Small Business Health Care Reform Act of 1991 - Title I: Improvements in Health Insurance Affordability for Small Employers - Amends the Internal Revenue code to raise from 25 to 100 percent the deduction allowed to self-employed individuals for health insurance premiums and makes the deduction permanent.
Directs the Secretary of Health and Human Services (the Secretary) to make grants to up to 15 States for the establishment and operation of small employer health insurance purchasing programs. Permits grant funds to be used to finance administrative costs associated with developing and operating a group purchasing program for small employers. Authorizes appropriations.
Title II: Improvements in Health Insurance for Small Employers - Amends the Social Security Act to add a new title, Title XXI: Standards for Small Employer Health Insurance and Certification of Managed Care Plans. Directs the Secretary to develop standards concerning requirements for health insurance plans for small employers. Requires such plans to provide for: (1) guaranteed eligibility; (2) guaranteed availability; and (3) guaranteed renewability. Prohibits: (1) an insurer from refusing to renew or terminate a plan, except for nonpayment of premiums, fraud, or failure to maintain minimum participation rates; and (2) for certain services, discrimination based on health status. Sets limits controlling the variation of premium charges permitted among all small employers insured by an insurer. Requires the full disclosure of an insurer's rating practices.
Requires a health insurance plan for small employers to offer: (1) both a standard benefit package and basic benefit package; and (2) a managed care option, if the insurer also offers such an option to other employers. Provides, under both the standard and basic package, for coverage of: (1) inpatient and outpatient hospital care; (2) inpatient and outpatient physician services; (3) diagnostic tests; and (4) preventive services. Provides, in addition, under the standard plan: (1) for the coverage of certain mental health care; (2) that, except as specified, there will be no limits on the amount, scope, or duration of benefits, and (3) for specified limits on deductibles, copayment, coinsurance, and out-of-pocket expenses. Provides under the basic plan that: (1) premiums, deductibles, copayments, or other cost-sharing may be imposed; and (2) there shall be an out-of-pocket limit.
Amends the Internal Revenue Code to impose an excise tax of 25 percent of gross premiums on the issuer of any health insurance plan to a small employer if the plan does not meet the requirements of title XXI.
Sets forth study and reporting requirements.
Title III: Improvements in Portability of Private Health Insurance - Imposes an excise tax of $100 per day, with respect to a covered individual, on a group health plan for its failure to provide coverage for a preexisting condition, subject to stated exceptions.
Title IV: Health Care Cost Containment - Establishes a Health Care Cost Commission which shall report annually to the President and the Congress on national health care costs. Authorizes appropriations.
Requires the Secretary of Health and Human Services, under title XXI of the Social Security Act, to establish a process for the certification of managed care plans and of utilization review programs. Sets forth requirements for certification.
Amends the Public Health Service Act to direct the Administrator of the Agency for Health Care Policy and Research to develop outcomes research and practice parameters for mental health services, including at least the diagnosis and treatment of childhood attention deficit syndrome disorders and manic depression. Amends Part A (General Provisions) of title XI of the Social Security Act to authorize appropriations for research outcomes of health care services and procedures.
Mandates development of uniform claims forms for use by beneficiaries and health care providers in submitting claims under group health plans and titles XVIII (Medicare) and XIX (Medicaid) of the Social Security Act.
Amends the Public Health Service Act to include entities receiving Federal funds under provisions relating to migrant health centers, community health centers, or health services for the homeless, and officers, employees, or contractors of such entities who are licensed health care practitioners, in the coverage of provisions regulating civil actions for injury resulting from medical or related functions against commissioned officers or employees of the Public Health Service. Subrogates to the United States any insurance claim such an entity or person has.
Prohibits grants under provisions relating to migrant or community health centers or health services for the homeless unless the applicant has: (1) implemented policies and procedures to assure against malpractice; (2) reviewed the professional credentials, claims history, and other information regarding its licensed health care practitioners; and (3) no history of claims against it under such provisions relating to officers and employees of the Public Health Service, or has cooperated with the Attorney General in defending against such claims and has taken corrective action.
Empowers the Attorney General, if certain conditions are met, to determine that an individual practitioner shall not be deemed a Public Health Service employee for purposes of these provisions.
Prohibits hospitals from denying admitting privileges to an otherwise qualified health care provider who is an officer, employee, or contractor of such an entity.
Title V: Medicare Prevention Benefits - Amends part B (Supplementary Medical Insurance Benefits for the Aged and Disabled) of title XVIII (Medicare) of the Social Security Act to establish frequency and payment limits for screening for fecal-occult blood tests and screening flexible sigmoidoscopies.
Amends part C (Miscellaneous Provisions) of title XVIII to provide coverage for tetanus-diphtheria booster and its administration.
Provides Medicare coverage for well-child services which is to include routine office visits, immunizations, laboratory tests, and preventive dental care.
Expands the coverage of a screening mammography to provide for one such screening annually for all covered women over age 49.
Directs the Secretary to establish and provide for a series of ongoing demonstration projects which provide coverage for specified preventive services, including: (1) glaucoma screening; (2) cholesterol screening; (3) osteoporosis screening and treatment; (4) screening services for pregnant women; (5) assessments for individuals beginning at age 65 or 75; and (6) other appropriate services. Authorizes appropriations.
Directs the Director of the Office of Technology Assessment to study and report concerning the development of a process for the regular review for the consideration of coverage of preventive services under Medicare.
HR 3923 IH 102d CONGRESS 1st Session H. R. 3923 To provide for improvements in access and affordability of health insurance coverage through small employer health insurance reform, for improvements in the portability of health insurance, and for health care cost containment, and for other purposes. IN THE HOUSE OF REPRESENTATIVES November 25, 1991 Mr. IRELAND (for himself, Mr. BROOMFIELD, Mrs. MEYERS of Kansas, Mr. COMBEST, Mr. BAKER, Mr. HANCOCK, Mr. MACHTLEY, Mr. CAMP, Mr. FRANKS of Connecticut, and Mr. BOEHNER) introduced the following bill; which was referred jointly to the Committees on Ways and Means and Energy and Commerce A BILL To provide for improvements in access and affordability of health insurance coverage through small employer health insurance reform, for improvements in the portability of health insurance, and for health care cost containment, and for other purposes. Be it enacted by the Senate and House of Representatives of the United States of America in Congress assembled, SECTION 1. SHORT TITLE; TABLE OF CONTENTS. (a) SHORT TITLE- This Act may be cited as the `Small Business Health Care Reform Act of 1991'. (b) TABLE OF CONTENTS- The table of contents of this Act is as follows: TITLE I--IMPROVEMENTS IN HEALTH INSURANCE AFFORDABILITY FOR SMALL EMPLOYERS Sec. 101. Permanent increase in deductible health insurance costs for self-employed individuals. Sec. 102. Grants to States for small employer health insurance purchasing programs. TITLE II--IMPROVEMENTS IN HEALTH INSURANCE FOR SMALL EMPLOYERS Subtitle A--Standards and Requirements of Small Employer Health Insurance Reform Sec. 201. Standards and requirements of small employer health insurance. `TITLE XXI--STANDARDS FOR SMALL EMPLOYER HEALTH INSURANCE AND CERTIFICATION OF MANAGED CARE PLANS `Part A--General Standards; Definitions `Sec. 2101. Application of requirements to small employer health insurance plans. `Sec. 2102. Establishment of standards. `Sec. 2103. Definitions. `Part B--Small Employer Health Insurance Reform `Sec. 2111. General requirements for health insurance plans issued to small employers. `Sec. 2112. Requirements related to restrictions on rating practices. `Sec. 2113. Requirements for small employer health insurance benefit package offerings. Subtitle B--Tax Penalty on Noncomplying Insurers Sec. 211. Excise tax on premiums received on health insurance policies which do not meet certain requirements. Subtitle C--Studies and Reports Sec. 221. GAO study and report on rating requirements and benefit packages for small group health insurance. TITLE III--IMPROVEMENTS IN PORTABILITY OF PRIVATE HEALTH INSURANCE Sec. 301. Excise tax imposed on failure to provide for preexisting condition. TITLE IV--HEALTH CARE COST CONTAINMENT Sec. 401. Establishment of Health Care Cost Commission. Sec. 402. Federal certification of managed care plans and utilization review programs. Sec. 403. Additional funding for outcomes research. Sec. 404. Uniform claims forms. Sec. 405. Liability protections for certain health care professionals; hospital admitting privileges for certain health care providers. TITLE V--MEDICARE PREVENTION BENEFITS Sec. 501. Coverage of colorectal screening. Sec. 502. Coverage of certain immunizations. Sec. 503. Coverage of well-child care. Sec. 504. Annual screening mammography. Sec. 505. Demonstration projects for coverage of other preventive services. Sec. 506. OTA study of process for review of medicare coverage of preventive services. TITLE I--IMPROVEMENTS IN HEALTH INSURANCE AFFORDABILITY FOR SMALL EMPLOYERS SEC. 101. PERMANENT INCREASE IN DEDUCTIBLE HEALTH INSURANCE COSTS FOR SELF-EMPLOYED INDIVIDUALS. (a) IN GENERAL- Paragraph (1) of section 162(l) of the Internal Revenue Code of 1986 (relating to special rules for health insurance costs of self-employed individuals) is amended by striking `25 percent' and inserting `100 percent'. (b) PERMANENT DEDUCTION- Section 162(l) of such Code is amended by striking paragraph (6). (c) EFFECTIVE DATE- The amendments made by this section shall apply to taxable years beginning after December 31, 1991. SEC. 102. GRANTS TO STATES FOR SMALL EMPLOYER HEALTH INSURANCE PURCHASING PROGRAMS. (a) IN GENERAL- The Secretary of Health and Human Services (hereafter in this section referred to as the `Secretary') shall make grants in amounts up to $10,000,000 to up to 15 States that submit applications meeting the requirements of this section for the establishment and operation of small employer health insurance purchasing programs. (b) USE OF FUNDS- Grant funds awarded under this section to a State may be used to finance administrative costs associated with developing and operating a group purchasing program for small employers, such as the costs associated with-- (1) engaging in marketing and outreach efforts to inform small employers about the group purchasing program, which may include the payment of sales commissions; (2) negotiating with insurers to provide health insurance through the group purchasing program; or (3) providing administrative functions, such as eligibility screening, claims administration, and customer service. (c) APPLICATION REQUIREMENTS- An application submitted by a State to the Secretary must describe-- (1) whether the program will be operated directly by the State or through one or more State-sponsored private organizations and the details of such operation; (2) any participation requirements for small employers; (3) the extent of insurance coverage among the eligible population, projections for change in the extent of such coverage, and the price