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SEC. 5. 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 (as added by sec-
tion 605(a) of the Newborn’s and Mother’s Health Protec-
tion Act of 1996) is amended by adding at the end the
following new section:
‘‘SEC. 2752. REQUIRED COVERAGE FOR MINIMUM HOSPITAL
STAY FOR MASTECTOMIES AND LYMPH NODE
DISSECTIONS 
FOR 
THE 
TREATMENT 
OF
BREAST 
CANCER 
AND 
SECONDARY 
CON-
SULTATIONS.
‘‘The provisions of section 2706 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) EFFECTIVE DATE.—The amendment made by
this section shall apply with respect to health insurance
coverage offered, sold, issued, renewed, in effect, or oper-
ated in the individual market on or after the date of enact-
ment of this Act.
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SEC. 6. AMENDMENTS TO THE INTERNAL REVENUE CODE
OF 1986.
(a) IN GENERAL.—Chapter 100 of the Internal Reve-
nue Code of 1986 (relating to group health plan port-
ability, access, and renewability requirements) is amended
by redesignating sections 9804, 9805, and 9806 as sec-
tions 9805, 9806, and 9807, respectively, and by inserting
after section 9803 the following new section:
‘‘SEC. 9804. REQUIRED COVERAGE FOR MINIMUM HOSPITAL
STAY FOR MASTECTOMIES AND LYMPH NODE
DISSECTIONS 
FOR 
THE 
TREATMENT 
OF
BREAST CANCER, COVERAGE FOR RECON-
STRUCTIVE 
SURGERY 
FOLLOWING
MASTECTOMIES, AND COVERAGE FOR SEC-
ONDARY 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 treatment
of breast cancer is provided for a period of time as
is determined by the attending physician, in con-
sultation with the patient, to be medically appro-
priate following—
‘‘(A) a mastectomy;
‘‘(B) a lumpectomy; or
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‘‘(C) a lymph node dissection for the treat-
ment of breast cancer.
‘‘(2) EXCEPTION.—Nothing in this section shall
be construed as requiring the provision of inpatient
coverage if the attending physician and patient de-
termine that a shorter period of hospital stay is
medically appropriate.
‘‘(b) RECONSTRUCTIVE SURGERY.—A group health
plan that provides medical and surgical benefits with re-
spect to a mastectomy shall ensure that, in a case in which
a mastectomy patient elects breast reconstruction, cov-
erage is provided for—
‘‘(1) all stages of reconstruction of the breast
on which the mastectomy has been performed; and
‘‘(2) surgery and reconstruction of the other
breast to produce a symmetrical appearance;
in the manner determined by the attending physician and
the patient to be appropriate, and consistent with any fee
schedule contained in the plan.
‘‘(c) 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) or (b).
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‘‘(d) 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
any literature or correspondence made available or distrib-
uted by the plan and shall be transmitted—
‘‘(1) in the next mailing made by the plan to
the participant or beneficiary;
‘‘(2) as part of any yearly informational packet
sent to the participant or beneficiary; or
‘‘(3) not later than January 1, 1998;
whichever is earlier.
‘‘(e) 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 full cov-
erage is provided for secondary 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 full coverage is provided for such secondary
consultation whether such consultation is based on a
positive or negative initial diagnosis. In any case in
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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.
‘‘(f) 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
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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 involved under sub-
section (e).’’.
(b) CONFORMING AMENDMENTS.—
(1) Sections 9801(c)(1), 9805(b) (as redesig-
nated by subsection (a)), 9805(c) (as so redesig-
nated), 4980D(c)(3)(B)(i)(I), 4980D(d)(3), and
4980D(f)(1) of such Code are each amended by
striking ‘‘9805’’ each place it appears and inserting
‘‘9806’’.
(2) The heading for subtitle K of such Code is
amended to read as follows:
‘‘Subtitle K—Group Health Plan
Portability, Access, Renewabil-
ity, and Other Requirements’’.
(3) The heading for chapter 100 of such Code
is amended to read as follows:
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‘‘CHAPTER 100—GROUP HEALTH PLAN PORT-
ABILITY, 
ACCESS, 
RENEWABILITY, 
AND
OTHER REQUIREMENTS’’.
(4) Section 4980D(a) of such Code is amended
by striking ‘‘and renewability’’ and inserting ‘‘renew-
ability, and other’’.
(c) CLERICAL AMENDMENTS.—
(1) The table of contents for chapter 100 of
such Code is amended by redesignating the items re-
lating to sections 9804, 9805, and 9806 as items re-
lating to sections 9805, 9806, and 9807, and by in-
serting after the item relating to section 9803 the
following new item:
‘‘Sec. 9804. Required coverage for minimum hospital stay for mastectomies and
lymph node dissections for the treatment of breast cancer, cov-
erage for reconstructive surgery following mastectomies, and
coverage for secondary consultations.’’.
(2) The item relating to subtitle K in the table
of subtitles for such Code is amended by striking
‘‘and renewability’’ and inserting ‘‘renewability, and
other’’.
(3) The item relating to chapter 100 in the
table of chapters for subtitle K of such Code is
amended by striking ‘‘and renewability’’ and insert-
ing ‘‘renewability, and other’’.
(d) EFFECTIVE DATES.—
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(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 BARGAIN-
ING AGREEMENTS.—In the case of a group health
plan maintained pursuant to 1 or more collective
bargaining agreements between employee representa-
tives 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 begin-
ning before the later of—
(A) the date on which the last collective
bargaining agreements relating to the plan ter-
minates (determined without regard to any ex-
tension thereof agreed to after the date of en-
actment of this Act), or
(B) January 1, 1998.
For purposes of subparagraph (A), any plan amend-
ment 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.
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