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H.R. 3535 (102nd): USHealth Program Act of 1991


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The summary below was written by the Congressional Research Service, which is a nonpartisan division of the Library of Congress, and was published on Oct 9, 1991.


USHealth Program Act of 1991 - Title I: Provision And Expansion Of Hospital, Medical, And Preventive Services To Cover All Americans Either Through A USHealth Program Or Qualified Employer Health Plans - Subtitle A: Coverage of Elderly, Disabled, Retired, and Other Non-Employed Individuals Through a USHealth Program - Part 1: Eligibility - Amends title XVIII (Medicare) of the Social Security Act to establish the USHealth Program (Program) for the provision of hospital as well as long-term care and certain preventive benefits to U.S. citizens and permanent U.S. residents. Provides for incorporating into the Program for hospital care: (1) aliens who are employed with a foreign government or an international organization and reside in the United States; and (2) foreign visitors. Provides for low-income assistance under the Program. Repeals provisions of various other benefit programs rendered superfluous by the comprehensive nature of the Program. Makes conforming amendments to the Railroad Retirement Act of 1974. Provides transitional Medicaid (title XIX of the Social Security Act) coverage of pregnant women and infants up to 185 percent of the Federal poverty level. Increases to 100 percent the Federal medical assistance percentage for additional populations covered. Part 2: Benefits - Revises the scope of benefits under Medicare part A (Hospital Insurance). Lists under such part Program benefits which comprise: (1) inpatient hospital services; (2) medical and other health services; (3) comprehensive outpatient rehabilitation facility services and home intravenous drug therapy services; (4) alcohol and drug abuse rehabilitation services; (5) outpatient mental health services; and (6) home health services. Changes payment provisions. Expands covered medical and other health services under Medicare to include the following preventive services as Program benefits: (1) prenatal care; (2) well-child care; (3) screening mammographies; (4) screening pap smears; (5) family planning services and supplies furnished to individuals of child-bearing age who desire such services and supplies; (6) colorectal cancer screening services; (7) counseling to modify risk factors for heart disease, cancer, and stroke, including dietary measures, weight reduction, smoking restriction, and physical conditioning; and (8) such other health services as the USHealth Board finds are cost-effective in the prevention of disease or illness. Directs the USHealth Board to establish: (1) frequency schedules for the provision of certain preventive services listed above; and (2) standards for entities furnishing preventive service under Medicare who otherwise are not qualified to provide other services under Medicare. Includes prescription drugs within such expanded coverage as Program benefits. Sets forth certification standards for comprehensive outpatient rehabilitation facility services, outpatient physical therapy services, outpatient speech pathology services, and home intravenous drug therapy services. Eliminates all mandatory benefits under the Medicaid program. Part 3: Payments For Services - Sets forth payment rules for inpatient hospital services, medical and other health services generally, prescription drugs, and home intravenous drug therapy services, which include no co-payments for inpatient hospital services. Directs the USHealth Board to: (1) establish a program to assure appropriate prescribing and dispensing practices; (2) prepare and update annually a guide for physicians concerning wholesale prices of commonly prescribed drugs; (3) establish a fee schedule for home intravenous drug therapy services; and (4) adjust Medicare payment rates for inpatient hospital services and physicians' services to reflect changes in the population served and other special circumstances. Requires the Prospective Payment Assessment Commission to conduct a study concerning appropriate adjustments in payments for inpatient hospital services to account for reduced hospital costs resulting from Medicare payment of prescription drugs and home intravenous drug therapy services. Provides protection against out-of-pocket expenses which exceed specified individual and family catastrophic limits. Prohibits service providers from imposing charges when a catastrophic limit has been reached. Details provisions with respect to the treatment of health maintenance organizations (HMOs). Repeals Medicare payment rules for outpatient mental health services. Subtitle B: Coverage of Employed Individuals Through Qualified Employer Health Plans - Part 1: General Provisions - Amends the Social Security Act to add a new title XXI (Access to Health Insurance For Health Services Through Employment) under which employers are required to enroll their employees and dependents in a qualified employer health plan or in the Program. Sets forth rules for the enrollment of full- and part-time, seasonal, and temporary employees, including rules applicable in cases of families with more than one worker and where both employers offer enrollment under a qualified employer health plan. Phases in implementation of enrollment requirements according to a schedule based on the size of the employer. Sets forth enforcement provisions. Outlines requirements for qualified employer health plan premiums and cost-sharing, including limitations on the amount that may be charged for premiums. Gives qualified employer health plans the option of electing Program rules governing payments for services. Sets forth the requirements for standards to certify a health plan provided