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OPM CONG REL .
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June 3 , 1994
MEfv10RANDUM FRorvt
IRA N. FORMAN. DIRECTOR
:bPM oFRce OF CONGRESSDNAL R8.ATlONS
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FOR: ..
CHRIS JENNINGS
"NATiONAL HEALTH REFORM PROPOSALS
SUBJECT:
Senator Kennedy and others have' proposed· that the Federal Employees
Health Benefits Program (FEHBP) be used as the vehicle for covering
individuals not insured through :Iarge group sponsored ,plans. Under the .
, Kennedy bill, OPM would have: a major contracting function in' every state,
and in some states might also: have' a significant communications role.
OPM certainly· has the experti~e neceSsarY to perform both of those
functions. However,. whether the tasks are assigned to us or to some other
entity, the absolute prerequisite is that a clearly defined, safe income
stream be available'.,for progr~m administration. Without such a
guarantee, the' irnph9r:ri'~ntation :of the program would be at risk.
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In order to assure the necess;ary financing of functions delegated to the
cooperatives, I would sugges~ the following clarifications 'to the Kennedy
bill. Similar provisions should be included in other versions of heaHh
reform legislation that may e~erge.
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Title I, Subtitle C, Sec. :1262(d)(2). provides for a maximum 2.5%
. administrative allowance! to the States, of which .75% shall be
distributed for cooperalive functions.
The bill needs to provide that funding for OPM to administer FEHBP
coops will not be, subject to the appropriations process. This money
comes from enrollee premiums and will be allocated to all coops. If
OPM is to have the same responsibilities as State created coops it
must receive the same: funding as other admitJistrators. Without
such an assured income stream, we could not handle our newly
acquired functions.
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Titl~
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I, Subtitle G _. Federal Responsibilities, Subpart B -
Responsibilities Relating to Review and Approval of State Systems,
Sec. 1615(b)(4) provi~ that "funds wiU be, appropriated to be made
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OPM CONG REL
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available to. the States t¢ provide grants for the establishment of
consumer purchasing cOQperatives ..
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If OPM Is to organize consumer purchasing cooperatives, the bill
needs to provide that it ~i11 be eligible for funding under the grant
provisions on the same basis as any other organization.
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Title I, Subtitle C .- State Responsibilities. Sec. 1206. Consumer
Information and Marketing. (c) Cooperatives--A State may delegate
the, responsibilities of tKe State to ,consumer, purchasing
cooperatives for individ~als enrolled in the community-rated plans
through such cooperatives.
If the State can delegat~ this responsibility, the bill needs to
provide specifically for a transfer of a ponion of. the State's
administrative surcharge I money to the cooperatives to defray the
. cost of carrying out thi~ function.
Also, it would appear that the' contracting process could be simplified.
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The bill provides that even though a plan may be offered in more ,than
one health care coverag. area the contracts must be separate. Even
if the rates are different: for each area. it should be possible, to
bundle the contracts to! simplify contract administration. The bill
should not preclude that .possibillty as it now appears to do..
The Ke~nedy proposal as wrltten has many provisions that' are either
unclear or. need technical pe~ecting. However. I've focused here on what
we see as key issues.
cc: Jack Lew, Jennifer Klein
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June 15, 1994
MEMORANDUM FOR DISTRIBUTION
FROM:
BARRY TOIV AND
RE:·
DRAFT OF SPEECH BY DIRECTOR PANETTA ON COST
CONTAINMENT
NANCY~ANN
MIN
Attached Is a draft of a speech to be delivered by Director
Panetta next Monday before the Center for National Policy on the
subject of cost containment in health care reform. The Director
has not yet reviewed this draft. ~
Please call us if you;have any questions, and get all
suggested changes or comments to Barry Toiv (x57254) by COB
Thursday, June 16.
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Distribution: Alice Rivli~
John Angell:
Bob Boorstin
Martha Foley
Chris Jennings - .
Greg Lqwler!
Jack .Lew
:
,
Ira Magaziner
Lorrie McHugh
Jo'e Minarik;
Meeghan'prunty
Laura Quinn·
Gene Sperling
�RAfT
LEON E. PANETTA
DIRECTOR
OFFICE OF MANAGEMENT AND BUDGET
SPEECH TO THE CENTER FOR NATIONAL POllCY
JUNE 20, 1994
I want to thank the Center for National Policy for inviting me here today. In
deciding whether to make this speech, I of course consulted with James Carville, Paul
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Begala, and the President's other political advisors. If you've read Bob Woodward's new
book, you know that we at the Office of Management and Budget don't do a thing without
running it by James and Paul. Oh, by the way, they strongly recommended that I not make
the speech.
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Today, I want to talk to you about health care reform, and I want to focus on what
the President believes, and what I believe, is an absolutely essential element of reform, and
that is controlling the skyrocketing costs of our health care system.
The President was elected in 1992 on his promise to focus on fundamental changes in
the nation's economy, in our government, and in the lives of America's families. That he
has done. Working with the Congress, he has put in place an economic plan that has
reduced budget deficits and increased investment in long-term economic growth and in the
education, skills, and well-being of our workers and our children. He has implemented a
trade policy that is already increasing exports and creating new opportunities and jobs
throughout this country. He has signed into law the Family Leave Act, Goals 2000
education reforms, a historic national service program, and reforms in Head Start and other
education programs. Last week, the President proposed a strong, measured reform plan to
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�tum the nation's outdated and, in so many ways, counterproductive welfare system into a
plan for work and responsibility.
Fundamentally tied to all of these changes in government, in the economy, in the
well-being of our families is the need to reform our health care system. There is a clear
consensus that the nation cannot sustain the inadequacies, the bureaucracy, the waste, or the
costs of the present system. Reform is essential to continuing deficit reduction, it is essential
to our efforts to restore America's economic strength, and it is essential to the security, to
the well-being, of every American family.
The United States devotes the highest proportion of GOP to health care of any
industrialized country -- 14 percent -- yet insures the smallest percentage of its citizens. If
current trends continue, by the end of the decade 14 percent will rise to 18 percent, yet some
38 million Americans will still have no health coverage. And government, businesses, and
families, will continue to face rapidly rising costs, with no end in sight.
Yet, as health care has been debated iIi the Congress and in the press, one of the
issues that has aroused controversy is whether to effectively control health care costs, a key
goal of the President's Health Security Act.
Without real cost control, health costs will continue to consume an ever-growing
share of household, business, and government budgets, robbing national income that we need
to save and invest now for a better future.
Some argue that we should just rely on the word of those in the health care system
that they can be. trusted to hold down costs. But the health care dilemma today is largely a
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�legacy of their failure to manage a system that has become, as Robert Samuelson has written,
overbuilt, overused, and overpriced.
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How can we not control costs? 'How can we not? The American people want real
. health care refonn. But does anyone
~riously
think that they want the Congress to go
through this process and end up not controlling costs? The reality is, the stakes in
constraining national health spending
are huge -
for .families, for businesses, and for
government.
First, government. And for government, read the taxpayers, all of us. Last year,
Congress and the President reversed the trend of rising budget deficits by making some very
tough choices about spending and taxes. Even so, the reality is that deficits will rise again in
the latter part of this decade. Why? It's not defense spending, and it's not foreign aid, and,
if you leave out health, it's not social spending.
If you consider all of the spending increases expected over the next five years, 90
percent come in three areas. Third is interest on the debt. Second is Social Security, largely
because of a growing senior population, although the Social Security trust fund continues to
run a substantial surplus. In first place, and easily leading the pack, is health costs, which
make up more than 50 percent of anticipated spending increases -- almost $476 billion over
the next five years.
Controlling costs is absolutely
~ssential to
maintaining the path of deficit reduction.
It is equally essential to the nation's economy. Businesses face the same problem as
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government -- skyrocketing costs which take a greater share of profits and payroll, which
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�force many to limit the insurance they provide their workers, and prevent all to many, as we
know, from providing it at all.
Perhaps the best known is example is the automobile industry. Health costs for the
Big Three automobile manufacturers average well over $1,000 per car, placing them at a
massive disadvantage to Japanese carmakers. Every product we manufacture, every service
we provide, contains a growing health care tax premium. And that is true regardless of the
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size of the business. For small businesses, which today are charged an average of 35 percent
more than large businesses for the same insurance, health reform would mean reduced costs,
largely because they would not face this huge disadvantage. But whether large or small,
businesses desperately need constraints on the cost of health care.
And finally, families live with the knowledge that rising health costs, combined with
the standard operating procedures of the insurance industry, place them one serious illness or
one job change away from lOSing their health insurance. Protecting families is at the core of
health care reform, and one of the fundamental ways in which we need to protect them is not
only to guarantee coverage but to control skyrocketing costs.
The President's plan uses three approaches to control costs, setting first-year
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premiums, controlling the growth of long-term premiums, and capping the cost of Federal
subsidies.
Setting an accurate premium level in the first year is a critical step towards real cost
containment. Today, when uninsured individuals do not pay for their use of the health care
system, these uncompensated costs do Inot simply vanish -- they are shifted to everyone else
who has insurance. Doctors and hospitals set their fees -- and insurers set their premiums
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�about 25 % higher to cover these costs.") That, of course, is one of the fundamental arguments
for universal coverage.
Under the Health Security Act, all Americans would be covered, so there would be
virtually no uncompensated costs. But if we do not set an appropriate - and lower
premium in the first year of health reform, the health industry will reap a huge windfall
because they will, in effect,continue the current rate structure, which enables them to
receive additional compensation for the uninsured. Through the year 2004, this windfall
would cost families an additional $150 billion, businesses an additional $450 billion, and the
Federal government another $450 billion. That is a $1. 1 trillion windfall that comes straight
out of all of our pockets.
The costs of the system are high enough. The health industry should not be permitted
to collect fees and premiums twice for the same care. To prevent that, setting an appropriate
first-year premium is essential.
After the first year, the President's plan ties the long-term rate of growth in health
insurance premiums to a reasonable scale of increases. As waste is squeezed out of the
system, health care costs should event\1ally grow no more rapidly than the general rate of
inflation. By setting premium growth limits reflecting that likelihood, the President's plan
will allow providers and insurers to negotiate among themselves within broadly-defmed
budget constraints. These national limits -- which allow for regional variations in health care
delivery and demographic shifts - decentralize budget decisions by putting responsibility for
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staying within those limits where it belongs: with providers and insurers.
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�These limits make sense. We believe that by reforming the way the health care
market works - permitting providers to compete efficiently and giving consumers the
information they need to make prudent ,and cost-effective choices -- health care costs will be
driven down. But if competition does not hold premium growth within reasonable targets,
then premium caps will be triggered.
These premium caps are much less invasive than direct Federal micro-management of
health care costs, such as Federal price controls for specific procedures. The Federal
government does not and should not have the central planning capability to set prices for the
tens of thousands of health transactions that take place every day. That is why the
Administration rejected such an approach in favor of broad limits on the growth in health
insurance premiums. The President's plan leaves it to the health plans and care providers to
figure out the best way to live within those limits. They will continue to set rates for
specific procedures.
Some argue that these limits become too severe too quickly. But the Congressional
Budget Office estimates that the limits 'on premium growth contained in the President's plan
will reduce the nation's health care bill by $150 billion per year by 2004. That leaves the
U.S. health industry with an income of $2.1 trillion in that year alone, about $1 trillion more
than their current revenues. The plan :would reduce the average annual growth in national
health spending between 1996 and 20Q4 to 7.3% per year from the 8.4% projected under
current law -- an important achievement but one that will more than allow providers to
dispense quality care.
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�Those who complain that limits on the growth of premiums "interfere with free
markets" ignore two facts.
First, every major industrial nation other than our own spends less than 10 percent of
its output on health care -- and most of those countries insure all of their citizens.
Second, what free markets? No economist would call the health care marketplace a
free market. Health care is not like any other product. The consumer bears only a fraction
of costs, providers have enonnous influence over consumer decisions to purchase services,
and there is great willingness to pay whatever providers charge. In such a market, real
competitive pressures must be created and then guaranteed with cost constraints.
Finally, an important element of the President's plan is to assist small businesses and
.low-income families and individuals in paying their share of .the cost of insurance. We will
budget what we think are sufficient funds to provide these subsidies. But the President
rejected the notion of an open-ended entitlement program. Instead, to protect against the
possibility of runaway costs, the plan sets a cap on total subsidies, so that if costs are going
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to rise beyond that level, Congress and the Administration must revisit the program and
detennine how to fix the problem.
We are all too familiar with the problem of exploding entitlement programs,
established without limits and coming back to haunt Congresses and Administrations. The
cap on aggregate subsidies is a backstop that we do not expect to use. But just as we are
asking the private sector to control its ,
health costs, we are also requiring the Federal
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government to be held to a measurable standard of cost containment, and we are protecting
the taxpayer as well as our commitment to deficit reduction.
