.
‘‘(b) NOTICE UNDER GROUP HEALTH PLAN.—The
imposition of the requirement of this section shall be treat-
ed as a material modification in the terms of the plan de-
scribed in section 102(a)(1), for purposes of assuring no-
tice of such requirements under the plan; except that the
summary description required to be provided under the
last sentence of section 104(b)(1) with respect to such
modification shall be provided by not later than 60 days
after the first day of the first plan year in which such
requirement apply.’’.
(B) Section 731(c) of such Act (29 U.S.C.
1191(c)) is amended by striking ‘‘section 711’’ and
inserting ‘‘sections 711 and 714’’.
(C) Section 732(a) of such Act (29 U.S.C.
1191a(a)) is amended by striking ‘‘section 711’’ and
inserting ‘‘sections 711 and 714’’.
(D) The table of contents in section 1 of such
Act is amended by inserting after the item relating
to section 713 the following new item:
‘‘Sec. 714. Coverage of second opinions.’’.
(3) 
INTERNAL
REVENUE
CODE
AMEND-
MENTS.—
(A) IN GENERAL.—Subchapter B of chap-
ter 100 of the Internal Revenue Code of 1986
is amended—
(i) in the table of sections, by insert-
ing after the item relating to section 9812
the following new item:
‘‘Sec. 9813. Coverage of second opinions.’’; and
(ii) by inserting after section 9812 the
following:
‘‘SEC. 9813. COVERAGE OF SECOND OPINIONS.
‘‘The requirements of section 2707 of the Public
Health Service Act shall apply under this section as if such
section were included herein.’’.
(B) CONFORMING
AMENDMENT.—Section
4980D(d)(1) of such Code is amended by strik-
ing ‘‘section 9811’’ and inserting ‘‘sections
9811 and 9813’’.
(b) INDIVIDUAL HEALTH INSURANCE.—(1) Part B
of title XXVII of the Public Health Service Act is amend-