[Congressional Bills 104th Congress]
[From the U.S. Government Publishing Office]
[H.R. 3013 Introduced in House (IH)]







104th CONGRESS
  2d Session
                                H. R. 3013

  To increase the availability and continuity of health coverage for 
individuals, small employers, and other groups, to reduce paperwork and 
 simplify administration of health care claims, and for other purposes.


_______________________________________________________________________


                    IN THE HOUSE OF REPRESENTATIVES

                             March 5, 1996

   Mr. Ney introduced the following bill; which was referred to the 
 Committee on Commerce, and in addition to the Committees on Economic 
 and Educational Opportunities and Ways and Means, for a period to be 
subsequently determined by the Speaker, in each case for consideration 
  of such provisions as fall within the jurisdiction of the committee 
                               concerned

_______________________________________________________________________

                                 A BILL


 
  To increase the availability and continuity of health coverage for 
individuals, small employers, and other groups, to reduce paperwork and 
 simplify administration of health care claims, and for other purposes.

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

SECTION 1. SHORT TITLE; TABLE OF CONTENTS.

    (a) Short Title.--This Act may be cited as the ``Insurance and 
Health Care Reform Act of 1995''.
    (b) Table of Contents.--The table of contents of this Act is as 
follows:

Sec. 1. Short title; table of contents.
                   TITLE I--HEALTH INSURANCE REFORMS

       Subtitle A--Improving Access to and Continuity of Coverage

Sec. 101. Limitation on pre-existing conditions provisions in the small 
                            employer market.
Sec. 102. Assurance of continuity of coverage through previous 
                            satisfaction of pre-existing condition 
                            requirement.
Sec. 103. Requirements relating to renewability generally.
Sec. 104. Limits on premiums and other rating practices in the small 
                            employer market.
Sec. 105. Small employer purchasing groups.
           Subtitle B--Open Enrollment and Related Practices

Sec. 111. Enrollment guidelines.
 Subtitle C--Preemption of State Mandated Benefits, Anti-managed Care 
                  Laws, and State Insurance Standards

Sec. 121. Preemption from State mandated benefits.
Sec. 122. Preemption of State law restrictions on managed care 
                            arrangements.
Sec. 123. Preemption of State insurance standards.
               Subtitle D--Administrative Simplification

Sec. 131. Adoption of data elements, uniform claims, and uniform 
                            electronic transmission standards.
Sec. 132. Application of standards.
Sec. 133. Periodic review and revision of standards.
        Subtitle E--Restriction on Genetic Screening and Testing

Sec. 141. Genetic screening and testing restrictions in health 
                            insurance.
                  Subtitle F--Administrative Expenses

Sec. 151. Limitation on administrative expenses.
               Subtitle G--Limitations on Balance Billing

Sec. 161. Medicare program.
Sec. 162. Other programs.
              Subtitle H--Enforcement; General Definitions

Sec. 171. General enforcement.
Sec. 172. General definitions.
            TITLE II--EXTENSION OF PREVENTIVE PUBLIC HEALTH

Sec. 201. Immunizations against vaccine-preventable diseases.
Sec. 202. Prevention, control, and elimination of tuberculosis.
Sec. 203. Lead poisoning prevention.
                       TITLE III--TAX PROVISIONS

Sec. 301. Increased deduction for health insurance costs of self-
                            employed individuals.
Sec. 302. Safe harbor for health care providers otherwise exempt under 
                            501(c)(3) or (4) which affiliate with 
                            certain health entities.

                   TITLE I--HEALTH INSURANCE REFORMS

       Subtitle A--Improving Access to and Continuity of Coverage

SEC. 101. LIMITATION ON PRE-EXISTING CONDITIONS PROVISIONS IN THE SMALL 
              EMPLOYER MARKET.

    (a) In General.--An insurer may impose a pre-existing conditions 
provision (as defined in subsection (b)) with respect to an individual 
under a health benefit plan covering small employers only if--
            (1) the limitation or exclusion does not extend for a 
        period beyond 12 months following the individual's effective 
        date of coverage under the plan and only relates to conditions 
        during the six months immediately preceding the effective date 
        of coverage; and
            (2) the limitation or exclusion does not apply to an 
        individual who, as of the date of birth, was covered under the 
        plan.
    (b) Pre-existing Conditions Provision Defined.--In this title, the 
term ``pre-existing conditions provision'' means a policy provision 
that excludes or limits coverage for charges or expenses incurred 
during a specified period following the insured's effective date of 
coverage as to a condition which, during a specified period immediately 
preceding the effective date of coverage, had manifested itself in such 
a manner as would cause an ordinarily prudent person to seek medical 
advice, diagnosis, care, or treatment or for which medical advice, 
diagnosis, care or treatment was recommended or received, or a 
pregnancy existing on the effective date of coverage.

SEC. 102. ASSURANCE OF CONTINUITY OF COVERAGE THROUGH PREVIOUS 
              SATISFACTION OF PRE-EXISTING CONDITION REQUIREMENT.

    (a) In General.--In determining whether a pre-existing conditions 
provision applies to an eligible employee or dependent covered under 
any health benefit plan, the plan shall credit the time the person was 
covered under a previous health benefit plan if the previous coverage 
was continuous to a date not more than 30 days prior to the effective 
date of the new coverage, exclusive of any applicable service waiting 
period under the plan.
    (b) Treatment of Waiting Periods.--In applying subsection (a), any 
waiting period, which may not exceed 90 days, imposed by an employer 
before an employee is eligible to be covered under a plan shall be 
treated as a period in which the employee was covered under a health 
benefit plan.

SEC. 103. REQUIREMENTS RELATING TO RENEWABILITY GENERALLY.

