[Congressional Bills 111th Congress]
[From the U.S. Government Publishing Office]
[H.R. 1330 Introduced in House (IH)]
111th CONGRESS
1st Session
H. R. 1330
To amend the Public Health Service Act, the Employee Retirement Income
Security Act of 1974, the Internal Revenue Code of 1986, and title 5,
United States Code, to require that group and individual health
insurance coverage and group health plans and Federal employees health
benefit plans provide coverage of colorectal cancer screening.
_______________________________________________________________________
IN THE HOUSE OF REPRESENTATIVES
March 5, 2009
Mr. Boren introduced the following bill; which was referred to the
Committee on Energy and Commerce, and in addition to the Committees on
Ways and Means, Education and Labor, and Oversight and Government
Reform, for a period to be subsequently determined by the Speaker, in
each case for consideration of such provisions as fall within the
jurisdiction of the committee concerned
_______________________________________________________________________
A BILL
To amend the Public Health Service Act, the Employee Retirement Income
Security Act of 1974, the Internal Revenue Code of 1986, and title 5,
United States Code, to require that group and individual health
insurance coverage and group health plans and Federal employees health
benefit plans provide coverage of colorectal cancer screening.
Be it enacted by the Senate and House of Representatives of the
United States of America in Congress assembled,
SECTION 1. SHORT TITLE.
This Act may be cited as the ``Colorectal Cancer Screening and
Detection Coverage Act of 2009''.
SEC. 2. COVERAGE OF COLORECTAL CANCER SCREENING.
(a) Group Health Plans.--
(1) Public health service act amendments.--
(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:
``SEC. 2708. COVERAGE OF COLORECTAL CANCER SCREENING.
``(a) Requirement.--
``(1) In general.--A group health plan, and a health
insurance issuer offering group health insurance coverage,
shall provide coverage under the plan or coverage,
respectively, for colorectal cancer screening for any
participant or beneficiary who is 50 years of age or older, or
is an individual who is at high risk for colorectal cancer (as
defined in section 1861(pp)(2) of the Social Security Act (42
U.S.C. 1395x(pp)(2))), under terms and conditions that are no
less favorable than the terms and conditions applicable to
other screening benefits otherwise provided under the plan or
coverage, respectively, except that--
``(A) the amount of any coinsurance applicable to
such screening may not be more than 5 percent of the
payment amount for such screening under such plan or
coverage, respectively, and such coverage provided
under the plan or coverage, respectively, may not be
subject to any deductible; and
``(B) such coverage--
``(i) with respect to individuals first
receiving benefits under such plan or coverage
after the applicable effective date described
in section 2(d) of the `Colorectal Cancer
Screening and Detection Coverage Act of 2009',
may require a waiting period of not more than 6
months beginning on the first date of coverage;
and
``(ii) with respect to individuals
receiving benefits under such plan or coverage
before such effective date, may not require a
waiting period.
``(2) Colorectal cancer screening defined.--For purposes of
this section, the term `colorectal cancer screening' means
procedures that--
``(A) are deemed appropriate by a physician (as
defined in section 1861(r) of the Social Security Act
(42 U.S.C. 1395x(r))) treating the participant or
beneficiary, in consultation with the participant or
beneficiary;
``(B) are--
``(i) described in section 1861(pp)(1) of
the Social Security Act (42 U.S.C.
1395x(pp)(1)) or section 410.37 of title 42,
Code of Federal Regulations;
``(ii) specified by the Secretary for the
detection of colorectal cancer, based upon the
recommendations of appropriate organizations
with special expertise in the field of
colorectal cancer, including the American
Cancer Society and the American College of
Gastroenterology; or
``(iii) specified by the Secretary, based
upon new scientific knowledge, technological
advances, or other updated medical practices
with respect to detection of colorectal cancer;
and
``(C) are performed at a frequency not greater
than--
``(i)(I) subject to subclause (II), that
described for such method in section 1834(d) of
the Social Security Act (42 U.S.C. 1395m(d)) or
section 410.37 of title 42, Code of Federal
Regulations; or
``(II) in the case of a colorectal cancer
screening test consisting of a screening
colonoscopy, once every 36 months; or
``(ii) that specified by the Secretary for
such method, if the Secretary finds, based upon
new scientific knowledge, technological
advances, or other updated medical practices
and consistent with the recommendations of
appropriate organizations with special
expertise in the field of colorectal cancer,
that a different frequency would not adversely
affect the effectiveness of such screening.
