Health Reform Consensus Act of 1994

TABLE OF CONTENTS:

Title I: Insurance Reform

Subtitle A: Increased Availability and Continuity of

Health Coverage for Employees and Their Families

Subtitle B: Reform of Health Insurance Marketplace for

Small Business

Subtitle C: Preemption

Subtitle D: Health Deduction Fairness

Title II: Preventing Fraud and Abuse

Subtitle A: Establishment of All-Payer Health Care

Fraud and Abuse Control Program

Subtitle B: Revisions to Current Sanctions for Fraud

and Abuse

Subtitle C: Administrative and Miscellaneous Provisions

Subtitle D: Amendments to Criminal Law

Title III: Malpractice Reform

Subtitle A: Findings; Purpose;

Definitions

Subtitle B: Uniform Standards for Malpractice Claims

Subtitle C: Requirements for State Alternative Dispute

Resolution Systems (ADE)

Title IV: Paperwork Reduction and Administrative

Simplification

Title V: Expanding Access/Preventive Care

Subtitle A: Expanding Access Through Community Health

Authorities

Subtitle B: Expansion of Public Health Programs on

Preventive Health

Title VI: Antitrust Provisions

Title VII: Prefunding Government Health Benefits for

Certain Annuitants

Health Reform Consensus Act of 1994 - Title I: Insurance Reform - Subtitle A: Increased Availability and Continuity of Health Coverage for Employees and Their Families - Requires each employer to make available to each eligible employee a group health plan under which: (1) coverage of each eligible individual with respect to such employee may be elected on an annual basis; (2) coverage is provided for at least the required coverage specified; and (3) employees may elect to have premiums collected through payroll deduction. Does not require employer contributions to the cost of coverage under such a plan.

Provides for the exclusion of: (1) employers who have been employers for less than two years or who have no more than two eligible employees or no more than two eligible employees not covered under any group health plan; and (2) family members under specified circumstances. Specifies that a group health plan shall not be treated as failing to meet the requirements of this Act solely because a period of service by an eligible employee of not more than 60 days is required for coverage.

Specifies that the required coverage is standard coverage, except that in the case of a small employer that has not contributed during the previous plan year to the cost of coverage for any eligible employee under any group health plan, the required coverage for the plan year is coverage under a standard plan and a catastrophic plan.

Provides for a five-year transition for existing group health plans.

(Sec. 1002) Sets forth provisions regarding: (1) compliance with applicable requirements through multiple employer health arrangements; and (2) coverage options under a State medical health allowance program.

(Sec. 1011) Prohibits a group health plan from imposing (and an insurer from requiring an employer from imposing through a waiting period for coverage under a plan or similar requirement) a limitation or exclusion of benefits relating to treatment of a preexisting condition if: (1) the condition relates to a condition that was not diagnosed or treated within three months before the date of coverage under the plan; or (2) the limitation or exclusion extends over more than six month after the date of coverage, applies to an individual who, as of the date of birth, was covered under the plan, or relates to pregnancy. Specifies that, in the case of an individual who is eligible for coverage under a plan but for a waiting period imposed by the employer, the individual shall be treated as having been covered under the plan as of the earliest date of the beginning of the waiting period.

(Sec. 1012) Requires each group health plan to waive any period applicable to a preexisting condition for similar benefits with respect to an individual to the extent that the individual, prior to enrollment in such plan, was covered for the condition under any other health plan.

(Sec. 1013) Prohibits: (1) a multiemployer plan and an exempted multiple employer health plan from canceling or denying renewal of coverage under such a plan for an employer other than for nonpayment of contributions, fraud or other misrepresentation, noncompliance with plan provisions, failure to maintain minimum participation rates (in the case of a small employer) misuse of a provider network provision, or because the plan is ceasing to provide any coverage in a geographic area; (2) an insurer from canceling a health insurance plan or denying renewal of coverage other than as prescribed above; and (3) an insurer who terminates the offering of health insurance plans in an area from offering such a plan to any employer in the area until five years after the date of the termination.

(Sec. 1021) Makes provisions of the Employee Retirement Income Security Act of 1974 applicable with respect to enforcement of this Act (by the Department of Labor).

