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STm <QISCUSSION
·O:\l\1AT\MAT94.539
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, 'IN THE SEXATE'OF'THE UNITED ,STATES ' .
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To 'prmide .for health care ref~rm! and 'for 'otherpurpQses: '
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2 'fives of the United
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State~ofAmericai1l~Congress
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3 .' SEC,TI()N
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1. SHORT
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TIn.:E~ TABLE
OF cor.rfE!\'Ts..
:' (~) Si.fORTTITl;E.-'TIps Act may be' cited as the
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5' .HHealth Refo~In Act";
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. ,7 ',this Act is as follo\\'s; ,
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/ Sec, L. Short title; tableof.~oritents.·
Se<:.2, Findings and purpo~es.'
Se~: 3: Definitions and special. rules, , .
'TITLE, i-,-BASIC I!\si,-R\.'\'CE REFORirSTO ,EXP.A~"D ACCESS TO .
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liEALTI~' Ixstiu.,\cE ':
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~Subtitl~ A-Standards for'RefOJTIl' .'
PART, l~EsT~LISB!liES'TA.'\D
..APPLICAT~OS'
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STA.':'DA..iD;
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September 16,1994
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O:\MAT\MAT9~.539
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, STAFF DISCUSSION DRAFT
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See. 1001.' Certified i,health plans ..
. Sec. 1002. General rules.
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2~StA..\-nARDS. APPLICABLE
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TO CERTrTIED J!-.:SrRED HEALTH.
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; . :Sec~ 1 01'1, Guar~nteed issue and renewal;
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. See:: 1012'. Enrollment:.
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Sec. 1013. Rating limitations for cOmmunity-rated market. . .
" ee.: l'014·,·'Rating .practices arid payment of premiuius.· . .
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Sec. 1015, Nondiscrimination-based on health·stat'\ls.
"Sec. 10'16.' :Benefits offe~ed,-' .
~c. ~ 017 .,Requirement.<;6f Sii-pplementals.
Sec. 1'018: 'Risk-'adjustment,'.
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,.. '. Sec: .1019. Financial reqtiirements, .
.Sec. ·i020: Collection and pro\ision'~f standardized information:
Se~.:102L QUality improverilentand assurance.:
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Sec:. 1022.' Patient 'prOt~ctions.and providerseleetiori", .
Sec.. 1023.. Dueiprocess fo~ heaJthcare pro\ide/~. "
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Sec. 192-1. Alternatiw disputeresolutiOl) procedures. relating to ma'practice
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Se.c·. 11025. Ar:rangements withessehtial community pro\'id~rs.
. ~ Sec':. 1026.' Access to speciali~ed senices: ,
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S.ec, .1027, . Cotnmunity rating area capacity: :'
Sec. 1028. Out-of-areacowrage:.. _ "
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,Sec!. 1031.. Standards appli~able to'certifi'ed self~inSul"ed health ,plans'.', .....
F'ART 4-PREE~!rT10X
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OF'. CERTIDSTATE' LA'\"s
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. Sec. ]0·:11: "Preemp~ion fronl.Statebenefit'mandat~s.: i
Sec~ 1042.. Preemptibll of Suite la\,·. restrictions' on certified health plaris:
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PART f\-'-:!;\"TERDf STAXDARDS, .
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. Subtitle B-Benefits
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Sel:, 1 tal. Defmitions:.
,~ec'. 11 02 ..Leg1~lath·e proposals e~tab1ishing standa;dized b~neQis packages.
.: Sec. n 03.' Additional duties of the Commission ~ith respect to mental illness
,and ~bstanc(> abuse senices.
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. Sec .. 110:;' f{ecommendationsfor pra~tice i;t;idelinc~ and coverage:
Sec, 1105. Report~ or; actuarial \~alU(~., '
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'.' Sec .. 11 o 'l\leai~al 'nec'essiiy or' ~ppropri~teness .
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. Sec. HOi, Flexibl(> senice opti~n ..
, Sec, 'llPS.Con'gressionalconsider<itionof Commissio'nproposals.
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,Sec, ,1109. ,Re\ie\\" of benefIt deterinination. ' : , .. :
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Subtitle C~E).:pa'nded\·A~cess to .Health Plans
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THROl'Gwi::~lPLOl.iRS
PART:l-.'\CCESS
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Sec. 1201. Employer aCcess .and 'enrollll~ent requireillents,
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&c,1202.,.S!,llall eniployer~equirements.
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STAFF DISCUSSION DRAFT
O:\l\1AT\MAT94.539 '
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Sec. 1203, Large employer ~equirements.
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PART' 2........-\CcESS
T~Ol;GH "Pt;RCHAS~G
C60PERATln:s
. Sec. '1211. Establishment of,purchaslng'cooperath:es,
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·Sec. i212,Agreements withsmall employers.
Sec. 1'213: Enrolling community-rated indi'lduals in, health ,plans, t~i-o~gh a
. purchasing cooperative:
Sec. 1214 Receipt of premiums:
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Sec. 1215; Cooperative marketing acthities.
'Sec. 1216. Speciai ,rule for~ertain State, and local e~ployeepurchasing, .co~
operatives.. .
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..Sec. 121 i .. Development, of pui:c.hasinggroups(or large emplo:-;ers; ,
,.pART '3-ACcESS
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THROUGH ASSOCLqIO:"<
Sl:BPART A-:-CERTIFIED ASSOcUTlO:"<
Sec.
Sec:
Sec.
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11221.
1222.
1223.
1224.
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Treatment of c~rtified as~o~iation plans..
?llodiflCations of standards apphcable to certified association, plans.
Certified association plan defined.
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Repeal of qUS,,-\ pro,isions,,
Sl"BPARTB-:-SPEClAL Rl'LE FOR CHt:'RCH AXD ~fl'LTIE)rPL01'"ER PLA.'I;S,
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Subtitle D~State &Iein Reform
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1301. Est.ablishment of State market reform pro{rrams.
1302.' Certificatioil'of insUred' health ,plans. : '., .
1303, E~tablish'nlent, of community ratirtgarea/>:
19,04. P~oce.dures for certification of purchasing cooperatives ..
'Sec. 1305. Coordina'tion among purchasing cooperatives.-
Sec. '1306. Preparation of. i~for~liltion . concerning plans, and purchasing co!'
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Sec., 130i ..~isk ad,iustm('nt rro~am':
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Sec.' 130S. Sp('cificatlon of annual general ang initial enrollment periods,'
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Sec.' 1309,. Publie :access sit~s.·
Sec. 1310: Spj:'cial rules regarding net"'''ork'plans .. " ,
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'1313.
1314.
1315.
Continullrice Of existing Federallawwah'ers.
Hawaii Prepaid Health'Care A c t . . !
Al!erna~i"e St..<tt('pro~ider p~:~nent systems: '
Al.ternatiwState uncompensated care pool. .
PART
a.....:REQl'ffiE!l!E·:"'TS FOR STATE Sr:"'GLE-PA'i"ER ,SYSTD!S
I$e~. 1321. Sinf!le.pay~r s:'stem described.
S~c. f322. 'Generahequirements fot singlc~paye\ system's, , .
Sec.·1323. Additionai. rules for ,singlc.pa~'er system.· ' ,
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, Subtitle E-Feqeral Role
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September 16. 1994
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�•STAFF DISCUSSION D&AF:T
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l~ESTABLISH~~'~ST
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orFEDEfw.; STAXDARDS roR CERTIFIED'
HEALTH
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Sec. 1401, Establishment and ,'c~rtificati9n pf standards appliCable to certified
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Sec, 14'02"Co~recfj\'e actions for'self-inSUred heahh plans .
. Sec"1403,. ERI8...\ appliCability to, self~insured healthplaris, , . ,
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Sec. }404. Disclosure and rel>en'e requirements .for. self"insuredhealth plans,
Sec,: 1405.~ruste~ship'by the'sec~eta~· ofinsolven.t self-insure? health plans.."
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PART 3-NATlO.!\'ALHEALTH BE!I."EF;'ITS
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: Sec. 1411. Cr~tiori :of National Health Benefits and Co\'erage 'Commi~io~;
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:Sec .. 141:;( Qualifications of COlJlmissi()Jlmembe!'S.
Sec, ,1413. Powers: .
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1421.' Federal role in the case of a default by a State.
1422. Establishment of residency rules.
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\i'4~3:R\lles determinin'g ~.eparat~ emplo~'er status, '
1424. Wbrkplace v;ellness program .
. ,TITLE ll..:.-I:\CE:\TrVES TQ PRO)JOTE· AFFORDABLE U~-:n"ER8..-\L
'CO\'ERA~E
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Se~, 2006, Amendment on. 986 'c&de,
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Sec, 200L Dedilction, for i~dhiduals aI}d self-employed mdi\iduals, pro\id.illg'
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Cost'Shari~gA.Ssistance
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Sec. 2}02,:Assistance "'ith certified'standard hea.lthplan premiums.
'Sec. 2103. Assistance "'ith cost-sharing for certifledstandard h~alt~ pl~n~.
Sec. 2104: 'EligibQi~' delermiJ~ations.
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Se\,. '2105., EIld~of-yearreconciliati~n for a!?sisiarice,
Sec. 2106: Penalties, for material misrepresentations.
','", Sec.' 2J07. Enroli'~ent outreahh.·
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Sec. ,2202" Congressionalconsi~eratiQnof comynission i recommendations,
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TITI:..EIII-E:\TITLE)[E~T REFOR)lS
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STAFFD'ISCUSSIONDRAFT'
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Sec. 3000. ·References in title..
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Subtitle .A-MediCaid
PART l-REFOR~!S'
Sl:BPAR1' A-COORDI~ATlci~, OF. THE· MEDICAID PROGRA.'I' \\1TH REFOR~IED
: HEALTH CARE, SYSTEM
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300L State 'plan requ~ement reg'aTdIDgeligibility: for m'erucalassistance,..
Sec. 3002,' integration of certain medicaid eligibles intQ reformed health .care '
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3004.De~onstratio·n projects 'permitting co\'erage' under' certified health
, ,plans of ssi ~eligible in,di\;duals. '~ "
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SUBPART B-:-STATE ELIGmILITY TO,. roxT,IiCT FOR' C00RI>I~A TED
SER'1CES
CARE
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Sec. 30n: ~lodificationofFederal requir~m'ents 'to allow Staies~ore f]exi~ilit\'
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Sec, 3IOL Replacement of DSH payimintprO\1Sions ,,;th proyis!onsrelating to
pa:.nlimts to hospitals sen;ng \UJnerable pOp'ulati~ns.
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Subtitle B"":"!lledicare
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PART l-REFOR~IS '
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See. 3201. Impro\'erilents to risk contrficts,
,Sec: 3202. Additional' irilpro\,ements fo risk contracts and incorroration' of inr
snrance reforms.
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Sec. 3293. Enrollment of ,m~dica~e beneficiaries, in certified standard heahh
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PART2-7-FI:-;AXC~G PR0\1S10~S
Sl:BPART'A-,:PRO\lSI00'S
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RELATI~G
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Se~; 321 L Inpatient'hospital sen1ces update for PPS h;spitals.
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Sec: 3212. Reduction in pa~lllentsfor capital~relatedcosts for inpatient ho.spital .
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Sec. 3213: Redllc,tions in disproportionate share pa~1llen!S"
Sec. 32i 4. :t'rospecti"e,' pa!1llenr methodolo~: ~nd reductions in' inflation ; up~
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dates for skillt>dnursing facilities.'
Sec. 3215, Re\;sed pa?1llent mettloQolo'~, for rehabilitation and long-term. care
. hospitals. '
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Sec. 3221. S~tlstit~ti?n~ of real GDP to lldjust for ,;ol~ine ~lJd int~nsity:' repeal
of restriction on.max:.imum reductib.n per.rnitted in defa4lt up- '
datc·:
Sec' 3222. Correction.ofM\"P:s up~~'ard bias, '
St>c, 3223, Reduction in c~n\'ersior;·factor for physician ft>t> schedule for 1995:'
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b':\,MAT\~tAT94,539 '
'STAFF DISCUSSION DRAFT
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Sec:. 3224, Elimination of formula-,driYen o\'erPayments for certain outpatient '
hospital services.
