HIV AIDS Resource Guide/HIV-AIDS Resource Guide.iso/STAT/PROP_FED/HSA01_3.ASC

Text File | 1993-01-14 | 87KB | 2,034 lines

/* Part 3 of 4 of Title I follows. */

            Section 1373   APPLICATION FOR PREMIUM DISCOUNTS
AND REDUCTION IN LIABILITIES TO ALLIANCES.
 (a)  In General. Any regional alliance eligible family may
apply for a determination of the family adjusted income of
the family, for the purpose of establishing eligibility for
a premium discount under section 6104 or a reduction in
liability under section 6113.

    (b)  Timing. Such an application may be filed at such
times as an application for a cost sharing reduction may be
filed under section 1372(b) and also may be filed after the
end of the year to obtain a rebate for excess premium
payments made during a year.

    (c)  Approval of Application.

        (1)  In general. A regional alliance shall approve
an application of a family under this section filed in a
month

            (A)  for a premium discount under section 6104,
if the application demonstrates that family adjusted income
of the family (as determined under paragraph (2)) is (or is
expected to be) less than 150 percent of the applicable
poverty level, or

            (B)  for a reduction in liability under section
6113, if the application demonstrates that the wage-adjusted
income (as defined in subsection 6113(d)) of the family (as
determined under paragraph (2)) is (or is expected to be)
less than 250 percent of the applicable poverty level.

        (2)  Use of current income. In making the
determination under paragraph (1), a regional alliance shall
take into account the income for the previous 3-month period
and current wages from employment (if any) and the statement
of estimated income for the year (filed under section
1374(c)), consistent with rules specified by the Secretary.

 (d)  Requirement for Periodic Confirmation and Verification
and Notices. The provisions of subsection (e) of section
1372 shall apply under this section in the same manner as it
applies under such section, except that any reference to
family adjusted income is deemed a reference to wage-
adjusted income.

            Section 1374   GENERAL PROVISIONS RELATING TO
APPLICATION PROCESS.

  (a)  Distribution of Applications. Each regional alliance
shall distribute applications under this subpart directly to
consumers and through employers, banks, and designated
public agencies.

   (b)  To Whom Application Made. Applications under this
subpart shall be filed, by person or mail, with a regional
alliance or an agency designated by the State for this
purpose. The application may be submitted with an
application to enroll with a health plan under this subtitle
or separately.

    (c)  Income Statement. Each application shall include a
declaration of estimated annual income for the year
involved.

  (d)  Form and Contents. An application for a discount or
reduction under this subpart shall be in a form and manner
specified by the Secretary and shall require the provision
of information necessary to make the determinations required
under this subpart.
    (e)  Frequency of Applications.
        (1)  In general. An application under this subpart
may be filed at any time during the year (including, in the
case of section 1373, during the reconciliation process).
        (2)  Correction of income. Nothing in paragraph (1)
shall be construed as preventing an individual or family
from, at any time, submitting an application to reduce the
amount of premium discount or reduction of liability under
this subpart based upon an increase in income from that
stated in the previous application.
    (f)  Timing of Reductions and Discounts.
        (1)  In general. Subject to reconciliation under
section 1375, premium discounts and cost sharing reductions
under this subpart shall be applied to premium payments
required (and for expenses incurred) after the date of
approval of the application under this subpart.
        (2)  AFDC and ssi recipients. In the case of an AFDC
or SSI family, in applying paragraph (1), the date of
approval of benefits under the AFDC or SSI program shall be
considered the date of approval of an application under this
subpart.
    (g)  Verification. The Secretary shall provide for
verification, on a sample basis or other basis, of the
information supplied in applications under this part. This
verification shall be separate from the reconciliation
provided under section 1375.
    (h)  Help in Completing Applications. Each regional
alliance shall assist individuals in the filing of
applications and income reconciliation statements under this
subpart.
    (i)  Penalties for Inaccurate Information.
        (1)  Interest for understatements. Each individual
who knowingly understates income reported in an application
to a regional alliance under this subpart or otherwise makes
a material misrepresentation of information in such an
application shall be liable to the alliance for excess
payments made based on such understatement or
misrepresentation, and for interest on such excess payments
at a rate specified by the Secretary.
        (2)  Penalties for misrepresentation. In addition to
the liability established under paragraph (1), each
individual who knowingly misrepresents material information
in an application under this subpart to a regional alliance
shall be liable to the State in which the alliance is
located for $2,000 or, if greater, three times the excess
payments made based on such misrepresentation. The State
shall provide for the transfer of a significant portion of
such amount to the regional alliance involved.
            Section 1375   END-OF-YEAR RECONCILIATION FOR
PREMIUM DISCOUNT AND REPAYMENT REDUCTION WITH ACTUAL INCOME.
    (a)  In General. In the case of a family whose
application for a premium discount or reduction of liability
for a year has been approved before the end of the year
under this subpart, the
family shall, subject to subsection (c) and by the deadline
specified in section 1344(b) file with the regional alliance
an income reconciliation statement to verify the family's
adjusted income or wage-adjusted income, as the case may be,
for the previous year. Such a statement shall contain such
information as the Secretary may specify. Each regional
alliance shall coordinate the submission of such statements
with the notice and payment of family payments due under
section 1344.

    (b)  Reconciliation of Premium Discount and Liability
Assistance Based on Actual Income. Based on and using the
income reported in the reconciliation statement filed under
subsection (a) with respect to a family, the regional
alliance shall compute the amount of premium discount or
reduction in liability that should have been provided under
section 6104 or section 6113 with respect for the family for
the year involved. If the amount of such discount or
liability reduction computed is

        (1)  greater than the amount that has been provided,
the family is liable to the regional alliance to pay
(directly or through an increase in future family share of
premiums or other payments) a total amount equal to the
amount of the excess payment, or

        (2)  less than the amount that has been provided,
the regional alliance shall pay to the family (directly or
through a reduction in future family share of premiums or
other payments) a total amount equal to the amount of the
deficit.

    (c)  No Reconciliation for AFDC and SSI Families; No
Reconciliation for Cost Sharing Reductions. No
reconciliation statement is required under this section

        (1)  with respect to cost sharing reductions
provided under section 1372, or

        (2)  for a family that only claims a premium
discount or liability reduction under this subpart on the
basis of being an AFDC or SSI family.

    (d)  Disqualification for Failure to File. In the case
of any family that is required to file a statement under
this section in a year and that fails to file such a
statement by the deadline specified, members of the family
shall not be eligible for premium reductions under section
6104 or reductions in liability under section 6113 until
such statement is filed. A regional alliance, using rules
established by the Secretary, shall waive the application of
this subsection if the family establishes, to the
satisfaction of the alliance under such rules, good cause
for the failure to file the statement on a timely basis.

    (e)  Penalties for False Information. Any individual
that provides false information in a statement under
subsection (a) is subject to the same liabilities as are
provided under section 1374(h) for a misrepresentation of
material fact described in such section.

    (f)  Notice of Requirement. Each regional alliance
(directly or in coordination with other regional alliances)
shall provide for written notice, at the end of each year,
of the requirement of this section to each family which had
received premium discount or reduction in liability under
this subpart in any month during the preceding year and to
which such requirement applies.

    (g)  Transmittal of Information; Verification.

        (1)  In general. Each participating State shall
transmit annually to the Secretary such information relating
to the income of families for the previous year as the
Secretary may require to verify such income under this
subpart.
        (2)  Verification. Each participating State may use
such information as it has available to it to assist
regional alliances in verifying income of families with
applications filed under this subpart. The Secretary of the
Treasury may, consistent with section 6103 of the Internal
Revenue Code of 1986, permit return information to be
disclosed and used by a participating State in verifying
such income but only in accordance with such section and
only if the information is not directly disclosed to a
regional alliance.
    (h)  Construction. Nothing in this section shall be
construed as authorizing reconciliation of any cost sharing
reduction provided under this subpart.
    Part 4   RESPONSIBILITIES AND AUTHORITIES OF CORPORATE
ALLIANCES

         Section 1381   CONTRACTS WITH HEALTH PLANS.

  (a)  Contracts with Plans. Subject to section 1382, each
corporate alliance may

        (1)  offer to individuals eligible to enroll under
section 1311(c) coverage under an appropriate self-insured
health plan (as defined in section 1400(b)), or

        (2)  negotiate with a State-certified health plan to
enter into a contract with the plan for the enrollment of
such individuals under the plan, or do both.

    (b)  Terms of Contracts with State-Certified Health
Plans. Contracts under this section between a corporate
alliance and a State-certified health plan may contain such
provisions (not inconsistent with the requirements of this
title) as the alliance and plan may provide, except that in
no case does such contract remove the obligation of the
sponsor of the corporate alliance to provide for health
benefits to corporate alliance eligible individuals
consistent with this part.

