[Congressional Bills 109th Congress]
[From the U.S. Government Publishing Office]
[S. 910 Introduced in Senate (IS)]
109th CONGRESS
1st Session
S. 910
To require that health plans provide coverage for a minimum hospital
stay for mastectomies, lumpectomies, and lymph node dissection for the
treatment of breast cancer and coverage for secondary consultations.
_______________________________________________________________________
IN THE SENATE OF THE UNITED STATES
April 26, 2005
Ms. Snowe (for herself, Ms. Landrieu, Mrs. Feinstein, Mrs. Boxer, Mrs.
Murray, Mr. Corzine, Mr. Durbin and Mr. Cochran) introduced the
following bill; which was read twice and referred to the Committee on
Health, Education, Labor, and Pensions
_______________________________________________________________________
A BILL
To require that health plans provide coverage for a minimum hospital
stay for mastectomies, lumpectomies, and lymph node dissection for the
treatment of breast cancer and coverage for secondary consultations.
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 ``Breast Cancer Patient Protection Act
of 2005''.
SEC. 2. FINDINGS.
Congress finds that--
(1) the offering and operation of health plans affect
commerce among the States;
(2) health care providers located in a State serve patients
who reside in the State and patients who reside in other
States; and
(3) in order to provide for uniform treatment of health
care providers and patients among the States, it is necessary
to cover health plans operating in 1 State as well as health
plans operating among the several States.
SEC. 3. AMENDMENTS TO THE EMPLOYEE RETIREMENT INCOME SECURITY ACT OF
1974.
(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. REQUIRED COVERAGE FOR MINIMUM HOSPITAL STAY FOR
MASTECTOMIES, LUMPECTOMIES, AND LYMPH NODE DISSECTIONS
FOR THE TREATMENT OF BREAST CANCER AND COVERAGE FOR
SECONDARY CONSULTATIONS.
``(a) Inpatient Care.--
``(1) In general.--A group health plan, and a health
insurance issuer providing health insurance coverage in
connection with a group health plan, that provides medical and
surgical benefits shall ensure that inpatient (and in the case
of a lumpectomy, outpatient) coverage and radiation therapy is
provided for breast cancer treatment. Such plan or coverage may
not--
``(A) except as provided for in paragraph (2)--
``(i) restrict benefits for any hospital
length of stay in connection with a mastectomy
or breast conserving surgery (such as a
lumpectomy) for the treatment of breast cancer
to less than 48 hours; or
``(ii) restrict benefits for any hospital
length of stay in connection with a lymph node
dissection for the treatment of breast cancer
to less than 24 hours; or
``(B) require that a provider obtain authorization
from the plan or the issuer for prescribing any length
of stay required under subparagraph (A) (without regard
to paragraph (2)).
``(2) Exception.--Nothing in this section shall be
construed as requiring the provision of inpatient coverage if
the attending physician and patient determine that either a
shorter period of hospital stay, or outpatient treatment, is
medically appropriate.
``(b) Prohibition on Certain Modifications.--In implementing the
requirements of this section, a group health plan, and a health
insurance issuer providing health insurance coverage in connection with
a group health plan, may not modify the terms and conditions of
coverage based on the determination by a participant or beneficiary to
request less than the minimum coverage required under subsection (a).
``(c) Notice.--A group health plan, and a health insurance issuer
providing health insurance coverage in connection with a group health
plan shall provide notice to each participant and beneficiary under
such plan regarding the coverage required by this section in accordance
with regulations promulgated by the Secretary. Such notice shall be in
writing and prominently positioned in any literature or correspondence
made available or distributed by the plan or issuer and shall be
transmitted--
``(1) in the next mailing made by the plan or issuer to the
participant or beneficiary; or
``(2) as part of any yearly informational packet sent to
the participant or beneficiary;
whichever is earlier.
``(d) Secondary Consultations.--
``(1) In general.--A group health plan, and a health
insurance issuer providing health insurance coverage in
connection with a group health plan, that provides coverage
with respect to medical and surgical services provided in
relation to the diagnosis and treatment of cancer shall ensure
that full coverage is provided for secondary consultations by
specialists in the appropriate medical fields (including
pathology, radiology, and oncology) to confirm or refute such
diagnosis. Such plan or issuer shall ensure that full coverage is
provided for such secondary consultation whether such consultation is
based on a positive or negative initial diagnosis. In any case in which
the attending physician certifies in writing that services necessary
for such a secondary consultation are not sufficiently available from
specialists operating under the plan with respect to whose services
coverage is otherwise provided under such plan or by such issuer, such
plan or issuer shall ensure that coverage is provided with respect to
the services necessary for the secondary consultation with any other
specialist selected by the attending physician for such purpose at no
additional cost to the individual beyond that which the individual
would have paid if the specialist was participating in the network of
the plan.
