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Text
FOIA Number:
2006-0885-1
FOIA
MARKER
This is not a textual record. This is used as an
administrative marker by the William J. Clinton
Presidential Library Staff.
Collection/Record Group:
Clinton Presidential Records
Subgroup/Office of Origin:
Health Care Task Force
Series/Staff Member:
Rueschemeyer
Subseries:
4719
OA/ID Number:
FolderlD:
Folder Title:
Health Care Working Group Drafts
Stack:
Row:
Section:
s
53
7
Shelf:
Position:
�DETERMINED TO BE AN ADMINISTRATIVE
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WORKING GROUP DRAFT
PRIVILEGED AND OQNElDENTIAr -
INTEGRATION OF WORKERS' COMPENSATION INSURANCE
Health plans provide treatment for individuals with work-related injuries covered
under workers' compensation insurance.
Workers' compensation insurers (including self-funding employers) continue to be
responsible for the costs of treatment based on current law and reimburse health plans for
services provided. Reimbursement is based on a fee schedule or on an alternative
arrangement established by alliances or negotiated between workers' compensation insurers
and health plans.
To obtain state certification, a health plan demonstrates its ability to provide or
arrange for comprehensive medical benefits for work related-injuries and illnesses, including
rehabilitation and long-term care services.
•
Health plans employ or enter into contracts with specialists in industrial
medicine and occupational therapy.
•
Health alliances are responsible for coordinating access to specialized health
providers or centers of excellence in industrial medicine and occupational
therapy.
^
sA ^ A j k ^ * '
•
Alliances may ^nterihto controcts with hoalth care professionals and
institutions that provide specialized services for the treatment of work-related
injuries and illnesses on behalf of all health plans serving the alliance region.
Individuals enrolled in health plans within the alliance receive treatment for workrelated injuries or illnesses from their health plans, although emergency treatment may be
obtained from any provider.
State laws regarding choice of provider for workers' compensation cases are
overridden with respect to individuals covered through health alliances. Exceptions may be
necessary in cases of disputes.
Each health plan designates a workers' compensation case manager to coordinate the
treatment and rehabilitation of injured workers. The case manager ensures that:
•
The plan of treatment for an injured worker meets appropriate protocols and is
designed to assure rapid return to work.
80
�WORKING GROUP DRAFT
PRIVILEGED AND eONFIDENTIAfc
•
The plan of treatment is coordinated with the workers' compensation insurance
carrier and/or the employer to facilitate rapid return to work.
•
The health plan complies with medical and legal requirements related to
workers' compensation.
•
If the health plan is unable to provide a needed service to treat a work-related
injury or illness, the workers' compensation case manager, in consultation with
the workers' compensation canier, refers the worker to an appropriate provider.
Health plans are reimbursed by workers' compensation insurance carriers or selffunded employers for work-related medical benefits in accordance to the fee-for-service
schedule in the alliance.
•
Alliance fee schedules include rehabilitation, long-term care and other services
commonly used for the treatment of work-related injuries and illnesses.
•
Alliances are permitted to adopt varying arrangements with health plans for
providing work-related medical benefits, including negotiating per case
capitation payments.
•
Health plans are permitted to negotiate fees that vary from the fee-for-service
rate schedule with workers' compensation insurers and employers.
Health plans and providers are not allowed to bill patients with work-related injuries
or illnesses for additional charges beyond those covered by the health plan.
Information related to provider and health plan performance in treating work-related
injuries and illnesses (including the health plan performance in facilitating injured workers'
returning to work) are included in reporting information about the quality of care provided by
the health plan.
Nothing in this policy alters or diminish the effects of state workers' compensation
laws as the exclusive remedy for work-related injuries or illnesses. [See language in OSHA
29 USG Sec. 653(b)(4)]. Disputes related to whether an injury or illness is work-related are
resolved in accordance with existing state laws.
Health benefits for work-related injuries and illnesses continue to be defined by States.
81
�March 26,; 1$93
Mrs, Hillary Rodham Clinton
c/o Task Force on Health Care Reform
The WhitaJ House
1600 Pennsylvania Avenue, N.W.
Washington/ D.C. 20500
Dear Hillary:
My name is Sheryla King, I l i v e i n Wichita. Kansas and I have a 6-year old
daughrer,, S.ara, born with Spina Bifida, I have enclosed a brochure, put
together by the Spina Bifida Association of Kansas, that explains Spina Bifida
i n simple terms. My daughter i s featured i n the brochure - she is on a
scooter board which she used to get around on before she got jbraces, She was
only 3 at; the time - she is now 6 and has Isocentric Reciprocating Gait
Braces. Jhlis type of brace is designed to provide walking capability to
individuals: with non-functioning legs. My daughter is paralyzed below her
waist due to her b i r t h defect. Without these braces she would have to spend
a l l her time i n a wheelchair or crawling on the floor.
1
1
Sara has ialso had 3 surgeries since b i r t h and i s about to have her fourth and
f i f t h procedure done on March 31st i n Children's Memorial Hosipital i n Chicago.
We have t;o take her there because these procedures are not done successfully
here i n Wichita, Sara has a shunt i n her head to alleviate pressure of excess
unused spinal f l u i d building up and causing her head to grow abnormally large.
Sara does not have normal voiding capabilities since the nerves affecting her
bowel and bladder are also damaged. She has to be catheterizad 4-5 times a
day to uriiiate and has to use d i g i t a l stimulation to evacuat^ her bowel.
Needless !tcj say, she also has to continue to wear a diaper
avoid embarrassing accidents at school or while In public. A l l these conditions are charact e r i s t i c ioi most Spina Bifida a f f l i c t e d individuals.
j
I
D^s.p.ifiejlljier medical_p_robl.em3 Sara_is_a very I n t e l l i g e n t ! loving, funny,
beautiful l i t t r e ^ I r J U a n d J ^ s n l t ^
stop her
~
"ffoirmn^tas^o^l^as^st^
wants to participatis i n wheelcHilr
-sportsi"ttii:srsuinmer and i s looking forward to going to Disney World, which is
where oul" National Spina Bifida Conference is being held. Twelve families
from our'Ideal chapter are raising money to attend this conference, which is
comprised of 4 days of workshops designed to educate.families with Spina
Bifida members on the advancements made i n treating Spina Bifida and help them
learn how to cope and l i v e with i t , and to deal with the barriers of the ablebodied world i n order to lead normal, productive lives. I would like to
invite youlto attend this conference: June 23-26, 1993 at the K i l t c n Hotel i n
Buana Vista Village at Dianey World In Orlando, to see for yburself what Spina
Bifida Is a l l about - the joys of these wonderful adults andj children, and to
learn first-hand of the financial devastation that strikes so many families of
Spina Bifida who are trying to pay for the expensive care needed i n order to
maintain the quality of l i f e they're entitled to.
-1-
LS:5
: es-zi-s
esnoH sum 9M1:A9 1N3S
�DETERMINED TO BE AN ADMINISTRATIVE
erMled,Scc.^3 (c)
(
MARKING Per EX). 12958 as amewled^cc.^
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WORKING GROUP DRAFT
PRIVILEGED AND-efiNfS66i
The Board certifies compliance with the budget. (See section
entitled "Budget Development and Enforcement")
NATIONAL QUALITY MANAGEMENT SYSTEM
The Board establishes and manages a performance-based system of quality
management and improvement described in the section entitled "Quality
Management and Improvement". The Board develops measures reported in the
annual quality performance report of health plans. In developing these
measures, the Board consults with appropriate parties, including providers,
consumers, health plans, states, purchasers of care, and experts in law,
medicine, economics, public health, and health services research including
appropriate agencies such as AHCPR, NIH and HCFA.
To measure quality, the Board develops and implements standards to establish
a National Health Information System as described in the section on
Information Systems and Administrative Simplification.
BREAKTHROUGH DRUG COMMITTEE
To encourage reasonable pricing of breakthrough drugs, a committee of the
National Health Board has the authority to make public declarations regarding
the reasonableness of launch prices.
The committee could address new drugs that represent a breakthrough or
significant advance over existing therapies. The committee could also address
all drugs subject to a "reasonable price" clause in a contract with the National
Institutes of Health.
The committee could investigate drug prices only in those cases where
available evidence suggests that the price may be unreasonable. The committee
could make an initial determination about the reasonableness of a drug price
based on a comparison of prices for therapeutically similar drugs in the United
States and seven other industrialized countries.
If the drug price exceeds what the committee thinks to be reasonable based on
the information available, or if there is insufficient data, the committee would
(9/1/93)
44
�WORKING GROUP DRAFT
PRIVILEGED AND €fe)l'll'lUbM I K E -
have the authority to obtain information from the company about the drug's
price. The committee could then issue a report regarding the reasonableness of
the drug price. The committee would have no authority to set or control drug
prices.
National Health Board decisions related to benefits, standards of performance and
accountability apply to health plans operating through both regional and corporate alliances.
(9/1/93)
45
�WORKING GROUP DRAFT
PRIVILEGED AND
DETERMINED TO BE AN ADMINISTRATIVE
MARKING Per E.0^12958 as
is amend
amcndedj
3.3 (c)
Initials: ^ \ 5 ' Y
t w - 'Sal \ I [o(
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REGIONAL HEALTH ALLIANCES
Regional health alliances assume the following responsibilities:
•
Representing the interests of consumers and purchasers of health care services.
•
Structuring the market for health care to encourage the delivery of high-quality
care and the control of costs.
•
Assuring that all residents in an area who are covered through the regional
alliance enroll in health plans that provide the nationally guaranteed benefits.
OPERATION OF ALLIANCES
A regional alliance may operate as a non-profit corporation, an independent state
agency or an agency of the state executive branch. A board of directors, composed of
representatives of consumers and employers who purchase coverage through the alliance,
governs alliances that are non-profit corporations. States establish a mechanism for selecting
members of alliance boards.
The board of each alliance includes an equal number of employer and consumer
representatives, plus one additional member to serve as chairman. The board must include
the following:
•
Employers who purchase health coverage through the alliance.
•
Employees who purchase through the alliance.
•
Self-employed individuals who purchase through the alliance.
•
Other individuals who obtain coverage through the alliance.
(9/1/93)
58
�WORKING GROUP DRAFT
PRIVILEGED AND,gQNFtDENT4AL-
The board of an alliance may not include members of the following groups or their
immediate families:
•
Health care providers or their employees, owners of health plans or their
employees, or other persons who derive substantial income from health
plans or the provision of health care.
•
Members of associations, law firms or other institutions or organizations
that represent the interests of health care providers, health plans or
others involved in the health care field, or who practice as a
professional in an area involving health care.
•
Owners, employees, board members or individuals who derive
substantial income from pharmaceutical companies and suppliers of
medical equipment, devices and services.
To ensure that alliances are accountable to consumers and employers, states may
establish statewide councils composed of representatives of employer and consumer
organizations to prepare lists of nominees for alliance boards.
States require each alliance to provide an ombudsman to assist consumers in dealing
with problems that arise with health plans and the alliance. States may also permit consumers
at annual enrollment to check off a $1 contribution from their premium payment to support
the office of the ombudsman or other consumer representatives.
In addition to a Board of Directors or Advisory Board, each regional alliance
establishes a Provider Advisory Board made up of representatives of health care professionals
who practice in health plans administered by the alliance.
In the case of a health alliance that is a state agency or an independent state entity
administered by a state-appointed authority, an advisory board consisting of representatives of
the same groups is appointed to provide advice to the agency.
(9/1/93)
59
�WORKING GROUP DRAFT
PRIVILEGED AND eONriDHNTlAfc—
ENROLLMENT
Each regional alliance enrolls all eligible persons, including low-income and nonworking persons, who reside in the geographic area it serves into a health plan that provides
the comprehensive benefits.
Alliances hold an annual open enrollment period during which each individual and
family participating in the alliance has the opportunity to choose among health plans offered
through the alliance. Enrollments made during the annual open season become effective on a
date established by law.
Alliances also provide a mechanism for promptly enrolling individuals and families
who become eligible for coverage between open-enrollment periods. Individuals and families
who move into the region served by an alliance notify the alliance within 30 days. If the
individual is employed, the employer notifies the alliance. If the individual is not employed,
he or she notifies the alliance.
Within 10 days of receiving notification that an eligible person has moved into its
service area, regional alliances provide enrollment materials. Within 30 days of receiving
enrollment materials, eligible individuals are responsible for choosing a health plan and
applying to the alliance for enrollment.
An application for coverage submitted by the fifteenth day of any month becomes
effective on the first day of the following month. An application made after the fifteenth of
the month becomes effective on the first day of the second month following application.
