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 insur-
ance coverage and group health plans provide coverage for annual screen-
ing 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) intro-
duced the following bill; which was referred to the Committee on Com-
merce, and in addition to the Committee on Ways and Means, and Edu-
cation and the Workforce, for a period to be subsequently determined by
the Speaker, in each case for consideration of such provisions as fall with-
in the jurisdiction of the committee concerned
A BILL
To amend the Public Health Service Act and Employee Re-
tirement 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.
Be it enacted by the Senate and House of Representa-
tives of the United States of America in Congress assembled,
SECTION 1. SHORT TITLE; FINDINGS.
(a) SHORT TITLE.—This Act may be cited as the
‘‘Mammogram Availability Act of 1997’’.
(b) FINDINGS.—Congress finds the following:
(1) Breast cancer is the single leading cause of
death for women between the ages of 40 and 49 in
the United States
(2) An expert panel convened by the National
Institutes of Health recommended on January 23,
1997, that all women between the ages of 40 and 49
should choose for themselves, following consultation
with their health care provider, whether to undergo
screening mammography.
(3) The same panel unanimously recommended
that for women between the ages of 40 and 49 who
choose to have a screening mammogram, costs of the
mammograms should be reimbursed by third-party
payers or covered by health maintenance organiza-
tions.
SEC. 2. COVERAGE OF ANNUAL SCREENING MAMMOG-
RAPHY UNDER GROUP HEALTH PLANS.
(a) PUBLIC HEALTH SERVICE ACT AMENDMENTS.—
(1) Subpart 2 of part A of title XXVII of the
Public Health Service Act, as amended by section
703(a) of Public Law 104–204, is amended by add-
ing at the end the following new section:
‘‘SEC. 2706. STANDARDS RELATING TO BENEFITS FOR
SCREENING MAMMOGRAPHY.
‘‘(a) REQUIREMENTS FOR COVERAGE OF ANNUAL
SCREENING MAMMOGRAPHY.—
‘‘(1) IN GENERAL.—A group health plan, and a
health insurance issuer offering group health insur-
ance coverage, that provides coverage for diagnostic
mammography for any woman who is 40 years of
age or older shall provide coverage for annual
screening mammography for such a woman under
terms and conditions that are not less favorable than
the terms and conditions for coverage of diagnostic
mammography.
‘‘(2) DIAGNOSTIC
AND
SCREENING
MAMMOG-
RAPHY DEFINED.—For purposes of this section—
‘‘(A) The term ‘diagnostic mammography’
means a radiologic procedure that is medically
necessary for the purpose of diagnosing breast
cancer and includes a physician’s interpretation
of the results of the procedure.
‘‘(B) The term ‘screening mammography’
means a radiologic procedure provided to a
woman for the purpose of early detection of
breast cancer and includes a physician’s inter-
pretation of the results of the procedure.
‘‘(b) PROHIBITIONS.—A group health plan, and a
health insurance issuer offering group health insurance
coverage in connection with a group health plan, may
not—
‘‘(1) deny coverage for annual screening mam-
mography on the basis that the coverage is not
medically necessary or on the basis that the screen-
ing mammography is not pursuant to a referral, con-
sent, or recommendation by any health care pro-
vider;
‘‘(2) deny to a woman eligibility, or continued
eligibility, to enroll or to renew coverage under the
terms of the plan, solely for the purpose of avoiding
the requirements of this section;
‘‘(3) provide monetary payments or rebates to
women to encourage such women to accept less than
the minimum protections available under this sec-
tion;
‘‘(4) penalize or otherwise reduce or limit the
reimbursement of an attending provider because
such provider provided care to an individual partici-
pant or beneficiary in accordance with this section;
or
‘‘(5) provide incentives (monetary or otherwise)
to an attending provider to induce such provider to
provide care to an individual participant or bene-
ficiary in a manner inconsistent with this section.
