I

104TH CONGRESS

2D SESSION H. R. 3630

To require coverage of screening mammography and pap smears under health

plans.

IN THE HOUSE OF REPRESENTATIVES

JUNE 12, 1996

Mr. FOX of Pennsylvania (for himself, Mr. GENE GREEN of Texas, Mr. LIPINSKI, Mrs. ROUKEMA, Mr. DAVIS, and Mr. FORBES) introduced the following bill; which was referred to the Committee on Commerce, and in addition to the Committee on Economic and Educational Opportunities, 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 require coverage of screening mammography and pap

smears under health plans.

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

3 SECTION 1. SHORT TITLE.

4 This Act may be cited as the ‘‘Women’s Preventive

5 Health Care Act of 1996’’.
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1 SEC. 2. REQUIRING COVERAGE OF SCREENING MAMMOG2 RAPHY AND PAP SMEARS UNDER HEALTH

3 PLANS.

4 (a) IN GENERAL.—Every policy or contract that pro5 vides health insurance coverage (as defined in subsection

6 (h)(1)) and every group health plan (as defined in sub7 section (h)(2)) shall include (consistent with this sec8 tion)—

9 (1) coverage for screening pap smears, and

10 (2) coverage for low-dose screening mammog11 raphy.

12 (b) DEFINITIONS RELATING TO COVERAGE.—In this

13 section:

14 (1) LOW-DOSE SCREENING MAMMOGRAPHY.—

15 The term ‘‘low-dose screening mammography’’

16 means a radiologic procedure for the early detection

17 of breast cancer provided to an asymptomatic

18 women using equipment dedicated specifically for

19 mammography and at a facility which meets mam20 mography accreditation standards established by the

21 Secretary for coverage of screening mammography

22 under the medicare program under title XVIII of the

23 Social Security Act. Such term also includes a physi24 cian’s interpretation of the results of the procedure.

25 (2) SCREENING PAP SMEAR.—The term

26 ‘‘screening pap smear’’ means a diagnostic labora-
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1 tory test consisting of a routine exfoliative cytology

2 test (Papanicolaou test) provided to a woman for the

3 purpose of early detection of cervical cancer and in4 cludes the examination, the laboratory test itself,

5 and a physician’s interpretation of the results of the

6 test. If the Secretary establishes qualify standards

7 for facilities furnishing screening pap smears, such

8 term shall only include a test if the test is performed

9 in a facility that has been determined to meet such

10 standards.

11 (c) RESTRICTIONS ON COST-SHARING.—The cov12 erage under this section shall not provide for the applica13 tion of deductibles, coinsurance, or other limitations for

14 low-dose screening mammography or screening pap

15 smears that are greater than the deductibles, coinsurance,

16 and limitations that are applied to similar services under

17 the health insurance coverage or group health plan.

18 (d) FREQUENCY OF COVERAGE OF SCREENING MAM19 MOGRAPHY.—

20 (1) IN GENERAL.—Coverage of low-dose screen21 ing mammography is consistent with this section

22 only if it is provided consistent with the following

23 periodicity schedule:
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1 (A) Coverage is made available for one

2 baseline low-dose screening mammography for

3 any woman between 35 and 40 years of age.

4 (B) Coverage is made available for such

5 mammography on an annual basis to any

6 woman who is 50 years or age or older or who

7 is determined by a physician to be at-risk of

8 breast cancer (as defined in paragraph (2)).

9 (C) Coverage is made available for such

10 mammography for a woman at least once every

11 other year.

12 (2) AT-RISK OF BREAST CANCER.—For pur13 poses of paragraph (1)(B), a woman is considered to

14 be ‘‘at-risk of breast cancer’’ if any of the following

15 is true:

16 (A) The woman has a personal history of

17 breast cancer.

18 (B) The woman has a personal history of

19 biopsy-proven benign breast disease.

20 (C) The woman’s mother, sister, or daugh21 ter has or has had breast cancer.

22 (D) The woman has not given birth prior

23 to the age of 30.

24 (e) FREQUENCY OF COVERAGE OF SCREENING PAP

25 SMEARS.—Coverage of screening pap smears is consistent
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1 with this section only if it is provided not more often than

2 once every year (or more frequently if recommended by

3 a physician).

4 (f) ENFORCEMENT.—

5 (1) REGULATED INSURERS.—It is the respon6 sibility of State regulators what regulate insurers

7 that offer health insurance coverage in a State to

8 apply the requirements of this section to such insur9 ers and coverage. If the Secretary determines that

10 such regulators do not have the intent or means of

11 enforcing such requirements with respect to such in12 surers in a State, the Secretary may provide such

13 remedies (which may include civil money penalties)

14 as may be necessary to assure compliance with the

15 requirements of this section in such State.

16 (2) GROUP HEALTH PLANS.—The requirements

17 of this section are deemed, in relation to group

18 health plans offered as employee welfare benefit

19 plans under title I of Employee Retirement Income

20 Security Act of 1974, to be provisions of such title,

21 for purposes of applying the enforcement related

22 provisions of such title.