Alliances establish a mechanism for enrolling individuals who have not chosen a
health plan or purchased insurance when they seek health services. The point-of-service
mechanism follows these guidelines:
•
Within 10 days of enrollment at a point of service, the alliance provides an
individual with materials describing health plans.
•
If the individual does not choose a health plan within 30 days, the alliance
assigns the individual to the lowest-cost plan available.
(9/1/93)
60
�WORKING GROUP DRAFT
PRIVILEGED AND SeflflUULNTlAtr
Using the fee-for-service schedule adopted by the alliance, the health plan to
which the patient is assigned reimburses the provider who brought the
uninsured individual into the system for services rendered prior to enrollment.
MANAGING ACCESS TO PLANS
In the event that more consumers apply to enroll in a particular health plan than its
capacity allows, alliances develop a process of random selection for use in determining which
new applicants may enroll. Consumers already enrolled .in the plan continue their coverage
without interruption.
MARKETING
Alliances control direct marketing to consumers by health plans. Marketing rules
include at least the following requirements:
•
The alliance must approve marketing materials used by health plans.
•
If a health plan uses direct marketing, it may not limit distribution to an area
smaller than the geographic area it serves within the alliance.
•
Health plans and their agents are prohibited from attempting to influence an
individual's choice of plans in conjunction with the sale of any other insurance.
(9/1/93)
61
�WORKING GROUP DRAFT
PRIVILEGED AND gftwwnrMTT i
INFORMATION
Alliances publish (or otherwise make available to consumers) easily understood, useful
information, including brochures, computerized information and interactive media, that allows
them to make valid comparisons among health plans. The following information must be
included:
•
Cost to consumers, including premiums and average out-of-pocket expenses.
•
Characteristics and availability of health care professionals and institutions
participating in the plan.
•
Any restrictions on access to providers and services.
•
The annual Quality Performance Report, which contains measures of quality
presented in a standard format.
INSURANCE RISK
An alliance may not bear insurance risk.
RELATIONS WITH PLANS
Each regional alliance negotiates with health plans to provide the comprehensive
benefit package to all eligible persons in the alliance area through a choice of plans. Only
health plans that enter into contracts with the appropriate regional or corporate alliance are
authorized to provide the guaranteed benefit package.
Alliances contract with health plans on at least an annual basis but may enter into
multi-year contracts. Multi-year contracts may not specify premium increases for future
years in excess of the projected inflation factor for the alliance budget.
(9/1/93)
62
�WORKING GROUP DRAFT
PRIVILEGED AND LU1 Jl IDLIMHAL
CONTRACTING REQUIREMENTS AND EXCLUSION OF PLANS
Alliances write uniform contracts with health plans, including all certification
requirements imposed by federal or state law. Alliances must offer a contract to each
qualified health plan seeking to serve its area unless:
•
The proposed premium exceeds the weighted-average premium within the
alliance by more than 20 percent.
•
The health plan's quality of service or care are unsatisfactory as determined by
the state.
•
The plan engages in practices that have the effect of discriminating against one
or more classes of persons based on race, ethnicity, gender, income or health
status.
•
The plan fails to comply with contract requirements.
•
The plan is a fee-for-service plan that is not a successful bidder.
Through a competitive bidding process, an alliance may limit to
three the number of plans that pay any willing provider on a
fee-for-service basis and have no network of providers
operating under a contract with the plan.
An alliance may decline to enter into a contract with a health plan if the health plan's
proposed premium would cause the alliance to exceed its budget target.
Alliances may not discriminate against health plans or providers on the basis of race,
gender, ethnicity, religion, mix of health professionals or organizational arrangement.
AREAS WITH INADEQUATE HEALTH SERVICES
Alliances may use financial incentives to encourage health plans to expand into areas
that have inadequate health services.
(9/1/93)
63
�WORKING GROUP DRAFT
PRIVILEGED AND fiUNHUbNlBfe-
Alliances may organize health providers to create a new health plan targeted at such
an area, providing assistance with setting up and administering the plan. An alliance may not
assume risk on behalf of a new health plan but may arrange favorable financing to encourage
a health plan to operate in an area with inadequate health services.
RISK ADJUSTMENT
Alliances use a risk-adjustment mechanism to account for variations in enrollment
across health plans with respect to the health status and risk of participants and access to
basic health services. (See section on Risk Adjustment)
F E E - F O R - S E R V I C E PLANS
Each Alliance includes among its health plan offerings at least one plan organized
around a fee-for-service system. A fee-for-service system is one in which patients have the
option of consulting any health provider subject to reasonable requirements. Reasonable
requirements may include utilization review and prior approval for certain services but do not
include a requirement to seek approval through a gatekeeper.
Under certain conditions, with approval from the National Health Board, a state may
waive the requirement for each alliance to offer a fee-for-service health plan if the alliance
demonstrates that:
•
A fee-for-service plan is not financially viable in the area.
•
There is insufficient provider interest in participating in a fee-for-service plan.
•
There is insufficient enrollment to sustain a fee-for- service plan.
Each alliance, after negotiations with providers, establishes a fee schedule for the feefor-service component of health plans in that alliance. Each health plan uses the same
schedule and must reimburse health providers under its fee-for-service option up to the level
of the fee schedule. Providers may collectively negotiate the fee schedule with the alliance.
A state may choose to adopt a state-wide fee schedule.
(9/1/93)
64
�WORKING GROUP DRAFT
PRIVILEGED AND eQNHPENTP^r
BALANCE BILLING
A provider may not charge or collect from a patient a fee in excess of the fee schedule
adopted by an alliance. A plan and its participants are not legally responsible for payment of
any amount in excess of the allowable charge.
PROSPECTIVE BUDGETING OF FEE-FOR-SERVICE
States have the authority to impose prospective budgeting on fee-for-service plans
offered through health alliances.
Under prospective budgeting:
•
The alliance chooses or develops one fee-for-service plan as the designated
plan for its service area. The alliance negotiates with health providers annually
to develop a budget for the plan.
•
The negotiated budget establishes spending targets for each sector of health
expenditures.
•
The fee-for-service plan periodically reviews service utilization and adjusts
payments to providers to assure compliance with the negotiated budget.
•
Provider groups may establish fee-for-service plans. A board composed of
representatives of providers may manage fee-for-service plans, developing a
utilization review system and other procedures to assure the financial viability
of the plan.
PORTABILITY
Health plans pay for urgent care delivered outside the plan's service area.
An eligible individual who intends to establish residence in an area for longer than six months
registers with the local health alliance.
An eligible individual who establishes residence in an area for more than three months
but less than six months may choose to:
(9/1/93)
65
�WORKING GROUP DRAFT
PRIVILEGED AND eeNHULWHAfc^
•
Continue coverage through the regional alliance and health plan in which he or
she is enrolled, limiting the use of health care to emergency services and urgent
care.
•
Register with the alliance serving the temporary residence and choose a local
health plan.
•
Enroll in a health plan with a fee-for-service component that covers care
provided outside the alliance service area.
ENFORCEMENT
The Department of Labor oversees the financial operations of the alliance. The Department
of Labor conducts audits of management and financial systems, and may recommend to the
National Board that remedial action is required.
(9/1/93)
66
�WORKING GROUP DRAFT
PRIVILEGED AND ISUNHLUaN EBSC
CORPORATE ALLIANCES
The following organizations and firms must either form corporate health alliances or
join regional health alliances:
•
Employers with more than 5000 employees.
•
Existing plans formed pursuant to collective bargaining with
more than 5000 covered employees, (or a group of plans within
the same union structure) such as Taft-Hartley plans, although
certain limitations apply to the ability of such plans to provide
coverage to associate union members.
•
Plans formed by rural electric and telephone cooperatives with more than 5000
covered employees.
The term employer is defined as it is under the ERISA statute.
The threshold of 5000 employees is applied by calculating the number of workers
employed by a firm nationally. The common control test determines whether separate trades
or businesses are treated as a single employer.
Employers whose primary occupation is employee leasing are required to participate in
regional health alliances regardless of the number of employees. Federal, state, local and
special purpose units of governments are required to participate in regional alliances
regardless of their size. The United States Postal Service may operate as a corporate alliance.
A firm or organization that is certified as a corporate alliance must discontinue as a
corporate alliance if the number of full-time employees of the firm or the number of fulltime employees covered by the organization falls below 4800.
The Department of Labor regulates employers and determines whether a corporate
alliance may continue to operate in the case of mergers, acquisitions and bankruptcies.
A state adopting a single payer approach may require all employers and individuals to
participate in the single payer system.
(9/1/93)
67
�WORKING GROUP DRAFT
PRIVILEGED AND eONFIDENTLl
ELECTION TO FORM A CORPORATE ALLIANCE
Large employers eligible to form corporate alliances elect to exercise that option or to
purchase health coverage through a regional alliance.
During the implementation of the new health system, a large employer has a one-time
opportunity to enroll in regional alliances at community rates workers residing in regional
alliances where less than 100 of the employer's workers reside.
Large employers periodically have the opportunity to switch to regional alliances,
according to the following terms:
iiphe area served
'fe gionaLal 1 ianc.e_for.
M the coi'puialc alliance covtns muic than 1,000 partieipantsJiLthe^area served
Jby a regional allijiiur'The employer-eaters^by paylfcg a risk-adjusted,
weighted-average premium for a period of four years, after which the rates
charged to that employer adjust to obtain a community rate over four years.
The election applies to all employees of the employer, nationwide.
Employers or establishments that join regional alliances must continue to
purchase coverage through them.
TAFT-HARTLEY PLANS AND RURAL COOPERATIVES
The board of directors of an existing Taft-Hartley plan or rural cooperative elects
whether to form a corporate alliance. If it elects not to form a corporate alliance, its member
employers purchase health coverage through regional alliances like any other employer.
These new rules regarding Taft-Hartley plans do not affect and are in addition to current
rules governing the collective bargaining process.
If an employer that participates in a Taft-Hartley plan or rural cooperative leaves the
arrangement, it purchases coverage through the regional alliance like any other employer.
(9/1/93)
68
�WORKING GROUP DRAFT
PRIVILEGED AND feUHl'lDLM UAL
ENROLLMENT
Each corporate alliance offers all eligible persons health plans that provide the
nationally guaranteed comprehensive benefits.
Corporate alliances hold annual open enrollment periods during which individuals and
families choose among health plans. The open enrollment period for the corporate alliance
coincides with the enrollment period for regional alliances.
ENROLLMENT OF NEWLY ELIGIBLE PERSONS
Corporate alliances provide a mechanism for promptly enrolling individuals and
families who become eligible for coverage between open enrollment periods.
OVER-SUBSCRIPTION IN A PLAN
A health plan may become over-subscribed, meaning that the plan does not have
sufficient capacity to serve everyone who wants to enroll. When a plan is over-subscribed,
existing members of the plan have preference to continue in the plan. In determining which
new members join an over-subscribed plan, a corporate alliance uses a process of random
selection.
HEALTH PLANS
Corporate alliances provide health benefits to eligible employees and dependents either
through a certified self-funded employee benefit plan or through contracts with state-certified
health plans.
Contracts between health plans and corporate alliances comply with the following
requirements:
•
(9/1/93)
Premium rates charged to the corporate alliance may be based on community
rating, adjusted community rating or experience rating.
69
�WORKING GROUP DRAFT
PRIVILEGED A N D ^ W l 1ULN UAL
For corporate alliances composed of more than one employer, such as TaftHartley plans and rural electric or telephone cooperatives, premium rates
charged to individual employers must be community rated.
Health plans that contract with corporate alliances must accept all eligible
employees and their dependents, regardless of individual characteristics, health
status, anticipated need for health services, occupation, affiliation with any
person or entity (except for affiliation with another alliance or health plan).
Health plans may not terminate, restrict or limit coverage for the nationally
guaranteed comprehensive benefit package.
•
Exclusions for existing medical conditions and waiting periods or riders
that exclude certain individuals are prohibited.
•
Health plans may not cancel coverage for eligible employees and
dependents until they enroll in another health plan.
FAILURE TO PAY PREMIUMS
If a corporate alliance fails to make premium payments to a health plan, the plan may
terminate coverage after reasonable notice. If coverage is terminated, the corporate alliance is
responsible for providing coverage to individuals previously insured under the contract.
A health plan that notifies a corporate alliance of its intention to terminate coverage
also sends a copy of the notice to the Secretary of Labor.
INFORMATION
Corporate alliances assure that employees have ready access to comparative
information about health plans. Information is obtained through a brochure published
annually. At a minimum, the brochure must include the following information about health
plans:
•
(9/1/93)
Cost to consumers, including premiums and average out-of-pocket expenses.
