I 

112TH CONGRESS 

1ST SESSION H. R. 1955 

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, burns, infection, 

tumor, or disease. 

IN THE HOUSE OF REPRESENTATIVES 

MAY 24, 2011 

Mr. TIBERI (for himself, Mrs. MCCARTHY of New York, Ms. SCHAKOWSKY, 

Ms. LEE of California, and Mrs. MALONEY) 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 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, burns, 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 2011’’. 

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

7 (a) PUBLIC HEALTH SERVICE ACT AMENDMENTS.— 

8 (1) Title XXVII of the Public Health Service Act is 

9 amended by inserting after section 2728 (42 U.S.C. 

10 300gg–28), as redesignated by section 1001(2) of the Pa11 tient Protection and Affordable Care Act (Public Law 

12 111–148), the following new section: 

13 ‘‘SEC. 2729. 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 or individual 

20 health insurance coverage, that provides coverage for 

21 surgical benefits shall provide coverage for out22 patient and inpatient diagnosis and treatment of a 

23 minor child’s congenital or developmental deformity, 

24 disease, or injury. A minor child shall include any 

25 individual through 21 years of age. 


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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.—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, burns, in17 fection, 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 


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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 (2) Section 2724(c) of such Act (42 U.S.C. 300gg– 

9 23(c)), as redesignated by section 1001(4) and subsection 

10 (c)(14) of the section 1563 (relating to conforming amend11 ments) of Public Law 111–148, is amended by striking 

12 ‘‘section 2704’’ and inserting ‘‘sections 2725 and 2729’’. 

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

14 300gg–62(b)(2)) is amended by striking ‘‘section 2751’’ 

15 and inserting ‘‘sections 2751 and 2729’’. 

16 (4) For purposes of applying section 2729 of the 

17 Public Health Service Act, as inserted by paragraph (1), 

18 to individual health insurance coverage before 2014, the 

19 provisions of such section shall be treated as also included 

20 under part B of title XXVII of the Public Health Service 

21 Act. 

22 (b) ERISA AMENDMENTS.—(1) Subpart B of part 

23 7 of subtitle B of title I of the Employee Retirement In24 come Security Act of 1974 is amended by adding at the 

25 end the following new section: 


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1 ‘‘SEC. 716. STANDARDS RELATING TO BENEFITS FOR MINOR 

2 CHILD’S CONGENITAL OR DEVELOPMENTAL 

3 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 who has not attained age 22. 

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.—For purposes of this 

23 section, the term ‘treatment’ includes recon24 structive surgical procedures (procedures that 

25 are generally performed to improve function, 

26 but may also be performed to approximate a 


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1 normal appearance) that are performed on ab2 normal structures of the body caused by con3 genital defects, developmental abnormalities, 

4 trauma, burns, infection, tumors, or disease, in5 cluding— 

6 ‘‘(i) procedures that do not materially 

7 affect the function of the body part being 

8 treated; and 

9 ‘‘(ii) procedures for secondary condi10 tions and follow-up treatment. 

11 ‘‘(B) EXCEPTION.—Such term does not in12 clude cosmetic surgery performed to reshape 

13 normal structures of the body to improve ap14 pearance or self-esteem. 

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

16 imposition of the requirements of this section shall be 

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

18 described in the last sentence of section 102(a), for pur19 poses of assuring notice of such requirements under the 

20 plan; except that the summary description required to be 

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

22 with respect to such modification shall be provided by not 

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

24 year in which such requirements apply.’’. 


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1 (2) Section 731(c) of such Act (29 U.S.C. 1191(c)) 

2 is amended by striking ‘‘section 711’’ and inserting ‘‘sec3 tions 711 and 716’’. 

4 (3) Section 732(a) of such Act (29 U.S.C. 1191a(a)) 

5 is amended by striking ‘‘section 711’’ and inserting ‘‘sec6 tions 711 and 716’’. 

7 (4) The table of contents in section 1 of such Act 

8 is amended by inserting after the item relating to section 

9 714 the following new items: 

‘‘Sec. 715. Additional market reforms. 

‘‘Sec. 716. Standards relating to benefits for minor child’s congenital or developmental deformity or disorder.’’. 

10 (c) INTERNAL REVENUE CODE AMENDMENTS.— 

11 (1) IN GENERAL.—Subchapter B of chapter 

12 100 of the Internal Revenue Code of 1986, as 

13 amended by subsection (f) of the section 1563 (relat14 ing to conforming amendments) of Public Law 111– 

15 148, is amended by adding at the end the following 

16 new section: 

17 ‘‘SEC. 9816. STANDARDS RELATING TO BENEFITS FOR 

18 MINOR CHILD’S CONGENITAL OR DEVELOP19 MENTAL DEFORMITY OR DISORDER. 

20 ‘‘(a) REQUIREMENTS FOR RECONSTRUCTIVE SUR21 GERY.— 

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

23 health insurance issuer offering group health insur24 ance coverage, that provides coverage for surgical 


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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 who has not attained age 22. 

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.—For purposes of this 

15 section, the term ‘treatment’ includes recon16 structive surgical procedures (procedures that 

17 are generally performed to improve function, 

18 but may also be performed to approximate a 

19 normal appearance) that are performed on ab20 normal structures of the body caused by con21 genital defects, developmental abnormalities, 

22 trauma, burns, infection, tumors, or disease, in23 cluding— 


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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 (2) CLERICAL AMENDMENT.—The table of sec11 tions for such subchapter is amended by adding at 

12 the end the following new items: 

‘‘Sec. 9815. Additional market reforms. 

‘‘Sec. 9816. Standards relating to benefits for minor child’s congenital or developmental deformity or disorder.’’. 

13 (d) CLARIFYING AMENDMENT REGARDING APPLICA14 TION TO GRANDFATHERED PLANS.—Section 

15 1251(a)(4)(A) of the Patient Protection and Affordable 

16 Care Act (Public Law 111–148; 42 U.S.C. 

17 18011(a)(4)(A)), as added by section 2301(a) of Public 

18 Law 111–152, is amended by adding at the end the fol19 lowing new clause: 

20 ‘‘(v) Section 2729 (relating to stand21 ards relating to benefits for minor child’s 

22 congenital or developmental deformity or 

23 disorder), as added by section 2(a) of the 


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1 Children’s Access to Reconstructive Eval2 uation & Surgery (CARES) Act of 2011.’’. 

3 (e) EFFECTIVE DATE.—The amendments made by 

4 this section shall apply with respect to group health plans 

5 for plan years beginning on or after January 1, 2012, and 

6 with respect to health insurance coverage offered, sold, 

7 issued, renewed, in effect, or operated in the individual 

8 market on or after such date. 

9 (f) COORDINATED REGULATIONS.—Section 104(1) of 

10 the Health Insurance Portability and Accountability Act 

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

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

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

14 I of the Employee Retirement Income Security Act of 

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

16 the Public Health Service Act, and chapter 100 of the In17 ternal Revenue Code of 1986’’. 

Æ 


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