I

107TH CONGRESS

1ST SESSION H. R. 1809

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

MAY 10, 2001

Mrs. MALONEY of New York (for herself, Mrs. KELLY, Mr. RANGEL, Mr. GILMAN, Mr. BONIOR, Mr. QUINN, Mr. FROST, Mr. SMITH of New Jersey,

Ms. PELOSI, Mrs. MORELLA, Mr. TOWNS, Mr. WYNN, Mr. OBERSTAR,

Mrs. MINK of Hawaii, Ms. WOOLSEY, Mr. BALDACCI, Mr. GONZALEZ,

Mr. LANGEVIN, Mrs. THURMAN, Ms. MILLENDER-MCDONALD, Mr.

HASTINGS of Florida, Ms. LEE, Mr. HILLIARD, Mr. LEWIS of Georgia,

Mr. LANTOS, Mr. CUMMINGS, Mr. WEXLER, Ms. JACKSON-LEE of Texas,

Mrs. TAUSCHER, Mr. CAPUANO, Ms. HARMAN, Mr. MEEKS of New York,

and Mr. KILDEE) introduced the following bill; which was referred to the

Committee on Energy and Commerce, and in addition to the Committees

on Education and the Workforce, Ways and Means, and Government Reform, 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.
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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 ‘‘Cancer Screening Cov5 erage Act of 2001’’.

6 SEC. 2. CANCER SCREENING COVERAGE.

7 (a) GROUP HEALTH PLANS.—

8 (1) PUBLIC HEALTH SERVICE ACT AMEND9 MENTS.—

10 (A) IN GENERAL.—Subpart 2 of part A of

11 title XXVII of the Public Health Service Act

12 (42 U.S.C. 300gg–4 et seq.) is amended by

13 adding at the end the following:

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

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

16 health insurance issuer offering group health insurance

17 coverage, shall provide coverage and payment under the

18 plan or coverage for the following items and services under

19 terms and conditions that are no less favorable than the

20 terms and conditions applicable to other screening benefits

21 otherwise provided under the plan or coverage:

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

23 participant or beneficiary who is 40 years of age or

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

25 (as defined in subsection (e)) of developing breast
3

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1 cancer, an annual mammography (as defined in sec2 tion 1861(jj) of the Social Security Act) conducted

3 by a facility that has a certificate (or provisional cer4 tificate) issued under section 354.

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

6 case of a female participant or beneficiary who—

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

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

9 and is at high risk of developing breast cancer,

10 an annual clinical breast examination; or

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

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

13 breast cancer, a clinical breast examination

14 each 3 years.

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

16 In the case of a female participant or beneficiary

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

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

19 ‘‘(A) an annual diagnostic laboratory test

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

21 of a routine exfoliative cytology test (Papani22 colaou test) provided to a woman for the pur23 pose of early detection of cervical or vaginal

24 cancer and including an interpretation by a
4

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1 qualified health professional of the results of

2 the test; and

3 ‘‘(B) an annual pelvic examination.

4 ‘‘(4) COLORECTAL CANCER SCREENING PROCE5 DURES.—In the case of a participant or beneficiary

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

7 years of age and is at high risk of developing

8 colorectal cancer, the procedures described in section

9 1861(pp)(1) of the Social Security Act (42 U.S.C.

10 1395x(pp)(1)) or section 4104(a)(2) of the Balanced

11 Budget Act of 1997 (111 Stat. 362), shall be fur12 nished to the individual for the purpose of early de13 tection of colorectal cancer. The group health plan

14 or health insurance issuer shall provide coverage for

15 the method and frequency of colorectal cancer

16 screening determined to be appropriate by a health

17 care provider treating such participant or bene18 ficiary, in consultation with the participant or bene19 ficiary.

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

21 case of a male participant or beneficiary who is 50

22 years of age or older, or who is younger than 50

23 years of age and is at high risk for prostate cancer

24 (including African American men or a male who has

25 a history of prostate cancer in 1 or more first degree
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1 family members), the procedures described in section

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

3 1395x(oo)(2)) shall be furnished to the individual

4 for the early detection of prostate cancer. The group

5 health plan or health insurance issuer shall provide

6 coverage for the method and frequency of prostate

7 cancer screening determined to be appropriate by a

8 health care provider treating such participant or

9 beneficiary, in consultation with the participant or

10 beneficiary.