70
�WORKING GROUP DRAFT
PRIVILEGED AND ^ONFIUEWTIAfe^
•
Characteristics and availability of health providers.
•
Restrictions on access to providers and services.
•
The annual Quality Performance Report for each health plan containing
measures of quality presented in a standard format.
Corporate alliances are responsible for assuring that employees are aware of
information they may obtain from participating plans.
CHOICE OF PLANS
Each corporate alliance contracts with at least one fee-for-service health plan. A
corporate health plan has a fee-for-service component if a participant has the option of
consulting any health provider, subject to reasonable plan requirements.
Reasonable plan requirements include utilization review and requirements to obtain
approval for certain service before they are obtained but does not involve primary care
physicians or networks acting as gatekeepers.
A corporate alliance may be excused from the requirement to offer a fee-for-service
option in a geographic area in which the regional alliance obtains a waiver from the
requirement.
In addition to a fee-for-service plan, a corporate alliance contracts with at least two
other health plans offering the comprehensive benefits. A corporate alliance may be excused
from this requirement if an insufficient number of state-certified plans exist in a particular
geographic area, or if the plans are unwilling to contract with the corporate alliance.
CONTRACTS WITH HEALTH PLANS
Corporate alliances contract with health plans on at least an annual basis but may enter
into multi-year contracts.
(9/1/93)
71
�WORKING GROUP DRAFT
PRIVILEGED AND
Contracts include certification requirements outlined in federal and state law, as well
as a statement regarding the maximum capacity the plan is willing to serve. A corporate
alliance may set additional requirements for contracting health plans.
RISK ADJUSTMENT
A corporate alliance may, but is not required to, use a risk adjustment system to
account for variations in enrollment among health plans with respect to risks and access to
basic health services among participants.
PAYMENTS AND RATINGS
A corporate alliance makes direct payments to health plans.
A corporate alliance has the option of using any type of rating arrangement with
health plans, including full or partial self-funding, prospective or retrospective experience
rating, adjusted community rating, community rating by class, or community rating. In a
Taft-Hartley plan or a rural cooperative, participating employers are charged on a community
rated basis within the plan.
Employees covered in all corporate alliances pay a community rate for their portion of
premiums, however.
PLAN OF OPERATION
Corporate alliances submit plans of operation to the Department of Labor. The
Secretary of the Department of Labor determines whether the plan meets all statutory and
regulatory requirements.
(9/1/93)
72
�WORKING GROUP DRAFT
PRIVILEGED AND
ERISA
The Health Security Act amends the Employee Retirement Income Security Act of
1974 (ERISA) to create a new chapter governing employee health benefit plans and
modifying the current ERISA preemption section.
REQUIREMENTS RELATED TO EMPLOYEE HEALTH BENEFIT PLANS
A new chapter or title of ERISA establishes fiduciary and enforcement requirements
for employers and others sponsoring health benefit plans in corporate alliances. Current
provisions of ERISA do not apply to health benefits except by specific reference. Provisions
address:
•
Ensuring that everyone enrolled in corporate health alliances obtains coverage
providing at least the nationally guaranteed benefit package
•
Establishing fiduciary requirements for employers, plan sponsors and plan
fiduciaries
•
Setting requirements related to information and notification made available to
employees
•
Ensuring compliance with national standards with respect to uniform claims
form, data reporting, electronic billing and other areas
^pplyingg^jevSiK^and benefit dispute procedures to self-funded health
plans
Establishing financial reporting requirements for self-funded health benefit
lans_and-for'corporate alliances
•
Setting financial reserve requirements for self-funded health benefit plans.
The new title or chapter also sets fiduciary requirements for employers in regional
alliances governing the withholding of employee contributions from wages. The Department
(9/1/93)
73
�WORKING GROUP DRAFT
PRIVILEGED AND COIUmDEHTIAL
of Labor may enter into agreements with states to enforce these requirements.
FINANCIAL RESERVE REQUIREMENTS
New requirements for financial reserves apply to self-funded health plans. Selffunded health plans establish a trust fund that is maintained at a level equal to the estimated
amount that the plan owes providers at any given time. The plan pays claims from the trust
fund. Trust funds are protected by special status in bankruptcy proceedings if the sponsoring
employer fails.
Reserve requirements may be met through letters of credit, bonds or other appropriate
security rather than establishing the trust fund.
A new national guaranty fund for self-funded health plans provides financial
protection for health providers in case of financial failure of a plan. The Department of
Labor oversees the national guaranty fund; it operates in a manner similar to state insurance
guaranty funds.
The Department of Labor may inspect the books and records of self-funded health
plans and assume control over plans if they fail to meet reserve requirements. Health benefit
plans notify the Department of Labor if they fail to meet requirements.
PREEMPTION OF STATE LAWS
The ERISA preemption provision is modified to:
•
Apply the preemption only with respect to employers and health benefit plans
in corporate alliances.
•
Permit taxes and assessments on employers or health benefit plans in corporate
alliances if the assessments are nondiscriminatory in nature.
•
Permit states to develop all-payer hospital rates or all-payer rate setting.
•
States also may require all payers, including health benefit plans
in corporate alliances, to reimburse essential community
(9/1/93)
74
�WORKING GROUP DRAFT
PRIVILEGED AND eONFIDEHTLVL •
providers.
(9/1/93)
75
�WORKING GROUP DRAFT
PRIVILEGED AND £ O W lUIil'l 1 lA'L >
HEALTH PLANS
Health plans provide coverage for the nationally guaranteed comprehensive benefit
package through contracts with regional or corporate alliances. Only state-certified health
plans are allowed to provide health insurance and benefits in regional alliances.
ENROLLMENT
Health plans accept every eligible person enrolled by an alliance without regard to
individual characteristics, health status, anticipated need for health care, occupation, affiliation
with any person or entity (except affiliation with a corporate alliance or health plan).
Health plans may not terminate, restrict or limit coverage for the comprehensive
benefit package for any reason, including non-payment of premiums. They may not cancel
coverage for any individual until that individual is enrolled in another health plan.
Health plans may not exclude participants because of existing medical conditions or
impose waiting periods before coverage begins. Riders that serve to exclude certain illnesses
or health conditions also are prohibited.
With the approval of the state, health plans may limit enrollment because of
restrictions on the plan's capacity to deliver services or to maintain financial stability.
COMMUNITY RATING
Health plans use community rating to determine premiums establishing separate rates
to reflect family status.
Beginning in August of each calendar year, alliances negotiate premium rates with
each health plan contracting for coverage through that alliance. Negotiations set individual
and family premiums for each health plan within the alliance. During an annual open
enrollment period, alliances publish the negotiated rates for all health plans.
(9/1/93)
76
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WORKING GROUP DRAFT
PRIVILEGED AND£eSEFHJbIN HAL
Alliances establish a mechanism for enrolling individuals who have not chosen a
health plan or purchased insurance when they seek health services. The point-of-service
mechanism follows these guidelines:
•
Within 10 days of enrollment at a point of service, the alliance provides an
individual with materials describing health plans.
•
If the individual does not choose a health plan within 30 days, the alliance
randomly assigns the individual to a health plan.
•
Using the fee-for-service schedule adopted by the alliance, the health plan
chosen reimburses the provider who cared for the uninsured individual prior to
enrollment.
MANAGING ACCESS TO PLANS
If more consumers apply to enroll in a health plan than its capacity allows, an alliance
uses a process of random selection to decide which new applicants may enroll.
MARKETING
Alliances control direct marketing to consumers by health plans. Marketing rules
include at least the following requirements:
•
The alliance must approve marketing materials used by health plans.
•
If a health plan uses direct marketing, it may not limit distribution to an area
smaller than the geographic area it serves within the alliance.
•
Health plans and their agents are prohibited from attempting to influence an
individual's choice of plans in conjunction with the sale of any other insurance.
54
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�DETERMINED TO BE AN ADMINISTRATIVE
MARKING Per £.0^12958 as amended, Sec. 33 (c)
WORKING GROUP DRAFT
PRIVILEGED AND «
INFORMATION
Alliances publish (or otherwise make available to consumers) easily understood, useful
information, including brochures, computerized information and interactive media, that allows
them to make valid comparisons among health plans. The following information must be
included:
•
Cost to consumers, including premiums and average out-of-pocket expenses
•
Characteristics and availability of health care professionals and institutions
participating in the plan
•
Any restrictions on access to providers and services
•
The annual Quality Performance Report, which contains measures of quality
presented in a standard format.
INSURANCE RISK
An alliance may not bear insurance risk.
RELATIONS W ITH PLANS
"
Each regional alliance negotiates with health plans to^ffovide the comprehensive
benefit package to all eligible persons in the alliance area/Only health plans that enter into
contracts with the appropriate regional or corporate alliance are authorized to provide the
guaranteed benefit package.
Alliances contract with health plans on at least an annual basis but may enter into
multi-year contracts. Multi-year contracts may not specify premium increases for future
years in excess of the projected inflation factor for the alliance budget.
CONTRACTING REQUIREMENTS AND EXCLUSION OF PLANS
Alliances write uniform contracts with, health plans, including all certification
requirements imposed by federal or state law.
55
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�DETERMINED TO BE AN ADMINISTRATIVE
MARKING^Pcr ELO. 12958 as amended,
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WORKING GROUP DRAFT
PRIVILEGED AND GeSEffiEifflAL
RISK ADJUSTMENT
States must ensure that each alliance establishes a risk-adjustment mechanism that
complies with the federal standard. Risk-adjustment mechanisms account for differences in
patient populations related to age, gender, family size, health status and services to
disadvantaged populations. (See section on "Risk Adjustment," Tab 10.)
STATE REGULATION OF PLANS
States qualify health plans to participate in alliances. Each state establishes a
mechanism to assess the quality of health plans, their financial stability and capacity to
deliver the comprehensive benefit package to the proper geographic market of each plan.
Only plans qualified by the state may offer health coverage through alliances.
yL ^fz-f*States define recma'ements related to levels of service and the geographic distribution
f service requiredoWiealth plans to ensure adequate choice for all eligible participants,
including residepts of low-income areas and areas in which the health care system is
inadequate. <^^provide c^nsume^s the opportunity to purchase a plan at the weightedaverage premium*-srs^'njjaw- either require at least some plans to cover the entire alliance
area,^ provide a subsidy that allows consumers to pay only the weighted-average premium.
^4^5>
In-
Where no plan applies, the state must assure that at least one health plan is available
for every eligible individual residing within its service area.
states may not discriminate against health plans on the basis of 4ocati«a
A state may not regulate premium rates charged by health plans, except when
necessary to meet budget requirements or regulate plan solvency. (See section on "Budget
Development and Enforcement," Tab 14.)
SOLVENCY AND FISCAL OVERSIGHT
Each state establishes capital standards for health plans that meet minimum federal
requirements established by the National Health Board in consultation with the states.
\
49
�WORKING GROUP DRAFT
PRIVILEGED AND CQNTOEimaE
The minimum capital requirement consists of $500,000. Additional capital may be
required for factors likely to affect the financial stability of health plans, including:
Projected enrollment, number of providers and rate of growth
Market share and strength of competition
Degree and approach to risk sharing with providers and financial
stability of providers
Staicture of the plan and degree of integration
Prior performance of plan, risk history and liquidity of its assets.
Each state defines financial reporting and auditing requirements and requirements for
fund reserv es adequate to monitor the financial status of plans.
States designate an agency that assumes control if a health plan fails. Procedures
established by states to handle the failure of health plans assures continuity of coverage for
consumers enrolled in the plan.
GUARANTY FUNDS
Each state has a guaranty fund to provide financial protection to health care providers
and others if a health plan becomes insolvent. States may use existing guaranty fund
arrangements provided that the arrangement meets national standards.
Guaranty funds pay health providers and others if a health plan is unable to meet its
obligations. Guaranty funds cover liability for services rendered prior to health plan
insolvency and for services to patients after the insolvency but prior to their enrollment in
other health plans. Guaranty funds are liable at least for payment of all services rendered by
a health plan for the comprehensive benefit package, including any supplemental coverage for
cost sharing provided by the health plan.
If a health plan cannot meet its financial obligations to health care providers, the
providers have no legal right to seek payment from patients for any services covered in the
comprehensive benefit package other than the patients' obligations under cost-sharing
arrangements.
50
�WORKING GROUP DRAFT
PRIVILEGED AND GONFffiFENTPSr
If a health plan fails, health providers are required to continue caring for patients until
they are enrolled in a new health plan.
