Health Coverage Availability and Affordability Act of 1996

TABLE OF CONTENTS:

Title I: Improved Availability and Portability of Health

Insurance Coverage

Subtitle A: Coverage Under Group Health Plans

Subtitle B: Certain Requirements for Insurers and HMOs

in the Group and Individual Markets

Subtitle C: Sense of Committee on Additional

Requirements

Subtitle D: Definitions; General Provisions

Title II: Preventing Health Care Fraud and Abuse;

Administrative Simplification

Subtitle A: Fraud and Abuse Control Program

Subtitle B: Revisions to Current Sanctions for Fraud

and Abuse

Subtitle C: Data Collection

Subtitle D: Civil Monetary Penalties

Subtitle E: Revisions to Criminal Law

Subtitle F: Administrative Simplification

Health Coverage Availability and Affordability Act of 1996 - Title I: Improved Availability and Portability of Health Insurance Coverage - Subtitle A: Coverage Under Group Health Plans - Requires a group health plan and an insurer or health maintenance organization (HMO) offering health insurance in connection with a group health plan to: (1) reduce any preexisting condition period by the aggregate period of prior coverage; and (2) limit any preexisting condition period to not more than 12 months. Prohibits: (1) considering genetic information to be a preexisting condition unless related treatment has been sought in the last six months; (2) preexisting condition periods for newborns and certain adoptions; and (3) treating pregnancy as a preexisting condition. Allows an HMO not using preexisting condition limitations to: (1) impose an eligibility period; and (2) use alternative methods to address adverse selection as approved by a State authority.

(Sec. 103) Prohibits coverage exclusion on the basis of health status. Requires a plan to allow an otherwise-eligible employee to enroll if the employee previously declined enrollment because of other coverage and subsequently lost the other coverage. Prohibits, if a plan offers family coverage, a waiting period for a newborn, certain adopted children, or a spouse.

(Sec. 104) Amends the Internal Revenue Code to impose a tax on any failure of a group health plan to meet certain requirements of this Act. Deems sections 101 through 103 of this Act to be provisions of the Employee Retirement Income Security Act of 1974 (ERISA). Provides civil money penalties for failure to meet requirements of this subtitle.

Subtitle B: Certain Requirements for Insurers and HMOs in the Group and Individual Markets - Requires insurers or HMOs that offer coverage in the small group market in a State to accept every applying small employer and every applying eligible individual. Allows minimum participation or contribution rules.

(Sec. 132) Requires insurers or HMOs that offer coverage in the small or large group market to renew or continue the coverage at the option of the employer, except for nonpayment of premiums, fraud, and similar reasons. Allows uniform termination or modification of coverage.

(Sec. 141) Requires insurers or HMOs that issue individual health insurance to offer coverage to each individual who previously had group coverage. Prohibits declining issuance based on health status. Allows superseding State mechanisms reasonably designed to meet the goals of guaranteeing coverage to qualifying individuals and assuring that the individuals receive credit for prior coverage toward the new coverage's preexisting condition exclusion period.

(Sec. 142) Mandates renewal or continuation of individual coverage, except for nonpayment of premiums, fraud, or similar matters.

(Sec. 151) Applies the civil money penalty provisions of subtitle A to subtitle B.

Subtitle C: Sense of Committee on Additional Requirements - Declares the sense of the House Committee on Commerce regarding: (1) the impact of mandating the inclusion in health insurance coverage and group health plans of bone marrow transplants for treatment of breast cancer and of minimum periods of inpatient care for child birth; (2) congressionally-imposed requirements concerning coverage of specific benefits under private and State health insurance plans; and (3) the intent of the Committee to hold hearings on requiring benefits under group health plans and coverage in group and individual markets.

Subtitle D: Definitions; General Provisions - Sets forth definitions and general provisions, including: (1) excluding church plans from the requirements of this title; (2) requiring (unless a State elects otherwise) that State plans under title XIX (Medicaid) of the Social Security Act be treated as group health plans; and (3) requiring that title XVIII (Medicare) of the Social Security Act be treated as a group health plan for purposes of applying portions of section 101.

Title II: Preventing Health Care Fraud and Abuse; Administrative Simplification - Subtitle A: Fraud and Abuse Control Program - Amends title XI of the Social Security Act (SSA) to direct the Secretary of Health and Human Services (HHS), acting through the HHS Office of Inspector General (IG), and 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 relating to the delivery of and payment for health care; (3) facilitate enforcement of certain provisions of SSA and other Acts applicable to health care fraud and abuse; (4) provide for the modification and establishment of safe harbors; (5) issue advisory opinions and special fraud alerts; and (6) provide for the reporting and disclosure of certain final adverse actions against health care providers, suppliers, or practitioners pursuant to the data collection system established below.

(Sec. 201) Establishes the Health Care Fraud and Abuse Control Account (Account) in Medicare's Federal Hospital Insurance Trust Fund (Trust Fund) to hold the criminal fines, civil monetary penalties and assessments, property forfeiture proceeds, and other amounts from Federal health care cases for financing the program above and the Medicare Integrity Program established below. Makes certain appropriations to the Trust Fund and Account, earmarking amounts for activities of HHS' Office of the Inspector General with respect to the Medicare and Medicaid programs under, respectively, SSA titles XVIII and XIX.

