Screening Mammography Act of 2005 - Amends the Public Health Service Act and the Employee Retirement Income Security Act of 1974 (ERISA) to require a group health plan, and a health insurance issuer offering group coverage, that provides coverage for diagnostic mammography for any class of participants or beneficiaries to also provide coverage for annual screening mammography for that class under terms that are not less favorable. Prohibits: (1) denying screening coverage on the basis that the screening is not medically necessary or is not pursuant to a referral or recommendation; (2) denying eligibility, enrollment, or renewal solely to avoid this requirement; (3) providing monetary incentives to participants or beneficiaries to encourage them to accept less than such minimum protections; (4) penalizing providers because they provide such care; or (5) providing incentives to induce providers to provide such care. Declares that this Act does not preempt any state laws providing at least these protections.
Applies such requirements and prohibitions to health coverage offered in the individual market.
Amends title XIX (Medicaid) of the Social Security Act to mandate coverage of annual screening mammographies.
[Congressional Bills 109th Congress]
[From the U.S. Government Publishing Office]
[H.R. 2761 Introduced in House (IH)]
109th CONGRESS
1st Session
H. R. 2761
To amend the Public Health Service Act and Employee Retirement Income
Security Act of 1974 to require that group and individual health
insurance coverage and group health plans provide coverage for annual
screening mammography for any class of covered individuals if the
coverage or plans include coverage for diagnostic mammography for such
class and to amend title XIX of the Social Security Act to provide for
coverage of annual screening mammography under the Medicaid Program.
_______________________________________________________________________
IN THE HOUSE OF REPRESENTATIVES
June 7, 2005
Mr. Andrews introduced the following bill; which was referred to the
Committee on Energy and Commerce, and in addition to the Committee on
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 amend the Public Health Service Act and Employee Retirement Income
Security Act of 1974 to require that group and individual health
insurance coverage and group health plans provide coverage for annual
screening mammography for any class of covered individuals if the
coverage or plans include coverage for diagnostic mammography for such
class and to amend title XIX of the Social Security Act to provide for
coverage of annual screening mammography under the Medicaid Program.
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 ``Screening Mammography Act of 2005''.
SEC. 2. COVERAGE OF ANNUAL SCREENING MAMMOGRAPHY UNDER GROUP HEALTH
PLANS.
(a) Public Health Service Act Amendments.--
(1) 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. 2707. STANDARDS RELATING TO BENEFITS FOR SCREENING MAMMOGRAPHY.
``(a) Requirements for Coverage of Annual Screening Mammography.--
``(1) In general.--A group health plan, and a health
insurance issuer offering group health insurance coverage, that
provides coverage for diagnostic mammography for any class of
participants or beneficiaries shall provide coverage for annual
screening mammography for such class under terms and conditions
that are not less favorable than the terms and conditions for
coverage of diagnostic mammography.
``(2) Diagnostic and annual screening mammography
defined.--For purposes of this section--
``(A) The term `diagnostic mammography' means a
radiologic procedure that is medically necessary for
the purpose of diagnosing breast cancer and includes a
physician's interpretation of the results of the
procedure.
``(B) The term `annual screening mammography' means
a radiologic procedure provided to an individual, not
more frequently than on an annual basis, for the
purpose of early detection of breast cancer and
includes a physician's interpretation of the results of
the procedure.
``(b) Prohibitions.--A group health plan, and a health insurance
issuer offering group health insurance coverage in connection with a
group health plan, may not--
``(1) deny coverage for annual screening mammography on the
basis that the coverage is not medically necessary or on the
basis that the screening mammography is not pursuant to a
referral, consent, or recommendation by any health care
provider;
``(2) deny to a participant or beneficiary eligibility, or
continued eligibility, to enroll or to renew coverage under the
terms of the plan, solely for the purpose of avoiding the
requirements of this section;
``(3) provide monetary payments or rebates to participants
or beneficiaries to encourage them to accept less than the
minimum protections available under this section;
``(4) penalize or otherwise reduce or limit the
reimbursement of an attending provider because such provider
provided care to an individual participant or beneficiary in
accordance with this section; or
``(5) provide incentives (monetary or otherwise) to an
attending provider to induce such provider to provide care to
an individual participant or beneficiary in a manner
inconsistent with this section.
