H.R.5300 - Affordable Health Care Now Act of 1994103rd Congress (1993-1994)
|Sponsor:||Rep. Michel, Robert H. [R-IL-18] (Introduced 11/29/1994)|
|Committees:||House - Education and Labor; Energy and Commerce; Judiciary; Ways and Means|
|Latest Action:||House - 12/15/1994 Referred to the Subcommittee on Health and the Environment. (All Actions)|
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Summary: H.R.5300 — 103rd Congress (1993-1994)All Information (Except Text)
Introduced in House (11/29/1994)
TABLE OF CONTENTS:
Title I: Improved Access to Affordable Health Care
Subtitle A: Increased Availability and Continuity of
Health Coverage for Individuals and Their Families
Subtitle B: Reform of Health Insurance
Subtitle C: Preemption Subtitle D: Health Deduction Fairness
Subtitle E: Improved Access to Community Health
Subtitle F: Improved Access to Rural Health Services
Subtitle G: Assistance in Enrolling Uninsured Children
in Health Insurance
Subtitle H: Medicaid Reform
Subtitle I: Remedies and Enforcement with Respect to
Group Health Plans
Subtitle J: Delivery of Health Care Services to Illegal
Title II: Health Care Cost Containment and Quality
Subtitle A: Medical Malpractice Liability Reform
Subtitle B: Administrative Cost Savings and Fair Health
Subtitle C: Deduction for Cost of Catastrophic Health
Plan; Medical Savings Accounts
Subtitle D: Anti-Fraud
Subtitle E: Increased Medicare Beneficiary Choice;
Additional Medicare Reforms
Subtitle F: Health Care Antitrust Improvements
Subtitle G: Encouraging Enforcement Activities of
Medical Self-Regulatory Entities
Subtitle H: Reform of Clinical Laboratory Requirements
for Simple Tests
Subtitle I: Miscellaneous Provisions
Title II: Long-Term Care
Subtitle A: Tax Treatment of Long-Term Care Insurance
Subtitle B: Establishment of Federal Standards for
Long-Term Care Insurance
Subtitle C: Protection of Assets Under Medicaid Through
Use of Qualified Long-term Care Insurance
Subtitle D: Studies
Subtitle E: Volunteer Service Credit Demonstration
Affordable Health Care Now Act of 1994 - Title I: Improved Access to Affordable Health Care - Subtitle A: Increased Availability and Continuity of Health Coverage for Individuals and Their Families - Part 1: Required Coverage Options for Eligible Employees, Spouses, and Dependents - Requires each employer to make available to each eligible employee a group health plan under which: (1) coverage of each eligible individual with respect to such employee may be elected on an annual basis; (2) coverage is provided for at least the required coverage specified; and (3) employees may elect to have premiums collected through payroll deduction. Does not require employer contributions to the cost of coverage under such a plan.
Provides for the exclusion of: (1) employers who have been employers for less than two years or who have no more than two eligible employees or no more than two eligible employees not covered under any group health plan; and (2) family members under specified circumstances. Specifies that a group health plan shall not be treated as failing to meet the requirements of this Act solely because a period of service by an eligible employee of not more than 60 days is required for coverage.
Specifies that the required coverage is standard coverage, except that in the case of a small employer that has not contributed during the previous plan year to the cost of coverage for any eligible employee under any group health plan, the required coverage for the plan year is coverage under a MedAccess standard, MedAccess catastrophic, and MedAccess medisave plan. Requires standard coverage to include at least one option, either a fee-for-service option and if available, a point-of-service option and a managed care option.
Provides for a five-year transition for existing group health plans.
(Sec. 1002) Sets forth provisions regarding: (1) compliance with applicable requirements through multiple employer health arrangements; and (2) coverage options under a State medical health allowance program.
Part 2: Portability and Nondiscrimination - Prohibits a group health plan from imposing (and an insurer from requiring an employer from imposing through a waiting period for coverage under a plan or similar requirement) a limitation or exclusion of benefits relating to treatment of a preexisting condition if: (1) the condition relates to a condition that was not diagnosed or treated within three months before the date of coverage under the plan; (2) the limitation or exclusion extends over more than six months after the date of coverage, applies to an individual who, as of the date of birth, was covered under the plan, or relates to pregnancy; or (3) an eligible individual has such coverage at the time the individual first became eligible. Specifies that, in the case of an individual who is eligible for coverage under a plan but for a waiting period imposed by the employer, the individual shall be treated as having been covered under the plan as of the earliest date of the beginning of the waiting period. Provides a one-time amnesty period for pre-existing condition exclusions.
(Sec. 1012) Requires each group health plan to waive any period applicable to a preexisting condition for similar benefits with respect to an individual to the extent that the individual, prior to enrollment in such plan, was covered for the condition under any other health plan.
(Sec. 1013) Prohibits: (1) a multiemployer plan and an exempted multiple employer health plan from canceling or denying renewal of coverage under such a plan for an employer other than for nonpayment of contributions, fraud or other misrepresentation, noncompliance with plan provisions, or because the plan is ceasing to provide any coverage in a geographic area; (2) an insurer from canceling a health insurance plan or denying renewal of coverage other than as prescribed above; and (3) an insurer who terminates the offering of health insurance plans in an area from offering such a plan to any employer in the area until five years after the date of the termination.