'Sec. 3225," ,
General , part B premium:"
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S1:BPART C~PRO\1SIO:"S REUTI:"G TO PARTS
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Sec. 3231. 'Red'uction ·in routine cost limits for honie "health s~~1~es.
'Sec. 323? Medie~re as secondar:': ,payer. " . ' "
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'dis~s~ Sel"\1Ces'tO 24 months. '
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SeC. 3?01. State' programs for home and co~munit;\'-based Sel"\1CeS for eligible
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Sec.
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. indi\1duals \\;th disabilities. .
3302. State plans'.
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3303. Indi\1duals~lth disabilities defined.
'33Q4 .. H~me and communjt~'-based,sel"\~ces covere'd ,under. State plan.
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3305. Cost sharing.' " '
3306, Quality,.assurance and safeg'uards. ,
.330i. Ad\1S0r:"group,s. ,
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330,8. Pa,trients to States.,
3309. Total Federal budget; ~llotments .to St8t~s;
3310. Fed~ral evaluations. ' .
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,TITLE, IY~I~r'RASTIifCTLRE '~FOR)!
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S~IJtltl~ A-':"Programs to Improve Access ,To t ndersel';"ed 'Areas
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j~GRA.,\TS'F6R THE,DE\"ELOP~IE:"T A.,-D OPERATIO:"OF: Cmim:'~1i1'
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,ORO'l"P'S'A.'l) F(;n( CAJ'iT~ 'AsSISTA.,\.CE
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,Sec: 4002. Community health I!roup; eertified coiiununit~: heaith pllin; cominu
, ,~ty hcaltll network; eligible ,erititie~; .is~lated, rural facilities.' ,
St.'BPAflT
A~r(\',\TSFO~ mft DE\'ELOPME:"T".A..'l) ~PERA1'IO:" ~F
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HEALTH GROCPS,
SE'c.~O 11" Grants a~d contraet~ for de\'elopment',of plans~~d networks'. " ,"
,Sec: 4012., Grants and contracts for operation of'plims and networks.
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See,,4013.,-Loansj loan guarantees, ~ndgrants:for capital i~vestn:,tent.,,'
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P AR'T
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OF TELEllEDIClXE IK
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Se'c: '402L Gr~nts for dp\,elopment
rural 'tele~ledicine,
'Sec, 4022. Report ,alide\,aluatfon of tel~medicihe. '
Sec: 4023'" R€!!Ulations on reimbursement of telemedicine,
'sec: 4024. Authoriza~ion, of appr6priations.
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~ART3~ESSE~TyiPt:BLIcH.EAtTHr:A&rI\iTIES
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Sp(', 4031. Gran,ts to St.at~!;:foressential public health acti\1ties.
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Sec, 4032. 'Submission of iriforrnatibn."
Sec. 4033.' Repon.s. ' .
Sec.4034':;Application for grant. I '
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O:\l\1AT\MAT94.539 .
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'Sec: 4035.
, See, '4036.
Sec. 4037.
Sec, '4CJ38,
Allocations for'ceriani; a~t~iti~s: . " " 1
Definitions, '
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AuthoriZation ()( appropriatjo~s,' .
,Sin~le' application 'and uniform reportin~ s:'>"Steinsfor essential pubhr
,health :artj\lties of J'mblie health" ano public health' categorical'.'
.irrant pro!n:~ms a.dministered by the Centers for Disease: Con~ , ','
trol and Prewntlon.
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5~ME~TAL HillTH{A.\-D:'St"BsTA.~CE' ~US~ SYSTEM iXTE(mATIO~'
, Sec. ,4051. lntegrationot'm'ental, health ands-qbsulrice abuse
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',pARi6--,-SrnooL.Ri:LATED, 'HEALTrt' :SERUCES'
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,Sec. 4061.A~thorization of appropri~tiohs.1
;Ser., 4062. Ehg;bility fo~ grapts. I ' ,;
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,Sec, 4063, Preferences, .'
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Sec~, 4064, Plannillg 'arid de"elopment' grants. , ' ,
See, 4065,Grants.for,op~ratiol1 of sc~ool healti1"seJ"vites .
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,'Sec', 40i3, . 'Parity forFederaLfacilitie~ shpportingreseardi. '
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'PART~'::':""!);'ATIOX;-\L HE.-\LTH SER:\lCE CORPS
SeC'. '4051. !\atiolla'l Health~enice, C,orp~. ,"
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PROG~ts
S~c:4 111 :/Fideral .formula payrri~nts .for
the direct. costs of the~rera~ion of'
'~. 'approyed pllysieiml training-programs. '
'. Sec. 4112., Application for:payinents,
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.' 'Set:. 4113, :Ayailability of funds:(or pa:1TIentsj'annua).llmountof pa:1TIents. '
Sec; 411,4. Tern;ira'tion of m~dical' e.ducation pa:~ents( '" ':., . ' ,', ',"
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<Sec. 5002.:Kational Q9alif:\:goals.'
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Sec.500a, Sta~dards a,nd performance measures of quality for ·health plans.
Sec;~5004.- Pian, data' analysis and consUmer ~e~i., i , ' ' , , '
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',' Sec., 5005: 'E~'aiJlat'ioh,and'~reporting of Qualif:\'performanc~: '
, 'See. ,5006. 'Quahtyinlpr~"~me~t, founciatjo~,
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Sec. 500i,.i\uthorization o'fappropriations,
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, ~ec. 510L Purpose:
Sec.. 51 02" De,flt~itions. ';'
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Gen~r~1 re~uirerrleT),son SecretaQ"
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'Sec: 5114. Standards rel~ting tON.Titte~ 'e~~l~nations'ofb~nefits.
'" 'Sec.' 5.115. Timetables for ad6ption 'of ~ta.ndatds.,I·
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" ISe~, '5113'. ,Information transaction standards. '
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51'21. Requirements WIth respe~tto ,~~rl.aili. ·trans'~ctlons ~nd inform,ation,
,.Sec, 5122. Timetables .f9r 'cQlnphance,with requlrem,ents.'
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HEALTH,I!>'''FOR~1ATIO::-:
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"'Sec::5131. A~(>essinghea'lth 'information forlluthor.ized purPoses,
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Sec. ;5133.,Leniihof time i~frirmation'~houid b~ ~ccessible.'
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Sec;5134,'~imetablesforadoption,of~tandar~s and co~npJiance.,·
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PART' 5-:-STA.'"DARDS, A.'"D,/ CERTIFICATIO::-: FOR HEA.:CtH b"FOR:'1ATIO::-:
':1\ETWORK ','
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he~ltl;)nformation' network, servires.
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, Sec ..5142. Ensuring'a\'ailability of information,
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PART 6",-PE:-\ALTIES,
Sec.'
5·151.Geneialpen'al~· fo~ 'failure
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Sec. 5162: 'Eff~ct on StatEdaw.
Sec. 5164, Healthirifo~ation continuity.
Sec. 51~5.Protection of cornrnerciarinformation.
~. ,5166. Payment for health'caresen;ces or,health planpremiuins
, ,Sec. 5167. Health securlt:n:ards., , "
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Sec", 5168.' Misuse of health 'security card or personal health identifier.
Sec. ,5169. Direct lJilling'for dinicaiiaborator;r,sen;ces. ' " / .
Sec. '5170. Authorizatlon of appropriations. i
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"'Sec. ,51 i i. ,G~~erafr~quirerdent~n Secretary.,'
See. 517'2" Health Infonnation Ad\;sory Committee,
Sec, 5181: Grants fof demonstration projects.
,PART
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9':"'-~IEDICARE
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A..'''D l\IEDICAID,CC)\-EItAGE DATA. '
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Sec,519L ~ledicare and l\Iedicaid CO\'erage Data
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Subtitle C-Pr'j\'acy
PART
Informa~fon
of Health
l.....:FI~"Dr~GS A..""D DEFIXITIO!':S' '
Sec.5'20 L Fj~ding"S ~nd purposes.
Sec,' 520'2. Definitiol'!s., "
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Sec. 5207. Authorizations for dlsc)o'sureof prot~cted health information ..
S~c.:5208: 'Certified healt~linforni~1ion network s~r\ices. '
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St:BPA.RT B-SP~CIFIC DISCLOSt:RES ~E4TI~(:(TO PATIE:-\T \'
,Sec., 5211. DiscJosures"'for treatment and financial and administratiw ,trans
',,) ,actions:
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' . ' . Sec, 5212,,·~ext orkin and directoA" information.
Sec. ,:5,213: Eme,rgenry circu~stan'c;s .
" l?t:BPART C-DISCLOSt:RE FOR, O\LRSIGHT: Pt:IiLIC HEALTH; ~~D RESEARCH
"Pt:RPOSES
Se~. 5216, O\'ersight.
SCt. 5217. Public health. '
Sec: '521.8. H~alth' resear:~h ..
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Sec, 5221. ' Judicial and administrative purposes
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See. 5222, l!.awenforcement·",
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Sec., 5226: ,Go\'emm~nt subpoenallimd warrants', '
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sec. 5227, Acc~~s procedures for hi\\' e~forcement ,subpoemis and wart~nts.
SeC. 5228:6hallehi~ procedu~s f~r law,enforcement ,warrants and sub~nas,
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.Sec, 5233,', 'Challe~ge procedures for'private party subpoenas, '
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, Sec, 5237: Accounting for cJ..isclosures,:
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,SeC.' 5242:ATnendnJent 6f protected 'health jnformation,
See, 5243, :~otice .of ihformation pradtic~~, ,
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PART ~SA.'\CTIO~S
SLBP~T A-'-~O SA..'\CTIO~SFOR PER~riSSIB~E, ACTio~s .
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.sec. 5252, :Soliabilit\- for institutional re\iewboard determinations. '
See,5253.R€lian,ce~n ~ertified ~nti~" '.
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Sec .. 5256. Ci\il, penalty. ,
Sec,: 5257, CivIl action:
Sec. 5261; \"rongful disclorure' of protected ,h.:althfu~ormation, "
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.Sec. 5266: Relationsliip to otber laws
8ee;5267: Rights of incompet.ents· \'
.Sec. '5268', Exercise of •rights'.
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Sec, 5301. Deful.itioris',
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Sec, 5302 Claims proced'ures for ·health plans.
Sec: 5303, ReYiew in area claims dispute offices,of grie\'ances based on acts ,or
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'Sec, 5305. Small claIms disPutes. , '
'" &:c.' 5306, AJtermitn:ebmding- arbitration.
Sec, 530i. Chi.! moneypel1alties. ' ,
'~.5308. Technical amenaIDents.
'Sec. 5309. Reasonable care in, conducting pre,authorization and· utilization re
vie\\,
Sec, 5310. Exclusi~'e remedies.
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Subtitle E-Enhanced Penalties for HeaJth ,Care -Fraud
Sec'. 5401. All-payer fraudan:d abuse control prograin.
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.Sec, 5403:, Heali'h care fraud anaabu·seguidance.
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Se(;, 5'414, Actions subject to criminal 'penalties,
Sec. 5·i15~ Slmctiori~ against practitioners arid peJ:'sons for .failure to: compl~: '
\lith stiuutor:' obligations:. .
Se.c:. 5416, Intermediate .sa~ctions 'for medi~are health maintenance organiza
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Sec. 5417. Eff~~ti\'e date,
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PART 2-RE\iSIO~STO Ct.tiRE~T SA."crl0~SFOR F'RAt"D A.'"D·ABrSE .
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Set/5421.
Establishm~nt
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Sec:.· 5442. Forfeitur~sfor FederaJhealth care offenses.
Sec, 5443, Injunctive relief ~elating- to Federai health care offens(;,s..
. PART6....:.;.f'AY)iE~TS FOR .STATE'HEAl.m CARE
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Sec.,5451. Est.ablishrnentof Stat~ fraud ~nits,.'
, . SE'C, 5452 Re.quirementi: for State·fr.aud units.'
F~t~D CO~TROl. .t'!'-.Trs
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S~c: 5454' 'Pa\,men:ts .to Sunes:
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, Sec'. 5501'. Findings- apq purpo~e.
Sec, 5502, Applicability.,,' " ,
Sec, .5503. Definit,ions ..
