I 

111TH CONGRESS 

1ST SESSION H. R. 1691 

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

for mastectomies, lumpectomies, and lymph node dissection for the treatment of breast cancer and coverage for secondary consultations. 

IN THE HOUSE OF REPRESENTATIVES 

MARCH 24, 2009 

Ms. DELAURO (for herself, Mr. BARTON of Texas, Mr. ACKERMAN, Mr. 

ARCURI, Mr. BACA, Ms. BALDWIN, Mr. HILL, Ms. BEAN, Ms. BERKLEY, 

Mr. BERMAN, Mr. BERRY, Mr. BISHOP of Georgia, Mr. BISHOP of New 

York, Mr. BLUMENAUER, Ms. BORDALLO, Mr. BOREN, Mr. BOSWELL, 

Mr. BOYD, Mr. BRADY of Pennsylvania, Ms. CORRINE BROWN of Florida, 

Mr. BRALEY of Iowa, Mr. BURTON of Indiana, Mr. CAPUANO, Mr. 

CARDOZA, Mr. CARNEY, Ms. SHEA-PORTER, Mr. CARSON of Indiana, Ms. 

CASTOR of Florida, Mr. CHANDLER, Mrs. CHRISTENSEN, Mr. CLAY, Mr. 

CLEAVER, Mr. COHEN, Mr. CONNOLLY of Virginia, Mr. CONYERS, Mr. 

COOPER, Mr. COURTNEY, Mr. CROWLEY, Mr. CUELLAR, Mr. CUMMINGS, 

Mr. DAVIS of Illinois, Mr. DAVIS of Tennessee, Mrs. DAVIS of California, 

Mrs. HALVORSON, Mr. DEFAZIO, Ms. DEGETTE, Mr. DELAHUNT, Mr. 

DICKS, Mr. DINGELL, Mr. DOGGETT, Ms. EDWARDS of Maryland, Mr. 

DOYLE, Mr. EDWARDS of Texas, Mr. ELLISON, Mr. ENGEL, Mr. MASSA, 

Ms. ESHOO, Mr. ETHERIDGE, Mr. FARR, Mr. FATTAH, Mr. PALLONE, 

Mr. FRANK of Massachusetts, Mr. GERLACH, Mr. NYE, Mr. GONZALEZ, 

Mr. GORDON of Tennessee, Mr. AL GREEN of Texas, Mr. GENE GREEN

of Texas, Mr. GRIFFITH, Mr. GRIJALVA, Mr. GUTIERREZ, Mr. HARE, Ms. 

HARMAN, Mr. HASTINGS of Florida, Mr. HIGGINS, Mr. HIMES, Mr. HINCHEY, Mr. HINOJOSA, Ms. HIRONO, Mr. HOLDEN, Mr. HOLT, Mr. INSLEE, Mr. ISRAEL, Mr. JACKSON of Illinois, Ms. JACKSON-LEE of Texas, 

Mr. MATHESON, Mr. BARROW, Mr. SARBANES, Ms. EDDIE BERNICE

JOHNSON of Texas, Mr. KAGEN, Mr. KANJORSKI, Ms. KAPTUR, Mrs. 

DAHLKEMPER, Mr. MEEK of Florida, Mr. KENNEDY, Mr. KILDEE, Ms. 

KILPATRICK of Michigan, Ms. KILROY, Mr. KIND, Mr. KLEIN of Florida, 

Mr. KUCINICH, Mr. LANGEVIN, Mr. LARSEN of Washington, Mr. LARSON

of Connecticut, Ms. LEE of California, Mr. LEVIN, Mr. LEWIS of Georgia, 

Mr. LOBIONDO, Mr. LOEBSACK, Ms. ZOE LOFGREN of California, Mrs. 

CAPPS, Mrs. LOWEY, Mr. LYNCH, Mr. MACK, Mr. MAFFEI, Mrs. 

MALONEY, Ms. FUDGE, Ms. MATSUI, Mrs. MCCARTHY of New York, Ms. 

MCCOLLUM, Mr. MCDERMOTT, Mr. MCGOVERN, Mr. MCHUGH, Mr. 

MCINTYRE, Mr. MEEKS of New York, Mr. MELANCON, Mr. MICHAUD, 


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Mr. MILLER of North Carolina, Mr. GEORGE MILLER of California, Mr. 

MOORE of Kansas, Ms. MOORE of Wisconsin, Mr. MORAN of Kansas, Mr. 

