[Congressional Bills 104th Congress]
[From the U.S. Government Publishing Office]
[H.R. 483 Introduced in House (IH)]
104th CONGRESS
1st Session
H. R. 483
To amend title XVIII of the Social Security Act to permit medicare
select policies to be offered in all States, and for other purposes.
_______________________________________________________________________
IN THE HOUSE OF REPRESENTATIVES
January 11, 1995
Mrs. Johnson of Connecticut (for herself, Mr. Pomeroy, Mr. Thomas, Mr.
Goss, Mr. Shays, Mr. Kolbe, Mr. Royce, Mr. Archer, Mr. Stump, Mr.
Boehlert, Mr. Houghton, Mr. Petri, Mr. Miller of Florida, Mr.
Rohrabacher, Mr. Barrett of Wisconsin, Mrs. Meek of Florida, Ms.
Woolsey, Mr. Manzullo, Mr. Oberstar, Mr. Forbes, Mr. Berman, Mr.
Talent, Mr. Walsh, Mr. Brown of California, Mr. Minge, Mr. Dooley, Mr.
Peterson of Florida, Mr. Porter, Mr. Young of Alaska, Mr. Martinez, Mr.
Kleczka, Mr. Zimmer, Mr. Baker of California, Mr. Hobson, Mr. Frank of
Massachusetts, Mr. Moorhead, Mr. Fox, Mr. Farr, and Mr. Greenwood)
introduced the following bill; which was referred to the Committee on
Commerce and, in addition, to the Committee on 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 amend title XVIII of the Social Security Act to permit medicare
select policies to be offered in all States, 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. EXPANSION AND REVISION OF MEDICARE SELECT POLICIES.
(a) Permitting Medicare Select Policies in All States.--
(1) In general.--Subsection (c) of section 4358 of the
Omnibus Budget Reconciliation Act of 1990 is hereby repealed.
(2) Conforming amendment.--Section 4358 of such Act is
amended by redesignating subsection (d) as subsection (c).
(b) Requirements of Medicare Select Policies.--Section 1882(t)(1)
of the Social Security Act (42 U.S.C. 1395ss(t)(1)) is amended to read
as follows:
``(1)(A) If a medicare supplemental policy meets the 1991 NAIC
Model Regulation or 1991 Federal Regulation and otherwise complies with
the requirements of this section except that--
``(i) the benefits under such policy are restricted to
items and services furnished by certain entities (or reduced
benefits are provided when items or services are furnished by
other entities), and
``(ii) in the case of a policy described in subparagraph
(C)(i)--
``(I) the benefits under such policy are not one of
the groups or packages of benefits described in
subsection (p)(2)(A),
``(II) except for nominal copayments imposed for
services covered under part B of this title, such
benefits include at least the core group of basic
benefits described in subsection (p)(2)(B), and
``(III) an enrollee's liability under such policy
for physician's services covered under part B of this
title is limited to the nominal copayments described in
subclause (II),
the policy shall nevertheless be treated as meeting those standards if
the policy meets the requirements of subparagraph (B).
``(B) A policy meets the requirements of this subparagraph if--
``(i) full benefits are provided for items and services
furnished through a network of entities which have entered into
contracts or agreements with the issuer of the policy;
``(ii) full benefits are provided for items and services
furnished by other entities if the services are medically
necessary and immediately required because of an unforeseen
illness, injury, or condition and it is not reasonable given
the circumstances to obtain the services through the network;
``(iii) the network offers sufficient access;
``(iv) the issuer of the policy has arrangements for an
ongoing quality assurance program for items and services
furnished through the network;
``(v)(I) the issuer of the policy provides to each enrollee
at the time of enrollment an explanation of the matters
described in subparagraph (D), and
``(II) each enrollee prior to enrollment acknowledges
receipt of the explanation provided under subclause (I); and
``(vi) the issuer of the policy makes available to
individuals, in addition to the policy described in this
subsection, any policy (otherwise offered by the issuer to
individuals in the State) that meets the 1991 Model NAIC
Regulation or 1991 Federal Regulation and other requirements of
this section without regard to this subsection.
``(C)(i) A policy described in this subparagraph--
``(I) is offered by an eligible organization (as defined in
section 1876(b)),
``(II) is not a policy providing benefits pursuant to a
contract under section 1876 or an approved demonstration
project described in section 603(c) of the Social Security
Amendments of 1983, section 2355 of the Deficit Reduction Act
of 1984, or section 9412(b) of the Omnibus Budget
Reconciliation Act of 1986, and
``(III) provides benefits which, when combined with
benefits which are available under this title, are
substantially similar to benefits under policies offered to
individuals who are not entitled to benefits under this title.
``(ii) In making a determination under subclause (III) of clause
(i) as to whether certain benefits are substantially similar, there
shall not be taken into account, except in the case of preventive
services, benefits provided under policies offered to individuals who
are not entitled to benefits under this title which are in addition to
the benefits covered by this title and which are benefits an entity
must provide in order to meet the definition of an eligible
organization under section 1876(b)(1).
``(D) The matters described in this subparagraph, with respect to a
policy, are as follows:
``(i) The restrictions on payment under the policy for
services furnished other than by or through the network.
``(ii) Out of area coverage under the policy.
``(iii) The policy's coverage of emergency services and
urgently needed care.
