• MANDATORY ELIGIBILITY PROVISIONS

• Provides $1.5 billion over 5 years for low-income Medicare beneficiary premium protections.
• Funds would cover 100% of the Medicare premiums for seniors with incomes up to 135% of poverty; and the portion of the premium attributable to transferring home health from Medicare Part A to Part B for seniors with incomes between 135%-175% of poverty

• NCSL supports federal NCSL supports for assistance to low-income Medicare beneficiaries and opposes any shifting of costs to the states through Medicaid.

• OPTIONAL ELIGIBILITY PROVISIONS

• States may, at their option, continue to provide Medicaid benefits to children who would have been eligible for benefits but for the enactment of PROWRA and their subsequent loss of SSI.

• No provision.

• NCSL supports House bill.

• Permits states to provide 12 months' continuous coverage for children.

• Same as House bill.

• NCSL supports provision. NCSL supports additional state options.

• Permits states to extend presumptive eligibility to children.

• No provision.

• NCSL supports House bill (state option)

• No provision.

• Permits states to allow disabled SSI beneficiaries with incomes up to 250% of poverty to buy into Medicaid by paying a premium.
• States would determine the premium and develop a sliding fee scale, based on the individual's income.

• NCSL supports Senate bill. NCSL supports additional state options.

• No provision.

• Permits states to expand Medicaid eligibility to include uninsured women, under age 65 who have been diagnosed with breast cancer through the CDC breast cancer screening program, satisfies the eligibility criteria for the CDC program and are not otherwise eligible for Medicaid.

• NCSL supports Senate bill. NCSL supports additional state options. NCSL also supports early detection and screening for cancer. Coverage for treatment provides an incentive to participate in screening programs.

• ELIGIBILITY FOR QUALIFIED ALIENS/REFUGEES/UNDOCUMENTED IMMIGRANTS

• Restores $9 billion over 5 years in benefits to qualified aliens.

• Restores $11.4 billion over 5 years in benefits to qualified aliens.
• This section also specifies that Cuban and Haitian entrants are to be considered qualified aliens, thereby continuing the SSI and Medicaid eligibility of those who were receiving SSI benefits on August 22, 1996.

• NCSL supports Senate bill.

• Legal noncitizens who were receiving SSI benefits on August 22, 1996 (the date of enactment of the welfare reform law) would remain eligible for SSI, despite underlying restrictions in the Personal Responsibility and Work Opportunity Act.
• Legal immigrants who were in the U.S. on 8/22/96, but were not receiving SSI are not eligible to receive benefits should they become disabled in the future.

• Legal noncitizens who were receiving SSI benefits on August 22, 1996 (the date of enactment of the welfare reform law) would remain eligible for SSI, despite underlying restrictions in the Personal Responsibility and Work Opportunity Act.
• Legal immigrants who were in the U.S. on 8/22/96, but were not receiving SSI are eligible to receive benefits should they become disabled in the future.

• NCSL supports Senate bill.

• No provision.

• The limitation on Medicaid eligibility would not apply to any alien lawfully residing in any state who has not attained the age of 19, but only with respect to eligibility for Medicaid

• NCSL supports Senate bill.

• No provision.

• States are permitted to exempt children from the 5 year ban on benefits to receive assistance under the MCH block grant.

• NCSL supports Senate bill.

• No provision.

• Restrictions on SSI benefits shall not apply to any individual who is receiving benefits under such program after July 1996 on the basis of an application filed before January 1, 1979 and with respect to whom the Commissioner of Social Security lacks clear and convincing evidence that such individual is an alien ineligible for such benefits.

• NCSL supports Senate bill.

• Extends Medicaid and SSI eligibility from 5 to 7 years for refugees, asylees and individuals granted withholding of deportation.

• Same as House bill.

• NCSL supports the provision.

• Cuban /Haitian Entrants and Amerasian refugees are defined as "qualified aliens," and therefore retain Medicaid and SSI eligibility for the first 7 years they are in the U.S.

• Same as House bill.