Imposes a civil penalty ($100 per day for each individual involved, subject to specified limitations) on the failure of an insurer to comply with the requirements of sections 1011 through 1013, unless the Secretary of Health and Human Services (Secretary) determines that the State has in effect a regulatory enforcement mechanism that provides adequate sanctions.

Subtitle B: Reform of Health Insurance Marketplace for Small Business - Requires each insurer that makes available a health insurance plan to a small employer in a State to make available to each small employer in the State a standard plan and a catastrophic plan, with exceptions for health maintenance organizations (HMOs) and if a State provides for guaranteed availability (rather than guaranteed issue).

Requires each insurer that offers a standard or catastrophic plan to a small employer in a State to accept: (1) every small employer in the State that applies for coverage; and (2) every eligible individual who applies for enrollment on a timely basis. Sets forth provision regarding: (1) special rules for HMOs; (2) timely enrollment requirements; and (3) enrollment of spouses and dependents. Makes such requirements inapplicable in a State that has provided (in accordance with specified standards) a mechanism under which each insurer offering a health insurance plan to a small employer in the State must participate in a program for assigning high-risk small employer groups (or individuals within such a group) among some or all such insurers, if the insurers comply.

(Sec. 1102) Defines "health plan" as a health insurance plan that: (1) is designed to provide standard coverage with substantial cost-sharing or only catastrophic coverage; (2) meets applicable requirements relating to guaranteed issue; (3) meets specified consumer protection standards; and (4) meets any participation requirements with respect to an applicable reinsurance or allocation of risk mechanism. States that standard coverage includes: (1) inpatient and outpatient hospital care; (2) inpatient and outpatient physicians' services; (3) diagnostic tests; (4) specified preventive services; and (5) specified inpatient hospital care for mental disorders. Sets forth coverage scope, including that there be no limits on the amount, scope, or duration of items number one, two, and three in the preceding sentence. Sets forth exceptions. Sets forth limitations on deductibles, copayments and coinsurance, and out-of-pocket expenses. Defines a catastrophic benefits package. Provides for the determination of target actuarial values for standard and catastrophic coverage.

(Sec. 1103) Directs the Secretary to request NAIC to develop model regulations that specify standards with respect to requirements: (1) that insurers make available health plans; (2) of guaranteed availability of health plans to small employers; (3) relating to limits on premiums and certain consumer protections; (4) relating to limitation of annual premium increases; and (5) for standard and catastrophic coverage. Requires the Secretary to review such standards and, if NAIC fails to specify standards meeting such requirements, to promulgate standards. Sets forth provisions regarding: (1) the application of health plan standards and consumer protection standards by the States; (2) the Federal role; and (3) consumer protection standards.

(Sec. 1104) Sets forth provisions: (1) regarding limits on premiums and annual premium increases; and (2) requiring an insurer, at the time of offering a health insurance plan to a small employer, to fully disclose rating practices for health insurance plans, including rating practices for different populations and benefit designs.

(Sec. 1106) Directs the Secretary to: (1) request NAIC to develop models for reinsurance or allocation of risk mechanisms for health insurance plans made available to small employers for whom an insurer is at risk of incurring high costs under the plan; and (2) review such models or specify models. Sets forth provisions regarding implementation of reinsurance or allocation of risk mechanisms by the States and the Federal role.

(Sec. 1108) Directs the Secretary to establish an Office of Private Health Care Coverage. Requires the Office Director to submit to the Congress annual reports evaluating health care coverage reform.

(Sec. 1109) Authorizes the Director to conduct: (1) research on the impact of this subtitle on the availability of affordable health coverage for employees and dependents in the small employers group health care coverage market and other specified topics; and (2) demonstration projects relating to such topics. Requires the Director to develop: (1) methods for measuring the relative health risks of eligible individuals in terms of the expected costs of providing benefits under health insurance plans and, in particular, health plans; (2) a model for equitably distributing health risks among insurers in the small employer health care coverage market. Authorizes appropriations.

Subtitle C: Preemption - Prohibits: (1) State benefit mandates for group health plans; and (2) State or local law prohibitions against two or more employers obtaining coverage under an insured multiple employer health plan.