            Section 1382   OFFERING CHOICE OF HEALTH PLANS
FOR ENROLLMENT.

    (a)  In General. Each corporate alliance must provide to
each eligible enrollee with respect to the alliance a choice
of health plans among the plans which have contracts with
the alliance under section 1381.

    (b)  Offering of Plans by Alliances. A corporate
alliance shall include among its health plan offerings for
any eligible enrollee at least 3 health plans to enrollees,
of which the alliance must offer

        (1)  at least one fee-for-service plan (as defined
in section 1322(b)(2)); and

        (2)  at least two health plans that are not fee-for
service plans.

            Section 1383   ENROLLMENT; ISSUANCE OF HEALTH
SECURITY CARD.

    (a)  In General.

        (1)  Enrollment of alliance eligible individuals.
Each corporate alliance shall assure that each alliance
eligible individual with respect to the alliance is enrolled
in a corporate alliance health plan offered by the alliance,
and shall establish and maintain methods and procedures
consistent with this section sufficient to assure such
enrollment. Such methods and procedures shall assure the
enrollment of such individuals at the time they first become
alliance eligible individuals with respect to the alliance.

        (2)  Issuance of health security cards. A corporate
alliance is responsible for the issuance of health security
cards to corporate alliance eligible individuals under
section 1001(b).

  (b)  Response to Point-of-Service Notices. If a corporate
alliance is notified under section 1323(b)(2) regarding an
individual who has received services and appears to be a
corporate alliance eligible individual

       (1)   the alliance shall promptly ascertain the
individual's eligibility as a corporate alliance eligible
individual; and

        (2)  if the alliance determines that the individual
is a corporate alliance eligible individual

            (A)  the alliance shall promptly provide for the
enrollment of the individual in a health plan offered by the
alliance (and notify the Secretary of Labor of such
enrollment), and

            (B)  the alliance shall forward the claim for
payment for the services to the health plan in which the
individual is so enrolled and the plan shall make payment to
the provider for such claim (in a manner consistent with
requirements of the Secretary of Labor).

 (c)  Annual Open Enrollment; Enrollment of Family Members;
Oversubscription of Plans. The provisions of subsections (d)
through (f) of section 1323 shall apply to a corporate
alliance in the same manner as such provisions apply to a
regional alliance.

    (d)  Termination.

        (1)  In general. The provisions of section
1323(g)(1) shall apply to a corporate alliance in the same
manner as such provisions apply to a regional alliance.

        (2)  Failure to pay premiums. If a corporate
alliance fails to make premium payments to a health plan,
the plan, after reasonable written notice to the alliance
and the Secretary of Labor, may terminate coverage (and any
contract with the alliance under this part). If such
coverage is terminated the corporate alliance is responsible
for the prompt enrollment of alliance eligible individuals
whose coverage is terminated in another corporate alliance
health plan.

 (e)  Corporate Alliance Transition. Each corporate alliance
must provide coverage

      (1)  as of the first day of any month in which an
individual first becomes a corporate alliance eligible
individual, and

        (2)  through the end of the month in the case of a
corporate alliance eligible individual who loses such
eligibility during the month.

            Section 1384   COMMUNITY-RATED PREMIUMS WITHIN
PREMIUM AREAS.

 (a)  Application of Community-Rated Premiums. The premiums
charged by a corporate alliance for enrollment in a
corporate alliance health plan (not taking into account any
employer premium payment required under section 6131) shall
vary only by class of family enrollment (specified in
section 1011(c)) and by premium area.

    (b)  Designation of Premium Areas.

        (1)  Designation. Each corporate alliance shall
designate premium areas to be used for the imposition of
premiums (and calculation of employer premium payments)
under this Act.

     (2)  Conditions. The boundaries of such areas shall
reasonably reflect labor market areas or health care
delivery areas and shall be consistent with rules the
Secretary of Labor establishes (consistent with paragraph
(3)) so that within such areas there are not substantial
differences in average per capita health care expenditures.

        (3)  Anti-redlining. The provisions of paragraphs
(4) and (5) of section 1202(b) (relating to redlining and
metropolitan statistical areas) shall apply to the
establishment of premium areas in the same manner as they
apply to the establishment of the boundaries of regional
alliance areas.

    (c)  Applications of Classes of Enrollment.

        (1)  In general. The premiums shall be applied under
this section based on class of family enrollment and shall
vary based on such class in accordance with factors
specified by the corporate alliance.

        (2)  Basis for factors. Such factors shall be the
same in each premium area and shall take into account such
appropriate considerations (including the considerations the
Board takes into account in the establishment of premium
class factors under section 1531 and the costs of regional
alliance health plans providing the comprehensive benefit
package for families enrolled in the different classes) as
the alliance considers appropriate, consistent with rules
the Secretary of Labor establishes.

    (d)  Special Treatment of Multiemployer Alliances. The
Secretary of Labor shall provide for such exceptions to the
requirements of this section in the case of a corporate
alliance with a sponsor described in section 1311(b)(1)(B)
as may be appropriate to reflect the unique and historical
relationship between the employers and employees under such
alliances.

            Section 1385   ASSISTANCE FOR LOW-WAGE FAMILIES.

    Each corporate alliance shall make an additional
contribution towards the enrollment in health plans of the
alliance by certain low-wage families in accordance with
section 6131(b)(2).

            Section 1386   CONSUMER INFORMATION AND
MARKETING; DATA COLLECTION AND QUALITY; ADDITIONAL DUTIES.

  The provisions of sections 1325(a), 1327, and 1328 shall
apply to a corporate alliance in the same manner as such
provisions apply to a regional alliance.

            Section 1387   PLAN AND INFORMATION
REQUIREMENTS.
    (a)  In General. A corporate alliance shall provide a
written submission to the Secretary of Labor (in such form
as the Secretary may require) detailing how the corporate
alliance will carry out its activities under this part.
 (b)  Annual Information. A corporate alliance shall provide
to the Secretary of Labor each year, in such form and manner
as the Secretary may require, such information as the
Secretary may require in order to monitor the compliance of
the alliance with the requirements of this part.

    (c)  Annual Notice of Employees or Participants.

        (1)  Corporate alliance. Each corporate alliance
shall submit to the Secretary of Labor, by not later than
March 1 of each year, information on the number of full-time
employees or participants obtaining coverage through the
alliance as of January 1 of that year.

        (2)  Employers that become large employers. Each
employer that is not a corporate alliance but employs 5,000
full-time employees as of January 1 of a year, shall submit
to the Secretary of Labor, by not later than March 1 of the
year, information on the number of such employees.

            Section 1388   MANAGEMENT OF FUNDS; RELATIONS
WITH EMPLOYEES.

    (a)  Management of Funds. The management of funds by a
corporate alliance shall be subject to the applicable
fiduciary requirements of part 4 of subtitle B of title I of
the Employee Retirement Income Security Act of 1974,
together with the applicable enforcement provisions of part
5 of subtitle B of title I of such Act.

 (b)  Management of Finances and Records; Accounting System.
Each corporate alliance shall comply with standards relating
to the management of finances and records and accounting
systems as the Secretary of Labor shall specify.

            Section 1389   COST CONTROL.

    Each corporate alliance shall control covered
expenditures in a manner that meets the requirements of part
2 of subtitle A of title VI.

            Section 1390   PAYMENTS BY CORPORATE ALLIANCE
EMPLOYERS TO CORPORATE ALLIANCES.

    (a)  Large Employer Alliances. In the case of a
corporate alliance with a sponsor described in section
1311(b)(1)(A), the sponsor shall provide for the funding of
benefits, through insurance or otherwise, consistent with
section 6131, the applicable solvency requirements of
sections 1394, 1395, and 1396, and any rules established by
the Secretary of Labor.

