I 
109TH CONGRESS 
1ST SESSION H. R. 1849 
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 
APRIL 26, 2005 
Mrs. KELLY (for herself, Ms. DELAURO, Mr. THOMPSON of California, Mrs. 
MALONEY, Mr. SERRANO, Mr. LYNCH, Mr. PLATTS, Ms. WOOLSEY, Mr. 
MCHUGH, Mr. VAN HOLLEN, Ms. SLAUGHTER, Mr. HALL, Mr. CROW-
LEY, Mr. WEINER, Mr. KIND, Mr. SCHIFF, Mr. TAYLOR of Mississippi, 
Ms. SCHAKOWSKY, Mr. LANTOS, Mr. STRICKLAND, Ms. VELA´ZQUEZ, Mr. 
OBERSTAR, Ms. KILPATRICK of Michigan, Mrs. TAUSCHER, Mr. HIN-
CHEY, Mr. HOLDEN, Mr. MCNULTY, Mr. BACA, Mr. DEFAZIO, Ms. ROY-
BAL-ALLARD, Mr. SPRATT, Ms. ESHOO, Mr. GEORGE MILLER of Cali-
fornia, Mr. DICKS, Mr. HOLT, Mr. REYES, Mr. BISHOP of New York, Mr. 
ALLEN, Mr. WATT, Mr. PAYNE, Mr. OLVER, Mr. TOWNS, Mr. MCIN-
TYRE, Mr. COOPER, Mr. FORD, Mr. KENNEDY of Rhode Island, Mr. 
MARKEY, Ms. MILLENDER-MCDONALD, Mr. BROWN
of Ohio, Mr. 
KUCINICH, Mr. MCGOVERN, Mrs. MCCARTHY, Mr. EMANUEL, Mr. FIL-
NER, Ms. HARMAN, Mr. ABERCROMBIE, Mr. SMITH of Washington, Mr. 
AL GREEN of Texas, Mrs. CHRISTENSEN, Mr. BERRY, Mr. WEXLER, Mr. 
MCDERMOTT, Mr. SCOTT of Virginia, Mr. JACKSON of Illinois, Mr. BOU-
CHER, Mr. PALLONE, Mr. NADLER, Mr. KILDEE, Mr. OWENS, Mr. 
WYNN, Mr. LANGEVIN, Mr. SHERMAN, Mr. PASTOR, Mr. TIERNEY, Mr. 
STUPAK, Ms. EDDIE BERNICE JOHNSON of Texas, Mr. MILLER of North 
Carolina, Ms. MCCOLLUM of Minnesota, Mr. HINOJOSA, Ms. DEGETTE, 
Mr. SANDERS, Mr. CHANDLER, Mr. MEEHAN, Ms. BORDALLO, Mr. 
LARSEN of Washington, Mr. DOYLE, Mr. LEWIS of Georgia, Mr. CON-
YERS, Ms. BALDWIN, Mrs. LOWEY, Mr. UDALL of Colorado, Mr. CLAY, 
Mr. LARSON of Connecticut, Mr. BURTON of Indiana, Mr. JEFFERSON, 
Mr. FATTAH, Mr. GONZALEZ, Mr. INSLEE, Ms. LEE, Mr. RUSH, Mr. 
SIMMONS, Ms. HART, Ms. HOOLEY, Mr. MORAN of Virginia, Ms. NOR-
TON, Ms. SOLIS, Mrs. JO ANN DAVIS of Virginia, Mrs. NAPOLITANO, Mr. 
RYAN of Ohio, Mr. LEVIN, Mr. GUTIERREZ, Mr. BAIRD, Mr. BERMAN, 
and Mr. ROSS) introduced the following bill; which was referred to the 
Committee on Energy and Commerce, and in addition to the Committees 
on Education and the Workforce and Ways and Means, 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 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. 
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 2005’’. 
SEC. 2. FINDINGS. 
Congress finds that— 
(1) the offering and operation of health plans 
affect commerce among the States; 
(2) health care providers located in a State 
serve patients who reside in the State and patients 
who reside in other States; and 
(3) in order to provide for uniform treatment of 
health care providers and patients among the States, 
it is necessary to cover health plans operating in 1 
State as well as health plans operating among the 
several States.
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: 
‘‘SEC. 714. 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) except as provided for in paragraph 
(2)— 
‘‘(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 or the issuer for pre-
scribing any length of stay required under sub-
paragraph (A) (without regard to paragraph 
(2)). 
‘‘(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 either a shorter period 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 any 
literature or correspondence 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 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 
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 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 
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; 
‘‘(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); or 
‘‘(4) deny to a woman eligibility, or continued 
eligibility, to enroll or to renew coverage under the 
terms of the plan or coverage solely for the purpose 
of avoiding the requirements of this section.’’. 
(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 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.’’. 
(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-
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 RELATING TO THE GROUP MARKET. 
(a) IN GENERAL.—Subpart 2 of part A of title 
XXVII of the Public Health Service Act (42 U.S.C. 
300gg–4 et seq.) is amended by adding at the end the 
following: 
‘‘SEC. 2707. 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) except as provided for in paragraph 
(2)— 
‘‘(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 or the issuer for pre-
scribing any length of stay required under sub-
paragraph (A) (without regard to paragraph 
(2)). 
‘‘(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 either a shorter period 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 any 
literature or correspondence 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 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 
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 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 
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; 
‘‘(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); or 
‘‘(4) deny to a woman eligibility, or continued 
eligibility, to enroll or to renew coverage under the 
terms of the plan or coverage solely for the purpose 
of avoiding the requirements of this section.’’. 
(b) EFFECTIVE DATES.— 
(1) IN GENERAL.—The amendments made by 
this section shall apply to group health plans for
plan years beginning on or after 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-
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. 5. AMENDMENT TO THE PUBLIC HEALTH SERVICE ACT 
RELATING TO THE INDIVIDUAL MARKET. 
(a) IN GENERAL.—The first subpart 3 of part B of 
title XXVII of the Public Health Service Act (42 U.S.C. 
300gg–11 et seq.) is amended— 
(1) by adding after section 2752 the following:
‘‘SEC. 2753. REQUIRED COVERAGE FOR MINIMUM HOSPITAL 
STAY FOR MASTECTOMIES, LUMPECTOMIES, 
AND LYMPH NODE DISSECTIONS FOR THE 
TREATMENT OF BREAST CANCER AND SEC-
ONDARY CONSULTATIONS. 
‘‘The provisions of section 2707 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.’’; and 
(2) by redesignating such subpart 3 as subpart 
2. 
(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. 
SEC. 6. 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 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.’’;
and 
(2) by inserting after section 9812 the fol-
lowing: 
‘‘SEC. 9813. 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— 
‘‘(A) except as provided for in paragraph 
(2)— 
‘‘(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 subparagraph (A) (with-
out regard to paragraph (2)). 
‘‘(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 either a shorter period 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 
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 
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; 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 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 
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 
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; 
‘‘(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); or 
‘‘(4) 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.’’. 
(b) CLERICAL AMENDMENT.—The table of contents 
for chapter 100 of such Code is amended by inserting after 
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.’’. 
(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 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 
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-