``(iv) The availability of a policy through the entity that
meets the 1991 Model NAIC Regulation or 1991 Federal Regulation
without regard to this subsection and the premium charged for
such policy.''.
(c) Renewability of Medicare Select Policies.--Section 1882(q)(1)
of the Social Security Act (42 U.S.C. 1395ss(q)(1)) is amended--
(1) by striking ``(1) Each'' and inserting ``(1)(A) Except
as provided in subparagraph (B), each'';
(2) by redesignating subparagraphs (A) and (B) as clauses
(i) and (ii), respectively; and
(3) by adding at the end the following new subparagraph:
``(B)(i) Except as provided in clause (ii), in the case of
a policy that meets the requirements of subsection (t), an
issuer may cancel or nonrenew such policy with respect to an
individual who leaves the service area of such policy.
``(ii) If an individual described in clause (i) moves to a
geographic area where an issuer described in clause (i), or
where an affiliate of such issuer, is issuing medicare
supplemental policies, such individual must be permitted to
enroll in any medicare supplemental policy offered by such
issuer or affiliate that provides benefits comparable to or
less than the benefits provided in the policy being canceled or
nonrenewed. An individual whose coverage is canceled or
nonrenewed under this subparagraph
shall, as part of the notice of termination or nonrenewal, be
notified of the right to enroll in other medicare supplemental
policies offered by the issuer or its affiliates.
``(iii) For purposes of this subparagraph, the term
`affiliate' shall have the meaning given such term by the 1991
NAIC Model Regulation.''.
(d) Civil Money Penalty.--Section 1882(t)(2) of the Social Security
Act (42 U.S.C. 1395ss(t)(2)) is amended--
(1) by striking ``(2)'' and inserting ``(2)(A)'';
(2) by redesignating subparagraphs (A), (B), (C), and (D)
as clauses (i), (ii), (iii), and (iv), respectively;
(3) in clause (iv), as so redesignated--
(A) by striking ``paragraph (1)(E)(i)'' and
inserting ``paragraph (1)(B)(v)(I), and
(B) by striking ``paragraph (1)(E)(ii)'' and
inserting ``paragraph (1)(B)(v)(II)'';
(4) by striking ``the previous sentence'' and inserting
``this subparagraph''; and
(5) by adding at the end the following new subparagraph:
``(B) If the Secretary determines that an issuer of a policy
approved under paragraph (1) has made a misrepresentation to the
Secretary or has provided the Secretary with false information
regarding such policy, the issuer is subject to a civil money penalty
in an amount not to exceed $100,000 for each such determination. The
provisions of section 1128A (other than the first sentence of
subsection (a) and other than subsection (b)) shall apply to a civil
money penalty under this subparagraph in the same manner as such
provisions apply to a penalty or proceeding under section 1128A(a).''.
SEC. 2. EFFECTIVE DATES.
(a) NAIC Standards.--If, within 6 months after the date of the
enactment of this Act, the National Association of Insurance
Commissioners (in this subsection referred to as the ``NAIC'') makes
changes in the 1991 NAIC Model Regulation (as defined in section
1882(p)(1)(A) of the Social Security Act) to incorporate the additional
requirements imposed by the amendments made by section 1, section
1882(g)(2)(A) of such Act shall be applied in each State, effective for
policies issued to policyholders on and after the date specified in
paragraph (3), as if the reference to the Model Regulation adopted on
June 6, 1979, were a reference to the 1991 NAIC Model Regulation (as so
defined) as changed under this paragraph (such changed Regulation
referred to in this subsection as the ``1995 NAIC Model Regulation'').
(b) Secretary Standards.--If the NAIC does not make changes in the
1991 NAIC Model Regulation (as so defined) within the 6-month period
specified in subsection (a), the Secretary of Health and Human Services
(in this subsection as the ``Secretary'') shall promulgate a regulation
and section 1882(g)(2)(A) of the Social Security Act shall be applied
in each State, effective for policies issued to policyholders on and
after the date specified in paragraph (3), as if the reference to the
Model Regulation adopted in June 6, 1979, were a reference to the 1991
NAIC Model Regulation (as so defined) as changed by the Secretary under
this paragraph (such changed Regulation referred to in this subsection
as the ``1995 Federal Regulation'').
(c) Date Specified.--
(1) In general.--Subject to paragraph (2), the date
specified in this subsection for a State is the earlier of--
(A) the date the State adopts the 1995 NAIC Model
Regulation or the 1995 Federal Regulation; or
(B) 1 year after the date the NAIC or the Secretary
first adopts such regulations.
(2) Additional legislative action required.--In the case of
a State which the Secretary identifies, in consultation with
the NAIC, as--
(A) requiring State legislation (other than
legislation appropriating funds) in order for medicare
supplemental policies to meet the 1995 NAIC Model
Regulation or the 1995 Federal Regulation, but
(B) having a legislature which is not scheduled to
meet in 1995 in a legislative session in which such
legislation may be considered,
the date specified in this subsection is the first day of the
first calendar quarter beginning after the close of the first
legislative session of the State legislature that begins on or
after January 1, 1995. For purposes of the previous sentence,
in the case of a State that has a 2-year legislative session,
each year of such session shall be deemed to be a separate
regular session of the State legislature.
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