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�Regardless of the means, we need to put an end to the fantasy that we can reform the
nation's health system and provide coverage to every American without containing health
costs. We cannot hope to have the full economic growth, the prosperity, and the security
that the American people deserve, and we cannot hope to keep Federal budget deficits down
in the future, if we do not contain health costs.
Indeed, what seems to get lost in the debate over specific cost-containment .
mechanisms is that we need to design
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system that is inherently more cost conscious than
the one we have today. We can debate forever about which specific cost containment
mechanisms to use, but the fact is that. most consumers, providers, and insurers do not now
have adequate incentives to spend our health care dollars wisely -- and that is one market
failure that health reform must correct.
The Health Security Act gives consumers more information about the price and
quality of health care, and it gives them this information in a form they can use to compare
health plans -- which most people don't have today. This system will allow consumers to
make an apples-to-apples comparison, ,measuring the price and quality of plans that have the
same benefit package.
And because the plan stresses responsibility by requiring consumers to pay a portion
of their premiums, they will have a firiancial stake in choosing the lowest cost plan that
meets their individual needs. And they will be given an annual opportunity to switch plans if
their plan does not live up to their exPectations.
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The plan also strengthens competition in health care by requiring providers and
insurers to provide care to all who seek coverage, and to provide that care within a set
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�premium. To be competitive in the reformed health marketplace, providers will have to
consider the cost-effectiveness of the we they give. And insurers will need to take a more
active interest in monitoring the cost and quality of the care they are asked to pay for. This
is how the President's plan uses the instruments of competition to squeeze excess costs out of
the system.
These policies are the building blocks of incentive-based cost containment in a
reformed health care system. We propose additional specific mechanisms because we need
to build accountability into the system as well.
Let me point out just how bizarre the debate over cost containment has become.
When the Administration said that health care spending would rise to.19 percent of GDP by
2004 without reform, everyone agreed with us that 19 percent was too high and that it would
crowd out important investments in the, economy. But when the Administration produced a
plan to reduce health's share of GDP to 17 percent by 2004, some claimed we were leading
the country down the road to rationing -- even though all of our industrial competitors spend
less than 10 percent of their output on· health today.
If 10 percent is enough for other industrialized nations to provide universal health
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coverage, why should 17 percent and another $1 trillion-plus in health industry revenues
mean rationing here? And if the uninsured are now receiving care - even' if it is expensive
care -- why should giving them health coverage, much of which would prevent disease, drive
costs higher than they are today? The Administration should have to defend 17 percent. It
is opponents of cost containment who have some explaining to do.
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�The bottom line is this: If we enact health care reform that does not control costs -
whether through the mechanisms proposed by the Administration or by some other means
this effort will have failed.
This is a debate that is taking place not only in the committee rooms and the
chambers of the Congress but in newspapers, in meeting halls, and over kitchen tables
throughout our country. For 16 years, I served as a member of Congress. And for· 16
years, the health care issue became a bigger and bigger problem. It was ignored until it
became a crisis, as costs for families, businesses, and government spiraled out of control, as
the number of uninsured Americans grew, and as more and more families came to fear the
loss of their insurance coverage.
We saw a lot of suggestions, a lot of ideas, a lot of concepts proposed. But until this
President, nobody presented the kind of specific, comprehensive, responsible, detailed, paid
for plan that the Congress has been considering.
As this great national debate has proceeded, we have been challenged on policy, as
we expected, and there has been a strenuous and far-reaching discussion of how best to
achieve the goal of comprehensive heaith care reform. The Administration does not pretend
to possess divine wisdom on this
issue~
We have welcomed alternative proposals and views.
But as the legislative process moves forward, let's make one thing clear. Let's be
sure that as the various plans are considered, they meet the tests that we have sought to meet
-- universal coverage, choice, cost containment. And let's try .:- to the extent possible -- to
be sure that the debate proceeds on the" substance, not the politics and not the personalities.
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The American people deserve that kind of debate because this is an issue that will directly
affect every one of them every day of their lives.
As you know, the legislative process is well under way. House and Senate
Committees are hard at work on .their versions of health care reform. Cost containment is a
critical element of their deliberations.· 'We all know that the legislative process is sometimes
not very pretty. We are in for a roller coaster ride with even steeper twists and turns than
last year with the enactment of the President's economic plan.
In the end, I am convinced that Congress will pass a plan that guarantees coverage for
every American and that controls health costs. And that is absolutely essential to the future
of our economy and our country.
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6/27/94
6.p.m.···
MAINSTREAM COALITION PROPOSED AGREEMENT
PART ONE - COVERAGE
I.
INSURANCE COVERAGE
This section guarantees access to Qualified Health Plans for all U.S. citizens and
lawful residents not covered under other public programs such as Medicare,
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Medicaid"CHAMPUS and DVA. 'This section details the establishment of Health
Care Coverage' Areas (HCCAs), iristitutes insurance market reforms, establishes
standardized benefits packages, c:reates Qualified Health Plans (QHP), establishes
. eligibility for low-income assistance vouchers and expands tax deductibIlity of
. health insurance premiums.
A.
Assurance of Universal Coyerage' .
. 1.
A National Health Commission '(as described in Section xrV.) must
report to Congress biennially on the status of health insurance
coverage in the nation. The report must include, but is not limited to, .
the structure and performance measures of every market 'area,
including the following:
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a.
Demographics of the uninsured, and findings on why those
individuals are uninsured;
b.
Structure of delivery system;
c.
Number, orgapizational form of health plans;
d.,
Level of enrol~ment in health plans;
e.
' State implem~ntatiqn of responsibilities, including
establishment pfcoverage 'areas;
f.
. Status of insurance reforms;
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g.
Development bf purchasing groups and other buyer reforms;
h.
Suc<;:ess of matket and other mechanisms' of controlling health
expenditures and premium costs in the market area and
nationally; ,
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Status of transition of MedicaId toward managed care and
.. integration .into .AHPs;
Adequacy of subsidies for low income ~dividuals;
.Status of Medicare beneficiaries,' transition int~ Medicare
managed care and QHPs;
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Coverage progress among those who are employed, including
status and level o~ voluntary employer contributions and,
participation rates in poolsand'among large employers;
.. Percentage of ,individuals who are enrolled in Qualified Health
. Plans, separated. i.rito categories of Medicare> Medicaid; employed
individuals and individuals eligible for low-income subsidies;
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Informal recomme'ndations, specific to each market area,' on
.. how the area might increase coverage among the residents and,
further moderate growth in.premiums; and,
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Evaluation of adequacy of benefit packages.
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B.Coverage Trigger
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,Establishes a national goal that 95% of all America:ns will have health
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. ,'care coverage by 2002.
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, ''If this goal is not met, the Commission must submit formal and
.specific recommendations to Congress by January 1, 2002 as draft
,legislation. The recommendations shall include methods to reach 95%
;'coverage in market areas that have failed to meet that target. They
, :must address all relevant parties, m~luding states, .employers,
'employees, unemployed and low income individuals, public program
'. tbeneficiaries, etc. .
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lIn addition to 'any other recommendations 'it' subm~ts, the Commission
;must make separate recommendations on ,the following: '
A schedule of assessments or contributions to encourage
employers who are not doing so to purchase c'overage for their
employees; .
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A method of encouraging full coverage which does not require
any assessments on or contributions from employers;
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d.
Possible adjuspnents to subsidies; and t
e.
4.
,Possible adjustments to the benefits package;
Possible adjustments to tax treatm~nt of benefits.
Congressional Consideration of the National Health Care Commission
Report.. This propos~d process is being reviewed by the Senate and
House Parliamentarians.
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A.
Rules for the Senate
1.
The Majority Leader must introduce the Report as a bill
on the first day of session following the submissioriof the
Report and legislative language. If the Majority, Leader
has not'introduced the billwithin five days of session t any
Senator: may do so.
2~
The bill will be referred to the appropriate Senate
Committee.
3:
If the Committee fails to report the legislation by July It
2002 (or if the Senate is not in session on this date t by the. '
first day of session after this dateL it shall be automatically
discharged from further consideration of the bill; and the
bill shall be placed on the appropriate Senate calendar.
4.
Within 5 session days after the bill is placed on the
calendart the Majority Leadert at a time to be determined
by the Majority Leader in consultation with the Minority
, Leadert:shall proceed to the consideration of the bill.
If on the sixth day of sessiont the Senate has not proceeded
to consiperation of the bilt then the presiding officer must
automatically put the bill before the Senate for
conside'ration.
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5.
30 Hours of consideration
a. .1lwo hours for first degree relevant amendments
b.
One hour for each relevant second degree
a'mendment.
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c.
30 minutes on each debatable motion t appeat or
point of order submitted by the presiding officer to
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�the Senate and no motion to recommit shall be in
order~
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6.
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.There shall be five hours of consideration of motions and
amendment appropriate to r~solve the differences'
between the Houses, at any particular stage of the "
proceedings.
B.Rules for·the House of Repn!sentatives
1.
The Majority Leader must introduce the Report as a bill
on the first. day of session following the submission of'the
Report and '. legislative language. If the Majority Leader
has'ilotintroduced the bill within five days of session, any
¥ember'may d.o .so.
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2.
The'bill'~illbe referred to th~appr~priateHouse '
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Committee, or Committees.
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3.
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If the committee or committees fails to report the
legislation by July 1, 200~ (or if the House is not in session
: on this date~ by the first day of session after this date), they
shall be automatically discharged from further
consideration· of the bill. ,
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,4.
On the sixth legislative day (the day on which the House
is in session) after the date on which the bill has been '.
placed on the appropriate calendar, it shall be privileged
for a.ny Member to move that the House resolve itself into
tl)e Committee of the Whole House'on the State of the
Union, for the consideration 'of the bill, and the first
reading of the bill shall be dispensed with .
. 5.
After general debate, which shall be confined to the bill
'and which shall not exceed four hours, to be equally
divided anq controlled by the Chairman and Ranking
Minority Member of the Committee or Committees to
which the bill had been referred, the bill shall be
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considered as read for amendment under the. five-minute
rule.. The total time for considering all amendments shall
be limited to 26 hours of which the total time for debating
each amendment, under the five minute rule shall not
exceed one hour.
6.
At the conclusion of the consideration dfthe bill for
, amendment~ the Committee shall rise and report the bill
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�to the House .wIth such amendments as may have been'
adopted, and the previous question shall be considered as
ordered: on the bill and the amendments thereto to final
passage:'without intervening. motion except one motion to
recommit.
C.
Health Care Coverage Area'
The major vehicle for reorganizing the health care mark~tplace. would be the
establishment of geographiC areas called Health Care Coverage Areas
(HCCAs).. Employees of employers with fewer than ioo employees and .
individuals residing or working in the HCCA would be pooled together and
would be eligible' for insurance at an age-adjusted community rate .. HCCAs
a,re established by each state and a minimum number of 250,000 lives must be
included in the HCCA rating pool. States may enter into cooperative
agreements to establish interstate HCCAs. States may decrease the number of
covered lives included in a ,rating pool.
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Within each HCCA, consumers will have several different options available
to purchase health insurance. Employers and individuals may purchase
coverage directly from an insurer or agent, they may enroll at designated
state enrollment sites or they may chose to join a purchasing cooperative.
Accountable Health Plans may charge different administrative (or
enrollment) fees depending :upon how the plan is purchased. If a Point of
Service (POS) Option plan is not available in the HCCA in which an
individual lives or works, the individual may purchase such a plan in an .
.,
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adjacent HCCA:
D.
Insurance Market Refonns .
. The Secretary of HHS shall, within six months of enactment, a~d in
. consultation with private expert entities such as the National Association of
Insurance Commissioners (NAIC), develop federal standards with which
Qualified Health Plans must comply in order to be deductible by an employer
or an individual. While these federal standards will be established by the
Secretary of Health and Human SerVices, the enforcement will be by the state
or the Department of Labor depending on the nature of the Qualified Health
Plan. All Qualified Health Plans must: .
.
1.
Gl,larantee issue to all qualified applicants.
2.
Guarantee availabilitY throughput' the entire'area in which it is offered.
3.
Guarantee renewal to,. all qualified enrollees, except in instances of non-· .
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�t .
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" .
payment of premiums or fraud or misrepresentation.
1,
,
. 4..
5.
•
.
'; ,Not deny~ limit, or condition coverage based on health status, claims
i experience, or medical history during the. annual open enrollment
i: period.· The bill includes a first-:time enrollment amnesty extended for .
