109th CONGRESS
1st Session
S. 1132
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 SENATE OF THE UNITED STATES
May 26, 2005
Mr. COLEMAN (for himself, Ms. LANDRIEU, Mr. DEWINE, Ms. SNOWE, Mr. COCHRAN,
Mr. VITTER, Mr. BAYH, and Mr. SMITH) introduced the following bill; which
was read twice and referred to the Committee on Health, Education, Labor,
and Pensions
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 `Treatment of Children's Deformities Act of 2005'.
SEC. 2. COVERAGE OF MINOR CHILD'S CONGENITAL OR DEVELOPMENTAL DEFORMITY
OR DISORDER.
(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.
`(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'.
(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.
`(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';
(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.
`(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.
`(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'.
(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'.
END
