To amend the Internal Revenue Code of 1986 to provide for reform of the health insurance market, to promote the availability and continuity of health coverage, to remove financial barriers to access, to enhance health care quality, to contain costs through market incentives and administrative reforms, and for other purposes.
TABLE OF CONTENTS:
Title I: Assuring Availability and Continuity of Health
Coverage
Subtitle A: Insurance Reform
Subtitle B: Facilitating Establishment of Health Plan
Choice Organization (HPCOs)
Subtitle C: Preemption of State Benefit Mandates and
Anti-Managed Care Laws
Subtitle D: Definitions; General Provisions
Title II: Administrative Simplification
Subtitle A: Standards for Data Elements and
Transactions
Subtitle B: Requirements With Respect to Certain
Transactions and Information
Subtitle C: Miscellaneous Provisions
Title III: Fraud and Abuse Reform: Advisory Opinions
Title IV: Malpractice Reform and Antitrust
Subtitle A: Malpractice Reform
Subtitle B: Antitrust
Basic Health Care Reform Act of 1995 - Title I: Assuring Availability and Continuity of Health Coverage - Subtitle A: Insurance Reform - Requires carriers that offer health insurance coverage in the individual-small group market in a fair rating area to make available qualified standard coverage and high-deductible coverage to small employers.
Exempts federally qualified health maintenance organizations (HMOs) and HMOs or managed care organizations recognized by State laws from the requirement to provide high-deductible coverage.
Prohibits the offer of high-deductible coverage unless the carrier also makes standard coverage available with identical benefits and the employee demonstrates that they have available assets equal to at least the deductible amount under the high-deductible coverage.
Requires carriers to provide for coverage of benefits for items and services furnished throughout the fair rating area.
Prohibits carriers from limiting coverage to portions of interstate metropolitan statistical areas (MSAs), requiring them to provide coverage throughout the entire MSA.
Requires coverage offers to include a family coverage option.
Prohibits carriers from requiring employers under group health plans to impose waiting periods for health coverage or require conditions on health coverage based on an individual's: (1) health status; (2) claims experience; (3) receipt of health care; (4) medical history; or (5) receipt of public subsidies.
(Sec. 1002) Requires carriers to accept every small employer and qualifying individual that applies for enrollment during the required enrollment period.
Provides that in the case of coverage offered by carriers or under group health plans that provide benefits through a managed care arrangement, the carriers or plans: (1) need not establish health care facilities throughout the fair rating area if the facilities are located in a manner that does not discriminate on the basis of health status of individuals residing in proximity to such facilities; and (2) may deny coverage under certain conditions. Permits carriers to deny coverage if they do not have the necessary financial reserves.
(Sec. 1003) Prohibits carriers from denying, cancelling, or refusing to renew health coverage except on the basis of nonpayment of premiums or fraud or because they are not providing a particular coverage option in the market. Sets limitations on market exit and re-entry by carriers. Establishes similar conditions for cancellation or denial by multiemployer plans.
(Sec. 1004) Prohibits carriers or group health plans from excluding coverage with respect to services provided for preexisting conditions, except as provided by this Act. Provides for exclusion periods of up to 12 months subject to certain conditions. Makes exclusions inapplicable to pregnancy, newborns, adopted children, and certain individuals enrolled or enrolling during an open enrollment period.
(Sec. 1005) Sets forth provisions regarding enrollment periods.
(Sec. 1011) Establishes standards for general coverage requirements, managed care arrangements and requirements, and utilization review programs.
(Sec. 1014) Amends the Internal Revenue Code to provide for the establishment of medical savings accounts. Makes the account beneficiary the owner of the account and includes distributions not used for qualified medical expenses in the beneficiary's gross income. Sets forth uses and limitations for such accounts.
Excludes: (1) employer contributions to any medical savings account of an eligible employee from gross income (to the extent such contributions do not exceed the excess of premiums for standard coverage over the premiums for high-deductible coverage); and (2) health benefit payments made by employers from employment taxes.
(Sec. 1021) Provides that the premium rate established by carriers for health insurance coverage in the small group market may not vary except by the following: (1) age; (2) geographic area; (3) family class; (4) benefit design of coverage and by type of coverage option; and (5) permitted expense category.