``(2) Exception.--Nothing in paragraph (1) shall be
construed as requiring the provision of secondary consultations
where the patient determines not to seek such a consultation.
``(e) Prohibition on Penalties or Incentives.--A group health plan,
and a health insurance issuer providing health insurance coverage in
connection with a group health plan, may not--
``(1) penalize or otherwise reduce or limit the
reimbursement of a provider or specialist because the provider
or specialist provided care to a participant or beneficiary in
accordance with this section;
``(2) provide financial or other incentives to a physician
or specialist to induce the physician or specialist to keep the
length of inpatient stays of patients following a mastectomy,
lumpectomy, or a lymph node dissection for the treatment of
breast cancer below certain limits or to limit referrals for
secondary consultations;
``(3) provide financial or other incentives to a physician
or specialist to induce the physician or specialist to refrain
from referring a participant or beneficiary for a secondary
consultation that would otherwise be covered by the plan or
coverage involved under subsection (d); or
``(4) deny to a woman eligibility, or continued
eligibility, to enroll or to renew coverage under the terms of
the plan or coverage solely for the purpose of avoiding the
requirements of this section.''.
(b) Clerical Amendment.--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. Required coverage for minimum hospital stay for
mastectomies, lumpectomies, and lymph node
dissections for the treatment of breast
cancer and coverage for secondary
consultations.''.
(c) Effective Dates.--
(1) In general.--The amendments made by this section shall
apply with respect to plan years beginning on or after the date
that is 90 days after the date of enactment of this Act.
(2) Special rule for collective bargaining agreements.--In
the case of a group health plan maintained pursuant to 1 or
more collective bargaining agreements between employee
representatives and 1 or more employers ratified before the
date of enactment of this Act, the amendments made by this
section shall not apply to plan years beginning before the date
on which the last collective bargaining agreements relating to
the plan terminates (determined without regard to any extension
thereof agreed to after the date of enactment of this Act). For
purposes of this paragraph, any plan amendment made pursuant to
a collective bargaining agreement relating to the plan which
amends the plan solely to conform to any requirement added by
this section shall not be treated as a termination of such
collective bargaining agreement.
SEC. 4. AMENDMENTS TO THE PUBLIC HEALTH SERVICE ACT RELATING TO THE
GROUP MARKET.
(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. REQUIRED COVERAGE FOR MINIMUM HOSPITAL STAY FOR
MASTECTOMIES, LUMPECTOMIES, AND LYMPH NODE DISSECTIONS
FOR THE TREATMENT OF BREAST CANCER AND COVERAGE FOR
SECONDARY CONSULTATIONS.
``(a) Inpatient Care.--
``(1) In general.--A group health plan, and a health
insurance issuer providing health insurance coverage in
connection with a group health plan, that provides medical and
surgical benefits shall ensure that inpatient (and in the case
of a lumpectomy, outpatient) coverage and radiation therapy is
provided for breast cancer treatment. Such plan or coverage may
not--
``(A) except as provided for in paragraph (2)--
``(i) restrict benefits for any hospital
length of stay in connection with a mastectomy
or breast conserving surgery (such as a
lumpectomy) for the treatment of breast cancer
to less than 48 hours; or
``(ii) restrict benefits for any hospital
length of stay in connection with a lymph node
dissection for the treatment of breast cancer
to less than 24 hours; or
``(B) require that a provider obtain authorization
from the plan or the issuer for prescribing any length
of stay required under subparagraph (A) (without regard
to paragraph (2)).
``(2) Exception.--Nothing in this section shall be
construed as requiring the provision of inpatient coverage if
the attending physician and patient determine that either a
shorter period of hospital stay, or outpatient treatment, is
medically appropriate.
``(b) Prohibition on Certain Modifications.--In implementing the
requirements of this section, a group health plan, and a health
insurance issuer providing health insurance coverage in connection with
a group health plan, may not modify the terms and conditions of
coverage based on the determination by a participant or beneficiary to
request less than the minimum coverage required under subsection (a).
``(c) Notice.--A group health plan, and a health insurance issuer
providing health insurance coverage in connection with a group health
plan shall provide notice to each participant and beneficiary under
such plan regarding the coverage required by this section in accordance
with regulations promulgated by the Secretary. Such notice shall be in
writing and prominently positioned in any literature or correspondence
made available or distributed by the plan or issuer and shall be
transmitted--
``(1) in the next mailing made by the plan or issuer to the
participant or beneficiary; or
``(2) as part of any yearly informational packet sent to
the participant or beneficiary;
whichever is earlier.
