Breast Cancer Patient Protect Act of 2013 - Amends the Employee Retirement Income Security Act of 1974 (ERISA), the Public Health Service Act, and the Internal Revenue Code to require a group or individual health plan that provides medical and surgical benefits to ensure that inpatient (and in the case of a lumpectomy, outpatient) coverage and radiation therapy are provided for breast cancer treatment. Prohibits such a plan from: (1) restricting benefits for any hospital length of stay to less than 48 hours in connection with a mastectomy or breast conserving surgery or 24 hours in connection with a lymph node dissection, insofar as the attending physician, in consultation with the patient, determines such stay to be medically necessary; or (2) requiring that a provider obtain authorization from the plan for prescribing any such length of stay.
Requires such a plan to: (1) provide notice to each participant and beneficiary regarding the coverage required under this Act, and (2) ensure that coverage is provided for secondary consultations.
Prohibits a health plan from taking specified actions to avoid the requirements of this Act.
Allows a health insurance issuer that provides individual health insurance coverage to nonrenew or discontinue an individual's coverage based on the intentional concealment of material facts regarding a health condition related to the condition for which coverage is being claimed.
[Congressional Bills 113th Congress]
[From the U.S. Government Publishing Office]
[H.R. 1531 Introduced in House (IH)]
113th CONGRESS
1st Session
H. R. 1531
To require that health plans provide coverage for a minimum hospital
stay for mastectomies, lumpectomies, and lymph node dissection for the
treatment of breast cancer and coverage for secondary consultations.
_______________________________________________________________________
IN THE HOUSE OF REPRESENTATIVES
April 12, 2013
Ms. DeLauro (for herself, Mr. Bishop of Georgia, Ms. Bordallo, Mr.
Braley of Iowa, Ms. Brown of Florida, Mrs. Capps, Mr. Carson of
Indiana, Ms. Castor of Florida, Ms. Chu, Mr. Clay, Mr. Cohen, Mr.
Connolly, Mr. Conyers, Mr. Cooper, Ms. DeGette, Mr. Dingell, Ms.
Edwards, Mr. Ellison, Mr. Engel, Mr. Farr, Ms. Fudge, Mr. Grijalva, Mr.
Hastings of Florida, Mr. Higgins, Mr. Himes, Mr. Holt, Mr. Israel, Ms.
Jackson Lee, Ms. Eddie Bernice Johnson of Texas, Mr. Johnson of
Georgia, Ms. Kaptur, Mr. Langevin, Mr. Larson of Connecticut, Ms. Lee
of California, Mr. Levin, Mr. Lewis, Mr. LoBiondo, Mr. Loebsack, Ms.
Lofgren, Mrs. Lowey, Mrs. Carolyn B. Maloney of New York, Mr. Markey,
Mr. McGovern, Mr. McIntyre, Ms. Moore, Mr. Moran, Mr. Nadler, Mrs.
Napolitano, Mr. Neal, Mr. Pastor of Arizona, Mr. Payne, Ms. Pingree of
Maine, Mr. Price of North Carolina, Mr. Rahall, Mr. Rangel, Ms. Roybal-
Allard, Mr. Ruppersberger, Mr. Rush, Mr. Ryan of Ohio, Mr. Sablan, Ms.
Linda T. Sanchez of California, Mr. Sarbanes, Ms. Schakowsky, Mr.
Schiff, Ms. Schwartz, Mr. David Scott of Georgia, Mr. Serrano, Mr.
Sherman, Ms. Slaughter, Ms. Speier, Ms. Tsongas, Mr. Van Hollen, Ms.
Wasserman Schultz, Ms. Wilson of Florida, and Mr. Young of Alaska)
introduced the following bill; which was referred to the Committee on
Energy and 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 consideration 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, lumpectomies, and lymph node dissection for the
treatment of breast cancer and coverage for secondary consultations.
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 ``Breast Cancer Patient Protection Act
of 2013''.
SEC. 2. FINDINGS.
Congress finds the following:
(1) According to the National Cancer Institute, excluding
cancers of the skin, breast cancer is the most frequently
diagnosed cancer in women.
(2) According to the National Cancer Institute, an
estimated 39,510 women and 410 men died from breast cancer in
2012.
(3) According to the National Cancer Institute, in 2012 an
estimated 226,870 new cases of breast cancer were diagnosed in
women, and an estimated 2,190 breast cancer cases were
diagnosed in men.
