[Congressional Bills 112th Congress]
[From the U.S. Government Publishing Office]
[H.R. 1955 Introduced in House (IH)]

112th CONGRESS
  1st Session
                                H. R. 1955

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, burns, infection, 
                           tumor, or disease.


_______________________________________________________________________


                    IN THE HOUSE OF REPRESENTATIVES

                              May 24, 2011

Mr. Tiberi (for himself, Mrs. McCarthy of New York, Ms. Schakowsky, Ms. 
  Lee of California, and Mrs. Maloney) introduced the following bill; 
  which was referred to the Committee on Energy and Commerce, and in 
  addition to the Committees on Ways and Means and Education and the 
 Workforce, 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, burns, 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 2011''.

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

    (a) Public Health Service Act Amendments.--(1) Title XXVII of the 
Public Health Service Act is amended by inserting after section 2728 
(42 U.S.C. 300gg-28), as redesignated by section 1001(2) of the Patient 
Protection and Affordable Care Act (Public Law 111-148), the following 
new section:

``SEC. 2729. 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 or individual 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, burns, 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.''.
    (2) Section 2724(c) of such Act (42 U.S.C. 300gg-23(c)), as 
redesignated by section 1001(4) and subsection (c)(14) of the section 
1563 (relating to conforming amendments) of Public Law 111-148, is 
amended by striking ``section 2704'' and inserting ``sections 2725 and 
2729''.
    (3) 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 
2729''.
    (4) For purposes of applying section 2729 of the Public Health 
Service Act, as inserted by paragraph (1), to individual health 
insurance coverage before 2014, the provisions of such section shall be 
treated as also included under part B of title XXVII of the Public 
Health Service Act.
    (b) ERISA Amendments.--(1) 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. 716. 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, burns, 
                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.''.
    (2) Section 731(c) of such Act (29 U.S.C. 1191(c)) is amended by 
striking ``section 711'' and inserting ``sections 711 and 716''.
    (3) Section 732(a) of such Act (29 U.S.C. 1191a(a)) is amended by 
striking ``section 711'' and inserting ``sections 711 and 716''.
    (4) The table of contents in section 1 of such Act is amended by 
inserting after the item relating to section 714 the following new 
items:

``Sec. 715. Additional market reforms.
``Sec. 716. Standards relating to benefits for minor child's congenital 
                            or developmental deformity or disorder.''.
    (c) Internal Revenue Code Amendments.--
            (1) In general.--Subchapter B of chapter 100 of the 
        Internal Revenue Code of 1986, as amended by subsection (f) of 
        the section 1563 (relating to conforming amendments) of Public 
        Law 111-148, is amended by adding at the end the following new 
        section:

``SEC. 9816. 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, burns, 
                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.''.
            (2) Clerical amendment.--The table of sections for such 
        subchapter is amended by adding at the end the following new 
        items:

``Sec. 9815. Additional market reforms.
``Sec. 9816. Standards relating to benefits for minor child's 
                            congenital or developmental deformity or 
                            disorder.''.
    (d) Clarifying Amendment Regarding Application to Grandfathered 
Plans.--Section 1251(a)(4)(A) of the Patient Protection and Affordable 
Care Act (Public Law 111-148; 42 U.S.C. 18011(a)(4)(A)), as added by 
section 2301(a) of Public Law 111-152, is amended by adding at the end 
the following new clause:
                            ``(v) Section 2729 (relating to standards 
                        relating to benefits for minor child's 
                        congenital or developmental deformity or 
                        disorder), as added by section 2(a) of the 
                        Children's Access to Reconstructive Evaluation 
                        & Surgery (CARES) Act of 2011.''.
    (e) Effective Date.--The amendments made by this section shall 
apply with respect to group health plans for plan years beginning on or 
after January 1, 2012, and with respect to health insurance coverage 
offered, sold, issued, renewed, in effect, or operated in the 
individual market on or after such date.
    (f) 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''.
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