    (a) Multiple Employer Welfare Arrangements.--A multiple employer 
welfare arrangement may not cancel coverage or deny renewal of coverage 
under such a plan with respect to an employer other than--
            (1) for nonpayment of contributions;
            (2) for fraud or other misrepresentation by the employer;
            (3) for noncompliance with plan provisions; and
            (4) because the plan is ceasing to provide any coverage in 
        a geographic area.
    (b) Insurers.--An insurer may not cancel a health benefit plan or 
deny renewal of coverage under such a plan other than--
            (1) for nonpayment of premiums;
            (2) for fraud or other misrepresentation by the insured;
            (3) for noncompliance with plan provisions;
            (4) in the case of a plan issued to a small employer, for 
        failure to maintain minimum participation rates (consistent 
        with subsection (d)); or
            (5) because the insurer is ceasing to provide any health 
        benefit plan in a State, or, in the case of an HMO, in a 
        geographic area.
    (c) Limitation on Market Re-entry.--If an insurer ceases to offer 
health benefit plans to employers in a geographic area, the insurer may 
not offer such a health benefit plan to any employer in the geographic 
area until 5 years after the date of the termination.
    (d) Minimum Participation Rates.--An insurer may require, with 
respect to a health benefit plan issued to a small employer, that a 
minimum percentage of eligible employees who do not otherwise have 
health insurance are enrolled in such plan if such percentage is 
applied uniformly to all plans offered to employers of comparable size.
    (e) Underwriting and Selective Exclusion.--
            (1) In general.--Except as provided in this subsection, an 
        insurer may underwrite and rate small employer groups using 
        accepted underwriting and actuarial practices.
            (2) Prohibition of health status underwriting.--Subject to 
        paragraph (3), an insurer shall not exclude any eligible 
        employee or dependent, who would otherwise be covered under a 
        health benefit plan offered by the insurer, on the basis of any 
        actual or expected health condition of the employee or 
        dependent.
            (3) Exclusion of late enrollees.--With respect to an 
        individual who is a late enrollee (as defined in paragraph 
        (4)), an insurer--
                    (A) may exclude the individual for a period of up 
                to 24 months or may, in the discretion of the insurer, 
                extend coverage to the individual at any time during 
                that period, and
                    (B) may medically underwrite the individual.
            (4) Late enrollee.--In this title, the term ``late 
        enrollee'' means an eligible employee or dependent who requests 
        enrollment in a small employer's health benefit plan following 
        the initial enrollment period provided under the terms of the 
        first plan for which the employee or dependent was eligible 
        through the small employer, unless any of the following apply:
                    (A) The individual--
                            (i) was covered under another employer-
                        provided health benefit plan at the time the 
                        individual was eligible to enroll;
                            (ii) states, at the time of the initial 
                        eligibility, that coverage under another 
                        employer health benefit plan was the reason for 
                        declining enrollment;
                            (iii) has lost coverage under another 
                        employer health benefit plan as a result of the 
                        termination of employment, the termination of 
                        the other plan's coverage, death of a spouse, 
                        or divorce; and
                            (iv) requests enrollment within 30 days 
                        after the termination of coverage under another 
                        employer health benefit plan.
                    (B) The individual is employed by an employer who 
                offers multiple health benefit plans and the individual 
                elects a different health benefit plan during an open 
                enrollment period.
                    (C) A court has ordered coverage to be provided for 
                a spouse or minor child under a covered employee's plan 
                and a request for enrollment is made within 30 days 
                after issuance of the court order.

SEC. 104. LIMITS ON PREMIUMS AND OTHER RATING PRACTICES IN THE SMALL 
              EMPLOYER MARKET.

    (a) Limits on Premiums.--
            (1) Limit on variation of rates.--
                    (A) New issuance.--With respect to a health benefit 
                plan offered to small employers by an insurer and 
                issued on or after the date of the enactment of this 
                Act, the premium rates charged or offered for a rating 
                period for the same or similar coverage under the plan 
                covering any small employer with similar case 
                characteristics may not vary from the applicable 
                midpoint rate by more than 35 percent of the midpoint 
                rate.
                    (B) Current issuance.--
                            (i) In general.--If the premium rate 
                        charged or offered for the same or similar 
                        coverage under the plan covering any small 
                        employer with similar case characteristics 
                        exceeds the applicable midpoint rate by more 
                        than 35 percent, any increase in premium for a 
                        new rating period shall not exceed the sum of 
                        the following:
                                    (I) Base premium increase.--Subject 
                                to clause (ii), any percentage change 
                                in the base premium rate measured from 
                                the first day of the prior rating 
                                period to the first day of the new 
                                rating period.
                                    (II) Adjustment for case 
                                characteristics.--Any adjustment due to 
                                change in case characteristics or plan 
                                design of the small employer, as 
                                determined by the insurer.
                            (ii) Limitation.--Any increase in premium 
                        rates for a new rating period shall not exceed 
                        any percentage change in the base premium rate 
                        measured from the first day of the prior rating 
                        period to the first day of the new rating 
                        period plus 15 percent, adjusted on a pro rata 
                        basis for rating periods greater or less than 
                        one year and adjustments due to a change in 
                        case characteristics or plan design of the 
                        small employer.
                            (iii) Rating period.--For purposes of this 
                        subsection, an insurer shall treat all health 
                        benefit plans covering small employers issued 
                        or renewed in the same calendar month as having 
                        the same rating period.
                    (C) Limitation on variation due to use of industry 
                as case characteristic.--If an insurer uses industry as 
                a case characteristic in establishing premium rates, 
                the rate factor associated with any industry 
                classification may not vary by more than 15 percent 
                from the arithmetic average of the rate factors 
                associated with all industry classifications.
            (2) Limit on variation of premium rates within a class a 
        business.--For a class of business (as defined in subsection 
        (e)(3)) of an insurer, the highest premium rates charged during 
        a rating period to small employers with similar case 
        characteristics for the same or similar coverage, or the 
        highest rates which could be charged to such employers under 
        the rating system for that class of business, shall not exceed 
        an amount that is 1.5 times the base premium rate for the class 
        of business for a rating period (or portion thereof) that 
        occurs in the first 3 years in which this section is in effect, 
        and 1.35 times the base premium rate thereafter.
            (3) Limit on transfer of employers among classes of 
        business.--An insurer may not involuntarily transfer a small 
        employer into or out of a class of business. An insurer may not 
        offer to transfer a small employer into or out of a class of 
        business unless such offer is made to transfer all small 
        employers in the class of business without regard to claim 
        experience, health status, or duration of coverage since issue.
    (b) Full Disclosure of Rating Practices.--At the time an insurer 
offers a health benefit plan to a small employer, the insurer shall 
fully disclose to the employer rating practices applicable to such 
plan.
    (c) Actuarial Certification.--Each insurer that offers a health 
benefit plan to a small employer in a State shall file annually with 
the State commissioner of insurance a written statement by a member of 
the American Academy of Actuaries (or other individual acceptable to 
the commissioner) that, based upon an examination by the individual 
which includes a review of the appropriate records and the actuarial 
assumptions of the insurer and methods used by the insurer in 
establishing premium rates for applicable health benefit plans--
            (1) the insurer is in compliance with the applicable 
        provisions of this section; and
            (2) the rating methods are actuarially sound.
Each such insurer shall retain a copy of such statement for examination 
at its principal place of business.
    (d) Registration and Reporting.--Each insurer that issues any 
health benefit plan to a small employer in a State shall be registered 
or licensed with the State commissioner of insurance and shall comply 
with any reporting requirements of the commissioner relating to such a 
plan.
    (e) Definitions.--In this section:
            (1) Base premium rate.--The term ``base premium rate'' 
        means, as to any health benefit plan that is issued by an 
        insurer and that covers more than 1 but less than 51 employees 
        of a small employer, the lowest premium rate for a new or 
        existing business for same or similar coverage covering any 
        small employer with small case characteristics.
            (2) Case characteristics.--The term ``case 
        characteristics'' means, with respect to a small employer, any 
        of the following:
                    (A) The geographic area in which the employees 
                reside.
                    (B) The age and sex of the individual employees and 
                their dependents.
                    (C) The appropriate industry classification as 
                determined by the insurer.
                    (D) The number of employees and dependents.
                    (E) Such other objective criteria as may be 
                established by the insurer, but not including claims 
                experience, health status, or duration of coverage from 
                the date of issue.
            (3) Class of business.--The term ``class of business'' 
        means, with respect to an insurer, all (or a distinct group of) 
        small employers as shown on the records of the insurer.
            (4) Midpoint rate ``midpoint rate'' means, for small 
        employers with similar case characteristics and plan designs 
        and as determined by the applicable insurer for a rating 
        period, the arithmetic average of the applicable base premium 
        rate and the corresponding highest premium rate.

