II

106TH CONGRESS

1ST SESSION S. 115

To require that health plans provide coverage for a minimum hospital stay

for mastectomies and lymph node dissection for the treatment of breast

cancer and coverage for secondary consultations.

IN THE SENATE OF THE UNITED STATES

JANUARY 19, 1999

Ms. SNOWE (for herself and Mrs. FEINSTEIN) 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 and lymph node dissection

for the treatment of breast cancer and coverage for secondary consultations.

1 Be it enacted by the Senate and House of Representa2 tives of the United States of America in Congress assembled,

3 SECTION 1. SHORT TITLE.

4 This Act may be cited as the ‘‘Women’s Health and

5 Cancer Rights Act of 1999’’.

6 SEC. 2. FINDINGS.

7 Congress finds that—
2

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1 (1) the offering and operation of health plans

2 affect commerce among the States;

3 (2) health care providers located in a State

4 serve patients who reside in the State and patients

5 who reside in other States; and

6 (3) in order to provide for uniform treatment of

7 health care providers and patients among the States,

8 it is necessary to cover health plans operating in 1

9 State as well as health plans operating among the

10 several States.

11 SEC. 3. AMENDMENTS TO THE EMPLOYEE RETIREMENT IN12 COME SECURITY ACT OF 1974.

13 (a) IN GENERAL.—Subpart B of part 7 of subtitle

14 B of title I of the Employee Retirement Income Security

15 Act of 1974, as amended by the Omnibus Consolidated

16 and Emergency Supplemental Appropriations Act, 1999

17 (Public Law 105–277), is amended by adding at the end

18 the following:

19 ‘‘SEC. 714. REQUIRED COVERAGE FOR MINIMUM HOSPITAL

20 STAY FOR MASTECTOMIES AND LYMPH NODE

21 DISSECTIONS FOR THE TREATMENT OF

22 BREAST CANCER AND COVERAGE FOR SEC23 ONDARY CONSULTATIONS.

24 ‘‘(a) INPATIENT CARE.—
3

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1 ‘‘(1) IN GENERAL.—A group health plan, and a

2 health insurance issuer providing health insurance

3 coverage in connection with a group health plan,

4 that provides medical and surgical benefits shall en5 sure that inpatient coverage with respect to the

6 treatment of breast cancer is provided for a period

7 of time as is determined by the attending physician,

8 in consultation with the patient, to be medically ap9 propriate following—

10 ‘‘(A) a mastectomy;

11 ‘‘(B) a lumpectomy; or

12 ‘‘(C) a lymph node dissection for the treat13 ment of breast cancer.

14 ‘‘(2) EXCEPTION.—Nothing in this section shall

15 be construed as requiring the provision of inpatient

16 coverage if the attending physician and patient de17 termine that a shorter period of hospital stay is

18 medically appropriate.

19 ‘‘(b) PROHIBITION ON CERTAIN MODIFICATIONS.—

20 In implementing the requirements of this section, a group

21 health plan, and a health insurance issuer providing health

22 insurance coverage in connection with a group health plan,

23 may not modify the terms and conditions of coverage

24 based on the determination by a participant or beneficiary
4

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1 to request less than the minimum coverage required under

2 subsection (a).

3 ‘‘(c) NOTICE.—A group health plan, and a health in4 surance issuer providing health insurance coverage in con5 nection with a group health plan shall provide notice to

6 each participant and beneficiary under such plan regard7 ing the coverage required by this section in accordance

8 with regulations promulgated by the Secretary. Such no9 tice shall be in writing and prominently positioned in any

10 literature or correspondence made available or distributed

11 by the plan or issuer and shall be transmitted—

12 ‘‘(1) in the next mailing made by the plan or

13 issuer to the participant or beneficiary;

14 ‘‘(2) as part of any yearly informational packet

15 sent to the participant or beneficiary; or

16 ‘‘(3) not later than January 1, 2000;

17 whichever is earlier.

