I 
108TH CONGRESS 
1ST SESSION H. R. 1448
To require that health plans provide coverage for a minimum hospital stay 
for mastectomies and lymph node dissection for the treatment of breast 
cancer and coverage for secondary consultations. 
IN THE HOUSE OF REPRESENTATIVES 
MARCH 26, 2003
Mr. LOBIONDO (for himself, Mrs. MYRICK, Mr. SMITH of New Jersey, Mr. 
PAYNE, Mr. CONYERS, Mr. FROST, Mrs. MCCARTHY of New York, Ms. 
HOOLEY of Oregon, Mr. WYNN, Mrs. JO ANN DAVIS of Virginia, Mr. 
MCINTYRE, Mr. BACA, Mrs. CAPPS, Mr. MCHUGH, Mr. OBERSTAR, and 
Mrs. MALONEY) 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 and lymph node dissection 
for the treatment of breast cancer and coverage for sec-
ondary 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 ‘‘Women’s Cancer Re-
covery Act of 2003’’. 
SEC. 2. 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 is amended by adding at the end the following 
new section:
‘‘SEC. 714. REQUIRED COVERAGE FOR MINIMUM HOSPITAL 
STAY FOR MASTECTOMIES AND LYMPH NODE 
DISSECTIONS 
FOR 
THE 
TREATMENT 
OF 
BREAST CANCER AND COVERAGE FOR SEC-
ONDARY 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 coverage with respect to the sur-
gical treatment of breast cancer (including a mastec-
tomy, lumpectomy, or lymph node dissection for the 
treatment of breast cancer) is provided for a period 
of time as is determined by the attending physician, 
in the physician’s professional judgment consistent 
with generally accepted principles of professional
medical practice, in consultation with the patient, to 
be medically necessary or appropriate. 
‘‘(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 a shorter period of 
hospital stay is medically necessary or 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 REQUIREMENT.—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 require-
ments under the plan; except that the summary descrip-
tion required to be provided under the last sentence of sec-
tion 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 and
shall be made available at the time of initial coverage and 
at any time upon request of a participant or beneficiary. 
‘‘(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 there is a financial rela-
tionship (including an ownership or investment in-
terest or compensation arrangement) between the 
specialist and the attending physician or 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
of breast cancer, that the hospital length of 
stay for such care is left to the decision of (or 
required to be made by) the attending provider 
in consultation with the woman involved. 
‘‘(2) CONSTRUCTION.—Section 731(a)(1) shall 
not be construed as superseding a State law de-
scribed in paragraph (1).’’. 
(b) CONFORMING AMENDMENT.—Section 731(c) of 
such Act (29 U.S.C. 1191(c)) is amended by striking ‘‘sec-
tion 711’’ and inserting ‘‘sections 711 and 714’’. 
(c) CLERICAL AMENDMENT.—The table of contents 
in section 1 of such Act is amended by inserting after the 
item relating to section 713 the following new item:
‘‘Sec. 714. Required coverage for minimum hospital stay for mastectomies and 
lymph node dissections for the treatment of breast cancer and 
coverage for secondary consultations.’’.
(d) 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 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, 2004. 
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. 
SEC. 3. 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 is amended by 
adding at the end the following new section:
‘‘SEC. 2707. REQUIRED COVERAGE FOR MINIMUM HOSPITAL 
STAY FOR MASTECTOMIES AND LYMPH NODE 
DISSECTIONS 
FOR 
THE 
TREATMENT 
OF 
BREAST CANCER AND COVERAGE FOR SEC-
ONDARY 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 coverage with respect to the sur-
gical treatment of breast cancer (including a mastec-
tomy, lumpectomy, or lymph node dissection for the 
treatment of breast cancer) is provided for a period 
of time as is determined by the attending physician, 
in the physician’s professional judgment consistent 
with generally accepted principles of professional 
medical practice, in consultation with the patient, to 
be medically necessary or appropriate. 
‘‘(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 a shorter period of 
hospital stay is medically necessary or 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 REQUIREMENT.—A group health plan 
under this part shall comply with the notice requirement 
under section 714(c) of the Employee Retirement Income 
Security Act of 1974 with respect to the requirements of 
this section as if such section applied to such plan. 
‘‘(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 there is a financial rela-
tionship (including an ownership or investment in-
terest or compensation arrangement) between the 
specialist and the attending physician or 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; 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). 
‘‘(f) EXCEPTION
FOR HEALTH INSURANCE COV-
ERAGE 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) of the Public Health Service Act) 
for a State that regulates such coverage that is de-
scribed in any of the following subparagraphs: 
‘‘(A) Such State law requires such cov-
erage to provide for at least a 48-hour hospital 
length of stay following a mastectomy per-
formed for treatment of breast cancer and at
least a 24-hour hospital length of stay following 
a lymph node dissection for treatment of breast 
cancer. 
‘‘(B) Such State law requires, in connec-
tion with such coverage for surgical treatment 
of breast cancer, that the hospital length of 
stay for such care is left to the decision of (or 
required to be made by) the attending provider 
in consultation with the woman involved. 
