I
106TH CONGRESS
1ST SESSION
H. R. 1806
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 adequate access to providers of obstetric and gynecological
services.
IN THE HOUSE OF REPRESENTATIVES
MAY 13, 1999
Mrs. LOWEY (for herself and Mr. LAZIO) introduced the following bill; which
was referred to the Committee on Commerce, and in addition to the Com-
mittees on Education and the Workforce, and Ways and Means, for a pe-
riod to be subsequently determined by the Speaker, in each case for con-
sideration of such provisions as fall within the jurisdiction of the com-
mittee 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 adequate access to providers of obstetric and
gynecological services.
Be it enacted by the Senate and House of Representa-
tives of the United States of America in Congress assembled,
SECTION 1. SHORT TITLE; FINDINGS.
(a) SHORT TITLE.—This Act may be cited as the
‘‘Access to Women’s Health Care Act of 1999’’.
(b) FINDINGS.—Congress finds the following:
(1) Women’s health historically has received lit-
tle attention.
(2) Women have a different set of primary care
needs than men and providing direct access to pro-
viders of obstetric and gynecological services is an
important way to address some of these differences.
(3) A majority of women view their provider of
obstetric and gynecological services as their primary
or sole care provider.
(4) 78 percent of women think direct access to
providers of obstetric and gynecological services is
very important.
(5) Access to obstetric and gynecological serv-
ices improves the health of a woman by providing
primary and preventive health care throughout the
woman’s lifetime, encompassing care of the whole
patient in addition to focusing on the processes of
the female reproductive system.
(6) More than 60 percent of all office visits to
providers of obstetric and gynecological services are
for preventive care.
(7) President Clinton’s Advisory Commission on
Consumer Protection and Quality in the Health
Care Industry recommended that women should be
able to choose a qualified provider, including obste-
trician-gynecologists, certified nurse midwives, and
other qualified care providers offered by a plan, for
the provision of routine and preventive women’s
health care services.
(8) Providers of obstetric and gynecological
services refer their patients to other health care pro-
fessionals less frequently than other primary care
providers, thus avoiding costly and time-consuming
referrals.
(9) Providers of obstetric and gynecological
services manage the health of women beyond the re-
productive system, and are uniquely qualified on the
basis of education and experience to provide basic
health care services to women.
(10) While more than 37 States have acted to
promote residents’ access to providers of obstetric
and gynecological services, patients in other States
or in Federally-governed health plans are not pro-
tected from access restrictions or limitations.
services provided by a participating health care pro-
fessional practicing in accordance with State law, to
the extent such care is otherwise covered; and
‘‘(2) shall treat the ordering of other gyneco-
logical services by such a participating health care
professional as the prior authorization of the pri-
mary care provider with respect to such care under
the coverage.
‘‘(b) ADEQUATE NUMBER OF PROVIDERS OF OB-
STETRIC AND GYNECOLOGICAL SERVICES.—Each group
health plan and health insurance issuer offering health in-
surance coverage in connection with a group health plan
shall have an adequate number of providers of obstetric
and gynecological services on its roster to satisfy the
health care needs of all female participants and bene-
ficiaries who choose to have such a provider as a primary
care provider, or who otherwise need the services of a pro-
vider of obstetric and gynecological services.
‘‘(c) DEFINITION OF ‘‘PROVIDER OF OBSTETRIC AND
GYNECOLOGICAL SERVICES’’.—For purposes of this sec-
tion the term ‘‘provider of obstetric and gynecological serv-
ices means—
‘‘(1) an obstetrician-gynecologist;
‘‘(2) a nurse practitioner as defined in section
1861(aa)(5)(A); or
‘‘(3) a certified nurse-midwife as defined in sec-
tion 1861(gg)(2).
‘‘(d) CONSTRUCTION.—Nothing in subsection (a)(2)
shall waive any requirements of coverage relating to med-
ical necessity or appropriateness with respect to coverage
of obstetric or gynecological services so ordered.
‘‘(e) PROHIBITIONS.—A group health plan, and a
health insurance issuer offering group health insurance
coverage in connection with a group health plan, may
not—
‘‘(1) deny to a woman eligibility, or continued
eligibility, to enroll or to renew coverage under the
terms of the plan, solely for the purpose of avoiding
the requirements of this section;
‘‘(2) provide monetary payments or rebates to
women to encourage such women to accept less than
the minimum protections available under this sec-
tion; or
‘‘(3) penalize or otherwise reduce or limit the
reimbursement of a provider because such provider
provided care to an individual participant or bene-
ficiary in accordance with this section.
