To amend the Employee Retirement Income Security Act of 1974 to ensure basic, affordable health insurance is available to all citizens through a UniMed program.
Universal Medical Care Act of 1992 - UniMed Act of 1992 - Creates the UniMed program with three components: MediWorkers, MediKids, and MediWrap.
Title I: MediWorkers Component of UniMed Program - Subtitle A: Employer-Sponsored Group Health Plans - Amends the Employee Retirement Income Security Act of 1974 to require each employer to provide coverage to each eligible full-time employee or spouse.
Provides for consumer protection by: (1) regulating claims procedures; (2) requiring certain disclosures; and (3) prohibiting financial arrangements between group health plans and physicians having the effect of reducing or limiting services.
Sets forth procedures and requirements for group health plan certification by the Health Benefits Board (Board) established under this Act. Requires: (1) the Board to establish minimum quality standards; and (2) each plan to issue a health plan card to each covered individual.
Mandates coverage of certain core services, including: (1) inpatient and outpatient hospital services; (2) physician and community health clinic services and certain other health professional services; (3) certain inpatient and outpatient mental health services; (4) certain alcohol and drug abuse treatment services; (5) pregnancy-related services; (6) specified preventive services; (7) diagnostic and laboratory services; and (8) case management.
Allows the Board to include additional preventive services and, in order to conduct demonstrations, additional services as core benefits. Establishes related advisory committees. Prohibits a plan which is not a network plan (defining a network plan as a plan which limits coverage to services provided by participating providers or which permits higher deductibles and coinsurance applicable to the use of non-participating providers) from limiting coverage of core services to specified providers. Regulates deductibles, coinsurance, and cost-sharing.
Requires the Board to: (1) annually establish reference payment rates, based on the payment methodology used under title XVIII (Medicare) of the Social Security Act, for all core services; or (2) substitute rates established by a State, unless that would increase expenditures or shift costs among UniMed's three components. Limits charges for: (1) institutional services to the reference rates; and (2) professional services to the same proportion above the reference rates as the limiting charge established under specified Medicare provisions.
Requires adequate core services payment rates and use of Medicare payment methodologies.
Mandates prospective reductions in reference payment rates for: (1) hospitals with excessive rates of increase of capital expenditures which were not pre-approved by the Board; and (2) medical residency programs inconsistent with number and specialty distribution standards.
Limits employee-paid premiums according to a specified formula which includes consideration of the employee's wages.
Prohibits excluding pre-existing conditions or exclusions for core services that are more restrictive than the exclusions under the MediWrap component.
Sets forth consumer protections, including: (1) prohibiting a plan which is not a network plan from restricting the covered individual's choice of provider; (2) requiring notice of the low-income assistance available under this Act; and (3) insolvency and escrow reserves protection.
Mandates issuance of health plan identification cards and use of standard claims forms and processes.
Requires: (1) coordination of coverage and termination of coverage among plans and between plans and the MediKids and MediWrap components; (2) coordination of deductibles and cost-sharing among plans; (3) notice of beginning and terminating coverage of an individual; (4) ongoing accounting, for each covered individual, regarding deductibles and cost-sharing to promote portability; and (5) that the MediWrap component cover each MediWrap eligible individual whose coverage under a plan or under Medicare part A is terminated.
Provides for certification of open (defined as not limited to a particular employer or industry or organized on behalf of a particular group) group health polices. Considers a plan as meeting certain certification requirements if it provides benefits through a contract with a carrier for an open certified policy. Prohibits a State from imposing any requirement on an open basic policy inconsistent with these requirements.
Requires a certified group health policy to meet requirements of this Act relating to claims procedures, financial arrangements between group health plans and physicians having the effect of reducing or limiting services, issuance of UniMed cards, core services, deductibles, coinsurance, cost-sharing, payment rates, pre-existing conditions, choice of provider, solvency, standardization of cards and claims processing, and coordination and portability of coverage. Requires the carrier of a certified policy to assume responsibility under this Act for equalization of premiums.
