Short title

This Act may be cited as the

Equity in Prescription Insurance and Contraceptive Coverage Act of 2005

Findings

Congress finds that— (1)each year, 3,000,000 pregnancies, or one half of all pregnancies, in this country are unintended; (2)contraceptives and contraceptive services are part of basic health care, allowing families to both adequately space desired pregnancies and avoid unintended pregnancy, and should be provided under the same terms and conditions as other basic health care; (3)studies show that contraceptives are cost effective: it is estimated that for every $1 of public funds invested in family planning, $3 is saved in medicaid costs from pregnancy-related healthcare and medical care for newborns; (4)by reducing rates of unintended pregnancy, contraceptives help reduce the need for abortion; (5)unintended pregnancies lead to higher rates of infant mortality, low-birth weight, and maternal morbidity, and threaten the economic viability of families; (6)the National Commission to Prevent Infant Mortality determined that infant mortality could be reduced by 10 percent if all women not desiring pregnancy used contraception; (7)most women in the United States, including three-quarters of women of childbearing age, rely on some form of private insurance (through their own employer, a family member’s employer, or the individual market) to defray their medical expenses; (8)the vast majority of private insurers cover prescription drugs, but many exclude coverage for prescription contraceptives; (9)private insurance provides extremely limited coverage of contraceptives: half of traditional indemnity plans and preferred provider organizations, 20 percent of point-of-service networks, and 7 percent of health maintenance organizations cover no contraceptive methods other than sterilization; (10)women of reproductive age spend 68 percent more than men on out-of-pocket health care costs, with contraceptives and reproductive health care services accounting for much of the difference; (11)the lack of contraceptive coverage in health insurance places many effective forms of contraceptives beyond the financial reach of many women, leading to unintended pregnancies; (12)the Institute of Medicine Committee on Unintended Pregnancy recommended that financial barriers to contraception be reduced by increasing the proportion of all health insurance policies that cover contraceptive services and supplies; (13)in 1998, Congress agreed to provide contraceptive coverage to the 2,000,000 women of reproductive age who are participating in the Federal Employees Health Benefits Program, the largest employer-sponsored health insurance plan in the world, and, in 2001, the Office of Personnel Management reported that it did not raise premiums as a result of such coverage because there was no cost increase due to contraceptive coverage; (14)eight in 10 privately insured adults support contraceptive coverage; (15)contraceptive coverage saves employers money: the Washington Business Group on Health estimates that not covering contraceptives in employee health plans costs employers 15 to 17 percent more than providing such coverage; and (16)Healthy People 2010, published by the Office of the Surgeon General, has established a 10-year national public health goal to increase the percentage of health plans that cover contraceptives.

Amendments to the Employee Retirement Income Security Act of 1974

(a)

In general

Subpart B of part 7 of subtitle B of title I of the Employee Retirement Income Security Act of 1974 (29 U.S.C. 1185 et seq.) is amended by adding at the end the following new section:

714.

Standards relating to benefits for contraceptives

(a)

Requirements for coverage

A group health plan, and a health insurance issuer providing health insurance coverage in connection with a group health plan, may not— (1)exclude or restrict benefits for prescription contraceptive drugs or devices approved by the Food and Drug Administration, or generic equivalents approved as substitutable by the Food and Drug Administration, if such plan or coverage provides benefits for other outpatient prescription drugs or devices; or (2)exclude or restrict benefits for outpatient contraceptive services if such plan or coverage provides benefits for other outpatient services provided by a health care professional (referred to in this section as outpatient health care services). (b)

Prohibitions

A group health plan, and a health insurance issuer providing 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 or coverage because of the individual’s or enrollee’s use or potential use of items or services that are covered in accordance with the requirements of this section; (2)provide monetary payments or rebates to a covered individual to encourage such individual to accept less than the minimum protections available under this section; (3)penalize or otherwise reduce or limit the reimbursement of a health care professional because such professional prescribed contraceptive drugs or devices, or provided contraceptive services, described in subsection (a), in accordance with this section; or (4)provide incentives (monetary or otherwise) to a health care professional to induce such professional to withhold from a covered individual contraceptive drugs or devices, or contraceptive services, described in subsection (a). (c)

Rules of construction

(1)

