143
(2) PROCESS.—The provisions of section 1128A
of the Social Security Act (other than subsections
(a) and (b)) shall apply to a civil money penalty
under paragraph (1) in the same manner as such
provisions apply to a penalty or proceeding under
section 1128A(a) of such Act.
(3) SUNSET
FOR
PENALTY.—No civil money
penalty may be imposed under this subsection for
submission (or rejection) of any claim on or after
the date that is 36 months after the effective date
specified in subsection (a)(3).
(c) STANDARDS RELATING TO UNIFORM CLAIMS AND
ELECTRONIC CLAIMS DATA SET.—
(1) ESTABLISHMENT
OF
STANDARDS.—The
Secretary shall establish standards that—
(A) relate to the form and manner of sub-
mission of claims for benefits under a health
benefit plan, and
(B) define the data elements to be con-
tained in a uniform electronic claims data set to
used with respect to such claims.
(2) SCOPE OF INFORMATION.—
(A) IN
GENERAL.—The standards under
this subsection are intended to cover substan-
tially most claims that are filed under health
144
benefit plans. Such information need not in-
clude all elements that may potentially be re-
quired to be reported under utilization review
provisions of plans.
(B) 
ENSURING
ACCOUNTABILITY
FOR
CLAIMS SUBMITTED ELECTRONICALLY.—In es-
tablishing such standards, the Secretary, in
consultation with appropriate agencies, shall in-
clude such methods of ensuring provider re-
sponsibility and accountability for claims sub-
mitted electronically that are designed to con-
trol fraud and abuse in the submission of such
claims.
(C) COMPONENTS.—In establishing such
standards the Secretary shall—
(i) with respect to data elements, de-
fine data fields, formats, and medical no-
menclature, and plan benefit and insurance
information;
(ii) develop a single, uniform coding
system for diagnostic and procedure codes;
and
(iii) provide for standards for the uni-
form electronic transmission of such ele-
ments.
145
(3) COORDINATION
WITH
STANDARDS
FOR
ELECTRONIC
MEDICAL
RECORDS.—In establishing
standards under this subsection, the Secretary shall
assure that—
(A) the development of such standards is
coordinated with the development of the stand-
ards for electronic medical records under sec-
tion 324, and
(B) the coding of data elements under the
uniform electronic claims data set and the cod-
ing of the same elements in the uniform hos-
pital clinical data set are consistent.
(4) USE OF TASK FORCES.—In adopting stand-
ards under this subsection—
(A) the Secretary shall take into account
the recommendations of current task forces, in-
cluding at least the Workgroup on Electronic
Data Interchange, National Uniform Billing
Committee, the Uniform Claim Task Force, and
the Computer-based Patient Record Institute,
and
(B) the Secretary shall provide that the
electronic transmission standards are consist-
ent, to the extent practicable, with the applica-
ble standards established by the Accredited
146
Standards Committee X–12 of the American
National Standards Institute.
(5) UNIFORM, UNIQUE PROVIDER IDENTIFICA-
TION CODES.—In establishing standards under this
subsection—
(A) the Secretary shall provide for a
unique identifier code for each health service
provider that furnishes services for which a
claim may be submitted under a health benefit
plan, and
(B) in the case of a provider that has a
unique identifier issued for purposes of the
medicare program, the code provided under
subparagraph (A) shall be the same as such
unique identifier.
(6) PUBLIC
DOMAIN
SOFTWARE
TO
PROVID-
ERS.—The Secretary shall provide for the develop-
ment, and shall make available without charge to
health service providers, such computer software as
will enable the providers to submit claims and to re-
ceive verification of claims status electronically.
(7) STANDARDS
FOR
PAPER
CLAIMS.—The
standards shall provide for a uniform paper claims
form which is consistent with data elements required
for the submission of claims electronically.
147
(8) STANDARDS
FOR
CLAIMS
FOR
CLINICAL
LABORATORY TESTS.—The standards shall provide
that claims for clinical laboratory tests for which
benefits are provided under a health benefit plan
shall be submitted directly by the person or entity
that performed (or supervised the performance of)
the tests to the plan in a manner consistent with
(and subject to such exceptions as are provided
under) the requirement for direct submission of such
claims under the medicare program.
(9) DEADLINE.—The Secretary shall first pro-
vide for the standards for the uniform claims under
this subsection (and shall develop and make avail-
able the software under paragraph (6)) by not later
than 1 year after the date of the enactment of this
Act.
(d) USE UNDER MEDICARE AND MEDICAID PRO-
GRAMS.—
(1) REQUIREMENT
FOR
PROVIDERS.—In the
case of a health service provider that submits a
claim for services furnished under the medicare pro-
gram or medicaid program in violation of subsection
(a)(1), no payment shall be made under such pro-
gram for such services.
148
(2) REQUIREMENTS OF INTERMEDIARIES AND
CARRIERS UNDER MEDICARE PROGRAM.—The Sec-
retary shall provide, in regulations promulgated to
carry out title XVIII of the Social Security Act, that
the claims process provided under that title is modi-
fied to the extent required to conform to the stand-
ards established under subsection (c).
(3) 
REQUIREMENTS
OF
STATE
MEDICAID
PLANS.—As a condition for the approval of State
plans under the medicaid program, effective as of
the effective date specified in subsection (a)(3), each
such plan shall provide, in accordance with regula-
tions of the Secretary, that the claims process pro-
vided under the plan is modified to the extent re-
quired to conform to the standards established under
subsection (c).
SEC. 324. ELECTRONIC MEDICAL RECORDS AND REPORT-
ING.
(a) 
STANDARDS
FOR
ELECTRONIC
MEDICAL
RECORDS FOR HOSPITALS.—
(1) PROMULGATION OF STANDARDS.—
(A) IN GENERAL.—Between July 1, 1994,
and January 1, 1995, the Secretary shall pro-
mulgate standards described in paragraph (2)
149
for hospitals concerning electronic medical
records.
(B) REVISION.—The Secretary may from
time to time revise the standards promulgated
under this paragraph.
(2) CONTENTS OF STANDARDS.—The standards
promulgated under paragraph (1) shall include at
least the following:
(A) A definition of a uniform hospital clini-
cal data set, including a definition of the set of
comprehensive data elements, for use by utiliza-
tion and quality control peer review organiza-
tions.
(B) Standards for an electronic patient
care information system with data obtained at
the point of care.
(C) A specification of, and manner of pres-
entation of, the individual data elements of the
set and system under this paragraph.
(D) Standards concerning the transmission
of electronic medical data.
(E) Standards relating to confidentiality of
patient-specific information, which include the
physical security of electronic data and the use
of keys, passwords, encryption, and other
150
means to ensure the protection of the confiden-
tiality and privacy of electronic data.