‘‘(c) RULES OF CONSTRUCTION.—
‘‘(1) Nothing in this section shall be construed
to require a woman who is a participant or bene-
ficiary to undergo annual screening mammography.
‘‘(2) This section shall not apply with respect to
any group health plan, or any group health insur-
ance coverage offered by a health insurance issuer,
which does not provide benefits for diagnostic mam-
mography.
‘‘(3) Nothing in this section shall be construed
as preventing a group health plan or issuer from im-
posing deductibles, coinsurance, or other cost-shar-
ing in relation to benefits for screening mammog-
raphy under the plan (or under health insurance
coverage offered in connection with a group health
plan), except that such coinsurance or other cost-
sharing for any portion may not be greater than
such coinsurance or cost-sharing that is otherwise
applicable with respect to benefits for diagnostic
mammography.
‘‘(4) Women between the ages of 40 and 49
should (but are not required to) consult with appro-
priate health care practitioners before undergoing
screening mammography, but nothing in this section
shall be construed as requiring the approval of such
a practitioner before undergoing an annual screening
mammography.
‘‘(d) NOTICE.—A group health plan under this part
shall comply with the notice requirement under section
713(d) of the Employee Retirement Income Security Act
of 1974 with respect to the requirements of this section
as if such section applied to such plan.
‘‘(e) LEVEL
AND TYPE
OF REIMBURSEMENTS.—
Nothing in this section shall be construed to prevent a
group health plan or a health insurance issuer offering
group health insurance coverage from negotiating the level
and type of reimbursement with a provider for care pro-
vided in accordance with this section.
‘‘(f) PREEMPTION; EXCEPTION FOR HEALTH INSUR-
ANCE COVERAGE IN CERTAIN STATES.—
‘‘(1) IN GENERAL.—The requirements of this
section shall not apply with respect to health insur-
ance coverage if there is a State law (as defined in
section 2723(d)(1)) for a State that regulates such
coverage, that requires coverage to be provided for
annual screening mammography for women who are
40 years of age or older and that provides at least
the protections described in subsection (b).
‘‘(2) CONSTRUCTION.—Section 2723(a)(1) shall
not be construed as superseding a State law de-
scribed in paragraph (1).’’.
(2) Section 2723(c) of such Act (42 U.S.C.
300gg–23(c)), as amended by section 604(b)(2) of
Public Law 104–204, is amended by striking ‘‘sec-
tion 2704’’ and inserting ‘‘sections 2704 and 2706’’.
(b) ERISA AMENDMENTS.—
(1) Subpart B of part 7 of subtitle B of title
I of the Employee Retirement Income Security Act
of 1974, as amended by section 702(a) of Public
Law 104–204, is amended by adding at the end the
following new section:
‘‘SEC. 713. STANDARDS RELATING TO BENEFITS FOR
SCREENING MAMMOGRAPHY.
‘‘(a) REQUIREMENTS FOR COVERAGE OF ANNUAL
SCREENING MAMMOGRAPHY.—
‘‘(1) IN GENERAL.—A group health plan, and a
health insurance issuer offering group health insur-
ance coverage, that provides coverage for diagnostic
mammography for any woman who is 40 years of
age or older shall provide coverage for annual
screening mammography for such a woman under
terms and conditions that are not less favorable than
the terms and conditions for coverage of diagnostic
mammography.
‘‘(2) DIAGNOSTIC
AND
SCREENING
MAMMOG-
RAPHY DEFINED.—For purposes of this section—
‘‘(A) The term ‘diagnostic mammography’
means a radiologic procedure that is medically
necessary for the purpose of diagnosing breast
cancer and includes a physician’s interpretation
of the results of the procedure.
‘‘(B) The term ‘screening mammography’
means a radiologic procedure provided to a
woman for the purpose of early detection of
breast cancer and includes a physician’s inter-
pretation of the results of the procedure.