, a certain period after the date of enactment. Individuals are
encouraged to maintain .continuous coverage. Continuous coverage
means that the period between the date of enrollment in a health plan'
and the last date of coverage may be no longer than three months. If
an individual. has not maintained continuous coverage or is enrolling
.. ( in a plzm for the first tin:te after the initial open enrollment period,
(.coverage maybe subject. to a pr~xisting condition limitation of no
': more than six months. Pregnancy and pre-natal care are exempted
, from .this limitation.
;::
Comply with all rating requirements, including age 'and family size
adfus!ments,within the 'coverage area. ( Special rules wil~ be
: established tqapply to Employer Sponsored Heatlh PlanS .and
;, Qualified Association Plans).
l'
."
~
6.
,7.
"
'l;'Comply with ~nrollment process.
: Comply with financial s()lvency requirements, premium and collection .
criteria. (Special solvency rules are established for certain types of plans
',for large erripl~yers).
:",
\
.
:;
"
E.. . Benefit Packages
,
,I
1. .
Within six months of enactment, the Commission (described in
::Section XIV.) shall develop and submit to the Congress clarification of
;:the initial standard .and basic benefits packages. These packages must
}·adhere to the following:
I
The actuarial value of the Standard Benefit Package can not
exceed the actuarial value of the Blue Cross/Blue Shield
Standard Option under the Federal Employees Health Benefits
program.
.h.
The Basic Benefit Package must contaIn higher cost sharing
and/or fewer categories of 'benefits.
. .'
c.
Both benefit packages must include a full range of medically
appropriate treatments and.preventive services..
6.
�2.
Categories:
. The following categories of benefits are to be included in the benefits
package:
.
·a.
b.
c.
d.
e.
f.
g.
h.
1.
j.
k..
1.
3.
,
Inpatient and outpatient care.
Emergency, including appropriate transport services.
Clinical preventive services, including services for high risk
populations, immunizations,' tests or clinician visits.
¥ental Illness and Substance Abuse.
. Family planni~g and services for pregnant women.
Prescription drugs and .biologicals.
Hospice Care.
.
Home health care.
Outpati~nt laboratory, radiology and diagnostic.
Outpatient rehabilitation services.
Vision carei hearing aids and dental care for individuals under
22 years of age.
'.
.
Patient care costs associated with investigational treatments that
are part. of approved clinical trial.
.
Priorities: .
Within the constraint:s of the actuarial limits set in this. act, Congress
directs the Commission to adhere to the .following.priorities:
a.
b.
Consideration for needs of children and vulnerable populations,
.
including rurai and underserved persons.
c.
4.
Parity for mental health and substance abuse servi<;es, which
shall consist of a broad array of mental health and rehabilitation
services managed to.ensure access to medically necessary, and
psychologically necessary treatment and to encourage the use of
. outpatient treatments to the greatest extent feasible.
Improving the: health of Americans through prevention.
Medically Necessary or Appropriate
A Qualified Health Plan shall provide for coverage of the categories of
benefits described in this section for treatment and diagnostic
procedures that are ~edically necessary or appropriate.
j
An item or service is "medically necessary or appropriate" if, consistent
with prevailing medical standards, it is;
.
7
\.
�'I
condition~
a.
b.
j,
For treatment of a medical
Safe and effective (i.e., there'is sufficient evidence to .
demonstrate ,that the item can reasol.1ablybe expected to produce
the intended health outcome or provide the intended
information).
'. ~
i' c.
. Medically 'appropriate for aspecifi~ patient (i.e., it can reasonably
be expected to provide a clinically meaningful benefit if
.
fumi~hed in a setting commensurate with the patient's' needs).
Criteria for determination of medically necessary or appropriate are set
(forth. QHPs shall make :all coverage decisions under these, criteria.
" The Commission can, in limited circumstances, issue interim coverage
, recommendations.
',
,
i!
5.
Cost-Sharing
. The 'Comtriission shall also develop multiple cost sharing schedules
which vary by' delivery system organization .. In making .these
, determinations, the Commission will consult with expert groups for
, appropriate schedules for covered services .. This clarification is subject ,
, to ~pi:>roval by Congress under expedited procedures. ,
6.
.' Limitations
.' The Commission is prohibited from specifying provider types or
'\, specifkprocedures in the benefit packages.
,.
7.
·Additional Commission duties related to defining the basic and
standl:ud benefits packages: .
",
.
,
i,: a.
,
,I
'
Develop interim coverage
decis~ons in
limited circumstances.
"
b.
. ;.
Design the basic and standard benefits packages to prevent
adverse risk selection when combined with the risk adjustments
. called for in the bill .
"
;: c.' .Maynot specify provider types when clarifying covered benefits ..
d.
" May not speCify particular procedures or treatments or classes'
thereof.'
.
L
8
.
�, ,8.
Consideration of Commission Recommendations
The Commission will have the authority to propose modifications to
the benefits package (within the actuarialyalue ceiling described above)
that would not go into effect unless approved by Congress under base
closing procedures. 'The Commission is responsible for any updates to
the benefits packages after the first year and these updates are also
subject to Congressional approval under expedited procedures.
ll.
Qualified Health Plans .
A;
Accountable Health Plans ·(AHPs)
1.
Definition:. a health plan that may be operated as a variety of delivery
systems such as indemnity plans, preferred provider organizations,
health maintenance organizations, or other delivery systems. An AHP
is a health plan that is certified by the state as meeting insurance .
market reform standards, health plan standards, quality, reporting
standards, and other standards.
2.
Standards
. The National Health Care Commission (described in Section XIV.) will
establish· standards for AHPs. In addition, AHPs:
a.
.b.
Must meet insurance reforms'described in (I.,. C.) .
May notengage in marketing or other practices intended to
.. discourage and/or limit the issuance to eligible individuals on
the basis of he~lth condition, industry, geographic area or other
risk factors.
.
c.
Must make a health plan available throughout the entire HCCA
area in which it is offered.
d.
Must demonstr,ate its ability to make available and accessible to
.
each potential enrolle in the area the full range of benefits
required under, the standard and basic benefit packages, when
medically necessary and promptly.
'.
...'
e.
Must provide for the application of coverage standards (for
benefits) which, are consistent with the coverage standards issued
by the Commission and disclosed to plan enrollees.
9
�-
'.
,~
f. '
Must not accept enrollment of an individual who is currently
enrolled in another AHP.
' '
Must make available to nonparticipi3ting providers the criteria
used in selecting those providers that are permitted to participate
in the plan.
;,:
, h.
Mtlst comply with federal information requirements.
i.
Must offer the standard and basic benefit packages, but may also
offer benefits in addition to these packages, if such additional
benefits are offered and, priced separately from the standard and
basic benefit packages.
,', ,
j.
Must comply with a system of binding arbitration for coverage
disputes.
"
,
B.
Employer-Sponsored (risk-bearing) Plans
. 1.
2.
Definition: a group health plan that may be operated as a, network plan
: or an indemnity plan for which the employer retains all or a portion of
;: the insur~nce risk, commonly referred to as self-insured.
pStandards:
. Employer sponsored plans must meet all the standards for AHPs
and insurance. market reforms, 'except they, are not required to
take all applicants, and' the population served and area covered
is defined by suchan employer's employeepopulafion. ,
" .,b.
~
:'
c. '
i
I
,
~inancial solvency, reserve, and guarcmtee fund standards 'will
, be established by the Secretary of the Department of Labor (DoL)'
consistent with the applicable rules under Part4 of Title I of
ERISA.'
'
The Secretary of DoL may take corrective actions to terminate or
disqualify an employer-sponsored plan that does not meet the
above standards. ,
'
The Secretary of DoL is appointed (as trustee for insolvent
employer-sponsored health plans.
J\
•
,
if
10
�C.
Qualified Association Plans (QAPs)
1.
Definition: Association health plans that have been in existence fof'
.t~ree years prior to the date of enactment ...
2;
Standards:
a.
Must meet all standards for AHPs with the following exceptions:
1.
ii.
3.
Special solvency requirements will be established by DoL
forQAPs.
Must only take any member in their designated
association.
Requirements for Sp0nsoring Entity (Association) .
a.
Must be orga~zed and maintained in good faith;
b.
Must have appropriate by-laws that specifically state the purpose;
as a trade assocIation, industry association, professional
association, chC;lmber of commerce, religious organization, or
public entity association ..
.
.
c.
d.
Must be, and have been, in operation (together with its
imx:nediate predecessor, if any) for a continuous period of not
less than 3 years.
e.
4.
. Must have been established and maintained for substantial
purposes other than to provide the health care required under
ili~~~oo.
.
.
Must receive the active support ~f its membership ..
Treatment of Multiple Employer Welfare Arrangements (MEWAs)
a.
In general, upon enactment,· a MEWA will meet the standards to
become either" QAP or a certified purchasing group.
b.·
Any MEWA that has been in effect for not less than 18 months
upon enactment and with respect to which there is application·
with the domicile state for.certification as a QAP, shall be treated
: for purposes of this subtitle as a Qualified f:Iealth Plan (if such
plan otherwise meets the requirements of this Act);
I
11
�t.
l:fowever,MEWAs will not be able to continue to operate if the
domicile state 'can demonstrate that -
" c.
the sponsor has made fraudulent or material
misrepresentation(s) in the application;
i.
:,'
. ii.
the plan thq.t is the subject of the application, on its face,
fails to meet the requirements for a complete application;
or
lll.
5~
. D.
a financial impairment exists with respect to the applicant
that is suffiCient to demonstrate the applicant's inability to
continue its operations.
Treatment of Rur~l Electric Cooperatives (RECs) and Rural Telephone
•Cooperative Associations (RTCs) ,
t
iRECs andRTCs can continue to exist if they meet the same standards as
:: QAPs; or if they are certified by the state as a purchasing group.
Multi:-Employer(Taft-Hartley) Plans
Taft-:t!artley plaIlS must meet the same requirements as large employers. (See.
Section nl.B.. below)
.
.
~.
E.
,'Public Programs
II
"
' "
ExistiPg public programs like Medicare, Medicaid, Department of Defense
. healtl) prograI1ls, Department df Veterans Affairs health programs and Indian
'HealtJ::t Service programs are considered to be Qualified Health Plans for the
purpqses of this sec;tion.
' .
.
F.'
.
.
Pre-eri,tption of Certain State Laws regulating ,Insurance Plans
II.
.
.
'
'
The f~llowmg statelaws relating to.heaith plans are preempted for any QHP;
1.'
: State laws that restrict plans from:
i;a.
;,
J~
limiting,the number and type .of pro~iders who participate in a'
'plan;'
.
requiring enrollees to obtain health services from participating
. providers; ,
.
12
�c.
requiririg enrollees to obtain referral for treatment by a specialist
or health· institution;
d.
establishing different payment rates for participating providers;
e.
creating incentives to encourage the use of participating
providers;
J
•
,
,
2.
3.
G.
State corporate practiCe of medicine laws;
. State mandated benefit laws ..
Advance Directives
1.
Right to Self.;.Determ~ation
.
a.
Each Qualified, Health Plan must notify enrollees of their rights
. to self-determination in health care decision-making and of the
plan's policy regarding advance directives. Plans must
.
maintain proceaures to require that the existence and content of
an advance directive is recorded in the patient's chart (written or.
electronic) ,and provide for a mechanism to notify all appropriate
health care providers of the information.
b.
' Plans must provide for, educational activities for patients and
provid~rs and must have a functioning process to provide for
communication between the patient' and the appropriate health
care provider regarding all aspects of the patient' scare, including
obtaining informed consent, patient prognosis and treatment
decisions, arid the formulation of advance directives.
Discussions of prognosis and treatment alternatives should
occur at the time of diagnosis, prior to treatment and whenever
there is a significant change of status which affects diagnosis, .
prognosis and treatment.
c.
In order to receive Medicare or Medicaid reimbursement for
, particular procedure codes to be determined by 'the Secretary of
. HHS, 'Claims forms, (written or electronic) must include the
physician's certification indicating that'the patient discussed
with the physician the diagnosis, prognosis and' treatment'
options and that the patient's questions were answ~red.
13
�2:
;: Decisiox:'5 by Surrogates ..
<
);
•
,
"
•
'.
;: In the event that a state does not ,have a law on surrogate decision-,
. " maker for health care decisions, a federal Dealthcare surrogate standard
: shall apply. This standard is: '
,
,
'
A .surrogate may make a health~caredecision for a patient who is
an adult or emancipated minor if the patient has been
.
determined. by the primary physician to lack, capaCity and no
agent or guardian has been appointed or the agent or guardian is
not reasonably available. ' .
'
An adult or emancipated rnirior may designate any_individual to
act as surrogate by personally informing the superv.ising health
, care provider or specifying it in a health care power of attorney.