``(b) Protections.--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 monetary payments or rebates to individuals
to encourage such individuals to accept less than the minimum
protections available under this section;
``(3) penalize or otherwise reduce or limit the
reimbursement of a provider because such provider provided care
to an individual participant or beneficiary in accordance with
this section; or
``(4) 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
an individual who is a participant or beneficiary to undergo
colorectal cancer screening.
``(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
colorectal cancer screening under the plan (or under health
insurance coverage offered in connection with a group health
plan), except that such coinsurance or other cost-sharing shall
not discriminate on any basis related to the coverage required
under this section.
``(d) Notice.--A group health plan under this part shall comply
with the notice requirement under section 715(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) Disclosure Requirement.--
``(1) In general.--A group health plan, and health
insurance issuer offering group health insurance coverage
shall--
``(A) provide to participants and beneficiaries at
the time of initial coverage under the plan (or the
effective date of this section, in the case of
individuals who are participants or beneficiaries as of
such date), and at least annually thereafter, the
information described in paragraph (2);
``(B) provide to participants and beneficiaries,
within a reasonable period (as specified by the
appropriate Secretary) before or after the date of
significant changes in the information described in
paragraph (2), information regarding such significant
changes; and
``(C) upon request, make available to participants
and beneficiaries, the applicable authority, and
prospective participants and beneficiaries, the
information described in paragraph (2).
``(2) Information described.--For purposes of paragraph
(1), the information described in this paragraph, with respect
to colorectal cancer screening, is the following:
``(A) Benefits.--Benefits offered under the plan or
coverage, including--
``(i) covered benefits, including benefit
limits and coverage exclusions;
``(ii) cost-sharing, such as deductibles,
coinsurance, and copayment amounts, including
any liability for balance billing, any maximum
limitations on out of pocket expenses, and the
maximum out of pocket costs for services that
are provided by nonparticipating providers or
that are furnished without meeting the
applicable utilization review requirements;
``(iii) the extent to which benefits may be
obtained from nonparticipating providers; and
``(iv) the extent to which a participant,
beneficiary, or enrollee may select from among
participating providers and the types of
providers participating in the plan or issuer
network.
``(B) Access.--A description of the following:
``(i) The number, mix, and distribution of
providers under the plan or coverage.
``(ii) Out-of-network coverage (if any)
provided by the plan or coverage.
``(iii) Any point-of-service option
(including any supplemental premium or cost-
sharing for such option).
``(iv) The procedures for participants,
beneficiaries, and enrollees to select, access,
and change participating primary and specialty
providers.
``(v) The rights and procedures for
obtaining referrals (including standing
referrals) to participating and
nonparticipating providers.
``(vi) The name, address, and telephone
number of participating health care providers
and an indication of whether each such provider
is available to accept new patients.
``(vii) How the plan or issuer addresses
the needs of participants, beneficiaries, and
enrollees and others who do not speak English
or who have other special communications needs
in accessing providers under the plan or
coverage, including the provision of
information under this paragraph.''.
(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 2708''.
(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:
``SEC. 715. COVERAGE OF COLORECTAL CANCER SCREENING.
``(a) Requirement.--
``(1) In general.--A group health plan, and a health
insurance issuer offering group health insurance coverage,
shall provide coverage under the plan or coverage,
respectively, for colorectal cancer screening for any
participant or beneficiary who is 50 years of age or older, or
is an individual who is at high risk for colorectal cancer (as
defined in section 1861(pp)(2) of the Social Security Act (42
U.S.C. 1395x(pp)(2)), under terms and conditions that are no
less favorable than the terms and conditions applicable to
other screening benefits otherwise provided under the plan or
coverage, respectively, except that--
``(A) the amount of any coinsurance applicable to
such screening may not be more than 5 percent of the
payment amount for such screening under such plan or
coverage, respectively, and such coverage provided
under the plan or coverage, respectively, may not be
subject to any deductible; and
``(B) such coverage--
``(i) with respect to individuals first
receiving benefits under such plan or coverage
after the applicable effective date described
in section 2(d) of the `Colorectal Cancer
Screening and Detection Coverage Act of 2009',
may require a waiting period of not more than 6
months beginning on the first date of coverage;
and
``(ii) with respect to individuals
receiving benefits under such plan or coverage
before such effective date, may not require a
waiting period.
