legislation: 103-s-2357
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| 103-s-2357 | 103 | s | 2357 | Health Security Act | Health | 1994-08-03 | 1994-08-05 | Read the second time. Placed on Senate Legislative Calendar under General Orders. Calendar No. 542. | Senate | Sen. Mitchell, George J. [D-ME] | ME | D | M000811 | 0 | TABLE OF CONTENTS: Title I: Improved Access to Standardized and Affordable Health Plans Subtitle A: Rules and Definitions of General Applicability Subtitle B: Health Plan Standards Subtitle C: Benefits and Cost-Sharing Subtitle D: Access to Health Plans Subtitle E: Federal Responsibilities Subtitle F: Participating State Responsibilities Subtitle G: Miscellaneous Provisions Title II: New Benefits Subtitle A: Coverage of Outpatient Prescription Drugs in Medicare Subtitle B: Home and Community-Based Services Subtitle C: Long-Term Care Insurance Improvement and Accountability Subtitle D: Life Care Subtitle E: Study and Report Title III: Health Professions Workforce Subtitle A: Workforce Priorities Under Federal Payments Subtitle B: Academic Health Centers Subtitle C: Health Research Initiatives Subtitle D: Core Functions of Public Health Programs; National Initiatives Regarding Preventive Health Subtitle E: Health Services for Medically Underserved Populations Subtitle F: Mental Health; Substance Abuse Subtitle G: Comprehensive School Health Education; School-Related Health Services Subtitle H: Public Health Service Initiative Subtitle I: Additional Provisions Regarding Public Health Subtitle J: Occupational Safety and Health Subtitle K: Full Funding for WIC Subtitle L: Border Health Improvement Title IV: Medicare and Medicaid Subtitle A: Medicare Subtitle B: Medicaid Program Title V: Quality and Consumer Protection Subtitle A: Quality Management and Improvement Subtitle B: Administrative Simplification Subtitle C: Privacy of Health Information Subtitle D: Expanded Efforts to Combat Health Care Fraud and Abuse Affecting Federal Outlay Programs Subtitle E: Medical Liability Reform Subtitle F: Remedies and Enforcement Subtitle G: Repeal of Exemption Title VI: Individual and Employer Subsidies Subtitle A: Individual Premium and Cost-Sharing Assistance Subtitle B: Employer Subsidies Title VII: Revenue Provisions Subtitle A: Financing Provisions Subtitle B: Tax Treatment of Employer-Provided Health Care Subtitle C: Exempt Health Care Organizations Subtitle D: Tax Treatment of Long-Term Care Insurance and Services Subtitle E: Other Revenue Provisions Subtitle F: Graduate Medical Education and Academic Health Centers Trust Fund Title VIII: Other Federal Programs Subtitle A: Indian Health Services Title IX: Workers Compensation Medical Services Title X: Premium Financing Subtitle A: National Health Care Cost and Coverage Commission Subtitle B: Employer and Individual Premium Requirements and Assistance Title XI: Ensuring Health Care Reform Financing Health Security Act - Title I: Improved Access to Standardized and Affordable Health Plans: Subtitle A: Rules and Definitions of General Applicability - Directs each participating State to require that each health plan or long-term care policy issued, sold, offered for sale, or operated in the State shall be certified by the appropriate certifying authority as one of the following: (1) a certified standard health plan; (2) a certified supplemental health benefits plan; or (3) a certified long-term care policy. Applies the following principles to all standard health plans: (1) no standard health plan may discriminate on the basis of medical history, health status, preexisting medical conditions, or genetic predisposition to medical conditions; (2) a standard plan shall offer an annual open enrollment period and accept all eligible individuals for coverage, shall not impose a rider that serves to exclude coverage to an individual, and shall not impose waiting periods before coverage begins; (3) a standard health plan shall ensure that all medically necessary or appropriate services, as defined in the benefits package, are provided; and (4) health benefits coverage shall be portable from one standard health plan to another. (Sec. 1003) States that nothing in this Act shall be construed as prohibiting the following: (1) an individual from purchasing any health care services; (2) an individual from purchasing supplemental insurance to cover health care services not included within the standard benefits package; (3) an individual who is not an eligible individual from purchasing health insurance; (4) employers from providing coverage for benefits in addition to such standard benefits package; or (5) an individual from obtaining health care from any health care provider of such individual's choice. Subtitle B: Health Plan Standards - Sets forth the following standards which a standard health plan must meet: (1) insurance market reform standards; (2) delivery system reform standards; (3) standards for participation in a guaranty fund; (4) standards for the collection and reporting of data; and (5) standards for effective grievance procedures for enrollees. (Sec. 1111) Requires a standard health plan sponsor to: (1) when offering a community-rated standard health plan, offer such plan to any community-rated individual applying for coverage; and (2) when offering an experience-rated standard health plan, offer such plan to any experience-rated indivudal eligible for coverage under the plan through such individuals' experience-rated employer. Defines: (1) a standard health plan as one providing the standard benefits package under subtitle C; (2) a community-rated plan as a plan provided to community-rated individuals; (3) a community-rated individual as one who not an experience-rated individual; (4) an experience-rated plan as a health plan which is a self-insured plan of an experience-rated employer or is an insured health plan which is experience-rated, but which covers only experience-rated individuals; (5) an experience-rated employer as an employer employing more than 500 employees or a multiemployer plan that covers 500 or more employees; and (6) an experience-rated individual as one who is an employee of an experience-rated employer. Requires a community-rated standard health plan to be made available to community-rated individuals throughout the entire community-rating area. Requires a State to be divided into one or more community rating areas in which there must be a minimum of 250,000 individuals residing. Prohibits a metropolitan statistical area in a State from being incorporated into more than one community rating area. Permits a standard health plan sponsor to refuse to renew an individual's plan only for: (1) fraud or materials misrepresentation on the individuals' part; or (2) nonpayment of premiums. (Sec. 1112) Sets forth enrollment process requirements, including the