I

106TH CONGRESS

1ST SESSION H. R. 1285

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 cancer screening.

IN THE HOUSE OF REPRESENTATIVES

MARCH 25, 1999

Mrs. MALONEY of New York (for herself, Mrs. KELLY, Mr. RANGEL, Mr.

MATSUI, Mr. GILMAN, Mrs. MINK of Hawaii, Mrs. MORELLA, Ms.

SCHAKOWSKY, Mr. FROST, Mr. LANTOS, Mr. GUTIERREZ, Mr. CROWLEY,

Mr. CUMMINGS, and Mr. SANDLIN) introduced the following bill; which

was referred to the Committee on Commerce, and in addition to the Committees on Education and the Workforce, and Ways and Means, 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 cancer screening.

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

2 This Act may be cited as the ‘‘Cancer Screening Cov3 erage Act of 1999’’.

4 SEC. 2. CANCER SCREENING COVERAGE.

5 (a) GROUP HEALTH PLANS.—

6 (1) PUBLIC HEALTH SERVICE ACT AMEND7 MENTS.—(A) Subpart 2 of part A of title XXVII of

8 the Public Health Service Act is amended by adding

9 at the end the following new section:

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

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

12 health insurance issuer offering group health insurance

13 coverage, shall provide coverage and payment under the

14 plan or coverage for the following items and services under

15 terms and conditions that are no less favorable than the

16 terms and conditions applicable to other screening benefits

17 otherwise provided under the plan or coverage:

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

19 participant or beneficiary who is 40 years of age or

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

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

22 cancer, an annual mammography (as defined in sec23 tion 1861(jj) of the Social Security Act) conducted

24 by a facility that has a certificate (or provisional cer25 tificate) issued under section 354 of the Public

26 Health Service Act.
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1 ‘‘(2) CLINICAL BREAST EXAMINATIONS.—In the

2 case of a female participant or beneficiary who—

3 ‘‘(A)(i) is 40 years of age or older or (ii)

4 is at least 20 (but less than 40) years of age

5 and is at high risk of developing breast cancer,

6 an annual clinical breast examination; or

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

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

9 breast cancer, a clinical breast examination

10 each 3 years.

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

12 In the case of a female participant or beneficiary

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

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

15 ‘‘(A) an annual diagnostic laboratory test

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

17 of a routine exfoliative cytology test (Papani18 colaou test) provided to a woman for the pur19 pose of early detection of cervical or vaginal

20 cancer and including an interpretation by a

21 qualified health professional of the results of

22 the test; and

23 ‘‘(B) an annual pelvic examination.

24 ‘‘(4) COLORECTAL CANCER SCREENING PROCE25 DURES.—In the case of a participant or beneficiary
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1 who is 50 years of age or older, or who is under 50

2 years of age and is at high risk of developing

3 colorectal cancer, all of the following procedures fur4 nished to the individual for the purpose of early de5 tection of colorectal cancer:

6 ‘‘(A) Screening fecal-occult blood test, but

7 not to exceed once every 12 months.

8 ‘‘(B) Screening flexible sigmoidoscopy, but

9 not to exceed once every 48 months.

10 ‘‘(C) In the case of an individual at high

11 risk for colorectal cancer, screening

12 colonoscopy, but not to exceed once every 24

13 months.

14 ‘‘(D) Such other tests or procedures, and

15 modifications to tests and procedures under this

16 paragraph, with such frequency, as the Sec17 retary determines appropriate, in consultation

18 with appropriate organizations.

19 Under this paragraph, a screening barium enema

20 may be substituted either for a screening flexible

21 sigmoidoscopy or for a screen colonoscopy at the at22 tending physician’s discretion.

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

24 case of a participant or beneficiary who is 50 years

25 of age or older, an annual test consisting of any (or
5

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1 all) of the procedures described in section

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

3 1395x(oo)(2)) provided for the purpose of early de4 tection of prostate cancer.

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

6 health insurance issuer offering group health insurance

7 coverage in connection with a group health plan, may

8 not—

9 ‘‘(1) deny to an individual eligibility, or contin10 ued eligibility, to enroll or to renew coverage under

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

12 avoiding the requirements of this section;

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

14 individuals to encourage such individuals to accept

15 less than the minimum protections available under

16 this section;

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

18 reimbursement of a provider because such provider

19 provided care to an individual participant or bene20 ficiary in accordance with this section; or

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

22 to a provider to induce such provider to provide care

23 to an individual participant or beneficiary in a man24 ner inconsistent with this section.