Part 3: Standards for Managed Care Arrangements and Essential Community Providers - Sets forth requirements for group health plans and insurers that provide health care coverage through managed care arrangements. Requires such arrangements to assure that covered individuals have reasonably prompt access through the entity's provider network to the benefits package and to centers of excellence.
(Sec. 1022) Requires the Secretary of Health and Human Services (Secretary) to establish standards for utilization review programs and periodically review and update such standards to reflect changes in the delivery of health care services.
Part 4: Enforcement; Effective Dates; Definitions - Makes provisions of the Employee Retirement Income Security Act of 1974 applicable with respect to enforcement of this Act (by the Department of Labor).
Amends the Internal Revenue Code (Code) to impose a tax ($100 per day for each individual involved, subject to specified limitations) on the failure of an insurer to comply with the requirements under part 2, unless the Secretary determines that the State has in effect a regulatory enforcement mechanism that provides adequate sanctions.
Subtitle B: Reform of Health Insurance - Part I: Marketplace for Small Business - Requires each insurer that makes available a health insurance plan to a small employer in a State to make available to each small employer in the State a MedAccess standard, MedAccess catastrophic, and MedAccess medisave plan, with exceptions for health maintenance organizations (HMOs) and if a State provides for guaranteed availability (rather than guaranteed issue).
Requires each insurer that offers a MedAccess plan to a small employer in a State to accept: (1) every small employer in the State that applies for coverage; and (2) every eligible individual who applies for enrollment on a timely basis. Sets forth provisions regarding: (1) special rules for HMOs; (2) timely enrollment requirements; and (3) enrollment of spouses and dependents. Makes such requirements inapplicable in a State that has provided (in accordance with specified standards) a mechanism under which each insurer offering a health insurance plan to a small employer in the State must participate in a program for assigning high-risk small employer groups (or individuals within such a group) among some or all such insurers, if the insurers comply.
(Sec. 1102) Defines "MedAccess coverage" as a health insurance plan that: (1) is designed to provide standard coverage with substantial cost-sharing, only catastrophic coverage, or medisave coverage; (2) includes only essential and medically necessary services; (3) meets applicable requirements relating to guaranteed issue; and (4) meets specifies consumer protection standards. Defines "MedAccess standard coverage," "MedAccess catastrophic coverage," and "MedAccess medisave coverage" to mean a MedAccess plan that provides for at least standard coverage, for only catastrophic coverage, or medisave coverage, respectively.
Requests the National Association of Insurance Commissioners (NAIC) to submit to the Secretary a set of rules which is sufficient for determining the actuarial value of coverage offered by a plan. Directs the Secretary to certify such set of rules for use under this subtitle if they meet such requirements or establish such a set of rules.
Specifies that a health insurance plan is considered to provide: (1) standard coverage if the benefits are determined, in accordance with certified rules of actuarial equivalence, to have a value that is within five percentage points of an established target actuarial value for standard coverage; (2) catastrophic coverage if benefits are available under the plan for a year only to the extent that expenses for covered services in a year exceed a deductible amount that is consistent with a specified requirement for a catastrophic health plan under the Code, and are determined, in accordance with certified actuarial equivalence rules, to have a value that is within five percentage points of an established target actuarial value for catastrophic coverage; and (3) medisave coverage if such plan consists of a catastrophic health plan within the meaning of the Code and a medical savings account. Requests NAIC to submit to the Secretary target actuarial values for standard and catastrophic coverage.
Permits NAIC to submit periodic revisions of, and permits the Secretary to revise, the set of rules of actuarial equivalence and target actuarial values where necessary to take into account changes in the relevant types of health benefits provisions, in deductible levels for catastrophic coverage, or in relevant demographic conditions.
(Sec. 1103) Directs the Secretary to request NAIC to develop model regulations that specify standards with respect to requirements: (1) that insurers make available MedAccess plans; (2) of guaranteed availability of MedAccess plans to small employers; (3) relating to limits on premiums and certain consumer protections; and (4) relating to limitation of annual premium increases. Requires the Secretary to review such standards and, if NAIC fails to specify standards meeting such requirements, to promulgate standards. Sets forth provisions regarding: (1) the application of MedAccess standards and consumer protection standards by the States; and (2) the Federal role.
(Sec. 1104) Sets forth provisions: (1) regarding limits on premium rate variations, including discounts for employer wellness programs; and (2) requiring an insurer, at the time of offering a health insurance plan to a small employer, to fully disclose rating practices for health insurance plans, including rating practices for different populations and benefit designs.
(Sec. 1105) Requires the Secretary of Labor to monitor the prevalence and impact of adverse risk selection in the full insured plans made available to small employers resulting from the decision of small employers to self-insure.
