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[Congressional Bills 103th Congress]
[From the U.S. Government Publishing Office]
[S. 1456 Introduced in Senate (IS)]

103d CONGRESS
  1st Session
                                S. 1456

To amend the Public Health Service Act to provide for health insurance 
   coverage for pregnant women and children, and for other purposes.

_______________________________________________________________________

                   IN THE SENATE OF THE UNITED STATES

           September 14 (legislative day, September 7), 1993

   Mr. Dodd introduced the following bill; which was read twice and 
         referred to the Committee on Labor and Human Resources

_______________________________________________________________________

                                 A BILL

 
To amend the Public Health Service Act to provide for health insurance 
   coverage for pregnant women and children, and for other purposes.

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

SECTION 1. SHORT TITLE; TABLE OF CONTENTS.

    (a) Short Title.--This Act may be cited as the ``Children and 
Pregnant Women Health Insurance Act of 1993''.
    (b) Table of Contents.--The table of contents is as follows:

Sec. 1. Short title; table of contents.
TITLE I--UNIVERSAL HEALTH INSURANCE COVERAGE FOR CHILDREN AND PREGNANT 
                                 WOMEN

Sec. 101. Universal health insurance coverage for children and pregnant 
                            women.
Sec. 102. Conforming amendments.
    TITLE II--PEDIATRIC REPRESENTATION ON HEALTH CARE REFORM BOARDS

Sec. 201. Membership of health care reform boards.
                       TITLE III--EFFECTIVE DATE

Sec. 301. Effective date.

TITLE I--UNIVERSAL HEALTH INSURANCE COVERAGE FOR CHILDREN AND PREGNANT 
                                 WOMEN

SEC. 101. UNIVERSAL HEALTH INSURANCE COVERAGE FOR CHILDREN AND PREGNANT 
              WOMEN

    The Public Health Service Act (42 U.S.C. 201 et seq.) is amended--
            (1) by redesignating title XXVII (42 U.S.C. 300cc et seq.) 
        as title XXVIII; and
            (2) by inserting after title XXVI the following new title:

    ``TITLE XXVII--HEALTH INSURANCE FOR CHILDREN AND PREGNANT WOMEN.

``SEC. 2700. DEFINITIONS.

    ``As used in this title:
            ``(1) Alliance.--The term `Alliance' means a Health 
        Insurance Purchasing Alliance established in the United States.
            ``(2) Child.--The term `child' means an individual who is 
        less than 22 years of age.
            ``(3) Covered services.--The term `covered services' means 
        the benefits and cost sharing limitations required for 
        qualified health plans under this title.
            ``(4) Family.--The term `family' means an individual, the 
        individual's spouse, any child of either such individual, and 
        the legal guardian of any such child if such guardian resides 
        with the child.
            ``(5) Family adjusted total income.--The term `family 
        adjusted total income' means, with respect to an individual, 
        the sum for the individual and all the other family members of 
        the individual, of the adjusted gross income (as defined in 
        section 62(a) of the Internal Revenue Code of 1986), determined 
        without the application of paragraphs (6) and (7) of such 
        section and without the application of section 162(l) of such 
        Code, plus the amount of social security benefits which is not 
        included in gross income under section 86 of such Code.
            ``(6) Legally residing.--The terms `legally residing in the 
        United States' or `legally residing' mean a citizen of the 
        United States, an alien lawfully admitted for permanent 
        residence or otherwise permanently residing in the United 
        States under color of law (including any alien who is lawfully 
        present in the United States as a result of the application of 
        any provision of 207(c) of the Immigration and Nationality Act 
        or as a result of the application of the provisions of section 
        208 or 212(d)(5) of such Act).
            ``(7) Official poverty line.--The term `official poverty 
        line' means, for an individual in a family, the official 
        poverty line (as defined by the Office of Management and 
        Budget, and revised annually in accordance with section 673 of 
        the Omnibus Budget Reconciliation Act of 1981) applicable to a 
        family of the size involved.
            ``(8) Qualified health plan.--The term `qualified health 
        plan' means a health insurance plan, a health maintenance 
        organization, or any other plan for providing health care that 
        meets the requirements imposed by this title.
            ``(9) Reside.--The term `reside' refers to the individual's 
        principal place of residence.
            ``(10) United states.--The term `United States' means the 
        50 States, the District of Columbia, the Commonwealth of Puerto 
        Rico, Guam, the Northern Mariana Islands, the U.S. Virgin 
        Islands, American Samoa, and the Trust Territory of the Pacific 
        Islands.