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l~ALTER~ATr\r; DISrXTERESOLUTio~'
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Sec., 5511. AJfernai~;edisPute relSolution:
sec. 5512" Court actionS. ,
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Sec. '5521: PreernPti~n of State la~., " "
Sec., 5522: Limitatiori 'on am,ount of attorney's contingency ,fees. ,',
Sec:" 5523. Reform of damages; "
,Subtitle
G~Patient's
rught to Seff-Detertnination
Relrcs~din'g
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fleaithCar.e
,Sec. 5601. Treatment, of advance directives:
Sec, 5.602. AIDendri1ents to rules under 'medicare and medicaid. '.'
',Sec: 5603. Study of issUes relat~a,w_ end of life caJ:e.
'; TITLE\l-RE\"E~rE'PRQ\lSIO~S
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Sec. 6000,Amendnl~n~.o(1986 Code.'
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Sec.' 6102" :Modifications of certain tobacco tax pro,;sions, 'j,:,
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importation"of .roll-yourO\\1i tobacco.
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. , Sec.. 6121: Recapture of certain 'healihcaresubsidies 'recei\'edby high-income
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Sec. -6131. Extenping medicare co,'era!,!e of,. and application' of hospital insur·
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'an~e tax to, all State .and' local government emplo:iees' ,
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Subtitle B~Tax Treatment ()fEroployer-:Pr~\ided He~lth .tare,
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PART
2--:LI;i:ITATJO~S O~ DEDlTTrim..ln' OF·E~iPL01r:R-PROYIDED
'., BE:-""EFITi:' ,
·f·
HE...u..TH
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• Sec. 621i. Limitations on.deduetibjlity of empJoyer-pro\ided heaJthbenefits:·
Sec. 6212. Application't~ tax-exempt organizati'On~ and, gOYernme~ts.,
. $'ec: 6213. Denial' of deduetion for ceruiin: contingent employer' ;i)'eaIth, contribl.}7
'tions.
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PART 3~OTHER PrW\'1sjo~S.
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Sec. 6221. Limitation on prep~~lIlerit of medical insurance' premiums. :,
Subtitle C'-':"ExemptHealth Care 9rganizatiolls " ;'
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Sec, 6302. Tax exemption for high-risk insuran'cepOOls~
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Sec, 6303. Special'rule for deferred compensation plans'offered by certain sec-, .
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'Subtitle D-Ta'x
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Sec. 6401. Qualified 10nIJ-term care senices treated as medical. Care:
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'Sec. '6402. 'T:eatment of 10nIJ-terhrcare ~surance:
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Sec; 6~12. ,Additional, requirements for issuers oflonlJ-term care ~surance poli~
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-See. 6413: rniform langUag~ :and definitions.
"Sec. 6414. Effeetiye' dates .., ..
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Sec:. 6421. ,Ta.x tre~if!1eni of ~ccelerated death benefits linder life insurance'
contraets.
Sec:. 6'4~2.' Tax. treatmel')t of corripalues issuing'. qualified acceler'ated death ben
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efit riders.
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Subtitl~ .E:-OtherReven~e Pro\1sions
PART1~TA.x I~CE~fr\~s F~W HEALTH
Si.RYlcES PRO\-inERS.'
, Sec. ~501., .KonrefUndablr credit for certain· primary heaithsei\1ces pro\i'clers.
Sec. 650::? Expensing of medical equipment., '
,,
' .
P ~T. 2-':I'.llSCELLA.,i;oi:s
PRO\-isIO~S
for costaf pers6nal,~sista~c~ ~en1ce~'fequ'iredby employed
.. ·.indi\iduals.
' '
.'
,:'
"
,Sec:. ,6512. Increal'e in sen;ces rep~rtirig penalties.
Sec:. 6.513. Disclosure of return infprmatiqn for administrat.ion,of certainpro-,
{ri-ams unQer, the Health·Refon.l A c t '
,
. Sec , 651·{ Disclosure of .return .information for'administrationof certain, pro;'
\ ' gTams'~lIder the Health Refoml Act:.' ' " ,
.~ ,
,
,
Sec. 6511.
'.
Cr~dit
September 16" 1994
;, '
"
.
'. f
I ..
I
:.' .13
.;
�.
P:\MAT\M.AT94:53~
,
"~
,
STAn', DISCUSSION DRAFT
(
'S.L,C..
14
!
.'
"",
r,
, SuhtitleF.
. ~raduate',~ledicai Education Trust Fund"
,
.
.
,
"'
"
"1
Sec,; 6S01' Establishm~nt'ofgtaduate
"~
"
I
,
'
~
"
medi~'1 educati~n ,trusffu~d,
. ,
•
" .
I
l""
" Subtiti~ G-Autorn~bile lrtsuranre CoordiJl~tion
. Sec, 16 i 0.1 , Defmitions,
.. '
"
:, PARr' i-REQt·IREM.:E~TS·
RELATI~G T6At·TO~iOBri.EI~St"RA."'~ M.EDICAL
" " SER\1CE~'
"
,
'
.'
. , ;
,
"
,\ sec,' 6il Pro\ision :of au(omobile insu~ance medical se'rvic~s through nealth
'"
"
'
" plans.'
,See. , .
6i12Pa\~ent . automobil~ insurance medical seMices.
for
•
,....
'.
-;
"0
,
.
i,'
.
.
i
./"',
,.
!
:
I
)
PART 2~AD~mmSTR.ATIO~.,·,
See,,672l.Pa\"me~t facilitation. .
j
"
. ' : ,:
'
, TITLE YII-.-:E:s'SF'RIXG HEALTH' CARE REFOR'IFI~.-L\-cI:s'G
,.
. ,
.
.
"
,Sec, 1001. E~'sUring health, ctire, reform fiQancing, ,\
" \, <'
'",
" ,t,
'.I
TITLE 'rqI-'-:~1]SCELiA""EOtSA.'Tl'TECH·:\iC4L 1\[EDICARE,AX~ ,
~[EPICAID A.'[E:\"D~[E~TS
'.
,-
'I
,",
•
r
" •
' .
".
of'.' .
Sec, 8000. References in ,title,
"
(
,
,)
, . !
:
•
'(
' .
, Subtitle "A-:Medicare
I
, PART ,1-PRO\lsIO~.S RELAT~G TOPART'A
Sec: 81 m, Limited sen;C'(' hospital ptio!!T~m,
,
Sec. 8102,1IIedicare.depelldeni,sm,all rut&1 hospitals,' ""
.' "
, '
Sec'. 8103,' Prc)\isions relating tQ'rural healtl1 t'ran~itiojq:rrant'pr6gram. I .
Sf'c: ,8104, Sub~~ute c,are sruely:'
,...
.'
,
Sec.' 8105. ,Psycholpgysef'\;ces in hospital!L ,
'
...
Sec.. 81OG:Med'icar~.dei)enderit l1.lralspcondary specialty cen;er demonstration
, ' .
.
. .~
proJect .. , "
Sec, :8107. Pro\ioer s\anl!"f~r blood' centers, '
......
,
,I
'I
/',
I',
"
"'\
\
"
)
.
, \
!'
'
",
: See .. 8201. 'De\'ei 9p ment' ~nd 'implementation of resource.b,ased methodQlo~' for
,
. practice, e x p e n s e s : . . ,
"
Sec. '~202:'Demonstration . .projectS for' medi~re' State:based ' performan,ce'
"'
.
1"
• - c- " . ,
' . 'standard rate of increase.
'
"
'
.' " " ,
Sec.' 8203, E},:panded' coYersg-e'for ph~~siciana~s'isia~tsand nurse pr~ctiti6ners\
Sec, 8204. Direct pa~l11ent for sen;cel> of registered nurse~ ,"'ho are certified
. . . .
! ,
.
"
,
as assIstants at surg·2r....
> ,
'
sec, 8205:' Pa~,.ne~t for anesthesia 'se~ices~'
"
,
See: 8206. E~;E' or e~'e an~ ear hosPitals,
~'l
,
,
,
"
0
,
''0.
, ',Sec, . 83()'1 ~ '. Ext~nsion ~fs()e1alheahllnHii~tenance org<inlzatiotl dembnstrations.
&ie.-S302:' StUdy on mE'dicatespel')ding., . '
.
' " ,,,..
, Sec, 8,303,' 'Stre~mlined proc~ssing- systems,' " "
Sec: 8304, "
Pa\'11lent .. ' certain.medJcal, "
for
de\;e(>s
.. '
.
,
I'
'~I
'
,
, ,
September 16, 1994
_. 'I
. i
"
I' '
�STAFF ,DISCUSSION DRAFT
O;\~1AT\MAT94~539
,.'(
,~
..
, 15
't.
"
,',
S.L.C,
Sec. 830p, Xecessan' ,stabilizing treatment, for 'emergEmc~' me!lical conditions
.' , "
and labor,
"
Sec. 8306,' Medicare seiect. ..,,
S~c, .. 830i.~ /,\Iedig-ap""
' ,,' \,
•
Sec. 8308., Funding under direct graduate medical education for, training in
"
, .', ~on.h~spit.al O\\l1ed facilities. . .
Sec, 8309., ~Clarification of'secondary payer Jorbeneficiaries co\'eredunder
, group health plans,
'
,
,
/
'
,
"
PART4-0rHER .PRonsloss
. Sec, 8401. Cooperative care 'research,
, 1
,,
/
PART l~LosO::TERM CARE PRO\"ISlOSS
Sec, 850l. Elimi~ation ,of rule regarding a\'ailability of beds in' certain institu
. ' '.
."
.,."
" "
':. tiOllS,
,0'.
•
•
'
Certain demonstrati~nprojects permitted:underthe, medicaid pro.'
,gram,
," "
"
'
Sec. ~503: Elimination of requiremenf ~f prior institutionalization \\ith respect
"
to habilitation senices furrushedunder Ii waiver, 'for home or
communitY-based seni'ces.
Sec, 850~, Relief from thi;dparty li~bilitr requirements\\ilen' cost-effective.
Sec', 8505. State t;!:l..-penditures for medical a~sistance \\ith. respect to 'home and
'commun'it;·.based.senices prO\ided under a wah:er, '
Sec, ;8506,· ExtenSion' ~nd con'solidationo~, frail elder,I~'demonstration project
.--,wah'ers, '
Spc, 8'50i, Certain impro\,(?~lents ~in medicaid casemar..agement senices and
,."
, 'home and ~omnl'unit~·~based'waiyers., '
Sec, 8508, Dt>monstr~ltion ,projects on acutt> and long-term cart> iritegration;
,.chroniC' care commission,
"
S~c, 8509, 'Preadrnission screeni,ngfor ~entall~' retarded indi,iduals,
Sec,
850~;
,.'"
\
,:
i',
;:.-
,
PART 2---:-0THER P:i,tm"ISlO!'S
\
,
Sec, ,860 L H<'\isio.n or' Fedf>ral, medical 'assistance percent.ag-€' for certai~ Sta,t'es, ,
Sec, 8602, Criteria for determining the amount of dishllowances,
,',
, ,
Sec. &603. Te~hnical corrections relating
secticin'47 52 of OBI}.-\-199'O '(phy:
sici~ms' senicesJ.
' ,
Sec: 8604, Technical' corr~ction relati~g,to ,section 4712 of OBRA....'1990 (com
, 'munity supported Ihin'g arrangement~~sen,ces), '
~c: 8605. •Ext~nsion of minnesota prepaid ~edicaid demonstration project. ,
Sec: '8606, Extensio'n of~loratorium on treatment of certain facilitIes as insti·,
, tution~ fQr mental diseases,
"
to
/
"
~
1 'SEC.,2. FTh'DINqS M'D P~P0SES. ,
"
"
\
,2
[To l?e supplied]
\
.
, 'j
3 SEC.'S: DEFThTJTIONS AND SPE'ClAL'RULES. '
(8) DEFI:;\lTIO:;\S' A.,\t>"SPEClAL R'L"LtS RE~'\TI~G TO '
4,
5
.
'HE.-\.LTH' PL\S,S.-For
.
,
,
purposes ofthis . Act-'" "
."
,.
