Osteoporosis Early Detection and Prevention Act of 1997

Summary: Osteoporosis Early Detection and Prevention Act of 1997 - Amends the Public Health Service Act and the Employee Retirement Income Security Act of 1974 to require a group health plan, and an insurer offering group coverage, to include coverage for bone mass measurement for individuals who:  (1) are estrogen-deficient women at clinical risk for osteoporosis; (2) have vertebral abnormalities; (3) are receiving chemotherapy or long-term gluococorticoid (steroid) therapy; (4) have primary hyperparathyroidism, hyperthyroidism, or excess thyroid replacement; or (5) are being monitored to assess the response to or efficacy of approved osteoporosis drug therapy. Regulates frequency and cost sharing.  Prohibits related denial of coverage, incentives to individuals, restrictions on provider-patient communications, and provider penalties.  Allows State laws providing greater detection or prevention benefits.  Amends the Public Health Service Act to apply the above requirements to coverage offered in the individual market.

SECTION 1. SHORT TITLE; FINDINGS.

    (a) Short Title.--This Act may be cited as the ``Osteoporosis Early 
Detection and Prevention Act of 1997''.
    (b) Findings.--Congress makes the following findings:
            (1) Nature of osteoporosis.--
                    (A) Osteoporosis is a disease characterized by low 
                bone mass and structural deterioration of bone tissue 
                leading to bone fragility and increased susceptibility 
                to fractures of the hip, spine, and wrist.
                    (B) Osteoporosis has no symptoms and typically 
                remains undiagnosed until a fracture occurs.
                    (C) Once a fracture occurs, the condition has 
                usually advanced to the stage where the likelihood is 
                high that another fracture will occur.
                    (D) There is no cure for osteoporosis, but drug 
                therapy has been shown to reduce new hip and spine 
                fractures by 50 percent and other treatments, such as 
                nutrition therapy, have also proven effective.
            (2) Incidence of osteoporosis.--Osteoporosis is a common 
        condition:
                    (A) Of the 28 million Americans who have (or are at 
                risk for) osteoporosis, 80 percent are women.
                    (B) Annually there are 1.5 million bone fractures 
                attributable to osteoporosis.
                    (C) Half of all women, and one-eighth of all men, 
                age 50 or older will have a bone fracture due to 
                osteoporosis.
            (3) Impact of osteoporosis.--The cost of treating 
        osteoporosis is significant:
                    (A) The annual cost of osteoporosis in the United 
                States is $13.8 billion.
                    (B) The average cost in the United States of 
                repairing a hip fracture due to osteoporosis is 
                $32,000.
                    (C) Fractures due to osteoporosis frequently result 
                in disability and institutionalization of individuals.
                    (D) Because osteoporosis is a progressive condition 
                and affects primarily aging individuals, reductions in 
                the incidence or severity of osteoporosis, particularly 
                for post menopausal women before they become eligible 
                for Medicare, has a significant potential of reducing 
                osteoporosis-related costs under the Medicare program.
            (4) Use of bone mass measurement.--
                    (A) Bone mass measurement is a non-invasive, 
                painless, and reliable way to diagnose osteoporosis 
                before costly fractures occur.
                    (B) Low bone mass is as predictive of future 
                fractures as is high cholesterol or high blood pressure 
                of heart disease or stroke.
                    (C) Bone mass measurement is the only reliable 
                method of detecting osteoporosis at an early stage.
                    (D) Under section 4106 of the Balanced Budget Act 
                of 1997, Medicare will provide coverage, effective July 
                1, 1998, for bone mass measurement for qualified 
                individuals who are at risk of developing osteoporosis.

SEC. 2. REQUIRING COVERAGE OF BONE MASS MEASUREMENT UNDER HEALTH PLANS.

    (a) Group Health Plans.--
            (1) Public health service act amendments.--(A) Subpart 2 of 
        part A of title XXVII of the Public Health Service Act, as 
        amended by section 703(a) of Public Law 104-204, is amended by 
        adding at the end the following new section:

``SEC. 2706. STANDARDS RELATING TO BENEFITS FOR BONE MASS MEASUREMENT.