(Sec. 1022) Requires the Secretary of Health and Human Services to request the National Association of Insurance Commissioners (NAIC) to develop a model risk adjustment system under which premiums applicable to coverage in the small group market would be adjusted to take into account factors to predict the future need and efficient use of services by covered individuals in the market. Incorporates such model into a rule that specifies risk adjustment mechanisms. Requires each State to develop systems that conform with the Federal model.
(Sec. 1031) Requires carriers and group health plans to provide information relating to their performance in providing coverage to specified individuals, including prospective enrollees.
(Sec. 1032) Prohibits carriers from varying the commission or other remuneration to a person based on the claims experience or health status of individuals enrolled by or through such person.
(Sec. 1041) Directs the Secretary to request the NAIC to develop model regulations that specify standards with respect to this subtitle for carriers and health insurance coverage.
(Sec. 1044) Imposes a tax on carriers or group health plans that fail to comply with provisions of this subtitle through Sec. 1033 unless a State has in effect a regulatory mechanism that provides sanctions.
(Sec. 1045) Prohibits a plan from offering health coverage other than through a carrier unless the plan has at least 50 eligible employees, except where the plan is a multiple employer welfare arrangement which covers at least 1,000 qualifying employees and meets State established solvency standards.
(Sec. 1051) Applies the provisions of this subtitle to carriers offering health insurance coverage to qualifying individuals in the individual market in the same manner as such provisions apply to carriers offering health insurance coverage to employers. Provides for an exception relating to risk adjustment systems.
Subtitle B: Facilitating Establishment of Health Plan Choice Organization (HPCOs) - Authorizes the establishment of health plan choice organizations (HPCOs).
(Sec. 1102) Requires HPCOs to enter into agreements with carriers that desire to make health coverage available in the small group market through HPCOs.
(Sec. 1104) Requires HPCOs to offer enrollment for coverage, on behalf of carriers, to individuals in the market through which the organization offers coverage in the area served by the choice organization. Authorizes HPCOs to impose administrative fees for enrollment.
Subtitle C: Preemption of State Benefit Mandates and Anti-Managed Care Laws - Preempts State laws that: (1) mandate health insurance benefits; (2) restrict managed care arrangements and utilization review programs; and (3) establish standards for health insurance coverage that differ from those established under this title.
Subtitle D: Definitions; General Provisions - Sets forth definitions and effective date provisions.
Title II: Administrative Simplification - Subtitle A: Standards for Data Elements and Transactions - Directs the Secretary to adopt standards for: (1) the electronic transmission of health information data; (2) information transactions; and (3) health information network privacy standards.
Subtitle B: Requirements with Respect to Certain Transactions and Information - Lists transactions to be considered as standard transactions with respect to plan sponsors and HPCOs.
(Sec. 2202) Requires certified health information security organizations to make available to Federal or State agencies, pursuant to a cost-type contract, any non-identifiable health information that is held by the service, consists of data elements that are subject to a standard under Subtitle A, and is requested by such an agency to fulfill a requirement under this Act.
(Sec. 2203) Directs the Secretary to establish a procedure under which a plan sponsor or health provider that does not have the ability to transmit standard data elements and does not have access to a certified health information network may comply with this part.
Subtitle C: Miscellaneous Provisions - Requires the Secretary to establish standards and a certification procedure for health information network services.
(Sec. 2303) Provides that this subtitle supersedes State law. Prohibits the enforcement of any State law that requires medical or health plan records to be maintained or transmitted in written rather than electronic form, except as provided by the Secretary.
Title III: Fraud and Abuse Reform: Advisory Opinions - Amends Social Security Act titles XI and XVIII to mandate the issuance of advisory opinions by the Secretary according to specified guidelines.
Title IV: Malpractice Reform and Antitrust - Subtitle A: Malpractice Reform - Makes provisions of this subtitle through Sec. 4010 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 (ADR) system that is initiated on or after January 1, 1996.
(Sec. 4002) Prohibits a medical malpractice liability action from being brought in any State court during a calendar year unless the relevant claim has been initially resolved (i.e., a decision has been reached on whether the defendant is liable to the plaintiff for damages and on the amount of damages) under a certified ADR system or an alternative Federal system.
Prohibits a medical malpractice liability action from being brought in Federal court based on diversity of citizenship during a calendar year unless the relevant claim has been initially resolved under such a system in the State whose law applies.
