TITLE X COORDINATION OF MEDICAL PORTION OF WORKERS COMPENSATION AND AUTOMOBILE
INSURANCE

table of contents of title                                                Page

Subtitle A Workers Compensation Insurance

Sec. 10000. Definitions                                                   1314

Part 1 Health Plan Requirements Relating to Workers Compensation

Sec. 10001. Provision of workers compensation services                    1315

Sec. 10002. Payment by workers compensation carrier                       1319

Part 2 Requirements of Participating States

Sec. 10011. Coordination of specialized workers compensation providers    1320

Sec. 10012. Preemption of State laws restricting delivery of workers
compensation medical benefits                                             1321

Sec. 10013. Development of supplemental schedule                          1322

Sec. 10014. Construction                                                  1322

Part 3 Application of Information Requirements; Report on Premium Reductions

Sec. 10021. Application of information requirements                       1323

Sec. 10022. Report on reduction in workers compensation premiums          1324

Part 4 Demonstration Projects

Sec. 10031. Authorization                                                 1325

Sec. 10032. Development of work-related protocols                         1325

Sec. 10033. Development of capitation payment models                      1326

Subtitle B Automobile Insurance

Sec. 10100. Definitions                                                   1326

Part 1 Health Plan Requirements Relating to Automobile Insurance

Sec. 10101. Provision of automobile insurance medical benefits through health
plans                                                                     1327

Sec. 10102. Payment by automobile insurance carrier                       1328

Part 2 Requirement of Participating States

Sec. 10111. Development of supplemental schedule                          1330

Sec. 10112. Construction                                                  1330

Part 3 Application of Information Requirements

Sec. 10121. Application of information requirements                       1330

Subtitle C Commission on Integration of Health Benefits

Sec. 10201. Commission                                                    1331

Subtitle D Federal Employees' Compensation Act

Sec. 10301. Application of policy                                         1333

Subtitle E Davis-Bacon Act and Service Contract Act

Sec. 10401. Coverage of benefits under Health Security Act                1333

Subtitle F Effective Dates

Sec. 10501. Regional alliances                                            1334

Sec. 10502. Corporate alliances                                           1334

Sec. 10503. Federal requirements                                          1334


Title X, Subtitle A

Subtitle A Workers Compensation Insurance

SEC. 10000. DEFINITIONS.

  In this subtitle:

  (1) Injured worker. The term "injured worker'' means, with respect to a
health plan, an individual enrolled under the plan who has a work-related
injury or illness for which workers compensation medical benefits are
available under State law.

  (2) Specialized workers compensation provider. The term "specialized workers
compensation provider'' means a health care provider that specializes in the
provision of treatment relating to work-related injuries or illness, and
includes specialists in industrial medicine, specialists in occupational
therapy, and centers of excellence in industrial medicine and occupational
therapy.

  (3) Workers compensation medical benefits. The term "workers compensation
medical benefits'' means, with respect to an enrollee who is an employee
subject to the workers compensation laws of a State, the comprehensive medical
benefits for work-related injuries and illnesses provided for under such laws
with respect to such an employee.

  (4) Workers compensation carrier. The term "workers compensation carrier''
means an insurance company that underwrites workers compensation medical
benefits with respect to one or more employers and includes an employer or
fund that is financially at risk for the provision of workers compensation
medical benefits.

  (5) Workers compensation services. The term "workers compensation services''
means items and services included in workers compensation medical benefits and
includes items and services (including rehabilitation services and long-term
care services) commonly used for treatment of work-related injuries and
illnesses.

PART 1 HEALTH PLAN REQUIREMENTS RELATING TO WORKERS COMPENSATION

SEC. 10001. PROVISION OF WORKERS COMPENSATION SERVICES.

  (a) Provision of Benefits. Subject to subsection (b)

  (1) Requirement for certain health plans.

  (A) In general. Each health plan that provides services to enrollees through
participating providers shall enter into such contracts and arrangements as
are necessary (in accordance with subparagraph (B)) to provide or arrange for
the provision of workers compensation services to such enrollees, in return
for payment from the workers compensation carrier under section 10002.

  (B) Provision of services. For purposes of this paragraph, a health plan
provides (or arranges for the provision of) workers compensation services with
respect to an enrollee if the services are provided by

  (i) a participating provider in the plan,

  (ii) any other provider with whom the plan has entered into an agreement for
the provision of such services, or

  (iii) a specialized workers compensation provider (designated by the State
under 10011(b)), whether or not the provider is a provider described in clause
(i) or (ii).