    (b)  Other Alliances. In the case of a corporate
alliance with a sponsor described in subparagraph (B) or (C)
of section 1311(b)(1), a corporate alliance employer shall
make payment of
the employer premiums required under section 6131 under
rules established by the corporate alliance, which rules
shall be consistent with rules established by the Secretary
of Labor.
          Section 1391   COORDINATION OF PAYMENTS.
    (a)  Payments of Certain Amounts to Regional Alliances.
In the case of a married couple in which one spouse is a
qualifying employee of a regional alliance employer and the
other spouse is a qualifying employee of a corporate
alliance employer, if the couple is enrolled with a regional
alliance health plan, the corporate alliance (which receives
employer premium payments from such corporate alliance
employer with respect to such employee) shall pay to the
regional alliance the amounts so paid.
    (b)  Payments of Certain Amounts to Corporate Alliances.
In the case of a married couple in which one spouse is a
qualifying employee of a corporate alliance employer and the
other spouse is a qualifying employee of another corporate
alliance employer, the corporate alliance of the corporate
alliance health plan in which the couple is not enrolled
shall pay to the corporate alliance of the plan in which the
couple is enrolled any employer premium payments received
from such corporate alliance employer with respect to such
employee.
            Section 1392   APPLICABILITY OF ERISA
ENFORCEMENT MECHANISMS FOR ENFORCEMENT OF CERTAIN
REQUIREMENTS.
    The provisions of sections 502 (relating to civil
enforcement) and 504 (relating to investigative authority)
of the Employee Retirement Income Security Act of 1974
shall apply to enforcement by the Secretary of Labor of this
part in the same manner and to same extent as such
provisions apply to enforcement of title I of such Act.
            Section 1393   APPLICABILITY OF CERTAIN ERISA
PROTECTIONS TO ENROLLED INDIVIDUALS.
    The provisions of sections 510 (relating to interference
with rights protected under Act) and 511 (relating to
coercive interference) of the Employee Retirement Income
Security Act of 1974 shall apply, in relation to the
provisions of this Act, with respect to individuals enrolled
under corporate alliance health plans in the same manner and
to the same extent as such provisions apply, in relation to
the provisions of the Employee Retirement Income Security
Act of 1974, with respect to participants and beneficiaries
under employee welfare benefit plans covered by title I of
such Act.
            Section 1394   DISCLOSURE AND RESERVE
REQUIREMENTS.
    (a)  In General. The Secretary of Labor shall ensure
that each corporate alliance health plan which is a self-
insured plan maintains plan assets in trust as provided in
section 403 of the Employee Retirement Income Security Act
of 1974
        (1)  without any exemption under section 403(b)(4)
of such Act, and
     (2)  in amounts which the Secretary determines are
sufficient to provide at any time for payment to health care
providers of all outstanding balances owed by the plan at
such time. The requirements of the preceding sentence may be
met through letters of credit, bonds, or other appropriate
security to the extent provided in regulations of the
Secretary.

    (b)  Disclosure. Each self-insured corporate alliance
health plan shall notify the Secretary at such time as the
financial reserve requirements of this section are not being
met. The Secretary may assess a civil money penalty of not
more than $100,000 against any corporate alliance for any
failure to provide such notification in such form and manner
and within such time periods as the Secretary may prescribe
by regulation.
            Section 1395   TRUSTEESHIP BY THE SECRETARY OF
INSOLVENT CORPORATE ALLIANCE HEALTH PLANS.
    (a)  Appointment of Secretary as Trustee for Insolvent
Plans. Whenever the Secretary of Labor determines that a
corporate alliance health plan which is a self-insured plan
will be unable to provide benefits when due or is otherwise
in a financially hazardous condition as defined in
regulations of the Secretary, the Secretary shall, upon
notice to the plan, apply to the appropriate United States
district court for appointment of the Secretary as trustee
to administer the plan for the duration of the insolvency.
The plan may appear as a party and other interested persons
may intervene in the proceedings at the discretion of the
court. The court shall appoint the Secretary trustee if the
court determines that the trusteeship is necessary to
protect the interests of the enrolled individuals or health
care providers or to avoid any unreasonable deterioration of
the financial condition of the plan or any unreasonable
increase in the liability of the Corporate Alliance Health
Plan Insolvency Fund. The trusteeship of the Secretary shall
continue until the conditions described in the first
sentence of this subsection are remedied or the plan is
terminated.
    (b)  Powers as Trustee. The Secretary of Labor, upon
appointment as trustee under subsection (a), shall have the
power
        (1)  to do any act authorized by the plan, this Act,
or other applicable provisions of law to be done by the plan
administrator or any trustee of the plan,
        (2)  to require the transfer of all (or any part) of
the assets and records of the plan to the Secretary as
trustee,
        (3)  to invest any assets of the plan which the
Secretary holds in accordance with the provisions of the
plan, regulations of the Secretary, and applicable
provisions of law,
        (4)  to do such other acts as the Secretary deems
necessary to continue operation of the plan without
increasing the potential liability of the Corporate Alliance
Health Plan Insolvency Fund, if such acts may be done under
the provisions of the plan,
      (5)  to require the corporate alliance, the plan
administrator, any contributing employer, and any employee
organization representing covered individuals to furnish any
information with respect to the plan which the Secretary as
trustee may reasonably need in order to administer the plan,

        (6)  to collect for the plan any amounts due the
plan and to recover reasonable expenses of the trusteeship,

        (7)  to commence, prosecute, or defend on behalf of
the plan any suit or proceeding involving the plan,

        (8)  to issue, publish, or file such notices,
statements, and reports as may be required under regulations
of the Secretary or by any order of the court,

        (9)  to terminate the plan and liquidate the plan
assets in accordance with applicable provisions of this Act
and other provisions of law, to restore the plan to the
responsibility of the corporate alliance, or to continue the
trusteeship,

        (10)  to provide for the enrollment of individuals
covered under the plan in an appropriate regional alliance
health plan, and

        (11)  to do such other acts as may be necessary to
comply with this Act or any order of the court and to
protect the interests of enrolled individuals and health
care providers.

    (c)  Notice of Appointment. As soon as practicable after
the Secretary's appointment as trustee, the Secretary shall
give notice of such appointment to

        (1)  the plan administrator,

        (2)  each enrolled individual,

        (3)  each employer who may be liable for
contributions to the plan, and

        (4)  each employee organization which, for purposes
of collective bargaining, represents enrolled individuals.

    (d)  Additional Duties. Except to the extent
inconsistent with the provisions of this Act or part 4 of
subtitle B of title I of the Employee Retirement Income
Security Act of 1974, or as may be otherwise ordered by the
court, the Secretary of Labor, upon appointment as trustee
under this section, shall be subject to the same duties as
those of a trustee under section 704 of title 11, United
States Code, and shall have the duties of a fiduciary for
purposes of such part 4.

 (e)  Other Proceedings. An application by the Secretary of
Labor under this subsection may be filed notwithstanding the
pendency in the same or any other court of any bankruptcy,
mortgage foreclosure, or equity receivership proceeding, or
any proceeding to reorganize, conserve, or liquidate such
plan or its property, or any proceeding to enforce a lien
against property of the plan.

    (f)  Jurisdiction of Court.

        (1)  In general. Upon the filing of an application
for the appointment as trustee or the issuance of a decree
under this subsection, the court to which the application is
made shall have exclusive jurisdiction of the plan involved
and its property wherever located with the powers, to the
extent consistent with the purposes of this subsection, of a
court of the United States having jurisdiction over cases
under chapter 11 of title 11, United States Code. Pending an
adjudication under this section such court shall stay, and
upon appointment by it of the Secretary of Labor as trustee,
such court shall continue the stay of, any pending mortgage
foreclosure, equity receivership, or other proceeding to
reorganize, conserve, or liquidate the plan, the sponsoring
alliance, or property of such plan or alliance, and any
other suit against any receiver, conservator, or trustee of
the plan, the sponsoring alliance, or property of the plan
or alliance. Pending such adjudication and upon the
appointment by it of the Secretary as trustee, the court may
stay any proceeding to enforce a lien against property of
the plan or the sponsoring alliance or any other suit
against the plan or the alliance.

     (2)  Venue. An action under this subsection may be
brought in the judicial district where the plan
administrator resides or does business or where any asset of
the plan is situated. A district court in which such action
is brought may issue process with respect to such action in
any other judicial district.

    (g)  Personnel. In accordance with regulations of the
Secretary of Labor, the Secretary shall appoint, retain, and
compensate accountants, actuaries, and other professional
service personnel as may be necessary in connection with the
Secretary's service as trustee under this section.
            Section 1396   GUARANTEED BENEFITS UNDER
TRUSTEESHIP OF THE SECRETARY.
    (a)  In General. Subject to subsection (b), the
Secretary of Labor shall guarantee the payment of all
benefits under a corporate alliance health plan which is a
self-insured plan while such plan is under the Secretary's
trusteeship under section 1395.
    (b)  Limitations. Any increase in the amount of benefits
under the plan resulting from a plan amendment which was
made, or became effective, whichever is later, within 180
days (or such other reasonable time as may be prescribed in
regulations of the Secretary of Labor) before the date of
the Secretary's appointment as trustee of the plan shall be
disregarded for purposes of determining the guarantee under
this section.
    (c)  Corporate Alliance Health Plan Insolvency Fund.
      (1)  Establishment. The Secretary of Labor shall
establish a Corporate Alliance Health Plan Insolvency Fund

(hereinafter in this part referred to as the "Fund") from

which the Secretary shall authorize payment of all

guaranteed benefits under this section.

        (2)  Receipts and disbursements.