(Sec. 1203) Preempts State restrictions concerning: (1) reimbursement rates or selective contracting; (2) differential financial incentives; and (3) utilization review methods. Directs the Comptroller General to conduct a study of the benefits and cost effectiveness of the use of managed care in the delivery of health services.

(Sec. 1211) Amends the Employee Retirement Income Security Act of 1974 (ERISA) to allow a limited exemption under preemption rules for multiple employer plans providing health benefits subject to certain Federal standards.

Relieves exempted multiple employer plans providing medical care benefits of certain restrictions on preemption of State law. Treats such plans as employee welfare benefit plans. Allows commencement of new arrangements only if such exemption is in effect or an application is pending and the Secretary of Labor determines that provisional protection is appropriate.

Sets forth exemption procedures, eligibility requirements, and additional requirements applicable to exempted arrangements. Requires certain disclosures to participating employers, maintenance of reserves, and corrective actions. Provides for expiration, suspension, and revocation of exemptions, and for review of actions by the Secretary.

(Sec. 1213) Revises provisions relating to scope of preemption rules, and to treatment of single employer arrangements and of certain collectively bargained arrangements.

(Sec. 1215) Establishes special rules for employee leasing healthcare arrangements. Treats such arrangements as multiple employer welfare arrangements except when they are multiple employer health plans.

(Sec. 1216) Sets forth enforcement provisions relating to multiple employer welfare arrangements and employee leasing health care arrangements.

(Sec. 1217) Sets forth filing requirements for multiple employer welfare arrangements.

(Sec. 1218) Provides for cooperation between Federal and State authorities in enforcing ERISA requirements for multiple employer welfare arrangements with the limited exemption.

(Sec. 1221) Amends the Internal Revenue Code to eliminate the commonality of interest or geographic location requirement for tax exempt trust status for multiple employer health plans and insured multiple employer health plans if they meet certain requirements under ERISA and this Act.

(Sec. 1231) Amends ERISA to direct the Secretary of Labor to prescribe an alternative method providing for a single annual report with respect to all employers who are covered under the same insured multiple employer health plan.

(Sec. 1241) Provides for compliance with applicable coverage requirements through multiemployer plans and other multiple employer health arrangements.

Subtitle D: Health Deduction Fairness - Amends the Internal Revenue Code to provide for a permanent extension and increase in the health insurance tax deduction for self-employed individuals.

Title II: Preventing Fraud and Abuse - Subtitle A: Establishment of All-Payer Health Care Fraud and Abuse Control Program - Directs the Attorney General to establish a program to: (1) coordinate Federal, State, and local law enforcement programs to control health care fraud and abuse; (2) conduct investigations, audits, and inspections relating to the delivery of payment for health care; and (3) facilitate enforcement of provisions of the Social Security and other Acts applicable to health care fraud and abuse. Authorizes additional appropriations as necessary.

(Sec. 2003) Establishes the Anti-Fraud and Abuse Trust Fund.

Subtitle B: Revisions to Current Sanctions for Fraud and Abuse - Excludes from participation in Medicare and State health care programs any individual or entity convicted of: (1) fraud in connection the delivery of a health care item or service; or (2) a felony related to a controlled substance.

(Sec. 2103) Subjects to a civil monetary penalty any individual or entity offering inducements to individuals to receive any service or supply from a particular provider.

(Sec. 2104) Permits the imposition of intermediate sanctions in addition to the current option of termination, for Medicare health maintenance organizations.

Subtitle C: Administrative and Miscellaneous Provisions - Directs the Secretary to establish a national health care fraud and abuse data collection program for the reporting of final adverse actions against health care providers, suppliers, or practitioners. Requires each government agency and health care plan to report to the Secretary any final adverse action taken against a health care provider, supplier, or practitioner.

Subtitle D: Amendments to Criminal Law - Establishes a penalty of up to five years' imprisonment for knowingly: (1) defrauding any health care plan; or (2) fraudulently obtaining money or property in connection with the delivery of health care items, benefits, or services. Permits a payment of up to $10,000 to any person furnishing information relating to any such crime.

Title III: Malpractice Reform - Subtitle A: Findings; Purpose; Definitions - Sets forth, for this title, findings, purposes, and definitions.