SEC. 105. SMALL EMPLOYER PURCHASING GROUPS.

    (a) Small Employer Purchasing Groups Described.--
            (1) In general.--As used in this section, the term ``small 
        employer purchasing group'' means an organization that--
                    (A) has a membership consisting solely of small 
                employers;
                    (B) is administered solely under the authority and 
                control of its member employers;
                    (C) with respect to each State in which its members 
                are located, consists of not fewer than the number of 
                small employers established by the State as appropriate 
                for such a group;
                    (D) offers a program to assist such small employer 
                members to obtain coverage for their employees under 
one or more health benefit plans; and
                    (E) is not directly or indirectly controlled, 
                through voting membership, representation on its 
                governing board or otherwise, by an insurer, agent, 
                broker, or any other individual or entity engaged in 
                the sale of insurance, provider, or by persons who are 
                officers, trustees, or directors of such enterprises.
            (2) Special rule.--An employer member of a small employer 
        purchasing group that meets the requirements of paragraph (1) 
        may retain its membership in the group if the number of 
        employees of the employer increases such that the employer is 
        no longer a small employer.
    (b) Authority.--A small employer purchasing group established under 
this section may do any of the following:
            (1) Offering health benefit plans.--Negotiate and enter 
        into agreements with one or more insurers for the insurers to 
        offer and provide one or more health benefit plans to small 
        employers for their employees and retirees, and the dependents 
        and members of the families of such employees and retirees, 
        which coverage may be made available to enrolled small 
        employers without regard to industrial, rating, or other 
        classifications, and for the purchasing group to perform, or 
        contract with others for the performance of, functions for or 
        with respect to such purchasing group.
            (2) Contracts with other groups.--Contract with another 
        small employer purchasing group for the inclusion of the small 
        employer members of one in the program of the other.
            (3) Information dissemination.--Provide or cause to be 
        provided to small employers information concerning the 
        availability coverage, benefits, premiums, and other 
        information regarding purchasing groups.
            (4) Administration.--Provide, or contract with others to 
        provide, enrollment, recordkeeping, information, premium 
        billing, collection and transmittal, and other services for a 
        purchasing group.
            (5) Audits.--Receive reports and information from the 
        insurer and negotiate and enter into agreements with respect to 
        inspection and audit of the books and records of the insurer.
    (c) Limitation on Activities.--A small employer purchasing group 
may not--
            (1) perform any activity involving approval or enforcement 
        of payment rates for providers;
            (2) assume financial risk in relation to any health benefit 
        plan; or
            (3) perform other activities identified by the State as 
        being inconsistent with the performance of its duties under 
        this section.
    (d) Rules of Construction.--
            (1) Establishment not required.--Nothing in this section 
        shall be construed as requiring--
                    (A) that a State organize, operate, or otherwise 
                establish a small employer purchasing group, or 
                otherwise require the establishment of purchasing 
                groups; and
                    (B) that there be only one small employer 
                purchasing group established with respect to a 
                community rating area.
            (2) Eligibility requirements.--Nothing in this section 
        shall be construed as inhibiting or preventing a small employer 
        purchasing group from adopting, imposing, and enforcing rules, 
        conditions, limitations, or restrictions that are based on 
        factors other than the health status of employees or their 
        dependents for the purpose of determining whether a small 
employer is eligible to become a member of a purchasing group.
    (e) Receipt of Premiums.--
            (1) Enrollment charge.--The amount charged by a small 
        employer purchasing group for coverage under a health benefit 
        plan shall be equal to the sum of--
                    (A) the premium rate offered by such health plan;
                    (B) the administrative charge for such health plan; 
                and
                    (C) the purchasing group administrative charge for 
                enrollment of eligible employees, eligible individuals 
                and certain uninsured individuals through the group.
            (2) Disclosure of premium rates and administrative 
        charges.--Each small employer purchasing group shall, prior to 
        the time of enrollment, disclose to enrollees and other 
        interested parties the premium rate for a health benefit plan, 
        administrative charge for such plan, and administrative charge 
        of the group, separately.
    (f) Special Rules.--No health benefit plan offered or provided by 
an insurer to a small employer in a small employer purchasing group is 
subject to any law that does any of the following:
            (1) Selective contracting.--Inhibits the insurer from 
        selectively contracting with providers or groups of providers 
        with respect to health care service or benefits.
            (2) Payment negotiation.--Imposes any restrictions on the 
        ability of the insurer to negotiate with providers regarding 
        the level or method of reimbursing for care or services.
            (3) Benefit or provider mandates.--Requires the 
        reimbursement, utilization, or consideration of a specific 
        category of health care services or benefits.
            (4) Beneficiary incentives.--Limits the financial 
        incentives that a health benefit plan may require a beneficiary 
        to pay when a nonplan provider is used on a nonemergency basis.
            (5) Utilization review.--(A) Prohibits utilization review 
        of any or all treatments and conditions, (B) requires the use 
        of specified standards of health care practice in such reviews 
        or requires the disclosure of the specific criteria used in 
        such reviews, (C) requires payments to providers for the 
        expenses of responding to utilization review requests, or (D) 
        imposes liability for delays in performing such review.