            (A)  Receipts. The Fund shall be credited with

    (i)  funds borrowed under paragraph (3),

    (ii)  assessments collected under section 1397, and

    (iii)  earnings on investment of the Fund.

            (B)  Disbursements.The Fund shall be available

    (i)  for making such payments as the Secretary of Labor
determines are necessary to pay benefits guaranteed under
this section,


    (ii)  to repay the Secretary of the Treasury such sums
as may be borrowed (together with interest thereon) under
paragraph (3), and


    (iii)  to pay the operational and administrative
expenses of the Fund.


      (3)  Borrowing authority.At the direction of the
Secretary of Labor, the Fund may, to the extent necessary to
carry out the purposes of paragraph (1), issue to the
Secretary of the Treasury notes or other obligations, in
such forms and
denominations, bearing such maturities, and subject to such
terms and conditions as may be prescribed by the Secretary
of the Treasury. The total balance of the Fund obligations
outstanding at any time shall not exceed $500,000,000. Such
notes or other obligations shall bear interest at a rate
determined by the Secretary of the Treasury, taking into
consideration the current average market yield on
outstanding marketable obligations of the United States of
comparable maturities during the month preceding the
issuance of such notes or other obligations by the Fund. The
Secretary of the Treasury shall purchase any notes or other
obligations issued by the Fund under this paragraph, and for
that purpose the Secretary of the Treasury may use as a
public debt transaction the proceeds from the sale of any
securities issued under chapter 31 of title 31, United
States Code and the purposes for which securities may be
issued under such chapter are extended to include any
purchase of such notes and obligations. The Secretary of the
Treasury may at any time sell any of the notes or other
obligations acquired by such Secretary under this paragraph.
All redemptions, purchases, and sales by the Secretary of
the Treasury of such notes or other obligations shall be
treated as public debt transactions of the United States.

        (4)  Investment authority. Whenever the Secretary of
Labor determines that the moneys of the Fund are in excess
of current needs, such Secretary may request the investment
of such amounts as such Secretary determines advisable by
the Secretary of the Treasury in obligations issued or
guaranteed by the United States, but, until all borrowings
under paragraph (3) have been repaid, the obligations in
which such excess moneys are invested may not yield a rate
of return in excess of the rate of interest payable on such
borrowings.

            Section 1397   IMPOSITION AND COLLECTION OF
PERIODIC ASSESSMENTS ON SELF-INSURED CORPORATE ALLIANCE
PLANS.

    (a)  Imposition of Assessments. Upon a determination
that additional receipts to the Fund are necessary in order
to enable the Fund to repay amounts borrowed by the Fund
under section 1396(c)(3) while maintaining a balance
sufficient to ensure the solvency of the Fund, the Secretary
of Labor may impose assessments under this section. The
Secretary shall prescribe from time to time such schedules
of assessment rates and bases for the application of such
rates as may be necessary to provide for such repayments.

    (b)  Uniformity of Assessments. The assessment rates so
prescribed by the Secretary for any period shall be uniform
for all plans, except that the Secretary may vary the amount
of such assessments by category, or waive the application of
such assessments by category, taking into account
differences in the financial solvency of, and financial
reserves maintained by, plans in each category.

  (c)  Limitation on Amount of Assessment. The total amount
assessed against a corporate alliance health plan under this
section during a year may not exceed 2 percent of the total
premiums paid to the plan with respect to corporate alliance
eligible individuals enrolled with the plan during the year.

    (d)  Payment of Assessments.

        (1)  Obligation to pay. The designated payor of each
plan shall pay the assessments imposed by the Secretary of
Labor under this section with respect to that plan when they
are due. Assessments under this section are payable at the
time, and on an estimated, advance, or other basis, as
determined by the
Secretary. Assessments shall continue to accrue until the
plan's assets are distributed pursuant to a termination
procedure or the Secretary is appointed to serve as trustee
of the plan under section 1395.

        (2)  Late payment charges and interest.

            (A)  Late payment charges. If any assessment is
not paid when it is due, the Secretary of Labor may assess a
late payment charge of not more than 100 percent of the
assessment payment which was not timely paid.

            (B)  Waivers. Subparagraph (A) shall not apply
to any assessment payment made within 60 days after the date
on which payment is due, if before such date, the designated
payor obtains a waiver from the Secretary of Labor based
upon a showing of substantial hardship arising from the
timely payment of the assessment. The Secretary may grant a
waiver under this subparagraph upon application made by the
designated payor, but the Secretary may not grant a waiver
if it appears that the designated payor will be unable to
pay the assessment within 60 days after the date on which it
is due.

            (C)  Interest. If any assessment is not paid by
the last date prescribed for a payment, interest on the
amount of such assessment at the rate imposed under section
6601(a) of the Internal Revenue Code of 1986 shall be paid
for the period from such last date to the date paid.

    (e)  Civil Action upon Nonpayment. If any designated
payor fails to pay an assessment when due, the Secretary of
Labor may bring a civil action in any district court of the
United States within the jurisdiction of which the plan
assets are located, the plan is administered, or in which a
defendant resides or is found, for the recovery of the
amount of the unpaid assessment, any late payment charge,
and interest, and process may be served in any other
district. The district courts of the United States shall
have jurisdiction over actions brought under this subsection
by the Secretary without regard to the amount in
controversy.

 (f)  Guarantee Held Harmless. The Secretary of Labor shall
not cease to guarantee benefits on account of the failure of
a designated payor to pay any assessment when due.

    (g)  Designated Payor Defined.

        (1)  In general. For purposes of this section, the
term "designated payor" means--

            (A)  the employer or plan administrator in any
case in which the eligible sponsor of the corporate alliance
health plan is described in subparagraph (A) of section
1311(b)(1); and

         (B)  the contributing employers or the plan
administrator in any case in which the eligible sponsor of
the corporate alliance is described in subparagraph (B) or
(C) of section 1311(b)(1).

        (2)  Controlled groups. If an employer is a member
of a controlled group, each member of such group shall be
jointly and severally liable for any assessments required to
be paid by such employer. For purposes of the preceding
sentence, the term "controlled group" means any group
treated as a single employer under subsection (b), (c), (m),
or (o) of section 414 of the Internal Revenue Code of 1986.

            Section 1398   PAYMENTS TO FEDERAL GOVERNMENT BY
MULTIEMPLOYER CORPORATE ALLIANCES FOR ACADEMIC HEALTH
CENTERS AND GRADUATE MEDICAL EDUCATION.

    (a)  In General. A corporate alliance with an eligible
sponsor described in section 1311(b)(1)(B) shall make
payment to the Secretary of an amount equivalent to the
amount (as estimated based on rules established by the
Secretary and based on the annual per capita expenditure
equivalent calculated under section 6021) that would have
been payable by the alliance under section 1353 if the
alliance were a regional alliance.

    (b)  Reference to Exemption from Assessment. For
provision exempting certain corporate alliance employers
participating in an alliance described in subsection (a)
from an assessment under section 3461 of the Internal
Revenue Code of 1986, as added by section 7121 of this Act,
see section 3461(c)(1) of such Code. Title I, Subtitle E

Subtitle E    Health Plans

            Section 1400   HEALTH PLAN DEFINED.

    (a)  In General. In this Act, the term "health plan"
means a plan that provides the comprehensive benefit package
and meets the requirements of parts 1, 3, and 4 applicable
to health plans.

    (b)  Appropriate Self-Insured Health Plan. In this Act,
the term "appropriate self-insured health plan" means a
group health plan (as defined in section 3(42) of the
Employee Retirement Income Security Act of 1974) which is a
self-insured health plan and with respect to which the
applicable requirements of title I of the Employee
Retirement Income Security Act of 1974 are met.

    (c)  State-Certified Health Plan. In this Act, the term
"State-certified health plan" means a health plan that has
been certified by a State under section 1203(a) (or, in the
case in which the Board is exercising certification
authority under section 1522(b), that has been certified by
the Board).

    (d)  Applicable Regulatory Authority Defined. In this
subtitle, the term "applicable regulatory authority" means

        (1)  with respect to a self-insured health plan, the
Secretary of Labor, or

        (2)  with respect to a State-certified health plan,
the State authority responsible for certification of the
plan.

   Part 1   REQUIREMENTS RELATING TO COMPREHENSIVE BENEFIT
PACKAGE

         Section 1401   APPLICATION OF REQUIREMENTS.

  No plan shall be treated under this Act as a health plan

        (1)  unless the plan is a self-insured plan or a
Statecertified plan; or

        (2)  on and after the effective date of a finding by
the applicable regulatory authority that the plan has failed
to comply with such applicable requirements.

            Section 1402   REQUIREMENTS RELATING TO
ENROLLMENT AND COVERAGE.

