[Congressional Record Volume 145, Number 149 (Thursday, October 28, 1999)]
[Senate]
[Pages S13407-S13408]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]

      By Mr. McCAIN (for himself and Ms. Snowe):
  S. 1822. 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; to the Committee on Finance.


            treatment of children's deformities act of 1999

 Mr. McCAIN. Mr. President, today I am introducing legislation 
with my colleague, Senator Snowe, to address the growing problem of 
HMOs denying insurance coverage for reconstructive surgery for children 
suffering from physical defects and deformities. This legislation would 
require medical plans to cover the medical procedures to reconstruct a 
child's appearance if they are born with abnormal structures of the 
body, including a cleft lip or palate.

  Today, approximately seven percent of American children are born with 
pediatric deformities and congenital defects such as cleft lip, cleft 
palate, missing limbs including ears, and other facial deformities. 
Unfortunately, it has become commonplace for insurance companies to 
label reconstructive procedures to correct these deformities as 
cosmetic surgery and deny coverage to help these children eradicate or 
reduce deformities and acquire a normal appearance.
  A recent survey of the American Society of Plastic and Reconstructive 
Surgeons indicated that over half the plastic surgeons questioned have 
had a pediatric patient in the last two years who has been denied, or 
experienced tremendous difficulty in obtaining, insurance coverage for 
reconstructive surgery.
  It is disgraceful that many insurance companies claim that medical 
services to restore to a child some semblance of a normal appearance 
are superfluous and merely for vanity or cosmetic purposes. My 
colleagues may be wondering how such a ludicrous and cruel argument can 
be made when these procedures are clearly reconstructive in nature. 
Helping a child born without ears or with a cleft so severe it extends 
to her hairline is not cosmetic surgery.
  The medical and developmental complications arise from these 
conditions are tremendous. Speech impediments, hearing difficulties and 
dental problems are a few of the physical side effects resulting from a 
child's physical deformity. In addition, the effect of a child's 
deformities on their personal development, confidence, and self-esteem 
and their future aspirations and achievements, is often very far 
reaching.
  A healthy self image is vitally important to develop self esteem and 
confidence. How people see themselves, and how others see them, helps 
determine how a person feels about himself and whether he has the 
strength to cope with difficult challenges, including the taunting of 
peers and disengagement from school activities. As parents, we want our 
children to be armed with a healthy self esteem and confidence. The 
best way to guarantee that happens is to help them develop a strong and 
healthy self image.
  At the same time, I recognize that we live in a society which places 
a high value on physical beauty and often unfairly uses it to measure a 
person's worth, ability or potential in society. It is unrealistic not 
to recognize the unfair obstacles facing children born with deformities 
if they are not provided access to medical services to help them attain 
a more normal physical appearance.
  Some of my colleagues may know that my daughter, Bridget, whom Cindy 
and I adopted from Mother Theresa's orphanage in Bangladesh, was born 
with a severe cleft. We are fortunate to have had the means and 
opportunities to provide the expert medical care necessary to help 
Bridget physically and emotionally. However, we, too, encountered 
numerous obstacles and denials by our insurance providers who did not 
believe that Bridget's medical treatment was necessary. Fortunately, 
Cindy and I were able to afford the reconstructive services Bridget 
needed, despite denials by our health plan. Most hard-working American 
families are not so fortunate. That is why I am introducing this 
important bill to assist all American children.
  This is not a new mandate that could cause health care premiums to 
escalate. What I am proposing simply prohibits plans from frivolously 
ruling that substantial, medically needed reconstructive surgeon for 
children to obtain a relatively normal appearance is cosmetic and 
refusing to pay for the procedures. This bill ensures that all children 
are afforded an opportunity to lead a more normal life and realize 
their full potential.
  Mr. President, I ask that the text of the bill be printed in the 
Record.
  The bill follows:

                                S. 1822

       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 ``Treatment of Children's 
     Deformities Act of 1999''.

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

       (a) Group Health Plans.--
       (1) Public health service act amendments.--
       (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 new section:

     ``SEC. 2707. 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 up to 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 713(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) Conforming amendment.--Section 2723(c) of the Public 
     Health Service Act (42 U.S.C. 300gg-23(c)) is amended by 
     striking ``section 2704'' and inserting ``sections 2704 and 
     2707''.
       (2) ERISA amendments.--
       (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.

[[Page S13408]]

     1185 et seq.) is amended by adding at the end the following 
     new section:

     ``SEC. 714. 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 up to 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 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 
     section 102(a)(1), for purposes of assuring notice of such 
     requirements under the plan; except that the summary 
     description required to be provided under the last 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) Conforming amendments.--
       (i) Section 731(c) of the Employee Retirement Income 
     Security Act of 1974 (29 U.S.C. 1191(c)) is amended by 
     striking ``section 711'' and inserting ``sections 711 and 
     714''.
       (ii) Section 732(a) of the Employee Retirement Income 
     Security Act of 1974 (29 U.S.C. 1191a(a)) is amended by 
     striking ``section 711'' and inserting ``sections 711 and 
     714''.
       (iii) The table of contents in section 1 of the Employee 
     Retirement Income Security Act of 1974 (29 U.S.C. 1001) is 
     amended by inserting after the item relating to section 713 
     the following new item:

``Sec. 714. Standards relating to benefits for minor child's congenital 
              or developmental deformity or disorder.''.

       (3) Internal revenue code amendments.--Subchapter B of 
     chapter 100 of the Internal Revenue Code of 1986 is amended--
       (A) in the table of sections, by inserting after the item 
     relating to section 9812 the following new item:

``Sec. 9813. Standards relating to benefits for minor child's 
              congenital or developmental deformity or disorder.''; and

       (B) by inserting after section 9812 the following:

     ``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 up to 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) Individual Health Insurance.--
       (1) In general.--Part B of title XXVII of the Public Health 
     Service Act (42 U.S.C. 300gg-41 et seq.) is amended by 
     inserting after section 2752 the following new section:

     ``SEC. 2753. 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 up to 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) Conforming amendment.--Section 2762(b)(2) of the Public 
     Health Service Act (42 U.S.C. 300gg-62(b)(2)) is amended by 
     striking ``section 2751'' and inserting ``sections 2751 and 
     2753''.
       (c) Effective Dates.--
       (1) Group market.--The amendments made by subsection (a) 
     shall apply with respect to group health plans for plan years 
     beginning on or after January 1, 2000.
       (2) Individual market.--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 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''.
                                 ______