-
,
'
I:)
�,STAFF DIS~USSfONDRAFr
, .b:\MAT.\M.A:r~4,539
~. 1
•
.. ,
16
(1) HEALTHPLA.\ .-". i.
J.
!
,
'9,
10._
;
. ~\
. .,.'
\ '
'
, ":' ·"(iii),A'
,
. .' '( ".
'.
.
,
,
.'
~ocia~. Secu~ity Act): '
.'
"
Ipe&c~re" .s~pplt;mentalJ)olicy·,
.: ' ... (iy) Coyerage issued as a 'stipple~lent.
"
Ii
17
,
"
.
.
.
" toliabilit,· illsurance'..
.
,
.;
. "',
"
,.
'J8
.' (v), Gel)eralliabiiity. hlsun.mc·e.·
. ..
.
,".
.
t , (1
.' : " ' .
'
20
. .- ~..... 1
.
21
-,'
\'
\
, (,,) \Vorket's' compensatioll or' ~inlihlr'
19
",'
.,. •. "
, - (asdefined-"il~ tsectio~·1882·(~)(I)of··the
';'
16
-
) . ,,;o'tk on'ac~oU:l~t or'sickness or injury..
14
15
t-
. .' ing which the . e~nployee . i~: .absent- fro,nl
-~3
,
',.
'
{
.
12
.
~nly Jo:r;-acddentai death
,mentsin ~'euof wages fotanyperiOd.dur-· ,
i
~
msurance..
.. ,
, ' . '
,
,
.
.....
(viirAutom~b~le: 'or 'autombbile inedj~'
, ,
22' .
I'
"""'.
"
(
. 23
. '. (yiii) A. ·}ollg-te·rni. car~polic~·, includ
"
a
ing . nur~ing. home fl..xed· indemnity .policy "
.'. ,24
..25··
(uDless.· the Secretary det~rmines'. that- such'
c
.
r -
.
•
~
•
.;
September,~6.1994 . '"
.
.
"
"
'..
:'; , (ii)Cm'eragepro,iding wages-,or",pay-'
';'
-1 1
. ':
t··
'
".,
"
"
,or disnlemberme~t..
8
..
te'rnt
,
(i)· Coyerag~
,
.
,
" '., ·iion ihereof: .'
7. '
I
,
' , '
,
6.
"
" .
.; does' n~t . ' . 'the' foU<)\\ing, :o~ an'~': conlhina
irtcluc1e , '
'
"" .
·5 '
,',
/
.or .pays the .c_ost of,healthb~~efits: such
, .•.·.,4'
,
. "'
"
'.>
/
.,,'1' .'
' .
. '.. , " ,means any pl~~, or a:r;-rangem~ht ,Hlich Pfmides,
:
.
'3
. ,'
.
.', ;(A)I0,,~ENERAL.~The term "healtlLplan;" ;
2
\ ....,
,-
,I,
..
'.
, . '
I
d
"
-',
.
'
�'. 0: \11AT\MAT94.539' "
1
'
..
STAFFDIS·CUSSION. DRAFT
..
. coverage of a.benefit
'2
3
4
. S.L.C. .
so 'that' ifshould be'
I •.
'
treated as ,a nealth plan).
.
,.
'.
.'
;
. ·.(i.x»'A" specified disease or illness .in.; .
.
.
.~
,8uran,ce policy.
5
.- .
6
come.:prOtection policy.. "
/
8,
')'
.'
~
,,(x)' A ,hospital or fued il)demruty' in-.·
, .
7
.
. ,
.. ,(xi) A disability income policy: . \
(xii). Irisurance ,\'iiH~ respect. to acci:
9
"
.
'...
"
. dents~· : '
10
::12-
'. gram,'
.
.
.
, (xh·r Sucp other plan 'orarr~i1gem¢nL .
13
.
"
*I
,
14
as t'he Secretarv .detehnines'
'15
\'"
,(i)
18
Ix
I
,
" . '
. '
16, '1994
,
•
61"
"
'.
,
.'
1·
. ,'. 'tion, or' preferred prm1der '.orgaruzation
,
!
\
.
group contract' offered by an insurer~ ..
.
'"
'
' .
, . (ii) J~Sl~RER~-.Th~ . term'. "insurer',"
.'
September
. .
1,.(
contrqct, ornealth n1ainten~nce organiza
22
,,25,
' .
certific~te, 11Ospi~a,1 ·or medical' se·n1ce.ph~n '
\
~,:,
'·24
:.
term "insured.'
is a hospital: ~r. medical se101Ce polic~'
21
23
. '.
GEXERAL.-·The
.
. health plan".'nleans any' health 'plan which
19,
,20
.
. (B) ISSt:I\ED HEALTH fL.4...."\.-·
17·
-
is hot a health
.. '
! .,
~
.
plan.",,'
~
16
..
.\
(xiii) An' equiYalent,' heaJth \care pro-
d1
\
.','
. means-, .'
. t 1.
�,i .
.
, ..
'
.0: \MAT\MAT94.539
i '
:'
,-,
" .
"
j,
..
,
'\'
,
.. ..
<.,
'
,
" .,:zatioii,
..
6,
,
l
"
.,. \J
_:
",'
.
'"
.~'.,
,
..
,
ari', entity.: described in" subparagraph".
,',(C)),
,
I
,
'
,.,'
:which'is engaged
,
1'2,
. \
I:
'
. • ,'
,
,
In thebusihess 'of prmio-
•
"
'1
~.
""
,
13 '
"
..
1,6 ',,'
'
,
~,
.' !
~
, ;, which
"
'.:
,
.' , \ .
"
is 'a group health plan-,'", ' '"
.
, (1)-: ,:wliich)s ,established~nd
l8,
,
,"
,
,
....
<',
rnaintairied,by' a.,' l~r'ge empl~J'er,~ and
,':19 '
•
\.,
I,'
',,_,'.
\',
.
'j
" .
, ',' ,(1]) under' wluch Ihe largee~l1-
"20'
,
'
'
,
,
2i
ployer 'retains a
,
'
sub~tantial
risk for
"
22' ,
, 23 '
"
, I
~
,"
"
'1
, the, prc)'iding
,
'
of~ealthbenefits, upder
\
,,-the plan.', .' ,
24' ,,'
.
,(ii):GR6rpHE.-\.LT~
pL.A.. .-Theterm' ':
~
,
,.' . I
'
,
","groupJl~a]t]1, ,plan" ,mea,ns ,all, emr1oye,e,'
,
,
.
..
Septembe'r 16, 1994
. i:'
•
,sured health plan" means a', health plan
" 17
','
,0'
.,(i) ,'I:-," GEXERAL.-,'The 'tern)' "self-in-,'
'
':
'
., ,
.
,.
:
'..
'.
,
;ben~fits,
15 '
',t
",
, ' . , • (C) SELF-I~srRED HEALTH PLL'\'-' ;'
,,'
14
.
-,
'ing'a' plan of health irtsur,ance, or health
,
'
"
'",
'10'
'
I
'
(\"')' .any similar entity ,(other. than·
.... .
.."
"
,
I
\,
or, '",
m~atlOI;l,
9
i '
,
' '"
"
8
prgaru;'
"
,,'
" ,
J,
,
7
..
'
,:. cry) a'health:maintenaIice 'org~"
"
\',
. II
'
; (IIi) ,a ,'preferred "prmid.er
'
,5
;
".
~,
,
\'
, J '
,
, , ,',senicepl~n" ,
4
,
"
•'(II), a.prepaicl hospital, or 'medical
3
,
,
. ,
, /(I)'a licensed insur~.ncecompany,
Ii
:2
,
,
'.
1
"
,
"
,
'
..
. ;
,
�'i"
0: \ MAT\iUT94.539'
.1
, STAFF, DISCUSSION
DR.A:FT '
S.L,C:
19'
I
,
.
,
'welfarebeneflC plan ('as.
. ,
' : defined in se~tion '
1
~.
, ',2 '
.,
'
,
I
;'
1,,"
,,3{t ) 'of ,the, Erriplbyee Retirement, In~on:e
'.
'
"
'
,
"
'
, Se~~rity Act ~f19 74) pr~)\-iding' medicai. "
3
,
4
.
.'.
,.
'
defi~ed' in, section '213'(d) ,'of
care, (as'
c
'-
: .
,~
'
"
'
the,'
"
(
.
. ", Ilft~tnar ;Re'tenue,Cod~of'1986),topa,rt.ici-',
5
,
6,'
',\
'
, pa'nis or beneficiaries, (as de~ned' i~~:ection
7
"
" 3 of theEmplo:;eeR~tirement Inc.ome ,Se': ~'
,,8,
." ...:
curit)" Act of 1974) directly or through re·' ,
,.
"
,
_.;
,
9,
•
.
0
•
>
"
"
'
. '.
.'~
" 11
, !
, ' 12
'/
.
.
...
','
,
r
,
~
.
,
-
'
'(2)'CERTIFIED 'HE~lliTH :PLA."\,-'Tile' terrn"cer-'"
'10
;
"
, lrpbursem'ent.
'
"
,
,'.,
'
;,'".
"
'~'tified 'health plan ','. m~ans a. , ,'})lan which,
,health
' .
'.,
,~:
\
is cer-:,
.
'.
,
.
,
"
"
'meeting the applicable require~lents ,of this Act", in
13
•
' , '
•
\
j
~
,
'
~
0
"
:14 ,'\ \; ch~~ng', the 'offe!ing of ,the' stal!da~dbellefits pack. "
;
",
I
.
, tified , b~' ' the" appropriate',' certif.\-ing authority as
":
" 15
',-
'age;: and,at the ~ plan~soption; . the
.
,
,
"
.
b~s~c'
'/,
i
.'
j'
benefits
. ..
,
, "'16 , " package or' the catastrophic benefits, packag~, 'A'
.
.'
, f;
, , 17")
,
.
:
.'
,
l '
'
."
.'
.
,
'
~.
health j)lanshallil0t fail tO,be treated' as'a certified,
,"
,
,.
•
.
,
I
,
'
,~"
i
~
\
.
retan" under section. 1876 of the Social Securitv'
'"
,
'
"
~.
,
,\;"
Act, qr
.'
tI._
'
I"
23
,•
24
'.
.
•
. ,
• .
::
."
,<' ' .
.
.~
..
.
(
I
benefits:' pursuant' to ail, 'agreement ',uilder' $ec
,~
'25
o·
"
, tion 1,833(a)(1. )(A)
"
,
of ~;uch Act.
-
'I
, I
."
,
,r
'
,
,
\
"
'
"
;
'
~
September 16.. 1994:
. '.
I
r '
"
19
�.':
:/'.
0; \ MAT \l\;1AT94.5;39 '.
,.
,
'1 .
"
.
.
.
'. STAFF DISC1.,'[SSION .DRAFT
S:L.C",
,
, 2.0'
I
'2,
,.,
'.
'
The.' term' ::'comm~nitY.;ra,te~' . ' health . plan".
"
(', , me~ns 'a' Jiealth pla.n, wruchmeets the require.:'
5
"
. mehts.of se'ction. 1013..
,
,6, ..
,
...
;.
.
""
':":,
",
•
'1'
12
.,
':
'/
•
..
.'. '13
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"
."
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,
:,'
..
.
.
.
.
.
,
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i'
,'"
..'
. '
~
I
(0) S)L-\LL E~1PLO\~R:-Theterm "small . .'
"
. ',' ,
,',
'.
'.
"
).
,
/ employer'.' nleim~; ,with fespect ::to~an~·,calendar: .
\
20" '
emplo~1er
year, .any
.\
"
·.··21
,
.'
:;
.
"19
:
,,;'
" roll in:a ,certified .~ealtl,l plan offered b~' the ',,'.
"
18
.
:.,
'.'
·~.al (deJern~l~ed ,dth'~uf~egard to t~s s~b~\ .
.
"
. . ; '2::> •
-
\
if,'
.
on:each~f 20
.
" {
:
.
days :dur- : .•.....
!
,I
'ing theprecedihgc~lend~r ye~r" (eachday'bei~g
in' ,a' diffe~'el~t'- week), such '~mployex .( Q~'~my. ",(
"
• .' I
• •
t.
"
;.
.',
•
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'.
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•
.