    (a)  No Underwriting.
        (1)  In general. Subject to paragraph (2), each
health plan offered by a regional alliance or a corporate
alliance must accept for enrollment every alliance eligible
individual who seeks such enrollment. No plan may engage in
any practice that has the effect of attracting or limiting
enrollees on the basis of personal characteristics, such as
health status, anticipated need for health care, age,
occupation, or affiliation with any person or entity.
     (2)  Capacity limitations. With the approval of the
applicable regulatory authority, a health plan may limit
enrollment because of the plan's capacity to deliver
services or to maintain financial stability. If such a
limitation is imposed, the limitation may not be imposed on
a basis referred to in paragraph (1).

    (b)  No Limits on Coverage; No Pre-Existing Condition
Limits. A health plan may not

     (1)  terminate, restrict, or limit coverage for the
comprehensive benefit package  in any portion of the plan's
service area for any reason, including nonpayment of
premiums;

        (2)  cancel coverage for any alliance eligible
individual until that individual is enrolled in another
applicable health plan;

        (3)  exclude coverage of an alliance eligible
individual because of existing medical conditions;

        (4)  impose waiting periods before coverage begins;
or

        (5)  impose a rider that serves to exclude coverage
of particular individuals.

    (c)  Antidiscrimination.

        (1)  In general. No health plan may discriminate, or
engage (directly or through contractual arrangements) in any
activity, including the selection of a service area, that
has the effect of discriminating, against an individual on
the basis of race, national origin, sex, language, socio-
economic status, age, disability, health status, or
anticipated need for health services.

        (2)  Selection of providers for plan network. In
selecting among providers of health services for membership
in a provider network, or in establishing the terms and
conditions of such membership, a health plan may not engage
in any practice that has the effect of discriminating
against a provider

            (A)  based on the race, national origin, sex,
language, age, or disability of the provider; or
            (B)  based on the socio-economic status,
disability, health status, or anticipated need for health
services of a patient of the provider.
        (3)  Business necessity. Except in the case of
intentional discrimination, it shall not be a violation of
this subsection, or of any regulation issued under this
subsection, for any person to take any action otherwise
prohibited under this subsection, if the action is required
by business necessity.

        (4)  Regulations. Not later than 1 year after the
date of the enactment of this Act, the Secretary of Health
and Human Services shall issue regulations to carry out this
subsection.

    (d)  Requirements for Plans Offering Lower Cost Sharing.
Each health plan that offers enrollees the lower cost
sharing schedule referred to in section 1131

        (1)  shall apply such schedule to all items and
services in the comprehensive benefit package;

        (2)  shall offer enrollees the opportunity to obtain
coverage for out-of-network items and services (as described
in subsection (f)(2)); and

        (3)  notwithstanding section 1403, in the case of an
enrollee who obtains coverage for such items and services,
may charge an alternative premium to take into account such
coverage.

    (e)  Treatment of Cost Sharing.  Each health plan, in
providing benefits in the comprehensive benefit package

        (1)  shall include in its payments to providers,
such additional reimbursement as may be necessary to reflect
cost sharing reductions to which individuals are entitled
under section 1371, and

        (2)  shall maintain such claims or encounter records
as may be necessary to audit the amount of such additional
reimbursements and the individuals for which such
reimbursement is provided.

    (f)  In-Network and Out-of-Network Items and Services
Defined.

        (1)  In-network items and services. For purposes of
this Act, the term "in-network", when used with respect to
items or services described in this subtitle, means items or
services provided to an individual enrolled under a health
plan by a health care provider who is a member of a provider
network of the plan (as defined in paragraph (3)).

        (2)  Out-of-network items and services. For purposes
of this Act, the term "out-of network", when used with
respect to items or services described in this subtitle,
means items or services provided to an individual enrolled
under a health plan by a health care provider who is not a
member of a provider network of the plan (as defined in
paragraph (3)).

        (3)  Provider network defined. A "provider network"
means, with respect to a health plan, providers who have
entered into an agreement with the plan under which such
providers are obligated to provide items and services in the
comprehensive benefit package to individuals enrolled in the
plan, or have an agreement to provide services on a fee-for-
service basis.

    (g)  Relation to Detention. A health plan is not
required to provide any reimbursement to any detention
facility for services performed in that facility for
detainees in the facility.

            Section 1403   COMMUNITY RATING.

 (a)  Regional Alliance Health Plans. Each regional alliance
health plan may not vary the premium imposed with respect to
residents of an alliance area, except as may be required
under
section 6102(a) with respect to different types of
individual and family coverage under the plan.

    (b)  Corporate Alliance Health Plans. Each corporate
alliance health plan may not vary the premium imposed with
respect to individuals enrolled in the plan, except as may
be required under section 1384 with respect to different
types of individual and family coverage under the plan.

          Section 1404   MARKETING OF HEALTH PLANS;
INFORMATION.

    (a)  Regional Alliance Marketing Restrictions.

        (1)  In general. The contract entered into between a
regional alliance and a regional alliance health plan shall
prohibit the distribution by the health plan of marketing
materials within the regional alliance that contain false or
materially misleading information and shall provide for
prior approval by the regional alliance of any marketing
materials to be distributed by the plan.

        (2)  Entire market. A health plan offered by a
regional alliance may not distribute marketing materials to
an area smaller than the entire area served by the plan.

        (3)  Prohibition of tie-ins. A regional alliance
health plan, and any agency of such a plan, may not seek to
influence an individual's choice of plans in conjunction
with the sale of any other insurance.

    (b)  Information Available.

        (1)  In general. Each regional alliance health plan
must provide to the regional alliance and make available to
alliance eligible individuals and health care professionals
complete and timely information concerning the following:

            (A)  Costs.

            (B)  The identity, locations, qualifications,
and availability of participating providers.

            (C)  Procedures used to control utilization of
services and expenditures.

            (D)  Procedures for assuring and improving the
quality of care.

            (E)  Rights and responsibilities of enrollees.

            (F)  Information on the number of plan members
who disenroll from the plan.

        (2)  Prohibition against certification of plans
providing inaccurate information. No regional alliance
health plan may be a State-certified health plan under this
title if the State determines that the plan submitted
materially inaccurate information under paragraph (1).

 (c)  Advance Directives. Each self-insured health plan and
each State-certified health plan shall meet the requirement
of section 1866(f) of the Social Security Act (relating to
maintaining written policies and procedures respecting
advance directives) in the same manner as such requirement
relates to organizations with contracts under section 1876
of such Act.

            Section 1405   GRIEVANCE PROCEDURE.
    (a)  In General. Each health plan must establish a
grievance procedure for enrollees to use in pursuing
complaints. Such procedure shall be consistent with subtitle
C of title V.
    (b)  Additional Remedies. If the grievance procedure
fails to resolve an enrollee's complaint
        (1)  in the case of an enrollee of a regional
alliance health plan, the enrollee has the option of seeking
assistance from the office of the ombudsman for the regional
alliance established under section 1326(a), and
        (2)  the enrollee may pursue additional legal
remedies, including those provided under subtitle C of title
V.
            Section 1406   HEALTH PLAN ARRANGEMENTS WITH
PROVIDERS.
   (a)  Requirement. Each health plan must enter into such
agreements with health care providers or have such other
arrangements as may be necessary to assure the provision of
all services covered by the comprehensive benefit package to
eligible individuals enrolled with the plan.

    (b)  Emergency and Urgent Care Services.

        (1)  In general. Each health plan must cover
emergency and urgent care services provided to enrollees,
without regard to whether or not the provider furnishing
such services has a contractual (or other) arrangement with
the plan to provide items or services to enrollees of the
plan and in the case of emergency services without regard to
prior authorization.

     (2)  Payment amounts. In the case of  emergency and
urgent care provided to an enrollee outside of a health
plan's service area, the payment amounts of the plan shall
be based on the fee for service rate schedule established by
the regional alliance for the alliance area where the
services were provided.

    (c)  Application of Fee Schedule.

        (1)  In general. Subject to paragraph (2), each
regional alliance health plan or corporate alliance health
plan that provides for payment for services on a fee-for-
service basis shall make such payment in the amounts
provided under the fee schedule established by the regional
alliance under section 1322(c) (or, in the case of a plan
offered in a State that has established a Statewide fee
schedule under section 1322(c)(3), under such Statewide fee
schedule).

        (2)  Reduction for providers voluntarily reducing
charges. If a provider under a health plan voluntarily
agrees to reduce the amount charged to an individual
enrolled under the plan, the plan shall reduce the amount
otherwise determined under the fee schedule applicable under
paragraph (1) by the proportion of the reduction in such
amount charged.

     (3)  Reduction for noncomplying plan. Each regional
alliance health plan that is a noncomplying plan shall
provide for reductions in payments under the fee schedule to
providers that are not participating providers in accordance
with section 6012(b).