requirement of an annual open enrollment period. (Sec. 1113) Includes in the definition of children, for purposes of coverage, a child who is under 25 years of age or disabled and who is unmarried. (Sec. 1114) Prohibits discrimination based on health status including medical condition, lack of evidence of insurability, or anticipated need for health care services. Prohibits imposing a waiting period before coverage begins. Permits a standard health plan to impose a limitation or exclusion of benefits relating to treatment of a condition based on a preexisting condition if: (1) the condition was diagnosed or treated during the three-month period ending on the day before the date of enrollment; (2) the limitation or exclusion extends for not more than six months; (3) the limitation or exclusion does not apply to an individual who, as of the date of birth, was covered under the plan; or (4) the limitation or exclusion does not relate to pregnancy. (Sec. 1116) Requires a plan to have uniform premiums within a community rating area. (Sec. 1117) Requires each standard health plan to participate in a standard health plan risk adjustment program and a reinsurance program. (Sec. 1118) Sets forth financial solvency requirements. (Sec. 1121) Sets forth provisions concerning: (1) antidiscrimination requirements; (2) quality assurance standards; (3) the consumer grievance process; (4) the issuance of a health security card to each individual enrolled in each standard health plan; (5) information and marketing standards; (6) patient's rights to self-determination in health care; and (7) contracts with purchasing cooperatives. (Sec. 1128) Requires each standard health plan to ensure that all health care providers reimbursed by the plan are authorized under State law to provide applicable services. Requires a plan to ensure that all nonnetwork items and services covered are reasonably available and accessible. Requires covered services to be available to all enrollees throughout the service plan area with reasonable promptness. Requires each plan to establish a program under which participating physicians shall agree to accept the plan's payment schedule as payment in full. States that nothing in this Act shall be construed to: (1) force an individual to receive health care solely through the individual's standard plan; or (2) prohibit any individual from privately contracting with any health care provider and paying for such treatment as agreed to between the individual and the provider. (Sec. 1141) States that nothing in this Act shall be construed as to prevent a standard health plan sponsor from offering and pricing supplemental health benefits plans pursuant to a State certification plan. Applies the same standards to supplemental plans as are applicable to the standard plan concerning issue, availability, enrollment, nondiscrimination, and rating limitation. Sets forth provisions concerning marketing abuses and requirements for cost-sharing plans. Subtitle C: Benefits and Cost-Sharing - Defines a standard benefits package as a benefit package that: (1) provides all the items and services under the categories of health care items and services described in section 1202; (2) provides for at least one of the three cost-sharing schedules established under section 1213 by the National Health Benefits Board; and (3) has an actuarial value that is equivalent to the actuarial value of the benefits package provided by the Blue Cross/Blue Shield Standard Option under the Federal Employees Health Benefits Program as in effect during 1994. Defines an alternative standard benefits package as a benefits package that: (1) provides all the items and services under the categories of health care items and services described in section 1202; (2) provides for the very high deductible cost-sharing schedule established under 1213 by the Board; and (3) has an actuarial value that is less than the actuarial value of the benefits package provided by the Blue Cross/Blue Shield Standard Option as in effect during 1994. (Sec. 1202) Lists the following items and services as categories of medical care to be furnished to health plan enrollees when medically necessary or appropriate: (1) hospital services, including inpatient hospital services, outpatient hospital services, and 24-hour a day hospital emergency services; (2) health professional services, including consultations that are provided in a home, office, or other ambulatory care setting, or an institutional setting and services and supplies furnished as incident to such health professional services; (3) 24-hour a day emergency services and ambulatory medical or surgical services; (4) clinical preventive services, including services for high risk populations, age-appropriate immunizations, tests, and clinician visits furnished consistent with any periodicity schedule specified by the Board; (5) mental illness and substance abuse services, including inpatient, outpatient, residential non-hospital, and intensive non-residential services, for the treatment of mental illness and substance abuse disorders; (6) voluntary comprehensive family planning services, including counseling and education, contraceptive drugs and devices, and services for pregnant women; (7) items and services provided for end of life care (hospice care); (8) home health care and home infusion drug therapy services provided as an alternative to inpatient hospital treatment, treatment in a skilled nursing facility, or treatment in a rehabilitation facility; (9) extended care services described in title XVIII (Medicare) of the Social Security Act, when provided to an inpatient of a skilled nursing facility or a rehabilitation facility and when provided as an alternative to receiving inpatient hospital services; (10) ambulance services; (11) laboratory, radiology, and diagnostic services provided upon prescription to individuals who are not inpatients of a hospital, hospice, skilled nursing facility, or rehabilitation facility; (12) outpatient prescription drugs, blood clotting factors, drugs used for home infusion therapy, biologicals, and accessories and supplies used directly with the above items; (13) outpatient occupational therapy, physical therapy, respiratory therapy, speech-language pathology services, and outpatient audiology services when used to restore or maintain functional capacity or prevent or minimize limitations on physical and cognitive functions as a result of an illness or other health condition, including attaining new functional abilities at an age-appropriate rate; (14) durable medical equipment, prosthetic devices, orthotics and prosthetics, and accessories and supplies used directly with the above equipment or devices; (15) routine eye examinations, diagnosis, and treatment for defects in vision furnished to individuals who are