‘‘(f) LEVEL
AND TYPE
OF REIMBURSEMENTS.—
Nothing in this section shall be construed to prevent a
group health plan or a health insurance issuer offering
group health insurance coverage from negotiating the level
and type of reimbursement with a provider for care pro-
vided in accordance with this section.
‘‘(g) NON-PREEMPTION
OF
MORE
PROTECTIVE
STATE LAW WITH RESPECT
TO HEALTH INSURANCE
ISSUERS.—This section shall not be construed to super-
sede any provision of State law which establishes, imple-
ments, or continues in effect any standard or requirement
solely relating to health insurance issuers in connection
with group health insurance coverage that provides great-
er protections to participant and beneficiaries than the
protections provided under this section.’’.
‘‘(h) 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.’’.
(2) INDIVIDUAL
HEALTH
INSURANCE
COV-
ERAGE.—Part B of title XXVII of such Act is
amended by inserting after section 2752 the fol-
lowing new section:
‘‘SEC. 2753. STANDARDS RELATING TO ACCESS TO UNRE-
STRICTED OBSTETRIC AND GYNECOLOGICAL
SERVICES.
‘‘(a) IN GENERAL.—The provisions of section 2707
shall apply to health insurance coverage offered by a
health insurance issuer in the individual market in the
same manner as it applies 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 this section as if such section applied to such issuer
and such issuer were a group health plan.’’.
(b) ERISA AMENDMENTS.—
(1) IN GENERAL.—Subpart B of part 7 of sub-
title B of title I of the Employee Retirement Income
Security Act of 1974 is amended by adding at the
end the following new section:
‘‘SEC. 714. STANDARDS RELATING TO ACCESS TO UNRE-
STRICTED OBSTETRIC AND GYNECOLOGICAL
SERVICES.
‘‘(a) IN GENERAL.—A group health plan (and a
health insurance issuer offering group health insurance
coverage in connection with such a plan) shall comply with
the requirements of section 2707 of the Public Health
Service Act.
‘‘(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.’’.
(2) 
CONFORMING
AMENDMENT.—Section
732(a) of such Act (29 U.S.C. 1191a(a)) is amended
by striking ‘‘section 711’’ and inserting ‘‘sections
711 and 714’’.
(3) CLERICAL AMENDMENT.—The table of con-
tents in section 1 of such Act is amended by insert-
ing after the item relating to section 713 the fol-
lowing new item:
‘‘Sec. 714. Standards relating to access to unrestricted obstetric and gyneco-
logical services.’’.
(c) INTERNAL REVENUE CODE AMENDMENTS.—
(1) IN
GENERAL.—Subchapter B of chapter
100 of the Internal Revenue Code of 1986 is amend-
ed by inserting after section 9812 the following new
section:
‘‘SEC. 9813. STANDARDS RELATING TO ACCESS TO UNRE-
STRICTED OBSTETRIC AND GYNECOLOGICAL
SERVICES.
‘‘(a) IN GENERAL.—In a case in which a group
health plan provides benefits under the terms of the plan
consisting of obstetric or gynecological services, including
appropriate follow-up services and referrals for diagnostic
testing related to obstetric or gynecological services, the
plan shall provide for a female participant or beneficiary
to designate a provider of obstetric and gynecological serv-
ices who has agreed to be designated as such, as the par-
ticipant or beneficiary’s primary care provider. If such
participant or beneficiary has not designated such a pro-
vider as a primary care provider, the plan—
‘‘(1) may not require prior authorization by the
participant or beneficiary’s primary care provider or
otherwise for coverage of obstetric or gynecological
services provided by a participating health care pro-
fessional practicing in accordance with State law, to
the extent such service is otherwise covered; and
‘‘(2) shall treat the ordering of other gyneco-
logical services by such a participating health care
professional as the prior authorization of the pri-
mary care provider with respect to such care under
the coverage.
‘‘(b) ADEQUATE NUMBER OF PROVIDERS OF OB-
STETRIC AND GYNECOLOGICAL SERVICES.—Each group
health plan shall have an adequate number of providers
of obstetric and gynecological services on its roster to sat-
isfy the health care needs of all female participants and
beneficiaries who choose to have such a provider as a pri-
mary care provider, or who otherwise need the services of
a provider obstetric and gynecological services.
