II 

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. 

1 Be it enacted by the Senate and House of Representa2 tives of the United States of America in Congress assembled, 
2 

•S 1132 IS

1 SECTION 1. SHORT TITLE. 

2 This Act may be cited as the ‘‘Treatment of Chil3 dren’s Deformities Act of 2005’’. 

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.— 

9 (A) IN GENERAL.—Subpart 2 of part A of 

10 title XXVII of the Public Health Service Act 

11 (42 U.S.C. 300gg–4 et seq.) is amended by 

12 adding at the end the following: 

13 ‘‘SEC. 2707. STANDARDS RELATING TO BENEFITS FOR 

14 MINOR CHILD’S CONGENITAL OR DEVELOP15 MENTAL DEFORMITY OR DISORDER. 

16 ‘‘(a) REQUIREMENTS FOR RECONSTRUCTIVE SUR17 GERY.— 

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

19 health insurance issuer offering group health insur20 ance coverage, that provides coverage for surgical 

21 benefits shall provide coverage for outpatient and in22 patient diagnosis and treatment of a minor child’s 

23 congenital or developmental deformity, disease, or 

24 injury. A minor child shall include any individual 

25 through 21 years of age. 
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•S 1132 IS

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

2 under paragraph (1) shall be subject to pre-author3 ization or pre-certification as required by the plan or 

4 issuer, and such coverage shall include any surgical 

5 treatment which, in the opinion of the treating phy6 sician, is medically necessary to approximate a nor7 mal appearance. 

8 ‘‘(3) TREATMENT DEFINED.— 

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

10 term ‘treatment’ includes reconstructive sur11 gical procedures (procedures that are generally 

12 performed to improve function, but may also be 

13 performed to approximate a normal appear14 ance) that are performed on abnormal struc15 tures of the body caused by congenital defects, 

16 developmental abnormalities, trauma, infection, 

17 tumors, or disease, including— 

18 ‘‘(i) procedures that do not materially 

19 affect the function of the body part being 

20 treated; and 

21 ‘‘(ii) procedures for secondary condi22 tions and follow-up treatment. 

23 ‘‘(B) EXCEPTION.—Such term does not in24 clude cosmetic surgery performed to reshape 
4 

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1 normal structures of the body to improve ap2 pearance or self-esteem. 

3 ‘‘(b) NOTICE.—A group health plan under this part 

4 shall comply with the notice requirement under section 

5 714(b) of the Employee Retirement Income Security Act 

6 of 1974 with respect to the requirements of this section 

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

8 (B) CONFORMING AMENDMENT.—Section 

9 2723(c) of the Public Health Service Act (42 

10 U.S.C. 300gg–23(c)) is amended by striking 

11 ‘‘section 2704’’ and inserting ‘‘sections 2704 

12 and 2707’’. 

13 (2) ERISA AMENDMENTS.— 

14 (A) IN GENERAL.—Subpart B of part 7 of 

15 subtitle B of title I of the Employee Retirement 

16 Income Security Act of 1974 (29 U.S.C. 1185 

17 et seq.) is amended by adding at the end the 

18 following: 

19 ‘‘SEC. 714. STANDARDS RELATING TO BENEFITS FOR MINOR 

20 CHILD’S CONGENITAL OR DEVELOPMENTAL 

21 DEFORMITY OR DISORDER. 

22 ‘‘(a) REQUIREMENTS FOR RECONSTRUCTIVE SUR23 GERY.— 

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

25 health insurance issuer offering group health insur-
5 

•S 1132 IS

1 ance coverage, that provides coverage for surgical 

2 benefits shall provide coverage for outpatient and in3 patient diagnosis and treatment of a minor child’s 

4 congenital or developmental deformity, disease, or 

5 injury. A minor child shall include any individual 

6 through 21 years of age. 

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

8 under paragraph (1) shall be subject to pre-author9 ization or pre-certification as required by the plan or 

10 issuer, and such coverage shall include any surgical 

11 treatment which, in the opinion of the treating phy12 sician, is medically necessary to approximate a nor13 mal appearance. 

14 ‘‘(3) TREATMENT DEFINED.— 

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

16 term ‘treatment’ includes reconstructive sur17 gical procedures (procedures that are generally 

18 performed to improve function, but may also be 

19 performed to approximate a normal appear20 ance) that are performed on abnormal struc21 tures of the body caused by congenital defects, 

22 developmental abnormalities, trauma, infection, 

23 tumors, or disease, including— 
6 

•S 1132 IS

1 ‘‘(i) procedures that do not materially 

2 affect the function of the body part being 

3 treated; and 

4 ‘‘(ii) procedures for secondary condi5 tions and follow-up treatment. 

6 ‘‘(B) EXCEPTION.—Such term does not in7 clude cosmetic surgery performed to reshape 

8 normal structures of the body to improve ap9 pearance or self-esteem. 

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

11 imposition of the requirements of this section shall be 

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

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

14 notice of such requirements under the plan; except that 

15 the summary description required to be provided under the 

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

17 modification shall be provided by not later than 60 days 

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

19 requirements apply.’’. 

20 (B) CONFORMING AMENDMENTS.— 

21 (i) Section 731(c) of the Employee 

22 Retirement Income Security Act of 1974 

23 (29 U.S.C. 1191(c)) is amended by strik24 ing ‘‘section 711’’ and inserting ‘‘sections 

25 711 and 714’’. 
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•S 1132 IS

1 (ii) Section 732(a) of the Employee 

2 Retirement Income Security Act of 1974 

3 (29 U.S.C. 1191a(a)) is amended by strik4 ing ‘‘section 711’’ and inserting ‘‘sections 

5 711 and 714’’. 

