IV

103D CONGRESS

2D SESSION H. RES. 498

Making in order, in the consideration by the House of Representatives of

H.R. 3600 (the ‘‘Health Security Act’’), an amendment providing for

an AMCARE plan that makes available a government-sponsored, feefor-service nationwide health plan to almost all eligible individuals not

covered under large group health plans.

IN THE HOUSE OF REPRESENTATIVES

JULY 28, 1994

Mr. SCOTT (for himself, Mr. STARK, Mr. MCDERMOTT, Mr. MILLER of California, Mr. OWENS, Ms. MCKINNEY, Ms. PELOSI, Mr. FARR of California, Mr. TUCKER, Ms. WOOLSEY, Mr. DELLUMS, Mr. WATT, Mr.

STOKES, Mr. HILLIARD, and Mr. ROMERO-BARCELO ́) submitted the following resolution; which was referred to the Committee on Rules

RESOLUTION

Making in order, in the consideration by the House of Representatives of H.R. 3600 (the ‘‘Health Security Act’’),

an amendment providing for an AMCARE plan that

makes available a government-sponsored, fee-for-service

nationwide health plan to almost all eligible individuals

not covered under large group health plans.

1 Resolved, That in the consideration of the bill (H.R.

2 3600), to ensure individual and family security through

3 health care coverage for all Americans in a manner that

4 contains the rate of growth in health care costs and pro-
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1 motes responsible insurance practices, to promote choice

2 in health care, and to ensure and protect the health care

3 of all Americans, in the Committee of the Whole, the fol4 lowing amendment, if offered by Mr. Scott of Virginia (or

5 his designee), shall be made in order to the amendment6 in-the-nature-of-a-substitute to title I, as reported by the

7 Committee on Education and Labor and that any points

8 of order against this amendment are hereby waived.

9 At the end of subtitle E of title I, add the following

10 new part (and conform the table of contents of title I

11 accordingly):

12 ‘‘PART 5—AMCARE PLAN

13 ‘‘SEC. 1497. ESTABLISHMENT, ELIGIBILITY, AND ENROLL14 MENT.

15 ‘‘(a) ESTABLISHMENT.—

16 ‘‘(1) IN GENERAL.—The Secretary of Health

17 and Human Services shall establish and operate in

18 accordance with this part a government-sponsored

19 health care plan (in this part referred to as the

20 ‘AMCARE plan’) for eligible individuals described in

21 subsection (b).

22 ‘‘(2) DEADLINE FOR INITIAL OPERATION.—The

23 Secretary shall establish the AMCARE plan in a

24 manner that permits eligible individuals to first ob25 tain benefits under the plan on January 1, 1996.
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1 ‘‘(b) ELIGIBILITY.—

2 ‘‘(1) ELIGIBLE INDIVIDUALS.—Except as pro3 vided in paragraph (2), each eligible individual (as

4 defined in section 1001(c)) is eligible to enroll in the

5 AMCARE plan.

6 ‘‘(2) EXCEPTION FOR CERTAIN INDIVIDUALS.—

7 An individual is not eligible to enroll in the

8 AMCARE plan if the individual—

9 ‘‘(A) is an experience-rated individual; or

10 ‘‘(B) resides in a State operating a State

11 single-payer program under subpart B of part

12 1 of subtitle C.

13 ‘‘(c) ENROLLMENT PROCEDURES.—The Secretary

14 shall establish procedures for the enrollment of individuals

15 described in subsection (a) in the AMCARE plan. Such

16 procedures shall be based on the procedures used with re17 spect to the enrollment of community-rated individuals

18 under community-rated plans.

19 ‘‘(d) TREATMENT AS COMMUNITY-RATED PLAN.—

20 For purposes of this Act (including titles VI and IX), ex21 cept as may otherwise be provided in this part or under

22 rules established by the Board—

23 ‘‘(1) the AMCARE plan offered in a commu24 nity-rating area shall be treated as a community25 rated plan offered in such area; and
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1 ‘‘(2) the AMCARE plan and the Secretary shall

2 comply with the requirements of this Act applicable

3 to community-rated plans and the carriers offering

4 such plans.

5 ‘‘SEC. 1498. REQUIREMENTS FOR PLAN.

6 ‘‘(a) IN GENERAL.—Except as provided in this sec7 tion, the AMCARE plan shall meet the requirements ap8 plicable for a community-rated, fee-for-service, higher cost

9 sharing plan.

10 ‘‘(b) ADDITIONAL SPECIFICATIONS.—

11 ‘‘(1) NATIONAL COVERAGE.—The plan shall

12 provide coverage for the items and services covered

13 in the comprehensive benefit package on a nation14 wide basis.

15 ‘‘(2) PAYMENT TO PROVIDERS.—Instead of ap16 plying an applicable fee-for-service fee schedule, the

17 Secretary may base payments for services furnished

18 under the AMCARE plan on alternative market19 based payment rates for classes and types of services

20 provided in various market areas.

