I 

114TH CONGRESS 

2D SESSION H. R. 5195 

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 

MAY 11, 2016 

Ms. DELAURO (for herself, Mr. VAN HOLLEN, Ms. WASSERMAN SCHULTZ, 

Mr. FARR, Mr. DAVID SCOTT of Georgia, Ms. MOORE, Ms. JUDY CHU

of California, Mr. TAKANO, Mr. ENGEL, Mr. GRIJALVA, Mr. RYAN of 

Ohio, Mrs. NAPOLITANO, Mr. PAYNE, Mr. HIGGINS, Ms. PINGREE, Ms. 

BORDALLO, Mr. SCHIFF, Mr. LANGEVIN, Ms. KAPTUR, Mr. NADLER, Mr. 

HASTINGS, Ms. TSONGAS, Mr. LARSON of Connecticut, Ms. LEE, Mr. 

SHERMAN, Mr. POCAN, Ms. MICHELLE LUJAN GRISHAM of New Mexico, 

Ms. SLAUGHTER, Mr. RANGEL, Mr. SWALWELL of California, Ms. CASTOR of Florida, Mr. YOUNG of Alaska, Ms. SCHAKOWSKY, Mr. HINOJOSA, 

Mr. PRICE of North Carolina, Ms. JACKSON LEE, Mr. CONNOLLY, Mr. 

YARMUTH, and Mr. LEVIN) 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 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. 


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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 2016’’. 

6 SEC. 2. FINDINGS. 

7 Congress finds the following: 

8 (1) According to the National Cancer Institute, 

9 excluding cancers of the skin, breast cancer is the 

10 most frequently diagnosed cancer in women. 

11 (2) According to the National Cancer Institute, 

12 an estimated 40,450 women and 440 men will die 

13 from breast cancer in 2016. 

14 (3) According to the National Cancer Institute, 

15 in 2016 an estimated 246,660 new cases of breast 

16 cancer will be diagnosed in women and an estimated 

17 2,600 breast cancer cases will be diagnosed in men. 

18 (4) According to the American Cancer Society, 

19 most breast cancer patients undergo some type of 

20 surgical treatment, which may involve lumpectomy 

21 or mastectomy with removal of some of the axillary 

22 lymph nodes. 

23 (5) The offering and operation of health plans 

24 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) Breast cancer patients have reported ad13 verse outcomes, including infection and inadequately 

14 controlled pain, resulting from premature hospital 

15 discharge following breast cancer surgery. 

16 SEC. 3. AMENDMENTS TO THE EMPLOYEE RETIREMENT IN17 COME SECURITY ACT OF 1974. 

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

19 B of title I of the Employee Retirement Income Security 

20 Act of 1974 (29 U.S.C. 1185 et seq.) is amended by add21 ing at the end the following: 


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1 ‘‘SEC. 716. 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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•HR 5195 IH

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 Sep 11 2014 00:48 May 14, 2016 Jkt 059200 PO 00000 Frm 00006 Fmt 6652 Sfmt 6201 E:\BILLS\H5195.IH H5195

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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. Additional market reforms. 

‘‘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.’’. 

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 collecVerDate Sep 11 2014 00:48 May 14, 2016 Jkt 059200 PO 00000 Frm 00008 Fmt 6652 Sfmt 6201 E:\BILLS\H5195.IH H5195

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1 tive bargaining agreements between employee rep2 resentatives and 1 or more employers ratified before 

3 the date of enactment of this Act, the amendments 

4 made by this section shall not apply to plan years 

5 beginning before the date on which the last collective 

6 bargaining agreements relating to the plan termi7 nates (determined without regard to any extension 

8 thereof agreed to after the date of enactment of this 

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

10 amendment made pursuant to a collective bargaining 

11 agreement relating to the plan which amends the 

12 plan solely to conform to any requirement added by 

13 this section shall not be treated as a termination of 

14 such collective bargaining agreement. 