      ``PART A--UNIVERSAL COVERAGE FOR CHILDREN AND PREGNANT WOMEN

``SEC. 2701. CHILDREN'S COVERAGE MANDATE.

    ``(a) Entitlement.--Every child who is legally residing in the 
United States shall be entitled to enrollment in a qualified health 
plan for the purpose of obtaining access to all covered services. 
Coverage for any child under a qualified health plan shall be 
continuous from the effective date of this title or, if later, from the 
birth of the child, until the child reaches the age of 22. The Alliance 
established to serve the region in which the child resides shall have 
direct responsibility for enrolling such children and pregnant women in 
qualified health plans.
    ``(b) Alliances.--Not later than January 1, 1995, all Alliances 
established in the United States shall identify every child born or 
legally residing in its geographic region and enroll such children in a 
qualified health plan. A physician or other provider that has rendered 
health care to a child who is not enrolled in a qualified health plan 
may inform the appropriate Alliance of such fact and the Alliance shall 
enroll the child in a qualified health plan and ensure that the 
physician or provider is compensated for any covered services rendered 
as if the child had been enrolled in the plan at the time care was 
sought.
    ``(c) Pregnant Women.--Upon application to the Alliance serving the 
region where she is legally residing, or upon seeking medical care from 
a physician or provider, every pregnant woman shall be enrolled in a 
qualified health plan for the duration of the pregnancy plus at least 
one calendar quarter post partum, and any physician or provider 
rendering a covered service to a pregnant woman shall be compensated 
for such service as if the individual were enrolled in a qualified 
health plan at the time care was sought.

                           ``PART B--BENEFITS

``SEC. 2711. QUALIFIED HEALTH PLANS.

    ``(a) In General.--A qualified health plan shall meet the 
requirements of this section.
    ``(b) Benefits.--A qualified health plan shall provide at least the 
covered services identified in section 2712. Nothing in this section 
shall be construed as preventing a qualified health plan from including 
benefits in addition to those required in section 2713.
    ``(c) Limitations on Exclusions.--A qualified health plan--
            ``(1) may not deny, limit, or condition the coverage (or 
        benefits) under the plan with respect to required health 
        services based on the health status, claims experience, receipt 
        of health care, medical history, or lack of evidence of 
        insurability, of an individual; and
            ``(2) may not exclude coverage with respect to required 
        health services related to treatment of a preexisting 
        condition.
    ``(d) Cost Sharing.--A qualified health plan may not impose 
premiums in excess of those permitted by the Alliance, or deductibles, 
copayments, or coinsurance with respect to covered services, in excess 
of what is permitted under this title.

``SEC. 2712. COVERED HEALTH SERVICES.

    ``(a) Required Health Services.--
            ``(1) In general.--Except as otherwise provided in this 
        part, a qualified health plan shall provide coverage for--
                    ``(A) preventive care services (as defined in 
                section 2713);
                    ``(B) major medical services (as defined in section 
                2714); and
                    ``(C) extended medical services (as defined in 
                section 2715).
            ``(2) Required health services defined.--As used in this 
        title, the term `required health services' means the health 
        services described in paragraph (1), subject to the deductible 
        and coinsurance permitted with respect to such services.
    ``(b) Required Outreach Services.--In addition to the required 
health services under subsection (a), each Alliance shall provide (or 
make payment) for outreach services to link low-income enrolled 
individuals with needed required health services. Such outreach 
services shall include--
            ``(1) transportation;
            ``(2) child care at service sites;
            ``(3) translation services;
            ``(4) case/care coordination;
            ``(5) screening follow-ups; and
            ``(6) health promotions.
    ``(c) Optional Additional Social Services.--An Alliance may provide 
(or make payment) for social services (such as family psycho-social 
support, therapeutic foster care, pediatric day treatment, parent 
training, and in-home crisis management) that are necessary to ensure 
the health of enrolled individuals.
    ``(d) Standards.--The Secretary shall establish standards to be 
applied with respect to required health services under this title.

