H.R.5228 - Bipartisan Health Care Reform Act of 1994103rd Congress (1993-1994)
|Sponsor:||Rep. Rowland, J. Roy [D-GA-8] (Introduced 10/06/1994)|
|Committees:||House - Education and Labor; Energy and Commerce; Judiciary; Veterans' Affairs; Ways and Means|
|Latest Action:||House - 11/14/1994 Referred to the Subcommittee on Labor-Management Relations. (All Actions)|
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Summary: H.R.5228 — 103rd Congress (1993-1994)All Information (Except Text)
Introduced in House (10/06/1994)
TABLE OF CONTENTS: Title I: Assuring Availability and Continuity of Health
Subtitle A: Insurance Reforms
Subtitle B: Benefits
Subtitle C: Employer Responsibilities
Subtitle D: Standards and Certification; Enforcement;
Subtitle E: Multiple Employer Health Benefits
Protection and Related Provisions
Subtitle F: Definitions; General Provisions
Title II: Removal of Financial Barriers to Access
Subtitle A: Tax Deductibility for Individuals and Self-
Subtitle B: Premiums and Cost-Sharing Subsidy Program
for Low-Income Individuals
Title III: Medicaid Reforms
Subtitle A: Treatment of Acute Care Benefits for AFDC
and Non-cash Beneficiaries
Subtitle B: Flexibility in Expenditures for
Supplemental Benefits for AFDC and Non-cash
Subtitle C: Increased State Flexibility in Contracting
for Coordinated Care
Subtitle D: Additional Medicaid Reforms
Title IV: Access Improvements
Subtitle A: Expanding Access in Underserved Areas
Subtitle B: Improved Access in Rural Areas
Subtitle C: Academic Health Centers
Subtitle D: United States-Mexico Border Health
Title V: Health Care Quality Enhancement
Subtitle A: Quality Assurance
Subtitle B: Primary Care Provider Education
Title VI: Market Incentives to Containing Costs
Subtitle A: Facilitating Establishment of Health Plan
Purchasing Organization (HPPOs)
Subtitle B: Preemption of State Benefit Mandates and
Anti-Managed Care Laws
Subtitle C: Malpractice Reform
Subtitle D: Administrative Simplification
Subtitle E: Fair Health Information Practices
Subtitle F: Antitrust
Subtitle G: Fraud and Abuse
Subtitle H: Billing for Laboratory Services
Title VII: Medicare
Subtitle A: Increased Beneficiary Choice; Improved
Subtitle B: Savings
Title VIII: Incentives to Purchase Long-Term Care Insurance
Subtitle A: Establishment of Federal Standards for
Long-term Care Insurance
Subtitle B: Tax Treatment of Long-term Care Insurance
Title IX: Department of Veterans Affairs
Title X: Miscellaneous Savings Provisions
Subtitle A: Automobile Insurance Coordination
Subtitle B: Prefunding Government Health Benefits
Bipartisan Health Care Reform Act of 1994 - Title I: Assuring Availability and Continuity of Health Coverage - Subtitle A: Insurance Reform - Part 1: Guaranteed Access to Health Coverage - Requires carriers that offer health insurance coverage in the individual-small group market in a fair rating area to make available qualified standard coverage and high-deductible coverage to qualifying individuals or small employers.
(Sec. 1001) Exempts federally qualified health maintenance organizations (HMOs) and HMOs or managed care organizations recognized by State laws from the requirement to provide high-deductible coverage.
Prohibits the offer of high-deductible coverage unless the carrier also makes standard coverage available with identical benefits and the individual or employee demonstrates that they have available assets equal to at least the deductible amount under the high-deductible coverage.
Requires carriers to provide for coverage of benefits for items and services furnished throughout the fair rating area.
Prohibits carriers from limiting coverage to portions of interstate metropolitan statistical areas (MSAs), requiring them to provide coverage throughout the entire MSA.
Requires coverage offers to include a family coverage option.
Prohibits carriers from requiring employers under group health plans to impose waiting periods for health coverage or require conditions on health coverage based on an individual's: (1) health status; (2) claims experience; (3) receipt of health care; (4) medical history; (5) receipt of public subsidies; or (6) lack of evidence of insurability.
(Sec. 1002) Requires carriers to accept every small employer and qualifying individual that applies for enrollment during the required enrollment period.
Provides that in the case of coverage offered by carriers or under group health plans that provide benefits through a managed care arrangement, the carriers or plans: (1) need not establish health care facilities throughout the fair rating area if the facilities are located in a manner that does not discriminate on the basis of health status of individuals residing in proximity to such facilities; and (2) may deny coverage under certain conditions. Permits carriers to deny coverage if they do not have the necessary financial reserves.
(Sec. 1003) Prohibits carriers from denying, cancelling, or refusing to renew health coverage except on the basis of nonpayment of premiums or fraud or because they are not providing a particular coverage option in the market. Sets limitations on market exit and re-entry by carriers. Establishes similar conditions for cancellation or denial by multiemployer plans and multiple employer health plans.
(Sec. 1004) Prohibits carriers or group health plans from excluding coverage with respect to services provided for preexisting conditions, except as provided by this Act. Provides for exclusion periods of up to six months subject to certain conditions. Makes exclusions inapplicable to pregnancy, newborns, adopted children, and certain individuals enrolled or enrolling during an open enrollment period.
(Sec. 1005) Sets forth provisions regarding enrollment periods.
Part 2: Provision of Benefits - Establishes: (1) standards for managed care arrangements and requirements and utilization review programs; and (2) requirements for arrangements with essential community providers.
(Sec. 1014) Provides for the establishment of medical savings accounts. Makes the account beneficiary the owner of the account and includes distributions not used for qualified medical expenses in the beneficiary's gross income. Sets forth uses and limitations for such accounts.