MORAN of Virginia, Mr. MURPHY of Connecticut, Mr. MURTHA, Mrs. 

MYRICK, Mr. NADLER of New York, Mrs. NAPOLITANO, Ms. NORTON, 

Mr. OBERSTAR, Mr. OLVER, Mr. ORTIZ, Mr. PASCRELL, Mr. TONKO, Mr. 

PAYNE, Mr. PETERSON, Ms. PINGREE of Maine, Mr. PLATTS, Mr. PRICE

of North Carolina, Mr. RANGEL, Mr. REYES, Mr. RODRIGUEZ, Ms. ROSLEHTINEN, Mr. ROTHMAN of New Jersey, Ms. ROYBAL-ALLARD, Mr. 

RUSH, Mr. RYAN of Ohio, Ms. LINDA T. SA ́NCHEZ of California, Ms. 

SCHAKOWSKY, Mr. SCHIFF, Ms. SCHWARTZ, Mr. SCOTT of Georgia, Mr. 

SCOTT of Virginia, Mr. SERRANO, Mr. SESTAK, Mr. SHERMAN, Mr. 

SIRES, Mr. SKELTON, Ms. SLAUGHTER, Mr. SMITH of Washington, Mr. 

SNYDER, Mr. SPACE, Ms. SPEIER, Mr. SPRATT, Mr. STARK, Mr. STUPAK, Ms. SUTTON, Mrs. TAUSCHER, Mr. TAYLOR, Mr. THOMPSON of 

California, Mr. TIERNEY, Mr. TOWNS, Ms. TSONGAS, Mr. VAN HOLLEN, 

Ms. VELA ́ZQUEZ, Ms. WASSERMAN SCHULTZ, Mr. WEINER, Mr. WELCH, 

Mr. WEXLER, Mr. WILSON of Ohio, Mr. WITTMAN, Mr. WOLF, Ms. 

WOOLSEY, Ms. TITUS, Mr. ALTMIRE, Mr. RUPPERSBERGER, Mr. 

MCNERNEY, Mr. CLYBURN, Ms. MARKEY of Colorado, Mr. HALL of 

Texas, Ms. KOSMAS, Mr. ROGERS of Alabama, Mr. FILNER, Mr. 

SOUDER, and Mr. POLIS of Colorado) introduced the following bill; which 

was referred to the Committee on Energy and Commerce, and in addition 

to the Committees on Ways and Means and Education and Labor, 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 require that health plans provide coverage for a minimum 

hospital stay for mastectomies, lumpectomies, 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 ‘‘Breast Cancer Patient 

5 Protection Act of 2009’’. 


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1 SEC. 2. FINDINGS. 

2 Congress finds the following: 

3 (1) According to the American Cancer Society, 

4 excluding cancers of the skin, breast cancer is the 

5 most frequently diagnosed cancer in women. 

6 (2) According to the American Cancer Society, 

7 an estimated 40,480 women and 450 men died from 

8 breast cancer in 2008. 

9 (3) According to the American Cancer Society, 

10 in 2008 an estimated 182,460 new cases of invasive 

11 breast cancer were diagnosed in women, and an esti12 mated 1,990 invasive breast cancer cases were diag13 nosed in men; and in addition, an estimated 67,770 

14 new cases of in situ breast cancer occurred in 

15 women in 2008, and of these, approximately 85 per16 cent were ductal carcinoma in situ. 

17 (4) According to the American Cancer Society, 

18 most breast cancer patients undergo some type of 

19 surgical treatment, which may involve lumpectomy 

20 (surgical removal of the tumor with clear margins) 

21 or mastectomy (surgical removal of the breast) with 

22 removal of some of the axillary (underarm) lymph 

23 nodes. 

24 (5) The offering and operation of health plans 

25 affect commerce among the States. 


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1 (6) Health care providers located in a State 

2 serve patients who reside in the State and patients 

3 who reside in other States. 

4 (7) In order to provide for uniform treatment 

5 of health care providers and patients among the 

6 States, it is necessary to cover health plans oper7 ating in one State as well as health plans operating 

8 among the several States. 

9 (8) Research has indicated that treatment for 

10 breast cancer varies according to type of insurance 

11 coverage and State of residence. 

12 (9) Currently, 20 States mandate minimum in13 patient coverage after a patient undergoes a mastec14 tomy. 