11 ‘‘(6) OTHER TESTS AND PROCEDURES.—Such

12 other tests or procedures for the detection of cancer,

13 and modifications to the tests and procedures, with

14 such frequency, as the Secretary determines to be

15 appropriate, in consultation with appropriate organi16 zations and agencies, for the diagnosis or detection

17 of cancer.

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, shall

21 not—

22 ‘‘(1) deny to an individual eligibility, or contin23 ued eligibility, to enroll or to renew coverage under

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

25 avoiding the requirements of this section;
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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 or issuer from im20 posing deductibles, coinsurance, or other cost-shar21 ing in relation to benefits described in subsection (a)

22 consistent with such subsection, except that such co23 insurance or other cost-sharing shall not discrimi24 nate on any basis related to the coverage required

25 under this section.
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1 ‘‘(d) NOTICE.—A group health plan under this part

2 shall comply with the notice requirement under section

3 714(d) of the Employee Retirement Income Security Act

4 of 1974 with respect to the requirements of this section

5 as if such section applied to such plan.

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

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

8 developing a particular type of cancer if, under guidelines

9 developed or recognized by the Secretary based upon sci10 entific evidence, the individual—

11 ‘‘(1) has 1 or more first degree family members

12 who have developed that type of cancer;

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

14 ‘‘(3) has the presence of an appropriate recog15 nized gene marker that is identified as putting the

16 individual at a higher risk of developing that type of

17 cancer; or

18 ‘‘(4) has other predisposing factors that signifi19 cantly increases the risk of the individual con20 tracting that type of cancer.

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

22 includes other types of cancer that the Secretary recog23 nizes as closely related for purposes of establishing risk.
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1 ‘‘SEC. 2708. PATIENT ACCESS TO INFORMATION.

2 ‘‘(a) DISCLOSURE REQUIREMENT.—A group health

3 plan, and health insurance issuer offering group health in4 surance coverage shall—

5 ‘‘(1) provide to participants and beneficiaries at

6 the time of initial coverage under the plan (or the

7 effective date of this section, in the case of individ8 uals who are participants or beneficiaries as of such

9 date), and at least annually thereafter, the informa10 tion described in subsection (b) in printed form;

11 ‘‘(2) provide to participants and beneficiaries,

12 within a reasonable period (as specified by the ap13 propriate Secretary) before or after the date of sig14 nificant changes in the information described in sub15 section (b), information in printed form regarding

16 such significant changes; and

17 ‘‘(3) upon request, make available to partici18 pants and beneficiaries, the applicable authority, and

19 prospective participants and beneficiaries, the infor20 mation described in subsection (b) in printed form.

21 ‘‘(b) INFORMATION PROVIDED.—The information de22 scribed in subsection (a) that shall be disclosed includes

23 the following, as such relates to cancer screening required

24 under section 2707(a):

25 ‘‘(1) BENEFITS.—Benefits offered under the

26 plan or coverage, including—
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1 ‘‘(A) covered benefits, including benefit

2 limits and coverage exclusions;

3 ‘‘(B) cost sharing, such as deductibles, co4 insurance, and copayment amounts, including

5 any liability for balance billing, any maximum

6 limitations on out of pocket expenses, and the

7 maximum out of pocket costs for services that

8 are provided by nonparticipating providers or

9 that are furnished without meeting the applica10 ble utilization review requirements;

11 ‘‘(C) the extent to which benefits may be

12 obtained from nonparticipating providers; and

13 ‘‘(D) the extent to which a participant,

14 beneficiary, or enrollee may select from among

15 participating providers and the types of pro16 viders participating in the plan or issuer net17 work.

18 ‘‘(2) ACCESS.—A description of the following:

19 ‘‘(A) The number, mix, and distribution of

20 providers under the plan or coverage.

21 ‘‘(B) Out-of-network coverage (if any) pro22 vided by the plan or coverage.

23 ‘‘(C) Any point-of-service option (including

24 any supplemental premium or cost-sharing for

25 such option).
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1 ‘‘(D) The procedures for participants,

2 beneficiaries, and enrollees to select, access, and

3 change participating primary and specialty pro4 viders.

5 ‘‘(E) The rights and procedures for obtain6 ing referrals (including standing referrals) to

7 participating and nonparticipating providers.