• NCSL supports the provision.

• No provision.

• Permits immigrants who are too severely disabled to naturalize to receive SSI.

• NCSL supports Senate bill.

• No provision.

• Restrictions on SSI eligibility under welfare reform do not apply to permanent resident aliens who are members of an Indian tribe (primarily pertains to certain tribes along the U.S./Canadian border).

• NCSL supports Senate bill.

• Authorizes $100 million over 5 fiscal years for grants to the 12 states with the highest number of undocumented immigrants. The funds are to be used to pay for costs incurred by state and local governments to provide emergency health services to undocumented aliens.
• The grant is an entitlement to states and was authorized, but not funded last year in the 1996 Immigration Reform law.

• No provision.

• NCSL supports House bill. NCSL believes all impacted states should be eligible for federal assistance.

• MANDATORY BENEFITS

• Requires HHS to study the actuarial value of the provision of EPSDT under the Medicaid program and to report to Congress no later than 18 months after the enactment of reconciliation.

• Same as House bill.

• NCSL supports the provision. NCSL supports modification of the EPSDT benefit to allow greater state flexibility.

• Adds the Hyde Amendment restrictions into the Medicaid statute, requiring states to provide abortion services in cases where the pregnancy is a result of rape or incest, or in cases where the mother's life would be endangered if the pregnancy were to continue.

• Same as House bill.

• NCSL has no position. The Hyde Amendment preempts state laws regarding the use of public funds for abortion services.

• COPAYMENTS

• No provision.

• States would be permitted to impose limited cost-sharing on services provided to individuals whom federal law does not require the state to cover.
• No additional cost-sharing would be allowed for individuals who are required to be covered under federal law except as allowed under current law or any waiver granted to any state.
• No copayments can be imposed on children in families with incomes at or below 150% of the federal poverty level.

• NCSL supports Senate bill. NCSL supports state option for imposing nominal cost-sharing.

• PROVIDER REIMBURSMENT

• Phases out the Boren Amendment by providing for an 18 month transition period, beginning 10/1/97, where states would have to maintain reimbursement rates effective on May 1, 1997, during that period.
• Establishes a public notice process for setting rates. In the case of hospitals, the rate would have to take into account the situation of hospitals that serve a disproportionate share of low-income patients.
  
  
  
  
  
  

• Repeals the Boren Amendment.
• Requires states to provide for a public notice process for reimbursement methodology and proposed payment rates for these institutional providers.
• Providers, beneficiaries, and their representatives, and other concerned individuals are to be given an opportunity to review proposed payment rates and the methodologies underlying the establishment of such rates.
• The notice must describe how the rate-setting methods used by the states will affect access to services, quality of services and safety of beneficiaries.
• Final payment rates, the methodologies underlying the establishments of such rates, and justifications for such rates that may take into account public comments received by the state (if any) must be published in 1 or more daily newspapers of general circulation in the state or in any publication used by the state to publish state statutes or rules.
• Not later than four years after enactment of this act, the Secretary shall study the effect on access to services, the quality of services, and the safety of beneficiaries and submit

a report to Congress with conclusions from the study, together with any recommendations.

• NCSL supports Senate bill. NCSL supports repeal of the Boren Amendment.

• Phases out cost-based reimbursement for FQHCs and RHCs over a five year period. Centers will be provided 100% of cost in 1998 and 1999, 95% in 2000, 90% in 2001, 85% in 2002, and then completely phased out in 2003.
• This provision also provides for states to make supplemental payments to FQHCs during the transition period (FY 1998-2002). If under contract with an MCO, an FQHC was paid less than the appropriate percentages stated above, the state would be required to pay the FQHC the difference between the contracted amount and the cost-based amount.
• The payments in the contract between the managed care organization and the FQHC must be reasonable in relation to payments made by the organization for similar services furnished by other providers.
• Modifies the definition of FQHC to provide additional flexibility to states.
• Additionally, by no later than February 1, 2001, the Comptroller General is required to submit a report to Congress on the impact of this provision on access to health care for Medicaid beneficiaries and the uninsured and the ability of health centers to be integrated into a managed care system.