15 SEC. 4. AMENDMENTS TO THE PUBLIC HEALTH SERVICE 

16 ACT. 

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

18 Service Act is amended by inserting after section 2728 of 

19 such Act (42 U.S.C. 300gg–28), as redesignated by sec20 tion 1001(2) of the Patient Protection and Affordable 

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


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1 ‘‘SEC. 2729. 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 group or individual 

9 health insurance coverage, that provides medical and 

10 surgical benefits shall ensure that inpatient (and in 

11 the case of a lumpectomy, outpatient) coverage and 

12 radiation therapy is provided for breast cancer treat13 ment. Such plan or coverage may not— 

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

15 consultation with the patient, determines it to 

16 be medically necessary— 

17 ‘‘(i) restrict benefits for any hospital 

18 length of stay in connection with a mastec19 tomy or breast conserving surgery (such as 

20 a lumpectomy) for the treatment of breast 

21 cancer to less than 48 hours; or 

22 ‘‘(ii) restrict benefits for any hospital 

23 length of stay in connection with a lymph 

24 node dissection for the treatment of breast 

25 cancer to less than 24 hours; or 


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•HR 5195 IH

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 group 

14 or individual health insurance coverage, may not modify 

15 the terms and conditions of coverage based on the deter16 mination by a participant or beneficiary to request less 

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

18 ‘‘(c) NOTICE.—A group health plan, and a health in19 surance issuer providing group or individual health insur20 ance coverage, shall provide notice to each participant and 

21 beneficiary under such plan or coverage regarding the cov22 erage required by this section in accordance with regula23 tions promulgated by the Secretary. Such notice shall be 

24 in writing and prominently positioned in the summary of 


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•HR 5195 IH

1 the plan or coverage 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 group or individual 

11 health insurance coverage, that provides coverage 

12 with respect to medical and surgical services pro13 vided in relation to the diagnosis and treatment of 

14 cancer shall ensure that coverage is provided for sec15 ondary consultations, on terms and conditions that 

16 are no more restrictive than those applicable to the 

17 initial consultations, by specialists in the appropriate 

18 medical fields (including pathology, radiology, and 

19 oncology) to confirm or refute such diagnosis. Such 

20 plan or issuer shall ensure that coverage is provided 

21 for such secondary consultation whether such con22 sultation is based on a positive or negative initial di23 agnosis. In any case in which the attending physi24 cian certifies in writing that services necessary for 

25 such a secondary consultation are not sufficiently 


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•HR 5195 IH

1 available from specialists operating under the plan 

2 or coverage with respect to whose services coverage 

3 is otherwise provided under such plan or by such 

4 issuer, such plan or issuer shall ensure that coverage 

5 is provided with respect to the services necessary for 

6 the secondary consultation with any other specialist 

7 selected by the attending physician for such purpose 

8 at no additional cost to the individual beyond that 

9 which the individual would have paid if the specialist 

10 was participating in the network of the plan. 

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

12 shall be construed as requiring the provision of sec13 ondary consultations where the patient determines 

14 not to seek such a consultation. 

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

16 A group health plan, and a health insurance issuer pro17 viding group or individual health insurance coverage, may 

18 not— 

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

20 reimbursement of a provider or specialist because 

21 the provider or specialist provided care to a partici22 pant or beneficiary in accordance with this section; 

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

24 physician or specialist to induce the physician or 

25 specialist to keep the length of inpatient stays of paVerDate Sep 11 2014 00:48 May 14, 2016 Jkt 059200 PO 00000 Frm 00013 Fmt 6652 Sfmt 6201 E:\BILLS\H5195.IH H5195

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•HR 5195 IH

1 tients following a mastectomy, lumpectomy, or a 

2 lymph node dissection for the treatment of breast 

3 cancer below certain limits or to limit referrals for 

4 secondary consultations; or 

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

6 physician or specialist to induce the physician or 

7 specialist to refrain from referring a participant or 

8 beneficiary for a secondary consultation that would 

9 otherwise be covered by the plan or coverage in10 volved under subsection (d).’’. 

