[Congressional Bills 111th Congress]
[From the U.S. Government Publishing Office]
[S. 1235 Introduced in Senate (IS)]

111th CONGRESS
  1st Session
                                S. 1235

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 SENATE OF THE UNITED STATES

                             June 11, 2009

  Ms. Landrieu (for herself, Mr. Cochran, Mr. Specter, and Mr. Bayh) 
introduced the following bill; which was read twice and referred to the 
          Committee on Health, Education, Labor, and Pensions

_______________________________________________________________________

                                 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 ``Children's Access to Reconstructive 
Evaluation & Surgery (CARES) Act of 2009''.

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 is 
        amended by adding at the end the following new section:

``SEC. 2708. 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 714(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)) is 
        amended by striking ``section 2704'' and inserting ``sections 
        2704 and 2708''.
            (2) ERISA amendments.--(A) 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. 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 who has not 
        attained age 22.
            ``(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.--For purposes of 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 the last sentence of 
section 102(a), for purposes of assuring notice of such requirements 
under the plan; except that the summary description required to be 
provided under the fourth 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)) is 
        amended by striking ``section 711'' and inserting ``sections 
        711 and 715''.
            (C) Section 732(a) of such Act (29 U.S.C. 1191a(a)) is 
        amended by striking ``section 711'' and inserting ``sections 
        711 and 715''.
            (D) The table of contents in section 1 of such Act is 
        amended by inserting after the item relating to section 714 the 
        following new item:

``Sec. 715. Standards relating to benefits for minor child's congenital 
                            or developmental deformity or disorder.''.
            (3) Internal revenue code amendments.--
                    (A) In general.--Subchapter B of chapter 100 of the 
                Internal Revenue Code of 1986 is amended by adding at 
                the end the following new section:

``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 who has not 
        attained age 22.
            ``(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.--For purposes of 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) Clerical amendment.--The table of sections for 
                such subchapter is amended by adding at the end the 
                following new item:

``Sec. 9813. Standards relating to benefits for minor child's 
                            congenital or developmental deformity or 
                            disorder.''.
    (b) Individual Health Insurance.--(1) Part B of title XXVII of the 
Public Health Service Act is amended by inserting after section 2752 
the following new section:

``SEC. 2754. 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 714(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)) is 
amended by striking ``section 2751'' and inserting ``sections 2751 and 
2754''.
    (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, 2010.
    (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 the 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''.
                                 <all>