1290
Title IX, Subtitle A
ment rates, or a reduction in access to
high quality services under the State med-
icaid plan.
(ii) PER
CAPITA
EXPENDITURES.—
The per capita expenditures specified in
this clause for a year is the quotient of the
baseline medicaid expenditures for the
State for the year, divided by the number
of AFDC recipients enrolled in the State
medicaid plan for the year.
(D) ADJUSTMENT AUTHORIZED TO TAKE
INTO
ACCOUNT
CASH
FLOW
VARIATIONS.—In
determining the update under paragraph (1),
the Secretary may provide for an adjustment in
a manner similar to the adjustment permitted
under section 9002(b)(3).
(2) UPDATE
FOR
SUBSEQUENT
YEARS.—For
each State for the first year and for each year after
the first year, the Board shall update the base per
capita expenditures described in subsection (c) (as
previously updated under this subsection) by a fac-
tor equal to 1 plus the general health care inflation
factor (as defined in section 6001(a)(3)) for the
year.
1291
Title IX, Subtitle A
(e) DETERMINATION OF BASELINE MEDICAID EX-
PENDITURES.—
(1) IN GENERAL.—For purposes of subsection
(c)(1), the ‘‘baseline medicaid expenditures’’ for a
State is the gross amount of payments under the
State medicaid plan with respect to medical assist-
ance furnished, for items and services included in
the comprehensive benefit package, for AFDC recipi-
ents for calendar quarters in fiscal year 1993, but
does not include such expenditures for which no
Federal financial participation is provided under
such plan.
(2) DISPROPORTIONATE SHARE PAYMENTS NOT
INCLUDED.—In applying paragraph (1), payments
made under section 1923 of the Social Security Act
shall not be counted in the gross amount of pay-
ments.
(3) TREATMENT
OF
DISALLOWANCES.—The
amount determined under this subsection shall take
into account amounts (or an estimate of amounts)
disallowed.
(f) APPLICATION TO PARTICULAR ITEMS AND SERV-
ICES IN COMPREHENSIVE BENEFIT PACKAGE.—For pur-
poses of this section, in determining the per capita State
medicaid expenditures for a category of items and services
1292
Title IX, Subtitle A
(within the comprehensive benefit package) furnished in
a State, there shall be counted only that proportion of
such expenditures (determined only with respect to med-
ical assistance furnished to AFDC recipients) that were
attributable to items and services included in the com-
prehensive benefit package (taking into account any limi-
tation on amount, duration, or scope of items and services
included in such package).
SEC. 9013. DETERMINATION OF SSI PER CAPITA PREMIUM
AMOUNT FOR REGIONAL ALLIANCES.
For each regional alliance in a State for each year,
the Secretary shall determine an SSI per capita premium
amount in accordance with this section. Such amount shall
be determined in the same manner as the AFDC per cap-
ita premium amount for the regional alliance is deter-
mined under section 9012 except that, for purposes of this
section—
(1) any reference in such section (or in sections
referred to in such section) to an ‘‘AFDC recipient’’
is deemed a reference to an ‘‘SSI recipient’’, and
(2) the following percents shall be substituted
for the percents specified in section 9012(d)(1)(B):
(A) For 1996, 29.4 percent.
(B) For 1997, 43.7 percent.
(C) For 1998, 58.8 percent.
1293
Title IX, Subtitle A
SEC. 9014. DETERMINATION OF NUMBER OF AFDC AND SSI
RECIPIENTS.
(a) BASELINE.—For purposes of section 9012 and
section 9013, the number of AFDC recipients and SSI
recipients for a State for fiscal year 1993 shall be deter-
mined based on actual reports submitted by the State to
the Secretary. In the case of individuals who were not re-
cipients for the entire fiscal year, the number shall take
into account only the portion of the year in which they
were such recipients. The Secretary may audit such re-
ports.
(b) SUBSEQUENT YEARS.—
(1) 
PAYMENTS.—For 
purposes 
of 
section
9011(a), the number of AFDC and SSI recipients
enrolled in regional alliance health plans for a re-
gional alliance shall be determined on a monthly
basis based on actual enrollment.
(2) COMPUTATION OF REGIONAL ADJUSTMENT
FACTORS AND BLENDED PLAN PAYMENT RATES.—
For purposes of computing regional alliance adjust-
ment factors under section 9015 and the AFDC and
SSI proportions under section 6202, the number of
AFDC and SSI recipients for a regional alliance in
a State for a year (beginning with 1997) shall be de-
termined by the State before the date the State is
required to compute AFDC and SSI proportions
1294
Title IX, Subtitle A
under section 6202 based on the best available esti-
mate of such proportion in the previous year.
SEC. 9015. REGIONAL ALLIANCE ADJUSTMENT FACTORS.
(a) IN GENERAL.—If a State—
(1) has more than one regional alliance oper-
ating in the State for a year, the State shall com-
pute under this section a regional alliance adjust-
ment factor for each such regional alliance for the
year in accordance with subsection (b), or
(2) has only one regional alliance for a year, the
regional alliance adjustment factor under this sec-
tion is 1.
(b) RULES.—The adjustment factors under sub-
section (a)(1) for a year shall be computed in a manner
so that—
(1) such factors for the different regional alli-
ances reflect—
(A) the variation in regional alliance per
capita premium targets (determined under sec-
tion 6003), and
(B) the variation in base per capita ex-
penditures for medicaid across regional alli-
ances; and
(2) the weighted average of such factors is 1.
1295
Title IX, Subtitle A
(c) USE
OF SAME DATA.—The weighted average
under subsection (b)(2) shall be determined based on the
number of AFDC recipients or SSI recipients (as the case
may be) enrolled in each regional alliance in a State (as
determined for each regional alliance under section
9014(b)(2)).
(d) CLARIFICATION OF SEPARATE COMPUTATIONS.—
Determinations of adjustment factors under this section
shall be made separately for AFDC recipients and for SSI
recipients.
PART 3—GENERAL AND MISCELLANEOUS
PROVISIONS
SEC. 9021. TIMING AND MANNER OF PAYMENTS.
The provisions of paragraphs (1) and (2) of section
9101(b) apply to payments by a State under this subtitle
in the same manner as they apply to payments by the Sec-
retary under section 9101, and any reference in such pro-
visions to the Secretary is deemed a reference to the State.
SEC. 9022. REVIEW OF PAYMENT LEVEL.
(a) IN GENERAL.—The National Health Board shall
review from time to time the appropriateness of the levels
of payments required of States under this subtitle.
(b) REPORT.—The Board may report to the Congress
on such adjustments as should be made to assure an equi-
1296
Title IX, Subtitle A
table distribution of State payments under this Act, taking
into account the revenue base in each of the States.
(c) LIMIT ON AUTHORITY.—Nothing in this subtitle
shall be construed as permitting the Board to change the
amount of the payments required by States under the pre-
vious sections in this subtitle.
SEC. 9023. SPECIAL RULES FOR PUERTO RICO AND OTHER
TERRITORIES.
(a) WAIVER
AUTHORITY.—Notwithstanding any
other requirement of this title or title VI, the Secretary
may waive or modify any requirement of this title or title
VI (other than financial contribution and subsidy require-
ments) with respect to Puerto Rico, the Virgin Islands,
Guam, American Samoa, and the Northern Mariana Is-
lands, consistent with this section, to accommodate their
unique geographic and social conditions and features of
their health care systems.
(b) TERRITORIAL MAINTENANCE OF EFFORT AND
DIVISION OF FINANCIAL RESPONSIBILITY.—
(1) IN GENERAL.—In the case of such a Com-
monwealth or territory, the Secretary shall deter-
mine the State payments under part 1 taking into
account—
1297
Title IX, Subtitle B
(A) payments that qualify for Federal fi-
nancial participation under the medicaid pro-
gram,
(B) payments that would qualify for such
participation in the absence of section 1108(c)
of the Social Security Act, and
(C) other factors that the Secretary may
consider.
(2) CASH ASSISTANCE RECIPIENTS.—With re-
spect to such Commonwealths and territories not
covered under the supplementary security income
program, in this Act, the term ‘‘SSI recipient’’ in-
cludes an individual receiving aid under a territorial
program for the aged, blind, or disabled under the
Social Security Act.
Subtitle B—Aggregate Federal
Alliance Payments
SEC. 9101. FEDERAL PREMIUM PAYMENTS FOR CASH AS-
SISTANCE RECIPIENTS.
(a) AMOUNT.—
(1) IN GENERAL.—The Secretary shall provide
each year (beginning with a State’s first year) for
payment to each regional alliance of an amount
equal to the Federal medical assistance percentage
(as defined in section 1905(b) of the Social Security
1298
Title IX, Subtitle B
Act) of (A) 95 percent of the sum of the products
described in section 9011(a) for that State for that
fiscal year, plus (B) the sum described in section
9011(c).
(2) 
SPECIAL
RULES
FOR
SINGLE-PAYER
STATES.—In determining the products referred to in
paragraph (1) in the case of a single-payer State,
the State is deemed to be a single regional alliance
and the regional alliance adjustment factor (under
section 9015) is deemed to be 1.
(b) TIMING AND MANNER OF PAYMENT.—
(1) IN GENERAL.—Amounts required to be paid
under this section shall be paid on a periodic basis
that reflects the cash flow requirements of regional
alliances for payments under this section in order to
meet obligations established under this Act and, in
consultation with the Secretary of the Treasury, the
cash management interests of the Federal Govern-
ment.