11 (b) EFFECTIVE DATES.— 

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

13 this section shall apply with respect to plan years be14 ginning on or after 90 days after the date of enact15 ment of this Act. 

16 (2) SPECIAL RULE FOR COLLECTIVE BAR17 GAINING AGREEMENTS.—In the case of a group 

18 health plan maintained pursuant to 1 or more collec19 tive bargaining agreements between employee rep20 resentatives and 1 or more employers ratified before 

21 the date of enactment of this Act, the amendments 

22 made by this section shall not apply to plan years 

23 beginning before the date on which the last collective 

24 bargaining agreements relating to the plan termi25 nates (determined without regard to any extension 


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•HR 5195 IH

1 thereof agreed to after the date of enactment of this 

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

3 amendment made pursuant to a collective bargaining 

4 agreement relating to the plan which amends the 

5 plan solely to conform to any requirement added by 

6 this section shall not be treated as a termination of 

7 such collective bargaining agreement. 

8 SEC. 5. AMENDMENTS TO THE INTERNAL REVENUE CODE 

9 OF 1986. 

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

11 the Internal Revenue Code of 1986 is amended— 

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

13 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.’’; 

14 and 

15 (2) by inserting after section 9813 the fol16 lowing: 

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

18 STAY FOR MASTECTOMIES, LUMPECTOMIES, 

19 AND LYMPH NODE DISSECTIONS FOR THE 

20 TREATMENT OF BREAST CANCER AND COV21 ERAGE FOR SECONDARY CONSULTATIONS. 

22 ‘‘(a) INPATIENT CARE.— 

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

24 provides medical and surgical benefits shall ensure 


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

2 outpatient) coverage and radiation therapy is pro3 vided for breast cancer treatment. Such plan may 

4 not— 

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

6 consultation with the patient, determines it to 

7 be medically necessary— 

8 ‘‘(i) restrict benefits for any hospital 

9 length of stay in connection with a mastec10 tomy or breast conserving surgery (such as 

11 a lumpectomy) for the treatment of breast 

12 cancer to less than 48 hours; or 

13 ‘‘(ii) restrict benefits for any hospital 

14 length of stay in connection with a lymph 

15 node dissection for the treatment of breast 

16 cancer to less than 24 hours; or 

17 ‘‘(B) require that a provider obtain author18 ization from the plan for prescribing any length 

19 of stay required under this paragraph. 

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

21 be construed as requiring the provision of inpatient 

22 coverage if the attending physician, in consultation 

23 with the patient, determines that either a shorter pe24 riod of hospital stay, or outpatient treatment, is 

25 medically appropriate. 


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

2 In implementing the requirements of this section, a group 

3 health plan may not modify the terms and conditions of 

4 coverage based on the determination by a participant or 

5 beneficiary to request less than the minimum coverage re6 quired under subsection (a). 

7 ‘‘(c) NOTICE.—A group health plan shall provide no8 tice to each participant and beneficiary under such plan 

9 regarding the coverage required by this section in accord10 ance with regulations promulgated by the Secretary. Such 

11 notice shall be in writing and prominently positioned in 

12 the summary of the plan made available or distributed by 

13 the plan and shall be transmitted— 

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

15 the participant or beneficiary; or 

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

17 sent to the participant or beneficiary; 

18 whichever is earlier. 

19 ‘‘(d) SECONDARY CONSULTATIONS.— 

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

21 provides coverage with respect to medical and sur22 gical 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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•HR 5195 IH

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.—A group health 

2 plan may not— 

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

4 reimbursement of a provider or specialist because 

5 the provider or specialist provided care to a partici6 pant or beneficiary in accordance with this section; 

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

8 physician or specialist to induce the physician or 

9 specialist to keep the length of inpatient stays of pa10 tients following a mastectomy, lumpectomy, or a 

11 lymph node dissection for the treatment of breast 

12 cancer below certain limits or to limit referrals for 

13 secondary consultations; or 

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

15 physician or specialist to induce the physician or 

16 specialist to refrain from referring a participant or 

17 beneficiary for a secondary consultation that would 

18 otherwise be covered by the plan involved under sub19 section (d).’’. 