In the ab'sence of a designation, or if the designee.is not
reasonably available, any member of the following. classes of the
patient's family who is teasonablyavailable, in descen.ding order
'of priority, may ~ct as surrogate: :,
'
i.
the spouse, :unless legally separated;
ii.
an adult child;
111.
IV. '
,
a parent; or
an adult brother or sister; ,
' - .
.
",
.
'
.
.
,
If,none of these individuals are reasonably available, an adult
. who has exhibited special care and concern for the patient, who
, .is.familiar with the patient's personal values, and who is '
". reasonably available may act as surrogate.
'
:, d.
" Ill.
A surrogate shall communicate his or her assumption of '
authority as promptly as practicable to the specified ,members of
the patient's family who can be readily contacted.
Large and StoallEmployer Resp~nslbHities and Purcbasing Groups
A.
Smail: Employer Purchasers
. ," ·i~ '.
'". ' '
1.' ,Definition: employers with 100 or fewer full-time employees.
.'
..
~ ',.
.
2 . ; Responsibilities:
"
"
14
�a.
,
May not be the sponsor of a risk-bearing plan, but if a member of
'an eligible Associ~tion may join a QAP.
b.
Must provide all employees (inc1ud,ing part-time and seasonal)
with information regarding all AHPs offered' in the HCCA in
which· the employer is located.
.
c.
If an employee resides in another HCCA, the employer must
provide information regarding how to obtain information .
regarding AHPs available in that HCCA.
d.
Small employ~rs must make available to their employees a .,
. choice of at least three Qualified Health Plans either by joining a
. ~ purchasing group or. through independent brokers or insurance
agents.
I
e.Small employers who contribute toward coverage must pay to
any Qualified Health Plan selected by the employee an amount
equal to the contribution they would make on the employee's
behalf to the health plan selected by the empl,?yer.
f.
Payroll Deduction. If an employee requests, employer must
arrange for payroll deduction to pay the premium amount due,
less any employer contribution, to the plan or purchasing group
. of the employee's choice. However/if the employee selects a
plan other,than those offered by the employer, the
administrative: cost of making such a payroll deduction may be
charged to the' employee.
i
B.
Large EmployerPurchasers!
1.
Definition: ' employ~rs with more than 100 full-time employees.
2.
Responsibilities:
a.
. All large employers must offer their employees a choice of at
least three QHPs, one of which must be a point-of-service option
and one of which must offer a basic benefits package. A large
employer may comply with this subsection by offering QHPs
provided by a single enQty. Large employers may also meetthis
obligation, in part, by making available to their employees the
choice of a Qualified Association Plan (see below).
b.
Large employers are ineligible to join the small employer and
individual pu~chasing groups or to purchase insurance at the
15
�.'
,
comri:lunity rate either through a: broker, .independent agent,
purchasing 'cooperative, or public enrollment office.
,I'
,!,
~I C.
Employees of large employers are a~so ineligible to purchase
insurance at the community rate either through a broker,
independent agent, purchasing cooperative, or public
enrollment office,
.
\i d.
All large employer purchasers are regulated by the DoL and
remain subject to .ERISA.
n
. e.
"
,
iI
f.
Ig.
'!,.
"
C.
If an employer contribute~ to its employee's health coverage, it
.must provide coverage as of the' first day of the month in which
an employee becop1es eligible. Once terminated, coverage'
continues througn the end.of the month of termination.
COBRA. An individual whpse employment has been
terminated by a large employer must elect within 30 days of the
termination· to either remain in the plan provided by the .
e.mployer for it period not to exceed 12 months; or until the
individual is reemployed, whichever is less. '
Selection of Plan by Majority of employees. Each employer shall .
make ,selection of health plans on an annual basis. Employers,
, . who are not contributing to coverage, shall comply with a
'
selection ma:de by mOre than 50% of employees.
Individual and Small Employer Pur.chasing Groups .
,1.' . These purchasing groups shall be chartered under state law.;
. , 2.
; Membe~ship -in these purchasing groups will be voluntary and limIted
.
. '.: to employers and employees of businesses with 100 or fewer
. employees, and to all other non-Medicaid U.S. citizens or legal
, residents. not,. employed by a large employer who live in the HCCA .
.
area.
'
.
3.
':. Nothing in the Act shall be construed to require any individual or
. small employer to purchase exc1usivelythrough a purchasing group.
4.
\ Nothing in the Act requires the establishment of a purchasing' group
:. nor prohibits the establishment·of a purchasing group in an area.
..
. 5;
.
: Nothing in the Act shallbe construed from preventing a purchasing·
group from being th~purchasing group for more than one HCCA.
I
16
�6. . Nothing shall be construed to prevent a' state from establishing or
designating more than one purchasing group in a HCCA.
7.
D.
Purchasing' groups are permitted to conttact selectively with Qualified
Health Plans. Purchasing groups are permitted to negotiate a price ,
lower than the community rate, if so, that price becomes the plan's
new community rate. Nothing in this act shall be construed to prevent
, a purchasing group from negotiating prices on administrative fees or
items outside the basic and standard benefits packages which may be
'
unique to the purchasing group.,
Allowing Access to, Federal Employee Health Benefit Program
Any plan under the Federa( Employee Health Benefit plan offered to federal
employees in'a HCCA must be'available for purchase by individual and small
group purchasers in that area. Non-federal employee purchasers shall pay a
, premium amount based on the local community rate for that plan; and shall ,
not be a part of the FEHB insurance pool. Plans offered nationally through
, FEHB shall not be required to be open to non-federal employee enrollment.
IV.
Nondiscrimination provisions tha~ apply to all employers:
A.
,
"
General Rules
Employers that contribute to the purchase of any employee's health care'
coverage may not discrimmate against any employee based on the employee's'
income. Employers that contribute to the purchase of any full-time ·
employee's health care coverage must make an equal dollar contribution to
all full-time employees choosing to purchase health care coverage offered by
such employer. In addition, employers that contribute to the purchase of any
part-time employee's health'care coverage must make a proratated equal
dollar contribution to all part-time employees choosing to purchase health
care,coverage offered by such employer.
1.
A large employer that otherwise contributes shall not be required to
offer an equal dollar contribution to an employee or "cash out" an '
employee that does not choose to purchase health care coverage offered
by such employer.
'
2.
'For purposes of part-time employees, a dollar ~ontribution will
constitute an equal dollar contribution if the employer makes a dollar
contribution proportionate to the number of hours' worked by the parttime employee.'
,
17
�n.'
Spe~~al R~lefor Small Employers
"
1. I' To, the ,extent a small employer contributes to 'an employee's health
care coverage, the employer cannot discriminate against an employee
that chooses to purchase health care coverage from other than such
~rhal1 employer.
'
'
,
';,
2.
: In no event shaH a small employer be required'to "cash out" an
i:employee who does notchoose to p'urchase health care coverage,
'throughthe employer. For example, if a small employer makes a
contributionon behalf of a full-time employee that chooses a plan the
employer offers,.it must also make a contribution to a fuH:~time
; employee that chooses a! Qualified ,Health Plan not offered by the
i: emp loyer~'
'
I'
3.
:, Small employers may charge a reasonable fee to cover their'
:: administrative costs associated with withholding and remitting..
,
:., employee health insurance premiums of employees not opting for the
:! health care coverage offered by the small employer.
Penalties
To th~ extent an employer does not comply with these nondiscrimination'
rules, a penalty will be assessed, for, the period of time the employer is in
noncompliance. Such penalty will be equal to $100 for each day, or part'
there9f, of such period. (See Section 4980B of tl).eIntemal'Revenue Code for
, ,
analogous rules)."
" D.'
DefiJ1itions
1.
A full-time employee is defined as an individual who is employed for'
an average of 30 or more hours per week.
'
2.
:' A part~time employee is defiried as' an individual who is employed for
, ;' an average of at least 10 hours, per week, but less than 30 hours per
week.
3.
i: An individual does not qualify as a full-time or part-time employee
~;
until the individual has been employed for six months (i.e., seasonal
, employees a~e not treated as 'part-time employees) .•
18
�E.
Exemption for. Collectively Bargained Plans·
.
Single-employer and multi-~mployer bona fide collectively bargained plans
are exempt from these nondiscrimination rules ..
V.
Assistance to Individuals and Families for the GeneralPurchase of Insurance
A.
Eligibility:
Individuals and! or families not otherwise eligible for Medicare or Medicaid,
whose income is less than 240% of the federal poverty level will be eligible for
a voucher·forthe purchase·0fa Qualified Health Plan.
B.
Amount of Voucher
1.
2.
C
For individuals and families with incomes less than 100%·of poverty
the voucher will be equal to 100% of the average premium of the
lowest 2!3 of Qualified Health Plans offered in the HCCA in which
they reside or work.
For individuals and families with income above 100% of the federal
poverty .level, the VO\:lcher amount will be ·decreased on a sliding scale .
basis to 240% of the federal poverty level. .
Phase.,in Schedule for Vouchers
1
Vouchers will be phased-in at the beginning of each year under the·
following schedule:
Calendar Year
1997
1998
1999
:WOO
2001
D.
Percentage of Poverty
I.
90%
120% .
150%
180%
240%
Administration of Vouchers
1.
The Secretary of HHS will establish a mechanism for
determining eligibility for vouchers, for distributing application
19
�forins, and to the extent practicable, for allowing enrollment in a
';: Qualified Health Plan at the time of application for subsidy;
"
2.
;:The Se~retary may provide for administra.tion of Vouchers through an
: appropriate State agency.
i:
VI. Assistance t,o Individuals ,and Families -Expanded TaX Deductibility
(Described ill Section XIII.,B.)
I'
VII. Expanding Access for Underserved Populations'
A.
Co~unity-Based'Primary Care Grant Program'.
,
1.
,
iThree grant programs would be established to promote community
i: health plans and practice networks.
I'
r
a.
,
The HHS Secretary will establish a program to administer grants,
to the, states for the purpose of creating or enhancing
community-based primary care entities that provide services to
low-income or medically underserved populations: This
, provision is designed to compleme:nt the existing federal ,
Community and Migrant Health Center programs by making
, " flexible funding available to local pul;>1ic health departments~ ,
rural,hospitals, an~ other public and private community care
entities.
r!
b.
i,C.
The Secretary of HHS may make grants to and enter into
cori.tracts with consortia of public and private healtnicare
providers for the development of qualified commuhity health
plans and practice'networks. The Secretary will give preference
to plans and networks with three or more categories of providers
such as EACH/RPCHs, MAFs and other rural hospitals, migrant
health centers, community health centers, homeless health '
services providers~ public housing providers, family 'planning
clinics, Indian health programs, maternal and, child health
, providers, federally qualified health centers and rural health
clinics, state and local health department programs' and healt1:t
professionals and institutions providing serviCes in one or more
Health Professional Shortage Areas (HPSAs) or to medicC:\lly
underserved populations.,
Loans and loan guarantees for capital costs would be authorized
for the development of qualified community health plans or
practice networks ..
i,
"
"
20
�B. .
Enhanced Assistance for Federally Qualified Health Centers
1.
Expanded resources will be provided for the Federally Qualified Health
Centers;
.
.
2.
C.
D.
. .
.
.
This provision is intended to complement the state-based community
primary care grant program described·above. Both provisions are
aimed at addressing -the shrir:tking availability of primary health care
services in the coun~ry's rural and inner-city communities.
Tax Incentives for Practice in Rural, Frontier, and Urban Underserved Areas
(As described in Section XIII., D.)
.Development of Networks ·ofCare in Rural and Frontier Areas
1.
The HHS Secretary is authorized to waive certain Medicare and
Medicaid requirements for demonstration projects to operate rural·
health networks. Public and private entities may apply for such
waivers. The Se£iretary may award grants to assist organizations in
rural networks planning. .
.
2.
. The Secretary w.ill cortduct a study bn the benefits of developing a ..
supplemental benefit package and making available premiums that
will improve access to health services in rural areas .
..
\
E.
Grant Program for Low Interest loans for Capital Improvement in Rural and
Underserved Areas
Loans and loan guarantees for capital costs would be authorized for the
development of qualified . .
community health plans or practice networks.
.
F.
Office of the Assistant Secr~taryfor Rural Health
.
.
p~SitiOn
. . Under this provision, the
of Director of the Office of Rural Health
would be elevated to the position of the Assistant Secretary for Rural Health.
The mission of the office would be expanded to include advising on how
health care reform could impact rural areas.
21
�II
~.
G.
Rural and Frontier, Emergency Care
A ruI'al emergency medical services program is established to improve'
~mergency
medical services (EMS) operating in tural and frontier
comIl)unities. This program will: '
1.
Offer a matching grant program for improving state EMS services.
These grants will, encour,agebetter, training for health professionals and
, provide necessary technical assistance to public and private entities
,. which provide ,emergency medical'services;
2. ,j: Provide fedenil grants to states for telecommunications demonstration
" projects linking rund and u:r:ban health care facilities; ,
3.