(3) COORDINATION WITH STANDARDS FOR UNI-
FORM ELECTRONIC CLAIMS DATA SET.—In establish-
ing standards under this subsection, the Secretary
shall assure that—
(A) the development of such standards is
coordinated with the development of the stand-
ards for the uniform electronic claims data set
under section 323, and
(B) the coding of data elements under the
uniform hospital clinical data set and the cod-
ing of the same elements under the uniform
electronic claims data set are consistent.
(4) CONSULTATION.—in establishing standards
under this subsection, the Secretary shall—
(A) consult with the American National
Standards Institute, hospitals, health benefit
plans, and other interested parties, and
(B) take into consideration, in developing
standards under paragraph (2)(A), the data set
used by the utilization and quality control peer
review program under part B of title XI of the
Social Security Act.
151
(b) REQUIREMENT
FOR APPLICATION
OF ELEC-
TRONIC RECORDS STANDARDS TO HOSPITALS.—
(1) AS
CONDITION
OF
MEDICARE
PARTICIPA-
TION.—As of January 1, 1996, each hospital, as a
requirement of each participation agreement under
section 1866 of the Social Security Act, shall, in ac-
cordance with the standards promulgated under sub-
section (a)(1)—
(A) maintain clinical data included in the
uniform hospital clinical data set under sub-
section (a)(2)(A) in electronic form on all inpa-
tients,
(B) upon request of the Secretary or of a
utilization and quality control peer review orga-
nization (with which the Secretary has entered
into a contract under part B of title XI of such
Act), transmit electronically data requested
from such data set, and
(C) upon request of the Secretary, or of a
fiscal intermediary or carrier, transmit elec-
tronically any data (with respect to a claim)
from such data set.
(2) APPLICATION
OF
PRESENTATION
AND
TRANSMISSION STANDARDS TO ELECTRONIC TRANS-
MISSION TO FEDERAL AGENCIES.—Effective Janu-
152
ary 1, 1996, if a hospital is required under a Fed-
eral program to transmit a data element that is sub-
ject to a standard, promulgated under subsection
(a)(1), described in subparagraph (C) or (D) of sub-
section (a)(2), the head of the Federal agency re-
sponsible for such program (if not otherwise author-
ized) is authorized to require the provider to present
and transmit the data element electronically in ac-
cordance with such a standard.
(c) LIMITATION ON DATA REQUIREMENTS WHERE
STANDARDS IN EFFECT.—
(1) IN
GENERAL.—On or after January 1,
1996, a health benefit plan may not require, for the
purpose of utilization review or as a condition of
providing benefits or making payments under the
plan, that a hospital—
(A) provide any data element not in the
uniform hospital clinical data set specified
under the standards promulgated under sub-
section (a), or
(B) transmit or present any such data ele-
ment in a manner inconsistent with such stand-
ards applicable to such transmission or presen-
tation.
153
(2) COMPLIANCE.—The Secretary may impose
a civil money penalty on any health benefit plan that
fails to comply with paragraph (1) in an amount not
to exceed $100 for each such failure. The provisions
of section 1128A of the Social Security Act (other
than the first sentence of subsection (a) and other
than subsection (b)) shall apply to a civil money
penalty under this paragraph in the same manner as
such provisions apply to a penalty or proceeding
under section 1128A(a) of such Act.
(3) APPLICATION TO MEDICARE PROGRAM.—Ef-
fective as of January 1, 1996, neither the Secretary,
nor any carrier or fiscal intermediary, nor any utili-
zation and quality control peer review organization
may require, for the purpose of utilization review or
as a condition of providing benefits or making pay-
ments under the medicare program, that a hos-
pital—
(A) provide any data element not in the
uniform hospital clinical data set specified
under the standards promulgated under sub-
section (a), or
(B) transmit or present any such data ele-
ment in a manner inconsistent with such stand-
154
ards applicable to such transmission or presen-
tation.
(4) APPLICATION TO MEDICAID PROGRAM.—As
a condition for the approval of State plans under the
medicaid program and in accordance with regula-
tions of the Secretary, effective as of January 1,
1996, each such plan may not require that a hos-
pital, for the purpose of utilization review or as a
condition of providing benefits or making payments
under the plan—
(A) provide any data element not in the
uniform hospital clinical data set specified
under the standards promulgated under sub-
section (a), or
(B) transmit or present any such data ele-
ment in a manner inconsistent with such stand-
ards applicable to such transmission or presen-
tation.
(d) PREEMPTION OF STATE QUILL PEN LAWS.—
(1) IN GENERAL.—Any provision of State law
that requires medical or health insurance records
(including billing information) to be maintained in
written, rather than electronic, form shall be deemed
to be satisfied if the records are maintained in an
155
electronic form that meets standards established by
the Secretary under paragraph (2).
(2) SECRETARIAL AUTHORITY.—Not later than
1 year after the the date of the enactment of this
Act, the Secretary shall issue regulations to carry
out paragraph (1). The regulations shall provide for
an electronic substitute that is in the form of a
unique identifier (assigned to each authorized indi-
vidual) that serves the functional equivalent of a sig-
nature. The regulations may provide for such excep-
tions to paragraph (1) as the Secretary determines
to be necessary to prevent fraud and abuse, to pre-
vent the illegal distribution of controlled substances,
and in such other cases as the Secretary deems ap-
propriate.
(3) EFFECTIVE
DATE.—Paragraph (1) shall
take effect on the first day of the first month that
begins more than 30 days after the date the Sec-
retary issues the regulations referred to in para-
graph (2).
SEC. 325. UNIFORM HOSPITAL COST REPORTING.
Each hospital, as a requirement under a participation
agreement under section 1866(a) of the Social Security
Act for each cost reporting period beginning during or
after fiscal year 1993, shall provide for the reporting of
156
information to the Secretary with respect to any hospital
care provided in a uniform manner consistent with stand-
ards established by the Secretary to carry out section
4007(c) of the Omnibus Budget Reconciliation Act of
1987 and in an electronic form consistent with standards
established by Secretary.
SEC. 326. DEFINITIONS.
(a) HEALTH BENEFIT PLAN.—In this subtitle:
(1) IN
GENERAL.—The term ‘‘health benefit
plan’’ means, except as provided in paragraphs (2)
through (4), any public or private entity or program
that provides for payments for health care services,
including—
(A) a group health plan (as defined in sec-
tion 5000(b)(1) of the Internal Revenue Code
of 1986), and
(B) any other health insurance arrange-
ment, including any arrangement consisting of
a hospital or medical expense incurred policy or
certificate, hospital or medical service plan con-
tract, or health maintenance organization sub-
scriber contract.
Such term includes a qualified health plan under
title XXI of the Social Security Act, the public
157
health plan under title XXII of such Act, and the
medicare program under title XVIII of such Act.