under 22 years of age, including eyeglasses and contact lenses furnished according to a periodicity schedule established by the Board; (16) to individuals under 22 years of age, emergency dental treatment, prevention and diagnosis of dental disease, treatment of dental disease, space maintenance procedures to prevent orthodontic complications, and interceptive orthodontic treatment to prevent severe malocclusion; (17) for individuals who are over 22 years of age, emergency dental treatment, as specified by the Board; (18) routine ear examinations and diagnosis for defects in hearing as part of a physician visit and hearing aids when recommended by a physician or audiologist; and (19) items and services required to provide patient care pursuant to the design of a qualified investigation treatment. (Sec. 1211) Establishes a National Health Benefits Board to: (1) promulgate regulations or establish guidelines as may be necessary to clarify and refine items and services under the categories of health care items and services described in section 1202; (2) establish and update periodicity schedules for the items and services in the categories of health care items and services described in section 1202; and (3) design mental illness substance and abuse services so as to achieve parity with services for other medical conditions. Authorizes the Board to establish: (1) criteria for determinations of medical necessity or appropriateness; (2) procedures for determinations of medical necessity or appropriateness; and (3) regulations or guidelines to be used in determining whether an item or service is medically necessary. Requires the Board to establish cost-sharing schedules to be provided by health plans providing a standard benefits package or an alternative standard benefits package. Authorizes the Board to develop legislative proposals for modifications to the actuarial equivalence provisions of section 1201 and the categories of items and services under section 1202. Authorizes appropriations to the Bord. (Sec. 1217) Sets forth procedures for the congressional consideration of Board proposals. Subtitle D: Access to Health Plans - Requires each employer to make available to each employee the opportunity: (1) in the case of an experience-rated employer, to enroll through the employer in one of at least three certified experience-rated standard health plans; or (2) in the case of a community-rated employer, to enroll in any community-rated plan offered through a purchasing cooperative operating in the community rating area of the employer and, at the employer's option, to enroll in one of at least three community-rated standard health plans. (Sec. 1321) Directs a State, in accordance with specified provisions, to certify health insurance purchasing cooperatives. Requires that each cooperative be chartered under State law and operated as a not-for-profit corporation. Permits a State to establish or sponsor a purchasing cooperative to serve a community rating area. Requires each purchasing cooperative to: (1) negotiate (regarding premiums and marketing fees) with and enter into agreements with standard health plans; (2) enter into agreements with community-rated employers; (3) enroll community-rated employees and community-rated individuals in standard health plans; (4) collect premiums and make payments to standard health plans on behalf of community-rated employers and community-rated individuals; (5) provide for coordination with other purchasing cooperatives; (6) provide comparative information to the public and the participating State on standard health plans offered through the purchasing opperative; (7) have the capability of accepting data from standard health plans; (8) comply with such fiduciary responsibility, financial management, and administrative requirements as the Secretary may establish; and (9) carry out other functions provided for under this title. Prohibits a cooperative from: (1) performing any activity (including review, approval, or enforcement) relating to payment rates for providers; (2) performing any activity (including certification or enforcement) relating to compliance of standard health plans with the requirements of this Act; (3) assuming insurance risk; or (4) performing other activities identified by the State as being inconsistent with the performance of its duties under this Act. (Sec. 1322) Requires a purchasing cooperative to offer all community-rated individuals and community-rated employees residing within the community rating area served by the cooperative the opportunity to enroll in any standard health plan that has entered into an agreement with the cooperative. (Sec. 1324) Directs a purchasing cooperative to charge members a uniform membership fee to cover costs. (Sec. 1331) Requires a purchasing cooperative for a community rating area to offer to enter into an agreement with each community-rated employer that employs individuals in the community rating area and that desires to join the cooperative. (Sec. 1341) Sets forth requirements applicable to the Federal Employees Health Benefits Program. (Sec. 1351) Sets forth rules relating to multiple employer welfare arrangements. Subtitle E: Federal Responsibilities - Directs the Secretary of Health and Human Services to implement all provisions of this Act, subject to stated exceptions, and report annually to the President and the Congress concerning the health care system of this Act. Authorizes appropriations. (Sec. 1411) Requires the Secretary to approve a State health care system for which a plan has been submitted, unless it does not meet applicable requirements. (Sec. 1412) Provides sanctions for participating States not in compliance, including Federal assumption of responsibilities. (Sec. 1422) Provides for Federal assumption of responsibilities in non-participating States. (Sec. 1431) Directs the Secretary to establish premium class and age class factors. (Sec. 1435) Directs the Secretary to develop a risk adjustment and reinsurance methodology. (Sec. 1441) Directs the Secretary to establish minimum capital requirements for workers, as well as additional capital requirements to reflect factors likely to affect the financial stability of a carriers. (Sec. 1461) Directs the Secretary to certify as an essential community provider any health care provider meeting the standards for certification or that is within any of the following categories of providers: (1) covered entities as defined under the Public Health Service Act, school health centers, public or nonprofit hospitals, public and private nonprofit mental health and substance abuse providers, runaway homeless youth centers or transitional living programs for homeless youth, public or nonprofit maternal and child health providers, rural health clinics, and programs of the Indian Health Service shall