8 ‘‘(F) The name, address, and telephone

9 number of participating health care providers

10 and an indication of whether each such provider

11 is available to accept new patients.

12 ‘‘(G) How the plan or issuer addresses the

13 needs of participants, beneficiaries, and enroll14 ees and others who do not speak English or

15 who have other special communications needs in

16 accessing providers under the plan or coverage,

17 including the provision of information under

18 this subsection.’’.

19 (B) TECHNICAL AMENDMENT.—Section

20 2723(c) of the Public Health Service Act (42

21 U.S.C. 300gg–23(c)) is amended by striking

22 ‘‘section 2704’’ and inserting ‘‘sections 2704

23 and 2707’’.

24 (2) ERISA AMENDMENTS.—
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1 (A) IN GENERAL.—Subpart B of part 7 of

2 subtitle B of title I of the Employee Retirement

3 Income Security Act of 1974 (29 U.S.C. 1185

4 et seq.) is amended by adding at the end the

5 following new section:

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

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

8 health insurance issuer offering group health insurance

9 coverage, shall provide coverage and payment under the

10 plan or coverage for the following items and services under

11 terms and conditions that are no less favorable than the

12 terms and conditions applicable to other screening benefits

13 otherwise provided under the plan or coverage:

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

15 participant or beneficiary who is 40 years of age or

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

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

18 cancer, an annual mammography (as defined in sec19 tion 1861(jj) of the Social Security Act) conducted

20 by a facility that has a certificate (or provisional cer21 tificate) issued under section 354 of the Public

22 Health Service Act.

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

24 case of a female participant or beneficiary who—
12

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

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

3 and is at high risk of developing breast cancer,

4 an annual clinical breast examination; or

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

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

7 breast cancer, a clinical breast examination

8 each 3 years.

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

10 In the case of a female participant or beneficiary

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

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

13 ‘‘(A) an annual diagnostic laboratory test

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

15 of a routine exfoliative cytology test (Papani16 colaou test) provided to a woman for the pur17 pose of early detection of cervical or vaginal

18 cancer and including an interpretation by a

19 qualified health professional of the results of

20 the test; and

21 ‘‘(B) an annual pelvic examination.

22 ‘‘(4) COLORECTAL CANCER SCREENING PROCE23 DURES.—In the case of a participant or beneficiary

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

25 years of age and is at high risk of developing
13

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1 colorectal cancer, the procedures described in section

2 1861(pp)(1) of the Social Security Act (42 U.S.C.

3 1395x(pp)(1)) or section 4104(a)(2) of the Balanced

4 Budget Act of 1997 (111 Stat. 362), shall be fur5 nished to the individual for the purpose of early de6 tection of colorectal cancer. The group health plan

7 or health insurance issuer shall provided coverage

8 for the method and frequency of colorectal cancer

9 screening determined to be appropriate by a health

10 care provider treating such participant or bene11 ficiary, in consultation with the participant or bene12 ficiary.

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

14 case of a male participant or beneficiary who is 50

15 years of age or older, or who is younger than 50

16 years of age and is at high risk for prostate cancer

17 (including African American men or a male who has

18 a history of prostate cancer in 1 or more first degree

19 family members), the procedures described in section

20 1861(oo)(2) of Social Security Act (42 U.S.C.

21 1395x(oo)(2)) shall be furnished to the individual

22 for the early detection of prostate cancer. The group

23 health plan or health insurance issuer shall provide

24 coverage for the method and frequency of prostate

25 cancer screening determined to be appropriate by a
14

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1 health care provider treating such participant or

2 beneficiary, in consultation with the participant or

3 beneficiary.

4 ‘‘(6) OTHER TESTS AND PROCEDURES.—Such

5 other tests or procedures for the detection of cancer,

6 and modifications to the tests and procedures, with

7 such frequency, as the Secretary determines to be

8 appropriate, in consultation with appropriate organi9 zations and agencies, for the diagnosis or detection

10 of cancer.

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

12 health insurance issuer offering group health insurance

13 coverage in connection with a group health plan, may

14 not—

15 ‘‘(1) deny to an individual eligibility, or contin16 ued eligibility, to enroll or to renew coverage under

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

18 avoiding the requirements of this section;

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

20 individuals to encourage such individuals to accept

21 less than the minimum protections available under

22 this section;

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

24 reimbursement of a provider because such provider
15

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1 provided care to an individual participant or bene2 ficiary in accordance with this section; or

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

4 to a provider to induce such provider to provide care

5 to an individual participant or beneficiary in a man6 ner inconsistent with this section.

