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[Congressional Bills 107th Congress]
[From the U.S. Government Publishing Office]
[H.R. 1485 Introduced in House (IH)]

107th CONGRESS
  1st Session
                                H. R. 1485

 To require that health plans provide coverage for a minimum hospital 
 stay for mastectomies and lymph node dissection for the treatment of 
        breast cancer and coverage for secondary consultations.

_______________________________________________________________________

                    IN THE HOUSE OF REPRESENTATIVES

                             April 4, 2001

 Mr. LoBiondo introduced the following bill; which was referred to the 
Committee on Energy and Commerce, and in addition to the Committees on 
  Education and the Workforce, and Ways and Means, 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 and lymph node dissection for the treatment of 
        breast cancer and coverage for secondary consultations.

    Be it enacted by the Senate and House of Representatives of the 
United States of America in Congress assembled,

SECTION 1. SHORT TITLE.

    This Act may be cited as the ``Women's Cancer Recovery Act of 
2001''.

SEC. 2. AMENDMENTS TO THE EMPLOYEE RETIREMENT INCOME SECURITY ACT OF 
              1974.

    (a) In General.--Subpart B of part 7 of subtitle B of title I of 
the Employee Retirement Income Security Act of 1974 is amended by 
adding at the end the following new section:

``SEC. 714. REQUIRED COVERAGE FOR MINIMUM HOSPITAL STAY FOR 
              MASTECTOMIES AND LYMPH NODE DISSECTIONS FOR THE TREATMENT 
              OF BREAST CANCER AND COVERAGE FOR SECONDARY 
              CONSULTATIONS.