(2) PLANS EXCLUDED.—Such term does not in-
clude—
(A) accident-only, credit, or disability in-
come insurance;
(B) coverage issued as a supplement to li-
ability insurance;
(C) an individual making payment on the
individual’s own behalf (or on behalf of a rel-
ative or other individual) for deductibles, coin-
surance, or services not covered under a health
benefit plan; and
(D) such other plans as the Secretary may
determine, because of the limitation of benefits
to a single type or kind of health care, such as
dental services, or other reasons should not be
subject to the requirements of this section.
(3) PLANS INCLUDED.—Such term includes—
(A) worker’s compensation or similar in-
surance, and
(B) automobile medical-payment insurance.
(4) TREATMENT OF DIRECT FEDERAL PROVI-
SION OF SERVICES.—Such term does not include a
158
Federal program that provides directly for the provi-
sion of health services to beneficiaries.
(b) HEALTH SERVICE PROVIDER.—In this subtitle,
the term ‘‘health service provider’’ includes a provider of
services (as defined in section 1861(u) of the Social Secu-
rity Act), physician, supplier, and other person furnishing
health care services.
(c) SECRETARY.—In this subtitle, the term ‘‘Sec-
retary’’ means Secretary of Health and Human Services.
Subtitle C—Malpractice Reform
SEC. 331. MALPRACTICE REFORM.
(a) STUDY BY PHYSICIAN PAYMENT REVIEW COM-
MISSION.—The Physician Payment Review Commission
shall conduct a study of—
(1) the need for reforms with respect to medical
malpractice liability claims, including the use of
practice guidelines developed by the Agency for
Health Care Policy and Research in such reforms,
and
(2) the impact of such reforms on—
(A) expenditures for health care services,
(B) access to such services,
(C) the quality of such services, and
(D) access of injured patients to the medi-
cal malpractice system.
159
(b) REPORT.—Not later than March 31, 1994, the
Commission shall submit a report to Congress on the
study conducted under subsection (a) and shall include in
the report such recommendations as the Commission con-
siders appropriate.
TITLE IV—GROUP HEALTH
INSURANCE REFORM
SEC. 401. EXCISE TAX ON PREMIUMS RECEIVED ON
HEALTH INSURANCE POLICIES WHICH DO
NOT MEET CERTAIN REQUIREMENTS.
(a) IN GENERAL.—Chapter 47 of the Internal Reve-
nue Code of 1986 (relating to taxes on group health
plans), as amended by section 101 of this Act, is further
amended by adding at the end thereof the following new
section:
‘‘SEC. 5000B. FAILURE TO SATISFY CERTAIN STANDARDS
FOR HEALTH INSURANCE.
‘‘(a) GENERAL RULE.—In the case of any person is-
suing applicable accident and health insurance contracts,
there is hereby imposed a tax on the failure of such person
to meet at any time during any taxable year the applicable
requirements of title XXIII of the Social Security Act. The
Secretary of Health and Human Services shall determine
whether any contract meets the requirements of such title.
‘‘(b) AMOUNT OF TAX.—
160
‘‘(1) IN GENERAL.—The amount of tax imposed
by subsection (a) by reason of 1 or more failures
during a taxable year shall be equal to 50 percent
of the gross premiums received during such taxable
year with respect to all accident and health insur-
ance contracts issued by the person on whom such
tax is imposed.
‘‘(2) GROSS PREMIUMS.—For purposes of para-
graph (1), gross premiums shall include any consid-
eration received with respect to any accident and
health insurance contract.
‘‘(c) LIMITATION ON TAX.—
‘‘(1) TAX NOT TO APPLY WHERE FAILURE NOT
DISCOVERED
EXERCISING
REASONABLE
DILI-
GENCE.—No tax shall be imposed by subsection (a)
with respect to any failure for which it is established
to the satisfaction of the Secretary that the person
on whom the tax is imposed did not know, and exer-
cising reasonable diligence would not have known,
that such failure existed.
‘‘(2) TAX
NOT
TO
APPLY
WHERE
FAILURES
CORRECTED WITHIN 30 DAYS.—No tax shall be im-
posed by subsection (a) with respect to any failure
if—
161
‘‘(A) such failure was due to reasonable
cause and not to willful neglect, and
‘‘(B) such failure is corrected during the
30-day period beginning on the 1st date any of
the persons on whom the tax is imposed knew,
or exercising reasonable diligence would have
known, that such failure existed.
‘‘(3) WAIVER BY SECRETARY.—In the case of a
failure which is due to reasonable cause and not to
willful neglect, the Secretary may waive part or all
of the tax imposed by subsection (a).
‘‘(d) LIABILITY FOR TAX.—The person issuing the
applicable accident and health contract with respect to
which a failure occurs shall be liable for the tax imposed
by subsection (a).
‘‘(e) DEFINITIONS.—For purposes of this section—
‘‘(1) IN GENERAL.—The term ‘applicable acci-
dent and health insurance contract’ means a con-
tract under which a person authorized under appli-
cable State insurance law provides a health insur-
ance plan or arrangement to any group consisting of
more than 2 individuals. Such term does not include
any self-insured plan of an employer and does not
include a qualified health maintenance organization
162
(as defined in section 1310(d) of the Public Health
Service Act).
‘‘(2) CERTAIN CONTRACTS NOT COVERED.—The
term ‘applicable accident and health insurance con-
tract’ does not include any contract—
‘‘(A) which provides for accident only, den-
tal only, or disability only coverage,
‘‘(B) which provides coverage as a supple-
ment to liability insurance,
‘‘(C) which provides insurance arising out
of a workmens’ compensation or similar law, or
automobile medical-payment insurance, or
‘‘(D) which provides insurance which is re-
quired by law to be contained under any self-
insured plan of an employer.’’.
(b) CLERICAL AMENDMENTS.—The table of sections
for such chapter 47 is amended by adding at the end
thereof the following new item:
‘‘Sec. 5000B. Failure to satisfy certain standards for health in-
surance.’’
SEC. 402. GROUP HEALTH INSURANCE STANDARDS.
The Social Security Act is amended by adding at the
end the following new title:
163
‘‘TITLE XXIII—GROUP HEALTH INSURANCE
STANDARDS
‘‘PART 1—GENERAL STANDARDS; DEFINITIONS
‘‘SEC. 2301. APPLICATION OF REQUIREMENTS TO EMPLOY-
MENT-RELATED HEALTH PLANS.
‘‘(a) APPROVAL BY SECRETARY REQUIRED.—
‘‘(1) IN
GENERAL.—No employment-related
health plan may be issued on or after the effective
date specified in subsection (d) (and no new contract
may be offered under such plan with respect to any
employer beginning on or after such effective date)
unless the plan has been certified by the Secretary
(in accordance with such procedures as the Sec-
retary establishes) as meeting the applicable stand-
ards established under section 2302 by such effective
date.
‘‘(2) PLAN DISAPPROVED.—If the Secretary de-
termines that an employment-related health plan
does not meet the applicable requirements of this
title on or after such effective date, no coverage may
be provided under the plan to individuals not en-
rolled as of the date of the determination and the
plan may not be continued for plan years beginning
after the date of such determination until the Sec-
164
retary determines that such plan is in compliance
with such requirements.
