II

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.

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; TABLE OF CONTENTS.

4 (a) SHORT TITLE.—This Act may be cited as the

5 ‘‘Children and Pregnant Women Health Insurance Act of

6 1993’’.

7 (b) TABLE OF CONTENTS.—The table of contents is

8 as follows:

Sec. 1. Short title; table of contents.
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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.

1 TITLE I—UNIVERSAL HEALTH

2 INSURANCE COVERAGE FOR

3 CHILDREN AND PREGNANT

4 WOMEN

5 SEC. 101. UNIVERSAL HEALTH INSURANCE COVERAGE FOR

6 CHILDREN AND PREGNANT WOMEN

7 The Public Health Service Act (42 U.S.C. 201 et

8 seq.) is amended—

9 (1) by redesignating title XXVII (42 U.S.C.

10 300cc et seq.) as title XXVIII; and

11 (2) by inserting after title XXVI the following

12 new title:

13 ‘‘TITLE XXVII—HEALTH INSUR14 ANCE FOR CHILDREN AND

15 PREGNANT WOMEN.

16 ‘‘SEC. 2700. DEFINITIONS.

17 ‘‘As used in this title:
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1 ‘‘(1) ALLIANCE.—The term ‘Alliance’ means a

2 Health Insurance Purchasing Alliance established in

3 the United States.

4 ‘‘(2) CHILD.—The term ‘child’ means an indi5 vidual who is less than 22 years of age.

6 ‘‘(3) COVERED SERVICES.—The term ‘covered

7 services’ means the benefits and cost sharing limita8 tions required for qualified health plans under this

9 title.

10 ‘‘(4) FAMILY.—The term ‘family’ means an in11 dividual, the individual’s spouse, any child of either

12 such individual, and the legal guardian of any such

13 child if such guardian resides with the child.

14 ‘‘(5) FAMILY ADJUSTED TOTAL INCOME.—The

15 term ‘family adjusted total income’ means, with re16 spect to an individual, the sum for the individual

17 and all the other family members of the individual,

18 of the adjusted gross income (as defined in section

19 62(a) of the Internal Revenue Code of 1986), deter20 mined without the application of paragraphs (6) and

21 (7) of such section and without the application of

22 section 162(l) of such Code, plus the amount of so23 cial security benefits which is not included in gross

24 income under section 86 of such Code.
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1 ‘‘(6) LEGALLY RESIDING.—The terms ‘legally

2 residing in the United States’ or ‘legally residing’

3 mean a citizen of the United States, an alien law4 fully admitted for permanent residence or otherwise

5 permanently residing in the United States under

6 color of law (including any alien who is lawfully

7 present in the United States as a result of the appli8 cation of any provision of 207(c) of the Immigration

9 and Nationality Act or as a result of the application

10 of the provisions of section 208 or 212(d)(5) of such

11 Act).

12 ‘‘(7) OFFICIAL POVERTY LINE.—The term ‘offi13 cial poverty line’ means, for an individual in a fam14 ily, the official poverty line (as defined by the Office

15 of Management and Budget, and revised annually in

16 accordance with section 673 of the Omnibus Budget

17 Reconciliation Act of 1981) applicable to a family of

18 the size involved.

19 ‘‘(8) QUALIFIED HEALTH PLAN.—The term

20 ‘qualified health plan’ means a health insurance

21 plan, a health maintenance organization, or any

22 other plan for providing health care that meets the

23 requirements imposed by this title.

24 ‘‘(9) RESIDE.—The term ‘reside’ refers to the

25 individual’s principal place of residence.
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1 ‘‘(10) UNITED STATES.—The term ‘United

2 States’ means the 50 States, the District of Colum3 bia, the Commonwealth of Puerto Rico, Guam, the

4 Northern Mariana Islands, the U.S. Virgin Islands,

5 American Samoa, and the Trust Territory of the Pa6 cific Islands.

7 ‘‘PART A—UNIVERSAL COVERAGE FOR CHILDREN

8 AND PREGNANT WOMEN

9 ‘‘SEC. 2701. CHILDREN’S COVERAGE MANDATE.

10 ‘‘(a) ENTITLEMENT.—Every child who is legally re11 siding in the United States shall be entitled to enrollment

12 in a qualified health plan for the purpose of obtaining ac13 cess to all covered services. Coverage for any child under

14 a qualified health plan shall be continuous from the effec15 tive date of this title or, if later, from the birth of the

16 child, until the child reaches the age of 22. The Alliance

17 established to serve the region in which the child resides

18 shall have direct responsibility for enrolling such children

19 and pregnant women in qualified health plans.