15 (10) Breast cancer patients have reported ad16 verse outcomes, including infection and inadequately 

17 controlled pain, resulting from premature hospital 

18 discharge following breast cancer surgery. 

19 SEC. 2. AMENDMENTS TO THE EMPLOYEE RETIREMENT IN20 COME SECURITY ACT OF 1974. 

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

22 B of title I of the Employee Retirement Income Security 

23 Act of 1974 (29 U.S.C. 1185 et seq.) is amended by add24 ing at the end the following: 


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1 ‘‘SEC. 715. REQUIRED COVERAGE FOR MINIMUM HOSPITAL 

2 STAY FOR MASTECTOMIES, LUMPECTOMIES, 

3 AND LYMPH NODE DISSECTIONS FOR THE 

4 TREATMENT OF BREAST CANCER AND COV5 ERAGE FOR SECONDARY CONSULTATIONS. 

6 ‘‘(a) INPATIENT CARE.— 

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

8 health insurance issuer providing health insurance 

9 coverage in connection with a group health plan, 

10 that provides medical and surgical benefits shall en11 sure that inpatient (and in the case of a 

12 lumpectomy, outpatient) coverage and radiation 

13 therapy is provided for breast cancer treatment. 

14 Such plan or coverage may not— 

15 ‘‘(A) insofar as the attending physician, in 

16 consultation with the patient, determines it to 

17 be medically necessary— 

18 ‘‘(i) restrict benefits for any hospital 

19 length of stay in connection with a mastec20 tomy or breast conserving surgery (such as 

21 a lumpectomy) for the treatment of breast 

22 cancer to less than 48 hours; or 

23 ‘‘(ii) restrict benefits for any hospital 

24 length of stay in connection with a lymph 

25 node dissection for the treatment of breast 

26 cancer to less than 24 hours; or 


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1 ‘‘(B) require that a provider obtain author2 ization from the plan or the issuer for pre3 scribing any length of stay required under this 

4 paragraph. 

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

6 be construed as requiring the provision of inpatient 

7 coverage if the attending physician, in consultation 

8 with the patient, determines that either a shorter pe9 riod of hospital stay, or outpatient treatment, is 

10 medically appropriate. 

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

12 In implementing the requirements of this section, a group 

13 health plan, and a health insurance issuer providing health 

14 insurance coverage in connection with a group health plan, 

15 may not modify the terms and conditions of coverage 

16 based on the determination by a participant or beneficiary 

17 to request less than the minimum coverage required under 

18 subsection (a). 

19 ‘‘(c) NOTICE.—A group health plan, and a health in20 surance issuer providing health insurance coverage in con21 nection with a group health plan shall provide notice to 

22 each participant and beneficiary under such plan regard23 ing the coverage required by this section in accordance 

24 with regulations promulgated by the Secretary. Such no25 tice shall be in writing and prominently positioned in the 


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1 summary of the plan made available or distributed by the 

2 plan or issuer and shall be transmitted— 

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

4 issuer to the participant or beneficiary; or 

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

6 sent to the participant or beneficiary; 

7 whichever is earlier. 

8 ‘‘(d) SECONDARY CONSULTATIONS.— 

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

10 health insurance issuer providing health insurance 

11 coverage in connection with a group health plan, 

12 that provides coverage with respect to medical and 

13 surgical services provided in relation to the diagnosis 

14 and treatment of cancer shall ensure that coverage 

15 is provided for secondary consultations, on terms 

16 and conditions that are no more restrictive than 

17 those applicable to the initial consultations, by spe18 cialists in the appropriate medical fields (including 

19 pathology, radiology, and oncology) to confirm or re20 fute such diagnosis. Such plan or issuer shall ensure 

21 that coverage is provided for such secondary con22 sultation whether such consultation is based on a 

23 positive or negative initial diagnosis. In any case in 

24 which the attending physician certifies in writing 

25 that services necessary for such a secondary conVerDate Nov 24 2008 03:56 Mar 25, 2009 Jkt 079200 PO 00000 Frm 00007 Fmt 6652 Sfmt 6201 E:\BILLS\H1691.IH H1691

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1 sultation are not sufficiently available from special2 ists operating under the plan with respect to whose 

3 services coverage is otherwise provided under such 

4 plan or by such issuer, such plan or issuer shall en5 sure that coverage is provided with respect to the 

6 services necessary for the secondary consultation 

7 with any other specialist selected by the attending 

8 physician for such purpose at no additional cost to 

9 the individual beyond that which the individual 

10 would have paid if the specialist was participating in 

11 the network of the plan. 