all be considered category one entities; and (2) Medicare dependent small rural hospitals and children's hospitals shall both be considered category two entities. (Sec. 1463) Directs the Secretary to publish standards for the certification of additional categories of health care providers and organizations as essential community providers. (Sec. 1466) Provides that for essential community providers electing to apply to a health plan, the plan shall either: (1) enter into a provider participation agreement; or (2) enter into an agreement under which the plan makes payments to the provider. (Sec. 1467) Requires the Secretary, within five years of enactment, to submit to the Congress specific recommendations, based on studies, concerning whether, and to what extent, sec. 1466 provisions should continue to apply to some or all essential community providers. Requires the recommendations to be implemented unless a congressional joint resolution disapproving such recommendations is enacted. (Sec. 1481) Sets forth the responsibilities of the Secretary of Labor. (Sec. 1491) Provides that the Office of Rural Health Policy shall be headed by an Assistant Secretary, instead of a Director. Subtitle F: Participating State Responsibilities - Sets forth provisions concerning approval of State plans and certification of standard health plans and supplemental health benefits plans. Requires the Secretary to establish a program for the accreditation, certification, and enforcement (the ACE program) of health plan standards by States. (Sec. 1502) Requires each participating State to be divided into one or more community rating areas. (Sec. 1503) Provides for: (1) open enrollment periods; (2) a risk adjustment program; (3) guaranty funds; and (4) public access sites. (Sec. 1511) Prohibits, as a general rule, any State law from applying to any services provided under a health plan that is not a fee-for-service plan. (Sec. 1512) Provides for the override of restrictive State practice laws. (Sec. 1521) Provides for the continuance of existing Federal law waivers under Medicare, Medicaid, or the Employee Retirement Income Security Act. (Sec. 1522) Sets forth provisions concerning: (1) the Hawaii Prepaid Health Care Act; (2) alternative State provider payment systems; and (3) alternative State hospital services payment systems. (Sec. 1531) Sets forth requirements for State single-payer systems. (Sec. 1541) Provides for the early implementation of comprehensive State programs. Subtitle G: Miscallenous Provisions - Permits a health professional or health facility to deny the provision of an item or service if the professional or facility objects on the basis of religious belief or moral conviction. Prohibits discrimination on the basis of race, national origin, sex, religion, language, income, age, sexual orientation, disability, health status, or anticipated need for health services. Title II: New Benefits - Subtitle A: Coverage of Outpatient Prescription Drugs in Medicare - Amends title XVIII (Medicare) of the Social Security Act to provide for: (1) Medicare coverage of certain outpatient prescription drugs and biologicals as well as home infusion drug therapy services; (2) payment rules and related requirements, such as those pertaining to deductibles, for covered outpatient prescription drugs; (3) manufacturer rebates to the Secretary under Medicare part B (Supplementary Medical Insurance) for covered outpatient prescription drugs; (4) a Prescription Drug Payment Review Commission appointed by the Director of the Congressional Office of Technology Assessment for reporting annually to the Congress on Medicare coverage of outpatient prescription drugs; and (5) the provision of covered outpatient drugs through Medicare drug benefit plans under contract with the Secretary to individuals entitled to benefits under Medicare part A (Hospital Insurance) and enrolled under Medicare part B. Authorizes appropriations. (Sec. 2007) Allows the Secretary, in providing for payments for covered outpatient drugs under Medicare contracts with HMOs and competitive medical plans, to base such payments on classes of enrollees or geographic factors that are different from those otherwise utilized for determining payment. Subtitle B: Home and Community Based Services - Entitles each State with an approved plan for home and community-based services for individuals with disabilities to specified payments. Authorizes appropriations. (Sec. 2111) Amends the Public Health Service Act to direct the Secretary to compile, evaluate, and disseminate information to assist in the replication of successful long-term health care services programs that are aimed at offering care management to hospitalized individuals in need of long-term care so that services to meet individual needs and preferences can be arranged in home and community-based settings as an alternative to long-term nursing home placement. Establishes a related grant program. Authorizes appropriations. Subtitle C: Long-Term Care Insurance Improvement and Accountability - Long-Term Care Insurance Improvement and Accountability Act - Provides for the promulgation of standards and model benefits with respect to long-term care insurance. (Sec. 2211) Prohibits the sale of a long-term care policy unless it meets specified standards. (Sec. 2212) Regulates sales practices and renewal practices for long-term care policies. (Sec. 2215) Establishes benefit standards for long-term care policies. Subtitle D: Life Care - Life Care Act - Amends the Public Health Service Act to add a new title, Title XXVII - Life Care: Public Insurance Program for Nursing Home Care. Directs the Secretary to: (1) establish a voluntary insurance program for individuals 35 yers of age and over to cover the nursing home stays of such individuals; and the nursing home stays of such individuals; and (2) establish a process for enrollment in the Life Care Program. Prohibits the coverage amount from exceeding $90,000. Provides coverage under the title for: (1) nursing care; (2) specified therapy services; (3) medical social work; (4) drugs and appliances; (5) other nursing home facility services; and (6) with respect to the first six months of covered residence in a nursing facility, such room and board costs as are not covered by beneficiary copayment. Subtitle E: Study and Report - Provides for a study on issues relating to appropriate care at the end of life. Title III: Health Professions Workforce - Subtitle A: Workforce Priorities Under Federal Payments - Establishes within the Department of Health and Human Services the National Council on Graduate Medical Education. Directs the Council to ensure that the aggregate number of individuals entering graduate medical education programs does not exceed specified limits. Directs the Council to designate the number of