Health Insurance Affordability Act of 1996

TABLE OF CONTENTS:

Title I: Assuring Availability and Continuity of Health Coverage

Subtitle A: Guaranteed Access to Health Coverage

Subtitle B: Provision of Benefits

Subtitle C: Fair Rating Practices

Subtitle D: Consumer Protections

Subtitle E: Benefits

Subtitle F: Standards and Certification; Enforcement;

Preemption; General Provisions

Subtitle G: Definitions; General Provisions

Title II: Administrative Simplification

Subtitle A: Standards for Data Elements and

Transactions

Subtitle B: Requirements with Respect to Certain

Transactions and Information

Subtitle C: Miscellaneous Provisions

Title III: Antitrust

Health Insurance Affordability Act of 1996 - Title I: Assuring Availability and Continuity of Health Coverage - Subtitle A: Guaranteed Access to Health Coverage - Requires carriers offering health coverage in the individual and small group market to make available standard and high-deductible coverage. Mandates a family option. Prohibits carriers from requiring limits based on health status, claims experience, or similar factors.

(Sec. 102) Mandates acceptance of every small employer and qualifying individual. Allows financial capacity limits and provides for multiple employer welfare arrangement treatment.

(Sec. 103) Prohibits denying, canceling, or refusing to renew coverage except for premium nonpayment or similar factors.

(Sec. 104) Regulates preexisting condition exclusions and enrollment periods.

Subtitle B: Provision of Benefits - Sets forth managed care requirements and mandates a utilization review report.

Subtitle C: Fair Rating Practices - Regulates rating variations and mandates a model risk adjustment system.

Subtitle D: Consumer Protections - Mandates disclosures by carriers and group plans.

(Sec. 132) Regulates carrier remuneration and compensation to agents and brokers.

(Sec. 133) Requires carriers and group plans to maintain written policies and procedures respecting advance directives.

Subtitle E: Benefits - Regulates standard and high-deductible coverage.

(Sec. 144) Mandates establishment of procedures for benefit valuation, the deductible amount for high-deductible coverage, and model benefit packages.

(Sec. 145) Regulates the offering of supplemental benefits.

(Sec. 146) Requires carriers to offer an option to treat children under 26 as family members.

Subtitle F: Standards and Certification; Enforcement; Preemption; General Provisions - Mandates standards regarding this subtitle's requirements. Requires implementation and enforcement regarding carriers, insurance coverage, and group plans. Deems provisions of this title relating to group plans and employers to be provisions of the Employee Retirement Income Security Act of 1974. Amends the Internal Revenue Code to impose a tax on a carrier's failure to comply with this Act's requirements.

(Sec. 155) Prohibits a single employer plan from offering coverage other than through a carrier unless the plan has at least 100 eligible employees.

Subtitle G: Definitions; General Provisions - Sets forth definitions for this Act and effective dates for this title.

Title II: Administrative Simplification - Subtitle A: Standards for Data Elements and Transactions - Mandates standards under this subtitle that are: (1) consistent with reducing health care costs; and (2) in use and generally accepted, developed, or modified by standard-setting organizations accredited by the American National Standard Institute.

(Sec. 212) Requires: (1) standards regarding electronic transmission of health information data elements; (2) a standard unique identifier for each individual, employer, plan sponsor, and health provider; (3) data element code sets; (4) technical standards consistent with network privacy standards; (5) regulations regarding electronic signature transmission and authentication; (6) direct laboratory claims submission; and (7) network privacy standards.

Subtitle B: Requirements with Respect to Certain Transactions and Information - Requires transactions between plan sponsors and providers to use standard data elements.

(Sec. 222) Requires a certified health information security organization to make non-identifiable health information available to Federal or State agencies.

(Sec. 223) Requires a procedure under which a sponsor or provider that is unable to transmit standard data elements directly may comply with this part.

Subtitle C: Miscellaneous Provisions - Mandates network operating standards and a network certification procedure.

(Sec. 232) Prohibits requiring data elements or transmission inconsistent with this Act. Allows waivers. Requires anonymity for those reporting violations.

(Sec. 233) Preempts contrary State law.

Title III: Antitrust - Mandates: (1) guidelines on antitrust law application to health plan activities; and (2) a review process enabling plans to request a Federal antitrust conformity opinion.