18 ‘‘(d) SECONDARY CONSULTATIONS.—

19 ‘‘(1) IN GENERAL.—A group health plan, and a

20 health insurance issuer providing health insurance

21 coverage in connection with a group health plan,

22 that provides coverage with respect to medical and

23 surgical services provided in relation to the diagnosis

24 and treatment of cancer shall ensure that full cov25 erage is provided for secondary consultations by spe-
5

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1 cialists in the appropriate medical fields (including

2 pathology, radiology, and oncology) to confirm or re3 fute such diagnosis. Such plan or issuer shall ensure

4 that full coverage is provided for such secondary

5 consultation whether such consultation is based on a

6 positive or negative initial diagnosis. In any case in

7 which the attending physician certifies in writing

8 that services necessary for such a secondary con9 sultation are not sufficiently available from special10 ists operating under the plan with respect to whose

11 services coverage is otherwise provided under such

12 plan or by such issuer, such plan or issuer shall en13 sure that coverage is provided with respect to the

14 services necessary for the secondary consultation

15 with any other specialist selected by the attending

16 physician for such purpose at no additional cost to

17 the individual beyond that which the individual

18 would have paid if the specialist was participating in

19 the network of the plan.

20 ‘‘(2) EXCEPTION.—Nothing in paragraph (1)

21 shall be construed as requiring the provision of sec22 ondary consultations where the patient determines

23 not to seek such a consultation.

24 ‘‘(e) PROHIBITION ON PENALTIES OR INCENTIVES.—

25 A group health plan, and a health insurance issuer provid-
6

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1 ing health insurance coverage in connection with a group

2 health plan, may not—

3 ‘‘(1) penalize or otherwise reduce or limit the

4 reimbursement of a provider or specialist because

5 the provider or specialist provided care to a partici6 pant or beneficiary in accordance with this section;

7 ‘‘(2) provide financial or other incentives to a

8 physician or specialist to induce the physician or

9 specialist to keep the length of inpatient stays of pa10 tients following a mastectomy, lumpectomy, or a

11 lymph node dissection for the treatment of breast

12 cancer below certain limits or to limit referrals for

13 secondary consultations; or

14 ‘‘(3) provide financial or other incentives to a

15 physician or specialist to induce the physician or

16 specialist to refrain from referring a participant or

17 beneficiary for a secondary consultation that would

18 otherwise be covered by the plan or coverage in19 volved under subsection (d).’’.

20 (b) CLERICAL AMENDMENT.—The table of contents

21 in section 1 of the Employee Retirement Income Security

22 Act of 1974, as amended by the Omnibus Consolidated

23 and Emergency Supplemental Appropriations Act, 1999

24 (Public Law 105–277), is amended by inserting after the

25 item relating to section 713 the following new item:
7

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‘‘Sec. 714. Required coverage for minimum hospital stay for mastectomies and

lymph node dissections for the treatment of breast cancer and

coverage for secondary consultations.’’.

1 (c) EFFECTIVE DATES.—

2 (1) IN GENERAL.—The amendments made by

3 this section shall apply with respect to plan years be4 ginning on or after the date of enactment of this

5 Act.

6 (2) SPECIAL RULE FOR COLLECTIVE BARGAIN7 ING AGREEMENTS.—In the case of a group health

8 plan maintained pursuant to 1 or more collective

9 bargaining agreements between employee representa10 tives and 1 or more employers ratified before the

11 date of enactment of this Act, the amendments made

12 by this section shall not apply to plan years begin13 ning before the later of—

14 (A) the date on which the last collective

15 bargaining agreements relating to the plan ter16 minates (determined without regard to any ex17 tension thereof agreed to after the date of en18 actment of this Act), or

19 (B) January 1, 2000.

20 For purposes of subparagraph (A), any plan amend21 ment made pursuant to a collective bargaining

22 agreement relating to the plan which amends the

23 plan solely to conform to any requirement added by
8

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1 this section shall not be treated as a termination of

2 such collective bargaining agreement.

3 SEC. 4. AMENDMENTS TO THE PUBLIC HEALTH SERVICE

4 ACT RELATING TO THE GROUP MARKET.

5 (a) IN GENERAL.—Subpart 2 of part A of title

6 XXVII of the Public Health Service Act, as amended by

7 the Omnibus Consolidated and Emergency Supplemental

8 Appropriations Act, 1999 (Public Law 105–277), is

9 amended by adding at the end the following new section:

10 ‘‘SEC. 2707. REQUIRED COVERAGE FOR MINIMUM HOSPITAL

11 STAY FOR MASTECTOMIES AND LYMPH NODE

12 DISSECTIONS FOR THE TREATMENT OF

13 BREAST CANCER AND COVERAGE FOR SEC14 ONDARY CONSULTATIONS.

15 ‘‘(a) INPATIENT CARE.—

16 ‘‘(1) IN GENERAL.—A group health plan, and a

17 health insurance issuer providing health insurance

18 coverage in connection with a group health plan,

19 that provides medical and surgical benefits shall en20 sure that inpatient coverage with respect to the

21 treatment of breast cancer is provided for a period

22 of time as is determined by the attending physician,

23 in consultation with the patient, to be medically ap24 propriate following—

25 ‘‘(A) a mastectomy;
9

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1 ‘‘(B) a lumpectomy; or

2 ‘‘(C) a lymph node dissection for the treat3 ment of breast cancer.

