I 

109TH CONGRESS 

1ST SESSION H. R. 2812 

To amend the Employee Retirement Income Security Act of 1974, Public 

Health Service Act, and the Internal Revenue Code of 1986 to require 

that group and individual health insurance coverage and group health 

plans provide coverage of screening for breast, prostate, and colorectal 

cancer. 

IN THE HOUSE OF REPRESENTATIVES 

JUNE 8, 2005 

Mrs. MALONEY introduced the following bill; which was referred to the Committee on Energy and Commerce, and in addition to the Committees on 

Education and the Workforce, Ways and Means, and Government Reform, 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 Employee Retirement Income Security Act 

of 1974, Public Health Service Act, and the Internal 

Revenue Code of 1986 to require that group and individual health insurance coverage and group health plans 

provide coverage of screening for breast, prostate, and 

colorectal cancer. 

1 Be it enacted by the Senate and House of Representa2 tives of the United States of America in Congress assembled, 
2 

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1 SECTION 1. SHORT TITLE. 

2 This Act may be cited as the ‘‘Cancer Screening Cov3 erage Act of 2005’’. 

4 SEC. 2. CANCER SCREENING COVERAGE. 

5 (a) GROUP HEALTH PLANS.— 

6 (1) PUBLIC HEALTH SERVICE ACT AMEND7 MENTS.— 

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

9 title XXVII of the Public Health Service Act 

10 (42 U.S.C. 300gg–4 et seq.) is amended by 

11 adding at the end the following: 

12 ‘‘SEC. 2707. COVERAGE OF CANCER SCREENING. 

13 ‘‘(a) REQUIREMENT.—A group health plan, and a 

14 health insurance issuer offering group health insurance 

15 coverage, shall provide coverage and payment under the 

16 plan or coverage for the following items and services under 

17 terms and conditions that are no less favorable than the 

18 terms and conditions applicable to other screening benefits 

19 otherwise provided under the plan or coverage: 

20 ‘‘(1) MAMMOGRAMS.—In the case of a female 

21 participant or beneficiary who is 40 years of age or 

22 older, or is under 40 years of age but is at high risk 

23 (as defined in subsection (e)) of developing breast 

24 cancer, an annual mammography (as defined in sec25 tion 1861(jj) of the Social Security Act) conducted 
3 

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1 by a facility that has a certificate (or provisional cer2 tificate) issued under section 354. 

3 ‘‘(2) CLINICAL BREAST EXAMINATIONS.—In the 

4 case of a female participant or beneficiary who— 

5 ‘‘(A)(i) is 40 years of age or older; or 

6 ‘‘(ii) is at least 20 (but less than 40) years 

7 of age and is at high risk of developing breast 

8 cancer, an annual clinical breast examination; 

9 or 

10 ‘‘(B) is at least 20, but less than 40, years 

11 of age and who is not at high risk of developing 

12 breast cancer, a clinical breast examination 

13 each 3 years. 

14 ‘‘(3) PAP TESTS AND PELVIC EXAMINATIONS.— 

15 In the case of a female participant or beneficiary 

16 who is 18 years of age or older, or who is under 18 

17 years of age and is or has been sexually active— 

18 ‘‘(A) an annual diagnostic laboratory test 

19 (popularly known as a ‘pap smear’) consisting 

20 of a routine exfoliative cytology test (Papani21 colaou test) provided to a woman for the pur22 pose of early detection of cervical or vaginal 

23 cancer and including an interpretation by a 

24 qualified health professional of the results of 

25 the test; and 
4 

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1 ‘‘(B) an annual pelvic examination. 

2 ‘‘(4) COLORECTAL CANCER SCREENING PROCE3 DURES.—In the case of a participant or beneficiary 

4 who is 50 years of age or older, or who is under 50 

5 years of age and is at high risk of developing 

6 colorectal cancer, the procedures described in section 

7 1861(pp)(1) of the Social Security Act (42 U.S.C. 

8 1395x(pp)(1)) or section 4104(a)(2) of the Balanced 

9 Budget Act of 1997 (111 Stat. 362), shall be fur10 nished to the individual for the purpose of early de11 tection of colorectal cancer. The group health plan 

12 or health insurance issuer shall provide coverage for 

13 the method and frequency of colorectal cancer 

14 screening determined to be appropriate by a health 

15 care provider treating such participant or bene16 ficiary, in consultation with the participant or bene17 ficiary. 