,,'
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'prede~essor) 'emplo~~e(r les,s' 'than 100;full~tirile. .
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•
.
,:
"
,
:.24 '
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. September 16,,1994 . '. .
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erqpioyees fqr somelportioriofih~- da~·.
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ofa ~l?irge employer.> a'nd :who 'doe'~noLei)~ "
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an, eA-perien~e-rated iri~ ," .
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EXPEiuE~CE-RATED: HE.\LTi-I PL~,\._i
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DISCUSSION DRA.FT
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:an insured: orself-ins,ur~d health ,plallCOyeri~lg
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anin,diYidl}af '~ho 'is an e~lplo~ree(or' the de~
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a' qrialifled association (as. defined in section'
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, (F) 'LARGE E)IPLOYER.~
12
(i), I~ 'GE~E~.-"The t'erm "large,'
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15 '
endar
~Tear,
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arty- emplo~'er if,. on each of 20
, ,,'days ' duri~g
, 16
the
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,emi)lo~;~r'i ineal~s, "ith' respeCt to, any' cal-,
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1-00 ,"~i more full-u'me employees' for- some,
, '.portion of the da~\.
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': • ,(ii) AGGREGATIOX Rt'J.;ES ,FOR E~t-
21
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,", PL01'"ERS.-'F or ,purposes
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of titJ~ 1-", ",,'
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'of Organiiati~ns which
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are under common, control with
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be treated' as'a, single'
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, section (a) or (b)of':section 52 of, ,
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one or more 'orgaI?ization~which
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Re,'enue, Code 'of J986 shall be
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tre&t'ed, aseinplo~~e~l>by ,~~ingle' ,
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,(II), ELECTIO;\!~NOT TO, AQGRE-<,
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coinInunit:~ rating. ar:eas. 'Upoi~ ~uch,
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, September 16,1994
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STAFFDISCU~SJON DRAFT
,O;\M.AT\MAT94.539 .
, " 23.-' :
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',' ~s a, ~maiI emplo~:er' in qnycommunit'y
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than 100"full-timeemplovees and as a'
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. large e,mployer in' any community .rat~ ,
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irig area in' vi"llich, it' employs' 100 ',or "
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,.' more full-time' employees.: Such ele,c- . "
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tion shall remain in .effect for a period:,,'
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'of not less than' 5 years. An employer
'mav, re\'oke, suei}' '~lection' after such
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period', by notifying the Secretary'of
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Labor Ullder rulespresGribedby:the', .
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Secretan<
13
, (iii) .. SPECIAL . RlJLE' FOR· LEASIXG ,,';,
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. BVSIXESSES.-'In ,the case' of .allf~mplo~:er
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()~ the::~mplo~'~es which,
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:0: \ MAT\,MAT94,539
I,.,
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(II) this'Act shall
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to its other. ·em- '
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."full-tim~ e~plo~Yee" means" with, resp~ct to an;;
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least ,30 .hOU1~S of senrice' per',~eek Jor' ~n ~m-.
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. September 16. 1994 '
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'~app~opriate 'ce;ti~ink . authc):dty",_
,
23
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.ApPROPRIA~E' 'CERTIFtlKG
"(1),
21,
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~tich: indi)idual shall have' the. status ofsucll 'ell- ..
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'~rage under a health .phm as th'e' sp~use or ,a
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�SrAFF DISCUSSION DRAFT-
Q:\MAT\MAT94.539
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of~n 5ns~red health pl~n;t ~llY " '
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: (2) , DELf'LRi", 'SYSTEM.'-!The' ter:m'-'delivery "
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9
'model health, 'l1~ai~ten'an~e' "o~ganizations, '. and ' SU~l,l
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(A) 1\~ho is', a child (,,~tlli~ the ,meaning of "
14
, , sectiOll ,15i(c)(3) of the Ii1tern~i ReyenueCode",
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)9"
20
(within ' "the
,,'
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151(c)(5)(C) of such Code}.'
(4) E:\rpLOYER,E:\lP~O\r:E, A.~D.E~fP!Lot:\m~T , "
22
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24
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. '3121 of' the ,;Iritenlal . Revenue' Code. of
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1986,
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22
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of section' '3121(h)
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,Eml)lo~l11ei1t . shall not
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include ,seJ\lce~' performed· in .a 'penal
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�.'. STAFF
O;\MAT\MAT94,539 .
DISCUSSION DRAFT.
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instituti0ri',by an irimate thereoLorin "
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a hospital dr'Qther health c~re institu-'
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(Ill) EXCLVSIO); OF PART-TI~fE'
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DOMES'rIC '; SERX1CE.-Employment
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in a
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priYate home of the employer (within
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'the; meanipg· sectiori~i21(a)(7)(B),
8
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. b~'an indhidual
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who is .not a Jull-tillle
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. '12
(IY,) . ,EXCLtSIQ); OF. SEASOXAL . - .
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TE)fPO~Y .-'Employment sl~aIi'·"
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not include' s'eason~l
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14
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temporary~
;
.
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senices performed for an emplo~'er' for.
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15
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.
less than 6 mOllths "in' a calendar ~·ear.
16
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'('VI) COXSIDER..\TIOx' OF ' I>:Drs~
.. 17 :', '
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TRY PRAQTICE:-...~ prmided '\lnder
19'
regulation b;·, the Secretary of J.Jabor, .
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'8n' ~nlployee .
shall be cohside~ed. to
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'''eiilployed' on,
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~f\Ill-time .basis'by
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be .
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enlplo~~er (and to be.a .ful1~time 'em:
22
23
:. ployee
of all
employer). fora month' .
24·'
(or foran'monthsina 12-m~nth pe
25
riod)
if theemploye.e
is' ernployed, by' .'
,~
, "
September 16: 1994 '
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, O:\MJ~:T\l\-tNr94.539
- STAFF'DISCUSSION DRAFT '
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tliat \ E(mplo~;~r' on a continuing' basis
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that) taking into account'the structure
or' nat~re ~f emplo~"A1ent in'the indus
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in that .industry.
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'(ii) EXCL"cSIO~ OF 'CERTM~FOREIGK"
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'senice~ if the individual is n&t a citizen' or':,
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ice is performed ;'0utside the: United Stat,es.
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term ,"employee" does'
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(C) 'tlH~' }ieai,th care program- for·' active.'"
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(D) the veterans health" care program
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Code.
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September -16, 1994,
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STAFF DISCUSSION DRAFT '
, O:\MAT\MAT94.539
\
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"29
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, , (Er:the Chilian Healthandl\ledical ,Pro
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gram' of~he: uriif~rnied"Se:nices (ClL~rpUS),
'2
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'asd'efined iii section .1073(4). of Jitle: l'O,Urtited
l
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',States Code, '
4
5.
6
~nde'r: the I~dial) Health Ca~e Impro'Tenie~t' Act ;'
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, (25 IV .S;C~'1601ets~q.),.arid, ,',',
'7
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,,:(F) the In~an', health se:n1ceprogram'
,(G)
8
a:, State' singi~-payer ~ystem' appro,red
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(6) /FA)I.ILY.-,The term'~f~Ip.ily;' inclup,esan
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10
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, ~ indhidual1j the ,indi~idua.f~:sspouse, an,d theind.i'id-,',
,
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12<
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u~.r~s dependents (if', any), as, defined in paragraph'
13,
14,
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'(At an insured / health plan, ;the ~in~urer,' '
arid ,','
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"healthphin, sponsor" nleallS"dth respect t~ , '
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" (13)a self-insured· health plan, the, large
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,:. employer ~ponsor.: . "
19
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(8) , "
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which such 'seD1c~s areprm~ded. ~
'24-, ','
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, gally authorized,topro~ide 'services ~in the State. iIi'
'23,
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term
';health 'professjonal" l11eans an ipdhidlial who is Ie-'
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'22"
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Hill TH ' , PROFESSIO~AL.-The
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LEG-:\,LLY' ArTH omzED .-The tetm "legally,
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au~llOrized" 'means, ,,,"lth respec~ to, a' pro'1der~ au
25
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~epl,ember 1,~. 1994
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O:\MAT\MAT94.539
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STAFF DISCUSSION:DRAFT
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, - 'I " . thoriz~tion :under lic~~lsing ,or ,certification la\'~s' of. a ,',
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, (i2) PROYIDER.-'
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(lay, "Pt:~CHASI~G,COOPERATtYE':-'The ·'ternl
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"Pui:Ch~Si~gCO~perative';; 'me~n8 ; lik~lth insur~'nce,
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"," purcha'sing cooperative'·establishedunder sectioli
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(11) .PARTICIPATIKG ;STATE.-:The term.""par- '
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8EC~ETARY.-'··'The," t(;rnl"
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,nleans· the Secreta~'"ofJlealth an:d HumanSer\1ces :
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'the~ew~rai "States, :':the'
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>Commollwealth oL Puerto Rico,' the
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:'(r5) 8TATE:~Tl~\eterril "St~te"me~ns each o'f
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Secretary:'s~delegate .•; ,.:', "
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DISCP~SION
. STAFF
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~TITtE I~BASIC INSURANCE'ltE
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" : FORl\iS , TO'ExPA1\TJJ;'
'ACCESS " '
3 ,,:'\' TO:HEALTH 'INSURANCE,
'. "4', Subtitle A-Standards. for Reform,
2
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5 PARr'l~ESTABLISmmNT AND APPLlCATIONOF:
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7 , SEC. IO()I. CERTiFIEplrEALTRPLANS•.
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A certifiedhealthC-plal):shal1, mee{the,apI?fi~able. te· '
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10 plans and pa,rt3 forself-insu'red hE;althplans.
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, -11 , SEC. 'I002",GEt.."ERAL RULES;
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13 ' ,quirement. or standard is imposeq 'on a'hE;alth'plan, the
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or ~~artQard is .deem~d to have ,been imposed' ,
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tl~~ ,insurer or spoi1~or of the plap::in ~elati~n to' that
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Secretary/and,,:the ,Secretar\~ 'of
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,- 22 '6fp~blicaJion, '.subject to change baseq hIl suqsequent pub~'
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, . 23 ,lie comment. - ", "
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Septeinber 16, 1994 '
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, ,STAFF 'I;>ISCUSSION DRAFI';
,",
, O!\MAT\MAT94.543
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, 2pos~s ~.f.thistltle,the· t~rnl.'/ref9~
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st~ndards", ~earis ,\h.e"
3 'sta~dards ~staqlished,and,,~pplied u~der 'this subtitle,'
"
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':,(C)i~Ef~RE'~9E'+O REF~R~i ST~l>a)~DS..~Forp:u;'~~ .
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SEC. lOll. GU~ED]SSUEANDRENEW,A.Ll
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September 16.
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.(2) Ay..u0lliLITY.- ;~"
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,(BJ s})all :offer'such plan for: e~ch: Class' 'of
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,',erage .uI)~~r' the plan through.'t~e .indi\1d~ .. "
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eA-perience·rated:, certified,
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'STAFF DISCUssiON DRAFT
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, ,paragraph ',(4), .' a' C;onu:puruty-rated~erti£ied,
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he,alth"plan'shaH be made. ,avall'abl,e throughQ~t'
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h'ealthplan maY''',deny coverage u,nd~r the
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15
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ing'in a contiguous c~hununity rating' atea'
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. September 16.1994
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,STAFF, DISCUSSI()N 'DRAFT,!
. O;\MAT\MAT94'.543
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applicable certifyirig 'aut}lOri(y:, if required, '
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that ,its. fill'anCi~l or provider capacity ,to
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s~rve' pr~viously c~ve~ed 'gro~p~' or mruvid-'
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graph (B), a:certi~ed/heal~h pl~n may cease en
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'to/ eIlr~ll other indi'~duals. ',','
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on
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,afirst-¢orpe-first-s~~'ed' basis (excepfinthe',,),
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para~apli' (A)(ii) }:' Indh1a~als shan be' prm1ded
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"1th ,a fair opportu,ility.to, enroll" regar~~ss, of ., '.
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, , ,September, 16, 1994
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'STAFF DISCUSSION DRAFT> '
, 0; \ MAT \ MAT94.543,
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IA..;..:J',
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the method· of enrollment or the date of' the '
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"open enrollmentpe~iod iI) accordance'vd~h ,~es~ ,
1
, established
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In" the' Secretary."
