[Congressional Bills 104th Congress]
[From the U.S. Government Publishing Office]
[S. 2167 Introduced in Senate (IS)]







104th CONGRESS
  2d Session
                                S. 2167

 To require that health plans provide coverage for medically necessary 
health care and related services for children who are age 3 or younger, 
                        and for other purposes.


_______________________________________________________________________


                   IN THE SENATE OF THE UNITED STATES

                           September 30, 1996

  Mr. Kerrey introduced the following bill; which was read twice and 
         referred to the Committee on Labor and Human Resources

_______________________________________________________________________

                                 A BILL


 
 To require that health plans provide coverage for medically necessary 
health care and related services for children who are age 3 or younger, 
                        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.

    This Act may be cited as the ``Children's Health Insurance for 
Long-Term Development Act of 1996''.

SEC. 2. PURPOSE.

    The purpose of this act is to provide health insurance coverage for 
children during the Infant Neurological Risk Exposure Period (INREP). 
The INREP extends through age 3 and encompasses the period of most 
rapid neurological changes in young children. Health coverage will 
improve children's health and, through routine health supervision, 
promote parents' caregiving skills through these critical years.

SEC. 3. FINDINGS.

    Congress finds that--
            (1) 86 percent of children with private health insurance 
        are under-insured with respect to well-child care;
            (2) because the human brain develops rapidly until the age 
        of 3, children need regular screenings and follow-up care to 
        detect neurological abnormalities and ensure normal 
        development;
            (3) regular pediatric visits enable physicians to provide 
        guidance on parental activities, such as reading, that 
        stimulate the brain development of infants; and
            (4) children deserve health care coverage that promotes 
        normal brain and nervous system development.

SEC. 4. DEFINITIONS.

