HR 4872 Sec. 10103

 

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SEC, 10103

SEC. 2301. INSURANCE REFORMS.

(a) EXTENDING CERTAIN INSURANCE REFORMS TO GRANDFATHERED PLANS.—Section 1251(a) of the Patient Protection and Affordable Care Act, as added by section 10103(d) of such Act, is amended by adding at the end the following:

 

‘‘(4) APPLICATION OF CERTAIN PROVISIONS.—

‘(A) IN GENERAL.—The following provisions of the Public Health Service Act (as added by this title) shall apply to grandfathered health plans for plan years beginning with the first plan year to which such provisions would otherwise apply:

‘‘(i) Section 2708 (relating to excessive waiting periods).

‘‘(ii) Those provisions of section 2711 relating to lifetime limits.  

‘‘(iii) Section 2712 (relating to rescissions).

‘‘(iv) Section 2714 (relating to extension of dependent coverage).

‘‘(B) PROVISIONS APPLICABLE ONLY TO GROUP HEALTH PLANS.—

‘‘(i) PROVISIONS DESCRIBED.—Those provisions of section 2711 relating to annual limits and the provisions of section 2704 (relating to pre-existing condition exclusions) of the Public Health Service Act (as added by this subtitle) shall apply to grandfathered health plans that are group health plans for plan years beginning with the first plan year to which such provisions otherwise apply.

‘‘(ii) ADULT DEPENDENT COVERAGE.—For plan years beginning before January 1, 2014, the provisions of section 2714 of the Public Health Service Act (as added by this subtitle) shall apply in the case of an adult dependent with respect to a grandfathered health plan that is a group health plan only if such dependent is not eligible to enroll in an eligible employer-sponsored health plan (as defined in

section 5000A(f)(2) of the Internal Revenue Code of 1986) other than such grandfathered health plan.’’.

(b) CLARIFICATION REGARDING DEPENDENT COVERAGE.—Section 2714(a) of the Public Health Service Act, as added by section 1001(5) of the Patient Protection and Affordable Care Act, is amended by striking ‘‘(who is not married)’’.

 
SEC. 10103. AMENDMENTS TO SUBTITLE C.

(a) Section 2701(a)(5) of the Public Health Service Act, as added by section 1201(4) of this Act, is amended by inserting ‘‘(other than self-insured group health plans offered in such market)’’ after ‘‘such market’’.

(b) Section 2708 of the Public Health Service Act, as added by section 1201(4) of this Act, is amended by striking ‘‘or individual’’.

 

(c) Subpart I of part A of title XXVII of the Public Health Service Act, as added by section 1201(4) of this Act, is amended by inserting after section 2708, the following:

 
‘‘SEC. 2709. COVERAGE FOR INDIVIDUALS PARTICIPATING IN APPROVED CLINICAL TRIALS.

‘‘(a) COVERAGE.—

‘‘(1) IN GENERAL.—If a group health plan or a health insurance issuer offering group or individual health insurance coverage provides coverage to a qualified individual, then such plan or issuer—

‘‘(A) may not deny the individual participation in the clinical trial referred to in subsection (b)(2);

‘‘(B) subject to subsection (c), may not deny (or limit or impose additional conditions on) the coverage of routine patient costs for items and services furnished in connection with participation in the trial; and

‘‘(C) may not discriminate against the individual on the basis of the individual’s participation in such trial.

‘‘(2) ROUTINE PATIENT COSTS.—

‘‘(A) INCLUSION.—For purposes of paragraph (1)(B), subject to subparagraph (B), routine patient costs include all items and services consistent with the coverage provided in the plan (or coverage) that is typically covered for a qualified individual who is not enrolled in a clinical trial.

‘‘(B) EXCLUSION.—For purposes of paragraph (1)(B), routine patient costs does not include—

‘‘(i) the investigational item, device, or service, itself;

‘‘(ii) items and services that are provided solely to satisfy data collection and analysis needs and that

are not used in the direct clinical management of the patient; or

‘‘(iii) a service that is clearly inconsistent with widely accepted and established standards of care for

a particular diagnosis.