20 ‘‘(b) ALLIANCES.—Not later than January 1, 1995,

21 all Alliances established in the United States shall identify

22 every child born or legally residing in its geographic region

23 and enroll such children in a qualified health plan. A phy24 sician or other provider that has rendered health care to

25 a child who is not enrolled in a qualified health plan may
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1 inform the appropriate Alliance of such fact and the Alli2 ance shall enroll the child in a qualified health plan and

3 ensure that the physician or provider is compensated for

4 any covered services rendered as if the child had been en5 rolled in the plan at the time care was sought.

6 ‘‘(c) PREGNANT WOMEN.—Upon application to the

7 Alliance serving the region where she is legally residing,

8 or upon seeking medical care from a physician or provider,

9 every pregnant woman shall be enrolled in a qualified

10 health plan for the duration of the pregnancy plus at least

11 one calendar quarter post partum, and any physician or

12 provider rendering a covered service to a pregnant woman

13 shall be compensated for such service as if the individual

14 were enrolled in a qualified health plan at the time care

15 was sought.

16 ‘‘PART B—BENEFITS

17 ‘‘SEC. 2711. QUALIFIED HEALTH PLANS.

18 ‘‘(a) IN GENERAL.—A qualified health plan shall

19 meet the requirements of this section.

20 ‘‘(b) BENEFITS.—A qualified health plan shall pro21 vide at least the covered services identified in section

22 2712. Nothing in this section shall be construed as pre23 venting a qualified health plan from including benefits in

24 addition to those required in section 2713.
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1 ‘‘(c) LIMITATIONS ON EXCLUSIONS.—A qualified

2 health plan—

3 ‘‘(1) may not deny, limit, or condition the cov4 erage (or benefits) under the plan with respect to re5 quired health services based on the health status,

6 claims experience, receipt of health care, medical his7 tory, or lack of evidence of insurability, of an indi8 vidual; and

9 ‘‘(2) may not exclude coverage with respect to

10 required health services related to treatment of a

11 preexisting condition.

12 ‘‘(d) COST SHARING.—A qualified health plan may

13 not impose premiums in excess of those permitted by the

14 Alliance, or deductibles, copayments, or coinsurance with

15 respect to covered services, in excess of what is permitted

16 under this title.

17 ‘‘SEC. 2712. COVERED HEALTH SERVICES.

18 ‘‘(a) REQUIRED HEALTH SERVICES.—

19 ‘‘(1) IN GENERAL.—Except as otherwise pro20 vided in this part, a qualified health plan shall pro21 vide coverage for—

22 ‘‘(A) preventive care services (as defined in

23 section 2713);

24 ‘‘(B) major medical services (as defined in

25 section 2714); and
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1 ‘‘(C) extended medical services (as defined

2 in section 2715).

3 ‘‘(2) REQUIRED HEALTH SERVICES DEFINED.—

4 As used in this title, the term ‘required health serv5 ices’ means the health services described in para6 graph (1), subject to the deductible and coinsurance

7 permitted with respect to such services.

8 ‘‘(b) REQUIRED OUTREACH SERVICES.—In addition

9 to the required health services under subsection (a), each

10 Alliance shall provide (or make payment) for outreach

11 services to link low-income enrolled individuals with need12 ed required health services. Such outreach services shall

13 include—

14 ‘‘(1) transportation;

15 ‘‘(2) child care at service sites;

16 ‘‘(3) translation services;

17 ‘‘(4) case/care coordination;

18 ‘‘(5) screening follow-ups; and

19 ‘‘(6) health promotions.

20 ‘‘(c) OPTIONAL ADDITIONAL SOCIAL SERVICES.—An

21 Alliance may provide (or make payment) for social services

22 (such as family psycho-social support, therapeutic foster

23 care, pediatric day treatment, parent training, and in24 home crisis management) that are necessary to ensure the

25 health of enrolled individuals.
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1 ‘‘(d) STANDARDS.—The Secretary shall establish

2 standards to be applied with respect to required health

3 services under this title.

4 ‘‘SEC. 2713. PREVENTIVE CARE SERVICES.

5 ‘‘(a) DEFINED.—As used in this title, the term ‘pre6 ventive care services’ means the following items and serv7 ices furnished in accordance with any applicable periodic8 ity schedule established under subsection (b):

9 ‘‘(1) Child preventive care, including—

10 ‘‘(A) routine office visits;

11 ‘‘(B) routine immunizations; and

12 ‘‘(C) routine laboratory tests.

13 ‘‘(2) Prenatal care, including care of all com14 plications of pregnancy.

15 ‘‘(3) Care of newborn infants, including attend16 ance at high-risk deliveries and normal newborn

17 care.