7 ‘‘(c) RULES OF CONSTRUCTION.—

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

9 to require an individual who is a participant or bene10 ficiary to undergo a procedure, examination, or test

11 described in subsection (a).

12 ‘‘(2) 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 described in subsection (a)

16 consistent with such subsection, except that such co17 insurance or other cost-sharing shall not discrimi18 nate on any basis related to the coverage required

19 under this section.

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

21 imposition of the requirement of this section shall be treat22 ed as a material modification in the terms of the plan de23 scribed in section 102(a), for purposes of assuring notice

24 of such requirements under the plan; except that the sum25 mary description required to be provided under the last
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1 sentence of section 104(b)(1) with respect to such modi2 fication shall be provided by not later than 60 days after

3 the first day of the first plan year in which such require4 ment apply.

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

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

7 developing a particular type of cancer if, under guidelines

8 developed or recognized by the Secretary based upon sci9 entific evidence, the individual—

10 ‘‘(1) has 1 or more first degree family members

11 who have developed that type of cancer;

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

13 ‘‘(3) has the presence of an appropriate recog14 nized gene marker that is identified as putting the

15 individual at a higher risk of developing that type of

16 cancer; or

17 ‘‘(4) has other predisposing factors that signifi18 cantly increases the risk of the individual con19 tracting that type of cancer.

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

21 includes other types of cancer that the Secretary recog22 nizes as closely related for purposes of establishing risk.
17

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1 ‘‘SEC. 715. PATIENT ACCESS TO INFORMATION.

2 ‘‘(a) DISCLOSURE REQUIREMENT.—A group health

3 plan, and health insurance issuer offering group health in4 surance coverage shall—

5 ‘‘(1) provide to participants and beneficiaries at

6 the time of initial coverage under the plan (or the

7 effective date of this section, in the case of individ8 uals who are participants or beneficiaries as of such

9 date), and at least annually thereafter, the informa10 tion described in subsection (b) in printed form;

11 ‘‘(2) provide to participants and beneficiaries,

12 within a reasonable period (as specified by the ap13 propriate Secretary) before or after the date of sig14 nificant changes in the information described in sub15 section (b), information in printed form regarding

16 such significant changes; and

17 ‘‘(3) upon request, make available to partici18 pants and beneficiaries, the applicable authority, and

19 prospective participants and beneficiaries, the infor20 mation described in subsection (b) in printed form.

21 ‘‘(b) INFORMATION PROVIDED.—The information de22 scribed in subsection (a) that shall be disclosed includes

23 the following, as such relates to cancer screening required

24 under section 714(a):

25 ‘‘(1) BENEFITS.—Benefits offered under the

26 plan or coverage, including—
18

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1 ‘‘(A) covered benefits, including benefit

2 limits and coverage exclusions;

3 ‘‘(B) cost sharing, such as deductibles, co4 insurance, and copayment amounts, including

5 any liability for balance billing, any maximum

6 limitations on out of pocket expenses, and the

7 maximum out of pocket costs for services that

8 are provided by nonparticipating providers or

9 that are furnished without meeting the applica10 ble utilization review requirements;

11 ‘‘(C) the extent to which benefits may be

12 obtained from nonparticipating providers; and

13 ‘‘(D) the extent to which a participant,

14 beneficiary, or enrollee may select from among

15 participating providers and the types of pro16 viders participating in the plan or issuer net17 work.

18 ‘‘(2) ACCESS.—A description of the following:

19 ‘‘(A) The number, mix, and distribution of

20 providers under the plan or coverage.

21 ‘‘(B) Out-of-network coverage (if any) pro22 vided by the plan or coverage.

23 ‘‘(C) Any point-of-service option (including

24 any supplemental premium or cost-sharing for

25 such option).
19

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1 ‘‘(D) The procedures for participants,

2 beneficiaries, and enrollees to select, access, and

3 change participating primary and specialty pro4 viders.

5 ‘‘(E) The rights and procedures for obtain6 ing referrals (including standing referrals) to

7 participating and nonparticipating providers.

8 ‘‘(F) The name, address, and telephone

9 number of participating health care providers

10 and an indication of whether each such provider

11 is available to accept new patients.

