I

106TH CONGRESS

1ST SESSION H. R. 524

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 annual screening mammography for any class of covered individuals if the coverage

or plans include coverage for diagnostic mammography for such class,

and to amend titles XVIII and XIX of the Social Security Act to

provide for coverage of annual screening mammography.

IN THE HOUSE OF REPRESENTATIVES

FEBRUARY 3, 1999

Mr. ANDREWS introduced the following bill; which was referred to the Committee on Commerce, and in addition to the Committees on Ways and

Means, and 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

group health plans provide coverage for annual screening

mammography for any class of covered individuals if

the coverage or plans include coverage for diagnostic

mammography for such class, and to amend titles XVIII

and XIX of the Social Security Act to provide for coverage of annual screening mammography.
2

HR 524 IH

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 ‘‘Screening Mammog5 raphy Act of 1999’’.

6 SEC. 2. COVERAGE OF ANNUAL SCREENING MAMMOG7 RAPHY UNDER GROUP HEALTH PLANS.

8 (a) PUBLIC HEALTH SERVICE ACT AMENDMENTS.—

9 (1) Subpart 2 of part A of title XXVII of the

10 Public Health Service Act, as amended by section

11 703(a) of Public Law 104–204, is amended by add12 ing at the end the following new section:

13 ‘‘SEC. 2706. STANDARDS RELATING TO BENEFITS FOR

14 SCREENING MAMMOGRAPHY.

15 ‘‘(a) REQUIREMENTS FOR COVERAGE OF ANNUAL

16 SCREENING MAMMOGRAPHY.—

17 ‘‘(1) IN GENERAL.—A group health plan, and a

18 health insurance issuer offering group health insur19 ance coverage, that provides coverage for diagnostic

20 mammography for any class of participants or bene21 ficiaries shall provide coverage for annual screening

22 mammography for such class under terms and con23 ditions that are not less favorable than the terms

24 and conditions for coverage of diagnostic mammog25 raphy.
3

HR 524 IH

1 ‘‘(2) DIAGNOSTIC AND ANNUAL SCREENING

2 MAMMOGRAPHY DEFINED.—For purposes of this

3 section—

4 ‘‘(A) The term ‘diagnostic mammography’

5 means a radiologic procedure that is medically

6 necessary for the purpose of diagnosing breast

7 cancer and includes a physician’s interpretation

8 of the results of the procedure.

9 ‘‘(B) The term ‘annual screening mam10 mography’ means a radiologic procedure pro11 vided to an individual, not more frequently than

12 on an annual basis, for the purpose of early de13 tection of breast cancer and includes a physi14 cian’s interpretation of the results of the proce15 dure.

16 ‘‘(b) 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 coverage for annual screening mam21 mography on the basis that the coverage is not

22 medically necessary or on the basis that the screen23 ing mammography is not pursuant to a referral, con24 sent, or recommendation by any health care pro25 vider;
4

HR 524 IH

1 ‘‘(2) deny to a participant or beneficiary eligi2 bility, or continued eligibility, to enroll or to renew

3 coverage under the terms of the plan, solely for the

4 purpose of avoiding the requirements of this section;

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

6 participants or beneficiaries to encourage them to

7 accept less than the minimum protections available

8 under this section;

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

10 reimbursement of an attending provider because

11 such provider provided care to an individual partici12 pant or beneficiary in accordance with this section;

13 or

14 ‘‘(5) provide incentives (monetary or otherwise)

15 to an attending provider to induce such provider to

16 provide care to an individual participant or bene17 ficiary in a manner inconsistent with this section.

18 ‘‘(c) RULES OF CONSTRUCTION.—

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

20 to require a participant or beneficiary to undergo

21 annual screening mammography.

22 ‘‘(2) This section shall not apply with respect to

23 any group health plan, or any group health insur24 ance coverage offered by a health insurance issuer,
5

HR 524 IH

1 which does not provide benefits for diagnostic mam2 mography.

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

4 as preventing a group health plan or a health insur5 ance issuer offering group health plan coverage from

6 imposing deductibles, coinsurance, or other cost7 sharing in relation to benefits for annual screening

8 mammography under the plan (or under health in9 surance coverage offered in connection with a group

10 health plan), except that such coinsurance or other

11 cost-sharing for any portion may not be greater than

12 such coinsurance or cost-sharing that is otherwise

13 applicable with respect to benefits for diagnostic

14 mammography.

15 ‘‘(4) Nothing in this section shall be construed

16 as preventing a group health plan or a health insur17 ance issuer offering group health insurance coverage

18 from requiring that a participant or beneficiary, be19 fore undergoing an annual screening mammography

20 more frequently than on an annual basis, consult

21 with an appropriate health care practitioner or ob22 tain a written authorization from such a practitioner

23 for submission to the plan or issuer, but nothing in

24 this section shall be construed as requiring prior au-
6

HR 524 IH

1 thorization before undergoing an annual screening

2 mammography.

