I 

112TH CONGRESS 

1ST SESSION H. R. 111 

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 

JANUARY 5, 2011 

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

Ms. BALDWIN, Mr. BARROW, Ms. BERKLEY, Mr. BERMAN, Mr. BISHOP

of Georgia, Mr. BOREN, Mr. BRALEY of Iowa, Ms. BROWN of Florida, 

Mrs. CAPPS, Mr. CARSON of Indiana, Ms. CASTOR of Florida, Mr. 

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

CRITZ, Mr. DINGELL, Mr. DONNELLY of Indiana, Ms. EDWARDS, Mr. 

ELLISON, Mr. ENGEL, Mr. FARR, Mr. FRANK of Massachusetts, Ms. 

FUDGE, Mr. GRIJALVA, Mr. HIMES, Ms. HIRONO, Mr. HOLT, Mr. 

ISRAEL, Mr. JACKSON of Illinois, Ms. JACKSON LEE of Texas, Mr. JOHNSON of Georgia, Mr. JONES, Mr. KILDEE, Mr. KIND, Mr. KISSELL, Mr. 

LANGEVIN, Mr. LARSEN of Washington, Mr. LARSON of Connecticut, Ms. 

LEE of California, Mr. LEVIN, Mr. LEWIS of Georgia, Mr. LOEBSACK, 

Ms. ZOE LOFGREN of California, Mrs. LOWEY, Mrs. MALONEY, Mrs. 

MCCARTHY of New York, Mr. MCDERMOTT, Mr. MCGOVERN, Mr. MCINTYRE, Mr. MEEKS, Mr. MILLER of North Carolina, Ms. MOORE, Mr. 

MORAN, Mr. MURPHY of Connecticut, Mr. NADLER, Mrs. NAPOLITANO, 

Mr. NEAL, Mr. OLVER, Mr. PASTOR of Arizona, Mr. PAYNE, Mr. RANGEL, Ms. ROYBAL-ALLARD, Mr. RUPPERSBERGER, Mr. RUSH, Mr. RYAN

of Ohio, Mr. SABLAN, Ms. LINDA T. SANCHEZ of California, Ms. 

SCHAKOWSKY, Mr. SCHIFF, Mrs. SCHMIDT, Ms. SCHWARTZ, Mr. DAVID

SCOTT of Georgia, Mr. SERRANO, Mr. SHERMAN, Ms. SLAUGHTER, Ms. 

SPEIER, Mr. STARK, Ms. SUTTON, Mr. TOWNS, Mr. VAN HOLLEN, Ms. 

WASSERMAN SCHULTZ, Mr. WEINER, Mr. WELCH, Mr. WU, Mr. 

YARMUTH, Mr. YOUNG of Alaska, Ms. PINGREE of Maine, Mr. SMITH of 

Washington, Mr. PRICE of North Carolina, Mr. CHANDLER, and Ms. 

EDDIE BERNICE JOHNSON of Texas) 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 


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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 2011’’. 

6 SEC. 2. FINDINGS. 

7 Congress finds the following: 

8 (1) According to the American Cancer Society, 

9 excluding cancers of the skin, breast cancer is the 

10 most frequently diagnosed cancer in women. 

11 (2) According to the American Cancer Society, 

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

13 breast cancer in 2008. 

14 (3) According to the American Cancer Society, 

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

16 breast cancer were diagnosed in women, and an esti17 mated 1,990 invasive breast cancer cases were diag18 nosed in men; and in addition, an estimated 67,770 

19 new cases of in situ breast cancer occurred in 

20 women in 2008, and of these, approximately 85 per21 cent were ductal carcinoma in situ. 


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1 (4) According to the American Cancer Society, 

2 most breast cancer patients undergo some type of 

3 surgical treatment, which may involve lumpectomy 

4 (surgical removal of the tumor with clear margins) 

5 or mastectomy (surgical removal of the breast) with 

6 removal of some of the axillary (underarm) lymph 

7 nodes. 

8 (5) The offering and operation of health plans 

9 affect commerce among the States. 

10 (6) Health care providers located in a State 

11 serve patients who reside in the State and patients 

12 who reside in other States. 

13 (7) In order to provide for uniform treatment 

14 of health care providers and patients among the 

15 States, it is necessary to cover health plans oper16 ating in one State as well as health plans operating 

17 among the several States. 

18 (8) Research has indicated that treatment for 

19 breast cancer varies according to type of insurance 

20 coverage and State of residence. 

21 (9) Currently, 20 States mandate minimum in22 patient coverage after a patient undergoes a mastec23 tomy. 