21 ‘‘(3) APPLICATION OF COST-SHARING REDUC22 TION PROVISIONS.—Under rules established by the

23 Board, the Secretary shall apply the provisions of

24 part 5 of subtitle C to families enrolled in the

25 AMCARE plan in the same manner as States apply
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1 such provisions to families enrolled in community2 rated plans in the State.

3 ‘‘(4) SUPPLEMENTAL BENEFITS.—

4 ‘‘(A) IN GENERAL.—With the approval of

5 the trustees of the AMCARE Trust Fund (es6 tablished under section 1499(e)), the Secretary

7 may offer benefits under the AMCARE plan in

8 addition to those provided under the com9 prehensive benefit package in the same manner

10 as community-rated plans may offer supple11 mental benefits to enrollees under part 3.

12 ‘‘(B) PREMIUM CHARGED.—The premium

13 charged for supplemental benefits offered under

14 subparagraph (A) shall be in an amount suffi15 cient to cover the costs of offering such benefits

16 (as determined by the Secretary in consultation

17 with the trustees of the AMCARE Trust Fund).

18 ‘‘(c) ADMINISTRATION.—

19 ‘‘(1) IN GENERAL.—The Secretary shall provide

20 for the administration of the AMCARE plan in a

21 manner similar to the administration of the medi22 care program. For this purpose, the Secretary may

23 enter into administrative agreements and contracts

24 with fiscal agents (which may or may not be the
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1 same fiscal agents through which the Secretary ad2 ministers the medicare program).

3 ‘‘(2) QUALITY ASSURANCE; UTILIZATION RE4 VIEW; CLAIMS PROCESSING.—In administering the

5 AMCARE plan, the Secretary shall take such steps

6 as the Secretary considers necessary—

7 ‘‘(A) to assure the quality and appropriate

8 utilization of the items and services furnished

9 under the plan, including the use of peer review

10 organizations described in title XI of the Social

11 Security Act;

12 ‘‘(B) to assure the timely and accurate

13 payment of claims for items and services fur14 nished under the plan; and

15 ‘‘(C) to otherwise assure that the plan pro16 vides high quality services in an efficient and

17 cost-effective manner.

18 ‘‘(3) LIMITATION ON EXPENDITURES FOR AD19 MINISTRATION.—The percentage of expenditures

20 under the AMCARE plan in a year attributable to

21 program administration may not exceed 3 percent.

22 ‘‘(d) OPTIONAL PRIMARY CARE CASE MANAGE23 MENT.—Nothing in this part shall be construed as pre24 venting the plan from implementing a primary care case
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1 management program to manage the delivery of the com2 prehensive benefit package to plan enrollees.

3 ‘‘(e) REFERRAL OF SUBSIDY-ELIGIBLE INDIVID4 UALS.—Under rules established by the Board, individuals

5 enrolled in the AMCARE plan who are provided a cost6 sharing reduction under subsection (b)(3) or a premium

7 discount or limitation of liability described in section

8 1499(b)(3) shall be referred for employment, job search,

9 job training, and other workforce support services as are

10 available to them through the Secretary or the Secretary

11 of Labor for development of family self-sufficiency.

12 ‘‘SEC. 1499. FINANCING.

13 ‘‘(a) DETERMINATION OF PREMIUM RATE.—In the

14 case of a family enrolled in the AMCARE plan—

15 ‘‘(1) IN GENERAL.—Subject to paragraph (3),

16 the premium applicable to the individual class of en17 rollment shall be such amount that (if applied under

18 this Act) will result in the payment of sufficient

19 funds to cover the costs of the AMCARE plan, in20 cluding a reasonable contingency margin and taking

21 into account risk adjustment under subsection (d).

22 ‘‘(2) FAMILY ENROLLMENT.—Subject to para23 graph (3), the premium applicable to a family class

24 of enrollment shall be equal to the product of—
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1 ‘‘(A) the premium amount determined

2 under paragraph (1), and

3 ‘‘(B) the premium class factor established

4 by the Board for that class under section 1531.

5 ‘‘(3) AREA ADJUSTMENT.—

6 ‘‘(A) IN GENERAL.—The Secretary shall

7 adjust the premiums determined under this

8 subsection for each community-rating area for

9 area differences in health care costs.

10 ‘‘(B) BASIS FOR ADJUSTMENT.—Such ad11 justment—

12 ‘‘(i) may reflect the final weighted av13 erage per capita premium rate (as defined

14 in section 6004(a)) for community-rated

15 plans offered in the area compared to the

16 weighted average of all such rates, and

17 ‘‘(ii) shall be made in a manner that

18 does not result in a change in the average

19 of the premium amounts under this sub20 section.

21 ‘‘(b) SPECIAL RULES FOR DETERMINING FAMILY

22 SHARE OF PREMIUMS.—In the case of a family enrolled

23 in the AMCARE plan—

24 ‘‘(1) FAMILY SHARE.—The family share of the

25 premium shall be determined by the Secretary in a
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1 manner similar to the determination described in

2 section 6101(b), but based upon the plan premium

3 rate determined under subsection (a).