``SEC. 2713. PREVENTIVE CARE SERVICES.

    ``(a) Defined.--As used in this title, the term `preventive care 
services' means the following items and services furnished in 
accordance with any applicable periodicity schedule established under 
subsection (b):
            ``(1) Child preventive care, including--
                    ``(A) routine office visits;
                    ``(B) routine immunizations; and
                    ``(C) routine laboratory tests.
            ``(2) Prenatal care, including care of all complications of 
        pregnancy.
            ``(3) Care of newborn infants, including attendance at 
        high-risk deliveries and normal newborn care.
            ``(4) Family planning services.
            ``(5) Child abuse assessment.
            ``(6) Preventive dental care for children.
    ``(b) Periodicity Schedules.--
            ``(1) Pediatric care.--With respect to preventive care 
        services furnished to children, the Secretary shall establish a 
        schedule of periodicity that reflects the general, appropriate 
        frequency with which such care should be provided routinely to 
        healthy children. Such schedule shall be established in 
        consultation with the American Academy of Pediatrics.
            ``(2) Prenatal care.--With respect to preventive care 
        services for pregnant women, the Secretary shall establish a 
        schedule of periodicity that reflects the appropriate frequency 
        with which such care should be provided to pregnant women, 
        taking into account age and other risk factors. Such schedule 
        shall be established in consultation with the American College 
        of Obstetricians and Gynecologists.
    ``(c) No Application of Deductible or Coinsurance.--A qualified 
health plan may not impose deductibles or coinsurance with respect to 
preventative care services.

``SEC. 2714. MAJOR MEDICAL SERVICES.

    ``(a) Defined.--As used in this title, the term `major medical 
services' means the following items and services (to the extent such 
items and services are not preventive care services, and subject to 
subsection (b)):
            ``(1) Inpatient and outpatient hospital services.
            ``(2) Physicians' services.
            ``(3) Professional services of certified nurse midwives, 
        nurse practitioners, and other health professionals (to the 
        extent authorized under applicable State law).
            ``(4) Diagnostic tests (including laboratory tests).
            ``(5) Ambulance services.
            ``(6) Short-term home health services.
            ``(7) Medical and surgical supplies and durable medical 
        equipment.
            ``(8) Corrective eyeglasses and lenses and hearing aids.
            ``(9) prescription drugs, insulin, and medically 
        recommended nutritional supplements.
            ``(10) Acute dental care.
    ``(b) Treatment of Mental Health Services, Substance Abuse 
Services, and Developmental and Learning Disability Services as 
Extended Medical Services.--Major medical services do not include items 
and services for the treatment of mental illness, for the treatment of 
substance abuse, or for the treatment of developmental and learning 
disabilities, but shall include psychiatric services. Such services for 
such treatment are included in the definition of extended medical 
services under section 2715.
    ``(c) Application of Deductible and Coinsurance.--In accordance 
with sections 2721 and 2722, a qualified health plan may impose 
deductibles and coinsurance with respect to major medical services, 
subject to the limitations specified in such sections.

``SEC. 2715. EXTENDED MEDICAL SERVICES.

    ``(a) Defined.--As used in this title, the term `extended medical 
services' means the following items and services (to the extent they 
are not preventive care services, and subject to subsection (b)):
            ``(1) Items and services described in section 2714(a) for 
        the treatment of mental illnesses connected with substance 
        abuse and for the treatment of development and learning 
        disabilities (other than the educational component of such 
        treatment).
            ``(2) Orthodontia (other than cosmetic orthodontia).
            ``(3) Substance abuse services.
            ``(4) Speech, occupational, and physical therapy.
            ``(5) Hospice care.
            ``(6) Respite care.
            ``(7) Short-term skilled nursing facility services.
            ``(8) Nutritional assessment and counseling.
    ``(b) Plan of Care Requirement.--A qualified health plan shall 
provide for coverage of extended medical services only in accordance 
with a plan of care that--
            ``(1) is developed in cooperation with the attending 
        primary care physician; and
            ``(2) applies to all required health services.
    ``(c) Application of Deductible and Coinsurance.--In accordance 
with sections 2721 and 2722, a qualified health plan may impose a 
deductible and coinsurance with respect to extended medical services, 
subject to the limitations specified in such sections.