  (2) Individual requirement. An individual entitled to workers compensation
medical benefits and enrolled in a health plan (whether or not the plan is
described in paragraph (1)(A)) shall receive workers compensation services
through the provision (or arrangement for the provision) of such services by
the health plan.

  (3) Exceptions.

  (A) Emergency services. Paragraphs (1) and (2) shall not apply in the case
of emergency services.

  (B) Electing veterans, military personnel and indians. Paragraphs (1) and
(2) shall not apply in the case of an individual described in section 1004(b)
and making an election described in such section.

  (4) Use of specialized workers compensation providers. If a participating
State has designated under section 10011(b) specialized workers compensation
providers with respect to one or more types of injuries or illnesses for a
geographic area, either a health plan or an injured worker who has an injury
or illness of such type may elect to provide or receive the benefits under
this subsection through such a provider.

  (b) Alternative Permitted. Subsection (a) shall not be construed as
preventing an injured worker and a workers compensation carrier from agreeing
that workers compensation services shall be provided other than by or through
the health plan in which the worker is enrolled.

  (c) Coordination.

  (1) Designation of case manager. Each health plan shall employ or contract
with one or more individuals, such as occupational nurses, with experience in
the treatment of occupational illness and injury to provide case management
services with respect to workers compensation services provided through the
plan under this section.

  (2) Functions of case manager. The health plan (through the case manager
described in paragraph (1)) is responsible for ensuring that

  (A) there is plan of treatment (when appropriate) for each enrollee who is
an injured worker designed to assure appropriate treatment and facilitate
return to work;

  (B) the plan of treatment is coordinated with the workers compensation
carrier, the employer, or both;

  (C) the health plan (and its providers) comply with legal duties and
requirements under State workers compensation law; and

  (D) if the health plan is unable to provide a workers compensation service
needed to treat a work-related injury or illness, the injured worker is
referred (in consultation with the workers compensation carrier) to an
appropriate provider.

  (c) Administration. The Secretary of Labor shall administer this part and,
for such purposes, the Secretary is authorized to prescribe such rules and
regulations as may be necessary and appropriate.

SEC. 10002. PAYMENT BY WORKERS COMPENSATION CARRIER.

  (a) Payment.

  (1) In general. Each workers compensation carrier that is liable for payment
for workers compensation services furnished by or through a health plan,
regardless of whether or not the services are included in the comprehensive
benefit package, shall make payment for such services.

  (2) Use of regional alliance fee schedule. Except as provided in subsection
(b), such payment shall be made in accordance with the applicable fee schedule
established under section 1322(c) or section 10013.

  (b) Alternative Payment Methodologies. Subsection (a)(2) shall not apply

  (1) in the case of a regional alliance or participating State that
establishes an alternative payment methodology (such as payment on a
negotiated fee for each case) for payment for workers compensation services;
or

  (2) in the case in which a workers compensation carrier and the health plan
negotiate alternative payment arrangements.

  (c) Limitation of Liability of Injured Worker. Nothing in this part shall be
construed as requiring an injured worker to make any payment (including
payment of any cost sharing or any amount in excess of the applicable fee
schedule) to any health plan or health care provider for the receipt of
workers compensation services.

PART 2 REQUIREMENTS OF PARTICIPATING STATES

SEC. 10011. COORDINATION OF SPECIALIZED WORKERS COMPENSATION PROVIDERS.

  (a) In General. Each participating State shall coordinate access to services
provided by specialized workers compensation providers on behalf of health
plans, providing coverage to individuals residing in the State, under part 1.

  (b) Optional Designation of Specialized Workers Compensation Providers. A
participating State may designate such specialized workers compensation
providers, with respect to one or more types of illnesses or injuries in a
geographic area as the State determines to be appropriate, to provide under
part 1 workers compensation services that

  (1) are not included in the comprehensive benefit package, or

  (2) are so included but are specialized services that are typically provided
(as determined by the State) by specialists in occupational or rehabilitative
medicine.

Injured workers and health plans may elect to use such providers under section
10001(a)(4).

SEC. 10012. PREEMPTION OF STATE LAWS RESTRICTING DELIVERY OF WORKERS
COMPENSATION MEDICAL BENEFITS.

  (a) In General. Subject to section 10011(b), no State law shall have any
effect that restricts the choice, or payment, of providers that may provide
workers compensation services for individuals enrolled in a health plan.

