ated in the individual market on or after the date of enact-
ment 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 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 
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— 
VerDate Nov 24 2008 
03:56 Mar 25, 2009
Jkt 079200
PO 00000
Frm 00017
Fmt 6652
Sfmt 6201
E:\BILLS\H1691.IH
H1691
rfrederick on PROD1PC67 with BILLS
‘‘(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. 
‘‘(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 
VerDate Nov 24 2008 
03:56 Mar 25, 2009
Jkt 079200
PO 00000
Frm 00018
Fmt 6652
Sfmt 6201
E:\BILLS\H1691.IH
H1691
rfrederick on PROD1PC67 with BILLS
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 
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 
VerDate Nov 24 2008 
03:56 Mar 25, 2009
Jkt 079200
PO 00000
Frm 00019
Fmt 6652
Sfmt 6201
E:\BILLS\H1691.IH
H1691
rfrederick on PROD1PC67 with BILLS
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. 
‘‘(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 
VerDate Nov 24 2008 
03:56 Mar 25, 2009
Jkt 079200
PO 00000
Frm 00020
Fmt 6652
Sfmt 6201
E:\BILLS\H1691.IH
H1691
rfrederick on PROD1PC67 with BILLS
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. 
(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 
VerDate Nov 24 2008 
03:56 Mar 25, 2009
Jkt 079200
PO 00000
Frm 00021
Fmt 6652
Sfmt 6201
E:\BILLS\H1691.IH
H1691
rfrederick on PROD1PC67 with BILLS