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105TH CONGRESS
1ST SESSION
H. R. 616
To require that health plans provide coverage for a minimum hospital stay
for mastectomies and lymph node dissection for the treatment of breast
cancer, coverage for reconstructive surgery following mastectomies, and
coverage for secondary consultations.
IN THE HOUSE OF REPRESENTATIVES
FEBRUARY 5, 1997
Ms. MOLINARI (for herself, Mrs. KELLY, Mr. LOBIONDO, Mr. FLAKE, Mr.
ACKERMAN, Mr. KING, Mrs. MORELLA, Mr. DEAL of Georgia, Mr.
SAXTON, Mr. LAZIO of New York, Mr. SMITH of New Jersey, Mr. FOX
of Pennsylvania, Mr. ANDREWS, Mr. PALLONE, Mr. WALSH, Mr. FROST,
Mr. ENGLISH of Pennsylvania, Mr. WOLF, Mr. MCNULTY, Mrs. ROU-
KEMA, Mr. FORBES, Mr. SMITH of Washington, Mrs. MCCARTHY of New
York, Ms. SLAUGHTER, Mr. PAPPAS, Mr. FILNER, Mr. HORN, Mr. DAVIS
of Virginia, Mr. MARTINEZ, Mr. WELLER, Mr. GUTIERREZ, Ms. DUNN,
Mr. GILMAN, Mr. SANDERS, Mr. FOLEY, Mr. SHAW, Ms. GRANGER, Mr.
GIBBONS, Ms. CHRISTIAN-GREEN, Mr. OLVER, Ms. STABENOW, Mr. LA-
FALCE, and Mr. BILBRAY) introduced the following bill; which was re-
ferred to the Committee on Commerce, and in addition to the Committees
on Ways and Means, and 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 require that health plans provide coverage for a minimum
hospital stay for mastectomies and lymph node dissection
for the treatment of breast cancer, coverage for recon-
structive surgery following mastectomies, and coverage
for secondary consultations.
•HR 616 IH1S
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 Health and
Cancer Rights Act of 1997’’.
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 (as added by section 603(a) of the Newborns’
and Mothers’ Health Protection Act of 1996 and amended
by section 702(a) of the Mental Health Parity Act of
•HR 616 IH1S
1996) is amended by adding at the end the following new
section:
‘‘SEC. 713. 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, 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
treatment of breast cancer is provided for a period
of time as is determined by the attending physician,
in consultation with the patient, to be medically ap-
propriate following—
‘‘(A) a mastectomy;
‘‘(B) a lumpectomy; or
‘‘(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
•HR 616 IH1S
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, and a health insurance issuer providing health insur-
ance coverage in connection with a group health plan, that
provides medical and surgical benefits with respect to a
mastectomy shall ensure that, in a case in which a mastec-
tomy patient elects breast reconstruction, coverage is pro-
vided 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, 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) or (b).
•HR 616 IH1S
‘‘(d) 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;
‘‘(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, 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-
•HR 616 IH1S
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.
‘‘(f) PROHIBITION ON PENALTIES OR INCENTIVES.—
A group health plan, and a health insurance issuer provid-
ing health insurance coverage in connection with a group
health plan, may not—
•HR 616 IH1S
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 (as added by sec-
tion 604(a) of the Newborns’ and Mothers’ Health Protec-
tion Act of 1996 and amended by section 703(a) of the
Mental Health Parity Act of 1996) is amended by adding
at the end the following new section:
‘‘SEC. 2706. REQUIRED COVERAGE FOR MINIMUM HOSPITAL
STAY FOR MASTECTOMIES AND LYMPH NODE
DISSECTIONS 
FOR 
THE 
TREATMENT 
OF
BREAST CANCER, COVERAGE FOR RECON-
STRUCTION 
SURGERY 
FOLLOWING
MASTECTOMIES, 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
treatment of breast cancer is provided for a period
of time as is determined by the attending physician,
in consultation with the patient, to be medically ap-
propriate following—
‘‘(A) a mastectomy;
•HR 616 IH1S
‘‘(B) a lumpectomy; or
‘‘(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, and a health insurance issuer providing health insur-
ance coverage in connection with a group health plan, that
provides medical and surgical benefits with respect to a
mastectomy shall ensure that, in a case in which a mastec-
tomy patient elects breast reconstruction, coverage is pro-
vided 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, and a health insurance issuer providing health
•HR 616 IH1S
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) or (b).
‘‘(d) 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;
‘‘(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, 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-
•HR 616 IH1S
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-
•HR 616 IH1S
ondary consultations where the patient determines
not to seek such a consultation.
‘‘(f) PROHIBITION ON PENALTIES OR INCENTIVES.—
A group health plan, and a health insurance issuer provid-
ing 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 (e).’’.
(b) EFFECTIVE DATES.—
•HR 616 IH1S
(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 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.