Equity in Prescription Insurance and Contraceptive Coverage Act of 1997

Summary: Equity in Prescription Insurance and Contraceptive Coverage Act of 1997 - Amends the Employee Retirement Income Security Act of 1974 and the Public Health Service Act to prohibit a group health plan, and a health insurance issuer providing group coverage, from: (1) excluding or restricting benefits for prescription contraceptive drugs, devices, and outpatient services if the plan provides benefits for other outpatient prescription drugs, devices, or outpatient services; (2) denying eligibility based on use or potential use of such items or services; (3) providing monetary payments or rebates to a covered individual to encourage acceptance of less than the minimum protections available; (4) penalizing, reducing, or limiting a professional's reimbursement because the professional prescribed such drugs or devices or provided such services; or (5) providing incentives to a professional to induce the professional to withhold drugs, devices, or services.  Amends the Public Health Service Act to apply those prohibitions to coverage offered in the individual market.

SECTION 1. SHORT TITLE.

    This Act may be cited as the ``Equity in Prescription Insurance and 
Contraceptive Coverage Act of 1997''.

SEC. 2. FINDINGS.

    Congress finds that--
            (1) each year, approximately 3,600,000 pregnancies, or 
        nearly 60 percent of all pregnancies, in this country are 
        unintended;
            (2) contraceptive services are part of basic health care, 
        allowing families to both adequately space desired pregnancies 
        and avoid unintended pregnancy;
            (3) studies show that contraceptives are cost effective: 
        for every $1 of public funds invested in family planning, $4 to 
        $14 of public funds is saved in pregnancy and health care-
        related costs;
            (4) by reducing rates of unintended pregnancy, 
        contraceptives help reduce the need for abortion;
            (5) unintended pregnancies lead to higher rates of infant 
        mortality, low-birth weight, and maternal morbidity, and 
        threaten the economic viability of families;
            (6) the National Commission to Prevent Infant Mortality 
        determined that ``infant mortality could be reduced by 10 
        percent if all women not desiring pregnancy used 
        contraception'';
            (7) most women in the United States, including two-thirds 
        of women of childbearing age, rely on some form of private 
        employment-related insurance (through either their own employer 
        or a family member's employer) to defray their medical 
        expenses;
            (8) the vast majority of private insurers cover 
        prescription drugs, but many exclude coverage for prescription 
        contraceptives;
            (9) private insurance provides extremely limited coverage 
        of contraceptives: half of traditional indemnity plans and 
        preferred provider organizations, 20 percent of point-of-
        service networks, and 7 percent of health maintenance 
        organizations cover no contraceptive methods other than 
        sterilization;
            (10) women of reproductive age spend 68 percent more than 
        men on out-of-pocket health care costs, with contraceptives and 
        reproductive health care services accounting for much of the 
        difference;
            (11) the lack of contraceptive coverage in health insurance 
        places many effective forms of contraceptives beyond the 
        financial reach of many women, leading to unintended 
        pregnancies; and
            (12) the Institute of Medicine Committee on Unintended 
        Pregnancy recently recommended that ``financial barriers to 
        contraception be reduced by increasing the proportion of all 
        health insurance policies that cover contraceptive services and 
        supplies''.

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 (as added by 
section 603(a) of the Newborns' and Mothers' Health Protection Act of 
1996 and amended by section 702(a) of the Mental Health Parity Act of 
1996) is further amended by adding at the end the following new 
section:

``SEC. 713. STANDARDS RELATING TO BENEFITS FOR CONTRACEPTIVES.