    ``(a) Inpatient Care.--
            ``(1) In general.--A group health plan, and a health 
        insurance issuer providing health insurance coverage in 
        connection with a group health plan, that provides medical and 
        surgical benefits shall ensure that inpatient coverage with 
        respect to the surgical treatment of breast cancer (including a 
        mastectomy, lumpectomy, or lymph node dissection for the 
        treatment of breast cancer) is provided for a period of time as 
        is determined by the attending physician, in the physician's 
        professional judgment consistent with generally accepted 
        principles of professional medical practice, in consultation 
        with the patient, to be medically necessary or appropriate.
            ``(2) Exception.--Nothing in this section shall be 
        construed as requiring the provision of inpatient coverage if 
        the attending physician in consultation with the patient 
        determines that a shorter period of hospital stay is medically 
        necessary or appropriate.
    ``(b) Prohibition on Certain Modifications.--In implementing the 
requirements of this section, a group health plan, and a health 
insurance issuer providing health insurance coverage in connection with 
a group health plan, may not modify the terms and conditions of 
coverage based on the determination by a participant or beneficiary to 
request less than the minimum coverage required under subsection (a).
    ``(c) Notice Requirement.--The imposition of the requirements of 
this section shall be treated as a material modification in the terms 
of the plan described in section 102(a)(1), for purposes of assuring 
notice of such requirements under the plan; except that the summary 
description required to be provided under the last sentence of section 
104(b)(1) with respect to such modification shall be provided by not 
later than 60 days after the first day of the first plan year in which 
such requirements apply and shall be made available at the time of 
initial coverage and at any time upon request of a participant or 
beneficiary.
    ``(d) Secondary Consultations.--
            ``(1) In general.--A group health plan, and a health 
        insurance issuer providing health insurance coverage in 
        connection with a group health plan, that provides coverage 
        with respect to medical and surgical services provided in 
        relation to the diagnosis and treatment of cancer shall ensure 
        that full coverage is provided for secondary consultations by 
        specialists in the appropriate medical fields (including 
        pathology, radiology, and oncology) to confirm or refute such 
        diagnosis. Such plan or issuer shall ensure that full coverage 
        is provided for such secondary consultation whether such 
        consultation is based on a positive or negative initial 
        diagnosis. In any case in which the attending physician 
        certifies in writing that services necessary for such a 
        secondary consultation are not sufficiently available from 
        specialists operating under the plan with respect to whose 
        services coverage is otherwise provided under such plan or by 
        such issuer, such plan or issuer shall ensure that coverage is 
        provided with respect to the services necessary for the 
        secondary consultation with any other specialist selected by 
        the attending physician for such purpose at no additional cost 
        to the individual beyond that which the individual would have 
paid if the specialist was participating in the network of the plan.
            ``(2) Exception.--Nothing in paragraph (1) shall be 
        construed as requiring the provision of secondary consultations 
        where there is a financial relationship (including an ownership 
        or investment interest or compensation arrangement) between the 
        specialist and the attending physician or where the patient 
        determines not to seek such a consultation.
    ``(e) Prohibition on Penalties or Incentives.--A group health plan, 
and a health insurance issuer providing health insurance coverage in 
connection with a group health plan, may not--
            ``(1) penalize or otherwise reduce or limit the 
        reimbursement of a provider or specialist because the provider 
        or specialist provided care to a participant or beneficiary in 
        accordance with this section;
            ``(2) provide financial or other incentives to a physician 
        or specialist to induce the physician or specialist to keep the 
        length of inpatient stays of patients following a mastectomy, 
        lumpectomy, or a lymph node dissection for the treatment of 
        breast cancer below certain limits or to limit referrals for 
        secondary consultations; or
            ``(3) provide financial or other incentives to a physician 
        or specialist to induce the physician or specialist to refrain 
        from referring a participant or beneficiary for a secondary 
        consultation that would otherwise be covered by the plan or 
        coverage involved under subsection (d).
    ``(f) Preemption; Exception for Health Insurance Coverage in 
Certain States.--
            ``(1) In general.--The requirements of this section shall 
        not apply with respect to health insurance coverage if there is 
        a State law (as defined in section 731(d)(1)) for a State that 
        regulates such coverage that is described in any of the 
        following subparagraphs:
                    ``(A) Such State law requires such coverage to 
                provide for at least a 48-hour hospital length of stay 
                following a mastectomy performed for treatment of 
                breast cancer and at least a 24-hour hospital length of 
                stay following a lymph node dissection for treatment of 
                breast cancer.
                    ``(B) Such State law requires, in connection with 
                such coverage for surgical treatment of breast cancer, 
                that the hospital length of stay for such care is left 
                to the decision of (or required to be made by) the 
                attending provider in consultation with the woman 
                involved.
            ``(2) Construction.--Section 731(a)(1) shall not be 
        construed as superseding a State law described in paragraph 
        (1).''.
    (b) Conforming Amendment.--Section 731(c) of such Act (29 U.S.C. 
1191(c)) is amended by striking ``section 711'' and inserting 
``sections 711 and 714''.
    (c) Clerical Amendment.--The table of contents in section 1 of such 
Act is amended by inserting after the item relating to section 713 the 
following new item:

``Sec. 714. Required coverage for minimum hospital stay for 
                            mastectomies and lymph node dissections for 
                            the treatment of breast cancer and coverage 
                            for secondary consultations.''.
    (d) Effective Dates.--
            (1) In general.--The amendments made by this section shall 
        apply with respect to plan years beginning on or after the date 
        of enactment of this Act.
            (2) Special rule for collective bargaining agreements.--In 
        the case of a group health plan maintained pursuant to 1 or 
        more collective bargaining agreements between employee 
        representatives and 1 or more employers ratified before the 
        date of enactment of this Act, the amendments made by this 
        section shall not apply to plan years beginning before the 
        later of--
                    (A) the date on which the last collective 
                bargaining agreements relating to the plan terminates 
                (determined without regard to any extension thereof 
                agreed to after the date of enactment of this Act), or
                    (B) January 1, 2002.
        For purposes of subparagraph (A), any plan amendment made 
        pursuant to a collective bargaining agreement relating to the 
        plan which amends the plan solely to conform to any requirement 
        added by this section shall not be treated as a termination of 
        such collective bargaining agreement.