(Sec. 1106) Directs the Secretary to: (1) request NAIC to develop models for reinsurance or allocation of risk mechanisms for health insurance plans made available to small employers for whom an insurer is at risk of incurring high costs under the plan; and (2) review such models or specify models. Sets forth provisions regarding implementation of reinsurance or allocation of risk mechanisms by the States and the Federal role.
Part : Marketplace for Individuals - Makes the provisions of Part 1 applicable to insurers offering health insurance coverage to individuals and their dependents.
Part 3: Voluntary Health Purchasing Arrangements - Provides for the establishment of voluntary health purchasing arrangements.
(Sec. 1124) Requires such arrangements to offer enrollment in health insurance coverage only to: (1) all eligible employees employed by small employers in a service area; and (2) all eligible individuals residing in such area.
Part 4: Definitions and Miscellaneous Provisions - Provides definitions for purposes of this subtitle.
(Sec. 1134) Requires the Secretary to make annual reports to the Congress on the implementation of this subtitle and the need for additional reforms to assure and expand coverage.
(Sec. 1135) Authorizes the Director to conduct: (1) research on the impact of this subtitle on the availability of affordable health coverage for employees and dependents in the small employers group health care coverage market and other specified topics; and (2) demonstration projects relating to such topics. Requires the Director to develop: (1) methods for measuring the relative health risks of eligible individuals in terms of the expected costs of providing benefits under health insurance plans and, in particular, MedAccess plans; and (2) a model for equitably distributing health risks among insurers in the small employer health care coverage market. Authorizes appropriations.
Subtitle C: Preemption - Part 1: Scope of State Regulation - Makes inapplicable to a group health plan any State or local law requiring coverage of specific benefits, services, or categories of health care, or services of any class or type of provider of health care.
(Sec. 1202) Makes inapplicable any State or local law prohibiting two or more employers from obtaining coverage under a multiple employer welfare arrangement under which all coverage: (1) consists of medical care described under specified provisions of the Employee Retirement Income Security Act of 1974 (ERISA); and (2) is fully insured.
(Sec. 1203) Preempts, for a five-year period, State law provisions which restrict: (1) reimbursement rates or selective contracting; (2) differential financing incentives; and (3) utilization review methods. Directs the Comptroller General to study benefits and cost effectiveness of use of managed care in health services delivery and to report to the Congress, including recommendations as to whether such preemption should be extended.
Part 2: Multiple Employer Health Benefits Protections - Amends the Employee Retirement Income Security Act of 1974 (ERISA) to provide a limited exemption from certain restrictions on ERISA preemption of State law for health plans maintained by multiple employers subject to certain Federal standards.
Relieves such exempted multiple employer health plans of certain restrictions on preemption of State law, and treats them as employee welfare benefit plans.
Sets forth exemption procedures, application and eligibility requirements, and additional notice, reporting, and actuarial requirements applicable to exempted multiple employer health plans.
Requires multiple employer welfare arrangements providing certain medical care benefits to issue specified disclosures to participating employers.
Requires each multiple employer welfare arrangement which is or has been an exempted multiple employer health plan, and under which coverage is not fully insured, to establish certain minimum reserves. Authorizes the Secretary of Labor to permit alternative means of compliance.
Sets forth corrective actions, including actions to avoid depletion of reserves and actions in connection with termination of arrangements.
Provides for expirations, renewals, suspensions, and revocations of exemptions. Provides for review of actions of the Secretary, including denials of applications and suspensions or revocations of exemptions. Provides for alternative means of distribution of summary plan descriptions.
(Sec. 1212) Revises provisions relating to scope of preemption rules, treatment of single employer arrangements, and treatment of certain collectively bargained arrangements.
(Sec. 1215) Sets forth special rules for employee leasing health care arrangements, providing that they be treated as multiple employer welfare arrangements.
(Sec. 1216) Sets forth enforcement provisions relating to multiple employer welfare arrangements and employee leasing health care arrangements, including enforcement of filing requirements, actions by States in Federal court, criminal penalties for certain willful misrepresentations, cease activities orders, and responsibility for claims procedures.
(Sec. 1217) Sets forth solvency requirements for certain self- insured group health plans.
(Sec. 1218) Sets forth filing requirements for multiple employer welfare arrangements providing health benefits.
(Sec. 1219) Provides for cooperation between Federal and State authorities, including: (1) agreements for State enforcement of ERISA provisions applicable to multiple employer welfare arrangements which are or have been exempted multiple employer health plans; and (2) enforcement and technical assistance to States with respect to issues involving multiple employer welfare arrangements.
(Sec. 1220) Sets forth transitional rules.
Part 3: 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 in the case of determining whether any multiple employer health plan or insured multiple employer health plan is a voluntary employees' beneficiary association meeting certain requirements, if: (1) such plan provides at least standard coverage consistent with specified provisions of this Act (the Affordable Health Care Now Act of 1994); and (2) in the case of such an insured plan, it meets specified ERISA requirements not preempted by this Act.
(Sec. 1222) Amends ERISA to direct the Secretary of Labor to prescribe an alternative method for the filing of a single annual report with respect to all employers participating under a multiple employer welfare arrangement under which all coverage consists of medical care and is fully insured.
