Health Care Improvement Act of 1995

TABLE OF CONTENTS:

Title I: Assuring Availability and Continuity of Health

Coverage

Subtitle A: Insurance Reform

Subtitle B: Benefits

Subtitle C: Standards and Certification; Enforcement;

Preemption; General Provisions

Subtitle D: Definitions; General Provisions

Title II: Removal of Financial Barriers to Access

Subtitle A: Tax Deductibility for Individuals and Self-

Employed

Subtitle B: Premium and Cost-Sharing Subsidy Program

and Supplemental Benefits Program for Low-Income Individuals

Title III: Access Improvements

Subtitle A: Improved Access in Rural Areas

Subtitle B: Public Health Grants

Subtitle C: Academic Health Centers

Title IV: Malpractice Reform

Subtitle A: Findings; Purpose; Definitions

Subtitle B: Uniform Standards for Malpractice Claims

Subtitle C: Requirements for State Alternative Dispute

Resolution Systems (ADR)

Subtitle D: Grants to States for Development of

Practice Guidelines

Title V: Market Incentives to Containing Costs

Subtitle A: Administrative Simplification

Subtitle B: Antitrust

Title VI: Medicare

Subtitle A: Increased Beneficiary Choice; Improved

Program Efficiency

Subtitle B: Savings

Health Care Improvement Act of 1995 - Title I: Assuring Availability and Continuity of Health Coverage - Subtitle A: Insurance Reform - Requires each carrier that offers health insurance coverage in the individual and small group market to make coverage available to each qualified individual or small employer and to accept every applying small employer and qualifying individual. Prohibits denial, cancellation, or refusal to renew except for specified reasons. Limits preexisting condition exclusions. Regulates enrollment periods.

(Sec. 1011) Sets forth requirements for plans that use managed care, including regarding consumer disclosure and provider disclosure and due process. Prohibits requiring physician referral for obstetric or gynecological services. Preempts certain State law restrictions on managed care.

(Sec. 1012) Mandates a study and report on utilization review.

(Sec. 1013) Amends the Internal Revenue Code (IRC) to treat the account beneficiary of a medical savings account (MSA) as the owner of the account and subjects them to taxation on the account in accordance with specified provisions. Includes in gross income, and imposes a penalty regarding, any account expenditure not used exclusively for medical expenses of the beneficiary or the beneficiary's spouse or dependents. Excludes limited employer payments to an MSA from the employee's gross income and from the definition of "wages" for purposes of provisions relating to Social Security contributions. Amends the Social Security Act to make a similar change in the definition of "wages." Amends the IRC to exclude such payments from the definition of: (1) "compensation" for provisions relating to railroad retirement taxes; and (2) "wages" for provisions relating to unemployment taxes and to withholding.

(Sec. 1021) Regulates premium rate variation, allowing limited variation based on the factors of age, geographic area, family class (individual, individual with children, couple without children, or couple with children), benefit design, and administrative categories.

(Sec. 1022) Requires each carrier or plan to accept and apply any premium certificate issued under a State premium assistance program under specified Social Security Act provisions.

(Sec. 1023) Mandates development of a model risk adjustment system composed of one or more risk adjustment mechanisms. Requires each State to establish and maintain a conforming risk adjustment system.

(Sec. 1031) Sets forth information carriers and plans must disclose to prospective enrollees, brokers, plans, and States.

(Sec. 1032) Prohibits carriers from: (1) varying or conditioning remuneration to a person, or terminating or failing to renew an agent or broker, based on the claims experience or health status of individuals enrolled by or through the person; or (2) conditioning coverage on the purchase of any other product.

(Sec. 1033) Requires carriers and plans to meet Social Security Act requirements relating to advance directives.

Subtitle B: Benefits - Defines "qualified health coverage" as meeting the requirements of subtitle A above and including standard or high-deductible coverage consistent with this subtitle.

(Sec. 1102) Includes in standard coverage: (1) hospital, surgical, in-hospital medical, ambulatory, supplemental, and obstetrical services; (2) drugs, medicines, and prosthetic devices; (3) routine medical costs of treatment as part of an approved research trial; (4) drug off-label use if listed in specified compendia; and (5) preventive measures (without cost sharing). Sets forth actuarial value requirements. Prohibits benefits in any benefit category from being less than the narrowest scope and shortest duration in any of the plans under the Federal Employees Health Benefits Program.