SEC. 3. AMENDMENTS TO THE PUBLIC HEALTH SERVICE ACT RELATING TO THE 
              GROUP MARKET.

    (a) In General.--Subpart 2 of part A of title XXVII of the Public 
Health Service Act is amended by adding at the end the following new 
section:

``SEC. 2707. REQUIRED COVERAGE FOR MINIMUM HOSPITAL STAY FOR 
              MASTECTOMIES AND LYMPH NODE DISSECTIONS FOR THE TREATMENT 
              OF BREAST CANCER AND COVERAGE FOR SECONDARY 
              CONSULTATIONS.

    ``(a) Inpatient Care.--
            ``(1) In general.--A group health plan, and a health 
        insurance issuer providing health insurance coverage in 
        connection with a group health plan, that provides medical and 
        surgical benefits shall ensure that inpatient coverage with 
        respect to the surgical treatment of breast cancer (including a 
        mastectomy, lumpectomy, or lymph node dissection for the 
        treatment of breast cancer) is provided for a period of time as 
        is determined by the attending physician, in the physician's 
        professional judgment consistent with generally accepted 
        principles of professional medical practice, in consultation 
        with the patient, to be medically necessary or appropriate.
            ``(2) Exception.--Nothing in this section shall be 
        construed as requiring the provision of inpatient coverage if 
        the attending physician in consultation with the patient 
        determines that a shorter period of hospital stay is medically 
        necessary or appropriate.
    ``(b) Prohibition on Certain Modifications.--In implementing the 
requirements of this section, a group health plan, and a health 
insurance issuer providing health insurance coverage in connection with 
a group health plan, may not modify the terms and conditions of 
coverage based on the determination by a participant or beneficiary to 
request less than the minimum coverage required under subsection (a).
    ``(c) Notice Requirement.--A group health plan under this part 
shall comply with the notice requirement under section 714(c) of the 
Employee Retirement Income Security Act of 1974 with respect to the 
requirements of this section as if such section applied to such plan.
    ``(d) Secondary Consultations.--
            ``(1) In general.--A group health plan, and a health 
        insurance issuer providing health insurance coverage in 
        connection with a group health plan that provides coverage with 
        respect to medical and surgical services provided in relation 
        to the diagnosis and treatment of cancer shall ensure that full 
        coverage is provided for secondary consultations by specialists 
        in the appropriate medical fields (including pathology, 
        radiology, and oncology) to confirm or refute such diagnosis. 
        Such plan or issuer shall ensure that full coverage is provided 
        for such secondary consultation whether such consultation is 
        based on a positive or negative initial diagnosis. In any case 
        in which the attending physician certifies in writing that 
        services necessary for such a secondary consultation are not 
        sufficiently available from specialists operating under the 
        plan with respect to whose services coverage is otherwise 
        provided under such plan or by such issuer, such plan or issuer 
        shall ensure that coverage is provided with respect to the 
        services necessary for the secondary consultation with any 
        other specialist selected by the attending physician for such 
        purpose at no additional cost to the individual beyond that 
        which the individual would have paid if the specialist was 
        participating in the network of the plan.
            ``(2) Exception.--Nothing in paragraph (1) shall be 
        construed as requiring the provision of secondary consultations 
        where there is a financial relationship (including an ownership 
        or investment interest or compensation arrangement) between the 