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

4 shall comply with the notice requirement under section

5 713(d) of the Employee Retirement Income Security Act

6 of 1974 with respect to the requirements of this section

7 as if such section applied to such plan.

8 ‘‘(e) LEVEL AND TYPE OF REIMBURSEMENTS.—

9 Nothing in this section shall be construed as preventing

10 a group health plan or a health insurance issuer offering

11 group health insurance coverage from negotiating the level

12 and type of reimbursement with a provider for care pro13 vided in accordance with this section.

14 ‘‘(f) PREEMPTION; EXCEPTION FOR HEALTH INSUR15 ANCE COVERAGE IN CERTAIN STATES.—

16 ‘‘(1) IN GENERAL.—The requirements of this

17 section shall not apply with respect to health insur18 ance coverage for any class of participants or bene19 ficiaries if there is a State law (as defined in section

20 2723(d)(1)) for a State that regulates such cov21 erage, that requires coverage to be provided for an22 nual screening mammography for such class, and

23 that provides at least the protections described in

24 subsection (b).
7

HR 524 IH

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

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

4 (2) Section 2723(c) of such Act (42 U.S.C.

5 300gg–23(c)), as amended by section 604(b)(2) of

6 Public Law 104–204, is amended by striking ‘‘sec7 tion 2704’’ and inserting ‘‘sections 2704 and 2706’’.

8 (b) ERISA AMENDMENTS.—

9 (1) Subpart B of part 7 of subtitle B of title

10 I of the Employee Retirement Income Security Act

11 of 1974, as amended by section 702(a) of Public

12 Law 104–204, is amended by adding at the end the

13 following new section:

14 ‘‘SEC. 713. STANDARDS RELATING TO BENEFITS FOR

15 SCREENING MAMMOGRAPHY.

16 ‘‘(a) REQUIREMENTS FOR COVERAGE OF ANNUAL

17 SCREENING MAMMOGRAPHY.—

18 ‘‘(1) IN GENERAL.—A group health plan, and a

19 health insurance issuer offering group health insur20 ance coverage, that provides coverage for diagnostic

21 mammography for any class of participants or bene22 ficiaries shall provide coverage for annual screening

23 mammography for such class under terms and con24 ditions that are not less favorable than the terms
8

HR 524 IH

1 and conditions for coverage of diagnostic mammog2 raphy.

3 ‘‘(2) DIAGNOSTIC AND ANNUAL SCREENING

4 MAMMOGRAPHY DEFINED.—For purposes of this

5 section—

6 ‘‘(A) The term ‘diagnostic mammography’

7 means a radiologic procedure that is medically

8 necessary for the purpose of diagnosing breast

9 cancer and includes a physician’s interpretation

10 of the results of the procedure.

11 ‘‘(B) The term ‘annual screening mam12 mography’ means a radiologic procedure pro13 vided to an individual, not more frequently than

14 on an annual basis, for the purpose of early de15 tection of breast cancer and includes a physi16 cian’s interpretation of the results of the proce17 dure.

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

19 health insurance issuer offering group health insurance

20 coverage in connection with a group health plan, may

21 not—

22 ‘‘(1) deny coverage described in subsection

23 (a)(1) on the basis that the coverage is not medically

24 necessary or on the basis that the annual screening

25 mammography is not pursuant to a referral, con-
9

HR 524 IH

1 sent, or recommendation by any health care pro2 vider;

3 ‘‘(2) deny to a participant or beneficiary eligi4 bility, or continued eligibility, to enroll or to renew

5 coverage under the terms of the plan, solely for the

6 purpose of avoiding the requirements of this section;

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

8 participants or beneficiaries to encourage them to

9 accept less than the minimum protections available

10 under this section;

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

12 reimbursement of an attending provider because

13 such provider provided care to an individual partici14 pant or beneficiary in accordance with this section;

15 or

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

17 to an attending provider to induce such provider to

18 provide care to an individual participant or bene19 ficiary in a manner inconsistent with this section.

20 ‘‘(c) RULES OF CONSTRUCTION.—

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

22 to require a participant or beneficiary to undergo

23 annual screening mammography.

24 ‘‘(2) This section shall not apply with respect to

25 any group health plan, or any group health insur-
10

HR 524 IH

1 ance coverage offered by a health insurance issuer,

2 which does not provide benefits for diagnostic mam3 mography.

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

5 as preventing a group health plan or a health insur6 ance issuer offering group health insurance coverage

7 from imposing deductibles, coinsurance, or other

8 cost-sharing in relation to benefits for annual

9 screening mammography under the plan (or under

10 health insurance coverage offered in connection with

11 a group health plan), except that such coinsurance

12 or other cost-sharing for any portion may not be

13 greater than such coinsurance or cost-sharing that is

14 otherwise applicable with respect to benefits for di15 agnostic mammography.