‘‘(b) SANCTIONS.—
‘‘(1) TAX.—For application of excise tax in the
case of a nonconforming plan, see section 5000B of
the Internal Revenue Code of 1986.
‘‘(2) NOTICE TO EMPLOYER IN THE CASE OF
INSURED PLANS.—If tax is imposed under section
5000B of the Internal Revenue Code of 1986, the
Secretary of the Treasury shall provide for notice to
be provided to each employer which meets the re-
quirement of section 2101 through coverage under
the plan of the imposition of the tax.
‘‘(3) LOSS
OF
STATUS
AS
QUALIFIED
EM-
PLOYER HEALTH PLAN.—
‘‘(A) IN GENERAL.—If an employment-re-
lated health plan is determined to be in viola-
tion of subsection (a) and is not determined to
have come into compliance with the applicable
standards within 6 months after the date of the
initial determination of such a violation, the
plan shall no longer be treated as a qualified
employer health plan under title XXI as of the
end of such 6-month period.
165
‘‘(B) NO
ENFORCEMENT
OF
INSURANCE
CONTRACTS.—In the case of an employer that
is required, under part A of title XXI, to pro-
vide enrollment under a qualified employer
health plan and that meets such requirement
through an insured plan that is determined to
be in violation of subsection (a)—
‘‘(i) if such plan is not brought into
compliance within 30 days after the date of
the violation, the employer may terminate
by notice the contract with the plan and is
not liable for payment of any additional
amounts under the plan, and
‘‘(ii) if such plan no longer qualifies
as a qualified employer health plan, such
contract shall be terminated and the em-
ployer is not liable for payment of any
amounts for periods in which the plan no
longer qualifies as a qualified employer
health plan.
‘‘(d) EFFECTIVE DATE.—The effective date specified
in this subsection is January 1, 1994.
‘‘SEC. 2302. ESTABLISHMENT OF STANDARDS.
‘‘(a) ESTABLISHMENT
OF STANDARDS.—The Sec-
retary shall develop and publish, by not later than October
166
1, 1993, specific standards to implement the requirements
of this title and to be applied under section 5000B of the
Internal Revenue Code of 1986.
‘‘(b) TELEPHONE INFORMATION SYSTEM.—The Sec-
retary shall provide for the establishment of a toll-free
telephone information and complaint system which
provides for—
‘‘(1) a system for the receipt and disposition of
consumer complaints or inquiries regarding compli-
ance of health plans with the requirements of this
title, and
‘‘(2) information to small employers about car-
riers that offer small employer health plans in the
area covered by the regulatory authority.
Such system shall provide for the recording of consumer
complaints in accordance with a uniform methodology rec-
ognized by the Secretary.
‘‘(c) APPLICATION TO ERISA.—The Secretary shall
consult with the Secretary of Labor concerning the appli-
cation of the requirements of this part to employee welfare
benefit plans under title I of the Employee Retirement In-
come Security Act of 1974.
167
‘‘SEC. 2303. REQUIREMENTS APPLICABLE TO ALL EMPLOY-
MENT-RELATED HEALTH PLANS.
‘‘(a) NO DISCRIMINATION BASED ON HEALTH STA-
TUS FOR CERTAIN SERVICES.—Except as provided under
subsection (b), an employment-related health plan may not
deny, limit, or condition the coverage under (or benefits
of) the plan with respect to required health services based
on the health status, claims experience, receipt of health
care, medical history, or lack of evidence of insurability,
of an individual.
‘‘(b) TREATMENT OF PRE-EXISTING CONDITION EX-
CLUSIONS FOR ALL SERVICES.—The provisions of section
2154(b) (relating to treatment of pre-existing condition
exclusion) shall apply to employer-related health plans
under this section in the same manner as they apply to
qualified health plans under that section.
‘‘SEC. 2304. DEFINITIONS.
‘‘(a) HEALTH PLAN AND OTHER DEFINITIONS RE-
LATING TO HEALTH PLANS.—In this title:
‘‘(1) HEALTH PLAN.—
‘‘(A) IN GENERAL.—The term ‘health plan’
means—
‘‘(i) a group health plan (as defined in
section 605 of the Employee Retirement
Income Security Act of 1974), and
168
‘‘(ii) any other health insurance ar-
rangement, including any arrangement
(other than a group health plan) consisting
of a hospital or medical expense incurred
policy or certificate, hospital or medical
service plan contract, health maintenance
organization subscriber contract;
but does not include a qualified health mainte-
nance organization (as defined in section
1310(d) of the Public Health Service Act).
‘‘(B) EXCLUSIONS.—
‘‘(i) 
CERTAIN
TYPES
OF
INSUR-
ANCE.—Such term does not include—
‘‘(I) accident-only, credit, or dis-
ability income insurance,
‘‘(II) coverage issued as a supple-
ment to liability insurance,
‘‘(III) worker’s compensation or
similar insurance, or
‘‘(IV) automobile medical-pay-
ment insurance.
‘‘(ii) PUBLIC
HEALTH
PLAN.—Such
term does not include the public health
plan under title XXII.
169
‘‘(2) EMPLOYMENT-RELATED HEALTH PLAN.—
The term ‘employment-related health plan’ means
any employee welfare benefit plan (as defined in sec-
tion 3(1) of the Employee Retirement Income Secu-
rity Act of 1974) that is a health plan.
‘‘(3) INSURED EMPLOYMENT-RELATED HEALTH
PLAN.—The 
term 
‘insured 
employment-related
health plan’ means an employment-related health
plan that has been provided by a person authorized
under applicable State insurance law, and does not
include any self-insured employment-related health
plan.
‘‘(4) 
SELF-INSURED
EMPLOYMENT-RELATED
HEALTH PLAN.—The term ‘self-insured employment-
related health plan’ means an employment-related
health plan in which the employer or employment-re-
lated group assumes the underwriting risk for the
plan (whether or not there is any reinsurance or
similar mechanism to underwrite a portion of that
risk).
‘‘(5) SMALL
EMPLOYER
HEALTH
PLAN.—The
term ‘small employer health plan’ means an employ-
ment-related health plan insofar as it offers benefits
with respect to any small employer, as defined in
171
‘‘(c) GENERAL DEFINITIONS.—In this part:
‘‘(1) COMMUNITY.—The term ‘community’ has
the meaning given such term in section 2131(e).
‘‘(2) FULL-TIME EMPLOYEE.—The term ‘full-
time employee’ has the meaning given such term in
section 2181(b)(1).
‘‘(3) REFERENCE PREMIUM RATE.—The term
‘reference premium rate’ means, for a rating period
in a community, the lowest premium rate charged or
which could have been charged by the small em-
ployer carrier to small employers under a rating sys-
tem in the community for health plans with the
same or similar coverage. The reference premium
rate is determined without regard to any adjustment
for age or sex described in section 2312(c).