    ``(a) Requirements for Coverage.--A group health plan, and a health 
insurance issuer providing health insurance coverage in connection with 
a group health plan, may not--
            ``(1) exclude or restrict benefits for prescription 
        contraceptive drugs or devices approved by the Food and Drug 
        Administration, or generic equivalents approved as 
        substitutable by the Food and Drug Administration, if such plan 
        provides benefits for other outpatient prescription drugs or 
        devices; or
            ``(2) exclude or restrict benefits for outpatient 
        contraceptive services if such plan provides benefits for other 
        outpatient services provided by a health care professional 
        (referred to in this section as `outpatient health care 
        services').
    ``(b) Prohibitions.--A group health plan, and a health insurance 
issuer providing 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 because of the individual's or enrollee's use or 
        potential use of items or services that are covered in 
        accordance with the requirements of this section;
            ``(2) provide monetary payments or rebates to a covered 
        individual to encourage such individual to accept less than the 
        minimum protections available under this section;
            ``(3) penalize or otherwise reduce or limit the 
        reimbursement of a health care professional because such 
        professional prescribed contraceptive drugs or devices, or 
        provided contraceptive services, described in subsection (a), 
        in accordance with this section; or
            ``(4) provide incentives (monetary or otherwise) to a 
        health care professional to induce such professional to 
        withhold from a covered individual contraceptive drugs or 
        devices, or contraceptive services, described in subsection 
        (a).
    ``(c) Rules of Construction.--
            ``(1) In general.--Nothing in this section shall be 
        construed--
                    ``(A) as preventing a group health plan and a 
                health insurance issuer providing health insurance 
                coverage in connection with a group health plan from 
                imposing deductibles, coinsurance, or other cost-
                sharing or limitations in relation to--
                            ``(i) benefits for contraceptive drugs 
                        under the plan, except that such a deductible, 
                        coinsurance, or other cost-sharing or 
                        limitation for any such drug may not be greater 
                        than such a deductible, coinsurance, or cost-
                        sharing or limitation for any outpatient 
                        prescription drug otherwise covered under the 
                        plan;
                            ``(ii) benefits for contraceptive devices 
                        under the plan, except that such a deductible, 
                        coinsurance, or other cost-sharing or 
                        limitation for any such device may not be 
                        greater than such a deductible, coinsurance, or 
                        cost-sharing or limitation for any outpatient 
                        prescription device otherwise covered under the 
                        plan; and
                            ``(iii) benefits for outpatient 
                        contraceptive services under the plan, except 
                        that such a deductible, coinsurance, or other 
                        cost-sharing or limitation for any such service 
                        may not be greater than such a deductible, 
                        coinsurance, or cost-sharing or limitation for 
                        any outpatient health care service otherwise 
                        covered under the plan; and
                    ``(B) as requiring a group health plan and a health 
                insurance issuer providing health insurance coverage in 
                connection with a group health plan to cover 
                experimental or investigational contraceptive drugs or 
                devices, or experimental or investigational 
                contraceptive services, described in subsection (a), 
                except to the extent that the plan or issuer provides 
                coverage for other experimental or investigational 
                outpatient prescription drugs or devices, or 
                experimental or investigational outpatient health care 
                services.
            ``(2) Limitations.--As used in paragraph (1), the term 
        `limitation' includes--
                    ``(A) in the case of a contraceptive drug or 
                device, restricting the type of health care 
                professionals that may prescribe such drugs or devices, 
                utilization review provisions, and limits on the volume 
                of prescription drugs or devices that may be obtained 
                on the basis of a single consultation with a 
                professional; or
                    ``(B) in the case of an outpatient contraceptive 
                service, restricting the type of health care 
                professionals that may provide such services, 
                utilization review provisions, requirements relating to 
                second opinions prior to the coverage of such services, 
                and requirements relating to preauthorizations prior to 
                the coverage of such services.
    ``(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) Preemption.--Nothing in this section shall be construed to 
preempt any provision of State law to the extent that such State law 
establishes, implements, or continues in effect any standard or 
requirement that provides protections for enrollees that are greater 
than the protections provided under this section.
    ``(f) Definition.--In this section, the term `outpatient 
contraceptive services' means consultations, examinations, procedures, 
and medical services, provided on an outpatient basis and related to 
the use of contraceptive methods (including natural family planning) to 
prevent an unintended pregnancy.''.
    (b) Clerical Amendment.--The table of contents in section 1 of such 
Act, as amended by section 603 of the Newborns' and Mothers' Health 
Protection Act of 1996 and section 702 of the Mental Health Parity Act 
of 1996, is amended by inserting after the item relating to section 712 
the following new item:

``Sec. 713. Standards relating to benefits for contraceptives.''.
    (c) Effective Date.--The amendments made by this section shall 
apply with respect to plan years beginning on or after January 1, 1998.

SEC. 4. AMENDMENTS TO THE PUBLIC HEALTH SERVICE ACT RELATING TO THE 
              GROUP MARKET.

    (a) In General.--Subpart 2 of part A of title XXVII of the Public 
Health Service Act (as added by section 604(a) of the Newborns' and 
Mothers' Health Protection Act of 1996 and amended by section 703(a) of 
the Mental Health Parity Act of 1996) is further amended by adding at 
the end the following new section:

``SEC. 2706. STANDARDS RELATING TO BENEFITS FOR CONTRACEPTIVES.