individuals authorized to be enrolled in each specialty. (Sec. 3031) Sets forth provisions concerning Federal formula payments to: (1) qualified entities for the costs of operating approved physician training programs; and (2) academic health centers and other eligible institutions. (Sec. 3061) Sets forth provisions concerning Federal payments to: (1) medical schools; (2) graduate nurse training programs; (3) dental schools; and (4) schools of public health. (Sec. 3081) Authorizes appropriations through FY 2000 for workforce development. Subtitle B: Academic Health Centers - Authorizes grants to: (1) eligible centers for the establishment and operation of information and referral systems to provide the services of such centers to rural health plans; and (2) community-and provider-based health plans for the purpose of providing the services of eligible centers to residents of rural or urban communities who otherwise would not have adequate access to such services. Subtitle C: Health Research Initiatives - Requires 0.25 percent of all premium-related payments made by employers, individuals, and families for coverage under this Act to be used for biomedical and behavioral research and health services research as specified. (Sec. 3221) Authorizes appropriations for a medical technology impact study. Subtitle D: Core Functions of Public Health Programs; National Initiatives Regarding Preventive Health - Authorizes appropriatons for: (1) core functions of public health programs; and (2) national initiatives regarding health promotion and disease prevention. Provides for grants to states for core functions of public health programs. Provides grants for agencies of State or local government and nonprofit organizations for national prevention initiatives. Provides for grants and authorizes appropriations for the development of rural telemedicine. Subtitle E: Health Services for Medically Underserved Populations - Authorizes appropriations for: (1) the development of community health groups and health care sites and services; and (2) the capital costs of the development of community health groups. (Sec. 3402) Authorizes approprations for grants and contracts for enabling and supplemental services. (Sec. 3471) Authorizes appropriations for the National Health Service Corps Program. (Sec. 3481) Provides for payments to hospitals with a low-income utilization rate of not less than 25 percent. Subtitle F: Mental Health; Substance Abuse - Requires each State, as a condition of participation under title I, to integrate the mental illness and substance abuse services of the State and its political subdivisions with the mental illness and substance abuse services offered by health plans pursuant to title I. Authorizes appropriations to States for grants for the development and operation of comprehensive managed mental health and substance abuse programs that are integrated with the health delivery system established under this Act. Subtitle G: Comprehensive School Health Education; School-Related Health Services - Provides for grants to State educational agencies in eligible States to integrate comprehensive school health education in schools within the State, with priority given to those communities in greatest need. Authorizes appropriations. (Sec. 3603) Establishes a Healthy Students-Healthy Schools Interagency Task Force. (Sec. 3681) Authorizes appropriations for grants to State health agencies or local community partnerships for the development and operation of school-related health services. Subtitle H: Public Health Service Initiative - Authorizes appropriations through FY 2004 for specified programs under title III, as well as programs of the Indian Health Service under title VIII. Subtitle I: Additional Provisions Regarding Public Health - Authorizes grants for the purpose of implementing and developing for trainees a curriculum that includes training in identification, treatment, and referral of victims of domestic violence and women's health needs. Subtitle J: Occupational Safety and Health - Directs the Secretary of Health and Human Services and the Secretary of Labor to work together to develop and implement a comprehensive program to expand and coordinate initiatives to prevent occupational injuries and illnesses. Establishes a National Advisory Board for Occupational Injury and Illness Prevention to provide oversight. Authorizes appropriations. Subtitle K: Full Funding for WIC - Amends provisions of the Child Nutrition Act of 1966 concerning the special supplemental food program to authorize to be: (1) appropriated such amounts as are necessary through FY 2000; and (2) made available other specified amounts through FY 2000. Subtitle L: Border Health Improvement - Authorizes the President to conclude an agreement with Mexico to establish a binational commission to be known as the United States - Mexico Border Health Commission to: (1) conduct a needs assessment; (2) develop and implement a plan to carry out actions recommended by the needs assessment; and (3) formulate recommendations to United States and Mexico concerning reimbursement for health care costs. Title IV: Medicare and Medicaid - Subtitle A: Medicare - Amends SSA title XVIII (Medicare) to allow individuals to elect to remain in certain plans. (Sec. 4002) Makes specified changes with regard to eligible organization and Medicare supplemental policy enrollment. (Sec. 4101) Revises provisions relating to Medicare part A and concerned with: (1) various specified hospital and skilled nursing facility payment adjustments for, among other things, capital-related costs for inpatient hospital services and services for low-income patients; (2) the Medicare-dependent, small rural hospital program and the rural health transition grant program; (3) payments for certain multi-campus, rehabilitation, and long-term care hospitals; (4) long-term hospital designation; and (5) indirect medical education payment termination. (Sec. 4111) Replaces the essential access community hospital (EACH) program with a limited service hospital program, prohibiting EACH designations after July 1, 1994, while permitting payment to prior designated EACHs. Authorizes appropriations. Makes part A and B amendments relating to rural primary care hospitals and medical assistance facilities. Repeals provisions for prospective payment systems (PPSs) for rural primary care services. (Sec. 4112) Requires the Secretary to study and report to the Congress with regard to subacute care. (Sec. 4201) Makes specified changes with regard to Medicare part B provisions on: (1) payment for physicians' services, adding limitations on payments relating to inpatient stays in certain hospitals and making various other changes concerning, among other things, service updates, adjustments for volume and intensity, and the performance standard