12 ‘‘(G) How the plan or issuer addresses the

13 needs of participants, beneficiaries, and enroll14 ees and others who do not speak English or

15 who have other special communications needs in

16 accessing providers under the plan or coverage,

17 including the provision of information under

18 this subsection.’’.

19 (B) TECHNICAL AMENDMENTS.—

20 (i) Section 731(c) of the Employee

21 Retirement Income Security Act of 1974

22 (29 U.S.C. 1191(c)) is amended by strik23 ing ‘‘section 711’’ and inserting ‘‘sections

24 711 and 714’’.
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1 (ii) Section 732(a) of the Employee

2 Retirement Income Security Act of 1974

3 (29 U.S.C. 1191a(a)) is amended by strik4 ing ‘‘section 711’’ and inserting ‘‘sections

5 711 and 714’’.

6 (iii) The table of contents in section 1

7 of the Employee Retirement Income Secu8 rity Act of 1974 is amended by inserting

9 after the item relating to section 713 the

10 following new items:

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

‘‘Sec. 715. Patient access to information.’’.

11 (3) INTERNAL REVENUE CODE AMEND12 MENTS.—Subchapter B of chapter 100 of the Inter13 nal Revenue Code of 1986 is amended—

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

15 after the item relating to section 9812 the fol16 lowing new items:

‘‘Sec. 9813. Coverage of cancer screening.

‘‘Sec. 9814. Patient access to information.’’;

17 and

18 (B) by inserting after section 9812 the fol19 lowing:

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

21 ‘‘(a) REQUIREMENT.—A group health plan shall pro22 vide coverage and payment under the plan for the fol23 lowing items and services under terms and conditions that
21

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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
22

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

2 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, the procedures described in section

17 1861(pp)(1) of the Social Security Act (42 U.S.C.

18 1395x(pp)(1)) or section 4104(a)(2) of the Balanced

19 Budget Act of 1997 (111 Stat. 362), shall be fur20 nished to the individual for the purpose of early de21 tection of colorectal cancer. The group health plan

22 or health insurance issuer shall provide coverage for

23 the method and frequency of colorectal cancer

24 screening determined to be appropriate by a health

25 care provider treating such participant or bene-
23

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1 ficiary, in consultation with the participant or bene2 ficiary.

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

4 case of a male participant or beneficiary who is 50

5 years of age or older, or who is younger than 50

6 years of age and is at high risk for prostate cancer

7 (including African American men or a male who has

8 a history of prostate cancer in 1 or more first degree

9 family members), the procedures described in section

10 1861(oo)(2) of Social Security Act (42 U.S.C.

11 1395x(oo)(2)) shall be furnished to the individual

12 for the early detection of prostate cancer. The group

13 health plan or health insurance issuer shall provide

14 coverage for the method and frequency of prostate

15 cancer screening determined to be appropriate by a

16 health care provider treating such participant or

17 beneficiary, in consultation with the participant or

18 beneficiary.

19 ‘‘(6) OTHER TESTS AND PROCEDURES.—Such

20 other tests or procedures for the detection of cancer,

21 and modifications to the tests and procedures, with

22 such frequency, as the Secretary determines to be

23 appropriate, in consultation with appropriate organi24 zations and agencies, for the diagnosis or detection

25 of cancer.
24

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

2 ‘‘(1) deny to an individual eligibility, or contin3 ued eligibility, to enroll or to renew coverage under

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

5 avoiding the requirements of this section;

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

7 individuals to encourage such individuals to accept

8 less than the minimum protections available under

9 this section;

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

11 reimbursement of a provider because such provider

12 provided care to an individual participant or bene13 ficiary in accordance with this section; or

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

15 to a provider to induce such provider to provide care

16 to an individual participant or beneficiary in a man17 ner inconsistent with this section.

18 ‘‘(c) RULES OF CONSTRUCTION.—

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

20 to require an individual who is a participant or bene21 ficiary to undergo a procedure, examination, or test

22 described in subsection (a).

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

24 as preventing a group health plan from imposing

25 deductibles, coinsurance, or other cost-sharing in re-
25

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1 lation to benefits described in subsection (a) con2 sistent with such subsection, except that such coin3 surance or other cost-sharing shall not discriminate

4 on any basis related to the coverage required under

5 this section.