by an employer or sold to an individual as a qualified health plan, including: (1) requirements that plan benefits must at least mirror the Medicare part A health services provided under the Program; (2) requirements respecting limits on pre-existing condition exclusions and coverage standards for such required plan benefits; and (3) disclosure and other requirements to protect consumers. Prohibits certain State benefit and coverage rules under a qualified health plan. Amends the Internal Revenue Code to allow a full deduction for health insurance costs of the self-employed and to make such deduction permanent. Part 2: Insurance Reform - Subpart A: General Reforms - Amends the Public Health Service Act to add a new title XXVII (Group Health Insurance Standards) under which insured and self-insured employment-related health plans must be ascertained as meeting certain standards established below in order to be, respectively, issued or offered. Provides sanctions for plans that fail to meet such standards, including possible loss of their qualified status. Requires the USHealth Board to request the National Association of Insurance Commissioners (NAIC) to develop specific standards to implement the requirements in the remaining paragraphs below which such plans must be ascertained as meeting. Provides that if NAIC fails to develop such standards or if the Board finds that such standards do not implement such requirements, the Board shall develop such standards. Requires that such plans may not discriminate on the basis of health status for certain services. Requires that pre-existing condition exclusions under such plans be treated in the same manner as is mandated under the Social Security Act for qualified health plans. Requires any carrier which offers such a plan to register with the applicable State regulatory authority. Requires that such carriers offer the same plans to all employers within their individual service areas. Details separate requirements with respect to HMOs. Specifies that a carrier may not offer or issue to an employer such a plan with a term of less than 12 months. Requires guaranteed renewability with some exceptions. Lists notice and other requirements applicable to renewals, including the requirement that the period of renewal for each employer plan be for a period of not less than 12 months. Provides an exception to the requirements in this paragraph for self-insured carriers and self-insured employment-related health plans. States that such requirements do apply to reinsurance carriers and employment-related reinsurance plans offered to such carriers or underwriting such self-insured plans. Requires that the premiums for all employer plans of the same entity shall be: (1) established based on a single cohesive rating system which is applied consistently for all employer groups and is designed not to treat groups, after a certain period, differently based on health or risk status; and (2) actuarially certified each year. Requires employer health plan premiums to be community-rated for a given geographical area. Disallows adjustments to premium rates based on age and gender of covered individuals. Requires a Program reimbursement election before employer health plan premium rates may be adjusted otherwise. Requires employer health plans to permit enrollment of individuals based on specified beneficiary classes. Provides an exception to the requirements in this paragraph for self-insured carriers and self-insured employment-related health plans. States that such requirements do apply to reinsurance carriers and employment-related reinsurance plans offered to such carriers or underwriting such self-insured plans. Prescribes a basic benefit package for employer health plans, with exceptions for employment-related reinsurance plans, self-insured plans, and HMO plans. Sets forth miscellaneous disclosure and recordkeeping requirements for employer health plans. Subpart B: Encouraging Establishment of Managed Care - Adds a new part 3 (Favorable Treatment of Network Plans and Utilization Review Programs) to new title XXVII of the Public Health Service Act added above to provide for favorable treatment of network plans and utilization review programs. Subpart C: Repeal of COBRA Continuation Requirements - Repeals COBRA continuation requirements under the Public Health Service Act, the Internal Revenue Code, and the Employee Retirement Income Security Act of 1974. Title II: Provision of Long-Term Home and Community-Based Care, Nursing Home Care, And Other Benefits For All Americans Through the USHealth Program - Adds a new part B (Long-Term Care Protection And Certain Preventive Benefits) to Medicare under which U.S. citizens and permanent U.S. residents are eligible for long-term care, without regard to age or disability status, and certain preventive benefits. Sets forth provisions respecting long-term care protection under new part B. Details eligibility criteria for long-term care which include requirements that only those individuals applying for benefits who have been determined by a Screening Agency to be limited in daily living activities or so cognitively impaired as to require ongoing supervision will be eligible for: (1) home and community-based services; (2) respite care; and (3) nursing facility services. Provides that the duration of such services shall be unlimited as long as the Case Management Agency determines, through its periodic review of a patient, that the patient continues to require such services. Requires that the determination of the need of an individual for such services shall be made by the Case Management Agency. Places limitations on coverage for respite care. Directs the USHealth Board to contract with States or other entities to act as Long-Term Care Screening Agencies for the State. Makes such agency responsible for assessing the eligibility