factor; (2) underserved area bonus payments; (3) payments for certain outpatient hospital services and durable medical equipment; (4) eye or eye and ear hospitals; and (5) the general Medicare part B premium. (Sec. 4206) Requires the Secretary to establish: (1) demonstration projects for Medicare State-based performance standard rates of increase; and (2) bidding areas for the competitive acquisition of specified items and services. Provides for a reduction in payment amounts if such competitive acquisition fails to achieve certain savings. (Sec. 4209) Imposes across-the-board co-payments for clinical diagnostic laboratory tests. (Sec. 4212) Provides for expanded coverage for physician assistants and nurse practitioners. Bases payments for physician assistants and certain nurse practitioners on the physician fee schedule. (Sec. 4213) Prohibits nonparticipating physicians and suppliers from receiving payment for items or services provided under Medicare. (Sec. 4214) Requires the Secretary to develop a methodology for implementing a resource-based system for determining practice expense relative value units for each physician's service. (Sec. 4301) Modifies provisions relating to Medicare parts A and B and concerned with: (1) medicare as secondary payer; (2) payments for home health services; and (3) Medicare supplemental policies. (Sec. 4303) Directs the Secretary to use a competitive process to contract with centers of excellence for certain appropriate services (including cataract surgery). (Sec. 4305) Imposes co-payments for home health services. (Sec. 4306) Terminates payments for direct graduate medical education costs attributable to an approved medical residency training program. (Sec. 4307) Amends the Omnibus Budget Reconciliation Act of 1990 to permit Medicare supplemental policies in all States. Subtitle B: Medicaid Program - Amends SSA title XIX (Medicaid) to prohibit a State Medicaid plan from paying for items and services in the standard benefit package described above in title I of this Act, with certain exceptions. (Sec. 4605) Limits State Medicaid expenditures to HMOs to HMOs that are certified as a standard health plan. Revises the 75/25 rule under Medicaid HMO provisions. (Sec. 4611) Modifies national DSH payment limit provisions. Creates a Medicaid part B (Payments to Hospitals Serving Vulnerable Populations). (Sec. 4615) Makes various specified changes with regard to Medicaid long-term care provisions (including provisions on frail elderly demonstration project waivers) as well as with regard to other provisions concerning: (1) Medicaid coverage of certified nurse practitioners and clinical nurse specialist services; and (2) relief from third party liability requirements. Title V: Quality and Consumer Protection - Subtitle A: Quality Management and Improvement - Directs the Secretary of Health and Human Services to establish the National Quality Council to oversee a program of quality management and improvement designed to enhance the quality, appropriateness, and effectiveness of health care services and access to such services. Authorizes appropriations. Subtitle B: Administrative Simplification - States that the purpose of this subtitle is to improve the efficiency and effectiveness of the health care system, including Medicare and Medicaid, by encouraging the development of a health information network through the establishment of standards and requirements for the electronic transmission of certain health information. Provides for standards for data elements and information transactions. Imposes penalties for violators of the standards. Requires standards relating to the form of health security cards issued by health plans and the information needed to be encoded electronically on such cards. Establishes the Health Care Information Advisory Committee. Provides for grants for demonstration projects to promote the development and use of electronically integrated community-based clinical information systems and computerized patient medical records. Repeals provisions of the Social Security Act that established the Medicare and Medicaid Coverage Data Bank. Subtitle C: Privacy of Health Information - States that the purpose of this subtitle is to establish effective mechanisms to protect the privacy of individuals with respect to individually identifiable health care information. Permits the disclosure of health information only in accordance with provisions of this subtitle. Specifies authorized disclosures. Subtitle D: Expanded Efforts to Combat Health Care Fraud and Abuse Affecting Federal Outlay Programs - Directs the Secretary and the Attorney General to establish a joint program to: (1) coordinate Federal, State, and local law enforcement programs to control fraud and abuse affecting Federal outlay programs; (2) conduct investigations and audits relating to the delivery of and payment of health care; and (3) facilitate the enforcement of this subtitle and other statutes applicable to health care fraud and abuse. (Sec. 5302) Establishes the Federal Outlay Program Fraud and Abuse Control Account to be available for carrying out such program. (Sec. 5303) Establishes the HHS Office of Inspector General Asset Forfeiture Proceeds Fund. (Sec. 5304) Authorizes monetary rewards for information relating to a possible prosecution of a Federal health care offfense. (Sec. 5311) Imposes civil penalties for certain violations, including fraud, with respect to certified standard health or long-term care plans or long-term care services. (Sec. 5313) Excludes an individual or entity from participating in any applicable health plan if the individual or entity: (1) is excluded from participation in a public program due to conviction for health care-related crimes or patient abuse; (2) has been convicted under Federal or State law of specified felonies in connection with the delivery of a health care item or service; or (3) has been convicted of a felony relating to the unlawful manufacture, distribution, prescription, or dispensing of a controlled substance. Waives mandatory exclusion if it would significantly harm or pose a risk to public health. Bars payments under a certified standard health plan for the delivery of or payment for any item or service furnished by an excluded individual. (Sec. 5321) Amends the Federal criminal code to provide criminal penalties for fraud, theft, embezzlement, false statements, bribery, and graft in connection with health care. (Sec. 5331) Imposes civil penalties for false claims regarding certified standard health plans or long-term care insurance policies. Subtitle E: Medical Liability Reform - Requires parties to any malpractice action, before the commencement of such action, to participate in a State-based alternative dispute resolution system. Limits attorney's contingency fees. Provides for