All health plans must participate in a guaranty fund, and the fund is liable for all
claims against the plan by health care providers, contractors, employees, governments or any
other claimants. The guaranty fund stands as a creditor for any payments made on behalf of
a plan.
If a health plan fails, the state may assess payments of up to 2 percent of premiums on
other plans within the alliance to generate sufficient revenue to cover outstanding claims
against the failed plan. The failure of a health plan is defined as the imminent inability to
pay legitimate claims.
A guaranty fund has the ability to borrow funds against future assessments in order to
meet the obligations of the failed plan.
ADDITIONAL BENEFITS
Any state may provide health benefits in addition to those required under the
nationally guaranteed package. However, in order to expand benefits, a state must
appropriate revenue from sources other than those established by the American Health
Security Act to support delivery of the nationally guaranteed benefit. A state may not rely on
a payroll tax on employers or another revenue source focusing solely on corporations.
SINGLE-PAYER OPTION
A state may establish a single-payer health care system rather than an alliance system
offering multiple plans. A state may establish a single-payer alliance for part of the state.
A single-payer system is one in which the state or its designated agency makes all
payments to health care providers with no intermediaries, health plans or other entities
assuming financial risk. However, providers, such as HMOs, networks of physicians and
hospitals, assume risk by accepting capitated payments to cover the health needs of
individuals.
51
�WORKING GROUP DRAFT
PRIVILEGED AND S O N F ^ E F f F M -
A. single-payer system provides, at a minimum, the health services defined in the
comprehensive benefit package and impose requirements for co-insurance, co-payments,
deductibles and out-of-pocket limits no greater than those charged by regional alliances.
Single-payer systems also must comply with requirements for quality management and
improvement, the collection of health data and other guidelines for health plans and alliances.
If a state chooses to establish a single-payer health system, the federal government
may waive any of the following requirements under the alliance system:
•
ERISA rules governing corporate alliances
•
Rules delineating participation in regional and corporate alliances
•
Rules continuing Medicare and Medicaid as separate programs outside
the alliance structure consistent with requirements for the protection of
Medicare and Medicaid recipients
•
Guaranty fund rules
A single-payer system established by a state may eliminate cost-sharing requirements;
however, a state must appropriate revenue from sources other than those established by this
Act to support delivery of the nationally guaranteed benefit.
52
�WORKING GROUP DRAFT
PRIVILEGED AND CDNf iLHiW HAfe-
REGIONAL HEALTH ALLIANCES
Regional health alliances assume the following responsibilities:
•
Representing the interests of consumers and purchasers of health care service's.
•
Structuring the market for health care to encourage the delivery of high-quality
care and the control of costs.
•
Assuring that all residents in an area who are covered through the regional
alliance enroll in health plans that provide the nationally guaranteed benefits.
ENROLLMENT
Each regional alliance enrolls all eligible persons, including low-income and nonworking persons, who reside in the geographic area it serves into a health plan that provides
the comprehensive benefits.
Alliances hold an annual open enrollment period during which each individual and
family participating in the alliance has the opportunity to choose among health plans offered
through the alliance. Enrollments made during the annual open season become effective on a
date established by law (e.g. February 1 of each year).
Alliances also provide a mechanism for promptly enrolling individuals and families
who become eligible for coverage between open-enrollment periods.
Individuals and families who move into the region served by an alliance notify the
alliance within 30 days. If the individual is employed, the employer notifies the alliance. If
the individual is not employed, he or she notifies the alliance.
Within 10 days of receiving notification that an eligible person has moved into its
service area, regional alliances provide enrollment materials. Within 30 days of receiving
enrollment materials, eligible individuals are responsible for choosing a health plan and
applying to the alliance for enrollment.
An application for coverage submitted by the fifteenth day of any month becomes
effective on the first day of the following month. An application made after the fifteenth of
the month becomes effective on the Grist day of the second month following application.
53
�c
�DETERMINED TO BE AN ADMINISTRATIVE
MARKING PcrfrQ-1 58 as amen(Jbdfic^L3 (c)
Initials:. )
Date:
29
t
WORKING GROUP DRAFT
PRIVILEGED AND eONHUE'N 14Afc-
Alliances must offer a contract to each qualified health plan seeking to serve its area
unless:
•
The proposed premium exceeds the weighted-average premium within the
alliance by more than 20 percent.
•
The health plan's quality of service or care are unsatisfactory as determined by
the state.
•
The plan engages in practices that have the effect of discriminating against one
or more classes of persons based on race, ethnicity, gender, income or health
status.
•
The plan fails to comply with contract requirements.
•
The plan is a fee-for-service plan that is not a successful bidder.
Through a competitive bidding process, an alliance may limit to
no more than three the number of plans that pay any willing
provider on a fee-for-service basis and have no network of
providers operating under a contract with the plan.
Alliances may not discriminate against health plans or providers on the basis of race,
gender, ethnicity, religion, mix of health professionals or organizational arrangement.
AREAS WITH INADEQUATE HEALTH SERMCES
Alliances may use financial incentives to encourage health plans to expand into areas
that have inadequate health services.
Alliances may organize health providers to create a new health plan targeted at such
an area, providing assistance with setting up and administering the plan. An alliance may'not
assume risk on behalf of a new health plan but may arrange favorable financing to encourage
a health plan to operate in an area with inadequate health services.
RISK ADJUSTMENT
Alliances use arisk-adjustmentmechanism to acxount for variations in enrollment
across health plans with respect to the health status and risk of participants and access to
basic health services. (See section on "Risk Adjustment," Tab 10.)
56
�WORKING GROUP DRAFT
PRIVILEGED AND BBJ^ffiEfifflA^
F E E - F O R - S E R V I C E PLANS
Each Alliance includes among its health plan offerings at least one plan organized
around a fee-for-service system. A fee-for-service system is one in which patients have the
option of consulting any health provider subject to reasonable requirements. Reasonable
requirements may include utilization review and prior approval for certain services but do not
include a requirement to seek approval through a gatekeeper.
Under certain conditions, with approval from the National Health Board, a state may
waive the requirement for each alliance to offer a fee-for-service health plan if the alliance
demonstrates that:
•
A fee-for-service plan is not financially viable in the area.
•
There is insufficient provider interest in participating in a fee-for-service plan.
•
There is insufficient enrollment to sustain a fee-for- service plan.
F E E - F O R - S E R V I C E RATES
Each state establishes a fee schedule and conversion factors for the fee-for-service
component of health plans in each regional health alliance. Each health plan uses the same
schedule and factor to reimburse health providers under its fee-for-service option.
States consult with health providers in determining conversion factors, relative values
and other variations in the schedule.
The Secretary of the Department of Health and Human Services establishes a national
model fee schedule for states and health alliances to use if they desire, based on the Medicare
RBRVS and DRG systems. The Department of Health and Human Services develops relative
values for services not now covered by Medicare, such as pediatric care, obstetrics and
workers' compensation.
BALANCE BILLING
A provider may not charge or collect from a patient a fee in excess of the rate
schedule adopted by an alliance. A plan and its participants are not legally responsible for
payment of any amount in excess of the allowable charge.
57
�WORKING GROUP DRAFT
PRIVILEGED AND CUN h fFTV NTEft^
PROSPECTIVE BUDGETING OF FEE-FOR-SERVICE
States have the authority to impose prospective budgeting on the fee-for-service
option offered through health alliances.
Under prospective budgeting:
•
The alliance chooses or develops one fee-for-service plan as the designated
plan for its service area. The alliance negotiates with health providers annually
to develop a budget for the plan.
•
The negotiated budget establishes spending targets for each sector of health
expenditures.
•
The fee-for-service plan periodically reviews service utilization and adjusts
payments to providers to assure compliance with the negotiated budget.
•
States have the authority to allow the provider community to establish the feefor-service plan. A board composed of representatives of providers may
manage the fee-for-service plan, developing a utilization review system and
other procedures to assure the financial viability of the plan.
PORTABILITY
Health plans pay for urgent care delivered outside the plan's service area.
An eligible individual who intends to establish residence in an area for longer than six
months registers with the local health alliance.
An eligible individual who establishes residence in an area for more than three months
but less "than six months may choose to:
•
Continue coverage through the regional alliance and health plan in which he or
she is enrolled, limiting the use of health care to emergency services and urgent
care.
•
Register with the alliance serving the temporary residence and choose a local
health plan.
•
Enroll in a health plan with a fcc-for-service component that covers care
provided outside the alliance service area.
58
�WORKING GROUP DRAFT
PRIVILEGED AND - a
CORPORATE ALLIANCES
The following organizations and firms are eligible to form corporate health alliances:
•
Employers with more than 5000 employees
•
Existing plans formed pursuant to collective bargaining (based on current
ERISA definitions) with more than 5000 covered employees, such as TaftHartley plans, although certain limitations apply to the ability of such plans to
provide coverage to associate union members
•
Plans formed by rural electric and telephone cooperatives with more than 5000
covered employees.
The term employer is defined as it is under the ERISA statute.
The threshold of 5000 employees is applied by calculating the number of workers
employed by a firm nationally. The common control test determines whether separate trades
or businesses are treated as a single employer.
Employers whose primary occupation is employee leasing are required to participate in
regional health alliances regardless of the number of employees. Federal, state, local and
special purpose units of governments are required to participate in regional alliances
regardless of their size.
A firm or organization that is certified as a corporate alliance must discontinue as a
corporate alliance if the number of full-time employees of the firm or the number of fulltime employees covered by the organization falls below 4800.
The Department of Labor regulates employers and determines whether a corporate
alliance may continue to operate in the case of mergers, acquisitions and bankruptcies.
A state adopting a single payer approach may require all employers and individuals to
participate in the single payer system.
ELECTION TO FORM A CORPORATE ALLIANCE
Large employers eligible to form corporate alliances elect to exercise that option or to
purchase health coverage through a regional alliance.
59
�WORKING GROUP DRAFT
PRIVILEGED AND UtffrlUfaW
IL'^
During the implementation of the new health system, a large employer has a one-time
opportunity to enroll all of its individual establishments employing fewer than 100 workers in
regional alliances at community rates.
Large employers periodically have the opportunity to switch to regional alliances,
according to the following terms:
•
The employer pays arisk-adjusted,weighted-average premium for a period of
four years, after which the rates charged to that employer adjust to obtain a
community rate over four years.
•
The election applies to all employees of the employer, nationwide.
•
Employers or establishments that join regional alliances must continue to
purchase coverage through them.
TAFT-HARTLEY PLANS AND RURAL COOPERATIVES
The board of directors of an existing Taft-Hartley plan or rural cooperative elects
whether to form a corporate alliance. If it elects not to form a corporate alliance, its member
employers purchase health coverage through regional alliances like any other employer.
If an employer that participates in a Taft-Hartley plan or rural cooperative leaves the
arrangement, it purchases coverage through the regional alliance like any other employer.
ENROLLMENT
Each corporate alliance offers all eligible persons health plans that provide the
nationally guaranteed comprehensive benefits.
Corporate alliances hold annual open enrollment periods during which individuals and
families choose among health plans. The open enrollment period for the corporate alliance
coincides with the enrollment period for regional alliances.
ENROLLMENT OF NEWLY ELIGIBLE PERSONS
-Corporate alliances provide a mechanism for promptly enrolling individuals and
families who become eligible for coverage between open enrollment periods.
60
�WORKING GROUP DRAFT
PRIVILEGED AND CONFIDEIHTSa-
A corporate alliance provides enrollment materials to each eligible person within 10
days of receiving notification of eligibility. Individuals choose a health plan within 30 days
of receiving enrollment materials. If an application for enrollment is submitted prior to the
fifteenth day of any month, coverage is effective on the first day of the following month. If
the application is made after the fifteenth of the month, coverage is effective on the first day
of the following month.
OVER-SUBSCRIPTION IN A PLAN
A health plan may become over-subscribed, meaning that the plan does not have
sufficient capacity to serve everyone who wants to enroll. When a plan is over-subscribed,
existing members of the plan have preference to continue in the plan. In determining which
new members join an over-subscribed plan, a corporate alliance uses a process of random
selection.
HEALTH PLANS
Corporate alliances provide health benefits to eligible employees and dependents either
through a self-funded employee benefit plan or through contracts with state-certified health
plans.
Contracts between health plans and corporate alliances comply with the following
requirements:
•
Premium rates charged to the corporate alliance may be based on community
rating, adjusted community rating or experience rating.
For corporate alliances composed of more than one employer, such as TaftHartley plans and rural electric or telephone cooperatives, premium rates
charged to individual employers must be community rated.