24 (10) Breast cancer patients have reported ad25 verse outcomes, including infection and inadequately 


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1 controlled pain, resulting from premature hospital 

2 discharge following breast cancer surgery. 

3 SEC. 3. AMENDMENTS TO THE EMPLOYEE RETIREMENT IN4 COME SECURITY ACT OF 1974. 

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

6 B of title I of the Employee Retirement Income Security 

7 Act of 1974 (29 U.S.C. 1185 et seq.) is amended by add8 ing at the end the following: 

9 ‘‘SEC. 716. REQUIRED COVERAGE FOR MINIMUM HOSPITAL 

10 STAY FOR MASTECTOMIES, LUMPECTOMIES, 

11 AND LYMPH NODE DISSECTIONS FOR THE 

12 TREATMENT OF BREAST CANCER AND COV13 ERAGE FOR SECONDARY CONSULTATIONS. 

14 ‘‘(a) INPATIENT CARE.— 

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

16 health insurance issuer providing health insurance 

17 coverage in connection with a group health plan, 

18 that provides medical and surgical benefits shall en19 sure that inpatient (and in the case of a 

20 lumpectomy, outpatient) coverage and radiation 

21 therapy is provided for breast cancer treatment. 

22 Such plan or coverage may not— 

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

24 consultation with the patient, determines it to 

25 be medically necessary— 


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1 ‘‘(i) restrict benefits for any hospital 

2 length of stay in connection with a mastec3 tomy or breast conserving surgery (such as 

4 a lumpectomy) for the treatment of breast 

5 cancer to less than 48 hours; or 

6 ‘‘(ii) restrict benefits for any hospital 

7 length of stay in connection with a lymph 

8 node dissection for the treatment of breast 

9 cancer to less than 24 hours; or 

10 ‘‘(B) require that a provider obtain author11 ization from the plan or the issuer for pre12 scribing any length of stay required under this 

13 paragraph. 

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

15 be construed as requiring the provision of inpatient 

16 coverage if the attending physician, in consultation 

17 with the patient, determines that either a shorter pe18 riod of hospital stay, or outpatient treatment, is 

19 medically appropriate. 

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

21 In implementing the requirements of this section, a group 

22 health plan, and a health insurance issuer providing health 

23 insurance coverage in connection with a group health plan, 

24 may not modify the terms and conditions of coverage 

25 based on the determination by a participant or beneficiary 


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1 to request less than the minimum coverage required under 

2 subsection (a). 

3 ‘‘(c) NOTICE.—A group health plan, and a health in4 surance issuer providing health insurance coverage in con5 nection with a group health plan, shall provide notice to 

6 each participant and beneficiary under such plan regard7 ing the coverage required by this section in accordance 

8 with regulations promulgated by the Secretary. Such no9 tice shall be in writing and prominently positioned in the 

10 summary of the plan made available or distributed by the 

11 plan or issuer and shall be transmitted— 

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

13 issuer to the participant or beneficiary; or 

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

15 sent to the participant or beneficiary; 

16 whichever is earlier. 

17 ‘‘(d) SECONDARY CONSULTATIONS.— 

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

19 health insurance issuer providing health insurance 

20 coverage in connection with a group health plan, 

21 that provides coverage with respect to medical and 

22 surgical services provided in relation to the diagnosis 

23 and treatment of cancer shall ensure that coverage 

24 is provided for secondary consultations, on terms 

25 and conditions that are no more restrictive than 


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1 those applicable to the initial consultations, by spe2 cialists in the appropriate medical fields (including 

3 pathology, radiology, and oncology) to confirm or re4 fute such diagnosis. Such plan or issuer shall ensure 

5 that coverage is provided for such secondary con6 sultation whether such consultation is based on a 

7 positive or negative initial diagnosis. In any case in 

8 which the attending physician certifies in writing 

9 that services necessary for such a secondary con10 sultation are not sufficiently available from special11 ists operating under the plan with respect to whose 

12 services coverage is otherwise provided under such 

13 plan or by such issuer, such plan or issuer shall en14 sure that coverage is provided with respect to the 

15 services necessary for the secondary consultation 

16 with any other specialist selected by the attending 

17 physician for such purpose at no additional cost to 

18 the individual beyond that which the individual 

19 would have paid if the specialist was participating in 

20 the network of the plan. 

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

22 shall be construed as requiring the provision of sec23 ondary consultations where the patient determines 

24 not to seek such a consultation. 


