[Congressional Bills 110th Congress]
[From the U.S. Government Publishing Office]
[H.R. 5615 Introduced in House (IH)]







110th CONGRESS
  2d Session
                                H. R. 5615

 To provide parity under group health plans and group health insurance 
   coverage in the provision of benefits for prosthetic devices and 
    components and benefits for other medical and surgical services.


_______________________________________________________________________


                    IN THE HOUSE OF REPRESENTATIVES

                             March 13, 2008

Mr. Andrews (for himself, Mr. George Miller of California, Mr. Platts, 
   Mr. Lincoln Diaz-Balart of Florida, and Mr. Mario Diaz-Balart of 
   Florida) introduced the following bill; which was referred to the 
                    Committee on Education and Labor

_______________________________________________________________________

                                 A BILL


 
 To provide parity under group health plans and group health insurance 
   coverage in the provision of benefits for prosthetic devices and 
    components and benefits for other medical and surgical services.

    Be it enacted by the Senate and House of Representatives of the 
United States of America in Congress assembled,

SECTION 1. SHORT TITLE; TABLE OF CONTENTS.

    This Act may be cited as the ``Group Health Plan Prosthetics Parity 
Act of 2007''.

SEC. 2. FINDINGS; PURPOSE.

    (a) Findings.--Congress finds the following:
            (1) There are more than 1,800,000 people in the United 
        States living with limb loss.
            (2) Every year, there are more than 130,000 people in the 
        United States who undergo amputation.
            (3) In addition, United States military personnel serving 
        in Iraq and Afghanistan and around the world have sustained 
        traumatic injuries resulting in amputation.
            (4) The number of amputations in the United States is 
        projected to increase in the years ahead due to rising 
        incidence of diabetes and other chronic illness.
            (5) Those suffering from limb loss can and want to regain 
        their lives as productive members of society.
            (6) Prosthetic devices enable amputees to continue working 
        and living productive lives.
            (7) Insurance companies have begun to limit reimbursement 
        of prosthetic equipment costs at unrealistic levels or not at 
        all and often restrict coverage over a person's lifetime, which 
        shifts costs onto the Medicare and Medicaid programs.
            (8) Eight States have addressed this problem and have 
        enacted prosthetic parity legislation.
            (9) Prosthetic parity legislation has been introduced and 
        is being actively considered in 30 States.
            (10) The States in which prosthetic parity laws have been 
        enacted have found there to be minimal or no increases in 
        insurance premiums and have reduced Medicare and Medicaid 
        costs.
            (11) Prosthetic parity legislation will not add to the size 
        of government or to the costs associated with the Medicare or 
        Medicaid programs.
            (12) If coverage for prosthetic devices and components are 
        offered by a group health insurance policy, then providing such 
        coverage of prosthetic devices on par with other medical and 
        surgical benefits will not increase the incidence of 
        amputations or the number of individuals for which a prosthetic 
        device would be medically necessary and appropriate.
            (13) In States where prosthetic parity legislation has been 
        enacted, amputees are able to return to a productive life, 
        State funds have been saved, and the health insurance industry 
        has continued to prosper.
            (14) Prosthetic services allow people to return more 
        quickly to their preexisting work.
    (b) Purpose.--The purpose of this Act is to require that each group 
health plan that provides both coverage for prosthetic devices and 
components and medical and surgical benefits, provide such coverage 
under terms and conditions that are no less favorable than the terms 
and conditions under which such benefits are provided under such plan.

SEC. 3. PROSTHETICS PARITY UNDER ERISA.

    (a) In General.--Subpart B of part 7 of subtitle B of title I of 
the Employee Retirement Income Security Act of 1974 is amended by 
inserting after section 713 (29 U.S.C. 1185b) the following new 
section:

``SEC. 714. PROSTHETICS PARITY.

