II

106TH CONGRESS

1ST SESSION S. 1106

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.

IN THE SENATE OF THE UNITED STATES

MAY 24, 1999

Mr. TORRICELLI (for himself and Ms. SNOWE) introduced the following bill;

which was read twice and referred to the Committee on Health, Education, Labor, and Pensions

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 qualified individuals for bone mass measurement (bone density testing)

to prevent fractures associated with osteoporosis.

1 Be it enacted by the Senate and House of Representa2 tives of the United States of America in Congress assembled,
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1 SECTION 1. SHORT TITLE; FINDINGS.

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

3 ‘‘Early Detection and Prevention of Osteoporosis and Re4 lated Bone Diseases Act of 1999’’.

5 (b) FINDINGS.—Congress makes the following find6 ings:

7 (1) NATURE OF OSTEOPOROSIS.—

8 (A) Osteoporosis is a disease characterized

9 by low bone mass and structural deterioration

10 of bone tissue leading to bone fragility and in11 creased susceptibility to fractures of the hip,

12 spine, and wrist.

13 (B) Osteoporosis has no symptoms and

14 typically remains undiagnosed until a fracture

15 occurs.

16 (C) Once a fracture occurs, the condition

17 has usually advanced to the stage where the

18 likelihood is high that another fracture will

19 occur.

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

21 drug therapy has been shown to reduce new hip

22 and spine fractures by 50 percent and other

23 treatments, such as nutrition therapy, have also

24 proven effective.

25 (2) INCIDENCE OF OSTEOPOROSIS AND RE26 LATED BONE DISEASES.—
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1 (A) 28 million Americans have (or are at

2 risk for) osteoporosis, 80 percent of which are

3 women.

4 (B) Osteoporosis is responsible for 1.5 mil5 lion bone fractures annually, including more

6 than 300,000 hip fractures, 700,000 vertebral

7 fractures and 200,000 fractures of the wrists.

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

9 all men, age 50 or older will have a bone frac10 ture due to osteoporosis.

11 (D) Between 3 and 4 million Americans

12 have Paget’s disease, osteogenesis imperfecta,

13 hyperparathyroidism, and other related meta14 bolic bone diseases.

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

16 treating osteoporosis is significant:

17 (A) The annual cost of osteoporosis in the

18 United States is $13.8 billion and is expected to

19 increase precipitously because the proportion of

20 the population comprised of older persons is ex21 panding and each generation of older persons

22 tends to have a higher incidence of osteoporosis

23 than preceding generations.
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1 (B) The average cost in the United States

2 of repairing a hip fracture due to osteoporosis

3 is $32,000.

4 (C) Fractures due to osteoporosis fre5 quently result in disability and institutionaliza6 tion of individuals.

7 (D) Because osteoporosis is a progressive

8 condition causing fractures primarily in aging

9 individuals, preventing fractures, particularly

10 for post menopausal women before they become

11 eligible for medicare, has a significant potential

12 of reducing osteoporosis-related costs under the

13 medicare program.

14 (4) USE OF BONE MASS MEASUREMENT.—

15 (A) Bone mass measurement is the only

16 reliable method of detecting osteoporosis at an

17 early stage.

18 (B) Low bone mass is as predictive of fu19 ture fractures as is high cholesterol or high

20 blood pressure of heart disease or stroke.

21 (C) Bone mass measurement is a non22 invasive, painless, and reliable way to diagnose

23 osteoporosis before costly fractures occur.

24 (D) Under section 4106 of the Balanced

25 Budget Act of 1997, Medicare provides cov-
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1 erage, effective July 1, 1999, for bone mass

2 measurement for qualified individuals who are

3 at risk of developing osteoporosis.

4 (5) RESEARCH ON OSTEOPOROSIS AND RE5 LATED BONE DISEASES.—

6 (A) Technology now exists, and new tech7 nology is developing, that will permit the early

8 diagnosis and prevention of osteoporosis and re9 lated bone diseases as well as management of

10 these conditions once they develop.

