To promote and facilitate expansion of coverage under group health plans, and for other purposes.

June 4, 2003

Mr. ANDREWS (for himself and Mr. PAYNE) introduced the following bill; which was referred to the Committee on Education and the Workforce, and in addition to the Committee on Ways and Means, for a period to be subsequently determined by the Speaker, in each case for consideration of such provisions as fall within the jurisdiction of the committee concerned

To promote and facilitate expansion of coverage under group health plans, and for other purposes.

Be it enacted by the Senate and House of Representatives of the United States of America in Congress assembled,

SECTION 1. SHORT TITLE.

This Act may be cited as the `Group Health Plan Coverage Expansion Act of 2003'.

SEC. 2. PROGRAM TO PROMOTE AND FACILITATE EXPANSION OF COVERAGE UNDER GROUP HEALTH PLANS.

(a) IN GENERAL- Part 5 of subtitle B of title I of the Employee Retirement Income Security Act of 1974 is amended by adding after section 518 (29 U.S.C. 1148) the following new section:

`SEC. 519. PROMOTION AND FACILITATION OF COVERAGE UNDER GROUP HEALTH PLANS.

`(a) IN GENERAL- The Secretary shall establish by regulation a program--

`(1) to promote and facilitate the availability to individuals of financial assistance provided by the Federal Government and by States and political subdivisions thereof for the purpose of assisting such individuals with the payment of employee contributions to group health plans, and

`(2) to promote and facilitate the establishment of alternative group purchasing or pooling arrangements, such as purchasing cooperatives for small businesses, reinsurance pools, or high risk pools.

`(b) INTERGOVERNMENTAL CONSULTATION- Under such program, the Secretary shall--

`(1) provide for such ongoing consultation with agencies and instrumentalities of the Federal Government and of the States and political subdivisions thereof as is necessary and appropriate to further the purposes such program, and

`(2) submit to each House of the Congress such recommendations for such legislative changes as the Secretary may, from time to time, consider to be appropriate to further the purposes of such program.

`(c) SAFEGUARDS TO ENSURE MAINTENANCE OF CURRENT LEVELS OF GOVERNMENTAL SUPPORT FOR HEALTH CARE- The Secretary shall ensure that participation in the program by any State or political subdivision thereof with respect to financial assistance described in subsection (a)(1) may not occur unless the Secretary finds that any reallocation of funds by such State or political subdivision in connection with participation in the program does not result in a decrease in the number of individuals in the applicable jurisdiction who have substantial coverage for health benefits under either public or private programs.'.

(b) DEADLINE FOR ESTABLISHING PROGRAM- The Secretary of Labor shall issue initial final regulations necessary to carry out the program established under section 518 of the Employee Retirement Income Security Act of 1974 (added by section 2) not later than December 31, 2004.

(c) CLERICAL AMENDMENTS- The table of contents in section 1 of such Act is amended by inserting after the item relating to section 517 the following new items:

`Sec. 518. Authority to postpone certain deadlines by reason of Presidentially declared disaster or terroristic or military actions.

`Sec. 519. Promotion and facilitation of coverage under group health plans.'.

SEC. 3. NOTIFICATION TO PARTICIPANTS IN EMPLOYEE BENEFIT PLANS OF AVAILABILITY OF CHILD HEALTH ASSISTANCE UNDER SCHIP AND CASH BENEFITS AVAILABLE UNDER SSI.

(a) IN GENERAL- Section 104 of the Employee Retirement Income Security Act of 1974 (29 U.S.C. 1024) is amended--

(1) by redesignating subsection (d) as subsection (e); and

(2) by inserting after subsection (c) the following new subsection:

`(d)(1) The administrator of an employee benefit plan shall include in each summary plan description, updated summary plan description, and summary description of a modification or change to the plan which is furnished to participants, and shall provide separately to individuals claiming benefits under the plan, a summary description of--

`(A) the child health assistance available under State child health plans under title XXI of the Social Security Act, and

`(B) the cash benefits available to eligible elderly or disabled individuals with limited income and resources under the supplemental security income program under title XVI of the Social Security Act.