(Sec. 1103) Requires that high-deductible coverage provide the benefits of standard coverage and use the deductible amount established under this Act, with the actuarial value of coverage equivalent to 80 percent of the actuarial value for standard coverage.

(Sec. 1104) Authorizes the Secretary of Health and Human Services to establish and modify benefit valuation procedures. Directs the Secretary to establish: (1) the deductible amount for high-deductible coverage; and (2) model benefit packages.

(Sec. 1105) Regulates supplemental coverage.

(Sec. 1106) Requires each carrier and plan to provide for an option under which children under 26 years old are treated as family members.

(Sec. 1107) Mandates certain coverage relating to Christian Science.

Subtitle C: Standards and Certification; Enforcement; Preemption; General Provisions - Mandates development of standards regarding the requirements of this subtitle.

(Sec. 1202) Requires each State to report on steps the State is taking to implement and enforce the standards. Provides for Federal action in the event of uncorrected State deficiency.

(Sec. 1204) Deems provisions of this title, as they relate to plans or employers and for purposes of administration and enforcement provisions of the Employee Retirement Income Security Act of 1974 (ERISA), to be provisions of ERISA.

Amends the IRC to impose a tax on the failure of a carrier to comply with specified provisions of this Act.

(Sec. 1205) Prohibits a single employer plan from offering coverage other than through a carrier unless the plan has at least 100 eligible employees.

Subtitle D: Definitions; General Provisions - Sets forth definitions for this Act and effective dates for this title.

Title II: Removal of Financial Barriers to Access - Subtitle A: Tax Deductibility for Individuals and Self-Employed - Amends the IRC to phase in a permanent 100 percent deduction for the health insurance costs of self-employed individuals.

(Sec. 2002) Allows individuals who are not self-employed to deduct 25 percent of the amount paid for insurance which constitutes medical care for the taxpayer, spouse, and dependents, except for months in which the taxpayer is eligible to participate in any subsidized plan maintained by an employer of the taxpayer or the taxpayer's spouse. Allows the deduction whether or not the taxpayer itemizes other deductions.

(Sec. 2003) Includes in employee gross income employer-provided coverage provided through a flexible spending or similar arrangement if any amount of cost-sharing may be paid for or reimbursed under the arrangement. Amends the definition of "qualified benefit," for cafeteria plan provisions, to exclude any benefits or coverage if any amount of cost-sharing or more than 20 percent of any premium may be paid for or reimbursed under the plan. Provides for transfers from flexible spending arrangements to medical savings accounts during 1997.

Subtitle B: Premium and Cost-Sharing Subsidy Program and Supplemental Benefits Program for Low-Income Individuals - Amends the Social Security Act (SSA) to add a new title XXI entitled "State Acute Care Benefits Programs For Low-Income Individuals." Outlines specific requirements for State premium and cost-sharing subsidy programs, as well as State supplemental acute care benefits programs, for low- income individuals. Requires operation of a premium and cost-sharing subsidy program as a State plan requirement under Medicaid.

(Sec. 2102) Amends SSA title XIX (Medicaid) to provide for the division of Medicaid benefits into core benefits and supplemental benefits for AFDC, SSI, and non-cash Medicaid beneficiaries. Places a limitation on the amount of Federal financial participation for benefits for acute medical services for such beneficiaries.

Title III: Access Improvements - Subtitle A: Improved Access in Rural Areas - Mandates grants to an eligible State for the development of plans to increase access to health care services for residents of chronically underserved areas.

(Sec. 3002) Requires that funds be made available for technical assistance (including regarding eligibility for other Federal programs) and advice, concerning establishing or enhancing a community rural health network in an underserved rural area, for: (1) entities receiving a grant under this subtitle for such a network; (2) state or local governmental units; and (3) entities providing health care services (including health professional education services) in the area. Authorizes appropriations.

(Sec. 3003) Mandates financial assistance for the development and implementation of such networks. Authorizes appropriations. Declares that, in order to provide for that authorization of appropriations and notwithstanding any other provision of law, no funds are authorized to be appropriated to carry out, after FY 1996: (1) the rural health transition grant program of the Omnibus Budget Reconciliation Act of 1987; and (2) the rural health outreach program.

(Sec. 3011) Amends the Internal Revenue Code to exclude from gross income any payment made on behalf of the taxpayer by the National Health Service Corps Loan Repayment Program.

(Sec. 3012) Amends the Public Health Service Act to require that, for frontier health professional shortage areas, the decision on whether the area is a rational area for the delivery of health services be made without regard to the travel time between population centers or to contiguous area resources.

