II 111th CONGRESS 1st Session S. 1235 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.

1.

Short title

This Act may be cited as the Children’s Access to Reconstructive Evaluation & Surgery (CARES) Act of 2009.

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:

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:

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:

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:

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.