``SEC. 2716. SCOPE OF COVERAGE.

    ``(a) No Amount, Duration or Scope Limitations.--A qualified health 
plan may not impose any limitation on the amount, duration, or scope 
for required health services.
    ``(b) Construction.--Subsection (a) shall not be construed as 
requiring coverage of--
            ``(1) preventive care services in a frequency greater than 
        the frequency specified in the appropriate periodicity schedule 
        established under this title;
            ``(2) extended medical services which are not specified in 
        a plan of care under this title; or
            ``(3) major medical services or extended medical services 
        which are not reasonable and medically necessary.
    ``(c) In General.--Except as otherwise provided in this section, 
section 1862 of the Social Security Act shall apply to expenses 
incurred for items and services provided under this title in the same 
manner as such section applies to items and services provided under 
title XVIII of such Act.
    ``(d) Preventive Services.--In the case of preventive services 
provided consistent with the applicable periodicity schedule--
            ``(1) such services shall be considered to be reasonable 
        and medically necessary; and
            ``(2) shall not be subject to exclusion through the 
        operation of paragraph (1), (7), or (12) of section 1862(a) of 
        the Social Security Act (as incorporated under subsection (c)).
    ``(e) Use of Same National Coverage Decision Review Process.--The 
provisions of section 1869(b)(3) of the Social Security Act shall apply 
under this title in the same manner as such provisions apply under 
title XVIII of such Act. Any determination under such title that, under 
subsection (a), would apply under this title shall not be subject to 
review under this subsection.

                     ``PART C--PAYMENT FOR SERVICES

``SEC. 2721. APPLICATION OF DEDUCTIBLE.

    ``(a) In General.--Except as provided in this section and section 
2713, a qualified health plan may provide for an annual deductible with 
respect to expenses for required health services of members of a 
family, not to exceed $200 with respect to any family.
    ``(b) Deductible Does Not Apply to Preventive Care Services or 
Outreach and Optional Services.--The deductible established under 
subsection (a) may not be applied to preventive health services or to 
services provided under subsection (b) or (c) of section 2712.

``SEC. 2722. COINSURANCE FOR MAJOR MEDICAL SERVICES AND EXTENDED 
              MEDICAL SERVICES.

    ``(a) Coinsurance Rates.--Subject to subsection (b), and section 
2731, a qualified health plan may require coinsurance with respect to 
payments for required health services, in an amount not to exceed--
            ``(1) 20 percent of the costs involved with respect to 
        major medical services; and
            ``(2) 30 percent of the costs involved with respect to 
        extended medical services.
    ``(b) No Coinsurance for Preventive Care Services or Outreach and 
Optional Services.--There shall be no coinsurance under this title in 
the case of preventive care services provided consistent with any 
applicable periodicity schedule or to services provided under 
subsection (b) or (c) of section 2712.

``SEC. 2723. LIMIT ON COST-SHARING FOR REQUIRED HEALTH SERVICES.

    ``Whenever in a calendar year the amount of deductibles and 
coinsurance required for family members with respect to required health 
services under a qualified health plan that are furnished during the 
year exceeds 10 percent of family adjusted total income, but in no 
event to exceed $1,000 for an individual or $3,000 per family, payment 
of benefits under the plan for the family members for required health 
services furnished during the remainder of the year shall be paid 
without the application of any coinsurance.

            ``PART D--ASSISTANCE FOR LOW-INCOME INDIVIDUALS

``SEC. 2731. ASSISTANCE FOR INDIVIDUALS.