           Subtitle B--Open Enrollment and Related Practices

SEC. 111. ENROLLMENT GUIDELINES.

    (a) Requirement of Open Enrollment.--
            (1) In general.--Beginning in January of each year, each 
        insurer shall accept applicants for open enrollment coverage 
        described in paragraph (2) or (3) in the order in which they 
        apply for coverage, subject to subsection (f).
            (2) Small employers.--In the case of an applicant that is a 
        small employer, the applicant must accept the employer if 
        coverage is not otherwise available and if coverage had not 
        been terminated by the employer (or by an insurer with respect 
        to the employer) during the preceding 12-month period.
            (3) Individuals.--In the case of an applicant that is an 
        individual, the applicant--
                    (A) is not applying for coverage as an employee of 
                an employer, as a member of an association, or as a 
                member of any other group; and
                    (B) is not covered, and is not eligible for 
                coverage, under any other private or public health 
benefits arrangement, including the Medicare program under title XVIII 
of the Social Security Act or any other Act of Congress or law of any 
State that provides benefits comparable to the benefits provided under 
this section or any conversion or continuation of coverage policy under 
State or Federal law.
    (b) Minimum Coverage.--An insurer shall provide to any individual 
or small employer group accepted under this section a health benefit 
plan that provides, at a minimum, coverage of the following health care 
services, when such services are provided within the scope of 
authorized practice by the applicable licensed providers:
            (1) Major medical.
            (2) Hospital services.
            (3) Basic medical-surgical services, both inpatient and 
        outpatient medical and surgical services, diagnostic services, 
        anesthesia services, and consultation services.
            (4) Prescription drugs, insulin, syringes, diagnostic x-
        rays and laboratory tests.
            (5) Screening by low-dose mammography for the presence of 
        breast cancer and cytologic screening for the presence of 
        cervical cancer in accordance with standards of the National 
        Cancer Institute.
            (6) Maternity services.
    (c) Preexisting Conditions Provisions.--Health benefit plans issued 
under this section may establish preexisting conditions provisions (as 
defined in section 101(b)) that exclude or limit coverage for a period 
of up to 12 months (or 24 months in the case of a late enrollee, as 
defined in section 101(e)(4) and at the option of the insurer) 
following the individual's effective date of coverage and that may 
relate only to conditions during the 6 months immediately preceding the 
effective date of coverage.
    (d) Premiums.--
            (1) Small employers.--Premiums charged to small employers 
        under this section may not exceed an amount that is 1\1/2\ 
        times the highest rate charged any other small employer with 
        similar case characteristics for same or similar coverage.
            (2) Individuals.--Premiums charged to individuals under 
        this section may not exceed an amount that is 1\1/2\ times the 
        highest rate charged to any other individual of the same age 
        and gender for same or similar coverage. If the insurer does 
        not have established individual rates in a State, the premium 
        charged to individuals may not exceed an amount that is 1\1/2\ 
        times the rate charged a small employer with case 
        characteristics similar to the individual seeking coverage for 
        same or similar coverage.
    (e) Use of Networks.--In offering health benefit plans under this 
section, an insurer may require the purchase of health benefit plans 
that condition the reimbursement of health services upon the use of a 
specific network of providers.
    (f) Limitation on Number of New Insureds Required To Accept.--
            (1) In general.--An insurer is not required to accept 
        annually under this section either individuals or small 
        employers that, in the aggregate, would cause the insurer to 
        have a total number of new insureds under this section that is 
        more than \1/2\ percent per year of its total number of insured 
        individuals or small group certificate holders, calculated as 
        of the immediately preceding 31st day of December and excluding 
        Medicare supplemental policies and conversion or continuation 
        of coverage policies under State or Federal law.
            (2) Certification.--An officer of the insurer shall certify 
        to the State commissioner of insurance of its domiciliary State 
        when it has met the enrollment limit under paragraph (1). Upon 
        providing such certification, the insurer shall be relieved of 
its open enrollment requirement under this section for the remainder of 
the calendar year.
    (g) Limitation on Acceptance of Certain Confined Individuals.--An 
insurer shall not be required to accept under this section applicants 
who, at the time of enrollment, are confined to a health care facility 
because of chronic illness, permanent injury, or other infirmity that 
would cause economic impairment to the insurer if the applicants were 
accepted, or to make the effective date of benefits for individuals or 
groups accepted under this section earlier than 90 days after the date 
of acceptance.
    (h) No Application to Insolvent Insurers.--The requirements of this 
section do not apply to any insurer that is in a state of supervision, 
insolvency, or liquidation. If the insurer demonstrates to the 
satisfaction of the State commissioner of insurance of the insurer's 
domiciliary State that the application of the requirements of this 
section would place the insurer in a State of supervision, insolvency, 
or liquidation, the commissioner may waive or modify the requirements 
of subsection (a) and (f). The actions of the commissioner under this 
subsection shall be effective for a period of not more than 1 year. At 
the expiration of such time, a new showing of need for a waiver or 
modification by the insurer shall be made before a new waiver or 
modification is issued or imposed.
    (i) Limitation on Agent Compensation.--No insurer shall pay or 
allow, or cause to be paid or allowed, and no agent shall accept, or 
agree to receive or accept, any commission, consideration, money, or 
other thing of value in excess of 5 percent of the premium charged for 
initial placement or for otherwise securing the issuance of, or in 
excess of 4 percent of the premium charged for the renewal of, a policy 
or contract issued to an individual or small employer group under this 
section. The Secretary may adopt such rules as are necessary to enforce 
this subsection.
    (j) Exclusion of Certain Policies.--This section does not apply to 
any policy that provides coverage for specified diseases or accidents 
only or to any hospital indemnity, Medicare supplement, long-term care, 
disability income, one-time-limited-duration policy of no longer than 6 
months, or other policy that offers only supplemental benefits.