(Sec. 1223) Sets forth provisions for determining compliance with coverage requirements through multiple employer health arrangements.
Subtitle D: Health Deduction Fairness - Amends the Internal Revenue Code to provide for: (1) a permanent extension and an increase in the health insurance tax deduction for self-employed individuals; and (2) a deduction of health insurance premiums for certain previously uninsured individuals.
Subtitle E: Improved Access to Community Health Services - Part 1: Increased Authorization for Community and Migrant Health Centers - Directs the Secretary to provide for grants to migrant and community health centers to promote primary health care services for underserved individuals. Allows grants to be used to promote the provision of off-site services, to improve birth outcomes in areas with high infant mortality and morbidity, to establish primary care clinics in areas in need, and for recruitment and training costs of necessary providers and operating costs for unreimbursed services. Authorizes appropriations. Directs the Secretary to conduct a study of the impact of such grants on access to health care, birth outcomes, and the use of emergency room services.
Part 2: Grants for Projects for Coordinating Delivery of Services - Amends the Public Health Service Act to authorize the Secretary to make grants to public and nonprofit private entities: (1) to carry out demonstration projects to increase access to outpatient primary health services in specified geographic areas (i.e., areas that are rational areas for the delivery of health services, have a population of not more than 500,000 individuals, and have been designated by the Secretary as areas with a shortage of personal health services or that have a significant number of individuals with low incomes or insufficient health care insurance) through coordinating the delivery of services under Federal, State, local, and private programs; and (2) for developing plans to carry out such projects. Authorizes appropriations.
Part 3: Community Health Networks - Sets forth qualifications for community health network arrangements.
Subtitle F: Improved Access to Rural Health Services - Part 1: Establishment of Rural Emergency Access Care Hospitals Under Medicare - Amends title XVIII (Medicare) of the Social Security Act (SSA) to provide for: (1) establishment of rural emergency access care hospitals under Medicare; and (2) coverage of and payment for rural emergency access care hospital services under Medicare part B (Supplementary Medical Insurance).
Part 2: Rural Medical Emergencies Air Transport - Amends the Public Health Service Act to direct the Secretary to make grants to States to assist in the creation or enhancement of air medical transport systems that provide victims of medical emergencies in rural areas with access to treatments. Sets forth provisions regarding: (1) application and State plan requirements; (2) considerations in awarding grants; (3) State administration and use of grants; (4) the number of grants; and (5) reporting requirements. Authorizes appropriations.
Part 3: Emergency Medical Services Amendments - Amends the Public Health Service Act to direct the Secretary to: (1) establish an Office of Emergency Medical Services, headed by a Director; (2) engage in specified emergency medical services activities, including disseminating information obtained in carrying out specified activities to public and private entities, providing technical assistance to State and local agencies, coordinating Department of Health and Human Services (DHHS) activities with those of other Federal agencies; and (3) ensure that such activities are carried out consistent with certain requirements regarding maintaining an adequate number of health professionals with expertise in the provision of services, developing, periodically reviewing, and revising as appropriate guidelines for the provision of such services, appropriately using available technologies, and serving the unique needs of underserved inner-city and rural areas.
(Sec. 1522) Authorizes the Secretary to make grants to States for the purpose of improving the availability and quality of emergency medical services through the operation of State offices of emergency medical services, subject to specified matching fund, budgetary, and other requirements.
(Sec. 1523) Provides for demonstration projects to establish telecommunications between rural medical facilities and medical facilities with expertise or equipment. Directs the Secretary to ensure that the telecommunications technologies demonstrated include interactive video telecommunications, static video imaging transmitted through the telephone system, and facsimiles transmitted through such system.
(Sec. 1524) Authorizes appropriations for: (1) emergency medical services (including for State offices of Emergency Medical Services and for telecommunications demonstrations); and (2) trauma care and certain other activities.
Part : Additional Rural Health Care Provisions - Authorizes the Secretary to make grants to public and nonprofit private entities to develop health plans to provide services exclusively in rural and frontier areas. Authorizes appropriations.
(Sec. 1532) Authorizes the Secretary to make grants to public and nonprofit private hospitals in medically underserved rural communities, and to public and nonprofit outpatient facilities in such communities, to develop or increase capacity to provide primary health services.
(Sec. 1533) Authorizes the Secretary to make grants to such entities to conduct research and carry out demonstration projects to develop innovative approaches to the delivery of health care in rural areas, such as the use of telemedicine and mobile delivery units.
(Sec. 1534) Authorizes appropriations for the training of rural health professionals other than physicians.
Subtitle G: Assistance in Enrolling Uninsured Children in Health Insurance - Amends title XIX (Medicaid) of the Social Security Act (SSA) to provide for the establishment of State premium subsidy programs to assist eligible needy children with premiums for standard health coverage.
