II

104TH CONGRESS

2D SESSION S. 2167

To require that health plans provide coverage for medically necessary health

care and related services for children who are age 3 or younger, and

for other purposes.

IN THE SENATE OF THE UNITED STATES

SEPTEMBER 30, 1996

Mr. KERREY introduced the following bill; which was read twice and referred

to the Committee on Labor and Human Resources

A BILL

To require that health plans provide coverage for medically

necessary health care and related services for children

who are age 3 or younger, and for other purposes.

1 Be it enacted by the Senate and House of Representa2 tives of the United States of America in Congress assembled,

3 SECTION 1. SHORT TITLE.

4 This Act may be cited as the ‘‘Children’s Health In5 surance for Long-Term Development Act of 1996’’.

6 SEC. 2. PURPOSE.

7 The purpose of this act is to provide health insurance

8 coverage for children during the Infant Neurological Risk

9 Exposure Period (INREP). The INREP extends through
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1 age 3 and encompasses the period of most rapid neuro2 logical changes in young children. Health coverage will im3 prove children’s health and, through routine health super4 vision, promote parents’ caregiving skills through these

5 critical years.

6 SEC. 3. FINDINGS.

7 Congress finds that—

8 (1) 86 percent of children with private health

9 insurance are under-insured with respect to well10 child care;

11 (2) because the human brain develops rapidly

12 until the age of 3, children need regular screenings

13 and follow-up care to detect neurological abnormali14 ties and ensure normal development;

15 (3) regular pediatric visits enable physicians to

16 provide guidance on parental activities, such as read17 ing, that stimulate the brain development of infants;

18 and

19 (4) children deserve health care coverage that

20 promotes normal brain and nervous system develop21 ment.

22 SEC. 4. DEFINITIONS.

23 As used in this Act:

24 (1) BENEFICIARY.—The term ‘‘beneficiary’’ has

25 the meaning given such term under section 3(8) of
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1 the Employee Retirement Income Security Act of

2 1974 (29 U.S.C. 1002(8)).

3 (2) CHILD.—The term ‘‘child’’ means an indi4 vidual who is age 3 or younger.

5 (3) EMPLOYEE HEALTH BENEFIT PLAN.—

6 (A) IN GENERAL.—The term ‘‘employee

7 health benefit plan’’ means any employee wel8 fare benefit plan, governmental plan, or church

9 plan (as defined under paragraphs (1), (32),

10 and (33) of section 3 of the Employee Retire11 ment Income Security Act of 1974 (29 U.S.C.

12 1002 (1), (32), and (33))) that provides or pays

13 for health benefits (such as provider and hos14 pital benefits) for participants and beneficiaries

15 whether—

16 (i) directly;

17 (ii) through a health plan offered by

18 a health plan issuer as defined in para19 graph (6); or

20 (iii) otherwise.

21 (B) RULE OF CONSTRUCTION.—An em22 ployee health benefit plan shall not be con23 strued to be a health plan or a health plan is24 suer.
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1 (C) ARRANGEMENTS NOT INCLUDED.—

2 Such term does not include the following, or

3 any combination thereof:

4 (i) Coverage only for accident, or dis5 ability income insurance, or any combina6 tion thereof.

7 (ii) Medicare supplemental health in8 surance (as defined under section

9 1882(g)(1) of the Social Security Act (42

10 U.S.C. 1395ss(g)(1))).

11 (iii) Coverage issued as a supplement

12 to liability insurance.

13 (iv) Liability insurance, including gen14 eral liability insurance and automobile li15 ability insurance.

16 (v) Workers’ compensation or similar

17 insurance.

18 (vi) Automobile medical payment in19 surance.

20 (vii) Coverage for a specified disease

21 or illness.

22 (viii) Hospital or fixed indemnity in23 surance.

24 (ix) Short-term limited duration in25 surance.
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1 (x) Credit-only, dental-only, or vision2 only insurance.

3 (xi) A health insurance policy provid4 ing benefits only for long-term care, nurs5 ing home care, home health care, commu6 nity-based care, or any combination there7 of.

8 (4) GROUP PURCHASER.—The term ‘‘group

9 purchaser’’ means any person (as defined in section

10 3(9) of the Employee Retirement Income Security

11 Act of 1974 (29 U.S.C. 1002(9))) or entity that

12 purchases or pays for health benefits (such as pro13 vider or hospital benefits) on behalf of participants

14 or beneficiaries in connection with an employee

15 health benefit plan.

16 (5) HEALTH PLAN.—

17 (A) IN GENERAL.—The term ‘‘health plan’’

18 means any group health plan or individual

19 health plan.

