II

106TH CONGRESS

1ST SESSION S. 1822

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

OCTOBER 28, 1999

Mr. MCCAIN (for himself and Mrs. SNOWE) introduced the following bill;

which was read twice and referred to the Committee on Finance

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

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1 SECTION 1. SHORT TITLE.

2 This Act may be cited as the ‘‘Treatment of Chil3 dren’s Deformities Act of 1999’’.

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 new section:

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 up

25 to 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, 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

5 713(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 new section:

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

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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 up

6 to 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

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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 ‘‘(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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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 (29 U.S.C. 1001) is

9 amended by inserting after the item relat10 ing to section 713 the following new item:

‘‘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 after

15 the item relating to section 9812 the following new

16 item:

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

and

17 (B) by inserting after section 9812 the fol18 lowing:
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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 up

13 to 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

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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 (42 U.S.C. 300gg–41 et

17 seq.) is amended by inserting after section 2752 the

18 following new section:

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

20 MINOR CHILD’S CONGENITAL OR DEVELOP21 MENTAL 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-
10

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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 up

6 to 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—
11

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

11 part shall comply with the notice requirement under sec12 tion 714(b) of the Employee Retirement Income Security

13 Act of 1974 with respect to the requirements referred to

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

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

16 (2) CONFORMING AMENDMENT.—Section

17 2762(b)(2) of the Public Health Service Act (42

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

19 ‘‘section 2751’’ and inserting ‘‘sections 2751 and

20 2753’’.

21 (c) EFFECTIVE DATES.—

22 (1) GROUP MARKET.—The amendments made

23 by subsection (a) shall apply with respect to group

24 health plans for plan years beginning on or after

25 January 1, 2000.
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1 (2) INDIVIDUAL MARKET.—The amendment

2 made by subsection (b) shall apply with respect to

3 health insurance coverage offered, sold, issued, re4 newed, in effect, or operated in the individual mar5 ket on or after such date.

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

7 of Health Insurance Portability and Accountability Act of

8 1996 is amended by striking ‘‘this subtitle (and the

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

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

11 I of the Employee Retirement Income Security Act of

12 1974, the provisions of parts A and C of title XXVII of

13 the Public Health Service Act, and chapter 100 of the In14 ternal Revenue Code of 1986’’.

Æ