‘‘(4) SMALL EMPLOYER.—The term ‘small em-
ployer’ has the meaning given such term in section
2181(c)(1) and also includes a medium-size em-
ployer (as defined in section 2181(c)(2)).
‘‘(5) STATE.—The term ‘State’ means the 50
States and the District of Columbia.
‘‘SEC. 2305. NOTICE OF PLANS MEETINGS REQUIREMENTS.
‘‘The Secretary of Health and Human Services shall
publish periodically the names and issuers of insured em-
ployment-related small employer health plans that have
172
been found to meet the applicable requirements of this
title.
‘‘PART 2—SMALL EMPLOYER HEALTH INSURANCE
REFORM
‘‘SEC. 2311. ENROLLMENT PRACTICE AND GUARANTEED RE-
NEWABILITY REQUIREMENTS FOR SMALL EM-
PLOYER HEALTH PLANS.
‘‘(a) REGISTRATION.—
‘‘(1) IN GENERAL.—Each small employer car-
rier (as defined in section 2304(b)(5)) shall register
with the Secretary.
‘‘(2) NO PREEMPTION OF STATE INFORMATION
REQUIREMENTS.—Nothing in paragraph (1) shall be
construed as preventing the applicable regulatory
authority in a State from requiring, in the case of
carriers that are not self-insurance carriers, such ad-
ditional information in conjunction with, or apart
from, the registration required under paragraph (1)
as the applicable regulatory authority may be au-
thorized to require under State law.
‘‘(b) GUARANTEED ISSUE.—
‘‘(1) IN GENERAL.—Subject to the succeeding
provisions of this subsection, a carrier that offers a
health plan to small employers located in a commu-
nity must offer the same plan to any other small
173
employer located in the community. Such require-
ment shall apply on a continuous, year-round basis.
‘‘(2) TREATMENT
OF
HEALTH
MAINTENANCE
ORGANIZATIONS.—
‘‘(A) 
GEOGRAPHIC
LIMITATIONS.—A
health maintenance organization may deny en-
rollment to employees (and family members) of
a small employer if the employees are located
outside the service area of the organization, but
only if such denial is applied uniformly without
regard to health status or insurability.
‘‘(B) SIZE LIMITS.—A health maintenance
organization may apply to the Secretary to
cease enrolling new small employer groups in its
small employer health plan (or in a geographic
area served by the plan) if—
‘‘(i) it ceases to enroll any new em-
ployer groups, and
‘‘(ii) it can demonstrate that its finan-
cial or administrative capacity to serve pre-
viously enrolled groups and individuals
(and additional individuals who will be ex-
pected to enroll because of affiliation with
such previously enrolled groups) will be im-
174
paired if it is required to enroll new em-
ployer groups.
‘‘(3) GROUNDS
FOR
REFUSAL
TO
ISSUE
OR
RENEW.—A carrier may refuse to issue or renew or
terminate a plan only for—
‘‘(A) nonpayment of premiums, and
‘‘(B) fraud or misrepresentation.
‘‘(c) MINIMUM PLAN PERIOD.—A carrier may not
offer to, or issue with respect to, a small employer a small
employer health plan with a term of less than 12 months.
‘‘(d) NOTICES AND RENEWAL PERIODS.—
‘‘(1) NOTICE
AND
SPECIFICATION
OF
RATES
AND ADMINISTRATIVE CHANGES.—
‘‘(A) NOTICE.—The small employer carrier
of a small employer health plan shall provide
for notice, at least 30 days before the date of
expiration of the health plan, of the terms for
renewal of the plan. Except with respect to
rates and administrative changes, the terms of
renewal (including benefits) shall be the same
as the terms of issuance.
‘‘(B) RENEWAL RATES SAME AS ISSUANCE
RATES.—The carrier may change the terms for
such renewal, but the premium rates charged
175
with respect to such renewal shall be the same
as that for a new issue.
‘‘(2) PERIOD OF RENEWAL.—The period of re-
newal of each small employer health plan shall be for
a period of not less than 12 months.
‘‘SEC. 2312. RATING PRACTICES FOR SMALL EMPLOYER
HEALTH PLANS.
‘‘(a) COHESIVE RATING SYSTEM AND ACTUARIAL
CERTIFICATION.—
‘‘(1) IN GENERAL.—The premiums (including
reference premium rate, as defined in section
2304(c)(3)) and age-sex adjustments under sub-
section (c) for all small employer health plans of the
same entity shall—
‘‘(A) be established based on a single cohe-
sive rating system which is applied consistently
for all employer groups and is designed not to
treat groups, after January 1, 1994, differently
based on health status or risk status; and
‘‘(B) be actuarially certified annually.
‘‘(2) ACTUARIAL
CERTIFIED
DEFINED.—For
purposes of paragraph (1)(B), a plan is considered
to be ‘actuarially certified’ if there is a written state-
ment, by a member of the American Academy of Ac-
tuaries or other individual acceptable to the Sec-
176
retary that a small employer carrier is in compliance
with this section, based upon the individual’s exam-
ination, including a review of the appropriate records
and of the actuarial assumptions and methods uti-
lized by the carrier in establishing premium rates for
applicable health plans.
‘‘(b) USE OF COMMUNITY-RATED REFERENCE PRE-
MIUM RATES.—The reference premium rate charged for
a small employer health plan with similar benefits in a
community for a type of family enrollment (described in
subsection (d)) shall be the same for all small employers.
‘‘(c) AGE AND SEX ADJUSTMENT TO COMMUNITY-
RATING.—
‘‘(1) IN GENERAL.—Subject to paragraph (2), a
small employer health plan may provide for an ad-
justment to the reference premium rate based on
age and gender of covered individuals. Any such ad-
justment shall be applied consistently to all small
employers.
‘‘(2) LIMITATION ON ADJUSTMENT.—The ad-
justment under paragraph (1) may not result, with
respect to small employer health plans with similar
benefits in a community, in a premium rate for the
most expensive age-sex group exceeding 133 percent
177
of the premium rate for the least expensive age-sex
group.
‘‘(d) TYPES OF FAMILY ENROLLMENT.—
‘‘(1) IN GENERAL.—Each small employer health
plan shall permit enrollment of (and shall compute
premiums separately for) individuals based on each
of the following beneficiary classes:
‘‘(A) 1 adult.
‘‘(B) A married couple without children.
‘‘(C) A married couple with 1 or more chil-
dren, or 1 adult with 1 or more children.
‘‘(2) APPLICATION OF DEFINITIONS.—The defi-
nitions in section 2282 shall apply for purposes of
this subsection.
‘‘SEC. 2313. BASIC BENEFIT PACKAGE FOR SMALL EM-
PLOYER HEALTH PLANS.