  (d)  Prohibition Against Balance Billing; Requirement of
Direct Billing.

        (1)  Prohibition of balance billing. A provider may
not charge or collect from an enrollee a fee in excess of
the applicable payment amount under the applicable fee
schedule under subsection (c), and the health plan and its
enrollees are not legally responsible for payment of any
amount in excess of such applicable payment amount for items
and services covered under the comprehensive benefits
package.

        (2)  Direct billing. A provider may not charge or
collect from an enrollee amounts that are payable by the
health plan (including any cost sharing reduction assistance
payable by the plan) and shall submit charges to such plan
in accordance with any applicable requirements of part 1 of
subtitle B of title V (relating to health information
systems).

        (3)  Coverage under agreements with plans. The
agreements or other arrangements entered into under
subsection (a) between a health plan and the health care
providers providing the comprehensive benefit package to
individuals enrolled with the plan shall prohibit a provider
from engaging in balance billing described in paragraph (1).

    (e)  Imposition of Participating Provider Assessment in
Case of a Noncomplying Plan. Each regional alliance health
plan shall provide that if the plan is a noncomplying plan
for a year under section 6012, payments to participating
providers shall be reduced by the applicable network
reduction percentage under such section.

            Section 1407   PREEMPTION OF CERTAIN STATE LAWS
RELATING TO HEALTH PLANS.

    (a)  Laws Restricting Plans Other Than Fee-for-Service
Plans. Except as may otherwise be provided in this section,
no State law shall apply to any services provided under a
health plan that is not a fee-for-service plan (or a fee-for-
service component of a plan) if such law has the effect of
prohibiting or otherwise restricting plans from

        (1)  except as provided in section 1203, limiting
the number and type of health care providers who participate
in the plan;

        (2)  requiring enrollees to obtain health services
(other than emergency services) from participating providers
or from providers authorized by the plan;

      (3)  requiring enrollees to obtain a referral for
treatment by a specialized physician or health institution;

        (4)  establishing different payment rates for
participating providers and providers outside the plan;

      (5)  creating incentives to encourage the use of
participating providers; or

        (6)  requiring the use of single-source suppliers
for pharmacy, medical equipment, and other health products
and services.

    (b)  Preemption of State Corporate Practice Acts. Any
State law related to the corporate practice of medicine and
to provider ownership of health plans or other providers
shall not apply to
arrangements between health plans that are not fee-for-
service plans and their participating providers.

    (c)  Participating Provider Defined. In this title, a
"participating provider" means, with respect to a health
plan, a provider of health care services who is a member of
a provider network of the plan (as described in section
1402(f)(3)).

            Section 1408   FINANCIAL SOLVENCY.

    Each regional alliance health plan must

      (1)  meet or exceed minimum capital requirements
established by States under section 1204(a);

        (2)  in the case of a plan operating in a State,
must participate in the guaranty fund established by the
State under section 1204(c); and

        (3)  meet such other requirements relating to fiscal
soundness as the State may establish (subject to the
establishment of any alternative standards by the Board).

            Section 1409   REQUIREMENT FOR OFFERING COST
SHARING POLICY.

    Each regional alliance health plan shall offer a cost
sharing policy (as defined in section 1421(b)(2)) to each
eligible family enrolled under the plan.

            Section 1410   QUALITY ASSURANCE.

  Each health plan shall comply with such quality assurance
requirements as are imposed under subtitle A of title V with
respect to such a plan.

            Section 1411   PROVIDER VERIFICATION.

    Each health plan shall

      (1)  verify the credentials of practitioners and
facilities;

        (2)  ensure that all providers participating in the
plan meet applicable State licensing and certification
standards;

        (3)  oversee the quality and performance of
participating providers, consistent with section 1410; and

        (4)  investigate and resolve consumer complaints
against participating providers.

            Section 1412   CONSUMER DISCLOSURES OF
UTILIZATION MANAGEMENT PROTOCOLS.

    Each health plan shall disclose to enrollees (and
prospective enrollees) the protocols used by the plan for
controlling utilization and costs.

            Section 1413   CONFIDENTIALITY, DATA MANAGEMENT,
AND REPORTING.

    (a)  In General. Each health plan shall comply with the
confidentiality, data management, and reporting requirements
imposed under subtitle B of title V.

    (b)  Treatment of Electronic Information.

        (1)  Accuracy and reliability. Each health plan
shall take such measures as may be necessary to ensure that
health care information in electronic form that the plan, or
a member of a provider network of the plan, collects for or
transmits to the Board under subtitle B of title V is
accurate and reliable.

        (2)  Privacy and security. Each health plan shall
take such measures as may be necessary to ensure that health
care information described in paragraph (1) is not
distributed to any individual or entity in violation of a
standard promulgated by the Board under part 2 of subtitle B
of title V.

            Section 1414   PARTICIPATION IN REINSURANCE
SYSTEM.

    Each regional alliance health plan of a State that has
established a reinsurance system under section 1203(g) shall
participate in the system in the manner specified by the
State.

  Part 2   REQUIREMENTS RELATING TO SUPPLEMENTAL INSURANCE

            Section 1421   IMPOSITION OF REQUIREMENTS ON
SUPPLEMENTAL INSURANCE.

    (a)  In General. An entity may offer a supplemental
insurance policy but only if

        (1)  in the case of a supplemental health benefit
policy (as defined in subsection (b)(1)), the entity and the
policy meet the requirements of section 1422; and

        (2)  in the case of a cost sharing policy (as
defined in subsection (b)(2)), the entity and the policy
meet the requirements of section 1423.

    (b)  Policies Defined.

        (1)  Supplemental health benefit policy.

            (A)  In general. In this part, the term
"supplemental health benefit policy" means a health
insurance policy or health benefit plan offered to an
alliance eligible individual which provides

  (i)  coverage for services and items not included in the
comprehensive benefit package, or

    (ii)  coverage for items and services included in such
package but not covered because of a limitation in amount,
duration, or scope provided under this title, or both.

            (B)  Exclusions. Such term does not include the
following:

  (i)  A cost sharing policy (as defined in paragraph (2)).

   (ii)  A long-term care insurance policy (as defined in
section 2304(10)).

    (iii)  Insurance that limits benefits with respect to
specific diseases (or conditions).

    (iv)  Hospital or nursing home indemnity insurance.

 (v)  A medicare supplemental policy (as defined in section
1882(g) of the Social Security Act).
    (vi)  Insurance with respect to accidents.
        (2)  Cost sharing policy. In this part, the term
"cost means a health insurance policy or health benefit plan
offered to an alliance eligible individual which provides
coverage for deductibles, coinsurance, and copayments
imposed as part of the comprehensive benefit package under
subtitle B, whether imposed under a higher cost sharing plan
or with respect to out-ofnetwork providers.
            Section 1422   STANDARDS FOR SUPPLEMENTAL HEALTH
BENEFIT POLICIES.
    (a)  Prohibiting Duplication of Coverage.
        (1)  In general. No health plan, insurer, or any
other person may offer
            (A)  to any eligible individual a supplemental
health benefit policy that duplicates any coverage provided
in the comprehensive benefit package; or
            (B)  to any medicare-eligible individual a
supplemental health benefit policy that duplicates any
coverage provided under the medicare program.
        (2)  Exception for medicare-eligible individuals.
For purposes of this subsection, for the period in which an
individual is a medicare-eligible individual and also is an
alliance eligible individual (and is enrolled under a
regional alliance or corporate alliance health plan),
paragraph (1)(A) (and not paragraph (1)(B)) shall apply.
    (b)  No Limitation on Individuals Offered Policy.
        (1)  In general. Except as provided in paragraph
(2), each entity offering a supplemental health benefit
policy must accept for enrollment every individual who seeks
such enrollment, subject to capacity and financial limits.
        (2)  Exception for certain offerors. Paragraph (1)
shall not apply to any supplemental health benefit policy
offered to an individual only on the basis of
            (A)  the individual's employment (in the case of
a policy offered by the individual's employer); or
            (B)  the individual's membership or enrollment
in a fraternal, religious, professional, educational, or
other similar organization.
    (c)  Restrictions on Marketing Abuses. Not later than
January 1, 1996, the Board shall develop (in consultation
with the States) minimum standards that prohibit marketing
practices by entities offering supplemental health benefit
policies that involve:
     (1)  Providing monetary incentives for or tying or
otherwise
            conditioning the sale of the policy to
enrollment in a regional
            alliance health plan of the entity.

        (2)  Using or disclosing to any party information
about
the health status or claims experience of participants in a
regional alliance health plan for the purpose of marketing
such a policy.