18 ‘‘(4) Family planning services.

19 ‘‘(5) Child abuse assessment.

20 ‘‘(6) Preventive dental care for children.

21 ‘‘(b) PERIODICITY SCHEDULES.—

22 ‘‘(1) PEDIATRIC CARE.—With respect to pre23 ventive care services furnished to children, the Sec24 retary shall establish a schedule of periodicity that

25 reflects the general, appropriate frequency with
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1 which such care should be provided routinely to

2 healthy children. Such schedule shall be established

3 in consultation with the American Academy of Pedi4 atrics.

5 ‘‘(2) PRENATAL CARE.—With respect to preven6 tive care services for pregnant women, the Secretary

7 shall establish a schedule of periodicity that reflects

8 the appropriate frequency with which such care

9 should be provided to pregnant women, taking into

10 account age and other risk factors. Such schedule

11 shall be established in consultation with the Amer12 ican College of Obstetricians and Gynecologists.

13 ‘‘(c) NO APPLICATION OF DEDUCTIBLE OR COINSUR14 ANCE.—A qualified health plan may not impose

15 deductibles or coinsurance with respect to preventative

16 care services.

17 ‘‘SEC. 2714. MAJOR MEDICAL SERVICES.

18 ‘‘(a) DEFINED.—As used in this title, the term

19 ‘major medical services’ means the following items and

20 services (to the extent such items and services are not pre21 ventive care services, and subject to subsection (b)):

22 ‘‘(1) Inpatient and outpatient hospital services.

23 ‘‘(2) Physicians’ services.

24 ‘‘(3) Professional services of certified nurse

25 midwives, nurse practitioners, and other health pro-
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1 fessionals (to the extent authorized under applicable

2 State law).

3 ‘‘(4) Diagnostic tests (including laboratory

4 tests).

5 ‘‘(5) Ambulance services.

6 ‘‘(6) Short-term home health services.

7 ‘‘(7) Medical and surgical supplies and durable

8 medical equipment.

9 ‘‘(8) Corrective eyeglasses and lenses and hear10 ing aids.

11 ‘‘(9) prescription drugs, insulin, and medically

12 recommended nutritional supplements.

13 ‘‘(10) Acute dental care.

14 ‘‘(b) TREATMENT OF MENTAL HEALTH SERVICES,

15 SUBSTANCE ABUSE SERVICES, AND DEVELOPMENTAL

16 AND LEARNING DISABILITY SERVICES AS EXTENDED

17 MEDICAL SERVICES.—Major medical services do not in18 clude items and services for the treatment of mental ill19 ness, for the treatment of substance abuse, or for the

20 treatment of developmental and learning disabilities, but

21 shall include psychiatric services. Such services for such

22 treatment are included in the definition of extended medi23 cal services under section 2715.

24 ‘‘(c) APPLICATION OF DEDUCTIBLE AND COINSUR25 ANCE.—In accordance with sections 2721 and 2722, a
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1 qualified health plan may impose deductibles and coinsur2 ance with respect to major medical services, subject to the

3 limitations specified in such sections.

4 ‘‘SEC. 2715. EXTENDED MEDICAL SERVICES.

5 ‘‘(a) DEFINED.—As used in this title, the term ‘ex6 tended medical services’ means the following items and

7 services (to the extent they are not preventive care serv8 ices, and subject to subsection (b)):

9 ‘‘(1) Items and services described in section

10 2714(a) for the treatment of mental illnesses con11 nected with substance abuse and for the treatment

12 of development and learning disabilities (other than

13 the educational component of such treatment).

14 ‘‘(2) Orthodontia (other than cosmetic ortho15 dontia).

16 ‘‘(3) Substance abuse services.

17 ‘‘(4) Speech, occupational, and physical ther18 apy.

19 ‘‘(5) Hospice care.

20 ‘‘(6) Respite care.

21 ‘‘(7) Short-term skilled nursing facility services.

22 ‘‘(8) Nutritional assessment and counseling.

23 ‘‘(b) PLAN OF CARE REQUIREMENT.—A qualified

24 health plan shall provide for coverage of extended medical

25 services only in accordance with a plan of care that—
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1 ‘‘(1) is developed in cooperation with the at2 tending primary care physician; and

3 ‘‘(2) applies to all required health services.

4 ‘‘(c) APPLICATION OF DEDUCTIBLE AND COINSUR5 ANCE.—In accordance with sections 2721 and 2722, a

6 qualified health plan may impose a deductible and coinsur7 ance with respect to extended medical services, subject to

8 the limitations specified in such sections.