 Subtitle C--Preemption of State Mandated Benefits, Anti-managed Care 
                  Laws, and State Insurance Standards

SEC. 121. PREEMPTION FROM STATE MANDATED BENEFITS.

    Effective as of January 1, 1996, no State shall establish or 
enforce any law or regulation that--
            (1) requires the offering, as part of health insurance 
        coverage, of any services, category of care, or services of any 
        class or type of provider; or
            (2) specifies the individuals to be provided health 
        insurance coverage or the duration of such coverage.

SEC. 122. PREEMPTION OF STATE LAW RESTRICTIONS ON MANAGED CARE 
              ARRANGEMENTS.

    Effective as of January 1, 1996--
            (1) a State may not prohibit or limit an insurer or health 
        benefit plan providing health coverage from including 
        incentives for enrollees to use the services of participating 
        providers;
            (2) a State may not prohibit or limit such insurer or plan 
        from limiting coverage of services to those provided by a 
        participating provider;
            (3) a State may not prohibit or limit the negotiation of 
        rates and forms of payments for providers by such insurer or 
        plan with respect to health coverage;
            (4) a State may not prohibit or limit such insurer or plan 
        from limiting the number of participating providers; and
            (5) a State may not prohibit or limit such insurer or plan 
        from requiring that services be provided (or authorized) by a 
        practitioner selected by the enrollee from a list of available 
        participating providers or from requiring enrollees to obtain 
        referral in order to have coverage for treatment by a 
        specialist or health institution.

SEC. 123. PREEMPTION OF STATE INSURANCE STANDARDS.

    A State may not establish or enforce standards for health insurance 
coverage made available in the individual and small group markets that 
are different from the standards established under this title, unless 
the State has already established or has been enforcing such standards 
for health insurance coverage prior to the effective date of this 
title.

               Subtitle D--Administrative Simplification

SEC. 131. ADOPTION OF DATA ELEMENTS, UNIFORM CLAIMS, AND UNIFORM 
              ELECTRONIC TRANSMISSION STANDARDS.

    (a) In General.--The Secretary of Health and Human Services (in 
this subtitle referred to as the ``Secretary'') shall adopt standards 
relating to each of the following:
            (1) Data elements.--Data elements for use in paper and 
        electronic claims processing under health benefit plans, as 
        well as for use in utilization review and management of care 
        (including data fields, formats, and medical nomenclature, and 
        including plan benefit and insurance information).
            (2) Uniform claims forms.--Uniform claims forms (including 
        uniform procedure and billing codes for use with such forms and 
        including information or other health benefit plans that may be 
        liable for benefits).
            (3) Uniform electronic transmission.--Uniform electronic 
        transmission of the date elements (for purposes of billing and 
        utilization review).
The standards under paragraph (3) (relating to electronic transmission 
of data elements) for claims for services) shall supersede (to the 
extent specified in such standards) the standards adopted under 
paragraph (2) (relating to the submission of paper claims) for such 
services. The standards under paragraph (3) shall include protections 
to assure the confidentiality of patient-specific information and to 
protect against the unauthorized use and disclosure of information.
    (b) Use of Task Forces.--In adopting standards under this section, 
the Secretary shall--
            (1) take into account the recommendations of current task 
        forces;
            (2) consult with the National Association of Insurance 
        Commissioners (and, with respect to standards under subsection 
        (a)(3), the American National Standards Institute); and
            (3) to the maximum extent practicable, seek to make the 
        standards consistent with any uniform clinical data sets which 
        have been adopted and are widely recognized.
    (c) Deadlines for Promulgation.--The Secretary shall promulgate the 
standards under--
            (1) subsection (a)(1) relating to claims processing data, 
        by not later than 12 months after the date of the enactment of 
        this Act;
            (2) subsection (a)(2) (relating to uniform claims forms) by 
        not later than 12 months after the date of the enactment of 
        this Act; and
            (3)(A) subsection (a)(3) relating to transmission of 
        information concerning hospital and physicians services, by not 
        later than 24 months after the date of the enactment of this 
        Act; and
            (B) subsection (a)(3) relating to transmission of 
        information on other services by such later date as the 
        Secretary may determine it to be feasible.

SEC. 132. APPLICATION OF STANDARDS.

    (a) In General.--If the Secretary determines, at the end of the 2-
year period beginning on the date that standards are adopted under 
section 131 with respect to classes of services, that a significant 
number of claims for benefits for such services under health benefit 
plans are not being submitted in accordance with such standards, the 
Secretary may require, after notice in the Federal Register of not less 
than 6 months, that all providers of such services must submit claims 
to health benefit plans in accordance with such standards. The 
Secretary may waive the application of such a requirement in such cases 
as the Secretary finds that the imposition of the requirement would not 
be economically practicable.
    (b) Significant Number.--The Secretary shall make an affirmative 
determination described in subsection (a) for a class of services only 
if the Secretary finds that there would be a significant, measurable, 
additional gain in efficiencies in the health care system that would be 
obtained by imposing the requirement described in such paragraph with 
respect to such services.
    (c) Application of Requirement.--
            (1) In general.--If the Secretary imposes the requirement 
        under subsection (a)--
                    (A) in the case of a requirement that imposes the 
                standards relating to electronic transmission of claims 
                for a class of services, each health care provider that 
                furnishes such services for which benefits are payable 
                under a health benefit plan shall transmit 
                electronically and directly to the plan on behalf of 
                the beneficiary involved a claim for such services in 
                accordance with such standards;
                    (B) any health benefit plan may reject any claim 
                subject to the standards adopted under section 131 but 
                which is not submitted in accordance with such 
                standards;
                    (C) it is unlawful for a health benefit plan--
                            (i) to reject any such claim on the basis 
                        of the form in which it is submitted if it is 
                        submitted in accordance with such standards; or
                            (ii) to require, for the purpose of 
                        utilization review or as a condition of 
                        providing benefits under the plan, a provider 
                        to transmit medical data elements that are 
                        inconsistent with the standards established 
                        under section 131; and
                    (D) the Secretary may impose a civil money penalty 
                on any provider that knowingly and repeatedly submits 
                claims in violation of such standards or on any health 
                benefit plan (other than a health benefit plan 
                described in paragraph (2)) that knowingly, and 
                repeatedly rejects claims in violation of subparagraph 
                (B), in an amount not to exceed $100 for each such 
                claim.
        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 
        subparagraph (D) in the same manner as such provisions apply to 
        penalty or proceeding under section 1128 of such Act.
            (2) Plans subject to effective state regulation.--A plan 
        described in this paragraph is a health benefit plan--
                    (A) that is subject to regulation by a State; and
                    (B) with respect to which the Secretary finds 
                that--
                            (i) the State provides for application of 
                        the standards established under section 131; 
                        and
                            (ii) the State regulatory program provides 
                        for the appropriate and effective enforcement 
                        of such standards.
    (d) Treatment of Rejections.--If a plan rejects a claim pursuant to 
subsection (c), the plan shall permit the person submitting the claim a 
reasonable opportunity to resubmit the claim on a form or in an 
electronic manner that meets the requirements for acceptance of the 
claim under such subsection.