`(2) The summary description required under paragraph (1) shall--

`(A) be in a form which shall be prescribed in regulations of the Secretary, in consultation with the Secretary of Health and Human Services,

`(B) be written in a manner calculated to be understood by the average plan participant, and

`(C) include--

`(i) the appropriate telephone number, Internet website, and mailing address for the State program providing the assistance described in paragraph (1)(A) in the State in which the participant or beneficiary resides, and

`(ii) the appropriate telephone number, Internet website, and mailing address for the supplemental security income program described in paragraph (1)(B),

together with the benefits information applicable to such programs.'.

(b) ENFORCEMENT- Section 502(c)(1)(A) of such Act (29 U.S.C. 1132(c)(1)) is amended by striking `paragraph (1) or (4) of section 606 or section 101(e)(1)' and inserting `section 101(e)(1), section 104(d), or paragraph (1) or (4) of section 606'.

(c) EFFECTIVE DATE- The amendments made by this section shall apply with respect to summary plan descriptions, updated summary plan descriptions, and summary descriptions of plan modifications or changes furnished to participants or beneficiaries, and in connection with benefit claims filed, after December 31, 2003.

SEC. 4. PROHIBITION OF LIFETIME LIMITS IN GROUP HEALTH PLANS.

(a) IN GENERAL- Subpart B of part 7 of subtitle B of title I of the Employee Retirement Income Security Act of 1974 is amended by adding at the end the following new section:

`SEC. 714. PROHIBITION ON APPLICATION OF LIFETIME LIMITATIONS.

`(a) REQUIREMENT- A group health plan, and a health insurance issuer offering group health insurance coverage, may not impose any aggregate lifetime limit on benefits, including any category of benefits, under the plan or coverage.

`(b) NOTICE UNDER GROUP HEALTH PLAN- The imposition of the requirement of this section shall be treated as a material modification in the terms of the plan described in section 102(a)(1), for purposes of assuring notice of such requirements under the plan; except that the summary description required to be provided under the last sentence of section 104(b)(1) with respect to such modification shall be provided by not later than 60 days after the first day of the first plan year in which such requirement apply.'.

(b) CONFORMING AMENDMENTS-

(1) Section 731(c) of such Act (29 U.S.C. 1191(c)) is amended by striking `section 711' and inserting `sections 711 and 714'.

(2) Section 732(a) of such Act (29 U.S.C. 1191a(a)) is amended by striking `section 711' and inserting `sections 711 and 714'.

(3) The table of contents in section 1 of such Act is amended by inserting after the item relating to section 713 the following new item:

`Sec. 714. Prohibition on application of lifetime limitations.'.

(c) EFFECTIVE DATES-

(1) IN GENERAL- Subject to paragraph (2), the amendments made by this section apply with respect to group health plans for plan years beginning on or after January 1, 2005.

(2) COLLECTIVE BARGAINING EXCEPTION- In the case of a group health plan maintained pursuant to 1 or more collective bargaining agreements between employee representatives and 1 or more employers ratified before the date of enactment of this Act, the amendments made by this section shall not apply to plan years beginning before the later of--

(A) the date on which the last collective bargaining agreements relating to the plan terminates (determined without regard to any extension thereof agreed to after the date of enactment of this Act), or

(B) January 1, 2005.

For purposes of subparagraph (A), any plan amendment made pursuant to a collective bargaining agreement relating to the plan which amends the plan solely to conform to any requirement added by this section shall not be treated as a termination of such collective bargaining agreement.

SEC. 5. PROHIBITION OF DISCRIMINATION BASED ON PRE-EXISTING CONDITIONS.

(a) IN GENERAL- Subpart B of part 7 of subtitle B of title I of the Employee Retirement Income Security Act of 1974 (as amended by section 4) is amended further by adding at the end the following new section:

`SEC. 715. PROHIBITION ON DISCRIMINATION BASED ON PRE-EXISTING CONDITIONS.

