I

105TH CONGRESS

1ST SESSION H. R. 617

To amend the Public Health Service Act and Employee Retirement Income

Security Act of 1974 to require that group and individual health insurance coverage and group health plans provide coverage for annual screening mammography for women 40 years of age or older if the coverage

or plans include coverage for diagnostic mammography.

IN THE HOUSE OF REPRESENTATIVES

FEBRUARY 5, 1997

Mr. NADLER (for himself, Mr. LAZIO of New York, Ms. SLAUGHTER, Ms.

EDDIE BERNICE JOHNSON of Texas, Mr. YATES, Mr. PALLONE, Mr.

ENGEL, Mr. LAFALCE, Mr. MARTINEZ, Mr. HINCHEY, Ms. LOFGREN,

Ms. NORTON, Mr. FALEOMAVAEGA, and Ms. CHRISTIAN-GREEN) introduced the following bill; which was referred to the Committee on Commerce, and in addition to the Committee on Ways and Means, and Education and the Workforce, for a period to be subsequently determined by

the Speaker, in each case for consideration of such provisions as fall within the jurisdiction of the committee concerned

A BILL

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

group and individual health insurance coverage and

group health plans provide coverage for annual screening

mammography for women 40 years of age or older if

the coverage or plans include coverage for diagnostic

mammography.
2

•HR 617 IH

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; FINDINGS.

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

5 ‘‘Mammogram Availability Act of 1997’’.

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

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

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

9 the United States

10 (2) An expert panel convened by the National

11 Institutes of Health recommended on January 23,

12 1997, that all women between the ages of 40 and 49

13 should choose for themselves, following consultation

14 with their health care provider, whether to undergo

15 screening mammography.

16 (3) The same panel unanimously recommended

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

18 choose to have a screening mammogram, costs of the

19 mammograms should be reimbursed by third-party

20 payers or covered by health maintenance organiza21 tions.

22 SEC. 2. COVERAGE OF ANNUAL SCREENING MAMMOG23 RAPHY UNDER GROUP HEALTH PLANS.

24 (a) PUBLIC HEALTH SERVICE ACT AMENDMENTS.—
3

•HR 617 IH

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

2 Public Health Service Act, as amended by section

3 703(a) of Public Law 104–204, is amended by add4 ing at the end the following new section:

5 ‘‘SEC. 2706. STANDARDS RELATING TO BENEFITS FOR

6 SCREENING MAMMOGRAPHY.

7 ‘‘(a) REQUIREMENTS FOR COVERAGE OF ANNUAL

8 SCREENING MAMMOGRAPHY.—

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

10 health insurance issuer offering group health insur11 ance coverage, that provides coverage for diagnostic

12 mammography for any woman who is 40 years of

13 age or older shall provide coverage for annual

14 screening mammography for such a woman under

15 terms and conditions that are not less favorable than

16 the terms and conditions for coverage of diagnostic

17 mammography.

18 ‘‘(2) DIAGNOSTIC AND SCREENING MAMMOG19 RAPHY DEFINED.—For purposes of this section—

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

21 means a radiologic procedure that is medically

22 necessary for the purpose of diagnosing breast

23 cancer and includes a physician’s interpretation

24 of the results of the procedure.
4

•HR 617 IH

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

2 means a radiologic procedure provided to a

3 woman for the purpose of early detection of

4 breast cancer and includes a physician’s inter5 pretation of the results of the procedure.

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

7 health insurance issuer offering group health insurance

8 coverage in connection with a group health plan, may

9 not—

10 ‘‘(1) deny coverage for annual screening mam11 mography on the basis that the coverage is not

12 medically necessary or on the basis that the screen13 ing mammography is not pursuant to a referral, con14 sent, or recommendation by any health care pro15 vider;

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

17 eligibility, to enroll or to renew coverage under the

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

19 the requirements of this section;

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

21 women to encourage such women to accept less than

22 the minimum protections available under this sec23 tion;

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

25 reimbursement of an attending provider because
5

•HR 617 IH

1 such provider provided care to an individual partici2 pant or beneficiary in accordance with this section;

3 or

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

5 to an attending provider to induce such provider to

6 provide care to an individual participant or bene7 ficiary in a manner inconsistent with this section.

8 ‘‘(c) RULES OF CONSTRUCTION.—

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

10 to require a woman who is a participant or bene11 ficiary to undergo annual screening mammography.

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

13 any group health plan, or any group health insur14 ance coverage offered by a health insurance issuer,

15 which does not provide benefits for diagnostic mam16 mography.

