I

106TH CONGRESS

1ST SESSION H. R. 1132

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 women 40 years of age or older if the coverage

or plans include coverage for diagnostic mammography.

IN THE HOUSE OF REPRESENTATIVES

MARCH 16, 1999

Mr. NADLER introduced the following bill; which was referred to the Committee on Commerce, and in addition to the Committee on Education and

the Workforce, for a period to be subsequently determined by the Speaker, in each case for consideration of such provisions as fall within the jurisdiction of the committee concerned

A BILL

To amend the Public Health Service Act and Employee Retirement Income Security Act of 1974 to require that

group and individual health insurance coverage and

group health plans provide coverage for annual screening

mammography for women 40 years of age or older if

the coverage or plans include coverage for diagnostic

mammography.

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; FINDINGS.

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

3 ‘‘Mammogram Availability Act of 1999’’.

4 (b) FINDINGS.—Congress finds the following:

5 (1) Breast cancer is the single leading cause of

6 death for women between the ages of 40 and 49 in

7 the United States

8 (2) An expert panel convened by the National

9 Institutes of Health recommended on January 23,

10 1997, that all women between the ages of 40 and 49

11 should choose for themselves, following consultation

12 with their health care provider, whether to undergo

13 screening mammography.

14 (3) The same panel unanimously recommended

15 that for women between the ages of 40 and 49 who

16 choose to have a screening mammogram, costs of the

17 mammograms should be reimbursed by third-party

18 payers or covered by health maintenance organiza19 tions.

20 SEC. 2. COVERAGE OF ANNUAL SCREENING MAMMOG21 RAPHY UNDER GROUP HEALTH PLANS.

22 (a) PUBLIC HEALTH SERVICE ACT AMENDMENTS.—

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

24 Public Health Service Act is amended by adding at

25 the end the following new section:
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1 ‘‘SEC. 2707. STANDARDS RELATING TO BENEFITS FOR

2 SCREENING MAMMOGRAPHY.

3 ‘‘(a) REQUIREMENTS FOR COVERAGE OF ANNUAL

4 SCREENING MAMMOGRAPHY.—

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

6 health insurance issuer offering group health insur7 ance coverage, that provides coverage for diagnostic

8 mammography for any woman who is 40 years of

9 age or older shall provide coverage for annual

10 screening mammography for such a woman under

11 terms and conditions that are not less favorable than

12 the terms and conditions for coverage of diagnostic

13 mammography.

14 ‘‘(2) DIAGNOSTIC AND SCREENING MAMMOG15 RAPHY DEFINED.—For purposes of this section—

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

17 means a radiologic procedure that is medically

18 necessary for the purpose of diagnosing breast

19 cancer and includes a physician’s interpretation

20 of the results of the procedure.

21 ‘‘(B) The term ‘screening mammography’

22 means a radiologic procedure provided to a

23 woman for the purpose of early detection of

24 breast cancer and includes a physician’s inter25 pretation of the results of the procedure.
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1 ‘‘(b) 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 coverage for annual screening mam6 mography on the basis that the coverage is not

7 medically necessary or on the basis that the screen8 ing mammography is not pursuant to a referral, con9 sent, or recommendation by any health care pro10 vider;

11 ‘‘(2) deny to a woman eligibility, or continued

12 eligibility, to enroll or to renew coverage under the

13 terms of the plan, solely for the purpose of avoiding

14 the requirements of this section;

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

16 women to encourage such women to accept less than

17 the minimum protections available under this sec18 tion;

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

20 reimbursement of an attending provider because

21 such provider provided care to an individual partici22 pant or beneficiary in accordance with this section;

23 or

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

25 to an attending provider to induce such provider to
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1 provide care to an individual participant or bene2 ficiary in a manner inconsistent with this section.

3 ‘‘(c) RULES OF CONSTRUCTION.—

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

5 to require a woman who is a participant or bene6 ficiary to undergo annual screening mammography.

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

8 any group health plan, or any group health insur9 ance coverage offered by a health insurance issuer,

10 which does not provide benefits for diagnostic mam11 mography.