`(a) IN GENERAL- A group health plan, and a health insurance issuer offering group health insurance coverage, may not impose any change in the premium rates charged for coverage of participants and beneficiaries under the plan so as to result in a premium charged to any such participant or beneficiary which is above that which is charged to otherwise similarly situated individuals solely on the basis of a pre-existing condition of such participant or beneficiary.

`(b) NOTICE UNDER GROUP HEALTH PLAN- The imposition of the requirement of this section shall be treated as a material modification in the terms of the plan described in section 102(a)(1), for purposes of assuring notice of such requirements under the plan; except that the summary description required to be provided under the last sentence of section 104(b)(1) with respect to such modification shall be provided by not later than 60 days after the first day of the first plan year in which such requirement apply.

`(c) PRE-EXISTING CONDITION- For purposes of this section, the term `pre-existing condition' means, in connection with any change in premium rates charged for coverage of a participant or beneficiary, a medical condition of the participant or beneficiary that was present before the effective date of the change in premium rates, whether or not any medical advice, diagnosis, care, or treatment was recommended or received before such date.'.

(b) CONFORMING AMENDMENTS-

(1) Section 732(a) of such Act (as amended by section 4 of this Act) is amended further by striking `sections 711 and 714' and inserting `sections 711, 714, and 715'.

(2) The table of contents in section 1 of such Act (as amended by section 4 of this Act) is amended further by inserting after the item relating to section 714 the following new item:

`Sec. 715. Prohibition on discrimination based on pre-existing conditions.'.

(c) EFFECTIVE DATES-

(1) IN GENERAL- Subject to paragraph (2), the amendments made by this section apply with respect to group health plans for plan years beginning on or after January 1, 2005.

(2) COLLECTIVE BARGAINING EXCEPTION- In the case of a group health plan maintained pursuant to 1 or more collective bargaining agreements between employee representatives and 1 or more employers ratified before the date of enactment of this Act, the amendments made by this section shall not apply to plan years beginning before the later of--

(A) the date on which the last collective bargaining agreements relating to the plan terminates (determined without regard to any extension thereof agreed to after the date of enactment of this Act), or

(B) January 1, 2005.

For purposes of subparagraph (A), any plan amendment made pursuant to a collective bargaining agreement relating to the plan which amends the plan solely to conform to any requirement added by this section shall not be treated as a termination of such collective bargaining agreement.

SEC. 6. PAYMENTS BY PENSION AND ANNUITY PLANS FOR COBRA BENEFITS.

(a) IN GENERAL- Section 401 of the Internal Revenue Code of 1986 is amended by redesignating subsection (o) as subsection (p) and by inserting after subsection (n) the following new subsection:

`(o) PAYMENTS BY PLANS FOR CONTINUATION COVERAGE PREMIUMS- Under regulations prescribed by the Secretary, a pension or annuity plan shall not be considered as not satisfying the requirements of subsection (a) merely because the plan makes payments for premiums for continuation coverage under a group health plan on behalf of a qualified beneficiary which meet the requirements of section 4980B(f), but such a plan making such payments shall be considered as not satisfying such requirements unless such benefits are subordinate to the retirement benefits provided by the plan and to the qualified current retiree health liabilities (as defined in section 420) of a health benefits account which is part of such plan.'.

(b) EFFECTIVE DATE- The amendment made by subsection (a) shall apply to taxable years beginning after the date of the enactment of this Act.

SEC. 7. NOTICE TO PARTICIPANTS AND BENEFICIARIES CLAIMING GROUP HEALTH PLAN BENEFITS OF AVAILABILITY OF SSI BENEFITS.

(a) IN GENERAL- Section 609 of the Employee Retirement Income Security Act of 1974 (29 U.S.C. 1169) is amended--

(1) by redesignating subsection (e) as subsection (f); and

(2) by inserting after subsection (d) the following new subsection:

`(e) NOTICE TO CLAIMANT OF AVAILABLE SSI BENEFITS- Upon receipt of a claim for benefits under a group health plan, the administrator of such plan shall, not later than 30 days after receipt of the claim, provide to the claimant written notice of the availability to eligible elderly or disabled individuals with limited income and resources to cash benefits under the supplemental security income program under title XVI of the Social Security Act. Such notice shall be in a form which shall be prescribed by the Secretary of Health and Human Services.'.