4.
H.,'
:: Establish an Office of Emergency. Medical Services to provide technical
,
: assistance to state EMS programs;
:.'Federal grant support will also be provided to the states for the
development of air transport systems to' enhance, access to emergency
. medical services.
'
,
Medic;:are Dependent Hospitals,
1. ' :. Modify Payments to Medicare Dependent Hospitals.in the following
'manner:
base payments on a 36 month period beginning with the first day
'of the cost reporting period that beginS on or after April 1, 1990;
"
; b.conform target amounts to extension of additional payments; ,
:! c.
." cl~rify of updates; and,
1
: d.
would extend Medicare-dependent hospital classification
through 1998.
. '
2. ':Would establish a demoristration project regarding payment to larger
.
,.,Medicare dependent hospitals.
'
I.
EACHlRPCH Program Improvemellts and Extension to all States
I"
'
,
"
;
,
iExpands the EACH/RPCh program to all states.
. .
,
:i"
"
2.
; Ruraf community hospitals meeting eligibility criteria may qualify as
22
�,
;.
Rural Emergency Access Community Hospitals (REACHs).
3.
Current special reimbursement to .small rural Medicare--dependent
hospitals enacted in Omnibus Budget Reconciliation Act of 1989 is
' . '
' ..
extended.
4.
Modify provisions that relate to hospital inpatient services in a' Rural
Primary Care Hospital so that:
;,.
a.
a· RPCH cannot have more than 6 beds;
I
j
.
.
b.
theRPCH cannot perform surgery or any service requiring
general anesthesia (unless the riskof transferring the patient
outweigh' the benefits); ;
c.
the Secretary a,an'terminate the RPCH designation if the average
length of stay for the previous year exceeded 72 hours. In
determining the average length ofstay, cases which exceed 72
hours due to inclement weather or other emergency conditions
are not included in the calculations;
,
. d.
..the GAO mus:t submit a report -determining if the revised RPCH
criteria have resulted in RPCHs· providing patient care beyond
their abilities ()r have limited RPCHs' abilities to-provide needed.
services.'
-.
.
5.
. Designates EACH
'L'
ho~pitals
•
so that: . .
a.
urban hospitals can be designated as EACHs and do not need to
meet the 35 mile criteria, but do have to meet all the remaining
criteria. Urban EACHswould still be subject to the MedIcare
.Protective Payment System; and, .'
.
b.
hospitals locat¢d in adjoining states cind otherwise eligible as
. EACHs and RPCHs can participate in a state'srural health'
network and t};l.ese hospitals or facilities are permitted to 'receive
grants.
,
6.
PeI1l\it'RPCHs to maintain swing beds in a Skilled. Nursing Facility
except that the number-of swing beds may not exceed the total number,
of swing beds establi~hed at the time the facility applied for its RPCH
designation.. Beds in 'a distin(t"'part SNF do not count towards. the total
number of swing beds.
.
7.
Extend·thedeadline for ttte development of prQspective payment
system for inpatient E,PCH services to January I, 1996.
-
.
,
23
�8..
. laritYth~t physicHm staffing criteria only apply to doctors. of medicine
C
and ost~opathy.< .
'.
9.
',Aciopftechnical·amendments~elating to Part A deductible, coinsurance
and. spell of illness. ,
.
10. ";,' The Departtilent of' Justi~e and' Federal. Trade Commission would be
:: instructed to issue formalg1liqelmes for EACFiiRPCHs.
.,..
I,
11. . The. Secretary would be permitted to designate an unlimited nu~ber ·of
RPCHs in non-EACH' states~ .The RPCHsmust establish relationships
with a full-~ervic~ rural, pospital that meet the same criteria as EACHs
, with the exception of the criteria that the EACH have 75 beds.
(. .
~t
it
HH!3'Wotild be 'requIred to conduct a' pUot program that would allow"
RPCHs.to,admitpatients, on a limited DRG basis instead of.using the
72-hour average Jength of stay·criteria.
.
, 12.·
13. , Codify the MAF requirements into Medicare; 'allowing Medicare to .
I reimburse on a cost basis those facilities which meet the MAF'
I: requirements.
.,
"
,
I-
'.'
.
".
1
"
.
,-'
"
14.
Ii Develop ~grant program for states that 'operate MAFs. The grant
',.: prograIIl would be' .modeled after the EACH/RPCH prqgram.
.
.
.
~
. .
,
j'
h
I
J.
Exte~ds the Rural Health Transition Grant Program
. .;
'
F·",.
.
)
'
. ..
.
ExteriCls the program through EY 1998 with authorized appropriations of $30
million 'arui.ually,FY 1993 - 1998. ReportsJrom grantees, would oe required
.' every:'12 months. As of October 1, 1994, RPCHs are eligible for rural health.
transftion grants. .
.,.
.'
.
,
~;
\:
"!:
.
K.
.,'
.' .
'i. '
~
.
Increases reimbursement to PAs and NPs under Medicare.
-
\;
,
"'."
il
.. '
.
, 1.' , I, Certified Nurse Practitioners and Physicians Assistants would be .
:Lreimbur:sed at 85% of the RBRVS rate, for .services performed in all
outpatient settings.
;
..
~
2.
Under Medicare, certified Nurse Practitioners would be reimbursed at
65% of'the RBRV5 rate fo,r assisting atsurgery in urban areas.
3.
States wouJd be required'to direc~lyreimburse all certified Nurse,
Practitioners in, a rural area: under Medicaid. This expands the current
II .
. , .
I
24
�requirement that all states directly reimburse pediatric and family
" Nurse Practitioners, which gives states the option of directly.
reimbursing other types of NPs.
L.
Telemedicine and Related Telecommunications Technology
1.
2.
M.
Coordinates various federal grant programs which fund telemedicine
arid relat~dtelecommunicationsdemonstrations and. grant programs.
This provision establishes a federal interagency task force, coordinated
and chaired by the Department of Health and Human Services, would
be established to oversee telemedicine and other telecommunications
deIl}onstration projects already underway.
A grant program would be established to fund telemedieine and· related
telecommunications technology in rural areas. The program would be
. administered through the AssistantSecretary JorRuralHealth.
Applicants for the grant would be rural health care providers such as
rural. referral centers, rural health clinics, community health centers,
migrant healthcentets~ area health and education centers, local health
departments and public hospitals. '
.
.
National Health Service. Corps
1.
Fully funds the Nati6nal Health Service Corps program and require
.. that at least 20% of those in the Scholarship and Loan Repayment
Program be nurses, and physicians assistants
2.
. Reauthorize the Community Scholarship Program .. In addition, the
criteria for selecting students should be modified and a 15%
administration fee for those agencies administering the scholarships
should be established.
N. . Indian Health Reform Amendments .
1.
2.
Indian Health Service remains as
.Indian population. :
aprovider of health care for the
.
. Reaffirms current federal policy ofguaranteeing that Indian Tribes.
should be eligible to apply for all appropriated funds and grants created
.under health reform legislation, at levels not less than any other
qualified entities. This provision is simply a reaffirmation of current
Federal policy.
.
�3.
Requires. the Assistant Secretary for Indian Health to establish a new
". formula for the distribution. to tribes. of all new funds thal become
available for health care initiatives and programs under health reform.
This formula would consider differences i.n local resources, status of
health, socioeconomic status o{Tribal people, and.
facilities/equipment/staff that are available.
,I
Retains' Indian eligibility under current law for additiomil benefits.
Under this provision, whatever comprehensive benefits one' accrues
through health reform legislation, Indians would not lose any current
benefits. Such benefits include all supplemental benefits, such as
environmental,health, mental health benefits, anda1cohol abuse
trea trrient.
':
. '
4.
1
H
0..
Transitional Requirements for Plans Serving Speci~l Needs Populations
1.;, Nondiscrimination Serv.ice Area Standards
:,: Health plans must not discriminate in the drawing of services area
'. boundadeson the basis of race, ethnicity, socioeconomic status, age, or
anticipated need for health serVices.
'
2.
Special Access Sta.I1dards
.
.,
!i Phins must meet special access standards that take into account the
special needs and circumstances of 4rban and rural underserved areas.
!, The Secretary would be required to establish access standards for
'.) enrollees living ill medically underserved areas that take into account
. the following indicators: .
.
a.
b.
c.
3. '
Accessibility of primary care services based OIl measures such as
the ratio of primary care providers to expected enrollees;
. Accessibility of other services, based on measures such as travel
.time; .
, Accessibility of health plans services for individuals with
,limited ability to speakthe English language, and for population
with similar needs.
.• Reporting Requirements
Healthplans must report on key indicators of access, quality and
servic~ in a manner that. provides separateinfonnatioll and
monitoring for those in medically underserved areas.
I
1~
(
4. '. " Des'ignation of Underserved Communities and Populations
."The Secretary would annually designate uriderserved areas and
populations as either of the following areas: , .
,
a.
Areas with a shortage of personal health services as designated
26
�b.
c.
d.
5.
Certification of Essential Community Providers
Any public or non-profit private entity furnishing services in a .
designated medically underserved community or population may
apply to the Secretary for certification as an essential community
provider., In order t~ be certified, the entity:
a.
b.
c.
d.
e.
f. .'
g.
, h.
1.
J.
6.
7.
under section 332(a)(3) or 1302(7) of the Public Health Service
Act;
Health Professional Shortage Areas a$ described in section
332(a)(1)(a) ofthe PHS Act;
.
.
High impact areas as described in section 329(a)(3) of the PHS
Act; or
.
an 'area which;includes a population group which the Secretary
determines as a health. manpower shortage area under Section
332(a)(I)(B) of .the PHS Act. .
Must be a pub.lic or non profit private entity;
Must be capable of providing for a full range of primary health
care services that are available and accessible promptly, as
appropriate and in a manner which assures continuity;
Have organization arrangements for quality assurance programs
and maintaining patient record confidentiality;
Demonstrate financial responsibility;
Accept all patients notwithstanding their ability to pay;
Make every effort to collect appropriate reimbursement from
Medicare, Medicaid and third party payers;
Establish a sliding-scale fee schedule based on ability to pay for
services;
Reviews annually its catchment area;
.Where appropriate,' provides access to patients with l~mited
english-speaki~g ability;
.
Meets the requirements of section 1861(z) of the SoCial SecuritY
Act, compiles appropriate statistical and other information.
Obligation to.Offer Contracts for Primary Care'Services
All health plans, including. self-insured plans, would be required to
offer' a contract with a reasonable number as determined by the '.
Se~retary of certified essential community providers. Mandatory
contracting would be.in effect for the first five years afterenactrnent.
. Scope of Contracts ,
The contract between health plans shall:
a.
Provide for primary health services that are included in the
uniform benefit package, furnished on an outpatient basis and
provided directly by the essential community provider.
27
�,
b.
"
, c:
8.
Terms and',conditions applied to the agreements shall be
comparable to terms anq conditions that apply to other
providersfilrnjshing comparable s~rvices to the health plan.
Payment will be based on Section 1876 of the Social Security Act.
Health Plan Obligation for Non-primary Care
;, Health plans must meet general access standards for non-primary care
,services to insure accessibility and availability of all covered and non
, covered primary, care services for all enrolled members. (Needs mpre
definition.)
,
,
9.
Access'in Underserved Areas
The Office of Technology Assessment (OTA) will conduct a study on '
improving access in underserved areas.
P. '
Urba:~
1/
Safety-Net" Hospitals
. Estab:lishes a revolving loan fund and grant program to fund capital
improvements for publicly owned and operated "safety-net" hospitals. ,
Q.
Other Urban Hospitals,
. Dem9,nstration for inaccessiblepther urban Hospitals to qualify as Sole
Community Hospitals. ' ,',
,',
.
VIII. New Ho:me~al1d Community Based Long Term Care Program
A~
Gen~ral
iiEstablishes a new capped program in the Social Security Act to provide
; home-and community.,.b~sed services for older Americans and
, :~ individuals with disabilities. The program is administered by the
, States with federal matching payments for services provided. Total
, funding is capped, and there is no individual entitlem,ent to services
under this program.
,;
;; The Secretary will issue regulation establishing uniform eligibilitY
'.' criteria and assessment protocols. In order to receive benefits under'
, the program, an individual must be determined eligible, must undergo
28
�a standardized assessment and have a individualized plan of care
. developed. To be eligible, an individual must be in one of the
following categories. The first three categories apply to individuals of
all ages; the final category applies only to <;hildren under age six.
!
1.
Requires hands-on or stand-by personal assistance supervision
or cues in three or more of five activities of daily living: eating
dressing bathing, toileting, and transferring in and out of ~ed.
