Insurance and Health Care Reform Act of 1995

TABLE OF CONTENTS:

Title I: Health Insurance Reforms

Subtitle A: Improving Access to and Continuity of

Coverage

Subtitle B: Open Enrollment and Related Practices

Subtitle C: Preemption of State Mandated Benefits,

Anti-managed Care Laws, and State Insurance

Standards

Subtitle D: Administrative Simplification

Subtitle E: Restriction on Genetic Screening and

Testing

Subtitle F: Administrative Expenses

Subtitle G: Limitations on Balance Billing

Subtitle H: Enforcement; General Definitions

Title II: Extension of Preventive Public Health

Title III: Tax Provisions

Insurance and Health Care Reform Act of 1995 - Title I: Health Insurance Reforms - Subtitle A: Improving Access to and Continuity of Coverage - Regulates preexisting condition provisions in health benefit plans covering small employers. Mandates crediting of previous coverage.

(Sec. 103) Prohibits cancellation or denial of renewal except for contribution nonpayment, fraud, or similar matters. Prohibits excluding an employee or dependent on the basis of any actual or expected health condition. Allows exclusion of certain late enrollees.

(Sec. 104) Limits premium rate variation. Mandates: (1) full disclosure of rating practices; (2) annual actuarial certification of compliance with the requirements of this section and of the actuarial soundness of rating practices; and (3) insurer registration or licensure with State authorities.

(Sec. 105) Regulates small employer purchasing group (SEPG) actions, including: (1) allowing the offering of health benefit plans and contracting with other SEPGs for the inclusion of small employer members of one in the program of the other; and (2) prohibiting approving or enforcing provider payment rates or assuming plan financial risk. Regulates SEPG premiums. Declares that SEPG plans are not subject to laws relating to selective contracting, payment negotiation, benefit or provider mandates, certain beneficiary incentives, and utilization reviews.

Subtitle B: Open Enrollment and Related Practices - Sets forth enrollment guidelines, including regarding open enrollment, minimum coverage, preexisting conditions, premiums, network use, limitations on the number of new insured an insurer is required to accept, and limitations on the required acceptance of persons confined to a health care facility. Limits agent compensation.

Subtitle C: Preemption of State Mandated Benefits, Anti-Managed Care Laws, and State Insurance Standards - Preempts State laws and regulations regarding mandated benefits, managed care, and insurance standards.

Subtitle D: Administrative Simplification - Directs the Secretary of Health and Human Services to adopt standards regarding data elements, uniform claims forms, and uniform electronic transmission. Allows the Secretary to require claim submission in accordance with the standards.

Subtitle E: Restriction on Genetic Screening and Testing - Prohibits insurers from requiring, considering or inquiring into the results of, or making an adverse decision based on reports of genetic screening or testing. Allows results consideration if voluntarily submitted and favorable to the applicant.

Subtitle F: Administrative Expenses - Limits insurers' administrative expenses for sickness and accident insurance, starting at 40 percent in 1996 and declining annually to 20 percent in 1999.

Subtitle G: Limitations on Balance Billing - Amends provisions of title XVIII (Medicare) of the Social Security Act relating to payment for physicians' services to reduce the limiting charge from 115 percent to 105 percent of the recognized payment amount.

(Sec. 162) Prohibits providers from balance billing any individual, dependent, or employee for any health care supplies or services provided to the individual, dependent, or employee who is insured under a health benefit plan. Requires the provider to accept payments by the insurer under the terms of the plan as payment in full.

Subtitle H: Enforcement; General Definitions - Makes the State commissioner of insurance for the insurer's State of domicile responsible, if the commissioner determines that an insurer has failed to comply with a requirement of subtitles A, B, E, or F of this title, for suspending the insurer's license. Allows the commissioner to impose a civil money penalty if the insurer continues business during suspension. Directs the Secretary of Health and Human Services, insofar as a requirement of subtitles A, B, or F of this title applies to a health plan not offered by an insurer, to take enforcement action. Allows that action to include injunctions and civil money penalties.

(Sec. 172) Sets forth general definitions for this title.

Title II: Extension of Preventive Public Health - Amends the Public Health Service Act to extend the authorizations of appropriations for immunization programs, tuberculosis prevention, control, and elimination, and lead poisoning screening, referral, and education.

Title III: Tax Provisions - Amends the Internal Revenue Code (IRC) to annually increase (reaching 100 percent in 1999) the deductible percentage of the medical care insurance costs of self-employed individuals.

(Sec. 302) Prohibits treating a health care provider as failing to be described in IRC sections 501(c)(3) (charitable, etc. organizations) or 501(c)(4) (civic leagues, nonprofit social welfare organizations, or local employee organizations) solely because the provider is affiliated with or controlled by an entity that primarily provides either health services or insurance related to such services. Prohibits treating obligations issued by a health care provider as failing to be qualified section 501(c)(3) bonds solely because the provider is so affiliated if the provider meets specified requirements.