(b) ENFORCEMENT- Section 502(c)(1)(A) of such Act (as amended by section 3(b)) is amended further by striking `or paragraph (1) or (4) of section 606' and inserting `paragraph (1) or (4) of section 606, or section 609(e)'.

(c) EFFECTIVE DATE- The amendments made by this section shall apply in connection with claims for benefits filed during plan years beginning on or after January 1, 2005.

SEC. 8. REQUIREMENT FOR QUALIFIED INDIVIDUALS WHO OBTAIN EMERGENCY ROOM SERVICES TO MAINTAIN SUBSTANTIAL HEALTH INSURANCE COVERAGE FOR 2 YEARS.

(a) ALIENATION OF PENSION BENEFITS TO ENFORCE COURT ORDER TO MAINTAIN COVERAGE- Section 206 of the Employee Retirement Income Security Act of 1974 (29 U.S.C. 1056) is amended by adding at the end the following new subsection:

`(g) ALIENATION OF PENSION BENEFITS TO ENFORCE CERTAIN COURT ORDERS TO MAINTAIN SUBSTANTIAL HEALTH INSURANCE COVERAGE-

`(1) ALIENATION OF PENSION BENEFITS- Subsection (d)(1) shall not apply in connection with any pension plan with respect to amounts payable, by an individual who is a participant or beneficiary under such plan and fails to meet the requirements of paragraph (2), for the purpose of acquiring and maintaining health insurance coverage pursuant to an order of a court of competent jurisdiction under section 502(c)(7).

`(2) REQUIREMENT OF COVERAGE UPON OBTAINING EMERGENCY ROOM SERVICES- In any case in which emergency room services are obtained for a qualified individual or for such individual's spouse or dependent, such individual shall be treated as failing to meet the requirements of this paragraph with respect to the patient if, at the time that such services are obtained, such patient is not covered under substantial health insurance coverage.

`(3) DEFINITIONS- For purposes of this subsection--

`(A) QUALIFIED INDIVIDUAL- The term `qualified individual' means an individual whose adjusted gross income for the taxable year preceding the time emergency room services described in paragraph (2) are obtained is greater than or equal to 500 percent of the poverty line (as defined by the Office of Management and Budget).

`(B) EMERGENCY ROOM SERVICES- The term `emergency room services' means medical care at a hospital emergency department (as defined for purposes of section 1867 of the Social Security Act (42 U.S.C. 1395dd)).'.

`(C) SUBSTANTIAL HEALTH INSURANCE COVERAGE-

`(i) IN GENERAL- The term `substantial health insurance coverage' means health insurance coverage (within the meaning of section 733(b)(1)) which is determined by the Secretary (in consultation with the Secretary of Health and Human Services) to meet the following requirements:

`(I) AGGREGATE ACTUARIAL VALUE EQUIVALENT TO BENCHMARK PACKAGE- The coverage has an aggregate actuarial value that is at least actuarially equivalent to one of the benchmark benefit packages.

`(II) INCLUSION OF BASIC SERVICES- The coverage includes benefits for items and services within each of the categories of basic services described in clause (iii).

`(III) SUBSTANTIAL ACTUARIAL VALUE FOR ADDITIONAL SERVICES INCLUDED IN BENCHMARK PACKAGE- With respect to each of the categories of additional services described in clause (iv) for which coverage is provided under the benchmark benefit package used under subclause (I), the coverage has an actuarial value that is equal to at least 75 percent of the actuarial value of the coverage of that category of services in such package.

`(ii) BENCHMARK BENEFIT PACKAGES- The benchmark benefit packages are as follows:

`(I) FEHBP-EQUIVALENT HEALTH INSURANCE COVERAGE- The standard Blue Cross/Blue Shield preferred provider option service benefit plan, described in and offered under section 8903(1) of title 5, United States Code.