of insurance currently available to these small employers; (4) program goals for reducing the price of health insurance for small employers and increasing insurance coverage among employees of small employers and their dependents; (5) the approaches proposed for enlisting participation by insurers and small employers, including any plans to use State funds to subsidize the cost of insurance for participating employers; and (6) the methods proposed for evaluating the effectiveness of the program in reducing the number of uninsured in the State and on lowering the price of health insurance to small employers in the State. (d) GRANT CRITERIA- In awarding grants, the Secretary shall consider the potential impact of the State's proposal on the cost of health insurance for small employers and on the number of uninsured, and the need for regional variation in the awarding of grants. To the extent the Secretary deems appropriate, grants shall be awarded to fund programs employing a variety of approaches for establishing small employer health insurance group purchasing programs. (e) PROHIBITION ON GRANTS- No grant funds shall be paid to States that do not meet the requirements of title XXI of the Social Security Act with respect to small employer health insurance plans, or to States with group purchasing programs involving small employer health insurance plans that do not meet the requirements of such title. (f) ANNUAL REPORT BY STATES- States receiving grants under this section must report to the Secretary annually on the numbers and rates of participation by eligible insurers and small employers, on the estimated impact of the program on reducing the number of uninsured, and on the price of insurance available to small employers in the State. (g) AUTHORIZATION OF APPROPRIATIONS- There are authorized to be appropriated for each of fiscal years 1992, 1993, and 1994, $150,000,000 for the purposes of awarding grants under this section. (h) SECRETARIAL REPORT- The Secretary shall report to Congress by no later than January 1, 1995, on the number and amount of grants awarded under this section, and include with such report an evaluation of the impact of the grant program on the number of uninsured and price of health insurance to small employers in participating States. TITLE II--IMPROVEMENTS IN HEALTH INSURANCE FOR SMALL EMPLOYERS Subtitle A--Standards and Requirements of Small Employer Health Insurance Reform SEC. 201. STANDARDS AND REQUIREMENTS OF SMALL EMPLOYER HEALTH INSURANCE. The Social Security Act is amended by adding at the end the following new title: `TITLE XXI--STANDARDS FOR SMALL EMPLOYER HEALTH INSURANCE AND CERTIFICATION OF MANAGED CARE PLANS `Part A--General Standards; Definitions `APPLICATION OF REQUIREMENTS TO SMALL EMPLOYER HEALTH INSURANCE PLANS `SEC. 2101. (a) PLAN UNDER STATE REGULATORY PROGRAM OR CERTIFIED BY THE SECRETARY- An insurer offering a health insurance plan to a small employer in a State on or after the effective date applicable to the State under subsection (b) shall be treated as meeting the requirements of this title if-- `(1) the Secretary determines that the State has established a regulatory program that provides for the application and enforcement of standards meeting the requirements under section 2102 to meet the requirements of part B of this title; and `(2) if the State has not established such a program or if the program has been decertified by the Secretary under section 2102(b), the health insurance plan has been certified by the Secretary (in accordance with such procedures as the Secretary establishes) as meeting the requirements of part B of this title. `(b) EFFECTIVE DATES- `(1) IN GENERAL- Except as specified in paragraph (2) and provided in paragraph (3), the standards established under section 2102 to meet the requirements of part B of this title shall apply to health insurance plans offered, issued, or renewed to a small employer in a State on or after January 1, 1994. `(2) EXCEPTION FOR LEGISLATION- In the case of a State which the Secretary identifies as-- `(A) requiring State legislation (other than legislation appropriating funds) in order for insurers and health insurance plans offered to small employers to meet the standards under the program established under subsection (a), and `(B) having a legislature which does not meet in 1993 in a legislative session in which such legislation may be considered, the date specified in this paragraph is the first day of the first calendar quarter beginning after the close of the first regular legislative session of the State legislature that begins on or after January 1, 1994. For purposes of the previous sentence, in the case of a State that has a 2-year legislative session, each year of such session shall be deemed to be a separate regular legislative session of the State legislature. `(3) REQUIREMENTS APPLIED TO EXISTING POLICIES- In the case of a health insurance plan in effect before the applicable effective date specified in paragraph (1) or (2), the requirements referred to in subsections (a) and (b) of section 2112 shall not apply to any such plan, or any renewal of such plan, before the date which is 2 years after such effective date. `(c) REPORTING REQUIREMENTS OF STATES- Each State shall submit to the Secretary, at intervals established by the Secretary, a report on the implementation and enforcement of the standards under the program established under subsection (a)(1) with respect to health insurance plans offered to small employers. `(d) MORE STRINGENT STATE STANDARDS PERMITTED- Except as provided in subsections (b)(8) and (c)(4) of section 2113, a State may implement standards that are more stringent than the standards established to meet the requirements of part B of this title. `ESTABLISHMENT OF STANDARDS `SEC. 2102. (a) ESTABLISHMENT OF STANDARDS- `(1) IN GENERAL- The Secretary shall develop and publish, by not later than December 31, 1992, specific standards to implement the requirements of part B of this title. `(2) STANDARDS ON GUARANTEED AVAILABILITY- The standards developed under paragraph (1) shall provide alternative standards for guaranteeing availability of health insurance plans for all small employers in a State as provided in section 2111(c). `(b) PERIODIC SECRETARIAL REVIEW OF STATE REGULATORY PROGRAM- The Secretary periodically shall review State regulatory programs to determine if they continue to meet and enforce the standards referred to in subsection (a). If the Secretary initially determines that a State regulatory program no longer meets and enforces such standards, the Secretary shall provide the State an opportunity to adopt a plan of correction that would bring such program into compliance with such standards. If the Secretary makes a final determination that the State regulatory program fails to meet and enforce such standards and requirements after such an opportunity, the Secretary shall decertify such program and assume responsibility under section 2101(a)(2) with respect to plans in the State. `(c) GAO AUDITS- The Comptroller General of the United States shall conduct periodic reviews on a sample of State regulatory programs to determine their compliance with the standards and requirements of this title. The Comptroller General of the United States shall report to the Secretary and Congress on the findings of such reviews. `DEFINITIONS `SEC. 2103. (a) HEALTH INSURANCE PLAN- As used in this title, the term `health insurance plan' means any hospital or medical service policy or certificate, hospital or medical service plan contract, or health maintenance organization group contract and, in States which have distinct licensure requirements, a multiple employer welfare arrangement, but does not include-- `(1) a self-insured health insurance plan; or `(2) any of the following offered by an insurer-- `(A) accident only, dental only, disability only insurance, or long-term care only insurance, `(B) coverage issued as a supplement to liability insurance, `(C) workmen's compensation or similar insurance, or `(D) automobile medical-payment insurance. `(b) INSURER AND HEALTH MAINTENANCE ORGANIZATION- As used in this title: `(1) INSURER- The term `insurer' means any person that offers a health insurance plan to a small employer. `(2) HEALTH MAINTENANCE ORGANIZATION- The term `health maintenance organization' has the meaning given the term `eligible organization' in section 1876(b) of this Act. `(c) GENERAL DEFINITIONS- As used in this title: `(1) APPLICABLE REGULATORY AUTHORITY- The term `applicable regulatory authority' means-- `(A) in the case of a health insurance plan offered in a State with a program meeting the requirements of part B of this title, the State commissioner or superintendent of insurance or other State authority responsible for regulation of health insurance; or `(B) in the case of a health insurance plan certified by the Secretary under section 2101(a)(2), the Secretary. `(2) SMALL EMPLOYER- The term `small employer' means, with respect to a calendar year, an employer that normally employs more than 1 but less than 51 eligible employees on a typical business day. For the purposes of this paragraph, the term `employee' includes a self-employed individual. `(3) ELIGIBLE EMPLOYEE- The term `eligible employee' means, with respect to an employer, an employee who normally performs on a monthly basis at least 30 hours of service per week for that employer. `Part B--Small Employer Health Insurance Reform `GENERAL REQUIREMENTS FOR HEALTH INSURANCE PLANS ISSUED TO SMALL EMPLOYERS `SEC. 2111. (a) REGISTRATION WITH APPLICABLE REGULATORY AUTHORITY- Each insurer shall register with the applicable regulatory authority for each State in which it issues or offers a health insurance plan to small employers. `(b) GUARANTEED ELIGIBILITY- `(1) IN GENERAL- No insurer may exclude from coverage any eligible employee, or the spouse or any dependent child of the eligible employee, to whom coverage is made available by a small employer. `(2) WAITING PERIODS- Paragraph (1) shall not apply to any period an eligible employee is excluded from coverage under the health insurance plan solely by reason of a requirement applicable to all employees that a minimum period of service with the small employer is required before the employee is eligible for such coverage. `(c) GUARANTEED AVAILABILITY- `(1) IN GENERAL- Subject to the succeeding provisions of this subsection, an insurer that offers a health insurance plan to small employers located in a State must meet the standards adopted by the State described in paragraph (2). `(2) STANDARDS ON GUARANTEED AVAILABILITY- `(A) IN GENERAL- In order to implement the requirements of this title, the standards developed under paragraphs (1) and (2) of section 2102(a) shall-- `(i) require that a State adopt a mechanism for guaranteeing the availability of health insurance plans for all small employers in the State, and `(ii) specify alternative mechanisms, including at least the alternative mechanisms described in subparagraph (B), that a State may adopt. `(B) ALTERNATIVE MECHANISMS- The alternative mechanisms described in this subparagraph are: `(i) A mechanism under which the State-- `(I) requires that any insurer offering a health insurance plan to a small employer in the State shall offer the same plan to all other small employers in the State, and `(II) requires the participation of all such insurers in a small employer reinsurance program established by the State. `(ii) A mechanism under which the State-- `(I) requires that any insurer offering a health insurance plan to a small employer in the State shall offer the same plan to all other small employers in the State, and `(II) permits any such insurer to participate in a small employer reinsurance program established by the State. `(iii) A mechanism under which the State requires that any insurer offering a health insurance plan to a small employer in the State shall participate in a program for assigning high-risk groups among all such insurers. `(iv) A mechanism under which the State requires that any insurer that-- `(I) offers a health insurance plan to a small employer in the State, and `(II) does not agree to offer the same plan to all other small employers in the State, shall participate in a program for assigning high-risk groups among all such insurers. `(C) STATE ADOPTION OF CERTAIN STANDARDS- A regulatory program adopted by the State under section 2101 must provide-- `(i) for the adoption of one of