A bill to require that health plans provide coverage for a minimum hospital stay for mastectomies and lymph node dissection for the treatment of breast cancer and coverage for secondary consultations

19 Pages·1999·0.75 MB·English

by  United States. Congress. Senate

—
CCi2'-lS07L-i1br3ary n
7500SecurityBlvd.
Baitimore. Marylond 21244
106thcongress S.115
1stSession
Torequirethat healthplanspro^^decoveragefora minimumhospital stay
formastectomiesandhmphnodedissectionforthetreatmentofbreast
cancerandcoverageforsecondaryconsultations.
IN THE SENATE OF THE UNITED STATES
January19,1999
Ms. Snoame (forherselfandMrs. Feinstein) introducedthefoUouingbill;
whichwasreadtwiceandreferred tothe Committeeon Health, Edu-
cation,Labor,andPensions
A
BILL
Torequirethathealthplanspro\'idecoverageforaminimum
hospitalstayformastectomiesandlymphnodedissection
forthe treatment ofbreast cancer and coverage for sec-
ondaryconsultations.
1 BeitenactedbytheSenateandHottseofRepresenta-
2 tivesoftheUnitedStatesofAmericainCongressassembled,
3 SECTION1.SHORTTITLE.
4 ThisActmaybecited asthe "Women'sHealth and
5 CancerRightsActof1999".
6 SEC.2.FINDINGS.
7 Congressfindsthat
2
1 (1) the offering and operation of health plans
2 affectcommerceamongtheStates;
3 (2) health care providers located in a State
4 serve patients who reside in the State and patients
5 whoresideinotherStates;and
6 (3) inordertopro\'ideforuniformtreatmentof
7 healthcareprovidersandpatientsamongtheStates,
8 it is necessary to cover health plans operating in 1
9 State as well as health plans operating among the
10 severalStates.
11 SEC,3.AMENDMENTSTOTHEEMPLOYEERETIREMENTIN-
12 COMESECURITYACTOF1974.
—
13 (a) In General. Subpart B ofpart 7 of subtitle
14 B oftitleI ofthe EmployeeRetirementIncome Security
15 Act of 1974, as amended by the Omnibus Consolidated
16 and Emergency Supplemental Appropriations Act, 1999
17 (PublicLaw 105-277), isamendedbyaddingatthe end
18 thefollowing:
19 "SEC.714.REQUIREDCOVERAGEFORMINIMUMHOSPITAL
20 STAYFORMASTECTOMIESANDLYMPHNODE
21 DISSECTIONS FOR THE TREATMENT OF
22 BREAST CANCER AND COVERAGE FOR SEC-
23 ONDARYCONSULTATIONS.
—
24 "(a)InpatientCare.
•S115IS
—
3
—
1 "(1) Ingeneral. grouphealthplan, anda
2 health insurance issuer providing health insurance
3 coverage in connection vnth a group health plan,
4 thatprovidesmedical and surgicalbenefits shall en-
5 sure that inpatient coverage with respect to the
6 treatment ofbreast cancer is provided for a period
7 oftime asisdeterminedbythe attendingphysician,
8 in consultationwiththe patient, tobe medicallyap-
9 propriatefollowing
10 "(A) amastectomy;
11 "(B) alumpectomy;or
12 "(C) alymphnodedissectionforthetreat-
13 mentofbreastcancer.
—
14 "(2) Exception. Nothinginthissectionshall
15 be construed as requiringthe provision ofinpatient
16 coverage ifthe attending physician and patient de-
17 termine that a shorter period of hospital stay is
18 medicallyappropriate.
—
19 "(b) Prohibition on Certain Modifications.
20 Inimplementingtherequirementsofthissection,agroup
21 healthplan,andahealthinsuranceissuerprovidinghealth
22 insurancecoverageinconnectionwithagrouphealthplan,
23 may not modify the terms and conditions of coverage
24 basedonthedeterminationbyaparticipantorbeneficiary
•S115IS
—
4
1 torequestlessthantheminimumcoveragerequiredunder
2 subsection(a).