``(c) Rules of Construction.--
``(1) Nothing in this section shall be construed to require
a participant or beneficiary to undergo annual screening
mammography.
``(2) This section shall not apply with respect to any
group health plan, or any group health insurance coverage
offered by a health insurance issuer, which does not provide
benefits for diagnostic mammography.
``(3) Nothing in this section shall be construed as
preventing a group health plan or a health insurance issuer
offering group health plan coverage from imposing deductibles,
coinsurance, or other cost-sharing in relation to benefits for
annual screening mammography under the plan (or under health
insurance coverage offered in connection with a group health
plan), except that such coinsurance or other cost-sharing for
any portion may not be greater than such coinsurance or cost-
sharing that is otherwise applicable with respect to benefits
for diagnostic mammography.
``(4) Nothing in this section shall be construed as
preventing a group health plan or a health insurance issuer
offering group health insurance coverage from requiring that a
participant or beneficiary, before undergoing an annual
screening mammography more frequently than on an annual basis,
consult with an appropriate health care practitioner or obtain
a written authorization from such a practitioner for submission
to the plan or issuer, but nothing in this section shall be
construed as requiring prior authorization before undergoing an
annual screening mammography.
``(d) Notice.--A group health plan under this part shall comply
with the notice requirement under section 714(d) 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.
``(e) Level and Type of Reimbursements.--Nothing in this section
shall be construed as preventing a group health plan or a health
insurance issuer offering group health insurance coverage from
negotiating the level and type of reimbursement with a provider for
care provided in accordance with this section.
``(f) Preemption; Exception for Health Insurance Coverage in
Certain States.--
``(1) In general.--The requirements of this section shall
not apply with respect to health insurance coverage for any
class of participants or beneficiaries if there is a State law
(as defined in section 2723(d)(1)) for a State that regulates
such coverage, that requires coverage to be provided for annual
screening mammography for such class, and that provides at
least the protections described in subsection (b).
``(2) Construction.--Section 2723(a)(1) shall not be
construed as superseding a State law described in paragraph
(1).''.
(2) Section 2723(c) of such Act (42 U.S.C. 300gg-23(c)) is
amended by striking ``section 2704'' and inserting ``sections
2704 and 2707''.
(b) ERISA Amendments.--
(1) 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. 714. STANDARDS RELATING TO BENEFITS FOR SCREENING MAMMOGRAPHY.
``(a) Requirements for Coverage of Annual Screening Mammography.--
``(1) In general.--A group health plan, and a health
insurance issuer offering group health insurance coverage, that
provides coverage for diagnostic mammography for any class of
participants or beneficiaries shall provide coverage for annual
screening mammography for such class under terms and conditions
that are not less favorable than the terms and conditions for
coverage of diagnostic mammography.
``(2) Diagnostic and annual screening mammography
defined.--For purposes of this section--
``(A) The term `diagnostic mammography' means a
radiologic procedure that is medically necessary for
the purpose of diagnosing breast cancer and includes a
physician's interpretation of the results of the
procedure.
``(B) The term `annual screening mammography' means
a radiologic procedure provided to an individual, not
more frequently than on an annual basis, for the
purpose of early detection of breast cancer and
includes a physician's interpretation of the results of
the procedure.
