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 treat-
ment 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. CAS-
TOR 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 re-
ferred 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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Be it enacted by the Senate and House of Representa-
tives of the United States of America in Congress assembled, 
SECTION 1. SHORT TITLE. 
This Act may be cited as the ‘‘Breast Cancer Patient 
Protection Act of 2016’’. 
SEC. 2. FINDINGS. 
Congress finds the following: 
(1) According to the National Cancer Institute, 
excluding cancers of the skin, breast cancer is the 
most frequently diagnosed cancer in women. 
(2) According to the National Cancer Institute, 
an estimated 40,450 women and 440 men will die 
from breast cancer in 2016. 
(3) According to the National Cancer Institute, 
in 2016 an estimated 246,660 new cases of breast 
cancer will be diagnosed in women and an estimated 
2,600 breast cancer cases will be diagnosed in men. 
(4) According to the American Cancer Society, 
most breast cancer patients undergo some type of 
surgical treatment, which may involve lumpectomy 
or mastectomy with removal of some of the axillary 
lymph nodes. 
(5) The offering and operation of health plans 
affect commerce among the States. 
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(6) Health care providers located in a State 
serve patients who reside in the State and patients 
who reside in other States. 
(7) In order to provide for uniform treatment 
of health care providers and patients among the 
States, it is necessary to cover health plans oper-
ating in one State as well as health plans operating 
among the several States. 
(8) Research has indicated that treatment for 
breast cancer varies according to type of insurance 
coverage and State of residence. 
(9) Breast cancer patients have reported ad-
verse outcomes, including infection and inadequately 
controlled pain, resulting from premature hospital 
discharge following breast cancer surgery. 
SEC. 3. AMENDMENTS TO THE EMPLOYEE RETIREMENT IN-
COME 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 (29 U.S.C. 1185 et seq.) is amended by add-
ing at the end the following: 
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‘‘SEC. 716. REQUIRED COVERAGE FOR MINIMUM HOSPITAL 
STAY FOR MASTECTOMIES, LUMPECTOMIES, 
AND LYMPH NODE DISSECTIONS FOR THE 
TREATMENT OF BREAST CANCER AND COV-
ERAGE 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 en-
sure that inpatient (and in the case of a 
lumpectomy, outpatient) coverage and radiation 
therapy is provided for breast cancer treatment. 
Such plan or coverage may not— 
‘‘(A) insofar as the attending physician, in 
consultation with the patient, determines it to 
be medically necessary— 
‘‘(i) restrict benefits for any hospital 
length of stay in connection with a mastec-
tomy or breast conserving surgery (such as 
a lumpectomy) for the treatment of breast 
cancer to less than 48 hours; or 
‘‘(ii) restrict benefits for any hospital 
length of stay in connection with a lymph 
node dissection for the treatment of breast 
cancer to less than 24 hours; or 
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‘‘(B) require that a provider obtain author-
ization from the plan or the issuer for pre-
scribing any length of stay required under this 
paragraph. 
‘‘(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 either a shorter pe-
riod of hospital stay, or outpatient treatment, is 
medically 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.—A group health plan, and a health in-
surance issuer providing health insurance coverage in con-
nection with a group health plan, shall provide notice to 
each participant and beneficiary under such plan regard-
ing the coverage required by this section in accordance 
with regulations promulgated by the Secretary. Such no-
tice shall be in writing and prominently positioned in the 
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summary of the plan made available or distributed by the 
plan or issuer and shall be transmitted— 
‘‘(1) in the next mailing made by the plan or 
issuer to the participant or beneficiary; or 
‘‘(2) as part of any yearly informational packet 
sent to the participant or beneficiary; 
whichever is earlier. 