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

2 A group health plan, and a health insurance issuer pro3 viding health insurance coverage in connection with a 

4 group health plan, may not— 

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

6 reimbursement of a provider or specialist because 

7 the provider or specialist provided care to a partici8 pant or beneficiary in accordance with this section; 

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

10 physician or specialist to induce the physician or 

11 specialist to keep the length of inpatient stays of pa12 tients following a mastectomy, lumpectomy, or a 

13 lymph node dissection for the treatment of breast 

14 cancer below certain limits or to limit referrals for 

15 secondary consultations; or 

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

17 physician or specialist to induce the physician or 

18 specialist to refrain from referring a participant or 

19 beneficiary for a secondary consultation that would 

20 otherwise be covered by the plan or coverage in21 volved under subsection (d).’’. 

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

23 in section 1 of the Employee Retirement Income Security 

24 Act of 1974 is amended by inserting after the item relat25 ing to section 715 the following: 


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‘‘Sec. 716. Required coverage for minimum hospital stay for mastectomies, 

lumpectomies, and lymph node dissections for the treatment of 

breast cancer and coverage for secondary consultations.’’. 

1 (c) EFFECTIVE DATES.— 

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

3 this section shall apply with respect to plan years be4 ginning on or after the date that is 90 days after 

5 the date of enactment of this Act. 

6 (2) SPECIAL RULE FOR COLLECTIVE BAR7 GAINING AGREEMENTS.—In the case of a group 

8 health plan maintained pursuant to 1 or more collec9 tive bargaining agreements between employee rep10 resentatives and 1 or more employers ratified before 

11 the date of enactment of this Act, the amendments 

12 made by this section shall not apply to plan years 

13 beginning before the date on which the last collective 

14 bargaining agreements relating to the plan termi15 nates (determined without regard to any extension 

16 thereof agreed to after the date of enactment of this 

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

18 amendment made pursuant to a collective bargaining 

19 agreement relating to the plan which amends the 

20 plan solely to conform to any requirement added by 

21 this section shall not be treated as a termination of 

22 such collective bargaining agreement. 


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1 SEC. 4. AMENDMENTS TO THE PUBLIC HEALTH SERVICE 

2 ACT. 

3 (a) IN GENERAL.—Title XXVII of the Public Health 

4 Service Act is amended by inserting after section 2728 of 

5 such Act (42 U.S.C. 300gg–28), as redesignated by sec6 tion 1001(2) of the Patient Protection and Affordable 

7 Care Act (Public Law 111–148), the following: 

8 ‘‘SEC. 2729. REQUIRED COVERAGE FOR MINIMUM HOSPITAL 

9 STAY FOR MASTECTOMIES, LUMPECTOMIES, 

10 AND LYMPH NODE DISSECTIONS FOR THE 

11 TREATMENT OF BREAST CANCER AND COV12 ERAGE FOR SECONDARY CONSULTATIONS. 

13 ‘‘(a) INPATIENT CARE.— 

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

15 health insurance issuer providing group or individual 

16 health insurance coverage, that provides medical and 

17 surgical benefits shall ensure that inpatient (and in 

18 the case of a lumpectomy, outpatient) coverage and 

19 radiation therapy is provided for breast cancer treat20 ment. Such plan or coverage may not— 

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

22 consultation with the patient, determines it to 

23 be medically necessary— 

24 ‘‘(i) restrict benefits for any hospital 

25 length of stay in connection with a mastec26 tomy or breast conserving surgery (such as 


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1 a lumpectomy) for the treatment of breast 

2 cancer to less than 48 hours; or 

3 ‘‘(ii) restrict benefits for any hospital 

4 length of stay in connection with a lymph 

5 node dissection for the treatment of breast 

6 cancer to less than 24 hours; or 

7 ‘‘(B) require that a provider obtain author8 ization from the plan or the issuer for pre9 scribing any length of stay required under this 

10 paragraph. 

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

12 be construed as requiring the provision of inpatient 

13 coverage if the attending physician, in consultation 

14 with the patient, determines that either a shorter pe15 riod of hospital stay, or outpatient treatment, is 

16 medically appropriate. 

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

18 In implementing the requirements of this section, a group 

19 health plan, and a health insurance issuer providing group 

20 or individual health insurance coverage, may not modify 

21 the terms and conditions of coverage based on the deter22 mination by a participant or beneficiary to request less 

23 than the minimum coverage required under subsection (a). 

