To establish the framework for a health care system that will bring about universal access to affordable, quality health care by containing the growth in health care costs through a national health budget, managed competition, and other means, by improving access to and simplifying the administration of health insurance, by deterring and prosecuting health care fraud and abuse, by expanding benefits under the medicare program, by expanding eligibility and increasing payment levels under the medicaid program, and by making health insurance available to all children.
TABLE OF CONTENTS:
Title I: Cost Containment
Subtitle A: National Health Budget
Subtitle B: State Provider Payment Control System
Subtitle C: Maximum Payment Rates for Services Not
Subject to State Provider Payment Control Systems or
Provided by Staff or Group Model Health Maintenance
Organizations
Title II: Managed Care And Managed Competition
Subtitle A: Managed Care
Subtitle B: Managed Competition
Subtitle C: National Patient Outcomes and Enrollee
Satisfaction Data Reporing Program
Subtitle D: Study of Universal Health Insurance Coverage
and Cost Containment
Title III: Health Systems Reform
Subtitle A: Health Insurance Reform
Subtitle B: Administrative Simplification
Subtitle C: Fraud and Abuse
Subtitle D: Other Provisions
Title IV: Expansions Of Health Benefits And Other Health
Initiatives
Subtitle A: Medicaid Benefit Improvements
Subtitle B: Expansion of Medicare Benefits
Subtitle C: Health Insurance Deduction for the
Self-Employed
Subtitle D: Health Insurance Program for Children
Health Care Cost Containment and Reform Act of 1993 - Title I: Cost Containment - Subtitle A: National Health Budget - (Sec. 101) Establishes a national health expenditure budget for each calendar year beginning with 1995 that is composed of separate budgets for both Medicare (title XVIII of the Social Security Act (SSA)) and non-Medicare related health care expenditures. Sets forth guidelines for the Secretary of Health and Human Services (HHS) to use in computing budget baselines for 1994.
(Sec. 102) Provides for the establishment of classes of health care services.
(Sec. 103) Requires the Secretary to allocate such respective budgets each year among such classes.
(Sec. 104) Requires the Secretary to adjust budgets and allocations for changes in Medicare coverage under title IV of this Act that have resulted in increased expenditures for Medicare services.
(Sec. 105) Requires the Secretary to establish a national health expenditures reporting system for purposes of carrying out this title.
Subtitle B: State Provider Payment Control Systems - (Secs. 121 and 122) Gives States the option of establishing systems (State systems) to provide payment rates for hospital, physician, and other services covered under the State system (for which the maximum payment rates established below shall not apply) and provided in the State. Allows States to permit health maintenance organizations (HMOs) to negotiate directly with providers of covererd services with respect to the HMO's rate of payment for such services.
(Sec. 123) Makes approval of a State system depend on State assurances that: (1) aggregate Medicare expenditures for a covered class of services will not exceed a certain limit; and (2) the sum of aggregate Medicare and non-Medicare expenditures for the class (or classes) will not exceed a specified maximum.
(Sec. 124) Authorizes sanctions against State systems with aggregate expenditures in excess of specified applicable limits.
Subtitle C: Maximum Payment Rates for Services Not Subject to State Provider Payment Control Systems or Provided by Staff or Group Model Health Maintenance Organizations - (Secs. 140, 141, 142, and 143) Provides for the establishment and general application and enforcement of maximum non-Medicare payment rates in States which have not opted to participate in State systems. Exempts services provided by staff or group model (S/GM) HMOs from such rates.
(Secs. 151 and 152) Details various methodologies for determining maximum non-Medicare rates of payment for inpatient hospital services, class of physicians' services and other professional medical services.
(Secs. 155, 161, and 162) Provides for: (1) development of prospectively-determined payment methodologies for each class of services for which non-Medicare payment rates are not specified and are not determined on a prospective basis; (2) conforming Medicare payment rates to Medicare health expenditure allocations; and (3) adjustments to Medicare payments for graduate medical education.
Title II: Managed Care and Managed Competition - Subtitle A: Managed Care - (Sec. 203) Repeals the termination date set under the Health Maintenance Organization Amendments of 1988 for dual choice requirements under the Public Health Service Act (PHSA).
(Sec. 204) Amends PHSA to revise such requirements to provide for multiple options of HMO membership. Provides that health benefit plans shall make available, to each individual eligible to enroll with a qualified HMO under such an option, such marketing materials as the HMO provides to the plan.
(Sec. 205) Requires the Secretary to provide for grants for the establishment and initial operation of S/GM HMOs. Authorizes appropriations.
(Sec. 206) Preempts State law provisions that restrict the ability of an HMO to negotiate reimbursement rates with providers (except in States with payment provider control systems) or to contract selectively with one provider or a limited number of providers.
(Sec. 207) Amends SSA to provide for adjustment in Medicare capitation payments to account for regional variations in application of secondary payor provisions.
(Sec. 208) Requires a General Accounting Office (GAO) study and report to the Congress on additional measures for HMO development and expansion.
Subtitle B: Managed Competition - (Secs. 221, 223, and 224) Provides for grants to States for the establishment of a new system of health plan purchasing cooperatives (HPPCs) in each State through which coverage under qualified managed-care health plans is made available for an employee whose employer has entered into an agreement with the HPPC for the area where the employee resides. Authorizes appropriations.
Subtitle C: National Patient Outcomes and Enrollee Satisfaction Data Reporting Program - (Secs. 271, 272, and 273) Requires the Secretary to: (1) establish national data bases on patient outcomes and enrollee health plan satisfaction from information reported annually to the Secretary by health benefit plans; (2) publish and distribute annual reports regarding patient outcomes and enrollee health plan satisfaction; and (3) provide for various research and demonstration projects. Authorizes appropriations.
