110th CONGRESS
1st Session
H. R. 1655
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.
IN THE HOUSE OF REPRESENTATIVES
March 22, 2007
Mrs. MCCARTHY of New York (for herself, Mr. TIBERI, Mrs. MALONEY of New
York, Mr. GORDON of Tennessee, Mr. MCDERMOTT, Mr. INSLEE, Mr. COBLE, and
Ms. HOOLEY) introduced the following bill; which was referred to the Committee
on Energy and Commerce, and in addition to the Committees on Education and
Labor and Ways and Means, for a period to be subsequently determined by
the Speaker, in each case for consideration of such provisions as fall within
the jurisdiction of the committee concerned
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.
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 `Children's Access to Reconstructive Evaluation
& Surgery (CARES) Act of 2007'.
SEC. 2. COVERAGE OF MINOR CHILD'S CONGENITAL OR DEVELOPMENTAL DEFORMITY
OR DISORDER.
(1) PUBLIC HEALTH SERVICE ACT AMENDMENTS- (A) Subpart 2 of part A of title
XXVII of the Public Health Service Act 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 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.
`(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) Section 2723(c) of such Act (42 U.S.C. 300gg-23(c)) is amended by
striking `section 2704' and inserting `sections 2704 and 2707'.
(2) ERISA AMENDMENTS- (A) Subpart B of part 7 of subtitle B of title I
of the Employee Retirement Income Security Act of 1974 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 who has not attained
age 22.
`(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.
`(A) IN GENERAL- For purposes of 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 the last sentence of section 102(a), for purposes
of assuring notice of such requirements under the plan; except that the
summary description required to be provided under the fourth 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) Section 731(c) of such Act (29 U.S.C. 1191(c)) is amended by striking
`section 711' and inserting `sections 711 and 714'.
(C) Section 732(a) of such Act (29 U.S.C. 1191a(a)) is amended by striking
`section 711' and inserting `sections 711 and 714'.
(D) The table of contents in section 1 of such Act 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-
(A) IN GENERAL- Subchapter B of chapter 100 of the Internal Revenue
Code of 1986 is amended by adding at the end the following new section:
`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 who has not attained
age 22.
`(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.
`(A) IN GENERAL- For purposes of 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) CLERICAL AMENDMENT- The table of sections for such subchapter is
amended by adding at the end the following new item:
`Sec. 9813. Standards relating to benefits for minor child's congenital
or developmental deformity or disorder.'.
(b) Individual Health Insurance- (1) Part B of title XXVII of the Public
Health Service Act 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 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.
`(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) Section 2762(b)(2) of such 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) The amendments made by subsection (a) shall apply
with respect to group health plans for plan years beginning on or after
January 1, 2008.
(2) 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'.
END