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

18 as preventing a group health plan or issuer from im19 posing deductibles, coinsurance, or other cost-shar20 ing in relation to benefits for screening mammog21 raphy under the plan (or under health insurance

22 coverage offered in connection with a group health

23 plan), except that such coinsurance or other cost24 sharing for any portion may not be greater than

25 such coinsurance or cost-sharing that is otherwise
6

•HR 617 IH

1 applicable with respect to benefits for diagnostic

2 mammography.

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

4 should (but are not required to) consult with appro5 priate health care practitioners before undergoing

6 screening mammography, but nothing in this section

7 shall be construed as requiring the approval of such

8 a practitioner before undergoing an annual screening

9 mammography.

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

11 shall comply with the notice requirement under section

12 713(d) of the Employee Retirement Income Security Act

13 of 1974 with respect to the requirements of this section

14 as if such section applied to such plan.

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

16 Nothing in this section shall be construed to prevent a

17 group health plan or a health insurance issuer offering

18 group health insurance coverage from negotiating the level

19 and type of reimbursement with a provider for care pro20 vided in accordance with this section.

21 ‘‘(f) PREEMPTION; EXCEPTION FOR HEALTH INSUR22 ANCE COVERAGE IN CERTAIN STATES.—

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

24 section shall not apply with respect to health insur25 ance coverage if there is a State law (as defined in
7

•HR 617 IH

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

2 coverage, that requires coverage to be provided for

3 annual screening mammography for women who are

4 40 years of age or older and that provides at least

5 the protections described in subsection (b).

6 ‘‘(2) CONSTRUCTION.—Section 2723(a)(1) shall

7 not be construed as superseding a State law de8 scribed in paragraph (1).’’.

9 (2) Section 2723(c) of such Act (42 U.S.C.

10 300gg–23(c)), as amended by section 604(b)(2) of

11 Public Law 104–204, is amended by striking ‘‘sec12 tion 2704’’ and inserting ‘‘sections 2704 and 2706’’.

13 (b) ERISA AMENDMENTS.—

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

15 I of the Employee Retirement Income Security Act

16 of 1974, as amended by section 702(a) of Public

17 Law 104–204, is amended by adding at the end the

18 following new section:

19 ‘‘SEC. 713. STANDARDS RELATING TO BENEFITS FOR

20 SCREENING MAMMOGRAPHY.

21 ‘‘(a) REQUIREMENTS FOR COVERAGE OF ANNUAL

22 SCREENING MAMMOGRAPHY.—

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

24 health insurance issuer offering group health insur25 ance coverage, that provides coverage for diagnostic
8

•HR 617 IH

1 mammography for any woman who is 40 years of

2 age or older shall provide coverage for annual

3 screening mammography for such a woman under

4 terms and conditions that are not less favorable than

5 the terms and conditions for coverage of diagnostic

6 mammography.

7 ‘‘(2) DIAGNOSTIC AND SCREENING MAMMOG8 RAPHY DEFINED.—For purposes of this section—

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

10 means a radiologic procedure that is medically

11 necessary for the purpose of diagnosing breast

12 cancer and includes a physician’s interpretation

13 of the results of the procedure.

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

15 means a radiologic procedure provided to a

16 woman for the purpose of early detection of

17 breast cancer and includes a physician’s inter18 pretation of the results of the procedure.

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

20 health insurance issuer offering group health insurance

21 coverage in connection with a group health plan, may

22 not—

23 ‘‘(1) deny coverage described in subsection

24 (a)(1) on the basis that the coverage is not medically
9

•HR 617 IH

1 necessary or on the basis that the screening mam2 mography is not pursuant to a referral, consent, or

3 recommendation by any health care provider;

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

5 eligibility, to enroll or to renew coverage under the

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

7 the requirements of this section;

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

9 women to encourage such women to accept less than

10 the minimum protections available under this sec11 tion;

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

13 reimbursement of an attending provider because

14 such provider provided care to an individual partici15 pant or beneficiary in accordance with this section;

16 or

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

18 to an attending provider to induce such provider to

19 provide care to an individual participant or bene20 ficiary in a manner inconsistent with this section.

21 ‘‘(c) RULES OF CONSTRUCTION.—

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

23 to require a woman who is a participant or bene24 ficiary to undergo annual screening mammography.
10

•HR 617 IH

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

2 any group health plan, or any group health insur3 ance coverage offered by a health insurance issuer,

4 which does not provide benefits for diagnostic mam5 mography.