23 (3) OTHER PLANS.—In the case of health cov24 erage not described in paragraph (1) or (2), the Sec25 retary shall develop such non-criminal enforcement
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1 mechanisms as may be necessary and appropriate to

2 carry out this section in relation to entities offering

3 such coverage.

4 (g) RELATION TO STATE LAW.—The provisions of

5 this section do not preempt State law to the extent such

6 State law provides greater protection to women in relation

7 to the benefits provided under this section.

8 (h) DEFINITIONS.—In this section:

9 (1) HEALTH INSURANCE COVERAGE.—

10 (A) IN GENERAL.—Except as provided in

11 subparagraph (B), the term ‘‘health insurance

12 coverage’’ means benefits consisting of medical

13 care (provided directly, through insurance or re14 imbursement, or otherwise) under any hospital

15 or medical service policy or certificate, hospital

16 or medical service plan contract, or health

17 maintenance organization group contract of18 fered by an insurer or a health maintenance or19 ganization.

20 (B) EXCEPTION.—Such term does not in21 clude coverage under any separate policy, cer22 tificate, or contract only for one or more of any

23 of the following:

24 (i) Coverage for accident, credit-only,

25 vision, disability income, long-term care,
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1 nursing home care, community-based care

2 dental, on-site medical clinics, or employee

3 assistance programs, or any combination

4 thereof.

5 (ii) Medicare supplemental health in6 surance (within the meaning of section

7 1882(g)(1) of the Social Security Act (42

8 U.S.C. 1395ss(g)(1))) and similar supple9 mental coverage provided under a group

10 health plan.

11 (iii) Coverage issued as a supplement

12 to liability insurance.

13 (iv) Liability insurance, including gen14 eral liability insurance and automobile li15 ability insurance.

16 (v) Workers’ compensation or similar

17 insurance.

18 (vi) Automobile medical-payment in19 surance.

20 (vii) Coverage for a specified disease

21 or illness.

22 (viii) Hospital or fixed indemnity in23 surance.

24 (ix) Short-term limited duration in25 surance.
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1 (x) Such other coverage, comparable

2 to that described in previous clauses, as

3 may be specified in regulations prescribed

4 by the Secretary.

5 (2) GROUP HEALTH PLAN.—

6 (A) IN GENERAL.—Subject to subpara7 graph (B), the term ‘‘group health plan’’ means

8 an employee welfare benefit plan (as defined in

9 section 3 of the Employee Retirement Income

10 Security Act of 1974) to the extent that the

11 plan provides medical care (as defined in para12 graph (5)) to employees or their dependents (as

13 defined under the terms of the plan) directly or

14 through insurance, reimbursement, or other15 wise, and includes a group health plan (within

16 the meaning of section 5000(b)(1) of the Inter17 nal Revenue Code of 1986).

18 (B) EXCLUSION OF PLANS WITH LIMITED

19 COVERAGE.—An employee welfare benefit plan

20 shall be treated as a group health plan under

21 this section only with respect to medical care

22 which is provided under the plan and which

23 does not consist of coverage excluded from the

24 definition of health insurance coverage under

25 paragraph (1)(B).
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1 (3) HEALTH MAINTENANCE ORGANIZATION.—

2 The term ‘‘health maintenance organization’’

3 means—

4 (A) a Federally qualified health mainte5 nance organization (as defined in section

6 1301(a) of the Public Health Service Act (42

7 U.S.C. 300e(a))),

8 (B) an organization recognized under State

9 law as a health maintenance organization, or

10 (C) a similar organization regulated under

11 State law for solvency in the same manner and

12 to the same extent as such a health mainte13 nance organization,

14 if it is subject to State law which regulates insur15 ance (within the meaning of section 514(b)(2) of the

16 Employee Retirement Income Security Act of 1974).

17 (4) INSURER.—The term ‘‘insurer’’ means an

18 insurance company, insurance service, or insurance

19 organization which is licensed to engage in the busi20 ness of insurance in a State and which is subject to

21 State law which regulates insurance (within the

22 meaning of section 514(b)(2)(A) of the Employee

23 Retirement Income Security Act of 1974).

24 (5) MEDICAL CARE.—The term ‘‘medical care’’

25 means—
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1 (A) amounts paid for, or items or services

2 in the form of, the diagnosis, cure, mitigation,

3 treatment, or prevention of disease, or amounts

4 paid for, or items or services provided for, the

5 purpose of affecting any structure or function

6 of the body,

7 (B) amounts paid for, or services in the

8 form of, transportation primarily for and essen9 tial to medical care referred to in subparagraph

10 (A), and

11 (C) amounts paid for insurance covering

12 medical care referred to in subparagraphs (A)

13 and (B).

14 (6) SECRETARY.—The term ‘‘Secretary’’ means

15 the Secretary of Health and Human Services.

16 (7) STATE.—The term ‘‘State’’ includes the

17 District of Columbia, Puerto Rico, the Virgin Is18 lands, the Northern Mariana Islands, Guam, and

19 American Samoa.

20 (i) EFFECTIVE DATE.—This section shall apply to

21 health insurance coverage that is issued, renewed, or

22 amended on or after January 1, 1997, and to group health

23 plans for plan years beginning on or after such date.

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