Requires a carrier which offers a certified policy to offer it without regard to the size of the employer. Allows health maintenance organizations to have certain geographic and size limits.
Prohibits open basic certified policies from being terminated, except for premium nonpayment, fraud or misrepresentation, or at the end of a year. Allows employers to change to another policy without penalty at the end of each calendar year.
Requires each open basic certified policy to provide coverage to eligible employees, if ordered by the Board because of employer failure to provide coverage.
Provides a process for the equalization of premiums according to specified formulas, considerations, and factors.
Mandates establishment of related advisory committees.
Entitles certain small (fewer than 25 employees) employers to a premium subsidy beginning at a specified percentage of the employer premium and phasing out over four years.
Establishes in the Health Benefits Administration the Federal Health Benefits Equalization Corporation to carry out provisions of this Act relating to equalization. Exempts the Corporation from Federal and, subject to exception, State and local taxes. Provides for the treatment of the Corporation and the Federal Health Benefits Equalization Fund (established under this Act) regarding the Federal budget and the Balanced Budget and Emergency Deficit Control Act of 1985.
Establishes in the Treasury the Federal Health Benefits Equalization Fund to carry out the functions of the Corporation under these provisions, crediting to the Fund equalization payments and other amounts. Appropriates to the Fund: (1) a specified portion of taxes received under certain provisions; (2) amounts equal to the small employer subsidies; and (3) amounts equal to the low income assistance provided under title V of this Act.
Sets forth reporting and disclosure requirements for all group health plans, including regarding a summary plan description, annual financial and other reports, the furnishing of certain information to covered individuals, and the publication of specified information. Regulates the retention of certain records.
Requires that charges of violation of this Act be filed with the Special Counsel of the Board.
Provides for the appointment of the Counsel. Requires the Counsel to investigate charges, issue complaints, and prosecute all complaints before administrative law judges of the Group Health Plan Review Board (Review Board) and the Health Benefits Board (Board).
Establishes the Review Board.
Provides for: (1) procedures for hearings before the administrative law judges; and (2) review of their decisions.
Establishes an Early Resolution Program to facilitate discussions, clarify issues, identify additional information, encourage settlement, and present an assessment of the likely outcome of litigation.
Establishes in the Health Benefits Administration the Claims Resolution Board (Claims Board) to take certain actions, including administering the Program.
Sets forth Program eligibility criteria and initiation procedures.
Prohibits formal rules of evidence, oaths, and transcripts.
Provides for enforcement, with regard to matters which are not eligible to be brought before the Special Counsel, through a civil action brought by the Board, the Corporation, or any aggrieved party. Imposes civil penalties for failure to comply with reporting and disclosure rules.
Prohibits interference with protected rights. Imposes criminal penalties for coercive interference.
Preempts State laws: (1) different from this Act; (2) specifying the individuals to be covered under a certified plan or the duration of coverage; or (3) requiring a conversion right from a certified group plan to an individual plan.
Prohibits State laws from prohibiting or unreasonably restricting network plans from taking specified actions. Defines a "network plan" as a plan which limits coverage of core services to those provided by participating providers or which permits higher deductibles and coinsurance applicable to the use of nonparticipating providers. Sets forth other requirements for network plans.
Mandates establishment of standards for utilization review programs. Preempts inconsistent State laws.
Subtitle B: Miscellaneous Provisions - Sets forth which provisions of title I (Protection of Employee Benefit Rights) of the Employee Retirement Income Security Act of 1974 (ERISA) apply and which provisions do not apply to group health plans.
Title II: MediKids Component of UniMed Program - Subtitle A: Eligibility and Coverage - Entitles to benefits under this title each child who is: (1) under 22 years old; (2) a U.S. citizen or national, a lawful permanent resident alien, or an alien residing permanently in the United States; and (3) a U.S. resident (MediKids eligible children). Declares that failure to pay a premium tax under specified provisions of the Internal Revenue Code shall not terminate benefits under this title.
Mandates issuance of identifying UniMed cards. Declares that MediKids eligible children are entitled to benefits whether or not a UniMed card has been issued with respect to them.