Subtitle H: Medicaid Reform - Amends SSA title XIX to: (1) provide for the establishment of State health allowance programs under which the State makes payments to an approved group health plan which provides coverage to eligible individuals as an allowance towards the costs of providing the individual with benefits under the plan; (2) modify Federal requirements to allow States more flexibility in contracting for coordinated care services under Medicaid; (3) make changes regarding the period of certain waivers under Medicaid; and (4) reduce the amount of Federal payment adjustments under Medicaid for disproportionate share hospitals.
(Sec. 1713) Eliminates the duplicative pediatric immunization program under Medicare.
Subtitle I: Remedies and Enforcement with Respect to Group Health Plans - Amends the Employee Retirement Income Security Act of 1974 (ERISA) to set forth claims procedure special rules for group health plans.
Directs the Secretary of Labor to establish a mediation program for disputes involving group health plan claims. Requires the Secretary to maintain a list of individuals with expertise to serve as facilitators under such program, and to propose a facilitator for each mediation subject to one objection by each party. Sets forth provisions for participation of attorneys, initiation of mediation, mediation procedures, time limits, costs, legal effect of participation, and confidentiality and admissibility.
Sets forth court remedies for participants and beneficiaries with respect to group health plans.
Subtitle J: Delivery of Health Care Services to Illegal Immigrants - Directs the Secretary of Health and Human Services to conduct a study of health care to illegal immigrants, including the effect of illegal immigration on health costs and the shifting of health costs. Requires a report to the Congress, with recommendations on appropriate means of: (1) alleviating health problems peculiar to illegal immigrants; (2) financing health care provided to illegal immigrants; and(3) increasing intergovernmental cooperation and coordination of efforts of the United States and other countries to alleviate such health problems and finance such efforts.
Title II: Health Care Cost Containment and Quality Enhancement - Subtitle A: Medical Malpractice Liability Reform - Part 1: General Provisions - Makes this subtitle applicable with respect to any medical malpractice liability claim and to any medical malpractice liability action brought in State or Federal court, except a claim or action for damages arising from a vaccine-related injury or death to the extent that title XXI of the Public Health Service Act applies. Sets forth provisions regarding: (1) preemption of State law; (2) effect on sovereign immunity and choice of law or venue; (3) jurisdiction; and (4) effective dates.
Part 2: Medical Malpractice and Product Liability Reform - 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 alternative dispute resolution (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 under chapter 171 of the Federal judicial code (U.S. Court of Federal Claims). 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. 2012) 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. Sets limits on punitive damages and on periodic payments for future losses. Reduces damages by any other payments made to compensate an individual for injuries.
(Sec. 2013) Set forth provisions regarding: (1) limits on attorney fees and other costs; (2) joint and several liability (generally, liability may be found only for those damages directly attributable to the person's proportionate share of fault or responsibility for the injury); (3) a statute of limitations of seven years; and (4) a uniform standard for determining negligence (the defendant's conduct at the time of providing the health care services was not reasonable).
(Sec. 2017) Specifies that in the case of a medical malpractice liability claim relating to services provided during labor or the delivery of a baby, if the health care professional did not previously treat the injured individual 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.
Part 3: Requirements for State Alternative Dispute Resolution Systems - 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. 2032) Directs the Secretary, by October 1 of each year, to certify State ADR systems that meet such requirements.
Directs 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. 2033) Directs the Secretary, within five years, to submit to the Congress a report describing and evaluating State ADR systems and the alternative Federal system, including: (1) information on the effect of the ADR systems on health care costs, access to health care, and quality of care provided within the State; and (2) to the extent that such report does not provide information on no-fault systems operated by States as ADR systems, an analysis of the feasibility and desirability of establishing a system for resolving medical malpractice liability claims on a no-fault basis.
Part 4: Other Provisions Relating to Medical Malpractice Liability - Authorizes a State agency responsible for disciplinary actions for a type of health care practitioner to enter into agreements with State or county professional societies to permit their participation in the licensing of such practitioner and to review any health care malpractice action, claims, or allegation, or other information concerning the practice patterns of any such practitioner. Sets forth agreement requirements.
(Sec. 2042) Directs the Secretary to study incentives adopted by State and local governments, insurers, medical societies, and other entities to encourage physicians to volunteer to provide health care services in medically underserved areas.
(Sec. 2043) Directs each State to require: (1) each health care professional and health care provider to participate in a risk management program to prevent, and provide early warning of, practices which may result in injuries to patients or endanger patient safety; and (2) each provider of health care professional and provider liability insurance in the State to establish risk management programs or sanction programs of risk management for health care professionals and providers provided by other entities, and require each such professional or provider, as a condition of maintaining insurance, to participate in one such program at least once in each three-year period.
(Sec. 2044) Directs the Secretary to make grants: (1) for basic research in the prevention of, and compensation for, injuries resulting from health care professional or provider malpractice and for research of the outcomes of health care procedures; (2) to States to assist in improving their ability to license and discipline health care professionals; and (3) to States and local governments, private nonprofit organizations, and health professional schools for educating the general public about the appropriate use of health care, realistic expectations of medical intervention, and the resources and role of health care professional licensing and disciplinary boards in investigating claims of incompetence or health care malpractice, and for developing programs of faculty training and curricula for educating health care professionals in quality assurance, risk management, and medical injury prevention. Authorizes appropriations.