(2) PERIODIC PROVISION OF INFORMATION.—
Each regional alliance shall periodically transmit to
the Secretary such information as the Secretary may
require to make such payments.
(3) RECONCILIATION.—
1299
Title IX, Subtitle B
(A) PRELIMINARY.—At such time after the
end of each year as the Secretary shall specify,
the State shall submit to the Secretary such in-
formation as the Secretary may require to do a
preliminary reconciliation of the amounts paid
under this section and the amounts due.
(B) FINAL.—No later than June 30 of
each year, the Secretary shall provide for a
final reconciliation for such payments for quar-
ters in the previous year. Amounts subsequently
payable are subject to adjustment to reflect the
results of such reconciliation.
(C) AUDIT.—Payments under this section
are subject to audits by the Secretary in accord-
ance with rules established by the Secretary.
SEC. 9102. CAPPED FEDERAL ALLIANCE PAYMENTS.
(a) CAPPED ENTITLEMENT.—
(1) PAYMENT.—The Secretary shall provide for
each calendar quarter (beginning on or after Janu-
ary 1, 1996) for payment to each regional alliance
of an amount equal to the capped Federal alliance
payment amount (as defined in subsection (b)(1))
for the regional alliance for the quarter.
(2) ENTITLEMENT.—This section constitutes
budget authority in advance of appropriations Acts,
1300
Title IX, Subtitle B
and represents the obligation of the Federal Govern-
ment to provide for the payment to regional alliances
of the capped Federal alliance payment amount
under this section.
(b) 
CAPPED
FEDERAL
ALLIANCE
PAYMENT
AMOUNT.—
(1) IN
GENERAL.—In this section, the term
‘‘capped Federal alliance payment amount’’ means,
for a regional alliance for a calendar quarter in a
year and subject to subsection (e), the amount by
which—
(A) 1⁄4 of the total payment obligation (de-
scribed in paragraph (2)) for the alliance for
the year, exceeds
(B) 1⁄4 of the total amounts receivable (de-
scribed in paragraph (3)) by the alliance for the
year.
(2) TOTAL PAYMENT OBLIGATION.—The total
payment obligation described in this paragraph for
an alliance for a year is the total amount payable by
the alliance for the following:
(A) PLAN PAYMENTS (AND CERTAIN COST
SHARING REDUCTIONS).—Payments to regional
alliance health plans under section 1351 (in-
cluding amounts attributable to cost sharing re-
1301
Title IX, Subtitle B
ductions under section 1371, not including a re-
duction under subsection (c)(2) thereof).
(B) 
ALLIANCE
ADMINISTRATIVE
EX-
PENSES.—Payments retained by the regional
alliance for administration (in accordance with
section 1352).
(3) TOTAL AMOUNTS RECEIVABLE.—The total
amounts receivable by a regional alliance for a year
is the sum of the following:
(A) PREMIUMS.—The amount payable to
the regional alliance for the family share of pre-
miums, employer premiums, and liabilities owed
the alliance under subtitle B of title VI, not
taking into account any failure to make or col-
lect such payments.
(B) OTHER
GOVERNMENT
PAYMENTS.—
The amounts payable to the regional alliance
under sections 9001, 9011, and 9101, and pay-
able under section 1894 of the Social Security
Act (as added by section 4003) during the year.
(4) NO PAYMENT FOR CERTAIN AMOUNTS.—
(A) 
UNCOLLECTED
ALLIANCE
PRE-
MIUMS.—Each regional alliance is responsible,
under section 1345(a), for the collection of all
amounts owed the alliance (whether by individ-
1302
Title IX, Subtitle B
uals, employers, or others and whether on the
basis of premiums owed, incorrect amounts of
discounts or premium, cost sharing, or other re-
ductions made, or otherwise), and no amounts
are payable by the Federal Goverment under
this section with respect to the failure to collect
any such amounts.
(B) ADMINISTRATIVE ERRORS.—
(i) IN GENERAL.—Each participating
State is responsible, under section 1202(g),
for the payment to regional alliances in the
State of amounts attributable to adminis-
trative errors (described in clause (ii)).
(ii) ADMINISTRATIVE
ERRORS
DE-
SCRIBED.—The administrative errors de-
scribed in this clause include the following:
(I) An eligibility error rate for
premium discounts, liability reduc-
tions, and cost sharing reductions
under sections 6104 and 6123, section
6113, and section 1371, respectively,
to the extent the applicable error rate
exceeds the maximum permissible
error rate, specified by the applicable
Secretary 
under 
section
1303
Title IX, Subtitle B
1361(b)(1)(C), with respect to the
section involved.
(II) Misappropriations or other
regional alliance expenditures that the
Secretary finds are attributable to
malfeasance or misfeasance by the re-
gional alliance or the State.
(5) 
SPECIAL
RULES
FOR
SINGLE-PAYER
STATES.—In applying this subsection in the case of
a single-payer State, the Secretary shall develop and
apply a methodology for computing an amount of
payment (with respect to each calendar quarter) that
is equivalent to the amount of payment that would
have been made to all regional alliances in the State
for the quarter if the State were not a single-payer
State.
(c) DETERMINATION OF CAPPED FEDERAL ALLI-
ANCE PAYMENT AMOUNTS.—
(1) REPORTS.—At such time as the Secretary
may require before the beginning of each fiscal year,
each regional alliance shall submit to the Secretary
such information as the Secretary may require to es-
timate the capped Federal alliance payment amount
under this section for the succeeding calendar year
1304
Title IX, Subtitle B
(and the portion of such year that falls in such fiscal
year).
(2) ESTIMATION.—Before the beginning of each
year, the Secretary shall estimate for each regional
alliance the capped Federal alliance payment amount
for calendar quarters in such year. Such estimate
shall be based on factors including prior financial ex-
perience in the alliance, future estimates of income,
wages, and employment, and other characteristics of
the area found relevant by the Secretary. The Sec-
retary shall transmit to Congress, on a timely basis
consistent with the timely appropriation of funds
under this section, a report that specifies an esti-
mate of the total capped Federal alliance payment
amounts owed to regional alliances under this sec-
tion for the fiscal and calendar year involved.
(d) PAYMENTS TO REGIONAL ALLIANCES.—Subject
to subsection (e), the provisions of section 9101(b) apply
to payments under this section in the same manner as
they apply to payments under section 9101.
(e) CAP ON PAYMENTS.—
(1) IN
GENERAL.—The total amount of the
capped Federal alliance payments made under this
section for quarters in a fiscal year may not exceed
1305
Title IX, Subtitle B
the cap specified under paragraph (2) for the fiscal
year.
(2) CAP.—Subject to paragraphs (3) and (6)—
(A) FISCAL YEARS 1996 THROUGH 2000.—
The cap under this paragraph—
(i) for fiscal year 1996, is $10.3 bil-
lion,
(ii) for fiscal year 1997, is $28.3 bil-
lion,
(iii) for fiscal year 1998, is $75.6 bil-
lion,
(iv) for fiscal year 1999, is $78.9 bil-
lion, and
(v) for fiscal year 2000, is $81.0 bil-
lion.
(B) SUBSEQUENT FISCAL YEAR.—The cap
under this paragraph for a fiscal year after fis-
cal year 2000 is the cap under this paragraph
for the previous fiscal year (not taking into ac-
count paragraph (3)) multiplied by the product
of the factors described in subparagraph (C) for
that fiscal year and for each previous year after
fiscal year 2000.
1306
Title IX, Subtitle B
(C) FACTOR.—The factor described in this
subparagraph for a fiscal year is 1 plus the fol-
lowing:
(i) CPI.—The percentage change in
the CPI for the fiscal year, determined
based upon the percentage change in the
average of the CPI for the 12-month pe-
riod ending with May 31 of the previous
fiscal year over such average for the pre-
ceding 12-month period.
(ii) POPULATION.—The average an-
nual percentage change in the population
of the United States during the 3-year pe-
riod ending in the preceding calendar year,
determined by the Board based on data
supplied by the Bureau of the Census.
(iii) REAL GDP PER CAPITA.—The av-
erage annual percentage change in the
real, per capita gross domestic product of
the United States during the 3-year period
ending in the preceding calendar year, de-
termined by the Board based on data sup-
plied by the Department of Commerce.
(3) CARRYFORWARD.—If the total of the
capped Federal alliance payment amounts for all re-
1307
Title IX, Subtitle B
gional alliances for all calendar quarters in a fiscal
year is less than the cap specified in paragraph (2)
for the fiscal year, then the amount of such surplus
shall be accumulated and will be available in the
case of a year in which the cap would otherwise be
breached.
(4) NOTIFICATION.—
(A) IN GENERAL.—If the Secretary antici-
pates that the amount of the cap, plus any
carryforward from a previous year accumulated
under paragraph (3), will not be sufficient for
a fiscal year, the Secretary shall notify the
President, the Congress, and each regional alli-
ance. Such notification shall include informa-
tion about the anticipated amount of the short-
fall and the anticipated time when the shortfall
will first occur.
(B) REQUIRED ACTION.—Within 30 days
after receiving such a notice, the President shall
submit to Congress a report containing specific
legislative recommendations for actions which
would eliminate the shortfall.
(5) CONGRESSIONAL CONSIDERATION.—
(A) EXPEDITED
CONSIDERATION.—If a
joint resolution the substance of which approves
1308
Title IX, Subtitle B
the specific recommendations submitted under
paragraph (4)(B) is introduced, subject to sub-
paragraph (B), the provisions of section 2908
(other than subsection (a)) of the Defense Base
Closure and Realignment Act of 1990 shall
apply to the consideration of the joint resolution
in the same manner as such provisions apply to
a joint resolution described in section 2908(a)
of such Act.