Excludes: (1) employer contributions to any medical savings account of an eligible employee from gross income (to the extent such contributions do not exceed the excess of premiums for standard coverage over the premiums for high-deductible coverage); and (2) health benefit payments made by employers from employment taxes.
Part 3: Fair Rating Practices - Provides that the premium rate established by carriers for health insurance coverage in the individual-small group market may not vary except by the following: (1) age; (2) geographic area; (3) family class; (4) benefit design of coverage and by type of coverage option; and (5) permitted expense category.
(Sec. 1022) Directs carriers and group health plans to accept and apply premium certificates issued under State premium assistance programs under title XXI of the Social Security Act (as established by this Act).
(Sec. 1023) Requires the Secretary of Health and Human Services to request the National Association of Insurance Commissioners (NAIC) to develop a model risk adjustment system under which premiums applicable to coverage in the individual-small group market and coverage under small employer pooling arrangements and multiple employer welfare arrangements that are fully insured would be adjusted to take into account factors to predict the future need and efficient use of services by covered individuals in the market. Incorporates such model into a rule that specifies risk adjustment mechanisms. Requires each State to develop systems that conform with the Federal model.
Part 4: Consumer Protections - Requires carriers and group health plans to provide information relating to their performance in providing coverage to specified individuals, including prospective enrollees.
(Sec. 1032) Prohibits carriers from varying the commission or other remuneration to a person based on the claims experience or health status of individuals enrolled by or through such person.
Subtitle B: Benefits - Sets forth provisions regarding standard coverage, preventive benefits to be covered without any deductible or cost-sharing, and high-deductible coverage.
(Sec. 1105) Sets forth conditions under which supplemental benefits may be provided.
(Sec. 1106) Requires carriers and group health plans to provide for an option under which children under 26 (without regard to whether they are students or disabled) will be treated as family members. Authorizes additional premiums for such option.
(Sec. 1107) Includes coverage provided by Christian Science practitioners or in a Christian Science sanitorium within benefits under standard coverage.
Subtitle C: Employer Responsibilities - Requires employers to make available to qualifying employees coverage under a group health plan that meets specified requirements, including: (1) an annual offering of coverage; (2) a choice of coverage and family coverage options; (3) an annual enrollment period; and (4) payroll withholding of premiums.
(Sec. 1201) Provides that an employer is not required, subject to provisions regarding an equal contribution rule, to make any contribution to the cost of health coverage.
Makes requirements regarding choice of coverage inapplicable if a group health plan is in effect as of July 1, 1994, and the employer makes contributions on behalf of employees under a collective bargaining agreement or similar contract.
Excludes from this subtitle's requirements certain new and small employers.
(Sec. 1202) Imposes an excise tax for failures of employers to comply with this subtitle.
Subtitle D: Standards and Certification; Enforcement; Preemption; General Provisions - Directs the Secretary to request the NAIC to develop model regulations that specify standards with respect to this subtitle for carriers and health insurance coverage.
(Sec. 1304) Imposes a tax on carriers that fail to comply with Parts 1 through 4 of Subtitle A and Subtitle B of this title unless a State has in effect a regulatory mechanism that provides sanctions.
(Sec. 1305) Prohibits a single employer plan from offering health coverage other than through a carrier unless the plan has at least 100 eligible employees.
Subtitle E: Multiple Employer Health Benefits Protections and Related Provisions - Part 1: Multiple Employer Health Benefits Protections - Amends the Employee Retirement Income Security Act of 1974 (ERISA) to establish certification standards under title I (Protection of Employee Benefit Rights) for multiple employer welfare arrangements (MEWAs) providing health benefits.
(Sec. 1401) Treats as employee welfare benefits plans, and exempts from certain restrictions on preemption, a MEWA which provides benefits consisting solely of specified medical care, which is not fully insured, and which applies for and receives a specified certification.
Requires certain disclosures to participating employers.
Requires certified MEWAs which are not fully insured to maintain excess-stop loss coverage and specified types of reserves.
Sets forth corrective actions which such MEWAs' operating committees must take: (1) to avoid depletion of reserves; or (2) in connection with termination of the MEWA.
Provides for review of actions by the Secretary of Labor with respect to denials of applications for, or suspensions or revocations of, such certifications.
Requires, in cases where coverage is provided under a multiple employer health plan and more than ten percent of the participating employers are small employers, that the arrangement is maintained in the form of a small employer pooling arrangement. Sets forth requirements for such arrangements.
(Sec. 1402) Revises ERISA with respect to: (1) a specified exemption from preemption; (2) treatment of single employer arrangements; and (3) treatment of certain collectively bargained arrangements.
(Sec. 1405) Sets forth ERISA requirements relating to employee leasing health care arrangements (ELHAs). Provides for treatment of ELHAs as MEWAs, with certain exceptions. Sets forth special rules under which an ELHA may receive a MEWA certification.
(Sec. 1408) Allows delegation to a State of some or all of the Secretary's enforcement authority with respect to MEWAs with certifications. Directs the Secretary to provide enforcement and technical assistance to the States with respect to MEWAs.
Part 2: Simplifying Filing of Reports for Employers Covered under Multiple Employer Welfare Arrangements Providing Fully Insured Coverage Consisting of Medical Care - Directs the Secretary to prescribe an alternative method for the filing of a single annual report for all participating employers under MEWAs under which all coverage consists of medical care and is fully insured.
Subtitle F: Definitions; General Provisions - Part 1: Definitions - Sets forth specified definitions.
(Sec. 1905) Makes this title effective for plan years beginning on or after 1997 with respect to group health plans and as of January 1, 1997, with respect to carriers (for coverage other than under a group health plan).