• Requires MCOs that have a contract with an FQHC or RHC to pay the center in a way that is comparable to other providers. At the election of the center, the MCO would be required to pay 100% of reasonable costs. Effective 10/1/97.

• NCSL supports House bill. NCSL supports repeal of cost-based reimbursement for FQHCs and RHCs.

• No provision.

• Provision clarifies that state Medicaid programs could limit Medicare cost-sharing to Medicaid payment rates and .
• The amount of payment made under Medicare plus the amount of payment (if any) under Medicaid is to be considered payment in full for the service and the beneficiary does not have any legal liability to make payment to the provider for the service.
• Sanctions that may be imposed on providers for excess charges under Medicaid or Medicare are to be applied to providers that impose excess charges on beneficiaries.
• This provision does not prevent payment of Medicare cost-sharing by a Medicare supplemental policy.
• Effective on or after 10/1/97 or the termination date of a provider agreement that is in effect on the date of enactment.

• NCSL supports Senate bill. This is an extremely important reimbursement issue for states.

• No provision.

• States must assure that the rates paid to managed care entities have been determined by an independent actuary that meets the standards for qualifications and practice established by the Actuarial Standards Board to be sufficient and not excessive with respect to the estimated costs of the services provided. (Similar to the Boren Amendment)

• NCSL supports House bill. The Senate provision imposes "Boren-like" requirements on states regarding reimbursement to managed care entities.

• No provision.

• Repeals federal requirements related to payment for obstetrical and pediatric services.

• NCSL supports Senate bill.

• FEDERAL MATCHING PAYMENTS

• No provision.

• Increases the FMAP for Alaska to 59.8% for each of fiscal years 1998-2000.

• NCSL has no position.

• No provision

• Temporarily increases the FMAP for the District to 60% for each of the fiscal years 1998-2000.

• NCSL has no position

• No provision.

• For FY 1998 and each fiscal year thereafter, the caps are raised and indexed from the FY 1997 levels for the commonwealths and territories by the following amounts:
  • Puerto Rico: $30 million.
  • Virgin Islands: $750,000.
  • Guam: $750,000.
  • Northern Mariana Islands: $500,000.
  • American Samoa: $500,000.
• The 50 percent match rate and indexing under current law are maintained.

• NCSL supports Senate bill.

• DISPROPORTIONATE SHARE HOSPITAL PAYMENTS (DSH)

• Establishes additional caps on the state DSH allotments for fiscal years 1998-2002, reducing expenditures by $15.3 billion.

• Establishes additional caps on the DSH allotments for FY 1998-2002, reducing expenditures by $16 billion.
• DSH limits would apply to all providers.
• States are to develop and report to the Secretary a methodology for setting priorities for DSH funding based on the proportion of low-income and Medicaid patients served by participating hospitals. An annual report on DSH payments to high volume hospitals is required.
• After 2002, DSH allotments would be equal to the previous year's allotment increased by the consumer price index for medical services.

• NCSL opposes deep cuts in DSH.

• Defined as states that had 1995 state DSH expenditures below one percent of their total medical assistance expenditures for Medicaid.
• DSH allotments would be frozen for each of the fiscal years 1998 through 2002 at its State's 1995 DSH spending.

• Low DSH states, defined as states below 3%, are reduced 1% in FY 1998 and would be frozen at this rate through FY 2002.

• NCSL has no position.

• the DSH allotment for each of fiscal years 1998 through 2002 is equal to the DSH allotment for 1995 (or if higher, fiscal year 1996) reduced by 2% in FY 1998; 5% in FY 1999; 20% in FY 2000; 30% in FY 2001; and 40% in FY 2002.

• The DSH allotment would be frozen in FY 1998. The FY 1999 allotment would equal a states' FY 1995 level plus 50% of their 1995 DSH payment to mental hospitals reduced by 8%; in FY 2000, the sum of FY 1995 levels and 20% of 1995 payments to mental hospitals, reduced by 15%; and in FY 2001 and 2002, FY 1995 DSH payments to inpatient general hospitals, reduced by 20%.

