I

106TH CONGRESS

1ST SESSION H. R. 925

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 qualified

individuals for bone mass measurement (bone density testing) to prevent

fractures associated with osteoporosis and to help women make informed

choices about their reproductive and post-menopausal health care.

IN THE HOUSE OF REPRESENTATIVES

MARCH 2, 1999

Mrs. MALONEY of New York (for herself, Mrs. MORELLA, Mr. PASCRELL,

Mrs. KELLY, Mr. GREEN of Texas, Mr. COOK, Ms. BERKLEY, Mrs.

MCCARTHY of New York, Mrs. THURMAN, Mrs. CHRISTIANCHRISTENSEN, Ms. KILPATRICK, Mrs. CLAYTON, Ms. MILLENDERMCDONALD, Ms. HOOLEY of Oregon, Ms. DELAURO, Ms. WOOLSEY,

Mrs. NAPOLITANO, Ms. VELA ́ZQUEZ, Mrs. MINK of Hawaii, Mr. KENNEDY of Rhode Island, Mr. FROST, Mr. WEINER, Mr. CROWLEY, Mr.

SHOWS, Mr. MCNULTY, Mr. KLECZKA, Mr. GUTIERREZ, Mr. FILNER,

Mr. RUSH, Mr. SHERMAN, Mr. NADLER, Mr. LANTOS, Mr. NEAL of Massachusetts, Mr. SANDLIN, Mr. BISHOP, Mr. CUMMINGS, Mr. HINCHEY,

Mr. FORD, Mr. BROWN of California, Mr. UNDERWOOD, Mr. DIXON, Mr.

BORSKI, Mr. SANDERS, Mr. CLEMENT, Mr. MASCARA, and Mr.

FALEOMAVAEGA) introduced the following bill; which was referred to the

Committee on 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
2

•HR 925 IH

group health plans provide coverage for qualified individuals for bone mass measurement (bone density testing)

to prevent fractures associated with osteoporosis and to

help women make informed choices about their reproductive and post-menopausal health care.

1 Be it enacted by the Senate and House of Representa2 tives of the United States of America in Congress assembled,

3 SECTION 1. SHORT TITLE; FINDINGS.

4 (a) SHORT TITLE.—This Act may be cited as the

5 ‘‘Osteoporosis Early Detection and Prevention Act of

6 1999’’.

7 (b) FINDINGS.—Congress makes the following find8 ings:

9 (1) NATURE OF OSTEOPOROSIS.—

10 (A) Osteoporosis is a disease characterized

11 by low bone mass and structural deterioration

12 of bone tissue leading to bone fragility and in13 creased susceptibility to fractures of the hip.

14 spine, and wrist.

15 (B) Osteoporosis has no symptoms and

16 typically remains undiagnosed until a fracture

17 occurs.

18 (C) Once a fracture occurs, the condition

19 has usually advanced to the stage where the

20 likelihood is high that another fracture will

21 occur.
3

•HR 925 IH

1 (D) There is no cure for osteoporosis, but

2 drug therapy has been shown to reduce new hip

3 and spine fractures by 50 percent and other

4 treatments, such as nutrition therapy, have also

5 proven effective.

6 (2) INCIDENCE OF OSTEOPOROSIS.—

7 Osteoporosis is a common condition:

8 (A) Of the 28 million Americans who have

9 (or are at risk for) osteoporosis, 80 percent are

10 women.

11 (B) Annually there are 1.5 million bone

12 fractures attributable to osteoporosis.

13 (C) Half of all women, and one-eighth of

14 all men, age 50 or older will have a bone frac15 ture due to osteoporosis.

16 (3) IMPACT OF OSTEOPOROSIS.—The cost of

17 treating osteoporosis is significant:

18 (A) The annual cost of osteoporosis in the

19 United States is $13.8 billion.

20 (B) The average cost in the United States

21 of repairing a hip fracture due to osteoporosis

22 is $32,000, while the average cost of an

23 osteoporosis screening test is $250.
4

•HR 925 IH

1 (C) Fractures due to osteoporosis fre2 quently result in disability and institutionaliza3 tion of individuals.

4 (D) Because osteoporosis is a progressive

5 condition causing fractures primarily in aging

6 individuals, preventing fractures particularly in

7 post menopausal women before they become eli8 gible for medicare, has a significant potential of

9 reducing osteoporosis-related costs under the

10 medicare program.

11 (4) USE OF BONE MASS MEASUREMENT.—

12 (A) Bone mass measurement is a non13 invasive, painless, and reliable way to diagnose

14 osteoporosis before costly fractures occur.

15 (B) Low bone mass is as predictive of fu16 ture fractures as is high cholesterol or high

17 blood pressure of heart disease or stroke.