the mechanisms described in clauses (i) through (iv) of subparagraph (B), or `(ii) for such other program that guarantees availability of health insurance to all small employers in the State and is approved by the Secretary. `(D) STANDARDS FOR NONCOMPLYING STATES- The Secretary, in consultation with the Secretary of the Treasury, shall develop requirements with respect to guaranteed availability to apply with respect to insurers located in a State that has not adopted the standards under section 2102 and who wish to apply for certification under section 2101(a)(2). `(3) GROUNDS FOR REFUSAL TO RENEW- `(A) IN GENERAL- An insurer may refuse to renew, or may terminate, a health insurance plan under this part only for-- `(i) nonpayment of premiums, `(ii) fraud or misrepresentation, or `(iii) failure to maintain minimum participation rates (consistent with subparagraph (B)). `(B) MINIMUM PARTICIPATION RATES- An insurer may require, with respect to a health insurance plan issued to a small employer, that a minimum percentage of eligible employees who do not otherwise have health insurance are enrolled in such plan if such percentage is applied uniformly to all plans offered to employers of comparable size. `(d) GUARANTEED RENEWABILITY- `(1) IN GENERAL- An insurer shall ensure that a health insurance plan issued to a small employer be renewed, at the option of the small employer, unless the plan is terminated for a reason specified in paragraph (2) or in subsection (c)(3)(A). `(2) TERMINATION OF SMALL EMPLOYER BUSINESS- An insurer is not required to renew a health insurance plan with respect to a small employer if the insurer-- `(A) elects not to renew all of its health insurance plans issued to small employers in a State; and `(B) provides notice to the applicable regulatory authority in the State and to each small employer covered under a plan of such termination at least 180 days before the date of expiration of the plan. In the case of such a termination, the insurer may not provide for issuance of any health insurance plan to a small employer in the State during the 5-year period beginning on the date of termination of the last plan not so renewed. `(e) NO DISCRIMINATION BASED ON HEALTH STATUS FOR CERTAIN SERVICES- `(1) IN GENERAL- Except as provided under paragraph (2), a health insurance plan offered to a small employer by an insurer may not deny, limit, or condition the coverage under (or benefits of) the plan based on the health status, claims experience, receipt of health care, medical history, or lack of evidence of insurability, of an individual. `(2) TREATMENT OF PREEXISTING CONDITION EXCLUSIONS FOR ALL SERVICES- `(A) IN GENERAL- Subject to the succeeding provisions of this paragraph, a health insurance plan offered to a small employer by an insurer may exclude coverage with respect to services related to treatment of a preexisting condition, but the period of such exclusion may not exceed 6 months. The exclusion of coverage shall not apply to services furnished to newborns. `(B) CREDITING OF PREVIOUS COVERAGE- `(i) IN GENERAL- A health insurance plan issued to a small employer by an insurer shall provide that if an individual under such plan is in a period of continuous coverage (as defined in clause (ii)(I)) with respect to particular services as of the date of initial coverage under such plan, any period of exclusion of coverage with respect to a preexisting condition for such services or type of services shall be reduced by 1 month for each month in the period of continuous coverage. `(ii) DEFINITIONS- As used in this subparagraph: `(I) PERIOD OF CONTINUOUS COVERAGE- The term `period of continuous coverage' means, with respect to particular services, the period beginning on the date an individual is enrolled under a health insurance plan, title XVIII, title XIX, or other health benefit arrangement including a self-insured plan which provides benefits with respect to such services and ends on the date the individual is not so enrolled for a continuous period of more than 3 months. `(II) PREEXISTING CONDITION- The term `preexisting condition' means, with respect to coverage under a health insurance plan issued to a small employer by an insurer, a condition which has been diagnosed or treated during the 3-month period ending on the day before the first date of such coverage (without regard to any waiting period). `REQUIREMENTS RELATED TO RESTRICTIONS ON RATING PRACTICES `SEC. 2112. (a) LIMIT ON VARIATION OF PREMIUMS BETWEEN BLOCKS OF BUSINESS- `(1) IN GENERAL- The base premium rate for any block of business of an insurer (as defined in section 2103(b)(1)) may not exceed the base premium rate for any other block of business by more than 20 percent. `(2) EXCEPTIONS- Paragraph (1) shall not apply to a block of business if the applicable regulatory authority determines that-- `(A) the block is one for which the insurer does not reject, and never has rejected, small employers included within the definition of employers eligible for the block of business or otherwise eligible employees and dependents who enroll on a timely basis, based upon their claims experience, health status, industry, or occupation, `(B) the insurer does not transfer, and never has transferred, a health insurance plan involuntarily into or out of the block of business, and `(C) health insurance plans offered under the block of business are currently available for purchase by small employers at the time an exception to paragraph (1) is sought by the insurer. `(b) LIMIT ON VARIATION IN PREMIUM RATES WITHIN A BLOCK OF BUSINESS- For a block of business of an insurer, the highest premium rates charged during a rating period to small employers with similar demographic characteristics (including age, sex, and geography and not relating to claims experience, health status, industry, occupation, or duration of coverage since issue) for the same or similar coverage, or the highest rates which could be charged to such employers under the rating system for that block of business, shall not exceed an amount that is 1.5 times the base premium rate for the block of business for a rating period (or portion thereof) that occurs in the first 3 years in which this section is in effect, and 1.35 times the base premium rate thereafter. `(c) CONSISTENT APPLICATION OF RATING FACTORS- In establishing premium rates for health insurance plans offered to small employers-- `(1) an insurer making adjustments with respect to age, sex, or geography must apply such adjustments consistently across small employers, and `(2) no insurer may use a geographic area that is smaller than a county or smaller than an area that includes all areas in which the first three digits of the zip code are identical, whichever is smaller. `(d) LIMIT ON TRANSFER OF EMPLOYERS AMONG BLOCKS OF BUSINESS- `(1) IN GENERAL- An insurer may not transfer a small employer from one block of business to another without the consent of the employer. `(2) OFFERS TO TRANSFER- An insurer may not offer to transfer a small employer from one block of business to another unless-- `(A) the offer is made without regard to age, sex, geography, claims experience, health status, industry, occupation or the date on which the policy was issued, and `(B) the same offer is made to all other small employers in the same block of business. `(e) LIMITS ON VARIATION IN PREMIUM INCREASES- The percentage increase in the premium rate charged to a small employer for a new rating period (determined on an annual basis) may not exceed the sum of the percentage change in the base premium rate plus 5 percentage points. `(f) DEFINITIONS- In this section: `(1) BASE PREMIUM RATE- The term `base premium rate' means, for each block of business for each rating period, the lowest premium rate which could have been charged under a rating system for that block of business by the insurer to small employers with similar demographic or other relevant characteristics (including age, sex, and geography and not relating to claims experience, health status, industry, occupation or duration of coverage since issue) for health insurance plans with the same or similar coverage. `(2) BLOCK OF BUSINESS- `(A) IN GENERAL- Except as provided in subparagraph (B), the term `block of business' means, with respect to an insurer, all of the small employers with a health insurance plan issued by the insurer (as shown on the records of the insurer). `(B) DISTINCT GROUPS- `(i) IN GENERAL- Subject to clause (ii), a distinct group of small employers with health insurance plans issued by an insurer may be treated as a block of business by such insurer if all of the plans in such group-- `(I) are marketed and sold through individuals and organizations that do not participate in the marketing or sale of other distinct groups by the insurer, `(II) have been acquired from another insurer as a distinct group, or `(III) are provided through an association with membership of not less than 25 small employers that has been formed for purposes other than obtaining health insurance. `(ii) EXCEPTION ALLOWED- Except as provided in subparagraph (C), an insurer may not establish more than one distinct group of small employers for each category specified in clause (i). `(C) SPECIAL RULE- An insurer may establish up to 2 groups under each category in subparagraph (A) or (B) to account for differences in characteristics (other than differences in plan benefits) of health insurance plans that are expected to produce substantial variation in health care costs. `(f) FULL DISCLOSURE OF RATING PRACTICES- `(1) IN GENERAL- At the time an insurer offers a health insurance plan to a small employer, the insurer shall fully disclose to the employer all of the following: `(A) Rating practices for small employer health insurance plans, including rating practices for different populations and benefit designs. `(B) The extent to which premium rates for the small employer are established or adjusted based upon the actual or expected variation in claims costs or health condition of the employees of such small employer and their dependents. `(C) The provisions concerning the insurer's right to change premium rates, the extent to which premiums can be modified, and the factors which affect changes in premium rates. `(2) NOTICE ON EXPIRATION- An insurer providing health insurance plans to small employers shall provide for notice, at least 60 days before the date of expiration of the health insurance plan, of the terms for renewal of the plan. Such notice shall include an explanation of the extent to which any increase in premiums is due to actual or expected claims experience of the individuals covered under the small employer's health insurance plan contract. `(g) ACTUARIAL CERTIFICATION- Each insurer shall file annually with the applicable regulatory authority a written statement by a member of the American Academy of Actuaries (or other individual acceptable to such authority) that, based upon an examination by the individual which includes a review of the appropriate records and of the actuarial assumptions of the insurer and methods used by the insurer in establishing premium rates for small employer health insurance plans-- `(1) the insurer is in compliance with the applicable provisions of this section, and `(2) the rating methods are actuarially sound. Each insurer shall retain a copy of such statement for examination at its principal place of business. `REQUIREMENTS FOR SMALL EMPLOYER HEALTH INSURANCE BENEFIT PACKAGE OFFERINGS `SEC. 2113. (a) BASIC AND STANDARD BENEFIT PACKAGES- `(1) IN GENERAL- If an insurer offers any health insurance plan to small employers in a State, the insurer shall also offer a health insurance plan providing for the standard benefit package defined in subsection (b) and a health insurance plan providing for the basic benefit package defined in subsection (c). `(2) MANAGED CARE OPTION- `(A) IN GENERAL- Except as provided in subparagraph (B), if an insurer offers a managed care plan in a State or a geographic area within a State to employers that are not small employers, the insurer must offer such managed care plan to small employers in the State or geographic area. `(B) SIZE LIMITS- An insurer may cease enrolling new small employer groups in a managed care plan if it ceases to enroll any new employer groups in such plan. `(b) STANDARD BENEFIT PACKAGE- `(1) IN GENERAL- Except as otherwise provided in this section, a health insurance plan providing for a standard benefit