Part 2: Report and Recommendations on Health Coverage and Access - Provides that it is an objective of this Act to assure by 2002 that: (1) all eligible individuals in the United States have access to health coverage; and (2) at least 95 percent of such individuals have such coverage.
(Sec. 1912) Requires the Secretary of Health and Human Services to report to the Congress on the extent to which eligible individuals have, or have access to, health care coverage.
Title II: Removal Of Financial Barriers To Access - Subtitle A: Tax Deductibility for Individuals and Self-Employed - Amends the Internal Revenue Code to: (1) increase on a graduated basis the tax deduction for health insurance costs of self-employed individuals; (2) make the deduction permanent; (3) allow a tax deduction, regardless of whether the taxpayer itemizes other deductions, for health insurance costs of non-self-employed individuals not eligible to participate in any subsidized employer health plan; and (4) subject to taxation certain health benefits provided through cafeteria plans and flexible spending arrangements.
Subtitle B: Premium and Cost-Sharing Subsidy Program for Low-Income Individuals - States that the amendments made by this subtitle and title III below provide for a transition from the current Medicaid system to a new system of acute care low-income assistance.
(Sec. 2101) Amends the Social Security Act (SSA) to add a new title XXI providing for the establishment of new State programs under which, as a requirement for State participation in Medicaid, certain low-income eligible individuals who are not Medicare beneficiaries, SSI recipients, prison inmates, or unlawful aliens will be eligible for premium and cost-sharing assistance for use in obtaining qualifying coverage of the standard and preventive health benefits discussed above under title I of this Act.
Sets forth specific requirements for such programs, allowing waivers in the case of any demonstration project which in the judgment of the Secretary of Health and Human Services is likely to assist in promoting the objectives of new SSA title XXI.
Creates in the Treasury the Health Care Assurance Trust Fund to contain the savings resulting from this Act and other specified amounts for use in paying States operating subsidy and supplemental acute care benefits programs.
Establishes a mechanism for financing such programs that is designed to be deficit neutral.
Prohibits the use of funds appropriated to carry out new SSA title XXI to provide premium or cost-sharing assistance or supplemental acute care benefits under part B added below in connection with any abortion, except in cases where an abortion is necessary to save the life of the mother or where the pregnancy results from rape or incest.
Title III: Medicaid Reforms - Subtitle A: Treatment of Acute Care Benefits for AFDC and Non-Cash Beneficiaries - Amends SSA title XIX (Medicaid) to: (1) establish Medicaid rules for benefits for acute medical services for AFDC recipients and non-cash Medicaid beneficiaries; (2) provide for the division of acute medical service benefits into core benefits and supplemental acute care benefits; (3) limit the amount of Federal financial participation for benefits for acute medical services for AFDC recipient and non-cash Medicaid beneficiaries; (4) condition Federal financial participation on State maintenance-of-effort; and (5) provide for the continuation of State Medicaid eligibility categories.
Subtitle B: Flexibility in Expenditures for Supplemental Benefits for AFDC and Non-Cash Beneficiaries - Amends new SSA title XXI to require each State to establish a State supplemental acute care benefits program.
Subtitle C: Increased State Flexibility in Contracting for Coordinated Care - Amends SSA title XIX to modify Federal requirements to allow States more flexibility in contracting for coordinated care services.
Subtitle D: Additional Medicaid Reforms - Amends SSA title XIX to make various specified changes providing for: (1) a reduction in the amount of payment adjustments for disproportionate share hospitals; (2) elimination of the medically needy program for individuals not in an institution; and (3) elimination of the Medicaid pediatric immunization program, and establishment of alternative delivery programs.
Title IV: Access Improvements - Subtitle A: Expanding Access in Underserved Areas - Amends SSA title XI to provide for community health authorities demonstration projects for providing access to cost-effective preventive and primary care and related services for various areas and populations, including low-income residents of medically underserved areas or for medically underserved populations.
Amends the Public Health Service Act to authorize the Secretary to make grants to migrant and community health centers for the development of health service networks for serving high impact areas, medically underserved areas, or medically underserved populations within the area they serve.
Subtitle B: Improved Access in Rural Areas - Part 1: Grants to Encourage Community Rural Health Networks - Directs the Secretary of Health and Human Services to make grants to an eligible State for the development of plans to increase access to health care services for residents of areas in the State designated as chronically underserved areas. Provides for technical assistance for entities establishing or enhancing a community rural health network in an underserved rural area. Provides financial assistance to entities to provide for the development and implementation of community rural health networks. Authorizes appropriations.
Part 2: Incentives for Health Professionals to Practice in Rural Areas - Subpart A: National Health Service Corps Program - Amends the Internal Revenue Code to exclude National Health Service Corps Loan Repayments from gross income.
(Sec. 4113) Increases the authorization of appropriations for the National Health Service Corps Scholarship and Loan Repayment Programs.
Subpart B: Incentives Under Other Programs - Amends title XVIII (Medicare) of the Social Security Act to provide incentives under such Act to physicians in former shortage areas. Directs the Secretary to develop and publish a model law for adoption by States to increase the access of individuals residing in underserved rural areas to health care services by expanding the services which non-physician health care professionals may provide in such areas.
Part 3: Assistance for Institutional Providers - Subpart A: Community and Migrant Health Centers - Extends and increases the authorizations of appropriations for migrant health centers and community health centers.
Subpart B: Emergency Medical Systems - Revises title XII (Trauma Care) of the Public Health Service Act. Renames such title Emergency Medical and Trauma Care Services. Directs the Secretary to establish the Office of Emergency Medical and Trauma Care Services. Requires the Secretary to: (1) conduct and support research and demonstration projects; (2) foster development of appropriate modern systems of services; (3) assist States; and (4) coordinate and sponsor related activities. Requires that activities meet the unique needs of underserved inner-city and rural areas.
