II

106TH CONGRESS

1ST SESSION S. 1200

To require equitable coverage of prescription contraceptive drugs and devices,

and contraceptive services under health plans.

IN THE SENATE OF THE UNITED STATES

JUNE 10, 1999

Ms. SNOWE (for herself, Mr. REID, Mr. WARNER, Mr. TORRICELLI, Mr. JEFFORDS, Mr. MOYNIHAN, Mr. CHAFEE, Ms. MIKULSKI, Mr. SMITH of Oregon, Mrs. BOXER, Mr. SPECTER, Mr. DURBIN, Mrs. MURRAY, Mr.

KERREY, Mr. ROBB, Mr. SCHUMER, Mr. JOHNSON, Mr. LAUTENBERG,

Mr. CLELAND, Mr. LEAHY, Mr. HARKIN, Mr. DODD, Mr. KENNEDY, Mr.

DASCHLE, Mrs. FEINSTEIN, Mrs. LINCOLN, Mr. INOUYE, Mr. AKAKA,

Mr. BAYH, Mr. LIEBERMAN, Mr. WELLSTONE, and Mr. BRYAN) introduced the following bill; which was read twice and referred to the Committee on Health, Education, Labor, and Pensions

A BILL

To require equitable coverage of prescription contraceptive

drugs and devices, and contraceptive services under

health plans.

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.

4 This Act may be cited as the ‘‘Equity in Prescription

5 Insurance and Contraceptive Coverage Act of 1999’’.
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1 SEC. 2. FINDINGS.

2 Congress finds that—

3 (1) each year, 3,000,000 pregnancies, or one

4 half of all pregnancies, in this country are unin5 tended;

6 (2) contraceptive services are part of basic

7 health care, allowing families to both adequately

8 space desired pregnancies and avoid unintended

9 pregnancy;

10 (3) studies show that contraceptives are cost ef11 fective: for every $1 of public funds invested in fam12 ily planning, $4 to $14 of public funds is saved in

13 pregnancy and health care-related costs;

14 (4) by reducing rates of unintended pregnancy,

15 contraceptives help reduce the need for abortion;

16 (5) unintended pregnancies lead to higher rates

17 of infant mortality, low-birth weight, and maternal

18 morbidity, and threaten the economic viability of

19 families;

20 (6) the National Commission to Prevent Infant

21 Mortality determined that ‘‘infant mortality could be

22 reduced by 10 percent if all women not desiring

23 pregnancy used contraception’’;

24 (7) most women in the United States, including

25 three-quarters of women of childbearing age, rely on

26 some form of private insurance (through their own
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1 employer, a family member’s employer, or the indi2 vidual market) to defray their medical expenses;

3 (8) the vast majority of private insurers cover

4 prescription drugs, but many exclude coverage for

5 prescription contraceptives;

6 (9) private insurance provides extremely limited

7 coverage of contraceptives: half of traditional indem8 nity plans and preferred provider organizations, 20

9 percent of point-of-service networks, and 7 percent

10 of health maintenance organizations cover no contra11 ceptive methods other than sterilization;

12 (10) women of reproductive age spend 68 per13 cent more than men on out-of-pocket health care

14 costs, with contraceptives and reproductive health

15 care services accounting for much of the difference;

16 (11) the lack of contraceptive coverage in health

17 insurance places many effective forms of contracep18 tives beyond the financial reach of many women,

19 leading to unintended pregnancies;

20 (12) the Institute of Medicine Committee on

21 Unintended Pregnancy recommended that ‘‘financial

22 barriers to contraception be reduced by increasing

23 the proportion of all health insurance policies that

24 cover contraceptive services and supplies’’;
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1 (13) in 1998, Congress agreed to provide con2 traceptive coverage to the 2,000,000 women of re3 productive age who are participating in the Federal

4 Employees Health Benefits Program, the largest

5 employer-sponsored health insurance plan in the

6 world; and

7 (14) eight in 10 privately insured adults sup8 port contraceptive coverage.

9 SEC. 3. AMENDMENTS TO THE EMPLOYEE RETIREMENT IN10 COME SECURITY ACT OF 1974.

11 (a) IN GENERAL.—Subpart B of part 7 of subtitle

12 B of title I of the Employee Retirement Income Security

13 Act of 1974 (29 U.S.C. 1185 et seq.) is amended by add14 ing at the end the following new section:

15 ‘‘SEC. 714. STANDARDS RELATING TO BENEFITS FOR CON16 TRACEPTIVES.