16 ‘‘(4) Nothing in this section shall be construed

17 as preventing a group health plan or a health insur18 ance issuer offering group health insurance coverage

19 from requiring that a participant or beneficiary, be20 fore undergoing an annual screening mammography

21 more frequently than on an annual basis, consult

22 with an appropriate health care practitioner or ob23 tain a written authorization from such a practitioner

24 for submission to the plan or issuer, but nothing in

25 this section shall be construed as requiring prior au-
11

HR 524 IH

1 thorization before undergoing an annual screening

2 mammography.

3 ‘‘(d) 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 ‘‘(e) LEVEL AND TYPE OF REIMBURSEMENTS.—

14 Nothing in this section shall be construed as preventing

15 a group health plan or a health insurance issuer offering

16 group health insurance coverage from negotiating the level

17 and type of reimbursement with a provider for care pro18 vided in accordance with this section.

19 ‘‘(f) PREEMPTION; EXCEPTION FOR HEALTH INSUR20 ANCE COVERAGE IN CERTAIN STATES.—

21 ‘‘(1) IN GENERAL.—The requirements of this

22 section shall not apply with respect to health insur23 ance coverage for any class of participants or bene24 ficiaries if there is a State law (as defined in section

25 731(d)(1)) for a State that regulates such coverage,
12

HR 524 IH

1 that requires coverage to be provided for annual

2 screening mammography for such class, and that

3 provides at least the protections described in sub4 section (b).

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

6 not be construed as superseding a State law de7 scribed in paragraph (1).’’.

8 (2) Section 731(c) of such Act (29 U.S.C.

9 1191(c)), as amended by section 603(b)(1) of Public

10 Law 104–204, is amended by striking ‘‘section 711’’

11 and inserting ‘‘sections 711 and 713’’.

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

13 1191a(a)), as amended by section 603(b)(2) of Pub14 lic Law 104–204, is amended by striking ‘‘section

15 711’’ and inserting ‘‘sections 711 and 713’’.

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

17 Act is amended by inserting after the item relating

18 to section 712 the following new item:

‘‘Sec. 713. Standards relating to benefits for screening mammography.’’.

19 (c) EFFECTIVE DATES.—(1) Subject to paragraph

20 (2), the amendments made by this section shall apply with

21 respect to group health plans (and health insurance cov22 erage offered in connection with group health plans) for

23 plan years beginning on or after January 1, 2000.

24 (2) In the case of a group health plan maintained

25 pursuant to 1 or more collective bargaining agreements
13

HR 524 IH

1 between employee representatives and 1 or more employ2 ers ratified before the date of enactment of this Act, the

3 amendments made by this section shall not apply to plan

4 years beginning before the later of—

5 (A) the date on which the last collective bar6 gaining agreements relating to the plan terminates

7 (determined without regard to any extension thereof

8 agreed to after the date of enactment of this Act),

9 or

10 (B) January 1, 2000.

11 For purposes of subparagraph (A), any plan amendment

12 made pursuant to a collective bargaining agreement relat13 ing to the plan which amends the plan solely to conform

14 to any requirement added by this section shall not be

15 treated as a termination of such collective bargaining

16 agreement.

17 SEC. 3. COVERAGE OF ANNUAL SCREENING MAMMOG18 RAPHY UNDER INDIVIDUAL HEALTH COV19 ERAGE.

20 (a) IN GENERAL.—Part B of title XXVII of the Pub21 lic Health Service Act, as amended by section 605(a) of

22 Public Law 104–204, is amended by inserting after sec23 tion 2751 the following new section:
14

HR 524 IH

1 ‘‘SEC. 2752. STANDARDS RELATING TO BENEFITS FOR

2 SCREENING MAMMOGRAPHY.

3 ‘‘(a) IN GENERAL.—The provisions of section 2706

4 (other than subsections (d) and (f)) shall apply to health

5 insurance coverage offered by a health insurance issuer

6 in the individual market in the same manner as it applies

7 to health insurance coverage offered by a health insurance

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

9 or large group market.

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

11 part shall comply with the notice requirement under sec12 tion 713(d) of the Employee Retirement Income Security

13 Act of 1974 with respect to the requirements referred to

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

15 and such issuer were a group health plan.

16 ‘‘(c) PREEMPTION; EXCEPTION FOR HEALTH INSUR17 ANCE COVERAGE IN CERTAIN STATES.—

18 ‘‘(1) IN GENERAL.—The requirements of this

19 section shall not apply with respect to health insur20 ance coverage for any class of individuals if there is

21 a State law (as defined in section 2723(d)(1)) for a

22 State that regulates such coverage, that requires

23 coverage in the individual health insurance market

24 to be provided for annual screening mammography

25 for such class and that provides at least the protec-
15

HR 524 IH

1 tions described in section 2706(b) (as applied under

2 subsection (a)).

