• The Right to a Second Medical Opinion Act
  • August 31, 2009 | Author: Chad C. Almy
  • Law Firm: Troutman Sanders LLP - Atlanta Office
  • On May 19, 2009, Rep. Susan Davis (D-Cal.) introduced The Right to a Second Medical Opinion Act (H.R. 2457) to the House. The bill would create significant costs for employers that provide health insurance benefits to their employees by adding mandatory coverage for second medical opinions under the Employee Retirement Income Security Act (ERISA), the Public Health Service Act (PHSA), and the Internal Revenue Code (IRC). Specifically, the bill would extend coverage at in-network prices for at least three appointments with a qualified physician for the purpose of seeking a second opinion, as well as any ancillary diagnostic tests used to formulate that opinion. If the physician is out-of-network, the employer must cover the difference in cost between the out-of-network doctor’s charges and the normal charge an employee would pay to see an in-network doctor.

    Beneficiaries of both the group plans provided under ERISA and the individual plans provided under the PHSA would receive full coverage for second opinions related to diagnoses, treatment plans, surgical procedures, and medical related therapy. The right to a second opinion would vest if the plan participant receives inconclusive, incomplete, or ineffective information or treatment from a primary-care provider. The only limitation on the participant’s ability to choose a physician is a provision that allows employers to compel workers to seek their second opinions from in-plan physicians, so long as the physician is qualified and within a 50-mile radius of the employee’s home. The in-plan physician must also have an available appointment within 30 days from when the request for a second opinion is made.

    Plan adminstrators may still require workers to obtain preapproval for a second opinion. However, such approval must be given to employees within 10 days of the request’s submission. Preapproval for life-threatening conditions is automatically waived.

    Health plans negotiated as part of a collective bargaining agreement before the effective date of the bill would be exempt from the second-opinion requirements. The current effective date of the bill is set as January 1, 2010, however, the bill is far from becoming a reality. The bill has not been brought to a vote in either the House or Senate, and is currently under further investigation in the House Committee on Ways & Means.