(B) SPECIAL RULES.—For purposes of ap-
plying subparagraph (A) with respect to such
provisions, any reference to the Committee on
Armed Services of the House of Representatives
shall be deemed a reference to an appropriate
Committee of the House of Representatives
(specified by the Speaker of the House of Rep-
resentatives at the time of submission of rec-
ommendations under paragraph (4)) and any
reference to the Committee on Armed Services
of the Senate shall be deemed a reference to an
appropriate Committee of the Senate (specified
by the Majority Leader of the Senate at the
time of submission of such recommendations).
(6) METHOD
FOR
ADJUSTING
THE
CAP
FOR
CHANGES IN INFLATION.—If the inflation rate, as
1309
Title IX, Subtitle C
measured by the percentage increase in the CPI, is
projected to be significantly different from the infla-
tion rate projected by the Council of Economic Advi-
sors to the President as of October 1993, the Sec-
retary may adjust the caps under paragraph (2) so
as to reflect such deviation from the projection.
Subtitle C—Borrowing Authority to
Cover Cash-flow Shortfalls
SEC. 9201. BORROWING AUTHORITY TO COVER CASH-FLOW
SHORTFALLS.
(a) IN GENERAL.—The Secretary shall make avail-
able loans to regional alliances in order to cover any period
of temporary cash-flow shortfall attributable to any of the
following:
(1) Any estimation discrepancy (including those
described in subsection (e)(1)).
(2) A period of temporary cash-flow shortfall
attributable to an administrative error (described in
subsection (e)(2)).
(3) A period of temporary cash-flow shortfall
relating to the relative timing during the year in
which amounts are received and payments are re-
quired to be made.
(b) TERMS AND CONDITIONS.—
1310
Title IX, Subtitle C
(1) IN GENERAL.—Loans shall be made under
this section under terms and conditions, consistent
with this subsection, specified by the Secretary, in
consultation with the Secretary of the Treasury and
taking into account Treasury cash management
rules.
(2) PERIOD.—Loans under this section shall be
repayable with interest over a period of not to exceed
2 years.
(3) INTEREST RATE.—The rate of interest on
such loans shall be at a rate determined by the Sec-
retary of the Treasury taking into consideration the
current average rate on outstanding marketable obli-
gations of the United States.
(4) APPROPRIATE PAYMENT ADJUSTMENTS.—
As a condition of providing a loan under subsection
(a)(1), the Secretary shall require the regional alli-
ance to make such adjustments under the appro-
priate estimation adjustment provision (described in
subsection (f)) in order to assure the repayment of
the amount so borrowed.
(5) LIMITATION
ON
LOAN
BALANCE
OUT-
STANDING
TO
A
REGIONAL
ALLIANCE.—The total
balance of loans outstanding at any time to a re-
gional alliance shall not exceed—
1311
Title IX, Subtitle C
(A) for the first year, 25 percent of the es-
timated total premiums for the alliance for such
year, or
(B) for a subsequent year, 25 percent of
the actual total premiums for the alliance for
the previous year.
(c) REPAYMENT.—
(1) ESTIMATION
DISCREPANCIES
AND
TIM-
ING.—Loans made under paragraphs (1) and (3) of
subsection (a) shall be repaid through a reduction in
the payment amounts otherwise required to be made
under section 9102 to the regional alliance.
(2) ADMINISTRATIVE
ERROR.—Loans made
under subsection (a)(2) shall be repaid through a
temporary increase in the amount of the State main-
tenance-of-effort payment required under section
9001.
(d) REPORTS.—The Secretary shall annually report
to Congress on the loans made (and loan amounts repaid)
under this section.
(e) SOURCES OF DISCREPANCY DESCRIBED.—
(1) ESTIMATION
DISCREPANCIES.—The esti-
mation discrepancies described in this paragraph are
discrepancies in estimating the following:
1312
Title IX, Subtitle C
(A) The average premium payments per
family under section 6122(b).
(B) The AFDC and SSI proportions under
section 6202.
(C) The distribution of enrolled families in
different risk categories for purposes of section
1351(c).
(D) The distribution of enrollment in ex-
cess premium plans (for purposes of calculating
and applying the reduced weighted average ac-
cepted bid under section 6105(c)(1)).
(E) The collection shortfalls (used in com-
puting the family collection shortfall add-on
under section 6107).
(2) ADMINISTRATIVE
ERRORS.—The adminis-
trative errors described in this paragraph are errors
described in section 9201(b)(4)(B)(ii).
(f) ESTIMATION
ADJUSTMENT
PROVISIONS
DE-
SCRIBED.—The estimation adjustment provisions, referred
to in subsection (b)(4)) are the following adjustments (cor-
responding to the respective estimation discrepancies spec-
ified in subsection (d)(1)):
(1) Adjustments for average premium payments
per family under section 6122(b)(4).
1313
Title X
(2) Adjustments in the AFDC and SSI propor-
tions under section 6202(d).
(3) Adjustments pursuant to the methodology
described in section 1541(b)(8).
(4) Adjustments in excess premium credit pur-
suant to section 6105(b)(2).
(5) Adjustment in the collection shortfall add-
on under section 6107(b)(2)(C)).
(g) ADVANCES; LIMITATIONS ON ADVANCES.—
(1) IN GENERAL.—Subject to paragraph (2),
the Secretary of the Treasury is authorized to ad-
vance to the Secretary, under terms and conditions
determined by the Secretary of the Treasury,
amounts sufficient to cover the loans made to re-
gional alliances by the Secretary under this section.
(2) LIMITATION.—The total balance of Treas-
ury advances outstanding at any time to the Sec-
retary under paragraph (1) shall not exceed
$3,500,000,000.
TITLE 
X—COORDINATION 
OF
MEDICAL PORTION OF WORK-
ERS 
COMPENSATION 
AND
AUTOMOBILE INSURANCE
TABLE OF CONTENTS OF TITLE
1314
Title X
Page
Subtitle A—Workers Compensation Insurance
Sec. 10000. Definitions ...........................................................................
1314
PART 1—HEALTH PLAN REQUIREMENTS RELATING TO WORKERS
COMPENSATION
Sec. 10001. Provision of workers compensation services ........................
1315
Sec. 10002. Payment by workers compensation carrier .........................
1319
PART 2—REQUIREMENTS OF PARTICIPATING STATES
Sec. 10011. Coordination of specialized workers compensation pro-
viders .............................................................................
1320
Sec. 10012. Preemption of State laws restricting delivery of workers
compensation medical benefits ......................................
1321
Sec. 10013. Development of supplemental schedule ...............................
1322
Sec. 10014. Construction ........................................................................
1322
PART 3—APPLICATION OF INFORMATION REQUIREMENTS; REPORT ON
PREMIUM REDUCTIONS
Sec. 10021. Application of information requirements .............................
1323
Sec. 10022. Report on reduction in workers compensation premiums ...
1324
PART 4—DEMONSTRATION PROJECTS
Sec. 10031. Authorization .......................................................................
1325
Sec. 10032. Development of work-related protocols ...............................
1325
Sec. 10033. Development of capitation payment models ........................
1326
Subtitle B—Automobile Insurance
Sec. 10100. Definitions ...........................................................................
1326
PART 1—HEALTH PLAN REQUIREMENTS RELATING TO AUTOMOBILE
INSURANCE
Sec. 10101. Provision of automobile insurance medical benefits
through health plans .....................................................
1327
Sec. 10102. Payment by automobile insurance carrier ...........................
1328
PART 2—REQUIREMENT OF PARTICIPATING STATES
Sec. 10111. Development of supplemental schedule ...............................
1330
Sec. 10112. Construction ........................................................................
1330
PART 3—APPLICATION OF INFORMATION REQUIREMENTS
Sec. 10121. Application of information requirements .............................
1330
Subtitle C—Commission on Integration of Health Benefits
Sec. 10201. Commission ..........................................................................
1331
Subtitle D—Federal Employees’ Compensation Act
Sec. 10301. Application of policy ............................................................
1333
1315
Title X, Subtitle A
Subtitle E—Davis-Bacon Act and Service Contract Act
Sec. 10401. Coverage of benefits under Health Security Act .................
1333
Subtitle F—Effective Dates
Sec. 10501. Regional alliances ................................................................
1334
Sec. 10502. Corporate alliances ..............................................................
1334
Sec. 10503. Federal requirements ..........................................................
1334
Subtitle A—Workers Compensation
Insurance
SEC. 10000. DEFINITIONS.
In this subtitle:
(1) INJURED
WORKER.—The term ‘‘injured
worker’’ means, with respect to a health plan, an in-
dividual enrolled under the plan who has a work-re-
lated injury or illness for which workers compensa-
tion medical benefits are available under State law.
(2) SPECIALIZED
WORKERS
COMPENSATION
PROVIDER.—The term ‘‘specialized workers com-
pensation provider’’ means a health care provider
that specializes in the provision of treatment relating
to work-related injuries or illness, and includes spe-
cialists in industrial medicine, specialists in occupa-
tional therapy, and centers of excellence in industrial
medicine and occupational therapy.
(3) WORKERS COMPENSATION MEDICAL BENE-
FITS.—The term ‘‘workers compensation medical
benefits’’ means, with respect to an enrollee who is
an employee subject to the workers compensation
1317
Title X, Subtitle A
(A) IN GENERAL.—Each health plan that
provides services to enrollees through partici-
pating providers shall enter into such contracts
and arrangements as are necessary (in accord-
ance with subparagraph (B)) to provide or ar-
range for the provision of workers compensation
services to such enrollees, in return for payment
from the workers compensation carrier under
section 10002.