SEC. 133. PERIODIC REVIEW AND REVISION OF STANDARDS.

    (a) In General.--The Secretary shall--
            (1) provide for the ongoing receipt and review of comments 
        and suggestions for changes in the standards adopted and 
        promulgated under section 131;
            (2) establish a schedule for the periodic review of such 
        standards; and
            (3) based upon such comments, suggestions, and review, 
        revise such standards and promulgate such revisions.
    (b) Application of Revised Standards.--If the Secretary under 
subsection (a) revises the standards described in section 131, then, in 
the case of any claim for benefits submitted under a health benefit 
plan more than the minimum period (of not less than 6 months specified 
by the Secretary) after the date the revision is promulgated under 
subsection (a), such standards shall apply under section 132 instead of 
the standards previously promulgated.

        Subtitle E--Restriction on Genetic Screening and Testing

SEC. 141. GENETIC SCREENING AND TESTING RESTRICTIONS IN HEALTH 
              INSURANCE.

    (a) In General.--No insurer, in processing an application for 
coverage under a health benefit plan or in determining insurability 
under such plan, shall do any of the following:
            (1) Require an individual seeking coverage to submit to 
        genetic screening or testing (as defined in subsection (g)).
            (2) Take into consideration, other than in accordance with 
        subsection (f), the results of genetic screening or testing.
            (3) Make any inquiry to determine the results of genetic 
        screening or testing.
            (4) Make a decision adverse to the applicant based on 
        entries in medical records or other reports of genetic 
        screening or testing.
    (b) No Questions.--In developing and asking questions regarding 
medical histories of applicants for an individual or group health 
benefit plan, no insurer shall ask for the results of genetic screening 
or testing or ask questions designed to ascertain the results of 
genetic screening or testing.
    (c) No Cancellation.--No insurer shall cancel or refuse to issue or 
renew coverage under a health benefit plan based on the results of 
genetic screening or testing.
    (d) No Benefit Limitation.--No insurer shall deliver, issue for 
delivery, or renew an individual or group health benefit plan that 
limits benefits based on the results of genetic screening or testing.
    (e) Use of Voluntary Testing.--Notwithstanding the previous 
provisions of this section, an insurer may consider the results of 
genetic screening or testing if the results are voluntarily submitted 
by an applicant for coverage or renewal of coverage and the results are 
favorable to the applicant.
    (f) Genetic Screening or Testing Defined.--As used in this section, 
the term ``genetic screening or testing'' means a laboratory test of a 
person's genes or chromosomes for abnormalities, defects, or 
deficiencies, including carrier status, that are linked to physical or 
mental disorders or impairments, or that indicate a susceptibility to 
illness, disease, or other disorders, whether physical or mental, which 
test is a direct test for abnormalities, defects, or deficiencies, and 
not an indirect manifestation of genetic disorders.

                  Subtitle F--Administrative Expenses

SEC. 151. LIMITATION ON ADMINISTRATIVE EXPENSES.

    (a) In General.--The following apply to every insurer with respect 
to administrative expenses for sickness and accident insurance business 
of the insurer offered in each State:
            (1) For calendar year 1996, each insurer shall have 
        aggregate administrative expenses for such business of no more 
        than 40 percent of the premium income of the insurer for such 
        business, based on the premiums received in that year on the 
        sickness and accident insurance business of the insurer.
            (2) For calendar year 1997, each insurer shall have 
        aggregate administrative expenses of no more than 30 percent of 
        the premium income of the insurer, based on the premiums 
        received in that year on the sickness and accident insurance 
        business of the insurer.
            (3) For calendar year 1998, each insurer shall have 
        aggregate administrative expenses of no more than 25 percent of 
        the premium income of the insurer, based on the premiums 
        received in that year on the sickness and accident insurance 
        business of the insurer.
            (4) For calendar year 1999 and each calendar year 
        thereafter, each insurer shall have aggregate administrative 
        expenses of no more than 20 percent of the premium income of 
        the insurer, based on the premiums received in that year on the 
        sickness and accident insurance business of the insurer.
    (b) Annual Statement.--Each insurer, during the first 2 months of 
each year (beginning with 1997), shall annually prepare, under oath, 
and deposit in the office of the commissioner of insurance of the 
insurer's State of domicile, a statement of the aggregate 
administrative expenses of the insurer, based on the premiums received 
in the immediately preceding calendar year on the sickness and accident 
insurance business of the insurer.
    (c) Definitions.--As used in this section:
            (1) Administrative expense.--
                    (A) In general.--The term ``Administrative 
                expense'' means the amount of premiums received by the 
                insurer for sickness and accident insurance business, 
                minus the sum of the following:
                            (i) The amount of claims for losses paid.
                            (ii) The amount of losses incurred but not 
                        reported.
                            (iii) The amount paid for State fees, 
                        Federal and State taxes, and reinsurance.
                            (iv) The amount paid for commissions.
                    (B) Exclusion of erisa items.--Such term does not 
                include any amounts collected, or administrative 
                expenses incurred, by an insurer for the administration 
                of an employee health benefit plan subject to 
                regulation by the Employee Retirement Income Security 
                Act of 1974. In the previous sentence, the term 
                ``amount collected or administrative expenses 
                incurred'' means the total amount paid to an 
                administrator for the administration and payment of 
                claims minus the sum of the amount of claims for losses 
                paid and the amount of losses incurred but not 
                reported.
            (2) Sickness and accident insurance business.--The term 
        ``sickness and accident insurance business'' does not include--
                    (A) coverage provided by an insurer for specific 
                diseases or accidents only;
                    (B) any hospital indemnity, Medicare supplement, 
                long-term care, disability income, one-time-limited-
                duration policy of no longer than 6 months, or other 
                policy that offers only supplemental benefits; or
                    (C) coverage provided to individuals who are not 
                residents of the State involved.