``(2) Colorectal cancer screening defined.--For purposes of
this section, the term `colorectal cancer screening' means
procedures that--
``(A) are deemed appropriate by a physician (as
defined in section 1861(r) of the Social Security Act
(42 U.S.C. 1395x(r))) treating the participant or
beneficiary, in consultation with the participant or
beneficiary;
``(B) are--
``(i) described in section 1861(pp)(1) of
the Social Security Act (42 U.S.C.
1395x(pp)(1)) or section 410.37 of title 42,
Code of Federal Regulations;
``(ii) specified by the Secretary for the
detection of colorectal cancer, based upon the
recommendations of appropriate organizations
with special expertise in the field of
colorectal cancer, including the American
Cancer Society and the American College of
Gastroenterology; or
``(iii) specified by the Secretary, based
upon new scientific knowledge, technological
advances, or other updated medical practices
with respect to detection of colorectal cancer;
and
``(C) are performed at a frequency not greater
than--
``(i)(I) subject to subclause (II), that
described for such method in section 1834(d) of
the Social Security Act (42 U.S.C. 1395m(d)) or
section 410.37 of title 42, Code of Federal
Regulations; or
``(II) in the case of a colorectal cancer
screening test consisting of a screening
colonoscopy, once every 36 months; or
``(ii) that specified by the Secretary for
such method, if the Secretary finds, based upon
new scientific knowledge, technological
advances, or other updated medical practices
and consistent with the recommendations of
appropriate organizations with special
expertise in the field of colorectal cancer,
that a different frequency would not adversely
affect the effectiveness of such screening.
``(b) Protections.--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 monetary payments or rebates to individuals
to encourage such individuals to accept less than the minimum
protections available under this section;
``(3) penalize or otherwise reduce or limit the
reimbursement of a provider because such provider provided care
to an individual participant or beneficiary in accordance with
this section; or
``(4) 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
an individual who is a participant or beneficiary to undergo
colorectal cancer screening.
``(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
colorectal cancer screening under the plan (or under health
insurance coverage offered in connection with a group health
plan), except that such coinsurance or other cost-sharing shall
not discriminate on any basis related to the coverage required
under this section.
``(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), for
purposes of assuring notice of such requirements under the plan; except
that the summary description required to be provided under the fourth
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) Disclosure Requirement.--
``(1) In general.--A group health plan, and health
insurance issuer offering group health insurance coverage
shall--
``(A) provide to participants and beneficiaries at
the time of initial coverage under the plan (or the
effective date of this section, in the case of
individuals who are participants or beneficiaries as of
such date), and at least annually thereafter, the
information described in paragraph (2);
``(B) provide to participants and beneficiaries,
within a reasonable period (as specified by the
appropriate Secretary) before or after the date of
significant changes in the information described in
paragraph (2), information regarding such significant
changes; and
``(C) upon request, make available to participants
and beneficiaries, the applicable authority, and
prospective participants and beneficiaries, the
information described in paragraph (2).
``(2) Information described.--For purposes of paragraph
(1), the information described in this paragraph, with respect
to colorectal cancer screening, is the following:
``(A) Benefits.--Benefits offered under the plan or
coverage, including--
``(i) covered benefits, including benefit
limits and coverage exclusions;
``(ii) cost-sharing, such as deductibles,
coinsurance, and copayment amounts, including
any liability for balance billing, any maximum
limitations on out of pocket expenses, and the
maximum out of pocket costs for services that
are provided by nonparticipating providers or
that are furnished without meeting the
applicable utilization review requirements;
``(iii) the extent to which benefits may be
obtained from nonparticipating providers; and
``(iv) the extent to which a participant,
beneficiary, or enrollee may select from among
participating providers and the types of
providers participating in the plan or issuer
network.
``(B) Access.--A description of the following:
``(i) The number, mix, and distribution of
providers under the plan or coverage.
``(ii) Out-of-network coverage (if any)
provided by the plan or coverage.
``(iii) Any point-of-service option
(including any supplemental premium or cost-
sharing for such option).
``(iv) The procedures for participants,
beneficiaries, and enrollees to select, access,
and change participating primary and specialty
providers.
``(v) The rights and procedures for
obtaining referrals (including standing
referrals) to participating and
nonparticipating providers.
``(vi) The name, address, and telephone
number of participating health care providers
and an indication of whether each such provider
is available to accept new patients.