(B) PROVISION
OF
SERVICES.—For pur-
poses of this paragraph, a health plan provides
(or arranges for the provision of) workers com-
pensation services with respect to an enrollee if
the services are provided by—
(i) a participating provider in the
plan,
(ii) any other provider with whom the
plan has entered into an agreement for the
provision of such services, or
(iii) a specialized workers compensa-
tion provider (designated by the State
under 10011(b)), whether or not the pro-
vider is a provider described in clause (i)
or (ii).
1318
Title X, Subtitle A
(2) INDIVIDUAL REQUIREMENT.—An individual
entitled to workers compensation medical benefits
and enrolled in a health plan (whether or not the
plan is described in paragraph (1)(A)) shall receive
workers compensation services through the provision
(or arrangement for the provision) of such services
by the health plan.
(3) EXCEPTIONS.—
(A) EMERGENCY
SERVICES.—Paragraphs
(1) and (2) shall not apply in the case of emer-
gency services.
(B) ELECTING VETERANS, MILITARY PER-
SONNEL
AND
INDIANS.—Paragraphs (1) and
(2) shall not apply in the case of an individual
described in section 1004(b) and making an
election described in such section.
(4) USE OF SPECIALIZED WORKERS COMPENSA-
TION PROVIDERS.—If a participating State has des-
ignated under section 10011(b) specialized workers
compensation providers with respect to one or more
types of injuries or illnesses for a geographic area,
either a health plan or an injured worker who has
an injury or illness of such type may elect to provide
or receive the benefits under this subsection through
such a provider.
1319
Title X, Subtitle A
(b) ALTERNATIVE PERMITTED.—Subsection (a) shall
not be construed as preventing an injured worker and a
workers compensation carrier from agreeing that workers
compensation services shall be provided other than by or
through the health plan in which the worker is enrolled.
(c) COORDINATION.—
(1) DESIGNATION
OF
CASE
MANAGER.—Each
health plan shall employ or contract with one or
more individuals, such as occupational nurses, with
experience in the treatment of occupational illness
and injury to provide case management services with
respect to workers compensation services provided
through the plan under this section.
(2) FUNCTIONS
OF
CASE
MANAGER.—The
health plan (through the case manager described in
paragraph (1)) is responsible for ensuring that—
(A) there is plan of treatment (when ap-
propriate) for each enrollee who is an injured
worker designed to assure appropriate treat-
ment and facilitate return to work;
(B) the plan of treatment is coordinated
with the workers compensation carrier, the em-
ployer, or both;
1320
Title X, Subtitle A
(C) the health plan (and its providers)
comply with legal duties and requirements
under State workers compensation law; and
(D) if the health plan is unable to provide
a workers compensation service needed to treat
a work-related injury or illness, the injured
worker is referred (in consultation with the
workers compensation carrier) to an appro-
priate provider.
(c) ADMINISTRATION.—The Secretary of Labor shall
administer this part and, for such purposes, the Secretary
is authorized to prescribe such rules and regulations as
may be necessary and appropriate.
SEC. 10002. PAYMENT BY WORKERS COMPENSATION CAR-
RIER.
(a) PAYMENT.—
(1) IN GENERAL.—Each workers compensation
carrier that is liable for payment for workers com-
pensation services furnished by or through a health
plan, regardless of whether or not the services are
included in the comprehensive benefit package, shall
make payment for such services.
(2) USE OF REGIONAL ALLIANCE FEE SCHED-
ULE.—Except as provided in subsection (b), such
payment shall be made in accordance with the appli-
1321
Title X, Subtitle A
cable fee schedule established under section 1322(c)
or section 10013.
(b) ALTERNATIVE
PAYMENT
METHODOLOGIES.—
Subsection (a)(2) shall not apply—
(1) in the case of a regional alliance or partici-
pating State that establishes an alternative payment
methodology (such as payment on a negotiated fee
for each case) for payment for workers compensation
services; or
(2) in the case in which a workers compensa-
tion carrier and the health plan negotiate alternative
payment arrangements.
(c) LIMITATION OF LIABILITY OF INJURED WORK-
ER.—Nothing in this part shall be construed as requiring
an injured worker to make any payment (including pay-
ment of any cost sharing or any amount in excess of the
applicable fee schedule) to any health plan or health care
provider for the receipt of workers compensation services.
PART 2—REQUIREMENTS OF
PARTICIPATING STATES
SEC. 10011. COORDINATION OF SPECIALIZED WORKERS
COMPENSATION PROVIDERS.
(a) IN GENERAL.—Each participating State shall co-
ordinate access to services provided by specialized workers
compensation providers on behalf of health plans, pro-
1322
Title X, Subtitle A
viding coverage to individuals residing in the State, under
part 1.
(b) OPTIONAL
DESIGNATION
OF
SPECIALIZED
WORKERS COMPENSATION PROVIDERS.—A participating
State may designate such specialized workers compensa-
tion providers, with respect to one or more types of ill-
nesses or injuries in a geographic area as the State deter-
mines to be appropriate, to provide under part 1 workers
compensation services that—
(1) are not included in the comprehensive ben-
efit package, or
(2) are so included but are specialized services
that are typically provided (as determined by the
State) by specialists in occupational or rehabilitative
medicine.
Injured workers and health plans may elect to use such
providers under section 10001(a)(4).
SEC. 10012. PREEMPTION OF STATE LAWS RESTRICTING
DELIVERY 
OF 
WORKERS 
COMPENSATION
MEDICAL BENEFITS.
(a) IN GENERAL.—Subject to section 10011(b), no
State law shall have any effect that restricts the choice,
or payment, of providers that may provide workers com-
pensation services for individuals enrolled in a health plan.
1323
Title X, Subtitle A
(b) DISPUTE RESOLUTION.—A State law may pro-
vide for a method for resolving disputes among parties re-
lated to—
(1) an individual’s entitlement to workers com-
pensation medical benefits under State law,
(2) the necessity and appropriateness of work-
ers compensation services provided to an injured
worker, and
(3) subject to section 10002, the reasonableness
of charges or fees charged for workers compensation
services.
SEC. 10013. DEVELOPMENT OF SUPPLEMENTAL SCHEDULE.
Each participating State shall develop a fee schedule
applicable to payment for workers compensation services
for which a fee is not included in the applicable fee sched-
ule established under section 1322(c).
SEC. 10014. CONSTRUCTION.
(a) IN GENERAL.—Nothing in this subtitle shall be
construed as altering—
(1) the effect of a State workers compensation
law as the exclusive remedy for work-related injuries
or illnesses,
(2) the determination of whether or not a per-
son is an injured worker and entitled to workers
compensation medical benefits under State law,
1324
Title X, Subtitle A
(3) the scope of items and services available to
injured workers entitled to workers compensation
medical benefits under State law, or
(4) the eligibility of any individual or class of
individuals for workers compensation medical bene-
fits under State law.
(b) EARLY INTEGRATION.—Nothing in this subtitle
shall prevent a State from integrating or otherwise coordi-
nating the payment for workers compensation medical
benefits with payment for benefits under health insurance
or health benefit plans before the date the Commission
submits its report under section 10201(e).
PART 
3—APPLICATION 
OF 
IN-
FORMATION REQUIREMENTS;
REPORT 
ON 
PREMIUM 
RE-
DUCTIONS
SEC. 10021. APPLICATION OF INFORMATION REQUIRE-
MENTS.
(a) IN GENERAL.—The provisions of—
(1) part 3 of subtitle B of title V (relating to
use of standard forms), and
(2) section 5101(e)(9) (relating to provision of
data on quality),
apply to the provision of workers compensation services
in the same manner as such provisions apply with respect
1325
Title X, Subtitle A
to the provision of services included in the comprehensive
benefit package.
(b) RULES.—The Secretary of Labor shall promul-
gate rules to clarify the responsibilities of health plans and
workers compensation carriers in carrying out the provi-
sions referred to in subsection (a).
SEC. 10022. REPORT ON REDUCTION IN WORKERS COM-
PENSATION PREMIUMS.
(a) STUDY AND REPORT.—
(1) STUDY.—The Secretary of Labor shall pro-
vide for a study of the impact of the provisions of
this subtitle on the premium rates charged to em-
ployers for workers compensation insurance. Such
study shall use information supplied by States relat-
ing to workers compensation premiums and such
other information as such Secretary finds appro-
priate.
(2) REPORT.—Such Secretary shall submit to
the Congress, by not later than 2 years after the
date that this subtitle applies in all States, a report
on the findings of the study.
(b) WORKERS COMPENSATION CARRIER FILINGS.—
(1) IN GENERAL.—Within six months after the
date this subtitle is effective in a participating State,
each workers compensation carrier (other than a
1326
Title X, Subtitle A
self-funded employer) providing workers compensa-
tion insurance in the State shall make a filing with
an agency designated by the State. Such filing shall
describe the manner in which such carrier has modi-
fied (or intends to modify) its premium rates for
workers compensation insurance provided in the
State to reflect the changes brought about by the
provisions in this subtitle. The filing shall include
such actuarial projections and assumptions as nec-
essary to support the modifications of such rates.
(2) REPORT
TO
SECRETARY.—Each partici-
pating State shall provide to the Secretary of Labor
such information on filings made under paragraph
(1) as such Secretary may specify.
PART 4—DEMONSTRATION PROJECTS
SEC. 10031. AUTHORIZATION.