17 ‘‘(a) REQUIREMENTS FOR COVERAGE.—A group

18 health plan, and a health insurance issuer providing health

19 insurance coverage in connection with a group health plan,

20 may not—

21 ‘‘(1) exclude or restrict benefits for prescription

22 contraceptive drugs or devices approved by the Food

23 and Drug Administration, or generic equivalents ap24 proved as substitutable by the Food and Drug Ad-
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1 ministration, if such plan provides benefits for other

2 outpatient prescription drugs or devices; or

3 ‘‘(2) exclude or restrict benefits for outpatient

4 contraceptive services if such plan provides benefits

5 for other outpatient services provided by a health

6 care professional (referred to in this section as ‘out7 patient health care services’).

8 ‘‘(b) PROHIBITIONS.—A group health plan, and a

9 health insurance issuer providing health insurance cov10 erage in connection with a group health plan, may not—

11 ‘‘(1) deny to an individual eligibility, or contin12 ued eligibility, to enroll or to renew coverage under

13 the terms of the plan because of the individual’s or

14 enrollee’s use or potential use of items or services

15 that are covered in accordance with the requirements

16 of this section;

17 ‘‘(2) provide monetary payments or rebates to

18 a covered individual to encourage such individual to

19 accept less than the minimum protections available

20 under this section;

21 ‘‘(3) penalize or otherwise reduce or limit the

22 reimbursement of a health care professional because

23 such professional prescribed contraceptive drugs or

24 devices, or provided contraceptive services, described

25 in subsection (a), in accordance with this section; or
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1 ‘‘(4) provide incentives (monetary or otherwise)

2 to a health care professional to induce such profes3 sional to withhold from a covered individual contra4 ceptive drugs or devices, or contraceptive services,

5 described in subsection (a).

6 ‘‘(c) RULES OF CONSTRUCTION.—

7 ‘‘(1) IN GENERAL.—Nothing in this section

8 shall be construed—

9 ‘‘(A) as preventing a group health plan

10 and a health insurance issuer providing health

11 insurance coverage in connection with a group

12 health plan from imposing deductibles, coinsur13 ance, or other cost-sharing or limitations in re14 lation to—

15 ‘‘(i) benefits for contraceptive drugs

16 under the plan, except that such a deduct17 ible, coinsurance, or other cost-sharing or

18 limitation for any such drug may not be

19 greater than such a deductible, coinsur20 ance, or cost-sharing or limitation for any

21 outpatient prescription drug otherwise cov22 ered under the plan;

23 ‘‘(ii) benefits for contraceptive devices

24 under the plan, except that such a deduct25 ible, coinsurance, or other cost-sharing or
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1 limitation for any such device may not be

2 greater than such a deductible, coinsur3 ance, or cost-sharing or limitation for any

4 outpatient prescription device otherwise

5 covered under the plan; and

6 ‘‘(iii) benefits for outpatient contra7 ceptive services under the plan, except that

8 such a deductible, coinsurance, or other

9 cost-sharing or limitation for any such

10 service may not be greater than such a de11 ductible, coinsurance, or cost-sharing or

12 limitation for any outpatient health care

13 service otherwise covered under the plan;

14 and

15 ‘‘(B) as requiring a group health plan and

16 a health insurance issuer providing health in17 surance coverage in connection with a group

18 health plan to cover experimental or investiga19 tional contraceptive drugs or devices, or experi20 mental or investigational contraceptive services,

21 described in subsection (a), except to the extent

22 that the plan or issuer provides coverage for

23 other experimental or investigational outpatient

24 prescription drugs or devices, or experimental
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1 or investigational outpatient health care serv2 ices.

3 ‘‘(2) LIMITATIONS.—As used in paragraph (1),

4 the term ‘limitation’ includes—

5 ‘‘(A) in the case of a contraceptive drug or

6 device, restricting the type of health care pro7 fessionals that may prescribe such drugs or de8 vices, utilization review provisions, and limits on

9 the volume of prescription drugs or devices that

10 may be obtained on the basis of a single con11 sultation with a professional; or

12 ‘‘(B) in the case of an outpatient contra13 ceptive service, restricting the type of health

14 care professionals that may provide such serv15 ices, utilization review provisions, requirements

16 relating to second opinions prior to the coverage

17 of such services, and requirements relating to

18 preauthorizations prior to the coverage of such

19 services.

