H.R. 4457 - Chronic Condition Copay Elimination Act

116TH CONGRESS
1ST SESSION

H.R. 4457

To amend the Employee Retirement Income Security Act of 1974, title XXVII of the Public Health Service Act, and the Internal Revenue Code of 1986 to require group health plans and health insurance issuers offering group or individual health insurance coverage to provide coverage for additional preventive care for individuals with chronic conditions without the imposition of cost sharing requirement, and for other purposes.

IN THE HOUSE OF REPRESENTATIVES

SEPTEMBER 24, 2019

Ms.UNDERWOOD introduced the following bill; which was referred to the Committee on Energy and Commerce, and in addition to the Committees on Education and Labor, and Ways and Means, 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 Employee Retirement Income Security Act of 1974, title XXVII of the Public Health Service Act, and the Internal Revenue Code of 1986 to require group health plans and health insurance issuers offering group or individual health insurance coverage to provide coverage for additional preventive care for individuals with chronic conditions without the imposition of cost sharing requirement, and for other purposes.

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 "Chronic Condition Copay Elimination Act".

SEC. 2. COVERAGE OF ADDITIONAL PREVENTIVE CARE FOR INDIVIDUALS WITH CHRONIC CONDITIONS WITHOUT IMPOSITION OF COST SHARING REQUIREMENTS.

(a) ERISA. —

(1) 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. 716. COVERAGE OF ADDITIONAL PREVENTIVE CARE FOR INDIVIDUALS WITH CHRONIC CONDITIONS WITHOUT IMPOSITION OF COST SHARING REQUIREMENTS.

"(a) IN GENERAL. — In addition to any item or service described in section 2713(a) of the Public Health Service Act, a group health plan and a health insurance issuer offering group health insurance coverage shall, at a minimum, provide coverage for, and shall not impose any cost sharing requirements for, with respect to individuals with chronic conditions (as defined in subsection (b)), such additional preventive care and screenings not described in paragraph (1) of such section 2713(a) that are determined by the Secretary to meet the criteria specified in subsection (c) with respect to the chronic condition involved.

"(b) CHRONIC CONDITION DEFINED. — In this section, the term 'chronic condition' has the meaning given such term by the Secretary and, at a minimum, includes the following conditions:

"(1) Heart disease, including congestive heart failure and coronary artery disease.

"(2) Diabetes.

"(3) Osteoporosis and osteopenia.

"(4) Hypertension.

"(5) Asthma.

"(6) Liver disease.

"(7) Bleeding disorders.

"(8) Depression.

"(c) CRITERIA SPECIFIED. — For purposes of subsection (a), the criteria specified in this subsection, with respect to an item or service and a chronic condition, are the following:

"(1) The item or service is low-cost.

"(2) There is medical evidence supporting high-cost efficiency, or a large expected impact, of the item or service in preventing exacerbation of the chronic condition or the development of a secondary condition.

"(3) There is a strong likelihood, documented by clinical evidence, that the item or service will prevent the exacerbation of the chronic condition or the development of a secondary condition that requires significantly higher-cost treatments.

"(d) UPDATES. —

"(1) IN GENERAL. — Once every three years, the Secretary shall review and update —

"(A) the list of conditions included within the meaning of the term 'chronic condition' under subsection (b); and

"(B) the items and services determined to meet the criteria specified in subsection (c) for purposes of subsection (a).

"(2) APPLICATION OF UPDATES. — The requirement under subsection (a) shall apply with respect to an update made under paragraph (1) beginning with the first plan year beginning after the date of such update.".

(2) CLERICAL AMENDMENT. — The table of contents in section 1 of such Act is amended by inserting after the item relating to section 714 the following new items:

"715. Additional market reforms.

"716. Coverage of additional preventive care for individuals with chronic conditions without imposition of cost sharing requirements.".

(b) PHSA. — Subpart II of part A of title XXVII of the Public Health Service Act (42 U.S.C. 300gg–11 et seq.) is amended by adding at the end the following new section:

"SEC. 2730. COVERAGE OF ADDITIONAL PREVENTIVE CARE FOR INDIVIDUALS WITH CHRONIC CONDITIONS WITHOUT IMPOSITION OF COST SHARING REQUIREMENTS.

"(a) IN GENERAL. — In addition to any item or service described in section 2713(a), a group health plan and a health insurance issuer offering group or individual health insurance coverage shall, at a minimum, provide coverage for, and shall not impose any cost sharing requirements for, with respect to individuals with chronic conditions (as defined in subsection (b)), such additional preventive care and screenings not described in paragraph

(1) of section 2713(a) that are determined by the Secretary to meet the criteria specified in subsection (c) with respect to the chronic condition involved.

