Cancer Drug Coverage Parity Act of 2013 - Amends the Employee Retirement Income Security Act of 1974 (ERISA), the Public Health Service Act, and the Internal Revenue Code to require a group or individual health plan providing benefits with respect to anticancer medications administered by a health care provider to provide no less favorable coverage for prescribed, patient-administered anticancer medications used to kill, slow, or prevent the growth of cancerous cells and that have been approved by the Food and Drug Administration (FDA).
Applies such requirement to medication that is prescribed based on a finding by the treating physician that the medication is: (1) medically necessary for the purpose of killing, slowing, or preventing the growth of cancerous cells in accordance with nationally accepted standards of medical practice; and (2) clinically appropriate in terms of type, frequency, extent site, and duration.
Permits such coverage to be subject to the same cost-sharing applicable to anticancer medications administered by a health care provider under the plan.
Prohibits a health plan from imposing an increase in out-of-pocket costs, reclassifying benefits with respect to anticancer medications, or applying more restrictive limitations on prescribed orally- or intravenously-administered or injected anticancer medications.
Requires a plan to provide notice to each participant and beneficiary regarding the coverage required under this Act.
Prohibits a health plan from taking specified actions to avoid the requirements of this Act.
Requires the Medicare Payment Advisory Commission to assess how closing the Medicare part D donut hole affects Medicare coverage for orally-administered anticancer medications, with a particular focus on cost and accessibility.
[Congressional Bills 113th Congress]
[From the U.S. Government Publishing Office]
[H.R. 1801 Introduced in House (IH)]
113th CONGRESS
1st Session
H. R. 1801
To amend the Employee Retirement Income Security Act of 1974, the
Public Health Service Act, and the Internal Revenue Code of 1986 to
require group and individual health insurance coverage and group health
plans to provide for coverage of oral anticancer drugs on terms no less
favorable than the coverage provided for anticancer medications
administered by a health care provider.
_______________________________________________________________________
IN THE HOUSE OF REPRESENTATIVES
April 26, 2013
Mr. Higgins (for himself, Ms. Moore, Ms. Pingree of Maine, Mr.
Cicilline, Mrs. Capps, Mr. Grijalva, Ms. Wilson of Florida, Mr.
Hastings of Florida, Mr. King of New York, Mr. Rangel, Mr. Larsen of
Washington, Mr. McGovern, Mr. Peters of California, Mr. Wolf, Mr.
Moran, and Mr. Farr) introduced the following bill; which was referred
to the Committee on Energy and Commerce, and in addition to the
Committees on Ways and Means and 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 amend the Employee Retirement Income Security Act of 1974, the
Public Health Service Act, and the Internal Revenue Code of 1986 to
require group and individual health insurance coverage and group health
plans to provide for coverage of oral anticancer drugs on terms no less
favorable than the coverage provided for anticancer medications
administered by a health care provider.
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 ``Cancer Drug Coverage Parity Act of
2013''.
SEC. 2. PARITY IN COVERAGE FOR ORAL ANTICANCER DRUGS.
(a) Employee Retirement Income Security Act of 1974 Amendments.--
(1) 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. 716. PARITY IN COVERAGE FOR ORAL ANTICANCER DRUGS.
``(a) In General.--Subject to subsection (b), a group health plan,
and a health insurance issuer providing health insurance coverage in
connection with a group health plan, that provides benefits with
respect to anticancer medications administered by a health care
provider shall provide for no less favorable coverage for prescribed,
patient-administered anticancer medications that are used to kill,
slow, or prevent the growth of cancerous cells and that have been
approved by the Food and Drug Administration.
``(b) Limitation.--Subsection (a) shall only apply to an anticancer
medication that is prescribed based on a finding by the treating
physician that the medication--
``(1) is medically necessary for the purpose of killing,
slowing, or preventing the growth of cancerous cells; or
``(2) is clinically appropriate in terms of type,
frequency, extent site, and duration.
``(c) Application of Cost-Sharing and Restrictions.--
``(1) In general.--The coverage of anticancer medication
under subsection (a) may be subject to annual deductibles and
coinsurance or copayments so long as such deductibles,
coinsurance, and copayments do not exceed the deductibles,
coinsurance, and copayments that are applicable to anticancer
medications administered by a health care provider under the
plan or coverage for the same purpose.
