Mammogram Availability 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 mammographies for any woman 40 years old or older to provide no less favorable coverage for annual screening mammographies for such a woman. Prohibits related enrollment and renewal discrimination, monetary incentives to women, and penalties or incentives to providers. Applies such requirements and prohibitions to coverage offered in the individual market.
[Congressional Bills 109th Congress]
[From the U.S. Government Publishing Office]
[H.R. 4540 Introduced in House (IH)]
109th CONGRESS
1st Session
H. R. 4540
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 women 40 years of age or older if the
coverage or plans include coverage for diagnostic mammography.
_______________________________________________________________________
IN THE HOUSE OF REPRESENTATIVES
December 14, 2005
Mr. Nadler (for himself, Mr. Wynn, Mr. Owens, Mr. Van Hollen, Mr.
Rangel, Mr. Hinojosa, Mr. Holden, Ms. Jackson-Lee of Texas, Ms. Kaptur,
Ms. Millender-McDonald, Mr. Hinchey, Mr. Sherman, Mr. Michaud, Ms.
Herseth, Ms. Carson, Mr. Pallone, Mr. Grijalva, Mr. McIntyre, Mr.
McDermott, Mr. Kucinich, Ms. Solis, Ms. Norton, Mr. Gutierrez, Mr.
Boucher, Mr. Ackerman, Mr. Scott of Georgia, Mr. Frank of
Massachusetts, Mr. Payne, Mr. Cleaver, Mrs. Christensen, Mr. Conyers,
Mr. Crowley, Mr. Honda, Mr. Ryan of Ohio, Ms. Ros-Lehtinen, Mr. Stark,
Ms. Matsui, Mr. Towns, Mr. Lynch, Mr. McNulty, Mr. Lantos, Mr. Weiner,
Mr. Kildee, Ms. Woolsey, Mr. Langevin, and Mr. Meehan) 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 women 40 years of age or older if the
coverage or plans include coverage for diagnostic mammography.
Be it enacted by the Senate and House of Representatives of the
United States of America in Congress assembled,
SECTION 1. SHORT TITLE; FINDINGS.
(a) Short Title.--This Act may be cited as the ``Mammogram
Availability Act of 2005''.
(b) Findings.--Congress finds the following:
(1) An estimated 211,000 women will have been diagnosed
with breast cancer and an estimated 40,000 women will have died
from breast cancer during 2005.
(2) Breast cancer is the second leading cause of death for
women in the United States and is the leading cause of death
for women between the ages of 40 and 49 in the United States.
(3) Breast cancer death rates were reduced by 24 percent
from 1990 to 2000.
(4) A study sponsored by the National Cancer Institute and
published on October 27, 2005, concluded that up to 65 percent
of the reduction in the number of breast cancer deaths was
directly attributable to screening mammography.
(5) An expert panel convened by the National Institutes of
Health's National Cancer Institute recommended on February 21,
2002, that women between the ages of 40 and 49 should be
screened every one to two years with mammography.
(6) The American Cancer Society recommends that women over
the age of 40 receive an annual mammogram.
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 woman who
is 40 years of age or older shall provide coverage for annual
screening mammography for such a woman under terms and
conditions that are not less favorable than the terms and
conditions for coverage of diagnostic mammography.
``(2) Diagnostic and 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 `screening mammography' means a
radiologic procedure provided to a woman for the
purpose of early detection of breast cancer and
includes a physician's interpretation of the results of
the procedure.
``(b) Protections.--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 woman 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 women to
encourage such women 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 woman who is 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 issuer from imposing
deductibles, coinsurance, or other cost-sharing in relation to
benefits for 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) Women between the ages of 40 and 49 should (but are
not required to) consult with appropriate health care
practitioners before undergoing screening mammography, but
nothing in this section shall be construed as requiring the
approval of a health care practitioner before a woman undergoes
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 to prevent 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 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 women who are 40 years of
age or older 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 woman who
is 40 years of age or older shall provide coverage for annual
screening mammography for such a woman under terms and
conditions that are not less favorable than the terms and
conditions for coverage of diagnostic mammography.
``(2) Diagnostic and 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 `screening mammography' means a
radiologic procedure provided to a woman for the
purpose of early detection of breast cancer and
includes a physician's interpretation of the results of
the procedure.
``(b) Protections.--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 screening mammography is not pursuant to a
referral, consent, or recommendation by any health care
provider;
``(2) deny to a woman 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 women to
encourage such women 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 woman who is 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 issuer from imposing
deductibles, coinsurance, or other cost-sharing in relation to
benefits for 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) Women between the ages of 40 and 49 should (but are
not required to) consult with appropriate health care
practitioners before undergoing screening mammography, but
nothing in this section shall be construed as requiring the
approval of a health care practitioner before a woman undergoes
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 summary plan described in section
102(a), 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 to prevent 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 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 women who are 40 years of
age or older, 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:
``Sec. 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 1 year after the date of
the enactment of this Act.
(2)(A) 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 the
enactment of this Act, the amendments made by this section shall not
apply to plan years beginning before the later of--
(i) 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 the enactment of this Act);
or
(ii) 1 year after the date of the enactment of this
Act.
(B) For purposes of subparagraph (A)(i), 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 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 women who are 40 years of age or
older 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-63(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 the date that is 1 year
after the date of the enactment of this Act.
<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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