(Sec. 4141) Authorizes grants to States to improve the availability and quality of emergency medical services through the operation of State offices of emergency medical services. Authorizes appropriations for emergency medical services.
(Sec. 4142) Directs the Secretary to make grants to assist States in the creation or enhancement of air medical transport systems that provide victims of medical emergencies in rural areas with access to treatments for injuries resulting from such emergencies. Authorizes appropriations.
Subpart C: Assistance to Rural Providers Under Medicare - Amends title XVIII (Medicare) of the Social Security Act to: (1) increase by two the number of States eligible to participate in the essential access community hospital program; and (2) make other revisions concerning such program, including permitting the participation of hospitals in urban areas and the participation of hospitals in States adjoining participating States. Extends, by three years, the deadline for the development of prospective payment systems for both inpatient and outpatient rural primary care hospital services.
(Sec. 4152) Defines a rural emergency access care hospital and rural emergency access care hospital services for purposes of title XVIII. Provides for the coverage of such services under part B (Supplementary Medical Insurance) of title XVIII.
Subpart D: Demonstration Projects to Encourage Primary Care and Rural-Based Graduate Medical Education - Directs the Secretary to establish and conduct a demonstration project to increase the number and percentage of medical students entering primary care practice. Authorizes appropriations.
Part 4: Hospital Affiliated Primary Care Center - Requires the Secretary to make grants and provide technical assistance to community hospitals for the development and operation of primary care services in medically underserved areas. Provides for a plan to allow primary care centers to retain income earned from operation under certain conditions. Authorizes appropriations.
Subtitle C: Academic Health Centers - Directs the Secretary to study and report to the Congress on: (1) the feasibility and desirability of making payments to facilities that are not hospitals for the costs of graduate medical education attributable to residents trained at such facilities; and (2) determining the funding needs of health professions schools.
Subtitle D: United States-Mexico Border Health Commission - Authorizes the President to conclude an agreement with Mexico to establish a binational commission to be known as the United States-Mexico Border Health Commission.
(Sec. 4302) Declares that it should be the duty of the Commission to: (1) conduct a needs assessment in the U.S.-Mexican border area to identify and resolve health problems that affect the general population of the area; and (2) formulate recommendations for a fair method by which the government of one country could reimburse a public or private entity in the other country for the cost of a health care service furnished to a citizen of the first country who is unable to pay for the service.
States that the Commission should establish at least two regional border offices in selected locations.
Title V: Health Care Quality Enhancement - Subtitle A: Quality Assurance - Directs the Secretary to establish a Health Quality Advisory Council to develop an initial set of quality measures to be used to assess the quality of carriers, group health plans, and multiple employer welfare arrangements. Provides for auditing of such entities to determine compliance with certain quality measure and reporting requirements.
Subtitle B: Primary Care Provider Education - Amends the Public Health Service Act to extend through FY 1999 authorized funding for training for certain health service providers.
Title VI: Market Incentives to Containing Costs - Subtitle A: Facilitating Establishment of Health Plan Purchasing Organization (HPPOs) - Part 1: Health Plan Purchasing Organizations - Authorizes the establishment of health plan purchasing organizations (HPPOs) in accordance with this part.
(Sec. 6002) Requires HPPOs to enter into agreements with carriers that desire to make health coverage available through HPPOs.
(Sec. 6004) Requires HPPOs to offer enrollment for coverage for carriers. Authorizes HPPOs to impose administrative fees for enrollment.
(Sec. 6006) Requires States to: (1) review the access of residents who are not employees of large employers or Medicare beneficiaries to obtain standard health insurance coverage through an HPPO; and (2) take actions to ensure that public or private entities provide access to residents who are unable to obtain such coverage.
Part 2: Encouragement of Multiple Employer Arrangements Providing Basic Health Benefits - Amends the Internal Revenue Code to eliminate the commonality of interest or geographic location requirement for tax exempt trust status for certified multiple employer health plans, fully-insured multiple employer welfare arrangements, and other specified plans described by ERISA.
Part 3: Tax Exemption for High Risk Pools - Provides tax-exempt status to corporations or similar legal entities created by States or political subdivisions to establish risk pools to provide health insurance coverage to persons unable to obtain such insurance because of health conditions.
Subtitle B: Preemption of State Benefit Mandates and Anti-Managed Care Laws - Preempts State laws that: (1) mandate health insurance benefits; (2) restrict managed care arrangements and utilization review programs; and (3) prohibit two or more employers from obtaining coverage that is fully-insured under multiple employer health plans.
(Sec. 6105) Prohibits States from enforcing standards for health insurance coverage that differ from those established under title I of this Act.
(Sec. 6106) Directs the Comptroller General to study and report to the Congress on the benefits and cost effectiveness of the use of managed care in the delivery of health care services.
Subtitle C: Malpractice Reform - Part 1: Uniform Standards for Malpractice Claims - Makes this part applicable to any medical malpractice liability action brought in a Federal or State court and to any medical malpractice claim subject to an alternative dispute resolution (ADR) system that is initiated on or after January 1, 1996.
(Sec. 6202) Prohibits a medical malpractice liability action from being brought in any State court during a calendar year unless the relevant claim has been initially resolved (i.e., a decision has been reached on whether the defendant is liable to the plaintiff for damages and on the amount of damages) under a certified ADR system or an alternative Federal system.
Prohibits a medical malpractice liability action from being brought in Federal court based on diversity of citizenship during a calendar year unless the relevant claim has been initially resolved under such a system in the State whose law applies.