4 ‘‘(2) REPAYMENT OF FAMILY EMPLOYMENT

5 CREDIT.—The Secretary shall promulgate rules re6 lating to the repayment of the family employment

7 credit in a manner similar to that provided under

8 subpart B of part 1 of subtitle A of title VI.

9 ‘‘(3) APPLICATION OF LOW-INCOME SUBSIDY

10 PROVISIONS.—In carrying out paragraphs (1) and

11 (2), section 6104 (relating to premium discount

12 based on income) and section 6113 (relating to limi13 tation of liability based on income) shall apply.

14 ‘‘(c) CONTRIBUTIONS BY EMPLOYERS.—The em15 ployer share of the premium for an individual enrolled in

16 the AMCARE plan shall be determined by the Secretary,

17 based upon the premium rate specified in subsection (a)

18 and taking into account the rules applicable to the estab19 lishment of employer premiums for community-rated em20 ployers under subpart A of part 2 of subtitle B of title

21 VI.

22 ‘‘(d) APPLICATION OF RISK ADJUSTMENT AND REIN23 SURANCE METHODOLOGY.—

24 ‘‘(1) IN GENERAL.—The Board shall establish

25 rules under which transfers are made between the
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1 AMCARE Trust Fund (established under subsection

2 (e)) and premium clearinghouses in States (acting

3 on behalf of community-rated plans offered in the

4 State) in a manner that reflects (using the meth5 odology developed under section 1541) the payment

6 adjustments that would have been made with respect

7 to the AMCARE plan and community-rated plans in

8 the State under section 6201(a)(3) if the AMCARE

9 plan were a community-rated plan in the State.

10 ‘‘(2) REINSURANCE SYSTEM.—If the Board in11 cludes a mandatory reinsurance system under the

12 methodology developed section 1541(c), the Board

13 shall establish rules under which the AMCARE plan

14 is treated as a health plan for purposes of applying

15 such system.

16 ‘‘(e) ESTABLISHMENT OF AMCARE TRUST FUND.—

17 ‘‘(1) IN GENERAL.—There is hereby established

18 in the Treasury of the United States a fund to be

19 known as the ‘AMCARE Trust Fund’ (in this sub20 section referred to as the ‘Fund’).

21 ‘‘(2) TRANSFERS.—

22 ‘‘(A) PREMIUMS COLLECTED.—There is

23 hereby deposited into the Fund amounts equiv24 alent to the amounts of the premiums collected

25 under this part.
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1 ‘‘(B) SUBSIDIES.—There is hereby trans2 ferred to the Fund, an amount equivalent to

3 the amount by which—

4 ‘‘(i) the total amount of premiums

5 payable (without regard to premium dis6 counts) under this part, exceeds

7 ‘‘(ii) the total amounts of the pre8 miums collected under this part.

9 ‘‘(C) EXPENDITURES FROM FUND.—

10 Amounts in the Fund are available to the Sec11 retary for the purpose of carrying out this part.

12 Amounts in the Fund shall remain available

13 until expended.

14 ‘‘(D) ADDITIONAL TRANSFERS.—The Sec15 retary shall make payments from the Trust

16 Fund with respect to the AMCARE plan in the

17 same amounts and in the same manner as

18 States provide for payment to the Secretary

19 under section 1263 with respect to community20 rated plans offered in the State. Such payments

21 shall be transferred to the Wrap-Around Fund

22 under section 1803, the annual health profes23 sions workforce account under section 3034(a),

24 the annual teaching hospital account under sec25 tion 3103(a), and the Rural Health Care Fund
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1 under section 3901(a) in the same manner as

2 payments made under section 1263 are trans3 ferred to such funds under this Act.

4 ‘‘(3) INCORPORATION OF PROVISIONS.—

5 ‘‘(A) IN GENERAL.—Subject to subpara6 graph (B), the provisions of subsections (b)

7 through (e), (h), (i), and (j) of section 1817 of

8 the Social Security Act shall apply to the Fund

9 and this part in the same manner as they apply

10 to the Federal Hospital Insurance Trust Fund

11 and part A of title XVIII of the Social Security

12 Act.

13 ‘‘(B) EXCEPTIONS.—In applying subpara14 graph (A)—

15 ‘‘(i) the Board of Trustees and Man16 aging Trustee of the Fund shall be com17 posed of the members of the Board of

18 Trustees and the Managing Trustee, re19 spectively, of the Federal Hospital Insur20 ance Trust Fund;

21 ‘‘(ii) any reference in section 1817 of

22 the Social Security Act to the Federal

23 Hospital Insurance Trust Fund, to title

24 XVIII of such Act (or part A thereof), or

25 (in subsection (f)(1)) to section 3102(b) of
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1 the Internal Revenue Code of 1986 is

2 deemed a reference to the Fund under this

3 subsection, this part, and to section

4 3151(a)(2) of such Code, respectively; and

5 ‘‘(iii) the authority specified in section

6 1817(j) of the Social Security Act may be

7 exercised with respect to the Fund without

8 regard to any dates or time limitations

9 specified in such section.’’.

Æ