    ``(a) In General.--In the case of a group health plan (or health 
insurance coverage offered in connection with such a plan) that 
provides both medical and surgical benefits and benefits for prosthetic 
devices and components (as defined under subsection (d)(1))--
            ``(1) such benefits for prosthetic devices and components 
        under the plan (or coverage) shall be provided under terms and 
        conditions that are no less favorable than the terms and 
        conditions applicable to substantially all medical and surgical 
        benefits provided under the plan (or coverage);
            ``(2) such benefits for prosthetic devices and components 
        under the plan (or coverage) may not be subject to separate 
        financial requirements (as defined in subsection (d)(2)) that 
        are applicable only with respect to such benefits, and any 
        financial requirements applicable to such benefits may be no 
        more restrictive than the financial requirements applicable to 
        substantially all medical and surgical benefits provided under 
        the plan (or coverage); and
            ``(3) any treatment limitations (as defined in subsection 
        (d)(3)) applicable to such benefits for prosthetic devices and 
        components under the plan (or coverage) may not be more 
        restrictive than the treatment limitations applicable to 
        substantially all medical and surgical benefits provided under 
        the plan (or coverage).
    ``(b) In-Network and Out-of-Network Standards.--
            ``(1) In general.--In the case of a group health plan (or 
        health insurance coverage offered in connection with such a 
        plan) that provides both medical and surgical benefits and 
        benefits for prosthetic devices and components, and that 
        provides both in-network benefits for prosthetic devices and 
        components and out-of-network benefits for prosthetic devices 
        and components, the requirements of this section shall apply 
        separately with respect to benefits provided under the plan (or 
        coverage) on an in-network basis and benefits provided under 
        the plan (or coverage) on an out-of-network basis.
            ``(2) Clarification.--Nothing in paragraph (1) shall be 
        construed as requiring that a group health plan (or health 
        insurance coverage offered in connection with such a plan) 
        eliminate an out-of-network provider option from such plan (or 
        coverage) pursuant to the terms of the plan (or coverage).
    ``(c) Additional Requirements.--
            ``(1) Prior authorization.--In the case of a group health 
        plan (or health insurance coverage offered in connection with 
        such a plan) that requires, as a condition of coverage or 
        payment for prosthetic devices and components under the plan 
        (or coverage), prior authorization, such prior authorization 
        must be required in the same manner as prior authorization is 
        required by the plan (or coverage) as a condition of coverage 
        or payment for all similar benefits provided under the plan (or 
        coverage).
            ``(2) Limitation on mandated benefits.--Required benefits 
        for prosthetic devices and components under this section are 
        limited to the most appropriate model that adequately meets the 
        medical requirements of the patient, as determined by the 
        treating physician of the patient.
            ``(3) Coverage for repair or replacement.--Benefits for 
        prosthetic devices and components required under this section 
        shall include coverage for repair or replacement of prosthetic 
        devices and components, if the repair or replacement is 
        determined appropriate by the treating physician of the patient 
        involved.
            ``(4) Annual or lifetime dollar limitations.--A group 
        health plan (or health insurance coverage offered in connection 
        with such a plan) may not impose any annual or lifetime dollar 
        limitation on benefits for prosthetic devices and components 
        unless such limitation applies in the aggregate to all medical 
        and surgical benefits provided under the plan (or coverage) and 
        benefits for prosthetic devices and components.
    ``(d) Definitions.--For the purposes of this section:
            ``(1) Prosthetic devices and components.--The term 
        `prosthetic devices and components' means the items and 
        services described in paragraphs (9) and (12) of section 
        1861(s) of the Social Security Act and includes external breast 
        prostheses incident to mastectomy resulting from breast cancer.
            ``(2) Financial requirements.--The term `financial 
        requirements' includes deductibles, coinsurance, co-payments, 
        other cost sharing, and limitations on the total amount that 
        may be paid by a participant or beneficiary with respect to 
        benefits under the plan or health insurance coverage and also 
        includes the application of annual and lifetime limits.
            ``(3) Treatment limitations.--The term `treatment 
        limitations' 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) Clerical Amendment.--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. Prosthetics parity.''.
    (c) Effective Date.--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 the date of the enactment of this Act.

SEC. 4. FEDERAL ADMINISTRATIVE RESPONSIBILITIES.

    (a) Assistance to Plan Participants and Beneficiaries.--The 
Secretary of Labor shall provide for assistance to participants and 
beneficiaries under such plans with any questions or problems regarding 
compliance with the requirements of this section.
    (b) Audits.--The Secretary of Labor shall provide for the conduct 
of random audits of group health plans (and health insurance coverage 
offered in connection with such plans) to ensure that such plans are in 
compliance with section 714 of the Employee Retirement Income Security 
Act of 1974, as added by section 3.
    (c) GAO Study.--
            (1) Study.--The Comptroller General of the United States 
        shall conduct a study that evaluates the effect of the 
        implementation of the amendments made by this Act on the cost 
        of health insurance coverage, on access to health insurance 
        coverage (including the availability of in-network providers), 
        on the quality of health care, on benefits and coverage for 
        prosthetic devices and components, on any additional cost or 
        savings to group health plans, on State prosthetic devices and 
        components benefit mandate laws, on the business community and 
        the Federal Government, and on other issues as determined 
        appropriate by the Comptroller General.
            (2) Report.--Not later than 2 years after the date of the 
        enactment of this Act, the Comptroller General of the United 
        States shall prepare and submit to the appropriate committees 
        of Congress a report containing the results of the study 
        conducted under paragraph (1).
    (d) Regulations.--Not later than 1 year after the date of the 
enactment of this Act, the Secretary of Labor shall promulgate final 
regulations to carry out this Act and the amendments made by this Act.
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