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'(4)NETWORK pLA-~s.-A network plan ma~' be '. '
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made
a,~ailable only in a seA1c~ 'a~ea '\\1thln ~r con
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, , tigllous , ..1 th the borders of a community rating area'
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, 7 i f the State
,8
•
det~rmines;1inder secti9n, 1302{b), that
" the follm'1ng, con,ditions are 'met-"
.
9,
"
ice area in
10
11
,
a manner
that has the effect of dis;.
" ~rirrllnating,a'gainst' an individual 'or' ,groups' of
,
12
,', indi'1d~als on the basis of -race, national origin, .'
,13,
,
,',gender,' la~guage,sacio;,econorrllc , status,' age;,
1',
disability; 'qr health.. st~t~~;' '
. -..
14
,15
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':county, or3~~git:zip 'code' 8:reai and
,
(iii) the "network, plan shall ,particIpate, In
18
'any 'risk "~ldjustmentpr~grah1 established for,
16
'the cominuruty '~ating area 'involved; or
19
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(B) the ',ser'dce a~e~'has' be~n ,:apPI:pved
, . , 20
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21 . ,p~rsua~t to' title' xIII of' the cPUblic H~alth
2.Z
, " 23 '
; 24,
'Sen1ceAct: ,: , "
' . (h) REt\EWAL.-', ,
, (1)
.
25: '
I~, GE~LrL.\.L.-Except as prm1dedin ,para.. '
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September 16, 1994
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�. / . 'O:\MAT\MAT94.543
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S.L.C.
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an indhidual shall be renewe'd at the option of t~e
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. indhi<iU:al..' "
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"\(2)GR'Or~"'DS FOR REFUML TO RE~"E'\:.-..
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(A) lK GE!\"ERAL.---;-Except. a~( pro)ided
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'a certified, health pian spon-··
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sor'may., 'under no . circumstances refuse . to
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or for any ;reas'oIi .terminate,.acertified ......
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health plan ',ith respect to~ny indi\;dual, 'f~m~'
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,{ii)'fra·p.d o~ the part of the ,indi\~duai·. .
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(i'ii)'niisrepresentation .'. 'of . "material
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\' benefits· or' .. ' . .
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,IK :GE!\'"ERAL.-.·An
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insurer shall " ",'
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,renew. ,a
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insured health plan
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of deliYery 's~·s.....
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September 16,1,994
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STAFF DISCUSSION DR.A.F'r
0; \ MAT \ MAT94.543 '
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teIl1",th, respect tp' a cpn~Il111nity-r~ted ill:"
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~nles~' such insurer-·
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,en }pro~rides iJ.otic¢, to 't~e appro~
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, ,;' priate certifying authority and toeacp
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ual$ in ',a State; and ~
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such irtdiviquaI covered'under the phtn " ' ,
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:ofsuch. termination at least 18'0. da\~s
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before the date of ;e}"-pirati9I1 of the
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plan. ,',
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,147
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'thecas~ of such a:' t~rmi-' "
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nation,· sllclL insurer> " .pro,ide'for
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the 'issuance,' of any certified' insured health
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C~Il1Il1unit~·.rated: individual' insu'ch 'State
18
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, during the5~yearperiod' b~gi~ng on the
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date of,ipe terminatio,n of.thelast plan 'not,
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.so renewed: '
22' , ";, (crFEirnp;,pLA.'\s:-,An~:i certifieq,he'alth plan' spOn.;
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'sor participa.ting in the Fe'deral:EmployeesHealtli Bene'· " '
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,. , , 25 \ acorri.hninit~;ratingarea,'shall offer,a,comrhupj,ty-rated
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S,eptemoer 16, 1994 "
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,', 'STAFF DISCUSSION DRAFr
O:\MAT\MAT9t.543 '
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l' certified health planirt such area,. ~xcept that'tlii~' requir.e
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3, graphs ~(1):,(2j,:and (3) 10£ section·8903?ftitle 5,:Unite,d "
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7, (other .than subsections." ('b)(l)(:B), (b)(2),' and· (~)( 4)),
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, ' 9' inexistence as of September}993,' which bears the risk
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'11'Drgariiz;tio,n described in sectiDn. 501{c)(fhof the Internal
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'12-. 'R€\t~nue C~d.e ~t, 198~;\\·}llch. is' exempt . £ron)' tax~tion'
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13 .~nc1ersection 501(a) ofsu~h\Code.',·,·
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(a)E!\~OLL~IE~T,PRod~ss.-·.,,· , , '
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'J6 ' , , ','", '(I)' I~' GEKEm'.-Acertitled,healthpian' shall"
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establisha~l ~nr611mertt ,prDCeSS c6nslstent "iiI?' tru,s,
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by the, app;Dpri~t'e'~erllf)~ng '~uth6rit~~ under'secti~n
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GE:,\ER.~", E!\ROLL~1E:,\T
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PERIob.-,Each
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�,'ST~ DISCUSSION DRAFT .
'0: \1\1AT\MAT94.543
S.L.C,.
IA.... 9· ':
.,' to;~nroll( or change:erirollment) in ~heplan during
'. 1
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g~neral '~n~uai' ~nrbllrnen~period specifi~d );;)i
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each
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t~e~ appropriate'certifying authority: under se'ction"
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1308(b). '
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(4). SPECur '~KROLLI\lE~T/ PERIODS.-,'In
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the;.
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case of an individual wh~,:'
7
,'(:A). throughm~rriage,separation', di~orce",
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" birtho~ ado,ption of,~,' child, death,expen~nces
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1 0 ' · ." .~B )eA;~riellces 'a chatige' ih employment '
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(including a significant', cl1ange - in tbe ,
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,13
'tiim8tioncov:erage;'
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"(C)'ch~nges re~id'ence to another c'omniu
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, (D)'clisenrolls for, :cause from a certifie<l,
16
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nit~· ratin~- area; '.'
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each' certified health'p'hm shallpro\;de for
a'special
21
22·
ual-is petinitted' to cha~lge :tl~ejndi~;dual or family
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23 ' ': '.basi~.of coverage or the plan' inV:'hich ,the ,'employe~.
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,or indi\;dual is enrolled.
25 '.
{b)CO)DIE!\CEME;\'T{)F COYERAGE.
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September 16, 1994
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�, , " . STAFF DISCUSSION
: ():\MAT\MAT94.543'
DRAFT
S.L,C.
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,en
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I~GE~""ERAL:-In
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. 'enroUmel1t 'period, ,coyerage under the~. plan shall ',' "
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b'egin ,notlater than the first dayo~ ,ihefirstmonth
4
" that. b~girisl5' da~'S:after the dat~ .of enroll,merit. '
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child un,der suchc'enrollee's 'certified: health' pian (re~ , '
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"adoption of a child o{an'~nrollee,'coverage of such
7
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duringaspecial'enrollmenf period ,provided' under ;, '
13
sutsectio~ (~)( 4), fo!' ;qeast45da~'s;
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SEC. ' 1013., RATING LIiUITATIONS FOR
.
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C()MJ\iID.m.RA'!'ED' , '
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" 16,"" '" '(a) ·STA.~"DARDPREMIU~IS ,\YrrH' RESPECT <T() COM~" '
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Ml'KIT1'-R...-\TE:b , ELIGIBLE,t~Dr\TI),(;ALS;-"Each
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c'e'rtified
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the plan <is, to be o,~ered"lJ.staridard pr~xntum' for indhid-. ',', '
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21 ',ual enrollment: for-'' ,', '
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(1) .t~e ~tandard b~1Jefits package"
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(2)' the' ,b~sie' benefits
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p~ckage, and'
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(3) tlie,catasfrophlc benepts pac~age,
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'" September 16, .19~4
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STAFFDISCUSSIQN'DRAFT
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2 "I!\G ARtis.-'
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(1) '1~ "GE::ERAL.-';Subject)o paragraphs (2)
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a~d (3)"the'sta~da~d' pre~um for' each p~ck~g~--de- ",'
' :scnbed,~n SlibsectioI;l\ (a) shall 'be, ,the same,but shall '
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rol.lr:O.ent that woUld ',~aI)' depen,cling on whether the '
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thr~)Ugh a' purchasing coop..
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tJ~rougha
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11
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, ,(A) I~, GB~;ERAL:-,''The premium charged',
12
13
"for cover~ge in"Rcertified health plan which, '
14
covers conmliJ.riit'r~ratedil1diyidtialsshallbe the
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(i) the,starid'ard prerhium :(established',
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than indh1dual enioUnient,', the, family ad
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graph (B); anq ,
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'Jllstrnent factor 'spe<;ifled
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"(ii) in the case', of- 'enrollmemt other'
18
21:
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, , (iii.), the age adjustment :factor (speci - ' '
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" ,; "(3) FA?lIILY
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, 0: \ M.AT\MAT94.543,
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·IA-12' .
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or IK GE>:ERAL.-.'Th~ ref~rni stand-",
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.' (iiY CLASSES,~O~ 'El\"ROLLMENT.-,For '
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.,: 'c(I) Co.verage· 'only of.,an' individual
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'ap inc4vidQal :described~ in ' '
D, ,
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sUQclause (II) (referred to in this Act
13
as the "illdhidual" em-ollme'nicit Class" /
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, "pUrposes qf this Act, there, are 6 classes of
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~or individual enrollment).", .
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, " ,of enrollment (as compared with such costs
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child~;' enrol.lnlent or' class' of enroll-:
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ferred to in thls' Act 'as the ,"single' "
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of two, or
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a~' the. "multiple children" enrollmen:,t'
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CO\~erageof.a.
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ple\,it~ouL chi,ldreh' (referted:tq in
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, ' . September 16, 1994 '
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b:\lt1AT\~'ll9~t543
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,tliis1\ct as ,the "couple-ollI~c" enroll- ,> '
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tv) , dQvetage'~/ ;an 'i~diYidu~i
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(VI) Coverage, ofa married ,cou~
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, en:rol1m~nt or, class, of enrollment).
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~EFEHE!\CES
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,(I) FA!;1ILY.-'The, terms "famlh- ,
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enrollment" ,and,"',(amily ~lass of en- ' :
-. 15
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. r~'llh1el1t":, refer' to eIirollment 'in a,
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class' of enrQllmenJ described in 'anY
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,sub,clause' ()f, clause(ii) (other than
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~', (II) COI;PLE.-The term', "couple' ;.
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Se'ptember
16. 1994
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, 'scribed in 'suQclause (IV), or' (\:1,),' of '
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CO:CPLECLASSES OF E!\"ROLL!\'!E!\T.-'In
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in this Act as the ,"single parent" en-:'
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clause,' (il).:,
(h-) SPOI;S:E; ~~HIEDj C(n;p~E'.-··, ,.' .
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O:\MAT~MAT94~543
DISCUSS~ON
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DRAFT ' ,
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LA-14 ,
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another :indh~dual 'who ,is the" spouse "
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(C) 'AGE :AriJU~T~1ENT FA.C'TOR.-Th~ Sec.;
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of;,:orismarried to., the individual, as'
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"'tkined' ~ge>: 18 but, not age 65" the ,higl~estage 1.,
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'adjlJst~eht<factor~n1ay,not exceed t\'1Ce, the ' '
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a~ertified' health, plan
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on )dentiliable "differences ' ~n' le'gitimhte ,
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Seplember16, 1~94 ,
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.~' (A) 1~' ~E~ERA.L.-1n' accord~nce i,"1th'th~',
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STAFF ,DISCUSSIOj\r DRAFT
, , 0: \ MAT \ MAT94.543
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adtninistrative, .'costs which vary b,~ size o'f' the'
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'eIlrollinggroup and, method, of enrollmen(in
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, , eluding 'enrollment through a pubijc' access: 'site
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or directly through a ~ealth"pla.n, an employ~r,
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"(B) E!\"ROLLMEXT THROUGH PtrRCHAsING ",
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COo:PERATn~.-··Except as prmided in ,subpara.'..