11 (B) Funding for research on osteoporosis

12 and related bone diseases is severely con13 strained at key research institutes, including

14 the National Institute of Arthritis and Musculo15 skeletal and Skin Diseases, the National Insti16 tute on Aging, the National Institute of Dia17 betics and Digestive and Kidney Diseases, the

18 National Institute of Dental Research, and the

19 National Institute of Child Health and Human

20 Development.

21 (C) Further research is needed to improve

22 medical knowledge concerning—

23 (i) cellular mechanisms related to the

24 processes of bone resorption and bone for-
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1 mation, and the effect of different agents

2 on bone remodeling;

3 (ii) risk factors for osteoporosis, in4 cluding newly discovered risk factors, risk

5 factors related to groups not ordinarily

6 studied (such as men and minorities), risk

7 factors related to genes that help to control

8 skeletal metabolism, and risk factors relat9 ing to the relationship of aging processes

10 to the development of osteoporosis;

11 (iii) bone mass measurement tech12 nology, including more widespread and

13 cost-effective techniques for making more

14 precise measurements and for interpreting

15 measurements;

16 (iv) calcium (including bioavailability,

17 intake requirements, and the role of cal18 cium in building heavier and denser skele19 tons), and vitamin D and its role as an es20 sential vitamin in adults;

21 (v) prevention and treatment, includ22 ing the efficacy of current therapies, alter23 native drug therapies for prevention and

24 treatment, and the role of exercise; and

25 (vi) rehabilitation.
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1 (D) Further educational efforts are needed

2 to increase public and professional knowledge of

3 the causes of, methods for avoiding, and treat4 ment of osteoporosis.

5 SEC. 2. REQUIRING COVERAGE OF BONE MASS MEASURE6 MENT UNDER HEALTH PLANS.

7 (a) GROUP HEALTH PLANS.—

8 (1) PUBLIC HEALTH SERVICE ACT AMEND9 MENTS.—

10 (A) IN GENERAL.—Subpart 2 of part A of

11 title XXVII of the Public Health Service Act

12 (42 U.S.C. 300gg–4) is amended by adding at

13 the end the following new section:

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

15 MASS MEASUREMENT.

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

17 MEASUREMENT.—A group health plan, and a health in18 surance issuer offering group health insurance coverage,

19 shall include (consistent with this section) coverage for

20 bone mass measurement for beneficiaries and participants

21 who are qualified individuals.

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

23 this section:

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

25 ‘bone mass measurement’ means a radiologic or
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1 radioisotopic procedure or other procedure approved

2 by the Food and Drug Administration performed on

3 an individual for the purpose of identifying bone

4 mass or detecting bone loss or determining bone

5 quality, and includes a physician’s interpretation of

6 the results of the procedure. Nothing in this para7 graph shall be construed as requiring a bone mass

8 measurement to be conducted in a particular type of

9 facility or to prevent such a measurement from

10 being conducted through the use of mobile facilities

11 that are otherwise qualified.

12 ‘‘(2) QUALIFIED INDIVIDUAL.—The term ‘quali13 fied individual’ means an individual who—

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

15 clinical risk for osteoporosis;

16 ‘‘(B) has vertebral abnormalities;

17 ‘‘(C) is receiving chemotherapy or long18 term gluococorticoid (steroid) therapy;

19 ‘‘(D) has primary hyperparathyroidism,

20 hyperthyroidism, or excess thyroid replacement;

21 ‘‘(E) is being monitored to assess the re22 sponse to or efficacy of approved osteoporosis

23 drug therapy;

24 ‘‘(F) is a man with a low trauma fracture;

25 or
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1 ‘‘(G) the Secretary determines is eligible.

2 ‘‘(c) LIMITATION ON FREQUENCY REQUIRED.—Tak3 ing into account the standards established under section

4 1861(rr)(3) of the Social Security Act, the Secretary shall

5 establish standards regarding the frequency with which a

6 qualified individual shall be eligible to be provided benefits

7 for bone mass measurement under this section. The Sec8 retary may vary such standards based on the clinical and

9 risk-related characteristics of qualified individuals.

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

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

12 nothing in this section shall be construed as pre13 venting a group health plan or issuer from imposing

14 deductibles, coinsurance, or other cost-sharing in re15 lation to bone mass measurement under the plan (or

16 health insurance coverage offered in connection with

17 a plan).