(Sec. 3013) Authorizes appropriations to carry out provisions relating to the Scholarship Program (mandating a set-aside for nurse education) and the Loan Repayment Program.

(Sec. 3021) Authorizes grants to States to improve the availability and quality of emergency medical services through the operation of State offices of emergency medical services.

Requires that projects under existing provisions relating to communications technologies and rural trauma care include demonstration projects to establish telecommunications between rural medical facilities and facilities with useful expertise or equipment.

Authorizes appropriations to carry out specified provisions relating to trauma care and emergency medical services.

(Sec. 3022) Mandates grants to States for the creation or enhancement of air medical transport systems that provide victims of medical emergencies in rural areas with access to treatment. Authorizes appropriations.

(Sec. 3031) Mandates a demonstration project to increase the number and percentage of medical students entering primary care practice. Requires a portion of direct graduate medical education cost payments (under title XVIII (Medicare) of the Social Security Act) be used for payments to States and training consortia. Authorizes grants to States and consortia for developing and evaluating the projects. Authorizes appropriations.

(Sec. 3041) Mandates demonstration projects to increase the number and percentage of medical students entering primary care practice. Requires payments to participating health care training consortia and prohibits payments under Medicare for direct and indirect costs of graduate medical education during the participation.

Subtitle B: Public Health Grants - Amends the Public Health Service Act to authorize grants to States for specified public health programs. Authorizes appropriations.

(Sec. 3102) Mandates programs of scholarships and educational loan repayment for attendance at schools of public health in return for the scholarship and loan recipients agreeing to provide services in public health positions, approved by the Secretary of Health and Human Services, serving a population with significant unmet need. Applies to these programs existing provisions of the National Health Service Corps scholarship and loan repayment programs. Authorizes appropriations.

Subtitle C: Academic Health Centers - Mandates studies of: (1) the feasibility and desirability of making payments to facilities that are not hospitals for the direct and indirect costs of graduate medical education costs attributable to residents trained at the facilities; (2) the funding needs of health professions schools.

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

Subtitle B: Uniform Standards for Malpractice Claims - Applies this subtitle to any medical malpractice liability action in a Federal or State court, and to any medical malpractice claim subject to an alternative dispute resolution system (ADR), initiated after a specified date.

(Sec. 4102) Prohibits medical malpractice actions in State or Federal courts unless the claim has been initially resolved under an ADR. Requires establishment of an ADR process for claims against the United States.

(Sec. 4103) Sets forth filing procedures, including regarding a certificate of merit and standard interrogatories and requests.

(Sec. 4104) Limits the dollar amount of noneconomic damages. Prohibits punitive or exemplary damages against manufacturers of medical products. Requires several and prohibits joint liability for noneconomic damages, except for defendants found liable as a result of gross negligence or fraud. Requires the total amount of punitive damages to be paid to the State in which the action is brought or in which the services were rendered to carry out activities to assure the safety and quality of health care. Requires development and submission to the Congress of alternative limits on noneconomic damages, including separate limits for specified categories of limits.

(Sec. 4105) Prohibits requiring a single payment of damages for future economic loss over a specified amount, subject to waiver.

(Sec. 4106) Requires claims to be initiated within 2 years after the alleged injury was or should have been discovered.

(Sec. 4107) Prohibits finding malpractice against a provider of services during labor or delivery, if the provider did not previously treat the claimant, unless the malpractice is proved by clear and convincing evidence.

(Sec. 4108) Allows finding malpractice only if the defendant's conduct was not reasonable unless, in accordance with State law, the action is based on a strict liability theory.

(Sec. 4110) Declares that this title supersedes any State law only to the extent that State law permits greater damages or establishes a less strict standard of proof.

Subtitle C: Requirements for State Alternative Dispute Resolution Systems (ADR) - Sets forth basic requirements for State ADRs, including: (1) application to all medical malpractice claims; (2) if multiple ADR procedures are available, allowing the parties to select the procedure to be used, assigning a procedure if the parties do not agree; and (3) transmitting findings of malpractice to the State agency responsible for monitoring or disciplining health care professionals and providers. Applies the provisions of subtitle B of this title, subject to exception, to claims brought under the State ADR.

(Sec. 4202) Provides for State certification of ADRs meeting applicable requirements. Mandates establishment of a Federal ADR system for the resolution of claims in States without certified ADRs.

(Sec. 4203) Mandates grants to States for implementing and operating ADRs.