of individuals for such services. Directs the USHealth Board to contract with a State or private nonprofit organization to establish and administer a Long-Term Care Case Management Agency for each designated area of a State. Requires such agency to: (1) provide case management services for eligible individuals directly or through contracts with home care or home health agencies; (2) develop a care plan for each individual determined to be eligible by a Screening Agency or approve such a plan which has been developed by a qualified service provider; (3) maintain a registry of qualified providers of home and community-based care and nursing facilities in the State; and (4) assist individuals in choosing qualified providers to carry out the care plan and in locating alternative providers if the individual becomes dissatisfied with the provider initially chosen. Requires a State, in addition to the USHealth Board, to monitor the performance of all designated Case Management Agencies and assure the fiscal stability of such agencies. Requires services provided to eligible individuals pursuant to a plan of care to be provided by qualified service providers. Lists service providers qualified to provide home and community-based services. Sets forth payment rules for home and community-based services and nursing facility services. Sets forth requirements for the certification of providers of such long-term care services. Establishes the Home and Community-Based Care Advisory Council to: (1) assist the USHealth Board in assuring the prompt and efficient implementation of long-term care protection under new part B; (2) regularly review the implementation of such protection; and (3) recommend to the Board and to the Congress any necessary modifications to such protection with respect to home and community-based services. Sets forth home- and community-based provider quality assurance requirements and case management agency quality assurance requirements. Directs the USHealth Board to develop and implement a standard and extended survey of home care agencies certified to receive payments for such long-term care services provided under new part B. Sets forth provisions respecting certain preventive benefits under new part B. Entitles U.S. citizens and permanent U.S. residents to the following preventive benefits: (1) routine physical checkups; (2) routine eye care (including the dispensing of corrective lenses); (3) dental care; and (4) hearing care. Specifies the specific items and services which comprise each such benefit. Sets forth special rules for children. Directs the USHealth Board to provide for a program for the certification of the safety and efficacy of hearing aids for which payment may be made under new part B. Sets forth payment rules, including rules prohibiting the application of deductibles or co-payments to payments for such preventive benefits. Directs the USHealth Board to make grants to: (1) educational institutions for programs to train individuals in the provision of home- and community-based care and nursing facility services; (2) State approved programs to develop and conduct programs to train individuals in the provision of home health aide services; and (3) accredited university schools of nursing to develop model consumer training programs to provide information and training about the delivery of home care services for caregivers as well as general information about the home- and community-based care service system. Authorizes appropriations for such grants. Directs the Board to assist public or private nonprofit entities in meeting the costs of planning, developing, and operating centers for long-term care planning and technical assistance. Authorizes appropriations. Directs the USHealth Board to conduct long-term home care demonstration projects for seriously mentally ill individuals and family caregivers. Authorizes appropriations. Title III: Low-Income Assistance - Adds a new part C (Assistance For Low-Income Individuals) to Medicare under which low-income U.S. citizens and permanent U.S. residents who are enrolled under part A or under a qualified employer health plan or are entitled to benefits under part B may apply for assistance to limit or eliminate their financial obligations for premiums, deductibles, and co-payments. Title IV: USHealth Program Administration - Subtitle A: USHealth Administration - Adds a new part D (USHealth Administration) to Medicare to establish, as an independent agency in the executive branch of the Government, a USHealth Administration, to be governed by a USHealth Board, to administer the USHealth Program created under this Act. Abolishes the Health Care Financing Administration. Subtitle B: Miscellaneous - Repeals provisions regarding the use of public agencies or private organizations to facilitate payment to providers of services. Permits States to be carriers for administration of part A benefits. Makes miscellaneous conforming changes in carrier provisions. Adds additional administrative provisions to part A relating to prescription drugs. Directs the Director of the Congressional Office of Technology Assessment to provide for the appointment of a Prescription Drug Payment Review Commission to report annually to the Congress on methods of determining payment for prescription drugs. Authorizes appropriations. Requires the Secretary of Health and Human Services to conduct various studies with respect to prescription drugs, including a study on the possible inclusion of experimental drugs under the Program, and to report to the Congress on the results of each such study. Requires General Accounting Office studies on wholesale prescription drug prices and the costs to pharmacies of doing business. Directs the USHealth Board to develop a standard prescription drug claims form. Subjects home intravenous drug therapy services to review by peer review