I

106TH CONGRESS

1ST SESSION H. R. 49

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

JANUARY 6, 1999

Mrs. KELLY (for herself, Mr. GANSKE, Mr. GILMAN, Mrs. MALONEY of New

York, and Mr. CONDIT) introduced the following bill; which was referred

to the Committee on Commerce, and in addition to the Committee on

Ways and Means, and Education and the Workforce, 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.

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

2 This Act may be cited as the ‘‘Treatment of Chil3 dren’s Deformities Act of 1998’’.

4 SEC. 2. COVERAGE OF MINOR CHILD’S CONGENITAL OR DE5 VELOPMENTAL DEFORMITY OR DISORDER.

6 (a) GROUP HEALTH PLANS.—

7 (1) PUBLIC HEALTH SERVICE ACT AMEND8 MENTS.—(A) Subpart 2 of part A of title XXVII of

9 the Public Health Service Act, as amended by sec10 tion 703(a) of Public Law 104–204, is amended by

11 adding at the end the following new section:

12 ‘‘SEC. 2706. STANDARDS RELATING TO BENEFITS FOR

13 MINOR CHILD’S CONGENITAL OR DEVELOP14 MENTAL DEFORMITY OR DISORDER.

15 ‘‘(a) REQUIREMENTS FOR RECONSTRUCTIVE SUR16 GERY.—

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

18 health insurance issuer offering group health insur19 ance coverage, that provides coverage for surgical

20 benefits shall provide coverage for outpatient and in21 patient diagnosis and treatment of a minor child’s

22 congenital or developmental deformity, disease, or

23 injury. A minor child shall include any individual

24 through 21 years of age.

25 ‘‘(2) REQUIREMENTS.—Any coverage provided

26 under paragraph (1) shall be subject to pre-author-
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1 ization or pre-certification as required by the plan or

2 issuer, and such coverage shall include any surgical

3 treatment which, in the opinion of the treating phy4 sician, is medically necessary to approximate a nor5 mal appearance.

6 ‘‘(3) TREATMENT DEFINED.—

7 ‘‘(A) IN GENERAL.—In this section, the

8 term ‘treatment’ includes reconstructive sur9 gical procedures (procedures that are generally

10 performed to improve function, but may also be

11 performed to approximate a normal appear12 ance) that are performed on abnormal struc13 tures of the body caused by congenital defects,

14 developmental abnormalities, trauma, infection,

15 tumors, or disease, including—

16 ‘‘(i) procedures that do not materially

17 affect the function of the body part being

18 treated; and

19 ‘‘(ii) procedures for secondary condi20 tions and follow-up treatment.

21 ‘‘(B) EXCEPTION.—Such term does not in22 clude cosmetic surgery performed to reshape

23 normal structures of the body to improve ap24 pearance or self-esteem.
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1 ‘‘(b) NOTICE.—A group health plan under this part

2 shall comply with the notice requirement under section

3 713(b) of the Employee Retirement Income Security Act

4 of 1974 with respect to the requirements of this section

5 as if such section applied to such plan.’’.

6 (B) Section 2723(c) of such Act (42 U.S.C.

7 300gg–23(c)), as amended by section 604(b)(2) of

8 Public Law 104–204, is amended by striking ‘‘sec9 tion 2704’’ and inserting ‘‘sections 2704 and 2706’’.

10 (2) ERISA AMENDMENTS.—(A) Subpart B of

11 part 7 of subtitle B of title I of the Employee Re12 tirement Income Security Act of 1974, as amended

13 by section 702(a) of Public Law 104–204, is amend14 ed by adding at the end the following new section:

15 ‘‘SEC. 713. STANDARDS RELATING TO BENEFITS FOR MINOR

16 CHILD’S CONGENITAL OR DEVELOPMENTAL

17 DEFORMITY OR DISORDER.

18 ‘‘(a) REQUIREMENTS FOR RECONSTRUCTIVE SUR19 GERY.—

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

21 health insurance issuer offering group health insur22 ance coverage, that provides coverage for surgical

23 benefits shall provide coverage for outpatient and in24 patient diagnosis and treatment of a minor child’s

25 congenital or developmental deformity, disease, or
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1 injury. A minor child shall include any individual

2 through 21 years of age.

