[Congressional Record Volume 149, Number 64 (Thursday, May 1, 2003)]
[Senate]
[Pages S5668-S5670]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]

      By Mr. FITZGERALD (for himself, Mr. Kennedy, and Ms. Snowe):
  S. 977. 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 from treatment of a minor 
child's congenital or developmental deformity or disorder due to 
trauma, infection, tumor, or disease; to the Committee on Health, 
Education, Labor, and Pensions.
  Mr. FITZGERALD. Mr. President, I rise today to introduce the 
Children's Deformities Act of 2003, which will require insurance 
companies to cover corrective surgeries for children with congenital or 
developmental deformities.
  According to the March of Dimes, 3.8 percent of babies born 
annually--about 150,000 babies per year suffer from birth defects. 
Approximately 50,000 of these babies require reconstructive surgery. 
Examples of these deformities include cleft lip, cleft palate, skin 
lesions, vascular anomalies, malformations of the ear, hand, or foot, 
and other more profound craniofacial deformities.
  Plastic surgeons are able to correct many of these problems, and 
doing so is critical to both the physical and mental health and 
development of the child. On average, children with congenital 
deformities or developmental anomalies will need three to five surgical 
procedures before normalcy is achieved. An increasing number of 
insurance companies are denying access

[[Page S5669]]

to care by labeling the surgical procedures cosmetic or nonfunctional 
in nature. In some cases, carriers may provide coverage for initial 
procedures, but resist covering later, necessary procedures, claiming 
that they are cosmetic and not medically necessary.
  Although insurance companies ultimately have decided to cover some of 
these procedures, families have had to battle through the appeals 
process of insurance companies for extended periods of time, thereby 
forcing children to wait unnecessarily for needed surgeries. The 
treatment plan for children with congenital defects usually requires 
staged surgical care in accordance with the child's growth pattern. 
Onerous and time-consuming appeals procedures can jeopardize the 
physical and psychological health of children with deformities.
  The American Medical Association defines cosmetic surgery as being 
performed to reshape normal structures of the body in order to improve 
the patient's appearance and self-esteem. In contrast, reconstructive 
surgery is defined as being performed on abnormal structures of the 
body, caused by congenital defects, developmental abnormalities, 
trauma, infection, tumors, or disease. According to the American 
Society of Plastic Surgeons, reconstructive surgery is performed in 
order to improve function and approximate a normal appearance.
  The Treatment of Children's Deformities Act of 2003 will prohibit 
insurers from denying coverage for reconstructive surgery for children. 
This bill identifies the difference between cosmetic and reconstructive 
surgery and incorporates the American Medical Association's definition 
of reconstructive surgery. The measure requires group and individual 
health insurers and group health plans to provide coverage for 
treatment of a minor child's congenital or developmental deformity, 
disease, or injury. The legislation defines ``treatment'' to include 
reconstructive surgical procedures. These are procedures that are 
performed on abnormal structures of the body caused by congenital 
defects, developmental abnormalities, trauma, infection, tumors, or 
disease.
  The Treatment of Children's Deformities Act of 2003 has been endorsed 
by the American Society of Plastic Surgeons, the American Medical 
Association, the American Academy of Pediatrics, and several other 
medical organizations. Fifteen States have already enacted legislation 
that to different degrees require insurance companies to cover 
treatment of craniofacial and congenital anomalies. While governor of 
Texas, George W. Bush signed into law legislation that is similar to 
the legislation I introduce today.
  I would like to thank Senator Kennedy and Senator Snowe for 
cosponsoring this important legislation. I urge all of my colleagues to 
join me in supporting this bill so that children who suffer from 
congenital deformities or developmental anomalies do not have to wait 
unnecessarily for needed treatment.
  I ask unanimous consent that the bill be printed in the Record 
following the conclusion of my remarks.
  There being no objection, the bill was ordered to be printed in the 
Record, as follows:

                                 S. 977

       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 2003''.

     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:

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

     ``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 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 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 is amended by 
     inserting after the item relating to section 713 the 
     following:

``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:

``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:

[[Page S5670]]

     ``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 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) Individual Health Insurance.--
       (1) In general.--Part B of title XXVII of the Public Health 
     Service Act is amended by inserting after section 2752 the 
     following:

     ``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 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) 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 health coverage.--The amendments made by 
     subsection (a) shall apply with respect to group health plans 
     for plan years beginning on or after January 1, 2004.
       (2) Individual health coverage.--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 (42 
     U.S.C. 300gg-92 note) 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''.

  Mr. KENNEDY. Mr. President, it is a privilege to join Senator 
Fitizgerald and Senator Snowe in introducing the Treatment of 
Children's Deformities Act. The purpose of our bill is to see that 
health insurers and health plans cover the treatment of children's 
congenital and developmental deformities and disorders.
  About 7 percent of all children are born with significant problems, 
including cleft lips or cleft palates, serious skin lesions such as 
port wine stains, malformations of the ear, or facial deformities. 
Plastic surgery can correct many of these conditions, but too often 
parents face significant barriers in obtaining care for their children. 
More than half of all plastic surgeons report that these patients are 
denied insurance coverage or had the struggle to receive it. Too often, 
insurers deny coverage by calling the treatment cosmetic or not 
medically necessary.
  The medical, developmental, and psychological problems associated 
with denied or delayed treatment of these deformities are enormous. 
Treatment often requires a series of treatments as the child grow. No 
child should be forced to live with an untreated cleft lip or a facial 
deformity while parents appeal an insurer's unfair denial. Delayed or 
denied treatment puts a child's physical and mental health at risk.
  Our bill requires health insurers and health plans to provide 
coverage to treat a child's congenial or developmental deformity, or 
disorders caused by disease, trauma, infection, or tumor. It is 
supported by many medical organizations, including the American Academy 
of Pediatrics, the American Medical Association, and the American 
Society of Plastic Surgeons. I urge the Senate to support this 
important bill, and give children and families the support they 
deserve.
                                 ______