    ``(a) Requirements for Coverage of Bone Mass Measurement.--A group 
health plan, and a health insurance issuer offering group health 
insurance coverage, shall include (consistent with this section) 
coverage for bone mass measurement for beneficiaries and participants 
who are qualified individuals.
    ``(b) Definitions Relating to Coverage.--In this section:
            ``(1) Bone mass measurement.--The term `bone mass 
        measurement' means a radiologic or radioisotopic procedure or 
        other procedure approved by the Food and Drug Administration 
        performed on an individual for the purpose of identifying bone 
        mass or detecting bone loss or determining bone quality, and 
        includes a physician's interpretation of the results of the 
        procedure. Nothing in this paragraph shall be construed as 
        requiring a bone mass measurement to be conducted in a 
        particular type of facility or to prevent such a measurement 
        from being conducted through the use of mobile facilities that 
        are otherwise qualified.
            ``(2) Qualified individual.--The term `qualified 
        individual' means an individual who--
                    ``(A) is an estrogen-deficient woman at clinical 
                risk for osteoporosis;
                    ``(B) has vertebral abnormalities;
                    ``(C) is receiving chemotherapy or long-term 
                gluococorticoid (steroid) therapy;
                    ``(D) has primary hyperparathyroidism, 
                hyperthyroidism, or excess thyroid replacement; or
                    ``(E) is being monitored to assess the response to 
                or efficacy of approved osteoporosis drug therapy.
    ``(c) Limitation on Frequency Required.--Taking into account the 
standards established under section 1861(rr)(3) of the Social Security 
Act, the Secretary shall establish standards regarding the frequency 
with which a qualified individual shall be eligible to be provided 
benefits for bone mass measurement under this section. The Secretary 
may vary such standards based on the clinical and risk-related 
characteristics of qualified individuals.
    ``(d) Restrictions on Cost-Sharing.--
            ``(1) In general.--Subject to paragraph (2), 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 bone mass measurement under the 
        plan (or health insurance coverage offered in connection with a 
        plan).
            ``(2) Limitation.--Deductibles, coinsurance, and other 
        cost-sharing or other limitations for bone mass measurement may 
        not be imposed under paragraph (1) to the extent they exceed 
        the deductibles, coinsurance, and limitations that are applied 
        to similar services under the group health plan or health 
        insurance coverage.
    ``(e) 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 to an individual 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;
            ``(2) provide incentives (monetary or otherwise) to 
        individuals to encourage such individuals not to be provided 
        bone mass measurements to which they are entitled under this 
        section or to providers to induce such providers not to provide 
        such measurements to qualified individuals;
            ``(3) prohibit a provider from discussing with a patient 
        osteoporosis preventive techniques or medical treatment options 
        relating to this section; or
            ``(4) penalize or otherwise reduce or limit the 
        reimbursement of a provider because such provider provided bone 
        mass measurements to a qualified individual in accordance with 
        this section.
    ``(f) Rule of Construction.--Nothing in this section shall be 
construed to require an individual who is a participant or beneficiary 
to undergo bone mass measurement.
    ``(g) Notice.--A group health plan under this part shall comply 
with the notice requirement under section 713(g) 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.
    ``(h) 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.
    ``(i) Preemption.--
            ``(1) In general.--The provisions of this section do not 
        preempt State law relating to health insurance coverage to the 
        extent such State law provides greater benefits with respect to 
        osteoporosis detection or prevention.
            ``(2) Construction.--Section 2723(a)(1) shall not be 
        construed as superseding a State law described in paragraph 
        (1).''.
            (B) Section 2723(c) of such Act (42 U.S.C. 300gg-23(c)), as 
        amended by section 604(b)(2) of Public Law 104-204, is amended 
        by striking ``section 2704'' and inserting ``sections 2704 and 
        2706''.
            (2) ERISA amendments.--(A) Subpart B of part 7 of subtitle 
        B of title I of the Employee Retirement Income Security Act of 
        1974, as amended by section 702(a) of Public Law 104-204, is 
        amended by adding at the end the following new section:

``SEC. 713. STANDARDS RELATING TO BENEFITS FOR BONE MASS MEASUREMENT.

