[Congressional Bills 105th Congress]
[From the U.S. Government Publishing Office]
[H.R. 4737 Introduced in House (IH)]

  2d Session
                                H. R. 4737

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 treatment of a minor child's congenital or 
developmental deformity or disorder due to trauma, infection, tumor, or 
                                disease.


_______________________________________________________________________


                    IN THE HOUSE OF REPRESENTATIVES

                            October 8, 1998

 Mrs. Kelly (for herself, Mr. Frost, Mr. Ganske, Mrs. McCarthy of New 
  York, Mr. Gilman, Mr. Condit, Mr. LoBiondo, and Mrs. Maloney of New 
    York) introduced the following bill; which was referred to the 
 Committee on Commerce, and in addition to the Committees on Education 
and the Workforce, and Ways and Means, for a period to be subsequently 
   determined by the Speaker, in each case for consideration of such 
 provisions as fall within the jurisdiction of the committee concerned

_______________________________________________________________________

                                 A BILL


 
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 treatment of a minor child's congenital or 
developmental deformity or disorder due to trauma, infection, tumor, or 
                                disease.

    Be it enacted by the Senate and House of Representatives of the 
United States of America in Congress assembled,

SECTION 1. SHORT TITLE.

    This Act may be cited as the ``Treatment of Children's Deformities 
Act of 1998''.

SEC. 2. COVERAGE OF MINOR CHILD'S CONGENITAL OR DEVELOPMENTAL DEFORMITY 
              OR DISORDER.

    (a) Group Health Plans.--
            (1) Public health service act amendments.--(A) Subpart 2 of 
        part A of title XXVII of the Public Health Service Act, as 
        amended by section 703(a) of Public Law 104-204, is amended by 
        adding at the end the following new section:

``SEC. 2706. STANDARDS RELATING TO BENEFITS FOR MINOR CHILD'S 
              CONGENITAL OR DEVELOPMENTAL DEFORMITY OR DISORDER.

    ``(a) Requirements for Reconstructive Surgery.--
            ``(1) In general.--A group health plan, and a health 
        insurance issuer offering group health insurance coverage, that 
        provides coverage for surgical benefits shall provide coverage 
        for outpatient and inpatient diagnosis and treatment of a minor 
        child's congenital or developmental deformity, disease, or 
        injury. A minor child shall include any individual through 21 
        years of age.
            ``(2) Requirements.--Any coverage provided under paragraph 
        (1) shall be subject to pre-authorization or pre-certification 
        as required by the plan or issuer, and such coverage shall 
        include any surgical treatment which, in the opinion of the 
        treating physician, is medically necessary to approximate a 
        normal appearance.
            ``(3) Treatment defined.--
                    ``(A) In general.--In this section, the term 
                `treatment' includes reconstructive surgical procedures 
                (procedures that are generally performed to improve 
                function, but may also be performed to approximate a 
                normal appearance) that are performed on abnormal 
                structures of the body caused by congenital defects, 
                developmental abnormalities, trauma, infection, tumors, 
                or disease, including--
                            ``(i) procedures that do not materially 
                        affect the function of the body part being 
                        treated; and
                            ``(ii) procedures for secondary conditions 
                        and follow-up treatment.
                    ``(B) Exception.--Such term does not include 
                cosmetic surgery performed to reshape normal structures 
                of the body to improve appearance or self-esteem.
    ``(b) Notice.--A group health plan under this part shall comply 
with the notice requirement under section 713(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)), as 
        amended by section 604(b)(2) of Public Law 104-204, is amended 
        by striking ``section 2704'' and inserting ``sections 2704 and 
        2706''.
            (2) ERISA amendments.--(A) Subpart B of part 7 of subtitle 
        B of title I of the Employee Retirement Income Security Act of 
        1974, as amended by section 702(a) of Public Law 104-204, is 
        amended by adding at the end the following new section:

``SEC. 713. STANDARDS RELATING TO BENEFITS FOR MINOR CHILD'S CONGENITAL 
              OR DEVELOPMENTAL DEFORMITY OR DISORDER.

    ``(a) Requirements for Reconstructive Surgery.--
            ``(1) In general.--A group health plan, and a health 
        insurance issuer offering group health insurance coverage, that 
        provides coverage for surgical benefits shall provide coverage 
        for outpatient and inpatient diagnosis and treatment of a minor 
        child's congenital or developmental deformity, disease, or 
        injury. A minor child shall include any individual through 21 
        years of age.
            ``(2) Requirements.--Any coverage provided under paragraph 
        (1) shall be subject to pre-authorization or pre-certification 
        as required by the plan or issuer, and such coverage shall 
        include any surgical treatment which, in the opinion of the 
        treating physician, is medically necessary to approximate a 
        normal appearance.
            ``(3) Treatment defined.--
                    ``(A) In general.--In this section, the term 
                `treatment' includes reconstructive surgical procedures 
                (procedures that are generally performed to improve 
                function, but may also be performed to approximate a 
                normal appearance) that are performed on abnormal 
                structures of the body caused by congenital defects, 
                developmental abnormalities, trauma, infection, tumors, 
                or disease, including--
                            ``(i) procedures that do not materially 
                        affect the function of the body part being 
                        treated; and
                            ``(ii) procedures for secondary conditions 
                        and follow-up treatment.
                    ``(B) Exception.--Such term does not include 
                cosmetic surgery performed to reshape normal structures 
                of the body to improve appearance or self-esteem.
    ``(b) Notice Under Group Health Plan.--The imposition of the 
requirements of this section shall be treated as a material 
modification in the terms of the plan described in section 102(a)(1), 
for purposes of assuring notice 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 requirements apply.''.
            (B) Section 731(c) of such Act (29 U.S.C. 1191(c)), as 
        amended by section 603(b)(1) of Public Law 104-204, is amended 
        by striking ``section 711'' and inserting ``sections 711 and 
        713''.
            (C) Section 732(a) of such Act (29 U.S.C. 1191a(a)), as 
        amended by section 603(b)(2) of Public Law 104-204, is amended 
        by striking ``section 711'' and inserting ``sections 711 and 
        713''.
            (D) The table of contents in section 1 of such Act is 
        amended by inserting after the item relating to section 712 the 
        following new item:

``Sec. 713. Standards relating to benefits for minor child's congenital 
                            or developmental deformity or disorder.''.
            (3) Internal revenue code amendments.--Subchapter B of 
        chapter 100 of the Internal Revenue Code of 1986 (as amended by 
        section 1531(a) of the Taxpayer Relief Act of 1997) is 
        amended--
                    (A) in the table of sections, by inserting after 
                the item relating to section 9812 the following new 
                item:

                              ``Sec. 9813. Standards relating to 
                                        benefits for minor child's 
                                        congenital or developmental 
                                        deformity or disorder.''; and
                    (B) by inserting after section 9812 the following:

``SEC. 9813. STANDARDS RELATING TO BENEFITS FOR MINOR CHILD'S 
              CONGENITAL OR DEVELOPMENTAL DEFORMITY OR DISORDER.

    ``(a) Requirements for Reconstructive Surgery.--
            ``(1) In general.--A group health plan, and a health 
        insurance issuer offering group health insurance coverage, that 
        provides coverage for surgical benefits shall provide coverage 
        for outpatient and inpatient diagnosis and treatment of a minor 
        child's congenital or developmental deformity, disease, or 
        injury. A minor child shall include any individual through 21 
        years of age.
            ``(2) Requirements.--Any coverage provided under paragraph 
        (1) shall be subject to pre-authorization or pre-certification 
        as required by the plan or issuer, and such coverage shall 
        include any surgical treatment which, in the opinion of the 
        treating physician, is medically necessary to approximate a 
        normal appearance.
            ``(3) Treatment defined.--
                    ``(A) In general.--In this section, the term 
                `treatment' includes reconstructive surgical procedures 
                (procedures that are generally performed to improve 
                function, but may also be performed to approximate a 
                normal appearance) that are performed on abnormal 
                structures of the body caused by congenital defects, 
                developmental abnormalities, trauma, infection, tumors, 
                or disease, including--
                            ``(i) procedures that do not materially 
                        affect the function of the body part being 
                        treated; and
                            ``(ii) procedures for secondary conditions 
                        and follow-up treatment.
                    ``(B) Exception.--Such term does not include 
                cosmetic surgery performed to reshape normal structures 
                of the body to improve appearance or self-esteem.''.
    (b) Individual Health Insurance.--(1) Part B of title XXVII of the 
Public Health Service Act, as amended by section 605(a) of Public Law 
104-204, is amended by inserting after section 2751 the following new 
section:

``SEC. 2752. STANDARDS RELATING TO BENEFITS FOR MINOR CHILD'S 
              CONGENITAL OR DEVELOPMENTAL DEFORMITY OR DISORDER.

    ``(a) Requirements for Reconstructive Surgery.--
            ``(1) In general.--A group health plan, and a health 
        insurance issuer offering group health insurance coverage, that 
        provides coverage for surgical benefits shall provide coverage 
        for outpatient and inpatient diagnosis and treatment of a minor 
        child's congenital or developmental deformity, disease, or 
        injury. A minor child shall include any individual through 21 
        years of age.
            ``(2) Requirements.--Any coverage provided under paragraph 
        (1) shall be subject to pre-authorization or pre-certification 
        as required by the plan or issuer, and such coverage shall 
        include any surgical treatment which, in the opinion of the 
        treating physician, is medically necessary to approximate a 
        normal appearance.
            ``(3) Treatment defined.--
                    ``(A) In general.--In this section, the term 
                `treatment' includes reconstructive surgical procedures 
                (procedures that are generally performed to improve 
                function, but may also be performed to approximate a 
                normal appearance) that are performed on abnormal 
                structures of the body caused by congenital defects, 
                developmental abnormalities, trauma, infection, tumors, 
                or disease, including--
                            ``(i) procedures that do not materially 
                        affect the function of the body part being 
                        treated; and
                            ``(ii) procedures for secondary conditions 
                        and follow-up treatment.
                    ``(B) Exception.--Such term does not include 
                cosmetic surgery performed to reshape normal structures 
                of the body to improve appearance or self-esteem.
    ``(b) Notice.--A health insurance issuer under this part shall 
comply with the notice requirement under section 713(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)), as 
added by section 605(b)(3)(B) of Public Law 104-204, is amended by 
striking ``section 2751'' and inserting ``sections 2751 and 2752''.
    (c) Effective Dates.--(1) The amendments made by subsection (a) 
shall apply with respect to group health plans for plan years beginning 
on or after January 1, 1999.
    (2) The amendment made by subsection (b) shall apply with respect 
to health insurance coverage offered, sold, issued, renewed, in effect, 
or operated in the individual market on or after such date.
    (d) Coordinated Regulations.--Section 104(1) of Health Insurance 
Portability and Accountability Act of 1996 is amended by striking 
``this subtitle (and the amendments made by this subtitle and section 
401)'' and inserting ``the provisions of part 7 of subtitle B of title 
I of the Employee Retirement Income Security Act of 1974, the 
provisions of parts A and C of title XXVII of the Public Health Service 
Act, and chapter 100 of the Internal Revenue Code of 1986''.
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