•
Health plans that contract with corporate alliances must accept all eligible
employees and their dependents, regardless of individual characteristics, health
status, anticipated need for health services, occupation, affiliation with any
person or entity (except for affiliation with another alliance or health plan).
•
Health plans may not terminate, restrict or limit coverage for the nationally
guaranteed comprehensive benefit paickage.
61
�WORKING GROUP DRAFT
PRIVILEGED AND COWWDfeN 1 lAS^
•
Exclusions for existing medical conditions and waiting periods of riders
that exclude certain individuals are prohibited.
•
Health plans may not cancel coverage for eligible employees and
dependents until they enroll in another health plan.
FAILURE TO PAY PREMIUMS
If a corporate alliance fails to make premium payments to a health plan, the plan may
terminate coverage after reasonable notice. If coverage is terminated, the corporate alliance is
responsible for providing coverage to individuals previously insured under the contract.
A health plan that notifies a corporate alliance of its intention to terminate coverage
also sends a copy of the notice to the Secretary of Labor.
INFORMATION
Corporate alliances assure that employees have ready access to comparative
information about health plans. Information is obtained through a brochure published
annually. At a minimum, the brochure must include the following information about health
plans:
•
Cost to consumers, including premiums and average out-of-pocket expenses.
•
Characteristics and availability of health providers.
•
Restrictions on access to providers and services.
•
The annual Quality Performance Report for each health plan containing
measures of quality presented in a standard format.
Corporate alliances are responsible for assuring that employees are aware of
information they may obtain from participating plans.
62
�WORKING GROUP DRAFT
PRIVILEGED AND
£Qmt&Emtfe*
•
Exclusions for existing medical conditions and waiting periods or riders
that exclude certain individuals are prohibited.
•
Health plans may not cancel coverage for eligible employees and
dependents until they enroll in another health plan.
FAILURE TO PAY PREMIUMS
If a corporate alliance fails to make premium payments to a health plan, the plan may
terminate coverage after reasonable notice. If coverage is terminated, the corporate alliance is
responsible for providing coverage to individuals previously insured under the contract.
A health plan that notifies a corporate alliance of its intention to terminate coverage
also sends a copy of the notice to the Secretary of Labor.
INFORMATION
Corporate alliances assure that employees have ready access to comparative
information about health plans. Information is obtained through a brochure published
annually. At a minimum, the brochure must include the following information about health
plans:
•
Cost to consumers, including premiums and average out-of-pocket expenses.
•
Characteristics and availability of health providers.
•
Restrictions on access to providers and services.
•
The annual Quality Performance Report for each health plan containing
measures of quality presented in a standard format.
- Corporate alliances are responsible for assuring that employees are aware of
information they may obtain from participating plans.
62
�WORKING GROUP DRAFF
PRIVILEGED AND CQNFIDEIvTTBSr
CHOICE OF PLANS
Each corporate alliance contracts with at least one fee-for-service health plan. A
corporate health plan has a fee-for-service component if a participant has the option of
consulting any health provider, subject to reasonable plan requirements.
Reasonable plan requirements include utilization review and requirements to obtain
approval for certain service before they are obtained but does not involve primary care
physicians or networks acting as gatekeepers.
A corporate alliance may be excused from the requirement to offer a fee-for-service
option in a geographic area in which the regional alliance obtains a waiver from the
requirement.
In addition to a fee-for-service plan, a corporate alliance contracts with at least two
other health plans offering the comprehensive benefits. A corporate alliance may be excused
from this requirement if an insufficient number of state-certified plans exist in a particular
geographic area, or if the plans are unwilling to contract with the corporate alliance.
CONTRACTS WITH HEALTH PLANS
Corporate alliances contract with health plans on at least an annual basis but may enter
into multi-year contracts.
Contracts include certification requirements outlined in federal and state law, as well
as a statement regarding the maximum capacity the plan is willing to serve. A corporate
alliance may set additional requirements for contracting health plans.
RISK ADJUSTMENT
. A corporate alliance may, but is not required.to, use a risk adjustment system to
account for variations in enrollment among health plans with respect to risks and access to
basic health services among participants.
PAYMENTS AND RATINGS
A corporate alliance makes direct payments to health plans.
63
�WORKING GROUP DRAFT
PRIVILEGED AND CONnDTNTEg^
A corporate alliance has the option of using any type of rating arrangement with
health plans, including full or partial self-funding, prospective or retrospective experience
rating, adjusted community rating, community rating by class, or community rating. In a
Taft-Hartley plan or a rural cooperative, participating employers are charged on a community
rated basis.
Employees covered in all corporate alliances pay a community rate for their portion of
premiums, however.
GRIEVANCE PROCEDURE
Each corporate alliance establishes a procedure through which individuals may file
complaints against health plans. The procedure includes a process through which the
corporate alliance works with the health plan to resolve complaints.
For a state-certified health plan, the corporate alliance reports to the state any
complaints that involve violations of state or federal certification requirements.
PLAN OF OPERATION
Corporate alliances submit plans of operation to the Department of Labor. The
Secretary determines whether the plan meets all statutory and regulatory requirements.
64
�WORKING GROUP DRAFT
PRIVILEGED AND CONFtPENTEaA
ERISA
The American Health Security Act amends the Employee Retirement Income Security
Act of 1974 (ERISA) to create a new chapter governing employee health benefit plans and
modifying the current ERISA preemption section.
REQUIREMENTS RELATED TO EMPLOYEE HEALTH BENEFIT PLANS
A new chapter or title of ERISA establishesfiduciaryand enforcement requirements
for employers and others sponsoring health benefit plans in corporate alliances. Current
provisions of ERISA do not apply to health benefits except by specific reference. Provisions
address:
Ensuring that everyone enrolled in corporate health alliances obtains coverage
providing at least the nationally guaranteed benefit package
Establishing fiduciary requirements for employers, plan sponsors and plan
fiduciaries
Setting requirements related to information and notification made available to
employees
Ensuring compliance with national standards with respect to uniform claims
form, data reporting, electronic billing and other areas
Establishing financial reporting requirements for self-funded health benefit
plans and for corporate alliances
Setting financial reserve requirements for self-funded health benefit plans.
The new title or chapter also sets fiduciary requirements for employers in regional
alliances governing the withholding of employee contributions from wages. The Department
of Labor may enter into agreements with states to enforce these requirements.
65
�WORKING GROUP DRAFT
PRIVILEGED AND
FINANCIAL RESERVE REQUIREMENTS
New requirements for financial reserves apply to self-funded health plans. Selffunded health plans establish a trust fund that is maintained at a level equal to the estimated
amount that the plan owes providers at any given time. The plan pays claims from the trust
fund. Trust funds are protected by special status in bankruptcy proceedings if the sponsoring
employer fails.
Reserve requirements may be met through letters of credit, bonds or other appropriate
security rather than establishing the trust fund.
A new national guaranty fund for self-funded health plans provides financial
protection for health providers in case of financial failure of a plan. The Department of
Labor oversees the national guaranty fund; it operates in a manner similar to state insurance
guaranty funds.
The Department of Labor may inspect the books and records of self-funded health
plans and assume control over plans if they fail to meet reserve requirements. Health benefit
plans notify the Department of Labor if they fail to meet requirements.
PREEMPTION OF STATE LAWS
The ERISA preemption provision is modified to:
•
Apply the preemption only with respect to employers and health benefit plans
in corporate alliances
•
Permit taxes and assessments on employers or health benefit plans in corporate
alliances if the assessments are nondiscriminatory in nature
•
Permit states to develop all-payer hospital rates or all-payer rate setting.
States also may require all payers, including health benefit plans
in corporate alliances, to reimburse essential community
providers.
66
�WORKING GROUP DRAFT
PRIVILEGED AND Cg^FUJbN HAL
HEALTH PLANS
Health plans provide coverage for the nationally guaranteed comprehensive benefit
package through contracts with regional or corporate alliances. Only state-certified health
plans are allowed to provide health insurance and benefits.
ENROLLMENT
Health plans accept every eligible person enrolled by an alliance without regard to
individual characteristics, health status, anticipated need for health care, occupation, affiliation
with any person or entity (except affiliation with a corporate alliance or health plan).
Health plans may not terminate, restrict or limit coverage for the comprehensive
benefit package for any reason, including non-payment of premiums. They may not cancel
coverage for any individual until that individual is enrolled in another health plan.
Health plans may not exclude participants because of existing medical conditions or
impose waiting periods before coverage begins. Riders that serve to exclude certain
participants also are prohibited.
With the approval of the state, health plans may limit enrollment because of
restrictions on the plan's capacity to deliver services or to maintain financial stability.
COMMUNITY RATING
Health plans use community rating to determine premiums, establishing separate rates
for individuals and for families that include children.
Beginning in August of each calendar year, alliances negotiate premium rates with
each health plan contracting for coverage through that alliance. Negotiations set individual
and family premiums for each health plan within the alliance. During an annual open
enrollment period, alliainces publish the negotiated rates for all health plans.
Employers and employees pay a community-rated premium. However, payments to
health plans by alliances are adjusted to account for the level of risk associated with
individuals enrolled in plans. The adjustment is made using a formula developed by the
National Health Board.
67
�WORKING GROUP DRAFT
PRIVILEGED AND C U N M D E N i m ,
REINSURANCE
Health plans also purchase reinsurance to cover disproportionate costs beyond those
predicted by risk ad ustment formulas.
INFORMATION
Each health plan provides to the alliance and makes available to consumers and health
care professionals information concerning:
Costs
Qualifications and availability of providers
Procedures used to control utilization of services and expenditures
Procedures for assuring and improving the quality of care
Rights and responsibilities of consumers and patients.
Health plans are responsible for the accuracy of information submitted and may be
disqualified from participating in an alliance if information is inaccurate.
In keeping with the overall goal of increased consumer knowledge about health care
issues and choices, health plans are expected to encourage patients to participate in decisions
about treatment options and to offer consumers up-to-date information regarding potential
benefits, risks, and costs of various medical and surgical procedures.
Health plans in states that allow advance directives and surrogate decision making
related to medical treatment are required to provide information about those legal options at
the time of enrollment in the plan.
GRIEVANCE PROCEDURE
Health plans establish a grievance procedure for participants to use in pursuing
complaints. If the grievance procedure fails to resolve a complaint, consumers have the
option of pursuing the issue with the alliance ombudsman or pursuing other legal remedies.
68
�WORKING GROUP DRAFT
PRIVILEGED AND
HEALTH PLAN ARRANGEMENTS WITH PROVIDERS
Health plans enter into agreements with health care providers to deliver services. Not
withstanding state laws to the contrary and except for services provided under a fee-forservice component, a health plan is authorized to:
Limit the number and type of health care providers who participate in the
health plan.
Require participants to obtain health services other than emergency services
from participating providers or from providers authorized by the health plan.
Require participants to obtain a referral for treatment by a specialized physician
or health institution.
Establish different payment rates for participating health providers and
providers outside the plan.
Create incentives to encourage the use of participating providers.
Use single-source suppliers for pharmacy, medical equipment and other health
products and services.
In addition, state laws related to corporate practice of medicine and to provider
ownership of health plans or other providers do not apply to arrangements between integrated
health plans and their participating providers.
Health plans cover emergency and urgent care provided to members outside of its
service area. Reimbursement is based on the fee-for-service rate schedule in the alliance
where the services are provided.
- During a transitional period, health plans must cover services provided to their
members by designated essential community providers. Payments to essential providers are
based on the Medicare method for community health centers.
Health plans may not discriminate against providers on the basis of race, ethnicity,
gender, religion, mix of health professionals or patient population.
69
�WORKING GROUP DRAFT
PRIVILEGED AND eONHfefeN-UAL
A state has the authority to waive the obligation to reimburse essential community
providers for a particular health plan operating in a particular area. To obtain a waiver, a
health plan demonstrates that it has the capacity to deliver a comparable range and level of
services to consumers in the area served by the essential community provider.
ADDITIONAL REQUIREMENTS FOR PLANS
In addition to the requirements discussed above, health plans must meet national,
uniform Conditions of Participation established by the National Health Board, including:
Fiscal soundness, including minimum standards for financial reserves, loss ratios etc,
and disclosure of financial condition to all purchasers.
Truth in marketing, including standards for fair marketing practices and disclosure to
consumers all material information regarding the plan and its performance.
Verifying credentials of practitioners and facilities, including bi-annual checks of
providers against national databases, investigating and resolving consumer complaints
and dropping providers who consistently fail to meet quality standards or are
responsible for fraud or mismanagement. Health plan must ensure that all practitioners
and health institutions meet state licensing standards.