Subtitle B: Uniform Standards for Malpractice Claims - Makes this subtitle applicable to any medical malpractice liability action brought in a Federal or State court and to any medical malpractice claim subject to an alternative dispute resolution system.

(Sec. 3102) Prohibits bringing a medical malpractice liability action in either a State or Federal court unless there has been an initial resolution of the action under an alternative dispute resolution system. Directs the Attorney General to establish an alternative dispute resolution process for medical malpractice liability claims brought against the United States.

(Sec. 3104) Sets limits on both noneconomic damages and punitive damages.

(Sec. 3105) Provides for the periodic payment of future losses.

(Sec. 3106) Limits attorney's fees.

(Sec. 3108) Sets forth special provisions for certain obstetric services.

Subtitle C: Requirements for State Alternative Dispute Resolution System (ADR) -Requires a State's alternative dispute resolution system, among other things to: (1) apply to all medical malpractice liability claims within the jurisdiction of the State's courts; (2) issue a written opinion resolving the dispute within six months of a defendant receiving notice; (3) qualify individuals who hear and resolve claims under the system; and (4) notify the appropriate State agency if there is a finding of malpractice, unless the provider contests the ADR decision.

(Sec. 3202) Directs the Secretary to establish an Alternative Dispute Resolution Advisory Board in order to advise the Secretary regarding the establishment of State and Federal ADR systems. Provides for the certification of State ADR systems by the Board.

Title IV: Paperwork Reduction and Administrative Simplification - Preempts State quill pen laws.

(Sec. 4102) Provides for the confidentiality of electronic health care information.

(Sec. 4003) Directs the Secretary to establish national goals for the health care industry concerning: (1) standardization for the electronic receipt and transmission of health plan information; (2) use of uniform health claims forms and identification numbers; (3) priority of insurers when benefits are payable under two or more health plans; and (4) availability of information among health plans when benefits are payable under two more plans. Requires the Secretary to promulgate requirements if the industry does not meet the goals. Provides for monetary penalties on any health plan that does not meet the Secretary's requirements.

Title V: Expanding Access/Preventive Care - Subtitle A: Expanding Access Through Community Health Authorities - Amends title XIX (Medicaid) of the Social Security Act to direct the Secretary to operate a program under which States establish projects to demonstrate the effectiveness of various innovative health care delivery approaches through the operation of community health authorities. Requires a community health authority to be a nonprofit entity that: (1) serves a geographic area that includes those designated by the Public Health Service Act as medically underserved or as being in a health professions shortage area; (2) enrolls the Medicaid eligible; and (3) provides for the provision of at least preventive services, primary care services, inpatient and outpatient hospital services, and other services.

(Sec. 5002) Authorizes the Secretary to make grants to migrant and community health centers for the development of health service networks to serve high impact areas, medically underserved areas, or medically underserved populations. Authorizes appropriations through FY 1999.

Subtitle B: Expansion of Public Health Programs on Preventive Health - Authorizes appropriations, under the Public Health Service Act, for the following: (1) immunizations against vaccine-preventable diseases; (2) prevention, control, and elimination of tuberculosis; (3) lead poisoning prevention; (4) preventive health measures with respect to breast and cervical cancers; (5) the Office of Minority Health Disease Prevention and Health Promotion; and (6) the Office of Minority Health; and (7) the preventive health and health services block grant.

Title VI: Antitrust Provisions - Directs the Attorney General to: (1) provide for the development and publication of explicit guidelines on the application of antitrust laws to the activities of health plans; and (2) establish a review process under which the administrator or sponsor of a health plan may submit a request to the Attorney General to obtain a prompt opinion from the Department of Justice on the plan's conformity with Federal antitrust laws.

(Sec. 6002) Authorizes the issuance of a certificate of public advantage by the Attorney General to each eligible health care collaborative activity if there is a finding that the benefits that are likely to result from carrying out the activity outweigh any reduction in competition that is likely to result and such reduction is reasonably necessary.

Title VII: Prefunding Government Health Benefits for Certain Annuitants - Requires certain executive branch agencies to prefund government health benefits contributors for their annuitants.