    ``(a) Individuals With Income Below 133 Percent of Poverty Level.--
Except as otherwise provided in this section, in the case of a child 
whose family adjusted total income does not exceed 133 percent of the 
official poverty line, the qualified health plan shall waive any 
deductible or coinsurance under the plan for the individual and the 
individual's family.
    ``(b) Pregnant Women and Infants Below 185 Percent of Poverty 
Level.--In the case of a pregnant woman or child under 1 year of age 
whose family adjusted total income does not exceed the percentage 
(established by the State under section 1902(l)(2)(A)(i) of the Social 
Security Act as of the date of the enactment of this title) of the 
official poverty line, the qualified health plan shall waive any 
deductible or coinsurance under the plan for such individual.
    ``(c) Individuals With Income Below 200 Percent of Poverty.--In the 
case of an individual not described in subsection (a) or (b), and whose 
family adjusted total income is less than 200 percent of the official 
poverty line, the qualified health plan shall provide for reductions in 
deductibles and coinsurance.
    ``(d) Individuals With Income Below 400 Percent of Poverty.--In the 
case of an individual not described in subsection (a) or (b), and whose 
family adjusted total income is less than 400 percent of the official 
poverty line, the qualified health plan shall provide for reductions in 
premiums.
    ``(e) Compensation for Waivers.--Qualified health plans shall be 
compensated for waivers of copayments and deductibles under this 
section.''.
    (b) Conforming Amendments.--
            (1) Sections 2701 through 2714 of the Public Health Service 
        Act (42 U.S.C. 300cc through 300cc-15) are redesignated as 
        sections 2801 through 2814, respectively.
            (2) Sections 465(f) and 497 of such Act (42 U.S.C. 286(f) 
        and 289(f)) are amended by striking out ``2701'' each place 
        that such appears and inserting in lieu thereof ``2801''.

SEC. 102. CONFORMING AMENDMENTS.

    (a) Federal Financial Participation for State Contribution Toward 
Children and Pregnant Women's Health Services.--
            (1) Transition rules.--The Secretary of Health and Human 
        Services shall, by regulation, develop transition rules for 
        ensuring that States that are required under title XIX of the 
        Social Security Act to pay for medical services to certain 
        children shall continue to maintain their level of effort in 
        contributing to the cost of providing medical services to 
        children enrolled in qualified health plans pursuant to title 
        XXVII of the Public Health Service Act.
            (2) Premium.--Section 1905(a) of the Social Security Act is 
        amended--
                    (A) in paragraph (24), by striking the period and 
                inserting ``; and''; and
                    (B) by adding after paragraph (24) the following 
                new paragraph:
            ``(25) paying the State's share of any premium to enroll a 
        child or pregnant woman in a qualified health plan pursuant to 
        title XXVII of the Public Health Service Act.''
    (b) Use of Uniform Claim Forms.--The Secretary of Health and Human 
Services shall develop (after consultation with insurers) uniform 
claims forms for the submission of any claims for payment that may be 
required by qualified health plans under the Children and Pregnant 
Women's Health Insurance Act of 1993.
    (c) Preemption of Certain State and Federal Requirements.--
Effective on January 1, 1995, no State shall establish or enforce any 
law or regulation that requires the offering, as part of a qualified 
health plan with respect to any pregnant woman or child, of any 
services, category of care, or services of any class or type of 
provider that is less than the benefits required to be provided 
pursuant to title XXVII of the Public Health Service Act.

    TITLE II--PEDIATRIC REPRESENTATION ON HEALTH CARE REFORM BOARDS

SEC. 201. MEMBERSHIP OF HEALTH CARE REFORM BOARDS.

    Any board or advisory panel that may be created under State or 
Federal health care reform legislation for purposes of reviewing fees, 
standards of care, outcomes research or other matters affecting the 
quality of care provided to children and pregnant women, shall include 
representation of pediatricians, family physicians, obstetricians, and 
experts and advocates on maternal and child health.

                       TITLE III--EFFECTIVE DATE

SEC. 301. GENERAL EFFECTIVE DATE.

    This Act shall become effective on the date of enactment of this 
Act regardless of whether regulations have been promulgated by the 
Secretary of Health and Human Services as required under title XXVII of 
the Public Health Service Act.

                                 <all>

S 1456 IS----2
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