I
105TH CONGRESS
1ST SESSION
H. R. 164
To amend the Public Health Service Act and Employee Retirement Income
Security Act of 1974 to require that group and individual health insur-
ance coverage and group health plans provide coverage for reconstructive
breast surgery if they provide coverage for mastectomies.
IN THE HOUSE OF REPRESENTATIVES
JANUARY 7, 1997
Ms. ESHOO (for herself, Ms. DELAURO, Mr. MCGOVERN, Mr. TOWNS, Mrs.
MINK of Hawaii, Ms. SLAUGHTER, and Mr. FROST) introduced the fol-
lowing bill; which was referred to the Committee on Commerce, and in
addition to the Committee on Education and the Workforce, for a period
to be subsequently determined by the Speaker, in each case for consider-
ation of such provisions as fall within the jurisdiction of the committee
concerned
A BILL
To amend the Public Health Service Act and Employee Re-
tirement Income Security Act of 1974 to require that
group and individual health insurance coverage and
group health plans provide coverage for reconstructive
breast surgery if they provide coverage for mastectomies.
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 ‘‘Reconstructive Breast
Surgery Benefits Act of 1997’’.
SEC. 2. COVERAGE OF RECONSTRUCTIVE BREAST SUR-
GERY.
(a) GROUP HEALTH PLANS.—
(1) PUBLIC
HEALTH
SERVICE
ACT
AMEND-
MENTS.—(A) Subpart 2 of part A of title XXVII of
the Public Health Service Act, as amended by sec-
tion 703(a) of Public Law 104–204, is amended by
adding at the end the following new section:
‘‘SEC. 2706. STANDARDS RELATING TO BENEFITS FOR RE-
CONSTRUCTIVE BREAST SURGERY.
‘‘(a) REQUIREMENTS FOR RECONSTRUCTIVE BREAST
SURGERY.—
‘‘(1) IN GENERAL.—A group health plan, and a
health insurance issuer offering group health insur-
ance coverage, that provides coverage for breast sur-
gery in connection with a mastectomy shall provide
coverage for reconstructive breast surgery resulting
from the mastectomy. Such coverage shall include
coverage for all stages of reconstructive breast sur-
gery performed on a nondiseased breast to establish
symmetry with the diseased when reconstruction on
the diseased breast is performed.
‘‘(2) RECONSTRUCTIVE BREAST SURGERY DE-
FINED.—In this section, the term ‘reconstructive
breast surgery’ means surgery performed as a result
of a mastectomy to reestablish symmetry between
Public Law 104–204, is amended by striking ‘‘sec-
tion 2704’’ and inserting ‘‘sections 2704 and 2706’’.
(2) ERISA AMENDMENTS.—(A) Subpart B of
part 7 of subtitle B of title I of the Employee Re-
tirement Income Security Act of 1974, as amended
by section 702(a) of Public Law 104–204, is amend-
ed by adding at the end the following new section:
‘‘SEC. 713. STANDARDS RELATING TO BENEFITS FOR RE-
CONSTRUCTIVE BREAST SURGERY.
‘‘(a) REQUIREMENTS FOR RECONSTRUCTIVE BREAST
SURGERY.—
‘‘(1) IN GENERAL.—A group health plan, and a
health insurance issuer offering group health insur-
ance coverage, that provides coverage for breast sur-
gery in connection with a mastectomy shall provide
coverage for reconstructive breast surgery resulting
from the mastectomy. Such coverage shall include
coverage for all stages of reconstructive breast sur-
gery performed on a nondiseased breast to establish
symmetry with the diseased when reconstruction on
the diseased breast is performed.
‘‘(2) RECONSTRUCTIVE BREAST SURGERY DE-
FINED.—In this section, the term ‘reconstructive
breast surgery’ means surgery performed as a result
of a mastectomy to reestablish symmetry between
two 
breasts, 
and 
includes 
augmentation
mammoplasty, 
reduction 
mammoplasty, 
and
mastopexy.
‘‘(3) MASTECTOMY DEFINED.—In this section,
the term ‘mastectomy’ means the surgical removal of
all or part of a breast.
‘‘(b) PROHIBITIONS.—A group health plan, and a
health insurance issuer offering group health insurance
coverage in connection with a group health plan, may
not—
‘‘(1) deny coverage described in subsection
(a)(1) on the basis that the coverage is for cosmetic
surgery;
‘‘(2) deny to a woman eligibility, or continued
eligibility, to enroll or to renew coverage under the
terms of the plan, solely for the purpose of avoiding
the requirements of this section;
‘‘(3) provide monetary payments or rebates to
women to encourage such women to accept less than
the minimum protections available under this sec-
tion;
‘‘(4) penalize or otherwise reduce or limit the
reimbursement of an attending provider because
such provider provided care to an individual partici-
pant or beneficiary in accordance with this section;
or
‘‘(5) provide incentives (monetary or otherwise)
to an attending provider to induce such provider to
provide care to an individual participant or bene-
ficiary in a manner inconsistent with this section.
