Short title; findings

(a)

Short title

This Act may be cited as the

Osteoporosis Early Detection and Prevention Act of 2005

. (b)

Findings

Congress makes the following findings: (1)

Nature of osteoporosis

(A)Osteoporosis is a disease characterized by low bone mass and structural deterioration of bone tissue leading to bone fragility and increased susceptibility to fractures of the hip, spine, and wrist. (B)Osteoporosis has no symptoms and typically remains undiagnosed until a fracture occurs. (C)Once a fracture occurs, the condition has usually advanced to the stage where the likelihood is high that another fracture will occur. (D)There is no cure for osteoporosis, but drug therapy has been shown to reduce new hip and spine fractures by 50 percent and other treatments, such as nutrition therapy, have also proven effective. (2)

Incidence of osteoporosis

Osteoporosis is a common condition: (A)Of the 44 million Americans who have (or are at risk for) osteoporosis, 80 percent are women. (B)Annually there are 1.5 million bone fractures attributable to osteoporosis. (C)Half of all women, and one-fourth of all men, age 50 or older will have a bone fracture due to osteoporosis. (3)

Impact of osteoporosis

The cost of treating osteoporosis is significant: (A)The annual cost of osteoporosis in the United States was $17 billion in 2001. (B)The average cost in the United States of repairing a hip fracture due to osteoporosis is $37,000, while the average cost of an osteoporosis screening test ranges from $59 to $300. (C)Fractures due to osteoporosis frequently result in disability and institutionalization of individuals. (D)Because osteoporosis is a progressive condition causing fractures primarily in aging individuals, preventing fractures particularly in post menopausal women before they become eligible for medicare, has a significant potential of reducing osteoporosis-related costs under the medicare program. (4)

Use of bone mass measurement

(A)Bone mass measurement is a non-invasive, painless, and reliable way to diagnose osteoporosis before costly fractures occur. (B)Low bone mass is as predictive of future fractures as is high cholesterol or high blood pressure of heart disease or stroke. (C)Bone mass measurement is the only reliable method of detecting osteoporosis at an early stage. (D)Under section 4106 of the Balanced Budget Act of 1997, medicare provides coverage, effective July 1, 1998, for bone mass measurement for qualified individuals who are at risk of developing osteoporosis.

Requiring coverage of bone mass measurement under health plans

(a)

Group health plans

(1)

Public Health Service Act amendments

(A)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 bone mass measurement

(a)

Requirements for coverage of bone mass measurement

A group health plan, and a health insurance issuer offering group health insurance coverage, shall include (consistent with this section) coverage for bone mass measurement for beneficiaries and participants who are qualified individuals. (b)

Definitions relating to coverage

In this section: (1)

Bone mass measurement

The term bone mass measurement means a radiologic or radioisotopic procedure or other procedure approved by the Food and Drug Administration performed on an individual for the purpose of identifying bone mass or detecting bone loss or determining bone quality, and includes a physician’s interpretation of the results of the procedure. Nothing in this paragraph shall be construed as requiring a bone mass measurement to be conducted in a particular type of facility or to prevent such a measurement from being conducted through the use of mobile facilities that are otherwise qualified. (2)

Qualified individual

The term qualified individual means an individual who— (A)is at clinical risk for osteoporosis, including an estrogen-deficient woman; (B)has vertebral abnormalities; (C)is receiving chemotherapy or long-term gluococorticoid (steroid) therapy; (D)has primary hyperparathyroidism, hyperthyroidism, or excess thyroid replacement; or (E)is being monitored to assess the response to or efficacy of approved osteoporosis drug therapy. (c)

Limitation on frequency required

Taking into account the standards established under section 1861(rr)(3) of the Social Security Act, the Secretary shall establish standards regarding the frequency with which a qualified individual shall be eligible to be provided benefits for bone mass measurement under this section. The Secretary may vary such standards based on the clinical and risk-related characteristics of qualified individuals. (d)

Restrictions on Cost-Sharing

(1)

In general

Subject to paragraph (2), 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 bone mass measurement under the plan (or health insurance coverage offered in connection with a plan). (2)

Limitation

Deductibles, coinsurance, and other cost-sharing or other limitations for bone mass measurement may not be imposed under paragraph (1) to the extent they exceed the deductibles, coinsurance, and limitations that are applied to similar services under the group health plan or health insurance coverage. (e)

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 to an individual 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; (2)provide incentives (monetary or otherwise) to individuals to encourage such individuals not to be provided bone mass measurements to which they are entitled under this section or to providers to induce such providers not to provide such measurements to qualified individuals; (3)prohibit a provider from discussing with a patient osteoporosis preventive techniques or medical treatment options relating to this section; or (4)penalize or otherwise reduce or limit the reimbursement of a provider because such provider provided bone mass measurements to a qualified individual in accordance with this section. (f)

Rule of construction

Nothing in this section shall be construed to require an individual who is a participant or beneficiary to undergo bone mass measurement. (g)

Notice

A group health plan under this part shall comply with the notice requirement under section 714(g) 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. (h)

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. (i)

Preemption

(1)

In general

The provisions of this section do not preempt State law relating to health insurance coverage to the extent such State law provides greater benefits with respect to osteoporosis detection or prevention. (2)

Construction

Section 2723(a)(1) shall not be construed as superseding a State law described in paragraph (1).

(B)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. (2)

ERISA amendments

(A)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 bone mass measurement

(a)

Requirements for coverage of bone mass measurement

Definitions relating to coverage

In this section: (1)

Bone mass measurement

Qualified individual

Limitation on frequency required

The standards established under section 2707(c) of the Public Health Service Act shall apply to benefits provided under this section in the same manner as they apply to benefits provided under section 2707 of such Act. (d)

Restrictions on Cost-Sharing

(1)

In general

Limitation

Prohibitions

Rule of construction

Nothing in this section shall be construed to require an individual who is a participant or beneficiary to undergo bone mass measurement. (g)

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. (h)

Preemption

(1)

In general

Construction

Section 731(a)(1) shall not be construed as superseding a State law described in paragraph (1).

(B)Section 731(c) of such Act (29 U.S.C. 1191(c)) is amended by striking section 711 and inserting sections 711 and 714. (C)Section 732(a) of such Act (29 U.S.C. 1191a(a)) is amended by striking section 711 and inserting sections 711 and 714. (D)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:

714. Standards relating to benefits for bone mass measurement.

(b)

Individual health insurance

(1)Part B of title XXVII of the Public Health Service Act is amended by inserting after section 2752 the following new section:

2753.

Standards relating to benefits for bone mass measurement

(a)

In general

The provisions of section 2707 (other than subsection (g)) 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 714(g) 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

(1)

In general

Construction

Section 2762(a) shall not be construed as superseding a State law described in paragraph (1).

(2)Section 2762(b)(2) of such Act (42 U.S.C. 300gg–62(b)(2)) is amended by striking section 2751 and inserting sections 2751 and 2753. (c)

Effective dates

(1)The amendments made by subsection (a) shall apply with respect to group health plans for plan years beginning on or after January 1, 2006. (2)The amendments made by subsection (b) shall apply with respect to health insurance coverage offered, sold, issued, renewed, in effect, or operated in the individual market on or after such date.