    As used in this Act:
            (1) Beneficiary.--The term ``beneficiary'' has the meaning 
        given such term under section 3(8) of the Employee Retirement 
        Income Security Act of 1974 (29 U.S.C. 1002(8)).
            (2) Child.--The term ``child'' means an individual who is 
        age 3 or younger.
            (3) Employee health benefit plan.--
                    (A) In general.--The term ``employee health benefit 
                plan'' means any employee welfare benefit plan, 
governmental plan, or church plan (as defined under paragraphs (1), 
(32), and (33) of section 3 of the Employee Retirement Income Security 
Act of 1974 (29 U.S.C. 1002 (1), (32), and (33))) that provides or pays 
for health benefits (such as provider and hospital benefits) for 
participants and beneficiaries whether--
                            (i) directly;
                            (ii) through a health plan offered by a 
                        health plan issuer as defined in paragraph (6); 
                        or
                            (iii) otherwise.
                    (B) Rule of construction.--An employee health 
                benefit plan shall not be construed to be a health plan 
                or a health plan issuer.
                    (C) Arrangements not included.--Such term does not 
                include the following, or any combination thereof:
                            (i) Coverage only for accident, or 
                        disability income insurance, or any combination 
                        thereof.
                            (ii) Medicare supplemental health insurance 
                        (as defined under section 1882(g)(1) of the 
                        Social Security Act (42 U.S.C. 1395ss(g)(1))).
                            (iii) Coverage issued as a supplement to 
                        liability insurance.
                            (iv) Liability insurance, including general 
                        liability insurance and automobile liability 
                        insurance.
                            (v) Workers' compensation or similar 
                        insurance.
                            (vi) Automobile medical payment insurance.
                            (vii) Coverage for a specified disease or 
                        illness.
                            (viii) Hospital or fixed indemnity 
                        insurance.
                            (ix) Short-term limited duration insurance.
                            (x) Credit-only, dental-only, or vision-
                        only insurance.
                            (xi) A health insurance policy providing 
                        benefits only for long-term care, nursing home 
care, home health care, community-based care, or any combination 
thereof.
            (4) Group purchaser.--The term ``group purchaser'' means 
        any person (as defined in section 3(9) of the Employee 
        Retirement Income Security Act of 1974 (29 U.S.C. 1002(9))) or 
        entity that purchases or pays for health benefits (such as 
        provider or hospital benefits) on behalf of participants or 
        beneficiaries in connection with an employee health benefit 
        plan.
            (5) Health plan.--
                    (A) In general.--The term ``health plan'' means any 
                group health plan or individual health plan.
                    (B) Group health plan.--The term ``group health 
                plan'' means any contract, policy, certificate, or 
                other arrangement offered by a health plan issuer to a 
                group purchaser that provides or pays for health 
                benefits (such as provider and hospital benefits) in 
                connection with an employee health benefit plan.
                    (C) Individual health plan.--The term ``individual 
                health plan'' means any contract, policy, certificate, 
                or other arrangement offered by a health plan issuer to 
                individuals that provides or pays for health benefits 
                (such as provider and hospital benefits) and that is 
                not a group health plan.
                    (D) Arrangements not included.--Such term does not 
                include the following, or any combination thereof:
                            (i) Coverage only for accident, or 
                        disability income insurance, or any combination 
                        thereof.
                            (ii) Medicare supplemental health insurance 
                        (as defined under section 1882(g)(1) of the 
                        Social Security Act).
                            (iii) Coverage issued as a supplement to 
                        liability insurance.
                            (iv) Liability insurance, including general 
                        liability insurance and automobile liability 
                        insurance.
                            (v) Workers' compensation or similar 
                        insurance.
                            (vi) Automobile medical payment insurance.
                            (vii) Coverage for a specified disease or 
                        illness.
                            (viii) Hospital or fixed indemnity 
                        insurance.
                            (ix) Short-term limited duration insurance.
                            (x) Credit-only, dental-only, or vision-
                        only insurance.
                            (xi) A health insurance policy providing 
                        benefits only for long-term care, nursing home 
                        care, home health care, community-based care, 
                        or any combination thereof.
                    (E) Certain plans included.--Such term includes any 
                plan or arrangement not described in any clause of 
                subparagraph (D) that provides for benefit payments, on 
                a periodic basis, for--
                            (i) a specified disease or illness; or
                            (ii) a period of hospitalization;
                without regard to the costs incurred or services 
                rendered during the period to which the payments 
                relate.
            (6) Health plan issuer.--The term ``health plan issuer'' 
        means any entity that is licensed (prior to or after the date 
        of enactment of this Act) by a State to offer a health plan.
            (7) Participant.--The term ``participant'' has the meaning 
        given such term under section 3(7) of the Employee Retirement 
        Income Security Act of 1974 (29 U.S.C. 1002(7)).
            (8) Secretary.--The term ``Secretary'' unless otherwise 
        specified means the Secretary of Labor.

SEC. 5. REQUIRED HEALTH CARE COVERAGE FOR CHILDREN.

    (a) In General.--Except as provided in subsection (b), a health 
plan or an employee health benefit plan shall ensure that coverage is 
provided with respect to a child who is a beneficiary under such plan 
for all medically necessary health care and related services, 
including--
            (1) appropriate screening services at intervals that meet 
        reasonable standards of medical and dental practice;
            (2) all appropriate immunizations;
            (3) necessary case management, transportation, and 
        scheduling assistance; and
            (4) such other necessary health care, diagnostic services, 
        treatment, and other measures to correct or ameliorate defects 
        and physical and mental illnesses and conditions discovered by 
        the screening services, whether or not such services are 
        covered for participants or policyholders under the plan.
    (b) Exception.--Notwithstanding subsection (a), a health plan or an 
employee health benefit plan shall not be required to provide coverage 
for health care and related services that are not safe, are not 
effective, or are experimental.

SEC. 6. PROHIBITIONS.

    In implementing the requirements of this Act, a health plan or an 
employee health benefit plan may not use a service limitation, 
including a lifetime benefit limit, of the plan to deny medically 
necessary health care and related services described in section 4 to a 
child.

SEC. 7. NOTICE.

    (a) Employee Health Benefit Plan.--An employee health benefit plan 
shall provide conspicuous notice to each participant regarding coverage 
required under this Act not later than 120 days after the date of 
enactment of this Act, and as part of its summary plan description.
    (b) Health Plan.--A health plan shall provide notice to each 
policyholder regarding coverage required under this Act. Such notice 
shall be in writing, prominently positioned, and be transmitted--
            (1) in a mailing made within 120 days after the date of 
        enactment of this Act by such plan to the policyholder; and
            (2) as part of the annual informational packet sent to the 
        policyholder.

