[Congressional Bills 105th Congress]
[From the U.S. Government Publishing Office]
[S. 249 Introduced in Senate (IS)]







105th CONGRESS
  1st Session
                                 S. 249

 To require that health plans provide coverage for a minimum hospital 
 stay for mastectomies and lymph node dissection for the treatment of 
     breast cancer, coverage for reconstructive surgery following 
        mastectomies, and coverage for secondary consultations.


_______________________________________________________________________


                   IN THE SENATE OF THE UNITED STATES

                            January 30, 1997

Mr. D'Amato (for himself, Ms. Snowe, Mrs. Feinstein, Mr. Hollings, Mr. 
 Moynihan, Mr. Domenici, Mr. Faircloth, Ms. Moseley-Braun, Mr. Biden, 
Mr. Inouye, Mr. Murkowski, Mr. Dodd, Mr. Kerrey, Mr. Hatch, Mr. Gregg, 
  Mr. Smith of New Hampshire, and Mr. Ford) introduced the following 
  bill; which was read twice and referred to the Committee on Finance

_______________________________________________________________________

                                 A BILL


 
 To require that health plans provide coverage for a minimum hospital 
 stay for mastectomies and lymph node dissection for the treatment of 
     breast cancer, coverage for reconstructive surgery following 
        mastectomies, and coverage for secondary consultations.

    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 ``Women's Health and Cancer Rights Act 
of 1997''.

SEC. 2. FINDINGS.

    Congress finds that--
            (1) the offering and operation of health plans affect 
        commerce among the States;
            (2) health care providers located in a State serve patients 
        who reside in the State and patients who reside in other 
        States; and
            (3) in order to provide for uniform treatment of health 
        care providers and patients among the States, it is necessary 
        to cover health plans operating in 1 State as well as health 
        plans operating among the several States.

SEC. 3. AMENDMENTS TO THE EMPLOYEE RETIREMENT INCOME SECURITY ACT OF 
              1974.

    (a) In General.--Subpart B of part 7 of subtitle B of title I of 
the Employee Retirement Income Security Act of 1974 (as added by 
section 603(a) of the Newborns' and Mothers' Health Protection Act of 
1996 and amended by section 702(a) of the Mental Health Parity Act of 
1996) is amended by adding at the end the following new section:

``SEC. 713. REQUIRED COVERAGE FOR MINIMUM HOSPITAL STAY FOR 
              MASTECTOMIES AND LYMPH NODE DISSECTIONS FOR THE TREATMENT 
              OF BREAST CANCER, COVERAGE FOR RECONSTRUCTIVE SURGERY 
              FOLLOWING MASTECTOMIES, AND COVERAGE FOR SECONDARY 
              CONSULTATIONS.