The Secretary of Health and Human Services and the
Secretary of Labor are authorized to conduct demonstra-
tion projects under this part in one or more States with
respect to treatment of work-related injuries and illnesses.
SEC. 10032. DEVELOPMENT OF WORK-RELATED PROTO-
COLS.
(a) IN GENERAL.—Under this part, the Secretaries,
in consultation with States and such experts on work-re-
lated injuries and illnesses as the Secretaries find appro-
1327
Title X, Subtitle B
priate, shall develop protocols for the appropriate treat-
ment of work-related conditions.
(b) TESTING OF PROTOCOLS.—The Secretaries shall
enter into contracts with one or more health alliances to
test the validity of the protocols developed under sub-
section (a).
SEC. 10033. DEVELOPMENT OF CAPITATION PAYMENT MOD-
ELS.
Under this part, the Secretaries shall develop, using
protocols developed under section 10032 if possible, meth-
ods of providing for payment by workers compensation
carriers to health plans on a per case, capitated payment
for the treatment of specified work-related injuries and ill-
nesses.
Subtitle B—Automobile Insurance
SEC. 10100. DEFINITIONS.
In this subtitle:
(1) INJURED INDIVIDUAL.—The term ‘‘injured
individual’’ means, with respect to a health plan, an
individual enrolled under the plan who has an injury
or illness sustained in an automobile accident for
which automobile insurance medical benefits are
available.
(2) AUTOMOBILE INSURANCE MEDICAL BENE-
FITS.—The term ‘‘automobile insurance medical
1328
Title X, Subtitle B
benefits’’ means, with respect to an enrollee, the
comprehensive medical benefits for injuries or ill-
nesses sustained in automobile accidents.
(3) AUTOMOBILE
INSURANCE
CARRIER.—The
term ‘‘automobile insurance carrier’’ means an in-
surance company that underwrites automobile insur-
ance medical benefits and includes an employer or
fund that is financially at risk for the provision of
automobile insurance medical benefits.
(4) AUTOMOBILE INSURANCE MEDICAL SERV-
ICES.—The term ‘‘automobile insurance medical
services’’ means items and services included in auto-
mobile insurance medical benefits and includes items
and services (such as rehabilitation services and
long-term care services) commonly used for treat-
ment of injuries and illnesses sustained in auto-
mobile accidents.
PART 1—HEALTH PLAN REQUIREMENTS
RELATING TO AUTOMOBILE INSURANCE
SEC. 10101. PROVISION OF AUTOMOBILE INSURANCE MED-
ICAL BENEFITS THROUGH HEALTH PLANS.
(a) IN GENERAL.—An individual entitled to auto-
mobile insurance medical benefits and enrolled in a health
plan shall receive automobile insurance medical services
1330
Title X, Subtitle B
(2) USE OF REGIONAL ALLIANCE FEE SCHED-
ULE.—Such payment shall be made in accordance
with the applicable fee schedule established under
section 1322(c) or section 10111.
(b) ALTERNATIVE
PAYMENT
METHODOLOGIES.—
Subsection (a) shall not apply—
(1) in the case of a regional alliance or partici-
pating State that establishes an alternative payment
methodology (such as payment on a negotiated fee
for each case) for payment for automobile insurance
medical services; or
(2) in the case in which a automobile insurance
carrier and the health plan negotiate alternative pay-
ment arrangements.
(c) LIMITATION OF LIABILITY OF INJURED INDI-
VIDUAL.—Nothing in this part shall be construed as re-
quiring an injured individual to make any payment (in-
cluding payment of any cost sharing or any amount in
excess of the applicable fee schedule) to any health plan
or health care provider for the receipt of automobile insur-
ance medical services.
1331
Title X, Subtitle B
PART 2—REQUIREMENT OF PARTICIPATING
STATES
SEC. 10111. DEVELOPMENT OF SUPPLEMENTAL SCHEDULE.
Each participating State shall develop a fee schedule
applicable to payment for automobile insurance medical
services for which a fee is not included in the applicable
fee schedule established under section 1322(c).
SEC. 10112. CONSTRUCTION.
Nothing in this subtitle shall be construed as
altering—
(1) the determination of whether or not a per-
son is an injured individual and entitled to auto-
mobile insurance medical benefits under State law,
or
(2) the scope of items and services available to
injured individuals entitled to automobile insurance
medical benefits under State law.
PART 3—APPLICATION OF INFORMATION
REQUIREMENTS.
SEC. 10121. APPLICATION OF INFORMATION REQUIRE-
MENTS.
(a) IN GENERAL.—The provisions of—
(1) part 3 of subtitle B of title V (relating to
use of standard forms), and
(2) section 5101(e)(9) (relating to provision of
data on quality),
1332
Title X, Subtitle C
apply to the provision of automobile insurance medical
services in the same manner as such provisions apply with
respect to the provision of services included in the com-
prehensive benefit package.
(b) RULES.—The Secretary of Labor shall promul-
gate rules to clarify the responsibilities of health plans and
automobile insurance carriers in carrying out the provi-
sions referred to in subsection (a).
Subtitle C—COMMISSION ON IN-
TEGRATION OF HEALTH BEN-
EFITS
SEC. 10201. COMMISSION.
(a) ESTABLISHMENT.—There is hereby created a
Commission on Integration of Health Benefits (in this sec-
tion referred to as the ‘‘Commission’’).
(b) COMPOSITION.—
(1) IN GENERAL.—The Commission shall con-
sist of 15 members appointed jointly by the Sec-
retary of Health and Human Services and the Sec-
retary of Labor.
(2) NO
COMPENSATION
EXCEPT
TRAVEL
EX-
PENSES.—Members of the Commission shall serve
without compensation, but the Secretaries shall pro-
vide that each member shall receive travel expenses,
including per diem in lieu of subsistence, in accord-
1333
Title X, Subtitle C
ance with sections 5702 and 5703 of title 5, United
States Code.
(c) DUTIES.—The Commission shall study the feasi-
bility and appropriateness of transferring financial respon-
sibility for all medical benefits (including those currently
covered under workers compensation and automobile in-
surance) to health plans.
(d) STAFF SUPPORT.—The Secretaries shall provide
staff support for the Commission.
(e) REPORT.—The Commission shall submit a report
on its work to the President by not later than July 1,
1995. If such report recommends the integration of finan-
cial responsibility for all medical benefits in health plans,
such report shall provide for a detailed plan as to how
(and when) such an integration should be effected under
this Act.
(f) TERMINATION.—The Commission shall terminate
90 days after the date of submission of its report under
subsection (e).
(g) AUTHORIZATION
OF APPROPRIATIONS.—There
are authorized to be appropriated such sums as may be
necessary to carry out this section.
1334
Title X, Subtitle E
Subtitle D—Federal Employees’
Compensation Act
SEC. 10301. APPLICATION OF POLICY.
(a) IN GENERAL.—Chapter 81 of title 5, United
States Code, known as the Federal Employees’ Compensa-
tion Act shall be interpreted and administered consistent
with the provisions of subtitle A.
(b) CONSTRUCTION.—In applying subsection (a),
subtitle A shall be applied as if the following modifications
had been made in subtitle A:
(1) Any reference in section 10000, section
10001(c)(2)(C), section 10012(b), or section 10014
to a State law is deemed to include a reference to
chapter 81 of title 5, United States Code.
(2) The term ‘‘workers compensation carrier’’
includes the Employees Compensation Fund (estab-
lished under section 8147 of title 5, United States
Code).
Subtitle E—Davis-Bacon Act and
Service Contract Act
SEC. 10401. COVERAGE OF BENEFITS UNDER HEALTH SE-
CURITY ACT.
(a) DAVIS-BACON ACT.—Subsection (b)(2) of the
first section of the Davis Bacon Act (40 U.S.C.
276a(b)(2)) is amended in the matter following subpara-
1335
Title X, Subtitle F
graph (B) by inserting after ‘‘local law’’ the following:
‘‘(other than benefits provided pursuant to the Health Se-
curity Act)’’.
(b) SERVICE CONTRACT ACT OF 1965.—The second
sentence of section 2(a)(2) of the Service Contract Act of
1965 (41 U.S.C. 351(a)(2)) is amended by inserting after
‘‘local law’’ the following: ‘‘(other than benefits provided
pursuant to the Health Security Act)’’.
Subtitle F—Effective Dates
SEC. 10501. REGIONAL ALLIANCES.
The provisions of subtitles A and B of this title apply
to regional alliances, and regional alliance health plans,
in a State 2 years after the State’s first year (as defined
in section 1902(17)).
SEC. 10502. CORPORATE ALLIANCES.
The provisions of subtitles A and B of this title apply
to corporate alliances, and corporate alliance health plans,
on the date under section 10501 that such subtitles apply
to regional alliances, and regional alliance health plans,
in the State.
SEC. 10503. FEDERAL REQUIREMENTS.
The provisions of subtitle D of this title shall take
effect on January 1, 1998.
1336
Title XI
TITLE XI—TRANSITIONAL
INSURANCE REFORM
TABLE OF CONTENTS OF TITLE
Page
Sec. 11001. Imposition of requirements .................................................
1335
Sec. 11002. Enforcement ........................................................................
1337
Sec. 11003. Requirements relating to preserving current coverage ........
1338
Sec. 11004. Restrictions on premium increases during transition .........
1340
Sec. 11005. Requirements relating to portability ...................................
1350
Sec. 11006. Requirements limiting reduction of benefits .......................
1353
Sec. 11007. National transitional health insurance risk pool .................