(4) According to the American Cancer Society, most breast
cancer patients undergo some type of surgical treatment, which
may involve lumpectomy or mastectomy with removal of some of
the axillary lymph nodes.
(5) The offering and operation of health plans affect
commerce among the States.
(6) Health care providers located in a State serve patients
who reside in the State and patients who reside in other
States.
(7) 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 one State as well as health
plans operating among the several States.
(8) Research has indicated that treatment for breast cancer
varies according to type of insurance coverage and State of
residence.
(9) Breast cancer patients have reported adverse outcomes,
including infection and inadequately controlled pain, resulting
from premature hospital discharge following breast cancer
surgery.
SEC. 3. AMENDMENTS TO THE EMPLOYEE RETIREMENT INCOME 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 (29 U.S.C. 1185 et
seq.) is amended by adding at the end the following:
``SEC. 716. REQUIRED COVERAGE FOR MINIMUM HOSPITAL STAY FOR
MASTECTOMIES, LUMPECTOMIES, AND LYMPH NODE DISSECTIONS
FOR THE TREATMENT OF BREAST CANCER AND COVERAGE FOR
SECONDARY 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 ensure 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 mastectomy
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 authorization
from the plan or the issuer for prescribing 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 period 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 insurance issuer
providing health insurance coverage in connection with a group health
plan, shall provide notice to each participant and beneficiary under
such plan regarding the coverage required by this section in accordance
with regulations promulgated by the Secretary. Such notice 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
``(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 specialists in the
appropriate medical fields (including pathology, radiology, and
oncology) to confirm or refute such diagnosis. Such plan or
issuer shall ensure that 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 consultation are not
sufficiently available from specialists 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 ensure 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 secondary 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 providing 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 participant 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 patients 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 involved 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 relating to section 715 the following:
``Sec. 716. 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 beginning on or after the date
that is 90 days after the date of enactment of this Act.
(2) Special rule for collective bargaining agreements.--In
the case of a group health plan maintained pursuant to 1 or
more collective bargaining agreements between employee
representatives 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 terminates (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. 4. AMENDMENTS TO THE PUBLIC HEALTH SERVICE ACT.
(a) In General.--Title XXVII of the Public Health Service Act is
amended by inserting after section 2728 of such Act (42 U.S.C. 300gg-
28), as redesignated by section 1001(2) of the Patient Protection and
Affordable Care Act (Public Law 111-148), the following:
``SEC. 2729. REQUIRED COVERAGE FOR MINIMUM HOSPITAL STAY FOR
MASTECTOMIES, LUMPECTOMIES, AND LYMPH NODE DISSECTIONS
FOR THE TREATMENT OF BREAST CANCER AND COVERAGE FOR
SECONDARY CONSULTATIONS.
``(a) Inpatient Care.--
``(1) In general.--A group health plan, and a health
insurance issuer providing group or individual health insurance
coverage, that provides medical and surgical benefits shall
ensure 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 mastectomy
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 authorization
from the plan or the issuer for prescribing 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 period 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 group or individual health insurance
coverage, 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 insurance issuer
providing group or individual health insurance coverage, shall provide
notice to each participant and beneficiary under such plan or coverage
regarding the coverage required by this section in accordance with
regulations promulgated by the Secretary. Such notice shall be in
writing and prominently positioned in the summary of the plan or
coverage 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 group or individual health insurance
coverage, 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 specialists in the appropriate medical fields
(including pathology, radiology, and oncology) to confirm or
refute such diagnosis. Such plan or issuer shall ensure that
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 consultation are not sufficiently available from
specialists operating under the plan or coverage with respect
to whose services coverage is otherwise provided under such
plan or by such issuer, such plan or issuer shall ensure 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 secondary 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 providing group or individual health
insurance coverage, 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 participant 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 patients 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 involved under subsection (d).''.
(b) Effective Dates.--
(1) In general.--The amendments made by this section shall
apply with respect to plan years beginning on or after 90 days
after the date of enactment of this Act.
(2) Special rule for collective bargaining agreements.--In
the case of a group health plan maintained pursuant to 1 or
more collective bargaining agreements between employee
representatives 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 terminates (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. 5. AMENDMENTS TO THE INTERNAL REVENUE CODE OF 1986.