9 ‘‘SEC. 2716. SCOPE OF COVERAGE.

10 ‘‘(a) NO AMOUNT, DURATION OR SCOPE LIMITA11 TIONS.—A qualified health plan may not impose any limi12 tation on the amount, duration, or scope for required

13 health services.

14 ‘‘(b) CONSTRUCTION.—Subsection (a) shall not be

15 construed as requiring coverage of—

16 ‘‘(1) preventive care services in a frequency

17 greater than the frequency specified in the appro18 priate periodicity schedule established under this

19 title;

20 ‘‘(2) extended medical services which are not

21 specified in a plan of care under this title; or

22 ‘‘(3) major medical services or extended medical

23 services which are not reasonable and medically nec24 essary.
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1 ‘‘(c) IN GENERAL.—Except as otherwise provided in

2 this section, section 1862 of the Social Security Act shall

3 apply to expenses incurred for items and services provided

4 under this title in the same manner as such section applies

5 to items and services provided under title XVIII of such

6 Act.

7 ‘‘(d) PREVENTIVE SERVICES.—In the case of preven8 tive services provided consistent with the applicable perio9 dicity schedule—

10 ‘‘(1) such services shall be considered to be rea11 sonable and medically necessary; and

12 ‘‘(2) shall not be subject to exclusion through

13 the operation of paragraph (1), (7), or (12) of sec14 tion 1862(a) of the Social Security Act (as incor15 porated under subsection (c)).

16 ‘‘(e) USE OF SAME NATIONAL COVERAGE DECISION

17 REVIEW PROCESS.—The provisions of section 1869(b)(3)

18 of the Social Security Act shall apply under this title in

19 the same manner as such provisions apply under title

20 XVIII of such Act. Any determination under such title

21 that, under subsection (a), would apply under this title

22 shall not be subject to review under this subsection.
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1 ‘‘PART C—PAYMENT FOR SERVICES

2 ‘‘SEC. 2721. APPLICATION OF DEDUCTIBLE.

3 ‘‘(a) IN GENERAL.—Except as provided in this sec4 tion and section 2713, a qualified health plan may provide

5 for an annual deductible with respect to expenses for re6 quired health services of members of a family, not to ex7 ceed $200 with respect to any family.

8 ‘‘(b) DEDUCTIBLE DOES NOT APPLY TO PREVEN9 TIVE CARE SERVICES OR OUTREACH AND OPTIONAL

10 SERVICES.—The deductible established under subsection

11 (a) may not be applied to preventive health services or to

12 services provided under subsection (b) or (c) of section

13 2712.

14 ‘‘SEC. 2722. COINSURANCE FOR MAJOR MEDICAL SERVICES

15 AND EXTENDED MEDICAL SERVICES.

16 ‘‘(a) COINSURANCE RATES.—Subject to subsection

17 (b), and section 2731, a qualified health plan may require

18 coinsurance with respect to payments for required health

19 services, in an amount not to exceed—

20 ‘‘(1) 20 percent of the costs involved with re21 spect to major medical services; and

22 ‘‘(2) 30 percent of the costs involved with re23 spect to extended medical services.

24 ‘‘(b) NO COINSURANCE FOR PREVENTIVE CARE

25 SERVICES OR OUTREACH AND OPTIONAL SERVICES.—

26 There shall be no coinsurance under this title in the case
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1 of preventive care services provided consistent with any

2 applicable periodicity schedule or to services provided

3 under subsection (b) or (c) of section 2712.

4 ‘‘SEC. 2723. LIMIT ON COST-SHARING FOR REQUIRED

5 HEALTH SERVICES.

6 ‘‘Whenever in a calendar year the amount of

7 deductibles and coinsurance required for family members

8 with respect to required health services under a qualified

9 health plan that are furnished during the year exceeds 10

10 percent of family adjusted total income, but in no event

11 to exceed $1,000 for an individual or $3,000 per family,

12 payment of benefits under the plan for the family mem13 bers for required health services furnished during the re14 mainder of the year shall be paid without the application

15 of any coinsurance.

16 ‘‘PART D—ASSISTANCE FOR LOW-INCOME

17 INDIVIDUALS

18 ‘‘SEC. 2731. ASSISTANCE FOR INDIVIDUALS.