—
3 "(e) Notice. grouphealthplan, andahealthin-
4 suraneeissuerprovidinghealthinsurancecoverageincon-
5 nection with a group health plan shall provide notice to
6 eachparticipantandbeneficiaryundersuchplan regard-
7 ing the coverage required by this section in accordance
8 with regulationspromulgatedbythe Secretary. Such no-
9 tieeshallbeinwritingandprominentlypositionedinany
10 literatureorcorrespondencemadeavailableordistributed
11 bytheplanorissuerandshallbetransmitted
12 "(1) in the next mailing made by the plan or
13 issuertotheparticipantorbeneficiary;
14 "(2) aspartofanyyearlyinformationalpacket
15 senttotheparticipantorbeneficiary;or
16 "(3)notlaterthanJanuary1,2000;
17 whicheverisearlier.
—
18 "(d)SecondaryConsultations.
19 "(1)Ingeneral.—agrouphealthplan, anda
20 health insurance issuer providing health insurance
21 coverage in connection with a group health plan,
22 that provides coverage with respect to medical and
23 surgicalservicesprovidedinrelationtothediagnosis
24 and treatment of cancer shall ensure that fall cov-
25 erageisprovidedforsecondary^consultationsbyspe-
•S115IS
—
5
1 eialists in the appropriate medical fields (including
2 pathology, radiology, andoncology) toconfirmorre-
3 futesuchdiagnosis. Suchplanorissuershallensure
4 that full coverage is provided for such secondary
5 consultationwhethersuchconsultationisbasedona
6 positive or negative initial diagnosis. In anycase in
7 which the attending physician certifies in writing
8 that services necessary for such a secondarj^ con-
9 sulfation are not sufficiently available from special-
10 ists operatingunder the planwith respect towhose
11 services coverage is otherwise provided under such
12 plan orbysuch issuer, suchplan orissuer shallen-
13 sure that coverage is provided with respect to the
14 services necessary for the secondary consultation
15 with any other specialist selected by the attending
16 physician for such purpose at no additional cost to
17 the individual beyond that which the indi\idual
18 wouldhavepaidifthespecialistwasparticipatingin
19 thenetworkoftheplan.
—
20 "(2) Exception. Nothing in paragraph (1)
21 shall be construed as requiringthe provision ofsec-
22 ondary consultations where the patient determines
23 nottoseeksuchaconsultation.
24 "(e)ProhibitiononPenaltiesoriNCENTrvnes.
25 Agrouphealthplan,andahealthinsuranceissuerprovid-
es115IS
—
6
1 inghealthinsurance coverageinconnectionwithagroup
2 healthplan,maynot
3 "(1) penaUze or otherwise reduce or limit the
4 reimbursement of a provider or specialist because
5 theprovider or specialistprovided care to apartiei-
6 pant or beneficiary in accordance with this section;
7 "(2) provide financial or other incentives to a
8 physician or speciahst to induce the physician or
9 specialisttokeepthelengthofinpatientstaysofpa-
10 tients following a mastectomy, lumpectomy, or a
11 lymph node dissection for the treatment of breast
12 cancer below certain limits or to limit referrals for
13 secondaryconsultations;or
14 "(3) provide financial or other incentives to a
15 physician or specialist to induce the physician or
16 specialist to refrain from referring a participant or
17 beneficiary for a secondary consultation that would
18 otherwise be covered by the plan or coverage in-
19 volvedundersubsection(d).".
—
20 (b) Clerical Amendment. The table ofcontents
21 insection 1 oftheEmployeeRetirementIncomeSecurity
22 Act of 1974, as amended by the Omnibus Consolidated
23 and Emergency Supplemental Appropriations Act, 1999
24 (PublicLaw 105-277), isamendedbyinsertingafterthe
25 itemrelatingtosection713thefollowingnewitem:
•S115IS
—
7
"Sec.714.Requiredcoverageforniininiunihospitalstayforniastectoniiesand
hiuphnodedissectionsforthetreatmentofbreastcancerand
coverageforsecondarj-consultations.".
—
1 (c)Effectr^Dates.
—
2 (1) Ix GENERAL. The amendments made by
3 thissectionshallapplywithrespecttoplanyearsbe-
4 ginning on or after the date of enactment of this
5 Act.
6 (2) Special rule for collective bargain-
—
7 ING AGREEMENTS. In the case of a group health
8 plan maintained pursuant to 1 or more collective
9 bargainingagreementsbetweenemployeerepresenta-
10 tives and 1 or more employers ratified before the
11 dateofenactmentofthisAct,theamendmentsmade
12 by this section shall not applyto planyears begin-
13 ningbeforethelaterof
14 (A) the date on which the last collective
15 bargainingagreements relatingto theplanter-
16 minates (determinedwithout regard to anyex-
17 tension thereof agreed to after the date ofen-
18 actmentofthisAct),or
19 (B)January1,2000.
