I
105TH CONGRESS
1ST SESSION
H. R. 586
To prohibit the restriction of certain types of medical communications between
a health care provider and a patient.
IN THE HOUSE OF REPRESENTATIVES
FEBRUARY 5, 1997
Mr. GANSKE (for himself, Mr. MARKEY, Mr. ABERCROMBIE, Mr. ACKERMAN,
Mr. BALDACCI, Mr. BALLENGER, Mr. BARCIA, Mr. BARRETT of Wiscon-
sin, Mr. BENTSEN, Mr. BOEHLERT, Mr. BORSKI, Mr. BOUCHER, Mr.
BROWN of Ohio, Mr. BURTON of Indiana, Mr. CANADY of Florida, Mr.
CHABOT, Mr. CHAMBLISS, Mrs. CLAYTON, Mr. CLEMENT, Mr. COBURN,
Mr. CONDIT, Mr. COOKSEY, Mr. CRAPO, Mr. CUMMINGS, Mr. DAVIS of
Virginia, Mr. DAVIS of Illinois, Mr. DEFAZIO, Mr. DELAHUNT, Ms.
DELAURO, Mr. DELLUMS, Mr. DOOLEY of California, Mr. EHLERS, Ms.
ESHOO, Mr. EVANS, Mr. FALEOMAVAEGA, Mr. FATTAH, Mr. FILNER, Mr.
FOGLIETTA, Mr. FOX of Pennsylvania, Mr. FRANK of Massachusetts, Mr.
FROST, Ms. Furse, Mr. GEJDENSON, Mr. GILLMOR, Mr. GILMAN, Mr.
GORDON, Mr. GRAHAM, Mr. GREEN, Mr. GREENWOOD, Mr. HANSEN, Mr.
HASTINGS of Florida, Mr. HEFLEY, Mr. HINCHEY, Mr. HOSTETTLER,
Mr. HOUGHTON, Ms. EDDIE BERNICE JOHNSON of Texas, Mrs. KELLY,
Mr. KENNEDY of Massachusetts, Mr. KILDEE, Ms. KILPATRICK, Mr.
KIND, Mr. KING, Mr. KLECZKA, Mr. KLINK, Mr. LAFALCE, Mr.
LATHAM, Mr. LEACH, Mr. LEWIS of Georgia, Mr. LATOURETTE, Mr.
LOBIONDO, Ms. LOFGREN, Mrs. LOWEY, Mr. MCDERMOTT, Ms. MCKIN-
NEY, Mrs. MALONEY of New York, Mr. MARTINEZ, Mr. MEEHAN, Mrs.
MEEK of Florida, Mr. MENENDEZ, Mr. MILLER of California, Mrs. MINK
of Hawaii, Mr. MORAN of Virginia, Mrs. MYRICK, Mr. NADLER, Mr.
NETHERCUTT, Mr. NEAL of Massachusetts, Mr. NEY, Mr. NORWOOD,
Mr. OLVER, Mr. OWENS, Mr. OXLEY, Mr. PASTOR, Mr. PAYNE, Ms.
PELOSI, Mr. PICKETT, Mr. PORTER, Mr. POSHARD, Ms. PRYCE of Ohio,
Mr. RAHALL, Mrs. ROUKEMA, Mr. RUSH, Mr. SANDERS, Mr. SAWYER,
Mr. SAXTON, Mr. SCARBOROUGH, Mr. SERRANO, Mr. SKAGGS, Mr.
SKEEN, Ms. SLAUGHTER, Mr. SMITH of New Jersey, Mr. SOLOMON, Mr.
STARK, Mr. STOKES, Mr. TAUZIN, Mr. THORNBERRY, Mrs. THURMAN,
Mr. TRAFICANT, Mr. WELDON of Florida, Mr. WALSH, Mr. WAXMAN,
Mr. WEYGAND, Mr. WHITFIELD, Mr. WISE, and Ms. WOOLSEY) intro-
duced the following bill; which was referred to the Committee on Com-
merce, and in addition to the Committees on Ways and Means, and Edu-
cation and the Workforce, for a period to be subsequently determined by
(5) It is critical that health care providers con-
tinue to exercise their best medical, ethical, and
moral judgment in advising patients without inter-
ference from health plans.
(6) The offering and operation of health plans
affect commerce among the States.
(c) PURPOSE.—It is the purpose of this Act to estab-
lish a Federal standard that protects medical communica-
tions between health care providers and patients.
SEC. 2. PROHIBITION OF INTERFERENCE WITH CERTAIN
MEDICAL COMMUNICATIONS.
(a) PROHIBITION.—
(1) GENERAL
RULE.—The provisions of any
contract or agreement, or the operation of any con-
tract or agreement, between an entity operating a
health plan (including any partnership, association,
or other organization that enters into or administers
such a contract or agreement) and a health care
provider (or group of health care providers) shall not
prohibit or restrict the provider from engaging in
medical communications with his or her patient.
(2) NULLIFICATION.—Any contract provision or
agreement described in paragraph (1) shall be null
and void.
(3) PROHIBITION ON PROVISIONS.—Effective on
the date described in section 5, a contract or agree-
ment described in paragraph (1) shall not include a
provision that violates paragraph (1).