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graph (C), in' .the case of" an administrative' ,,
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,( cf1a~geund~'r,' subparagraph '(A)' for enrollment
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through"a ,purchasing/ cooperative, ,8~ch 'charge', ':,
10
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may not' ex~ee,d th~,10,,'est charge of such ,plan'
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coopera tive iin such' area~'
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'for~nrollm~nt other' than through a, purch~sinK:-',
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(C) EXCEPTIO~.-'In"t4e case of a charge'
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"~_ m~nt' through a purchas~Iigcooperative or -if,'
18
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'such" plan' is' ,not offered: through a 'purchasing'
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20 'coo})~r,atiy~, the ',lowe'stadmlni~trative, charge,'
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pl;;l:n'~in 'such ,area.
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, (c) 'TREATMEX;OF
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N~GOTIATED RATE~' 'CO~L\n:'
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,24 section"a certifi~d Ih~ahhpl~n wrpch negotiates&. premium
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: September 16':1994 '
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.. O:\~T\MAT94.543:
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STAFF DISCUSSI()N tmAFT
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':)srib~ection (b}(3»)withapu~chasirig cooperative !n~C6m~: .. ",', .•
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.2" munity 'rating area. sha,ll charge the same premium rate
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'. 3 'to, all c()mmunitv-rafed indhlduals.···. '
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4: 'sEC. '101~;' RATING 'PRAC~CE~ AND 'PAYMENT ,~F. PRE.,
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: notari,employ~eof 'the plan certif:\ing that,' baseq : . ~ " .
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'.upon -ari'exa~nati~m by the iridiyidual:whlchin- :- :'
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appropriate, records and of the . •
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" . actuarial' assumptlons.· of such .sponsor.art,d methods
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of the ArnericariAcademy of.Actriarie~ "(or ,\
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sp~nsor\'sh~W file arinuallY'~'ith tiir
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of the: plan, of .
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.'(~) ACTl·ARIALCERTIFICAT~OK.-··Ea'cb'eeitified . ~
: health plan
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date :bf eAlJiration .
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the terms f~rrenewal of the plan: .'
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!OKEXPIRA,TION.~A certified
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60 'da~'sbeforetlle
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,health plan, sponsor shall provide for'riotice, at least'
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fully disclose fatirig practices' Jot s~ch~lan
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sor shall:
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,(l)I~ GE~~RAL.-'A certified health plan.spon
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,,·,(a).F(;LL'DIS,CLOSUREOF RATING PltAG~ICES.-''
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.0; \~T\MAT94.543
. STAFF .'DISCUSSION DRAFT: .
. S.L.C ..
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··:'!A..;.17
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(A) such'. sponS6r' is 'in compliance with ·th~
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3
actuariall~: .
, CB) the' rating methods ·'a.re·
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Each· sponsor shall retam a .copy 'of such 'state~erit
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O:\MAT\MAT94.543,
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STAFF DISCUSSION DRAFT
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NOl'.~ISCiu:I\IINArioN
'1 SEC. 10i5.
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BASED ON
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Ciusi~n ofb~n~fits';~l~ti~g tDt'reatmentofa condi., <'
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, 'STA.FF DISCUSSION-DRAFT
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o~ exclusion does not
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, any 'period" of exclusion' of ~ coverage "ith respect, to'
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for
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(A)PE,RIOD OF co~ti~'iovs tOYERAGE.-'-:,
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Th~term"peri()d 'or' conti~,uous, coverage" ,':
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periodbe~nping
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,care'prograin'~dlleh prm'ides benefits equival~nt.'
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'to those p~9'ided b~· ~h~c~rti~ed healtll pl~m 'in
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" 21
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,", 'ends on,tlie9.ate the' hlQjvidual'is not s~ en~
23
rolled fo'r a continuous'period'ofmoretha~ 3
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�• ' ,STAFF DISCUSSION DRAFT
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period describ~din section 1012(a)(2).
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",~ certified health plan shall offerto all enrollees~n' '
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STAFF
O:\MAT\MAT94.543 '
DISCUSSION DR.AFT', :
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'lA-21
•,.(2). the
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.purc4ase~fthe
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notconditionedupoll the purchase of such additional
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cove:tlige of such" additiomil bene~ts is al'so
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offe~ed' to rihdividu~ls ~'h~'
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are' riot 'enrolled in' the, '
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cost sharing re4uction is, offered only to
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, 12 SEC. 1018. RI~K ADJUSTMEl'-"T.
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'(a)' tKGE~"'ERAL.:-'Each comri1UrutY-rat~d ·certified-.,
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, : 17 " JrSTMEXTPROGIL·\-'IS.-"
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, ,( 1) ',,1!\' ,GEXE"RAL:-''The, Secretary 'shaH, develop ,
19
st().ndards' under par().graph" (2) 'for:participati~g'
20
. States ,to provide rrsk adju~tmentp~6gtams under'
21
s~ctiori 1307 for ,pa'rticipatioIi bjr. certified he<;lltp
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GE~ERAL.-··The stal~dards
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September 16. 1994'
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O:\MAT\MA~4.543
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STAFF'DISCU&SIQN J)RAFI' '
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,shall ,'include, ,a " risk' , adjustment, program
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utilization \ and' ei']Jenditures: for co~u-,
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nity~~ated\ndiYiduals;
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iha.i enroll
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prop'or£iohateshar~ \of ,such "'~di\jdtials
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"plan's enrollees'~ompared, to 'the "a:verage' ,
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p~ogram" the' Secretary ('may take' ~to accou~t'
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'veloping, the "'~tand~rd~' for a ~risk ',adjustmen.t •
,18
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, (l3)FACTo'RS TO ,BE,CO::\SIDERED:-,
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e>"']Jendituies for 'sucheliiible indi\'iduals~ ''.
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15
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',', ,(i)' Derl19graphic characteristics~" '
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(ii),Health
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llo~llestatus,'asdeternlln~d' appropriate, by
'," 24·
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the Secretary.,
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,'September 16,1994,
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52
�--f.
, STAFF DISCUSSION DRAFT,
'S,L,C, "
,IA-2'3 '
, "" risk' adjustment 'prDgra~l:, meth~dDIDg.v' '~h~ll as~
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sure thai' the tDtal pa~"ments to. 'all cDmmunity- "~I:
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'c~rtified"health plans afrer 'applicatiDn'~ Df '
the, !TIeihDdDIDgy are the' same' as the, amount ~f
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(C) ZER9; st':\1.~The ' standards, for the
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~pplicatiDri of tliemet,hDdoIDgy.'
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8 ,SEC.IOl9,. FiNANCIAL REQUIREMENTS.
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'(a).goLYE!\ctPR()TECTIO~.-'Eacll spDnsDr offering'"
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20 'been ,liable i~ the 'plan wer~ to" have made payments' iIi' a
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AND
SEC. 1020. COLLECTION
23
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PROVISION OF STANDARD·.
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ADDITIO~AL' REQ'CIRE!\1EXTS.-"Each '" certIfied', •
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: 20 SEC: 1021. QUALITY.fMPROVEMEJ:\'T AJ\'D ASSURANCE.-
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'E'~qh' c~rtified he(llth plan shall ,
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0: \MAT\MAT94)43 "
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, shall be 'maqe ,by . licensed, ,certified, ,
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,routi~e'.case~b)T:~ase review, .beconsistent,and 'timely ..
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211876'(i}(8)(A)', 'of-the, .,Social ,\Sec~nty, Act ' : " '.
(42, U.S.C. '
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(1) verify, tlie ereden1Jais of participating'phys,i
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(2) en~ure that' participating, providers ,and f~- ,{',
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P:ATIE~T I~FOR)L-\TIO:~"'-'"Each certified health
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(b) lKFbR)t.-\TIO~ REGARPI~G A', PATIENT'S RIGHT
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. \ ,22 Security 'Act .for pprposes'of- applJ~ng the rUles u'ndersec-." "
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,',1 ,u'ndueburden f~r' enrollees, with 'compl(:x or .Cil~6nic health
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still DISCUSSION
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.(1) IK' GEXERAL.-Each certified health. plan •.
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sh~ll comp'lY· with the remed.les "and ~nforcement ;r.e.....
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3' \ .quire.ments' described in subtitleF of title V•..
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,health plan shall ~stablisii a ~ev~nce process'· for
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'(h) IETHlCAL' BUS~KES? '. COXDU,CT.Each .cery,ified , .
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, 10b~siness'con9uet foz: its acthities,' includirig. tho~e'(jfits .
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16' '.( (j) PROVIDER SELECTI01'.-·, ....
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v.;ork; ,or' in esta6lisiimg the terms land ,conditions ~f' :,.
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,provider . based . on the actu~lor' anticjpated health'
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ADDiTIO!\~ ":"'TIJji~CRnn!\ATIO~"
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·QU'IRE~I:E~TS.-.·K6 Stat~1certifi~d 'health plan; or .
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�~TAFF DISCUSSION D.RAFT
O:\h~T\M.AT94.543
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'ceriified health' Pl~~ , sp6nsor 'ma:\' ,'Oiscrhninat~', in"
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, plilrticlpation,' :reimburseqlent,',or ,indemnification'
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~thescope" oftheprm;der'sllceI1se: or: ,'certification
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5',' , ',under applicable: St,ate or Feder.al, law'splely ,on ,the',,'
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or certification' 9f '~uch provide'reo ' '
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(3)'NU?t~EH'A.'CJ) ;TPE.-Notbing in ~his",~ub.'
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to' maintainqualit:~or 'to'c.ontrol costs; ""
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, \care'prmid~rs to the ,needs of tp~ p'la:t;t mem~ "
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,Illatchi~g'ihe nu~ber',a~d~'1:J'Pe of
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", (k}Pffi·?IC!A.~' PARTICIPATIO!\'-~-"'Each"certified' ;
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into matters~ffectiilg: pat'ient;c~re and, :,
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19 ,mary care physi~ia~,;froni' am()ng ,partic,ipatingprmiders:,
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":20 ,SEC~ l023.:DUE PROCESS FOR HEALm CARE'PROVIDERS: '
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',(at PUi3.LI,CL'y"'AtMLABLE \ STA.,,\DARDS~A.''D' PROC:'
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'22 ~·ss.-'Each ,certified· "health' pl~n shall: establish and,'
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(1), publici:' 'a\~ai1able "standar'ds 'f~r,col1tracting
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, , , -September 16, 1994'
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' ,\,\;th ,health' care .providers; and
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0: \ MAT HdAT94.543 '
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, (2) apubU?ly available proc~ss for di~~ssing
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~uch:pro~lders or_ failing'·, to,' renew, co~tracts with'
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(b) NOTICE REQCffiEME:\T.-, '
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'(1)' IN'GE?\ERAL.-The, process
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sian t~ dismis's, ,such prmider: or' not to' r,~new 'a con::'
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(2),- EXCEPTIO~.-;The' notice:', required· under
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:paragraph. (1) shall not;appb< if failur~ to dismiss a '.
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, ,'versely affect the healtp or' safety.of a pa~i,enL .','
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,', health, care. providerurider' paragra:ph (1), shaUcon- "
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tr~ct' with ~llch' pr.ovide~ ,not' lat~r, th~n' 45 daysbe'-''':',
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reasons' for" the disrmssa-l, or' failure to' ,"
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:stahdards established:under silb~~ctibn (a).
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pr~vide~'~\'hois dis~s~edby,acertifiedhe~lthpl~n o~ with,
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Seplemb6r 16,199,4
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IO;\MAT\MA~4.S43 '
'STAFF DISCUSSI~N DRAFT,
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,; (1)' the ,'pro'ider'
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pro,'\iper'inay have' an ~attorIley ,present
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'(e) ,EFFECT OX Q.THER ,11AWS.-'The, provisions of"
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',1 SEC. 1025. AiutANGErtItNTSW'ITa ESSEl'.'TIAL COMMUNITY
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','(1) CATEGORY j'."'-A .provider isa "categOI:Y I '
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0:.\ MAT \MAT94, 543 '
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. curity'Act (42U.S.C.~1395x(aa}(4»),o'r' ,
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(ti) a rural health clinic th(~.t is
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16'. '':" ". ess~ntial' ,commucity pn)~ider" 'if such~, pro'ider ap;.. ,',
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may prescribe) and the< '
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qrurements of subsection '(c): '" ,
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CATEGORY" II
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STAFF DISCUSSI~N' DRAFT '
, O:\MAT\MAT94.543
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"( 1)' furnisllessen~ces in a'medicallyunde'served
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, (3), pro\~des" the ~ range of prhruiry' health' "
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, sen1~es '(as 'defi~ed in section:'330(b)(1) of 'the Pub,:
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.fic Health 'Se~ice Act' (42~ U.S:C. 254c(b)(1))): that
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'are included iI',l thest~mdardperiefitsp~Gkage estab
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d~rh'esa:£ least30'perc~nt
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any .revenu~s, a~tributable to a' State plan a:pp~o,rea:, '
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,. under title :xix of the'' . Security Act); . .
