S AMDT 1235

S 1235 IS

To amend the Public Health Service Act, the Employee Retirement Income Security Act of 1974, and the Internal Revenue Code of 1986 to require that group and individual health insurance coverage and group health plans provide coverage for treatment of a minor child’s congenital or developmental deformity or disorder due to trauma, infection, tumor, or disease.

June 11, 2009

Ms. LANDRIEU (for herself, Mr. COCHRAN, Mr. SPECTER, and Mr. BAYH) introduced the following bill; which was read twice and referred to the Committee on Health, Education, Labor, and Pensions

To amend the Public Health Service Act, the Employee Retirement Income Security Act of 1974, and the Internal Revenue Code of 1986 to require that group and individual health insurance coverage and group health plans provide coverage for treatment of a minor child’s congenital or developmental deformity or disorder due to trauma, infection, tumor, or disease.

Be it enacted by the Senate and House of Representatives of the United States of America in Congress assembled,

SECTION 1. SHORT TITLE.

This Act may be cited as the ‘Children’s Access to Reconstructive Evaluation & Surgery (CARES) Act of 2009’.

SEC. 2. COVERAGE OF MINOR CHILD’S CONGENITAL OR DEVELOPMENTAL DEFORMITY OR DISORDER.

(a) Group Health Plans-

(1) PUBLIC HEALTH SERVICE ACT AMENDMENTS- (A) 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. 2708. STANDARDS RELATING TO BENEFITS FOR MINOR CHILD’S CONGENITAL OR DEVELOPMENTAL DEFORMITY OR DISORDER.

‘(a) Requirements for Reconstructive Surgery-

‘(1) IN GENERAL- A group health plan, and a health insurance issuer offering group health insurance coverage, that provides coverage for surgical benefits shall provide coverage for outpatient and inpatient diagnosis and treatment of a minor child’s congenital or developmental deformity, disease, or injury. A minor child shall include any individual through 21 years of age.

‘(2) REQUIREMENTS- Any coverage provided under paragraph (1) shall be subject to pre-authorization or pre-certification as required by the plan or issuer, and such coverage shall include any surgical treatment which, in the opinion of the treating physician, is medically necessary to approximate a normal appearance.

‘(3) TREATMENT DEFINED-

‘(A) IN GENERAL- In this section, the term ‘treatment’ includes reconstructive surgical procedures (procedures that are generally performed to improve function, but may also be performed to approximate a normal appearance) that are performed on abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease, including--

‘(i) procedures that do not materially affect the function of the body part being treated; and

‘(ii) procedures for secondary conditions and follow-up treatment.

‘(B) EXCEPTION- Such term does not include cosmetic surgery performed to reshape normal structures of the body to improve appearance or self-esteem.

‘(b) Notice- A group health plan under this part shall comply with the notice requirement under section 714(b) 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.’.

(B) Section 2723(c) of such Act (42 U.S.C. 300gg-23(c)) is amended by striking ‘section 2704’ and inserting ‘sections 2704 and 2708’.

(2) ERISA AMENDMENTS- (A) 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. 715. STANDARDS RELATING TO BENEFITS FOR MINOR CHILD’S CONGENITAL OR DEVELOPMENTAL DEFORMITY OR DISORDER.

‘(a) Requirements for Reconstructive Surgery-

‘(1) IN GENERAL- A group health plan, and a health insurance issuer offering group health insurance coverage, that provides coverage for surgical benefits shall provide coverage for outpatient and inpatient diagnosis and treatment of a minor child’s congenital or developmental deformity, disease, or injury. A minor child shall include any individual who has not attained age 22.

‘(2) REQUIREMENTS- Any coverage provided under paragraph (1) shall be subject to pre-authorization or pre-certification as required by the plan or issuer, and such coverage shall include any surgical treatment which, in the opinion of the treating physician, is medically necessary to approximate a normal appearance.

‘(3) TREATMENT DEFINED-

‘(A) IN GENERAL- For purposes of this section, the term ‘treatment’ includes reconstructive surgical procedures (procedures that are generally performed to improve function, but may also be performed to approximate a normal appearance) that are performed on abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease, including--

‘(i) procedures that do not materially affect the function of the body part being treated; and

‘(ii) procedures for secondary conditions and follow-up treatment.

‘(B) EXCEPTION- Such term does not include cosmetic surgery performed to reshape normal structures of the body to improve appearance or self-esteem.

‘(b) 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 the last sentence of section 102(a), for purposes of assuring notice of such requirements under the plan; except that the summary description required to be provided under the fourth 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.’.

(B) Section 731(c) of such Act (29 U.S.C. 1191(c)) is amended by striking ‘section 711’ and inserting ‘sections 711 and 715’.

(C) Section 732(a) of such Act (29 U.S.C. 1191a(a)) is amended by striking ‘section 711’ and inserting ‘sections 711 and 715’.

(D) The table of contents in section 1 of such Act is amended by inserting after the item relating to section 714 the following new item:

‘Sec. 715. Standards relating to benefits for minor child’s congenital or developmental deformity or disorder.’.

(3) INTERNAL REVENUE CODE AMENDMENTS-

(A) IN GENERAL- Subchapter B of chapter 100 of the Internal Revenue Code of 1986 is amended by adding at the end the following new section:

‘SEC. 9813. STANDARDS RELATING TO BENEFITS FOR MINOR CHILD’S CONGENITAL OR DEVELOPMENTAL DEFORMITY OR DISORDER.

‘(a) Requirements for Reconstructive Surgery-

‘(1) IN GENERAL- A group health plan, and a health insurance issuer offering group health insurance coverage, that provides coverage for surgical benefits shall provide coverage for outpatient and inpatient diagnosis and treatment of a minor child’s congenital or developmental deformity, disease, or injury. A minor child shall include any individual who has not attained age 22.

‘(2) REQUIREMENTS- Any coverage provided under paragraph (1) shall be subject to pre-authorization or pre-certification as required by the plan or issuer, and such coverage shall include any surgical treatment which, in the opinion of the treating physician, is medically necessary to approximate a normal appearance.

‘(3) TREATMENT DEFINED-

‘(A) IN GENERAL- For purposes of this section, the term ‘treatment’ includes reconstructive surgical procedures (procedures that are generally performed to improve function, but may also be performed to approximate a normal appearance) that are performed on abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease, including--

‘(i) procedures that do not materially affect the function of the body part being treated; and

‘(ii) procedures for secondary conditions and follow-up treatment.

‘(B) EXCEPTION- Such term does not include cosmetic surgery performed to reshape normal structures of the body to improve appearance or self-esteem.’.

(B) CLERICAL AMENDMENT- The table of sections for such subchapter is amended by adding at the end the following new item:

‘Sec. 9813. Standards relating to benefits for minor child’s congenital or developmental deformity or disorder.’.

(b) Individual Health Insurance- (1) Part B of title XXVII of the Public Health Service Act is amended by inserting after section 2752 the following new section:

‘SEC. 2754. STANDARDS RELATING TO BENEFITS FOR MINOR CHILD’S CONGENITAL OR DEVELOPMENTAL DEFORMITY OR DISORDER.

Full Text of Legislation