        specialist and the attending physician or where the patient 
        determines not to seek such a consultation.
    ``(e) Prohibition on Penalties or Incentives.--A group health plan, 
and a health insurance issuer providing health insurance coverage in 
connection with a group health plan, may not--
            ``(1) penalize or otherwise reduce or limit the 
        reimbursement of a provider or specialist because the provider 
        or specialist provided care to a participant or beneficiary in 
        accordance with this section;
            ``(2) provide financial or other incentives to a physician 
        or specialist to induce the physician or specialist to keep the 
        length of inpatient stays of patients following a mastectomy, 
        lumpectomy, or a lymph node dissection for the treatment of 
        breast cancer below certain limits or to limit referrals for 
        secondary consultations; or
            ``(3) provide financial or other incentives to a physician 
        or specialist to induce the physician or specialist to refrain 
        from referring a participant or beneficiary for a secondary 
        consultation that would otherwise be covered by the plan or 
        coverage involved under subsection (d).
    ``(f) Exception for Health Insurance Coverage in Certain States.--
            ``(1) In general.--The requirements of this section shall 
        not apply with respect to health insurance coverage if there is 
        a State law (as defined in section 2723(d)(1) of the Public 
        Health Service Act) for a State that regulates such coverage 
        that is described in any of the following subparagraphs:
                    ``(A) Such State law requires such coverage to 
                provide for at least a 48-hour hospital length of stay 
                following a mastectomy performed for treatment of 
                breast cancer and at least a 24-hour hospital length of 
                stay following a lymph node dissection for treatment of 
                breast cancer.
                    ``(B) Such State law requires, in connection with 
                such coverage for surgical treatment of breast cancer, 
                that the hospital length of stay for such care is left 
                to the decision of (or required to be made by) the 
                attending provider in consultation with the woman 
                involved.
            ``(2) Construction.--Section 2723(a)(1) shall not be 
        construed as superseding a State law described in paragraph 
        (1).''.
    (b) Conforming Amendment.--Section 2723(c) of such Act (42 U.S.C. 
300gg-23(c)) is amended by striking ``section 2704'' and inserting 
``sections 2704 and 2707''.
    (c) Effective Dates.--
            (1) In general.--The amendments made by this section shall 
        apply to group health plans for plan years beginning on or 
        after the date of enactment of this Act.
            (2) Special rule for collective bargaining agreements.--In 
        the case of a group health plan maintained pursuant to 1 or 
        more collective bargaining agreements between employee 
        representatives and 1 or more employers ratified before the 
        date of enactment of this Act, the amendments made by this 
        section shall not apply to plan years beginning before the 
        later of--
                    (A) the date on which the last collective 
                bargaining agreements relating to the plan terminates 
                (determined without regard to any extension thereof 
                agreed to after the date of enactment of this Act), or
                    (B) January 1, 2002.
        For purposes of subparagraph (A), any plan amendment made 
        pursuant to a collective bargaining agreement relating to the 
        plan which amends the plan solely to conform to any requirement 
        added by this section shall not be treated as a termination of 
        such collective bargaining agreement.