• NCSL has no position.

• Allotments for each of FY 1998- 2002 is equal to one-half of the percentage applied to high-DSH states in those years respectively: 1% in FY 1998, 2.5% in FY 1999; 10% in FY 2000; 15% in FY 2001; and 20% in FY 2002.

• Allotments to mid-DSH states, defined as states with DSH expenditures between 4-12%, would be reduced 2% in FY 1999; 5% in FY 2000; 10% in FY 2001; 15% in FY 2002. No reductions are taken in FY 1998.

• NCSL has no position.

• No provision

• Limits DSH spending on IMDs to no more than 50% of DSH spending in 2001, 40% in 2002; and 33% in FY 2003.

• NCSL supports House bill. NCSL opposes limitations on spending to IMDs.

• MANAGED CARE

• Permits states to require Medicaid beneficiaries to enroll in Medicaid managed care plans or primary care case management plans without obtaining a waiver, so long as individuals have a choice of more than one plan option.
• States would be required to offer a choice of plan or delivery system, except in rural areas.

• Similar provision.
  
  
  
  
  
  

• NCSL supports the provision. NCSL supports state flexibility to require Medicaid beneficiaries to participate in managed care without a federal waiver.

• Allows states to use PCCMs as a managed care option through a state plan amendment, with out the need to apply to HCFA for a waiver. Effective 10/1/97.
• A contract with a PCCM must provide that: (1) reasonable and adequate hours of operation, including 24-hour availability of information, referral, and treatment with respect to emergencies; (2) enrollment is restricted to individuals living near a service delivery site; (3) a sufficient number of providers will be available; (4) individuals will not be discriminated against in enrollment, disenrollment, or reenrollment, based on health status or need for care; and (5) enrollees can disenroll without cause during the first month of each enrollment period and can disenroll for cause at any time.

• Similar to House bill, except repeals "freedom-of-choice" waiver authority.

• NCSL supports the provision. NCSL supports state flexibility to require Medicaid beneficiaries to participate in managed care without a federal waiver.

• Native Americans/Alaskan Natives
• Special Needs Children
• Qualified Medicare Beneficiaries

• Same as House bill.

• NCSL has no position.

• Permits managed care companies to impose nominal copayments on beneficiaries, but clarifies that protections against copayments for pregnant women and children still apply.

• States would be permitted to impose nominal copayments on HMO enrollees as allowed in fee-for-service.
• If any charges are imposed under the state plan for cost-sharing, the cost-sharing must be pursuant to a public schedule and reflect economic factors, employment status, and family size.
• Total cost-sharing for a family with income less than 150 percent of the federal poverty level is subject to an annual limit of 3 percent of gross earnings less child care expenses.
• Total cost-sharing for a family with income greater than 150 percent but less than 200 percent of the poverty level is subject to an annual limit of 5 percent of gross earnings less child care expenses.
• Existing waivers, if any, which have been approved by the Secretary and may allow for greater cost-sharing are not subject to this limit.
• Cost-sharing charges cannot be counted as state expenditures for purposes of matching requirements.

• NCSL supports House bill. House provision provides more flexibility to states.

• MANAGED CARE: QUALITY

• Requires the state, in its state plan, to describe standards for: (1) access to care so that covered services are available within a reasonable time frames and in a manner that ensures continuity of care and adequate primary care; and (2) access to specialized services, including pediatric services for special needs children.
• Managed care entities would be required to submit any data to the State which the State requires to monitor care and provide effective grievance procedures.
• Stricter state standards would not be preempted by standards established in the Act.

• Similar to House bill except, it requires primary care case managers and managed care organizations to obtain an annual external independent review of the quality outcomes and timeliness of, and access to the services included in the manager's or organization's contract with the state.
• Authorizes the Secretary and the state to establish an incentive program to reward high quality MCOs.
• Prescribes the data MCOs must provide to the states.