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

19 and other cost-sharing or other limitations for bone

20 mass measurement may not be imposed under para21 graph (1) to the extent they exceed the deductibles,

22 coinsurance, and limitations that are applied to simi23 lar services under the group health plan or health

24 insurance coverage.
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1 ‘‘(e) PROHIBITIONS.—A group health plan, and a

2 health insurance issuer offering group health insurance

3 coverage in connection with a group health plan, may

4 not—

5 ‘‘(1) deny to an individual eligibility, or contin6 ued eligibility, to enroll or to renew coverage under

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

8 avoiding the requirements of this section;

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

10 to individuals to encourage such individuals not to

11 be provided bone mass measurements to which they

12 are entitled under this section or to providers to in13 duce such providers not to provide such measure14 ments to qualified individuals;

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

16 patient osteoporosis preventive techniques or medical

17 treatment options relating to this section; or

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

19 reimbursement of a provider because such provider

20 provided bone mass measurements to a qualified in21 dividual in accordance with this section.

22 ‘‘(f) RULE OF CONSTRUCTION.—Nothing in this sec23 tion shall be construed to require an individual who is a

24 participant or beneficiary to undergo bone mass measure25 ment.
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1 ‘‘(g) NOTICE.—A group health plan under this part

2 shall comply with the notice requirement under section

3 714(g) of the Employee Retirement Income Security Act

4 of 1974 with respect to the requirements of this section

5 as if such section applied to such plan.

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

7 Nothing in this section shall be construed to prevent a

8 group health plan or a health insurance issuer offering

9 group health insurance coverage from negotiating the level

10 and type of reimbursement with a provider for care pro11 vided in accordance with this section.

12 ‘‘(i) PREEMPTION.—

13 ‘‘(1) IN GENERAL.—The provisions of this sec14 tion do not preempt State law relating to health in15 surance coverage to the extent such State law pro16 vides greater benefits with respect to osteoporosis

17 detection or prevention.

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

19 not be construed as superseding a State law de20 scribed in paragraph (1).’’.

21 (B) CONFORMING AMENDMENT.—Section

22 2723(c) of such Act (42 U.S.C. 300gg–23(c)) is

23 amended by striking ‘‘section 2704’’ and insert24 ing ‘‘sections 2704 and 2707’’.

25 (2) ERISA AMENDMENTS.—
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1 (A) IN GENERAL.—Subpart B of part 7 of

2 subtitle B of title I of the Employee Retirement

3 Income Security Act of 1974 (29 U.S.C. 1185

4 et seq.) is amended by adding at the end the

5 following new section:

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

7 MASS MEASUREMENT.

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

9 MEASUREMENT.—A group health plan, and a health in10 surance issuer offering group health insurance coverage,

11 shall include (consistent with this section) coverage for

12 bone mass measurement for beneficiaries and participants

13 who are qualified individuals.

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

15 this section:

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

17 ‘bone mass measurement’ means a radiologic or

18 radioisotopic procedure or other procedure approved

19 by the Food and Drug Administration performed on

20 an individual for the purpose of identifying bone

21 mass or detecting bone loss or determining bone

22 quality, and includes a physician’s interpretation of

23 the results of the procedure. Nothing in this para24 graph shall be construed as requiring a bone mass

25 measurement to be conducted in a particular type
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1 of facility or to prevent such a measurement from

2 being conducted through the use of mobile facilities

3 that are otherwise qualified.

4 ‘‘(2) QUALIFIED INDIVIDUAL.—The term ‘quali5 fied individual’ means an individual who—

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

7 clinical risk for osteoporosis;

8 ‘‘(B) has vertebral abnormalities;

9 ‘‘(C) is receiving chemotherapy or long10 term gluococorticoid (steroid) therapy;

11 ‘‘(D) has primary hyperparathyroidism,

12 hyperthyroidism, or excess thyroid replacement;

13 ‘‘(E) is being monitored to assess the re14 sponse to or efficacy of approved osteoporosis

15 drug therapy;

16 ‘‘(F) is a man with a low trauma fracture;

17 or

18 ‘‘(G) the Secretary determines is eligible.

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

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

21 Health Service Act shall apply to benefits provided under

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

23 provided under section 2707 of such Act.

24 ‘‘(d) RESTRICTIONS ON COST-SHARING.—
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1 ‘‘(1) IN GENERAL.—Subject to paragraph (2),

2 nothing in this section shall be construed as pre3 venting a group health plan or issuer from imposing

4 deductibles, coinsurance, or other cost-sharing in re5 lation to bone mass measurement under the plan (or

6 health insurance coverage offered in connection with

7 a plan).