SEC. 4. AMENDMENT TO THE PUBLIC HEALTH SERVICE ACT RELATING TO THE 
              INDIVIDUAL MARKET.

    (a) In General.--Subpart 3 of part B of title XXVII of the Public 
Health Service Act is amended by adding at the end the following new 
section:

``SEC. 2753. REQUIRED COVERAGE FOR MINIMUM HOSPITAL STAY FOR 
              MASTECTOMIES AND LYMPH NODE DISSECTIONS FOR THE TREATMENT 
              OF BREAST CANCER AND SECONDARY CONSULTATIONS.

    ``(a) In General.--The provisions of section 2707 (other than 
subsection (c)) shall apply to health insurance coverage offered by a 
health insurance issuer in the individual market in the same manner as 
they apply to health insurance coverage offered by a health insurance 
issuer in connection with a group health plan in the small or large 
group market.
    ``(b) Requirement.--A health insurance issuer under this part shall 
comply with the notice requirement under section 714(c) of the Employee 
Retirement Income Security Act of 1974 with respect to the requirements 
referred to in subsection (a) as if such section applied to such issuer 
and such issuer were a group health plan.
    ``(c) Exception for Health Insurance Coverage in Certain States.--
            ``(1) In general.--The requirements of this section shall 
        not apply with respect to health insurance coverage if there is 
        a State law (as defined in section 2723(d)(1) of the Public 
        Health Service Act) for a State that regulates such coverage 
        that is described in any of the following subparagraphs:
                    ``(A) Such State law requires such coverage to 
                provide for at least a 48-hour hospital length of stay 
                following a mastectomy performed for treatment of 
                breast cancer and at least a 24-hour hospital length of 
                stay following a lymph node dissection for treatment of 
                breast cancer.
                    ``(B) Such State law requires, in connection with 
                such coverage for surgical treatment of breast cancer, 
                that the hospital length of stay for such care is left 
                to the decision of (or required to be made by) the 
                attending provider in consultation with the woman 
                involved.
            ``(2) Construction.--Section 2762(a) shall not be construed 
        as superseding a State law described in paragraph (1).''.
    (b) Conforming Amendment.--Section 2762(b)(2) of such Act (42 
U.S.C. 300gg-62(b)(2)) is amended by striking ``section 2751'' and 
inserting ``sections 2751 and 2753''.
    (c) Effective Date.--The amendments made by this section shall 
apply with respect to health insurance coverage offered, sold, issued, 
renewed, in effect, or operated in the individual market on or after 
the date of enactment of this Act.

SEC. 5. AMENDMENTS TO THE INTERNAL REVENUE CODE OF 1986.

    (a) In General.--Subchapter B of chapter 100 of the Internal 
Revenue Code of 1986 (relating to other requirements) is amended by 
inserting after section 9812 the following new section:

``SEC. 9813. REQUIRED COVERAGE FOR MINIMUM HOSPITAL STAY FOR 
              MASTECTOMIES AND LYMPH NODE DISSECTIONS FOR THE TREATMENT 
              OF BREAST CANCER AND COVERAGE FOR SECONDARY 
              CONSULTATIONS.