18 ‘‘(5) PROSTATE CANCER SCREENING.—In the 

19 case of a male participant or beneficiary who is 50 

20 years of age or older, or who is younger than 50 

21 years of age and is at high risk for prostate cancer 

22 (including African American men or a male who has 

23 a history of prostate cancer in 1 or more first degree 

24 family members), the procedures described in section 

25 1861(oo)(2) of Social Security Act (42 U.S.C. 
5 

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1 1395x(oo)(2)) shall be furnished to the individual 

2 for the early detection of prostate cancer. The group 

3 health plan or health insurance issuer shall provide 

4 coverage for the method and frequency of prostate 

5 cancer screening determined to be appropriate by a 

6 health care provider treating such participant or 

7 beneficiary, in consultation with the participant or 

8 beneficiary. 

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

10 health insurance issuer offering group health insurance 

11 coverage in connection with a group health plan, shall 

12 not— 

13 ‘‘(1) deny to an individual eligibility, or contin14 ued eligibility, to enroll or to renew coverage under 

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

16 avoiding the requirements of this section; 

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

18 individuals to encourage such individuals to accept 

19 less than the minimum protections available under 

20 this section; 

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

22 reimbursement of a provider because such provider 

23 provided care to an individual participant or bene24 ficiary in accordance with this section; or 
6 

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

2 to a provider to induce such provider to provide care 

3 to an individual participant or beneficiary in a man4 ner inconsistent with this section. 

5 ‘‘(c) RULES OF CONSTRUCTION.— 

6 ‘‘(1) Nothing in this section shall be construed 

7 to require an individual who is a participant or bene8 ficiary to undergo a procedure, examination, or test 

9 described in subsection (a). 

10 ‘‘(2) Nothing in this section shall be construed 

11 as preventing a group health plan or issuer from im12 posing deductibles, coinsurance, or other cost-shar13 ing in relation to benefits described in subsection (a) 

14 consistent with such subsection, except that such co15 insurance or other cost-sharing shall not discrimi16 nate on any basis related to the coverage required 

17 under this section. 

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

19 shall comply with the notice requirement under section 

20 714(d) of the Employee Retirement Income Security Act 

21 of 1974 with respect to the requirements of this section 

22 as if such section applied to such plan. 

23 ‘‘(e) HIGH RISK DEFINED.—For purposes of this 

24 section, an individual is considered to be at ‘high risk’ of 

25 developing a particular type of cancer if, under guidelines 
7 

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1 developed or recognized by the Secretary based upon sci2 entific evidence, the individual— 

3 ‘‘(1) has 1 or more first degree family members 

4 who have developed that type of cancer; 

5 ‘‘(2) has previously had that type of cancer; 

6 ‘‘(3) has the presence of an appropriate recog7 nized gene marker that is identified as putting the 

8 individual at a higher risk of developing that type of 

9 cancer; or 

10 ‘‘(4) has other predisposing factors that signifi11 cantly increase the risk of the individual contracting 

12 that type of cancer. 

13 For purposes of this subsection, the term ‘type of cancer’ 

14 includes other types of cancer that the Secretary recog15 nizes as closely related for purposes of establishing risk. 

16 ‘‘SEC. 2708. PATIENT ACCESS TO INFORMATION. 

17 ‘‘(a) DISCLOSURE REQUIREMENT.—A group health 

18 plan, and health insurance issuer offering group health in19 surance coverage shall— 

20 ‘‘(1) provide to participants and beneficiaries at 

21 the time of initial coverage under the plan (or the 

22 effective date of this section, in the case of individ23 uals who are participants or beneficiaries as of such 

24 date), and at least annually thereafter, the informa25 tion described in subsection (b) in printed form; 
8 

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1 ‘‘(2) provide to participants and beneficiaries, 

2 within a reasonable period (as specified by the ap3 propriate Secretary) before or after the date of sig4 nificant changes in the information described in sub5 section (b), information in printed form regarding 

6 such significant changes; and 

7 ‘‘(3) upon request, make available to partici8 pants and beneficiaries, the applicable authority, and 

9 prospective participants and beneficiaries, the infor10 mation described in subsection (b) in printed form. 

11 ‘‘(b) INFORMATION PROVIDED.—The information de12 scribed in subsection (a) that shall be disclosed includes 

13 the following, as such relates to cancer screening required 

14 under section 2707(a): 

15 ‘‘(1) BENEFITS.—Benefits offered under the 

16 plan or coverage, including— 

17 ‘‘(A) covered benefits, including benefit 

18 limits and coverage exclusions; 

19 ‘‘(B) cost sharing, such as deductibles, co20 insurance, and copayment amounts, including 

21 any liability for balance billing, any maximum 

22 limitations on out of pocket expenses, and the 

23 maximum out of pocket costs for services that 

24 are provided by nonparticipating providers or 
9 

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1 that are furnished without meeting the applica2 ble utilization review requirements; 

3 ‘‘(C) the extent to which benefits may be 

4 obtained from nonparticipating providers; and 

5 ‘‘(D) the extent to which a participant, 

6 beneficiary, or enrollee may select from among 

7 participating providers and the types of pro8 viders participating in the plan or issuer net9 work. 