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

13 as preventing a group health plan or issuer from im14 posing deductibles, coinsurance, or other cost-shar15 ing in relation to benefits for screening mammog16 raphy under the plan (or under health insurance

17 coverage offered in connection with a group health

18 plan), except that such coinsurance or other cost19 sharing for any portion may not be greater than

20 such coinsurance or cost-sharing that is otherwise

21 applicable with respect to benefits for diagnostic

22 mammography.

23 ‘‘(4) Women between the ages of 40 and 49

24 should (but are not required to) consult with appro25 priate health care practitioners before undergoing
6

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1 screening mammography, but nothing in this section

2 shall be construed as requiring the approval of such

3 a practitioner before undergoing an annual screening

4 mammography.

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

6 shall comply with the notice requirement under section

7 714(d) of the Employee Retirement Income Security Act

8 of 1974 with respect to the requirements of this section

9 as if such section applied to such plan.

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

11 Nothing in this section shall be construed to prevent a

12 group health plan or a health insurance issuer offering

13 group health insurance coverage from negotiating the level

14 and type of reimbursement with a provider for care pro15 vided in accordance with this section.

16 ‘‘(f) 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 if there is a State law (as defined in

21 section 2723(d)(1)) for a State that regulates such

22 coverage, that requires coverage to be provided for

23 annual screening mammography for women who are

24 40 years of age or older and that provides at least

25 the protections described in subsection (b).
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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)) is amended by striking ‘‘section 2704’’

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

7 (b) ERISA AMENDMENTS.—

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

9 I of the Employee Retirement Income Security Act

10 of 1974 is amended by adding at the end the fol11 lowing new section:

12 ‘‘SEC. 714. STANDARDS RELATING TO BENEFITS FOR

13 SCREENING MAMMOGRAPHY.

14 ‘‘(a) REQUIREMENTS FOR COVERAGE OF ANNUAL

15 SCREENING MAMMOGRAPHY.—

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

17 health insurance issuer offering group health insur18 ance coverage, that provides coverage for diagnostic

19 mammography for any woman who is 40 years of

20 age or older shall provide coverage for annual

21 screening mammography for such a woman under

22 terms and conditions that are not less favorable than

23 the terms and conditions for coverage of diagnostic

24 mammography.
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1 ‘‘(2) DIAGNOSTIC AND SCREENING MAMMOG2 RAPHY DEFINED.—For purposes of this section—

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

4 means a radiologic procedure that is medically

5 necessary for the purpose of diagnosing breast

6 cancer and includes a physician’s interpretation

7 of the results of the procedure.

8 ‘‘(B) The term ‘screening mammography’

9 means a radiologic procedure provided to a

10 woman for the purpose of early detection of

11 breast cancer and includes a physician’s inter12 pretation of the results of the procedure.

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

14 health insurance issuer offering group health insurance

15 coverage in connection with a group health plan, may

16 not—

17 ‘‘(1) deny coverage described in subsection

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

19 necessary or on the basis that the screening mam20 mography is not pursuant to a referral, consent, or

21 recommendation by any health care provider;

22 ‘‘(2) deny to a woman eligibility, or continued

23 eligibility, to enroll or to renew coverage under the

24 terms of the plan, solely for the purpose of avoiding

25 the requirements of this section;
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1 ‘‘(3) provide monetary payments or rebates to

2 women to encourage such women to accept less than

3 the minimum protections available under this sec4 tion;

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

6 reimbursement of an attending provider because

7 such provider provided care to an individual partici8 pant or beneficiary in accordance with this section;

9 or

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

11 to an attending provider to induce such provider to

12 provide care to an individual participant or bene13 ficiary in a manner inconsistent with this section.

14 ‘‘(c) RULES OF CONSTRUCTION.—

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

16 to require a woman who is a participant or bene17 ficiary to undergo annual screening mammography.

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

19 any group health plan, or any group health insur20 ance coverage offered by a health insurance issuer,

21 which does not provide benefits for diagnostic mam22 mography.

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

24 as preventing a group health plan or issuer from im25 posing deductibles, coinsurance, or other cost-shar-
10

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1 ing in relation to benefits for screening mammog2 raphy under the plan (or under health insurance

3 coverage offered in connection with a group health

4 plan), except that such coinsurance or other cost5 sharing for any portion may not be greater than

6 such coinsurance or cost-sharing that is otherwise

7 applicable with respect to benefits for diagnostic

8 mammography.