``(b) Prohibitions.--A group health plan, and a health insurance
issuer offering group health insurance coverage in connection with a
group health plan, may not--
``(1) deny coverage described in subsection (a)(1) on the
basis that the coverage is not medically necessary or on the
basis that the annual screening mammography is not pursuant to
a referral, consent, or recommendation by any health care
provider;
``(2) deny to a participant or beneficiary eligibility, or
continued eligibility, to enroll or to renew coverage under the
terms of the plan, solely for the purpose of avoiding the
requirements of this section;
``(3) provide monetary payments or rebates to participants
or beneficiaries to encourage them to accept less than the
minimum protections available under this section;
``(4) penalize or otherwise reduce or limit the
reimbursement of an attending provider because such provider
provided care to an individual participant or beneficiary in
accordance with this section; or
``(5) provide incentives (monetary or otherwise) to an
attending provider to induce such provider to provide care to
an individual participant or beneficiary in a manner
inconsistent with this section.
``(c) Rules of Construction.--
``(1) Nothing in this section shall be construed to require
a participant or beneficiary to undergo annual screening
mammography.
``(2) This section shall not apply with respect to any
group health plan, or any group health insurance coverage
offered by a health insurance issuer, which does not provide
benefits for diagnostic mammography.
``(3) Nothing in this section shall be construed as
preventing a group health plan or a health insurance issuer
offering group health insurance coverage from imposing
deductibles, coinsurance, or other cost-sharing in relation to
benefits for annual screening mammography under the plan (or
under health insurance coverage offered in connection with a
group health plan), except that such coinsurance or other cost-
sharing for any portion may not be greater than such
coinsurance or cost-sharing that is otherwise applicable with
respect to benefits for diagnostic mammography.
``(4) Nothing in this section shall be construed as
preventing a group health plan or a health insurance issuer
offering group health insurance coverage from requiring that a
participant or beneficiary, before undergoing an annual
screening mammography more frequently than on an annual basis,
consult with an appropriate health care practitioner or obtain
a written authorization from such a practitioner for submission
to the plan or issuer, but nothing in this section shall be
construed as requiring prior authorization before undergoing an
annual screening mammography.
``(d) 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.
``(e) Level and Type of Reimbursements.--Nothing in this section
shall be construed as preventing a group health plan or a health
insurance issuer offering group health insurance coverage from
negotiating the level and type of reimbursement with a provider for
care provided in accordance with this section.
``(f) Preemption; Exception for Health Insurance Coverage in
Certain States.--
``(1) In general.--The requirements of this section shall
not apply with respect to health insurance coverage for any
class of participants or beneficiaries if there is a State law
(as defined in section 731(d)(1)) for a State that regulates
such coverage, that requires coverage to be provided for annual
screening mammography for such class, and that provides at
least the protections described in subsection (b).
``(2) Construction.--Section 731(a)(1) shall not be
construed as superseding a State law described in paragraph
(1).''.
(2) Section 731(c) of such Act (29 U.S.C. 1191(c)) is
amended by striking ``section 711'' and inserting ``sections
711 and 714''.
(3) Section 732(a) of such Act (29 U.S.C. 1191a(a)) is
amended by striking ``section 711'' and inserting ``sections
711 and 714''.
(4) The table of contents in section 1 of such Act is
amended by inserting after the item relating to section 713 the
following new item:
``714. Standards relating to benefits for screening mammography.''.
(c) Effective Dates.--(1) Subject to paragraph (2), the amendments
made by this section shall apply with respect to group health plans
(and health insurance coverage offered in connection with group health
plans) for plan years beginning on or after January 1, 2006.
(2) 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 later of--
(A) the date on which the last collective bargaining
agreements relating to the plan terminate (determined without
regard to any extension thereof agreed to after the date of
enactment of this Act), or
(B) January 1, 2006.
For purposes of subparagraph (A), 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. 3. COVERAGE OF ANNUAL SCREENING MAMMOGRAPHY UNDER INDIVIDUAL
HEALTH COVERAGE.
(a) In General.--Part B of title XXVII of the Public Health Service
Act is amended by inserting after section 2752 the following new
section:
``SEC. 2753. STANDARDS RELATING TO BENEFITS FOR SCREENING MAMMOGRAPHY.