``(vii) How the plan or issuer addresses
the needs of participants, beneficiaries, and
enrollees and others who do not speak English
or who have other special communications needs
in accessing providers under the plan or
coverage, including the provision of
information under this paragraph.''.
(B) Section 731(c) of such Act (29 U.S.C. 1191(c))
is amended by striking ``section 711'' and inserting
``sections 711 and 715''.
(C) Section 732(a) of such Act (29 U.S.C. 1191a(a))
is amended by striking ``section 711'' and inserting
``sections 711 and 715''.
(D) The table of contents in section 1 of such Act
is amended by inserting after the item relating to
section 714 the following new item:
``Sec. 715. Coverage of colorectal cancer screening.''.
(3) Internal revenue code amendments.--
(A) Subchapter B of chapter 100 of the Internal
Revenue Code of 1986 is amended by inserting after
section 9813 the following new section:
``SEC. 9814. COVERAGE OF COLORECTAL CANCER SCREENING.
``(a) Requirement.--
``(1) In general.--A group health plan shall provide
coverage under the plan for colorectal cancer screening for any
participant or beneficiary who is 50 years of age or older, or
is an individual who is at high risk for colorectal cancer (as
defined in section 1861(pp)(2) of the Social Security Act (42
U.S.C. 1395x(pp)(2))), under terms and conditions that are no
less favorable than the terms and conditions applicable to
other screening benefits otherwise provided under the plan,
except that--
``(A) the amount of any coinsurance applicable to
such screening may not be more than 5 percent of the
payment amount for such screening under such plan and
such coverage provided under the plan may not be
subject to any deductible; and
``(B) such coverage--
``(i) with respect to individuals first
receiving benefits under such plan after the
applicable effective date described in section
2(d) of the `Colorectal Cancer Screening and
Detection Coverage Act of 2009', may require a
waiting period of not more than 6 months
beginning on the first date of coverage; and
``(ii) with respect to individuals
receiving benefits under such plan before such
effective date, may not require a waiting
period.
``(2) Colorectal cancer screening defined.--For purposes of
this section, the term `colorectal cancer screening' means
procedures that--
``(A) are deemed appropriate by a physician (as
defined in section 1861(r) of the Social Security Act
(42 U.S.C. 1395x(r))) treating the participant or
beneficiary, in consultation with the participant or
beneficiary;
``(B) are--
``(i) described in section 1861(pp)(1) of
the Social Security Act (42 U.S.C.
1395x(pp)(1)) or section 410.37 of title 42,
Code of Federal Regulations;
``(ii) specified by the Secretary of Health
and Human Services for the detection of
colorectal cancer, based upon the
recommendations of appropriate organizations
with special expertise in the field of
colorectal cancer, including the American
Cancer Society and the American College of
Gastroenterology; or
``(iii) specified by the Secretary of
Health and Human Services, based upon new
scientific knowledge, technological advances,
or other updated medical practices with respect
to detection of colorectal cancer; and
``(C) are performed at a frequency not greater
than--
``(i)(I) subject to subclause (II), that
described for such method in section 1834(d) of
the Social Security Act (42 U.S.C. 1395m(d)) or
section 410.37 of title 42, Code of Federal
Regulations; or
``(II) in the case of a colorectal cancer
screening test consisting of a screening
colonoscopy, once every 36 months; or
``(ii) that specified by the Secretary for
such method, if the Secretary finds, based upon
new scientific knowledge, technological
advances, or other updated medical practices
and consistent with the recommendations of
appropriate organizations with special
expertise in the field of colorectal cancer,
that a different frequency would not adversely
affect the effectiveness of such screening.
``(b) Protections.--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 monetary payments or rebates to individuals
to encourage such individuals to accept less than the minimum
protections available under this section;
``(3) penalize or otherwise reduce or limit the
reimbursement of a provider because such provider provided care
to an individual participant or beneficiary in accordance with
this section; or
``(4) 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
an individual who is a participant or beneficiary to undergo
colorectal cancer screening.
``(2) Nothing in this section shall be construed as
preventing a group health plan from imposing deductibles,
coinsurance, or other cost-sharing in relation to colorectal
cancer screening under the plan, except that such coinsurance
or other cost-sharing shall not discriminate on any basis
related to the coverage required under this section.