10 ‘‘(2) ACCESS.—A description of the following: 

11 ‘‘(A) The number, mix, and distribution of 

12 providers under the plan or coverage. 

13 ‘‘(B) Out-of-network coverage (if any) pro14 vided by the plan or coverage. 

15 ‘‘(C) Any point-of-service option (including 

16 any supplemental premium or cost-sharing for 

17 such option). 

18 ‘‘(D) The procedures for participants, 

19 beneficiaries, and enrollees to select, access, and 

20 change participating primary and specialty pro21 viders. 

22 ‘‘(E) The rights and procedures for obtain23 ing referrals (including standing referrals) to 

24 participating and nonparticipating providers. 
10 

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1 ‘‘(F) The name, address, and telephone 

2 number of participating health care providers 

3 and an indication of whether each such provider 

4 is available to accept new patients. 

5 ‘‘(G) How the plan or issuer addresses the 

6 needs of participants, beneficiaries, and enroll7 ees and others who do not speak English or 

8 who have other special communications needs in 

9 accessing providers under the plan or coverage, 

10 including the provision of information under 

11 this subsection.’’. 

12 (B) TECHNICAL AMENDMENT.—Section 

13 2723(c) of the Public Health Service Act (42 

14 U.S.C. 300gg–23(c)) is amended by striking 

15 ‘‘section 2704’’ and inserting ‘‘sections 2704 

16 and 2707’’. 

17 (2) ERISA AMENDMENTS.— 

18 (A) IN GENERAL.—Subpart B of part 7 of 

19 subtitle B of title I of the Employee Retirement 

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

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

22 following new section: 

23 ‘‘SEC. 714. COVERAGE OF CANCER SCREENING. 

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

25 health insurance issuer offering group health insurance 
11 

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1 coverage, shall provide coverage and payment under the 

2 plan or coverage for the following items and services under 

3 terms and conditions that are no less favorable than the 

4 terms and conditions applicable to other screening benefits 

5 otherwise provided under the plan or coverage: 

6 ‘‘(1) MAMMOGRAMS.—In the case of a female 

7 participant or beneficiary who is 40 years of age or 

8 older, or is under 40 years of age but is at high risk 

9 (as defined in subsection (e)) of developing breast 

10 cancer, an annual mammography (as defined in sec11 tion 1861(jj) of the Social Security Act) conducted 

12 by a facility that has a certificate (or provisional cer13 tificate) issued under section 354 of the Public 

14 Health Service Act. 

15 ‘‘(2) CLINICAL BREAST EXAMINATIONS.—In the 

16 case of a female participant or beneficiary who— 

17 ‘‘(A)(i) is 40 years of age or older; or 

18 ‘‘(ii) is at least 20 (but less than 40) years 

19 of age and is at high risk of developing breast 

20 cancer, an annual clinical breast examination; 

21 or 

22 ‘‘(B) is at least 20, but less than 40, years 

23 of age and who is not at high risk of developing 

24 breast cancer, a clinical breast examination 

25 each 3 years. 
12 

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1 ‘‘(3) PAP TESTS AND PELVIC EXAMINATIONS.— 

2 In the case of a female participant or beneficiary 

3 who is 18 years of age or older, or who is under 18 

4 years of age and is or has been sexually active— 

5 ‘‘(A) an annual diagnostic laboratory test 

6 (popularly known as a ‘pap smear’) consisting 

7 of a routine exfoliative cytology test (Papani8 colaou test) provided to a woman for the pur9 pose of early detection of cervical or vaginal 

10 cancer and including an interpretation by a 

11 qualified health professional of the results of 

12 the test; and 

13 ‘‘(B) an annual pelvic examination. 

14 ‘‘(4) COLORECTAL CANCER SCREENING PROCE15 DURES.—In the case of a participant or beneficiary 

16 who is 50 years of age or older, or who is under 50 

17 years of age and is at high risk of developing 

18 colorectal cancer, the procedures described in section 

19 1861(pp)(1) of the Social Security Act (42 U.S.C. 