4 ‘‘(2) EXCEPTION.—Nothing in this section shall

5 be construed as requiring the provision of inpatient

6 coverage if the attending physician and patient de7 termine that a shorter period of hospital stay is

8 medically appropriate.

9 ‘‘(b) PROHIBITION ON CERTAIN MODIFICATIONS.—

10 In implementing the requirements of this section, a group

11 health plan, and a health insurance issuer providing health

12 insurance coverage in connection with a group health plan,

13 may not modify the terms and conditions of coverage

14 based on the determination by a participant or beneficiary

15 to request less than the minimum coverage required under

16 subsection (a).

17 ‘‘(c) NOTICE.—A group health plan, and a health in18 surance issuer providing health insurance coverage in con19 nection with a group health plan shall provide notice to

20 each participant and beneficiary under such plan regard21 ing the coverage required by this section in accordance

22 with regulations promulgated by the Secretary. Such no23 tice shall be in writing and prominently positioned in any

24 literature or correspondence made available or distributed

25 by the plan or issuer and shall be transmitted—
10

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1 ‘‘(1) in the next mailing made by the plan or

2 issuer to the participant or beneficiary;

3 ‘‘(2) as part of any yearly informational packet

4 sent to the participant or beneficiary; or

5 ‘‘(3) not later than January 1, 2000;

6 whichever is earlier.

7 ‘‘(d) SECONDARY CONSULTATIONS.—

8 ‘‘(1) IN GENERAL.—A group health plan, and a

9 health insurance issuer providing health insurance

10 coverage in connection with a group health plan that

11 provides coverage with respect to medical and sur12 gical services provided in relation to the diagnosis

13 and treatment of cancer shall ensure that full cov14 erage is provided for secondary consultations by spe15 cialists in the appropriate medical fields (including

16 pathology, radiology, and oncology) to confirm or re17 fute such diagnosis. Such plan or issuer shall ensure

18 that full coverage is provided for such secondary

19 consultation whether such consultation is based on a

20 positive or negative initial diagnosis. In any case in

21 which the attending physician certifies in writing

22 that services necessary for such a secondary con23 sultation are not sufficiently available from special24 ists operating under the plan with respect to whose

25 services coverage is otherwise provided under such
11

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1 plan or by such issuer, such plan or issuer shall en2 sure that coverage is provided with respect to the

3 services necessary for the secondary consultation

4 with any other specialist selected by the attending

5 physician for such purpose at no additional cost to

6 the individual beyond that which the individual

7 would have paid if the specialist was participating

8 in the network of the plan.

9 ‘‘(2) EXCEPTION.—Nothing in paragraph (1)

10 shall be construed as requiring the provision of sec11 ondary consultations where the patient determines

12 not to seek such a consultation.

13 ‘‘(e) PROHIBITION ON PENALTIES OR INCENTIVES.—

14 A group health plan, and a health insurance issuer provid15 ing health insurance coverage in connection with a group

16 health plan, may not—

17 ‘‘(1) penalize or otherwise reduce or limit the

18 reimbursement of a provider or specialist because

19 the provider or specialist provided care to a partici20 pant or beneficiary in accordance with this section;

21 ‘‘(2) provide financial or other incentives to a

22 physician or specialist to induce the physician or

23 specialist to keep the length of inpatient stays of pa24 tients following a mastectomy, lumpectomy, or a

25 lymph node dissection for the treatment of breast
12

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1 cancer below certain limits or to limit referrals for

2 secondary consultations; or

3 ‘‘(3) provide financial or other incentives to a

4 physician or specialist to induce the physician or

5 specialist to refrain from referring a participant or

6 beneficiary for a secondary consultation that would

7 otherwise be covered by the plan or coverage in8 volved under subsection (d).’’.