3 ‘‘(2) REQUIREMENTS.—Any coverage provided

4 under paragraph (1) shall be subject to pre-author5 ization or pre-certification as required by the plan or

6 issuer, and such coverage shall include any surgical

7 treatment which, in the opinion of the treating phy8 sician, is medically necessary to approximate a nor9 mal appearance.

10 ‘‘(3) TREATMENT DEFINED.—

11 ‘‘(A) IN GENERAL.—In this section, the

12 term ‘treatment’ includes reconstructive sur13 gical procedures (procedures that are generally

14 performed to improve function, but may also be

15 performed to approximate a normal appear16 ance) that are performed on abnormal struc17 tures of the body caused by congenital defects,

18 developmental abnormalities, trauma, infection,

19 tumors, or disease, including—

20 ‘‘(i) procedures that do not materially

21 affect the function of the body part being

22 treated; and

23 ‘‘(ii) procedures for secondary condi24 tions and follow-up treatment.
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1 ‘‘(B) EXCEPTION.—Such term does not in2 clude cosmetic surgery performed to reshape

3 normal structures of the body to improve ap4 pearance or self-esteem.

5 ‘‘(b) NOTICE UNDER GROUP HEALTH PLAN.—The

6 imposition of the requirements of this section shall be

7 treated as a material modification in the terms of the plan

8 described in section 102(a)(1), for purposes of assuring

9 notice of such requirements under the plan; except that

10 the summary description required to be provided under the

11 last sentence of section 104(b)(1) with respect to such

12 modification shall be provided by not later than 60 days

13 after the first day of the first plan year in which such

14 requirements apply.’’.

15 (B) Section 731(c) of such Act (29 U.S.C.

16 1191(c)), as amended by section 603(b)(1) of Public

17 Law 104–204, is amended by striking ‘‘section 711’’

18 and inserting ‘‘sections 711 and 713’’.

19 (C) Section 732(a) of such Act (29 U.S.C.

20 1191a(a)), as amended by section 603(b)(2) of Pub21 lic Law 104–204, is amended by striking ‘‘section

22 711’’ and inserting ‘‘sections 711 and 713’’.

23 (D) The table of contents in section 1 of such

24 Act is amended by inserting after the item relating

25 to section 712 the following new item:
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‘‘Sec. 713. Standards relating to benefits for minor child’s congenital or developmental deformity or disorder.’’.

1 (3) INTERNAL REVENUE CODE AMEND2 MENTS.—Subchapter B of chapter 100 of the Inter3 nal Revenue Code of 1986 (as amended by section

4 1531(a) of the Taxpayer Relief Act of 1997) is

5 amended—

6 (A) in the table of sections, by inserting after

7 the item relating to section 9812 the following new

8 item:

‘‘Sec. 9813. Standards relating to benefits for minor child’s congenital or developmental deformity or disorder.’’;

and

9 (B) by inserting after section 9812 the follow10 ing:

11 ‘‘SEC. 9813. STANDARDS RELATING TO BENEFITS FOR

12 MINOR CHILD’S CONGENITAL OR DEVELOP13 MENTAL DEFORMITY OR DISORDER.

14 ‘‘(a) REQUIREMENTS FOR RECONSTRUCTIVE SUR15 GERY.—

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

17 health insurance issuer offering group health insur18 ance coverage, that provides coverage for surgical

19 benefits shall provide coverage for outpatient and in20 patient diagnosis and treatment of a minor child’s

21 congenital or developmental deformity, disease, or
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1 injury. A minor child shall include any individual

2 through 21 years of age.

3 ‘‘(2) REQUIREMENTS.—Any coverage provided

4 under paragraph (1) shall be subject to pre-author5 ization or pre-certification as required by the plan or

6 issuer, and such coverage shall include any surgical

7 treatment which, in the opinion of the treating phy8 sician, is medically necessary to approximate a nor9 mal appearance.