24 ‘‘(c) NOTICE.—A group health plan, and a health in25 surance issuer providing group or individual health insurVerDate Mar 15 2010 04:39 Jan 08, 2011 Jkt 099200 PO 00000 Frm 00011 Fmt 6652 Sfmt 6201 E:\BILLS\H111.IH H111

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1 ance coverage, shall provide notice to each participant and 

2 beneficiary under such plan or coverage regarding the cov3 erage required by this section in accordance with regula4 tions promulgated by the Secretary. Such notice shall be 

5 in writing and prominently positioned in the summary of 

6 the plan or coverage made available or distributed by the 

7 plan or issuer and shall be transmitted— 

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

9 issuer to the participant or beneficiary; or 

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

11 sent to the participant or beneficiary; 

12 whichever is earlier. 

13 ‘‘(d) SECONDARY CONSULTATIONS.— 

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

15 health insurance issuer providing group or individual 

16 health insurance coverage, that provides coverage 

17 with respect to medical and surgical services pro18 vided in relation to the diagnosis and treatment of 

19 cancer shall ensure that coverage is provided for sec20 ondary consultations, on terms and conditions that 

21 are no more restrictive than those applicable to the 

22 initial consultations, by specialists in the appropriate 

23 medical fields (including pathology, radiology, and 

24 oncology) to confirm or refute such diagnosis. Such 

25 plan or issuer shall ensure that coverage is provided 


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1 for such secondary consultation whether such con2 sultation is based on a positive or negative initial di3 agnosis. In any case in which the attending physi4 cian certifies in writing that services necessary for 

5 such a secondary consultation are not sufficiently 

6 available from specialists operating under the plan 

7 or coverage with respect to whose services coverage 

8 is otherwise provided under such plan or by such 

9 issuer, such plan or issuer shall ensure that coverage 

10 is provided with respect to the services necessary for 

11 the secondary consultation with any other specialist 

12 selected by the attending physician for such purpose 

13 at no additional cost to the individual beyond that 

14 which the individual would have paid if the specialist 

15 was participating in the network of the plan. 

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

17 shall be construed as requiring the provision of sec18 ondary consultations where the patient determines 

19 not to seek such a consultation. 

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

21 A group health plan, and a health insurance issuer pro22 viding group or individual health insurance coverage, may 

23 not— 

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

25 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 or coverage in15 volved under subsection (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 90 days after the date of enact20 ment 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 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. 5. AMENDMENTS TO THE INTERNAL REVENUE CODE 

14 OF 1986. 

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

16 the Internal Revenue Code of 1986 is amended— 

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

18 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.’’; 

19 and 

20 (2) by inserting after section 9813 the fol21 lowing: 


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1 ‘‘SEC. 9814. 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 that 

8 provides medical and surgical benefits shall ensure 

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

10 outpatient) coverage and radiation therapy is pro11 vided for breast cancer treatment. Such plan may 

12 not— 

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

14 consultation with the patient, determines it to 

15 be medically necessary— 

16 ‘‘(i) restrict benefits for any hospital 

17 length of stay in connection with a mastec18 tomy or breast conserving surgery (such as 

19 a lumpectomy) for the treatment of breast 

20 cancer to less than 48 hours; or 

21 ‘‘(ii) restrict benefits for any hospital 

22 length of stay in connection with a lymph 

23 node dissection for the treatment of breast 

24 cancer to less than 24 hours; or 


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1 ‘‘(B) require that a provider obtain author2 ization from the plan for prescribing any length 

3 of stay required under this paragraph. 

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

5 be construed as requiring the provision of inpatient 

6 coverage if the attending physician, in consultation 

7 with the patient, determines that either a shorter pe8 riod of hospital stay, or outpatient treatment, is 

9 medically appropriate. 

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

11 In implementing the requirements of this section, a group 

12 health plan may not modify the terms and conditions of 

13 coverage based on the determination by a participant or 

14 beneficiary to request less than the minimum coverage re15 quired under subsection (a). 

16 ‘‘(c) NOTICE.—A group health plan shall provide no17 tice to each participant and beneficiary under such plan 

18 regarding the coverage required by this section in accord19 ance with regulations promulgated by the Secretary. Such 

20 notice shall be in writing and prominently positioned in 

21 the summary of the plan made available or distributed by 

22 the plan and shall be transmitted— 

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

24 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 that 

6 provides coverage with respect to medical and sur7 gical services provided in relation to the diagnosis 

8 and treatment of cancer shall ensure that coverage 

9 is provided for secondary consultations, on terms 

10 and conditions that are no more restrictive than 

11 those applicable to the initial consultations, by spe12 cialists in the appropriate medical fields (including 

13 pathology, radiology, and oncology) to confirm or re14 fute such diagnosis. Such plan or issuer shall ensure 

15 that coverage is provided for such secondary con16 sultation whether such consultation is based on a 

17 positive or negative initial diagnosis. In any case in 

18 which the attending physician certifies in writing 

19 that services necessary for such a secondary con20 sultation are not sufficiently available from special21 ists operating under the plan with respect to whose 

22 services coverage is otherwise provided under such 

23 plan or by such issuer, such plan or issuer shall en24 sure that coverage is provided with respect to the 

25 services necessary for the secondary consultation 


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1 with any other specialist selected by the attending 

2 physician for such purpose at no additional cost to 

3 the individual beyond that which the individual 

4 would have paid if the specialist was participating in 

5 the network of the plan. 