``(d) Secondary Consultations.--
``(1) In general.--A group health plan, and a health
insurance issuer providing health insurance coverage in
connection with a group health plan that provides coverage with
respect to medical and surgical services provided in relation to the
diagnosis and treatment of cancer shall ensure that full coverage is
provided for secondary consultations by specialists in the appropriate
medical fields (including pathology, radiology, and oncology) to
confirm or refute such diagnosis. Such plan or issuer shall ensure that
full coverage is provided for such secondary consultation whether such
consultation is based on a positive or negative initial diagnosis. In
any case in which the attending physician certifies in writing that
services necessary for such a secondary consultation are not
sufficiently available from specialists operating under the plan with
respect to whose services coverage is otherwise provided under such
plan or by such issuer, such plan or issuer shall ensure that coverage
is provided with respect to the services necessary for the secondary
consultation with any other specialist selected by the attending
physician for such purpose at no additional cost to the individual
beyond that which the individual would have paid if the specialist was
participating in the network of the plan.
``(2) Exception.--Nothing in paragraph (1) shall be
construed as requiring the provision of secondary consultations
where the patient determines not to seek such a consultation.
``(e) Prohibition on Penalties or Incentives.--A group health plan,
and a health insurance issuer providing health insurance coverage in
connection with a group health plan, may not--
``(1) penalize or otherwise reduce or limit the
reimbursement of a provider or specialist because the provider
or specialist provided care to a participant or beneficiary in
accordance with this section;
``(2) provide financial or other incentives to a physician
or specialist to induce the physician or specialist to keep the
length of inpatient stays of patients following a mastectomy,
lumpectomy, or a lymph node dissection for the treatment of
breast cancer below certain limits or to limit referrals for
secondary consultations;
``(3) provide financial or other incentives to a physician
or specialist to induce the physician or specialist to refrain
from referring a participant or beneficiary for a secondary
consultation that would otherwise be covered by the plan or
coverage involved under subsection (d); or
``(4) deny to a woman eligibility, or continued
eligibility, to enroll or to renew coverage under the terms of
the plan or coverage solely for the purpose of avoiding the
requirements of this section.''.
(b) Effective Dates.--
(1) In general.--The amendments made by this section shall
apply to group health plans for plan years beginning on or
after 90 days after the date of enactment of this Act.
(2) Special rule for collective bargaining agreements.--In
the case of a group health plan maintained pursuant to 1 or
more collective bargaining agreements between employee
representatives and 1 or more employers ratified before the
date of enactment of this Act, the amendments made by this
section shall not apply to plan years beginning before the date
on which the last collective bargaining agreements relating to
the plan terminates (determined without regard to any extension
thereof agreed to after the date of enactment of this Act). For
purposes of this paragraph, any plan amendment made pursuant to
a collective bargaining agreement relating to the plan which
amends the plan solely to conform to any requirement added by
this section shall not be treated as a termination of such
collective bargaining agreement.
SEC. 5. AMENDMENT TO THE PUBLIC HEALTH SERVICE ACT RELATING TO THE
INDIVIDUAL MARKET.
(a) In General.--The first subpart 3 of part B of title XXVII of
the Public Health Service Act (42 U.S.C. 300gg-11 et seq.) is amended--
(1) by adding after section 2752 the following:
``SEC. 2753. REQUIRED COVERAGE FOR MINIMUM HOSPITAL STAY FOR
MASTECTOMIES, LUMPECTOMIES, AND LYMPH NODE DISSECTIONS
FOR THE TREATMENT OF BREAST CANCER AND SECONDARY
CONSULTATIONS.
``The provisions of section 2707 shall apply to health insurance
coverage offered by a health insurance issuer in the individual market
in the same manner as they apply to health insurance coverage offered
by a health insurance issuer in connection with a group health plan in
the small or large group market.''; and
(2) by redesignating such subpart 3 as subpart 2.
(b) Effective Date.--The amendment made by this section shall apply
with respect to health insurance coverage offered, sold, issued,
renewed, in effect, or operated in the individual market on or after
the date of enactment of this Act.
SEC. 6. AMENDMENTS TO THE INTERNAL REVENUE CODE OF 1986.
(a) In General.--Subchapter B of chapter 100 of the Internal
Revenue Code of 1986 is amended--
(1) in the table of sections, by inserting after the item
relating to section 9812 the following:
``Sec. 9813. Required coverage for
minimum hospital stay for
mastectomies, lumpectomies, and
lymph node dissections for the
treatment of breast cancer and
coverage for secondary
consultations.'';
and
(2) by inserting after section 9812 the following:
``SEC. 9813. REQUIRED COVERAGE FOR MINIMUM HOSPITAL STAY FOR
MASTECTOMIES, LUMPECTOMIES, AND LYMPH NODE DISSECTIONS
FOR THE TREATMENT OF BREAST CANCER AND COVERAGE FOR
SECONDARY CONSULTATIONS.