20 (B) GROUP HEALTH PLAN.—The term

21 ‘‘group health plan’’ means any contract, policy,

22 certificate, or other arrangement offered by a

23 health plan issuer to a group purchaser that

24 provides or pays for health benefits (such as
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1 provider and hospital benefits) in connection

2 with an employee health benefit plan.

3 (C) INDIVIDUAL HEALTH PLAN.—The term

4 ‘‘individual health plan’’ means any contract,

5 policy, certificate, or other arrangement offered

6 by a health plan issuer to individuals that pro7 vides or pays for health benefits (such as pro8 vider and hospital benefits) and that is not a

9 group health plan.

10 (D) ARRANGEMENTS NOT INCLUDED.—

11 Such term does not include the following, or

12 any combination thereof:

13 (i) Coverage only for accident, or dis14 ability income insurance, or any combina15 tion thereof.

16 (ii) Medicare supplemental health in17 surance (as defined under section

18 1882(g)(1) of the Social Security Act).

19 (iii) Coverage issued as a supplement

20 to liability insurance.

21 (iv) Liability insurance, including gen22 eral liability insurance and automobile li23 ability insurance.

24 (v) Workers’ compensation or similar

25 insurance.
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1 (vi) Automobile medical payment in2 surance.

3 (vii) Coverage for a specified disease

4 or illness.

5 (viii) Hospital or fixed indemnity in6 surance.

7 (ix) Short-term limited duration in8 surance.

9 (x) Credit-only, dental-only, or vision10 only insurance.

11 (xi) A health insurance policy provid12 ing benefits only for long-term care, nurs13 ing home care, home health care, commu14 nity-based care, or any combination there15 of.

16 (E) CERTAIN PLANS INCLUDED.—Such

17 term includes any plan or arrangement not de18 scribed in any clause of subparagraph (D) that

19 provides for benefit payments, on a periodic

20 basis, for—

21 (i) a specified disease or illness; or

22 (ii) a period of hospitalization;

23 without regard to the costs incurred or services

24 rendered during the period to which the pay25 ments relate.
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1 (6) HEALTH PLAN ISSUER.—The term ‘‘health

2 plan issuer’’ means any entity that is licensed (prior

3 to or after the date of enactment of this Act) by a

4 State to offer a health plan.

5 (7) PARTICIPANT.—The term ‘‘participant’’ has

6 the meaning given such term under section 3(7) of

7 the Employee Retirement Income Security Act of

8 1974 (29 U.S.C. 1002(7)).

9 (8) SECRETARY.—The term ‘‘Secretary’’ unless

10 otherwise specified means the Secretary of Labor.

11 SEC. 5. REQUIRED HEALTH CARE COVERAGE FOR CHIL12 DREN.

13 (a) IN GENERAL.—Except as provided in subsection

14 (b), a health plan or an employee health benefit plan shall

15 ensure that coverage is provided with respect to a child

16 who is a beneficiary under such plan for all medically nec17 essary health care and related services, including—

18 (1) appropriate screening services at intervals

19 that meet reasonable standards of medical and den20 tal practice;

21 (2) all appropriate immunizations;

22 (3) necessary case management, transportation,

23 and scheduling assistance; and

24 (4) such other necessary health care, diagnostic

25 services, treatment, and other measures to correct or
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1 ameliorate defects and physical and mental illnesses

2 and conditions discovered by the screening services,

3 whether or not such services are covered for partici4 pants or policyholders under the plan.

5 (b) EXCEPTION.—Notwithstanding subsection (a), a

6 health plan or an employee health benefit plan shall not

7 be required to provide coverage for health care and related

8 services that are not safe, are not effective, or are experi9 mental.

10 SEC. 6. PROHIBITIONS.

11 In implementing the requirements of this Act, a

12 health plan or an employee health benefit plan may not

13 use a service limitation, including a lifetime benefit limit,

14 of the plan to deny medically necessary health care and

15 related services described in section 4 to a child.

16 SEC. 7. NOTICE.

17 (a) EMPLOYEE HEALTH BENEFIT PLAN.—An em18 ployee health benefit plan shall provide conspicuous notice

19 to each participant regarding coverage required under this

20 Act not later than 120 days after the date of enactment

21 of this Act, and as part of its summary plan description.

22 (b) HEALTH PLAN.—A health plan shall provide no23 tice to each policyholder regarding coverage required

24 under this Act. Such notice shall be in writing, promi25 nently positioned, and be transmitted—
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1 (1) in a mailing made within 120 days after the

2 date of enactment of this Act by such plan to the

3 policyholder; and

4 (2) as part of the annual informational packet

5 sent to the policyholder.