Subtitle B: Administrative Cost Savings and Fair Health Information Practices - Part 1: Administrative Cost Savings - Subpart A: Standards for Data Elements and Transactions - Directs the Secretary to adopt standards and modifications to standards that a: (1) consistent with the objective of reducing the costs of providing and paying for health care; and (2) in use and generally accepted, developed, or modified by the standard-setting organizations accredited by the American National Standard Institute.
(Sec. 2104) Directs the Secretary to adopt standards: (1) for data elements of health information; and (2) for transmitting information electronically.
Subpart B: Requirements With Respect to Certain Transactions and Information - Specifies standard transactions.
Subpart C: Miscellaneous Provisions - Requires the Secretary to establish standards with respect to the operation of health information network services.
(Sec. 2124) 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.
Subpart D: Assistance to the Secretary - Establishes the Health Care Information Advisory Committee to: (1) assist the Secretary in complying with requirements under this Act; (2) be generally responsible for advising the Secretary and the Congress on the status of the health information network; and (3) make recommendations to correct problems in the network and to refine and improve the network.
Part 2: Fair Health Information Practices - Subpart A: Duties of Health Information Trustees - Specifies the duties of health information trustees with respect to inspection of protected health information.
(Sec. 2142) Provides a procedure to amend protected health information.
Subpart B: Use and Disclosure of Protected Health Information - Sets forth general limitations on the use and disclosure of protected health information by health information trustees.
(Sec. 2152) Authorizes a health information trustee to disclose protected health information pursuant to a written authorization by the protected individual.
(Sec. 2153) Describes the circumstances under which health information trustees may disclose protected health information to: (1) health plans, health care providers, and oversight agencies; (2) next of kin; (3) public health authorities; (4) health research entities; (5) authorities under emergencies; (6) courts or administrative agencies; (6) law enforcement agencies; (7) entities under subpoenas, warrants, and search warrants; and (8) health information service organizations.
Subpart C: Access Procedures and Challenge Rights - Prohibits a government authority from obtaining protected health information about a protected individual from a health information trustee through subpoenas, warrants, and search warrants unless there is probable cause that the information is relevant to the law enforcement inquiry.
(Sec. 2172) Establishes challenge procedures to such subpoenas.
Subpart D: Miscellaneous Provisions - Restricts the information a health information trustee may disclose when a protected individual pays for health care through a payment card or electronic means.
(Sec. 2183) Directs the Secretary to develop standards for electronic documents and communications.
(Sec. 2184) Provides for the disclosure of protected health information to affiliated persons and agents and attorneys.
(Sec. 2187) Requires States to establish a process for the maintenance of certain protected health information.
Subpart : Enforcement - Provides for civil actions against health information trustees.
(Sec. 2192) Authorizes the Secretary to impose a civil money penalty against such trustees for a demonstrated pattern of failure to comply with this subpart.
(Sec. 2193) Requires the Secretary to develop an alternative dispute resolution method for resolving claims for civil actions.
(Sec. 2194) Amends the Federal criminal code to impose penalties for violations in disclosing and obtaining protected health information.
Subpart F: Amendments to Title 5, United States Code - Requires certain Federal agency heads to promulgate rules protecting health information.
Subpart G: Regulations, Research, and Education; Effective Dates; Applicability; and Relationship to Other Laws - Requires the Secretary to prescribe regulations to carry out this part not later than July 1, 1996.
(Sec. 2197) Makes this part effective on January 1, 1997, except for certain provisions that take effect upon enactment.
Subtitle C: Deduction for Cost of Catastrophic Health Plan; Medical Savings Accounts - Amends the Internal Revenue Code to include under the medical expense deduction the portion of such expense attributable to coverage under a catastrophic health plan.
(Sec. 2202) Allows individuals a tax deduction for a percentage of contributions made to a medical care savings account established for the benefit of an eligible individual.
Allows such deduction whether or not an individual itemizes deductions.
Disallows distributions from such accounts as medical expense deductions.
Excludes employer contributions to such accounts from employment taxes.
Establishes an excise tax for excess contributions to medical care savings accounts.
Subtitle D: Anti-Fraud - Directs the Attorney General to establish an all-payer health care fraud and abuse control program.
(Sec. 2302) Authorizes additional appropriations for such program and AG investigations of possible health care fraud.
(Sec. 2303) Establishes in the Treasury the Anti-Fraud and Abuse Trust Fund for use in preventing anti-fraud and abuse law violations and repaying Medicaid and other beneficiaries for cost-sharing.
(Sec. 2311) Amends SSA title XI and the Federal criminal code to: (1) revise current sanctions to provide for, among other things, mandatory exclusion from Medicare and State health care program participation of individuals or entities convicted of a fraud-related felony in connection with the delivery of a health care item or service, and criminal penalties of fines and imprisonment for health care fraud; and (2) authorize the Secretary of Health and Human Services (Secretary) to issue advisory opinions with regard to specified matters, including matters concerning prohibited remuneration and service inducements.