``(a) Inpatient Care.--
``(1) In general.--A group health plan that provides
medical and surgical benefits shall ensure that inpatient (and
in the case of a lumpectomy, outpatient) coverage and radiation
therapy is provided for breast cancer treatment. Such plan may
not--
``(A) except as provided for in paragraph (2)--
``(i) restrict benefits for any hospital
length of stay in connection with a mastectomy
or breast conserving surgery (such as a
lumpectomy) for the treatment of breast cancer
to less than 48 hours; or
``(ii) restrict benefits for any hospital
length of stay in connection with a lymph node
dissection for the treatment of breast cancer
to less than 24 hours; or
``(B) require that a provider obtain authorization
from the plan for prescribing any length of stay
required under subparagraph (A) (without regard to
paragraph (2)).
``(2) Exception.--Nothing in this section shall be
construed as requiring the provision of inpatient coverage if
the attending physician and patient determine that either a
shorter period of hospital stay, or outpatient treatment, is
medically appropriate.
``(b) Prohibition on Certain Modifications.--In implementing the
requirements of this section, a group health plan may not modify the
terms and conditions of coverage based on the determination by a
participant or beneficiary to request less than the minimum coverage
required under subsection (a).
``(c) Notice.--A group health plan shall provide notice to each
participant and beneficiary under such plan regarding the coverage
required by this section in accordance with regulations promulgated by
the Secretary. Such notice shall be in writing and prominently
positioned in any literature or correspondence made available or
distributed by the plan and shall be transmitted--
``(1) in the next mailing made by the plan to the
participant or beneficiary; or
``(2) as part of any yearly informational packet sent to
the participant or beneficiary;
whichever is earlier.
``(d) Secondary Consultations.--
``(1) In general.--A group health plan that provides
coverage with respect to medical and surgical services provided
in relation to the diagnosis and treatment of cancer shall
ensure that full coverage is provided for secondary
consultations by specialists in the appropriate medical fields
(including pathology, radiology, and oncology) to confirm or
refute such diagnosis. Such plan or issuer shall ensure that
full coverage is provided for such secondary consultation
whether such consultation is based on a positive or negative
initial diagnosis. In any case in which the attending physician
certifies in writing that services necessary for such a
secondary consultation are not sufficiently available from
specialists operating under the plan with respect to whose
services coverage is otherwise provided under such plan or by
such issuer, such plan or issuer shall ensure that coverage is
provided with respect to the services necessary for the
secondary consultation with any other specialist selected by
the attending physician for such purpose at no additional cost
to the individual beyond that which the individual would have
paid if the specialist was participating in the network of the
plan.
``(2) Exception.--Nothing in paragraph (1) shall be
construed as requiring the provision of secondary consultations
where the patient determines not to seek such a consultation.
``(e) Prohibition on Penalties.--A group health plan may not--
``(1) penalize or otherwise reduce or limit the
reimbursement of a provider or specialist because the provider
or specialist provided care to a participant or beneficiary in
accordance with this section;
``(2) provide financial or other incentives to a physician
or specialist to induce the physician or specialist to keep the
length of inpatient stays of patients following a mastectomy,
lumpectomy, or a lymph node dissection for the treatment of
breast cancer below certain limits or to limit referrals for
secondary consultations;
``(3) provide financial or other incentives to a physician
or specialist to induce the physician or specialist to refrain
from referring a participant or beneficiary for a secondary
consultation that would otherwise be covered by the plan
involved under subsection (d); or
``(4) deny to a woman eligibility, or continued
eligibility, to enroll or to renew coverage under the terms of
the plan solely for the purpose of avoiding the requirements of
this section.''.
(b) Clerical Amendment.--The table of contents for chapter 100 of
such Code is amended by inserting after the item relating to section
9812 the following:
``Sec. 9813. Required coverage for minimum hospital stay for
mastectomies, lumpectomies, and lymph node
dissections for the treatment of breast
cancer and coverage for secondary
consultations.''.
(c) Effective Dates.--
(1) In general.--The amendments made by this section shall
apply with respect to plan years beginning on or after the date
of enactment of this Act.
(2) Special rule for collective bargaining agreements.--In
the case of a group health plan maintained pursuant to 1 or
more collective bargaining agreements between employee
representatives and 1 or more employers ratified before the
date of enactment of this Act, the amendments made by this
section shall not apply to plan years beginning before the date
on which the last collective bargaining agreements relating to
the plan terminates (determined without regard to any extension
thereof agreed to after the date of enactment of this Act). For
purposes of this paragraph, any plan amendment made pursuant to
a collective bargaining agreement relating to the plan which
amends the plan solely to conform to any requirement added by
this section shall not be treated as a termination of such
collective bargaining agreement.
<all>