,
I
'
2.
3. ,
Has severe or profound mental retardation.
4.
C.
Presents evidence of severe cognitive or mental impairment.
Is under age si?, and would otherWise require hospital or
institutional care for a severe disability or chronic medical
condition.
Covered Services
1.
2.
D.
At a minimum, a state's array of services must include personal
assistance (both agency administered,and consumer directed) for every
'eligible category of participant. Services may include, but are not". .
limited to: case management, homemaker and chore' assistance, home
modifications, respite services" assistive technology, adult day services,
habilitation and rehabilitation, supported employment" and home
health services.
'
Services may be delivered in a home; a range of community residential
arrangements, or outside ,the home. ,Services may not be provided in
licensed nursing homes or intermediate care facilities for the mentally
retarded. ,
.
Cost Sharing
Eligible individuals with inc;omes over 150% of the federal poverty level pay',
co-'insuraJ;lce to cover a port~on of the cost of all services they receive
according to a sliding scale. Persons with incomes between 150% and 200 0/? of '
the federal poverty level pay 10% of the cost of care; between 200% and 250%
of poverty 20% co-insurance, and, persons with income over 250% of poverty
pay a 25% co-insurance. ','
29
�E.
Stat~, Administra~ion
I,
,
.
Each~state must hav~ an appr<?v~d plan, which specifies: administering'
agen~y
or agencies; serVices tobe covered, and how the needs ofall types of
eligi~le individuals will be met; provide a plan for making eligibility
detez:mina~ions: provide information on how the state will develop care,
plans, coordinate services, reimbui'se providers and'plans, administer,
.. vouchers or cash payments, license or certify providers. In addition, the state
. ':must;develop a system of determining allocation of resources and how the
, new program with be integrated with existing long-term care programs, and
must' assure that low-income persons in the program is at least equal to the
propc;»rtion of low-mcome persons in the state's population.
'F.
Qua1~ty
Assurance
1
I
.
State~. are respoIlsible for deve~opingc6mprehensive quality assurance
, programs that monitor health and safety of participants as well as assure that
services are of the highest quality. States must develop, for federal approval,
quality assurance systems that mc1ude consumer satisfaction surveys .. In
addition, consumer advisory groups are expected to playa strong role in
,assur~ng and enhancing quality.
:,
G.
Feder~l
Matching Payments to States
A federal matching payment will be made to states based on the.current
Medic:aid match rate plus 28 percentage 'points. Federal matching percentages
can b~ no less than 78 percent and no more than 95 percent. No federal
matching payments will be made .once the cap' is reached.
~,1
H.
.
.
•
•
'
ii
Funding, Allotments to States
For federal Fiscal years 1996-2002 - No federal funds allocated.
PART TWO,i- COST CONTAINMENT & CONSUMER PROTECTION
A.
.High Cost Plan Assessment .
(described in Section XIII., A.)
"
"
30
Il!
�,
B.
:
/
Medical Liability Reform ,
I
1.
Alternative Dispute jResoliItion
a.
b.
2.
No healthcat~ malpractice action may be brought in court until '
final resolution of the claim under an alternative dispute
resolution (ADR) method adopted by the state from models
" developed by ~he Secretary of HHS, or developed by the state and
, approved by ~e Secretary of HHS.
If the party initiating court action following the ADR receives a
worse result ,with respect to liability or a level of damages 33
1/3% below th'at awarded in the ADR, that party must pay the,
costs and attorneys fees of the other party incurred subsequent to
the ADR.
.
Damages
Non-economic damages awarded loa plaintIff in a health care
malpractice claim or ~ction may not exceed $250,000, indexed for
'inflation.
.
.
"
.
3..
Several Liability
The liability of each defendant in a h~alth care malpractice ~cti()n for
non-economic and P4nitive damages will'be based on each defendant's
proportion of responsibility for the claimant's harm.
'.
4.
Punitive
.
Dam~ges
.
I · ' ,',
. .
~
, '
.
.,
Seventy-five percent '0f punitive damage awards will be paid to the
state in which the action is brought and such funds will be used for
provider licensing, di~ciplinary activities and quality as~urance
programs.
5.
Statute of Repose
A twenty year statute 'of repose will be applied to health care
'malpractice actions.
'
.
6~
Fee' Reform
Lawyers may notcha~ge contingency fees greater than 33 1/3% of the
first $150,000 of the award in a health care malpractice action and 25%
of' am01mtsin excess :of .$150,000. Calculation of permissible
contingency fees is based .after tax amounts.
on
.
'
.
31
�ll.
."
.' :"
;J
7.. ' 'Limited Preemption
Stale laws that have higher limits on attorneys fees and non
economic. damages are preempted. State laws that provide for longer'
statutes .of repose are preempted. ',Ooes nqt preempt those laws with
". 'lower ,Hmitson attorneys fees and' non-economic damages are '.'
preempted. Does not preempt state:Iaws with shorter statutes of
i: repose.
"!"
h
.i
C,
'
.
:Adm~nistrative Simplification and Paperwork Reduction
Impl~m~nt~
a national health htlormation network to reduce the burden of
.admiP,istrativecomplexity, paper work, and cost on the health care system; to
provifle the iriformation on cost and quality necessary for competition in
health care; and to provide informatiqn tools that allow imptov~d fraud',
, . detection,outcomes research, and' quality. of care;
.
i'
j~
.
;
1.,( Na'tional Health Information Network
.
.
,
',;Requires theSecretaryofHHS t~ implement a na~ional health
information network by 'j;ldopting standard~ for: .
.'
.
2"
..
!
'a.
b.
.
representing the content and' format ·of health information in
both, paper and electronic forms,
.
.
transmitting inloitna tionelectronicaHy,
'ctmd ucting transa'ctions using this informatiqn,
:t
h
. ;d.
I
'i
fl!
certifying public or private entities to p~rform the intermediary
functions, which itpplement the network, ,.,'
. ~'
,!'e;'·:'
, monitoring performance to assure compliance,
, establishing procedures' ror adding codes to previously adopted ."
standards,
'",
g.' . making changes to previously adopted standards, and'
;',
h.
developing, testing,' and adopting new standards.'
.
'
-
"
32
�. .,)
2.
Health Information Advisory Commission·
.
,
'
In carrying out duties under this part, the Secretary would consult with
an Advisory Commi9sion consisting of 15. members fro.m the private
sector with expertise and· practical experience in developing and
applying health information and networking standards. The members
would be appointed by the President and serve staggered 5 year terms,
and would include providers and consumers .
. ,~
3.
,
Requirements for Qualified Health Plans and Health Care Providers
All 'Qualified Health Plans, including Federal and State' plans, and all
health care providers would be required to comply with federal
standards, for formatt;ing information and electronic transactions.
The Secretary may require transactions to be consistent with the goal of
reducing administrative costs. In addition, certain standard data must
be made available el~ctronically on the health information network to.
authorized inquiries.' Other requirements .for electronic information,
, such as quality related information, may be specified in other parts of
the law and would be put.through the same standards setting
procedure before becqming required.
.
4.
Accessing Health Information
a.
b.
,5.
The Secretary would ~stablish technical standards for requesting
standard health information froin participants in the health
information network which assure that a request for health
informatIon is authorized under federal privacy provisions.
,The Secretary would establish standards for the appropriate
release of health information to researchers :and government '
agenCies, including public health agencies. The Secretary would
establish standards for the electronic identification of a request as
one which comes from a person authorized to receive health
'information u~der federal privacy provisions.
Effective Date
. A timetable of effective· dates would be included which would specify
when each requirement would take effect relative to the date of
enactment. ., In general, the Secretary. would adopt existing standards
. within 9 months of e~actment and more time is given for standards
which must be developed. At least 12 months grace period is allowed
after any standard is adopted before use of that standard becomes
required. '
' .
33
�D.
'.
~
. Qu~ity .Assurance
. The ~oalof health .reform is to' ensure that
Ame~icanshave access to health
.care plans .that compete on the basis of price and quality. Assessmg quality
requires reliable and comparable· information on the outcomes and
effec~veness of services provided by plans. Under this subtitle, Qualified
Healtp Plans are required to annually report data ~:m the quality of their
servi~es to the Secretary of HHS in a format prescribed under the National'
Health Information Network.. ' The Secretary may determine the manner in
whicp. these data are provided to certifying authorities in states. This title also
provides direction to the. Secretary to improve and expand the capability of
HHSI,to supporfaQd encourage research and evaluation of mediCal outcomes .
.
.
."
\
,
'
.
St~nci'ards and Measurements of Quality
The 5.ecretary, in. consultation with relevant private entities, will develop
qualify, standards with which all Qualified Health Plans must comply. These
standards are designed to improve the data available upon which to assess
quality and the' processes by which'quality care is continuously improved.
j"
The ~ecretary will study the capabilities of entities within its jurisdiction to
accoqiplish these goals including:
.
1.
i: setting priorities for strengthening the medical research base;
..
',/
.
.
.
'2.
,
'
.
.
'
.
supporting research and evaluation on medical effectiveness through
. technology assessment, consensus development, outcomes research
.. :: and the use of practice guidelines;
.
3.conductmg:effectiveness trials in collaboration with. medical specialty
,
societies; medical educators and qualified health plans;
\-:
4.
.' maintaining a clearinghouse and oilier registries on 'clinical trials and
outcomes research data; ,
.
5."
'assuring the systematic evaluation of existing andrtew treatments,' and·
jidiagnostic technologies iI'). an effort to upgrade the knowledge base for
. , . .'
..
. i:.clinical decision making and policy choice;.
,6.
';designing an interactive,:computerized dissemination system of
;:informati6n on outcomes research, practice guidelines, and other
',:information for providers.
'
l '
.
34
�E.
Anti-fraud and Abuse Control Program
.
This subtitle establishes a stronger, better coordinated federal effort to combat
'fraud and abuse in our health care system. It expands criminal and civil
penalties for health care fraud to provide a stronger deterrent to the billing of
fraudulent claims and to eliminate waste in our health care system resulting
from such practices. It also seeks to deter fraudulent utilization of health care
1
services. It would:
1.
Require the HHS Secretary and Attorney General to jointly establish
and'coordm,ate a national health care fraud program to combat fraud
. and abuse in gove~ent and Qualified f:Iealth Plans;
2.
Finance'the anti-fraud: effodsby 'setting up an Anti-Fraud and Abuse
Trust Fund. .Monies from penalties, fines, and damages assessed for
health care fraud are dedicated to the Trust Fund to pay for the anti
. fraud efforts;
3.
. 4.
Increase and extend Medieare and Medicaid civil money and criminal
penalties for fraud to: all' health care programs;
Bar providers convicted of health care fraud felonies from participating
in the Medicare program;
.
5.
6.
x.
Require HHS to publish the names of providers ~d suppliers who
have had final adverse actions taken against them for health care
fraud; and, .
:
'
. Establish a new health care fraud statute patterned after existing mail
and wire fraud statutes under Title XXIII of the Criminal Code and
allows for, criminal forfeiture of proceeds.
REFORM OF EXISTING PUBLIC PROGRAMS
A.
. M~dicaid (Some would like to integrate Medicaid faster if it did not adversely
affect the cost of health care, reform.)
1.
Integration ofMedic~id' beneficiaries into Qualified Health Plans
a.
The Secretary shall make recommendations on the integration
of AFDC and non-cash recipients into the community-rated pool
and into Qualified Health Plans. The Secretary's
recommendations shall address:
35
�,
it
::
i..
the impact on private health insurancepreIriiums,
ii.
theadmin'istration ofsubsidies,
iii.
the adequacy of services for Medicaid recipients and the
need for and structure of wrap around services.
.
2.
.
. ..
.
.
.
New State Option for Medicaid Coverage in Qualified Health Plans
,
.'
Stat~s
may give their AFDC and noit;.cash eligible beneficiaries
(excluding medically needy) the option to receive medical assistance
through enrollment in a Qualified Health Plan offered in'a local HCCA
instead of through the Medica:id plan. . '
;
The state may not restrict an individual's choice of plan and is
not required to pay more than the applicable dollar limit for the'
HCCAarea..
,: b.
.
'
i:
..
The number of, individuals electing to enroll in a Qualified
Health Plan' is limited' to a fifteen percent of the eligible
.population in each of the first three years, and ten percent in
each year thereafter .
. 3 . ' Limitation on Certain Federal Medicaid Payments
.
, i
. Federal financial participation for acute l!ledical services, including
expenditures for payments to Qualified Health Plans, is subject to an
.annual federal . payment cap.
"
, a.
The cap is determined by multiplying a per capita lfrnit (defined
below) by the average number of Medicaid categorical'
individuals entitled to receive medical assistance in the state
. plan.
b.
