II 

111TH CONGRESS 

1ST SESSION S. 1235 

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 

JUNE 11, 2009 

Ms. LANDRIEU (for herself, Mr. COCHRAN, Mr. SPECTER, and Mr. BAYH) 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, 


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1 SECTION 1. SHORT TITLE. 

2 This Act may be cited as the ‘‘Children’s Access to 

3 Reconstructive Evaluation & Surgery (CARES) Act of 

4 2009’’. 

5 SEC. 2. COVERAGE OF MINOR CHILD’S CONGENITAL OR DE6 VELOPMENTAL DEFORMITY OR DISORDER. 

7 (a) GROUP HEALTH PLANS.— 

8 (1) PUBLIC HEALTH SERVICE ACT AMEND9 MENTS.—(A) Subpart 2 of part A of title XXVII of 

10 the Public Health Service Act is amended by adding 

11 at the end the following new section: 

12 ‘‘SEC. 2708. 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-authorVerDate Nov 24 2008 23:34 Jun 11, 2009 Jkt 079200 PO 00000 Frm 00002 Fmt 6652 Sfmt 6201 E:\BILLS\S1235.IS S1235

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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 

3 714(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)) is amended by striking ‘‘section 2704’’ 

8 and inserting ‘‘sections 2704 and 2708’’. 

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

10 part 7 of subtitle B of title I of the Employee Re11 tirement Income Security Act of 1974 is amended by 

12 adding at the end the following new section: 

13 ‘‘SEC. 715. STANDARDS RELATING TO BENEFITS FOR MINOR 

14 CHILD’S CONGENITAL OR DEVELOPMENTAL 

15 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 who has not attained age 22. 


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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.—For purposes of this 

10 section, the term ‘treatment’ includes recon11 structive surgical procedures (procedures that 

12 are generally performed to improve function, 

13 but may also be performed to approximate a 

14 normal appearance) that are performed on ab15 normal structures of the body caused by con16 genital defects, developmental abnormalities, 

17 trauma, infection, tumors, or disease, includ18 ing— 

19 ‘‘(i) procedures that do not materially 

20 affect the function of the body part being 

21 treated; and 

22 ‘‘(ii) procedures for secondary condi23 tions and follow-up treatment. 

24 ‘‘(B) EXCEPTION.—Such term does not in25 clude cosmetic surgery performed to reshape 


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

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

4 imposition of the requirements of this section shall be 

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

6 described in the last sentence of section 102(a), for pur7 poses of assuring notice of such requirements under the 

8 plan; except that the summary description required to be 

9 provided under the fourth sentence of section 104(b)(1) 

10 with respect to such modification shall be provided by not 

11 later than 60 days after the first day of the first plan 

12 year in which such requirements apply.’’. 

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

14 1191(c)) is amended by striking ‘‘section 711’’ and 

15 inserting ‘‘sections 711 and 715’’. 

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

17 1191a(a)) is amended by striking ‘‘section 711’’ and 

18 inserting ‘‘sections 711 and 715’’. 

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

20 Act is amended by inserting after the item relating 

21 to section 714 the following new item: 

‘‘Sec. 715. Standards relating to benefits for minor child’s congenital or developmental deformity or disorder.’’. 

22 (3) INTERNAL REVENUE CODE AMEND23 MENTS.— 


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1 (A) IN GENERAL.—Subchapter B of chap2 ter 100 of the Internal Revenue Code of 1986 

3 is amended by adding at the end the following 

4 new section: 

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

6 MINOR CHILD’S CONGENITAL OR DEVELOP7 MENTAL DEFORMITY OR DISORDER. 

8 ‘‘(a) REQUIREMENTS FOR RECONSTRUCTIVE SUR9 GERY.— 

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

11 health insurance issuer offering group health insur12 ance coverage, that provides coverage for surgical 

13 benefits shall provide coverage for outpatient and in14 patient diagnosis and treatment of a minor child’s 

15 congenital or developmental deformity, disease, or 

16 injury. A minor child shall include any individual 

17 who has not attained age 22. 

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

19 under paragraph (1) shall be subject to pre-author20 ization or pre-certification as required by the plan or 

21 issuer, and such coverage shall include any surgical 

22 treatment which, in the opinion of the treating phy23 sician, is medically necessary to approximate a nor24 mal appearance. 