Social
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STA.'~ARDS~-'Not,
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pation. ~~eement refeIT~d 'to in . subsection
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( subparagraphs (B) and (Cj, ,the 'writtenpartici-:-.
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.(A) IK .GEKERAL.-.·Except' as pr~\rided in.'
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1) .CATEGORY I
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. ditionsthat a c~rtified health plan includes in··
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(iv), accessibili~' of,care,
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(xi)'6ther terms ana conditio'ns that''''
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(B) PA\~lEXT.-"'Th~' written 'participatio'n,
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agreement referred to in 'subsection (a)(l) shall;
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,STAl"F DISCUSSIO~ DRAFT'
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, ' • and ~he pian~' Payments to, providers, UIJ.der this.
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· subpara~aph shall-include payment fo~' services' .,
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sh~ll i~~l~de terms 'and, conditions'
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,that are nb more're'strictive than the terms and
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tween th,e plans' and prm-iders,' and" ,
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'(Xi) other termsartd conditions' that'"
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·for.payment .'to theptO\ider 'on ,a
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P A l~rEXT:-T_he \\Tltten partidipation .
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STAFF DISclisSION DRAFr
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PERIOD.~The' trans~tiop:" period
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, 10 ' SEC~ 1026. ACCESS TO SPECIALIZED SERVICES.
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(Ii) ,I~GEl';ERAL.~E~ci; certified·.health,plan ~hall ,
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retary sh~lL de~lgriat~,c¢nter$ of ~peciali~edcare, in
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'. O:\MAT\MAT94.,543
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.. criteria established b:r the SecretarY fo~ the ,'delivenr ·.
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ment and also meet· 2 or, more; o('the' follo\\ing re.;
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SEC. 10,27. COMMUNITY .RATING AREA CAPACITY. '
On'~ild after January 1, 1997; each certified~ealth
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22' plan -,shall have the capaclty "lthin the, plan's network, 'or
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STAFF DISCUSSION DRAFT.
'.' .. IA--42
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; 1 community rating :area (designated lillder', se'cti'on~1303) .' •.
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in which 'such'plan' is offered.. Services .shall' be pro,~ded .
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a manner
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,SEC. 1028. Ot1T~()F.~ COVERAGE.
'Each ~ertified,healthplan ~ shall. provide Jor~urgent ' '
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10' PART 3~~TANDARDS APPLICAaLETO q~RTIFIED
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, . INSUREDBEALTHPLANS~"
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.(a) ~~' GEXERAL.-Subjectto\suhsecti'on (lJ)"the re-',
14
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1031.' STANDARDS APPLICABLE TO CERTIFIED' SELF.
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SELF·INSURED HEALTH PLANS! ' .• '
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; ,16 are the requirements: specified' in 'the, following provisions:
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(1) Subsection' (a)"of sectioil 1011 (rel&ting to '.....
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tablish such... comparable Emrqllinent· procedpres . as
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',.(2): Sectiml 1'012 (relating :to::e~rollment) or es-'
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spect .to, e,mployees of the employer. ~pon'sor:"
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sectio~, 'e~cept ';~hat slIchsubsection (a)-shall be ap~
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guaranteed issue),: sUbject· to sllbsectiori' (d) o{such,
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September 16, 1994. '.,
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0: \ MAT \ MAT94~543
DR.A.F:f,' '
STm DISCUSSION
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S.L.C,'
, ·lA-43
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/'
::,(3) ,Sectiph 10f3, (relating to ~remiuin' rating'
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,uals.
'(4) Section 1014(b) (r,elating. to payment ,of
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'premi~s):
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(7) Sectioh 1019 (relating 'to ,finanCial 'require
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sistent with, the applicable 'rlJ.les 'under section '414 'of,'
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(8).Sectioil 1920 (relating 'to cqUectio,n, and 'pro
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15
,J"ision of standardized: 'information).
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the EinployeeRetirem'ent' Income' Security Act, of
12·
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, ments), except ~~at $uc4 requir~ments shall' be ,.con
10
11
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(6) Secti6~ 1016 (relating to'''benefits). '. : '
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:,(5) Section 1015, (r~lating'to~oncliscrimination
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to
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to' du~ p'~oce$~ for '. '
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24-
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'cialized care).
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, ~eplember 1~.1994
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, ' (13),S.ect~on102,6 (relating to c~nters of 'spe-:: "
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pute resolution for meclipalmalpractice). ' , ' '
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DRAFT
.' STAFF DISCUSSION
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. lA-44:.·
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(b) JjoLLECTIYE.'BARGAI;\I~G: EXCE:r>TIO::\.-·Para- .'
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certified~ self.:insured
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health 'plan sponsor that, isprovid- ..,"
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certifIed. self- "
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'of.1974"t~geth~r wiih, the 'applic~ble 'eIi(or~eme~t .
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I of the ,Emp+oyee',Retire·ment. Income', Sec;urh~· ,Act
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of subtitle B ,of title, , .
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1\~~AGEME~r PP'FU~1)S.-.·A
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1\1A.~AGEMENT OF
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6sured 'h~althplari' shall meet . the sohTe~cy, ,reserv~,arid:'
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plan spon~or shall coniply,,;tq
~tandards
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, l~ting to'themanagement'.?f'finance~, apd re~ords
22
. "and 'accQu'nting •s~istetns as, the Secretary'. 6f Labor
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STAFl"DISCUSSION Dn..ui-T "
.O:\MI,\T\MAT94.543,
S.L,C.,
IA-45
"
lu~de;"subsectioi;t (a)" . the Secretary of Labor 'shall. .
estab
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section lS0S(e) '(relating ,to 'geographicdiscrimina~
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ployer sponsor of'theplans:off'ere& '
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'as of January'1,19~5, :no State shall estab':
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heal~h; plan,· of any ,senices, category of care" or,,' "
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(1) ,~equtres" the'offering, as pa~' of a, certified
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lish or enforce any law or regulation that-', '....
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se~lces
of
ail~T' cl~ss
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:(2) specifies th~ 'indh;idual~' to be ~oyered u~der, '
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a ~right of conversion from' a ,grqup'
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(S),requlres
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to a:~ indi:
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Seotember 16, 199'~
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" 'STAFF DISCUSSION'DRAFT'
, .
'O;,\MAT\MAT94.543 "
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',1 ' SEC. lO.ci.'PREEl\IPTION:OF STATE LA\\' RESTRICTIONS ON
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linuting, coverage of', se~ices ,to ,those ,provided" ' ,
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(3) a State niay n?t~rohibit,or ~mit,t~e nego-~",
tiation of rat~s an,d forms 'of paj"l11ents for p~oYiders
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from llnu~in'g the number 'of participating prm'idersj ,
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. (5)' a. St~ tein'ay not prohibit'or.limit ,su~h
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fr~m requiriifgtha,t services b,e' pr(h'ided (~r author~
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"(2},a 'Stat~' may~o~ ptohibit
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,: Effective" as .ofJanuary 1,'1995-" : "
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CERTIFIED HEALTH PLANS.
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. (8)- '? State maynoLprohibito;r limit a, health' '
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September 16; 1994
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O:\MAT\M.AT94.543; ..
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sen1ces, .~edical equipm~nt, and other ·supplles·'mld·,'.
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sen1ce~; .a~d,'
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not'., prohibit a certified health
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lA-:-47 .
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DRAFT
STAFF DIscuSStON
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nance .organizition,from offering a, point of, service
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SEC.'lOsi.APPLICArION,OFIl".iri:ru1t1 STANDARDS.,
':9 " (a)'IK GE~"ERAL:-During the' interim standards ap.~
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(B) secti6~s 10i5(a) and ,l031:(d)(1), '
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RE~E,y..\L.-·The:s~anda~ds, specified 'in 'sec~
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, :(3)CO'\"ERAGE.-A self-:ii1s~red health plan may
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24
(c) I~TERB( STA.\cDARDS 4PPLICATIO:\ PEIUODS,-' ,
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,
§.eptember 16, '99~ .
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DR.A:Fr '
, ,'STAFFD.ISCUSSION
O:\MAT\MA.T94:543 '
,
IA-48
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st~mdaf.d'specified( in s~b~ ,
, '( 1) ,in the case of the
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,section (p)(l), 'ori' or after, J,a:J:1Uai:r 1, 19~5, and be
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5
subs~ctions (bH2) ~~d'(b){~)l'OilOr"after June 28,
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8 ~ " ,"section (bH'3}, ~n,,'or' after' the date of the 'en~c~ment
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,:(d) PREEMPTIO!\;-'
'The requirement§ of this 'se~tio~,
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Dublin Core
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Title
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Chris Jennings - Health Securities Act
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Domestic Policy Council
Chris Jennings
Health Securities Act
Is Part Of
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<a href="http://clinton.presidentiallibraries.us/items/show/36173" target="_blank">Collection Finding Aid</a>
<a href="https://catalog.archives.gov/id/647904" target="_blank">National Archives Catalog Description</a>
Description
An account of the resource
The Health Security Act (HSA) was an effort by the Clinton Administration to provide universal health care in the form of a comprehensive national health care bill which emphasized managed care and called for the creation of regional health care alliances. This series contains material which provides a detailed analysis of the Health Security Act. A chronological subseries within this file focuses on legislative strategies to enact the HSA, as well as efforts on the part of the Clinton Administration and its supporters to counter intense opposition to the legislation from opponents in Congress and powerful interest groups. This file also contains material which examines in detail the alternatives to the Health Security Act, particularly single-payer plans and a compromise proposal from a bipartisan group of moderates in Congress called the Mainstream Coalition. This series contains memoranda, correspondence, reports, press releases, briefing papers, statistical data, graphs, legislative drafts, publications, and news clippings related to the Health Security Act.
Provenance
A statement of any changes in ownership and custody of the resource since its creation that are significant for its authenticity, integrity, and interpretation. The statement may include a description of any changes successive custodians made to the resource.
Clinton Presidential Records: White House Staff and Office Files
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Clinton Presidential Library & Museum
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293 folders in 16 boxes
Text
A resource consisting primarily of words for reading. Examples include books, letters, dissertations, poems, newspapers, articles, archives of mailing lists. Note that facsimiles or images of texts are still of the genre Text.
Original Format
The type of object, such as painting, sculpture, paper, photo, and additional data
Paper
Dublin Core
The Dublin Core metadata element set is common to all Omeka records, including items, files, and collections. For more information see, http://dublincore.org/documents/dces/.
Title
A name given to the resource
Mainstream [Bill Draft] [1]
Creator
An entity primarily responsible for making the resource
Domestic Policy Council
Chris Jennings
Health Securities Act
Is Part Of
A related resource in which the described resource is physically or logically included.
Box 34
<a href="http://clintonlibrary.gov/assets/Documents/Finding-Aids/Systematic/JenningsHSA.pdf" target="_blank">Collection Finding Aid</a>
<a href="https://catalog.archives.gov/id/647904" target="_blank">National Archives Catalog Description</a>
Provenance
A statement of any changes in ownership and custody of the resource since its creation that are significant for its authenticity, integrity, and interpretation. The statement may include a description of any changes successive custodians made to the resource.
Clinton Presidential Records: White House Staff and Office Files
Format
The file format, physical medium, or dimensions of the resource
Adobe Acrobat Document
Publisher
An entity responsible for making the resource available
Clinton Presidential Library & Museum
Medium
The material or physical carrier of the resource.
Reproduction-Reference
Date Created
Date of creation of the resource.
10/26/2011
Source
A related resource from which the described resource is derived
647904-mainstream-bill-draft-1.pdf
647904