20 1395x(pp)(1)) or section 4104(a)(2) of the Balanced 

21 Budget Act of 1997 (111 Stat. 362), shall be fur22 nished to the individual for the purpose of early de23 tection of colorectal cancer. The group health plan 

24 or health insurance issuer shall provided coverage 

25 for the method and frequency of colorectal cancer 
13 

•HR 2812 IH 

1 screening determined to be appropriate by a health 

2 care provider treating such participant or bene3 ficiary, in consultation with the participant or bene4 ficiary. 

5 ‘‘(5) PROSTATE CANCER SCREENING.—In the 

6 case of a male participant or beneficiary who is 50 

7 years of age or older, or who is younger than 50 

8 years of age and is at high risk for prostate cancer 

9 (including African American men or a male who has 

10 a history of prostate cancer in 1 or more first degree 

11 family members), the procedures described in section 

12 1861(oo)(2) of Social Security Act (42 U.S.C. 

13 1395x(oo)(2)) shall be furnished to the individual 

14 for the early detection of prostate cancer. The group 

15 health plan or health insurance issuer shall provide 

16 coverage for the method and frequency of prostate 

17 cancer screening determined to be appropriate by a 

18 health care provider treating such participant or 

19 beneficiary, in consultation with the participant or 

20 beneficiary. 

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

22 health insurance issuer offering group health insurance 

23 coverage in connection with a group health plan, may 

24 not— 
14 

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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, solely for the purpose of 

4 avoiding the requirements of this section; 

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

6 individuals to encourage such individuals to accept 

7 less than the minimum protections available under 

8 this section; 

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

10 reimbursement of a provider because such provider 

11 provided care to an individual participant or bene12 ficiary in accordance with this section; or 

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

14 to a provider to induce such provider to provide care 

15 to an individual participant or beneficiary in a man16 ner inconsistent with this section. 

17 ‘‘(c) RULES OF CONSTRUCTION.— 

18 ‘‘(1) Nothing in this section shall be construed 

19 to require an individual who is a participant or bene20 ficiary to undergo a procedure, examination, or test 

21 described in subsection (a). 

22 ‘‘(2) Nothing in this section shall be construed 

23 as preventing a group health plan or issuer from im24 posing deductibles, coinsurance, or other cost-shar25 ing in relation to benefits described in subsection (a) 
15 

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1 consistent with such subsection, except that such co2 insurance or other cost-sharing shall not discrimi3 nate on any basis related to the coverage required 

4 under this section. 

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

6 imposition of the requirement of this section shall be treat7 ed as a material modification in the terms of the plan de8 scribed in section 102(a), for purposes of assuring notice 

9 of such requirements under the plan; except that the sum10 mary description required to be provided under the last 

11 sentence of section 104(b)(1) with respect to such modi12 fication shall be provided by not later than 60 days after 

13 the first day of the first plan year in which such require14 ment apply. 

15 ‘‘(e) HIGH RISK DEFINED.—For purposes of this 

16 section, an individual is considered to be at ‘high risk’ of 

17 developing a particular type of cancer if, under guidelines 

18 developed or recognized by the Secretary based upon sci19 entific evidence, the individual— 

20 ‘‘(1) has 1 or more first degree family members 

21 who have developed that type of cancer; 

22 ‘‘(2) has previously had that type of cancer; 

23 ‘‘(3) has the presence of an appropriate recog24 nized gene marker that is identified as putting the 
16 

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1 individual at a higher risk of developing that type of 

2 cancer; or 

3 ‘‘(4) has other predisposing factors that signifi4 cantly increase the risk of the individual contracting 

5 that type of cancer. 

6 For purposes of this subsection, the term ‘type of cancer’ 

7 includes other types of cancer that the Secretary recog8 nizes as closely related for purposes of establishing risk. 

9 ‘‘SEC. 715. PATIENT ACCESS TO INFORMATION. 

10 ‘‘(a) DISCLOSURE REQUIREMENT.—A group health 

11 plan, and health insurance issuer offering group health in12 surance coverage shall— 

13 ‘‘(1) provide to participants and beneficiaries at 

14 the time of initial coverage under the plan (or the 

15 effective date of this section, in the case of individ16 uals who are participants or beneficiaries as of such 

17 date), and at least annually thereafter, the informa18 tion described in subsection (b) in printed form; 

19 ‘‘(2) provide to participants and beneficiaries, 

20 within a reasonable period (as specified by the ap21 propriate Secretary) before or after the date of sig22 nificant changes in the information described in sub23 section (b), information in printed form regarding 

24 such significant changes; and 
17 

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1 ‘‘(3) upon request, make available to partici2 pants and beneficiaries, the applicable authority, and 

3 prospective participants and beneficiaries, the infor4 mation described in subsection (b) in printed form. 