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

4 not be construed as superseding a State law de5 scribed in paragraph (1).’’.

6 (b) CONFORMING AMENDMENT.—Section 2763(b)(2)

7 of such Act (42 U.S.C. 300gg–63(b)(2)), as added by sec8 tion 605(b)(3)(B) of Public Law 104–204, is amended by

9 striking ‘‘section 2751’’ and inserting ‘‘sections 2751 and

10 2752’’.

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

12 this section shall apply with respect to health insurance

13 coverage offered, sold, issued, or renewed in the individual

14 market on or after such January 1, 2000.

15 SEC. 4. ANNUAL SCREENING MAMMOGRAPHY UNDER MEDI16 CARE PROGRAM.

17 (a) PROVIDING ANNUAL SCREENING MAMMOGRAPHY

18 FOR WOMEN OF ALL AGES.—Paragraph (2) of section

19 1834(c) of the Social Security Act (42 U.S.C. 1395m(c))

20 is amended to read as follows:

21 ‘‘(2) COVERED ON AN ANNUAL BASIS.—Pay22 ment may not be made under this part for a screen23 ing mammography performed within the 11 months

24 following the month in which a previous screening

25 mammography was performed.’’.
16

HR 524 IH

1 (b) EFFECTIVE DATE.—The amendments made by

2 subsection (a) shall apply to screening mammography per3 formed on or after January 1, 2000.

4 SEC. 5. COVERAGE OF ANNUAL SCREENING MAMMOG5 RAPHY UNDER MEDICAID.

6 (a) IN GENERAL.—Section 1905(a) of the Social Se7 curity Act (42 U.S.C. 1396d(a)) is amended—

8 (1) by striking ‘‘and’’ at the end of paragraph

9 (24);

10 (2) by redesignating paragraph (25) as para11 graph (26); and

12 (3) by inserting after paragraph (24) the fol13 lowing new paragraph:

14 ‘‘(25) annual screening mammography (as de15 fined in subsection (t)) that is conducted by a facil16 ity that has a certificate (or provisional certificate)

17 issued under section 354 of the Public Health Serv18 ice Act; and’’.

19 (b) ANNUAL SCREENING MAMMOGRAPHY DE20 FINED.—Section 1905 of such Act (42 U.S.C. 1396d) is

21 amended by adding at the end the following new sub22 section:

23 ‘‘(t) The term ‘annual screening mammography’

24 means a radiologic procedure provided to a woman, not

25 more frequently than on an annual basis, for the purpose
17

HR 524 IH

1 of early detection of breast cancer and includes a physi2 cian’s interpretation of the results of the procedure.’’.

3 (c) MAKING COVERAGE MANDATORY.—Section

4 1902(a)(10)(A) of such Act (42 U.S.C. 1396a(a)(10)(A))

5 is amended by striking ‘‘(17) and (21)’’ and inserting

6 ‘‘(17), (21), and (25)’’.

7 (d) CONFORMING AMENDMENTS.—Section 1902 of

8 such Act (42 U.S.C. 1396a) is amended—

9 (1) in subsection (a)(10)(C)(iv)—

10 (A) by striking ‘‘and (17)’’ and inserting

11 ‘‘, (17), and (25)’’, and

12 (B) by striking ‘‘through (24)’’ and insert13 ing ‘‘through (25)’’; and

14 (2) in subsection (j), by striking ‘‘through (25)’’

15 and inserting ‘‘through (26)’’.

16 (e) EFFECTIVE DATE.—(1) Except as provided in

17 paragraph (2), the amendments made by this section shall

18 apply to screening mammography performed on or after

19 January 1, 2000, without regard to whether or not final

20 regulations to carry out such amendments have been pro21 mulgated by such date.

22 (2) In the case of a State plan for medical assistance

23 under title XIX of the Social Security Act which the Sec24 retary of Health and Human Services determines requires

25 State legislation (other than legislation appropriating
18

HR 524 IH

1 funds) in order for the plan to meet the additional require2 ment imposed by the amendments made by this section,

3 the State plan shall not be regarded as failing to comply

4 with the requirements of such title solely on the basis of

5 its failure to meet this additional requirement before the

6 first day of the first calendar quarter beginning after the

7 close of the first regular session of the State legislature

8 that begins after the date of the enactment of this Act.

9 For purposes of the previous sentence, in the case of a

10 State that has a 2-year legislative session, each year of

11 such session shall be deemed to be a separate regular ses12 sion of the State legislature.

Æ