Directs the Attorney General to establish an ADR process for tort claims consisting of medical malpractice liability claims brought against the United States. Prohibits a medical malpractice liability action based on such a claim from being brought in any Federal court unless the claim has been initially resolved under such process.
Sets forth procedures for filing actions.
(Sec. 4003) Authorizes States to develop specialty clinical practice guidelines to be certified by the Secretary.
(Sec. 4004) Limits to $250,000 the amount of noneconomic damages that may be awarded to a claimant and family members in a medical malpractice liability action.
(Sec. 4006) Sets forth provisions regarding: (1) limits on attorney's fees and other costs; and (2) statutes of limitations.
(Sec. 4008) Specifies that in the case of a medical malpractice claim relating to services provided during labor or the delivery of a baby, if the health care professional or provider did not previously treat the claimant for the pregnancy, the trier of fact may not find that the defendant committed malpractice nor assess damages unless the malpractice is proven by clear and convincing evidence.
(Sec. 4010) Provides that this part preempts State law, except for State law that imposes greater restrictions than those provided in this part.
(Sec. 4021) Lists requirements for State ADR systems, including that such a system: (1) applies to all medical malpractice liability claims under the jurisdiction of the courts of that State; (2) requires that a written opinion resolving the dispute be issued within six months after each party against whom the claim is filed has received notice of the claim; (3) is approved by the State or local governments; (4) provides for the transmittal to the State agency responsible for monitoring or disciplining health care professionals and providers of any findings of malpractice; and (5) provides for the regular transmittal of information on disputes resolved under the system to the Administrator for Health Care Policy and Research in a manner that protects the identity of the parties involved.
(Sec. 4022) Directs the Secretary to certify State ADR systems that meet such requirements on an annual basis.
Requires the Secretary to establish an alternative Federal ADR system for the resolution of medical malpractice liability claims in States that do not have in effect a certified ADR system.
(Sec. 4023) Directs the Secretary to submit to the Congress a report describing and evaluating State ADR systems and the alternative Federal system.
(Sec. 4031) Sets forth definitions for this subtitle.
Subtitle B: Antitrust - Directs the Attorney General to: (1) provide for the development of guidelines on the application of antitrust laws to the activities of health plans; and (2) establish a review process under which a health plan may request the Department of Justice's opinion on the plan's conformity with the Federal antitrust laws.
(Sec. 4102) Requires the Attorney General to issue a certificate of public advantage to each eligible health care collaborative activity that complies with this section's requirements. Provides that such activity shall not be liable under the antitrust laws for conduct described in the certificate if such conduct occurs while the certificate is in effect. Directs the Attorney General to issue such a certificate if: (1) the benefits that are likely to result from the activity outweigh the reduction in competition that is likely to result; and (2) such reduction is necessary to obtain such benefits. Sets forth activity eligibility requirements.
Introduced in House
Introduced in House
Referred to the Committee on Ways and Means, and in addition to the Committees on Commerce, Economic and Educational Opportunities, and the Judiciary, for a period to be subsequently determined by the Speaker, in each case for consideration of such provisions as fall within the jurisdiction of the committee concerned.
Referred to the Committee on Ways and Means, and in addition to the Committees on Commerce, Economic and Educational Opportunities, and the Judiciary, for a period to be subsequently determined by the Speaker, in each case for consideration of such provisions as fall within the jurisdiction of the committee concerned.
Referred to the Committee on Ways and Means, and in addition to the Committees on Commerce, Economic and Educational Opportunities, and the Judiciary, for a period to be subsequently determined by the Speaker, in each case for consideration of such provisions as fall within the jurisdiction of the committee concerned.
Referred to the Committee on Ways and Means, and in addition to the Committees on Commerce, Economic and Educational Opportunities, and the Judiciary, for a period to be subsequently determined by the Speaker, in each case for consideration of such provisions as fall within the jurisdiction of the committee concerned.
Referred to the Committee on Ways and Means, and in addition to the Committees on Commerce, Economic and Educational Opportunities, and the Judiciary, for a period to be subsequently determined by the Speaker, in each case for consideration of such provisions as fall within the jurisdiction of the committee concerned.
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Referred to the Subcommittee on Health.
Referred to the Subcommittee on Employer-Employee Relations.
Referred to the Subcommittee on Health and Environment, for a period to be subsequently determined by the Chairman.