5 ‘‘(b) INFORMATION PROVIDED.—The information de6 scribed in subsection (a) that shall be disclosed includes 

7 the following, as such relates to cancer screening required 

8 under section 714(a): 

9 ‘‘(1) BENEFITS.—Benefits offered under the 

10 plan or coverage, including— 

11 ‘‘(A) covered benefits, including benefit 

12 limits and coverage exclusions; 

13 ‘‘(B) cost sharing, such as deductibles, co14 insurance, and copayment amounts, including 

15 any liability for balance billing, any maximum 

16 limitations on out of pocket expenses, and the 

17 maximum out of pocket costs for services that 

18 are provided by nonparticipating providers or 

19 that are furnished without meeting the applica20 ble utilization review requirements; 

21 ‘‘(C) the extent to which benefits may be 

22 obtained from nonparticipating providers; and 

23 ‘‘(D) the extent to which a participant, 

24 beneficiary, or enrollee may select from among 

25 participating providers and the types of pro-
18 

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1 viders participating in the plan or issuer net2 work. 

3 ‘‘(2) ACCESS.—A description of the following: 

4 ‘‘(A) The number, mix, and distribution of 

5 providers under the plan or coverage. 

6 ‘‘(B) Out-of-network coverage (if any) pro7 vided by the plan or coverage. 

8 ‘‘(C) Any point-of-service option (including 

9 any supplemental premium or cost-sharing for 

10 such option). 

11 ‘‘(D) The procedures for participants, 

12 beneficiaries, and enrollees to select, access, and 

13 change participating primary and specialty pro14 viders. 

15 ‘‘(E) The rights and procedures for obtain16 ing referrals (including standing referrals) to 

17 participating and nonparticipating providers. 

18 ‘‘(F) The name, address, and telephone 

19 number of participating health care providers 

20 and an indication of whether each such provider 

21 is available to accept new patients. 

22 ‘‘(G) How the plan or issuer addresses the 

23 needs of participants, beneficiaries, and enroll24 ees and others who do not speak English or 

25 who have other special communications needs in 
19 

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1 accessing providers under the plan or coverage, 

2 including the provision of information under 

3 this subsection.’’. 

4 (B) TECHNICAL AMENDMENTS.— 

5 (i) Section 731(c) of the Employee 

6 Retirement Income Security Act of 1974 

7 (29 U.S.C. 1191(c)) is amended by strik8 ing ‘‘section 711’’ and inserting ‘‘sections 

9 711 and 714’’. 

10 (ii) Section 732(a) of the Employee 

11 Retirement Income Security Act of 1974 

12 (29 U.S.C. 1191a(a)) is amended by strik13 ing ‘‘section 711’’ and inserting ‘‘sections 

14 711 and 714’’. 

15 (iii) The table of contents in section 1 

16 of the Employee Retirement Income Secu17 rity Act of 1974 is amended by inserting 

18 after the item relating to section 713 the 

19 following new items: 

‘‘714. Coverage of cancer screening. 

‘‘715. Patient access to information.’’. 

20 (3) INTERNAL REVENUE CODE AMEND21 MENTS.—Subchapter B of chapter 100 of the Inter22 nal Revenue Code of 1986 is amended— 
20 

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1 (A) in the table of sections, by inserting 

2 after the item relating to section 9812 the fol3 lowing new items: 

‘‘9813. Coverage of cancer screening. 

‘‘9814. Patient access to information.’’; 

4 and 

5 (B) by inserting after section 9812 the fol6 lowing: 

7 ‘‘SEC. 9813. COVERAGE OF CANCER SCREENING. 

8 ‘‘(a) REQUIREMENT.—A group health plan shall pro9 vide coverage and payment under the plan for the fol10 lowing items and services under terms and conditions that 

11 are no less favorable than the terms and conditions appli12 cable to other screening benefits otherwise provided under 

13 the plan: 

14 ‘‘(1) MAMMOGRAMS.—In the case of a female 

15 participant or beneficiary who is 40 years of age or 

16 older, or is under 40 years of age but is at high risk 

17 (as defined in subsection (d)) of developing breast 

18 cancer, an annual mammography (as defined in sec19 tion 1861(jj) of the Social Security Act) conducted 

20 by a facility that has a certificate (or provisional cer21 tificate) issued under section 354 of the Public 

22 Health Service Act. 

23 ‘‘(2) CLINICAL BREAST EXAMINATIONS.—In the 

24 case of a female participant or beneficiary who— 
21 

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1 ‘‘(A)(i) is 40 years of age or older; or 

2 ‘‘(ii) is at least 20 (but less than 40) years 

3 of age and is at high risk of developing breast 

4 cancer, an annual clinical breast examination; 

5 or 

6 ‘‘(B) is at least 20, but less than 40, years 

7 of age and who is not at high risk of developing 

8 breast cancer, a clinical breast examination 

9 each 3 years. 