‘‘(a) BENEFITS AND COST-SHARING IN QUALIFIED
EMPLOYER HEALTH PLANS.—Except as provided in sub-
section (b), no small employer health plan may be issued
to a small employer by a carrier unless—
‘‘(1) the plan provides for benefits for all re-
quired health services (as defined in section
2211(a)(2));
‘‘(2) the plan does not impose cost-sharing with
respect to required health services in excess of the
178
deductibles and coinsurance permitted under title
XXII with respect to such services (not taking into
account any low-income assistance under part E of
such title); and
‘‘(3) the carrier makes available to the employer
a small employer health plan that, subject to sub-
section (b), only provides the benefits for required
health services and the maximum cost-sharing con-
sistent with paragraphs (1) and (2).
‘‘(b) EXCEPTIONS FOR HMO’S.—Subsection (a)(3)
shall not apply to the plan of a health maintenance organi-
zation.
‘‘SEC. 2314. MISCELLANEOUS DISCLOSURE AND RECORD-
KEEPING REQUIREMENTS FOR SMALL EM-
PLOYER HEALTH PLANS.
‘‘(a) DISCLOSURE TO EMPLOYERS.—
‘‘(1) GENERAL DISCLOSURE.—Each small em-
ployer carrier shall disclose to each small employer
before issuing a small employer health plan the fol-
lowing:
‘‘(A) The availability (pursuant to the re-
quirement of section 2313(a)(3) of a plan in-
cluding only basic benefits.
179
‘‘(B) The limits, imposed under section
2312, on the premiums permitted to be charged
for such plans.
‘‘(C) The rights of guaranteed issue pro-
vided under section 2311.
Such disclosure shall be in addition to any disclosure
required generally of qualified health plans under
section 2158(a).
‘‘(2) 
STANDARD
FORMAT.—The 
disclosure
under paragraph (1) shall be made in a uniform for-
mat established by the Secretary.
‘‘(b) INFORMATION FILED.—
‘‘(1) IN GENERAL.—Each small employer car-
rier shall disclose to the Secretary, in a manner
specified by the Secretary, information concerning
applicable premiums for small employer health
plans.
‘‘(2) ADDITIONAL
INFORMATION.—Nothing in
this subsection shall be construed as limiting the in-
formation which a State may require to be reported
by small employer carriers (other than self-insured
carriers).
‘‘SEC. 2315. PAYMENT OF COMMISSIONS.
‘‘A small employer carrier may not vary the remu-
neration paid a broker for the sale or renewal of any small
180
employer health plan based, directly or indirectly, on the
claims experience associated with the group to which the
plan was sold.
‘‘SEC. 2316. NONAPPLICATION IN PUERTO RICO AND THE
TERRITORIES.
‘‘This part shall not apply outside the 50 States or
the District of Columbia.’’.
TITLE V—CHANGES IN
MEDICARE PROGRAM
SEC. 501. COVERAGE OF COLORECTAL SCREENING.
(a) IN GENERAL.—Section 1834 of the Social Secu-
rity Act (42 U.S.C. 1395m), as amended by section
4163(b)(2) of the Omnibus Budget Reconciliation Act of
1990 (in this title referred to as ‘‘OBRA–1990’’), is
amended by inserting after subsection (c) the following
new subsection:
‘‘(d) FREQUENCY
AND
PAYMENT
LIMITS
FOR
SCREENING FECAL-OCCULT BLOOD TESTS AND SCREEN-
ING FLEXIBLE SIGMOIDOSCOPIES.—
‘‘(1) 
SCREENING
FECAL-OCCULT
BLOOD
TESTS.—
‘‘(A) PAYMENT LIMIT.—In establishing fee
schedules under section 1833(h) with respect to
screening fecal-occult blood tests provided for
the purpose of early detection of colon cancer,
181
except as provided by the Secretary under para-
graph (3)(A), the payment amount established
for tests performed—
‘‘(i) in 1994 shall not exceed $5; and
‘‘(ii) in a subsequent year, shall not
exceed the limit on the payment amount
established under this subsection for such
tests for the preceding year, adjusted by
the applicable adjustment under section
1833(h) for tests performed in such year.
‘‘(B) FREQUENCY LIMIT.—Subject to revi-
sion by the Secretary under paragraph (3)(B),
no payment may be made under this part for
a screening fecal-occult blood test provided to
an individual for the purpose of early detection
of colon cancer—
‘‘(i) if the individual is under 50 years
of age; or
‘‘(ii) if the test is performed within
the 11 months after a previous screening
fecal-occult blood test.
‘‘(2) 
SCREENING
FLEXIBLE
SIGMOIDOS-
COPIES.—
‘‘(A) PAYMENT AMOUNT.—The Secretary
shall establish a payment amount under section
182
1848 
with 
respect 
to 
screening 
flexible
sigmoidoscopies provided for the purpose of
early detection of colon cancer that is consistent
with payment amounts under such section for
similar or related services, except that such
payment amount shall be established without
regard to subsection (a)(2)(A) of such section.
‘‘(B) FREQUENCY LIMIT.—Subject to revi-
sion by the Secretary under paragraph (3)(B),
no payment may be made under this part for
a screening flexible sigmoidoscopy provided to
an individual for the purpose of early detection
of colon cancer—
‘‘(i) if the individual is under 50 years
of age; or
‘‘(ii) if the procedure is performed
within the 59 months after a previous
screening flexible sigmoidoscopy.
‘‘(3) REDUCTIONS IN PAYMENT LIMIT AND RE-
VISION OF FREQUENCY.—
‘‘(A) REDUCTIONS IN PAYMENT LIMIT.—
The Secretary shall review from time to time
the appropriateness of the amount of the pay-
ment limit established for screening fecal-occult
blood tests under paragraph (1)(A). The Sec-
183
retary may, with respect to tests performed in
a year after 1996, reduce the amount of such
limit as it applies nationally or in any area to
the amount that the Secretary estimates is re-
quired to assure that such tests of an appro-
priate quality are readily and conveniently
available during the year.
‘‘(B) REVISION OF FREQUENCY.—
‘‘(i) REVIEW.—The Secretary, in con-
sultation with the Director of the National
Cancer Institute, shall review periodically
the appropriate frequency for performing
screening fecal-occult blood tests and
screening flexible sigmoidoscopies based on
age and such other factors as the Sec-
retary believes to be pertinent.
‘‘(ii) REVISION OF FREQUENCY.—The
Secretary, taking into consideration the re-
view made under clause (i), may revise
from time to time the frequency with
which such tests and procedures may be
paid for under this subsection, but no such
revision shall apply to tests or procedures
performed before January 1, 1997.
184
‘‘(4) LIMITING CHARGES OF NONPARTICIPATING
PHYSICIANS.—
‘‘(A) IN
GENERAL.—In the case of a
screening flexible sigmoidoscopy provided to an
individual for the purpose of early detection of
colon cancer for which payment may be made
under this part, if a nonparticipating physician
provides the procedure to an individual enrolled
under this part, the physician may not charge
the individual more than the limiting charge (as
defined in subparagraph (B), or, if less, as de-
fined in section 1848(g)(2)).