Consumer Protection, including disclosure of all material information regarding the
plan and their rights and responsibilities, providing due process for patients to appeal
denial, termination or reduction of coverage and resolving appeals of complaints.
Confidentiality, including maintaining a policy for protecting patient privacy and
confidentiality in compliance with law and allowing patients to obtain copies of their
medical records upon request. (See "Adminstrative Simplification and Information
Systems," Tab 16.)
Complaints, including investigating and attempting to resolve complaints about
- practitioners, providers, treatments, access to care and health plan policies and
procedures.
Disenrollment for cause, including permitting consumers to resign from health plans
at any time for good cause. The purchaser is responsible for ensuring that gaps in
coverage do not occur as a result.
70
�WORKING GROUP DRAFT
PRIVILEGED AND gONFIDEimga
Utilization Management, including disclosure of protocols for controlling utilization
and costs.
Methods used to manage the network of providers, such as the selection criteria
and internal performance standards.
Compensation methods for providers, such as capitation;
Incentives to providers to control utilization;
Utilization review criteria - criteria by which health care services are
determined to be inappropriate; and
Protocols for managing the care of high-cost patients.
Data Management and Reporting, including maintaining encounter data and required
quality data electronically and reporting the data to the national network. (See
"Information Systems and Administrative Simplification," Tab 16 and "Quality
Management and Improvement," Tab 15.)
71
�WORKING GROUP DRAFF
PRIVILEGED AND C e N F I B E i m ^
SUPPLEMENTAL INSURANCE
Supplemental insurance to cover both cost sharing and additional health benefits is
allowed.
A supplemental benefit policy might cover all or some portion of benefits not included
in the comprehensive package, such as long-term rehabilitation services and cosmetic surgery.
A policy covering cost sharing might pay a portion of co-payments and co-insurance
required by a health plan.
Any entity that offers supplemental policies must abide by the rules for supplemental
insurance. However, the following types of insurance policies are not subject to these rules:
• Long-term care insurance
• Insurance against specific diseases
• Hospital or nursing home indemnity insurance
• Medigap insurance
• Insurance against accidents
COST SHARING
The National Health Board develops two standard supplemental cost-sharing policies.
One model provides standard coverage; the other maximum coverage. Once developed, only
the model policies may be offered, and every health plan that uses the high cost sharing
model (described under Benefits) is required to offer both.
Limitations on pre-existing medical conditions are prohibited, and supplemental
policies must be available to every participant in a health plan at the same price. Policies
may not exclude cost-sharing coverage for specific diseases or conditions.
Only qualified health plans with the high cost sharing option (see section on
"Guaranteed Comprehensive Benefits," Tab.4) may offer supplemental insurance for cost,
sharing under the comprehensive benefit packagfe. A member of a health plan may purchase
supplemental insurance for cost sharing only during the annual enrollment period.
The price of any insurance policy covering cost sharing includes the cost of additional
72
�WORKING GROUP DRAFT
PRIVILEGED AND eONFIBEWTIAL
benefits plus any expected increase in utilization caused by the insurance.
No plan may sell coverage for cost sharing at a price that results in a loss-ratio less
than 90 percent. (The loss ratio is the ratio of the premium returned to the consumer in
payout relative to the total premium collected.)
The National Health Board develops rules for the coverage of cost sharing in corporate
alliances. The rules may require that only one standard, supplemental policy is offered, or
that no policy is offered if an employer already substantially covers cost-sharing.
ADDITIONAL BENEFITS
No health plan, insurer, or any other person may offer anyone eligible for the
guaranteed benefit package a supplemental insurance policy that duplicates coverage in the
national benefit package.
Any health plan that sells duplicate coverage is disqualified from participating in
alliances. Any firm or individual who offers such policies is subject to loss of the license to
sell insurance.
No policy covering additional health services may fail to cover, limit or restrict
coverage for any illness, disease, or other condition that existed prior to the purchase of the
policy. All policies covering additional benefits must be offered at a single price to all
individuals in a alliance.
Insurance policies providing coverage for additional benefits must be available to any
purchaser, subject to the capacity and financial limits of the insurer. Coverage available only
through membership in fraternal, religious, professional and other organizations and policies
sold to employers to cover benefits for their employees are exceptions.
The National Health Board develops, in consultation with the states, minimum
standards that prohibit marketing practices by insurance companies and agents that involve:
. •
•
Tying or otherwise conditioning the sale of supplemental
insurance to the purchase of the comprehensive benefit package.
Providing compensation to an agent selling supplemental benefits for
promoting or otherwise encouraging the purchaser of supplemental
benefits.
73
�WORKING GROUP DRAFT
PRIVILEGED AND eONl'lDENHAfe'
Using or disclosing to any party information about the health status or
claims experience of participants in the plan for the purpose of
marketing supplemental benefits.
74
�WORKING GROUP DRAFT
PRIVILEGED AND
ADVISORY COMMITTEE
The National Health Board creates an advisory committee to provide technical advice
and recommendations regarding the development of therisk-adjustmentsystem. The
advisory committee is composed of fifteen representatives of health plans, alliances,
consumers, employers and health providers. Once it is adopted, the committee makes'
recommendations for updating therisk-adjustmentsystem.
The National Health Board may conduct research and undertake demonstration
projects to support the development of the system.
RISK ADJUSTMENT SYSTEM REQUIRED
States are required to assure that alliances use the federal risk-adjustment system.
A state that wishes to modify the system or substitute another risk-adjustment
mechanism applies to the National Health Board. The Board grants a waiver if the alliance
demonstrates that its proposed system is at least as effective and accurate as the model
system.
76
�WORKING GROUP DRAFT
PRIVILEGED AND UJIN11DLIJ IL"iL
RURAL COMMUNITIES IN THE NEW SYSTEM
Economic and demographic characteristics of many rural communities result in a
larger number of uninsured and underinsured citizens in rural areas. Under the American
Health Security Act, access to care is ensured for Americans who live in rural areas through:
Alliance requirements to serve rural areas
Investment in infrastructure
Creation of incentives to expand rural community-based networks and plans
Investments for the development of the health workforce
Expansion of the rural public health system.
GUARANTEED UNIVERSAL ACCESS
Alliances have the capacity to ensure adequate health services in rural areas by:
Creating alliance-sponsored plans
Fostering cooperative relationships among rural and urban
providers
Requiring urban health plans to serve rural areas in the alliance
Developing an information and referral infrastructure to link academic health
centers and rural health providers
Offering long-term contracts to health plans serving rural areas.
77
�WORKING GROUP DRAFT
PRIVILEGED AND
INFRASTRUCTURE DEVELOPMENT DURING TRANSITION
As described in more detail in the section on Protecting Underserved Populations (Tab
25), qualifying community-based organizations in rural areas have access to federal loan
guarantees for capital improvements. A budget authority of $16 million per year supports the
loan guarantee program, which is estimated to be sufficient to finance $1.1 billion in new
capital expenditures and $500 million in renovations. It is expected that approximately 56
percent of this capacity will develop in rural areas.
RURAL COMMUNITY-BASED NETWORKS AND PLANS
Federal funding and technical assistance become available to support local planning
and development of primary care systems in areas with inadequate health services, such as
rural areas. Grants support the development of telecommunications capacity to link rural
providers with health care centers and institutions as well as continuing education and
professional support.
A net increase over current activities of about $60 million is anticipated as a result of
these development activities. Resources follow the distribution of target populations; rural
areas will receive approximately 56 percent of this fund.
WORKFORCE
The National Health Services Corps and related programs expand to reduce the
shortage of health care providers in rural areas. Incentives are provided to attract and retain
health professionals in rural areas.
Tax incentives encourage practice in rural areas. Incentives include:
•
A non-refundable personal tax credit of $1,000 per month that can be
recaptured during the first five years pf practice by a physician, in a rural area
with a shortage of health professionals ($500 for physician assistants and nurse
practitioners).
•
The exclusion from gross income of National Health Service Corps Loan
Repayments received under section 338B.
78
�WORKING GROUP DRAFT
PRIVILEGED AND
1I>MN 1IAL
•
An allowance of up to $10,000 annually (depreciation not required) for the
purchase of medical equipment used in areas with a shortage of health
professionals.
•
Deductibility of up to $5,000 in annual student loan interest for physicians,
physician assistants, advanced practice nurses and registered nurses performing
services under agreements with rural communities.
The allocation of residency positions in new health care systems involves special
attention to geographic factors.
Increased relative compensation for primary care physicians also encourages practice
in rural areas. (See section on "Creating a New Health Workforce," Tab 17).
PUBLIC HEALTH SYSTEM
To assure access to health care in rural areas, supplemental services are provided for
low-income populations. . These siervices include: transportation, outreach, non-medical case
management, translation, child care during clinic visits, health education, nutrition, social
support and home visiting services. (See section on "Protecting Underserved Populations,"
Tab 25.)
These services are provided through current authority for Migrant Health Centers,
Community Health Centers and Health Care for the Homeless under the Public Health Act.
New authorities make funds available to other providers of comprehensive primary
care, such as federally qualified health centers, local health departments, maternal and child
health clinics, primary care physician graduate medical practices and disproportionate share
hospital clinics.
79
�TRANSITION TO THE NEW SYSTEM
The f o l l o w i n g t r a n s i t i o n scenario assumes i n t r o d u c t i o n o f
h e a l t h care reform l e g i s l a t i o n i n June/and enactment o f n a t i o n a l
h e a l t h reform by December 1993.
June 1993
1.
Upon announcing the i n t r o d u c t i o n o f health care reform, t h e
President along w i t h physician, nurse, h o s p i t a l , some
insurance aricJ pharmaceutical and other provider groups wotrld
announce a/voluntary freeze on health care p r i c e s t o begin
immediately. The freeze weuich l i m i t ^ p r i c e increases t o the
—
,1^
/ O i ^ — t - —
IV^U-t-
„
,
lieg±slati?pn-^oTr!ra—i"nclude)-a—standby—trigger-mechanism-to-'go
iwfeo—e-f-fe*et—a—year—f-rom^J-une j[f voluntary
e f f o r t s do not
succeed//
Pa?a?ees would then be frozen
by law adjusted
to
June 1993 revels
plus CPI^
J ,
The-j|r^g?e_^t^-dr-eove-r—:i-nsuranee—premiums^and^rices f o r a l l
h e a l t h c a r e products and s e r v i c e s .
N
An independent board w
—exeGuti'Ve~braneh—to-mi
Gen*ro-ts w±l~l cea-set
-
—
P. Hae—e s t ab'ti'shed ^.w i t h i n—the
t o r compliance w i t h the freeze
' a s t a t e moves/j onto a DuagetT
-
January 1994f^2.
Insurance reform ftuuld b"e implemented t o ensure t h e
v i a b i l i t y o f the small group insurance^market.
Cox*.
Premiums would be set aeee^Eding-^fed-^the v o l u n t a r y freeze« l^^sf"
. ^sut may be adjusted tiue Lir-demegfaphie—changes—wi^fehi-n—aj .
Per\ cu^^tty i^ly^co g-roup.—^These ~adj ustment—f actors—wou-l-d—b&^rbased. on a <2-^<-Jr>-J~~\
J-d D^- s i n g l e r a t e t a b l e developed by each i n s u r e r an*^S
approved by a s t a t e . Premiums f o r new groups wettld— a^-*-.
also be based on t h i s t a b l e .
3
Insurers wouid—be required t o accept a l l new f u l l - t i m e
employees added t o c u r r e n t l y - i n s u r e d groups, w i t h rates
set according t o the S%ate-approved
rate table.
AInsurers wouixLbe p r o h i b i t e d from t e r m i n a t i n g o r not
renewing any policies—except—for^-non-payment—of—prem-}
bap-other s t r i c t l y defined cause.
Insurers wettid—bB~- required t o p a r t i c i p a t e i n asmall
market s t a b i l i z a t i o n program or they woui-d—be
permanently p r o h i b i t e d from p a r t i c i p a t i n g as
A€«ettritHb±e~^*ealth Plan i n the new f e d e r a l system.
�A/federal insurance board would -be established to
guarantee coverage i n the event, of^-insurance companies
i e j ^ l n g the market.
^feP^t
•
States yS^i^federal assistance
develop a bSS^ppstate health insurance pool to cover displaced or
uninsured persons. The^pools wOul-d* provide coverage to
displaced groups or uninsured individuals that .efl^Sra
(v<£*.not find voluntary insurance. Traditional premium
rating methodologies /-wSS^Ea- apply. The pools w6tiHS3==be- ^— subsidized by premium assessments on existing insurers.