‘‘(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 coverage 
is provided for secondary consultations, on terms 
and conditions that are no more restrictive than 
those applicable to the initial consultations, by spe-
cialists in the appropriate medical fields (including 
pathology, radiology, and oncology) to confirm or re-
fute such diagnosis. Such plan or issuer shall ensure 
that coverage is provided for such secondary con-
sultation 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 con-
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sultation are not sufficiently available from special-
ists 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 en-
sure 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 sec-
ondary consultations 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 pro-
viding 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 partici-
pant or beneficiary in accordance with this section; 
‘‘(2) provide financial or other incentives to a 
physician or specialist to induce the physician or 
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specialist to keep the length of inpatient stays of pa-
tients 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 in-
volved under subsection (d).’’. 
(b) CLERICAL AMENDMENT.—The table of contents 
in section 1 of the Employee Retirement Income Security 
Act of 1974 is amended by inserting after the item relat-
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.’’. 
(c) EFFECTIVE DATES.— 
(1) IN GENERAL.—The amendments made by 
this section shall apply with respect to plan years be-
ginning on or after the date that is 90 days after 
the date of enactment of this Act. 
(2) SPECIAL
RULE
FOR
COLLECTIVE
BAR-
GAINING
AGREEMENTS.—In the case of a group 
health plan maintained pursuant to 1 or more collec-
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tive bargaining agreements between employee rep-
resentatives 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 date on which the last collective 
bargaining agreements relating to the plan termi-
nates (determined without regard to any extension 
thereof agreed to after the date of enactment of this 
Act). For purposes of this paragraph, 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. AMENDMENTS TO THE PUBLIC HEALTH SERVICE 
ACT. 
(a) IN GENERAL.—Title XXVII of the Public Health 
Service Act is amended by inserting after section 2728 of 
such Act (42 U.S.C. 300gg–28), as redesignated by sec-
tion 1001(2) of the Patient Protection and Affordable 
Care Act (Public Law 111–148), the following: 
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‘‘SEC. 2729. REQUIRED COVERAGE FOR MINIMUM HOSPITAL 
STAY FOR MASTECTOMIES, LUMPECTOMIES, 
AND LYMPH NODE DISSECTIONS FOR THE 
TREATMENT OF BREAST CANCER AND COV-
ERAGE FOR SECONDARY CONSULTATIONS. 
‘‘(a) INPATIENT CARE.— 
‘‘(1) IN GENERAL.—A group health plan, and a 
health insurance issuer providing group or individual 
health insurance coverage, that provides medical and 
surgical benefits shall ensure that inpatient (and in 
the case of a lumpectomy, outpatient) coverage and 
radiation therapy is provided for breast cancer treat-
ment. Such plan or coverage may not— 
‘‘(A) insofar as the attending physician, in 
consultation with the patient, determines it to 
be medically necessary— 
‘‘(i) restrict benefits for any hospital 
length of stay in connection with a mastec-
tomy or breast conserving surgery (such as 
a lumpectomy) for the treatment of breast 
cancer to less than 48 hours; or 
‘‘(ii) restrict benefits for any hospital 
length of stay in connection with a lymph 
node dissection for the treatment of breast 
cancer to less than 24 hours; or 
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‘‘(B) require that a provider obtain author-
ization from the plan or the issuer for pre-
scribing any length of stay required under this 
paragraph. 
‘‘(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 either a shorter pe-
riod of hospital stay, or outpatient treatment, is 
medically appropriate. 
‘‘(b) PROHIBITION ON CERTAIN MODIFICATIONS.— 
In implementing the requirements of this section, a group 
health plan, and a health insurance issuer providing group 
or individual health insurance coverage, may not modify 
the terms and conditions of coverage based on the deter-
mination by a participant or beneficiary to request less 
than the minimum coverage required under subsection (a). 
‘‘(c) NOTICE.—A group health plan, and a health in-
surance issuer providing group or individual health insur-
ance coverage, shall provide notice to each participant and 
beneficiary under such plan or coverage regarding the cov-
erage required by this section in accordance with regula-
tions promulgated by the Secretary. Such notice shall be 
in writing and prominently positioned in the summary of 
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the plan or coverage made available or distributed by the 
plan or issuer and shall be transmitted— 
‘‘(1) in the next mailing made by the plan or 
issuer to the participant or beneficiary; or 
‘‘(2) as part of any yearly informational packet 
sent to the participant or beneficiary; 
whichever is earlier. 
