Requiring parity in cost-sharing and treatment limitations with respect to diagnostic and screening examinations for breast cancer

(a)

In general

Section 2719A of the Public Health Service Act (42 U.S.C. 300gg–19a) is amended by adding at the end the following new subsection:

(e)

Diagnostic and screening examinations for breast cancer parity

(1)

In general

In the case of a group health plan, or a health insurance issuer offering group or individual health insurance coverage, that provides benefits with respect to a diagnostic examination for breast cancer furnished to an individual enrolled under such plan or such coverage, such plan or such coverage shall ensure that— (A)the cost-sharing requirements applicable to such examination for such individual are no less favorable than such requirements applicable to a screening examination for breast cancer for such individual; and (B)the treatment limitations applicable to such diagnostic examination for breast cancer for such individual are no less favorable than such limitations applicable to a screening examinations for breast cancer for such individual. (2)

Restriction on certain changes

A group health plan or health insurance issuer may not, for the sole purpose of complying with paragraph (1), increase cost-sharing requirements with respect to screening examinations for breast cancer. (3)

Construction

Nothing in this subsection shall be construed— (A)to require the use of diagnostic examinations for breast cancer as a replacement for screening examinations for breast cancer; (B)to prohibit a group health plan or health insurance issuers from requiring prior authorization or imposing other appropriate utilization controls in approving coverage for any screening or diagnostic imaging; or (C)to supersede a State law that provides greater protections with respect to the coverage of diagnostic examinations for breast cancer than is provided under this subsection. (4)

Definitions

In this subsection: (A)

Cost-sharing requirement

The term cost-sharing requirement includes a deductible, coinsurance, copayment, and any maximum limitation on the application of such a deductible, coinsurance, copayment, or similar out-of-pocket expense. (B)

Diagnostic examination for breast cancer

The term diagnostic examination for breast cancer means a medically necessary and appropriate (as determined by the health care professional treating the individual) examination for breast cancer to evaluate an abnormality in the breast that is— (i)seen or suspected from a screening examination for breast cancer; (ii)detected by another means of examination; or (iii)suspected based on the medical history or family medical history of the individual. (C)

Examination for breast cancer

The term examination for breast cancer includes such an examination using breast ultrasound, breast magnetic resonance imaging, or mammography. (D)

Treatment limitation

The term treatment limitation includes limits on the frequency of treatment, number of visits, days of coverage, or other similar limits on the scope or duration of treatment.

(b)

Application to grandfathered health plans

Section 1251(a)(4)(A) of the Patient Protection and Affordable Care Act (42 U.S.C. 18011(a)(4)(A)) is amended— (1)by striking title and inserting title, or as added after the date of the enactment of this Act); and (2)by adding at the end the following new clause:

(v)Section 2719A(e) (relating to parity for diagnostic and screening examinations for breast cancer).

(c)

Effective date

The amendments made by this section shall apply with respect to plan years beginning on or after January 1, 2020.