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

7 as preventing a group health plan or issuer from im8 posing deductibles, coinsurance, or other cost-shar9 ing in relation to benefits for screening mammog10 raphy under the plan (or under health insurance

11 coverage offered in connection with a group health

12 plan), except that such coinsurance or other cost13 sharing for any portion may not be greater than

14 such coinsurance or cost-sharing that is otherwise

15 applicable with respect to benefits for diagnostic

16 mammography.

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

18 should (but are not required to) consult with appro19 priate health care practitioners before undergoing

20 screening mammography, but nothing in this section

21 shall be construed as requiring the approval of such

22 a practitioner before undergoing an annual screening

23 mammography.

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

25 imposition of the requirements of this section shall be
11

•HR 617 IH

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

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

3 notice of such requirements under the plan; except that

4 the 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 requirements apply.

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

10 Nothing in this section shall be construed to prevent a

11 group health plan or a health insurance issuer offering

12 group health insurance coverage from negotiating the level

13 and type of reimbursement with a provider for care pro14 vided in accordance with this section.

15 ‘‘(f) PREEMPTION; EXCEPTION FOR HEALTH INSUR16 ANCE COVERAGE IN CERTAIN STATES.—

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

18 section shall not apply with respect to health insur19 ance coverage if there is a State law (as defined in

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

21 coverage, that requires coverage to be provided for

22 annual screening mammography for women who are

23 40 years of age or older, and that provides at least

24 the protections described in subsection (b).
12

•HR 617 IH

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

2 not be construed as superseding a State law de3 scribed in paragraph (1).’’.

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

5 1191(c)), as amended by section 603(b)(1) of Public

6 Law 104–204, is amended by striking ‘‘section 711’’

7 and inserting ‘‘sections 711 and 713’’.

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

9 1191a(a)), as amended by section 603(b)(2) of Pub10 lic Law 104–204, is amended by striking ‘‘section

11 711’’ and inserting ‘‘sections 711 and 713’’.

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

13 Act is amended by inserting after the item relating

14 to section 712 the following new item:

‘‘Sec. 713. Standards relating to benefits for screening mammography.’’.

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

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

17 respect to group health plans (and health insurance cov18 erage offered in connection with group health plans) for

19 plan years beginning on or after January 1, 1998.

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

21 pursuant to 1 or more collective bargaining agreements

22 between employee representatives and 1 or more employ23 ers ratified before the date of enactment of this Act, the

24 amendments made by this section shall not apply to plan

25 years beginning before the later of—
13

•HR 617 IH

1 (A) the date on which the last collective bar2 gaining agreements relating to the plan terminates

3 (determined without regard to any extension thereof

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

5 or

6 (B) January 1, 1998.

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

8 made pursuant to a collective bargaining agreement relat9 ing to the plan which amends the plan solely to conform

10 to any requirement added by this section shall not be

11 treated as a termination of such collective bargaining

12 agreement.

13 SEC. 3. COVERAGE OF ANNUAL SCREENING MAMMOG14 RAPHY UNDER INDIVIDUAL HEALTH COV15 ERAGE.

16 (a) IN GENERAL.—Part B of title XXVII of the Pub17 lic Health Service Act, as amended by section 605(a) of

18 Public Law 104–204, is amended by inserting after sec19 tion 2751 the following new section:

20 ‘‘SEC. 2752. STANDARDS RELATING TO BENEFITS FOR

21 SCREENING MAMMOGRAPHY.

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

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

24 insurance coverage offered by a health insurance issuer

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

•HR 617 IH

1 to health insurance coverage offered by a health insurance

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

3 or large group market.

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

5 part shall comply with the notice requirement under sec6 tion 713(d) of the Employee Retirement Income Security

7 Act of 1974 with respect to the requirements referred to

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

9 and such issuer were a group health plan.

10 ‘‘(c) PREEMPTION; EXCEPTION FOR HEALTH INSUR11 ANCE COVERAGE IN CERTAIN STATES.—

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

13 section shall not apply with respect to health insur14 ance coverage if there is a State law (as defined in

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

16 coverage, that requires coverage in the individual

17 health insurance market to be provided for annual

18 screening mammography for women who are 40

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

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

21 under subsection (a)).

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

23 not be construed as superseding a State law de24 scribed in paragraph (1).’’.
15

•HR 617 IH

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

2 of such Act (42 U.S.C. 300gg–63(b)(2)), as added by sec3 tion 605(b)(3)(B) of Public Law 104–204, is amended by

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

5 2752’’.