(Sec. 2315) Modifies: (1) current limitations under Medicare (SSA title XVIII) on physician self-referral; and (2) effective date exceptions under the Omnibus Budget Reconciliation Act of 1993 for such referrals made for clinical laboratory services.
(Sec. 2316) Directs the Comptroller General to study and report to the Congress on the costs of peer review contracts for Medicare HMOs.
(Sec. 2332) Amends SSA title XVIII to require the Secretary to issue advisory opinions relating to prohibited referrals under Medicare.
Directs the Secretary to issue regulations establishing systems under SSA titles XI and XVIII for the issuance of advisory opinions.
Subtitle E: Increased Medicare Beneficiary Choice; Additional Medicare Reforms - Amends SSA title XVIII and the Omnibus Budget Reconciliation Act of 1990 to make specified changes in HMO and Medicare supplemental policy provisions. Imposes mandates on the Secretary in order to afford Medicare beneficiaries additional avenues for choosing health care coverage, including enrollment in private health insurance plans.
(Sec. 2411) Extends current rules for computing Medicare part B (Supplementary Medical Insurance) premiums.
(Sec. 2412) Amends the Internal Revenue Code to provide for the imposition of a Medicare part B premium tax for high-income Medicare part B beneficiaries.
(Sec. 2413) Directs the Secretary to take such steps as necessary to consolidate administration of Medicare parts A (Hospital Insurance) and B.
(Sec. 2414) Makes specified extensions with regard to Medicare as secondary payer, including those concerning data matches.
Subtitle F: Health Care Antitrust Improvements - Exempts from all antitrust claims an activity relating to the provision of health care services that is: (1) within a "safe harbor" designated by the Attorney General, except for claims for injunctive relief asserted by the Attorney General or the Chair of the Federal Trade Commission in extraordinary circumstances; and (2) specified in and in compliance with the terms of a certificate of review issued by the Attorney General, where the activity occurs while the certificate is in effect, except for claims for injunctive relief. Sets forth provisions regarding the award of attorney fees and costs of suit to the prevailing party in an action based on a claim involving activity found to be exempt.
(Sec. 2502) Directs the Attorney General to develop and designate specified safe harbors relating to the following, as well as to such other categories of activities as the Attorney General may designate (subject to specified requirements): (1) joint purchasing of health care services; (2) small hospital mergers; (3) startup and operation of collaborations between State-licensed providers through partial or full integration; (4) standard setting and enforcement activities by medical self-regulatory entities; (5) health care providers collectively supplying non-price medical information to buyers and consumers; (6) health care provider participation in surveys; (7) health care joint ventures' purchase or use of equipment or provision of advanced tertiary care services; (8) provision of market power screens at appropriate levels below which combinations of providers are too small to pose a realistic antitrust threat; (9) joint purchasing arrangements; and (10) good faith negotiations relating to legitimate collaborative activities.
Directs the Attorney General to publish notice in the Federal Register soliciting proposals for additional safe harbors. Authorizes the Attorney General to modify or remove a safe harbor following notice and comment upon a determination that the safe harbor does not meet specified criteria.
Sets forth criteria in establishing safe harbors, including: (1) the extent to which a competitive or collaborative activity will accomplish an increase in health care access and quality, the establishment of cost efficiencies, and increased ability of health care facilities to provide services in medically underserved areas or to underserved populations; and (2) whether designation as a safe harbor will result in specified desirable outcomes.
(Sec. 2503) Directs the Attorney General to issue certificates of review for providers of health care services and to assist persons in applying for such certificates. Sets forth procedures regarding applications for, renovation of, and review of determinations regarding, such certificates. Limits the disclosure of information.
(Sec. 2504) Sets forth provisions regarding notifications providing for a reduction in certain penalties under the antitrust laws for health care cooperative ventures.
(Sec. 2505) Directs the Attorney General to periodically review the safe harbors, certificates of review, and notifications.
(Sec. 2507) Establishes within the Department of Health and Human Services an Office of Health Care Competition Policy.
Subtitle G: Encouraging Enforcement Activities of Medical Self- Regulatory Entities - Part 1: Application of the Clayton Act to Medical Self-Regulatory Entities - Provides that no damages, cost of suit, or attorney fee may be recovered under section 4, 4A, or 4C of the Clayton Act, or under any similar State law, except by a State or the United States, from any medical self-regulatory entity as a result of engaging in standard setting or enforcement activities that are: (1) designed to promote the quality of health care provided to patients; and (2) not conducted for purposes of financial gain. Directs the court to award the cost of such a suit, including a reasonable attorney fee, to a substantially prevailing defendant.
Part 2: Consultation by Federal Agencies - Requires any Federal agency engaged in the establishment of medical professional standards to consult with appropriate medical societies or associations, specialty boards, or recognized accrediting agencies, if available, in carrying out medical professional standard setting and guidelines or standards relating to the practice of medicine.
Subtitle H: Reform of Clinical Laboratory Requirements for Simple Tests - Amends the Public Health Service Act to exempt clinical laboratories performing only simple examinations and procedures from certificate requirements.