20 Forpurposesofsubparagraph (A), anyplanamend-
21 ment made pursuant to a collective bargaining
22 agreement relating to the plan which amends the
23 plan solelyto conform to anyrequirement addedby
•S115IS
—
8
1 this section shall notbetreated as atermination of
2 suchcollectivebargainingagreement.
3 SEC. 4.AMENDMENTS TO THE PUBLIC HEALTH SERVICE
4 ACTRELATINGTOTHEGROUPMARKET.
—
5 (a) Ix General. Subpart 2 of part A of title
6 XXVII ofthe Public Health ServiceAct, as amendedby
7 the Omnibus Consolidated and Emergency Supplemental
8 Appropriations Act, 1999 (Pubhc Law 105-277), is
9 amendedbyaddingattheendthefollowingnewsection:
10 "SEC.2707.REQUIREDCOVERAGEFORMINIMUMHOSPITAL
11 STAYFORMASTECTOMIESANDLYMPHNODE
12 DISSECTIONS FOR THE TREATMENT OF
13 BREAST CANCERAND COVERAGE FOR SEC-
14 ONDARYCONSULTATIONS.
—
15 "(a)InpatientCare.
—
16 "(1) In general. ^Agrouphealthplan, anda
17 health insurance issuer providing health insurance
18 coverage in connection with a group health plan,
19 thatprovides medical and surgical benefits shallen-
20 sure that inpatient coverage with respect to the
21 treatment ofbreast cancer is pro\dded for a period
22 oftime asis determinedbythe attendingphysician,
23 inconsultationwiththepatient, to be medicallyap-
24 propriatefollowing
25 "(A)amastectomy;
•S115IS
—
9
1 "(B) alumpectomy;or
2 "(C) alymphnodedissectionforthetreat-
3 mentofbreastcancer.
—
4 "(2)Exception. Nothinginthissectionshall
5 be construed as requiringthe pro\ision ofinpatient
6 coverage ifthe attending physician and patient de-
7 termine that a shorter period of hospital stay is
8 medicallyappropriate.
—
9 "(b) Prohibition on Certain Modifications.
10 Inimplementingtherequirementsofthissection,agroup
11 healthplan,andahealthinsuranceissuerprovidinghealth
12 insurancecoverageinconnectionwithagrouphealthplan,
13 may not modify the terms and conditions of coverage
14 basedonthedeterminationbyaparticipantorbeneficiary
15 torequestlessthantheminimumcoveragerequiredunder
16 subsection(a).
—
17 "(c) Notice. grouphealthplan,andahealthin-
18 suranceissuerprovidinghealthinsurancecoverageineon-
19 nection with a group health plan shall provide notice to
20 eachparticipantandbeneficiary^under suchplanregard-
21 ing the coverage required by this section in accordance
22 with regulations promulgatedbythe Seeretarv^ Such no-
23 ticeshallbeinwritingandprominentlypositionedin any
24 literatureorcorrespondencemadeavailableordistributed
25 bytheplanorissuerandshallbetransmitted
•S115IS
10
1 "(1) in the next mailing made by the plan or
2 issuertotheparticipantorbeneficiary;
3 "(2) aspartofan}^yearlyinformationalpacket
4 senttotheparticipantorbeneficiary;or
5 "(3)notlaterthanJanuary1,2000;
6 whicheverisearlier.
—
7 "(d)SecondaryConsultations.
—
8 "(1)Ingeneral. grouphealthplan, anda
9 health insurance issuer providing- health insurance
10 coverageinconnectionwithagrouphealthplanthat
11 provides coverage with respect to medical and sur-
12 gical services provided in relation to the diagnosis
13 and treatment of cancer shall ensure that full cov-
14 erageisprovidedforsecondaryconsultationsbyspe-
15 cialists in the appropriate medical fields (including
16 pathology,radiology, andoncology)toconfirmorre-
17 futesuchdiagnosis. Suchplanorissuershallensure
18 that full coverage is provided for such secondary
19 consultationwhethersuchconsultationisbasedona
20 positive ornegative initial diagnosis. In anycase in
21 which the attending physician certifies in writing
22 that sendees necessar}^ for such a secondary con-
23 sulfation are not sufficiently available from special-
24 ists operatingunderthe planwith respect towhose
25 services coverage is otherv\ase provided under such
•S115IS