    ``(a) Inpatient Care.--
            ``(1) In general.--A group health plan, and a health 
        insurance issuer providing health insurance coverage in 
        connection with a group health plan, that provides medical and 
        surgical benefits shall ensure that inpatient coverage with 
        respect to the treatment of breast cancer is provided for a 
        period of time as is determined by the attending physician, in 
        consultation with the patient, to be medically appropriate 
        following--
                    ``(A) a mastectomy;
                    ``(B) a lumpectomy; or
                    ``(C) a lymph node dissection for the treatment of 
                breast cancer.
            ``(2) Exception.--Nothing in this section shall be 
        construed as requiring the provision of inpatient coverage if 
        the attending physician and patient determine that a shorter 
        period of hospital stay is medically appropriate.
    ``(b) Reconstructive Surgery.--A group health plan, and a health 
insurance issuer providing health insurance coverage in connection with 
a group health plan, that provides medical and surgical benefits with 
respect to a mastectomy shall ensure that, in a case in which a 
mastectomy patient elects breast reconstruction, coverage is provided 
for--
            ``(1) all stages of reconstruction of the breast on which 
        the mastectomy has been performed; and
            ``(2) surgery and reconstruction of the other breast to 
        produce a symmetrical appearance;
in the manner determined by the attending physician and the patient to 
be appropriate, and consistent with any fee schedule contained in the 
plan.
    ``(c) Prohibition on Certain Modifications.--In implementing the 
requirements of this section, a group health plan, and a health 
insurance issuer providing health insurance coverage in connection with 
a group health plan, may not modify the terms and conditions of 
coverage based on the determination by a participant or beneficiary to 
request less than the minimum coverage required under subsection (a) or 
(b).
    ``(d) Notice.--A group health plan, and a health insurance issuer 
providing health insurance coverage in connection with a group health 
plan shall provide notice to each participant and beneficiary under 
such plan regarding the coverage required by this section in accordance 
with regulations promulgated by the Secretary. Such notice shall be in 
writing and prominently positioned in any literature or correspondence 
made available or distributed by the plan or issuer and shall be 
transmitted--
            ``(1) in the next mailing made by the plan or issuer to the 
        participant or beneficiary;
            ``(2) as part of any yearly informational packet sent to 
        the participant or beneficiary; or
            ``(3) not later than January 1, 1998;
whichever is earlier.
    ``(e) Secondary Consultations.--
            ``(1) In general.--A group health plan, and a health 
        insurance issuer providing health insurance coverage in 
        connection with a group health plan, that provides coverage 
        with respect to medical and surgical services provided in 
        relation to the diagnosis and treatment of cancer shall ensure 
        that full coverage is provided for secondary consultations by 
        specialists in the appropriate medical fields (including 
        pathology, radiology, and oncology) to confirm or refute such 
        diagnosis. Such plan or issuer shall ensure that full coverage 
        is provided for such secondary consultation whether such 
        consultation is based on a positive or negative initial 
        diagnosis. In any case in which the attending physician 
        certifies in writing that services necessary for such a 
        secondary consultation are not sufficiently available from 
        specialists operating under the plan with respect to whose 
        services coverage is otherwise provided under such plan or by 
        such issuer, such plan or issuer shall ensure that coverage is 
        provided with respect to the services necessary for the 
        secondary consultation with any other specialist selected by 
        the attending physician for such purpose at no additional cost 
        to the individual beyond that which the individual would have 
        paid if the specialist was participating in the network of the 
        plan.
            ``(2) Exception.--Nothing in paragraph (1) shall be 
        construed as requiring the provision of secondary consultations 
        where the patient determines not to seek such a consultation.
    ``(f) Prohibition on Penalties or Incentives.--A group health plan, 
and a health insurance issuer providing health insurance coverage in 
connection with a group health plan, may not--
            ``(1) penalize or otherwise reduce or limit the 
        reimbursement of a provider or specialist because the provider 
        or specialist provided care to a participant or beneficiary in 
        accordance with this section;
            ``(2) provide financial or other incentives to a physician 
        or specialist to induce the physician or specialist to keep the 
        length of inpatient stays of patients following a mastectomy, 
        lumpectomy, or a lymph node dissection for the treatment of 
        breast cancer below certain limits or to limit referrals for 
        secondary consultations; or
            ``(3) provide financial or other incentives to a physician 
        or specialist to induce the physician or specialist to refrain 
        from referring a participant or beneficiary for a secondary 
        consultation that would otherwise be covered by the plan or 
        coverage involved under subsection (e).''.
    (b) Clerical Amendment.--The table of contents in section 1 of such 
Act, as amended by section 603 of the Newborns' and Mothers' Health 
Protection Act of 1996 and section 702 of the Mental Health Parity Act 
of 1996, is amended by inserting after the item relating to section 712 
the following new item:

``Sec. 713. Required coverage for minimum hospital stay for 
                            mastectomies and lymph node dissections for 
                            the treatment of breast cancer, coverage 
                            for reconstructive surgery following 
                            mastectomies, and coverage for secondary 
                            consultations.''.
    (c) Effective Dates.--
            (1) In general.--The amendments made by this section shall 
        apply with respect to plan years beginning on or after the date 
        of enactment of this Act.
            (2) Special rule for collective bargaining agreements.--In 
        the case of a group health plan maintained pursuant to 1 or 
        more collective bargaining agreements between employee 
        representatives and 1 or more employers ratified before the 
        date of enactment of this Act, the amendments made by this 
        section 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 terminates 
                (determined without regard to any extension thereof 
                agreed to after the date of enactment of this Act), or
                    (B) January 1, 1998.
        For purposes of subparagraph (A), any plan amendment made 
        pursuant to a collective bargaining agreement relating to the 
        plan which amends the plan solely to conform to any requirement 
        added by this section shall not be treated as a termination of 
        such collective bargaining agreement.

SEC. 4. AMENDMENTS TO THE PUBLIC HEALTH SERVICE ACT RELATING TO THE 
              GROUP MARKET.

    (a) In General.--Subpart 2 of part A of title XXVII of the Public 
Health Service Act (as added by section 604(a) of the Newborns' and 
Mothers' Health Protection Act of 1996 and amended by section 703(a) of 
the Mental Health Parity Act of 1996) is amended by adding at the end 
the following new section:

``SEC. 2706. REQUIRED COVERAGE FOR MINIMUM HOSPITAL STAY FOR 
              MASTECTOMIES AND LYMPH NODE DISSECTIONS FOR THE TREATMENT 
              OF BREAST CANCER, COVERAGE FOR RECONSTRUCTION SURGERY 
              FOLLOWING MASTECTOMIES, AND COVERAGE FOR SECONDARY 
              CONSULTATIONS.

