II 

109TH CONGRESS 

1ST SESSION S. 910 

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 SENATE OF THE UNITED STATES 

APRIL 26, 2005 

Ms. SNOWE (for herself, Ms. LANDRIEU, Mrs. FEINSTEIN, Mrs. BOXER, Mrs. 

MURRAY, Mr. CORZINE, Mr. DURBIN and Mr. COCHRAN) introduced the 

following bill; which was read twice and referred to the Committee on 

Health, Education, Labor, and Pensions 

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 2005’’. 

6 SEC. 2. FINDINGS. 

7 Congress finds that— 
2 

•S 910 IS 

1 (1) the offering and operation of health plans 

2 affect commerce among the States; 

3 (2) health care providers located in a State 

4 serve patients who reside in the State and patients 

5 who reside in other States; and 

6 (3) in order to provide for uniform treatment of 

7 health care providers and patients among the States, 

8 it is necessary to cover health plans operating in 1 

9 State as well as health plans operating among the 

10 several States. 

11 SEC. 3. AMENDMENTS TO THE EMPLOYEE RETIREMENT IN12 COME SECURITY ACT OF 1974. 

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

14 B of title I of the Employee Retirement Income Security 

15 Act of 1974 (29 U.S.C. 1185 et seq.) is amended by add16 ing at the end the following: 

17 ‘‘SEC. 714. 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, and a 

24 health insurance issuer providing health insurance 

25 coverage in connection with a group health plan, 
3 

•S 910 IS 

1 that provides medical and surgical benefits shall en2 sure that inpatient (and in the case of a 

3 lumpectomy, outpatient) coverage and radiation 

4 therapy is provided for breast cancer treatment. 

5 Such plan or coverage may not— 

6 ‘‘(A) except as provided for in paragraph 

7 (2)— 

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 or the issuer for pre19 scribing any length of stay required under sub20 paragraph (A) (without regard to paragraph 

21 (2)). 

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

23 be construed as requiring the provision of inpatient 

24 coverage if the attending physician and patient de-
4 

•S 910 IS 

1 termine that either a shorter period of hospital stay, 

2 or outpatient treatment, is medically appropriate. 

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

4 In implementing the requirements of this section, a group 

5 health plan, and a health insurance issuer providing health 

6 insurance coverage in connection with a group health plan, 

7 may not modify the terms and conditions of coverage 

8 based on the determination by a participant or beneficiary 

9 to request less than the minimum coverage required under 

10 subsection (a). 

11 ‘‘(c) NOTICE.—A group health plan, and a health in12 surance issuer providing health insurance coverage in con13 nection with a group health plan shall provide notice to 

14 each participant and beneficiary under such plan regard15 ing the coverage required by this section in accordance 

16 with regulations promulgated by the Secretary. Such no17 tice shall be in writing and prominently positioned in any 

18 literature or correspondence made available or distributed 

19 by the plan or issuer and shall be transmitted— 

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

21 issuer to the participant or beneficiary; or 

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

23 sent to the participant or beneficiary; 

24 whichever is earlier. 

25 ‘‘(d) SECONDARY CONSULTATIONS.— 
5 

•S 910 IS 

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

2 health insurance issuer providing health insurance 

3 coverage in connection with a group health plan, 

4 that provides coverage with respect to medical and 

5 surgical services provided in relation to the diagnosis 

6 and treatment of cancer shall ensure that full cov7 erage is provided for secondary consultations by spe8 cialists in the appropriate medical fields (including 

9 pathology, radiology, and oncology) to confirm or re10 fute such diagnosis. Such plan or issuer shall ensure 

11 that full coverage is provided for such secondary con12 sultation whether such consultation is based on a 

13 positive or negative initial diagnosis. In any case in 

14 which the attending physician certifies in writing that 

15 services necessary for such a secondary consultation 

16 are not sufficiently available from specialists oper17 ating under the plan with respect to whose services 

18 coverage is otherwise provided under such plan or by 

19 such issuer, such plan or issuer shall ensure that cov20 erage is provided with respect to the services nec21 essary for the secondary consultation with any other 

22 specialist selected by the attending physician for such 

23 purpose at no additional cost to the individual beyond 

24 that which the individual would have paid if the spe25 cialist was participating in the network of the plan. 
6 

•S 910 IS 

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

2 shall be construed as requiring the provision of sec3 ondary consultations where the patient determines 

4 not to seek such a consultation. 