    ``(a) Inpatient Care.--
            ``(1) In general.--A group health plan that provides 
        medical and surgical benefits shall ensure that inpatient 
        coverage with respect to the surgical treatment of breast 
        cancer (including a mastectomy, lumpectomy, or lymph node 
        dissection for the treatment of breast cancer) is provided for 
        a period of time as is determined by the attending physician, 
        in the physician's professional judgment consistent with 
        generally accepted principles of professional medical practice, 
        in consultation with the patient, to be medically necessary or 
        appropriate.
            ``(2) Exception.--Nothing in this section shall be 
        construed as requiring the provision of inpatient coverage if 
        the attending physician in consultation with the patient 
        determines that a shorter period of hospital stay is medically 
        necessary or appropriate.
    ``(b) Prohibition on Certain Modifications.--In implementing the 
requirements of this section, a group health plan may not modify the 
terms and conditions of coverage based on the determination by a 
participant or beneficiary to request less than the minimum coverage 
required under subsection (a).
    ``(c) Secondary Consultations.--
            ``(1) In general.--A group health plan that provides 
        coverage with respect to medical and surgical services provided 
        in relation to the diagnosis and treatment of cancer shall 
        ensure that full coverage is provided for secondary 
        consultations by specialists in the appropriate medical fields 
        (including pathology, radiology, and oncology) to confirm or 
        refute such diagnosis. Such plan or issuer shall ensure that 
        full coverage is provided for such secondary consultation 
        whether such consultation is based on a positive or negative 
        initial diagnosis. In any case in which the attending physician 
        certifies in writing that services necessary for such a 
        secondary consultation are not sufficiently available from 
        specialists operating under the plan with respect to whose 
        services coverage is otherwise provided under such plan or by 
        such issuer, such plan or issuer shall ensure that coverage is 
        provided with respect to the services necessary for the 
        secondary consultation with any other specialist selected by 
        the attending physician for such purpose at no additional cost 
        to the individual beyond that which the individual would have 
paid if the specialist was participating in the network of the plan.
            ``(2) Exception.--Nothing in paragraph (1) shall be 
        construed as requiring the provision of secondary consultations 
        where there is a financial relationship (including an ownership 
        or investment interest or compensation arrangement) between the 
        specialist and the attending physician or where the patient 
        determines not to seek such a consultation.
    ``(d) Prohibition on Penalties.--A group health plan may not--
            ``(1) penalize or otherwise reduce or limit the 
        reimbursement of a provider or specialist because the provider 
        or specialist provided care to a participant or beneficiary in 
        accordance with this section;
            ``(2) provide financial or other incentives to a physician 
        or specialist to induce the physician or specialist to keep the 
        length of inpatient stays of patients following a mastectomy, 
        lumpectomy, or a lymph node dissection for the treatment of 
        breast cancer below certain limits or to limit referrals for 
        secondary consultations; or
            ``(3) provide financial or other incentives to a physician 
        or specialist to induce the physician or specialist to refrain 
        from referring a participant or beneficiary for a secondary 
        consultation that would otherwise be covered by the plan 
        involved under subsection (d).
    ``(e) Exception for Health Insurance Coverage in Certain States.--
The requirements of this section shall not apply with respect to health 
insurance coverage if there is a State law (including a decision, rule, 
regulation, or other State action having the effect of law) for a State 
that regulates such coverage that is described in any of the following 
paragraphs:
            ``(1) Such State law requires such coverage to provide for 
        at least a 48-hour hospital length of stay following a 
        mastectomy performed for treatment of breast cancer and at 
        least a 24-hour hospital length of stay following a lymph node 
        dissection for treatment of breast cancer.
            ``(2) Such State law requires, in connection with such 
        coverage for surgical treatment of breast cancer, that the 
        hospital length of stay for such care is left to the decision 
        of (or required to be made by) the attending provider in 
        consultation with the woman involved.''.
    (b) Clerical Amendment.--The table of sections for such subchapter 
is amended by adding at the end the following new item:

``Sec. 9813. Required coverage for minimum hospital stay for 
                            mastectomies and lymph node dissections for 
                            the treatment of breast cancer and coverage 
                            for secondary consultations.''.
    (c) Effective Dates.--
            (1) In general.--The amendments made by this section shall 
        apply with respect to plan years beginning on or after the date 
        of enactment of this Act.
            (2) Special rule for collective bargaining agreements.--In 
        the case of a group health plan maintained pursuant to 1 or 
        more collective bargaining agreements between employee 
        representatives and 1 or more employers ratified before the 
        date of enactment of this Act, the amendments made by this 
        section shall not apply to plan years beginning before the 
        later of--
                    (A) the date on which the last collective 
                bargaining agreements relating to the plan terminates 
                (determined without regard to any extension thereof 
                agreed to after the date of enactment of this Act), or
                    (B) January 1, 2002.
        For purposes of subparagraph (A), any plan amendment made 
        pursuant to a collective bargaining agreement relating to the 
        plan which amends the plan solely to conform to any requirement 
        added by this section shall not be treated as a termination of 
        such collective bargaining agreement.

SEC. 6. COORDINATION OF ADMINISTRATION.

    The Secretary of Labor, the Secretary of the Treasury, and the 
Secretary of Health and Human Services shall ensure, through the 
execution of an interagency memorandum of understanding among such 
Secretaries, that--
            (1) regulations, rulings, and interpretations issued by 
        such Secretaries relating to the same matter over which two or 
        more such Secretaries have responsibility under the provisions 
        of this Act (and the amendments made thereby) are administered 
        so as to have the same effect at all times; and
            (2) coordination of policies relating to enforcing the same 
        requirements through such Secretaries in order to have a 
        coordinated enforcement strategy that avoids duplication of 
        enforcement efforts and assigns priorities in enforcement.
                                 <all>
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