[Congressional Bills 105th Congress]
[From the U.S. Government Publishing Office]
[S. 727 Introduced in Senate (IS)]







105th CONGRESS
  1st Session
                                 S. 727

 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 SENATE OF THE UNITED STATES

                              May 8, 1997

Mrs. Feinstein  (for herself, Ms. Mikulski, Mr. Wellstone, Mr. Johnson, 
 and Mrs. Murray) introduced the following bill; which was read twice 
                and referred to the Committee on Finance

_______________________________________________________________________

                                 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.

    Be it enacted by the Senate and House of Representatives 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 
        organizations.

SEC. 2. COVERAGE OF ANNUAL SCREENING MAMMOGRAPHY UNDER GROUP HEALTH 
              PLANS.

    (a) Public Health Service Act Amendments.--
            (1) In general.--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 adding 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 insurance 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 mammography 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 interpretation 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 mammography on the 
        basis that the coverage is not medically necessary or on the 
        basis that the screening mammography 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 section;
            ``(4) penalize or otherwise reduce or limit the 
        reimbursement of an attending provider because such provider 
        provided care to an individual participant 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 beneficiary 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 beneficiary to undergo annual 
        screening mammography.
            ``(2) This section shall not apply with respect to any 
        group health plan, or any group health insurance coverage 
        offered by a health insurance issuer, which does not provide 
        benefits for diagnostic mammography.
            ``(3) Nothing in this section shall be construed as 
        preventing a group health plan or issuer from imposing 
        deductibles, coinsurance, or other cost-sharing in relation to 
        benefits for screening mammography 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 appropriate 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 provided in 
accordance with this section.
    ``(f) Preemption; Exception for Health Insurance Coverage in 
Certain States.--
            ``(1) In general.--The requirements of this section shall 
        not apply with respect to health insurance 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 described in paragraph 
        (1).''.
            (2) Conforming amendment.--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 ``section 2704'' and 
        inserting ``sections 2704 and 2706''.
    (b) ERISA Amendments.--
            (1) In general.--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 insurance 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 mammography 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 interpretation 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 mammography 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 section;
            ``(4) penalize or otherwise reduce or limit the 
        reimbursement of an attending provider because such provider 
        provided care to an individual participant 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 beneficiary 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 beneficiary to undergo annual 
        screening mammography.
            ``(2) This section shall not apply with respect to any 
        group health plan, or any group health insurance coverage 
        offered by a health insurance issuer, which does not provide 
        benefits for diagnostic mammography.
            ``(3) Nothing in this section shall be construed as 
        preventing a group health plan or issuer from imposing 
        deductibles, coinsurance, or other cost-sharing in relation to 
        benefits for screening mammography 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 appropriate 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 provided in 
accordance with this section.
    ``(f) Preemption; Exception for Health Insurance Coverage in 
Certain States.--
            ``(1) In general.--The requirements of this section shall 
        not apply with respect to health insurance 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 described in paragraph 
        (1).''.
            (2) Conforming amendments.--
                    (A) 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''.
                    (B) Section 732(a) of such Act (29 U.S.C. 
                1191a(a)), as amended by section 603(b)(2) of Public 
                Law 104-204, is amended by striking ``section 711'' and 
                inserting ``sections 711 and 713''.
                    (C) 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) In general.--Subject to paragraph (2), the amendments 
        made by this section shall apply with respect to group health 
        plans (and health insurance coverage offered in connection with 
        group health plans) for plan years beginning on or after 
        January 1, 1998.
            (2) Collective bargaining agreements.--In the case of a 
        group health plan maintained pursuant to 1 or more collective 
        bargaining agreements between employee representatives and 1 or 
        more employers 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 
                bargaining 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 relating 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 MAMMOGRAPHY UNDER INDIVIDUAL 
              HEALTH COVERAGE.

    (a) In General.--Part B of title XXVII of the Public Health Service 
Act, as amended by section 605(a) of Public Law 104-204, is amended by 
inserting after section 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 section 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 Insurance Coverage in 
Certain States.--
            ``(1) In general.--The requirements of this section shall 
        not apply with respect to health insurance 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 described in paragraph (1).''.
    (b) Conforming Amendment.--Section 2763(b)(2) of such Act (42 
U.S.C. 300gg-63(b)(2)), as added by section 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 MEDICARE 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), respectively, 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 performed on or after January 1, 1998.

SEC. 5. COVERAGE OF SCREENING MAMMOGRAPHY UNDER MEDICAID.

    (a) In General.--Section 1905(a) of the Social Security 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 paragraph (26); and
            (3) by inserting after paragraph (24) the following 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 mammography' 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 assistance shall be made 
        available under this title with respect 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 mammography 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 promulgated by 
such date.
    (2) In the case of a State plan for medical assistance under title 
XIX of the Social Security Act which the Secretary of Health and Human 
Services determines requires State legislation (other than legislation 
appropriating funds) in order for the plan to meet the additional 
requirement 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 session of the State legislature.
                                 <all>