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: Affordable and Available Health Coverage

Through Multiple Employer Pooling Arrangements

Subtitle D: Definitions; General Provisions

Title II: Preventing Health Care Fraud and Abuse;

Administrative Simplifications; Medical Liability Reform

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

Subtitle F: Administrative Simplification

Subtitle G: Duplication and Coordination of

Medicare-Related Plans

Subtitle H: Medical Liability Reform

Title III: Tax-Related Health Provisions

Subtitle A: Medical Savings Accounts

Subtitle B: Increase in Deduction for Health Insurance

Costs of Self-Employed Individuals

Subtitle C: Long-Term Care Services and Contracts

Subtitle D: Treatment of Accelerated Death Benefits

Subtitle E: High-Risk Pools

Subtitle F: Organizations Subject to Section 833

Title IV: Revenue Offsets

Subtitle A: Repeal of Bad Debt Reserve Method for Thrift

Savings Associations

Subtitle B: Reform of the Earned Income Credit

Subtitle C: Treatment of Individuals Who Lose United

States Citizenship

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) preexisting condition periods for newborns and regarding certain adoptions; and (2) treating pregnancy as a preexisting condition. Allows an HMO that does not use 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 and premium or contribution discrimination 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 subtitle and subtitle D as it is applicable to those sections to be provisions of the Employee Retirement Income Security Act of 1974 (ERISA). Provides for civil money penalties for failure to meet a requirement of this subtitle.

Subtitle B: Certain Requirements for Insurers and HMOs in the Group and Individual Markets - Part 1: Availability of Group Health Insurance Coverage - Requires each insurer or HMO that offers health insurance 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 an insurer or HMO that offers 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.

Part 2: Availability of Individual Health Insurance Coverage - Requires each insurer or HMO that issues 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.

Part 3: Enforcement - Applies the civil money penalty provisions of section 104 of this Act to parts 1 and 2.

Subtitle C: Affordable and Available Health Coverage Through Multiple Employer Pooling Arrangements - Amends the Employee Retirement Income Security Act of 1974 (ERISA) to set forth rules regarding multiple employer health plans. Treats a multiple employer welfare arrangement (MEWA) under which the benefits consist solely of medical care, and under which some or all benefits are not fully insured, as an employee welfare benefit plan that is a health plan. Provides for the treatment of such arrangements under preemption rules. Regulates reserves, notice regarding voluntary termination, and corrective actions and mandatory termination.

(Sec. 166) Provides for the treatment of church plans.

(Sec. 167) Provides for enforcement through civil monetary penalties, injunctions, and criminal penalties, as well as Federal- State cooperation in enforcement.

(Sec. 169) Requires each MEWA to register before beginning operations and annually thereafter.

(Sec. 170) Provides for a single annual report regarding all employers participating in a MEWA.

Subtitle D: Definitions; General Provisions - Excludes church plans from the requirements of this title as they apply to group health plans. Allows governmental plans to elect not to be subject to such requirements. Requires treatment as group health plans of State Medicaid (unless a State elects otherwise) and Medicare plans and Indian Health Service programs for individual coverage certification purposes. Provides for the treatment of partnerships.

Title II: Preventing Health Care Fraud and Abuse; Administrative Simplification; Medical Liability Reform - 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, audits, and inspections 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 and to issue advisory opinions and special fraud alerts; and (5) 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 by this title.

(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 and civil monetary penalties and assessments obtained from Federal health care cases, as well as property forfeiture proceeds resulting from such cases, and other specified amounts for financing the program above and the Medicare Integrity Program established by this title. Makes certain appropriations to the Trust Fund and Account, earmarking certain amounts for activities of the Department of Health and Human Services' (HHS) Office of the Inspector General (IG) with respect to the Medicare and Medicaid programs under SSA titles XVIII and XIX.

(Sec. 202) Establishes under Medicare 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 the activities of service providers under Medicare and audit cost reports to determine whether payment should not have been made; (2) educate service providers, beneficiaries, and other persons with respect to payment and benefit issues; and (3) develop and periodically update a list of items of durable medical equipment which are subject to prior authorization.

Prohibits fiscal intermediaries under Medicare part A (Hospital Insurance) and carriers under Medicare part B (Supplementary Medical Insurance) from carrying out certain activities to the extent the activity is carried out pursuant to a contract under the Medicare Integrity Program.