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

13 shall be construed as requiring the provision of sec14 ondary consultations where the patient determines 

15 not to seek such a consultation. 

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

17 A group health plan, and a health insurance issuer pro18 viding health insurance coverage in connection with a 

19 group health plan, may not— 

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

21 reimbursement of a provider or specialist because 

22 the provider or specialist provided care to a partici23 pant or beneficiary in accordance with this section; 

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

25 physician or specialist to induce the physician or 


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1 specialist to keep the length of inpatient stays of pa2 tients following a mastectomy, lumpectomy, or a 

3 lymph node dissection for the treatment of breast 

4 cancer below certain limits or to limit referrals for 

5 secondary consultations; or 

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

7 physician or specialist to induce the physician or 

8 specialist to refrain from referring a participant or 

9 beneficiary for a secondary consultation that would 

10 otherwise be covered by the plan or coverage in11 volved under subsection (d).’’. 

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

13 in section 1 of the Employee Retirement Income Security 

14 Act of 1974 is amended by inserting after the item relat15 ing to section 714 the following: 

‘‘Sec. 715. Required coverage for minimum hospital stay for mastectomies, 

lumpectomies, and lymph node dissections for the treatment of 

breast cancer and coverage for secondary consultations.’’. 

16 (c) EFFECTIVE DATES.— 

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

18 this section shall apply with respect to plan years be19 ginning on or after the date that is 90 days after 

20 the date of enactment of this Act. 

21 (2) SPECIAL RULE FOR COLLECTIVE BAR22 GAINING AGREEMENTS.—In the case of a group 

23 health plan maintained pursuant to 1 or more collec24 tive bargaining agreements between employee repVerDate Nov 24 2008 03:56 Mar 25, 2009 Jkt 079200 PO 00000 Frm 00009 Fmt 6652 Sfmt 6201 E:\BILLS\H1691.IH H1691

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1 resentatives and 1 or more employers ratified before 

2 the date of enactment of this Act, the amendments 

3 made by this section shall not apply to plan years 

4 beginning before the date on which the last collective 

5 bargaining agreements relating to the plan termi6 nates (determined without regard to any extension 

7 thereof agreed to after the date of enactment of this 

8 Act). For purposes of this paragraph, any plan 

9 amendment made pursuant to a collective bargaining 

10 agreement relating to the plan which amends the 

11 plan solely to conform to any requirement added by 

12 this section shall not be treated as a termination of 

13 such collective bargaining agreement. 

14 SEC. 3. AMENDMENTS TO THE PUBLIC HEALTH SERVICE 

15 ACT RELATING TO THE GROUP MARKET. 

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

17 XXVII of the Public Health Service Act (42 U.S.C. 

18 300gg–4 et seq.) is amended by adding at the end the 

19 following: 

20 ‘‘SEC. 2708. REQUIRED COVERAGE FOR MINIMUM HOSPITAL 

21 STAY FOR MASTECTOMIES, LUMPECTOMIES, 

22 AND LYMPH NODE DISSECTIONS FOR THE 

23 TREATMENT OF BREAST CANCER AND COV24 ERAGE FOR SECONDARY CONSULTATIONS. 

25 ‘‘(a) INPATIENT CARE.— 


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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 (and in the case of a 

6 lumpectomy, outpatient) coverage and radiation 

7 therapy is provided for breast cancer treatment. 

8 Such plan or coverage may not— 

9 ‘‘(A) insofar as the attending physician, in 

10 consultation with the patient, determines it to 

11 be medically necessary— 

12 ‘‘(i) restrict benefits for any hospital 

13 length of stay in connection with a mastec14 tomy or breast conserving surgery (such as 

15 a lumpectomy) for the treatment of breast 

16 cancer to less than 48 hours; or 

17 ‘‘(ii) restrict benefits for any hospital 

18 length of stay in connection with a lymph 

19 node dissection for the treatment of breast 

20 cancer to less than 24 hours; or 

21 ‘‘(B) require that a provider obtain author22 ization from the plan or the issuer for pre23 scribing any length of stay required under this 

24 paragraph. 


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

2 be construed as requiring the provision of inpatient 

3 coverage if the attending physician, in consultation 

4 with the patient, determines that either a shorter pe5 riod of hospital stay, or outpatient treatment, is 

6 medically appropriate. 