‘‘(B) LIMITING
CHARGE
DEFINED.—In
subparagraph (A), the term ‘limiting charge’
means, 115 percent of the payment limit estab-
lished under paragraph (2)(A).
‘‘(C) ENFORCEMENT.—If a physician or
supplier knowingly and willfully imposes a
charge in violation of subparagraph (A), the
Secretary may apply sanctions against such
physician or supplier in accordance with section
1842(j)(2).’’.
(b) CONFORMING AMENDMENTS.—(1) Paragraphs
(1)(D) and (2)(D) of section 1833(a) of such Act (42
U.S.C. 1395l(a)) are each amended by striking ‘‘sub-
185
section (h)(1),’’ and inserting ‘‘subsection (h)(1) or section
1834(d)(1),’’.
(2) Section 1833(h)(1)(A) of such Act (42 U.S.C.
1395l(h)(1)(A)) is amended by striking ‘‘The Secretary’’
and inserting ‘‘Subject to paragraphs (1) and (3)(A) of
section 1834(d), the Secretary’’.
(3) Clauses (i) and (ii) of section 1848(a)(2)(A) of
such Act (42 U.S.C. 1395w–4(a)(2)(A)) are each amended
by striking ‘‘a service’’ and inserting ‘‘a service (other
than a screening flexible sigmoidoscopy provided to an
individual for the purpose of early detection of colon
cancer)’’.
(4) Section 1862(a) of such Act (42 U.S.C. 1395y(a))
is amended—
(A) in paragraph (1)—
(i) in subparagraph (E), by striking ‘‘and’’
at the end,
(ii) in subparagraph (F), by striking the
semicolon at the end and inserting ‘‘, and’’, and
(iii) by adding at the end the following new
subparagraph:
‘‘(G) in the case of screening fecal-occult blood
tests and screening flexible sigmoidoscopies provided
for the purpose of early detection of colon cancer,
186
which are performed more frequently than is covered
under section 1834(d);’’; and
(B) in paragraph (7), by striking ‘‘paragraph
(1)(B) or under paragraph (1)(F)’’ and inserting
‘‘subparagraphs (B), (F), or (G) of paragraph (1)’’.
(c) EFFECTIVE DATE.—The amendments made by
this section shall apply to screening fecal-occult blood tests
and screening flexible sigmoidoscopies performed on or
after January 1, 1994.
SEC. 502. COVERAGE OF CERTAIN IMMUNIZATIONS.
(a) IN GENERAL.—Section 1861(s)(10) of the Social
Security Act (42 U.S.C. 1395x(s)(10)) is amended—
(1) in subparagraph (A)—
(A) by striking ‘‘, subject to section
4071(b) of the Omnibus Budget Reconciliation
Act of 1987,’’, and
(B) by striking ‘‘; and’’ and inserting a
comma;
(2) in subparagraph (B), by striking the semi-
colon at the end and inserting ‘‘, and’’; and
(3) by adding at the end the following new sub-
paragraph:
‘‘(C) tetanus-diphtheria booster and its admin-
istration;’’.
187
(b) 
LIMITATION
ON
FREQUENCY.—Section
1862(a)(1) of such Act (42 U.S.C. 1395y(a)(1)), as
amended by section 502(b)(4)(A), is amended—
(1) in subparagraph (F), by striking ‘‘and’’ at
the end;
(2) in subparagraph (G), by striking the semi-
colon at the end and inserting ‘‘, and’’; and
(3) by adding at the end the following new sub-
paragraph:
‘‘(H) in the case of an influenza vaccine, which
is administered within the 11 months after a pre-
vious influenza vaccine, and, in the case of a teta-
nus-diphtheria booster, which is administered within
the 119 months after a previous tetanus-diphtheria
booster;’’.
(c) CONFORMING AMENDMENT.—Section 1862(a)(7)
of such Act (42 U.S.C. 1395y(a)(7)), as amended by sec-
tion 502(b)(4)(B), is amended by striking ‘‘or (G)’’ and
inserting ‘‘(G), or (H)’’.
(d) EFFECTIVE DATE.—The amendments made by
this section shall apply to influenza vaccines and tetanus-
diphtheria boosters administered on or after January 1,
1994.
188
SEC. 503. COVERAGE OF WELL-CHILD CARE.
(a) IN GENERAL.—Section 1861(s)(2) of the Social
Security Act (42 U.S.C. 1395x(s)(2)), as amended by sec-
tion 4201(d)(1) of OBRA–1990, is amended—
(1) by striking ‘‘and’’ at the end of subpara-
graph (O);
(2) by striking the semicolon at the end of sub-
paragraph (P) and inserting ‘‘; and’’; and
(3) by adding at the end the following new sub-
paragraph:
‘‘(Q) well-child services (as defined in sub-
section (ll)(1)) provided to an individual entitled to
benefits under this title who is under 19 years of
age;’’.
(b) SERVICES DEFINED.—Section 1861 of such Act
(42 U.S.C. 1395x) is amended—
(1) by redesignating the subsection (jj) added
by section 4163(a)(2) of OBRA–1990 as subsection
(kk); and
(2) by inserting after subsection (kk) (as so re-
designated) the following new subsection:
‘‘well-child services
‘‘(ll)(1) The term ‘well-child services’ means well-
child care, including routine office visits, routine immuni-
zations (including the vaccine itself), routine laboratory
tests, and preventive dental care, provided in accordance
189
with the periodicity schedule established with respect to
the services under paragraph (2).
‘‘(2) The Secretary, in consultation with the Amer-
ican Academy of Pediatrics, the Advisory Committee on
Immunization Practices, and other entities considered ap-
propriate by the Secretary, shall establish a schedule of
periodicity which reflects the appropriate frequency with
which the services referred to in paragraph (1) should be
provided to healthy children.’’.
(c) 
CONFORMING
AMENDMENTS.—(1) 
Section
1862(a)(1) of such Act (42 U.S.C. 1395y(a)(1)), as
amended by sections 502(b)(4)(A) and 503(b), is amend-
ed—
(A) in subparagraph (G), by striking ‘‘and’’ at
the end;
(B) in subparagraph (H), by striking the semi-
colon at the end and inserting ‘‘, and’’; and
(C) by adding at the end the following new sub-
paragraph:
‘‘(I) in the case of well-child services, which are
provided more frequently than is provided under the
schedule of periodicity established by the Secretary
under section 1861(ll)(2) for such services;’’.
(2) Section 1862(a)(7) of such Act (42 U.S.C.
1395y(a)(7)), as amended by sections 502(b)(4)(B) and
190
503(c), is amended by striking ‘‘or (H)’’ and inserting
‘‘(H), or (I)’’.
(d) EFFECTIVE DATE.—The amendments made by
this section shall apply to well-child services provided on
or after January 1, 1994.