• NCSL supports the House bill. The House provisions provide more flexibility to states.

• Establishes state option to deem managed care organizations that are eligible to contract with Medicare or are accredited by an organization that is a private, nonprofit with the primary function of accrediting managed care organizations or health care providers and is independent of health care providers and their associations.
• Effective for contracts entered into or renewed on or after 1/1/99.

• No provision.

• NCSL supports House bill.

• Eliminates 25/75 rule, effective on date of enactment.

• Same as House bill, except effective date is 6/20/97.

• NCSL supports.

• Requires managed care plans meet the same solvency requirements set by the States for private managed care organizations.
• Provides for a 3 year transition for existing contractors.

• Requires the Secretary to establish federal solvency standards.

• NCSL supports House bill. NCSL vigorously opposes federal preemption of state insurance regulation.

• Prohibits Health Maintenance Organizations from restricting a covered health care professional from advising an enrollee who is a patient of the professional about the health status of the enrollee or medical care or treatment for the individual's condition or disease, regardless of whether benefits for the care or treatment are provided under the plan, if the professional is acting within the lawful scope of practice.

• Similar provision.

• NCSL opposes provision. NCSL opposes federal intrusion in insurance regulation.

• MANAGED CARE: BENEFICIARY ACCESS

• No provision.

• Establishes a series of beneficiary access requirements.

• NCSL supports House bill. The Senate bill imposes several mandates related to consumer protection and managed care. NCSL opposes federal intrusion in insurance regulation.

• Requires managed care entities to permit female enrollees to designate an obstetrician/gynecologist as their primary care physician, provided the physician has agreed to the designation.
• Prohibits a managed care organization from requiring prior authorization from a primary care provider for obstetric or gynecological services.

• No provision.

• NCSL supports Senate bill. NCSL opposes federal intrusion in insurance regulation.

• Requires the state, in its state plan, to describe standards for: (1) access to care so that covered services are available within a reasonable time frames and in a manner that ensures continuity of care and adequate primary care; and (2) access to specialized services, including pediatric services for special needs children.
• Requires states to develop procedures to monitor and evaluate quality.

• Requires each managed care entity to assure adequate access to primary care services by meeting standards set by the Secretary.
• The standards may vary by area and population served and must be based on standards commonly applied in the commercial market.

• NCSL opposes provision. NCSL opposes federal intrusion in insurance regulation.

• Requires managed care entities to provide a meaningful and expedited procedure for resolving grievances.
• Requires timely notice of denial of services or the termination of a service.
• Requires each entity to establish a board of appeals to hear and make determinations regarding complaints by enrollees.

• Requires MCOs to establish an internal grievance procedure where enrollees and providers, on behalf of enrollees, may challenge the denial of coverage or payment for a service.

• NCSL supports House bill, but believes states should establish or set guidelines for grievance procedures.

• NURSING FACILITY/LONG TERM CARE PROVISIONS

• The provision would provide that a person who for a fee assists an individual to dispose of assets in order to obtain Medicaid eligibility for nursing home care would be subject to criminal liability if the individual disposes of assets and a period of ineligibility is imposed against such individual.

• Same as House bill.

• NCSL has no position.

• WAIVERS

• Repeals the provision.

• No provision.

• NCSL supports House bill. NCSL support additional state options.

• Provides for a simplified renewal or extension process.
• Within a year before the waiver is due to expire, the governor of a state may submit a request to the Secretary to extend the project for up to 3 years.
• The project extension would be on the same terms and conditions as the original project.

• Similar to the House bill, but would provide for an extension of up to 2 years for projects that: (1) have been successfully operated for 5 or more years; and (2) have been shown, through independent HCFA-sponsored evaluations, to successfully contained costs and provide access to care.
• A state waiver program, meeting both requirements and where an independent HCFA evaluation finds that the waiver program is more effective than the fee-for-service program, may expand to cover individuals up to 100% of poverty and be deemed budget neutral.
• The permanent continuation of a project will be on the same terms and conditions, including financing, and subject to the same set of waivers. No test of budget neutrality can apply to waiver projects meeting the above requirements after a permanent waiver extension is granted.

