I
106TH CONGRESS
1ST SESSION
H. R. 2275
To amend title I of the Employee Retirement Income Security Act to ensure
choice of physicians.
IN THE HOUSE OF REPRESENTATIVES
JUNE 17, 1999
Mr. FLETCHER (for himself, Mr. NORWOOD, and Mr. MCKEON) introduced
the following bill; which was referred to the Committee on Education and
the Workforce
A BILL
To amend title I of the Employee Retirement Income
Security Act to ensure choice of physicians.
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 ‘‘Ensuring Physician
Choice Act of 1999’’.
SEC. 2. CHOICE OF PHYSICIANS.
(a) IN GENERAL.—Subpart B of part 7 of subtitle
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. 715. CHOICE OF PHYSICIANS.
‘‘(a) REQUIREMENT TO OFFER COVERAGE OPTION
TO CERTAIN EMPLOYEES.—Except as provided in sub-
section (b), if a group health plan provides, directly or
through insurance, for coverage of services in connection
with the group health plan only if such services are fur-
nished exclusively through health care professionals who
are members of a closed panel of health care professionals,
such plan shall make available a coverage option which
provides for coverage of such services regardless of wheth-
er or not the professionals are members of such a panel.
‘‘(b) EXCEPTIONS.—
‘‘(1) ALTERNATIVE
GROUP
HEALTH
PLAN.—
Subsection (a) shall not apply in the case of any
group health plan with respect to coverage provided
to any participant or beneficiary of such plan if any
other group health plan maintained by the same
plan sponsor offers to the same participant or bene-
ficiary a coverage option that provides coverage for
services that may be furnished by professionals
whether or not they are members of such a panel.
‘‘(2) SMALL EMPLOYER.—
‘‘(A) IN
GENERAL.—Subsection (a) shall
not apply to any group health plan (other than
a plan under which all benefits consist of health
insurance coverage) of a small employer, as de-
fined, for purposes of this paragraph, with re-
spect to a calendar year and a plan year, as an
employer who employed an average of at least
2 but not more than 25 employees on business
days during the preceding calendar year and
who employs at least 2 employees on the first
day of the plan year.
‘‘(B) APPLICATION OF CERTAIN RULES IN
DETERMINATION
OF
EMPLOYER
SIZE.—For
purposes of this paragraph—
‘‘(i) APPLICATION
OF
AGGREGATION
RULE FOR EMPLOYERS.—Rules similar to
the rules under subsections (b), (c), (m),
and (o) of section 414 of the Internal Rev-
enue Code of 1986 shall apply for purposes
of treating persons as a single employer.
‘‘(ii) EMPLOYERS NOT IN EXISTENCE
IN PRECEDING YEAR.—In the case of an
employer which was not in existence
throughout the preceding calendar year,
the determination of whether such em-
ployer is a small employer shall be based
on the average number of employees that
it is reasonably expected such employer
will employ on business days in the current
calendar year.
‘‘(iii) PREDECESSORS.—Any reference
in this paragraph to an employer shall in-
clude a reference to any predecessor of
such employer.
‘‘(c) CONSTRUCTION.—Nothing in this section shall
be construed—
‘‘(1) as requiring coverage for benefits for a
particular type of health care provider;
‘‘(2) as requiring an employer to pay any costs
as a result of this section or to make equal contribu-
tions with respect to different health coverage op-
tions;
‘‘(3) as preventing a group health plan or
health insurance issuer from imposing higher pre-
miums or cost-sharing on a participant for the exer-
cise of a coverage option that provides coverage for
services that may be furnished by professionals
whether or not they are members of a closed panel;
or
‘‘(4) as applying to any excepted benefits as de-
fined in section 733(c).
‘‘(d) DEFINITIONS.—For purposes of this section:
‘‘(1) COVERAGE THROUGH A CLOSED PANEL OF
HEALTH
CARE
PROFESSIONALS.—The term ‘cov-
erage through a closed panel of health care profes-
sionals’ means coverage of items or services which
are reimbursed for or provided only within a limited
network of such professionals.
‘‘(2) HEALTH CARE PROFESSIONAL.—The term
‘health care professional’ means a physician (as de-
fined in section 1861(r) of the Social Security Act)
or other health care professional if coverage for the
professional’s services is provided under the group
health plan for the services of the professional. Such
term includes a podiatrist, optometrist, chiropractor,
psychologist, dentist, physician assistant, physical or
occupational therapist and therapy assistant, speech-
language pathologist, audiologist, registered or li-
censed practical nurse (including nurse practitioner,
clinical nurse specialist, certified registered nurse
anesthetist, and certified nurse-midwife), licensed
certified social worker, registered respiratory thera-
pist, and certified respiratory therapy technician.’’.
(b) CONFORMING AMENDMENT.—The table of con-
tents in section 1 of such Act is amended by adding at
the end of the items relating to subpart B of part 7 of
subtitle B of title I of such Act the following new item:
‘‘Sec. 715. Ensuring choice of physicians.’’.
SEC. 3. EFFECTIVE DATE AND RELATED RULES.
(a) IN GENERAL.—The amendments made by this
Act shall apply with respect to plan years beginning on
or after January 1 of the second calendar year following
the date of the enactment of this Act, except that the Sec-
retary of Labor may issue regulations before such date
under such amendments. The Secretary shall first issue
regulations necessary to carry out the amendments made
by this Act before the effective date thereof.
(b) LIMITATION ON ENFORCEMENT ACTIONS.—No
enforcement action shall be taken, pursuant to the amend-
ments made by this Act, against a group health plan or
health insurance issuer with respect to a violation of a re-
quirement imposed by such amendments before the date
of issuance of regulations issued in connection with such
requirement, if the plan or issuer has sought to comply
in good faith with such requirement.
(c) SPECIAL RULE FOR COLLECTIVE BARGAINING
AGREEMENTS.—In the case of a group health plan main-
tained pursuant to one or more collective bargaining
agreements between employee representatives and one or
more employers ratified before the date of the enactment
of this Act, the amendments made by this Act shall not
apply with respect to plan years beginning before the later
of—