"(b) CHRONIC CONDITION DEFINED. — In this section, the term 'chronic condition' has the meaning given such term by the Secretary and, at a minimum, includes the following conditions:

"(1) Heart disease, including congestive heart failure and coronary artery disease.

"(2) Diabetes.

"(3) Osteoporosis and osteopenia.

"(4) Hypertension.

"(5) Asthma.

"(6) Liver disease.

"(7) Bleeding disorders.

"(8) Depression.

"(c) CRITERIA SPECIFIED. — For purposes of subsection (a), the criteria specified in this subsection, with respect to an item or service and a chronic condition, are the following:

"(1) The item or service is low-cost.

"(2) There is medical evidence supporting high-cost efficiency, or a large expected impact, of the item or service in preventing exacerbation of the chronic condition or the development of a secondary condition.

"(3) There is a strong likelihood, documented by clinical evidence, that the item or service will prevent the exacerbation of the chronic condition or the development of a secondary condition that requires significantly higher-cost treatments. "(d) UPDATES. —

"(1) IN GENERAL. — Once every three years, the Secretary shall review and update —

"(A) the list of conditions included within the meaning of the term 'chronic condition' under subsection (b); and

"(B) the items and services determined to meet the criteria specified in subsection (c) for purposes of subsection (a).

"(2) APPLICATION OF UPDATES. — The requirement under subsection (a) shall apply with respect to an update made under paragraph (1) beginning with the first plan year beginning after the date of such update.".

(c) IRC. —

(1) IN GENERAL. — Subchapter B of chapter 100 of subtitle K of the Internal Revenue Code of 1986 is amended by adding at the end the following new section:

"SEC. 9816. COVERAGE OF ADDITIONAL PREVENTIVE CARE FOR INDIVIDUALS WITH CHRONIC CONDITIONS WITHOUT IMPOSITION OF COST SHARING REQUIREMENTS.

"(a) IN GENERAL. — In addition to any item or service described in section 2713(a) of the Public Health Service Act, a group health plan shall, at a minimum, provide coverage for, and shall not impose any cost sharing requirements for, with respect to individuals with chronic conditions (as defined in subsection (b)), such additional preventive care and screenings not described in paragraph (1) of such section 2713(a) that are determined by the Secretary to meet the criteria specified in subsection (c) with respect to the chronic condition involved.

"(b) CHRONIC CONDITION DEFINED. — In this section, the term 'chronic condition' has the meaning given such term by the Secretary and, at a minimum, includes the following conditions:

"(1) Heart disease, including congestive heart failure and coronary artery disease.

"(2) Diabetes.

"(3) Osteoporosis and osteopenia. "(4) Hypertension.

"(5) Asthma.

"(6) Liver disease.

"(7) Bleeding disorders. "(8) Depression.

"(c) CRITERIA SPECIFIED. — For purposes of subsection (a), the criteria specified in this subsection, with respect to an item or service and a chronic condition, are the following:

"(1) The item or service is low-cost.

"(2) There is medical evidence supporting high-cost efficiency, or a large expected impact, of the item or service in preventing exacerbation of the chronic condition or the development of a secondary condition.

"(3) There is a strong likelihood, documented by clinical evidence, that the item or service will prevent the exacerbation of the chronic condition or the development of a secondary condition that requires significantly higher-cost treatments.

"(d) UPDATES. —

"(1) IN GENERAL. — Once every three years, the Secretary shall review and update —

"(A) the list of conditions included within the meaning of the term 'chronic condition' under subsection (b); and

"(B) the items and services determined to meet the criteria specified in subsection (c) for purposes of subsection (a).

"(2) APPLICATION OF UPDATES. — The requirement under subsection (a) shall apply with respect to an update made under paragraph (1) beginning with the first plan year beginning after the date of such update.".

(2) CLERICAL AMENDMENT. — The table of contents for subchapter B of chapter 100 of subtitle K of such Code is amended by adding at the end the following new item:

"9816. Coverage of additional preventive care for individuals with chronic conditions without imposition of cost sharing requirements.".

(3) HIGH DEDUCTIBLE HEALTH PLANS. — Section 223(c)(2)(C) of the Internal Revenue Code of 1986 is amended by inserting "or for additional preventive care for individuals with chronic conditions described in section 9816" before the period.

(d) EFFECTIVE DATE. — The amendments made by this section shall apply with respect to plan years beginning on or after the date that is one year after the date of the enactment of this Act.