    ``(a) Requirements for Coverage of Bone Mass Measurement.--A group 
health plan, and a health insurance issuer offering group health 
insurance coverage, shall include (consistent with this section) 
coverage for bone mass measurement for beneficiaries and participants 
who are qualified individuals.
    ``(b) Definitions Relating to Coverage.--In this section:
            ``(1) Bone mass measurement.--The term `bone mass 
        measurement' means a radiologic or radioisotopic procedure or 
        other procedure approved by the Food and Drug Administration 
        performed on an individual for the purpose of identifying bone 
        mass or detecting bone loss or determining bone quality, and 
        includes a physician's interpretation of the results of the 
        procedure. Nothing in this paragraph shall be construed as 
        requiring a bone mass measurement to be conducted in a 
        particular type of facility or to prevent such a measurement 
        from being conducted through the use of mobile facilities that 
        are otherwise qualified.
            ``(2) Qualified individual.--The term `qualified 
        individual' means an individual who--
                    ``(A) is an estrogen-deficient woman at clinical 
                risk for osteoporosis;
                    ``(B) has vertebral abnormalities;
                    ``(C) is receiving chemotherapy or long-term 
                gluococorticoid (steroid) therapy;
                    ``(D) has primary hyperparathyroidism, 
                hyperthyroidism, or excess thyroid replacement; or
                    ``(E) is being monitored to assess the response to 
                or efficacy of approved osteoporosis drug therapy.
            ``(c) Limitation on Frequency Required.--The standards 
        established under section 2706(c) of the Public Health Service 
        Act shall apply to benefits provided under this section in the 
        same manner as they apply to benefits provided under section 
        2706 of such Act.
    ``(d) Restrictions on Cost-Sharing.--
            ``(1) In general.--Subject to paragraph (2), 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 bone mass measurement under the 
        plan (or health insurance coverage offered in connection with a 
        plan).
            ``(2) Limitation.--Deductibles, coinsurance, and other 
        cost-sharing or other limitations for bone mass measurement may 
        not be imposed under paragraph (1) to the extent they exceed 
        the deductibles, coinsurance, and limitations that are applied 
        to similar services under the group health plan or health 
        insurance coverage.
    ``(e) 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 to an individual 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;
            ``(2) provide incentives (monetary or otherwise) to 
        individuals to encourage such individuals not to be provided 
        bone mass measurements to which they are entitled under this 
        section or to providers to induce such providers not to provide 
        such measurements to qualified individuals;
            ``(3) prohibit a provider from discussing with a patient 
        osteoporosis preventive techniques or medical treatment options 
        relating to this section; or
            ``(4) penalize or otherwise reduce or limit the 
        reimbursement of a provider because such provider provided bone 
        mass measurements to a qualified individual in accordance with 
        this section.
    ``(f) Rule of Construction.--Nothing in this section shall be 
construed to require an individual who is a participant or beneficiary 
to undergo bone mass measurement.
    ``(g) 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.
    ``(h) Preemption.--
            ``(1) In general.--The provisions of this section do not 
        preempt State law relating to health insurance coverage to the 
        extent such State law provides greater benefits with respect to 
        osteoporosis detection or prevention.
            ``(2) Construction.--Section 731(a)(1) shall not be 
        construed as superseding a State law described in paragraph 
        (1).''.
            (B) Section 731(c) of such Act (29 U.S.C. 1191(c)), as 
        amended by section 603(b)(1) of Public Law 104-204, is amended 
        by striking ``section 711'' and inserting ``sections 711 and 
        713''.
            (C) Section 732(a) of such Act (29 U.S.C. 1191a(a)), as 
        amended by section 603(b)(2) of Public Law 104-204, is amended 
        by striking ``section 711'' and inserting ``sections 711 and 
        713''.
            (D) The table of contents in section 1 of such Act is 
        amended by inserting after the item relating to section 712 the 
        following new item:

``Sec. 713. Standards relating to benefits for bone mass measurement.
    (b) Individual Health Insurance.--(1) Part B of title XXVII of the 
Public Health Service Act, as amended by section 605(a) of Public Law 
104-204, is amended by inserting after section 2751 the following new 
section:

``SEC. 2752. STANDARDS RELATING TO BENEFITS FOR BONE MASS MEASUREMENT.

    ``(a) In General.--The provisions of section 2706 (other than 
subsection (g)) 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 713(g) 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.--
            ``(1) In general.--The provisions of this section do not 
        preempt State law relating to health insurance coverage to the 
        extent such State law provides greater benefits with respect to 
        osteoporosis detection or prevention.
            ``(2) Construction.--Section 2762(a) shall not be construed 
        as superseding a State law described in paragraph (1).''.
    (2) Section 2762(b)(2) of such Act (42 U.S.C. 300gg-62(b)(2)), as 
added by section 605(b)(3)(B) of Public Law 104-204, is amended by 
striking ``section 2751'' and inserting ``sections 2751 and 2752''.
    (c) Effective Dates.--(1) The amendments made by subsection (a) 
shall apply with respect to group health plans for plan years beginning 
on or after January 1, 1999.
    (2) The amendments 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.