Reconstructive Breast Surgery Benefits Act of 1997

Summary: Reconstructive Breast Surgery Benefits Act of 1997 - Amends the Public Health Service Act and the Employee Retirement Income Security Act of 1974 to require group health plans and insurers offering group health coverage, if they cover a mastectomy, to also cover reconstructive breast surgery resulting from the mastectomy, including surgery on a nondiseased breast to establish symmetry and coverage of prostheses and complications of mastectomy.  Prohibits related:  (1) denial of coverage or monetary incentives to women; and (2) penalties or incentives to providers. 
Amends the Public Health Service Act to apply the above requirements to individual health insurance coverage.

SECTION 1. SHORT TITLE.

    This Act may be cited as the ``Reconstructive Breast Surgery 
Benefits Act of 1997''.

SEC. 2. COVERAGE OF RECONSTRUCTIVE BREAST SURGERY.

    (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, as amended by section 
                703(a) of Public Law 104-204, is amended by adding at 
                the end the following:

``SEC. 2706. STANDARDS RELATING TO BENEFITS FOR RECONSTRUCTIVE BREAST 
              SURGERY.

    ``(a) Requirements for Reconstructive Breast Surgery.--
            ``(1) In general.--A group health plan, and a health 
        insurance issuer offering group health insurance coverage, that 
        provides coverage for breast surgery in connection with a 
        mastectomy shall provide coverage for reconstructive breast 
        surgery resulting from the mastectomy. Such coverage shall 
        include coverage for all stages of reconstructive breast 
        surgery performed on a nondiseased breast to establish symmetry 
        with the diseased when reconstruction on the diseased breast is 
        performed and coverage of prostheses and complications of 
        mastectomy including lymphedema.
            ``(2) Reconstructive breast surgery defined.--In this 
        section, the term `reconstructive breast surgery' means surgery 
        performed as a result of a mastectomy to reestablish symmetry 
        between two breasts, and includes augmentation mammoplasty, 
        reduction mammoplasty, and mastopexy.
            ``(3) Mastectomy defined.--In this section, the term 
        `mastectomy' means the surgical removal of all or part of a 
        breast.
    ``(b) Prohibitions.--A group health plan, and a health insurance 
issuer offering group health insurance coverage in connection with a 
group health plan, may not--
            ``(1) deny coverage described in subsection (a)(1) on the 
        basis that the coverage is for cosmetic surgery;
            ``(2) 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;
            ``(3) provide monetary payments or rebates to women to 
        encourage such women to accept less than the minimum 
        protections available under this section;
            ``(4) penalize or otherwise reduce or limit the 
        reimbursement of an attending provider because such provider 
        provided care to an individual participant or beneficiary in 
        accordance with this section; or
            ``(5) provide incentives (monetary or otherwise) to an 
        attending provider to induce such provider to provide care to 
        an individual participant or beneficiary in a manner 
        inconsistent with this section.
    ``(c) Rules of Construction.--
            ``(1) Nothing in this section shall be construed to require 
        a woman who is a participant or beneficiary to undergo 
        reconstructive breast surgery.
            ``(2) This section shall not apply with respect to any 
        group health plan, or any group health insurance coverage 
        offered by a health insurance issuer, which does not provide 
        benefits for mastectomies.
            ``(3) Nothing in this section shall be construed as 
        preventing a group health plan or issuer from imposing 
        deductibles, coinsurance, or other cost-sharing in relation to 
        benefits for reconstructive breast surgery under the plan (or 
        under health insurance coverage offered in connection with a 
        group health plan), except that such coinsurance or other cost-
        sharing for any portion may not be greater than such 
        coinsurance or cost-sharing that is otherwise applicable with 
        respect to benefits for mastectomies.
    ``(d) Notice.--A group health plan under this part shall comply 
with the notice requirement under section 713(d) 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.
    ``(e) Level and Type of Reimbursements.--Nothing in this section 
shall be construed to prevent a group health plan or a health insurance 
issuer offering group health insurance coverage from negotiating the 
level and type of reimbursement with a provider for care provided in 
accordance with this section.
    ``(f) Preemption; Exception for Health Insurance Coverage in 
Certain States.--
            ``(1) In general.--The requirements of this section shall 
        not apply with respect to health insurance coverage if there is 
        a State law (as defined in section 2723(d)(1)) for a State that 
        regulates such coverage and that requires coverage of at least 
        the coverage of reconstructive breast surgery otherwise 
        required under this section.
            ``(2) Construction.--Section 2723(a)(1) shall not be 
        construed as superseding a State law described in paragraph 
        (1).''.
                    (B) Conforming amendment.--Section 2723(c) of the 
                Public Health Service Act (42 U.S.C. 300gg-23(c)), as 
                amended by section 604(b)(2) of Public Law 104-204, is 
                amended by striking ``section 2704'' and inserting 
                ``sections 2704 and 2706''.
            (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, as amended by section 702(a) of Public Law 
                104-204, is amended by adding at the end the following 
                new section:

``SEC. 713. STANDARDS RELATING TO BENEFITS FOR RECONSTRUCTIVE BREAST 
              SURGERY.