-
Ci
These federal rules "WlFMb- terminate upon new system
implementation i n a state.
3.
Preemptions of state anti-managed care laws, anti-Medicaid
managed care laws, scope of practice limitations and a n t i t r u s t laws, as well as ERISA reform and malpractice reform
5*£±1- go into ftspce easing provider burdens.
4.
Planning grants WiTr~be made available to each state to help
them prepare to establish the new system.
5.
CLIA, PRO and Medicare reimbursement simplification begins.
6.
Medicare comes under budget -in—sync^w-ith private sector
<C
do
controls^
July 1994
^jg,
Q^L<A .
^
7.
The National Health Board i s established.
8.
A l l senior c i t i z e n s e l i g i b l e under Medicare w±ii—be e n t i t l e d
to the drug benefit. Revenue from the cigarette tax which
also goes into effect at t h i s time -wili-be used to pay for
the benefit.
Jje^- Following ^enactment of state l e g i s l a t i o n , additional federal/
p5X^ funds wi-H be^provided to states i n two allotments/^ T-toes^,
^fiiRds—w4it^re^a'teh6d~by^sta'besT-- /-TH^s^ieftds—vrt*l—support
state development of the health a l l i a n c e u n t i l the a l l i a n c e
can be supported by premium revenue. These funds are
structured to provide states -an^incentive to implement ^ n
1995.
^>rV
''
lw<
/
Vrr
•
One-third of start-up funds are provided to the
states upon passage of state enabling l e g i s l a t i
The remaining two^thirds of the start-up funds
w i l l be provided after the acceptance of the state
plan RTKt-jTfftnltlT^A'l.Vi^^
.
The benefits of the reform, i n general, provide states
incentives to act early. Those benefits include:
�Provision of health care security to a l l t h e i r
residents
Budget control and predictability
Insurance market reform
Relief from an increasing Medicaid burden
Minimizing the period of market uncertainty.
n addition to thesei ince
incentives., states are provided with
federal
financial
incentives
r e l a t e^^ to technical assistance
_
—le^nti
an&Mnaintenance--o'f effort to encourage<^hem to implement in
1995>
^
. ^
^
For states which expand coverage ^throughr-the-heal-th-alliance
s^rxrcSture^rn^tQ-g57 /federal funding wlii-^fee-available at
higher l e v e l s . The schedule for funding i s as follows:
Implementation Date:
Percent of Federal Funding:
1/1/95 - 12/31/95
after 1/1/96
120%
100%
States' maintenance of effort obligation w i l l be reduced i f
states implement i n 1995.
The schedule i s as follows:
Implementation on or by:
% Maintenance of Effort
1/1/95 - 12/31/95
after 1/1/96
90%
100%
Graduated penalties w i l l incur to states which have not
implemented by January 1, 1997. These penalties are
structured to increase the purchaser and provider pressure
for state reform.
After January 1, 1997, tax deductibility of health insurance
benefits would-be decreased and ultimately eliminated i n
those states which have not implemented health reform.
January 1995
10.
Single reimbursement form i s introduced.
11.
F i r s t group of states implements mandate and universal
coverage.
^ - i -
12.
Quality system guidelines/initiated.
13.
Phase-in of long-term care program begins.
�14.
Funding of underserved area i n i t i a t i v e s conunences.
January 1996
15.
Universal coverage and mandate extendito a l l states. A l l
Americans wlfiT receive their health security cards. Where
health a l l i a n c e s do not exist, the insurance market w-illsign^up new enrollees under state and federal supervision.
16. Auto insurance reforms begin. Either auto insurance rates
.^--j^iiir-Bie required to go down by 15% or a federal surcharge
w±Ai_be placed on rates to help fund the program.
17. ^tates^wfio^lra^i^^
isudget^ ^ f\Jr- i~~ lU^-^
18.
•
V -(f^c.
Research projects and educational
idtd^-rL^
' ^ r ^ ^ i ^ s -
i n i t i a t i v e s begin.
January 1997
19.
A l l states must be under a budget and must e s t a b l i s h t h e i r
health a l l i a n c e s .
20.
Workers' compensation insurance reforms are implemented.
fl
O ^ J ^ > ^ ^
�PRIVILEGED AND
HEALTH SECURITY CLEARINGHOUSE
In addition to the Board, health reform creates an
electronic clearinghouse that transfers money across states.
For example, an individual covered by a health plan i n
Michigan may use services while vacationing i n Florida. The
provider i n Florida submits a b i l l to the clearinghouse which
debits the plan's account.
The Clearinghouse ensures payments to states and health
a l l i a n c e s and invests those monies not needed to meet current
obligations. Monies i n the Trust Fund are not counted i n the
budget t o t a l s for the United States government.
DETERMINED TO BE AN
ADMINI§]
INITIALS:
18
�13
FINANCING OF HEALTH REFORM
Americans younger than age 65 purchase h e a l t h c a r e p r i m a r i l y
through
insurance
premium c o n t r i b u t i o n s
by businesses and
households, out-of-pocket spending and government programs, such as
Medicaid.
Amorioano—oider—than—age—65—rely—prima-r-i-l-y—on—the
Med±care "pregram-.
I n a d d i t i o n , f e d e r a l , s t a t e and l o c a l t a x revenues fund c a r e
provided by the Department of Defense, the Department of Veterans
A f f a i r s , the Indian Health S e r v i c e , p u b l i c h o s p i t a l s , c l i n i c s and
the p u b l i c h e a l t h s e r v i c e .
Medicare p r i m a r i l y funds h e a l t h care f o r people o l d e r than age
65; Medicare obtains i t s funding through a t r u s t fund i n t o which
general fund revenues and proceeds from a p a y r o l l t a x flow.
Medicare
b e n e f i c i a r i e s a l s o purchase supplemental
insurance
p o l i c i e s , o r "Medigap," and pay out of t h e i r pockets f o r v a r i o u s
other s e r v i c e s , i n c l u d i n g p r e s c r i p t i o n drugs.
Health reform proposes a financing system t h a t adopts the same
fundamental s t r u c t u r e but with the following changes:
•
^
1
^""^
Employers
and employees w i i l — b e — r e q u i r e d — - " t o
coataHLbuto to-tho cost—of h e a l t h insurance through
a w a g e - b a s e d premium r a t h e r than c o n t r i b u t i n g
v o l u n t a r i l y , as many do now. The wage-based premium
replaces
the current
system
of payments by
i n d i v i d u a l s and firms based on r i s k f a c t o r s and
experience.
•
Medicare
b e n e f i c i a r i e s wtH. r e c e i v e
coverage to pay f o r ^ p r e s c r i p t i o n drugs.
•
A d d i t i o n a l f e d e r a l funds wi#± pay f o r investments
i n h e a l t h care i n underserved areas, f o r h e a l t h
education, f o r research and f o r long term c a r e .
The Employer-Based
federal
System
Under h e a l t h reform, employers and employees oaeh c o n t r i b u t e
a f i x e d percentage of p a y r o l l each year t o purchase h e a l t h
insurance.
Employers contribute 80 percent of the c o s t and
employees 20 percent.
Self-employed persons contribute the f u l l amount Qf the
premium but can deduct i t from f e d e r a l tax l i a b i l i t y . ^ I n d i v i d u a l s ^ „h,-ij
who—aaee—not—employed contribute a percentage of t h e i r unearned
income comparable to the amount paid by employed i n d i v i d u a l s , which
0
�14
a l s o i s tax
deductible.
Employers may e l e c t to pay the t o t a l premium, i n c l u d i n g the
employee's share out of pre-tax income.
The
percentage of p a y r o l l required to purchase h e a l t h
insurance t h a t provides the n a t i o n a l , guaranteed b e n e f i t package
v a r i e s from s t a t e to s t a t e depending upon the c o s t of the s t a t e ' s
h e a l t h system.
The S o c i a l S e c u r i t y wage base w i l l be used to
c a l c u l a t e percentages.
Premium payments w i l l be made to h e a l t h
alliances.
A n a t i o n a l budget imposed to l i m i t growth i n h e a l t h - c a r e
spending determines the annual i n c r e a s e allowed
i n payments
r e q u i r e d from employers and employees.
I f a s t a t e exceeds i t s
budget, the s t a t e seeks a d d i t i o n a l revenue to make up
the
d i f f e r e n c e from sources other than assessments on employers or
employees.
As an a l t e r n a t i v e , i f companies are allowed to purchase h e a l t h
insurance outside the a l l i a n c e , employers and
employees of
companies t h a t e l e c t to follow that route c o n t r i b u t e t h e i r premiums
to an escrow fund from which they withdraw funds to purchase h e a l t h
c a r e f o r employees.
Escrow funds would be required to make
c o n t r i b u t i o n s to the h e a l t h a l l i a n c e i n i t s area to cover the c o s t
of providing c a r e f o r underserved populations, the unemployed and
to support education, research and p u b l i c h e a l t h .
The r a t e of growth of t h i s escrow account would be l i m i t e d to
the i n c r e a s e i n h e a l t h expenditures allowed for t h a t s t a t e under
the n a t i o n a l h e a l t h care budget.
0
Contributions
from employers and employees e n t i t l e a l l
r e s i d e n t s of an area to choose a h e a l t h plan through the h e a l t h
a l l i a n c e l o c a t e d i n that area. I n s t a t e s that e l e c t to e s t a b l i s h
a s i n g l e - p a y e r h e a l t h system, employers and employees are required
to c o n t r i b u t e to the s t a t e h e a l t h plan, and consumers simply choose
the provider they v i s i t . I n s t a t e s i n which h e a l t h plans compete,
consumers choose a plan or the f e e - f o r - s e r v i c e network from which
they want to obtain c a r e .
Depending on how a s t a t e chooses to organize i t s h e a l t h c a r e
system, c o n t r i b u t i o n s required from employers and employees provide
a c c e s s to a benchmark, or the p r i c e for which consumers are
guaranteed coverage i n a t l e a s t one plan without a d d i t i o n a l
expenditures. Choosing a more expensive plan r e q u i r e s i n d i v i d u a l s
and f a m i l i e s to make a d d i t i o n a l out-of- pocket expenditures.
Alternatively,
the
required
c o n t r i b u t i o n could
provide
consumers access to an average-priced plan or to a l l p l a n s .
If
consumers want to choose a low-cost plan but l i m i t e d plan c a p a c i t y
prevents them from doing so, a l l i a n c e s cannot r e q u i r e consumers to
�15
pay more out-of-pocket expenses for a higher cost plan.
Cost—to-the Private S oe%er—of—Mandate..
Cosf -m -rue
Fer-h'mpluyei and Kmployos Contributionc
The l i k e l y cost to the private sector of health reform i f
f u l l y implemented i n 1994 totals approximately $65 b i l l i o n or an
increase of 2.3 percent of payroll.
Employers pay a total
billion.
of $52 b i l l i o n
and employees $13
I f health reform i s f u l l y implemented i n 1996, assuming
implementation of effective cost controls, the total cost that year
amounts to $72 b i l l i o n , a»d- Wi-thout cost controls.,$77 b i l l i o n .
fit to rt-^ t-o/'f J
The—total—new cost—eventually i~s~~assumed—by Employers and
employees who do not now purchase insurance a n d t ^ = a — i osser
extent^—>by firms that purchase inadequate insurancei^^During ~the~
t r a n s i t i o n to the new health care system, other employers and
employees may also bear part of the burden for expanding health
coverage.
1994
CURRENT LAW
1994
PHASED-IN
UNIVERSAL
COVERAGE
'"7
Co,
Vy
INCREASE
BB $
BB $
EMPLOYER
HEALTH
PREMIUMS
225
273
47
EMPLOYEE
HEALTH
PREMIUMS
45
63
18
TOTAL
271
338
65
% OF TOTAL
PAYROLL
9.3
11.6
2.3
The- tab 3,0 abovg^ i-ndudes a l l premiums paid for ^.services, such as
eyeglasses or adult dentures, ^ h i c h are not included i n the
/"^^r«v
benefit package. The—feiiowing -tatrle-shewa numbojis-^er-eests-the-^—=T
<l3
•
5
�16
1994
CURRENT LAW
1994
PHASED IN
COVERAGE
£NS6M£-
EMPLOYER HEALTH
PREMIUMS
168
215
47
EMPLOYEE HEALTH
PREMIUMS
45
63
18
TOTAL
213
278
65
% OF PAYROLL
7.3
9.6
2.3
1
f^N±ran^reion to vt\G new system a l t e r s the distribji-ti^Dn of
• i n a n c i a l buro^n^fdr he thpsfre arnpng emE^loy^s a n d ^ m p l o y e e s ^
the c u r r e n t system s i g n l f c a n t l y :
Employers and employees who do not now contribute
to pay for health insurance coverage or who
purchase only "bare bone" policies will be required
to pay for comprehensive benefits.