Subtitle D: Grants to States for Development of Practice Guidelines - Mandates grants to States for the development of medical practice guidelines for health care professionals that may be applied to resolve claims and actions.

Title V: Market Incentives to Containing Costs - Subtitle A: Administrative Simplification - Requires adoption of standards: (1) consistent with the objective of reducing the costs of providing and paying for health care; and (2) in use and generally accepted, developed, or modified by the standard-setting organizations accredited by the American National Standard Institute.

(Sec. 5012) Mandates adoption of standards to make uniform and compatible for electronic transmission through the health information network the data elements of any health information the Secretary of Health and Human Services determines appropriate for transmission in connection with standard transactions under this subtitle. Establishes a system to provide for a standard unique health identifier for each individual, employer, plan sponsor, and provider.

(Sec. 5013) Requires adoption of technical standards consistent with the health information network privacy standards under this subtitle relating to the transmission method for health information. Mandates regulations specifying procedures for the electronic transmission and authentication of signatures.

(Sec. 5014) Requires adoption of information privacy standards.

(Sec. 5021) Declares to be standard transactions (and requires the information transmitted in the transaction to be in the form of standard data elements): verification of benefit eligibility, coordination of benefits, claim submission, claim attachment submission, claim status notification, claim status verification, claim adjudication, payment and remittance advice, and certification or authorization of a referral to a non-network provider.

(Sec. 5022) Requires a health information security organization certified under this subtitle to make certain non-identifiable information available to a Federal or State agency, on a cost-type contract, as requested by the agency to fulfill a requirement of this Act.

(Sec. 5023) Mandates establishment of a procedure under which a sponsor or provider that does not have the ability to transmit standard data elements directly and does not have access to a health information network may comply with these provisions.

(Sec. 5031) Requires the establishment of: (1) standards regarding the operation of health information network services; and (2) a certification procedure for network services.

(Sec. 5032) Prohibits an individual or entity, after the establishment under this subtitle of standards to make data elements uniform and compatible for electronic transmission, from requiring any additional data element in connection with the transaction or an inquiry regarding the transaction. Makes a similar prohibition regarding the transmission method. Allows waivers.

(Sec. 5033) Declares that a provision, requirement, or standard under this subtitle supersedes any contrary provision of State law.

Subtitle B: Antitrust - Mandates the development and publication of explicit guidelines on the application of antitrust laws to the activities of health plans.

(Sec. 5102) Directs the Attorney General to issue a certificate of public advantage to each eligible health care collaborative activity complying with the requirements of this paragraph. Declares that such activity and the parties to it shall not be liable under any of the antitrust laws (as defined in specified provisions of the Clayton Act, including specified provisions of the Federal Trade Commission Act relating to unfair methods of competition, and similar State laws). Requires issuance of the certificate if the likely benefits outweigh the likely reduction in competition and the reduction is necessary to obtain the benefits.

Title VI: Medicare - Subtitle A: Increased Beneficiary Choice; Improved Program Efficiency - Outlines various specified requirements for HMOs and other eligible organizations under the Medicare program, including the use of metropolitan statistical areas to determine adjusted average per capita cost and enrollment periods for Medicare HMOs.

(Sec. 6002) Amends the Omnibus Budget Reconciliation Act of 1990 to permit Medicare select policies in all States.

Revises requirements of such policies under the Medicare program.

(Sec. 6003) Includes notice of available HMOs in the annual notices to Medicare beneficiaries.

(Sec. 6004) Requires the Secretary of Health and Human Services to develop and submit to the Congress a proposal for legislation which provides for the voluntary enrollment of Medicare beneficiaries in private health insurance plans.

(Sec. 6005) Provides for optional interim enrollment of Medicare beneficiaries in private health plans.

(Sec. 6011) Directs the Secretary to take such steps as may be necessary to consolidate the administration of Medicare parts A (Hospital Insurance) and B (Supplementary Medical Insurance) over a four year period.

(Sec. 6021) Provides under Medicare for notice of advance directive rights to individuals entering Medicare.

Subtitle B: Savings - Provides for a reduction in: (1) the conversion factor for the physician fee schedule for non-primary care services; and (2) hospital outpatient services through establishment of the prospective payment system.

(Sec. 6103) Amends the Internal Revenue Code to provide for an increase in the Medicare part B premium for individuals with high income.

(Sec. 6104) Provides for phased-in elimination of Medicare hospital disproportionate share adjustment payments.

(Sec. 6105) Provides for imposition of 20 percent coinsurance on laboratory services.