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

6 A group health plan, and a health insurance issuer pro7 viding health insurance coverage in connection with a 

8 group health plan, may not— 

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

10 reimbursement of a provider or specialist because 

11 the provider or specialist provided care to a partici12 pant or beneficiary in accordance with this section; 

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

14 physician or specialist to induce the physician or 

15 specialist to keep the length of inpatient stays of pa16 tients following a mastectomy, lumpectomy, or a 

17 lymph node dissection for the treatment of breast 

18 cancer below certain limits or to limit referrals for 

19 secondary consultations; 

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

21 physician or specialist to induce the physician or 

22 specialist to refrain from referring a participant or 

23 beneficiary for a secondary consultation that would 

24 otherwise be covered by the plan or coverage in25 volved under subsection (d); or 
7 

•S 910 IS 

1 ‘‘(4) deny to a woman eligibility, or continued 

2 eligibility, to enroll or to renew coverage under the 

3 terms of the plan or coverage solely for the purpose 

4 of avoiding the requirements of this section.’’. 

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

6 in section 1 of the Employee Retirement Income Security 

7 Act of 1974 is amended by inserting after the item relat8 ing to section 713 the following: 

‘‘Sec. 714. Required coverage for minimum hospital stay for mastectomies, 

lumpectomies, and lymph node dissections for the treatment of 

breast cancer and coverage for secondary consultations.’’. 

9 (c) EFFECTIVE DATES.— 

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

11 this section shall apply with respect to plan years be12 ginning on or after the date that is 90 days after 

13 the date of enactment of this Act. 

14 (2) SPECIAL RULE FOR COLLECTIVE BAR15 GAINING AGREEMENTS.—In the case of a group 

16 health plan maintained pursuant to 1 or more collec17 tive bargaining agreements between employee rep18 resentatives and 1 or more employers ratified before 

19 the date of enactment of this Act, the amendments 

20 made by this section shall not apply to plan years 

21 beginning before the date on which the last collective 

22 bargaining agreements relating to the plan termi23 nates (determined without regard to any extension 

24 thereof agreed to after the date of enactment of this 
8 

•S 910 IS 

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

2 amendment made pursuant to a collective bargaining 

3 agreement relating to the plan which amends the 

4 plan solely to conform to any requirement added by 

5 this section shall not be treated as a termination of 

6 such collective bargaining agreement. 

7 SEC. 4. AMENDMENTS TO THE PUBLIC HEALTH SERVICE 

8 ACT RELATING TO THE GROUP MARKET. 

9 (a) IN GENERAL.—Subpart 2 of part A of title 

10 XXVII of the Public Health Service Act (42 U.S.C. 

11 300gg–4 et seq.) is amended by adding at the end the 

12 following: 

13 ‘‘SEC. 2707. REQUIRED COVERAGE FOR MINIMUM HOSPITAL 

14 STAY FOR MASTECTOMIES, LUMPECTOMIES, 

15 AND LYMPH NODE DISSECTIONS FOR THE 

16 TREATMENT OF BREAST CANCER AND COV17 ERAGE FOR SECONDARY CONSULTATIONS. 

18 ‘‘(a) INPATIENT CARE.— 

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

20 health insurance issuer providing health insurance 

21 coverage in connection with a group health plan, 

22 that provides medical and surgical benefits shall en23 sure that inpatient (and in the case of a 

24 lumpectomy, outpatient) coverage and radiation 
9 

•S 910 IS 

1 therapy is provided for breast cancer treatment. 

2 Such plan or coverage may not— 

3 ‘‘(A) except as provided for in paragraph 

4 (2)— 

5 ‘‘(i) restrict benefits for any hospital 

6 length of stay in connection with a mastec7 tomy or breast conserving surgery (such as 

8 a lumpectomy) for the treatment of breast 

9 cancer to less than 48 hours; or 

10 ‘‘(ii) restrict benefits for any hospital 

11 length of stay in connection with a lymph 

12 node dissection for the treatment of breast 

13 cancer to less than 24 hours; or 

14 ‘‘(B) require that a provider obtain author15 ization from the plan or the issuer for pre16 scribing any length of stay required under sub17 paragraph (A) (without regard to paragraph 

18 (2)). 

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

20 be construed as requiring the provision of inpatient 

21 coverage if the attending physician and patient de22 termine that either a shorter period of hospital stay, 

23 or outpatient treatment, is medically appropriate. 