18 (C) Bone mass measurement is the only

19 reliable method of detecting osteoporosis at an

20 early stage.

21 (D) Under section 4106 of the Balanced

22 Budget Act of 1997, medicare provides cov23 erage, effective July 1, 1998, for bone mass

24 measurement for qualified individuals who are

25 at risk of developing osteoporosis.
5

•HR 925 IH

1 SEC. 2. REQUIRING COVERAGE OF BONE MASS MEASURE2 MENT UNDER HEALTH PLANS.

3 (a) GROUP HEALTH PLANS.—

4 (1) PUBLIC HEALTH SERVICE ACT AMEND5 MENTS.—(A) Subpart 2 of part A of title XXVII of

6 the Public Health Service Act is amended by adding

7 at the end the following new section:

8 ‘‘SEC. 2707. STANDARDS RELATING TO BENEFITS FOR BONE

9 MASS MEASUREMENT.

10 ‘‘(a) REQUIREMENTS FOR COVERAGE OF BONE MASS

11 MEASUREMENT.—A group health plan, and a health in12 surance issuer offering group health insurance coverage,

13 shall include (consistent with this section) coverage for

14 bone mass measurement for beneficiaries and participants

15 who are qualified individuals.

16 ‘‘(b) DEFINITIONS RELATING TO COVERAGE.—In

17 this section:

18 ‘‘(1) BONE MASS MEASUREMENT.—The term

19 ‘bone mass measurement’ means a radiologic or

20 radioisotopic procedure or other procedure approved

21 by the Food and Drug Administration performed on

22 an individual for the purpose of identifying bone

23 mass or detecting bone loss or determining bone

24 quality, and includes a physician’s interpretation of

25 the results of the procedure. Nothing in this para26 graph shall be construed as requiring a bone mass
6

•HR 925 IH

1 measurement to be conducted in a particular type of

2 facility or to prevent such a measurement from

3 being conducted through the use of mobile facilities

4 that are otherwise qualified.

5 ‘‘(2) QUALIFIED INDIVIDUAL.—The term ‘quali6 fied individual’ means an individual who—

7 ‘‘(A) is an estrogen-deficient woman at

8 clinical risk for osteoporosis;

9 ‘‘(B) has vertebral abnormalities;

10 ‘‘(C) is receiving chemotherapy or long11 term gluococorticoid (steroid) therapy;

12 ‘‘(D) has primary hyperparathyroidism,

13 hyperthyroidism, or excess thyroid replacement;

14 or

15 ‘‘(E) is being monitored to assess the re16 sponse to or efficacy of approved osteoporosis

17 drug therapy.

18 ‘‘(c) LIMITATION ON FREQUENCY REQUIRED.—Tak19 ing into account the standards established under section

20 1861(rr)(3) of the Social Security Act, the Secretary shall

21 establish standards regarding the frequency with which a

22 qualified individual shall be eligible to be provided benefits

23 for bone mass measurement under this section. The Sec24 retary may vary such standards based on the clinical and

25 risk-related characteristics of qualified individuals.
7

•HR 925 IH

1 ‘‘(d) RESTRICTIONS ON COST-SHARING.—

2 ‘‘(1) IN GENERAL.—Subject to paragraph (2),

3 nothing in this section shall be construed as prevent4 ing a group health plan or issuer from imposing

5 deductibles, coinsurance, or other cost-sharing in re6 lation to bone mass measurement under the plan (or

7 health insurance coverage offered in connection with

8 a plan).

9 ‘‘(2) LIMITATION.—Deductibles, coinsurance,

10 and other cost-sharing or other limitations for bone

11 mass measurement may not be imposed under para12 graph (1) to the extent they exceed the deductibles,

13 coinsurance, and limitations that are applied to simi14 lar services under the group health plan or health

15 insurance coverage.

16 ‘‘(e) PROHIBITIONS.—A group health plan, and a

17 health insurance issuer offering group health insurance

18 coverage in connection with a group health plan, may

19 not—

20 ‘‘(1) deny to an individual eligibility, or contin21 ued eligibility, to enroll or to renew coverage under

22 the terms of the plan, solely for the purpose of

23 avoiding the requirements of this section;

24 ‘‘(2) provide incentives (monetary or otherwise)

25 to individuals to encourage such individuals not to
8

•HR 925 IH

1 be provided bone mass measurements to which they

2 are entitled under this section or to providers to in3 duce such providers not to provide such measure4 ments to qualified individuals;

5 ‘‘(3) prohibit a provider from discussing with a

6 patient osteoporosis preventive techniques or medical

7 treatment options relating to this section; or

8 ‘‘(4) penalize or otherwise reduce or limit the

9 reimbursement of a provider because such provider

10 provided bone mass measurements to a qualified in11 dividual in accordance with this section.