20 ‘‘(d) NOTICE UNDER GROUP HEALTH PLAN.—The

21 imposition of the requirements of this section shall be

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

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

24 notice of such requirements under the plan, except that

25 the summary description required to be provided under the
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1 last sentence of section 104(b)(1) with respect to such

2 modification shall be provided by not later than 60 days

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

4 requirements apply.

5 ‘‘(e) PREEMPTION.—Nothing in this section shall be

6 construed to preempt any provision of State law to the

7 extent that such State law establishes, implements, or con8 tinues in effect any standard or requirement that provides

9 protections for enrollees that are greater than the protec10 tions provided under this section.

11 ‘‘(f) DEFINITION.—In this section, the term ‘out12 patient contraceptive services’ means consultations, exami13 nations, procedures, and medical services, provided on an

14 outpatient basis and related to the use of contraceptive

15 methods (including natural family planning) to prevent an

16 unintended pregnancy.’’.

17 (b) CLERICAL AMENDMENT.—The table of contents

18 in section 1 of the Employee Retirement Income Security

19 Act of 1974 (29 U.S.C. 1001 note) is amended by insert20 ing after the item relating to section 713 the following

21 new item:

‘‘Sec. 714. Standards relating to benefits for contraceptives.’’.

22 (c) EFFECTIVE DATE.—The amendments made by

23 this section shall apply with respect to plan years begin24 ning on or after January 1, 2000.
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1 SEC. 4. AMENDMENTS TO THE PUBLIC HEALTH SERVICE

2 ACT RELATING TO THE GROUP MARKET.

3 (a) IN GENERAL.—Subpart 2 of part A of title

4 XXVII of the Public Health Service Act (42 U.S.C.

5 300gg–4 et seq.) is amended by adding at the end the

6 following new section:

7 ‘‘SEC. 2707. STANDARDS RELATING TO BENEFITS FOR CON8 TRACEPTIVES.

9 ‘‘(a) REQUIREMENTS FOR COVERAGE.—A group

10 health plan, and a health insurance issuer providing health

11 insurance coverage in connection with a group health plan,

12 may not—

13 ‘‘(1) exclude or restrict benefits for prescription

14 contraceptive drugs or devices approved by the Food

15 and Drug Administration, or generic equivalents ap16 proved as substitutable by the Food and Drug Ad17 ministration, if such plan provides benefits for other

18 outpatient prescription drugs or devices; or

19 ‘‘(2) exclude or restrict benefits for outpatient

20 contraceptive services if such plan provides benefits

21 for other outpatient services provided by a health

22 care professional (referred to in this section as ‘out23 patient health care services’).

24 ‘‘(b) PROHIBITIONS.—A group health plan, and a

25 health insurance issuer providing health insurance cov26 erage in connection with a group health plan, may not—
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1 ‘‘(1) deny to an individual eligibility, or contin2 ued eligibility, to enroll or to renew coverage under

3 the terms of the plan because of the individual’s or

4 enrollee’s use or potential use of items or services

5 that are covered in accordance with the requirements

6 of this section;

7 ‘‘(2) provide monetary payments or rebates to

8 a covered individual to encourage such individual to

9 accept less than the minimum protections available

10 under this section;

11 ‘‘(3) penalize or otherwise reduce or limit the

12 reimbursement of a health care professional because

13 such professional prescribed contraceptive drugs or

14 devices, or provided contraceptive services, described

15 in subsection (a), in accordance with this section; or

16 ‘‘(4) provide incentives (monetary or otherwise)

17 to a health care professional to induce such profes18 sional to withhold from covered individual contracep19 tive drugs or devices, or contraceptive services, de20 scribed in subsection (a).