(Sec. 203) Directs the HHS Secretary to provide an explanation of Medicare benefits with respect to each furnished item or service for which payment may be made to an individual without regard to whether or not a deductible or coinsurance may be imposed.

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

(Sec. 204) Amends SSA title XI to require application of criminal penalties for acts involving the Medicare program to similar violations of any plan or program that provides health benefits, whether directly, through insurance, or otherwise, which is funded directly, in whole or in part, by the Federal Government, except the Federal Employees' Health Benefits Program (Federal health care programs).

(Sec. 205) Directs the HHS Secretary to periodically publish a notice in the Federal Register 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 serve as the basis for an exclusion; (3) advisory opinions by the HHS IG with regard to prohibited remuneration constituting grounds for the imposition of a sanction; 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 the Secretary to issue appropriate implementing regulations.

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 after the enactment of this Act of a felony related to: (1) fraud in connection with 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, among other changes establishing minimum periods of exclusion for: (1) certain individuals and entities subject to permissive exclusion from Medicare and State health care programs; and (2) practitioners and persons failing to meet certain statutory obligations with regard to services or items.

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 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 health maintenance organizations in addition to the current option of termination. Provides additional intermediate sanctions for miscellaneous program violations.

(Sec. 216) Provides an additional exception to anti-kickback penalties for discounting and managed care arrangements.

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

Subtitle C: Data Collection - Directs the HHS 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.

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

Subtitle D: Civil Monetary Penalties - Revises civil monetary penalties, providing among other changes for: (1) the exclusion from participation in Federal and State health care programs of persons subject to penalties and assessments for applicable program violations; (2) modifications in the amounts of various specified penalties and assessments, including the sanctions against health care practitioners who violate their statutory obligations with regard to the services or items ordered or provided by them to a covered beneficiary or recipient; (3) a prohibition against offering inducements to individuals enrolled under Medicare or a State health care program; (4) subjecting to civil money penalties certain excluded individuals retaining an ownership or control interest in a participating entity if they knew or should have known of the action constituting the basis for the exclusion of such entity at the time of violation; (5) a specific definition, for such penalty purposes, for remuneration which includes the waiver of coinsurance and deductible amounts and transfers of items or services for free or for other than fair market value; and (6) a penalty for false certification for home health services.

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

(Sec. 247) Provides for injunctive relief relating to covered health care offenses, as well as for property forfeitures.

Subtitle F: Administrative Simplification - Amends SSA title XI to add a new part C (Administrative Simplification) for development of an electronic system for: (1) processing health care information consistent with the goal of improving the operation of the overall health care system; and (2) reducing related administrative costs through the HHS Secretary's adoption of certain standards for information transactions (including enrollment, disenrollment, claims attachments, and coordination of benefits) and data elements as well as standards relating to security and privacy, and performance of tasks pursuant to specified requirements, assisted by the National Committee on Vital and Health Statistics.

(Sec. 252) Provides penalties for violations of provisions of this subtitle, including for the wrongful disclosure of individually identifiable health information.

(Sec. 253) Amends the Public Health Service Act to provide for a change in the membership and duties of the National Committee on Vital and Health Statistics, including responsibility for advising the HHS Secretary and the Congress on the implementation of SSA title XI part C added above.

Subtitle G: Duplication and Coordination of Medicare-Related Plans - Provides for the treatment of certain health insurance policies as nonduplicative under Medicare or Medicaid, such as policies providing for benefits which are payable to or on behalf of an individual without regard to other health benefit coverage of such individual.

Subtitle H: Medical Liability Reform - Outlines various specified measures addressing health care liability issues, including changes establishing: (1) limitations for health care liability actions brought in a State or Federal court against a health care provider; (2) a limitation on the total amount of noneconomic damages which may be awarded to a claimant for losses resulting from an injury; (3) certain restrictions on punitive damage awards; and (4) standards for alternative dispute resolution used to resolve a health care liability action or claim.