‘‘(d) SECONDARY CONSULTATIONS.— 
‘‘(1) IN GENERAL.—A group health plan, and a 
health insurance issuer providing group or individual 
health insurance coverage, that provides coverage 
with respect to medical and surgical services pro-
vided in relation to the diagnosis and treatment of 
cancer shall ensure that coverage is provided for sec-
ondary consultations, on terms and conditions that 
are no more restrictive than those applicable to the 
initial 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 coverage is provided 
for such secondary consultation whether such con-
sultation is based on a positive or negative initial di-
agnosis. In any case in which the attending physi-
cian certifies in writing that services necessary for 
such a secondary consultation are not sufficiently 
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available from specialists operating under the plan 
or coverage 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 sec-
ondary consultations 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 pro-
viding group or individual health insurance coverage, 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 partici-
pant 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 pa-
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tients 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 in-
volved under subsection (d).’’. 
(b) EFFECTIVE DATES.— 
(1) IN GENERAL.—The amendments made by 
this section shall apply with respect to plan years be-
ginning on or after 90 days after the date of enact-
ment of this Act. 
(2) SPECIAL
RULE
FOR
COLLECTIVE
BAR-
GAINING
AGREEMENTS.—In the case of a group 
health plan maintained pursuant to 1 or more collec-
tive bargaining agreements between employee rep-
resentatives 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 date on which the last collective 
bargaining agreements relating to the plan termi-
nates (determined without regard to any extension 
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thereof agreed to after the date of enactment of this 
Act). For purposes of this paragraph, 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. 5. AMENDMENTS TO THE INTERNAL REVENUE CODE 
OF 1986. 
(a) IN GENERAL.—Subchapter B of chapter 100 of 
the Internal Revenue Code of 1986 is amended— 
(1) in the table of sections, by inserting after 
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.’’; 
and 
(2) by inserting after section 9813 the fol-
lowing: 
‘‘SEC. 9814. REQUIRED COVERAGE FOR MINIMUM HOSPITAL 
STAY FOR MASTECTOMIES, LUMPECTOMIES, 
AND LYMPH NODE DISSECTIONS FOR THE 
TREATMENT OF BREAST CANCER AND COV-
ERAGE FOR SECONDARY CONSULTATIONS. 
‘‘(a) INPATIENT CARE.— 
‘‘(1) IN GENERAL.—A group health plan that 
provides medical and surgical benefits shall ensure 
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that inpatient (and in the case of a lumpectomy, 
outpatient) coverage and radiation therapy is pro-
vided for breast cancer treatment. Such plan may 
not— 
‘‘(A) insofar as the attending physician, in 
consultation with the patient, determines it to 
be medically necessary— 
‘‘(i) restrict benefits for any hospital 
length of stay in connection with a mastec-
tomy or breast conserving surgery (such as 
a lumpectomy) for the treatment of breast 
cancer to less than 48 hours; or 
‘‘(ii) restrict benefits for any hospital 
length of stay in connection with a lymph 
node dissection for the treatment of breast 
cancer to less than 24 hours; or 
‘‘(B) require that a provider obtain author-
ization from the plan for prescribing any length 
of stay required under this paragraph. 
‘‘(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 either a shorter pe-
riod of hospital stay, or outpatient treatment, is 
medically appropriate. 
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‘‘(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 re-
quired under subsection (a). 
‘‘(c) NOTICE.—A group health plan shall provide no-
tice to each participant and beneficiary under such plan 
regarding the coverage required by this section in accord-
ance with regulations promulgated by the Secretary. Such 
notice shall be in writing and prominently positioned in 
the summary of the plan made available or distributed by 
the plan and shall be transmitted— 
‘‘(1) in the next mailing made by the plan to 
the participant or beneficiary; or 
‘‘(2) as part of any yearly informational packet 
sent to the participant or beneficiary; 
whichever is earlier. 