‘‘(3) USE OF IN-NETWORK PROVIDERS.—If one or more participating providers is participating in a clinical trial, nothing in paragraph (1) shall be construed as preventing a plan or issuer from requiring that a qualified individual participate in the trial through such a participating provider if the provider will accept the individual as a participant in the trial.

‘‘(4) USE OF OUT-OF-NETWORK.—Notwithstanding paragraph (3), paragraph (1) shall apply to a qualified individual participating in an approved clinical trial that is conducted outside the State in which the qualified individual resides.

‘‘(b) QUALIFIED INDIVIDUAL DEFINED.—For purposes of subsection (a), the term ‘qualified individual’ means an individual who is a participant or beneficiary in a health plan or with coverage described in subsection (a)(1) and who meets the following conditions:

‘‘(1) The individual is eligible to participate in an approved clinical trial according to the trial protocol with respect to treatment of cancer or other life-threatening disease or condition.

‘‘(2) Either—

‘‘(A) the referring health care professional is a participating health care provider and has concluded that the

individual’s participation in such trial would be appropriate based upon the individual meeting the conditions described in paragraph (1); or

‘‘(B) the participant or beneficiary provides medical and scientific information establishing that the individual’s

participation in such trial would be appropriate based upon the individual meeting the conditions described in paragraph (1).

‘‘(c) LIMITATIONS ON COVERAGE.—This section shall not be construed to require a group health plan, or a health insurance issuer benefits for routine patient care services provided outside of the plan’s (or coverage’s) health care provider network unless out-ofnetwork benefits are otherwise provided under the plan (or coverage).

‘‘(d) APPROVED CLINICAL TRIAL DEFINED.—

‘‘(1) IN GENERAL.—In this section, the term ‘approved clinical trial’ means a phase I, phase II, phase III, or phase IV clinical trial that is conducted in relation to the prevention, detection, or treatment of cancer or other life-threatening disease or condition and is described in any of the following subparagraphs:

‘‘(A) FEDERALLY FUNDED TRIALS.—The study or investigation is approved or funded (which may include funding through in-kind contributions) by one or more of the following:

 
‘‘(i) The National Institutes of Health.

‘‘(ii) The Centers for Disease Control and Prevention.

‘‘(iii) The Agency for Health Care Research and Quality.

‘‘(iv) The Centers for Medicare & Medicaid Services.

‘‘(v) cooperative group or center of any of the entities described in clauses (i) through (iv) or the Department of Defense or the Department of Veterans Affairs.

‘‘(vi) A qualified non-governmental research entity identified in the guidelines issued by the National

Institutes of Health for center support grants.

‘‘(vii) Any of the following if the conditions described in paragraph (2) are met:

‘‘(I) The Department of Veterans Affairs.

‘‘(II) The Department of Defense.

‘‘(III) The Department of Energy.

‘‘(B) The study or investigation is conducted under an investigational new drug application reviewed by the

Food and Drug Administration.

‘‘(C) The study or investigation is a drug trial that is exempt from having such an investigational new drug

application.

‘‘(2) CONDITIONS FOR DEPARTMENTS.—The conditions described in this paragraph, for a study or investigation conducted by a Department, are that the study or investigation has been reviewed and approved through a system of peer review that the Secretary determines—

‘‘(A) to be comparable to the system of peer review of studies and investigations used by the National

Institutes of Health, and

‘‘(B) assures unbiased review of the highest scientific standards by qualified individuals who have no interest

in the outcome of the review.

‘‘(e) LIFE-THREATENING CONDITION DEFINED.—In this section, the term ‘life-threatening condition’ means any disease or condition from which the likelihood of death is probable unless the course of the disease or condition is interrupted.

‘‘(f) CONSTRUCTION.—Nothing in this section shall be construed to limit a plan’s or issuer’s coverage with respect to clinical trials.