‘‘(b) PROHIBITIONS.—A group health plan, and a
health insurance issuer offering group health insurance
coverage in connection with a group health plan, may
not—
‘‘(1) deny coverage described in subsection
(a)(1) on the basis that the coverage is not medically
necessary or on the basis that the screening mam-
mography is not pursuant to a referral, consent, or
recommendation by any health care provider;
‘‘(2) deny to a woman eligibility, or continued
eligibility, to enroll or to renew coverage under the
terms of the plan, solely for the purpose of avoiding
the requirements of this section;
‘‘(3) provide monetary payments or rebates to
women to encourage such women to accept less than
the minimum protections available under this sec-
tion;
‘‘(4) penalize or otherwise reduce or limit the
reimbursement of an attending provider because
such provider provided care to an individual partici-
pant or beneficiary in accordance with this section;
or
‘‘(5) provide incentives (monetary or otherwise)
to an attending provider to induce such provider to
provide care to an individual participant or bene-
ficiary in a manner inconsistent with this section.
‘‘(c) RULES OF CONSTRUCTION.—
‘‘(1) Nothing in this section shall be construed
to require a woman who is a participant or bene-
ficiary to undergo annual screening mammography.
‘‘(2) This section shall not apply with respect to
any group health plan, or any group health insur-
ance coverage offered by a health insurance issuer,
which does not provide benefits for diagnostic mam-
mography.
‘‘(3) Nothing in this section shall be construed
as preventing a group health plan or issuer from im-
posing deductibles, coinsurance, or other cost-shar-
ing in relation to benefits for screening mammog-
raphy under the plan (or under health insurance
coverage offered in connection with a group health
plan), except that such coinsurance or other cost-
sharing for any portion may not be greater than
such coinsurance or cost-sharing that is otherwise
applicable with respect to benefits for diagnostic
mammography.
‘‘(4) Women between the ages of 40 and 49
should (but are not required to) consult with appro-
priate health care practitioners before undergoing
screening mammography, but nothing in this section
shall be construed as requiring the approval of such
a practitioner before undergoing an annual screening
mammography.
‘‘(d) NOTICE UNDER GROUP HEALTH PLAN.—The
imposition of the requirements of this section shall be
treated as a material modification in the terms of the plan
described in section 102(a)(1), for purposes of assuring
notice of such requirements under the plan; except that
the summary description required to be provided under the
last sentence of section 104(b)(1) with respect to such
modification shall be provided by not later than 60 days
after the first day of the first plan year in which such
requirements apply.
‘‘(e) LEVEL
AND TYPE
OF REIMBURSEMENTS.—
Nothing in this section shall be construed to prevent a
group health plan or a health insurance issuer offering
group health insurance coverage from negotiating the level
and type of reimbursement with a provider for care pro-
vided in accordance with this section.
‘‘(f) PREEMPTION; EXCEPTION FOR HEALTH INSUR-
ANCE COVERAGE IN CERTAIN STATES.—
‘‘(1) IN GENERAL.—The requirements of this
section shall not apply with respect to health insur-
ance coverage if there is a State law (as defined in
section 731(d)(1)) for a State that regulates such
coverage, that requires coverage to be provided for
annual screening mammography for women who are
40 years of age or older, and that provides at least
the protections described in subsection (b).
‘‘(2) CONSTRUCTION.—Section 731(a)(1) shall
not be construed as superseding a State law de-
scribed in paragraph (1).’’.
(2) Section 731(c) of such Act (29 U.S.C.
1191(c)), as amended by section 603(b)(1) of Public
Law 104–204, is amended by striking ‘‘section 711’’
and inserting ‘‘sections 711 and 713’’.
(3) Section 732(a) of such Act (29 U.S.C.
1191a(a)), as amended by section 603(b)(2) of Pub-
lic Law 104–204, is amended by striking ‘‘section
711’’ and inserting ‘‘sections 711 and 713’’.