‘‘(d) SECONDARY CONSULTATIONS.— 
‘‘(1) IN GENERAL.—A group health plan that 
provides coverage with respect to medical and sur-
gical services provided in relation to the diagnosis 
and treatment of cancer shall ensure that coverage 
is provided for secondary consultations, on terms 
and conditions that are no more restrictive than 
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those applicable to the initial consultations, by spe-
cialists in the appropriate medical fields (including 
pathology, radiology, and oncology) to confirm or re-
fute such diagnosis. Such plan or issuer shall ensure 
that coverage is provided for such secondary con-
sultation 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 con-
sultation are not sufficiently available from special-
ists 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 en-
sure 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 sec-
ondary consultations where the patient determines 
not to seek such a consultation. 
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‘‘(e) 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 partici-
pant 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 pa-
tients 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 sub-
section (d).’’. 
(b) EFFECTIVE DATES.— 
(1) IN GENERAL.—The amendments made by 
this section shall apply with respect to plan years be-
ginning on or after the date of enactment of this 
Act. 
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(2) SPECIAL
RULE
FOR
COLLECTIVE
BAR-
GAINING
AGREEMENTS.—In the case of a group 
health plan maintained pursuant to 1 or more collec-
tive bargaining agreements between employee rep-
resentatives 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 date on which the last collective 
bargaining agreements relating to the plan termi-
nates (determined without regard to any extension 
thereof agreed to after the date of enactment of this 
Act). For purposes of this paragraph, 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. OPPORTUNITY FOR INDEPENDENT, EXTERNAL 
THIRD PARTY REVIEWS OF CERTAIN NON-
RENEWALS 
AND 
DISCONTINUATIONS, 
IN-
CLUDING 
RESCISSIONS, 
OF 
INDIVIDUAL 
HEALTH INSURANCE COVERAGE. 
(a) CLARIFICATION REGARDING APPLICATION
OF 
GUARANTEED RENEWABILITY OF INDIVIDUAL HEALTH 
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INSURANCE COVERAGE.—Section 2742 of the Public 
Health Service Act (42 U.S.C. 300gg–42) is amended— 
(1) in its heading, by inserting ‘‘AND CON-
TINUATION
IN
FORCE, INCLUDING
PROHIBI-
TION OF RESCISSION,’’ after ‘‘GUARANTEED RE-
NEWABILITY’’; 
(2) in subsection (a), by inserting ‘‘, including 
without rescission,’’ after ‘‘continue in force’’; and 
(3) in subsection (b)(2), by inserting before the 
period at the end the following: ‘‘, including inten-
tional concealment of material facts regarding a 
health condition related to the condition for which 
coverage is being claimed’’. 
(b) OPPORTUNITY FOR INDEPENDENT, EXTERNAL 
THIRD PARTY REVIEW IN CERTAIN CASES.—Subpart 1 
of part B of title XXVII of the Public Health Service Act 
is amended by adding at the end the following new section: 
‘‘SEC. 2746. OPPORTUNITY FOR INDEPENDENT, EXTERNAL 
THIRD PARTY REVIEW IN CERTAIN CASES. 
‘‘(a) NOTICE AND REVIEW RIGHT.—If a health in-
surance issuer determines to nonrenew or not continue in 
force, including rescind, health insurance coverage for an 
individual in the individual market on the basis described 
in section 2742(b)(2) before such nonrenewal, discontinu-
ation, or rescission, may take effect the issuer shall pro-
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vide the individual with notice of such proposed non-
renewal, discontinuation, or rescission and an opportunity 
for a review of such determination by an independent, ex-
ternal third party under procedures specified by the Sec-
retary. 
‘‘(b) INDEPENDENT DETERMINATION.—If the indi-
vidual requests such review by an independent, external 
third party of a nonrenewal, discontinuation, or rescission 
of health insurance coverage, the coverage shall remain in 
effect until such third party determines that the coverage 
may be nonrenewed, discontinued, or rescinded under sec-
tion 2742(b)(2).’’. 
(c) EFFECTIVE DATE.—The amendments made by 
this section shall apply after the date of the enactment 
of this Act with respect to health insurance coverage 
issued before, on, or after such date. 
Æ 
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