package shall be limited to payment for-- `(A) inpatient and outpatient hospital care, except that treatment for a mental disorder is subject to the special limitations described in subparagraph (E)(i); `(B) inpatient and outpatient physicians' services, except that psychotherapy or counseling for a mental disorder is subject to the special limitations described in subparagraph (E)(ii); `(C) diagnostic tests; `(D) preventive services limited to-- `(i) prenatal care and well-baby care provided to children who are 1 year of age or younger; `(ii) well child care; `(iii) Pap smears; `(iv) mammograms; and `(v) colorectal screening services; and `(E)(i) inpatient hospital care for a mental disorder for not less than 45 days per year, except that days of partial hospitalization or residential care may be substituted for days of inpatient care; and `(ii) outpatient psychotherapy and counseling for a mental disorder for not less than 20 visits per year provided by a provider who is acting within the scope of State law and who-- `(I) is a physician; or `(II) is a duly licensed or certified clinical psychologist or a duly licensed or certified clinical social worker, a duly licensed or certified equivalent mental health professional, or a clinic or center providing duly licensed or certified mental health services. `(2) AMOUNT, SCOPE, AND DURATION OF CERTAIN BENEFITS- `(A) IN GENERAL- Except as provided in subparagraph (B) and in paragraph (3), a health insurance plan providing for a standard benefit package shall place no limits on the amount, scope, or duration of benefits described in subparagraphs (A) through (C) of paragraph (1). `(B) PREVENTIVE SERVICES- A health insurance plan providing for a standard benefit package may limit the amount, scope, and duration of preventive services described in subparagraph (D) of paragraph (1) provided that the amount, scope, and duration of such services are reasonably consistent with recommendations and periodicity schedules developed by appropriate medical experts. `(3) EXCEPTIONS- Paragraph (1) shall not be construed as requiring a plan to include payment for-- `(A) items and services that are not medically necessary; `(B) routine physical examinations or preventive care (other than care and services described in subparagraph (D) of paragraph (1)); or `(C) experimental services and procedures. `(4) LIMITATION ON PREMIUMS- `(A) IN GENERAL- Except as provided in subparagraph (B), an insurer issuing a health insurance plan providing for a standard benefit package shall not require an employee to pay a monthly premium which exceeds 20 percent of the total monthly premium. `(B) PART-TIME EMPLOYEE EXCEPTED- In the case of a part-time employee, an insurer issuing a health insurance plan providing for a standard benefit package may require that such an employee pay a monthly premium that does not exceed 50 percent of the total monthly premium. `(5) LIMITATION ON DEDUCTIBLES- `(A) IN GENERAL- Except as permitted under subparagraph (B), a health insurance plan providing for a standard benefit package shall not provide a deductible amount for benefits provided in any plan year that exceeds-- `(i) with respect to benefits payable for items and services furnished to any employee with no family member enrolled under the plan, for a plan year beginning in-- `(I) a calendar year prior to 1993, $400; or `(II) for a subsequent calendar year, the limitation specified in this clause for the previous calendar year increased by the percentage increase in the consumer price index for all urban consumers (United States city average, as published by the Bureau of Labor Statistics) for the 12-month period ending on September 30 of the preceding calendar year; and `(ii) with respect to benefits payable for items and services furnished to any employee with a family member enrolled under the standard benefit package plan, for a plan year beginning in-- `(I) a calendar year prior to 1993, $400 per family member and $700 per family; or `(II) for a subsequent calendar year, the limitation specified in this clause for the previous calendar year increased by the percentage increase in the consumer price index for all urban consumers (United States city average, as published by the Bureau of Labor Statistics) for the 12-month period ending on September 30 of the preceding calendar year. If the limitation computed under clause (i)(II) or (ii)(II) is not a multiple of $10, it shall be rounded to the next highest multiple of $10. `(B) WAGE-RELATED DEDUCTIBLE- A health insurance plan may provide for any other deductible amount instead of the limitations under-- `(i) subparagraph (A)(i), if such amount does not exceed (on an annualized basis) 1 percent of the total wages paid to the employee in the plan year; or `(ii) subparagraph (A)(ii), if such amount does not exceed (on an annualized basis) 1 percent per family member or 2 percent per family of the total wages paid to the employee in the plan year. `(6) LIMITATION ON COPAYMENTS AND COINSURANCE- `(A) IN GENERAL- Subject to subparagraphs (B) through (D), a health insurance plan providing for a standard health benefit package may not require the payment of any copayment or coinsurance for an item or service for which coverage is required under this section-- `(i) in an amount that exceeds 20 percent of the amount payable for the item or service under the plan; or `(ii) after an employee and family covered under the plan have incurred out-of-pocket expenses under the plan that are equal to the out-of-pocket limit (as defined in subparagraph (E)(ii)) for a plan year. `(B) EXCEPTION FOR MANAGED CARE PLANS- A health insurance plan that is a managed care plan may require payments in excess of the amount permitted under subparagraph (A) in the case of items and services furnished by nonparticipating providers. `(C) EXCEPTION FOR IMPROPER UTILIZATION- A health insurance plan may provide for copayment or coinsurance in excess of the amount permitted under subparagraph (A) for any item or service that an individual obtains without complying with procedures established by a managed care plan or under a utilization program to ensure the efficient and appropriate utilization of covered services. `(D) EXCEPTIONS FOR MENTAL HEALTH CARE- In the case of care described in paragraph (1)(E)(ii), a health insurance plan shall not require payment of any copayment or coinsurance for an item or service for which coverage is required by this part in an amount that exceeds 50 percent of the amount payable for the item or service. `(7) LIMIT ON OUT-OF-POCKET EXPENSES- `(A) OUT-OF-POCKET EXPENSES DEFINED- As used in this section, the term `out-of-pocket expenses' means, with respect to an employee in a plan year, amounts payable under the plan as deductibles and coinsurance with respect to items and services provided under the plan and furnished in the plan year on behalf of the employee and family covered under the plan. `(B) OUT-OF-POCKET LIMIT DEFINED- As used in this section and except as provided in subparagraph (C), the term `out-of-pocket limit' means for a plan year beginning in-- `(i) a calendar year prior to 1993, $3,000; or `(ii) for a subsequent calendar year, the limit specified in this subparagraph for the previous calendar year increased by the percentage increase in the consumer price index for all urban consumers (United States city average, as published by the Bureau of Labor Statistics) for the 12-month period ending on September 30 of the preceding calendar year. If the limit computed under clause (ii) is not a multiple of $10, it shall be rounded to the next highest multiple of $10. `(C) ALTERNATIVE OUT-OF-POCKET LIMIT- A health insurance plan may provide for an out-of-pocket limit other than that defined in subparagraph (B) if, for a plan year with respect to an employee and the family of the employee, the limit does not exceed (on an annualized basis) 10 percent of the total wages paid to the employee in the plan year. `(c) BASIC BENEFITS PACKAGE- `(1) IN GENERAL- A health insurance plan providing for a basic benefit package shall be limited to payment for-- `(A) inpatient and outpatient hospital care, including emergency services; `(B) inpatient and outpatient physicians' services; `(C) diagnostic tests; `(D) preventive services (which may include one or more of the following services)-- `(i) prenatal care and well-baby care provided to children who are 1 year of age or younger; `(ii) well-child care; `(iii) Pap smears; `(iv) mammograms; and `(v) colorectal screening services. `(2) COST-SHARING- Each health insurance plan providing for the basic benefit package issued to a small employer by an insurer may impose premiums, deductibles, copayments, or other cost-sharing on enrollees of such plan. `(3) OUT-OF-POCKET LIMIT- Each health insurance plan providing for a basic benefit package shall provide for a limit on out-of-pocket expenses. `(d) PREEMPTION OF STATE MANDATED BENEFITS- No State law or regulation in effect in a State that requires health insurance plans offered to small employers in the State to include specified items and services other than those described in subsection (c) shall apply.'. Subtitle B--Tax Penalty on Noncomplying Insurers SEC. 211. EXCISE TAX ON PREMIUMS RECEIVED ON HEALTH INSURANCE POLICIES WHICH DO NOT MEET CERTAIN REQUIREMENTS. (a) IN GENERAL- Chapter 47 of the Internal Revenue Code of 1986 (relating to taxes on group health plans) is amended by adding at the end thereof the following new section: `SEC. 5000A. FAILURE TO SATISFY CERTAIN STANDARDS FOR HEALTH INSURANCE. `(a) GENERAL RULE- In the case of any person issuing a health insurance plan to a small employer, there is hereby imposed a tax on the failure of such person to meet at any time during any taxable year the applicable requirements of title XXI of the Social Security Act. The Secretary of Health and Human Services shall determine whether any person meets the requirements of such title. `(b) AMOUNT OF TAX- `(1) IN GENERAL- The amount of tax imposed by subsection (a) by reason of 1 or more failures during a taxable year shall be equal to 25 percent of the gross premiums received during such taxable year with respect to all health insurance plans issued to a small employer by the person on whom such tax is imposed. `(2) GROSS PREMIUMS- For purposes of paragraph (1), gross premiums shall include any consideration received with respect to any accident and health insurance contract. `(3) CONTROLLED GROUPS- For purposes of paragraph (1)-- `(A) CONTROLLED GROUP OF CORPORATIONS- All corporations which are members of the same controlled group of corporations shall be treated as 1 person. For purposes of the preceding sentence, the term `controlled group of corporations' has the meaning given to such term by section 1563(a), except that-- `(i) `more than 50 percent' shall be substituted for `at least 80 percent' each place it appears in section 1563(a)(1), and `(ii) the determination shall be made without regard to subsections (a)(4) and (e)(3)(C) of section 1563. `(B) PARTNERSHIPS, PROPRIETORSHIPS, ETC., WHICH ARE UNDER COMMON CONTROL- Under regulations prescribed by the Secretary, all trades or business (whether or not incorporated) which are under common control shall be treated as 1 person. The regulations prescribed under this subparagraph shall be based on principles similar to the principles which apply in the case of subparagraph (A). `(c) LIMITATION ON TAX- `(1) TAX NOT TO APPLY WHERE FAILURE NOT DISCOVERED EXERCISING REASONABLE DILIGENCE- No tax shall be imposed by subsection (a) with respect to any failure for which it is established to the satisfaction of the Secretary that the person on whom the tax is imposed did not know, and exercising reasonable diligence would not have known, that such failure existed. `(2) TAX NOT TO APPLY WHERE FAILURES CORRECTED WITHIN 30 DAYS- No tax shall be imposed by subsection (a) with respect to any failure if-- `(A) such failure was due to reasonable cause and not to willful neglect, and `(B) such failure is corrected during the 30-day period beginning on the 1st date any of the persons on whom the tax is imposed knew, or exercising reasonable diligence would have known, that such failure existed. `(3) WAIVER BY SECRETARY- In the case of a failure which is due to reasonable cause and not to willful neglect, the Secretary may waive part or all of the tax imposed by subsection (a) to the extent that the payment of such tax would be excessive relative to the failure involved. `(d) DEFINITIONS- For purposes of this section: `(1) HEALTH INSURANCE PLAN- The term `health insurance plan' means any hospital or medical service policy or certificate, hospital or medical service plan contract, or health maintenance organization group contract, and in States which have distinct licensure requirements, a multiple employer welfare arrangement, but does not include-- `(A) a self-insured health insurance plan; or `(B) any of the following: `(i) accident only, dental only, disability only, or long-term care only insurance, `(ii) coverage issued as a supplement to liability insurance, `(iii) workmen's compensation or similar insurance, or `(iv) automobile medical-payment insurance. `(2) SMALL EMPLOYER- The term `small employer' means, with respect to a calendar year, an employer that normally employs more than 1 but less than 51 eligible employees on a typical business day. For the purposes of this paragraph, the term `employee' includes a self-employed individual. `(3) ELIGIBLE EMPLOYEE- The term `eligible employee' means, with respect to an employer, an employee who normally performs on a monthly basis at least 30 hours of service per week for that employer. `(4) PERSON- The term `person' means any person that offers a health insurance plan to a small employer, including a licensed insurance company, a prepaid hospital or medical service plan, a health maintenance organization, or in States which have distinct insurance licensure requirements, a multiple employer welfare arrangement.'