    ``(a) Inpatient Care.--
            ``(1) In general.--A group health plan, and a health 
        insurance issuer providing health insurance coverage in 
        connection with a group health plan, that provides medical and 
        surgical benefits shall ensure that inpatient coverage with 
        respect to the treatment of breast cancer is provided for a 
        period of time as is determined by the attending physician, in 
        consultation with the patient, to be medically appropriate 
        following--
                    ``(A) a mastectomy;
                    ``(B) a lumpectomy; or
                    ``(C) a lymph node dissection for the treatment of 
                breast cancer.
            ``(2) Exception.--Nothing in this section shall be 
        construed as requiring the provision of inpatient coverage if 
        the attending physician and patient determine that a shorter 
        period of hospital stay is medically appropriate.
    ``(b) Reconstructive Surgery.--A group health plan, and a health 
insurance issuer providing health insurance coverage in connection with 
a group health plan, that provides medical and surgical benefits with 
respect to a mastectomy shall ensure that, in a case in which a 
mastectomy patient elects breast reconstruction, coverage is provided 
for--
            ``(1) all stages of reconstruction of the breast on which 
        the mastectomy has been performed; and
            ``(2) surgery and reconstruction of the other breast to 
        produce a symmetrical appearance;
in the manner determined by the attending physician and the patient to 
be appropriate, and consistent with any fee schedule contained in the 
plan.
    ``(c) Prohibition on Certain Modifications.--In implementing the 
requirements of this section, a group health plan, and a health 
insurance issuer providing health insurance coverage in connection with 
a group health plan, may not modify the terms and conditions of 
coverage based on the determination by a participant or beneficiary to 
request less than the minimum coverage required under subsection (a) or 
(b).
    ``(d) Notice.--A group health plan, and a health insurance issuer 
providing health insurance coverage in connection with a group health 
plan shall provide notice to each participant and beneficiary under 
such plan regarding the coverage required by this section in accordance 
with regulations promulgated by the Secretary. Such notice shall be in 
writing and prominently positioned in any literature or correspondence 
made available or distributed by the plan or issuer and shall be 
transmitted--
            ``(1) in the next mailing made by the plan or issuer to the 
        participant or beneficiary;
            ``(2) as part of any yearly informational packet sent to 
        the participant or beneficiary; or
            ``(3) not later than January 1, 1998;
whichever is earlier.
    ``(e) Secondary Consultations.--
            ``(1) In general.--A group health plan, and a health 
        insurance issuer providing health insurance coverage in 
        connection with a group health plan that provides coverage with 
        respect to medical and surgical services provided in relation 
        to the diagnosis and treatment of cancer shall ensure that full 
        coverage is provided for secondary consultations by specialists 
        in the appropriate medical fields (including pathology, 
        radiology, and oncology) to confirm or refute such diagnosis. 
        Such plan or issuer shall ensure that full coverage is provided 
        for such secondary consultation whether such consultation is 
        based on a positive or negative initial diagnosis. In any case 
        in which the attending physician certifies in writing that 
        services necessary for such a secondary consultation are not 
        sufficiently available from specialists operating under the 
        plan with respect to whose services coverage is otherwise 
        provided under such plan or by such issuer, such plan or issuer 
        shall ensure that coverage is provided with respect to the 
        services necessary for the secondary consultation with any 
        other specialist selected by the attending physician for such 
        purpose at no additional cost to the individual beyond that 
        which the individual would have paid if the specialist was 
        participating in the network of the plan.
            ``(2) Exception.--Nothing in paragraph (1) shall be 
        construed as requiring the provision of secondary consultations 
        where the patient determines not to seek such a consultation.
    ``(f) Prohibition on Penalties or Incentives.--A group health plan, 
and a health insurance issuer providing health insurance coverage in 
connection with a group health plan, may not--
            ``(1) penalize or otherwise reduce or limit the 
        reimbursement of a provider or specialist because the provider 
        or specialist provided care to a participant or beneficiary in 
        accordance with this section;
            ``(2) provide financial or other incentives to a physician 
        or specialist to induce the physician or specialist to keep the 
        length of inpatient stays of patients following a mastectomy, 
        lumpectomy, or a lymph node dissection for the treatment of 
        breast cancer below certain limits or to limit referrals for 
        secondary consultations; or
            ``(3) provide financial or other incentives to a physician 
        or specialist to induce the physician or specialist to refrain 
        from referring a participant or beneficiary for a secondary 
        consultation that would otherwise be covered by the plan or 
        coverage involved under subsection (e).''.
    (b) Effective Dates.--
            (1) In general.--The amendments made by this section shall 
        apply to group health plans for plan years beginning on or 
        after the date of enactment of this Act.
            (2) Special rule for collective bargaining agreements.--In 
        the case of a group health plan maintained pursuant to 1 or 
        more collective bargaining agreements between employee 
        representatives and 1 or more employers ratified before the 
        date of enactment of this Act, the amendments made by this 
        section 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 terminates 
                (determined without regard to any extension thereof 
                agreed to after the date of enactment of this Act), or
                    (B) January 1, 1998.
        For purposes of subparagraph (A), any plan amendment made 
        pursuant to a collective bargaining agreement relating to the 
        plan which amends the plan solely to conform to any requirement 
        added by this section shall not be treated as a termination of 
        such collective bargaining agreement.

SEC. 5. AMENDMENT TO THE PUBLIC HEALTH SERVICE ACT RELATING TO THE 
              INDIVIDUAL MARKET.

    (a) In General.--Subpart 3 of part B of title XXVII of the Public 
Health Service Act (as added by section 605(a) of the Newborn's and 
Mother's Health Protection Act of 1996) is amended by adding at the end 
the following new section:

``SEC. 2752. REQUIRED COVERAGE FOR MINIMUM HOSPITAL STAY FOR 
              MASTECTOMIES AND LYMPH NODE DISSECTIONS FOR THE TREATMENT 
              OF BREAST CANCER AND SECONDARY CONSULTATIONS.

