Treatment of Children's Deformities Act of 2005 - Amends the Public Health Service Act, the Employee Retirement Income Security Act of 1974 (ERISA), and the Internal Revenue Code to require a group health plan, and a health issuer offering group health insurance coverage, that cover surgical benefits to also cover outpatient and inpatient diagnosis and treatment of a child's congenital or developmental deformity, disease, or injury. Requires that such coverage: (1) be subject to pre-authorization or pre-certification requirements of the plan or issuer; and (2) include any surgical treatment deemed by the treating physician to be medically necessary to approximate a normal appearance. Defines "treatment" to include reconstructive surgical procedures that are performed on abnormal structures of the body caused by congenital defects, abnormalities, trauma, infection, tumors, or disease, including: (1) procedures that do not materially affect the function of the body part being treated; and (2) procedures for secondary conditions and follow-up treatment. Excludes cosmetic surgery performed to reshape normal structures of the body to improve appearance or self-esteem.
[Congressional Bills 109th Congress]
[From the U.S. Government Publishing Office]
[S. 1132 Introduced in Senate (IS)]
109th CONGRESS
1st Session
S. 1132
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.
_______________________________________________________________________
IN THE SENATE OF THE UNITED STATES
May 26, 2005
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
_______________________________________________________________________
A BILL
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 ``Treatment of Children's Deformities
Act of 2005''.
SEC. 2. COVERAGE OF MINOR CHILD'S CONGENITAL OR DEVELOPMENTAL DEFORMITY
OR DISORDER.
(a) Group Health Plans.--
(1) Public health service act amendments.--
(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.
``(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) 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''.
(2) ERISA amendments.--
(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.
``(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 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.''.
(B) Conforming amendments.--
(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''.
(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''.
(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:
``Sec. 714. Standards relating to benefits for minor child's congenital
or developmental deformity or disorder''.
(3) Internal revenue code amendments.--Subchapter B of
chapter 100 of the Internal Revenue Code of 1986 is amended--
(A) in the table of sections, by inserting after
the item relating to section 9812 the following:
``Sec. 9813. Standards relating to benefits for minor child's
congenital or developmental deformity or
disorder'';
and
(B) by inserting after section 9812 the following:
``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 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) Individual Health Insurance.--
(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.
``(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.''.
(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''.
(c) Effective Dates.--
(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.
(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.
(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''.
<all>
Introduced in Senate
Sponsor introductory remarks on measure. (CR S6028)
Read twice and referred to the Committee on Health, Education, Labor, and Pensions. (text of measure as introduced: CR S6028-6029)
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