25 ‘‘(c) RULES OF CONSTRUCTION.—
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1 ‘‘(1) Nothing in this section shall be construed

2 to require an individual who is a participant or bene3 ficiary to undergo a procedure, examination, or test

4 described in subsection (a).

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

6 as preventing a group health plan or issuer from im7 posing deductibles, coinsurance, or other cost-shar8 ing in relation to benefits described in subsection (a)

9 consistent with such subsection, except that such co10 insurance or other cost-sharing shall not discrimi11 nate on any basis related to the coverage required

12 under this section.

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

14 shall comply with the notice requirement under section

15 714(d) of the Employee Retirement Income Security Act

16 of 1974 with respect to the requirements of this section

17 as if such section applied to such plan.

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

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

20 developing a particular type of cancer if, under guidelines

21 developed or recognized by the Secretary based upon sci22 entific evidence, the individual—

23 ‘‘(1) has one or more close family members who

24 have developed that type of cancer;

25 ‘‘(2) has previously had that type of cancer;
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1 ‘‘(3) has the presence of an appropriate recog2 nized gene marker that is identified as putting the

3 individual at a higher risk of developing that type of

4 cancer; or

5 ‘‘(4) has other predisposing factors that signifi6 cantly increases the risk of the individual con7 tracting that type of cancer.

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

9 includes other types of cancer that the Secretary recog10 nizes as closely related for purposes of establishing risk.’’.

11 (B) Section 2723(c) of such Act (42 U.S.C.

12 300gg–23(c)) is amended by striking ‘‘section 2704’’

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

14 (2) ERISA AMENDMENTS.—(A) Subpart B of

15 part 7 of subtitle B of title I of the Employee Re16 tirement Income Security Act of 1974 is amended by

17 adding at the end the following new section:

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

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

20 health insurance issuer offering group health insurance

21 coverage, shall provide coverage and payment under the

22 plan or coverage for the following items and services under

23 terms and conditions that are no less favorable than the

24 terms and conditions applicable to other screening benefits

25 otherwise provided under the plan or coverage:
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1 ‘‘(1) MAMMOGRAMS.—In the case of a female

2 participant or beneficiary who is 40 years of age or

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

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

5 cancer, an annual mammography (as defined in sec6 tion 1861(jj) of the Social Security Act) conducted

7 by a facility that has a certificate (or provisional cer8 tificate) issued under section 354 of the Public

9 Health Service Act.

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

11 case of a female participant or beneficiary who—

12 ‘‘(A)(i) is 40 years of age or older or (ii)

13 is at least 20 (but less than 40) years of age

14 and is at high risk of developing breast cancer,

15 an annual clinical breast examination; or

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

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

18 breast cancer, a clinical breast examination

19 each 3 years.

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

21 In the case of a female participant or beneficiary

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

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

24 ‘‘(A) an annual diagnostic laboratory test

25 (popularly known as a ‘pap smear’) consisting
9

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1 of a routine exfoliative cytology test (Papani2 colaou test) provided to a woman for the pur3 pose of early detection of cervical or vaginal

4 cancer and including an interpretation by a

5 qualified health professional of the results of

6 the test; and

7 ‘‘(B) an annual pelvic examination.

8 ‘‘(4) COLORECTAL CANCER SCREENING PROCE9 DURES.—In the case of a participant or beneficiary

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

11 years of age and is at high risk of developing

12 colorectal cancer, all of the following procedures fur13 nished to the individual for the purpose of early de14 tection of colorectal cancer:

15 ‘‘(A) Screening fecal-occult blood test, but

16 not to exceed once every 12 months.

17 ‘‘(B) Screening flexible sigmoidoscopy, but

18 not to exceed once every 48 months.

19 ‘‘(C) In the case of an individual at high

20 risk for colorectal cancer, screening

21 colonoscopy, but not to exceed once every 24

22 months.

23 ‘‘(D) Such other tests or procedures, and

24 modifications to tests and procedures under this

25 paragraph, with such frequency, as the Sec-
10

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1 retary of Health and Human Services deter2 mines appropriate, in consultation with appro3 priate organizations.

4 Under this paragraph, a screening barium enema

5 may be substituted either for a screening flexible

6 sigmoidoscopy or for a screen colonoscopy at the at7 tending physician’s discretion.

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

9 case of a participant or beneficiary who is 50 years

10 of age or older, an annual test consisting of any (or

11 all) of the procedures described in section

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

13 1395x(oo)(2)) provided for the purpose of early de14 tection of prostate cancer.