19 ‘‘(a) INDIVIDUALS WITH INCOME BELOW 133 PER20 CENT OF POVERTY LEVEL.—Except as otherwise provided

21 in this section, in the case of a child whose family adjusted

22 total income does not exceed 133 percent of the official

23 poverty line, the qualified health plan shall waive any de24 ductible or coinsurance under the plan for the individual

25 and the individual’s family.
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1 ‘‘(b) PREGNANT WOMEN AND INFANTS BELOW 185

2 PERCENT OF POVERTY LEVEL.—In the case of a preg3 nant woman or child under 1 year of age whose family

4 adjusted total income does not exceed the percentage (es5 tablished by the State under section 1902(l)(2)(A)(i) of

6 the Social Security Act as of the date of the enactment

7 of this title) of the official poverty line, the qualified health

8 plan shall waive any deductible or coinsurance under the

9 plan for such individual.

10 ‘‘(c) INDIVIDUALS WITH INCOME BELOW 200 PER11 CENT OF POVERTY.—In the case of an individual not de12 scribed in subsection (a) or (b), and whose family adjusted

13 total income is less than 200 percent of the official poverty

14 line, the qualified health plan shall provide for reductions

15 in deductibles and coinsurance.

16 ‘‘(d) INDIVIDUALS WITH INCOME BELOW 400 PER17 CENT OF POVERTY.—In the case of an individual not de18 scribed in subsection (a) or (b), and whose family adjusted

19 total income is less than 400 percent of the official poverty

20 line, the qualified health plan shall provide for reductions

21 in premiums.

22 ‘‘(e) COMPENSATION FOR WAIVERS.—Qualified

23 health plans shall be compensated for waivers of

24 copayments and deductibles under this section.’’.

25 (b) CONFORMING AMENDMENTS.—
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1 (1) Sections 2701 through 2714 of the Public

2 Health Service Act (42 U.S.C. 300cc through

3 300cc–15) are redesignated as sections 2801

4 through 2814, respectively.

5 (2) Sections 465(f) and 497 of such Act (42

6 U.S.C. 286(f) and 289(f)) are amended by striking

7 out ‘‘2701’’ each place that such appears and insert8 ing in lieu thereof ‘‘2801’’.

9 SEC. 102. CONFORMING AMENDMENTS.

10 (a) FEDERAL FINANCIAL PARTICIPATION FOR STATE

11 CONTRIBUTION TOWARD CHILDREN AND PREGNANT

12 WOMEN’S HEALTH SERVICES.—

13 (1) TRANSITION RULES.—The Secretary of

14 Health and Human Services shall, by regulation, de15 velop transition rules for ensuring that States that

16 are required under title XIX of the Social Security

17 Act to pay for medical services to certain children

18 shall continue to maintain their level of effort in

19 contributing to the cost of providing medical services

20 to children enrolled in qualified health plans pursu21 ant to title XXVII of the Public Health Service Act.

22 (2) PREMIUM.—Section 1905(a) of the Social

23 Security Act is amended—

24 (A) in paragraph (24), by striking the pe25 riod and inserting ‘‘; and’’; and
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1 (B) by adding after paragraph (24) the

2 following new paragraph:

3 ‘‘(25) paying the State’s share of any premium

4 to enroll a child or pregnant woman in a qualified

5 health plan pursuant to title XXVII of the Public

6 Health Service Act.’’

7 (b) USE OF UNIFORM CLAIM FORMS.—The Secretary

8 of Health and Human Services shall develop (after con9 sultation with insurers) uniform claims forms for the sub10 mission of any claims for payment that may be required

11 by qualified health plans under the Children and Pregnant

12 Women’s Health Insurance Act of 1993.

13 (c) PREEMPTION OF CERTAIN STATE AND FEDERAL

14 REQUIREMENTS.—Effective on January 1, 1995, no State

15 shall establish or enforce any law or regulation that re16 quires the offering, as part of a qualified health plan with

17 respect to any pregnant woman or child, of any services,

18 category of care, or services of any class or type of pro19 vider that is less than the benefits required to be provided

20 pursuant to title XXVII of the Public Health Service Act.
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1 TITLE II—PEDIATRIC REP2 RESENTATION ON HEALTH

3 CARE REFORM BOARDS

4 SEC. 201. MEMBERSHIP OF HEALTH CARE REFORM

5 BOARDS.

6 Any board or advisory panel that may be created

7 under State or Federal health care reform legislation for

8 purposes of reviewing fees, standards of care, outcomes

9 research or other matters affecting the quality of care pro10 vided to children and pregnant women, shall include rep11 resentation of pediatricians, family physicians, obstetri12 cians, and experts and advocates on maternal and child

13 health.

14 TITLE III—EFFECTIVE DATE

15 SEC. 301. GENERAL EFFECTIVE DATE.

16 This Act shall become effective on the date of enact17 ment of this Act regardless of whether regulations have

18 been promulgated by the Secretary of Health and Human

19 Services as required under title XXVII of the Public

20 Health Service Act.

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