1354
Sec. 11008. Definitions ...........................................................................
1358
Sec. 11009. Termination .........................................................................
1363
SEC. 11001. IMPOSITION OF REQUIREMENTS.
(a) IN GENERAL.—The Secretary and the Secretary
of Labor shall apply the provisions of this title to assure,
to the extent possible, the maintenance of current health
care coverage and benefits during the period between the
enactment of this Act and the dates its provisions are im-
plemented in the various States.
(b) ENFORCEMENT.—
(1) HEALTH
INSURANCE
PLANS.—The Sec-
retary shall enforce the requirements of this title
with respect to health insurance plans. The Sec-
retary shall promulgate regulations to carry out the
requirements under this title with respect to health
insurance plans. The Secretary shall promulgate reg-
ulations with respect to section 11004 within 90
days after the date of the enactment of this Act.
1337
Title XI
(2) SELF-INSURED PLANS.—The Secretary of
Labor shall enforce the requirements of this title
with respect to self-insured plans. Such Secretary
shall promulgate regulations to carry out the re-
quirements under this title as they relate to self-
funded plans.
(3) ARRANGEMENTS WITH STATES.—The Sec-
retary and the Secretary of Labor may enter into ar-
rangements with a State to enforce the requirements
of this title with respect to health insurance plans
and self-insured plans issued or sold, or established
and maintained, in the State.
(c) PREEMPTION.—The requirements of this title do
not preempt any State law unless State law directly con-
flicts with such requirements. The provision of additional
protections under State law shall not be considered to di-
rectly conflict with such requirements. The Secretary (or,
in the case of a self-insured plan, the Secretary of Labor)
may issue letter determinations with respect to whether
this Act preempts a provision of State law.
(d) INTERIM FINAL REGULATIONS.—Section 1911
shall apply to regulations issued to carry out this title.
The Secretary may consult with States and the National
Association of Insurance Commissioners in issuing regula-
tions and guidelines under this title.
1338
Title XI
(e) CONSTRUCTION.—The provisions of this title shall
be construed in a manner that assures, to the greatest
extent practicable, continuity of health benefits under
health benefit plans in effect on the effective date of this
Act.
(f) SPECIAL RULES FOR ACQUISITIONS AND TRANS-
FERS.—The Secretary may issue regulations regarding the
application of this title in the case of health insurance
plans (or groups of such plans) which are transferred from
one insurer to another insurer through assumption, acqui-
sition, or otherwise.
SEC. 11002. ENFORCEMENT.
(a) IN GENERAL.—Any health insurer or health ben-
efit plan sponsor that violates a requirement of this title
shall be subject to a civil money penalty of not more than
$25,000 for each such violation. The provisions of section
1128A of the Social Security Act (other than subsections
(a) and (b)) shall apply to civil money penalties under this
subsection in the same manner as they apply to a penalty
or proceeding under section 1128A(a) of such Act.
(b) EQUITABLE REMEDIES.—
(1) IN
GENERAL.—A civil action may be
brought by the applicable Secretary—
(A) to enjoin any act or practice which vio-
lates any provision of this title, or
1339
Title XI
(B) to obtain other appropriate equitable
relief (i) to redress such violations, or (ii) to en-
force any provision of this title, including, in
the case of a wrongful termination of (or re-
fusal to renew) coverage, reinstating coverage
effective as of the date of the violation.
SEC. 11003. REQUIREMENTS RELATING TO PRESERVING
CURRENT COVERAGE.
(a) PROHIBITION OF TERMINATION.—
(1) GROUP HEALTH INSURANCE PLANS.—Each
health insurer that provides a group health insur-
ance plan may not terminate (or fail to renew) cov-
erage for any covered employee if the employer of
the employee continues the plan, except in the case
of—
(A) nonpayment of required premiums,
(B) fraud, or
(C) misrepresentation of a material fact re-
lating to an application for coverage or claim
for benefits.
(2) INDIVIDUAL HEALTH INSURANCE PLANS.—
Each health insurer that provides coverage to a cov-
ered individual under an individual health insurance
plan may not terminate (or fail to renew) coverage
1340
Title XI
for such individual (or a covered dependent), except
in the case of—
(A) nonpayment of required premiums,
(B) fraud, or
(C) misrepresentation of a material fact re-
lating to an application for coverage or claim
for benefits.
(2) EFFECTIVE DATE OF TITLE.—
(A) IN
GENERAL.—This subsection shall
take effect on the effective date of this title and
shall apply to coverage on or after such date.
(B) DEFINITION.—Except as otherwise
provided, in this title the term ‘‘effective date of
this title’’ means the date of the enactment of
this Act.
(b) ACCEPTANCE OF NEW MEMBERS IN A GROUP
HEALTH INSURANCE PLAN.—
(1) IN GENERAL.—In the case of a health in-
surer that provides a group health insurance plan
that is in effect on the effective date of this title, the
insurer is required—
(A) to accept all individuals, and their eli-
gible dependents, who become full-time employ-
ees (as defined in section 1901(b)(2)(C)) of an
employer covered after such effective date;
1341
Title XI
(B) to establish and apply premium rates
that are consistent with section 11004(b); and
(C) to limit the application of pre-existing
condition restrictions in accordance with section
11005.
(2) CONSISTENT APPLICATION OF RULES RE-
LATING TO DEPENDENTS AND WAITING PERIODS.—
In this subsection, the term ‘‘eligible dependent’’,
with respect to a group health insurance plan, has
the meaning provided under the plan as of October
27, 1993, or, in the case of a plan not established
as of such date, as of the date of establishment of
the plan.
SEC. 11004. RESTRICTIONS ON PREMIUM INCREASES DUR-
ING TRANSITION.
(a) DIVISION OF HEALTH INSURANCE PLANS BY
SECTOR.—For purposes of this section, each health in-
surer shall divide its health insurance business into the
following 3 sectors:
(1) Health insurance for groups with at least
100 covered lives (in this section referred to as the
‘‘large group sector’’)
(2) Health insurance for groups with fewer
than 100 covered lives (in this section referred as
the ‘‘small group sector’’).
1342
Title XI
(3) Health insurance for individuals, and not
for groups (in this section referred to as the ‘‘indi-
vidual sector’’).
(b) PREMIUM CHANGES TO REFLECT CHANGES IN
GROUP OR INDIVIDUAL CHARACTERISTICS OR TERMS OF
COVERAGE.—
(1) APPLICATION.—The provisions of this sub-
section shall apply to changes in premiums that
reflect—
(A) changes in the number of individuals
covered under a plan;
(B) changes in the group or individual
characteristics (including age, gender, family
composition or geographic area but not includ-
ing health status, claims experience or duration
of coverage under the plan) of individuals cov-
ered under a plan;
(C) changes in the level of benefits (includ-
ing changes in cost-sharing) under the plan;
and
(D) changes in any material terms and
conditions of the health insurance plan (other
than factors related to health status, claims ex-
perience, and duration of coverage under the
plan).
1343
Title XI
(2) SPECIFICATION OF REFERENCE RATE FOR
EACH SECTOR.—Each health insurer shall calculate
a reference rate for each such sector. The reference
rate for a sector shall be calculated so that, if it
were applied using the rate factors specified under
paragraph (3), the average premium rate for individ-
uals and groups in that sector would approximate
the average premium rate charged individuals and
groups in the sector as of the effective date of this
title.
(3) SINGLE
SET
OF
RATE
FACTORS
WITHIN
EACH SECTOR.—
(A) IN
GENERAL.—Each health insurer
shall develop for each sector a single set of rate
factors which will be used to calculate any
changes in premium that relate to the reasons
described in subparagraphs (B) through (D) of
paragraph (1).
(B) STANDARDS.—Such rate factors—
(i) shall relate to reasonable and ob-
jective differences in demographic charac-
teristics, in the design and in levels of cov-
erage, and in other terms and conditions of
a contract,
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(ii) shall not relate to expected health
status, claims experience, or duration of
coverage of the one or more groups or indi-
viduals, and
(iii) shall comply with regulations es-
tablished under subsection (f).
(4) COMPUTATION OF PREMIUM CHANGES.—
(A) IN
GENERAL.—Changes in premium
rates that relate to the reasons described in
paragraph (1) shall be calculated using the rate
factors developed pursuant to paragraph (3).
(B) APPLICATION TO CHANGES IN NUMBER
OF COVERED INDIVIDUALS.—In the case of a
change in premium rates related to the reason
described in paragraph (1)(A), the change in
premium rates shall be calculated to reflect,
with respect to the enrollees who enroll or
disenroll in a health insurance plan, the sum of
the products, for such individuals, of the ref-
erence rate (determined under paragraph (2))
and the rate factors (specified under paragraph
(3)) applicable to such enrollees.
(C) APPLICATION OF OTHER FACTORS.—
(i) IN
GENERAL.—In the case of a
change in premium rates related to a rea-
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son described in subparagraph (B), (C), or
(D) of paragraph (1), the change in pre-
mium rates with respect to each health in-
surance plan in each sector shall reflect the
rate factors specified under paragraph (3)
applicable to the reason as applied to the
current premium charged for the health in-
surance plan. Such rate factors shall be
applied in a manner so that the resulting
adjustment, to the extent possible, reflects
the premium that would have been charged
under the plan if the reason for the change
in premium had existed at the time that
the current premium rate was calculated.
(ii) NO REFLECTION OF CHANGE IN
HEALTH
STATUS.—In applying the rate
factors under this subparagraph, the ad-
justment shall not reflect any change in
the health status, claims experience or du-
ration of coverage with respect to any em-
ployer or individual covered under the
plan.