10 ‘‘(3) TREATMENT DEFINED.—

11 ‘‘(A) IN GENERAL.—In this section, the

12 term ‘treatment’ includes reconstructive sur13 gical procedures (procedures that are generally

14 performed to improve function, but may also be

15 performed to approximate a normal appear16 ance) that are performed on abnormal struc17 tures of the body caused by congenital defects,

18 developmental abnormalities, trauma, infection,

19 tumors, or disease, including—

20 ‘‘(i) procedures that do not materially

21 affect the function of the body part being

22 treated; and

23 ‘‘(ii) procedures for secondary condi24 tions and follow-up treatment.
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1 ‘‘(B) EXCEPTION.—Such term does not in2 clude cosmetic surgery performed to reshape

3 normal structures of the body to improve ap4 pearance or self-esteem.’’.

5 (b) INDIVIDUAL HEALTH INSURANCE.—(1) Part B

6 of title XXVII of the Public Health Service Act, as amend7 ed by section 605(a) of Public Law 104–204, is amended

8 by inserting after section 2751 the following new section:

9 ‘‘SEC. 2752. STANDARDS RELATING TO BENEFITS FOR

10 MINOR CHILD’S CONGENITAL OR DEVELOP11 MENTAL DEFORMITY OR DISORDER.

12 ‘‘(a) REQUIREMENTS FOR RECONSTRUCTIVE SUR13 GERY.—

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

15 health insurance issuer offering group health insur16 ance coverage, that provides coverage for surgical

17 benefits shall provide coverage for outpatient and in18 patient diagnosis and treatment of a minor child’s

19 congenital or developmental deformity, disease, or

20 injury. A minor child shall include any individual

21 through 21 years of age.

22 ‘‘(2) REQUIREMENTS.—Any coverage provided

23 under paragraph (1) shall be subject to pre-author24 ization or pre-certification as required by the plan or

25 issuer, and such coverage shall include any surgical
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1 treatment which, in the opinion of the treating phy2 sician, is medically necessary to approximate a nor3 mal appearance.

4 ‘‘(3) TREATMENT DEFINED.—

5 ‘‘(A) IN GENERAL.—In this section, the

6 term ‘treatment’ includes reconstructive sur7 gical procedures (procedures that are generally

8 performed to improve function, but may also be

9 performed to approximate a normal appear10 ance) that are performed on abnormal struc11 tures of the body caused by congenital defects,

12 developmental abnormalities, trauma, infection,

13 tumors, or disease, including—

14 ‘‘(i) procedures that do not materially

15 affect the function of the body part being

16 treated; and

17 ‘‘(ii) procedures for secondary condi18 tions and follow-up treatment.

19 ‘‘(B) EXCEPTION.—Such term does not in20 clude cosmetic surgery performed to reshape

21 normal structures of the body to improve ap22 pearance or self-esteem.

23 ‘‘(b) NOTICE.—A health insurance issuer under this

24 part shall comply with the notice requirement under sec25 tion 713(b) of the Employee Retirement Income Security
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1 Act of 1974 with respect to the requirements referred to

2 in subsection (a) as if such section applied to such issuer

3 and such issuer were a group health plan.’’.

4 (2) Section 2762(b)(2) of such Act (42 U.S.C.

5 300gg–62(b)(2)), as added by section 605(b)(3)(B) of

6 Public Law 104–204, is amended by striking ‘‘section

7 2751’’ and inserting ‘‘sections 2751 and 2752’’.

8 (c) EFFECTIVE DATES.—(1) The amendments made

9 by subsection (a) shall apply with respect to group health

10 plans for plan years beginning on or after January 1,

11 1999.

12 (2) The amendment made by subsection (b) shall

13 apply with respect to health insurance coverage offered,

14 sold, issued, renewed, in effect, or operated in the individ15 ual market on or after such date.

16 (d) COORDINATED REGULATIONS.—Section 104(1)

17 of Health Insurance Portability and Accountability Act of

18 1996 is amended by striking ‘‘this subtitle (and the

19 amendments made by this subtitle and section 401)’’ and

20 inserting ‘‘the provisions of part 7 of subtitle B of title

21 I of the Employee Retirement Income Security Act of

22 1974, the provisions of parts A and C of title XXVII of

23 the Public Health Service Act, and chapter 100 of the In24 ternal Revenue Code of 1986’’.

Æ