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

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

8 developing a particular type of cancer if, under guidelines

9 developed or recognized by the Secretary based upon sci10 entific evidence, the individual—

11 ‘‘(1) has 1 or more first degree family members

12 who have developed that type of cancer;

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

14 ‘‘(3) has the presence of an appropriate recog15 nized gene marker that is identified as putting the

16 individual at a higher risk of developing that type of

17 cancer; or

18 ‘‘(4) has other predisposing factors that signifi19 cantly increases the risk of the individual con20 tracting that type of cancer.

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

22 includes other types of cancer that the Secretary recog23 nizes as closely related for purposes of establishing risk.
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1 ‘‘SEC. 9814. PATIENT ACCESS TO INFORMATION.

2 ‘‘(a) DISCLOSURE REQUIREMENT.—A group health

3 plan, and health insurance issuer offering group health in4 surance coverage shall—

5 ‘‘(1) provide to participants and beneficiaries at

6 the time of initial coverage under the plan (or the

7 effective date of this section, in the case of individ8 uals who are participants or beneficiaries as of such

9 date), and at least annually thereafter, the informa10 tion described in subsection (b) in printed form;

11 ‘‘(2) provide to participants and beneficiaries,

12 within a reasonable period (as specified by the ap13 propriate Secretary) before or after the date of sig14 nificant changes in the information described in sub15 section (b), information in printed form regarding

16 such significant changes; and

17 ‘‘(3) upon request, make available to partici18 pants and beneficiaries, the applicable authority, and

19 prospective participants and beneficiaries, the infor20 mation described in subsection (b) in printed form.

21 ‘‘(b) INFORMATION PROVIDED.—The information de22 scribed in subsection (a) that shall be disclosed includes

23 the following, as such relates to cancer screening required

24 under section 9813(a):

25 ‘‘(1) BENEFITS.—Benefits offered under the

26 plan or coverage, including—
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1 ‘‘(A) covered benefits, including benefit

2 limits and coverage exclusions;

3 ‘‘(B) cost sharing, such as deductibles, co4 insurance, and copayment amounts, including

5 any liability for balance billing, any maximum

6 limitations on out of pocket expenses, and the

7 maximum out of pocket costs for services that

8 are provided by nonparticipating providers or

9 that are furnished without meeting the applica10 ble utilization review requirements;

11 ‘‘(C) the extent to which benefits may be

12 obtained from nonparticipating providers; and

13 ‘‘(D) the extent to which a participant,

14 beneficiary, or enrollee may select from among

15 participating providers and the types of pro16 viders participating in the plan or issuer net17 work.

18 ‘‘(2) ACCESS.—A description of the following:

19 ‘‘(A) The number, mix, and distribution of

20 providers under the plan or coverage.

21 ‘‘(B) Out-of-network coverage (if any) pro22 vided by the plan or coverage.

23 ‘‘(C) Any point-of-service option (including

24 any supplemental premium or cost-sharing for

25 such option).
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1 ‘‘(D) The procedures for participants,

2 beneficiaries, and enrollees to select, access, and

3 change participating primary and specialty pro4 viders.

5 ‘‘(E) The rights and procedures for obtain6 ing referrals (including standing referrals) to

7 participating and nonparticipating providers.

8 ‘‘(F) The name, address, and telephone

9 number of participating health care providers

10 and an indication of whether each such provider

11 is available to accept new patients.

12 ‘‘(G) How the plan or issuer addresses the

13 needs of participants, beneficiaries, and enroll14 ees and others who do not speak English or

15 who have other special communications needs in

16 accessing providers under the plan or coverage,

17 including the provision of information under

18 this subsection.’’.

19 (b) INDIVIDUAL HEALTH INSURANCE.—

20 (1) IN GENERAL.—Part B of title XXVII of the

21 Public Health Service Act is amended by inserting

22 after section 2752 (42 U.S.C. 300gg–52) the fol23 lowing new section:
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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 ‘‘SEC. 2754. PATIENT ACCESS TO INFORMATION.

18 ‘‘The provisions of section 2708 shall apply health in19 surance coverage offered by a health insurance issuer in

20 the individual market with respect to an enrollee under

21 such coverage in the same manner as they apply to health

22 insurance coverage offered by a health insurance issuer

23 in connection with a group health plan in the small or

24 large group market to a participant or beneficiary in such

25 plan.’’.
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1 (2) TECHNICAL AMENDMENT.—Section

2 2762(b)(2) of such Act (42 U.S.C. 300gg–62(b)(2))

3 is amended by striking ‘‘section 2751’’ and inserting

4 ‘‘sections 2751 and 2753’’.