9 (b) EFFECTIVE DATES.—

10 (1) IN GENERAL.—The amendments made by

11 this section shall apply to group health plans for

12 plan years beginning on or after the date of enact13 ment of this Act.

14 (2) SPECIAL RULE FOR COLLECTIVE BARGAIN15 ING AGREEMENTS.—In the case of a group health

16 plan maintained pursuant to 1 or more collective

17 bargaining agreements between employee representa18 tives and 1 or more employers ratified before the

19 date of enactment of this Act, the amendments made

20 by this section shall not apply to plan years begin21 ning before the later of—

22 (A) the date on which the last collective

23 bargaining agreements relating to the plan ter24 minates (determined without regard to any ex-
13

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1 tension thereof agreed to after the date of en2 actment of this Act), or

3 (B) January 1, 2000.

4 For purposes of subparagraph (A), any plan amend5 ment made pursuant to a collective bargaining

6 agreement relating to the plan which amends the

7 plan solely to conform to any requirement added by

8 this section shall not be treated as a termination of

9 such collective bargaining agreement.

10 SEC. 5. AMENDMENT TO THE PUBLIC HEALTH SERVICE ACT

11 RELATING TO THE INDIVIDUAL MARKET.

12 (a) IN GENERAL.—Subpart 3 of part B of title

13 XXVII of the Public Health Service Act, as amended by

14 the Omnibus Consolidated and Emergency Supplemental

15 Appropriations Act, 1999 (Public Law 105–277), is

16 amended by adding at the end the following new section:

17 ‘‘SEC. 2753. REQUIRED COVERAGE FOR MINIMUM HOSPITAL

18 STAY FOR MASTECTOMIES AND LYMPH NODE

19 DISSECTIONS FOR THE TREATMENT OF

20 BREAST CANCER AND SECONDARY CON21 SULTATIONS.

22 ‘‘The provisions of section 2707 shall apply to health

23 insurance coverage offered by a health insurance issuer

24 in the individual market in the same manner as they apply

25 to health insurance coverage offered by a health insurance
14

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1 issuer in connection with a group health plan in the small

2 or large group market.’’.

3 (b) EFFECTIVE DATE.—The amendment made by

4 this section shall apply with respect to health insurance

5 coverage offered, sold, issued, renewed, in effect, or oper6 ated in the individual market on or after the date of enact7 ment of this Act.

8 SEC. 6. AMENDMENTS TO THE INTERNAL REVENUE CODE

9 OF 1986.

10 (a) IN GENERAL.—Subchapter B of chapter 100 of

11 the Internal Revenue Code of 1986 (as amended by sec12 tion 1531(a) of the Taxpayer Relief Act of 1997) is

13 amended—

14 (1) in the table of sections, by inserting after

15 the item relating to section 9812 the following new

16 item:

‘‘Sec. 9813. Required coverage for minimum hospital stay for

mastectomies and lymph node dissections for the

treatment of breast cancer and coverage for secondary consultations.’’; and

17 (2) by inserting after section 9812 the follow18 ing:
15

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1 ‘‘SEC. 9813. REQUIRED COVERAGE FOR MINIMUM HOSPITAL

2 STAY FOR MASTECTOMIES AND LYMPH NODE

3 DISSECTIONS FOR THE TREATMENT OF

4 BREAST CANCER AND COVERAGE FOR SEC5 ONDARY CONSULTATIONS.

6 ‘‘(a) INPATIENT CARE.—

7 ‘‘(1) IN GENERAL.—A group health plan that

8 provides medical and surgical benefits shall ensure

9 that inpatient coverage with respect to the treatment

10 of breast cancer is provided for a period of time as

11 is determined by the attending physician, in con12 sultation with the patient, to be medically appro13 priate following—

14 ‘‘(A) a mastectomy;

15 ‘‘(B) a lumpectomy; or

16 ‘‘(C) a lymph node dissection for the treat17 ment of breast cancer.

18 ‘‘(2) EXCEPTION.—Nothing in this section shall

19 be construed as requiring the provision of inpatient

20 coverage if the attending physician and patient de21 termine that a shorter period of hospital stay is

22 medically appropriate.

23 ‘‘(b) PROHIBITION ON CERTAIN MODIFICATIONS.—

24 In implementing the requirements of this section, a group

25 health plan may not modify the terms and conditions of

26 coverage based on the determination by a participant or
16

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1 beneficiary to request less than the minimum coverage re2 quired under subsection (a).