Directs the Attorney General to establish an ADR process for tort claims consisting of medical malpractice liability claims brought against the United States. Prohibits a medical malpractice liability action based on such a claim from being brought in any Federal court unless the claim has been initially resolved under such process.
Sets forth procedures for filing actions.
(Sec. 6203) Authorizes States to develop specialty clinical practice guidelines to be certified by the Secretary.
(Sec. 6204) Limits to $250,000 the amount of noneconomic damages that may be awarded to a claimant and family members in a medical malpractice liability action.
(Sec. 6206) Sets forth provisions regarding: (1) limits on attorney fees and other costs; and (2) statutes of limitations.
(Sec. 6208) Specifies that in the case of a medical malpractice claim relating to services provided during labor or the delivery of a baby, if the health care professional or provider did not previously treat the claimant for the pregnancy, the trier of fact may not find that the defendant committed malpractice nor assess damages unless the malpractice is proven by clear and convincing evidence.
(Sec. 6210) Provides that this part preempts State law, except for State law that imposes greater restrictions than those provided in this part.
Part 2: Requirements for State Alternative Dispute Resolution Systems (ADR) - Lists requirements for State ADR systems, including that such a system: (1) applies to all medical malpractice liability claims under the jurisdiction of the courts of that State; (2) requires that a written opinion resolving the dispute be issued within six months after each party against whom the claim is filed has received notice of the claim; (3) is approved by the State or local governments; (4) provides for the transmittal to the State agency responsible for monitoring or disciplining health care professionals and providers of any findings of malpractice; and (5) provides for the regular transmittal of information on disputes resolved under the system to the Administrator for Health Care Policy and Research in a manner that protects the identity of the parties involved.
(Sec. 6222) Directs the Secretary to certify State ADR systems that meet such requirements on an annual basis.
Requires the Secretary to establish an alternative Federal ADR system for the resolution of medical malpractice liability claims in States that do not have in effect a certified ADR system.
(Sec. 6223) Directs the Secretary to submit to the Congress a report describing and evaluating State ADR systems and the alternative Federal system.
Part 3: Definitions - Sets forth definitions for this subtitle.
Subtitle D: Administrative Simplification - Part 1: Standards for Data Elements and Transactions - Directs the Secretary to adopt standards for: (1) the electronic transmission of health information data; and (2) information transactions.
Part 2: Requirements with Respect to Certain Transactions and Information - Lists transactions to be considered as standard transactions with respect to plan sponsors and HPPOs.
(Sec. 6322) Requires certified health information security organizations to make available to Federal or State agencies, pursuant to a cost-type contract, any non-identifiable health information that is held by the service, consists of data elements that are subject to a standard under part 1, and is requested by such an agency to fulfill a requirement under this Act.
(Sec. 6323) Directs the Secretary to establish a procedure under which a plan sponsor or health provider that does not have the ability to transmit standard data elements and does not have access to a certified health information network may comply with this part.
Part 3: Miscellaneous Provisions - Requires the Secretary to establish standards and a certification procedure for health information network services.
(Sec. 6333) Provides that this subtitle supersedes State law. Prohibits the enforcement of any State law that requires medical or health plan records to be maintained or transmitted in written rather than electronic form, except as provided by the Secretary.
(Sec. 6334) Authorizes the Secretary to make grants for demonstration projects to promote the development and use of electronically integrated community-based clinical information systems and computerized patient medical records.
Part 4: Assistance to the Secretary - Establishes the Health Care Information Advisory Committee to: (1) provide assistance to the Secretary in complying with the requirements imposed on the Secretary under this subtitle and subtitle E; (2) be responsible for advising the Secretary and the Congress on the status of the health information network; and (3) make recommendations to correct any problems that may occur in the network's implementation and operations and to refine and improve the network.
Subtitle E: Fair Health Information Practices - Part 1: Duties of Health Information Trustees - Sets forth rights of individuals with respect to inspection of protected health information maintained by a health information trustee (specified entities, including health care providers, health benefit plan sponsors, and public health authorities). Makes exceptions to inspection rights if: (1) the information relates to mental health treatment notes or persons other than the protected individual; (2) the inspection could be expected to threaten an individual's life or personal safety; (3) the information could lead to the identification of a confidential source; (4) the information is used solely for administrative purposes or is duplicative; or (5) the information is compiled principally in anticipation of a legal proceeding.
(Sec. 6402) Sets forth conditions under which a trustee must correct or amend information at the request of a protected individual.
(Sec. 6404) Provides for: (1) recordkeeping with respect to health information disclosures; and (2) safeguards to ensure confidentiality and protection of information.
Part 2: Use and Disclosure of Protected Health Information - Permits a health information trustee to use protected health information only for a purpose that is compatible with and related to the purpose for which the information was collected or received or for which the trustee is authorized to disclose under this subtitle.
(Sec. 6411) Limits the use or disclosure of protected health information by a health information trustee to the minimum amount of information necessary.
(Sec. 6412) Authorizes a health information trustee to disclose protected health information pursuant to an authorization executed by the individual who is the subject of the information if specified requirements are met.
(Sec. 6413) Authorizes the disclosure of protected health information, subject to specified restrictions: (1) in connection with treatment and payment; or (2) for use in an action against or investigation of an individual relating to receipt of or payment for health care.
(Sec. 6414) Sets forth provisions regarding the disclosure of protected health information to next of kin and others.
(Sec. 6415) Establishes requirements with respect to the reporting of protected health information: (1) to a public health authority; (2) for a health research project; (3) in emergency circumstances; (4) for judicial and administrative purposes; (5) to a law enforcement agency; (6) pursuant to subpoena or warrant; and (7) to a health information service organization.