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

7 shall be construed as requiring the provision of sec8 ondary consultations where the patient determines 

9 not to seek such a consultation. 

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

11 plan may not— 

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

13 reimbursement of a provider or specialist because 

14 the provider or specialist provided care to a partici15 pant or beneficiary in accordance with this section; 

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

17 physician or specialist to induce the physician or 

18 specialist to keep the length of inpatient stays of pa19 tients following a mastectomy, lumpectomy, or a 

20 lymph node dissection for the treatment of breast 

21 cancer below certain limits or to limit referrals for 

22 secondary consultations; or 

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

24 physician or specialist to induce the physician or 

25 specialist to refrain from referring a participant or 


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1 beneficiary for a secondary consultation that would 

2 otherwise be covered by the plan involved under sub3 section (d).’’. 

4 (b) EFFECTIVE DATES.— 

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

6 this section shall apply with respect to plan years be7 ginning on or after the date of enactment of this 

8 Act. 

9 (2) SPECIAL RULE FOR COLLECTIVE BAR10 GAINING AGREEMENTS.—In the case of a group 

11 health plan maintained pursuant to 1 or more collec12 tive bargaining agreements between employee rep13 resentatives and 1 or more employers ratified before 

14 the date of enactment of this Act, the amendments 

15 made by this section shall not apply to plan years 

16 beginning before the date on which the last collective 

17 bargaining agreements relating to the plan termi18 nates (determined without regard to any extension 

19 thereof agreed to after the date of enactment of this 

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

21 amendment made pursuant to a collective bargaining 

22 agreement relating to the plan which amends the 

23 plan solely to conform to any requirement added by 

24 this section shall not be treated as a termination of 

25 such collective bargaining agreement. 


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1 SEC. 6. OPPORTUNITY FOR INDEPENDENT, EXTERNAL 

2 THIRD PARTY REVIEWS OF CERTAIN NON3 RENEWALS AND DISCONTINUATIONS, IN4 CLUDING RESCISSIONS, OF INDIVIDUAL 

5 HEALTH INSURANCE COVERAGE. 

6 (a) CLARIFICATION REGARDING APPLICATION OF

7 GUARANTEED RENEWABILITY OF INDIVIDUAL HEALTH

8 INSURANCE COVERAGE.—Section 2742 of the Public 

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

10 (1) in its heading, by inserting ‘‘AND CON11 TINUATION IN FORCE, INCLUDING PROHIBI12 TION OF RESCISSION,’’ after ‘‘GUARANTEED RE13 NEWABILITY’’; 

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

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

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

17 period at the end the following: ‘‘, including inten18 tional concealment of material facts regarding a 

19 health condition related to the condition for which 

20 coverage is being claimed’’. 

21 (b) OPPORTUNITY FOR INDEPENDENT, EXTERNAL

22 THIRD PARTY REVIEW IN CERTAIN CASES.—Subpart 1 

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

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


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

2 THIRD PARTY REVIEW IN CERTAIN CASES. 

3 ‘‘(a) NOTICE AND REVIEW RIGHT.—If a health in4 surance issuer determines to nonrenew or not continue in 

5 force, including rescind, health insurance coverage for an 

6 individual in the individual market on the basis described 

7 in section 2742(b)(2) before such nonrenewal, discontinu8 ation, or rescission, may take effect the issuer shall pro9 vide the individual with notice of such proposed non10 renewal, discontinuation, or rescission and an opportunity 

11 for a review of such determination by an independent, ex12 ternal third party under procedures specified by the Sec13 retary. 

14 ‘‘(b) INDEPENDENT DETERMINATION.—If the indi15 vidual requests such review by an independent, external 

16 third party of a nonrenewal, discontinuation, or rescission 

17 of health insurance coverage, the coverage shall remain in 

18 effect until such third party determines that the coverage 

19 may be nonrenewed, discontinued, or rescinded under sec20 tion 2742(b)(2).’’. 

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

22 this section shall apply after the date of the enactment 

23 of this Act with respect to health insurance coverage 

24 issued before, on, or after such date. 

Æ 


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