^
r^jr,.-,
Many employers and employees who c u r r e n t l y purchase
h e a l t h insurance pay d i f f e r e n t amounts under the
new system.
Low-wage workers and t h e i r employers who purchase h e a l t h
insurance pay l e s s i n the new system than—they-do^feoday.
High-wage
more.
workers
and
their
employers
pay
Younger workers and t h e i r employers pay more than-they do
today-.
Older employees, r e t i r e e s and t h e i r employers
pay l e s s .
Small companies
that c u r r e n t l y purchase insurance f o r
�17
employees pay l e s s .
Single individuals and their employers pay more.
Employees who
have
employers pay l e s s .
families
and
their
Because of these changes, the transition to the new system
should occur gradually, particularly i n the case of businesses that
are providing health insurance to workers for the f i r s t time and
those that currently provide r e l a t i v e l y l i t t l e coverage.
Employers and employees who benefit from the implementation of
the new system w i l l subsidize the transition for those smaller
companies and for low-wage workers who w i l l purchase insurance for
the f i r s t time.
An eight-year schedule phasing i n the system,
beginning from current spending for health insurance as a baseline,
accomplishes t h i s goal.
In 1993, expenditures for premiums by employers and employees
are established, using that year as a baseline i n each state. As
states make the transition to the new program, the percentage of
payroll payments are adjusted upward or downward on a gradual
schedule u n t i l an average rate for a l l firms i s achieved.
Firms for which averacper^contribution rates i n IS^J'exceed the
target rate f o ^ a state^dontinue at that l e v e l ^ ^ d j u s t e d for the
difference i n growth/between ba^e-year payroll and health-care
i n f l a t i o n i n the f i p ^ t year of/universal coverage.
Beginning i n
the second year, the rate proceeds throtogh an eight-year cycle,
reducing the amoym: by equal portions u n t i l they reach the average.
Firms i n whir^h average contribution-rates i n 1993 f a l l below
the target rate for a state^~increase^ their contributions by 2
percent of payroll, adjusted for the^ difference in-'growth between"
base-yearpayroll and h^alth-ca^e inflation in/-t5he f i r s t year^of
universajr coverage. / Beginnipg i n the sepond year, the' rate
proceeds on a sixryear cypie, increasing the amount /by equal
portiems u n t i l th^y reach the average.
3
EXHIBIT *
/
,
^
_
^l^^"
.
r^.S'
/Health c a r e premium\ Company 1
ias a % of p a y r o l l
\employer/employee /
Company 2
Company 3
1993
0
5
17
1994
0
5
17
1995
0
5
17
9*
�18
2
7
17
1997
3.5
7.6
16
1998
5.2
8.2
15
1999
6.8
8.8
14
2000
8.4
9.4
13
2001
10
10
12
2002
10
10
11
| 2003
10
10
10
1996
universal
coverage
* 10% o f p a y r o l l employers and employees are required t o pay f o r
h e a l t h insurance.
** assumes health-care i n f l a t i o n i n l i n e w i t h increases i n p a y r o l l .
I f not, percentages w i l l r i s e , but the concept remains t h e same.
To defray adverse impacts, each s t a t e also establishes a
"rainy day" fund t o a s s i s t small business t h a t
experience
d i f f i c u l t y i n meeting the new requirements t o purchase h e a l t h
insurance.
The o r g a n i z a t i o n o f h e a l t h a l l i a n c e s should r e s u l t i n an
immediate cost savings t o the p r i v a t e sector when a d m i n i s t r a t i v e
costs f o r small groups and the cost of u n d e r w r i t i n g d e c l i n e . This
savings, i n a d d i t i o n t o savings—to s t a t e and l o c a l government^ " a ^
a r o s u l t o f u n i v e r s a l insurance coverage, allows a l l i a n c e s t o make
up t h e d l f f e r e n o e - ^ e r i n i t i a l subsidies t o businesses.
Federal Costs
Under h e a l t h reform,
the f e d e r a l government assumes
r e s p o n s i b i l i t y f o r f i n a n c i n g the proposed new investments i n p u b l i c
7
health, underserved areas, health research and education, long-term
care and the Medicare drug b e n e f i t .
The $39 t o $44 b i l l i o n cost of these programs can be financed
w i t h some combination o f t h e f o l l o w i n g RDIIXP.P.S-O^ revenue^
SAVINGS
BB $
NEW REVENUES
BB $
�19
REDUCTION I N
DISPROPORTIONATE SHARE
PAYMENTS TO OFFSET
SAVINGS FROM
UNCOMPENSATED CARE
11
$1 PER PACK
CIGARETTE TAX
13
MEDICARE/CHAMPUS/OTHER
GOVERNMENT SAVINGS
BEYOND THE BUDGET
10-17
ALCOHOL TAX
5
MEDICAID SAVINGS FROM
MANAGED CARE
5-10
A SURCHARGE TO RECOVER
SAVINGS I N AUTO
INSURANCE
5
TOTAL
30-40
18
The pace o f phase i n f o r the long-term care program and f o r
p u b l i c h e a l t h i n i t i a t i v e s could be keyed t o t h e achievement o f
savings from uncompensated care. Medicare, e t c .
Total Program Cost
Total program costs amount to approximately $104 to $109
billion, of which the federal government will spend approximately
$39 to 44 billion^ f^u^r r )
TOTAL COST OF PROGRAM
1994 $
EMPLOYER
PREMIUMS
EMPLOYEE
PREMIUMS
FEDERAL
GOVERNMENT
TOTAL
UNIVERSAL
COVERAGE
52
13
-
65
MEDICARE
DRUG
BENEFIT
-
-
17
17
LONG TERM
CARE
-
-
15-20
15-20
�20
OTHER
PROGRAMS
-
-
7
TOTAL
52
13
39-44
104-109
1
The total program cost must ultimately be weighed against system
savings achieve* by the program. Both the private and public
sectors will achieve significant savings in the last half of the
decade which will exceed the extra cost of the program. More
importantly, the total system will come under control. C <c)
As discussions with CBO proceed over the coming two weeks, we w i l l
be able to itemize scoreable savings and put them up against the
costs. Our best estimates s t i l l indicate system savings which w i l l
exceed system costs significantly.
�PRIVILEGED
AND
eGf&ZBElFFHSb
DETERMINED TO BE AN
ADMINISJR^VE MARKING
INITIALS:
DATE^^J^.
106
TOTAL SYSTEM
r^Z
INVESTMENT AND SAVINGS I N HEALTH CARE
MEDICARE &
MEDICAID SAVINGS
ABOVE BUDGET
TOTAL GROSS
SAVINGS
NET
SAVINGS
YEAR
INVESTMENT
MANAGED
COMPETITION AND
BUDGET SAVINGS
1994
17
4
4
8
(9)
1995
25
25
6
31
6
1996
95
54
15
69
(26)
1997
IS i #2
87
21
108
-
133
29
162
33
1998
1999
141
154
40
194
53
2000
153
166
52
218
65
I
�
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
Health Care Task Force Records
Creator
An entity primarily responsible for making the resource
White House Health Care Task Force
Is Part Of
A related resource in which the described resource is physically or logically included.
<a href="https://catalog.archives.gov/id/10443060" target="_blank">National Archives Catalog Description</a>
Description
An account of the resource
<p>This collection contains records on President Clinton’s efforts to overhaul the health care system in the United States. In 1993 he appointed First Lady Hillary Rodham Clinton to be the head of the Health Care Task Force (HCTF). She traveled across the country holding hearings, conferred with Senators and Representatives, and sought advice from sources outside the government in an attempt to repair the health care system in the United States. However, the administration’s health care plan, introduced to Congress as the Health Security Act, failed to pass in 1994.</p>
<p>Due to the vast amount of records from the Health Care Task Force the collection has been divided into segments. Segments will be made available as they are digitized.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+1"><strong>Segment One</strong></a><br /> This collection consists of Ira Magaziner’s Health Care Task Force files including: correspondence, reports, news clippings, press releases, and publications. Ira Magaziner a Senior Advisor to President Clinton for Policy Development was heavily involved in health care reform. Magaziner assisted the Task Force by coordinating health care policy development through numerous working groups. Magaziner and the First Lady were the President’s primary advisors on health care. The Health Care Task Force eventually produced the administration’s health care plan, introduced to Congress as the Health Security Act. This bill failed to pass in 1994.<br /> Contains 1065 files from 109 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+2"><strong>Segment Two</strong></a><br /> This segment consists of records describing the efforts of First Lady Hillary Rodham Clinton to get health care reform through Congress. This collection consists of correspondence, newspaper and magazine articles, memos, papers, and reports. A significant feature of the records are letters from constituents describing their feelings about health care reform and disastrous financial situations they found themselves in as the result of inadequate or inappropriate health insurance coverage. The collection also contains records created by Robert Boorstin, Roger Goldblatt, Steven Edelstein, Christine Heenan, Lynn Margherio, Simone Rueschemeyer, Meeghan Prunty, Marjorie Tarmey, and others.<br /> Contains 697 files from 47 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+3"><strong>Segment Three</strong></a><br /> The majority of the records in this collection consist of reports, polls, and surveys concerning nearly all aspects of health care; many letters from the public, medical professionals and organizations, and legislators to the Task Force concerning its mission; as well as the telephone message logs of the Task Force.<br /> Contains 592 files from 44 boxes.</p>
<p><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+4"><strong>Segment Four</strong></a><br /> This collection consists of records describing the efforts of the Clinton Administration to pass the Health Security Act, which would have reformed the health care system of the United States. This collection contains memoranda, correspondence, handwritten notes, reports, charts, graphs, bills, drafts, booklets, pamphlets, lists, press releases, schedules, newspaper articles, and faxes. The collection contains lists of experts from the field of medicine willing to testify to the viability of the Health Security Act. Much of the remaining material duplicates records from the previous segments.<br /> Contains 590 files from 52 boxes.</p>
<p><strong><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+5">Segment Five</a></strong><br /> This collection of the Health Care Task Force records consists of materials from the files of Robert Boorstin, Alice Dunscomb, Richard Veloz and Walter Zelman. The files contain memoranda, correspondence, handwritten notes, reports, charts, graphs, bills, drafts, booklets, pamphlets, lists, press releases, schedules, statements, surveys, newspaper articles, and faxes. Much of the material in this segment duplicates records from the previous segments.<br /> Contains 435 files from 47 boxes.</p>
<p><strong><a href="http://clinton.presidentiallibraries.us/items/browse?advanced%5B0%5D%5Belement_id%5D=43&advanced%5B0%5D%5Btype%5D=is+exactly&advanced%5B0%5D%5Bterms%5D=2006-0885-F+Segment+6">Segment Six</a></strong><br /> This collection consists of the files of the Health Care Task Force, focusing on material from Jack Lew and Lynn Margherio. Lew’s records reflect a preoccupation with figures, statistics, and calculations of all sorts. Graphs and charts abound on the effect reform of the health care system would have on the federal budget. Margherio, a Senior Policy Analyst on the Domestic Policy Council, has documents such as: memoranda, notes, summaries, and articles on individuals (largely doctors) deemed to be experts on the Health Security Act of 1993 qualified to travel across the country and speak to groups in glowing terms about the groundbreaking initiative put forward by President Clinton in his first year in the White House. <br /> Contains 804 files from 40 boxes.</p>
Publisher
An entity responsible for making the resource available
William J. Clinton Presidential Library & Museum
Identifier
An unambiguous reference to the resource within a given context
2006-0885-F
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
Health Care Working Group Drafts
Creator
An entity primarily responsible for making the resource
Task Force on National Health Care
White House Health Care Task Force
Simone Rueschemeyer
Identifier
An unambiguous reference to the resource within a given context
2006-0885-F Segment 2
Is Part Of
A related resource in which the described resource is physically or logically included.
Box 34
<a href="http://clintonlibrary.gov/assets/Documents/Finding-Aids/2006/2006-0885-F-2.pdf" target="_blank">Collection Finding Aid</a>
<a href="https://catalog.archives.gov/id/12092987" 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
Publisher
An entity responsible for making the resource available
William J. Clinton Presidential Library & Museum
Format
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Adobe Acrobat Document
Medium
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Preservation-Reproduction-Reference
Date Created
Date of creation of the resource.
2/6/2015
Source
A related resource from which the described resource is derived
42-t-12092987-20060885F-Seg2-034-005-2015
12092987