Part 3: Access Procedures and Challenge Rights - Sets forth access procedures and challenge rights with respect to attempts to obtain protected health information.
Part 4: Miscellaneous Provisions - Provides that if a protected individual pays a health information trustee for health care by presenting a debit, credit, or other payment card or by other electronic means, the trustee may only disclose protected health information as is necessary for the processing of the payment transaction.
(Sec. 6442) Sets forth conditions under which protected health information may be released to persons outside the United States.
(Sec. 6443) Directs the Secretary to establish standards with respect to the creation, transmission, receipt, and maintenance, in electronic and magnetic form, of documents required or authorized under this subtitle.
(Sec. 6444) Sets forth duties of affiliated persons to whom health information trustees are authorized to provide protected health information.
(Sec. 6445) Sets forth the rights of persons acting as agents or attorneys of protected individuals or on behalf of minors.
Part 5: Enforcement - Authorizes persons whose rights under this subtitle have been knowingly or negligently violated to maintain civil actions. Sets forth penalty provisions.
(Sec. 6453) Directs the Secretary to develop alternative dispute resolution methods for use by individuals, health information trustees, and others in resolving claims made in civil actions.
(Sec. 6454) Amends the Federal criminal code to provide penalties for offenses related to protected health information.
Part 6: Amendments to Title 5, United States Code - Requires Federal agencies that are health information trustees to promulgate rules to exempt systems of records within such agencies, to the extent that such systems contain protected health information, from certain provisions regarding access and other requirements with respect to an individual's records.
Part 7: Regulations, Research, and Education; Effective Dates; Applicability; and Relationship to Other Laws - Directs the Secretary to prescribe regulations to carry out this subtitle.
(Sec. 6471) Authorizes the Secretary to sponsor: (1) research relating to the privacy and security of protected health information; (2) the development of consent forms governing the disclosure of such information; and (3) the development of technology to implement standards regarding such information.
Directs the Secretary to establish education and awareness programs to: (1) foster security practices by health information trustees; (2) train personnel of health information trustees respecting their duties with respect to such information; and (3) inform individuals and employers who purchase health care respecting their rights with respect to such information.
(Sec. 6474) Prohibits States from enforcing any law that is inconsistent with certain requirements of this subtitle or imposes additional requirements with respect to health information trustees.
Subtitle F: Antitrust - Directs the Attorney General to: (1) provide for the development of guidelines on the application of antitrust laws to the activities of health plans; and (2) establish a review process under which a health plan may request the Department of Justice's opinion on the plan's conformity with the Federal antitrust laws.
(Sec. 6502) Requires the Attorney General to issue a certificate of public advantage to each eligible health care collaborative activity that complies with this section's requirements. Provides that such activity shall not be liable under the antitrust laws for conduct described in the certificate if such conduct occurs while the certificate is in effect. Directs the Attorney General to issue such a certificate if: (1) the benefits that are likely to result from the activity outweigh the reduction in competition that is likely to result; and (2) such reduction is necessary to obtain such benefits.
Sets forth activity eligibility requirements.
(Sec. 6503) Directs the Attorney General to report annually to the Congress as part of the annual budget oversight proceedings concerning the Antitrust Division of the Department of Justice. Requires the report to enable the Congress to determine how enforcement of antitrust laws is affecting the formation of efficient, cost-saving joint ventures and if the certificate of public advantage procedure has resulted in undesirable reduction in competition in the health care marketplace.
Subtitle G: Fraud and Abuse - Directs the Attorney General to establish a program to: (1) coordinate Federal, State, and local law enforcement programs to control fraud and abuse with respect to the delivery of and payment for health care in the United States; (2) conduct investigations, audits, evaluations, and inspections relating to the delivery of and payment for health care in the United States; and (3) facilitate the enforcement of certain SSA title XI mandatory exclusion and other provisions applicable to health care fraud and abuse.
Requires the Attorney General in carrying out such program to provide for coordination with law enforcement agencies, State Medicaid Fraud Control Units, State licensing agencies, as well as with third party insurers.
(Sec. 6602) Authorizes additional appropriations for the Attorney General to investigate allegations of health care fraud and otherwise carry out the program established above.
(Sec. 6603) Creates in the Treasury the Anti-Fraud and Abuse Trust Fund consisting of Federal health anti-fraud and abuse penalties for use in: (1) carrying out the program above; (2) supporting educational activities to prevent the occurrence of violations of anti-fraud and abuse laws; and (3) repaying beneficiaries for cost- sharing.
(Sec. 6611) Amends SSA title XI to revise current sanctions for health care fraud and abuse, among other changes, providing for: (1) mandatory exclusion from participation in Medicare and State health care programs of any individuals convicted of a felony relating to fraud or the unlawful manufacture, distribution, prescription, or dispensing of a controlled substance; and (2) establishment of a minimum period of exclusion for certain individuals and entities subject to permissive exclusion from Medicare and State health care programs.
(Sec. 6615) Amends SSA title XVIII to modify the limitations on physician self-referral.
(Sec. 6616) Directs the Comptroller General to study and report to the Congress on the costs incurred by eligible organizations with risk-sharing contracts of complying with the requirement of entering into a written agreement with an entity providing peer review services with respect to services provided by the organization.
(Sec. 6621) Amends the Federal criminal code to provide for: (1) penalties for health care fraud, including making it a felony; (2) rewards for information leading to prosecution relating to health care fraud; and (3) broadened application of mail fraud statute provisions.
(Sec. 6631) Amends SSA titles XI and XVIII to authorize the issuance of advisory opinions by the Secretary according to specified guidelines.