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

9 and other cost-sharing or other limitations for bone

10 mass measurement may not be imposed under para11 graph (1) to the extent they exceed the deductibles,

12 coinsurance, and limitations that are applied to simi13 lar services under the group health plan or health

14 insurance coverage.

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

16 health insurance issuer offering group health insurance

17 coverage in connection with a group health plan, may

18 not—

19 ‘‘(1) deny to an individual eligibility, or contin20 ued eligibility, to enroll or to renew coverage under

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

22 avoiding the requirements of this section;

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

24 to individuals to encourage such individuals not to

25 be provided bone mass measurements to which they
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1 are entitled under this section or to providers to in2 duce such providers not to provide such measure3 ments to qualified individuals;

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

5 patient osteoporosis preventive techniques or medical

6 treatment options relating to this section; or

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

8 reimbursement of a provider because such provider

9 provided bone mass measurements to a qualified in10 dividual in accordance with this section.

11 ‘‘(f) RULE OF CONSTRUCTION.—Nothing in this sec12 tion shall be construed to require an individual who is a

13 participant or beneficiary to undergo bone mass measure14 ment.

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

16 imposition of the requirements of this section shall be

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

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

19 notice of such requirements under the plan; except that

20 the summary description required to be provided under the

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

22 modification shall be provided by not later than 60 days

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

24 requirements apply.

25 ‘‘(h) PREEMPTION.—
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1 ‘‘(1) IN GENERAL.—The provisions of this sec2 tion do not preempt State law relating to health in3 surance coverage to the extent such State law pro4 vides greater benefits with respect to osteoporosis

5 detection or prevention.

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

7 not be construed as superseding a State law de8 scribed in paragraph (1).’’.

9 (B) CONFORMING AMENDMENTS.—

10 (i) Section 731(c) of such Act (29

11 U.S.C. 1191(c)), as amended by section

12 603(b)(1) of Public Law 104–204, is

13 amended by striking ‘‘section 711’’ and in14 serting ‘‘sections 711 and 714’’.

15 (ii) Section 732(a) of such Act (29

16 U.S.C. 1191a(a)), as amended by section

17 603(b)(2) of Public Law 104–204, is

18 amended by striking ‘‘section 711’’ and in19 serting ‘‘sections 711 and 714’’.

20 (iii) The table of contents in section 1

21 of such Act is amended by inserting after

22 the item relating to section 713 the fol23 lowing new item:

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

24 (b) INDIVIDUAL HEALTH INSURANCE.—
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1 (1) IN GENERAL.—Part B of title XXVII of the

2 Public Health Service Act is amended by inserting

3 after section 2752 (42 U.S.C. 300gg–52) the fol4 lowing new section:

5 ‘‘SEC. 27530. STANDARDS RELATING TO BENEFITS FOR

6 BONE MASS MEASUREMENT.

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

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

9 coverage offered by a health insurance issuer in the indi10 vidual market in the same manner as it applies to health

11 insurance coverage offered by a health insurance issuer

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

13 large group market.

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

15 part shall comply with the notice requirement under sec16 tion 714(g) of the Employee Retirement Income Security

17 Act of 1974 with respect to the requirements referred to

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

19 and such issuer were a group health plan.

20 ‘‘(c) PREEMPTION.—

21 ‘‘(1) IN GENERAL.—The provisions of this sec22 tion do not preempt State law relating to health in23 surance coverage to the extent such State law pro24 vides greater benefits with respect to osteoporosis

25 detection or prevention.
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1 ‘‘(2) CONSTRUCTION.—Section 2762(a) shall

2 not be construed as superseding a State law de3 scribed in paragraph (1).’’.

4 (2) CONFORMING AMENDMENTS.—Section

5 2762(b)(2) of such Act (42 U.S.C. 300gg–62(b)(2)),

6 as added by section 605(b)(3)(B) of Public Law

7 104–204, is amended by striking ‘‘section 2751’’

8 and inserting ‘‘sections 2751 and 2753’’.

9 (c) EFFECTIVE DATES.—

10 (1) GROUP HEALTH PLANS.—The amendments

11 made by subsection (a) shall apply with respect to

12 group health plans for plan years beginning on or

13 after January 1, 2000.

14 (2) INDIVIDUAL MARKET.—The amendments

15 made by subsection (b) shall apply with respect to

16 health insurance coverage offered, sold, issued, re17 newed, in effect, or operated in the individual mar18 ket on or after such date.

Æ