               Subtitle G--Limitations on Balance Billing

SEC. 161. MEDICARE PROGRAM.

    (a) In General.--Section 1848(g)(2)(B) of the Social Security Act 
(42 U.S.C. 1395w-4(g)(2)(B)) is amended by striking ``115 percent'' and 
inserting ``105 percent''.
    (b) Effective Date.--The amendment made by subsection (a) shall 
apply to charges for items and services furnished on or after the first 
January 1 that occurs after the date of the enactment of this Act.

SEC. 162. OTHER PROGRAMS.

    (a) In General.--No provider shall balance bill any individual or 
dependent of an individual or any eligible employee or dependent of an 
employee for any health care supplies or services provided to the 
individual or dependent or the eligible employee or dependent, who is 
insured under a health benefit plan. The provider shall accept payments 
made to it by the insurer under the terms of the plan insuring or 
covering such individual as payment in full for such health care 
supplies or services.
    (b) Balanced Bill Defined.--As used in this section, the term 
``balance bill'' means charging or collecting an amount in excess of 
the amount reimbursable or payable under a health benefit plan for such 
health care supply or service. Such term does not include charging for 
or collecting copayments or deductibles required by the plan.

              Subtitle H--Enforcement; General Definitions

SEC. 171. GENERAL ENFORCEMENT.

    (a) Insurers.--If a commissioner of insurance for an insurer's 
State of domicile determines that an insurer has failed to comply with 
a requirement of subtitle A, B, E, or F of this title applicable to the 
insurer, the commissioner is responsible for suspending the insurer's 
license to do the business of sickness and accident insurance in the 
State until the commissioner is satisfied that the insurer is in 
compliance with such requirements. If the insurer continues to do the 
business of sickness and accident insurance in the State while under 
the suspension order, the commissioner may impose a civil money penalty 
(specified by the commissioner) for each day of the violation. Any 
funds collected by the commissioner under the previous sentence shall 
be deposited into the State treasury to the credit of the operating 
fund for the commissioner.
    (b) Other Health Benefit Plans.--Insofar as a requirement under 
subtitle A, B, or F of this title applies to a health benefit plan that 
is not offered by an insurer, the Secretary of Health and Human 
Services, in consultation with the Secretary of Labor, shall take such 
actions as may be appropriate to ensure enforcement with such 
requirement. Such actions may include--
            (1) an action in an appropriate court to enjoin violations 
        of such requirements, and
            (2) a civil money penalty (of not to exceed $50,000) for 
        each violation of such a requirement.

SEC. 172. GENERAL DEFINITIONS.

    As used in this title:
            (1) Commissioner of insurance.--The term ``commissioner of 
        insurance'' includes a superintendent of insurance.
            (2) Eligible employee.--The term ``eligible employee'' 
        means an employee who works a normal work week of 25 or more 
        hours. Such term does not include a temporary or substitute or 
        seasonal employee who works only part of the calendar year.
            (3) Health benefit plan.--The term ``health benefit plan'' 
        means any contract or arrangement under which an entity bears 
        all or part of the cost of providing health care items and 
        services. Such term includes a hospital or medical service 
        policy or certificate, hospital or medical service plan 
        contract, or health maintenance organization group contract 
        offered by an insurer, but does not include any of the 
        following:
                    (A) Coverage only for accident, dental, vision, 
                disability, or long term care, Medicare supplemental 
                health insurance, or any combination thereof.
                    (B) Coverage issued as supplemental to liability 
                insurance.
                    (C) Workers' compensation or similar insurance.
                    (D) Automobile medical-payment insurance.
                    (E) Liability insurance, including general 
                liability insurance and automobile insurance.
                    (F) Coverage for a specified disease or illness.
            (4) HMO.--The term ``HMO'' means an organization that is 
        recognized under State law as an HMO or managed care 
        organization or a similar organization regulated under State 
        law for solvency and that offers health care services on a 
        prepaid, at-risk basis primarily through a defined set of 
        providers.
            (5) Insurer.--The term ``Insurer'' means--
                    (A) a licensed insurance company;
                    (B) an entity offering prepaid hospital or medical 
                services;
                    (C) an HMO; or
                    (D) a multiple small employer welfare arrangement 
                or other combination of small employers associated for 
                the purpose of providing health insurance plan coverage 
                for their employers.
            (6) Provider.--The term ``provider'' means a physician, 
        hospital, pharmacy, laboratory, or other person licensed or 
        otherwise authorized under applicable State laws to furnish 
        health care items or services.
            (7) Small employer.--The term ``small employer'' means, 
        with respect to a calendar year, an employer whose total 
        employed work force consisted of, on at least 50 percent of its 
        working days during the preceding year, more than 1 but less 
        than 51 eligible employees. For purposes of determining if an 
        employer is a small employer, rules similar to the rules of 
        subsections (B) of (C) of Section 414 of the Internal Revenue 
        Code of 1986 shall apply.
            (8) State.--The term ``State'' means the 50 States, the 
        District of Columbia, Puerto Rico, the Virgin Islands, Guam, 
        American Samoa, and the Northern Mariana Islands.

            TITLE II--EXTENSION OF PREVENTIVE PUBLIC HEALTH

SEC. 201. IMMUNIZATIONS AGAINST VACCINE-PREVENTABLE DISEASES.

    Section 317(j)(1) of the Public Health Service Act (42 U.S.C. 
247b(j)(1)) is amended by striking ``through 1995'' and inserting 
``through 1999''.

SEC. 202. PREVENTION, CONTROL, AND ELIMINATION OF TUBERCULOSIS.

    Section 317E(g)(1)(A) of the Public Health Service Act (42 U.S.C. 
247b-6(g)(1)(A)) is amended by striking ``through 1998'' and inserting 
``through 1999''.

SEC. 203. LEAD POISONING PREVENTION.

    Section 317A(l)(1) of the Public Health Service Act (42 U.S.C. 
247b-1(l)(1)) is amended by striking ``through 1998'' and inserting 
``through 1999''.

                       TITLE III--TAX PROVISIONS

SEC. 301. INCREASED DEDUCTION FOR HEALTH INSURANCE COSTS OF SELF-
              EMPLOYED INDIVIDUALS.