(5) LIMITATION ON APPLICATION.—This sub-
section shall only apply—
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(A) to changes in premiums occurring on
or after the date of the enactment of this Act
to groups and individuals covered as of such
date, and
(B) with respect to groups and individuals
subsequently covered, to changes in premiums
subsequent to such coverage.
(6) 
APPLICATION
TO
COMMUNITY-RATED
PLANS.—Nothing in this subsection shall require the
application of rate factors related to individual or
group characteristics with respect to community-
rated plans.
(c) LIMITATIONS ON CHANGES IN PREMIUMS RE-
LATED TO INCREASES IN HEALTH CARE COSTS AND UTI-
LIZATION.—
(1) APPLICATION.—The provisions of this sub-
section shall apply to changes in premiums that re-
flect increases in health care costs and utilization.
(2) EQUAL INCREASE FOR ALL PLANS IN ALL
SECTORS.—
(A) IN
GENERAL.—Subject to subpara-
graph (B), the annual percentage increase in
premiums by a health insurer for health insur-
ance plans in the individual sector, small group
sector, and large group sector, to the extent
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such increase reflect increases in health care
costs and utilization, shall be the same for all
such plans in those sectors.
(B) SPECIAL
RULE
FOR
LARGE
GROUP
SECTOR.—The annual percentage increase in
premiums by a health insurer for health insur-
ance plans in the large group sector may vary
among such plans based on the claims experi-
ence of an employer (to the extent the experi-
ence is credible), so long as the weighted aver-
age of such increases for all such plans in the
sector complies with the requirement of sub-
paragraph (A).
(C) GEOGRAPHIC APPLICATION.—Subpara-
graphs (A) and (B)—
(i) may be applied on a national level,
or
(ii) may vary based on geographic
area, but only if (I) such areas are suffi-
ciently large to provide credible data on
which to calculate the variation and (II)
the variation is due to reasonable factors
related to the objective differences among
such areas in costs and utilization of
health services.
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(D) EXCEPTIONS TO ACCOMMODATE STATE
RATE REFORM EFFORTS.—Subparagraphs (A)
and (B) shall not apply, in accordance with
guidelines of the Secretary, to the extent nec-
essary to permit a State to narrow the vari-
ations in premiums among health insurance
plans offered by health insurers to similarly sit-
uated groups or individuals within a sector.
(E) EXCEPTION FOR RATES SUBJECT TO
PRIOR APPROVAL.—Subparagraphs (A) and (B)
shall not apply to premiums that are subject to
prior approval by a State insurance commis-
sioner (or similar official) and are approved by
such official.
(F) OTHER REASONS SPECIFIED BY THE
SECRETARY.—The 
Secretary 
may 
specify
through regulations such other exceptions to
the provisions of this subsection as the Sec-
retary determines are required to enhance sta-
bility of the health insurance market and con-
tinued availability of coverage.
(3) 
EVEN
APPLICATION
THROUGHOUT
A
YEAR.—In applying the provisions of this subsection
to health insurance plans that are renewed in dif-
ferent months of a year, the annual percentage in-
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crease shall be applied in a consistent, even manner
so that any variations in the rate of increase applied
in consecutive months are even and continuous dur-
ing the year.
(4) PETITION FOR EXCEPTION.—A health in-
surer may petition the Secretary (or a State acting
under a contract with the Secretary under section
11001(b)(3)) for an exception from the application
of the provisions of this subsection. The Secretary
may approve such an exception if—
(A) the health insurer demonstrates that
the application of this subsection would threat-
en the financial viability of the insurer, and
(B) the health insurer offers an alternative
method for increasing premiums that is not
substantially discriminatory to any sector or to
any group or individual covered by a health in-
surance plan offered by the insurer.
(d) PRIOR
APPROVAL
FOR
CERTAIN
RATE
IN-
CREASES.—
(1) IN GENERAL.—If the percentage increase in
the premium rate for the individual and small group
sector exceeds a percentage specified by the Sec-
retary under paragraph (2), annualized over any 12-
month period, the increase shall not take effect un-
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less the Secretary (or a State acting under a con-
tract with the Secretary under section 11001(b)(3))
has approved the increase.
(2) PERCENTAGE.—The Secretary shall specify,
for each 12-month period beginning after the date of
the enactment of this Act, a percentage that will
apply under paragraph (1). Such percentage shall be
determined taking into consideration the rate of in-
crease in health care costs and utilization, previous
trends in health insurance premiums, and the condi-
tions in the health insurance market. Within 30 days
after the date of the enactment of this Act, the Sec-
retary shall first specify a percentage under this
paragraph.
(e) DOCUMENTATION OF COMPLIANCE.—
(1) PERIOD FOR CONFORMANCE.—Effective 1
year after the date of the enactment of this Act, the
premium for each health insurance plan shall be
conformed in a manner that complies with the provi-
sions of this section.
(2) METHODOLOGY.—Each health insurer shall
document the methodology used in applying sub-
sections (b) and (c) with respect to each sector (and
each applicable health plan). Such documentation
shall be sufficient to permit the auditing of the ap-
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plication of such methodology to determine if such
application was consistent with such subsections.
(3) CERTIFICATION.—For each 6-month period
in which this section is effective, each health insurer
shall file a certification with the Secretary (or with
a State with which the Secretary has entered into an
arrangement under section 11001(b)(3)) that the in-
surer is in compliance with such requirements.
(f) REGULATIONS.—The Secretary shall establish
regulations to carry out this section. Such regulations may
include guidelines relating to the permissible variation
that results from the use of demographic or other charac-
teristics in the development of rate factors. Such guide-
lines may be based on the guidelines currently used by
States in applying rate limitations under State insurance
regulations.
(g) EFFECTIVE PERIOD.—This section shall apply to
premium increases occurring during the period beginning
on the date of the enactment of this Act and ending, for
a health insurance plan provided in a State, on the first
day of the State’s first year.
SEC. 11005. REQUIREMENTS RELATING TO PORTABILITY.
(a) TREATMENT OF PREEXISTING CONDITION EX-
CLUSIONS.—
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(1) IN
GENERAL.—Subject to the succeeding
provisions of this subsection, a group health benefit
plan may exclude coverage with respect to services
related to treatment of a preexisting condition, but
the period of such exclusion may not exceed 6
months. The exclusion of coverage shall not apply to
services furnished to newborns or in the case of a
plan that did not apply such exclusions as of the ef-
fective date of this title.
(2) CREDITING OF PREVIOUS COVERAGE.—
(A) IN GENERAL.—A group health benefit
plan shall provide that if an individual covered
under such plan is in a period of continuous
coverage (as defined in subparagraph (B)(i))
with respect to particular services as of the date
of initial coverage under such plan, any period
of exclusion of coverage with respect to a pre-
existing condition for such services or type of
services shall be reduced by 1 month for each
month in the period of continuous coverage.
(B) DEFINITIONS.—As used in this para-
graph:
(i) PERIOD
OF
CONTINUOUS
COV-
ERAGE.—The term ‘‘period of continuous
coverage’’ means, with respect to par-
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ticular services, the period beginning on
the date an individual is enrolled under a
group or individual health benefit plan,
self-insured plan, the medicare program, a
State medicaid plan, or other health ben-
efit arrangement which provides benefits
with respect to such services and ends on
the date the individual is not so enrolled
for a continuous period of more than 3
months.
(ii) PREEXISTING
CONDITION.—The
term ‘‘preexisting condition’’ means, with
respect to coverage under a health benefits
plan, a condition which has been diagnosed
or treated during the 6-month period end-
ing on the day before the first date of such
coverage (without regard to any waiting
period).
(b) WAITING PERIODS.—A self-insured plan, and an
employer with respect to a group health insurance plan,
may not discriminate among employees in the establish-
ment of a waiting period before making health insurance
coverage available based on the health status, claims expe-
rience, receipt of health care, medical history, or lack of
1354
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evidence of insurability, of the employee or the employee’s
dependents.
SEC. 11006. REQUIREMENTS LIMITING REDUCTION OF BEN-
EFITS.
(a) IN GENERAL.—A self-insured sponsor may not
make a modification of benefits described in subsection
(b).
(b) MODIFICATION OF BENEFITS DESCRIBED.—
(1) IN GENERAL.—A modification of benefits
described in this subsection is any reduction or limi-
tation in coverage, effected on or after the effective
date of this title, with respect to any medical condi-
tion or course of treatment for which the anticipated
cost is likely to exceed $5,000 in any 12-month pe-
riod.
(2) TREATMENT
OF
TERMINATION.—A modi-
fication of benefits includes the termination of a
plan if the sponsor, within a period (specified by the
Secretary of Labor) establishes a substitute plan
that reflects the reduction or limitation described in
paragraph (1).
(c) REMEDY.—Any modification made in violation of
this section shall not be effective and the self-insured
sponsor shall continue to provide benefits as though the
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modification (described in subsection (b)) had not oc-
curred.
SEC. 11007. NATIONAL TRANSITIONAL HEALTH INSURANCE
RISK POOL.
(a) ESTABLISHMENT.—In order to assure access to
health insurance during the transition, the Secretary is
authorized to establish a National Transitional Health In-
surance Risk Pool (in this section referred to as the ‘‘na-
tional risk pool’’) in accordance with this section.
(b) ADMINISTRATION.—
(1) IN GENERAL.—The Secretary may admin-
ister the national risk pool through contracts with—
(A) one or more existing State health in-
surance risk pools,
(B) one or more private health insurers, or
(C) such other contracts as the Secretary
deems appropriate.