(4) The table of contents in section 1 of such
Act is amended by inserting after the item relating
to section 712 the following new item:
‘‘Sec. 713. Standards relating to benefits for screening mammography.’’.
(c) EFFECTIVE DATES.—(1) Subject to paragraph
(2), the amendments made by this section shall apply with
respect to group health plans (and health insurance cov-
erage offered in connection with group health plans) for
plan years beginning on or after January 1, 1998.
(2) In the case of a group health plan maintained
pursuant to 1 or more collective bargaining agreements
between employee representatives and 1 or more employ-
ers ratified before the date of enactment of this Act, the
amendments made by this section shall not apply to plan
years beginning before the later of—
(A) the date on which the last collective bar-
gaining agreements relating to the plan terminates
(determined without regard to any extension thereof
agreed to after the date of enactment of this Act),
or
(B) January 1, 1998.
For purposes of subparagraph (A), any plan amendment
made pursuant to a collective bargaining agreement relat-
ing to the plan which amends the plan solely to conform
to any requirement added by this section shall not be
treated as a termination of such collective bargaining
agreement.
SEC. 3. COVERAGE OF ANNUAL SCREENING MAMMOG-
RAPHY UNDER INDIVIDUAL HEALTH COV-
ERAGE.
(a) IN GENERAL.—Part B of title XXVII of the Pub-
lic Health Service Act, as amended by section 605(a) of
Public Law 104–204, is amended by inserting after sec-
tion 2751 the following new section:
‘‘SEC. 2752. STANDARDS RELATING TO BENEFITS FOR
SCREENING MAMMOGRAPHY.
‘‘(a) IN GENERAL.—The provisions of section 2706
(other than subsections (d) and (f)) shall apply to health
insurance coverage offered by a health insurance issuer
in the individual market in the same manner as it applies
to health insurance coverage offered by a health insurance
issuer in connection with a group health plan in the small
or large group market.
‘‘(b) NOTICE.—A health insurance issuer under this
part shall comply with the notice requirement under sec-
tion 713(d) of the Employee Retirement Income Security
Act of 1974 with respect to the requirements referred to
in subsection (a) as if such section applied to such issuer
and such issuer were a group health plan.
‘‘(c) PREEMPTION; EXCEPTION FOR HEALTH INSUR-
ANCE COVERAGE IN CERTAIN STATES.—
‘‘(1) IN GENERAL.—The requirements of this
section shall not apply with respect to health insur-
ance coverage if there is a State law (as defined in
section 2723(d)(1)) for a State that regulates such
coverage, that requires coverage in the individual
health insurance market to be provided for annual
screening mammography for women who are 40
years of age or older and that provides at least the
protections described in section 2706(b) (as applied
under subsection (a)).
‘‘(2) CONSTRUCTION.—Section 2762(a) shall
not be construed as superseding a State law de-
scribed in paragraph (1).’’.
(b) CONFORMING AMENDMENT.—Section 2763(b)(2)
of such Act (42 U.S.C. 300gg–63(b)(2)), as added by sec-
tion 605(b)(3)(B) of Public Law 104–204, is amended by
striking ‘‘section 2751’’ and inserting ‘‘sections 2751 and
2752’’.
(c) EFFECTIVE DATE.—The amendments made by
this section shall apply with respect to health insurance
coverage offered, sold, issued, or renewed in the individual
market on or after such January 1, 1998.
SEC. 4. ANNUAL SCREENING MAMMOGRAPHY UNDER MEDI-
CARE PROGRAM.