. (b) NONDEDUCTIBILITY OF TAX- Paragraph (6) of section 275(a) of such Code (relating to nondeductibility of certain taxes) is amended by inserting `47,' after `46,'. (c) CLERICAL AMENDMENTS- The table of sections for such chapter 47 is amended by adding at the end thereof the following new item: `Sec. 5000A. Failure to satisfy certain standards for health insurance.'. (d) EFFECTIVE DATES- (1) IN GENERAL- The amendments made by subsections (a) and (c) shall take effect on the date of the enactment of this Act. (2) NONDEDUCTIBILITY OF TAX- The amendment made by subsection (b) shall apply to taxable years beginning after December 31, 1991. Subtitle C--Studies and Reports SEC. 221. GAO STUDY AND REPORT ON RATING REQUIREMENTS AND BENEFIT PACKAGES FOR SMALL GROUP HEALTH INSURANCE. (a) IN GENERAL- The Comptroller General of the United States shall study and report to the Congress by no later than January 1, 1995, on-- (1) the impact of the standards for rating practices for small group health insurance established under section 2112 of the Social Security Act and the requirements for benefit packages established under section 2113 of such Act on the availability and price of insurance offered to small employers, differences in available benefit packages, and the number of small employers choosing standard or basic packages; and (2) differences in State laws and regulations affecting the availability and price of health insurance plans sold to individuals and the impact of such laws and regulations, including the extension of requirements for health insurance plans sold to small employers in the State to individual health insurance and the establishment of State risk pools for individual health insurance. (b) RECOMMENDATIONS- The Comptroller General shall include in the report to Congress under this section recommendations for adjusting rating standards under section 2112 of the Social Security Act-- (1) to eliminate variation in premiums charged to small employers resulting from adjustments for such factors as claims experience and health status, and (2) to eliminate variation in premiums associated with age, sex, and other demographic factors. TITLE III--IMPROVEMENTS IN PORTABILITY OF PRIVATE HEALTH INSURANCE SEC. 301. EXCISE TAX IMPOSED ON FAILURE TO PROVIDE FOR PREEXISTING CONDITION. (a) IN GENERAL- Chapter 47 of the Internal Revenue Code of 1986 (relating to taxes on group health plans), as amended by section 211, is further amended by adding at the end thereof the following new section: `SEC. 5000B. FAILURE TO SATISFY PREEXISTING CONDITION REQUIREMENTS OF GROUP HEALTH PLANS. `(a) GENERAL RULE- There is hereby imposed a tax on the failure of-- (1) a group health plan to meet the requirements of subsection (e), or (2) any person to meet the requirements of subsection (f), with respect to any covered individual. `(b) AMOUNT OF TAX- `(1) IN GENERAL- The amount of the tax imposed by subsection (a) on any failure with respect to a covered individual shall be $100 for each day in the noncompliance period with respect to such failure. `(2) NONCOMPLIANCE PERIOD- For purposes of this section, the term `noncompliance period' means, with respect to any failure, the period-- `(A) beginning on the date such failure first occurs, and `(B) ending on the date such failure is corrected. `(3) CORRECTION- A failure of a group health plan to meet the requirements of subsection (e) with respect to any covered individual shall be treated as corrected if-- `(A) such failure is retroactively undone to the extent possible, and `(B) the covered individual is placed in a financial position which is as good as such individual would have been in had such failure not occurred. For purposes of applying subparagraph (B), the covered individual shall be treated as if the individual had elected the most favorable coverage in light of the expenses incurred since the failure first occurred. `(c) LIMITATIONS ON AMOUNT OF TAX- `(1) TAX NOT TO APPLY WHERE FAILURE NOT DISCOVERED EXERCISING REASONABLE DILIGENCE- No tax shall be imposed by subsection (a) on any failure during any period for which it is established to the satisfaction of the Secretary that none of the persons referred to in subsection (d) knew, or exercising reasonable diligence would have known, that such failure existed. `(2) TAX NOT TO APPLY TO FAILURES CORRECTED WITHIN 30 DAYS- No tax shall be imposed by subsection (a) on any failure if-- `(A) such failure was due to reasonable cause and not to willful neglect, and `(B) such failure is corrected during the 30-day period beginning on the first date any of the persons referred to in subsection (d) knew, or exercising reasonable diligence would have known, that such failure existed. `(3) WAIVER BY SECRETARY- In the case of a failure which is due to reasonable cause and not to willful neglect, the Secretary may waive part or all of the tax imposed by subsection (a) to the extent that the payment of such tax would be excessive relative to the failure involved. `(d) LIABILITY FOR TAX- `(1) IN GENERAL- Except as otherwise provided in this subsection, the following shall be liable for the tax imposed by subsection (a) on a failure: `(A) In the case of a group health plan other than a self-insured group health plan, the issuer. `(B)(i) In the case of a self-insured group health plan other than a multiemployer group health plan, the employer. `(ii) In the case of a self-insured group health multiemployer plan, the plan. `(C) Each person who is responsible (other than in a capacity as an employee) for administering or providing benefits under the group health plan, health insurance plan, or other health benefit arrangement (including a self-insured plan) and whose act or failure to act caused (in whole or in part) the failure. `(2) SPECIAL RULES FOR PERSONS DESCRIBED IN PARAGRAPH (1)(C)- A person described in subparagraph (C) (and not in subparagraphs (A) and (B)) of paragraph (1) shall be liable for the tax imposed by subsection (a) on any failure only if such person assumed (under a legally enforceable written agreement) responsibility for the performance of the act to which the failure relates. `(e) NO DISCRIMINATION BASED ON HEALTH STATUS FOR CERTAIN SERVICES- `(1) IN GENERAL- Except as provided under paragraph (2), group health plans may not deny, limit, or condition the coverage under (or benefits of) the plan based on the health status, claims experience, receipt of health care, medical history, or lack of evidence of insurability, of an individual. `(2) TREATMENT OF PREEXISTING CONDITION EXCLUSIONS FOR ALL SERVICES- `(A) IN GENERAL- Subject to the succeeding provisions of this paragraph, group health plans may exclude coverage with respect to services related to treatment of a preexisting condition, but the period of such exclusion may not exceed 6 months. The exclusion of coverage shall not apply to services furnished to newborns. `(B) CREDITING OF PREVIOUS COVERAGE- `(i) IN GENERAL- A group health plan shall provide that if an individual under such plan is in a period of continuous coverage (as defined in clause (ii)(I)) with respect to particular services as of the date of initial coverage under such plan (determined without regard to any waiting period under such plan), any period of exclusion of coverage with respect to a preexisting condition for such services or type of services shall be reduced by 1 month for each month in the period of continuous coverage without regard to any waiting period. `(ii) DEFINITIONS- As used in this subparagraph: `(I) PERIOD OF CONTINUOUS COVERAGE- The term `period of continuous coverage' means, with respect to particular services, the period beginning on the date an individual is enrolled under a health insurance plan, title XVIII or XIX of the Social Security Act, or other health benefit arrangement (including a self-insured plan) which provides benefits with respect to such services and ends on the date the individual is not so enrolled for a continuous period of more than 3 months. `(II) PREEXISTING CONDITION- The term `preexisting condition' means, with respect to coverage under a group health plan, a condition which has been diagnosed or treated during the 3-month period ending on the day before the first date of such coverage without regard to any waiting period. `(f) DISCLOSURE OF COVERAGE, ETC- Any person who has provided coverage (other than under title XVIII or XIX of the Social Security Act) during a period of continuous coverage (as defined in subsection (e)(2)(B)(ii)(I)) with respect to a covered individual shall disclose, upon the request of a group health plan subject to the requirements of subsection (e), the coverage provided the covered individual, the period of such coverage, and the benefits provided under such coverage. `(g) DEFINITIONS- For purposes of this section-- `(1) COVERED INDIVIDUAL- The term `covered individual' means-- `(A) an individual who is (or will be) provided coverage under a group health plan by virtue of the performance of services by the individual for 1 or more persons maintaining the plan (including as an employee defined in section 401(c)(1)), and `(B) the spouse or any dependent child of such individual. `(2) GROUP HEALTH PLAN- The term `group health plan' has the meaning given such term by section 5000(b)(1).'. (b) CLERICAL AMENDMENT- The table of sections for such chapter 47 is amended by adding at the end thereof the following new item: `Sec. 5000B. Failure to satisfy preexisting condition requirements of group health plans.'