(2) COORDINATION WITH STATE RISK POOLS.—
The Secretary may enter into such arrangements
with existing State health insurance risk pools to co-
ordinate the coverage under such pools with the cov-
erage under the national risk pool. Such coordina-
tion may address eligibility and funding of coverage
for individuals currently covered under State risk
pools.
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(c) ELIGIBILITY FOR COVERAGE.—The national risk
pool shall provide health insurance coverage to individuals
who are unable to secure health insurance coverage from
private health insurers because of their health status or
condition (as determined in accordance with rules and pro-
cedures specified by the Secretary).
(d) BENEFITS.—
(1) IN GENERAL.—Benefits and terms of cov-
erage provided through the national risk pool shall
include items and services, conditions of coverage,
and cost sharing (subject to out-of-pocket limits on
cost sharing) comparable to the benefits and terms
of coverage available in State health insurance risk
pools.
(2) PAYMENT RATES.—Payments under the na-
tional risk pool for covered items and services shall
be made at rates (specified by the Secretary) based
on payment rates for comparable items and services
under the medicare program. Providers who accept
payment from the national risk pool shall accept
such payment as payment in full for the service,
other than for cost sharing provided under the na-
tional risk pool.
(e) PREMIUMS.—
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(1) IN GENERAL.—Premiums for coverage in
the national risk pool shall be set in a manner speci-
fied by the Secretary.
(2) VARIATION.—Such premiums shall vary
based upon age, place of residence, and other tradi-
tional underwriting factors other than on the basis
of health status or claims experience.
(3) LIMITATION.—The premiums charged indi-
viduals shall be set at a level that is no less than
150 percent of the premiums that the Secretary esti-
mates would be charged to a population of average
risk for the covered benefits.
(f) TREATMENT OF SHORTFALLS.—
(1) ESTIMATES.—The Secretary shall estimate
each year the extent to which the total premiums
collected under subsection (e) in the year are insuffi-
cient to cover the expenses of the national risk pool
with respect to the year.
(2) TEMPORARY BORROWING AUTHORITY.—The
Secretary of the Treasury is authorized to advance
to the Secretary amounts sufficient to cover the
amount estimated under paragraph (1) during the
year before assessments are collected under para-
graph (3), except that the total balance of such
Treasury advances at any time shall not exceed
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$1,500,000,000. The Secretary shall repay such
amounts, with interest at a rate specified by the Sec-
retary of the Treasury, from the assessments under
paragraph (3).
(3) ASSESSMENTS.—
(A) IN
GENERAL.—Each health benefit
plan sponsor shall be liable for an assessment
in the amount specified in subparagraph (C).
(B) AMOUNT.—For each year for which
amounts are advanced under paragraph (2), the
Secretary shall—
(i) estimate the total amount of pre-
miums (and premium equivalents) for
health benefits under health benefit plans
for the succeeding year, and
(ii) calculate a percentage equal to (I)
the total amounts repayable by the Sec-
retary to the Secretary of the Treasury
under paragraph (2) for the year, divided
by the amount determined under clause (i).
(C) ASSESSMENT AMOUNT.—The amount
of an assessment for a sponsor of a health ben-
efit plan for a year shall be equal to the per-
centage calculated under subparagraph (B)(ii)
(or, if less, 1⁄2 of 1 percent) of the total amount
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of premiums (and premium equivalents) for
health benefits under the plan for the previous
year.
(D) SELF-INSURED PLANS.—The amount
of premiums (and premium equivalents) under
this paragraph shall be estimated—
(i) by the Secretary for health insur-
ance plans, and
(ii) by the Secretary of Labor for self-
insured plans.
Such estimates may be based on a methodology
that requires plans liable for assessment to file
information with the applicable Secretary.
SEC. 11008. DEFINITIONS.
In this title:
(1) APPLICABLE SECRETARY.—The term ‘‘ap-
plicable Secretary’’ means—
(A) the Secretary with respect to health in-
surance plans and insurers, or
(B) the Secretary of Labor with respect to
self-insured plans and self-insured plan spon-
sors.
(2) COVERED EMPLOYEE.—The term ‘‘covered
employee’’ means an employee (or dependent of such
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an employee) covered under a group health benefits
plan.
(3) COVERED INDIVIDUAL.—The ‘‘covered indi-
vidual’’ means, with respect to a health benefit plan,
an individual insured, enrolled, eligible for benefits,
or otherwise covered under the plan.
(4) GROUP
HEALTH
BENEFITS
PLAN.—The
term ‘‘group health benefits plan’’ means a group
health insurance plan and a self-insured plan.
(5) GROUP HEALTH INSURANCE PLAN.—
(A) IN
GENERAL.—The term ‘‘group
health insurance plan’’ means a health insur-
ance plan offered primarily to employers for the
purpose of providing health insurance to the
employees (and dependents) of the employer.
(B) INCLUSION
OF
ASSOCIATION
PLANS
AND MEWAS.—Such term includes—
(i) any arrangement in which coverage
for health benefits is offered to employers
through an association, trust, or other ar-
rangement, and
(ii) a multiple employer welfare ar-
rangement (as defined in section 3(40) of
the Employee Retirement Income Security
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Act of 1974), whether funded through in-
surance or otherwise.
(6) HEALTH
BENEFITS
PLAN.—The term
‘‘health benefits plan’’ means health insurance plan
and a self-insured health benefit plan.
(7) HEALTH
BENEFIT
PLAN
SPONSOR.—The
term ‘‘health benefit plan sponsor’’ means, with re-
spect to a health insurance plan or self-insured plan,
the insurer offering the plan or the self-insured
sponsor for the plan, respectively.
(8) HEALTH INSURANCE PLAN.—
(A) IN GENERAL.—Except as provided in
subparagraph (B), the term ‘‘health insurance
plan’’ means any contract of health insurance,
including any hospital or medical service policy
or certificate, any major medical policy or cer-
tificate, any hospital or medical service plan
contract, or health maintenance organization
subscriber contract offered by an insurer.
(B) EXCEPTION.—Such term does not in-
clude any of the following—
(i) coverage only for accident, dental,
vision, disability income, or long-term care
insurance, or any combination thereof,
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Title XI
(ii) medicare supplemental health in-
surance,
(iii) coverage issued as a supplement
to liability insurance,
(iv) worker’s compensation or similar
insurance, or
(v) automobile medical payment insur-
ance,
or any combination thereof.
(C) STOP
LOSS
INSURANCE
NOT
COV-
ERED.—Such term does not include any aggre-
gate or specific stop-loss insurance or similar
coverage applicable to a self-insured plan. The
Secretary may develop rules determining the
applicability of this subparagraph with respect
to minimum premium plans or other partially
insured plans.
(9) HEALTH INSURER.—The term ‘‘health in-
surer’’ means a licensed insurance company, a pre-
paid hospital or medical service plan, a health main-
tenance organization, or other entity providing a
plan of health insurance or health benefits with re-
spect to which the State insurance laws are not pre-
empted under section 514 of the Employee Retire-
ment Income Security Act of 1974.
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Title XI
(10) INDIVIDUAL HEALTH INSURANCE PLAN.—
(A) IN GENERAL.—The term ‘‘individual
health insurance plan’’ means any health insur-
ance plan directly purchased by an individual or
offered primarily to individuals (including fami-
lies) for the purpose of permitting individuals
(without regard to an employer contribution) to
purchase health insurance coverage.
(B) INCLUSION OF ASSOCIATION PLANS.—
Such term includes any arrangement in which
coverage for health benefits is offered to indi-
viduals through an association, trust, list-billing
arrangement, or other arrangement in which
the individual purchaser is primarily responsible
for the payment of any premium associated
with the contract.
(C) TREATMENT OF CERTAIN ASSOCIATION
PLANS.—In the case of a health insurance plan
sponsored by an association, trust, or other ar-
rangement that provides health insurance cov-
erage both to employers and to individuals, the
plan shall be treated as—
(i) a group health insurance plan with
respect to such employers, and
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Title XI
(ii) an individual health insurance
plan with respect to such individuals.
(11) SELF-INSURED PLAN.—The term ‘‘self-in-
sured plan’’ means an employee welfare benefit plan
or other arrangement insofar as the plan or arrange-
ment provides benefits with respect to some or all of
the items and services included in the comprehensive
benefit package (as in effect as of January 1, 1996)
that is funded in a manner other than through the
purchase of one or more health insurance plans.
Such term shall not include a group health insur-
ance plan described in paragraph (5)(B)(ii).
(12) SELF-INSURED SPONSOR.—The term ‘‘self-
insured sponsor’’ includes, with respect to a self-in-
sured plan, any entity which establishes or main-
tains the plan.
(13) STATE COMMISSIONER OF INSURANCE.—
The term ‘‘State commissioner of insurance’’ in-
cludes a State superintendent of insurance.
SEC. 11009. TERMINATION.
(a) HEALTH INSURANCE PLANS.—The provisions of
this title shall not apply to a health insurance plan pro-
vided in a State on and after the first day of the first
year for the State.
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Title XI
(b) SELF-INSURED PLANS.—The provisions of this
title shall not apply to a self-insured plan that—
(1) is sponsored by a sponsor that is an eligible
sponsor of a corporate alliance (described in section
1311(b)(1)), as of the effective date of the election
under section 1312(c); and
(2) is sponsored by a sponsor that is not such
an eligible sponsor, with respect to individuals or
groups in a State on and after the first day of the
first year for the State.
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