Subtitle B: Benefits - Includes in core services those core services described in title I of this Act, as modified with regard to inpatient and outpatient mental health services, preventive services, prescription drugs, and developmental services. Establishes an advisory committee to advise the Board on medically necessary and reasonable core services. Allows the Board, in order to conduct demonstrations, to include additional services as core benefits. Mandates a study and report to the Congress on the appropriateness of providing coverage for long-term care under the MediKids component.
Regulates (in some cases prohibits) coinsurance, copayment, and cost-sharing.
Requires payment of benefits under this title to be made without regard to whether a MediKids eligible child is also entitled to benefits under titles XVIII (Medicare) and XIX (Medicaid) of the Social Security Act. Requires that Medicare benefits be coordinated with, and supplement, benefits under this title.
Subtitle C: Payments; Premium Computation - Requires: (1) MediKids payments to be made on the same basis as MediWorkers payment rates, adjusting for the different populations and services; and (2) the Board to establish similar rates and methodologies for MediKids benefits that are not core services. Applies Medicare provisions (relating to withholding of payments for certain Medicaid providers and to offset of payments to individuals to collect past-due obligations arising from breach of scholarship and loan contracts) to this title.
Prohibits providers from charging in excess of the applicable payment amount or charging for a service which is not medically necessary or reasonable.
Provides for computation of the MediKids monthly premium amount.
Subtitle D: Miscellaneous - Authorizes the Board to: (1) require providers to enter into participation agreements with the Board in order to be eligible for payments; or (2) permit such agreements.
Authorizes the Board to provide for the administration of this title through a contract or agreement with one or more fiscal agents. Mandates application of the MediWorkers early resolution program and the claims review procedures to MediKids disputes and claims.
Authorizes the Board to enter into a contract with health maintenance organizations and other prepaid capitation organizations for MediKids services and a monthly, prospectively determined capitated amount. Requires the Board to establish an optional primary care capitation payment methodology for pediatric practices involving a fixed, periodic payment.
Authorizes agreements for utilization and quality control activities.
Title III: MediWrap Component of UniMed Program - Subtitle A: Eligibility and Coverage - Entitles to MediWrap benefits each individual who is: (1) between 21 and 60 years old; (2) a U.S. citizen or national, a lawful permanent resident alien, or an alien otherwise permanently residing in the United States; and (3) a U.S. resident. Exempts from the entitlement persons entitled to benefits under Medicare part A or under MediWorkers provisions of this Act. Declares that failure to pay a premium tax under specified provisions of the Internal Revenue Code shall not terminate benefits.
Mandates issuance of identifying UniMed cards. Declares that MediWrap eligible individuals are entitled to benefits whether or not a UniMed card has been issued with respect to them.
Subtitle B: Benefits - Requires that MediWrap benefits be the same as MediWorkers core benefits. Allows the Board, in order to conduct demonstrations, to include additional benefits. Mandates establishment of an advisory committee to advise the Board on medical necessity and reasonableness.
Regulates deductibles, coinsurance, and cost-sharing.
Requires MediWrap payments to be made without regard to whether a MediWrap eligible individual is also entitled to benefits under title XIX (Medicaid) of the Social Security Act.
Subtitle C: Payments; Premium Computation - Requires MediWrap payments to be made on the same basis as MediWorkers payment rates. Applies Medicare provisions (relating to withholding of payments for certain Medicaid providers and to offset of payments to individuals to collect past-due obligations arising from breach of scholarship and loan contracts) to this title.
Prohibits providers from charging in excess of the applicable payment amount or charging for a service which is not medically necessary or reasonable.
Provides for computation of the MediWrap monthly premium amount.
Subtitle D: Miscellaneous - Authorizes the Board to: (1) require providers to enter into participation agreements with the Board in order to be eligible for payments; or (2) permit such agreements.
Authorizes the Board to provide for the administration of this title through a contract or agreement with one or more fiscal agents. Mandates application of the MediWorkers early resolution program and the claims review procedures to MediWrap disputes and claims.