The per-capita limit for fiscal year 1996 is equal to 118% of the
base per capita funding amount (determined by dividing the
total expenditures made for pledical assistance furnished in 1994
.'by the averagetQtal number of Medicaid categorical individuals
for that year)., ,
.
;,. c.
Aft~r 1996, the per-capita limit is equal to the per-capita.funding
. amount determiJ;led for the previous fiscal year increased by 6
percent for .fiscal years 1997 through 2000, and 5 percent for fiscal
year 2001 and beypnd.
)
36
�'.
d. .
Expenditures for which no federal financial participation was
provided and disproportionate share payments are excluded
. from this calculation.
. '
..
e.
4.
States are req~ired to continue to make eligible for medical
assistance any class category of individuals that were eligible for
assistance in fi~caf year 1994.
.
State Flexibility to Contract for Coordinated Care. Services
a.
States have the option, to establish a program under Medicaid
program to allow states to enter into contracts with at-risk
primary care case management (PCCM) providers.
.
.
.
b.
An at-risk PCCM' provider must be a physician, group of .
physicians, it federally qualified health center, a rurC\1 health
clinic or otherrentity having other arrangements with physicians
operating under contract with a state to provide. services under a
primary care case management program.
.
c.
Qualified risk contracting entities must: .
1.
.
meet federal organizational requirements;
ii.guarantee enrolled access; and,
iii.
have a written contract with the state agency that includes:
. (a). . an experienced-based payment methodology;
, .
.
(b).
. premiums that do not discriminate among eligible
individuals based on health status;
(c).
requirements for health care serVices; and,
(d). detailed specification of the responsibilities of the ..
contracting entity and the state for providing for, or
arranging for, health care services.
;
d.
Meet federal standards for. internal quality assurance.
.
.
.
.
e;
Enter into wriften provider participation agreements with
essential community providers;
1.
States ate required to contract directly with essential·
community providers, or at the election of the ECP, each
37
�. risk contracting entity may.enter into agreement to make
payments to the essential community provider for'
I
•
'
serVIces.
~!
..
, 2.
. Essential community providers include:
a.
Federally Qualified Health Centers,
b~Public
Housing Providers,
c.
Family Planning Clinics,.'
d.
AIDS providers under the Ryan White Act,
"
.,,
Maternal and Child· Health Providers, and
"
"
.f.
Rural Health Clinics .
"
I
~j
"
B.
Medkare'
. 1.
2.
.", Medicare remainsa separate program and continues to be federally
',administered.· Beneficiaries enrolled in Part B continue to pay a
, monthly premium. The.'statutorily defined Medicare benefits continue
. to be the Medicare·benefit package in both fee-for-service and managed
. care.
" Beneficiary opt-in to private qualified health plans.
:; a.
.!
b. '
"
nC.
,.
I'
Medicare beneficiaries.may opt mto a qualified health plan in
.
~
. their HCCA.'
will
For individuals choosing an AHP, Medicare
pay the federal
'contribution ca1culatedfor Medicare risk contracts. Individuals
are responsible for paying the difference between the premium
charged and 'the ,federal contribution.
During the annual enrollment period, Medicare-eligibles may
choose a new plan through their employer/purchasing
,
cooperative or they may return to the t,raditional Medicare,'
progt:am.
. if
3.
;J
Medicare Select
"
The' Medicare SeleCt program would become a permanent option
in all States.
�b.
c.
4.
Medicare Select policies will be offered during Medicare's
coordinated open enrollment period.
'
Plans may not, discriminate based on
health'status~
Medicare Risk Contract Program
a.
Medicare health plans must meet Qualified' Health Plan
standards and .cover all Medicare benefits under a risk contract
for a uniform ~onthly premium for a year.
b.
Employers may sponsor Medicare health plans for former
current employees.
c.
Cost contracts" SHMOs, etc. would continue as under current
law. The 50/50 requirement is terminated at the point at which
the Secretary .determines that health plans have alternative
quality assurance mechanisms in place that effectively provide
sufficient quality safeguards. In the interim, the Secretary may
grant waivers of the 50/50 requirement.
e.
.Medicare health plans will offer a standard benefit package
comprised of the current Medicare benefits defined in statute or
an alternative package, defined by the Secretary, covering
identical serviees but with cost-sharing consistent with typical
managed care practice and not to exceed the actuarial value of
FFS.
.
'
f.
Standardize supplemental benefits that risk contractors may
offerjn addition' to Medicare benefits. In addition to the
standardized policies, health pl~nsmay offer other supplemental
policies. However, Medicare health plans must at least offer two
supplements tQ be defined by the Secretary: one which would
cover catastrophic costs (out-pf-pocket limit) and other items
traditionally covered in employer-sponsored plans, and one
covering outpatient prescription drugs.
g.
The current standardized Medigap plans would be changed so
that Medigap, may only pay up to one-half of the 20% part B
coinsurance. Beneficiaries currently holding Medigap plans
covering the entire 20% coinsurance would be exempt from this
change ·as long as they renew their cU,rrent insurance.
h.
The Secretary shall define Medicare market areas which shall be
consistent with t1).e health care coverage areas defined by the
01:
"
39
�;,
'.
non-Medicare population. For the Medicare program, the MSAs
may cross state lines if the Secretary determines it is necessary to
increase choices to Medicare' beneficiaries. .The federal
contiibuti(~m fora' Medicare health plan wHl be the same ,
,throughout the Medicare market area.
~i.
,.
The Secretary wil~ administer a coordinated annual open ,
enrollment period. during which Medicare beneficiaries will
choose from all plans (including Medigap. insurers) offering
products to Medicare beneficiaries. The Secretary may authorize
any variations of .participation in the enrollment process. '
j.
The Secretary of HHS will' provide to all Medicare beneficiaries
in ,a market area uniform materials for enrolling in health plans~
k.
The federal contribution is calculated as the weigh~~d average' of .
. fee-for-service per,capita cost in the market·area and the
premiums submit!ed by Medicare health plans to the Secretary
to provide Medicare benefits. The.Se~retary is authorized to
adjust for.heart.disease,. cancer, ,or stroke.
.,t
i·"
:1:
.1
",'
,
<.
"
Beneficiaries pay the difference between the federal contribution
and the total premium charged by the health plan they select. If
the health plan's premium is less than the federal contribution,
, the beneficiary is entitled to a rebate that. the plan may provide
in cash or apply to supplementary coverage~ The rebate would
be treated as non-taxable income ..
i.
Beneficiaries eligible for Medicare prior to 1999 are
grandfathered under these provisions and may always'
.enroll in' M~dieare FFS (regardless of local costs) for the
.
regular part Bpremium only.
ii.
If the federal contribution is less than the FFS per capita
cost in the market area and the beneficiary selects
Medicare FFS, the beneficiary pays an additional premium
to the Federal Government equal to the difference
1;ietween the fe<:ieral contribution and FFSPCC..
5.'
"Administrative Simplification
"
I,
The Secretary has authority to ~onsolidate the functions of fiscal
': iittermediaries and carriers. Provides for coordination of Medicare and
::supplementalinsurance claims processing." Permits standardized,
'paperless process.'
.
,
•
I'
"~I
�6.
Study and Demonstration for Medicare Cost Containment
a.
h.
C
Requires ProPi\C to study and make recommendations to
Congress regarding ways to slow the rate of Medicare growth at
the local market level. The study should include ways to set·
local expenditure targets and monitor success in controlling
costs. Updates for payment rates under Parts A and B shoulcl be
set to achieve local targeted expenditure levels, while rewarding
efficient provigers and/or markets.
A demonstration is authorized to evaluate Part A expenditures
fer hospital service and/or PartB expenditures in fee for service
using· provider-group or State-level v:olume performance.
standards.
.
GRADUATE MEDICAL EDUCATION
[Under Discussion]
.
.
41
�I.
FINANCING
"
A.
.
"
'
. '
.
.
Fina#cing Totals ·(Estimated OverS years; $ in Billions)
.:
SavIngs
,I
1,
MediCare, Siflvings
Medicaid Sa virigs '.
Postal' Servf~e Retirement
',,'
$70.1
$55.8
, $13.0
SUBTOTAL, SPENDING REDUCTIONS
,
$138.9
.
Revenues ::
High ost p;lan Premium Assessment
C
Tobacco Tax ($1.00 increase)
HI State/Local
Income Rel~ting Medicare Part B Premiums
,
$30.0*
$62.3.;",
$ 7.6'
$ 8.0
'II
SUBTOTAU REVENUES
$107.9
TOTAL FINANCING
* Prelimina?r, estimate based oriavailable information
$246.8
B.
Desc~ptions of Medicare Savi~gs .
1.
' " Adjust Inpatient Capital Payments. This proposal combines three
" inpatient payment adjustments to reflect more accurate base year data
and cost projections. The first would reduce inpatient capital payments
to hospitals excluded from Medicare's prospective payment system by
, , 15%. The second would reduce PPS Federal capital payments by 7.31%
and hospital-specific amountby 10.41% to reflect new data on the FY 89
,capital cost per discharge and the increase in Medicare inpatient costs.
~; The third piece would reduce payments for hospital inpatient capital
with,a 22.1% reduction to the updates of the capital rates.
.
2.
Revise Disproportionate Share ,Hospital Adjustment. This Act limits
the current disproportionate share hospital adjustment with a new
:,: voucher program to cover health care provided to those with out
! health insuranc:e.
I
j;
,
"
. 3.. " ;, Extend OBRA93 Provision to Catch~up after the SNF Freeze Expires,
. , Included in OBRA 93. OBRA 93 established a two-year freeze on .
update to the cost limits for skilled nursing facilities. A catch-up is
, allowed after the freeze expires on October I, 1995. This. Act eliminates
Ii the catch-up:"
,
.
,
4..
,:Changethe Medieare Volume Performance Standard to Real Growth
.. ':GDP. This Act substitutes the five-year average growth in real GDP
42
�per-capita fDr this volume and intensity factDr and the perfDrmance
standard factDr fDr physician's services. '
.
5.
Establish Cumulative Growth Targets for Physician Services. Under
" this Act"the Medical' VDlume PerfDrmance Standard fDr each categDry
Df physician services ;wDuld be built Dn a designated base-year and
updated annually fDr changes in beneficiary enrDllment and inflatiDn,
but nDt fDr actual Du~lay grDwth abDve and below the target.
6.
Reduce the Medicare Fee Schedule Conversion Factor by 3% in 1995,
Except Primary Care Services.· The cDnversiDn factDr is a dDllar amDunt
that CDnverts the fee:schedule's relative value units into. a payment
amDilnt fDr each physician service. This Act reduces the factDr by 3% to.
'accDunt fDrexcessively high targets. '
7.,
Extend OBRA-93 PrQvisions on Part B Premium Collections. OBRA 93
established the Part B premium cDllectiDns at 25% Df prDgram CDStS.
This Act extends the ,cDllectiDn Df these premiums.
. :
'
8.
9.
Extend OBRA 93 Medicare Secondary Payor Data Match with SSA and
IRS. OBRA 93 included an extensiDn Dfthe data match between HCFA,
IRS and SSA to. identify the primary payers fDr Medicare enrollees with
health cDverage in additiDn to. Medicare.
10.
Increase Part B Deductible for Enrollees. Increase theamDunt that
enrDllees must pay fDr services each year befDre the gDvernment shares
, respDnsibility for physicianserviees. The deductible wDuld be
increased to. $150 and' indexed to. the rate Df grDwth.
11.
C
Extend OBRA 93 Catch-up After the Home Health Freeze Expires.
OBRA 93 eliminated the inflatiDn adjustment to. the hDme health
limits fDr two. years. This,Act eliminates the'inflatiDn catch-up
currently allDwed after the freeze expires Dn July 1, 1996.
Reduce 'Hospital Market basket Index Update. This prDpDsal reduces
the HDspital Market Basket Index Update by 2%. Currently Medicare
changes the inpatient per-discharge standardized amDunt by a certain
amDunt every year to. reflect input CDStS changes in. CDngressiDnal
directiDn. OBRA 1993 reduced the Index' in Fiscal Years 1994thrDugh
1997. ,'this propDsal wDuld reduce the updates by 2% fDr Fiscal Years
1997 thrDugh 2000.
'
Medicaid Savings '
1.
Revise Disproportionate Share Hospital Adjustment. This propDsal
eliminates the current disprDpDrtiDnate sh~re hDspital adjustment
with the new voucher prDgram to. CDver health care provided to. thDse
with Dut health insurance.' Medicaid DSH payments are to. be
'
43
�,
.
;
"
eliminated in FY 1996 - 15%,FY 1997 - 25 FY 1998 - 60.% and 1999
10.0.% (unless 95% cover~ge is not reached m which case it will not be
completely pha~~d-out)'
.