. (c) EFFECTIVE DATE- The amendments made by this section shall apply to plan years beginning after December 31, 1992. TITLE IV--HEALTH CARE COST CONTAINMENT SEC. 401. ESTABLISHMENT OF HEALTH CARE COST COMMISSION. (a) IN GENERAL- There is hereby established a Health Care Cost Commission (in this title referred to as the `Commission'). The Commission shall be composed of 11 members, appointed by the President by and with the advice and consent of the Senate. The membership of the Commission shall include individuals with national recognition for their expertise in health insurance, health economics, health care provider reimbursement, and related fields. In appointing individuals, the President shall assure representation of consumers of health services, large and small employers, State and local governments, labor organizations, health care providers, and health care insurers. (b) TERMS- Members of the Commission shall be appointed to serve for terms of 3 years, except that the terms of the members first appointed shall be staggered so that the terms of no more than 4 members expire in any year. The term of the Chairman shall be coincident with the term of the President. Individuals appointed to fill a vacancy created in the Commission shall be appointed for the remainder of the term. (c) DUTIES- (1) ANNUAL REPORT- (A) IN GENERAL- The Commission shall report annually to the President and the Congress on national health care costs. Such report shall be made by March 30 of each year and shall include information on-- (i) levels and trends in public and private health care spending by type of health care service, geographic region of the country, and public and private sources of payment; (ii) levels and trends in the cost of private health insurance coverage for individuals and groups; (iii) sources of high and rising health care costs, including inflation in input prices, demographic changes and the utilization, supply and distribution of health care services; and (iv) comparative trends in other countries and reasons for any differences from trends in the United States. (B) ASSESSMENT AND RECOMMENDATIONS- The report shall also discuss and assess the impact of public and private efforts to reduce growth in health care spending, and shall include recommendations for cost containment efforts. (2) STUDY OF ADMINISTRATIVE COSTS- As part of its first annual report, the Commission shall report on the impact of administrative costs on national health spending, and make recommendations as to how these costs could be minimized. The Commission shall, in consultation with health care insurers and providers, recommend a model national uniform claims form and model national reporting standards for clinical and administrative data, and assess the impact of mandating the use of these models on national health care spending. (3) STANDARDS FOR MANAGED CARE- The Commission shall make recommendations to the Secretary of Health and Human Services for the development and ongoing review of standards for managed care plans and utilization review programs (as defined under section 2114 of title XXI of the Social Security Act). (d) MISCELLANEOUS- (1) AUTHORITY- The Commission may-- (A) employ and fix compensation of an Executive Director and such other personnel (not to exceed 25) as may be necessary to carry out its duties (without regard to the provisions of title 5, United States Code, governing appointments in the competitive service); (B) seek such assistance and support as may be required in the performance of its duties from appropriate Federal departments and agencies; (C) enter into contracts or make other arrangements, as may be necessary for the conduct of the work of the Commission (without regard to section 3709 of the Revised Statutes (41 U.S.C. 5)); and (D) make advance, progress, and other payments which relate to the work of the Commission. (2) COMPENSATION- While serving on the business of the Commission (including traveltime), a member of the Commission shall be entitled to compensation at the per diem equivalent of the rate provided for level IV of the Executive Schedule under section 5315 of title 5, United States Code; and while so serving away from the member's home and regular place of business, a member may be allowed travel expenses, as authorized by the Chairman of the Commission. Physicians serving as personnel of the Commission may be provided a physician comparability allowance by the Commission in the same manner as Government physicians may be provided such an allowance by an agency under section 5948 of title 5, United States Code, and for such purpose subsection (i) of such section shall apply to the Commission in the same manner as it applies to the Tennessee Valley Authority. (3) ACCESS TO INFORMATION, ETC- The Commission shall have access to such relevant information and data as may be available from appropriate Federal agencies and shall assure that its activities, especially the conduct of original research and medical studies, are coordinated with the activities of Federal agencies. The Commission shall be subject to periodic audit by the General Accounting Office. (4) AUTHORIZATION OF APPROPRIATIONS- There are authorized to be appropriated such sums as may be necessary to carry out this section. SEC. 402. FEDERAL CERTIFICATION OF MANAGED CARE PLANS AND UTILIZATION REVIEW PROGRAMS. Title XXI of the Social Security Act, as added by title II of this Act, is amended by adding at the end the following part: `Part C--Federal Certification of Managed Care Plans `FEDERAL CERTIFICATION OF MANAGED CARE PLANS AND UTILIZATION REVIEW PROGRAMS `SEC. 2114. (a) VOLUNTARY CERTIFICATION PROCESS- `(1) CERTIFICATION- The Secretary shall establish a process for certification of managed care plans meeting the requirements of subsection (b)(1) and of utilization review programs meeting the requirements of subsection (b)(2). `(2) QUALIFIED MANAGED CARE PLAN- For purposes of this title, the term `qualified managed care plan' means a managed care plan that the Secretary certifies, upon application by the program, as meeting the requirements of this section. `(3) QUALIFIED UTILIZATION REVIEW PROGRAM- For purposes of this title, the term `qualified utilization review program' means a utilization review program that the Secretary certifies, upon application by the program, as meeting the requirements of this section. `(4) UTILIZATION REVIEW PROGRAM- For purposes of this title, the term `utilization review program' means a system of reviewing the medical necessity, appropriateness, or quality of health care services and supplies provided under a health insurance plan or a managed care plan using specified guidelines. Such a system may include preadmission certification, the application of practice guidelines, continued stay review, discharge planning, preauthorization of ambulatory procedures, and retrospective review. `(5) MANAGED CARE PLAN- `(A) IN GENERAL- For purposes of this title the term `managed care plan' means a plan operated by a managed care entity as described in subparagraph (B), that provides for the financing and delivery of health care services to persons enrolled in such plan through-- `(i) arrangements with selected providers to furnish health care services; `(ii) explicit standards for the selection of participating providers; `(iii) organizational arrangements for ongoing quality assurance and utilization review programs; and `(iv) financial incentives for persons enrolled in the plan to use the participating providers and procedures provided for by the plan. `(B) MANAGED CARE ENTITY DEFINED- For purposes of this title, a managed care entity includes a licensed insurance company, hospital or medical service plan, health maintenance organization, an employer, or employee organization, or a managed care contractor as described in subparagraph (C), that operates a managed care plan. `(C) MANAGED CARE CONTRACTOR DEFINED- For purposes of this title, a managed care contractor means a person that-- `(i) establishes, operates or maintains a network of participating providers; `(ii) conducts or arranges for utilization review activities; and `(iii) contracts with an insurance company, a hospital or medical service plan, an employer, an employee organization, or any other entity providing coverage for health care services to operate a managed care plan. `(6) PARTICIPATING PROVIDER- The term `participating provider' means a physician, hospital, pharmacy, laboratory, or other appropriately licensed provider of health care services or supplies, that has entered into an agreement with a managed care entity to provide such services or supplies to a patient enrolled in a managed care plan. `(7) REVIEW AND RECERTIFICATION- The Secretary shall establish procedures for the periodic review and recertification of qualified managed care plans and qualified utilization review programs. `(8) TERMINATION OF CERTIFICATION- The Secretary shall terminate the certification of a qualified managed care plan or a qualified utilization review program if the Secretary determines that such plan or program no longer meets the applicable requirements for certification. Before effecting a termination, the Secretary shall provide the plan notice and opportunity for a hearing on the proposed termination. `(9) CERTIFICATION THROUGH ALTERNATIVE REQUIREMENTS- `(A) CERTAIN ORGANIZATIONS RECOGNIZED- An eligible organization as defined in section 1876(b), shall be deemed to meet the requirements of subsection (b) for certification as a qualified managed care plan. `(B) RECOGNITION OF ACCREDITATION- If the Secretary finds that a State licensure program or a national accreditation body establishes a requirement or requirements for accreditation of a managed care plan or utilization review program that are at least equivalent to a requirement or requirements established under subsection (b), the Secretary may, to the extent he finds it appropriate, treat a managed care plan or a utilization review program thus accredited as meeting the requirement or requirements of subsection (b) with respect to which he made such finding. `(b) REQUIREMENTS FOR CERTIFICATION- `(1) MANAGED CARE PLANS- The Secretary, in consultation with the Health Care Cost Commission, shall establish Federal standards for the certification of qualified managed care plans, including standards related to-- `(A) the qualification and selection of participating providers; `(B) the number, type, and distribution of participating providers necessary to assure that all covered items and services are available and accessible to plan enrollees; `(C) the establishment and operation of an ongoing quality assurance program, which includes procedures for-- `(i) evaluating the quality and appropriateness of care; `(ii) using the results of quality evaluations to promote and improve quality of care; and `(iii) resolving complaints from enrollees regarding quality and appropriateness of care; `(D) the provision of benefits for covered items and services not furnished by participating providers if the items and services are medically necessary and immediately required because of an unforeseen illness, injury, or condition; `(E) the qualifications of individuals performing utilization review activities; `(F) utilization review procedures and criteria for evaluating the necessity and appropriateness of health care services; `(G) the timeliness with which utilization review determinations are to be made; `(H) procedures for the operation of an appeals process which provides a fair opportunity for individuals adversely affected by a managed care review determination to have such determination reviewed; and `(I) procedures for ensuring that all applicable Federal and State laws designed to protect the confidentiality of individual medical records are followed. `(2) QUALIFIED UTILIZATION REVIEW PROGRAMS- The Secretary, in consultation with the Health Care Cost Commission, shall establish Federal standards for the certification of qualified utilization review programs, including standards related to-- `(A) the qualifications of individuals performing utilization review activities; `(B) procedures for evaluating the necessity and appropriateness of health care services; `(C) the timeliness with which utilization review determinations are to be made; `(D) procedures for the operation of an appeals process which provides a fair opportunity for individuals adversely affected by a utilization review determination to have such determination reviewed; and `(E) procedures for ensuring that all applicable Federal and State laws designed to protect the confidentiality of individual medical records are followed. `(3) APPLICATION OF STANDARDS- `(A) IN GENERAL- Standards shall first be established under this subsection by not later than 24 months after the date of the enactment of this section. In developing standards under this subsection, the Secretary shall-- `(i) review standards in use by national private accreditation organizations and State licensure programs; `(ii) recognize, to the extent appropriate, differences in the organizational structure and operation of managed care plans; and `(iii) establish procedures for the timely consideration of applications for certification by managed care plans and utilization review programs. `(B) REVISION OF STANDARDS- The Secretary shall periodically review the standards established under this subsection, taking into account recommendations by the Health Care Cost Commission, and may revise the standards from time to time to assure that such standards continue to reflect appropriate policies and practices for the cost-effective and medically appropriate use of services within managed care plans and utilization review programs. `(c) LIMITATION ON STATE RESTRICTIONS ON QUALIFIED MANAGED CARE PLANS AND UTILIZATION REVIEW PROGRAMS- `(1) IN GENERAL- No requirement of any