demonstration projects concerning medical malpractice liability. Authorizes appropriations for such projects. Subtitle F: Remedies and Enforcement - Establishes procedures for the review of health claims, including the review of claims, proceedings in complaint review offices, civil money penalties, the establishment of early resolution programs, mediation proceedings, enforcement of settlement agreements, due process for health care providers, judicial review, civil enforcement, private enforcement rights, consumer protections, discrimination claims, and facial constitutional challenges to invalidate this Act or any provision of this Act. Subtitle G: Repeal of Exemption - Establishes the applicability of the following Acts to the health insurance business: (1) the Sherman Act; (2) the Clayton Act; (3) the Federal Trade Commission Act; and (4) the Robinson-Patman Antidiscrimination Act. Title VI: Individual and Employer Subsidies - Subtitle A: Individual Premium and Cost-Sharing Assistance - Requires a participating State to have in effect a program for furnishing premium assistance and cost-sharing assistance in accordance with the provisions of this subtitle. Sets forth eligibility standards for such assistance. Provides for payments to States furnishing premium assistance. Subtitle B: Employer Subsidies - States that it is the purpose of this subtitle to provide subsidies to eligible employers in providing, or expanding the provision of, health care coverage for the employer's employees. Sets forth provisions concerning the eligibility for and amount of such subsidy. Declares ineligible for such a subsidy: (1) the self-employed; (2) employee leasing firms; and (3) State or local governments. Title VII: Revenue Provisions - Subtitle A: Financing Provisions - Amends the Internal Revenue Code to increase the excise taxes on cigarettes and other tobacco products. Applies such increases to tobacco products manufactured and sold in Puerto Rico. (Sec. 7103) Imposes an excise tax on the manufacture or importation of roll-your-own tobacco. (Sec. 7111) Imposes a tax: (1) on a percentage of premiums received under taxable health insurance policies; and (2) on a percentage of amounts received for health-related administrative services. Imposes on self-insured plans a monthly tax on a percentage of the accident or health coverage expenditures and direct administrative expenditures. (Sec. 7112) Imposes a 25 percent tax on community-rated high cost health plans to be paid by the issuer. Requires the Secretary of Health and Human Services to establish a reference premium for each class of enrollment for community-rated plans within a community rating area. Imposes a 25 percent tax on the excess premium equivalents of an experience-related standard health plan. (Sec. 7121) Provides for the recapture of certain health care subsidies received by high-income individuals. Transfers such amounts to the Supplemental Medical Insurance Trust Fund. (Sec. 7131) Increases the excise tax on certain hollow point and large caliber handgun ammunition. (Sec. 7132) Requires certain shareholders of S corporations and limited partners who materially participate in corporate activities to include their share of income or loss from such corporation when determining net earnings from self-employment. (Sec. 7133) Provides for extending Medicare coverage and applying the hospital insurance tax to all State and local government employees. Subtitle B: Tax Treatment of Employer-Provided Health Care - Declares that on and after January 1, 2004, gross income of an employee includes employer-provided coverage under an accident or health plan which is not permitted coverage. (Sec. 7202) Prohibits health benefits from being provided under cafeteria plans. (Sec. 7203) Increases and makes permanent the deduction for health insurance costs of self-employed individuals. (Sec. 7211) Imposes a tax on employer-provided health benefits that do not meet the requirements for permitted coverage. Subtitle C: Exempt Health Care Organizations - Sets forth qualification and disclosure requirements for tax-exempt health care organizations. (Sec. 7302) Imposes an excise tax on the beneficiary of a taxable inurement and on the management of the participating tax-exempt health care organization. (Sec. 7303) Provides for the treatment of health maintenance organizations, parent organizations, and health insurance purchasing cooperatives as tax-exempt entities. (Sec. 7304) Provides for the taxation as an insurance company other than a life insurance company of certain organizations that provide health insurance and other prepaid health care services. (Sec. 7305) Repeals the special rules for Blue Cross and Blue Shield and similar organizations. (Sec. 7306) Provides a tax exemption for certain qualified high risk insurance pools. (Sec. 7308) Provides for the tax treatment of bonds of certain nonprofit tax-exempt organizations in a manner similar to governmental bonds. Subtitle D: Tax Treatment of Long-Term Care Insurance and Services - Treats qualified long-term care services as medical care for purposes of the medical expense deduction. (Sec. 7402) Provides for the treatment of long-term care insurance as accident and health insurance. (Sec. 7403) Allows accelerated death benefits under life insurance contracts to be paid to terminally ill individuals. Subtitle E: Other Revenue Provisions - Requires the Secretary of the Treasury to submit to specified congressional committees a legislative proposal providing statutory standards for the classification of workers as employees or independent contractors. (Sec. 7502) Increases the penalty for failure to file correct information for returns involving payments for services. (Sec. 7505) Allows a tax credit for certain primary health services providers that practice in health professional shortage areas. (Sec. 7506) Increases the amount allowed to be expensed as a depreciable business asset if such asset is medical equipment. (Sec. 7521) Requires additional reserves for post-retirement medical and life insurance benefits to cover not less than ten years of the working lives of covered employees and to be maintained as separate accounts. (Sec. 7522) Allows a tax credit for the cost of personal assistance services required by certain employed individuals. Limits the amount of such credit and provides a cost-of-living adjustment. Subtitle F: Graduate Medical Education and Academic Health Centers Trust Fund - Establishes the Graduate Medical Education and Academic Health Centers Trust Fund, consisting of the Graduate Medical Education Accountand the Academic Health Centers Account. Provides funding for such trust fund through tax and assessments on insured and self-insured plans and transfers from certain social security trust funds. Title VIII: Other Federal Programs - Subtitle A: Indian Health Service - Makes qualifying Indians eligible for health and supplemental benefits under the Indian Health Service (IHS). (Sec. 8105) Authorizes an IHS program to contract with a health plan to provide health care services to non-Indians. (Sec. 8107) Makes IHS programs eligible for Medicare payments. (Sec. 8109) Directs the Secretary of Health and Human Services to: (1) establish an advisory group to access budget aspects of IHS programs; (2) conduct health service transitional studies and establish a related advisory group; (3) develop a long-term care demonstration program; (4) survey health services available to Indian veterans; and (5) develop new funding methodologies. (Sec. 8118) Authorizes appropriations. Subtitle B: Department of Veterans Affairs - Veterans Health Care Reform Act of 1994 - Allows veterans, individuals currently enrolled in a health plan under the Civilian Health and Medical Program of the Uniformed Services (CHAMPUS), and their family members to be enrolled in a Department of Veterans Affairs health plan (VA plan). Requires the Secretary of Veterans Affairs to ensure that each VA plan provides to enrolled individuals the items and services in the standard benefit package under this Act. Allows such plans to offer supplemental health benefits and cost-sharing plans consistent with this Act. Provides a limitation with regard to veterans enrolled with health plans outside the VA. Prohibits the imposition of any plan enrollment charges upon service-connected disabled veterans, veterans receiving disability compensation from the VA, former prisoners of war, veterans of the Mexican border period or World War I, and veterans unable to defray the costs of such care. Allows the Secretary to establish plan charges for other veterans. Deems a VA facility to be a Medicare provider, and a VA health plan to be a Medicare HMO, for purposes of any program administered by the Secretary of Health and Human Services under Medicare (title XXVIII of the Social Security Act). Allows for the recovery of certain care and services provided under a VA plan in the case of an individual who has coverage under another plan. Establishes in the Treasury the Department of Veterans Affairs Health Plan Fund to be used for VA health plan payments and services. Preserves existing benefits for VA facilities not operating within a health plan certified under this Act. Directs the Secretary to organize health plans and operate VA facilities as, or within, health plans under this Act. Preempts conflicting State health plan standards or requirements. Directs the Secretary to designate a health plan director for each VA health plan organized and operated under this subtitle. Authorizes such directors to enter into contracts and agreements for the provision of care and services under the VA plan as well as related services (equipment, maintenance, and repair). Authorizes the Secretary to enter into resource-sharing agreements with other health care plans and providers, health industry organizations, individuals, and other Government departments and agencies. Provides certain administrative and personnel flexibility, as well as expenditure authority, for care and services under a VA plan. Establishes in the Treasury the Veterans Health Care Investment Fund. Authorizes appropriations. Provides specified credits to the Fund for FY 1995 through 1997 for operation of VA health plans. Requires a report from the Secretary to the Congress on the operation of such plans. Authorizes the Secretary to accept and use grants for health care services provided to special populations if used by the VA while operating under a VA health plan. Title IX: Workers Compensation Medical Services - Applies the provisions of subtitle B of title V of this Act to the provision of workers compensation medical services in the same manner as such provisions apply with respect to the provision of services included in the standard benefit package. Requires that, in cases where a workers compensation claim is challenged, a health plan must provide or pay for all medical care in the standard benefit package according to the applicable workers compensation for schedule, until the challenge is adjudicated. Provides for demonstration projects with respect to treatment of work-related injuries and illness. Establishes a Commission on Workers Compensation Medical Services. Title X: Premium Financing - Subtitle A: National Health Care Cost and Coverage Commission - Establishes the National health Care Cost and Coverage Commission to monitor and respond to: (1) trends in health care coverage; and (2) changes in per-capita premiums and other indicators of health care inflation. Provides for congressional consideration of Commission recommendations. Subtitle B: Employer and Indiandual Premium Requirements and Assistance - Requires, with respect to a participating State, each resident U.S. citizen or lawful alien to: (1) enroll in or be covered under a health plan; (2) pay any premium required, consistent with this Act. Excludes individuals covered under an equivalent health care program such as Medicare, Medicaid, a military or veterans health care program, CHAMPUS, the Indian Health Care Improvement Act, or an approved State single-payer system. Provides for a religious exemption. Excludes inmates. Requires employers of 25 or more and employers of less than 25 than make an election, to make health care coverage premium payments on behalf of the employer's qualifying employees. Permits other employers to elect to be treated as community-rated employers. Sets forth provisions for providing for the determination premium payments. Title XI: Ensuring Health Care Reform Financing - States that it is the purpose of this title to ensure that this Act does not result in unanticipated increases in the Federal deficit. States that any entitlement provided by this Act, including premium assistance, shall be subject to the operation of this Act. Requires the President, annually through FY 2004, to issue a health care baseline. Requires the President's budget to include a current health care baseline. Provides that if a baseline exceeds the initial (1995) baseline by more than a specified amount there is to be a proposed order that offsets the excess through a combination of: (1) reductions in premium assistance; (2) reductions in the Medicare deductible for drugs; and (3) reductions in each direct spending program of this Act by a uniform percentage. Requires the eligibility percentage for children and pregnant women to be reduced last. Sets forth provisions in the event of war or low growth. Provides for a Government Accounting Office audit and for additonal reporting requirements by the Office of Management and Budget and the National Health Care Commission. | 2025-08-26T13:50:52Z |