SEC. 504. ANNUAL SCREENING MAMMOGRAPHY.
(a) 
ANNUAL
SCREENING
MAMMOGRAPHY
FOR
WOMEN OVER AGE 64.—Section 1834(c)(2)(A) of the So-
cial Security Act (42 U.S.C. 1395m(b)(2)(A)), as added
by section 4163(b)(2) of OBRA–1990, is amended—
(1) in clause (iv), by striking ‘‘but under 65
years of age,’’; and
(2) by striking clause (v).
(b) EFFECTIVE DATE.—The amendments made by
subsection (a) shall apply to screening mammography per-
formed on or after January 1, 1994.
SEC. 505. DEMONSTRATION PROJECTS FOR COVERAGE OF
OTHER PREVENTIVE SERVICES.
(a) ESTABLISHMENT.—The Secretary of Health and
Human Services (in this title referred to as the ‘‘Sec-
retary’’) shall establish and provide for the conduct of a
series of ongoing demonstration projects under which the
Secretary shall provide for coverage of the preventive serv-
ices described in subsection (c) under the medicare pro-
gram in order to determine—
191
(1) the feasibility and desirability of expanding
coverage of medical and other health services under
the medicare program to include coverage of such
services for all individuals enrolled under part B of
title XVIII of the Social Security Act; and
(2) appropriate methods for the delivery of
those services to medicare beneficiaries.
(b) SITES FOR PROJECT.—The Secretary shall pro-
vide for the conduct of the demonstration projects estab-
lished under subsection (a) at the sites at which the Sec-
retary conducts the demonstration program established
under section 9314 of the Consolidated Omnibus Budget
Reconciliation Act of 1985 and at such other sites as the
Secretary considers appropriate.
(c) SERVICES COVERED UNDER PROJECTS.—The
Secretary shall cover the following services under the se-
ries 
of 
demonstration 
projects 
established 
under
subsection (a):
(1) Glaucoma screening.
(2) Cholesterol screening and cholesterol-reduc-
ing drug therapies.
(3) Screening and treatment for osteoporosis,
including tests for bone-marrow density and hor-
mone replacement therapy.
192
(4) Screening services for pregnant women, in-
cluding ultra-sound and clamydial testing and ma-
ternal serum alfa-protein.
(5) One-time comprehensive assessment for in-
dividuals beginning at age 65 or 75.
(6) Other services considered appropriate by the
Secretary.
(d) REPORTS TO CONGRESS.—Not later than October
1, 1995, and every 2 years thereafter, the Secretary shall
submit a report to the Committee on Finance of the Sen-
ate and the Committee on Ways and Means and the Com-
mittee on Energy and Commerce of the House of Rep-
resentatives describing findings made under the dem-
onstration projects conducted pursuant to subsection (a)
during the preceding 2-year period and the Secretary’s
plans for the demonstration projects during the succeeding
2-year period.
(e) AUTHORIZATION
OF APPROPRIATIONS.—There
are authorized to be appropriated from the Federal Sup-
plementary Medical Insurance Trust Fund for expenses
incurred in carrying out the series of demonstration
projects established under subsection (a) the following
amounts:
(1) $4,000,000 for fiscal year 1994.
(2) $4,000,000 for fiscal year 1995.
193
(3) $5,000,000 for fiscal year 1996.
(4) $5,000,000 for fiscal year 1997.
(5) $6,000,000 for fiscal year 1998.
SEC. 506. OTA STUDY OF PROCESS FOR REVIEW OF MEDI-
CARE COVERAGE OF PREVENTIVE SERVICES.
(a) STUDY.—The Director of the Office of Tech-
nology Assessment (in this section referred to as the ‘‘Di-
rector’’) shall, subject to the approval of the Technology
Assessment Board, conduct a study to develop a process
for the regular review for the consideration of coverage
of preventive services under the medicare program, and
shall include in such study a consideration of different
types of evaluations, the use of demonstration projects to
obtain data and experience, and the types of measures,
outcomes, and criteria that should be used in making cov-
erage decisions.
(b) REPORT.—Not later than 2 years after the date
of the enactment of this Act, the Director shall submit
a report to the Committee on Finance of the Senate and
the Committee on Ways and Means and the Committee
on Energy and Commerce of the House of Representatives
on the study conducted under subsection (a).
194
SEC. 507. PHASED-IN REQUIREMENT OF PART B ENROLL-
MENT.
(a) IN GENERAL.—Section 1811 of the Social Secu-
rity Act (42 U.S.C. 1395c) is amended by inserting ‘‘(a)’’
after ‘‘1811.’’ and by adding at the end the following new
subsection:
‘‘(b) Notwithstanding sections 226 and 226A and any
other provision of this title, effective for services furnished
on or after January 1, 1997, payment may not be made
under this part for items and services during any period
in which the individual is not enrolled under part B or
under a qualified employer health plan (as defined in sec-
tion 2121(a)). For purposes of the previous sentence, enti-
tlement to benefits under this part (but for this sub-
section) shall not be considered enrollment in a qualified
health plan.’’.
(b) CLARIFICATION OF COVERAGE PERIOD.—Section
1838(b) of such Act (42 U.S.C. 1395q(b)) is amended to
read as follows:
‘‘(b)(1) An individual’s coverage period shall continue
until the individual’s enrollment is terminated by the filing
of notice that the individual—
‘‘(A) no longer wishes to participate in the in-
surance program established by this part,
‘‘(B) is covered under a qualified health plan,
and
195
‘‘(C) has notified the plan that the individual is
entitled to benefits under part A of this title.
‘‘(2) The termination of coverage under paragraph
(1) shall take effect at the close of the month following
the month in which the notice is filed.
‘‘(3) Such termination shall no longer be effective at
such time as the individual is eligible to be enrolled under
this part and is no longer covered under a qualified health
plan.’’.
(c) ELIMINATION
OF LATE ENROLLMENT PEN-
ALTIES.—
(1) IN GENERAL.—Section 1839 of such Act
(42 U.S.C. 1395r) is amended by striking subsection
(b).
(2) CONFORMING AMENDMENTS.—(A) Section
1839(a)(2) of such Act (42 U.S.C. 1395r(a)(2)) is
amended—
(i) in subsection (a)(2), by striking ‘‘sub-
sections (b) and (e)’’ and inserting ‘‘subsection
(e)’’, and
(ii) by striking subsection (d).
(B) Section 1843(d)(1) of such Act (42 U.S.C.
1395v(d)(1)) is amended by striking ‘‘(without any
increase under subsection (b) thereof)’’.
208
(1) changing the eligibility of individuals for
medical assistance under title XIX of the Social Se-
curity Act, or
(2) subject to the amendments made by sub-
section (a), changing the amount, duration, or scope
of medical assistance required (or permitted) to be
provided under such title.
Æ
HR 1398 IH——2
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