3 ‘‘(c) NOTICE.—A group health plan shall provide no4 tice to each participant and beneficiary under such plan

5 regarding the coverage required by this section in accord6 ance with regulations promulgated by the Secretary. Such

7 notice shall be in writing and prominently positioned in

8 any literature or correspondence made available or distrib9 uted by the plan and shall be transmitted—

10 ‘‘(1) in the next mailing made by the plan to

11 the participant or beneficiary;

12 ‘‘(2) as part of any yearly informational packet

13 sent to the participant or beneficiary; or

14 ‘‘(3) not later than January 1, 2000;

15 whichever is earlier.

16 ‘‘(d) SECONDARY CONSULTATIONS.—

17 ‘‘(1) IN GENERAL.—A group health plan that

18 provides coverage with respect to medical and sur19 gical services provided in relation to the diagnosis

20 and treatment of cancer shall ensure that full cov21 erage is provided for secondary consultations by spe22 cialists in the appropriate medical fields (including

23 pathology, radiology, and oncology) to confirm or re24 fute such diagnosis. Such plan or issuer shall ensure

25 that full coverage is provided for such secondary
17

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1 consultation whether such consultation is based on a

2 positive or negative initial diagnosis. In any case in

3 which the attending physician certifies in writing

4 that services necessary for such a secondary con5 sultation are not sufficiently available from special6 ists operating under the plan with respect to whose

7 services coverage is otherwise provided under such

8 plan or by such issuer, such plan or issuer shall en9 sure that coverage is provided with respect to the

10 services necessary for the secondary consultation

11 with any other specialist selected by the attending

12 physician for such purpose at no additional cost to

13 the individual beyond that which the individual

14 would have paid if the specialist was participating in

15 the network of the plan.

16 ‘‘(2) EXCEPTION.—Nothing in paragraph (1)

17 shall be construed as requiring the provision of sec18 ondary consultations where the patient determines

19 not to seek such a consultation.

20 ‘‘(e) PROHIBITION ON PENALTIES.—A group health

21 plan may not—

22 ‘‘(1) penalize or otherwise reduce or limit the

23 reimbursement of a provider or specialist because

24 the provider or specialist provided care to a partici25 pant or beneficiary in accordance with this section;
18

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1 ‘‘(2) provide financial or other incentives to a

2 physician or specialist to induce the physician or

3 specialist to keep the length of inpatient stays of pa4 tients following a mastectomy, lumpectomy, or a

5 lymph node dissection for the treatment of breast

6 cancer below certain limits or to limit referrals for

7 secondary consultations; or

8 ‘‘(3) provide financial or other incentives to a

9 physician or specialist to induce the physician or

10 specialist to refrain from referring a participant or

11 beneficiary for a secondary consultation that would

12 otherwise be covered by the plan involved under sub13 section (d).’’.

14 (b) CLERICAL AMENDMENT.—The table of contents

15 for chapter 100 of such Code is amended by inserting after

16 the item relating to section 9812 the following new item:

‘‘Sec. 9813. Required coverage for minimum hospital stay for mastectomies and

lymph node dissections for the treatment of breast cancer and

coverage for secondary consultations.’’.

17 (c) EFFECTIVE DATES.—

18 (1) IN GENERAL.—The amendments made by

19 this section shall apply with respect to plan years be20 ginning on or after the date of enactment of this

21 Act.

22 (2) SPECIAL RULE FOR COLLECTIVE BARGAIN23 ING AGREEMENTS.—In the case of a group health

24 plan maintained pursuant to 1 or more collective
19

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1 bargaining agreements between employee representa2 tives and 1 or more employers ratified before the

3 date of enactment of this Act, the amendments made

4 by this section shall not apply to plan years begin5 ning before the later of—

6 (A) the date on which the last collective

7 bargaining agreements relating to the plan ter8 minates (determined without regard to any ex9 tension thereof agreed to after the date of en10 actment of this Act), or

11 (B) January 1, 2000.

12 For purposes of subparagraph (A), any plan amend13 ment made pursuant to a collective bargaining

14 agreement relating to the plan which amends the

15 plan solely to conform to any requirement added by

16 this section shall not be treated as a termination of

17 such collective bargaining agreement.

Æ