20 (b) EFFECTIVE DATES.— 

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

22 this section shall apply with respect to plan years be23 ginning on or after the date of enactment of this 

24 Act. 


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1 (2) SPECIAL RULE FOR COLLECTIVE BAR2 GAINING AGREEMENTS.—In the case of a group 

3 health plan maintained pursuant to 1 or more collec4 tive bargaining agreements between employee rep5 resentatives and 1 or more employers ratified before 

6 the date of enactment of this Act, the amendments 

7 made by this section shall not apply to plan years 

8 beginning before the date on which the last collective 

9 bargaining agreements relating to the plan termi10 nates (determined without regard to any extension 

11 thereof agreed to after the date of enactment of this 

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

13 amendment made pursuant to a collective bargaining 

14 agreement relating to the plan which amends the 

15 plan solely to conform to any requirement added by 

16 this section shall not be treated as a termination of 

17 such collective bargaining agreement. 

18 SEC. 6. OPPORTUNITY FOR INDEPENDENT, EXTERNAL 

19 THIRD PARTY REVIEWS OF CERTAIN NON20 RENEWALS AND DISCONTINUATIONS, IN21 CLUDING RESCISSIONS, OF INDIVIDUAL 

22 HEALTH INSURANCE COVERAGE. 

23 (a) CLARIFICATION REGARDING APPLICATION OF

24 GUARANTEED RENEWABILITY OF INDIVIDUAL HEALTH


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1 INSURANCE COVERAGE.—Section 2742 of the Public 

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

3 (1) in its heading, by inserting ‘‘AND CON4 TINUATION IN FORCE, INCLUDING PROHIBI5 TION OF RESCISSION,’’ after ‘‘GUARANTEED RE6 NEWABILITY’’; 

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

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

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

10 period at the end the following: ‘‘, including inten11 tional concealment of material facts regarding a 

12 health condition related to the condition for which 

13 coverage is being claimed’’. 

14 (b) OPPORTUNITY FOR INDEPENDENT, EXTERNAL

15 THIRD PARTY REVIEW IN CERTAIN CASES.—Subpart 1 

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

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

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

19 THIRD PARTY REVIEW IN CERTAIN CASES. 

20 ‘‘(a) NOTICE AND REVIEW RIGHT.—If a health in21 surance issuer determines to nonrenew or not continue in 

22 force, including rescind, health insurance coverage for an 

23 individual in the individual market on the basis described 

24 in section 2742(b)(2) before such nonrenewal, discontinu25 ation, or rescission, may take effect the issuer shall proVerDate Sep 11 2014 00:48 May 14, 2016 Jkt 059200 PO 00000 Frm 00021 Fmt 6652 Sfmt 6201 E:\BILLS\H5195.IH H5195

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1 vide the individual with notice of such proposed non2 renewal, discontinuation, or rescission and an opportunity 

3 for a review of such determination by an independent, ex4 ternal third party under procedures specified by the Sec5 retary. 

6 ‘‘(b) INDEPENDENT DETERMINATION.—If the indi7 vidual requests such review by an independent, external 

8 third party of a nonrenewal, discontinuation, or rescission 

9 of health insurance coverage, the coverage shall remain in 

10 effect until such third party determines that the coverage 

11 may be nonrenewed, discontinued, or rescinded under sec12 tion 2742(b)(2).’’. 

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

14 this section shall apply after the date of the enactment 

15 of this Act with respect to health insurance coverage 

16 issued before, on, or after such date. 

Æ 


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