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

25 In implementing the requirements of this section, a group 
10 

•S 910 IS 

1 health plan, and a health insurance issuer providing health 

2 insurance coverage in connection with a group health plan, 

3 may not modify the terms and conditions of coverage 

4 based on the determination by a participant or beneficiary 

5 to request less than the minimum coverage required under 

6 subsection (a). 

7 ‘‘(c) NOTICE.—A group health plan, and a health in8 surance issuer providing health insurance coverage in con9 nection with a group health plan shall provide notice to 

10 each participant and beneficiary under such plan regard11 ing the coverage required by this section in accordance 

12 with regulations promulgated by the Secretary. Such no13 tice shall be in writing and prominently positioned in any 

14 literature or correspondence made available or distributed 

15 by the plan or issuer and shall be transmitted— 

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

17 issuer to the participant or beneficiary; or 

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

19 sent to the participant or beneficiary; 

20 whichever is earlier. 

21 ‘‘(d) SECONDARY CONSULTATIONS.— 

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

23 health insurance issuer providing health insurance 

24 coverage in connection with a group health plan that 

25 provides coverage with respect to medical and sur-
11 

•S 910 IS 

1 gical services provided in relation to the diagnosis and 

2 treatment of cancer shall ensure that full coverage 

3 is provided for secondary consultations by specialists 

4 in the appropriate medical fields (including pathol5 ogy, radiology, and oncology) to confirm or refute 

6 such diagnosis. Such plan or issuer shall ensure that 

7 full coverage is provided for such secondary consulta8 tion whether such consultation is based on a positive 

9 or negative initial diagnosis. In any case in which the 

10 attending physician certifies in writing that services 

11 necessary for such a secondary consultation are not 

12 sufficiently available from specialists operating under 

13 the plan with respect to whose services coverage is 

14 otherwise provided under such plan or by such issuer, 

15 such plan or issuer shall ensure that coverage is pro16 vided with respect to the services necessary for the 

17 secondary consultation with any other specialist se18 lected by the attending physician for such purpose at 

19 no additional cost to the individual beyond that which 

20 the individual would have paid if the specialist was 

21 participating in the network of the plan. 

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

23 shall be construed as requiring the provision of sec24 ondary consultations where the patient determines 

25 not to seek such a consultation. 
12 

•S 910 IS 

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; 

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); or 

22 ‘‘(4) deny to a woman eligibility, or continued 

23 eligibility, to enroll or to renew coverage under the 

24 terms of the plan or coverage solely for the purpose 

25 of avoiding the requirements of this section.’’. 
13 

•S 910 IS 

1 (b) EFFECTIVE DATES.— 

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

3 this section shall apply to group health plans for 

4 plan years beginning on or after 90 days after the 

5 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. 
14 

•S 910 IS 

1 SEC. 5. AMENDMENT TO THE PUBLIC HEALTH SERVICE ACT 

2 RELATING TO THE INDIVIDUAL MARKET. 

3 (a) IN GENERAL.—The first subpart 3 of part B of 

4 title XXVII of the Public Health Service Act (42 U.S.C. 

5 300gg–11 et seq.) is amended— 

6 (1) by adding after section 2752 the following: 

7 ‘‘SEC. 2753. REQUIRED COVERAGE FOR MINIMUM HOSPITAL 

8 STAY FOR MASTECTOMIES, LUMPECTOMIES, 

9 AND LYMPH NODE DISSECTIONS FOR THE 

10 TREATMENT OF BREAST CANCER AND SEC11 ONDARY CONSULTATIONS. 

12 ‘‘The provisions of section 2707 shall apply to health 

13 insurance coverage offered by a health insurance issuer 

14 in the individual market in the same manner as they apply 

15 to health insurance coverage offered by a health insurance 

16 issuer in connection with a group health plan in the small 

17 or large group market.’’; and 

18 (2) by redesignating such subpart 3 as subpart 

19 2. 

20 (b) EFFECTIVE DATE.—The amendment made by 

21 this section shall apply with respect to health insurance 

22 coverage offered, sold, issued, renewed, in effect, or oper23 ated in the individual market on or after the date of enact24 ment of this Act. 
15 

•S 910 IS 

1 SEC. 6. AMENDMENTS TO THE INTERNAL REVENUE CODE 

2 OF 1986. 

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

4 the Internal Revenue Code of 1986 is amended— 

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

6 the item relating to section 9812 the following: 

‘‘Sec. 9813. Required coverage for minimum hospital stay for 

mastectomies, lumpectomies, and lymph node dissections for the treatment of breast cancer and coverage for secondary consultations.’’; 