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

8 In implementing the requirements of this section, a group 

9 health plan, and a health insurance issuer providing health 

10 insurance coverage in connection with a group health plan, 

11 may not modify the terms and conditions of coverage 

12 based on the determination by a participant or beneficiary 

13 to request less than the minimum coverage required under 

14 subsection (a). 

15 ‘‘(c) NOTICE.—A group health plan, and a health in16 surance issuer providing health insurance coverage in con17 nection with a group health plan shall provide notice to 

18 each participant and beneficiary under such plan regard19 ing the coverage required by this section in accordance 

20 with regulations promulgated by the Secretary. Such no21 tice shall be in writing and prominently positioned in the 

22 summary of the plan made available or distributed by the 

23 plan or issuer and shall be transmitted— 

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

25 issuer to the participant or beneficiary; or 


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

2 sent to the participant or beneficiary; 

3 whichever is earlier. 

4 ‘‘(d) SECONDARY CONSULTATIONS.— 

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

6 health insurance issuer providing health insurance 

7 coverage in connection with a group health plan, 

8 that provides coverage with respect to medical and 

9 surgical services provided in relation to the diagnosis 

10 and treatment of cancer shall ensure that coverage 

11 is provided for secondary consultations, on terms 

12 and conditions that are no more restrictive than 

13 those applicable to the initial consultations, by spe14 cialists in the appropriate medical fields (including 

15 pathology, radiology, and oncology) to confirm or re16 fute such diagnosis. Such plan or issuer shall ensure 

17 that coverage is provided for such secondary con18 sultation whether such consultation is based on a 

19 positive or negative initial diagnosis. In any case in 

20 which the attending physician certifies in writing 

21 that services necessary for such a secondary con22 sultation are not sufficiently available from special23 ists operating under the plan with respect to whose 

24 services coverage is otherwise provided under such 

25 plan or by such issuer, such plan or issuer shall enVerDate Nov 24 2008 03:56 Mar 25, 2009 Jkt 079200 PO 00000 Frm 00013 Fmt 6652 Sfmt 6201 E:\BILLS\H1691.IH H1691

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1 sure that coverage is provided with respect to the 

2 services necessary for the secondary consultation 

3 with any other specialist selected by the attending 

4 physician for such purpose at no additional cost to 

5 the individual beyond that which the individual 

6 would have paid if the specialist was participating in 

7 the network of the plan. 

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

9 shall be construed as requiring the provision of sec10 ondary consultations where the patient determines 

11 not to seek such a consultation. 

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

13 A group health plan, and a health insurance issuer pro14 viding health insurance coverage in connection with a 

15 group health plan, may not— 

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

17 reimbursement of a provider or specialist because 

18 the provider or specialist provided care to a partici19 pant or beneficiary in accordance with this section; 

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

21 physician or specialist to induce the physician or 

22 specialist to keep the length of inpatient stays of pa23 tients following a mastectomy, lumpectomy, or a 

24 lymph node dissection for the treatment of breast 


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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 90 days after the 

13 date of enactment of this Act. 

14 (2) SPECIAL RULE FOR COLLECTIVE BAR15 GAINING AGREEMENTS.—In the case of a group 

16 health plan maintained pursuant to 1 or more collec17 tive bargaining agreements between employee rep18 resentatives and 1 or more employers ratified before 

19 the date of enactment of this Act, the amendments 

20 made by this section shall not apply to plan years 

21 beginning before the date on which the last collective 

22 bargaining agreements relating to the plan termi23 nates (determined without regard to any extension 

24 thereof agreed to after the date of enactment of this 

25 Act). For purposes of this paragraph, any plan 


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1 amendment made pursuant to a collective bargaining 

2 agreement relating to the plan which amends the 

3 plan solely to conform to any requirement added by 

4 this section shall not be treated as a termination of 

5 such collective bargaining agreement. 

6 SEC. 4. AMENDMENT TO THE PUBLIC HEALTH SERVICE ACT 

7 RELATING TO THE INDIVIDUAL MARKET. 

8 (a) IN GENERAL.—Subpart 2 of part B of title 

9 XXVII of the Public Health Service Act (42 U.S.C. 

10 300gg–51 et seq.) is amended by adding at the end the 

11 following new section: 

12 ‘‘SEC. 2754. REQUIRED COVERAGE FOR MINIMUM HOSPITAL 

13 STAY FOR MASTECTOMIES, LUMPECTOMIES, 

14 AND LYMPH NODE DISSECTIONS FOR THE 

15 TREATMENT OF BREAST CANCER AND SEC16 ONDARY CONSULTATIONS. 

17 ‘‘The provisions of section 2708 shall apply to health 

18 insurance coverage offered by a health insurance issuer 

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

20 to health insurance coverage offered by a health insurance 

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

22 or large group market.’’. 