10 ‘‘(3) PAP TESTS AND PELVIC EXAMINATIONS.— 

11 In the case of a female participant or beneficiary 

12 who is 18 years of age or older, or who is under 18 

13 years of age and is or has been sexually active— 

14 ‘‘(A) an annual diagnostic laboratory test 

15 (popularly known as a ‘pap smear’) consisting 

16 of a routine exfoliative cytology test (Papani17 colaou test) provided to a woman for the pur18 pose of early detection of cervical or vaginal 

19 cancer and including an interpretation by a 

20 qualified health professional of the results of 

21 the test; and 

22 ‘‘(B) an annual pelvic examination. 

23 ‘‘(4) COLORECTAL CANCER SCREENING PROCE24 DURES.—In the case of a participant or beneficiary 

25 who is 50 years of age or older, or who is under 50 
22 

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1 years of age and is at high risk of developing 

2 colorectal cancer, the procedures described in section 

3 1861(pp)(1) of the Social Security Act (42 U.S.C. 

4 1395x(pp)(1)) or section 4104(a)(2) of the Balanced 

5 Budget Act of 1997 (111 Stat. 362), shall be fur6 nished to the individual for the purpose of early de7 tection of colorectal cancer. The group health plan 

8 or health insurance issuer shall provide coverage for 

9 the method and frequency of colorectal cancer 

10 screening determined to be appropriate by a health 

11 care provider treating such participant or bene12 ficiary, in consultation with the participant or bene13 ficiary. 

14 ‘‘(5) PROSTATE CANCER SCREENING.—In the 

15 case of a male participant or beneficiary who is 50 

16 years of age or older, or who is younger than 50 

17 years of age and is at high risk for prostate cancer 

18 (including African American men or a male who has 

19 a history of prostate cancer in 1 or more first degree 

20 family members), the procedures described in section 

21 1861(oo)(2) of Social Security Act (42 U.S.C. 

22 1395x(oo)(2)) shall be furnished to the individual 

23 for the early detection of prostate cancer. The group 

24 health plan or health insurance issuer shall provide 

25 coverage for the method and frequency of prostate 
23 

•HR 2812 IH 

1 cancer screening determined to be appropriate by a 

2 health care provider treating such participant or 

3 beneficiary, in consultation with the participant or 

4 beneficiary. 

5 ‘‘(b) PROHIBITIONS.—A group health plan may not— 

6 ‘‘(1) deny to an individual eligibility, or contin7 ued eligibility, to enroll or to renew coverage under 

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

9 avoiding the requirements of this section; 

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

11 individuals to encourage such individuals to accept 

12 less than the minimum protections available under 

13 this section; 

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

15 reimbursement of a provider because such provider 

16 provided care to an individual participant or bene17 ficiary in accordance with this section; or 

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

19 to a provider to induce such provider to provide care 

20 to an individual participant or beneficiary in a man21 ner inconsistent with this section. 

22 ‘‘(c) RULES OF CONSTRUCTION.— 

23 ‘‘(1) Nothing in this section shall be construed 

24 to require an individual who is a participant or bene-
24 

•HR 2812 IH 

1 ficiary to undergo a procedure, examination, or test 

2 described in subsection (a). 

3 ‘‘(2) Nothing in this section shall be construed 

4 as preventing a group health plan from imposing 

5 deductibles, coinsurance, or other cost-sharing in re6 lation to benefits described in subsection (a) con7 sistent with such subsection, except that such coin8 surance or other cost-sharing shall not discriminate 

9 on any basis related to the coverage required under 

10 this section. 

11 ‘‘(d) HIGH RISK DEFINED.—For purposes of this 

12 section, an individual is considered to be at ‘high risk’ of 

13 developing a particular type of cancer if, under guidelines 

14 developed or recognized by the Secretary based upon sci15 entific evidence, the individual— 

16 ‘‘(1) has 1 or more first degree family members 

17 who have developed that type of cancer; 

18 ‘‘(2) has previously had that type of cancer; 

19 ‘‘(3) has the presence of an appropriate recog20 nized gene marker that is identified as putting the 

21 individual at a higher risk of developing that type of 

22 cancer; or 

23 ‘‘(4) has other predisposing factors that signifi24 cantly increase the risk of the individual contracting 

25 that type of cancer. 
25 

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1 For purposes of this subsection, the term ‘type of cancer’ 

2 includes other types of cancer that the Secretary recog3 nizes as closely related for purposes of establishing risk. 

