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.
(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.
`(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;
`(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.'.
(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.
`(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;
`(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.'.
(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.';
(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.
`(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;
`(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.'.
(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.
END