25 ‘‘(3) TREATMENT DEFINED.— 


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1 ‘‘(A) IN GENERAL.—For purposes of this 

2 section, the term ‘treatment’ includes recon3 structive surgical procedures (procedures that 

4 are generally performed to improve function, 

5 but may also be performed to approximate a 

6 normal appearance) that are performed on ab7 normal structures of the body caused by con8 genital defects, developmental abnormalities, 

9 trauma, infection, tumors, or disease, includ10 ing— 

11 ‘‘(i) procedures that do not materially 

12 affect the function of the body part being 

13 treated; and 

14 ‘‘(ii) procedures for secondary condi15 tions and follow-up treatment. 

16 ‘‘(B) EXCEPTION.—Such term does not in17 clude cosmetic surgery performed to reshape 

18 normal structures of the body to improve ap19 pearance or self-esteem.’’. 

20 (B) CLERICAL AMENDMENT.—The table of 

21 sections for such subchapter is amended by 

22 adding at the end the following new item: 

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

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

24 of title XXVII of the Public Health Service Act is amendVerDate Nov 24 2008 23:34 Jun 11, 2009 Jkt 079200 PO 00000 Frm 00008 Fmt 6652 Sfmt 6201 E:\BILLS\S1235.IS S1235

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1 ed by inserting after section 2752 the following new sec2 tion: 

3 ‘‘SEC. 2754. STANDARDS RELATING TO BENEFITS FOR 

4 MINOR CHILD’S CONGENITAL OR DEVELOP5 MENTAL DEFORMITY OR DISORDER. 

6 ‘‘(a) REQUIREMENTS FOR RECONSTRUCTIVE SUR7 GERY.— 

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

9 health insurance issuer offering group health insur10 ance coverage, that provides coverage for surgical 

11 benefits shall provide coverage for outpatient and in12 patient diagnosis and treatment of a minor child’s 

13 congenital or developmental deformity, disease, or 

14 injury. A minor child shall include any individual 

15 through 21 years of age. 

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

17 under paragraph (1) shall be subject to pre-author18 ization or pre-certification as required by the plan or 

19 issuer, and such coverage shall include any surgical 

20 treatment which, in the opinion of the treating phy21 sician, is medically necessary to approximate a nor22 mal appearance. 

23 ‘‘(3) TREATMENT DEFINED.— 

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

25 term ‘treatment’ includes reconstructive surVerDate Nov 24 2008 23:34 Jun 11, 2009 Jkt 079200 PO 00000 Frm 00009 Fmt 6652 Sfmt 6201 E:\BILLS\S1235.IS S1235

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1 gical procedures (procedures that are generally 

2 performed to improve function, but may also be 

3 performed to approximate a normal appear4 ance) that are performed on abnormal struc5 tures of the body caused by congenital defects, 

6 developmental abnormalities, trauma, infection, 

7 tumors, or disease, including— 

8 ‘‘(i) procedures that do not materially 

9 affect the function of the body part being 

10 treated; and 

11 ‘‘(ii) procedures for secondary condi12 tions and follow-up treatment. 

13 ‘‘(B) EXCEPTION.—Such term does not in14 clude cosmetic surgery performed to reshape 

15 normal structures of the body to improve ap16 pearance or self-esteem. 

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

18 part shall comply with the notice requirement under sec19 tion 714(b) of the Employee Retirement Income Security 

20 Act of 1974 with respect to the requirements referred to 

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

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

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

24 300gg–62(b)(2)) is amended by striking ‘‘section 2751’’ 

25 and inserting ‘‘sections 2751 and 2754’’. 


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

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

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

4 2010. 

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

6 apply with respect to health insurance coverage offered, 

7 sold, issued, renewed, in effect, or operated in the indi8 vidual market on or after such date. 

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

10 of the Health Insurance Portability and Accountability 

11 Act of 1996 is amended by striking ‘‘this subtitle (and 

12 the amendments made by this subtitle and section 401)’’ 

13 and inserting ‘‘the provisions of part 7 of subtitle B of 

14 title I of the Employee Retirement Income Security Act 

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

16 of the Public Health Service Act, and chapter 100 of the 

17 Internal Revenue Code of 1986’’. 

Æ 


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