    (d)  Civil Monetary Penalty. An entity that knowingly
and willfully violates any provision of this section with
respect to the offering of a supplemental health benefit
policy to any individual shall be subject to a civil
monetary penalty (not to exceed $10,000) for each such
violation. The provisions of section 1128A of the Social
Security Act (other than subsections (a) and (b)) shall
apply to civil money penalties under this subsection in the
same manner as they apply to a penalty or proceeding under
section 1128A(a) of such Act.

            Section 1423   STANDARDS FOR COST SHARING
POLICIES.

    (a)  Rules for Offering of Policies. Subject to
subsection (f), a cost sharing policy may be offered to an
individual only if

     (1)  the policy is offered by the regional alliance
health plan in which the individual is enrolled;

        (2)  the regional alliance health plan offers the
policy to all individuals enrolled in the plan;

        (3)  the plan offers each such individual a choice
of a policy that provides standard coverage and a policy
that provides maximum coverage (in accordance with standards
established by the Board); and

        (4)  the policy is offered only during the annual
open enrollment period for regional alliance health plans
(described in section 1323(d)(1)).

    (b)  Prohibition of Coverage of Copayments. Each cost
sharing policy may not provide any benefits relating to any
copayments established under the table of copayments and
coinsurance under section 1135.

    (c)  Equivalent Coverage for All Services. Each cost
sharing policy must provide coverage for items and services
in the comprehensive benefit package to the same extent as
the policy provides coverage for all items and services in
the package.

    (d)  Requirements for Pricing.

        (1)  In general. The price of any cost sharing
policy shall

            (A)  be the same for each individual to whom the
policy is offered;

            (B)  take into account any expected increase in
utilization resulting from the purchase of the policy by
individuals enrolled in the regional alliance health plan;
and

            (C)  not result in a loss-ratio of less than 90
percent.

        (2)  Loss-ratio defined. In paragraph (1)(C), a
"lossratio" is the ratio of the premium returned to the
consumer in payout relative to the total premium collected.

    (e)  Loss of State Certification for Regional Alliance
Health Plans Failing to Meet Standards. A State may not
certify a
regional alliance health plan that offers a cost sharing
policy unless the plan and the policy meet the standards
described in this section.
 (f)  Special Rules for FEHBP Supplemental Plans. Subsection
(a) shall not apply to an FEHBP supplemental plan described
in section 8203(f)(1), but only if the plan meets the
following requirements:

        (1)  The plan must be offered to all individuals to
whom such a plan is required to be offered under section
8203.
        (2)  The plan must offer each such individual a
choice of a policy that provides standard coverage and a
policy that provides maximum coverage (in accordance with
standards established by the Board under subsection (a)(3)).
        (3)  The plan is offered only during the annual open
enrollment period for regional alliance health plans
(described in section 1323(d)(1)).
        (4) (A) The price of the plan shall include an
amount, established in accordance with rules established by
the Board in consultation with the Office of Personnel
Management, that takes into account any expected increase in
utilization of the items and services in the comprehensive
benefit package resulting from the purchase of the plan by
individuals enrolled in a regional alliance health plan.
            (B)  The plan provides for payment, in a manner
specified by the Board in the case of an individual enrolled
in the plan and in a regional alliance health plan, to the
regional alliance health plan of an amount equivalent to the
additional amount described in subparagraph (A).
    Part 3   REQUIREMENTS RELATING TO ESSENTIAL COMMUNITY
PROVIDERS

           Section 1431   HEALTH PLAN REQUIREMENT.

    (a)  In General. Subject to section 1432, each health
plan shall, with respect to each electing essential
community provider (as defined in subsection (d), other than
a provider of school health services) located within the
plan's service area, either

        (1)  enter into a written provider participation
agreement (described in subsection (b)) with the provider,
or

        (2)  enter into a written agreement under which the
plan shall make payment to the provider in accordance with
subsection (c).

   (b)  Participation Agreement. A participation agreement
between a health plan and an electing essential community
provider under this subsection shall provide that the health
plan agrees to treat the provider in accordance with terms
and conditions at least as favorable as those that are
applicable to other providers participating in the health
plan with respect to each of the following:

        (1)  The scope of services for which payment is made
by the plan to the provider.

        (2)  The rate of payment for covered care and
services.

      (3)  The availability of financial incentives to
participating providers.

        (4)  Limitations on financial risk provided to other
participating providers.

        (5)  Assignment of enrollees to participating
providers.

        (6)  Access by the provider's patients to providers
in medical specialties or subspecialties participating in
the plan.

    (c)  Payments for Providers Without Participation
Agreements.

        (1)  In general. Payment in accordance with this
subsection is payment based, as elected by the electing
essential community provider, either

            (A)  on the fee schedule developed by the
applicable regional alliance (or the State) under section
1322(c), or

            (B)  on payment methodologies and rates used
under the applicable Medicare payment methodology and rates
(or the most closely applicable methodology under such
program as the Secretary of Health and Human Services
specifies in regulations).

        (2)  No application of gate-keeper limitations.
Payment in accordance with this subsection may be subject to
utilization review, but may not be subject to otherwise
applicable gatekeeper requirements under the plan.

    (d)  Election.

      (1)  In general. In this part, the term "electing
essential community provider" means, with respect to a
health plan, an essential community provider that elects
this subpart to apply to the health plan.

        (2)  Form of election. An election under this
subsection shall be made in a form and manner specified by
the Secretary, and shall include notice to the health plan
involved. Such an election may be made annually with respect
to a health plan, except that the plan and provider may
agree to make such an election on a more frequent basis.

    (e)  Special Rule for Providers of School Health
Services. A health plan shall pay, to each provider of
school health services located in the plan's service area an
amount determined by the Secretary for such services
furnished to enrollees of the plan.

            Section 1432   SUNSET OF REQUIREMENT.

 (a)  In General. Subject to subsection (d), the requirement
of section 1431 shall only apply to health plans offered by
a health alliance during the 5-year period beginning with
the first year in which any health plan is offered by the
alliance.

    (b)  Studies. In order to prepare recommendations under
subsection (c), the Secretary shall conduct studies
regarding essential community providers, including studies
that assess

        (1)  the definition of essential community provider,

        (2)  the sufficiency of the funding levels for
providers, for both covered and uncovered benefits under
this Act,

        (3)  the effects of contracting requirements
relating to such providers on such providers, health plans,
and enrollees,

        (4)  the impact of the payment rules for such
providers, and

      (5)  the impact of national health reform on such
providers.

    (c)  Recommendations to Congress. The Secretary shall
submit to Congress, by not later than March 1, 2001,
specific recommendations respecting whether, and to what
extent, section 1431 should continue to apply to some or all
essential community providers. Such recommendations may
include a description of the particular types of such
providers and circumstances under which such section should
continue to apply.

    (d)  Congressional Consideration.

        (1)  In general. Recommendations submitted under
subsection (c) shall apply under this part (and may
supersede the provisions of subsection (a)) unless a joint
resolution (described in paragraph (2)) disapproving such
recommendations is enacted, in accordance with the
provisions of paragraph (3), before the end of the 60-day
period beginning on the date on which such recommendations
were submitted. For purposes of applying the preceding
sentence and paragraphs (2) and (3), the days on which
either House of Congress is not in session because of an
adjournment of more than three days to a day certain shall
be excluded in the computation of a period.

        (2)  Joint resolution of disapproval. A joint
resolution described in this paragraph means only a joint
resolution which is introduced within the 10-day period
beginning on the date on which the Secretary submits
recommendations under subsection (c) and

            (A)  which does not have a preamble;

            (B)  the matter after the resolving clause of
which is as follows: "That Congress disapproves the
recommendations of the Secretary of Health and Human
Services concerning the continued application of certain
essential community provider requirements under section 1431
of the Health Security Act, as submitted by the Secretary on
XXXXXXX.", the blank space being filled in with the
appropriate date; and

            (C)  the title of which is as follows: "Joint
resolution disapproving recommendations of the Secretary of
Health and Human Services concerning the continued
application of certain essential community provider
requirements under section 1431 of the Health Security Act,
as submitted by the Secretary on XXXXXXX.", the blank space
being filled in with the appropriate date.

        (3)  Procedures for consideration of resolution of
disapproval. Subject to paragraph (4), the provisions of
section 2908 (other than subsection (a)) of the Defense Base
Closure and Realignment Act of 1990 shall apply to the
consideration of a joint resolution described in paragraph
(2) in the same manner as such provisions apply to a joint
resolution described in section 2908(a) of such Act.

        (4)  Special rules. For purposes of applying
paragraph (3) with respect to such provisions

            (A)  any reference to the Committee on Armed
Services of the House of Representatives shall be deemed a
reference to an
appropriate Committee of the House of Representatives
(specified by the Speaker of the House of Representatives at
the time of submission of recommendations under subsection
(c)) and any reference to the Committee on Armed Services of
the Senate shall be deemed a reference to an appropriate
Committee of the Senate (specified by the Majority Leader of
the Senate at the time of submission of recommendations
under subsection (c)); and

            (B)  any reference to the date on which the
President transmits a report shall be deemed a reference to
the date on which the Secretary submits recommendations
under subsection (c).