organizations. Revises administrative provisions under Medicare regarding home intravenous drug therapy services. Makes miscellaneous and technical changes with respect to HMO coverage and payment. Sets forth special rules for frail elderly demonstration projects and similar projects. Title V: Quality Assurance And Cost Containment - Subtitle A: Quality Assurance - Amends part B (Peer Review) of title XI of the Social Security Act to require contracts with peer review organizations to provide that: (1) major organizational efforts be devoted to quality assurance activities; and (2) quality assurance activities be conducted with respect to all the different types of health and long-term care covered by Medicare or through a private payor. Revises the definition of the term "peer review organization" to require such an entity to include representatives of providers of services for which quality assurance activities are conducted. Provides funding for increased quality assurance activities. Requires each utilization and quality control peer review organization to establish and staff a quality assurance board that will monitor the quality of care provided under Medicare in the area served by the organization. Amends the Medicare program to: (1) prohibit payments to health care providers which are not licensed and certified by the State; (2) direct the USHealth Board to promulgate a consumers' bill of rights which shall recognize specified rights as rights of consumers which may be asserted by the consumer or his or her representative or guardian; (3) revise the hospital discharge planning process to require a discharge planning process which meets guidelines and standards to be established by the USHealth Board that guard against early inappropriate hospital discharges and ensure a timely and smooth transition to the most appropriate type of and setting for post-hospital care; and (4) require HMOs to make outpatient mental health services available to their clients and ensure that quality assurance activities include such services. Amends the Peer Review program to require peer review organizations to monitor hospitals' compliance with discharge planning process requirements. Subtitle B: Cost-Containment - Sets forth a formula to determine the overall annual health care amount allowed to be spent under the Program. Directs the USHealth Board to conduct negotiations each year with representatives of the classes of health care providers in order to allocate overall spending among the different classes of providers. Requires a report to the Congress on negotiation results along with a specification of the amount to be allocated to each class of provider. Requires the Board to adjust each year the payment rates by each class of provider. Title VI: Financing - Amends the Medicare program to: (1) set forth rules for determining the premiums to be charged individuals and employers for enrollment under part A; (2) specify the early year premiums for aged and disabled part A enrollees and set forth rules for determining the premiums for later years; and (3) revise procedures for collecting part B premiums to provide for the collection of delinquent premiums. Amends the Internal Revenue Code to: (1) eliminate the limit on wages and self-employment income subject to social security and railroad retirement taxes; and (2) increase the health insurance tax rate. Requires State maintenance of effort payments. Redesignates the Federal Hospital Insurance Trust Fund as the USHealth Program Trust Fund. Provides for off-budget treatment of the Fund. Extends the borrowing authority of the Fund. Dedicates additional specified revenues to the support of the Program. Repeals the Federal Supplementary Medical Insurance Trust Fund and transfers the funds in, and obligations of, such Fund to the USHealth Program Trust Fund. Repeals the separate authorization of appropriations to cover Government contributions and provide a contingency reserve applicable to the former Federal Supplementary Medical Insurance Trust Fund. Title VII: Rural And Central City Demonstration Projects And Expansion Of Primary Care And Public Health Delivery Capacity - Directs the Administrator of the Health Care Financing Administration to provide for additional research and demonstration projects into how Medicare could be changed to better cover care for beneficiaries residing in rural areas and in central city areas of large cities. Requires an annual report to the Congress on the progress of such projects. Extends the authorizations for the following programs or services under the Public Health Service Act through the year 2000: (1) immunization programs; (2) tuberculosis prevention and control programs; (3) lead poisoning prevention programs; (4) programs (and projects) for the prevention and control of sexually transmitted diseases; (5) migrant and community health center services; (6) homeless programs; (7) public housing programs; (8) family planning services; and (9) early intervention services for individuals with HIV disease. Directs the USHealth Board to make grants to public and nonprofit private entities for projects to plan and develop primary care centers and public health clinics which will serve medically underserved populations. Directs the USHealth Board, every five years, beginning with 1994, to submit to the Congress a report on the impact of this Act in meeting the following Goals for the Nation stated in "Health People, 2000": (1) to increase the span of healthy life for Americans; (2) to reduce health disparities among Americans; and (3) to achieve access to preventive services for all Americans. Requires each report to include such recommendations with respect to changes in the benefits and payment policies under this Act as will best promote achievement of national health promotion and disease prevention goals and objectives.