12 ‘‘(f) RULE OF CONSTRUCTION.—Nothing in this sec13 tion shall be construed to require an individual who is a

14 participant or beneficiary to undergo bone mass measure15 ment.

16 ‘‘(g) NOTICE.—A group health plan under this part

17 shall comply with the notice requirement under section

18 714(g) of the Employee Retirement Income Security Act

19 of 1974 with respect to the requirements of this section

20 as if such section applied to such plan.

21 ‘‘(h) LEVEL AND TYPE OF REIMBURSEMENTS.—

22 Nothing in this section shall be construed to prevent a

23 group health plan or a health insurance issuer offering

24 group health insurance coverage from negotiating the level
9

•HR 925 IH

1 and type of reimbursement with a provider for care pro2 vided in accordance with this section.

3 ‘‘(i) PREEMPTION.—

4 ‘‘(1) IN GENERAL.—The provisions of this sec5 tion do not preempt State law relating to health in6 surance coverage to the extent such State law pro7 vides greater benefits with respect to osteoporosis

8 detection or prevention.

9 ‘‘(2) CONSTRUCTION.—Section 2723(a)(1) shall

10 not be construed as superseding a State law de11 scribed in paragraph (1).’’.

12 (B) Section 2723(c) of such Act (42 U.S.C.

13 300gg–23(c)) is amended by striking ‘‘section 2704’’

14 and inserting ‘‘sections 2704 and 2707’’.

15 (2) ERISA AMENDMENTS.—(A) Subpart B of

16 part 7 of subtitle B of title I of the Employee Re17 tirement Income Security Act of 1974 is amended by

18 adding at the end the following new section:

19 ‘‘SEC. 714. STANDARDS RELATING TO BENEFITS FOR BONE

20 MASS MEASUREMENT.

21 ‘‘(a) REQUIREMENTS FOR COVERAGE OF BONE MASS

22 MEASUREMENT.—A group health plan, and a health in23 surance issuer offering group health insurance coverage,

24 shall include (consistent with this section) coverage for
10

•HR 925 IH

1 bone mass measurement for beneficiaries and participants

2 who are qualified individuals.

3 ‘‘(b) DEFINITIONS RELATING TO COVERAGE.—In

4 this section:

5 ‘‘(1) BONE MASS MEASUREMENT.—The term

6 ‘bone mass measurement’ means a radiologic or

7 radioisotopic procedure or other procedure approved

8 by the Food and Drug Administration performed on

9 an individual for the purpose of identifying bone

10 mass or detecting bone loss or determining bone

11 quality, and includes a physician’s interpretation of

12 the results of the procedure. Nothing in this para13 graph shall be construed as requiring a bone mass

14 measurement to be conducted in a particular type

15 of facility or to prevent such a measurement from

16 being conducted through the use of mobile facilities

17 that are otherwise qualified.

18 ‘‘(2) QUALIFIED INDIVIDUAL.—The term ‘quali19 fied individual’ means an individual who—

20 ‘‘(A) is an estrogen-deficient woman at

21 clinical risk for osteoporosis;

22 ‘‘(B) has vertebral abnormalities;

23 ‘‘(C) is receiving chemotherapy or long24 term gluococorticoid (steroid) therapy;
11

•HR 925 IH

1 ‘‘(D) has primary hyperparathyroidism,

2 hyperthyroidism, or excess thyroid replacement;

3 or

4 ‘‘(E) is being monitored to assess the re5 sponse to or efficacy of approved osteoporosis

6 drug therapy.

7 ‘‘(c) LIMITATION ON FREQUENCY REQUIRED.—The

8 standards established under section 2707(c) of the Public

9 Health Service Act shall apply to benefits provided under

10 this section in the same manner as they apply to benefits

11 provided under section 2707 of such Act.

12 ‘‘(d) RESTRICTIONS ON COST-SHARING.—

13 ‘‘(1) IN GENERAL.—Subject to paragraph (2),

14 nothing in this section shall be construed as prevent15 ing a group health plan or issuer from imposing

16 deductibles, coinsurance, or other cost-sharing in re17 lation to bone mass measurement under the plan (or

18 health insurance coverage offered in connection with

19 a plan).

20 ‘‘(2) LIMITATION.—Deductibles, coinsurance,

21 and other cost-sharing or other limitations for bone

22 mass measurement may not be imposed under para23 graph (1) to the extent they exceed the deductibles,

24 coinsurance, and limitations that are applied to simi-
12

•HR 925 IH

1 lar services under the group health plan or health

2 insurance coverage.