 Part 4   REQUIREMENTS RELATING TO WORKERS' COMPENSATION AND
AUTOMOBILE MEDICAL LIABILITY COVERAGE

            Section 1441   REFERENCE TO REQUIREMENTS
RELATING TO WORKERS COMPENSATION SERVICES.

    Each health plan shall meet the applicable requirements
of part 2 of subtitle A of title X (relating to provision of
workers compensation services to enrollees).

            Section 1442   REFERENCE TO REQUIREMENTS
RELATING TO AUTOMOBILE MEDICAL LIABILITY SERVICES.

 Each health plan shall meet the applicable requirements of
part 2 of subtitle B of title X (relating to provision of
automobile medical liability services to enrollees).
Title I, Subtitle F

Subtitle F    Federal Responsibilities

    Part 1   NATIONAL HEALTH BOARD

        Subpart A    Establishment of National Health Board
            Section 1501   CREATION OF NATIONAL HEALTH
            BOARD;
MEMBERSHIP.

  (a)  In General. There is hereby created in the Executive
Branch a National Health Board.

    (b)  Composition. The Board is composed of 7 members
appointed by the President, by and with the advice and
consent of the Senate.

    (c)  Chair. The President shall designate one of the
members as chair. The chair serves a term concurrent with
that of the President. The chair may serve a maximum of 3
terms. The chair shall serve as the chief executive officer
of the Board.

    (d)  Terms.

        (1)  In general. Except as provided in paragraphs
(2) and (4), the term of each member of the Board, except
the chair, is 4 years and begins when the term of the
predecessor of that member ends.


        (2)  Initial terms. The initial terms of the members
of the Board (other than the chair) first taking office
after the date of the enactment of this Act, shall expire as
designated by the President, two at the end of one year, two
at the end of two years, and two at the end of three years.

        (3)  Reappointment. A member (other than the chair)
may
be reappointed for one additional term.
        (4)  Continuation in office. Upon the expiration of
a term of office, a member shall continue to serve until a
successor is appointed and qualified.
    (e)  Vacancies.
        (1)  In general. Whenever a vacancy shall occur,
other than by expiration of term, a successor shall be
appointed by the President, by and with the consent of the
Senate, to fill such vacancy, and is appointed for the
remainder of the term of the predecessor.
      (2)  No impairment of function. A vacancy in the
membership of the Board does not impair the authority of the
remaining members to exercise all of the powers of the
Board.

        (3)  Acting chair. The Board may designate a Member
to act as chair during any period in which there is no chair
designated by the President.

    (f)  Meetings; Quorum.

        (1)  Meetings. At meetings of the Board the chair
shall preside, and in the absence of the chair, the Board
shall elect a member to act as chair pro tempore.

        (2)  Quorum. Four members of the Board shall
constitute a quorum thereof.

            Section 1502   QUALIFICATIONS OF BOARD MEMBERS.
    (a)  Citizenship. Each member of the Board shall be a
citizen of the United States.
    (b)  Basis of Selection. Board members will be selected
on the basis of their experience and expertise in relevant
subjects, including the practice of medicine, nursing, or
other clinical practices, health care financing and
delivery, state health systems, consumer protection,
business, law, and delivery of care to vulnerable
populations.
    (c)  Exclusive Employment. During the term of
appointment, Board members shall serve as employees of the
Federal Government and shall hold no other employment.
    (d)  Prohibition of Conflict of Interest. A member of
the Board may not have a pecuniary interest in or hold an
official relation to any health care plan, health care
provider, insurance company, pharmaceutical company, medical
equipment company, or other affected industry. Before
entering upon the duties as a member of the Board, the
member shall certify under oath compliance with this
requirement.
 (e)  Post-Employment Restrictions. After leaving the Board,
former members are subject to post-employment restrictions
applicable to comparable Federal employees.

    (f)  Compensation of Board Members. Each member of the
Board (other than the chair) shall receive an annual salary
at the annual rate payable from time to time for level IV of
the Executive Schedule. The chair of the Board, during the
period of service as chair, shall receive an annual salary
at the annual rate payable from time to time for level III
of the Executive Schedule.

            Section 1503   GENERAL DUTIES AND
RESPONSIBILITIES.

    (a)  Comprehensive Benefit Package.

        (1)  Interpretation. The Board shall interpret the
comprehensive benefit package, adjust the delivery of
preventive services under section 1153, and take such steps
as may be necessary to assure that the comprehensive benefit
package is available on a uniform national basis to all
eligible individuals.

        (2)  Recommendations. The Board may recommend to the
President and the Congress appropriate revisions to such
package. Such recommendations may reflect changes in
technology, health care needs, health care costs, and
methods of service delivery.

    (b)  Administration of Cost Containment Provisions.The
Board shall oversee the cost containment requirements of
subtitle A of title VI and certify compliance with such
requirements.

    (c)  Coverage and Families. The Board shall develop and
implement standards relating to the eligibility of
individuals for coverage in applicable health plans under
subtitle A of title I and may provide such additional
exceptions and special rules relating to the treatment of
family members under section 1012 as the Board finds
appropriate.

    (d)  Quality Management and Improvement. The Board shall
establish and have ultimate responsibility for a performance
based system of quality management and improvement as
required by section 5001.

    (e)  Information Standards. The Board shall develop and
implement standards to establish national health information
system to measure quality as required by section 5101.

 (f)  Participating State Requirements. Consistent with the
provisions of subtitle C, the Board shall

        (1)  establish requirements for participating
States,

        (2)  monitor State compliance with those
requirements,

        (3)  provide technical assistance, and in a manner
that ensures access to the comprehensive benefit package for
all eligible individuals.

  (g)  Development of Premium Class Factors.The Board shall
establish premium class factors under subpart D of this
part.

 (h)  Development of Risk-Adjustment Methodology. The Board
shall develop a methodology for the risk-adjustment of
premium payments to regional alliance health plans in
accordance with subpart E of this part.

    (i)  Financial Requirements. The Board shall establish
minimum capital requirements and requirements for guaranty
funds under subpart F of this part.

  (j)  Standards for Health Plan Grievance Procedures. The
Board shall establish standards for health plan grievance
procedures that are used by enrollees in pursuing
complaints.

            Section 1504   ANNUAL REPORT.

    (a)  In General. The Board shall prepare and send to the
President and Congress an annual report addressing the
overall implementation of the new health care system.

    (b)  Matters to be Included. The Board shall include in
each annual report under this section the following:

        (1)  Information on Federal and State
implementation.

        (2)  Data related to quality improvement.

        (3)  Recommendations or changes in the
administration, regulation and laws related to health care
and coverage.

     (4)  A full account of all actions taken during the
previous year.

            Section 1505   POWERS.

    (a)  Staff; Contract Authority. The Board shall have
authority, subject to the provisions of the civil-service
laws and chapter 51 and subchapter III of chapter 53 of
title 5, United States Code, to appoint such officers and
employees as are necessary to carry out its functions. To
the extent provided in advance in appropriations Acts, the
Board may contract with any person (including an agency of
the Federal Government) for studies and analysis as required
to execute its functions. Any employee of the Executive
Branch may be detailed to the Board to assist the Board in
carrying out its duties.

  (b)  Establishment of Advisory Committees. The Board may
establish advisory committees.

    (c)  Access to Information. The Board may secure
directly from any department or agency of the United States
information necessary to enable it to carry out its
functions, to the extent such information is otherwise
available to a department or agency of the United States.
Upon request of the chair,  the head of that department or
agency shall furnish that information to the Board.

    (d)  Delegation of Authority. Except as otherwise
provided in this Act, the Board may delegate any function to
such officers and employees as the Board may designate and
may authorize such successive redelegations of such
functions with the Board as the Board deems to be necessary
or appropriate. No delegation of functions by the Board
shall relieve the Board of responsibility for the
administration of such functions.

 (e)  Rulemaking. The National Health Board is authorized to
establish such rules as may be necessary to carry out this
Act.

            Section 1506   FUNDING.

    (a)  Authorization of Appropriations. There are
authorized to be appropriated to the Board such sums as may
be necessary for fiscal years 1994, 1995, 1996, 1997, and
1998.

    (b)  Submission of Budget. Under the procedures of
chapter 11 of title 31, United States Code, the budget for
the Board for a fiscal year shall be reviewed by the
Director of the Office of Management and Budget and
submitted to the Congress as part of the President's
submission of the Budget of the United States for the fiscal
year.