State law or regulation shall-- `(A) prohibit or limit a qualified managed care plan from including financial incentives for enrollees to use the services of participating providers; `(B) prohibit or limit a qualified managed care plan from restricting coverage of services to those-- `(i) provided by a participating provider; or `(ii) authorized by a designated participating provider; `(C) subject to paragraph (2)-- `(i) restrict the amount of payment made by a qualified managed care plan to participating providers for services provided to enrollees; or `(ii) restrict the ability of a qualified managed care plan to pay participating providers for services provided to enrollees on a per-enrollee basis; `(D) prohibit or limit a qualified managed care plan from restricting the location, number, type, or professional qualifications of participating providers; `(E) prohibit or limit a qualified managed care plan from requiring that services be authorized by a primary care physician selected by the enrollee from a list of available participating providers; `(F) prohibit or limit the use of utilization review procedures or criteria by a qualified utilization review program or a qualified managed care plan; `(G) require a qualified utilization review program or a qualified managed care plan to make public utilization review procedures or criteria; `(H) prohibit or limit a qualified utilization review program or a qualified managed care plan from determining the location or hours of operation of a utilization review, provided that emergency services furnished during the hours in which the utilization review program is not open are not subject to utilization review; `(I) require a qualified utilization review program or a qualified managed care plan to pay providers for the expenses associated with responding to requests for information needed to conduct utilization review; `(J) restrict the amount of payment made to a qualified utilization review program or a qualified managed care plan for the conduct of utilization review; `(K) restrict access by a qualified utilization review program or a qualified managed care plan to medical information or personnel required to conduct utilization review; `(L) define utilization review as the practice of medicine or another health care profession; or `(M) require that utilization review be conducted (i) by a resident of the State in which the treatment is to be offered or by an individual licensed in such State, or (ii) by a physician in any particular specialty or with any board certified specialty of the same medical specialty as the provider whose services are being rendered. `(2) EXCEPTIONS TO CERTAIN REQUIREMENTS- `(A) SUBPARAGRAPH (C)- Subparagraph (C) shall not apply where the amount of payments with respect to a block of services or providers is established under a statewide system applicable to all non-Federal payors with respect to such services or providers. `(B) SUBPARAGRAPHS (L) AND (M)- Nothing in subparagraphs (L) or (M) shall be construed as prohibiting a State from (i) requiring that utilization review be conducted by a licensed health care professional or (ii) requiring that any appeal from such a review be made by a licensed physician or by a licensed physician in any particular specialty or with any board certified specialty of the same medical specialty as the provider whose services are being rendered.'. SEC. 403. ADDITIONAL FUNDING FOR OUTCOMES RESEARCH. (a) INITIAL GUIDELINES AND STANDARDS- Subsection (d) of section 912 of the Public Health Service Act is amended to read as follows: `(d) INITIAL GUIDELINES AND STANDARDS- `(1) IN GENERAL- Not later than January 1, 1992, the Administrator shall assure the development of an initial set of guidelines as described in subsection (a)(1) that shall include not less than three clinical treatments or conditions that-- `(A) account for a significant portion of national health expenditures; `(B) have a significant variation in the frequency or the type of treatment provided; or `(C) otherwise meet the needs and priorities described in this section. `(2) MENTAL HEALTH SERVICES- The Administrator, in consultation with the National Institute of Mental Health and mental health providers, shall develop outcomes research and practice parameters for mental health services including at least the diagnosis and treatment of childhood attention deficit syndrome disorders and manic depression.'. (b) AMENDMENTS TO THE SOCIAL SECURITY ACT- Section 1142(i) of the Social Security Act is amended-- (1) in paragraph (1), to read as follows: `(1) IN GENERAL- There are authorized to be appropriated to carry out this section-- `(A) $175,000,000 for fiscal year 1992; `(B) $225,000,000 for fiscal year 1993; and `(C) $275,000,000 for fiscal year 1994.'; and (2) in paragraph (2), by striking out `70 percent' and inserting in lieu thereof `50 percent'. SEC. 404. UNIFORM CLAIMS FORMS. (a) DEVELOPMENT- The Secretary of Health and Human Services, after consultation with the Commission, entities offering group health plans, and health care providers, shall develop uniform claims forms for use by beneficiaries and health care providers in submitting claims under group health plans and the medicare and medicaid programs. (b) DEADLINE- Such forms shall be developed so that their acceptance by group health plans and the medicare and medicaid programs may be required for services furnished on or after January 1, 1994. SEC. 405. LIABILITY PROTECTIONS FOR CERTAIN HEALTH CARE PROFESSIONALS; HOSPITAL ADMITTING PRIVILEGES FOR CERTAIN HEALTH CARE PROVIDERS. (a) LIABILITY PROTECTIONS FOR CERTAIN HEALTH CARE PROVIDERS- Section 224 of the Public Health Service Act (42 U.S.C. 233) is amended by adding at the end the following new subsection: `(g)(1) For purposes of this section, a public or nonprofit private entity receiving Federal funds under section 329, 330, or 340, and any officer, employee, or contractor of such an entity who is a physician or other licensed health care practitioner shall, while performing functions pursuant to any of such sections, be deemed to be an employee of the Public Health Service. `(2) If, with respect to an entity or person deemed to be an employee for purposes of paragraph (1), a cause of action is instituted against the United States pursuant to this section, any claim of the entity or person for benefits under an insurance policy with respect to medical malpractice relating to such cause of action shall be subrogated to the United States. `(3) This subsection shall apply with respect to a cause of action only if the claim accrues on or after the effective date of this subsection.'. (b) REQUIREMENT OF APPROPRIATE POLICIES AND PROCEDURES REGARDING HEALTH CARE PROFESSIONALS- (1) IN GENERAL- Section 224 of the Public Health Service Act, as amended by subsection (a) of this section, is further amended by adding at the end the following new subsection: `(h) The Secretary may not make a grant to an entity under section 329, 330, or 340 unless the entity-- `(1) has implemented appropriate policies and procedures to assure against malpractice in all health or health-related functions performed by the entity; `(2) has reviewed and verified the professional credentials, references, claims history, fitness, professional review organization findings, and license status of its physicians and other licensed health care practitioners, and, where necessary, has obtained the permission from these individuals to gain access to this information; and `(3) has no history of claims having been filed against it pursuant to this section, or, if such a history exists, has fully cooperated with the Attorney General in defending against any such claims and either has taken, or will take, such corrective steps to assure against such claims in the future.'. (2) EFFECTIVE DATE- The amendment made by paragraph (1) shall take effect on October 1, 1992, or on the date of the enactment of this Act, whichever occurs later. (c) AUTHORIZATION FOR THE ATTORNEY GENERAL TO EXCLUDE CERTAIN HEALTH CARE PROFESSIONALS FROM COVERAGE- Section 224 of the Public Health Service Act, as amended by subsections (a) and (b) of this section, is further amended by adding at the end the following new subsection: `(i)(1) Notwithstanding subsection (g)(1), the Attorney General, in consultation with the Secretary, may determine, after notice and opportunity for a hearing, that an individual physician or other licensed health care practitioner who is an officer, employee, or contractor of an entity described in subsection (g)(1) shall not be deemed to be an employee of the Public Health Service for purposes of this section, if treating such individual as such an employee would expose the Government to an unreasonably high degree of risk of loss because such individual-- `(A) does not comply with the policies and procedures to assure against malpractice that the entity has implemented pursuant to subsection (h)(1); `(B) has a history of claims filed against him or her pursuant to this section that is outside the norm for a Public Health Service physician or other licensed health care practitioner; `(C) refused to reasonably cooperate with the Attorney General in defending against any such claim; `(D) provided false information relevant to the individual's performance of his or her duties to the Secretary, the Attorney General, or an applicant for or recipient of funds under section 329, 330, or 340; or `(E) was the subject of disciplinary action taken by a State medical licensing authority or a State or national professional society. `(2) A final determination by the Attorney General under this subsection that an individual physician or other licensed health care professional shall not be deemed to be an employee of the Public Health Service shall be effective upon receipt by the entity employing such individual of notice of such determination, and shall apply only to claims accruing after the date such notice is received.'. (d) HOSPITAL ADMITTING PRIVILEGES FOR CERTAIN HEALTH CARE PROVIDERS- Section 224 of the Public Health Service Act, as amended by subsections (a), (b), and (c) of this section, is further amended by adding at the end the following new subsection: `(j) In the case of a health care provider who is an officer, employee, or contractor of an entity described in subsection (g)(1), section 335(e) shall apply with respect to the provider to the same extent and in the same manner as such section applies to any member of the National Health Service Corps.'. (e) EFFECTIVE DATE- Except as provided in subsection (b)(2), the amendments made by this section shall take effect on the date of the enactment of this Act. TITLE V--MEDICARE PREVENTION BENEFITS SEC. 501. COVERAGE OF COLORECTAL SCREENING. (a) IN GENERAL- Section 1834 of the Social Security Act (42 U.S.C. 1395m) is amended by inserting after subsection (c) the following new subsection: `(d) FREQUENCY AND PAYMENT LIMITS FOR SCREENING FECAL-OCCULT BLOOD TESTS AND SCREENING FLEXIBLE SIGMOIDOSCOPIES- `(1) SCREENING FECAL-OCCULT BLOOD TESTS- `(A) PAYMENT LIMIT- In establishing fee schedules under section 1833(h) with respect to screening fecal-occult blood tests provided for the purpose of early detection of colon cancer, except as provided by the Secretary under paragraph (3)(A), the payment amount established for tests performed-- `(i) in 1992 shall not exceed $5; and `(ii) in a subsequent year, shall not exceed the limit on the payment amount established under this subsection for such tests for the preceding year, adjusted by the applicable adjustment under section 1833(h) for tests performed in such year. `(B) FREQUENCY LIMIT- Subject to revision by the Secretary under paragraph (3)(B), no payment may be made under this part for a screening fecal-occult blood test provided to an individual for the purpose of early detection of colon cancer-- `(i) if the individual is under 50 years of age; or `(ii) if the test is performed within 11 months after a previous screening fecal-occult blood test. `(2) SCREENING FLEXIBLE SIGMOIDOSCOPIES- `(A) PAYMENT AMOUNT- The Secretary shall establish a payment amount under section 1848 with respect to screening flexible sigmoidoscopies provided for the purpose of early detection of colon cancer that is consistent with payment amounts under such section for similar or related services, except that such payment amount shall be established without regard to subsection (a)(2)(A) of such