9 ‘‘(4) Women between the ages of 40 and 49

10 should (but are not required to) consult with appro11 priate health care practitioners before undergoing

12 screening mammography, but nothing in this section

13 shall be construed as requiring the approval of such

14 a practitioner before undergoing an annual screening

15 mammography.

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

17 imposition of the requirements of this section shall be

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

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

20 notice of such requirements under the plan; except that

21 the summary description required to be provided under the

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

23 modification shall be provided by not later than 60 days

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

25 requirements apply.
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1 ‘‘(e) LEVEL AND TYPE OF REIMBURSEMENTS.—

2 Nothing in this section shall be construed to prevent a

3 group health plan or a health insurance issuer offering

4 group health insurance coverage from negotiating the level

5 and type of reimbursement with a provider for care pro6 vided in accordance with this section.

7 ‘‘(f) PREEMPTION; EXCEPTION FOR HEALTH INSUR8 ANCE COVERAGE IN CERTAIN STATES.—

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

10 section shall not apply with respect to health insur11 ance coverage if there is a State law (as defined in

12 section 731(d)(1)) for a State that regulates such

13 coverage, that requires coverage to be provided for

14 annual screening mammography for women who are

15 40 years of age or older, and that provides at least

16 the protections described in subsection (b).

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

18 not be construed as superseding a State law de19 scribed in paragraph (1).’’.

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

21 1191(c)) is amended by striking ‘‘section 711’’ and

22 inserting ‘‘sections 711 and 714’’.

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

24 1191a(a)) is amended by striking ‘‘section 711’’ and

25 inserting ‘‘sections 711 and 714’’.
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1 (4) The table of contents in section 1 of such

2 Act is amended by inserting after the item relating

3 to section 713 the following new item:

‘‘Sec. 714. Standards relating to benefits for screening mammography.’’.

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

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

6 respect to group health plans (and health insurance cov7 erage offered in connection with group health plans) for

8 plan years beginning on or after January 1, 1999.

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

10 pursuant to 1 or more collective bargaining agreements

11 between employee representatives and 1 or more employ12 ers ratified before the date of enactment of this Act, the

13 amendments made by this section shall not apply to plan

14 years beginning before the later of—

15 (A) the date on which the last collective bar16 gaining agreements relating to the plan terminates

17 (determined without regard to any extension thereof

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

19 or

20 (B) January 1, 1999.

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

22 made pursuant to a collective bargaining agreement relat23 ing to the plan which amends the plan solely to conform

24 to any requirement added by this section shall not be
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1 treated as a termination of such collective bargaining

2 agreement.

3 SEC. 3. COVERAGE OF ANNUAL SCREENING MAMMOG4 RAPHY UNDER INDIVIDUAL HEALTH COV5 ERAGE.

6 (a) IN GENERAL.—Part B of title XXVII of the Pub7 lic Health Service Act is amended by inserting after sec8 tion 2751 the following new section:

9 ‘‘SEC. 2753. STANDARDS RELATING TO BENEFITS FOR

10 SCREENING MAMMOGRAPHY.

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

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

13 insurance coverage offered by a health insurance issuer

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

15 to health insurance coverage offered by a health insurance

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

17 or large group market.

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

19 part shall comply with the notice requirement under sec20 tion 714(d) of the Employee Retirement Income Security

21 Act of 1974 with respect to the requirements referred to

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

23 and such issuer were a group health plan.

24 ‘‘(c) PREEMPTION; EXCEPTION FOR HEALTH INSUR25 ANCE COVERAGE IN CERTAIN STATES.—
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1 ‘‘(1) IN GENERAL.—The requirements of this

2 section shall not apply with respect to health insur3 ance coverage if there is a State law (as defined in

4 section 2723(d)(1)) for a State that regulates such

5 coverage, that requires coverage in the individual

6 health insurance market to be provided for annual

7 screening mammography for women who are 40

8 years of age or older and that provides at least the

9 protections described in section 2706(b) (as applied

10 under subsection (a)).

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

12 not be construed as superseding a State law de13 scribed in paragraph (1).’’.

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

15 of such Act (42 U.S.C. 300gg–63(b)(2)) is amended by

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

17 2753’’.

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

19 this section shall apply with respect to health insurance

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

21 market on or after such January 1, 1999.

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