21 ‘‘(c) RULES OF CONSTRUCTION.—

22 ‘‘(1) IN GENERAL.—Nothing in this section

23 shall be construed—

24 ‘‘(A) as preventing a group health plan

25 and a health insurance issuer providing health
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1 insurance coverage in connection with a group

2 health plan from imposing deductibles, coinsur3 ance, or other cost-sharing or limitations in re4 lation to—

5 ‘‘(i) benefits for contraceptive drugs

6 under the plan, except that such a deduct7 ible, coinsurance, or other cost-sharing or

8 limitation for any such drug may not be

9 greater than such a deductible, coinsur10 ance, or cost-sharing or limitation for any

11 outpatient prescription drug otherwise cov12 ered under the plan;

13 ‘‘(ii) benefits for contraceptive devices

14 under the plan, except that such a deduct15 ible, coinsurance, or other cost-sharing or

16 limitation for any such device may not be

17 greater than such a deductible, coinsur18 ance, or cost-sharing or limitation for any

19 outpatient prescription device otherwise

20 covered under the plan; and

21 ‘‘(iii) benefits for outpatient contra22 ceptive services under the plan, except that

23 such a deductible, coinsurance, or other

24 cost-sharing or limitation for any such

25 service may not be greater than such a de-
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1 ductible, coinsurance, or cost-sharing or

2 limitation for any outpatient health care

3 service otherwise covered under the plan;

4 and

5 ‘‘(B) as requiring a group health plan and

6 a health insurance issuer providing health in7 surance coverage in connection with a group

8 health plan to cover experimental or investiga9 tional contraceptive drugs or devices, or experi10 mental or investigational contraceptive services,

11 described in subsection (a), except to the extent

12 that the plan or issuer provides coverage for

13 other experimental or investigational outpatient

14 prescription drugs or devices, or experimental

15 or investigational outpatient health care serv16 ices.

17 ‘‘(2) LIMITATIONS.—As used in paragraph (1),

18 the term ‘limitation’ includes—

19 ‘‘(A) in the case of a contraceptive drug or

20 device, restricting the type of health care pro21 fessionals that may prescribe such drugs or de22 vices, utilization review provisions, and limits on

23 the volume of prescription drugs or devices that

24 may be obtained on the basis of a single con25 sultation with a professional; or
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1 ‘‘(B) in the case of an outpatient contra2 ceptive service, restricting the type of health

3 care professionals that may provide such serv4 ices, utilization review provisions, requirements

5 relating to second opinions prior to the coverage

6 of such services, and requirements relating to

7 preauthorizations prior to the coverage of such

8 services.

9 ‘‘(d) NOTICE.—A group health plan under this part

10 shall comply with the notice requirement under section

11 714(d) of the Employee Retirement Income Security Act

12 of 1974 with respect to the requirements of this section

13 as if such section applied to such plan.

14 ‘‘(e) PREEMPTION.—Nothing in this section shall be

15 construed to preempt any provision of State law to the

16 extent that such State law establishes, implements, or con17 tinues in effect any standard or requirement that provides

18 protections for enrollees that are greater than the protec19 tions provided under this section.

20 ‘‘(f) DEFINITION.—In this section, the term ‘out21 patient contraceptive services’ means consultations, exami22 nations, procedures, and medical services, provided on an

23 outpatient basis and related to the use of contraceptive

24 methods (including natural family planning) to prevent an

25 unintended pregnancy.’’.
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1 (b) EFFECTIVE DATE.—The amendments made by

2 this section shall apply with respect to group health plans

3 for plan years beginning on or after January 1, 2000.

4 SEC. 5. AMENDMENT TO THE PUBLIC HEALTH SERVICE ACT

5 RELATING TO THE INDIVIDUAL MARKET.

6 (a) IN GENERAL.—Part B of title XXVII of the Pub7 lic Health Service Act (42 U.S.C. 300gg–41 et seq.) is

8 amended—

9 (1) by redesignating the first subpart 3 (relat10 ing to other requirements) as subpart 2; and

11 (2) by adding at the end of subpart 2 the fol12 lowing new section:

13 ‘‘SEC. 2753. STANDARDS RELATING TO BENEFITS FOR CON14 TRACEPTIVES.

15 ‘‘The provisions of section 2707 shall apply to health

16 insurance coverage offered by a health insurance issuer

17 in the individual market in the same manner as they apply

18 to health insurance coverage offered by a health insurance

19 issuer in connection with a group health plan in the small

20 or large group market.’’.

21 (b) EFFECTIVE DATE.—The amendment made by

22 this section shall apply with respect to health insurance

23 coverage offered, sold, issued, renewed, in effect, or oper24 ated in the individual market on or after January 1, 2000.

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