    ``(a) Requirements for Coverage.--A group health plan, and a health 
insurance issuer providing health insurance coverage in connection with 
a group health plan, may not--
            ``(1) exclude or restrict benefits for prescription 
        contraceptive drugs or devices approved by the Food and Drug 
        Administration, or generic equivalents approved as 
        substitutable by the Food and Drug Administration, if such plan 
        provides benefits for other outpatient prescription drugs or 
        devices; or
            ``(2) exclude or restrict benefits for outpatient 
        contraceptive services if such plan provides benefits for other 
        outpatient services provided by a health care professional 
        (referred to in this section as `outpatient health care 
        services').
    ``(b) Prohibitions.--A group health plan, and a health insurance 
issuer providing 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 because of the individual's or enrollee's use or 
potential use of items or services that are covered in accordance with 
the requirements of this section;
            ``(2) provide monetary payments or rebates to a covered 
        individual to encourage such individual to accept less than the 
        minimum protections available under this section;
            ``(3) penalize or otherwise reduce or limit the 
        reimbursement of a health care professional because such 
        professional prescribed contraceptive drugs or devices, or 
        provided contraceptive services, described in subsection (a), 
        in accordance with this section; or
            ``(4) provide incentives (monetary or otherwise) to a 
        health care professional to induce such professional to 
        withhold from covered individual contraceptive drugs or 
        devices, or contraceptive services, described in subsection 
        (a).
    ``(c) Rules of Construction.--
            ``(1) In general.--Nothing in this section shall be 
        construed--
                    ``(A) as preventing a group health plan and a 
                health insurance issuer providing health insurance 
                coverage in connection with a group health plan from 
                imposing deductibles, coinsurance, or other cost-
                sharing or limitations in relation to--
                            ``(i) benefits for contraceptive drugs 
                        under the plan, except that such a deductible, 
                        coinsurance, or other cost-sharing or 
                        limitation for any such drug may not be greater 
                        than such a deductible, coinsurance, or cost-
                        sharing or limitation for any outpatient 
                        prescription drug otherwise covered under the 
                        plan;
                            ``(ii) benefits for contraceptive devices 
                        under the plan, except that such a deductible, 
                        coinsurance, or other cost-sharing or 
                        limitation for any such device may not be 
                        greater than such a deductible, coinsurance, or 
                        cost-sharing or limitation for any outpatient 
                        prescription device otherwise covered under the 
                        plan; and
                            ``(iii) benefits for outpatient 
                        contraceptive services under the plan, except 
                        that such a deductible, coinsurance, or other 
                        cost-sharing or limitation for any such service 
                        may not be greater than such a deductible, 
                        coinsurance, or cost-sharing or limitation for 
                        any outpatient health care service otherwise 
                        covered under the plan; and
                    ``(B) as requiring a group health plan and a health 
                insurance issuer providing health insurance coverage in 
                connection with a group health plan to cover 
                experimental or investigational contraceptive drugs or 
                devices, or experimental or investigational 
                contraceptive services, described in subsection (a), 
                except to the extent that the plan or issuer provides 
                coverage for other experimental or investigational 
                outpatient prescription drugs or devices, or 
                experimental or investigational outpatient health care 
                services.
            ``(2) Limitations.--As used in paragraph (1), the term 
        `limitation' includes--
                    ``(A) in the case of a contraceptive drug or 
                device, restricting the type of health care 
                professionals that may prescribe such drugs or devices, 
                utilization review provisions, and limits on the volume 
                of prescription drugs or devices that may be obtained 
                on the basis of a single consultation with a 
                professional; or
                    ``(B) in the case of an outpatient contraceptive 
                service, restricting the type of health care 
                professionals that may provide such services, 
                utilization review provisions, requirements relating to 
                second opinions prior to the coverage of such services, 
                and requirements relating to preauthorizations prior to 
                the coverage of such services.
    ``(d) Notice.--A group health plan under this part shall comply 
with the notice requirement under section 713(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) Preemption.--Nothing in this section shall be construed to 
preempt any provision of State law to the extent that such State law 
establishes, implements, or continues in effect any standard or 
requirement that provides protections for enrollees that are greater 
than the protections provided under this section.
    ``(f) Definition.--In this section, the term `outpatient 
contraceptive services' means consultations, examinations, procedures, 
and medical services, provided on an outpatient basis and related to 
the use of contraceptive methods (including natural family planning) to 
prevent an unintended pregnancy.''.
    (b) Effective Date.--The amendments made by this section shall 
apply with respect to group health plans for plan years beginning on or 
after January 1, 1998.

SEC. 5. AMENDMENT TO THE PUBLIC HEALTH SERVICE ACT RELATING TO THE 
              INDIVIDUAL MARKET.

    (a) In General.--Subpart 3 of part B of title XXVII of the Public 
Health Service Act (as added by section 605(a) of the Newborn's and 
Mother's Health Protection Act of 1996) is amended by adding at the end 
the following new section:

``SEC. 2752. STANDARDS RELATING TO BENEFITS FOR CONTRACEPTIVES.

    ``The provisions of section 2706 shall apply to health insurance 
coverage offered by a health insurance issuer in the individual market 
in the same manner as they apply 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) Effective Date.--The amendment made by this section shall apply 
with respect to health insurance coverage offered, sold, issued, 
renewed, in effect, or operated in the individual market on or after 
January 1, 1998.