%
,
2. ,Capitate theFed~ral PaYments Made for Medicaid Acute Care Medical
,. Services under Medicaid Program.. The per-capita federal financial
" participation growth rate for acute medical services under the Medicaid
program-would be.capped at 6% for fiscal years 1997 through 20.0.0. and
at 5% for fiscal year 20.01 and beyond.
\i
I'
O.Revenues '
'1.: 'Postal SerVice Retirement. Require the U.S.P.S. to fund the' U.S.P.S.
'Retirement System in the U.s:P.S. budget rather than the Federal
.i; Budget. This would free funds from the Federal budget. ','
2.
Tobacco Tax. The proposal increases the tax on tobacco by $50. per
thousand cigarettes ($1 per pack of 20. cigarettes). Described in Section
XIII., G.)
3.
", HI State and Local. State and local jurisdictions can opt to pay the HI
i: payroll tax for State and local workers hired before April 1, 1986. The,
proposal would extend the payroll tax to all remaining exempt State
and local workers., ,
4.
'Income Related Part B Premiums. This proposal would charge high
income enrollees a premium up to 75% of program costs based' on an
,. enrolle's modified adjusted gross 'income.
.
P
,
i
XII. Fiscal Resp~nsibility
.
,
Fail-Safe M~chanism
.
.
.
..
.'.
The bill establishes a Fail-Safe mechanism to ensure health care reform does
not increase the deficit. Details are described below~
1.
A' Cutrent Health Spending Baseline (CHSB) is established. The CHSB
includes:
I
;.
a.
. b.
c."
Medicare Expenditures
Medicaid Expenditures
'Health Related Tax Expenditures
i.
'The employee exclusion of employer-provided 'health,
insurance premiums.,
44
�,.
.
.
~.
,
.
'.
11.
iii.
2.
Employer deduction for health insurance premiums.
7.5% flqor for deduction of medical expenses.
.A Health Reform Spending Estimate (HRSE) is established. The HRSE
includes:
.
a.
b.
Everything included in the CHSB.
Deduction for purchase of Qualified Health Plans by all
. individuals..
c.
Cigarette excise tax.
d.
Vouchers for purchase of a Qualified Health Plan .
High~Cost
. .e.
3.
Plan Assessment·
In any year that the Director of OMB notifies Congress that HRSE will
exceed the CHSB, the following automatic actions will occur to prevent
deficit spending:
a.
The voucher
. b.
is delayed .
The assessment on high cost insurance plans is increased.
.
c.
~hase-in
.
.
'
. .' The expanded: tax deduction phase-in is slowed' down.
.
"
'
d.
e.
. 4.
Out-of-pocket limits in the standard and basic benefit packages
are increased.
.
Starting in the year 2004, an employer may no longer deduct and
an employer may no longer exclude supplemental benefits
provided to employees and contributed to by employers. "
Congress may act on alternative recommendations made by the
. National Health Commission to avoid the actions listed above ..
XIII. Tax Provisions
A.
High Cost Plan Assessment .
,
1.
.
'.
. ' .
' Beginning in 1996, an annual assessment.will be imposed on High Cost
Plans. High Cost Plans are those health care packages whose premiums
exceed a target amount. The target amount will be set by the IRS at the
beginning of each year based on the premium bids submitted to the,
HCCA for Basic plans (Primary Basics) and Standard plans (Primary
Standards). The target amount will be set at a level such that forty
45
�"
percent of the plans in each area are above·that amount.
a.
To determine wh~ther a plan is a High Cost Plan, an insurer
divides its plans into two categories: '
'
,,'I .
Primary Basics including the value of any supplemental
benefits, and
i. ..
.' ii.
!; ,
" Primary Standards ,including the value 'of any
'
supplemental benefits.,
'
. ~t
,: b.
I:
~! c.
'An insurer then determines which, if any, of such plans are
'above the applicable target amount.
'
The IRS will also determine the lowest 25% of geographically
adjusted Primary Basic and Primary Standard premiums '
nationally. Plans (inclu~ing supplemental benefits)~that fall
within the lowest 25% of the geographically-:-adjusted premiums
are exempt from the High Cost Plan Assessment.
"
.
. .
'
.
, d.
,e.
,2.
The geographically adjusted premium will be calculated by the
IRS by adjusting each accountable health plan's premium for
regional variations., Such adjustments'shall include, but not be
limited to; variations in the cost of living and demographicS.
Treasury will be given the authority to develop regulations
implementing this provision.
i' The
assessment on 'a High' Cost Plan is equal to 25% of the difference
j'between the,pr~mium charged for the Primary Basic plus·
,'
::supplementals, if any, and the Primary Standard plus supplementals, if
;'any,anda reference premium.
'
, For purposes of determining the assessment on the Primary
Basic plus supplementals, if any, the applicable reference
premium is the average of all Primary Basic premiums in the
HCCA.
'
'For purposes of determining the assessment on the Primary
Standard plus supplementals, if any, the applicable reference
premium is the average of all Primary Standard ,premiums in
the area.
'
3.' :The High Cost Pla.~'.Assessment also, applies to self-insured plans. The
:tax will apply to the difference between the self-insured High Cost
iPlan's,premium (including any supplementals) and the applicable,
"reference premium for the HCCA. In calculating this tax, the high cost,
'self-insured plan's premium will be the premium used for meeting the
~COBRA requirement. The Departn:\ent of Treasury will be given
46
�authority to develop regulations implementing this provision.
B.
Assistance to Individuals and Families;... EXpanded Tax Deductibili~
1.
Self-employed individuals purchasing health insurance may take an
above-the-line deduction for 100% of the cost of such insurance (i.e.,
not subject to the 7.5% floor), subject to a phase-in period. However,
the deduction is limited to the cost of either a basic or standard benefits
package., To the extent self-employed individuals purchase benefits
supplementing such packages, the cost of such supplemental benefits
will be deductible as medical expenses under current law (i.e., subject to
the 7.5% floor). '
,
~.
C
,
' Individuals (other than self-employed) that purchase health insurance
will ,be allowed, an above-the-line deduction (Le., not subject to the
7.5% floor) for 100% of the cost of either a basic or standard benefit
package. To the extent an individual purchases benefits
, supplementing the packages, ,the cost of such supplemental benefits
will be deductible as medical expenses under current law (Le., subject to
the 7.5% floor).
Employer-Provided Health Insurance
1.
2.
Employers may take a deduction for amounts contributed towards a '
standard benefits pac~age, as well as all benefits supplementing such
package, if any.
3.
Employers may take a deduction for amounts contributed towards a
basic benefits package., However, no deduction is permitted for any
contributions made towards benefits supplementing the basic benefits
package.. ' , ,
,
4.
D.,
Employees may continue to exclude from gross income all employerprovided health insurance.
'
Fail-Safe option includes possible employer and employee cap on
supple~entals after ~004. ,
Tax Incentives for Practice in Rural, Frontier, and Urban Underserved Areas
.
1.
.
,
'
Physicians practicing ;full.:.time and either newly certified or newly
relocated to·a rural, frontier, or urban Health Professional Shortage
Areas (HPSA) are allowed a tax credit equal to $1,000 a month up to a
total of $36,000. Tax credits will be prorated in direct relation to the
time worked in the HPSA, up to a total of $36,000;
47
�2.
Nurse practitioners and physician assistants practicing full-time and
either newly certified or newly relocated to a rural, frontier, or urban
HPSA would b,e eligible for a similar credit equal to $500 per month up
to thea total of $18,000;
.',:"
;i
'.i
): .
.
..
3.
In order to retain the hill val\.l.e of the credit, the physIcian, nurse
practitioner or physici~n's assistant must practice continuously in the
area' for five years. ,
4.
Loan repayments .made on behalf on an individual as part of the '
National Health Service' Corps Loan Repayment Program are excluded
from taxable income of the individual;
.
5: '
'The cost of ann:ually purchased meqical equipment, owned directly or
:. indirectly, ~nd used by a physician ina rural or frontier Health
Professional Shortage Area (HPSA) can be immediately,'e){pensed, up to
" $32,500;
\.
,
,
,
Inte~est, up to $5,000 ~uallYi paid on professional medical education
6.
, loans of a physician, registered nurse, nurse practitioner, or physician's'
':' assistant will be allowed as an itemized deduction if the individual
. agrees to practice in a rural, frontier or urban Health Professional
, Shortage Area (HPSA).
,E.
Long"Term Care Tax Provisions
,1.
.• Expenditures for qualified long-term care services are deductible as
~
:. medical expenses' (i.e. subject to the 7.5% floor). Such services include
'; diagnostic, preventive, therapeutic, rehabilitative, maintenance and'
:' personal care. Provision of such services must be contingent upon
"I certification of impairment in three or more activities, of daily living by
. I: a,licensed health care practitioner;
,' ,
,
.',
2 . ' Employer providedqualffied long-term care coverage which meets
: certain consumer protection standards promulgated by the Natio,nal
" Association of Insurance, Commissioners, is excluded from an
L employee's taxable income. Premiums paid by an individual for
;' qualified long-term car~ coverage are ,deductible as'a medical expense
'. (Le. s~bject to the 7.5% floor); ,
3.
F.
NAIC is directed to promulgate standards for the use of uniform
:: language and definitions'in qualified long-term care coverage
::insurance policies, with permissible variations to take into' account
differences in. state licensing ,requirements for long-term care
, providers. '
'Accelerated Death Benefits'
48
�Clarifies the income tax treatment of accelerated death benefits paid to
terminally ill persons. Payments made under a qualified terminal illness
rider can be received tax-free as if they were paid after the insured's death.
G.Tobacco Tax
Theproposalmcreases the tax on tobacco by approximately $16.67 per pound
of tobacco for cigarettes. At proportional increase is applied to all other'
tobacco products. In addition it extends the tax to tobacco to be used in "roll
your-own" cigarettes. The t:lew tax rates would be:
, 1.
Cigarettes: '
$62 p~r thousand (Le., $1.24 per pack of
20 cigaretteS)
,
large cigarettes
2.
$130.20 per thousand'
Cigars:
, small cigars
$5.82 per thousand
65.875 percent of manufacturers price ' '
(not more than $155 per thousand)
large cigars
3.
Cigarette papers and tubes:
cigarette papers
cigarette tubes
, 4.
3.88 centsper 50 papers
7.75 cents per 50 tubes
Snuff, chewing tobacco, pipe tobacco; "roll-your-own" tobacco: .
$1.86 per pound
snuff
chewing tobacco
,
62 cerits per pound
'
pipe tobacco
$3.49 per pound
"roll-your-own" tobacco
$3.49 per pound
5.
The proposal would repeal the present-law exemptions for tobacco,
products provided to employees of the ,manufacturer and for use by the
United States.
'
6.
The proposal also inchi'des several ad'ministrative and compliance
provisions designed to improve the collection of the excise tax.
;
I
.
49
�•
I'
I
'
,t,
..
i:
,I'
,
• I
XIV. National H~a1th Commission
.
i',
Anii)dependent National Health Commission is established to oversee the
, health market much like the Securities and Exchange Commission oversees'
the fmancial markets ..
A.' Operation
"
'
" 1.
2.
The Commission ~hall be composed of 7 members appointed by
the President with the advice and consent of the Senate. The
Commission members will serve 6 year overlapping terms. No
more than four members of the Commission may be from the
same political party. The.members shall be compensated at level
IV of the Executive Schedule. One member of the Commission
shall be designated. as the Chairman by the President.
The Commission members will have gained national
recognition for their expertise in health markets.
The Commission shall appoint an Executive Director and such
additional officers and employees it deems necessary to carry out
its responsibilities' under, this act.
',4.
I,'
The Commission will be advised by. expert private sector boards
which focus on health benefits and health plan standards.,
.. B. ,;' Responsibilities
: 1. . .Clarify the standard and basic benefits packages.
2.
Develop and clarify the quality standards set in this act. for
Qualified Health Plans and provide. for this information to be
distributed to consumers in a standardized format. This .
information will include reporting prices, evaluating health'
outcomes and measuring consumer satisfaction.
'
: 3.
.
.
Report to Congress' on a biannual basis (described in Section
L,A.).
d.
Develop risk c:djustment factors for Accountable Health Plans.
':e.
Monitor the Fai1-Safe Mechanism to prevent deficit spending
(described in Section X1.,B,4.)..
Recommend methods to achieve universal coverCigeif trigger
. mechanism is engaged in the year 2002 (described in Section
L,B.).
"
50
,:
"
.1
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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
Chris Jennings - Health Securities Act
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.
<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
Publisher
An entity responsible for making the resource available
Clinton Presidential Library & Museum
Extent
The size or duration of the resource.
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
June 1994 HSA [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 41
<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-june-1994-hsa-1.pdf
647904