4 ‘‘SEC. 9814. PATIENT ACCESS TO INFORMATION. 

5 ‘‘(a) DISCLOSURE REQUIREMENT.—A group health 

6 plan, and health insurance issuer offering group health in7 surance coverage shall— 

8 ‘‘(1) provide to participants and beneficiaries at 

9 the time of initial coverage under the plan (or the 

10 effective date of this section, in the case of individ11 uals who are participants or beneficiaries as of such 

12 date), and at least annually thereafter, the informa13 tion described in subsection (b) in printed form; 

14 ‘‘(2) provide to participants and beneficiaries, 

15 within a reasonable period (as specified by the ap16 propriate Secretary) before or after the date of sig17 nificant changes in the information described in sub18 section (b), information in printed form regarding 

19 such significant changes; and 

20 ‘‘(3) upon request, make available to partici21 pants and beneficiaries, the applicable authority, and 

22 prospective participants and beneficiaries, the infor23 mation described in subsection (b) in printed form. 

24 ‘‘(b) INFORMATION PROVIDED.—The information de25 scribed in subsection (a) that shall be disclosed includes 
26 

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1 the following, as such relates to cancer screening required 

2 under section 9813(a): 

3 ‘‘(1) BENEFITS.—Benefits offered under the 

4 plan or coverage, including— 

5 ‘‘(A) covered benefits, including benefit 

6 limits and coverage exclusions; 

7 ‘‘(B) cost sharing, such as deductibles, co8 insurance, and copayment amounts, including 

9 any liability for balance billing, any maximum 

10 limitations on out of pocket expenses, and the 

11 maximum out of pocket costs for services that 

12 are provided by nonparticipating providers or 

13 that are furnished without meeting the applica14 ble utilization review requirements; 

15 ‘‘(C) the extent to which benefits may be 

16 obtained from nonparticipating providers; and 

17 ‘‘(D) the extent to which a participant, 

18 beneficiary, or enrollee may select from among 

19 participating providers and the types of pro20 viders participating in the plan or issuer net21 work. 

22 ‘‘(2) ACCESS.—A description of the following: 

23 ‘‘(A) The number, mix, and distribution of 

24 providers under the plan or coverage. 
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1 ‘‘(B) Out-of-network coverage (if any) pro2 vided by the plan or coverage. 

3 ‘‘(C) Any point-of-service option (including 

4 any supplemental premium or cost-sharing for 

5 such option). 

6 ‘‘(D) The procedures for participants, 

7 beneficiaries, and enrollees to select, access, and 

8 change participating primary and specialty pro9 viders. 

10 ‘‘(E) The rights and procedures for obtain11 ing referrals (including standing referrals) to 

12 participating and nonparticipating providers. 

13 ‘‘(F) The name, address, and telephone 

14 number of participating health care providers 

15 and an indication of whether each such provider 

16 is available to accept new patients. 

17 ‘‘(G) How the plan or issuer addresses the 

18 needs of participants, beneficiaries, and enroll19 ees and others who do not speak English or 

20 who have other special communications needs in 

21 accessing providers under the plan or coverage, 

22 including the provision of information under 

23 this subsection.’’. 

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. 2753. STANDARD RELATING PATIENT FREEDOM OF 

6 CHOICE. 

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

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

9 coverage offered by a health insurance issuer in the indi10 vidual market with respect to an enrollee under such cov11 erage in the same manner as they apply to health insur12 ance coverage offered by a health insurance issuer in con13 nection with a group health plan in the small or large 

14 group market to a participant or beneficiary in such plan. 

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

16 part shall comply with the notice requirement under sec17 tion 714(d) of the Employee Retirement Income Security 

18 Act of 1974 with respect to the requirements referred to 

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

20 and such issuer were a group health plan. 

21 ‘‘SEC. 2754. PATIENT ACCESS TO INFORMATION. 

22 ‘‘The provisions of section 2708 shall apply health in23 surance coverage offered by a health insurance issuer in 

24 the individual market with respect to an enrollee under 

25 such coverage in the same manner as they apply to health 
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1 insurance coverage offered by a health insurance issuer 

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

3 large group market to a participant or beneficiary in such 

4 plan.’’. 