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

16 health insurance issuer offering group health insurance

17 coverage in connection with a group health plan, may

18 not—

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

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

22 avoiding the requirements of this section;

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

24 individuals to encourage such individuals to accept
11

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1 less than the minimum protections available under

2 this section;

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

4 reimbursement of a provider because such provider

5 provided care to an individual participant or bene6 ficiary in accordance with this section; or

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

8 to a provider to induce such provider to provide care

9 to an individual participant or beneficiary in a man10 ner inconsistent with this section.

11 ‘‘(c) RULES OF CONSTRUCTION.—

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

13 to require an individual who is a participant or bene14 ficiary to undergo a procedure, examination, or test

15 described in subsection (a).

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

17 as preventing a group health plan or issuer from im18 posing deductibles, coinsurance, or other cost-shar19 ing in relation to benefits described in subsection (a)

20 consistent with such subsection, except that such co21 insurance or other cost-sharing shall not discrimi22 nate on any basis related to the coverage required

23 under this section.

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

25 imposition of the requirement of this section shall be treat-
12

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1 ed as a material modification in the terms of the plan de2 scribed in section 102(a)(1), for purposes of assuring no3 tice of such requirements under the plan; except that the

4 summary description required to be provided under the

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

6 modification shall be provided by not later than 60 days

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

8 requirement apply.

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

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

11 developing a particular type of cancer if, under guidelines

12 developed or recognized by the Secretary based upon sci13 entific evidence, the individual—

14 ‘‘(1) has one or more close family members who

15 have developed that type of cancer;

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

17 ‘‘(3) has the presence of an appropriate recog18 nized gene marker that is identified as putting the

19 individual at a higher risk of developing that type of

20 cancer; or

21 ‘‘(4) has other predisposing factors that signifi22 cantly increases the risk of the individual con23 tracting that type of cancer.
13

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

5 1191(c)) is amended by striking ‘‘section 711’’ and

6 inserting ‘‘sections 711 and 714’’.

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

8 1191a(a)) is amended by striking ‘‘section 711’’ and

9 inserting ‘‘sections 711 and 714’’.

10 (D) The table of contents in section 1 of such

11 Act is amended by inserting after the item relating

12 to section 713 the following new item:

‘‘Sec. 714. Coverage of cancer screening.’’.

13 (3) INTERNAL REVENUE CODE AMEND14 MENTS.—Subchapter B of chapter 100 of the Inter15 nal Revenue Code of 1986 is amended—

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

17 after the item relating to section 9812 the fol18 lowing new item:

‘‘Sec. 9813. Coverage of cancer screening.’’; and

19 (B) by inserting after section 9812 the fol20 lowing:

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

22 ‘‘(a) REQUIREMENT.—A group health plan shall pro23 vide coverage and payment under the plan for the fol24 lowing items and services under terms and conditions that
14

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1 are no less favorable than the terms and conditions appli2 cable to other screening benefits otherwise provided under

3 the plan:

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

5 participant or beneficiary who is 40 years of age or

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

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

8 cancer, an annual mammography (as defined in sec9 tion 1861(jj) of the Social Security Act) conducted

10 by a facility that has a certificate (or provisional cer11 tificate) issued under section 354 of the Public

12 Health Service Act.

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

14 case of a female participant or beneficiary who—

15 ‘‘(A)(i) is 40 years of age or older or (ii)

16 is at least 20 (but less than 40) years of age

17 and is at high risk of developing breast cancer,

18 an annual clinical breast examination; or

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

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

21 breast cancer, a clinical breast examination

22 each 3 years.

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

24 In the case of a female participant or beneficiary
15

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

2 18 years of age and is or has been sexually active—

3 ‘‘(A) an annual diagnostic laboratory test

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

5 of a routine exfoliative cytology test (Papani6 colaou test) provided to a woman for the pur7 pose of early detection of cervical or vaginal

8 cancer and including an interpretation by a

9 qualified health professional of the results of

10 the test; and

11 ‘‘(B) an annual pelvic examination.

12 ‘‘(4) COLORECTAL CANCER SCREENING PROCE13 DURES.—In the case of a participant or beneficiary

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

15 years of age and is at high risk of developing

16 colorectal cancer, all of the following procedures fur17 nished to the individual for the purpose of early de18 tection of colorectal cancer:

19 ‘‘(A) Screening fecal-occult blood test, but

20 not to exceed once every 12 months.

21 ‘‘(B) Screening flexible sigmoidoscopy, but

22 not to exceed once every 48 months.

23 ‘‘(C) In the case of an individual at high

24 risk for colorectal cancer, screening
16

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1 colonoscopy, but not to exceed once every 24

2 months.

3 ‘‘(D) Such other tests or procedures, and

4 modifications to tests and procedures under this

5 paragraph, with such frequency, as the Sec6 retary of Health and Human Services deter7 mines appropriate, in consultation with appro8 priate organizations.