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

24 this section shall apply with respect to health insurance 

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1 ated in the individual market on or after the date of enact2 ment of this Act. 

3 SEC. 5. AMENDMENTS TO THE INTERNAL REVENUE CODE 

4 OF 1986. 

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

6 the Internal Revenue Code of 1986 is amended— 

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

8 the item relating to section 9813 the following: 

‘‘Sec. 9814. Required coverage for minimum hospital stay for mastectomies, 

lumpectomies, and lymph node dissections for the treatment of 

breast cancer and coverage for secondary consultations.’’; 

9 and 

10 (2) by inserting after section 9813 the fol11 lowing: 

12 ‘‘SEC. 9814. REQUIRED COVERAGE FOR MINIMUM HOSPITAL 

13 STAY FOR MASTECTOMIES, LUMPECTOMIES, 

14 AND LYMPH NODE DISSECTIONS FOR THE 

15 TREATMENT OF BREAST CANCER AND COV16 ERAGE FOR SECONDARY CONSULTATIONS. 

17 ‘‘(a) INPATIENT CARE.— 

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

19 provides medical and surgical benefits shall ensure 

20 that inpatient (and in the case of a lumpectomy, 

21 outpatient) coverage and radiation therapy is pro22 vided for breast cancer treatment. Such plan may 

23 not— 


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1 ‘‘(A) insofar as the attending physician, in 

2 consultation with the patient, determines it to 

3 be medically necessary— 

4 ‘‘(i) restrict benefits for any hospital 

5 length of stay in connection with a mastec6 tomy or breast conserving surgery (such as 

7 a lumpectomy) for the treatment of breast 

8 cancer to less than 48 hours; or 

9 ‘‘(ii) restrict benefits for any hospital 

10 length of stay in connection with a lymph 

11 node dissection for the treatment of breast 

12 cancer to less than 24 hours; or 

13 ‘‘(B) require that a provider obtain author14 ization from the plan for prescribing any length 

15 of stay required under this paragraph. 

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

17 be construed as requiring the provision of inpatient 

18 coverage if the attending physician, in consultation 

19 with the patient, determines that either a shorter pe20 riod of hospital stay, or outpatient treatment, is 

21 medically appropriate. 

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

23 In implementing the requirements of this section, a group 

24 health plan may not modify the terms and conditions of 

25 coverage based on the determination by a participant or 


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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 the summary of the plan made available or distributed by 

9 the plan and shall be transmitted— 

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

11 the participant or beneficiary; or 

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

13 sent to the participant or beneficiary; 

14 whichever is earlier. 

15 ‘‘(d) SECONDARY CONSULTATIONS.— 

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

17 provides coverage with respect to medical and sur18 gical services provided in relation to the diagnosis 

19 and treatment of cancer shall ensure that coverage 

20 is provided for secondary consultations, on terms 

21 and conditions that are no more restrictive than 

22 those applicable to the initial consultations, by spe23 cialists in the appropriate medical fields (including 

24 pathology, radiology, and oncology) to confirm or re25 fute such diagnosis. Such plan or issuer shall ensure 


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1 that coverage is provided for such secondary con2 sultation whether such consultation is based on a 

3 positive or negative initial diagnosis. In any case in 

4 which the attending physician certifies in writing 

5 that services necessary for such a secondary con6 sultation are not sufficiently available from special7 ists operating under the plan with respect to whose 

8 services coverage is otherwise provided under such 

9 plan or by such issuer, such plan or issuer shall en10 sure that coverage is provided with respect to the 

11 services necessary for the secondary consultation 

12 with any other specialist selected by the attending 

13 physician for such purpose at no additional cost to 

14 the individual beyond that which the individual 

15 would have paid if the specialist was participating in 

16 the network of the plan. 

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

18 shall be construed as requiring the provision of sec19 ondary consultations where the patient determines 

20 not to seek such a consultation. 