• NCSL supports provision. NCSL policy calls for the development of statutory authority for successful demonstration programs, eliminating the need for renewal.

• Permits allow States to cover services provided in IMDs to individuals between ages 21 and 65.

• No provision.

• NCSL supports House bill. NCSL supports additional state options.

• MISCELLANEOUS PROVISIONS

• States would be permitted, but not required to, pay for private health insurance premiums for Medicaid beneficiaries where cost-effective.

• Same as House bill.

• NCSL supports provision. NCSL supports additional state options and opposes federal mandates.

• Repeals this minimum qualification.

• Same as House bill.

• NCSL supports provision.

• Provides that the payments made from any fund established pursuant to the settlement in the case of In re Factor VIII or IX Concentrate Blood Products Litigation, MDL±986, no. 93±C7452 (N.D. Ill.) will not be considered income or resources in determining eligibility for, or the amount of benefits under Medicaid.

• No provision.

• NCSL supports House bill.

• Permits states to contract out eligibility determination functions to entities outside of government.

• No provision.

• NCSL has no position.

• States get allotments for: providing health coverage to targeted low income children; providing health services for improving the health of children including targeted low-income children and other low income children; expenditures for outreach activities; and other reasonable costs incurred by the state.
• Targeted low income children are those whose family's income exceeds the Medicaid income eligibility requirements in the state in effect as of June 1 but is not greater than 75 points higher than this amount, or if higher, 133% of the federal poverty level (FPL).
• A low-income child is one whose family income does not exceed 300% FPL.
• Methods to achieve coverage may include any or all of the following: a Medicaid expansion, group or individual health insurance plans, direct purchase of services from providers or other methods specified in state plan.

• States get allotments to provide health care coverage to children not eligible for Medicaid as of June 1, 1997 in families with household incomes up to 200% FPL either through a Medicaid expansion or by providing coverage equivalent to Blue Cross and Blue Shield standard option preferred provider plan plus vision and hearing.

• NCSL supports House bill. The House bill provides more flexibility for states.

• MEDICARE MANAGED CARE/SPECIAL PROVISIONS FOR PROVIDER-SPONSORED ORGANIZATIONS

• Creates the "MedicarePlus" program, which builds on the existing Medicare program that allows HMOs to enter into risk contracts with HCFA. The following choices are available:
  • Coordinated care plans;
  • Provider-Sponsored Organization plans;
  • Combination of Medical Savings Account (MSA) plan and contributions to MedicarePlus MSAs

• Same as House bill, except the program is called "MedicareChoice," and the following choices are available:
  • Fee-for-service indemnity plans;
  • Preferred Provider Organizations (PPOs);
  • Point-of-service plans (POS);
  • Provider-sponsored Organizations (PSOs);
  • Health Maintenance Organizations (HMOs);
  • Medical Savings Accounts (MSAs);
  • Other plans that meet the.

• NCSL has no position.

• A public or private entity established or organized by a health care provider, or group of affiliated providers that provides a substantial proportion of services directly through the provider or through an affiliated group of providers. Those providers that share, directly or indirectly, substantial financial risk with respect to the provision of items and services, must have at least a majority financial interest in the entity.
• Substantial proportion is to be defined by the Secretary and takes into account: (1) the need of the PSO to assume responsibility for a substantial portion of services to assure financial stability and the practical difficulties of integrating a wide range of service providers; and (2) relevant differences among organizations, such as their location in urban or rural areas.

• Similar to the House bill except:
• the health care providers and the group of affiliated providers must be local.
• With respect to defining "substantial proportion" requires the Secretary to take into account: (1) the need for the PSO to provide significantly more than the majority of the services through its won affiliated providers and most of the remainder through contractual providers;

• NCSL supports the Senate bill. NCSL supports the emphasis on "local" providers. NCSL also supports the concept that a majority of the services should be provided directly by the PSO and its affiliates.

