Coverage of annual screening mammography 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 is amended by adding at the end the following new section:

2707.

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 class of participants or beneficiaries shall provide coverage for annual screening mammography for such class under terms and conditions that are not less favorable than the terms and conditions for coverage of diagnostic mammography. (2)

Diagnostic and annual 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 annual screening mammography means a radiologic procedure provided to an individual, not more frequently than on an annual basis, 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 participant or beneficiary 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 participants or beneficiaries to encourage them 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 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 a health insurance issuer offering group health plan coverage from imposing deductibles, coinsurance, or other cost-sharing in relation to benefits for annual 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)Nothing in this section shall be construed as preventing a group health plan or a health insurance issuer offering group health insurance coverage from requiring that a participant or beneficiary, before undergoing an annual screening mammography more frequently than on an annual basis, consult with an appropriate health care practitioner or obtain a written authorization from such a practitioner for submission to the plan or issuer, but nothing in this section shall be construed as requiring prior authorization before undergoing an annual screening mammography. (d)

Notice

A group health plan under this part shall comply with the notice requirement under section 714(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 as preventing 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 for any class of participants or beneficiaries 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 such class, 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)Section 2723(c) of such Act (42 U.S.C. 300gg–23(c)) is amended by striking section 2704 and inserting sections 2704 and 2707. (b)

ERISA amendments

(1)Subpart B of part 7 of subtitle B of title I of the Employee Retirement Income Security Act of 1974 is amended by adding at the end the following new section:

714.

Standards relating to benefits for screening mammography

(a)

Requirements for coverage of annual screening mammography

(1)

In general

Diagnostic and annual screening mammography defined

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 annual screening mammography is not pursuant to a referral, consent, or recommendation by any health care provider; (2)deny to a participant or beneficiary 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 participants or beneficiaries to encourage them 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 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 a health insurance issuer offering group health insurance coverage from imposing deductibles, coinsurance, or other cost-sharing in relation to benefits for annual 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)Nothing in this section shall be construed as preventing a group health plan or a health insurance issuer offering group health insurance coverage from requiring that a participant or beneficiary, before undergoing an annual screening mammography more frequently than on an annual basis, consult with an appropriate health care practitioner or obtain a written authorization from such a practitioner for submission to the plan or issuer, but nothing in this section shall be construed as requiring prior authorization 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

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 for any class of participants or beneficiaries 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 such class, 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)Section 731(c) of such Act (29 U.S.C. 1191(c)) is amended by striking section 711 and inserting sections 711 and 714. (3)Section 732(a) of such Act (29 U.S.C. 1191a(a)) is amended by striking section 711 and inserting sections 711 and 714. (4)The table of contents in section 1 of such Act is amended by inserting after the item relating to section 713 the following new item:

Sec. 714. 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 coverage offered in connection with group health plans) for plan years beginning on or after January 1, 2006. (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 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 terminate (determined without regard to any extension thereof agreed to after the date of enactment of this Act), or (B)January 1, 2006.

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.

Coverage of annual 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 (27); (2)by redesignating paragraph (28) as paragraph (29); and (3)by inserting after paragraph (27) the following new paragraph:

(28)annual screening mammography (as defined in subsection (x)) that is conducted by a facility that has a certificate (or provisional certificate) issued under section 354 of the Public Health Service Act; and

(b)

Annual screening mammography defined

Section 1905 of such Act (42 U.S.C. 1396d) is amended by adding at the end the following new subsection:

(y)The term annual screening mammography means a radiologic procedure provided to a woman, not more frequently than on an annual basis, for the purpose of early detection of breast cancer and includes a physician’s interpretation of the results of the procedure.

(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 (27). (d)

Conforming amendments

Section 1902(a)(10)(C)(iv) of such Act (42 U.S.C. 1396a(a)(10)(C)(iv)) is amended— (1)by striking and (17) and inserting , (17), and (27), and (2)by striking through (24) and inserting through (28); and (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, 2006, 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.