‘‘(2) CONSTRUCTION.—Section 2723(a)(1) shall 
not be construed as superseding a State law de-
scribed in paragraph (1).’’. 
(b) CONFORMING AMENDMENT.—Section 2723(c) of 
such Act (42 U.S.C. 300gg–23(c)) is amended by striking 
‘‘section 2704’’ and inserting ‘‘sections 2704 and 2707’’. 
(c) EFFECTIVE DATES.—
(1) IN GENERAL.—The amendments made by 
this section shall apply to group health plans for 
plan years beginning on or 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 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, 2004. 
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. 
SEC. 4. 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 is amended by 
adding at the end the following new section:
‘‘SEC. 2753. REQUIRED COVERAGE FOR MINIMUM HOSPITAL 
STAY FOR MASTECTOMIES AND LYMPH NODE 
DISSECTIONS 
FOR 
THE 
TREATMENT 
OF 
BREAST 
CANCER 
AND 
SECONDARY 
CON-
SULTATIONS. 
‘‘(a) IN GENERAL.—The provisions of section 2707 
(other than subsection (c)) shall apply to health insurance 
coverage offered by a health insurance issuer in the indi-
vidual 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) REQUIREMENT.—A health insurance issuer 
under this part shall comply with the notice requirement 
under section 714(c) of the Employee Retirement Income 
Security Act of 1974 with respect to the requirements re-
ferred to in subsection (a) as if such section applied to 
such issuer and such issuer were a group health plan. 
‘‘(c) EXCEPTION
FOR HEALTH INSURANCE COV-
ERAGE 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) of the Public Health Service Act) 
for a State that regulates such coverage that is de-
scribed in any of the following subparagraphs:
‘‘(A) Such State law requires such cov-
erage to provide for at least a 48-hour hospital 
length of stay following a mastectomy per-
formed for treatment of breast cancer and at 
least a 24-hour hospital length of stay following 
a lymph node dissection for treatment of breast 
cancer. 
‘‘(B) Such State law requires, in connec-
tion with such coverage for surgical treatment 
of breast cancer, that the hospital length of 
stay for such care is left to the decision of (or 
required to be made by) the attending provider 
in consultation with the woman involved. 
‘‘(2) CONSTRUCTION.—Section 2762(a) shall 
not be construed as superseding a State law de-
scribed in paragraph (1).’’. 
(b) CONFORMING AMENDMENT.—Section 2762(b)(2) 
of such Act (42 U.S.C. 300gg–62(b)(2)) is amended by 
striking ‘‘section 2751’’ and inserting ‘‘sections 2751 and 
2753’’. 
(c) EFFECTIVE DATE.—The amendments 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. 5. AMENDMENTS TO THE INTERNAL REVENUE CODE 
OF 1986. 
(a) IN GENERAL.—Subchapter B of chapter 100 of 
the Internal Revenue Code of 1986 (relating to other re-
quirements) is amended by inserting after section 9812 
the following new section:
‘‘SEC. 9813. REQUIRED COVERAGE FOR MINIMUM HOSPITAL 
STAY FOR MASTECTOMIES AND LYMPH NODE 
DISSECTIONS 
FOR 
THE 
TREATMENT 
OF 
BREAST CANCER 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 surgical 
treatment of breast cancer (including a mastectomy, 
lumpectomy, or lymph node dissection for the treat-
ment of breast cancer) is provided for a period of 
time as is determined by the attending physician, in 
the physician’s professional judgment consistent with 
generally accepted principles of professional medical 
practice, in consultation with the patient, to be 
medically necessary or appropriate. 
‘‘(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 a shorter period of 
hospital stay is medically necessary or 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) 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 there is a financial rela-
tionship (including an ownership or investment in-
terest or compensation arrangement) between the 
specialist and the attending physician or where the 
patient determines not to seek such a consultation. 
‘‘(d) 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
is left to the decision of (or required to be made by) 
the attending provider in consultation with the 
woman involved.’’. 
(b) CLERICAL AMENDMENT.—The table of sections 
for such subchapter is amended by adding at the end the 
following new item:
‘‘Sec. 9813. Required coverage for minimum hospital stay for mastectomies 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 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, 2004. 
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. 
SEC. 6. COORDINATION OF ADMINISTRATION. 
The Secretary of Labor, the Secretary of the Treas-
ury, and the Secretary of Health and Human Services 
shall ensure, through the execution of an interagency 
memorandum of understanding among such Secretaries, 
that—
(1) regulations, rulings, and interpretations 
issued by such Secretaries relating to the same mat-
ter over which two or more such Secretaries have re-
sponsibility under the provisions of this Act (and the 
amendments made thereby) are administered so as 
to have the same effect at all times; and 
(2) coordination of policies relating to enforcing 
the same requirements through such Secretaries in 
order to have a coordinated enforcement strategy 
that avoids duplication of enforcement efforts and 
assigns priorities in enforcement.
Æ