5 (c) EFFECTIVE DATES.—

6 (1) GROUP HEALTH PLANS.—Subject to para7 graph (3), the amendments made by subsection (a)

8 shall apply with respect to group health plans for

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

10 (2) INDIVIDUAL PLANS.—The amendment made

11 by subsection (b) shall apply with respect to health

12 insurance coverage offered, sold, issued, renewed, in

13 effect, or operated in the individual market on or

14 after such date.

15 (3) COLLECTIVE BARGAINING AGREEMENT.—In

16 the case of a group health plan maintained pursuant

17 to 1 or more collective bargaining agreements be18 tween employee representatives and 1 or more em19 ployers ratified before the date of enactment of this

20 Act, the amendments made to subsection (a) shall

21 not apply to plan years beginning before the later

22 of—

23 (A) the date on which the last collective

24 bargaining agreements relating to the plan ter25 minates (determined without regard to any ex-
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1 tension thereof agreed to after the date of en2 actment of this Act), or

3 (B) January 1, 2002.

4 For purposes of subparagraph (A), any plan amend5 ment made pursuant to a collective bargaining

6 agreement relating to the plan which amends the

7 plan solely to conform to any requirement added by

8 subsection (a) shall not be treated as a termination

9 of such collective bargaining agreement.

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

11 of Health Insurance Portability and Accountability Act of

12 1996 (Public Law 104–191) is amended by striking ‘‘this

13 subtitle (and the amendments made by this subtitle and

14 section 401)’’ and inserting ‘‘the provisions of part 7 of

15 subtitle B of title I of the Employee Retirement Income

16 Security Act of 1974, the provisions of parts A and C of

17 title XXVII of the Public Health Service Act, and chapter

18 100 of the Internal Revenue Code of 1986’’.

19 (e) MODIFICATION OF COVERAGE.—

20 (1) IN GENERAL.—The Secretary of Health and

21 Human Services may modify the coverage require22 ments for the amendments under this Act to allow

23 such requirements to incorporate and reflect new sci24 entific and technological advances regarding cancer

25 screening, practice pattern changes in such screen-
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1 ing, or other updated medical practices regarding

2 such screening, such as the use of new tests or other

3 emerging technologies. Such modifications shall not

4 in any way diminish the coverage requirements listed

5 under this Act. Such modifications may be made on

6 the Secretary’s own initiative or upon petition to the

7 Secretary by an individual or organization.

8 (2) CONSULTATION.—In modifying coverage re9 quirements under paragraph (1), the Secretary of

10 Health and Human Services shall consult with ap11 propriate organizations, experts, and agencies.

12 (3) PETITIONS.—The Secretary of Health and

13 Human Services may issue requirements for the pe14 titioning process under paragraph (1), including re15 quirements that the petition be in writing and in16 clude scientific or medical bases for the modification

17 sought. Upon receipt of such a petition, the Sec18 retary shall respond to the petitioner and decide

19 whether to propose a regulation proposing a change

20 within 90 days of such receipt. If a regulation is re21 quired, the Secretary shall propose such regulation

22 within 6 months of such determination. The Sec23 retary shall provide the petitioner the reasons for

24 the decision of the Secretary. The Secretary may
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1 make changes requested by a petitioner in whole or

2 in part.

3 SEC. 3. APPLICATION TO OTHER HEALTH CARE COVERAGE.

4 Chapter 89 of title 5, United States Code, is amended

5 by adding at the end the following:

6 ‘‘§ 8915. Standards relating to coverage of cancer

7 screening and patient access to informa8 tion

9 ‘‘(a) The provisions of sections 2707 and 2708 of the

10 Public Health Service Act shall apply to the provision of

11 items and services under this chapter.

12 ‘‘(b) Nothing in this section or section 2707(c) of the

13 Public Health Service Act shall be construed as author14 izing a health insurance issuer or entity to impose cost

15 sharing with respect to the coverage or benefits required

16 to be provided under section 2707 of the Public Health

17 Service Act that is inconsistent with the cost sharing that

18 is otherwise permitted under this chapter.’’.

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