I

107TH CONGRESS

1ST SESSION H. R. 1064

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 title XIX of the Social Security Act to provide for coverage

of annual screening mammography under the Medicaid Program.

IN THE HOUSE OF REPRESENTATIVES

MARCH 15, 2001

Mr. ANDREWS introduced the following bill; which was referred to the Committee on Energy and 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 any class of covered individuals if

the coverage or plans include coverage for diagnostic

mammography for such class and to amend title XIX

of the Social Security Act to provide for coverage of

annual screening mammography under the Medicaid Program.
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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 2001’’.

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 is amended by adding at

11 the end the following new section:

12 ‘‘SEC. 2707. 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 class of participants or bene20 ficiaries shall provide coverage for annual screening

21 mammography for such class under terms and con22 ditions that are not less favorable than the terms

23 and conditions for coverage of diagnostic mammog24 raphy.
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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;
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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,
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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-
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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

5 714(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).
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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 class of participants or bene20 ficiaries shall provide coverage for annual screening

21 mammography for such class under terms and con22 ditions that are not less favorable than the terms

23 and conditions for coverage of diagnostic mammog24 raphy.
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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 described in subsection

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

22 necessary or on the basis that the annual screening

23 mammography is not pursuant to a referral, con24 sent, or recommendation by any health care pro25 vider;
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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,
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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 insurance coverage

6 from imposing deductibles, coinsurance, or other

7 cost-sharing in relation to benefits for annual

8 screening mammography under the plan (or under

9 health insurance coverage offered in connection with

10 a group health plan), except that such coinsurance

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

12 greater than such coinsurance or cost-sharing that is

13 otherwise applicable with respect to benefits for di14 agnostic 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-
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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,
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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)) is amended by striking ‘‘section 711’’ and

10 inserting ‘‘sections 711 and 714’’.

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

12 1191a(a)) is amended by striking ‘‘section 711’’ and

13 inserting ‘‘sections 711 and 714’’.

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

15 Act is amended by inserting after the item relating

16 to section 713 the following new item:

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

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

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

19 respect to group health plans (and health insurance cov20 erage offered in connection with group health plans) for

21 plan years beginning on or after January 1, 2002.

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

23 pursuant to 1 or more collective bargaining agreements

24 between employee representatives and 1 or more employ25 ers ratified before the date of enactment of this Act, the
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1 amendments made by this section shall not apply to plan

2 years beginning before the later of—

3 (A) the date on which the last collective bar4 gaining agreements relating to the plan terminates

5 (determined without regard to any extension thereof

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

7 or

8 (B) January 1, 2002.

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

10 made pursuant to a collective bargaining agreement relat11 ing to the plan which amends the plan solely to conform

12 to any requirement added by this section shall not be

13 treated as a termination of such collective bargaining

14 agreement.

15 SEC. 3. COVERAGE OF ANNUAL SCREENING MAMMOG16 RAPHY UNDER INDIVIDUAL HEALTH COV17 ERAGE.

18 (a) IN GENERAL.—Part B of title XXVII of the Pub19 lic Health Service Act is amended by inserting after sec20 tion 2752 the following new section:

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

22 SCREENING MAMMOGRAPHY.

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

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

25 insurance coverage offered by a health insurance issuer
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1 in the individual market in the same manner as it applies

2 to health insurance coverage offered by a health insurance

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

4 or large group market.

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

6 part shall comply with the notice requirement under sec7 tion 714(d) of the Employee Retirement Income Security

8 Act of 1974 with respect to the requirements referred to

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

10 and such issuer were a group health plan.

11 ‘‘(c) PREEMPTION; EXCEPTION FOR HEALTH INSUR12 ANCE COVERAGE IN CERTAIN STATES.—

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

14 section shall not apply with respect to health insur15 ance coverage for any class of individuals if there is

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

17 State that regulates such coverage, that requires

18 coverage in the individual health insurance market

19 to be provided for annual screening mammography

20 for such class and that provides at least the protec21 tions described in section 2707(b) (as applied under

22 subsection (a)).

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

24 not be construed as superseding a State law de25 scribed in paragraph (1).’’.
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1 (b) CONFORMING AMENDMENT.—Section 2762(b)(2)

2 of such Act (42 U.S.C. 300gg–62(b)(2)) is amended by

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

4 2753’’.

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

6 this section shall apply with respect to health insurance

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

8 market on or after such January 1, 2002.

9 SEC. 4. COVERAGE OF ANNUAL SCREENING MAMMOG10 RAPHY UNDER MEDICAID.

11 (a) IN GENERAL.—Section 1905(a) of the Social Se12 curity Act (42 U.S.C. 1396d(a)) is amended—

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

14 (26);

15 (2) by redesignating paragraph (27) as para16 graph (28); and

17 (3) by inserting after paragraph (26) the fol18 lowing new paragraph:

19 ‘‘(27) annual screening mammography (as de20 fined in subsection (x)) that is conducted by a facil21 ity that has a certificate (or provisional certificate)

22 issued under section 354 of the Public Health Serv23 ice Act; and’’.

24 (b) ANNUAL SCREENING MAMMOGRAPHY DE25 FINED.—Section 1905 of such Act (42 U.S.C. 1396d) is
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1 amended by adding at the end the following new sub2 section:

3 ‘‘(x) The term ‘annual screening mammography’

4 means a radiologic procedure provided to a woman, not

5 more frequently than on an annual basis, for the purpose

6 of early detection of breast cancer and includes a physi7 cian’s interpretation of the results of the procedure.’’.

8 (c) MAKING COVERAGE MANDATORY.—Section

9 1902(a)(10)(A) of such Act (42 U.S.C. 1396a(a)(10)(A))

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

11 ‘‘(17), (21), and (27)’’.

12 (d) CONFORMING AMENDMENTS.—Section

13 1902(a)(10)(C)(iv) of such Act (42 U.S.C.

14 1396a(a)(10)(C)(iv)) is amended—

15 (1) by striking ‘‘and (17)’’ and inserting ‘‘,

16 (17), and (27)’’, and

17 (2) by striking ‘‘through (24)’’ and inserting

18 ‘‘through (28)’’; and

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

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

21 apply to screening mammography performed on or after

22 January 1, 2002, without regard to whether or not final

23 regulations to carry out such amendments have been pro24 mulgated by such date.
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1 (2) In the case of a State plan for medical assistance

2 under title XIX of the Social Security Act which the Sec3 retary of Health and Human Services determines requires

4 State legislation (other than legislation appropriating

5 funds) in order for the plan to meet the additional require6 ment imposed by the amendments made by this section,

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

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

9 its failure to meet this additional requirement before the

10 first day of the first calendar quarter beginning after the

11 close of the first regular session of the State legislature

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

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

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

15 such session shall be deemed to be a separate regular ses16 sion of the State legislature.

Æ