‘‘(B) require that a provider obtain author-
ization from the plan or the issuer for pre-
scribing any length of stay required under this 
paragraph. 
‘‘(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 either a shorter pe-
riod 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 the 
VerDate Nov 24 2008 
03:56 Mar 25, 2009
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summary of the plan 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 coverage 
is provided for secondary consultations, on terms 
and conditions that are no more restrictive than 
those applicable to the initial 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 coverage is provided for such secondary con-
sultation 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-
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03:56 Mar 25, 2009
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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 
VerDate Nov 24 2008 
03:56 Mar 25, 2009
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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 or coverage in-
volved under subsection (d).’’. 
(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 714 the following: 
‘‘Sec. 715. 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-
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03:56 Mar 25, 2009
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rfrederick on PROD1PC67 with BILLS
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. 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 (42 U.S.C. 
300gg–4 et seq.) is amended by adding at the end the 
following: 
‘‘SEC. 2708. 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.— 
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‘‘(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) insofar as the attending physician, in 
consultation with the patient, determines it to 
be medically necessary— 
‘‘(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 this 
paragraph. 
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‘‘(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 either a shorter pe-
riod 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 the 
summary of the plan 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 
VerDate Nov 24 2008 
03:56 Mar 25, 2009
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rfrederick on PROD1PC67 with BILLS
‘‘(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 coverage 
is provided for secondary consultations, on terms 
and conditions that are no more restrictive than 
those applicable to the initial 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 coverage is provided for such secondary con-
sultation 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-
VerDate Nov 24 2008 
03:56 Mar 25, 2009
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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 
VerDate Nov 24 2008 
03:56 Mar 25, 2009
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PO 00000
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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).’’. 
(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 
VerDate Nov 24 2008 
03:56 Mar 25, 2009
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E:\BILLS\H1691.IH
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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. AMENDMENT TO THE PUBLIC HEALTH SERVICE ACT 
RELATING TO THE INDIVIDUAL MARKET. 
(a) IN GENERAL.—Subpart 2 of part B of title 
XXVII of the Public Health Service Act (42 U.S.C. 
300gg–51 et seq.) is amended by adding at the end the 
following new section: 
‘‘SEC. 2754. 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 2708 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-
VerDate Nov 24 2008 
03:56 Mar 25, 2009
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