(a) PROVIDING ANNUAL SCREENING MAMMOGRAPHY
FOR WOMEN OVER AGE 39.—Paragraph (2) of section
1834(c) of the Social Security Act (42 U.S.C. 1395m(c))
is amended—
(1) in subparagraph (A)—
(A) in clause (iv), by striking ‘‘over 49
years of age, but under 65 years of age’’ and
inserting ‘‘over 39 years of age’’,
(B) by striking (A) IN GENERAL’’ and all
that follows through ‘‘under subparagraph
(B)—’’,
(C) by striking clauses (iii) and (v), and
(D) by redesignating clauses (i), (ii), and
(iv) as subparagraphs (A), (B), and (C), respec-
tively, and moving the indentation of such
clauses 2 ems to the left; and
(2) by striking subparagraph (B).
(b) EFFECTIVE DATE.—The amendments made by
subsection (a) shall apply to screening mammography per-
formed on or after January 1, 1998.
SEC. 5. COVERAGE OF SCREENING MAMMOGRAPHY UNDER
MEDICAID.
(a) IN GENERAL.—Section 1905(a) of the Social Se-
curity Act (42 U.S.C. 1396d(a)) is amended—
(1) by striking ‘‘and’’ at the end of paragraph
(24);
(2) by redesignating paragraph (25) as para-
graph (26); and
(3) by inserting after paragraph (24) the fol-
lowing new paragraph:
‘‘(25) screening mammography (as defined in
subsection (t)(1)) that is conducted by a facility that
has a certificate (or provisional certificate) issued
under section 354 of the Public Health Service Act,
to the extent consistent with the frequency permitted
under subsection (t)(2); and’’.
(b) FREQUENCY OF COVERAGE.—Section 1905 of
such Act (42 U.S.C. 1396d) is amended by adding at the
end the following new subsection:
‘‘(t) COVERAGE OF SCREENING MAMMOGRAPHY.—
‘‘(1) DEFINITION.—The term ‘screening mam-
mography’ means a radiologic procedure provided to
a woman for the purpose of early detection of breast
cancer and includes a physician’s interpretation of
the results of the procedure.
‘‘(2) FREQUENCY
COVERED.—Medical assist-
ance shall be made available under this title with re-
spect to screening mammography that is performed
consistent with the frequency at which payment may
be made for such screening mammography under the
medicare program under section 1834(c)(2) (which
includes payment for annual screening mammog-
raphy for women over 39 years of age).’’.
(c) 
MAKING
COVERAGE
MANDATORY.—Section
1902(a)(10)(A) of such Act (42 U.S.C. 1396a(a)(10)(A))
is amended by striking ‘‘(17) and (21)’’ and inserting
‘‘(17), (21), and (25)’’.
(d) 
CONFORMING
AMENDMENTS.—(1) 
Section
1902(a)(10)(C)(iv) 
of 
such 
Act 
(42 
U.S.C.
1396a(a)(10)(C)(iv)) is amended—
(A) by striking ‘‘(5) and (17)’’ and inserting
‘‘(5), (17), and (25)’’; and
(B) by striking ‘‘through (21)’’ and inserting
‘‘through (25)’’.
(2) Section 1902(j) (42 U.S.C. 1396a(j)) of such Act
is amended by striking ‘‘through (22)’’ and inserting
‘‘through (26)’’.
(e) EFFECTIVE DATE.—(1) Except as provided in
paragraph (2), the amendments made by this section shall
apply to screening mammography performed on or after
January 1, 1998, without regard to whether or not final
regulations to carry out such amendments have been pro-
mulgated by such date.
(2) In the case of a State plan for medical assistance
under title XIX of the Social Security Act which the Sec-
retary of Health and Human Services determines requires
State legislation (other than legislation appropriating
funds) in order for the plan to meet the additional require-
ment imposed by the amendments made by this section,
the State plan shall not be regarded as failing to comply
with the requirements of such title solely on the basis of
its failure to meet this additional requirement before the
first day of the first calendar quarter beginning after the
close of the first regular session of the State legislature
that begins after the date of the enactment of this Act.
For purposes of the previous sentence, in the case of a
State that has a 2-year legislative session, each year of
such session shall be deemed to be a separate regular ses-
sion of the State legislature.
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