    (a) Phase-in of Increased Deduction.--Paragraph (1) of section 
162(l) of the Internal Revenue Code of 1986 (relating to special rules 
for health insurance costs of self-employed individuals) is amended to 
read as follows:
            ``(1) In general.--
                    ``(A) Deduction.--In the case of an individual who 
                is an employee within the meaning of section 401(c)(1), 
                there shall be allowed as a deduction under this 
                section an amount equal to the applicable percentage of 
                the amount paid during the taxable year for insurance 
                which constitutes medical care for the taxpayer, his 
                spouse, and dependents.
                    ``(B) Applicable percentage.--For purposes of 
                subparagraph (A), the applicable percentage for any 
                taxable year beginning in a calendar year is the 
                percentage determined in accordance with the following 
                table:

  

        Calendar year:
                                                 Applicable percentage:
                1996.................................       30 percent 
                1997.................................       55 percent 
                1998.................................       75 percent 
                1999 or any subsequent year..........    100 percent.''

    (b) Effective Date.--The amendment made by this section shall apply 
to taxable years beginning after December 31, 1995.

SEC. 302. SAFE HARBOR FOR HEALTH CARE PROVIDERS OTHERWISE EXEMPT UNDER 
              501(c) (3) OR (4) WHICH AFFILIATE WITH CERTAIN HEALTH 
              ENTITIES.

    (a) In General.--Section 501 of the Internal Revenue Code of 1986 
(relating to exemption from tax on corporations, certain trusts, etc.) 
is amended by redesignating subsection (n) as subsection (o) and 
inserting after subsection (m) the following new subsection:
    ``(n) Safe Harbor for Health Care Providers Otherwise Exempt Under 
Subsection (c) (3) or (4) Which Affiliate With Certain Health 
Entities.--
            ``(1) In general.--For purposes of this title, a health 
        care provider shall not be treated as failing to be described 
        in paragraph (3) or (4) of subsection (c) for any taxable year 
        solely for the reason that such health care provider is 
        affiliated with or controlled by a qualified health entity 
        (through a management services agreement, joint venture, 
        membership, or other arrangement) if such health care provider 
        meets the requirements of paragraph (3) for such year.
            ``(2) Bonds issued by Health Care Providers Otherwise 
        Exempt Under Subsection (c)(3) Which Affiliate With Certain 
        Health Entities.--
                    ``(A) In general.--For purposes of this title, 
                obligations issued by a health care provider shall not 
                be treated as failing to be described in section 145(a) 
                for any taxable year solely for the reason that such 
                health care provider is affiliated with or controlled 
                by a qualified health entity (through a management 
                services agreement, joint venture, membership, or other 
                arrangement) if such health care provider meets the 
                requirements of paragraph (3) for such year.
                    ``(B) Special rules for mergers, consolidations, 
                and partnerships.--For purposes of applying section 150 
                to an obligation described in subparagraph (A), if the 
                affiliation or control referred to in subparagraph (A) 
                is a merger or consolidation, or the creation of a 
                partnership--
                            ``(i) property owned by the entity 
                        resulting from such merger or consolidation (or 
                        by such partnership) shall be treated as owned 
                        by a 501(c)(3) organization to the extent that 
                        such property was owned, on the day preceding 
                        the affiliation date, by the 501(c)(3) 
                        organization issuing such obligation, and
                            ``(ii) each trade or business of such 
                        resulting entity (or such partnership) shall be 
                        treated as a trade or business of a 501(c)(3) 
                        organization to the extent that such trade or 
                        business was conducted, on the day preceding 
                        the affiliation date, by the 501(c)(3) 
                        organization issuing such obligation.
                    ``(C) Affiliation date.--For purposes of 
                subparagraph (B), the term `affiliation date' means--
                            ``(i) with respect to a merger or 
                        consolidation, the date of such merger or 
                        consolidation, and
                            ``(ii) with respect to a partnership, the 
                        date on which the property referred to in 
                        section 150(b) is contributed to such 
                        partnership.
                    ``(D) Obligations issued to refund.--An obligation 
                issued to refund an obligation described in 
                subparagraph (A) shall be treated as described in 
                subparagraph (A) if such refunding obligation meets the 
                requirements of subclauses (I), (II), and (III) of 
                section 144(a)(12)(A)(ii).
            ``(3) Requirements.--A health care provider meets the 
        requirements of this paragraph if, for the taxable year, such 
        health care provider--
                    ``(A)(i) assesses the health care needs of the 
                community in which the health care provider is located,
                    ``(ii) develops a written plan which states the 
                manner in which the health care provider plans to meet 
                such needs, consistent with the purpose of the health 
                care provider, and
                    ``(iii) makes the plan available in the same manner 
                as a return filed under section 6033 is required to be 
                made available under section 6104(e)(1),
                    ``(B) maintains a board of directors or trustees, 
                at least 50 percent of whom are representatives of the 
                community in which the health care provider is located, 
                and at least 80 percent of whom receive no compensation 
                (directly or indirectly) from the health care provider 
                for the taxable year for medical services performed in 
                connection with the health care provider or as an 
                officer of the health care provider,
                    ``(C) does not discriminate in the provision of 
                health care services on the basis of whether an 
                individual is insured by Medicare, Medicaid, or a 
                health care provider who contracts with a State to 
                provide health care services under a government-
                sponsored health plan, and
                    ``(D) does not discriminate in the provision of 
                emergency health care services on the basis of the 
                patient's ability to pay.
            ``(4) Definitions.--For purposes of this subsection:
                    ``(A) Health care provider.--The term `health care 
                provider' means any person whose predominant activity 
                is the provision of health care services.
                    ``(B) Health care services.--The term `health care 
                services' means any activity described in section 
                213(d)(1)(A).
                    ``(C) Qualified health entity.--The term `qualified 
                health entity' means any organization--
                            ``(i) the predominant activity of which is 
                        the provision of health care services, or
                            ``(ii) a primary activity of which is the 
                        provision of insurance relating to such 
                        services,
                either directly or through arrangements with health 
                care providers, to individuals enrolled with the 
                organization.''
    (b) Effective Date.--The amendments made by this section shall 
apply to taxable years beginning after December 31, 1995, except that 
the requirements of section 501(n)(3)(B) of such Code (as added by this 
Act) shall apply to taxable years beginning after December 31, 1996.
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