6 SEC. 8. APPLICABILITY.

7 (a) CONSTRUCTION.—

8 (1) IN GENERAL.—A requirement or standard

9 imposed under this Act on a health plan shall be

10 deemed to be a requirement or standard imposed on

11 the health plan issuer. Such requirements or stand12 ards shall be enforced by the State insurance com13 missioner for the State involved or the official or of14 ficials designated by the State to enforce the re15 quirements of this Act. In the case of a health plan

16 offered by a health plan issuer in connection with an

17 employee health benefit plan, the requirements or

18 standards imposed under this Act shall be enforced

19 with respect to the health plan issuer by the State

20 insurance commissioner for the State involved or the

21 official or officials designated by the State to enforce

22 the requirements of this Act.

23 (2) LIMITATION.—Except as provided in section

24 8(c), the Secretary shall not enforce the require25 ments or standards of this Act as they relate to
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1 health plan issuers or health plans. In no case shall

2 a State enforce the requirements or standards of

3 this Act as they relate to employee health benefit

4 plans.

5 (b) RULE OF CONSTRUCTION.—Nothing in this Act

6 shall be construed to affect or modify the provisions of

7 section 514 of the Employee Retirement Income Security

8 Act of 1974 (29 U.S.C. 1144).

9 SEC. 9. ENFORCEMENT.

10 (a) HEALTH PLAN ISSUERS.—Each State shall re11 quire that each health plan issued, sold, renewed, offered

12 for sale or operated in such State by a health plan issuer

13 meet the standards established under this Act. A State

14 shall submit such information as required by the Secretary

15 demonstrating effective implementation of the require16 ments of this Act.

17 (b) EMPLOYEE HEALTH BENEFIT PLANS.—With re18 spect to employee health benefit plans, the standards es19 tablished under this Act shall be enforced in the same

20 manner as provided for under sections 502, 504, 506, and

21 510 of the Employee Retirement Income Security Act of

22 1974 (29 U.S.C. 1132, 1134, 1136, and 1140). The civil

23 penalties contained in paragraphs (1) and (2) of section

24 502(c) of such Act (29 U.S.C. 1132(c) (1) and (2)) shall
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1 apply to any information required by the Secretary to be

2 disclosed and reported under this section.

3 (c) FAILURE TO ENFORCE.—In the case of the fail4 ure of a State to substantially enforce the standards and

5 requirements set forth in this Act with respect to health

6 plans, the Secretary, in consultation with the Secretary

7 of Health and Human Services, shall enforce the stand8 ards of this Act in such State. In the case of a State that

9 fails to substantially enforce the standards set forth in this

10 Act, each health plan issuer operating in such State shall

11 be subject to civil enforcement as provided for under sec12 tions 502, 504, 506, and 510 of the Employee Retirement

13 Income Security Act of 1974 (29 U.S.C. 1132, 1134,

14 1136, and 1140). The civil penalties contained in para15 graphs (1) and (2) of section 502(c) of such Act (29

16 U.S.C. 1132(c)(1) and (2)) shall apply to any information

17 required by the Secretary to be disclosed and reported

18 under this section.

19 (d) REGULATIONS.—The Secretary, in consultation

20 with the Secretary of Health and Human Services, may

21 promulgate such regulations as may be necessary or ap22 propriate to carry out this Act.

23 SEC. 10. PREEMPTION.

24 (a) IN GENERAL.—The provisions of sections 4, 5,

25 and 6 shall not preempt a State law or regulation—
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1 (1) that provides greater protections to patients

2 or policyholders than those required in this Act; or

3 (2) that requires health plans to provide cov4 erage for pediatric care in accordance with guide5 lines established by the American Academy of Pedi6 atrics or other established professional medical asso7 ciations.

8 (b) EMPLOYEE HEALTH BENEFIT PLANS.—Nothing

9 in this section affects the application of this Act to em10 ployee health benefit plans, as defined in section 2(3).

11 SEC. 11. EFFECTIVE DATE.

12 Except as otherwise provided for in this Act, the pro13 visions of this Act shall apply as follows:

14 (1) With respect to health plans, such provi15 sions shall apply to such plans on the first day of

16 the contract year beginning on or after June 1,

17 1997.

18 (2) With respect to employee health benefit

19 plans, such provisions shall apply to such plans on

20 the first day of the first plan year beginning on or

21 after June 1, 1997.

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