``(a) In General.--The provisions of section 2707 (other than
subsections (d) and (f)) shall apply to health insurance coverage
offered by a health insurance issuer in the individual market in the
same manner as it applies to health insurance coverage offered by a
health insurance issuer in connection with a group health plan in the
small or large group market.
``(b) Notice.--A health insurance issuer under this part shall
comply with the notice requirement under section 714(d) 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.
``(c) Preemption; Exception for Health Insurance Coverage in
Certain States.--
``(1) In general.--The requirements of this section shall
not apply with respect to health insurance coverage for any
class of individuals if there is a State law (as defined in
section 2723(d)(1)) for a State that regulates such coverage,
that requires coverage in the individual health insurance
market to be provided for annual screening mammography for such
class and that provides at least the protections described in
section 2707(b) (as applied under subsection (a)).
``(2) Construction.--Section 2762(a) shall not be construed
as superseding a State law described in paragraph (1).''.
(b) Conforming Amendment.--Section 2762(b)(2) of such Act (42
U.S.C. 300gg-62(b)(2)) is amended by striking ``section 2751'' and
inserting ``sections 2751 and 2753''.
(c) Effective Date.--The amendments made by this section shall
apply with respect to health insurance coverage offered, sold, issued,
or renewed in the individual market on or after such January 1, 2006.
SEC. 4. COVERAGE OF ANNUAL SCREENING MAMMOGRAPHY UNDER MEDICAID.
(a) In General.--Section 1905(a) of the Social Security Act (42
U.S.C. 1396d(a)) is amended--
(1) by striking ``and'' at the end of paragraph (27);
(2) by redesignating paragraph (28) as paragraph (29); and
(3) by inserting after paragraph (27) the following new
paragraph:
``(28) annual screening mammography (as defined in
subsection (x)) that is conducted by a facility that has a
certificate (or provisional certificate) issued under section
354 of the Public Health Service Act; and''.
(b) Annual Screening Mammography Defined.--Section 1905 of such Act
(42 U.S.C. 1396d) is amended by adding at the end the following new
subsection:
``(y) The term `annual screening mammography' means a radiologic
procedure provided to a woman, not more frequently than on an annual
basis, for the purpose of early detection of breast cancer and includes
a physician's interpretation of the results of the procedure.''.
(c) Making Coverage Mandatory.--Section 1902(a)(10)(A) of such Act
(42 U.S.C. 1396a(a)(10)(A)) is amended by striking ``(17) and (21)''
and inserting ``(17), (21), and (27)''.
(d) Conforming Amendments.--Section 1902(a)(10)(C)(iv) of such Act
(42 U.S.C. 1396a(a)(10)(C)(iv)) is amended--
(1) by striking ``and (17)'' and inserting ``, (17), and
(27)'', and
(2) by striking ``through (24)'' and inserting ``through
(28)''; and
(e) Effective Date.--(1) Except as provided in paragraph (2), the
amendments made by this section shall apply to screening mammography
performed on or after January 1, 2006, without regard to whether or not
final regulations to carry out such amendments have been promulgated by
such date.
(2) In the case of a State plan for medical assistance under title
XIX of the Social Security Act which the Secretary of Health and Human
Services determines requires State legislation (other than legislation
appropriating funds) in order for the plan to meet the additional
requirement imposed by the amendments made by this section, the State
plan shall not be regarded as failing to comply with the requirements
of such title solely on the basis of its failure to meet this
additional requirement before the first day of the first calendar
quarter beginning after the close of the first regular session of the
State legislature that begins after the date of the enactment of this
Act. For purposes of the previous sentence, in the case of a State that
has a 2-year legislative session, each year of such session shall be
deemed to be a separate regular session of the State legislature.
<all>
Introduced in House
Introduced in House
Referred to the Committee on Energy and Commerce, and in addition to the Committee on 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 Committee on 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 Committee on 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 Employer-Employee Relations.
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