    ``(a) Requirements for Reconstructive Breast Surgery.--
            ``(1) In general.--A group health plan, and a health 
        insurance issuer offering group health insurance coverage, that 
        provides coverage for breast surgery in connection with a 
        mastectomy shall provide coverage for reconstructive breast 
        surgery resulting from the mastectomy. Such coverage shall 
        include coverage for all stages of reconstructive breast 
        surgery performed on a nondiseased breast to establish symmetry 
        with the diseased when reconstruction on the diseased breast is 
        performed and coverage of prostheses and complications of 
        mastectomy including lymphedema.
            ``(2) Reconstructive breast surgery defined.--In this 
        section, the term `reconstructive breast surgery' means surgery 
        performed as a result of a mastectomy to reestablish symmetry 
        between two breasts, and includes augmentation mammoplasty, 
        reduction mammoplasty, and mastopexy.
            ``(3) Mastectomy defined.--In this section, the term 
        `mastectomy' means the surgical removal of all or part of a 
        breast.
    ``(b) Prohibitions.--A group health plan, and a health insurance 
issuer offering group health insurance coverage in connection with a 
group health plan, may not--
            ``(1) deny coverage described in subsection (a)(1) on the 
        basis that the coverage is for cosmetic surgery;
            ``(2) 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;
            ``(3) provide monetary payments or rebates to women to 
        encourage such women to accept less than the minimum 
        protections available under this section;
            ``(4) penalize or otherwise reduce or limit the 
        reimbursement of an attending provider because such provider 
        provided care to an individual participant or beneficiary in 
        accordance with this section; or
            ``(5) provide incentives (monetary or otherwise) to an 
        attending provider to induce such provider to provide care to 
        an individual participant or beneficiary in a manner 
        inconsistent with this section.
    ``(c) Rules of Construction.--
            ``(1) Nothing in this section shall be construed to require 
        a woman who is a participant or beneficiary to undergo 
        reconstructive breast surgery.
            ``(2) This section shall not apply with respect to any 
        group health plan, or any group health insurance coverage 
        offered by a health insurance issuer, which does not provide 
        benefits for mastectomies.
            ``(3) Nothing in this section shall be construed as 
        preventing a group health plan or issuer from imposing 
        deductibles, coinsurance, or other cost-sharing in relation to 
        benefits for reconstructive breast surgery under the plan (or 
        under health insurance coverage offered in connection with a 
        group health plan), except that such coinsurance or other cost-
sharing for any portion may not be greater than such coinsurance or 
cost-sharing that is otherwise applicable with respect to benefits for 
mastectomies.
    ``(d) 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.
    ``(e) Level and Type of Reimbursements.--Nothing in this section 
shall be construed to prevent a group health plan or a health insurance 
issuer offering group health insurance coverage from negotiating the 
level and type of reimbursement with a provider for care provided in 
accordance with this section.
    ``(f) Preemption; Exception for Health Insurance Coverage in 
Certain States.--
            ``(1) In general.--The requirements of this section shall 
        not apply with respect to health insurance coverage if there is 
        a State law (as defined in section 731(d)(1)) for a State that 
        regulates such coverage and that requires coverage of at least 
        the coverage of reconstructive breast surgery otherwise 
        required under this section.
            ``(2) Construction.--Section 731(a)(1) shall not be 
        construed as superseding a State law described in paragraph 
        (1).''.
                    (B) Conforming amendments.--
                            (i) Section 731(c) of the Employee 
                        Retirement Income Security Act of 1974 (29 
                        U.S.C. 1191(c)), as amended by section 
                        603(b)(1) of Public Law 104-204, is amended by 
                        striking ``section 711'' and inserting 
                        ``sections 711 and 713''.
                            (ii) Section 732(a) of the Employee 
                        Retirement Income Security Act of 1974 (29 
                        U.S.C. 1191a(a)), as amended by section 
                        603(b)(2) of Public Law 104-204, is amended by 
                        striking ``section 711'' and inserting 
                        ``sections 711 and 713''.
                            (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 712 the following new item:

``Sec. 713. Standards relating to benefits for reconstructive breast 
                            surgery.''.
    (b) Individual Health Insurance.--
            (1) In general.--Part B of title XXVII of the Public Health 
        Service Act, as amended by section 605(a) of Public Law 104-
        204, is amended by inserting after section 2751 the following:

``SEC. 2752. STANDARDS RELATING TO BENEFITS FOR RECONSTRUCTIVE BREAST 
              SURGERY.

    ``(a) In General.--The provisions of section 2706 (other than 
subsection (d)) shall apply to health insurance coverage offered by a 
health insurance issuer in the individual market in the same manner as 
it applies to health insurance coverage offered by a health insurance 
issuer in connection with a group health plan in the small or large 
group market.
    ``(b) Notice.--A health insurance issuer under this part shall 
comply with the notice requirement under section 713(d) 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.
    ``(c) Preemption; Exception for Health Insurance Coverage in 
Certain States.--
            ``(1) In general.--The requirements of this section shall 
        not apply with respect to health insurance coverage if there is 
        a State law (as defined in section 2723(d)(1)) for a State that 
        regulates such coverage and that requires coverage of at least 
        the coverage of reconstructive breast surgery otherwise 
        required under this section.
            ``(2) Construction.--Section 2762(a) shall not be construed 
        as superseding a State law described in paragraph (1).''.
            (2) Conforming amendment.--Section 2762(b)(2) of the Public 
        Health Service Act (42 U.S.C. 300gg-62(b)(2)), as added by 
        section 605(b)(3)(B) of Public Law 104-204, is amended by 
        striking ``section 2751'' and inserting ``sections 2751 and 
        2752''.
    (c) Effective Dates.--
            (1) Group health plans.--The amendments made by subsection 
        (a) shall apply with respect to group health plans for plan 
        years beginning on or after January 1, 1998.
            (2) Individual market.--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.