Authorizes the Board to enter into a contract with health maintenance organizations and other prepaid capitation organizations for MediWrap services and a monthly, prospectively determined capitated amount.
Authorizes agreements for utilization and quality control activities.
Title IV: Cost Containment and Quality Control - Subtitle A: Cost Containment Provisions Contained Within UniMed Components - Sets forth references to other provisions of this Act.
Subtitle B: Encouraging Use of "Managed" or "Coordinated" Care - Sets forth references to other provisions of this Act.
Amends provisions of the Social Security Act relating to research on outcomes of health care services and procedures to mandate reflection of UniMed component needs in treatment- or condition-specific practice guidelines. Mandates inclusion of information UniMed impact in an annual report to the Congress. Authorizes appropriations to carry out the provisions. Modifies specifications regarding the source of appropriations under the provisions.
Subtitle C: Quality Control - Amends the Employee Retirement Income Security Act of 1974 to require the Health Benefits Board to establish a locally-based, consumer-oriented process for providing information to employers, MediWorkers eligible individuals, and organizations representing the individuals on the quality and appropriateness of care provided under certified plans.
Establishes the National Quality Advisory Committee.
Requires the Board to establish a process for the recognition in each locality of a local health care quality review monitoring organization.
Subtitle D: Improvements in Administrative Efficiency - Requires the Board to establish standards for: (1) UniMed cards, including electronic coding on the cards; and (2) forms to be used and electronic data to be submitted regarding claims.
Subtitle E: Medical Malpractice Reform - Requires the Board to report to the Congress detailing specific reforms of medical malpractice. Allows the Board to provide for the implementation under the MediKids and MediWrap components of the early resolution program.
Title V: Low Income Assistance - Mandates a sliding scale of subsidies to low income individuals for UniMed component deductibles and coinsurance.
Requires, for those receiving advance assistance, subsequent filing of income statements and related payment adjustments. Disqualifies from assistance under this title all members of a family for which the statements are not filed by a specified deadline. Requires the Secretary of the Treasury to transmit income information to the Board as necessary for verification.
Considers a family eligible under this title, without filing an application or an income statement, if the family that has been determined to be eligible for aid under parts A or E of title IV (Aid to Families with Dependent Children) or title XVI (Supplemental Security Income) of the Social Security Act.
Title VI: Financing - Subtitle A: Amendments to Internal Revenue Code of 1986 - Amends the Internal Revenue Code to impose taxes on employers (including railroads), certain employees, railroad employee representatives, and self-employed individuals. Reduces the employer tax for small employers (under 25 employees), phasing out the reduction over four years.
Imposes a tax on individuals who: (1) are covered by MediWrap; (2) are covered by MediKids, if their custodial parent is not covered by MediWrap and neither parent is covered by MediWorkers.
Imposes a tax on a percentage of the excess (if any) of UniMed income (adjusted gross income determined without regard to specified provisions, plus interest income) over the income taxed by certain other provisions, plus an amount determined according to a specified formula.
Modifies: (1) the percentage of health insurance costs of self-employed individuals which is deductible; and (2) requirements regarding the hospital insurance applicable contribution base.
Excludes from gross income employer contributions to UniMed premiums. Phases out the exclusion for highly compensated employees.
Subtitle B: Maintenance of Effort - Requires each State to pay to the UniMed Trust Fund amounts, determined according to specified formulas, relating to: (1) for the MediKids amount, the number of Medicaid-eligible children in the State, the average per child expenditures to be made under the MediKids component, and the Federal medical assistance percentage under Medicaid; and (2) for the MediWrap amount, the amount of MediWrap expenditures under the State Medicaid plan and the Federal medical assistance percentage under Medicaid. Appropriates equivalent amounts to the Fund.