(Sec. 6641) Requires each State to establish and maintain a State agency to act as a Health Care Fraud and Abuse Control Unit for: (1) investigating and prosecuting violations under any Federally-funded or mandated health care program relating to fraud under State laws; (2) reviewing complaints of abuse or neglect involving patients of facilities receiving Federal payments and, where appropriate, investigate and prosecute such complaints; and (3) providing for the collection, or referral for collection, of overpayments made under any such program and found by the Unit.
Subtitle H: Billing for Laboratory Services - Amends the Public Health Service Act to make it unlawful for any person who furnishes ancillary health services to present a bill or demand for payment to any person other than the patient receiving such services, with specified exceptions. Exempts ancillary health services for which payment may be made under Medicare.
(Sec. 6701) Defines "ancillary health services" as clinical laboratory services, diagnostic x-rays and other diagnostic tests, durable medical equipment, and physical therapy services.
Sets forth conditions under which a person who furnishes ancillary health services may present a bill or demand for payment to specified entities other than the patient.
Imposes civil penalties for repeated and knowing demands for payment in violation of this subtitle. Provides for other sanctions for such violations, including the suspension of laboratory certifications and exclusion from participation in Medicare programs.
Title VII: Medicare - Subtitle A: Increased Beneficiary Choice; Improved Program Efficiency - Amends SSA title XVIII to revise provisions for payments to health maintenance organizations (HMOs) to: (1) provide for the use of metropolitan statistical areas to determine adjusted average per capita cost; (2) require the Secretary to develop additional specified model packages of health benefits providing coverage for catastrophic illness, prescription drugs, and preventive services which an HMO may provide at its option; and (3) make various specified changes in HMO membership requirements, including changes in associated waiver provisions, and enrollment periods.
(Sec. 7002) Amends the Omnibus Budget Reconciliation Act of 1990 to permit Medicare supplemental policies in all States.
Modifies Medicare supplemental policy provisions.
(Sec. 7003) Includes notice of available HMOs and carriers offering Medicare supplemental policies in the annual notice of Medicare benefits mailed to Medicare beneficiaries.
(Sec. 7004) Directs the Secretary to: (1) develop and submit to the Congress a proposal for legislation which provides for the voluntary enrollment of Medicare beneficiaries in private health insurance plans; (2) provide for a monthly payment to a qualified private health insurance plan on behalf of enrolled Medicare beneficiaries who choose to enroll in such a plan (with the enrollee paying any difference between the monthly premium charged under the plan and the amount paid for under Medicare for the enrollee's class, while maintaining budget-neutrality); and (3) take such steps as may be necessary to consolidate the administration of Medicare parts A (Hospital Insurance) and B (Supplementary Medical Insurance).
(Sec. 7003) Includes notice of an individual's rights under State law with regard to the formulation of advance directives in the annual notice of Medicare benefits mailed to Medicare beneficiaries.
Subtitle B: Savings - Amends Medicare provisions relating to Medicare part A to provide for reductions in: (1) the update for payments for inpatient hospital services; and (2) payments for capital-related costs for inpatient hospital services.
(Sec. 7111) Amends Medicare part B provisions on payment for physicians' services to provide for: (1) use of cumulative performance standards; (2) treatment of default update; (3) use of real GDP to adjust for volume and intensity; (4) repeal of restriction on maximum reduction under conversion factor update adjustment provisions; and (5) reduction in the conversion factor for the physician fee schedule for 1995.
(Sec. 7112) Provides for the imposition of coinsurance on laboratory services.
(Sec. 7113) Amends the Internal Revenue Code to provide for an increase in the Medicare part B premiums for high-income individuals.
(Sec. 7114) Amends Medicare to provide for: (1) the extension of the 25 percent part B premium; (2) a reduction in hospital outpatient services and home health services through the establishment of a prospective payment system; and (3) various specified changes with regard to Medicare as secondary payer.
Title VIII: Incentives to Purchase Long-Term Care Insurance - Subtitle A: Establishment of Federal Standards for Long-Term Care Insurance - Amends SSA to provide for model standards incorporating specified requirements for sales practices, benefits, and other matters that long-term care insurance policies must meet. Establishes civil monetary penalties for violations.
Requires the National Association of Insurance Commissioners to issue guidelines for endorsements of long-term care insurance policies, or that permit such policies to be offered for sale through the organization or association.
Subtitle B: Tax Treatment of Long-Term Care Insurance - Amends the Internal Revenue Code to provide for the treatment of long-term care insurance contracts as accident or health insurance contracts generally, with qualified long-term services treated as medical care, among other changes with regard to long-term care insurance.
Subtitle C: Studies - Requires the Comptroller General to conduct a study on the feasibility of: (1) encouraging health care providers to donate their services to homebound patients; and (2) providing heads of households who care for elderly family members in their homes with a tax credit.
(Sec. 8203) Directs the Secretary to conduct a study and report to the Congress on: (1) case management of current long-term care benefits; and (2) subacute care.
Title IX: Department of Veterans Affairs - Authorizes each veteran residing in the United States, certain surviving spouses and children of such veterans (also living in the United States) who are not otherwise eligible for medical care under the Civilian Health and Medical Program of the Uniformed Services (CHAMPUS), and family members thereof to be enrolled with a Department of Veterans Affairs (VA) health care plan. Requires the payment of appropriate premiums, deductibles, copayments, or coinsurance with respect to such family members. Continues the eligibility of family members after the death of the veteran originally enrolled. Directs the Secretary of Veterans Affairs (Secretary, for purposes of this title) to establish enrollment ceilings to limit the number of eligible individuals enrolling for such coverage. Requires conformity of such plans with health plan requirements set forth in this Act and inclusion of all the items and services in the standard coverage under this Act. Directs the Secretary to continue to provide to veterans authorized VA care and services which are not included in the standard coverage provided under this Act. Provides for the continuation in the VA of specialized disabled veteran treatment and rehabilitative needs and facilities and requires a report on such continuation from the Secretary to specified congressional committees.