(b) RULES OF CONSTRUCTION.—Nothing in this Act
shall be construed—
(1) to prohibit the enforcement, as part of a
contract or agreement to which a health care pro-
vider is a party, of any mutually agreed upon terms
and conditions, including terms and conditions re-
quiring a health care provider to participate in, and
cooperate with, all programs, policies, and proce-
dures developed or operated by a health plan to as-
sure, review, or improve the quality and effective uti-
lization of health care services (if such utilization is
according to guidelines or protocols that are based
on clinical or scientific evidence and the professional
judgment of the provider) but only if the guidelines
or protocols under such utilization do not prohibit or
restrict medical communications between providers
and their patients; or
(2) to permit a health care provider to mis-
represent the scope of benefits covered under a
health plan or to otherwise require the plan to reim-
burse providers for benefits not covered under the
plan
(c) ENFORCEMENT.—
(1) STATE
AUTHORITY.—Except as otherwise
provided in this subsection, each State shall enforce
the provisions of this Act with respect to health in-
surance issuers that issue, sell, renew, or offer
health plans in the State.
(2) ENFORCEMENT BY SECRETARY.—
(A) IN GENERAL.—Effective on January 1,
1998, if the Secretary, after consultation with
the chief executive officer of a State and the in-
surance commissioner or chief insurance regu-
latory official of the State, determines that the
State has failed to substantially enforce the re-
quirements of this Act with respect to health in-
surance issuers in the State, the Secretary shall
enforce the requirements of this Act with re-
spect to such State.
(B) ENFORCEMENT THROUGH IMPOSITION
OF CIVIL MONEY PENALTY.—
(i) IN GENERAL.—With respect to a
State in which the Secretary is enforcing
the requirements of this Act, an entity op-
erating a health plan in that State that
violates subsection (a) shall be subject to a
civil money penalty of up to $25,000 for
each such violation.
(ii) PROCEDURES.—For purposes of
imposing a civil money penalty under
clause (i), the provisions of subparagraphs
(C) through (G) of section 2722(b)(2) of
the Health Insurance Portability and Ac-
countability Act of 1996 (42 U.S.C.
300gg–22(b)(2)) shall apply except that
the provisions of clause (i) of subpara-
graph (C) of such section shall not apply.
(3) SELF-INSURED PLANS.—Effective on Janu-
ary 1, 1998, the Secretary of Labor shall enforce the
requirements of this section in the case of a health
plan not subject to State regulation by reason of sec-
tion 514(b) of the Employee Retirement Income Se-
curity Act of 1974 (29 U.S.C. 1144(b)).
(4) RULE OF CONSTRUCTION.—Nothing in this
Act shall be construed to affect or modify the provi-
sions of section 514 of the Employee Retirement In-
come Security Act of 1974 (29 U.S.C. 1144).
(d) NO
PREEMPTION
OF
MORE
PROTECTIVE
LAWS.—A State may establish or enforce requirements
with respect to the protection of medical communications,
but only if such requirements are equal to or more protec-
tive of such communications than the requirements estab-
lished under this section.
SEC. 3. PROTECTION OF RELIGIOUS OR MORAL EXPRES-
SION.
(a) IN GENERAL.—An entity operating a health plan
may fully advise—
(1) licensed or certified health care providers at
the time of their employment with the plan or at any
time during such employment; or
(2) participants or beneficiaries at the time of
their enrollment under the plan or at any time dur-
ing which such participants or enrollees are covered
under the plan;
of the plan’s limitations on providing particular medical
services (including limitations on referrals for care pro-
vided outside of the plan) based on the religious or moral
convictions of the entity.
(b) HEALTH CARE PROVIDERS.—Nothing in this Act
shall be construed to alter the rights and duties of a health
care provider to determine what medical communications
are appropriate with respect to each patient, except as
provided for in section 2.
SEC. 4. DEFINITIONS.
In this Act:
(1) HEALTH
CARE
PROVIDER.—The term
‘‘health care provider’’ means anyone licensed or cer-
tified under State law to provide health care services
who is operating within the scope of such license.
(2) HEALTH
INSURANCE
ISSUER.—The term
‘‘health insurance issuer’’ has the meaning given
such term in section 2791(b)(2) of the Public Health
Service Act (as added by the Health Insurance Port-
ability and Accountability Act of 1996).
(3) HEALTH PLAN.—The term ‘‘health plan’’
means a group health plan (as defined in section
2791(a) of the Public Health Service Act (as added
by the Health Insurance Portability and Account-
ability Act of 1996)) and any individual health in-
surance (as defined in section 2791(b)(5)) operated
by a health insurance issuer and includes any other
health care coverage provided through a private or
public entity. In the case of a health plan that is an
employee welfare benefit plan (as defined in section
3(1) of the Employee Retirement Income Security
Act of 1974), any third party administrator or other
person with responsibility for contracts with health
care providers under the plan shall be considered,
for purposes of enforcement under this section, to be
a health insurance issuer operating such health plan.
(4) MEDICAL COMMUNICATION.—
(A) IN
GENERAL.—The term ‘‘medical
communication’’ means any communication
made by a health care provider with a patient
of the health care provider (or the guardian or
legal representative of such patient) with re-
spect to—
(i) the patient’s health status, medical
care, or treatment options;
(ii) any utilization review require-
ments that may affect treatment options
for the patient; or
(iii) any financial incentives that may
affect the treatment of the patient.
(B) 
MISREPRESENTATION.—The 
term
‘‘medical communication’’ does not include a
communication by a health care provider with a
patient of the health care provider (or the
guardian or legal representative of such patient)
if the communication involves a knowing or will-
ful misrepresentation by such provider.
(5) SECRETARY.—The term ‘‘Secretary’’ means
the Secretary of Health and Human Services.
SEC. 5. EFFECTIVE DATE.
This Act shall take effect on the date of enactment
of this Act, except that section 2(a)(3) shall take effect
180 days after such date of enactment.
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