Subtitle C: UniMed Trust Fund - Establishes the UniMed Trust Fund with separate MediKids, MediWrap, and low income assistance accounts. Excludes Fund receipts and disbursements from the Federal budget and the Balanced Budget and Emergency Deficit Control Act of 1985. Makes the United States not liable for any obligation or liability of the Fund. Authorizes appropriations equal to the amount by which MediKids and MediWrap expenditures exceed Fund deposits. Transfers certain tax receipts and State and Federal payments to the various accounts of the Fund. Makes amounts in the Fund also available for payments under the provisions of the Social Security Act relating to outcomes of health care services and procedures.
Title VII: Administration of UniMed Program - Establishes, as an independent agency in the executive branch, the Health Benefits Administration, governed by the Health Benefits Board, to administer the components of the UniMed program.
Authorizes the Board to investigate and, where appropriate, refer civil and criminal violations regarding this Act, the Employee Retirement Income Security Act of 1974, or other Federal laws.
Authorizes the Board to collect, analyze, and publish information relating to the UniMed program. Mandates studies regarding: (1) the effects of the program on the provisions and costs of group health plans; (2) the role of the program in meeting national health needs; (3) the operation of group health plans; (4) methods of encouraging the growth of the group health plan systems; and (5) the appropriateness of providing coverage for long-term care under the MediWorkers and MediWrap components.
Title VIII: Medicare Program - Amends provisions of title II (Old-Age, Survivors, and Disability Insurance (OASDI)) of the Social Security Act relating to entitlement to hospital insurance benefits to replace references to age 65 with references to age 60 and to otherwise modify eligibility requirements for Medicare parts A (Hospital Insurance) and B (Supplementary Medical Insurance). Repeals Medicare provisions relating to: (1) hospital insurance for uninsured individuals not otherwise eligible; and (2) hospital insurance benefits for disabled individuals who have exhausted other entitlements. Amends specified Medicare provisions to replace references to age 65 with references to age 60.
Makes Medicare a secondary payer after payment under MediKids.
Appropriates to the Federal Hospital Insurance Trust Fund and the Federal Supplementary Medical Insurance Trust Fund, both established under the Social Security Act, the taxes received under specified provisions of the Internal Revenue Code with respect to the wages of individuals 60 years old or older or who are otherwise entitled to benefits under Medicare part A, less the decrease in income taxes resulting from such taxes.
Title IX: Miscellaneous Provisions - Repeals provisions of: (1) the Internal Revenue Code relating to failure to satisfy continuation coverage requirements of group health plans; (2) the Employee Retirement Income Security Act of 1974 relating to continuation coverage under group health plans; and (3) the Public Health Service Act relating to requirements for certain group health plans for certain State and local employees.
Amends the Internal Revenue Code to allow returns and return information to be furnished to the Health Benefits Administration and the Federal Health Benefits Equalization Corporation for the purposes of, and to the extent necessary in the administration of, this Act.
Amends the Public Health Service Act to mandate grants to provide access to services for medically underserved populations or in high impact areas not currently being serviced by a Federally-qualified health center. Allows grant funds to be used for: (1) recruiting, training, and compensating staff; (2) facilities construction, acquisition, expansion, and modernization; (3) purchasing equipment; (4) principal and interest on related loans; (5) all services of a Federally-qualified health center; (6) any other services such a center may provide and be reimbursed under Medicaid; and (7) unreimbursed costs as described under provisions relating to community health centers. Authorizes appropriations.
Mandates a study on the relationship and interaction between community health centers and hospitals in providing services to underserved areas. Authorizes appropriations.
Prohibits a State, as a condition for receiving Medicaid payments, from reducing the eligibility for, or the amount of, benefits for children under 22 years old below those in effect before enactment of this Act.
Amends Medicaid provisions to prohibit Medicaid payments for items and services for which payment is made under UniMed. Adds a requirement that a State Medicaid plan take all reasonable measures to ascertain the legal liability of third parties, including certified plans under MediWorkers, to pay for services under the plan.
Title X: Glossary of Terms - Sets forth references to where terms are defined in this Act.
Introduced in House
Introduced in House
Referred to the House Committee on Education and Labor.
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 Health and the Environment.
Referred to the Subcommittee on Commerce, Consumer Protection and Competitiveness.
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