• Eligible organizations may obtain insurance or make other arrangements for: (1) the cost of providing health care services to any enrollee that exceeds $5,000; (2) the cost of services provided to enrollees by providers outside the PSO because medically necessary services were needed before they could be secured within the PSO; (3) not more than 90% of the amount by which its costs for any fiscal year exceeds 115% of its income for the fiscal year.
• PSOs with a full risk contract may, with approval of the Secretary, obtain reinsurance or make other arrangement for covering costs and may make arrangements with participating providers to assume all or part of the financial risk on a prospective basis.

• Same as House bill, except requires the Secretary to set threshold cost for seeking reinsurance and requires the Secretary to adjust the amount annually.

• Waives the 50/50 rule if the Secretary finds it in the public interest.

• Waives the 50/50 rule if the entity meets all other applicable beneficiary protections and quality standards.

• NCSL supports both provisions, so that a waiver would occur if both standards were met.

• Requires the Secretary to contract with MedicarePlus organizations with at least 5,000 members, or 1,500 in the case of a PSO. A lesser number of members can may be permitted, but never less than 500 for PSOs.

• Requires the Secretary to contract with MedicareChoice organizations with at least 1,500 members, or 500 members in the case of rural entities.

• NCSL supports the House bill. The House bill requires larger numbers of enrollees to better spread risk.

• A MedicareChoice organization is exempt from state licensure requirements if the state requires, as a condition of licensure, the offering of any product or plan other than a MedicareChoice plan.

• Same as House bill.

• NCSL has no position.

• The Secretary must waive the state licensure requirement if: (1) the PSO files an application with the Secretary; and (2) the Secretary finds that any one of the following grounds for a waiver as been met:
• State failed to complete action on a completed license application within 90 days;
• State denied a license application and (a) imposed nonsolvency documentation or information requirements no applicable to other entities in substantially similar business; or (b) imposed state standards, or review processes that condition licensure on material nonsolvency requirements, procedures or standards not applicable to entities in substantially similar business.
• State denied license application based, at least in part, on PSO's failure to meet state solvency requirements that differ from applicable federal standards.
• The waiver is effective for 36 months and there are no limits on the number of renewals.
• The Secretary must grant or deny a waiver within 60 days of receiving a substantially complete application

• Prior to 2001, the Secretary must waive state licensure requirements for any year if: (1) the PSO files an application with the Secretary; and (2) the Secretary requires in its contract with the PSO that it meet all non-solvency requirements of state law relating to licensure.
• The waiver must specify the years it remains effective and can be renewed based on a subsequent application.
• Waivers cannot be extended beyond the earlier of 12/31/2000 or the date the Secretary determines that the state solvency standards are no less stringent than the federal standards.
• The Secretary must grant or deny a waiver within 60 days of receiving a substantially complete application

• NCSL opposes federal preemption of state licensure requirements for PSOs. NCSL opposes the waiver process. If the waiver process is adopted:
• NCSL supports the limited set of circumstances under which the Secretary may grant a waiver and the fact that it assumes the PSO is actively pursuing state licensure.
• NCSL the Senate bill regarding the sunset of the waiver provision. We would recommend that the waiver authority sunset the earlier of when a state adopts a solvency standard no less stringent than the federal standard or 12/13/99, instead of 12/31/2000.
• NCSL opposes the House bill provision that would permit PSOs to resubmit waiver applications, after being denied licensure without making material changes to the application. PSOs should be required to modify the application before resubmittal.

• Requires the Secretary, through negotiated rulemaking to establish federal solvency standards for PSOs and to develop a process for certify these standards within 60 days or receiving an application.
• Requires the Secretary to consult with interested parties and to consider: (1) the delivery system assets of the PSO and its ability to provide services directly through its affiliated providers; (2) alternative means of protecting against insolvency including reinsurance, unrestricted surplus, letters of credit, guarantees, organizational structure coverage, partnerships with other licensed entities, and "sweat equity."
• Enrollees must be held harmless from any liability to any person or entity for the organization's debts in the event of insolvency.
• The target date for publication of rule is 4/1/98.