7 and 

8 (2) by inserting after section 9812 the fol9 lowing: 

10 ‘‘SEC. 9813. REQUIRED COVERAGE FOR MINIMUM HOSPITAL 

11 STAY FOR MASTECTOMIES, LUMPECTOMIES, 

12 AND LYMPH NODE DISSECTIONS FOR THE 

13 TREATMENT OF BREAST CANCER AND COV14 ERAGE FOR SECONDARY CONSULTATIONS. 

15 ‘‘(a) INPATIENT CARE.— 

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

17 provides medical and surgical benefits shall ensure 

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

19 outpatient) coverage and radiation therapy is pro20 vided for breast cancer treatment. Such plan may 

21 not— 

22 ‘‘(A) except as provided for in paragraph 

23 (2)— 
16 

•S 910 IS 

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 for prescribing any length 

12 of stay required under subparagraph (A) (with13 out regard to paragraph (2)). 

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

15 be construed as requiring the provision of inpatient 

16 coverage if the attending physician and patient de17 termine that either a shorter period of hospital stay, 

18 or outpatient treatment, is medically appropriate. 

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

20 In implementing the requirements of this section, a group 

21 health plan may not modify the terms and conditions of 

22 coverage based on the determination by a participant or 

23 beneficiary to request less than the minimum coverage re24 quired under subsection (a). 
17 

•S 910 IS 

1 ‘‘(c) NOTICE.—A group health plan shall provide no2 tice to each participant and beneficiary under such plan 

3 regarding the coverage required by this section in accord4 ance with regulations promulgated by the Secretary. Such 

5 notice shall be in writing and prominently positioned in 

6 any literature or correspondence made available or distrib7 uted by the plan and shall be transmitted— 

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

9 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 that 

15 provides coverage with respect to medical and sur16 gical services provided in relation to the diagnosis 

17 and treatment of cancer shall ensure that full cov18 erage is provided for secondary consultations by spe19 cialists in the appropriate medical fields (including 

20 pathology, radiology, and oncology) to confirm or re21 fute such diagnosis. Such plan or issuer shall ensure 

22 that full coverage is provided for such secondary 

23 consultation whether such consultation is based on a 

24 positive or negative initial diagnosis. In any case in 

25 which the attending physician certifies in writing 
18 

•S 910 IS 

1 that services necessary for such a secondary con2 sultation are not sufficiently available from special3 ists operating under the plan with respect to whose 

4 services coverage is otherwise provided under such 

5 plan or by such issuer, such plan or issuer shall en6 sure that coverage is provided with respect to the 

7 services necessary for the secondary consultation 

8 with any other specialist selected by the attending 

9 physician for such purpose at no additional cost to 

10 the individual beyond that which the individual 

11 would have paid if the specialist was participating in 

12 the network of the plan. 

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

14 shall be construed as requiring the provision of sec15 ondary consultations where the patient determines 

16 not to seek such a consultation. 

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

18 plan may 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 pa-
19 

•S 910 IS 

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; 

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 involved under sub10 section (d); or 

11 ‘‘(4) deny to a woman eligibility, or continued 

12 eligibility, to enroll or to renew coverage under the 

13 terms of the plan solely for the purpose of avoiding 

14 the requirements of this section.’’. 

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

16 for chapter 100 of such Code is amended by inserting after 

17 the item relating to section 9812 the following: 

‘‘Sec. 9813. Required coverage for minimum hospital stay for mastectomies, 

lumpectomies, and lymph node dissections for the treatment of 

breast cancer and coverage for secondary consultations.’’. 

18 (c) EFFECTIVE DATES.— 

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

20 this section shall apply with respect to plan years be21 ginning on or after the date of enactment of this 

22 Act. 

23 (2) SPECIAL RULE FOR COLLECTIVE BAR24 GAINING AGREEMENTS.—In the case of a group 
20 

•S 910 IS 

1 health plan maintained pursuant to 1 or more collec2 tive bargaining agreements between employee rep3 resentatives and 1 or more employers ratified before 

4 the date of enactment of this Act, the amendments 

5 made by this section shall not apply to plan years 

6 beginning before the date on which the last collective 

7 bargaining agreements relating to the plan termi8 nates (determined without regard to any extension 

9 thereof agreed to after the date of enactment of this 

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

11 amendment made pursuant to a collective bargaining 

12 agreement relating to the plan which amends the 

13 plan solely to conform to any requirement added by 

14 this section shall not be treated as a termination of 

15 such collective bargaining agreement. 

Æ