(Sec. 2703) Directs the Secretary to use existing appropriations to conduct the study relating to the reliability and quality control procedures of clinical laboratory testing programs and the effect of errors in the testing procedures and results on the diagnosis and treatment of patients.
(Sec. 2704) Directs the Secretary to revise the membership of the Clinical Laboratory Improvement Advisory Committee to contain a number of practicing physicians proportionate to the number of physician regulated clinical laboratories.
Subtitle I: Miscellaneous Provisions - Requires certain Government agencies to prefund health benefit contributions for their annuitants.
(Sec. 2802) Makes aliens ineligible for social security and Medicaid benefits.
(Sec. 2803) Limits the eligibility for social security benefits of certain drug and alcohol addicts.
Title III: Long-Term Care - Subtitle A: Tax Treatment of Long-Term Care Insurance - Amends the Internal Revenue Code to provide for the treatment of qualified long-term care insurance as accident and health insurance for purposes of insurance company taxation.
(Sec. 3002) Excludes from gross income benefits provided under a long-term care insurance contract. Includes in gross income employer-provided coverage for long-term care services.
(Sec. 3003) Includes amounts paid for qualified long-term care services as medical expenses for individual itemized deductions. Includes any parent or grandparent as a dependent for purposes of such expenses.
Subtitle B: Establishment of Federal Standards for Long-Term Care Insurance - Amends the Public Health Service Act to mandate the establishment of model Federal standards for long-term care insurance.
Prohibits the offering of a long-term care insurance policy in a State unless the State has a regulatory program meeting the requirements of this Act or the policy has been certified by the Secretary of Health and Human Services.
Authorizes grants to States for demonstration programs to improve enforcement of the standards. Authorizes appropriations.
Imposes on agents selling long-term policies a duty of good faith and fair dealing. Prohibits twisting, high pressure tactics, and cold lead advertising. Mandates minimum financial standards, including income and asset criteria, for advising individuals considering the purchase of a long-term policy. Prohibits sales: (1) to an individual eligible for assistance under title XIX (Medicaid) of the Social Security Act; (2) of duplicate service policies; and (3) of policies that reduce, limit, or coordinate benefits on the basis of eligibility for other coverage or benefits. Provides for: (1) criminal and civil penalties; and (2) agent training and certification.
Sets forth additional carrier responsibilities relating to refunding of premiums, mailing of policies, providing information on denials of claims, reporting of information, and limiting compensation to agents for the sale or renewal of policies.
Prohibits cancellation or nonrenewal of a long-term care policy except for nonpayment of premium or material misrepresentation. Sets forth continuation and conversion rights for group policies, regulating premiums for converted policies. Requires guaranteed issuance to an individual if the individual meets the minimum medical requirements of the policy. Mandates standards regarding upgraded benefits. Limits cancellation for nonpayment by an incapacitated individual.
Requires: (1) subject to exceptions, uniform language and definitions, a uniform format, and at least one standard benefit package; and (2) disclosure of certain matters, including an outline of coverage. Mandates recommendations by the National Association of Insurance Commissioners (NAIC) regarding informing consumers on the long-term economic viability of long-term care insurance carriers. Limits certain conditions on benefits. Requires, if benefits are provided for home health care or community-based services, that certain minimum benefits be provided. Prohibits treating cognitive or mental impairments (including Alzheimer's disease and mental illness) differently from other medical conditions. Limits preexisting condition requirements. Requires: (1) each claimant to have a functional assessment by an individual or entity meeting NAIC qualifications and unconnected to the policy issuer; (2) inflation protection, unless rejected in writing by a policyholder; (3) disclosure of certain premium increases; and (4) nonforfeiture benefits. Prohibits a carrier from contesting a policy or claim based on fraud or misrepresentation unless notice is provided within a time period set by NAIC. Establishes the right of a purchaser to return a policy within a specified period.
Defines "long-term care insurance policy," excluding: (1) any basic Medicare supplemental policies; (2) other insurance offered primarily to provide specified types of coverage; and (3) certain life insurance policies.
Authorizes grants for programs to provide information, counseling, and assistance regarding the procurement of long-term insurance. Authorizes appropriations.
Subtitle : Protection of Assets Under Medicaid Through Use of Qualified Long-term Care Insurance - Amends the title XIX of the Social Security Act to require State Medicaid plans to disregard some or all of the individual's assets attributable to coverage under a qualified long-term care insurance contract in determining the individual's eligibility for long-term care services.
Subtitle D: Studies - Requires the Comptroller General to study 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 home with an income tax credit.
(Sec. 3303) Requires the Secretary of Health and Human Services to study and report to the Congress on the feasibility of encouraging or requiring the use of a single designated public or nonprofit agency to coordinate, through case management, the provision of long-term care benefits under current Federal, State, and local programs in a geographic area.
Subtitle E: Volunteer Service Credit Demonstration Projects - Amends the Older Americans Act of 1965 to require the Commissioner of the Administration on Aging to establish and operate a volunteer service credit demonstration project in each State.