``(d) Disclosure Requirement.--
``(1) In general.--A group health plan shall--
``(A) provide to participants and beneficiaries at
the time of initial coverage under the plan (or the
effective date of this section, in the case of
individuals who are participants or beneficiaries as of
such date), and at least annually thereafter, the
information described in paragraph (2);
``(B) provide to participants and beneficiaries,
within a reasonable period (as specified by the
appropriate Secretary) before or after the date of
significant changes in the information described in
paragraph (2), information regarding such significant
changes; and
``(C) upon request, make available to participants
and beneficiaries, the applicable authority, and
prospective participants and beneficiaries, the
information described in paragraph (2).
``(2) Information described.--For purposes of paragraph
(1), the information described in this paragraph, with respect
to colorectal cancer screening, is the following:
``(A) Benefits.--Benefits offered under the plan,
including--
``(i) covered benefits, including benefit
limits and coverage exclusions;
``(ii) cost-sharing, such as deductibles,
coinsurance, and copayment amounts, including
any liability for balance billing, any maximum
limitations on out of pocket expenses, and the
maximum out of pocket costs for services that
are provided by nonparticipating providers or
that are furnished without meeting the
applicable utilization review requirements;
``(iii) the extent to which benefits may be
obtained from nonparticipating providers; and
``(iv) the extent to which a participant,
beneficiary, or enrollee may select from among
participating providers and the types of
providers participating in the plan or issuer
network.
``(B) Access.--A description of the following:
``(i) The number, mix, and distribution of
providers under the plan.
``(ii) Out-of-network coverage (if any)
provided by the plan.
``(iii) Any point-of-service option
(including any supplemental premium or cost-
sharing for such option).
``(iv) The procedures for participants,
beneficiaries, and enrollees to select, access,
and change participating primary and specialty
providers.
``(v) The rights and procedures for
obtaining referrals (including standing
referrals) to participating and
nonparticipating providers.
``(vi) The name, address, and telephone
number of participating health care providers
and an indication of whether each such provider
is available to accept new patients.
``(vii) How the plan or issuer addresses
the needs of participants, beneficiaries, and
enrollees and others who do not speak English
or who have other special communications needs
in accessing providers under the plan,
including the provision of information under
this paragraph.''.
(B) The table of sections of such subchapter of
such Code is amended by inserting after the item
relating to section 9813 the following new item:
``Sec. 9814. Coverage of colorectal cancer screening.''.
(C) Section 4980D(d)(1) of such Code is amended by
striking ``section 9811'' and inserting ``sections 9811
and 9814''.
(b) Individual Health Insurance.--
(1) In general.--Part B of title XXVII of the Public Health
Service Act is amended by inserting after section 2753 the
following new section:
``SEC. 2754. COVERAGE OF COLORECTAL CANCER SCREENING.
``(a) In General.--The provisions of section 2708 (other than
subsection (d)) 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 715(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.''.
(2) Conforming amendment.--Section 2762(b)(2) of such Act
(42 U.S.C. 300gg-63(b)(2)) is amended by striking ``section
2751'' and inserting ``sections 2751 and 2754''.
(c) Application Under Federal Employees Health Benefits Program
(FEHBP).--Section 8902 of title 5, United States Code, is amended by
adding at the end the following new subsection:
``(p) A contract may not be made or a plan approved which does not
comply with the requirements of section 2708 of the Public Health
Service Act.''.
(d) Effective Dates.--
(1) Group health plans and health benefit plans.--The
amendments made by subsections (a) and (c) shall apply with
respect to group health plans (and health insurance coverage
offered in connection with group health plans) and health
benefit plans, respectively, for plan years beginning on or
after January 1, 2010.
(2) Individual health insurance.--The amendments made by
subsection (b) shall apply with respect to health insurance
coverage offered, sold, issued, or renewed in the individual
market on or after January 1, 2010.
(e) Coordination of Administration.--The Secretary of Health and
Human Services, the Secretary of Labor, and the Secretary of the
Treasury shall ensure, through the execution of an interagency
memorandum of understanding among such Secretaries, that--
(1) regulations, rulings, and interpretations issued by
such Secretaries relating to the same matter over which two or
more such Secretaries have responsibility under the provisions
of this section (and the amendments made thereby) are
administered so as to have the same effect at all times; and
(2) coordination of policies relating to enforcing the same
requirements through such Secretaries in order to have a
coordinated enforcement strategy that avoids duplication of
enforcement efforts and assigns priorities in enforcement.
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