3 ‘‘(e) PROHIBITIONS.—A group health plan, and a

4 health insurance issuer offering group health insurance

5 coverage in connection with a group health plan, may

6 not—

7 ‘‘(1) deny to an individual eligibility, or contin8 ued eligibility, to enroll or to renew coverage under

9 the terms of the plan, solely for the purpose of

10 avoiding the requirements of this section;

11 ‘‘(2) provide incentives (monetary or otherwise)

12 to individuals to encourage such individuals not to

13 be provided bone mass measurements to which they

14 are entitled under this section or to providers to in15 duce such providers not to provide such measure16 ments to qualified individuals;

17 ‘‘(3) prohibit a provider from discussing with a

18 patient osteoporosis preventive techniques or medical

19 treatment options relating to this section; or

20 ‘‘(4) penalize or otherwise reduce or limit the

21 reimbursement of a provider because such provider

22 provided bone mass measurements to a qualified in23 dividual in accordance with this section.

24 ‘‘(f) RULE OF CONSTRUCTION.—Nothing in this sec25 tion shall be construed to require an individual who is a
13

•HR 925 IH

1 participant or beneficiary to undergo bone mass measure2 ment.

3 ‘‘(g) NOTICE UNDER GROUP HEALTH PLAN.—The

4 imposition of the requirements of this section shall be

5 treated as a material modification in the terms of the plan

6 described in section 102(a)(1), for purposes of assuring

7 notice of such requirements under the plan; except that

8 the summary description required to be provided under the

9 last sentence of section 104(b)(1) with respect to such

10 modification shall be provided by not later than 60 days

11 after the first day of the first plan year in which such

12 requirements apply.

13 ‘‘(h) PREEMPTION.—

14 ‘‘(1) IN GENERAL.—The provisions of this sec15 tion do not preempt State law relating to health in16 surance coverage to the extent such State law pro17 vides greater benefits with respect to osteoporosis

18 detection or prevention.

19 ‘‘(2) CONSTRUCTION.—Section 731(a)(1) shall

20 not be construed as superseding a State law de21 scribed in paragraph (1).’’.

22 (B) Section 731(c) of such Act (29 U.S.C.

23 1191(c)) is amended by striking ‘‘section 711’’ and

24 inserting ‘‘sections 711 and 714’’.
14

•HR 925 IH

1 (C) Section 732(a) of such Act (29 U.S.C.

2 1191a(a)) is amended by striking ‘‘section 711’’ and

3 inserting ‘‘sections 711 and 714’’.

4 (D) The table of contents in section 1 of such

5 Act is amended by inserting after the item relating

6 to section 712 the following new item:

‘‘Sec. 714. Standards relating to benefits for bone mass measurement.

7 (b) INDIVIDUAL HEALTH INSURANCE.—(1) Part B

8 of title XXVII of the Public Health Service Act is amend9 ed by inserting after section 2751 the following new sec10 tion:

11 ‘‘SEC. 2752. STANDARDS RELATING TO BENEFITS FOR BONE

12 MASS MEASUREMENT.

13 ‘‘(a) IN GENERAL.—The provisions of section 2707

14 (other than subsection (g)) shall apply to health insurance

15 coverage offered by a health insurance issuer in the indi16 vidual market in the same manner as it applies to health

17 insurance coverage offered by a health insurance issuer

18 in connection with a group health plan in the small or

19 large group market.

20 ‘‘(b) NOTICE.—A health insurance issuer under this

21 part shall comply with the notice requirement under sec22 tion 714(g) of the Employee Retirement Income Security

23 Act of 1974 with respect to the requirements referred to

24 in subsection (a) as if such section applied to such issuer

25 and such issuer were a group health plan.
15

•HR 925 IH

1 ‘‘(c) PREEMPTION.—

2 ‘‘(1) IN GENERAL.—The provisions of this sec3 tion do not preempt State law relating to health in4 surance coverage to the extent such State law pro5 vides greater benefits with respect to osteoporosis

6 detection or prevention.

7 ‘‘(2) CONSTRUCTION.—Section 2762(a) shall

8 not be construed as superseding a State law de9 scribed in paragraph (1).’’.

10 (2) Section 2762(b)(2) of such Act (42 U.S.C.

11 300gg–62(b)(2)) is amended by striking ‘‘section 2751’’

12 and inserting ‘‘sections 2751 and 2752’’.

13 (c) EFFECTIVE DATES.—(1) The amendments made

14 by subsection (a) shall apply with respect to group health

15 plans for plan years beginning on or after January 1,

16 2000.

17 (2) The amendments made by subsection (b) shall

18 apply with respect to health insurance coverage offered,

19 sold, issued, renewed, in effect, or operated in the individ20 ual market on or after such date.

Æ