[Congressional Record Volume 151, Number 72 (Thursday, May 26, 2005)]
[Senate]
[Pages S6028-S6029]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]

      By Mr. COLEMAN (for himself, Ms. Landrieu, Mr. DeWine, Ms. Snowe, 
        Mr. Cochran, Mr. Vitter, Mr. Bayh, and Mr. Smith):
  S. 1132. 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 Health, 
Education, Labor, and Pensions.
  Mr. COLEMAN. Mr. President, I am pleased today to be introducing the 
bipartisan Treatment of Children's Deformities Act. I am pleased to be 
joined by many of my friends and colleagues, including Senators 
Landrieu, DeWine, Snowe, Cochran, Vitter and Bayh.
  Imagine being a parent with a child who has a cleft lip and palate or 
another more severe congenital facial deformity that requires 
reconstructive surgery to achieve a sense of normalcy and function. Now 
imagine receiving a letter from your insurance carrier that states the 
following:

       The reviewer determined that although the procedures listed 
     above would enhance the appearance of the patient, the 
     procedures listed are not necessary to correct a functional 
     disorder and therefore do not meet the criteria for benefits 
     as outlined in the medical plan.

  Unfortunately, there are numerous examples of children and families 
around the country that have been confronted with this kind of heart 
wrenching situation. Examples of congenital deformities include cleft 
lip, cleft palate, skin lesions, vascular anomalies, malformations of 
the ear, hand, or foot, and other more profound craniofacial 
deformities. It is essential for children with these problems to 
receive timely surgical care in order to have a chance at leading 
normal, healthy, happy lives. And yet, an increasing number of kids go 
without life changing treatment because treatment is regarded as 
``cosmetic'' or ``non-functional.''
  It's unfortunate that legislation is necessary. However, this 
legislation will ensure that children who are born with a congenital 
deformity--whether a cleft lip and palate or a more severe deformity--
receive the reconstructive surgery they need to achieve a sense of 
normalcy and function.
  According to the March of Dimes, 150,000 newborns suffer from birth 
defects each year. Of the 150,000 born, approximately 50,000 require 
reconstructive surgery. Although surgeons are able to correct many of 
these problems, an increasing number of these children are denied 
access to care by the labeling of the procedures as ``cosmetic'' or 
``non-functional'' in nature.
  A common Federal definition of reconstructive surgery, based on the 
American Medical Association's definition, will help clarify coverage 
nationally and reduce the delay for children in need of surgery.
  It is essential for children with these problems to receive timely 
surgical care in order to have a chance at leading normal, healthy, and 
happy lives. Also, many times these surgeries are best performed while 
children are young and their bodies can more readily recover and 
respond to the corrective surgery.
  The Treatment of Children's Deformities Act differentiates between 
cosmetic and reconstructive surgery. The legislation defines 
reconstructive surgery as that being performed on abnormal structures 
of the body, caused by congenital defects, developmental abnormalities, 
trauma, infection, tumors or disease.
  Cosmetic surgery, in contrast, is defined by the American Medical 
Association as being performed to reshape normal structures of the body 
in order to improve the patient's appearance and self-esteem.
  Children born with deformities should receive the help they need and 
this legislation will make it happen. I look forward to working with my 
colleagues to pass this legislation that will improve the quality of 
life for children born with congenital deformities. I urge my 
colleagues to join me in supporting this legislation.
  I ask unanimous consent that the text of the bill be printed in the 
Record.
  There being no objection, the bill was ordered to be printed in the 
Record, as follows:

                                S. 1132

       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 2005''.

     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.

[[Page S6029]]

       ``(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:

     ``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, 2006.
       (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''.
                                 ______