‘‘(c) DEFINITION OF ‘‘PROVIDER OF OBSTETRIC AND
GYNECOLOGICAL SERVICES’’.—For purposes of this sec-
tion the term ‘‘provider of obstetric and gynecological serv-
ices means—
‘‘(1) an obstetrician-gynecologist;
‘‘(2) a nurse practitioner as defined in section
1861(aa)(5)(A) of the Social Security Act (42
U.S.C. 1395x(aa)(5(A)); or
‘‘(3) a certified nurse-midwife as defined in sec-
tion 1861(gg)(2) of the Social Security Act (42
U.S.C. 1395x(gg)(2)).
‘‘(d) CONSTRUCTION.—Nothing in subsection (a)(2)
shall waive any requirements of coverage relating to med-
ical necessity or appropriateness with respect to coverage
of obstetric or gynecological services so ordered.
‘‘(e) PROHIBITIONS.—A group health plan, and a
health insurance issuer offering group health insurance
coverage in connection with a group health plan, may
not—
‘‘(1) deny to a woman eligibility, or continued
eligibility, to enroll or to renew coverage under the
terms of the plan, solely for the purpose of avoiding
the requirements of this section;
‘‘(2) provide monetary payments or rebates to
women to encourage such women to accept less than
the minimum protections available under this sec-
tion; or
‘‘(3) penalize or otherwise reduce or limit the
reimbursement of a provider because such provider
provided care to an individual participant or bene-
ficiary in accordance with this section.
‘‘(f) LEVEL
AND TYPE
OF REIMBURSEMENTS.—
Nothing in this section shall be construed to prevent a
group health plan from negotiating the level and type of
reimbursement with a provider for care provided in ac-
cordance with this section.’’.
(2) 
CONFORMING
AMENDMENT.—Section
4980D(d)(1) of such Code is amended by striking
‘‘section 9811’’ and inserting ‘‘sections 9811 and
9813’’.
(3) CLERICAL AMENDMENT.—The table of sec-
tions of subchapter B of chapter 100 of such Code
is amended by inserting after the item relating to
section 9812 the following new item:
‘‘Sec. 9813. Standards relating to access to unrestricted obstetric
and gynecological services.’’.
(d) EFFECTIVE DATES AND RELATED RULES.—
(1) 
GROUP
HEALTH
PLANS
AND
GROUP
HEALTH INSURANCE COVERAGE.—
(A) IN
GENERAL.—Subject to subpara-
graph (B), the amendments made by sub-
sections (a)(1), (b), and (c) apply with respect
to group health plans for plan years beginning
on or after the first day of the first month that
begins more than 1 year after the date of the
enactment of this Act.
(B) 
COLLECTIVE
BARGAINING
EXCEP-
TION.—In the case of a group health plan
maintained pursuant to 1 or more collective
bargaining agreements between employee rep-
resentatives and 1 or more employers ratified
before the date of enactment of this Act, the
amendments made subsections (a)(1), (b), and
(c) shall not apply to plan years beginning be-
fore the later of—
(i) the date on which the last collec-
tive bargaining agreements relating to the
plan terminates (determined without re-
gard to any extension thereof agreed to
after the date of enactment of this Act), or
(ii) the first day described in subpara-
graph (A).
For purposes of clause (i), any plan amendment
made pursuant to a collective bargaining agree-
ment relating to the plan which amends the
plan solely to conform to any requirement
added by subsection (a)(1), (b), or (c) shall not
be treated as a termination of such collective
bargaining agreement.
(2) INDIVIDUAL
HEALTH
INSURANCE
COV-
ERAGE.—The amendment made by subsection (a)(2)
applies with respect to health insurance coverage of-
fered, sold, issued, renewed, in effect, or operated in
the individual market on or after the first day of the
first month that begins more than 1 year after the
date of the enactment of this Act.
(3) LIMITATION ON ENFORCEMENT ACTIONS.—
No enforcement action shall be taken, pursuant to
the amendments made by this section, against a
group health plan or health insurance issuer with re-
spect to a violation of a requirement imposed by
such amendments, and no penalty shall be imposed
on any failure by such plan to comply with any re-
quirement imposed by such amendments, to the ex-
tent that violation or failure occurs before the date
of issuance of final regulations issued in connection
with such requirement, if the plan or issuer has
sought to comply in good faith with such require-
ment.
SEC. 3. COORDINATION OF ADMINISTRATION.
The Secretary of Labor, the Secretary of the Treas-
ury, 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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