SEC. 8. APPLICABILITY.

    (a) Construction.--
            (1) In general.--A requirement or standard imposed under 
        this Act on a health plan shall be deemed to be a requirement 
        or standard imposed on the health plan issuer. Such 
        requirements or standards shall be enforced by the State 
        insurance commissioner for the State involved or the official 
        or officials designated by the State to enforce the 
        requirements of this Act. In the case of a health plan offered 
        by a health plan issuer in connection with an employee health 
        benefit plan, the requirements or standards imposed under this 
        Act shall be enforced with respect to the health plan issuer by 
        the State insurance commissioner for the State involved or the 
        official or officials designated by the State to enforce the 
        requirements of this Act.
            (2) Limitation.--Except as provided in section 8(c), the 
        Secretary shall not enforce the requirements or standards of 
        this Act as they relate to health plan issuers or health plans. 
        In no case shall a State enforce the requirements or standards 
        of this Act as they relate to employee health benefit plans.
    (b) Rule of Construction.--Nothing in this Act shall be construed 
to affect or modify the provisions of section 514 of the Employee 
Retirement Income Security Act of 1974 (29 U.S.C. 1144).

SEC. 9. ENFORCEMENT.

    (a) Health Plan Issuers.--Each State shall require that each health 
plan issued, sold, renewed, offered for sale or operated in such State 
by a health plan issuer meet the standards established under this Act. 
A State shall submit such information as required by the Secretary 
demonstrating effective implementation of the requirements of this Act.
    (b) Employee Health Benefit Plans.--With respect to employee health 
benefit plans, the standards established under this Act shall be 
enforced in the same manner as provided for under sections 502, 504, 
506, and 510 of the Employee Retirement Income Security Act of 1974 (29 
U.S.C. 1132, 1134, 1136, and 1140). The civil penalties contained in 
paragraphs (1) and (2) of section 502(c) of such Act (29 U.S.C. 1132(c) 
(1) and (2)) shall apply to any information required by the Secretary 
to be disclosed and reported under this section.
    (c) Failure To Enforce.--In the case of the failure of a State to 
substantially enforce the standards and requirements set forth in this 
Act with respect to health plans, the Secretary, in consultation with 
the Secretary of Health and Human Services, shall enforce the standards 
of this Act in such State. In the case of a State that fails to 
substantially enforce the standards set forth in this Act, each health 
plan issuer operating in such State shall be subject to civil 
enforcement as provided for under sections 502, 504, 506, and 510 of 
the Employee Retirement Income Security Act of 1974 (29 U.S.C. 1132, 
1134, 1136, and 1140). The civil penalties contained in paragraphs (1) 
and (2) of section 502(c) of such Act (29 U.S.C. 1132(c)(1) and (2)) 
shall apply to any information required by the Secretary to be 
disclosed and reported under this section.
    (d) Regulations.--The Secretary, in consultation with the Secretary 
of Health and Human Services, may promulgate such regulations as may be 
necessary or appropriate to carry out this Act.

SEC. 10. PREEMPTION.

    (a) In General.--The provisions of sections 4, 5, and 6 shall not 
preempt a State law or regulation--
            (1) that provides greater protections to patients or 
        policyholders than those required in this Act; or
            (2) that requires health plans to provide coverage for 
        pediatric care in accordance with guidelines established by the 
        American Academy of Pediatrics or other established 
        professional medical associations.
    (b) Employee Health Benefit Plans.--Nothing in this section affects 
the application of this Act to employee health benefit plans, as 
defined in section 2(3).

SEC. 11. EFFECTIVE DATE.

    Except as otherwise provided for in this Act, the provisions of 
this Act shall apply as follows:
            (1) With respect to health plans, such provisions shall 
        apply to such plans on the first day of the contract year 
        beginning on or after June 1, 1997.
            (2) With respect to employee health benefit plans, such 
        provisions shall apply to such plans on the first day of the 
        first plan year beginning on or after June 1, 1997.
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