[Congressional Bills 109th Congress]
[From the U.S. Government Publishing Office]
[S. 910 Introduced in Senate (IS)]







109th CONGRESS
  1st Session
                                 S. 910

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


_______________________________________________________________________


                   IN THE SENATE OF THE UNITED STATES

                             April 26, 2005

Ms. Snowe (for herself, Ms. Landrieu, Mrs. Feinstein, Mrs. Boxer, Mrs. 
    Murray, Mr. Corzine, Mr. Durbin and Mr. Cochran) introduced the 
 following bill; which was read twice and referred to the Committee on 
                 Health, Education, Labor, and Pensions

_______________________________________________________________________

                                 A BILL


 
 To require that health plans provide coverage for a minimum hospital 
stay for mastectomies, lumpectomies, and lymph node dissection for the 
  treatment of breast cancer 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 ``Breast Cancer Patient Protection Act 
of 2005''.

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 (29 U.S.C. 1185 et 
seq.) is amended by adding at the end the following:

``SEC. 714. REQUIRED COVERAGE FOR MINIMUM HOSPITAL STAY FOR 
              MASTECTOMIES, LUMPECTOMIES, AND LYMPH NODE DISSECTIONS 
              FOR THE TREATMENT OF BREAST CANCER 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 (and in the case 
        of a lumpectomy, outpatient) coverage and radiation therapy is 
        provided for breast cancer treatment. Such plan or coverage may 
        not--
                    ``(A) except as provided for in paragraph (2)--
                            ``(i) restrict benefits for any hospital 
                        length of stay in connection with a mastectomy 
                        or breast conserving surgery (such as a 
                        lumpectomy) for the treatment of breast cancer 
                        to less than 48 hours; or
                            ``(ii) restrict benefits for any hospital 
                        length of stay in connection with a lymph node 
                        dissection for the treatment of breast cancer 
                        to less than 24 hours; or
                    ``(B) require that a provider obtain authorization 
                from the plan or the issuer for prescribing any length 
                of stay required under subparagraph (A) (without regard 
                to paragraph (2)).
            ``(2) Exception.--Nothing in this section shall be 
        construed as requiring the provision of inpatient coverage if 
        the attending physician and patient determine that either a 
        shorter period of hospital stay, or outpatient treatment, is 
        medically appropriate.
    ``(b) 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).
    ``(c) 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; or
            ``(2) as part of any yearly informational packet sent to 
        the participant or beneficiary;
whichever is earlier.
    ``(d) 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.
    ``(e) 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;
            ``(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 (d); or
            ``(4) deny to a woman eligibility, or continued 
        eligibility, to enroll or to renew coverage under the terms of 
        the plan or coverage solely for the purpose of avoiding the 
        requirements of this section.''.
    (b) Clerical Amendment.--The table of contents in section 1 of the 
Employee Retirement Income Security Act of 1974 is amended by inserting 
after the item relating to section 713 the following:

``Sec. 714. Required coverage for minimum hospital stay for 
                            mastectomies, lumpectomies, and lymph node 
                            dissections for the treatment of breast 
                            cancer 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 
        that is 90 days 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 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). For 
        purposes of this paragraph, 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 (42 U.S.C. 300gg-4 et seq.) is amended by adding at 
the end the following:

``SEC. 2707. REQUIRED COVERAGE FOR MINIMUM HOSPITAL STAY FOR 
              MASTECTOMIES, LUMPECTOMIES, AND LYMPH NODE DISSECTIONS 
              FOR THE TREATMENT OF BREAST CANCER 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 (and in the case 
        of a lumpectomy, outpatient) coverage and radiation therapy is 
        provided for breast cancer treatment. Such plan or coverage may 
        not--
                    ``(A) except as provided for in paragraph (2)--
                            ``(i) restrict benefits for any hospital 
                        length of stay in connection with a mastectomy 
                        or breast conserving surgery (such as a 
                        lumpectomy) for the treatment of breast cancer 
                        to less than 48 hours; or
                            ``(ii) restrict benefits for any hospital 
                        length of stay in connection with a lymph node 
                        dissection for the treatment of breast cancer 
                        to less than 24 hours; or
                    ``(B) require that a provider obtain authorization 
                from the plan or the issuer for prescribing any length 
                of stay required under subparagraph (A) (without regard 
                to paragraph (2)).
            ``(2) Exception.--Nothing in this section shall be 
        construed as requiring the provision of inpatient coverage if 
        the attending physician and patient determine that either a 
        shorter period of hospital stay, or outpatient treatment, is 
        medically appropriate.
    ``(b) 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).
    ``(c) 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; or
            ``(2) as part of any yearly informational packet sent to 
        the participant or beneficiary;
whichever is earlier.
    ``(d) 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.
    ``(e) 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;
            ``(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 (d); or
            ``(4) deny to a woman eligibility, or continued 
        eligibility, to enroll or to renew coverage under the terms of 
        the plan or coverage solely for the purpose of avoiding the 
        requirements of this section.''.
    (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 90 days 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 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). For 
        purposes of this paragraph, 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.--The first subpart 3 of part B of title XXVII of 
the Public Health Service Act (42 U.S.C. 300gg-11 et seq.) is amended--
            (1) by adding after section 2752 the following:

``SEC. 2753. REQUIRED COVERAGE FOR MINIMUM HOSPITAL STAY FOR 
              MASTECTOMIES, LUMPECTOMIES, AND LYMPH NODE DISSECTIONS 
              FOR THE TREATMENT OF BREAST CANCER AND SECONDARY 
              CONSULTATIONS.

    ``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 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.''; and
            (2) by redesignating such subpart 3 as subpart 2.
    (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.--Subchapter B of chapter 100 of the Internal 
Revenue Code of 1986 is amended--
            (1) in the table of sections, by inserting after the item 
        relating to section 9812 the following:

                              ``Sec. 9813. Required coverage for 
                                        minimum hospital stay for 
                                        mastectomies, lumpectomies, and 
                                        lymph node dissections for the 
                                        treatment of breast cancer and 
                                        coverage for secondary 
                                        consultations.'';
        and
            (2) by inserting after section 9812 the following:

``SEC. 9813. REQUIRED COVERAGE FOR MINIMUM HOSPITAL STAY FOR 
              MASTECTOMIES, LUMPECTOMIES, AND LYMPH NODE DISSECTIONS 
              FOR THE TREATMENT OF BREAST CANCER 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 (and 
        in the case of a lumpectomy, outpatient) coverage and radiation 
        therapy is provided for breast cancer treatment. Such plan may 
        not--
                    ``(A) except as provided for in paragraph (2)--
                            ``(i) restrict benefits for any hospital 
                        length of stay in connection with a mastectomy 
                        or breast conserving surgery (such as a 
                        lumpectomy) for the treatment of breast cancer 
                        to less than 48 hours; or
                            ``(ii) restrict benefits for any hospital 
                        length of stay in connection with a lymph node 
                        dissection for the treatment of breast cancer 
                        to less than 24 hours; or
                    ``(B) require that a provider obtain authorization 
                from the plan for prescribing any length of stay 
                required under subparagraph (A) (without regard to 
                paragraph (2)).
            ``(2) Exception.--Nothing in this section shall be 
        construed as requiring the provision of inpatient coverage if 
        the attending physician and patient determine that either a 
        shorter period of hospital stay, or outpatient treatment, is 
        medically appropriate.
    ``(b) 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).
    ``(c) 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; or
            ``(2) as part of any yearly informational packet sent to 
        the participant or beneficiary;
whichever is earlier.
    ``(d) 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.
    ``(e) 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;
            ``(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 (d); or
            ``(4) 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.''.
    (b) Clerical Amendment.--The table of contents for chapter 100 of 
such Code is amended by inserting after the item relating to section 
9812 the following:

``Sec. 9813. Required coverage for minimum hospital stay for 
                            mastectomies, lumpectomies, and lymph node 
                            dissections for the treatment of breast 
                            cancer 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 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). For 
        purposes of this paragraph, 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>