``(2) Restriction.--A group health plan or health insurance
issuer may not, in order to comply with the requirement of
subsection (a)--
``(A) impose an increase in out-of-pocket costs
with respect to anticancer medications;
``(B) reclassify benefits with respect to
anticancer medications; or
``(C) apply more restrictive limitations on
prescribed orally-administered anticancer medications
or intravenously administered or injected anticancer
medications.
``(d) Application of Notice, Prohibitions, etc.--The provisions of
subsections (b), (c), (d), and (e)(2) of section 713 shall apply with
respect to the coverage required by subsection (a) in the same manner
as they apply with respect to the coverage required under such section,
except that January 1, 2014, shall be substituted for the date referred
to in subsection (b)(3) of such section.
``(e) Construction.--Nothing in this section shall be construed--
``(1) to require the use of orally-administered anticancer
medications as a replacement for other anticancer medications;
or
``(2) to prohibit a group health plan or health insurance
issuer from requiring prior authorization or imposing other
appropriate utilization controls in approving coverage for any
chemotherapy.''.
(2) Section 731(c) of such Act (29 U.S.C. 1191(c)) is amended by
striking ``section 711'' and inserting ``sections 711 and 716''.
(3) Section 732(a) of such Act (29 U.S.C. 1191a(a)) is amended by
striking ``section 711'' and inserting ``sections 711 and 716''.
(4) 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:
``Sec. 715. Additional market reforms.
``Sec. 716. Parity in coverage for oral anticancer drugs.''.
(b) Public Health Service Act Amendments.--(1) Title XXVII of the
Public Health Service Act is amended by inserting after section 2728
(42 U.S.C. 300gg-28), as redesignated by section 1001(2) of the Patient
Protection and Affordable Care Act (Public Law 111-148), the following
new section:
``SEC. 2729. PARITY IN COVERAGE FOR ORAL ANTICANCER DRUGS.
``(a) In General.--Subject to subsection (b), a group health plan,
and a health insurance issuer offering health insurance coverage, that
provides benefits with respect to anticancer medications administered
by a health care provider shall provide for no less favorable coverage
for prescribed, patient-administered anticancer medications that are
used to kill, slow, or prevent the growth of cancerous cells and that
have been approved by the Food and Drug Administration.
``(b) Limitation.--Subsection (a) shall only apply to an anticancer
medication that is prescribed based on a finding by the treating
physician that the medication--
``(1) is medically necessary for the purpose of killing,
slowing, or preventing the growth of cancerous cells; or
``(2) is clinically appropriate in terms of type,
frequency, extent site, and duration.
``(c) Application of Cost-Sharing and Restrictions.--
``(1) In general.--The coverage of anticancer medication
under subsection (a) may be subject to annual deductibles and
coinsurance or copayments so long as such deductibles,
coinsurance, and copayments do not exceed the deductibles,
coinsurance, and copayments that are applicable to anticancer
medications administered by a health care provider under the
plan or coverage for the same purpose.
``(2) Restriction.--A group health plan or health insurance
issuer may not, in order to comply with the requirement of
subsection (a)--
``(A) impose an increase in out-of-pocket costs
with respect to anticancer medications;
``(B) reclassify benefits with respect to
anticancer medications; or
``(C) apply more restrictive limitations on
prescribed orally-administered anticancer medications
or intravenously administered or injected anticancer
medications.
``(d) Application of Notice, Prohibitions, etc.--The provisions of
subsections (b), (c), (d), and (e)(2) of section 713 of the Employee
Retirement and Income Security Act of 1974 shall apply with respect to
the coverage required by subsection (a) in the same manner as they
apply with respect to the coverage required under such section, except
that January 1, 2014, shall be substituted for the date referred to in
subsection (b)(3) of such section.
``(e) Construction.--Nothing in this section shall be construed--
``(1) to require the use of orally-administered anticancer
medications as a replacement for other anticancer medications;
or
``(2) to prohibit a group health plan or health insurance
issuer from requiring prior authorization or imposing other
appropriate utilization controls in approving coverage for any
chemotherapy.''.
(2) Section 2724(c) of such Act (42 U.S.C. 300gg-23(c)), as
redesignated by section 1001(4) and subsection (c)(14) of the section
1563 (relating to conforming amendments) of Public Law 111-148, is
amended by striking ``section 2704'' and inserting ``sections 2725 and
2729''.
(3) Section 2762(b)(2) of such Act (42 U.S.C. 300gg-62(b)(2)) is
amended by striking ``section 2751'' and inserting ``sections 2751 and
2729''.