‘‘(g) APPLICATION TO FEHBP.—Notwithstanding any provision of chapter 89 of title 5, United States Code, this section shall apply to health plans offered under the program under such chapter.

‘‘(h) PREEMPTION.—Notwithstanding any other provision of this Act, nothing in this section shall preempt State laws that require a clinical trials policy for State regulated health insurance plans that is in addition to the policy required under this section.’’.

 

(d) Section 1251(a) of this Act is amended—

(1) in paragraph (2), by striking ‘‘With’’ and inserting ‘‘Except as provided in paragraph (3), with’’; and

(2) by adding at the end the following:

‘‘(3) APPLICATION OF CERTAIN PROVISIONS.—The provisions of sections 2715 and 2718 of the Public Health Service Act (as added by subtitle A) shall apply to grandfathered health plans for plan years beginning on or after the date of enactment of this Act.’’.
 

Other Group Health Plan Reforms

Group health plan reforms are also found in other Sections of the PPACA. In particular, PPACA Section 1201, as amended by Section 10103 (amending Section 1253 of the PPACA) and further amended by the reconciliation bill at Section 2301 prohibits pre-existing condition exclusions for dependents under age 19 for the first plan year beginning on or after September 23, 2010, which would be January 1, 2011 for calendar year plans. The prohibition on preexisting exclusions would generally be applicable to all participants beginning January 1, 2014.

 
 

(e) Section 1253 of this Act is amended insert before the period the following: ‘‘, except that—

‘‘(1) section 1251 shall take effect on the date of enactment of this Act; and

‘‘(2) the provisions of section 2704 of the Public Health Service Act (as amended by section 1201), as they apply to enrollees who are under 19 years of age, shall become effective for plan years beginning on or after the date that is 6 months after the date of enactment of this Act.’’. 
(f) Subtitle C of title I of this Act is amended—

(1) by redesignating section 1253 as section 1255; and

(2) by inserting after section 1252, the following:
 

‘‘SEC. 1253. ANNUAL REPORT ON SELF-INSURED PLANS.

‘‘Not later than 1 year after the date of enactment of this Act, and annually thereafter, the Secretary of Labor shall prepare an aggregate annual report, using data collected from the Annual Return/Report of Employee Benefit Plan (Department of Labor Form 5500), that shall include general information on self-insured group health plans (including plan type, number of participants, benefits offered, funding arrangements, and benefit arrangements) as well as data from the financial filings of self-insured employers (including information on assets, liabilities, contributions, investments, and expenses). The Secretary shall submit such reports to the appropriate committees of Congress.

 
‘‘SEC. 1254. STUDY OF LARGE GROUP MARKET.

‘‘(a) IN GENERAL.—The Secretary of Health and Human Services shall conduct a study of the fully-insured and self-insured group health plan markets to—

‘‘(1) compare the characteristics of employers (including industry, size, and other characteristics as determined appropriate by the Secretary), health plan benefits, financial solvency, capital reserve levels, and the risks of becoming insolvent; and

‘‘(2) determine the extent to which new insurance market reforms are likely to cause adverse selection in the large group market or to encourage small and midsize employers to selfinsure.

‘‘(b) COLLECTION OF INFORMATION.—In conducting the study under subsection (a), the Secretary, in coordination with the Secretary of Labor, shall collect information and analyze— can offer less costly coverage and, if so, whether lower costs are due to more efficient plan administration and lower overhead or to the denial of claims and the offering very limited benefit packages;

‘‘(2) claim denial rates, plan benefit fluctuations (to evaluate the extent that plans scale back health benefits during

economic downturns), and the impact of the limited recourse options on consumers; and

‘‘(3) any potential conflict of interest as it relates to the health care needs of self-insured enrollees and self-insured

employer’s financial contribution or profit margin, and the impact of such conflict on administration of the health plan.

‘‘(c) REPORT.—Not later than 1 year after the date of enactment of this Act, the Secretary shall submit to the appropriate committees of Congress a report concerning the results of the study conducted under subsection (a).’’.

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