Subtitle D: Study of Universal Health Insurance Coverage and Cost Containment - (Sec. 291) Requires the Congressional Budget Office to study and report to specified congressional committees on options for providing universal health insurance coverage.
Title III: Health Systems Reform - Subtitle A: Health Insurance Reform - (Sec. 301) Amends the Internal Revenue Code (IRC) to impose an excise tax on any health benefit plan that is not certified under this Act or is providing coverage in violation of certain requirements discussed below. Specifies the amount of and liability for such tax.
(Sec. 302) Amends SSA to provide that no health benefit plan may be issued unless it has been certified as meeting specific standards established by the Secretary. Requires such standards to implement specified requirements relating to: (1) health benefit plan coverage and health status; (2) premium charges within self-insured health benefit plans; (3) small employer plans; (4) insured health benefit plan enrollment, issuance, and renewal; (5) use of community-rated premium rates for insured plans; (6) minimum insured plan periods; (7) payment of commissions; and (8) insured plans that are multiple employer welfare arrangements.
(Sec. 303) Prohibits States from establishing or enforcing any law or regulation that prevents the health benefit plan of a college or university from offering eligible individuals continuation of coverage under the plan.
Subtitle B: Administrative Simplification - (Secs. 321, 322, 323, 324, and 325) Requires each health benefit plan to issue to each U.S. resident entitled to benefits under the plan a uniform health claims card that meets specified requirements. Mandates: (1) entitlement verification systems; and (2) uniform electronic claims submission and hospital cost reporting. Provides for standards for entitlement verification systems and uniform electronic claims submission and hospital medical records transmission. Sets forth enforcement provisions.
Subtitle C: Fraud and Abuse - (Sec. 341) Requires the Secretary to establish in the Office of Inspector General a program to coordinate law enforcement programs to control health care fraud and abuse and facilitate SSA and other statutory enforcement of health care fraud and abuse prohibitions. Creates in the Treasury the Anti-Fraud and Abuse Trust Fund. Authorizes appropriations.
(Secs. 341 and 342) Amends SSA title XI to: (1) permit the exclusion from participation in Medicare and any State health care program (SHCP) for any failure under such Inspector General program to supply requested information; (2) provide for the application of Federal anti-fraud and abuse sanctions to all fraud and abuse involving any health benefit plan; (3) add treble damages to the list of criminal penalties for acts involving Medicare, SHCPs, or health benefit plans; and (4) require the Secretary to make law enforcement officers aware of opportunities that may satisfy court imposed community service obligations for Medicare or SHCP fraud and abuse convictions.
(Sec. 343) Subjects to SSA civil monetary penalties any offer of inducements to individuals enrolled under or employed by Medicare or other health programs or plans.
(Sec. 344) Provides for intermediate sanctions for HMO Medicare violations. Requires: (1) agreements between HMOs and peer review organizations (PROs) to be written; and (2) a GAO study and report to the Congress on the cost of HMO and PRO agreements.
(Sec. 351 and 352) Extends the ban on Medicare payment for physician self-referrals to all payors and additional specified services.
(Sec. 353) Makes changes in exceptions and other provisions relating to compensation arrangements under Medicare.
Subtitle D: Other Provisions - (Sec. 361) Requires the Physician Payment Review Commission to study and report to the Congress on: (1) tort reforms needed with respect to medical malpractice liability claims; and (2) the impact of such reforms on health care expenditures and access.
Title IV: Expansions of Health Benefits And Other Health Initiatives - Subtitle A: Medicaid Benefits Improvements - (Sec. 401) Sets a floor on Medicaid payment levels for inpatient hospital services and physician services.
(Sec. 402) Provides for expanded Medicaid eligibility for certain low-income individuals.
(Sec. 403) Provides for full Federal payment for newly mandated Medicaid expenditures.
Subtitle B: Expansion of Medicare Benefits - (Secs. 411, 412, 413, 414, and 421) Provides for Medicare coverage of annual breast cancer screening for women over age 64, colon cancer screening, child immunizations, prescription drugs, and well-child care.
(Sec. 421) Authorizes demonstration projects for coverage of other specified preventive services under Medicare. Authorizes appropriations.
(Sec. 422) Requires the Director of the Office of Technology Assessment to provide for a Prescription Drug Payment Review Commission which shall report annually to the Congress on methods for prescription drug payment. Authorizes appropriations.
(Sec. 423) Provides for coverage of prescription drugs for qualified Medicare beneficiaries and qualified disabled and working individuals.
(Sec. 431) Requires the Secretary to: (1) determine whether newly eligible Medicare beneficiaries are eligible for Medicaid (SSA title XIX) payment of their out-of-pocket Medicare expenses; and (2) enroll in Medicaid those beneficiaries determined to be so eligible.
Amends SSA to require annual notices of Medicare benefits to contain information on Medicaid payment of out-of-pocket Medicare expenses.
Subtitle C: Health Insurance Deduction for the Self-Employed - (Sec. 441) Amends the IRC to make permanent and increase the deduction for self-employed individuals' health insurance costs.
Subtitle D: Health Insurance Program for Children - (Sec. 451) Amends SSA to make children under age 19 who are U.S. citizens or permanent residents eligible to enroll for specified health benefits (generally the same as those under Medicare for the aged and disabled, plus well-child services). Creates in the Treasury the Children's Health Insurance Fund. Authorizes appropriations.
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.
Sponsor introductory remarks on measure. (CR H130-132)
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.
Referred to the Subcommittee on Labor-Management Relations.
Sponsor introductory remarks on measure. (CR E944, E947, E954)
Sponsor introductory remarks on measure. (CR E1095-1096, E1098-1099)
Sponsor introductory remarks on measure. (CR H3303-3304)
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Sponsor introductory remarks on measure. (CR H294-295)