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

22 plan may not— 

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

24 reimbursement of a provider or specialist because 


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1 the provider or specialist provided care to a partici2 pant or beneficiary in accordance with this section; 

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

4 physician or specialist to induce the physician or 

5 specialist to keep the length of inpatient stays of pa6 tients following a mastectomy, lumpectomy, or a 

7 lymph node dissection for the treatment of breast 

8 cancer below certain limits or to limit referrals for 

9 secondary consultations; or 

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

11 physician or specialist to induce the physician or 

12 specialist to refrain from referring a participant or 

13 beneficiary for a secondary consultation that would 

14 otherwise be covered by the plan involved under sub15 section (d).’’. 

16 (b) EFFECTIVE DATES.— 

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

18 this section shall apply with respect to plan years be19 ginning on or after the date of enactment of this 

20 Act. 

21 (2) SPECIAL RULE FOR COLLECTIVE BAR22 GAINING AGREEMENTS.—In the case of a group 

23 health plan maintained pursuant to 1 or more collec24 tive bargaining agreements between employee rep25 resentatives and 1 or more employers ratified before 


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1 the date of enactment of this Act, the amendments 

2 made by this section shall not apply to plan years 

3 beginning before the date on which the last collective 

4 bargaining agreements relating to the plan termi5 nates (determined without regard to any extension 

6 thereof agreed to after the date of enactment of this 

7 Act). For purposes of this paragraph, any plan 

8 amendment made pursuant to a collective bargaining 

9 agreement relating to the plan which amends the 

10 plan solely to conform to any requirement added by 

11 this section shall not be treated as a termination of 

12 such collective bargaining agreement. 

13 SEC. 6. OPPORTUNITY FOR INDEPENDENT, EXTERNAL 

14 THIRD PARTY REVIEWS OF CERTAIN NON15 RENEWALS AND DISCONTINUATIONS, IN16 CLUDING RESCISSIONS, OF INDIVIDUAL 

17 HEALTH INSURANCE COVERAGE. 

18 (a) CLARIFICATION REGARDING APPLICATION OF

19 GUARANTEED RENEWABILITY OF INDIVIDUAL HEALTH

20 INSURANCE COVERAGE.—Section 2742 of the Public 

21 Health Service Act (42 U.S.C. 300gg–42) is amended— 

22 (1) in its heading, by inserting ‘‘, CONTINU23 ATION IN FORCE, INCLUDING PROHIBITION OF

24 RESCISSION,’’ after ‘‘GUARANTEED RENEW25 ABILITY’’; 


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1 (2) in subsection (a), by inserting ‘‘, including 

2 without rescission,’’ after ‘‘continue in force’’; and 

3 (3) in subsection (b)(2), by inserting before the 

4 period at the end the following: ‘‘, including inten5 tional concealment of material facts regarding a 

6 health condition related to the condition for which 

7 coverage is being claimed’’. 

8 (b) OPPORTUNITY FOR INDEPENDENT, EXTERNAL

9 THIRD PARTY REVIEW IN CERTAIN CASES.—Subpart 1 

10 of part B of title XXVII of the Public Health Service Act 

11 is amended by adding at the end the following new section: 

12 ‘‘SEC. 2746. OPPORTUNITY FOR INDEPENDENT, EXTERNAL 

13 THIRD PARTY REVIEW IN CERTAIN CASES. 

14 ‘‘(a) NOTICE AND REVIEW RIGHT.—If a health in15 surance issuer determines to nonrenew or not continue in 

16 force, including rescind, health insurance coverage for an 

17 individual in the individual market on the basis described 

18 in section 2742(b)(2) before such nonrenewal, discontinu19 ation, or rescission, may take effect the issuer shall pro20 vide the individual with notice of such proposed non21 renewal, discontinuation, or rescission and an opportunity 

22 for a review of such determination by an independent, ex23 ternal third party under procedures specified by the Sec24 retary. 


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1 ‘‘(b) INDEPENDENT DETERMINATION.—If the indi2 vidual requests such review by an independent, external 

3 third party of a nonrenewal, discontinuation, or rescission 

4 of health insurance coverage, the coverage shall remain in 

5 effect until such third party determines that the coverage 

6 may be nonrenewed, discontinued, or rescinded under sec7 tion 2742(b)(2).’’. 

8 (c) EFFECTIVE DATE.—The amendments made by 

9 this section shall apply after the date of the enactment 

10 of this Act with respect to health insurance coverage 

11 issued before, on, or after such date. 

Æ 


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