(4) For purposes of applying section 2729 of the Public Health
Service Act, as inserted by paragraph (1), to individual health
insurance coverage before 2014, the provisions of such section shall be
treated as also included under part B of title XXVII of the Public
Health Service Act.
(c) Internal Revenue Code Amendments.--
(1) In general.--Subchapter B of chapter 100 of the
Internal Revenue Code of 1986, as amended by subsection (f) of
the section 1563 (relating to conforming amendments) of Public
Law 111-148, is amended by adding at the end the following new
section:
``SEC. 9816. PARITY IN COVERAGE FOR ORAL ANTICANCER DRUGS.
``(a) In General.--Subject to subsection (b), a group health plan
that provides benefits with respect to anticancer medications
administered by a health care provider shall provide for no less
favorable coverage for prescribed, patient-administered anticancer
medications that are used to kill, slow, or prevent the growth of
cancerous cells and that have been approved by the Food and Drug
Administration.
``(b) Limitation.--Subsection (a) shall only apply to an anticancer
medication that is prescribed based on a finding by the treating
physician that the medication--
``(1) is medically necessary for the purpose of killing,
slowing, or preventing the growth of cancerous cells; or
``(2) is clinically appropriate in terms of type,
frequency, extent site, and duration.
``(c) Application of Cost-Sharing and Restrictions.--
``(1) In general.--The coverage of anticancer medication
under subsection (a) may be subject to annual deductibles and
coinsurance or copayments so long as such deductibles,
coinsurance, and copayments do not exceed the deductibles,
coinsurance, and copayments that are applicable to anticancer
medications administered by a health care provider under the
plan for the same purpose.
``(2) Restriction.--A group health plan may not, in order
to comply with the requirement of subsection (a)--
``(A) impose an increase in out-of-pocket costs
with respect to anticancer medications;
``(B) reclassify benefits with respect to
anticancer medications; or
``(C) apply more restrictive limitations on
prescribed orally-administered anticancer medications
or intravenously administered or injected anticancer
medications.
``(d) Application of Notice, Prohibitions, etc.--The provisions of
subsections (b), (c), (d), and (e)(2) of section 713 of the Employee
Retirement and Income Security Act of 1974 shall apply with respect to
the coverage required by subsection (a) in the same manner as they
apply with respect to the coverage required under such section, except
that January 1, 2014, shall be substituted for the date referred to in
subsection (b)(3) of such section.
``(e) Construction.--Nothing in this section shall be construed--
``(1) to require the use of orally-administered anticancer
medications as a replacement for other anticancer medications;
or
``(2) to prohibit a group health plan or health insurance
issuer from requiring prior authorization or imposing other
appropriate utilization controls in approving coverage for any
chemotherapy.''.
(2) Clerical amendment.--The table of sections for such
subchapter is amended by adding at the end the following new
items:
``Sec. 9815. Additional market reforms.
``Sec. 9816. Parity in coverage for oral anticancer drugs.''.
(d) Clarifying Amendment Regarding Application to Grandfathered
Plans.--Section 1251(a)(4)(A) of the Patient Protection and Affordable
Care Act (Public Law 111-148; 42 U.S.C. 18011(a)(4)(A)), as added by
section 2301(a) of Public Law 111-152, is amended by adding at the end
the following new clause:
``(v) Section 2729, as added by section
2(b) of the Cancer Drug Coverage Parity Act of
2013.''.
(e) 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, 2014, and with respect to health insurance coverage
offered, sold, issued, renewed, in effect, or operated in the
individual market on or after such date.
(f) Study.--Not later than 2 years after the date of the enactment
of this Act--
(1) the Medicare Payment Advisory Commission shall complete
a study that assesses how closing the Medicare part D donut
hole under the amendments made by section 3301 of the Patient
Protection and Affordable Care Act (Public Law 111-148), as
amended by section 1101 of the Health Care and Education
Reconciliation Act of 2010 (Public Law 111-152), affects
Medicare coverage for orally administered anticancer
medications, with a particular focus on cost and accessibility;
and
(2) submit a report to Congress on the results of such
study.
<all>
Introduced in House
Introduced in House
Referred to the Committee on Energy and Commerce, and in addition to the Committees on Ways and Means, and 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.
Referred to the Committee on Energy and Commerce, and in addition to the Committees on Ways and Means, and 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.
Referred to the Committee on Energy and Commerce, and in addition to the Committees on Ways and Means, and 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.
Referred to the Subcommittee on Health.
Referred to the Subcommittee on Health.
Referred to the Subcommittee on Health, Employment, Labor, and Pensions.
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