Allows such plans to offer supplemental health benefits and cost-sharing policies consistent with this Act. Provides a limitation with regard to veterans who elect not to enroll to obtain such coverage. Prohibits the imposition of a cost-share charge of any kind upon a veteran for the treatment of a service-connected disability that requires specialized treatment by the VA. Prohibits funds appropriated to carry out this title from being used to provide abortions except when necessary to save the life of the mother or when the pregnancy is the result of rape or incest.
Prohibits the imposition of cost-sharing charges of any kind upon veterans who are disabled to a degree of ten percent or more, veterans released from service due to a service-connected disability, veterans receiving disability compensation from the VA, former prisoners of war, veterans of the Mexican border period or World War I, and veterans unable to defray the costs of such care. Directs the Secretary to establish rates for premiums and other applicable charges with respect to all other enrollees. Empowers the Secretary to recover from third parties the cost of providing such care and services if such care and services would have been required to be provided by such third party.
Establishes in the Treasury the Department of Veterans Affairs Health Coverage Fund to be used for VA health plan payments and services. Preserves existing health care benefits for facilities not offering qualified health coverage under this Act.
Authorizes the Secretary to organize VA health plans and facilities as plans and facilities offering qualified health coverage under this Act. Requires any health insurance program provided for Federal employees to include as an option enrollment to obtain VA coverage. Requires the Secretary to take appropriate steps to ensure the financial solvency and stability of the VA coverage and of the contractors and subcontractors providing services as part of such coverage. Preempts certain State action with respect to standards and requirements of such coverage.
Requires VA health care facilities to serve as providers to individuals residing in a State that operates as a single payer system, with appropriate reimbursement. Authorizes the head official offering VA health coverage or the director of a VA health care facility to enter into agreements with health care plans, insurers, health care providers, and other entities to furnish or obtain any health-care resource. Provides certain other administrative and personnel flexibility to the Secretary in providing or obtaining such services.
Directs the Secretary of the Treasury to: (1) credit to a special fund specified amounts for FY 1995 and 1996 to be used for providing VA health coverage under this Act; and (2) report to the Congress on the operation of the VA health care system with respect to national health care reform as set forth under this Act. Authorizes the Secretary to apply for and accept grants and other forms of assistance to meet the needs of special populations.
(Sec. 9003) Makes veterans enrolled with a VA plan under this title eligible for nursing home care, outpatient care, and care provided to obviate the need for hospital admission.
(Sec. 9004) Makes any herbicide-exposed veteran eligible for hospital and nursing home care for any disease for which the National Academy of Sciences has determined: (1) that there is a positive association between disease occurrence and herbicide exposure; (2) that there is evidence suggesting such an association, though the evidence is limited; or (3) that available studies are insufficient to permit a conclusion about the presence or absence of such an association. Limits the authorized length of such care for eligible veterans.
(Sec. 9005) Extends the authority to provide priority outpatient health care to veterans for exposure to environmental hazards until October 1, 1998, for any disability which becomes manifest before October 1, 1996.
(Sec. 9006) Directs the Secretary to report to the Congress on the desirability and feasibility of waiving any requirement for cost-sharing under a VA health plan in the case of medical care provided to a family member of a Persian Gulf War veteran for any disease or disability which may be related to such service.
(Sec. 9007) Directs the Secretary, during FY 1995 through 1997, to carry out and report to specified congressional committees on a study of the effect of telemedicine on the delivery of VA health care services.
(Sec. 9008) Directs the Secretary of Health and Human Services to develop and submit to the Congress a proposal for legislation which provides for obtaining VA health coverage for Medicare beneficiaries who are veterans.
(Sec. 9009) Directs the Secretary to carry out a pilot program to reduce waiting times for patients seeking health-care services in VA outpatient clinics and the traveling distance to such clinics by providing for operation of approximately 20 new outpatient clinics around two VA medical centers. Authorizes appropriations for FY 1998 through 2004.
Title X: Miscellaneous Savings Provisions - Subtitle A: Automobile Insurance Coordination - Requires individuals enrolled in a health plan to receive automobile insurance medical services exclusively through the health plan. Makes such services subject to all quality, cost containment, and anti-fraud and abuse provisions that apply generally to medical services provided by or through health plans.
(Sec. 10002) Permits an individual and an automobile insurance carrier to agree that treatment for bodily injury sustained in an automobile accident shall be provided by other than the health plan through which such individual is enrolled. Authorizes States to require such carriers to make direct payment to health care providers for automobile insurance medical services that are covered by Medicare or Medicaid and an automobile insurance contract that provides for direct payment of medical services regardless of fault.
(Sec. 10003) Requires carriers liable for payment for automobile insurance medical services to make payment to health plans to the extent of obligations under the contract. Grants federally funded health care plans first priority to receive payment pursuant to any obligation under an automobile insurance policy covering such medical services.
(Sec. 10004) Directs States to establish systems for prompt payment for automobile insurance medical services by such carriers to health plans, including mechanisms for resolution of disputes. Requires sanctions to be prescribed for failures to comply with this subtitle's requirements.
(Sec. 10005) Requires the Secretary of Health and Human Services to provide for allotments to States for administrative expenses in carrying out this subtitle.
Subtitle B: Prefunding Government Health Benefits Contributions - Directs each Federal agency within the executive branch whose receipts and disbursements are not generally included in the totals of the Government budget submitted by the President, effective FY 1994 (or February 1, 1995, in the case of the agency with the greatest number of employees), to prepay the Government contributions which will be required in connection with providing health-benefits coverage for annuitants of such agency.