(a) In General.--Subchapter B of chapter 100 of the Internal
Revenue Code of 1986 is amended--
(1) in the table of sections, by inserting after the item
relating to section 9813 the following:
``Sec. 9814. Required coverage for minimum hospital stay for
mastectomies, lumpectomies, and lymph node
dissections for the treatment of breast
cancer and coverage for secondary
consultations.'';
and
(2) by inserting after section 9813 the following:
``SEC. 9814. REQUIRED COVERAGE FOR MINIMUM HOSPITAL STAY FOR
MASTECTOMIES, LUMPECTOMIES, AND LYMPH NODE DISSECTIONS
FOR THE TREATMENT OF BREAST CANCER AND COVERAGE FOR
SECONDARY CONSULTATIONS.
``(a) Inpatient Care.--
``(1) In general.--A group health plan that provides
medical and surgical benefits shall ensure that inpatient (and
in the case of a lumpectomy, outpatient) coverage and radiation
therapy is provided for breast cancer treatment. Such plan 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 mastectomy
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 authorization
from the plan for prescribing 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 period 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 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 shall provide notice to each
participant and beneficiary under such plan regarding the coverage
required by this section in accordance with regulations promulgated by
the Secretary. Such notice shall be in writing and prominently
positioned in the summary of the plan made available or distributed by
the plan and shall be transmitted--
``(1) in the next mailing made by the plan 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 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 specialists in the
appropriate medical fields (including pathology, radiology, and
oncology) to confirm or refute such diagnosis. Such plan or
issuer shall ensure that 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 consultation are not
sufficiently available from specialists 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 ensure 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 secondary consultations
where the patient determines not to seek such a consultation.
``(e) Prohibition on Penalties.--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 participant 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 patients 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
involved under subsection (d).''.
(b) Effective Dates.--
(1) In general.--The amendments made by this section shall
apply with respect to plan years beginning on or after the date
of enactment of this Act.
(2) Special rule for collective bargaining agreements.--In
the case of a group health plan maintained pursuant to 1 or
more collective bargaining agreements between employee
representatives 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 terminates (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. 6. OPPORTUNITY FOR INDEPENDENT, EXTERNAL THIRD PARTY REVIEWS OF
CERTAIN NONRENEWALS AND DISCONTINUATIONS, INCLUDING
RESCISSIONS, OF INDIVIDUAL HEALTH INSURANCE COVERAGE.
(a) Clarification Regarding Application of Guaranteed Renewability
of Individual Health Insurance Coverage.--Section 2742 of the Public
Health Service Act (42 U.S.C. 300gg-42) is amended--
(1) in its heading, by inserting ``and continuation in
force, including prohibition of rescission,'' after
``guaranteed renewability'';
(2) in subsection (a), by inserting ``, including without
rescission,'' after ``continue in force''; and
(3) in subsection (b)(2), by inserting before the period at
the end the following: ``, including intentional concealment of
material facts regarding a health condition related to the
condition for which coverage is being claimed''.
(b) Opportunity for Independent, External Third Party Review in
Certain Cases.--Subpart 1 of part B of title XXVII of the Public Health
Service Act is amended by adding at the end the following new section:
``SEC. 2746. OPPORTUNITY FOR INDEPENDENT, EXTERNAL THIRD PARTY REVIEW
IN CERTAIN CASES.
``(a) Notice and Review Right.--If a health insurance issuer
determines to nonrenew or not continue in force, including rescind,
health insurance coverage for an individual in the individual market on
the basis described in section 2742(b)(2) before such nonrenewal,
discontinuation, or rescission, may take effect the issuer shall
provide the individual with notice of such proposed nonrenewal,
discontinuation, or rescission and an opportunity for a review of such
determination by an independent, external third party under procedures
specified by the Secretary.
``(b) Independent Determination.--If the individual requests such
review by an independent, external third party of a nonrenewal,
discontinuation, or rescission of health insurance coverage, the
coverage shall remain in effect until such third party determines that
the coverage may be nonrenewed, discontinued, or rescinded under
section 2742(b)(2).''.
(c) Effective Date.--The amendments made by this section shall
apply after the date of the enactment of this Act with respect to
health insurance coverage issued before, on, or after such date.
<all>
Introduced in House
Introduced in House
Referred to the Committee on Energy and 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 consideration of such provisions as fall within the jurisdiction of the committee concerned.
Referred to the Committee on Energy and 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 consideration of such provisions as fall within the jurisdiction of the committee concerned.
Referred to the Committee on Energy and 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 consideration of such provisions as fall within the jurisdiction of the committee concerned.
Referred to the Subcommittee on Health.
Referred to the Subcommittee on Health.
Referred to the Subcommittee on Health, Employment, Labor, and Pensions.
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