section. `(B) FREQUENCY LIMIT- Subject to revision by the Secretary under paragraph (3)(B), no payment may be made under this part for a screening flexible sigmoidoscopy provided to an individual for the purpose of early detection of colon cancer-- `(i) if the individual is under 50 years of age; or `(ii) if the procedure is performed within 59 months after a previous screening flexible sigmoidoscopy. `(3) REDUCTIONS IN PAYMENT LIMIT AND REVISION OF FREQUENCY- `(A) REDUCTIONS IN PAYMENT LIMIT- The Secretary shall review from time to time the appropriateness of the amount of the payment limit established for screening fecal-occult blood tests under paragraph (1)(A). The Secretary may, with respect to tests performed in a year after 1994, reduce the amount of such limit as it applies nationally or in any area to the amount that the Secretary estimates is required to assure that such tests of an appropriate quality are readily and conveniently available during the year. `(B) REVISION OF FREQUENCY- `(i) REVIEW- The Secretary, in consultation with the Director of the National Cancer Institute, shall review periodically the appropriate frequency for performing screening fecal-occult blood tests and screening flexible sigmoidoscopies based on age and such other factors as the Secretary believes to be pertinent. `(ii) REVISION OF FREQUENCY- The Secretary, taking into consideration the review made under clause (i), may revise from time to time the frequency with which such tests and procedures may be paid for under this subsection, but no such revision shall apply to tests or procedures performed before January 1, 1995. `(4) LIMITING CHARGES OF NONPARTICIPATING PHYSICIANS- `(A) IN GENERAL- In the case of a screening flexible sigmoidoscopy provided to an individual for the purpose of early detection of colon cancer for which payment may be made under this part, if a nonparticipating physician provides the procedure to an individual enrolled under this part, the physician may not charge the individual more than the limiting charge (as defined in subparagraph (B), or, if less, as defined in section 1848(g)(2)). `(B) LIMITING CHARGE DEFINED- In subparagraph (A), the term `limiting charge' means, with respect to a procedure performed-- `(i) in 1992, 120 percent of the payment limit established under paragraph (2)(A); or `(ii) after 1992, 115 percent of such applicable limit. `(C) ENFORCEMENT- If a physician or supplier knowing and willfully imposes a charge in violation of subparagraph (A), the Secretary may apply sanctions against such physician or supplier in accordance with section 1842(j)(2).'. (b) CONFORMING AMENDMENTS- (1) Paragraphs (1)(D) and (2)(D) of section 1833(a) of such Act (42 U.S.C. 1395l(a)) are each amended by striking `subsection (h)(1),' and inserting `subsection (h)(1) or section 1834(d)(1),'. (2) Section 1833(h)(1)(A) of such Act (42 U.S.C. 1395l(h)(1)(A)) is amended by striking `The Secretary' and inserting `Subject to paragraphs (1) and (3)(A) of section 1834(d), the Secretary'. (3) Clauses (i) and (ii) of section 1848(a)(2)(A) of such Act (42 U.S.C. 1395w-4(a)(2)(A)) are each amended by striking `a service' and inserting `a service (other than a screening flexible sigmoidoscopy provided to an individual for the purpose of early detection of colon cancer)'. (4) Section 1862(a) of such Act (42 U.S.C. 1395y(a)) is amended-- (A) in paragraph (1)-- (i) in subparagraph (E), by striking `and' at the end, (ii) in subparagraph (F), by striking the semicolon at the end and inserting `, and', and (iii) by adding at the end the following new subparagraph: `(G) in the case of screening fecal-occult blood tests and screening flexible sigmoidoscopies provided for the purpose of early detection of colon cancer, which are performed more frequently than is covered under section 1834(d);'; and (B) in paragraph (7), by striking `paragraph (1)(B) or under paragraph (1)(F)' and inserting `subparagraphs (B), (F), or (G) of paragraph (1)'. (c) EFFECTIVE DATE- The amendments made by this section shall apply to screening fecal-occult blood tests and screening flexible sigmoidoscopies performed on or after January 1, 1992. SEC. 502. COVERAGE OF CERTAIN IMMUNIZATIONS. (a) IN GENERAL- Section 1861(s)(10) of the Social Security Act (42 U.S.C. 1395x(s)(10)) is amended-- (1) in subparagraph (A)-- (A) by striking `, subject to section 4071(b) of the Omnibus Budget Reconciliation Act of 1987,', and (B) by striking `; and' and inserting a comma; (2) in subparagraph (B), by striking the semicolon at the end and inserting `, and'; and (3) by adding at the end the following new subparagraph: `(C) tetanus-diphtheria booster and its administration;'. (b) LIMITATION ON FREQUENCY- Section 1862(a)(1) of such Act (42 U.S.C. 1395y(a)(1)), as amended by section 502(b)(4)(A), is amended-- (1) in subparagraph (F), by striking `and' at the end; (2) in subparagraph (G), by striking the semicolon at the end and inserting `, and'; and (3) by adding at the end the following new subparagraph: `(H) in the case of an influenza vaccine, which is administered within the 11 months after a previous influenza vaccine, and, in the case of a tetanus-diphtheria booster, which is administered within the 119 months after a previous tetanus-diphtheria booster;'. (c) CONFORMING AMENDMENT- Section 1862(a)(7) of such Act (42 U.S.C. 1395y(a)(7)), as amended by section 502(b)(4)(B), is amended by striking `or (G)' and inserting `(G), or (H)'. (d) EFFECTIVE DATE- The amendments made by this section shall apply to influenza vaccines and tetanus-diphtheria boosters administered on or after January 1, 1992. SEC. 503. COVERAGE OF WELL-CHILD CARE. (a) IN GENERAL- Section 1861(s)(2) of the Social Security Act (42 U.S.C. 1395x(s)(2)) is amended-- (1) by striking `and' at the end of subparagraph (O); (2) by striking the semicolon at the end of subparagraph (P) and inserting `; and'; and (3) by adding at the end the following new subparagraph: `(Q) well-child services (as defined in subsection (ll)(1)) provided to an individual entitled to benefits under this title who is under 7 years of age;'. (b) SERVICES DEFINED- Section 1861 of such Act (42 U.S.C. 1395x) is amended-- (1) by redesignating the subsection (jj) added by section 4163(a)(2) of the Omnibus Budget Reconciliation Act of 1990 as subsection (kk); and (2) by inserting after subsection (kk) (as so redesignated) the following new subsection: `WELL-CHILD SERVICES `(ll)(1) The term `well-child services' means well-child care, including routine office visits, routine immunizations (including the vaccine itself), routine laboratory tests, and preventive dental care, provided in accordance with the periodicity schedule established with respect to the services under paragraph (2). `(2) The Secretary, in consultation with the American Academy of Pediatrics, the Advisory Committee on Immunization Practices, and other entities considered appropriate by the Secretary, shall establish a schedule of periodicity which reflects the appropriate frequency with which the services referred to in paragraph (1) should be provided to healthy children.'. (c) CONFORMING AMENDMENTS- (1) Section 1862(a)(1) of such Act (42 U.S.C. 1395y(a)(1)), as amended by sections 502(b)(4)(A) and 503(b), is amended-- (A) in subparagraph (G), by striking `and' at the end; (B) in subparagraph (H), by striking the semicolon at the end and inserting `, and'; and (C) by adding at the end the following new subparagraph: `(I) in the case of well-child services, which are provided more frequently than is provided under the schedule of periodicity established by the Secretary under section 1861(ll)(2) for such services;'. (2) Section 1862(a)(7) of such Act (42 U.S.C. 1395y(a)(7)), as amended by sections 502(b)(4)(B) and 503(c), is amended by striking `or (H)' and inserting `(H), or (I)'. (d) EFFECTIVE DATE- The amendments made by this section shall apply to well-child services provided on or after January 1, 1992. SEC. 504. ANNUAL SCREENING MAMMOGRAPHY. (a) ANNUAL SCREENING MAMMOGRAPHY FOR WOMEN OVER AGE 64- Section 1834(c)(2)(A) of the Social Security Act (42 U.S.C. 1395m(b)(2)(A)) is amended-- (1) in clause (iv), by striking `but under 65 years of age,'; and (2) by striking clause (v). (b) EFFECTIVE DATE- The amendments made by subsection (a) shall apply to screening mammography performed on or after January 1, 1992. SEC. 505. DEMONSTRATION PROJECTS FOR COVERAGE OF OTHER PREVENTIVE SERVICES. (a) ESTABLISHMENT- The Secretary of Health and Human Services (hereafter referred to as the `Secretary') shall establish and provide for a series of ongoing demonstration projects under which the Secretary shall provide for coverage of the preventive services described in subsection (c) under the medicare program in order to determine-- (1) the feasibility and desirability of expanding coverage of medical and other health services under the medicare program to include coverage of such services for all individuals enrolled under part B of title XVIII of the Social Security Act; and (2) appropriate methods for the delivery of those services to medicare beneficiaries. (b) SITES FOR PROJECT- The Secretary shall provide for the conduct of the demonstration projects established under subsection (a) at the sites at which the Secretary conducts the demonstration program established under section 9314 of the Consolidated Omnibus Budget Reconciliation Act of 1985 and at such other sites as the Secretary considers appropriate. (c) SERVICES COVERED UNDER PROJECTS- The Secretary shall cover the following services under the series of demonstration projects established under subsection (a): (1) Glaucoma screening. (2) Cholesterol screening and cholesterol-reducing drug therapies. (3) Screening and treatment for osteoporosis, including tests for bone-marrow density and hormone replacement therapy. (4) Screening services for pregnant women, including ultra-sound and clamydial testing and maternal serum alfa-protein. (5) One-time comprehensive assessment for individuals beginning at age 65 or 75. (6) Other services considered appropriate by the Secretary. (d) REPORTS TO CONGRESS- Not later than October 1, 1993, and every 2 years thereafter, the Secretary shall submit a report to the Committee on Finance of the Senate and the Committee on Ways and Means and the Committee on Energy and Commerce of the House of Representatives describing findings made under the demonstration projects conducted pursuant to subsection (a) during the preceding 2-year period and the Secretary's plans for the demonstration projects during the succeeding 2-year period. (e) AUTHORIZATION OF APPROPRIATIONS- There are authorized to be appropriated from the Federal Supplementary Medical Insurance Trust Fund for expenses incurred in carrying out the series of demonstration projects established under subsection (a) the following amounts: (1) $4,000,000 for fiscal year 1992. (2) $4,000,000 for fiscal year 1993. (3) $5,000,000 for fiscal year 1994. (4) $5,000,000 for fiscal year 1995. (5) $6,000,000 for fiscal year 1996. SEC. 506. OTA STUDY OF PROCESS FOR REVIEW OF MEDICARE COVERAGE OF PREVENTIVE SERVICES. (a) STUDY- The Director of the Office of Technology Assessment (hereafter referred to as the `Director') shall, subject to the approval of the Technology Assessment Board, conduct a study to develop a process for the regular review for the consideration of coverage of preventive services under the medicare program, and shall include in such study a consideration of different types of evaluations, the use of demonstration projects to obtain data and experience, and the types of measures, outcomes, and criteria that should be used in making coverage decisions. (b) REPORT- Not later than 2 years after the date of the enactment of this title, the Director shall submit a report to the Committee on Finance of the Senate and the Committee on Ways and Means and the Committee on Energy and Commerce of the House of Representatives on the study conducted under subsection (a).
Introduced in House
Introduced in House
Referred to the House Committee on Energy and Commerce.
Referred to the House Committee on Ways and Means.
Referred to the Subcommittee on Health.
Referred to the Subcommittee on Commerce, Consumer Protection and Competitiveness.
Referred to the Subcommittee on Health and the Environment.
Llama 3.2 · runs locally in your browser
Ask anything about this bill. The AI reads the full text to answer.
Enter to send · Shift+Enter for new line