`(II) STATE EMPLOYEE COVERAGE- A health benefits coverage plan that is offered and generally available to State employees in the State involved.

`(III) COVERAGE OFFERED THROUGH HMO- The health insurance coverage plan that is offered by a health maintenance organization (as defined in section 2791(b)(3) of the Public Health Service Act), and has the largest insured commercial, non-medicaid enrollment of covered lives of such coverage plans offered by such a health maintenance organization in the State involved.

`(iii) CATEGORIES OF BASIC SERVICES- For purposes of this subparagraph, the categories of basic services described in this clause are as follows:

`(I) Inpatient and outpatient hospital services.

`(II) Physicians' surgical and medical services.

`(III) Laboratory and x-ray services.

`(IV) Well-baby and well-child care, including age-appropriate immunizations.

`(iv) CATEGORIES OF ADDITIONAL SERVICES- For purposes of this subparagraph, the categories of additional services described in this clause are as follows:

`(I) Coverage of prescription drugs.

`(II) Mental health services.

`(III) Vision services.

`(IV) Hearing services.

`(v) TREATMENT OF OTHER CATEGORIES- Nothing in this subparagraph shall be construed as preventing substantial health insurance coverage from including coverage of benefits that are not within a category of services described in clause (iii) or (iv).

`(vi) DETERMINATION OF ACTUARIAL VALUE- The actuarial value of coverage of benchmark benefit packages and coverage of any categories of additional services under benchmark benefit packages and under coverage offered by such a plan shall be set forth in an actuarial opinion in an actuarial report that has been prepared--

`(I) by an individual who is a member of the American Academy of Actuaries;

`(II) using generally accepted actuarial principles and methodologies;

`(III) using a standardized set of utilization and price factors;

`(IV) using a standardized population that is representative of privately insured individuals similarly situated when compared to individuals expected to be covered under the substantial health insurance coverage;

`(V) applying the same principles and factors in comparing the value of different coverage (or categories of services); and

`(VI) without taking into account any differences in coverage based on the method of delivery or means of cost control or utilization used.

The actuary preparing the opinion shall select and specify in the memorandum the standardized set and population to be used under subclauses (III) and (IV).'.

(b) REMEDY AGAINST QUALIFIED INDIVIDUALS FOR NOT MAINTAINING SUBSTANTIAL HEALTH INSURANCE COVERAGE WHILE OBTAINING EMERGENCY ROOM SERVICES-

(1) IN GENERAL- Section 502 of the Employee Retirement Income Security Act of 1974 (29 U.S.C. 1102) is amended--

(A) in subsection (a)(8), by striking `or' at the end;

(B) in subsection (a)(9), by striking the period and inserting `; or';

(C) by adding at the end of subsection (a) the following new paragraph:

`(10) by the Secretary or a State, in accordance with subsection (c)(7), to provide appropriate equitable remedies for failures to meet the requirements of section 206(g)(2).';

(D) by redesignating subsection (c)(8) as subsection (c)(9); and

(E) by inserting after subsection (c)(7) the following new paragraph:

`(8) In any action under subsection (a)(10), the court may provide appropriate equitable relief in connection with failures to meet the requirements of section 206(g)(2). Such relief may include an order that the defendant maintain, for at least the 2-year period commencing with the date of the failure described in section 206(g)(2), substantial health insurance coverage (as defined in section 206(g)(3)(B)) covering the patient involved.'.

(2) CONCURRENT JURISDICTION- Section 502(e)(1) of such Act (29 U.S.C. 1132(e)(1)) is amended--

(A) in the first sentence, by striking `subsection (a)(1)(B)' and inserting `paragraph (1)(B), (7), or (10) of subsection (a) of this section'; and

(B) in the last sentence, by striking `paragraphs (1)(B) and (7)' and inserting `paragraphs (1)(B), (7), and (10)'.

(c) EFFECTIVE DATE- The amendments made by this section shall apply with respect to failures (to meet the requirements of section 206(g)(2) of the Employee Retirement Income Security Act of 1974) occurring on or after the date of the enactment of this Act.

END