‘‘(c) RULES OF CONSTRUCTION.—
‘‘(1) Nothing in this section shall be construed
to require a woman who is a participant or bene-
ficiary to undergo reconstructive breast surgery.
‘‘(2) This section shall not apply with respect to
any group health plan, or any group health insur-
ance coverage offered by a health insurance issuer,
which does not provide benefits for mastectomies.
‘‘(3) Nothing in this section shall be construed
as preventing a group health plan or issuer from im-
posing deductibles, coinsurance, or other cost-shar-
ing in relation to benefits for reconstructive breast
surgery under the plan (or under health insurance
coverage offered in connection with a group health
plan), except that such coinsurance or other cost-
sharing for any portion may not be greater than
such coinsurance or cost-sharing that is otherwise
applicable with respect to benefits for mastectomies.
‘‘(d) NOTICE UNDER GROUP HEALTH PLAN.—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.
‘‘(e) LEVEL
AND TYPE
OF REIMBURSEMENTS.—
Nothing in this section shall be construed to prevent a
group health plan or a health insurance issuer offering
group health insurance coverage from negotiating the level
and type of reimbursement with a provider for care pro-
vided in accordance with this section.
‘‘(f) PREEMPTION; EXCEPTION FOR HEALTH INSUR-
ANCE COVERAGE IN CERTAIN STATES.—
‘‘(1) IN GENERAL.—The requirements of this
section shall not apply with respect to health insur-
ance coverage if there is a State law (as defined in
section 731(d)(1)) for a State that regulates such
coverage and that requires coverage of at least the
coverage of reconstructive breast surgery otherwise
required under this section.
‘‘(2) CONSTRUCTION.—Section 731(a)(1) shall
not be construed as superseding a State law de-
scribed in paragraph (1).’’.
(B) Section 731(c) of such Act (29 U.S.C.
1191(c)), as amended by section 603(b)(1) of Public
Law 104–204, is amended by striking ‘‘section 711’’
and inserting ‘‘sections 711 and 713’’.
(C) Section 732(a) of such Act (29 U.S.C.
1191a(a)), as amended by section 603(b)(2) of Pub-
lic Law 104–204, is amended by striking ‘‘section
711’’ and inserting ‘‘sections 711 and 713’’.
(D) The table of contents in section 1 of such
Act is amended by inserting after the item relating
to section 712 the following new item:
‘‘Sec. 713. Standards relating to benefits for reconstructive breast surgery.’’.
(b) INDIVIDUAL HEALTH INSURANCE.—(1) Part B
of title XXVII of the Public Health Service Act, as amend-
ed by section 605(a) of Public Law 104–204, is amended
by inserting after section 2751 the following new section:
‘‘SEC. 2752. STANDARDS RELATING TO BENEFITS FOR RE-
CONSTRUCTIVE BREAST SURGERY.
‘‘(a) IN GENERAL.—The provisions of section 2706
(other than subsection (d)) shall apply to health insurance
coverage offered by a health insurance issuer in the indi-
vidual market in the same manner as it applies 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) NOTICE.—A health insurance issuer under this
part shall comply with the notice requirement under sec-
tion 713(d) 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) PREEMPTION; EXCEPTION FOR HEALTH INSUR-
ANCE COVERAGE IN CERTAIN STATES.—
‘‘(1) IN GENERAL.—The requirements of this
section shall not apply with respect to health insur-
ance coverage if there is a State law (as defined in
section 2723(d)(1)) for a State that regulates such
coverage and that requires coverage of at least the
coverage of reconstructive breast surgery otherwise
required under this section.
‘‘(2) CONSTRUCTION.—Section 2762(a) shall
not be construed as superseding a State law de-
scribed in paragraph (1).’’.
(2) Section 2762(b)(2) of such Act (42 U.S.C.
300gg–62(b)(2)), as added by section 605(b)(3)(B) of
Public Law 104–204, is amended by striking ‘‘section
2751’’ and inserting ‘‘sections 2751 and 2752’’.
(c) EFFECTIVE DATES.—(1) The amendments made
by subsection (a) shall apply with respect to group health
plans for plan years beginning on or after January 1,
1998.
(2) The amendment made by subsection (b) shall
apply with respect to health insurance coverage offered,
sold, issued, renewed, in effect, or operated in the individ-
ual market on or after such date.
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