9 Under this paragraph, a screening barium enema

10 may be substituted either for a screening flexible

11 sigmoidoscopy or for a screen colonoscopy at the at12 tending physician’s discretion.

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

14 case of a participant or beneficiary who is 50 years

15 of age or older, an annual test consisting of any (or

16 all) of the procedures described in section

17 1861(oo)(2) of Social Security Act (42 U.S.C.

18 1395x(oo)(2)) provided for the purpose of early de19 tection of prostate cancer.

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

21 ‘‘(1) deny to an individual eligibility, or contin22 ued eligibility, to enroll or to renew coverage under

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

24 avoiding the requirements of this section;
17

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

2 individuals to encourage such individuals to accept

3 less than the minimum protections available under

4 this section;

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

6 reimbursement of a provider because such provider

7 provided care to an individual participant or bene8 ficiary in accordance with this section; or

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

10 to a provider to induce such provider to provide care

11 to an individual participant or beneficiary in a man12 ner inconsistent with this section.

13 ‘‘(c) RULES OF CONSTRUCTION.—

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

15 to require an individual who is a participant or bene16 ficiary to undergo a procedure, examination, or test

17 described in subsection (a).

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

19 as preventing a group health plan from imposing

20 deductibles, coinsurance, or other cost-sharing in re21 lation to benefits described in subsection (a) con22 sistent with such subsection, except that such coin23 surance or other cost-sharing shall not discriminate

24 on any basis related to the coverage required under

25 this section.
18

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

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

3 developing a particular type of cancer if, under guidelines

4 developed or recognized by the Secretary based upon sci5 entific evidence, the individual—

6 ‘‘(1) has one or more close family members who

7 have developed that type of cancer;

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

9 ‘‘(3) has the presence of an appropriate recog10 nized gene marker that is identified as putting the

11 individual at a higher risk of developing that type of

12 cancer; or

13 ‘‘(4) has other predisposing factors that signifi14 cantly increases the risk of the individual con15 tracting that type of cancer.

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

17 includes other types of cancer that the Secretary recog18 nizes as closely related for purposes of establishing risk.’’.

19 (b) INDIVIDUAL HEALTH INSURANCE.—(1) Part B

20 of title XXVII of the Public Health Service Act is amend21 ed by inserting after section 2752 the following new sec22 tion:
19

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1 ‘‘SEC. 2753. STANDARD RELATING PATIENT FREEDOM OF

2 CHOICE.

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

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

5 coverage offered by a health insurance issuer in the indi6 vidual market with respect to an enrollee under such cov7 erage in the same manner as they apply to health insur8 ance coverage offered by a health insurance issuer in con9 nection with a group health plan in the small or large

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

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

12 part shall comply with the notice requirement under sec13 tion 714(d) of the Employee Retirement Income Security

14 Act of 1974 with respect to the requirements referred to

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

16 and such issuer were a group health plan.’’.

17 (2) Section 2762(b)(2) of such Act (42 U.S.C.

18 300gg–62(b)(2)) is amended by striking ‘‘section 2751’’

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

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

21 (3), the amendments made by subsection (a) shall apply

22 with respect to group health plans for plan years begin23 ning on or after January 1, 2000.

24 (2) The amendment made by subsection (b) shall

25 apply with respect to health insurance coverage offered,
20

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1 sold, issued, renewed, in effect, or operated in the indi2 vidual market on or after such date.

3 (3) In the case of a group health plan maintained

4 pursuant to 1 or more collective bargaining agreements

5 between employee representatives and 1 or more employ6 ers ratified before the date of enactment of this Act, the

7 amendments made to subsection (a) shall not apply to

8 plan years beginning before the later of—

9 (A) the date on which the last collective bar10 gaining agreements relating to the plan terminates

11 (determined without regard to any extension thereof

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

13 or

14 (B) January 1, 2000.

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

16 made pursuant to a collective bargaining agreement relat17 ing to the plan which amends the plan solely to conform

18 to any requirement added by subsection (a) shall not be

19 treated as a termination of such collective bargaining

20 agreement.

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

22 of Health Insurance Portability and Accountability Act of

23 1996 is amended by striking ‘‘this subtitle (and the

24 amendments made by this subtitle and section 401)’’ and

25 inserting ‘‘the provisions of part 7 of subtitle B of title
21

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1 I of the Employee Retirement Income Security Act of

2 1974, the provisions of parts A and C of title XXVII of

3 the Public Health Service Act, and chapter 100 of the In4 ternal Revenue Code of 1986’’.

Æ