109th CONGRESS
1st Session
H. R. 4651
To require equitable coverage of prescription contraceptive drugs
and devices, and contraceptive services under health plans.
IN THE HOUSE OF REPRESENTATIVES
December 22, 2005
Mrs. LOWEY introduced the following bill; which was referred to the Committee
on Energy and Commerce, and in addition to the Committee on Education and
the Workforce, 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 require equitable coverage of prescription contraceptive drugs
and devices, and contraceptive services under health plans.
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 `Equity in Prescription Insurance and Contraceptive
Coverage Act of 2005'.
SEC. 2. FINDINGS.
(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.
SEC. 3. 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:
`SEC. 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.
SEC. 4. 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:
`SEC. 2707. 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 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- 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- 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) 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.
SEC. 5. 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:
`SEC. 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.
END