6 (iii) The table of contents in section 1 

7 of the Employee Retirement Income Secu8 rity Act of 1974 is amended by inserting 

9 after the item relating to section 713 the 

10 following: 

‘‘Sec. 714. Standards relating to benefits for minor child’s congenital or developmental deformity or disorder’’. 

11 (3) INTERNAL REVENUE CODE AMEND12 MENTS.—Subchapter B of chapter 100 of the Inter13 nal Revenue Code of 1986 is amended— 

14 (A) in the table of sections, by inserting 

15 after the item relating to section 9812 the fol16 lowing: 

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

17 and 

18 (B) by inserting after section 9812 the fol19 lowing: 
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•S 1132 IS

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

2 MINOR CHILD’S CONGENITAL OR DEVELOP3 MENTAL DEFORMITY OR DISORDER. 

4 ‘‘(a) REQUIREMENTS FOR RECONSTRUCTIVE SUR5 GERY.— 

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

7 health insurance issuer offering group health insur8 ance coverage, that provides coverage for surgical 

9 benefits shall provide coverage for outpatient and in10 patient diagnosis and treatment of a minor child’s 

11 congenital or developmental deformity, disease, or 

12 injury. A minor child shall include any individual 

13 through 21 years of age. 

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

15 under paragraph (1) shall be subject to pre-author16 ization or pre-certification as required by the plan or 

17 issuer, and such coverage shall include any surgical 

18 treatment which, in the opinion of the treating phy19 sician, is medically necessary to approximate a nor20 mal appearance. 

21 ‘‘(3) TREATMENT DEFINED.— 

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

23 term ‘treatment’ includes reconstructive sur24 gical procedures (procedures that are generally 

25 performed to improve function, but may also be 

26 performed to approximate a normal appear-
9 

•S 1132 IS

1 ance) that are performed on abnormal struc2 tures of the body caused by congenital defects, 

3 developmental abnormalities, trauma, infection, 

4 tumors, or disease, including— 

5 ‘‘(i) procedures that do not materially 

6 affect the function of the body part being 

7 treated; and 

8 ‘‘(ii) procedures for secondary condi9 tions and follow-up treatment. 

10 ‘‘(B) EXCEPTION.—Such term does not in11 clude cosmetic surgery performed to reshape 

12 normal structures of the body to improve ap13 pearance or self-esteem.’’. 

14 (b) INDIVIDUAL HEALTH INSURANCE.— 

15 (1) IN GENERAL.—Part B of title XXVII of the 

16 Public Health Service Act is amended by inserting 

17 after section 2752 the following: 

18 ‘‘SEC. 2753. STANDARDS RELATING TO BENEFITS FOR 

19 MINOR CHILD’S CONGENITAL OR DEVELOP20 MENTAL DEFORMITY OR DISORDER. 

21 ‘‘(a) REQUIREMENTS FOR RECONSTRUCTIVE SUR22 GERY.— 

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

24 health insurance issuer offering group health insur25 ance coverage, that provides coverage for surgical 
10 

•S 1132 IS

1 benefits shall provide coverage for outpatient and in2 patient diagnosis and treatment of a minor child’s 

3 congenital or developmental deformity, disease, or 

4 injury. A minor child shall include any individual 

5 through 21 years of age. 

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

7 under paragraph (1) shall be subject to pre-author8 ization or pre-certification as required by the plan or 

9 issuer, and such coverage shall include any surgical 

10 treatment which, in the opinion of the treating phy11 sician, is medically necessary to approximate a nor12 mal appearance. 

13 ‘‘(3) TREATMENT DEFINED.— 

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

15 term ‘treatment’ includes reconstructive sur16 gical procedures (procedures that are generally 

17 performed to improve function, but may also be 

18 performed to approximate a normal appear19 ance) that are performed on abnormal struc20 tures of the body caused by congenital defects, 

21 developmental abnormalities, trauma, infection, 

22 tumors, or disease, including— 

23 ‘‘(i) procedures that do not materially 

24 affect the function of the body part being 

25 treated; and 
11 

•S 1132 IS

1 ‘‘(ii) procedures for secondary condi2 tions and follow-up treatment. 

3 ‘‘(B) EXCEPTION.—Such term does not in4 clude cosmetic surgery performed to reshape 

5 normal structures of the body to improve ap6 pearance or self-esteem. 

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

8 part shall comply with the notice requirement under sec9 tion 714(b) of the Employee Retirement Income Security 

10 Act of 1974 with respect to the requirements referred to 

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

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

13 (2) CONFORMING AMENDMENT.—Section 

14 2762(b)(2) of the Public Health Service Act (42 

15 U.S.C. 300gg–62(b)(2)) is amended by striking 

16 ‘‘section 2751’’ and inserting ‘‘sections 2751 and 

17 2753’’. 

18 (c) EFFECTIVE DATES.— 

19 (1) GROUP HEALTH COVERAGE.—The amend20 ments made by subsection (a) shall apply with re21 spect to group health plans for plan years beginning 

22 on or after January 1, 2006. 

23 (2) INDIVIDUAL HEALTH COVERAGE.—The 

24 amendment made by subsection (b) shall apply with 

25 respect to health insurance coverage offered, sold, 
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1 issued, renewed, in effect, or operated in the indi2 vidual market on or after such date. 

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

4 of Health Insurance Portability and Accountability Act of 

5 1996 (42 U.S.C. 300gg–92 note) is amended by striking 

6 ‘‘this subtitle (and the amendments made by this subtitle 

7 and section 401)’’ and inserting ‘‘the provisions of part 

8 7 of subtitle B of title I of the Employee Retirement In9 come Security Act of 1974, the provisions of parts A and 

10 C of title XXVII of the Public Health Service Act, and 

11 chapter 100 of the Internal Revenue Code of 1986’’. 

Æ