I 
108TH CONGRESS 
1ST SESSION H. R. 1319
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 
MARCH 18, 2003
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 2003’’.
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 
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
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 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
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-
ed by inserting after section 2752 the following new sec-
tion: 
‘‘SEC. 2753. COVERAGE OF SECOND OPINIONS. 
‘‘(a) IN GENERAL.—The provisions of section 2707 
(other than subsection (l)) shall apply to health insurance 
coverage offered by a health insurance issuer in the indi-
vidual market in the same manner as they apply to health 
insurance coverage offered by a health insurance issuer 
in connection with a group health plan in the small or 
large group market. 
‘‘(b) NOTICE.—A health insurance issuer under this 
part shall comply with the notice requirement under sec-
tion 714(b) of the Employee Retirement Income Security 
Act of 1974 with respect to the requirements referred to 
in subsection (a) as if such section applied to such issuer 
and such issuer were a group health plan.’’. 
(2) Section 2762(b)(2) of such Act (42 U.S.C. 
300gg–62(b)(2)) is amended by striking ‘‘section 2751’’ 
and inserting ‘‘sections 2751 and 2753’’. 
(c) EFFECTIVE DATES.—
(1) 
GROUP
HEALTH
PLANS
AND
GROUP 
HEALTH INSURANCE COVERAGE.—Subject to para-
graph (3), the amendments made by subsection (a) 
apply with respect to group health plans for plan 
years beginning on or after January 1, 2004.
(2) INDIVIDUAL
HEALTH
INSURANCE
COV-
ERAGE.—The amendments made by subsection (b) 
apply with respect to health insurance coverage of-
fered, sold, issued, renewed, in effect, or operated in 
the individual market on or after such date. 
(3) COLLECTIVE BARGAINING EXCEPTION.—In 
the case of a group health plan maintained pursuant 
to 1 or more collective bargaining agreements be-
tween employee representatives and 1 or more em-
ployers ratified before the date of enactment of this 
Act, the amendments made subsection (a) shall not 
apply to plan years beginning before the later of—
(A) the date on which the last collective 
bargaining agreements relating to the plan ter-
minates (determined without regard to any ex-
tension thereof agreed to after the date of en-
actment of this Act), or 
(B) January 1, 2004. 
For purposes of subparagraph (A), any plan amend-
ment made pursuant to a collective bargaining 
agreement relating to the plan which amends the 
plan solely to conform to any requirement added by 
subsection (a) shall not be treated as a termination 
of such collective bargaining agreement.
(d) COORDINATION OF ADMINISTRATION.—The Sec-
retary of Labor, the Secretary of the Treasury, and the 
Secretary of Health and Human Services shall ensure, 
through the execution of an interagency memorandum of 
understanding among such Secretaries, that—
(1) regulations, rulings, and interpretations 
issued by such Secretaries relating to the same mat-
ter over which two or more such Secretaries have re-
sponsibility under the provisions of this Act (and the 
amendments made thereby) are administered so as 
to have the same effect at all times; and 
(2) coordination of policies relating to enforcing 
the same requirements through such Secretaries in 
order to have a coordinated enforcement strategy 
that avoids duplication of enforcement efforts and 
assigns priorities in enforcement.
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