In general

Nothing in this section shall be construed— (A)as preventing a group health plan and a health insurance issuer providing health insurance coverage in connection with a group health plan from imposing deductibles, coinsurance, or other cost-sharing or limitations in relation to— (i)benefits for contraceptive drugs under the plan or coverage, except that such a deductible, coinsurance, or other cost-sharing or limitation for any such drug shall be consistent with those imposed for any outpatient prescription drug otherwise covered under the plan or coverage; (ii)benefits for contraceptive devices under the plan or coverage, except that such a deductible, coinsurance, or other cost-sharing or limitation for any such device shall be consistent with those imposed for any outpatient prescription device otherwise covered under the plan or coverage; and (iii)benefits for outpatient contraceptive services under the plan or coverage, except that such a deductible, coinsurance, or other cost-sharing or limitation for any such service shall be consistent with those imposed for any outpatient health care service otherwise covered under the plan or coverage; (B)as requiring a group health plan and a health insurance issuer providing health insurance coverage in connection with a group health plan to cover experimental or investigational contraceptive drugs or devices, or experimental or investigational contraceptive services, described in subsection (a), except to the extent that the plan or issuer provides coverage for other experimental or investigational outpatient prescription drugs or devices, or experimental or investigational outpatient health care services; or (C)as modifying, diminishing, or limiting the rights and protections of an individual under any other Federal law. (2)

Limitations

As used in paragraph (1), the term limitation includes— (A)in the case of a contraceptive drug or device, restricting the type of health care professionals that may prescribe such drugs or devices, utilization review provisions, and limits on the volume of prescription drugs or devices that may be obtained on the basis of a single consultation with a professional; or (B)in the case of an outpatient contraceptive service, restricting the type of health care professionals that may provide such services, utilization review provisions, requirements relating to second opinions prior to the coverage of such services, and requirements relating to preauthorizations prior to the coverage of such services. (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)

Preemption

Nothing in this section shall be construed to preempt any provision of State law to the extent that such State law establishes, implements, or continues in effect any standard or requirement that provides coverage or protections for participants or beneficiaries that are greater than the coverage or protections provided under this section. (f)

Definition

In this section, the term outpatient contraceptive services means consultations, examinations, procedures, and medical services, provided on an outpatient basis and related to the use of contraceptive methods (including natural family planning) to prevent an unintended pregnancy.

(b)

Clerical amendment

The table of contents in section 1 of the Employee Retirement Income Security Act of 1974 (29 U.S.C. 1001 note) is amended by inserting after the item relating to section 713 the following new item:

714. Standards relating to benefits for contraceptives.

(c)

Effective date

The amendments made by this section shall apply with respect to plan years beginning on or after January 1, 2007.

Amendments to the Public Health Service Act relating to the group market

(a)

In general

Subpart 2 of part A of title XXVII of the Public Health Service Act (42 U.S.C. 300gg–4 et seq.) is amended by adding at the end the following new section:

2707.

Standards relating to benefits for contraceptives

(a)

Requirements for coverage

Prohibitions

A group health plan, and a health insurance issuer providing 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 or coverage because of the individual’s or enrollee’s use or potential use of items or services that are covered in accordance with the requirements of this section; (2)provide monetary payments or rebates to a covered individual to encourage such individual to accept less than the minimum protections available under this section; (3)penalize or otherwise reduce or limit the reimbursement of a health care professional because such professional prescribed contraceptive drugs or devices, or provided contraceptive services, described in subsection (a), in accordance with this section; or (4)provide incentives (monetary or otherwise) to a health care professional to induce such professional to withhold from covered individual contraceptive drugs or devices, or contraceptive services, described in subsection (a). (c)

Rules of construction

(1)

In general

Limitations

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)

Preemption

Nothing in this section shall be construed to preempt any provision of State law to the extent that such State law establishes, implements, or continues in effect any standard or requirement that provides coverage or protections for enrollees that are greater than the coverage or protections provided under this section. (f)

Definition

(b)

Effective date

The amendments made by this section shall apply with respect to group health plans for plan years beginning on or after January 1, 2007.

Amendment to the Public Health Service Act relating to the individual market

(a)

In general

Part B of title XXVII of the Public Health Service Act (42 U.S.C. 300gg–41 et seq.) is amended— (1)by redesignating the first subpart 3 (relating to other requirements) as subpart 2; and (2)by adding at the end of subpart 2 the following new section:

2753.

Standards relating to benefits for contraceptives

The provisions of section 2707 shall apply to health insurance coverage offered by a health insurance issuer in the individual market in the same manner as they apply 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)

Effective date

The amendment made by this section shall apply with respect to health insurance coverage offered, sold, issued, renewed, in effect, or operated in the individual market on or after January 1, 2007.