    ``The provisions of section 2706 shall apply to health insurance 
coverage offered by a health insurance issuer in the individual 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) Effective Date.--The amendment made by this section shall apply 
with respect to health insurance coverage offered, sold, issued, 
renewed, in effect, or operated in the individual market on or after 
the date of enactment of this Act.

SEC. 6. AMENDMENTS TO THE INTERNAL REVENUE CODE OF 1986.

    (a) In General.--Chapter 100 of the Internal Revenue Code of 1986 
(relating to group health plan portability, access, and renewability 
requirements) is amended by redesignating sections 9804, 9805, and 9806 
as sections 9805, 9806, and 9807, respectively, and by inserting after 
section 9803 the following new section:

``SEC. 9804. REQUIRED COVERAGE FOR MINIMUM HOSPITAL STAY FOR 
              MASTECTOMIES AND LYMPH NODE DISSECTIONS FOR THE TREATMENT 
              OF BREAST CANCER, COVERAGE FOR RECONSTRUCTIVE SURGERY 
              FOLLOWING MASTECTOMIES, AND COVERAGE FOR SECONDARY 
              CONSULTATIONS.

    ``(a) Inpatient Care.--
            ``(1) In general.--A group health plan that provides 
        medical and surgical benefits shall ensure that inpatient 
        coverage with respect to the treatment of breast cancer is 
        provided for a period of time as is determined by the attending 
        physician, in consultation with the patient, to be medically 
        appropriate following--
                    ``(A) a mastectomy;
                    ``(B) a lumpectomy; or
                    ``(C) a lymph node dissection for the treatment of 
                breast cancer.
            ``(2) Exception.--Nothing in this section shall be 
        construed as requiring the provision of inpatient coverage if 
        the attending physician and patient determine that a shorter 
        period of hospital stay is medically appropriate.
    ``(b) Reconstructive Surgery.--A group health plan that provides 
medical and surgical benefits with respect to a mastectomy shall ensure 
that, in a case in which a mastectomy patient elects breast 
reconstruction, coverage is provided for--
            ``(1) all stages of reconstruction of the breast on which 
        the mastectomy has been performed; and
            ``(2) surgery and reconstruction of the other breast to 
        produce a symmetrical appearance;
in the manner determined by the attending physician and the patient to 
be appropriate, and consistent with any fee schedule contained in the 
plan.
    ``(c) Prohibition on Certain Modifications.--In implementing the 
requirements of this section, a group health plan may not modify the 
terms and conditions of coverage based on the determination by a 
participant or beneficiary to request less than the minimum coverage 
required under subsection (a) or (b).
    ``(d) Notice.--A group health plan shall provide notice to each 
participant and beneficiary under such plan regarding the coverage 
required by this section in accordance with regulations promulgated by 
the Secretary. Such notice shall be in writing and prominently 
positioned in any literature or correspondence made available or 
distributed by the plan and shall be transmitted--
            ``(1) in the next mailing made by the plan to the 
        participant or beneficiary;
            ``(2) as part of any yearly informational packet sent to 
        the participant or beneficiary; or
            ``(3) not later than January 1, 1998;
whichever is earlier.
    ``(e) Secondary Consultations.--
            ``(1) In general.--A group health plan that provides 
        coverage with respect to medical and surgical services provided 
        in relation to the diagnosis and treatment of cancer shall 
        ensure that full coverage is provided for secondary 
        consultations by specialists in the appropriate medical fields 
        (including pathology, radiology, and oncology) to confirm or 
        refute such diagnosis. Such plan or issuer shall ensure that 
        full coverage is provided for such secondary consultation 
        whether such consultation is based on a positive or negative 
        initial diagnosis. In any case in which the attending physician 
        certifies in writing that services necessary for such a 
        secondary consultation are not sufficiently available from 
        specialists operating under the plan with respect to whose 
        services coverage is otherwise provided under such plan or by 
        such issuer, such plan or issuer shall ensure that coverage is 
        provided with respect to the services necessary for the 
        secondary consultation with any other specialist selected by 
        the attending physician for such purpose at no additional cost 
        to the individual beyond that which the individual would have 
        paid if the specialist was participating in the network of the 
        plan.
            ``(2) Exception.--Nothing in paragraph (1) shall be 
        construed as requiring the provision of secondary consultations 
        where the patient determines not to seek such a consultation.
    ``(f) Prohibition on Penalties.--A group health plan may not--
            ``(1) penalize or otherwise reduce or limit the 
        reimbursement of a provider or specialist because the provider 
        or specialist provided care to a participant or beneficiary in 
        accordance with this section;
            ``(2) provide financial or other incentives to a physician 
        or specialist to induce the physician or specialist to keep the 
        length of inpatient stays of patients following a mastectomy, 
        lumpectomy, or a lymph node dissection for the treatment of 
        breast cancer below certain limits or to limit referrals for 
        secondary consultations; or
            ``(3) provide financial or other incentives to a physician 
        or specialist to induce the physician or specialist to refrain 
        from referring a participant or beneficiary for a secondary 
        consultation that would otherwise be covered by the plan 
        involved under subsection (e).''.
    (b) Conforming Amendments.--
            (1) Sections 9801(c)(1), 9805(b) (as redesignated by 
        subsection (a)), 9805(c) (as so redesignated), 
        4980D(c)(3)(B)(i)(I), 4980D(d)(3), and 4980D(f)(1) of such Code 
        are each amended by striking ``9805'' each place it appears and 
        inserting ``9806''.
            (2) The heading for subtitle K of such Code is amended to 
        read as follows:

``Subtitle K--Group Health Plan Portability, Access, Renewability, and 
                         Other Requirements''.

            (3) The heading for chapter 100 of such Code is amended to 
        read as follows:

``CHAPTER 100--GROUP HEALTH PLAN PORTABILITY, ACCESS, RENEWABILITY, AND 
                         OTHER REQUIREMENTS''.

            (4) Section 4980D(a) of such Code is amended by striking 
        ``and renewability'' and inserting ``renewability, and other''.
    (c) Clerical Amendments.--
            (1) The table of contents for chapter 100 of such Code is 
        amended by redesignating the items relating to sections 9804, 
        9805, and 9806 as items relating to sections 9805, 9806, and 
        9807, and by inserting after the item relating to section 9803 
        the following new item:

``Sec. 9804. Required coverage for minimum hospital stay for 
                            mastectomies and lymph node dissections for 
                            the treatment of breast cancer, coverage 
                            for reconstructive surgery following 
                            mastectomies, and coverage for secondary 
                            consultations.''.
            (2) The item relating to subtitle K in the table of 
        subtitles for such Code is amended by striking ``and 
        renewability'' and inserting ``renewability, and other''.
            (3) The item relating to chapter 100 in the table of 
        chapters for subtitle K of such Code is amended by striking 
        ``and renewability'' and inserting ``renewability, and other''.
    (d) Effective Dates.--
            (1) In general.--The amendments made by this section shall 
        apply with respect to plan years beginning on or after the date 
        of enactment of this Act.
            (2) Special rule for collective bargaining agreements.--In 
        the case of a group health plan maintained pursuant to 1 or 
        more collective bargaining agreements between employee 
        representatives and 1 or more employers ratified before the 
        date of enactment of this Act, the amendments made by this 
        section 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 terminates 
                (determined without regard to any extension thereof 
                agreed to after the date of enactment of this Act), or
                    (B) January 1, 1998.
        For purposes of subparagraph (A), any plan amendment made 
        pursuant to a collective bargaining agreement relating to the 
        plan which amends the plan solely to conform to any requirement 
        added by this section shall not be treated as a termination of 
        such collective bargaining agreement.
                                 <all>