5 (2) TECHNICAL AMENDMENT.—Section 

6 2762(b)(2) of such Act (42 U.S.C. 300gg–62(b)(2)) 

7 is amended by striking ‘‘section 2751’’ and inserting 

8 ‘‘sections 2751 and 2753’’. 

9 (c) EFFECTIVE DATES.— 

10 (1) GROUP HEALTH PLANS.—Subject to para11 graph (3), the amendments made by subsection (a) 

12 shall apply with respect to group health plans for 

13 plan years beginning on or after January 1, 2006. 

14 (2) INDIVIDUAL PLANS.—The amendment made 

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

16 insurance coverage offered, sold, issued, renewed, in 

17 effect, or operated in the individual market on or 

18 after such date. 

19 (3) COLLECTIVE BARGAINING AGREEMENT.—In 

20 the case of a group health plan maintained pursuant 

21 to 1 or more collective bargaining agreements be22 tween employee representatives and 1 or more em23 ployers ratified before the date of enactment of this 

24 Act, the amendments made to subsection (a) shall 
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1 not apply to plan years beginning before the later 

2 of— 

3 (A) the date on which the last collective 

4 bargaining agreements relating to the plan ter5 minates (determined without regard to any ex6 tension thereof agreed to after the date of en7 actment of this Act), or 

8 (B) January 1, 2006. 

9 For purposes of subparagraph (A), any plan amend10 ment made pursuant to a collective bargaining 

11 agreement relating to the plan which amends the 

12 plan solely to conform to any requirement added by 

13 subsection (a) shall not be treated as a termination 

14 of such collective bargaining agreement. 

15 (d) COORDINATED REGULATIONS.—Section 104(1) 

16 of Health Insurance Portability and Accountability Act of 

17 1996 (Public Law 104–191) is amended by striking ‘‘this 

18 subtitle (and the amendments made by this subtitle and 

19 section 401)’’ and inserting ‘‘the provisions of part 7 of 

20 subtitle B of title I of the Employee Retirement Income 

21 Security Act of 1974, the provisions of parts A and C of 

22 title XXVII of the Public Health Service Act, and chapter 

23 100 of the Internal Revenue Code of 1986’’. 

24 (e) MODIFICATION OF COVERAGE.— 
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1 (1) IN GENERAL.—The Secretary of Health and 

2 Human Services may modify the coverage require3 ments for the amendments under this Act to allow 

4 such requirements to incorporate and reflect new sci5 entific and technological advances regarding cancer 

6 screening, practice pattern changes in such screen7 ing, or other updated medical practices regarding 

8 such screening, such as the use of new tests or other 

9 emerging technologies. Such modifications shall not 

10 in any way diminish the coverage requirements listed 

11 under this Act. Such modifications may be made on 

12 the Secretary’s own initiative or upon petition to the 

13 Secretary by an individual or organization. 

14 (2) CONSULTATION.—In modifying coverage re15 quirements under paragraph (1), the Secretary of 

16 Health and Human Services shall consult with ap17 propriate organizations, experts, and agencies. 

18 (3) PETITIONS.—The Secretary of Health and 

19 Human Services may issue requirements for the pe20 titioning process under paragraph (1), including re21 quirements that the petition be in writing and in22 clude scientific or medical bases for the modification 

23 sought. Upon receipt of such a petition, the Sec24 retary shall respond to the petitioner and decide 

25 whether to propose a regulation proposing a change 
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1 within 90 days of such receipt. If a regulation is re2 quired, the Secretary shall propose such regulation 

3 within 6 months of such determination. The Sec4 retary shall provide the petitioner the reasons for 

5 the decision of the Secretary. The Secretary may 

6 make changes requested by a petitioner in whole or 

7 in part. 

8 SEC. 3. APPLICATION TO OTHER HEALTH CARE COVERAGE. 

9 Chapter 89 of title 5, United States Code, is amended 

10 by adding at the end the following: 

11 ‘‘§ 8915. Standards relating to coverage of cancer 

12 screening and patient access to informa13 tion 

14 ‘‘(a) The provisions of sections 2707 and 2708 of the 

15 Public Health Service Act shall apply to the provision of 

16 items and services under this chapter. 

17 ‘‘(b) Nothing in this section or section 2707(c) of the 

18 Public Health Service Act shall be construed as author19 izing a health insurance issuer or entity to impose cost 

20 sharing with respect to the coverage or benefits required 

21 to be provided under section 2707 of the Public Health 

22 Service Act that is inconsistent with the cost sharing that 

23 is otherwise permitted under this chapter.’’. 

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