Title III: Tax-Related Health Provisions - Subtitle A: Medical Savings Accounts - Amends the Internal Revenue Code to allow a deduction for limited amounts paid to a medical savings account (MSA). Defines "medical savings account" as a trust for paying the account holder's medical expenses. Exempts an MSA from taxation unless it has ceased being an MSA. Provides for the treatment of distributions. Allows the MSA deduction to be taken whether or not the individual itemizes deductions. Excludes limited employer MSA contributions from employee gross income. Excludes employer MSA contributions from provisions relating to social security, railroad retirement, unemployment, and withholding taxes. Makes MSA contributions unavailable under cafeteria plans. Excludes MSAs from the value of taxable estates. Imposes a tax on excess MSA contributions. Exempts an MSA holder from prohibited transactions taxes if the MSA ceases to be an MSA. Imposes a penalty on MSA reporting failure. Exempts MSAs from the definition of "specified insurance contract" for provisions relating to capitalization of certain policy acquisition expenses.

Subtitle B: Increase in Deduction for Health Insurance Costs of Self-Employed Individuals - Allows self-employed individuals to deduct a portion of their expenditures for medical insurance for the individual, spouse, and dependents.

Subtitle C: Long-Term Care Services and Contracts - Part I: General Provisions - Requires treating: (1) a long-term care insurance as accident and health insurance and associated amounts received as received for personal injuries and sickness and as reimbursement for medical care expenses actually incurred; (2) an employer's plan providing long-term care as an accident and health plan; (3) limited amounts paid for such insurance as payments for medical care; and (4) such insurance as guaranteed renewable under specified provisions. Provides for the treatment of: (1) excess aggregate long-term care payments; and (2) long-term care coverage provided in conjunction with life insurance. Excludes long-term care from cafeteria plans. Includes in an employee's gross income employer-provided long-term care overage provided through a flexible spending arrangement. Declares that a group health plan does not fail to meet continuation requirements solely because it fails to provide long-term coverage.

(Sec. 322) Amends the definition of "medical care" (for provisions allowing a deduction for medical care expenses) to include qualified long-term care services.

(Sec. 323) Imposes reporting requirements on long-term care benefit payors.

Part II: Consumer Protection Provisions - Sets forth provisions regarding: (1) the model regulation and model Act promulgated by the National Association of Insurance Commissioners; and (2) certain disclosure and nonforfeitability requirements.

(Sec. 326) Imposes a tax the failure to meet requirements regarding: (1) the model regulation and model Act; (2) policy or certificate delivery; and (3) claims denials information.

Subtitle D: Treatment of Accelerated Death Benefits - Treats life insurance amounts paid as an amount paid because of death if the insured is terminally or chronically ill and the amount is received under a provision that is treated as long-term care insurance. Treats the amount paid by a viatical settlement provider for a life insurance contract as an amount paid by reason of the death of the insured.

(Sec. 332) Treats, for life insurance company provisions, references to life insurance contracts as including references to accelerated death benefit riders (unless a rider is treated as a long-term care contract).

Subtitle E: High-Risk Pools - Exempts from taxation a State-established membership organization providing nonprofit medical care coverage to high risk individuals.

Subtitle F: Organizations Subject to Section 833 - Allows (for provisions affording a special deduction) an organization that is not a blue cross or blue shield (BCBS) organization to be treated as if it were a BCBS organization if it is not for profit and meets other requirements.

Title IV: Revenue Offsets - Subtitle A: Repeal of Bad Debt Reserve Method for Thrift Savings Associations - Declares that bad debt reserve banking provisions shall not apply after a specified date. Provides for the resulting accounting method change.

Subtitle B: Reform of the Earned Income Credit - Requires, in order to be eligible for the earned income credit (EIC), that a taxpayer include on the return the taxpayer's (and, if married, the spouse's) social security number (SSN). Adds to the definition of "mathematical or clerical error" references to omission of a SSN required by EIC provisions.

Subtitle C: Treatment of Individuals Who Lose United States Citizenship - Requires that individuals who lose U.S. citizenship and who meet specified criteria be treated (for income, estate, and gift tax provisions) as having a principal purpose to avoid taxes. Requires, for these purposes, treating long-term U.S. residents who cease being permanent U.S. residents or begin being the resident of a foreign country as if they were U.S. citizens who lost U.S. citizenship.

(Sec. 422) Requires a person who loses U.S. citizenship or ceases to be a long-term U.S. resident to provide a statement with specified contents.

(Sec. 423) Mandates a report to specified congressional committees on income tax compliance by citizens and lawful permanent U.S. residents residing outside the United States.