• Same as House bill except the Secretary is required to consider the "risk-based capital" standards developed by the National Association of Insurance Commissioners (NAIC) in developing the federal solvency standards.

• NCSL supports the Senate bill, particularly the provision that requires the Secretary to consider the risk-based capital standards that have been developed by the National Association of Insurance Commissioners (NAIC). The use of state expertise regarding the development and implementation of solvency standards is important.

• A PSO waiver from state licensure supersedes state laws that would otherwise prohibit the entity from operating in the state.
• Consumer protection standards established by the Secretary through regulation preempt state laws or regulations to the extent these state laws are inconsistent with the federal standards.
• The House Commerce Committee version provides that state laws or regulations that: (1) are not related to solvency; (2) are applied uniformly to all entities engaged in substantially similar business; and (3) provides consumer protections in addition to, or more stringent than those established by the Secretary would not be preempted.

• Same as House Ways and Means Committee version.

• NCSL opposes the broad preemption of state laws, but supports the House Commerce Committee clarification regarding the preemption of state consumer protection laws that are not related to solvency.

• Establishes a MSA demonstration for Medicare beneficiaries, limited to 500,00 enrollees.

• Same as House bill, except limits enrollees to 100,000.

• No position.

• States may not impose a premium tax or similar tax on MedicarePlus plans.

• Same as House bill.

• NCSL opposes federal preemption of state taxes.

• MEDICARE REFORM

• No provision.

• Phases-in change to Medicare eligibility age from 65 to 67.

• NCSL has no position.

• No provision.

• Phases-in premium increase to cover 100% of program cost.

• NCSL has no position.

• No provision.

• Establishes a $5 copayment, capped at the annual hospital deductible, for home health visits under Part B.

• NCSL has no position.

• MULTIPLE EMPLOYER WELFARE ASSOCIATIONS

• Creates a new category of ERISA plans, certified Association Health Plans (AHPs) that would be exempt from state insurance regulation. Also exempts the following entities currently defined as MEWAs from state regulation: franchise networks, certain collectively bargained arrangements, and other arrangements that are not single-employer plans.
• Weakens current law standards regarding the affiliation between the group sponsors and members.
• Establishes solvency standards where AHPs are not required to meet capital and surplus requirements and establishes minimum reserve requirements that are below the average required in the states.

• No provision.

• NCSL supports Senate bill. NCSL vigorously opposes any expansion of the ERISA preemption with respect to state health insurance regulation.

• MEDICAL LIABILITY REFORM

• Establishes Federal standards in health care liability actions and would govern any health care and health products liability action brought in any State or Federal court.
• Does not apply to any action for damages arising from a vaccine-related injury or death or to the extent that the provisions of the National Vaccine Injury Compensation Program apply.
• The provisions preempt State or applicable Federal law to the extent State law provisions were inconsistent with the new requirements, but would not preempt State law or applicable Federal law to the extent the provisions were more stringent.
• Provisions would not affect or waive the defense of sovereign immunity asserted by any State or the U.S., affect the applicability of the Foreign Sovereign Immunities Act of 1976, pre-empt state choice-of-law rules with respect to claims brought by a foreign nation or citizen, or affect the right of any court to transfer venue.

• No provision.

• No position on medical liability reform. NCSL opposes federal preemption of state products liability law.

• Prohibits the award of punitive damages against a manufacturer or product seller in a case where a drug or device was subject to premarket approval by the Food and Drug Administration (FDA) (or generally recognized as safe and effective

according to conditions established by the FDA), unless there was misrepresentation or fraud.

• A manufacturer would not be held liable for punitive damages related to adequacy of required tamper resistant packaging unless the packaging or labeling was found by clear and convincing evidence to be substantially out of compliance with the regulations.

• No provision.

• NCSL supports Senate bill. NCSL opposes federal preemption of state products liability law.