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

7 this section shall apply with respect to health insurance

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

9 market on or after such January 1, 1998.

10 SEC. 4. ANNUAL SCREENING MAMMOGRAPHY UNDER MEDI11 CARE PROGRAM.

12 (a) PROVIDING ANNUAL SCREENING MAMMOGRAPHY

13 FOR WOMEN OVER AGE 39.—Paragraph (2) of section

14 1834(c) of the Social Security Act (42 U.S.C. 1395m(c))

15 is amended—

16 (1) in subparagraph (A)—

17 (A) in clause (iv), by striking ‘‘over 49

18 years of age, but under 65 years of age’’ and

19 inserting ‘‘over 39 years of age’’,

20 (B) by striking (A) IN GENERAL’’ and all

21 that follows through ‘‘under subparagraph

22 (B)—’’,

23 (C) by striking clauses (iii) and (v), and
16

•HR 617 IH

1 (D) by redesignating clauses (i), (ii), and

2 (iv) as subparagraphs (A), (B), and (C), respec3 tively, and moving the indentation of such

4 clauses 2 ems to the left; and

5 (2) by striking subparagraph (B).

6 (b) EFFECTIVE DATE.—The amendments made by

7 subsection (a) shall apply to screening mammography per8 formed on or after January 1, 1998.

9 SEC. 5. COVERAGE OF SCREENING MAMMOGRAPHY UNDER

10 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 (24);

15 (2) by redesignating paragraph (25) as para16 graph (26); and

17 (3) by inserting after paragraph (24) the fol18 lowing new paragraph:

19 ‘‘(25) screening mammography (as defined in

20 subsection (t)(1)) that is conducted by a facility that

21 has a certificate (or provisional certificate) issued

22 under section 354 of the Public Health Service Act,

23 to the extent consistent with the frequency permitted

24 under subsection (t)(2); and’’.
17

•HR 617 IH

1 (b) FREQUENCY OF COVERAGE.—Section 1905 of

2 such Act (42 U.S.C. 1396d) is amended by adding at the

3 end the following new subsection:

4 ‘‘(t) COVERAGE OF SCREENING MAMMOGRAPHY.—

5 ‘‘(1) DEFINITION.—The term ‘screening mam6 mography’ means a radiologic procedure provided to

7 a woman for the purpose of early detection of breast

8 cancer and includes a physician’s interpretation of

9 the results of the procedure.

10 ‘‘(2) FREQUENCY COVERED.—Medical assist11 ance shall be made available under this title with re12 spect to screening mammography that is performed

13 consistent with the frequency at which payment may

14 be made for such screening mammography under the

15 medicare program under section 1834(c)(2) (which

16 includes payment for annual screening mammog17 raphy for women over 39 years of age).’’.

18 (c) MAKING COVERAGE MANDATORY.—Section

19 1902(a)(10)(A) of such Act (42 U.S.C. 1396a(a)(10)(A))

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

21 ‘‘(17), (21), and (25)’’.

22 (d) CONFORMING AMENDMENTS.—(1) Section

23 1902(a)(10)(C)(iv) of such Act (42 U.S.C.

24 1396a(a)(10)(C)(iv)) is amended—
18

•HR 617 IH

1 (A) by striking ‘‘(5) and (17)’’ and inserting

2 ‘‘(5), (17), and (25)’’; and

3 (B) by striking ‘‘through (21)’’ and inserting

4 ‘‘through (25)’’.

5 (2) Section 1902(j) (42 U.S.C. 1396a(j)) of such Act

6 is amended by striking ‘‘through (22)’’ and inserting

7 ‘‘through (26)’’.

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

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

10 apply to screening mammography performed on or after

11 January 1, 1998, without regard to whether or not final

12 regulations to carry out such amendments have been pro13 mulgated by such date.

14 (2) In the case of a State plan for medical assistance

15 under title XIX of the Social Security Act which the Sec16 retary of Health and Human Services determines requires

17 State legislation (other than legislation appropriating

18 funds) in order for the plan to meet the additional require19 ment imposed by the amendments made by this section,

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

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

22 its failure to meet this additional requirement before the

23 first day of the first calendar quarter beginning after the

24 close of the first regular session of the State legislature

25 that begins after the date of the enactment of this Act.
19

•HR 617 IH

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

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

3 such session shall be deemed to be a separate regular ses4 sion of the State legislature.

Æ