S 1132 IS
Mr. COLEMAN (for himself, Ms. LANDRIEU, Mr. DEWINE, Ms. SNOWE, Mr. COCHRAN, Mr. VITTER, Mr. BAYH, and Mr. SMITH) introduced the following bill; which was read twice and referred to the Committee on Health, Education, Labor, and Pensions
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Be it enacted by the Senate and House of Representatives
of the United States of America in Congress assembled,
SECTION 1. SHORT TITLE.
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This Act may be cited as the `Treatment of Children's
Deformities Act of 2005'.
SEC. 2. COVERAGE OF MINOR CHILD'S CONGENITAL OR DEVELOPMENTAL DEFORMITY OR DISORDER.
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(a) Group Health Plans-
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(1) PUBLIC HEALTH SERVICE ACT AMENDMENTS-
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(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. STANDARDS RELATING TO BENEFITS FOR MINOR CHILD'S CONGENITAL OR DEVELOPMENTAL DEFORMITY OR DISORDER.
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`(a) Requirements for Reconstructive Surgery-
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`(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.
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`(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.
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`(3) TREATMENT DEFINED-
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`(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--
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`(i) procedures that do not materially affect
the function of the body part being treated; and
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`(ii) procedures for secondary conditions and
follow-up treatment.
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`(B) EXCEPTION- Such term does not include cosmetic
surgery performed to reshape normal structures of
the body to improve appearance or self-esteem.
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`(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.'.
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(B) CONFORMING AMENDMENT- Section 2723(c) of the
Public Health Service Act (42 U.S.C. 300gg-23(c)) is
amended by striking `section 2704' and inserting
`sections 2704 and 2707'.
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(2) ERISA AMENDMENTS-
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(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
adding at the end the following:
`SEC. 714. STANDARDS RELATING TO BENEFITS FOR MINOR CHILD'S CONGENITAL OR DEVELOPMENTAL DEFORMITY OR DISORDER.
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`(a) Requirements for Reconstructive Surgery-
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`(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.
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`(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.
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`(3) TREATMENT DEFINED-
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`(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--
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`(i) procedures that do not materially affect
the function of the body part being treated; and
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`(ii) procedures for secondary conditions and
follow-up treatment.
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`(B) EXCEPTION- Such term does not include cosmetic
surgery performed to reshape normal structures of
the body to improve appearance or self-esteem.
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`(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 section
102(a)(1), for purposes of assuring notice of such
requirements under the plan; except that the summary
description required to be provided under the last 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.'.
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(B) CONFORMING AMENDMENTS-
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(i) Section 731(c) of the Employee Retirement
Income Security Act of 1974 (29 U.S.C. 1191(c))
is amended by striking `section 711' and
inserting `sections 711 and 714'.
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(ii) Section 732(a) of the Employee Retirement
Income Security Act of 1974 (29 U.S.C. 1191a(a))
is amended by striking `section 711' and
inserting `sections 711 and 714'.
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(iii) The table of contents in section 1 of the
Employee Retirement Income Security Act of 1974
is amended by inserting after the item relating
to section 713 the following:
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`Sec. 714. Standards relating to benefits for minor
child's congenital or developmental deformity or
disorder'.
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(3) INTERNAL REVENUE CODE AMENDMENTS- Subchapter B of
chapter 100 of the Internal Revenue Code of 1986 is
amended--
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(A) in the table of sections, by inserting after the
item relating to section 9812 the following:
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`Sec. 9813. Standards relating to benefits for minor
child's congenital or developmental deformity or
disorder';
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and
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(B) by inserting after section 9812 the following:
`SEC. 9813. STANDARDS RELATING TO BENEFITS FOR MINOR CHILD'S CONGENITAL OR DEVELOPMENTAL DEFORMITY OR DISORDER.
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`(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.'.
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(b) Individual Health Insurance-
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(1) IN GENERAL- Part B of title XXVII of the Public
Health Service Act is amended by inserting after section
2752 the following:
`SEC. 2753. STANDARDS RELATING TO BENEFITS FOR MINOR CHILD'S CONGENITAL OR DEVELOPMENTAL DEFORMITY OR DISORDER.
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`(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 health insurance issuer 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 referred to in subsection (a) as
if such section applied to such issuer and such issuer were
a group health plan.'.
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(2) CONFORMING AMENDMENT- Section 2762(b)(2) of the
Public Health Service Act (42 U.S.C. 300gg-62(b)(2)) is
amended by striking `section 2751' and inserting
`sections 2751 and 2753'.
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(c) Effective Dates-
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(1) GROUP HEALTH COVERAGE- The amendments made by
subsection (a) shall apply with respect to group health
plans for plan years beginning on or after January 1,
2006.
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(2) INDIVIDUAL HEALTH COVERAGE- The amendment made by
subsection (b) shall apply with respect to health
insurance coverage offered, sold, issued, renewed, in
effect, or operated in the individual market on or after
such date.
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(d) Coordinated Regulations- Section 104(1) of Health
Insurance Portability and Accountability Act of 1996 (42
U.S.C. 300gg-92 note) is amended by striking `this subtitle
(and the amendments made by this subtitle and section 401)'
and inserting `the provisions of part 7 of subtitle B of
title I of the Employee Retirement Income Security Act of
1974, the provisions of parts A and C of title XXVII of the
Public Health Service Act, and chapter 100 of the Internal
Revenue Code of 1986'.