(Sec. 202) Establishes the Medicare Integrity Program under which the HHS Secretary shall promote the integrity of the Medicare program by entering into contracts with certain eligible private entities to: (1) review and audit Medicare service providers to determine whether payment should not have been made; (2) educate service providers, beneficiaries, and others regarding payment and benefit issues; and (3) develop and update a list of items of durable medical equipment subject to prior authorization.

Eliminates the responsibilities of fiscal intermediaries under Medicare part A (Hospital Insurance) and carriers under Medicare part B (Supplementary Medical Insurance) for carrying out certain activities to the extent such activities are carried out pursuant to a contract under the Medicare Integrity Program.

(Sec. 203) Directs the HHS Secretary to provide an explanation of benefits under the Medicare program with respect to each furnished item or service for which payment may be made, whether or not a deductible or coinsurance payment may be imposed against the individual with respect to the item or service.

Directs the HHS Secretary to establish a program to encourage individuals to: (1) report information on fraud and abuse under Medicare; and (2) submit suggestions on improvements in the Medicare program. Provides for the payment to such individuals of a portion of: (1) amounts collected due to reports of fraud or abuse; or (2) savings resulting from adopted suggestions.

(Sec. 204) Amends SSA title XI to extend the application of criminal penalties for acts involving the Medicare program to similar violations of any plan providing health benefits which is funded directly by the Federal Government, except the Federal Employees' Health Benefits Program.

(Sec. 205) Directs the HHS Secretary to publish a notice soliciting proposals for: (1) modifications to existing safe harbors issued under the Medicare and Medicaid Patient and Program Protection Act of 1987; (2) additional safe harbors specifying payment practices that shall not be treated as a criminal offense or exclusion; (3) advisory opinions by the Secretary regarding SSA title XI civil monetary and criminal penalty provisions; and (4) special fraud alerts by the HHS IG, upon request, with regard to suspect practices under the Medicare program or a State health care program. Requires subsequent issuance of any appropriate implementing regulations.

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

(Sec. 212) Revises specified current sanctions involving exclusion for fraud and abuse under Medicare and State health care programs.

Repeals the prerequisite that a health care practitioner or person be determined "unwilling or unable" to comply substantially with a corrective action plan before sanctions may be imposed (thus permitting the HHS Secretary to exclude such practitioner or person from eligibility to provide services for failure to comply with a corrective action plan, regardless of circumstances).

(Sec. 215) Permits the imposition of intermediate sanctions on Medicare HMOs, in addition to the current option of termination.

(Sec. 216) Excepts from anti-kickback penalties for discounting and managed care arrangements any remuneration between an organization and an item or service provider under a written agreement if: (1) the organization is a Medicare-eligible HMO or competitive medical plan; or (2) the written agreement places the provider at substantial financial risk for the cost or utilization of such items or services which it is obligated to provide, whether through a withhold, capitation, or other similar risk arrangement.

(Sec. 217) Establishes a criminal penalty for fraudulent disposition of assets in order to obtain Medicaid benefits.

Subtitle C: Data Collection - Directs the establishment of 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 Government agencies and health care plans to report to the Secretary any final adverse action.

(Sec. 221) Allows the HHS Secretary, under the system for unique identifiers for Medicare physicians, to impose fees on such physicians to cover costs of investigation and recertification activities.

Subtitle D: Civil Monetary Penalties - Revises civil monetary penalty and other related SSA title XI provisions, including: (1) subjecting to civil penalties certain program-excluded individuals who retain an ownership or control interest in a participating entity if they know or should know of the action constituting the basis for the exclusion at the time they violated such provisions; (2) increasing the amounts of specified penalties and assessments, including those against health care practitioners failing to comply with statutory obligations; (3) prohibiting the offering of inducements to individuals enrolled under Medicare or a State health care program, including waiver of coinsurance and deductible amounts and transfer of items or services for free or for other than fair market value; and (4) establishing a penalty for false certification for home health services.

(Sec. 232) Requires a knowing level of intent in a violation to justify the imposition of civil money penalties.

Subtitle E: Revisions to Criminal Law - Amends the Federal criminal code to define a Federal health care offense and to cover health care fraud, theft, embezzlement, obstruction of criminal investigations, and other related matters, such as the laundering of monetary instruments.

(Sec. 247) Authorizes injunctive relief enjoining health care offenses and property disposals.

Subtitle F: Administrative Simplification - Amends SSA title XI to add a new part C (Administrative Simplification) providing for development of an electronic system for: (1) processing health care information with the goal of improving overall health care system operations; and (2) reducing administrative costs through adoption of standards for information transactions (including enrollment, disenrollment, claims attachments, and coordination of benefits), data elements, security and privacy standards, and performance of required tasks, assisted by a new Health Information Advisory Committee established by this Act.

(Sec. 252) Establishes penalties for the wrongful disclosure of individually identifiable health information, among other violations of this subtitle.