  (b) Dispute Resolution. A State law may provide for a method for resolving
disputes among parties related to

  (1) an individual's entitlement to workers compensation medical benefits
under State law,

  (2) the necessity and appropriateness of workers compensation services
provided to an injured worker, and

  (3) subject to section 10002, the reasonableness of charges or fees charged
for workers compensation services.

SEC. 10013. DEVELOPMENT OF SUPPLEMENTAL SCHEDULE.

  Each participating State shall develop a fee schedule applicable to payment
for workers compensation services for which a fee is not included in the
applicable fee schedule established under section 1322(c).

SEC. 10014. CONSTRUCTION.

  (a) In General. Nothing in this subtitle shall be construed as altering

  (1) the effect of a State workers compensation law as the exclusive remedy
for work-related injuries or illnesses,

  (2) the determination of whether or not a person is an injured worker and
entitled to workers compensation medical benefits under State law,

  (3) the scope of items and services available to injured workers entitled to
workers compensation medical benefits under State law, or

  (4) the eligibility of any individual or class of individuals for workers
compensation medical benefits under State law.

  (b) Early Integration. Nothing in this subtitle shall prevent a State from
integrating or otherwise coordinating the payment for workers compensation
medical benefits with payment for benefits under health insurance or health
benefit plans before the date the Commission submits its report under section
10201(e).

PART 3 APPLICATION OF INFORMATION REQUIREMENTS; REPORT ON PREMIUM REDUCTIONS

SEC. 10021. APPLICATION OF INFORMATION REQUIREMENTS.

  (a) In General. The provisions of

  (1) part 3 of subtitle B of title V (relating to use of standard forms), and

  (2) section 5101(e)(9) (relating to provision of data on quality),

apply to the provision of workers compensation services in the same manner as
such provisions apply with respect to the provision of services included in
the comprehensive benefit package.

  (b) Rules. The Secretary of Labor shall promulgate rules to clarify the
responsibilities of health plans and workers compensation carriers in carrying
out the provisions referred to in subsection (a).

SEC. 10022. REPORT ON REDUCTION IN WORKERS COMPENSATION PREMIUMS.

  (a) Study and Report.

  (1) Study. The Secretary of Labor shall provide for a study of the impact of
the provisions of this subtitle on the premium rates charged to employers for
workers compensation insurance. Such study shall use information supplied by
States relating to workers compensation premiums and such other information as
such Secretary finds appropriate.

  (2) Report. Such Secretary shall submit to the Congress, by not later than 2
years after the date that this subtitle applies in all States, a report on the
findings of the study.

  (b) Workers Compensation Carrier Filings.

  (1) In general. Within six months after the date this subtitle is effective
in a participating State, each workers compensation carrier (other than a
self-funded employer) providing workers compensation insurance in the State
shall make a filing with an agency designated by the State. Such filing shall
describe the manner in which such carrier has modified (or intends to modify)
its premium rates for workers compensation insurance provided in the State to
reflect the changes brought about by the provisions in this subtitle. The
filing shall include such actuarial projections and assumptions as necessary
to support the modifications of such rates.

  (2) Report to secretary. Each participating State shall provide to the
Secretary of Labor such information on filings made under paragraph (1) as
such Secretary may specify.

PART 4 DEMONSTRATION PROJECTS

SEC. 10031. AUTHORIZATION.

  The Secretary of Health and Human Services and the Secretary of Labor are
authorized to conduct demonstration projects under this part in one or more
States with respect to treatment of work-related injuries and illnesses.

SEC. 10032. DEVELOPMENT OF WORK-RELATED PROTOCOLS.

  (a) In General. Under this part, the Secretaries, in consultation with
States and such experts on work-related injuries and illnesses as the
Secretaries find appropriate, shall develop protocols for the appropriate
treatment of work-related conditions.

  (b) Testing of Protocols. The Secretaries shall enter into contracts with
one or more health alliances to test the validity of the protocols developed
under subsection (a).

SEC. 10033. DEVELOPMENT OF CAPITATION PAYMENT MODELS.

  Under this part, the Secretaries shall develop, using protocols developed
under section 10032 if possible, methods of providing for payment by workers
compensation carriers to health plans on a per case, capitated payment for the
treatment of specified work-related injuries and illnesses.

Title X, Subtitle B

Subtitle B Automobile Insurance

SEC. 10100. DEFINITIONS.

  In this subtitle:

  (1) Injured individual. The term "injured individual'' means, with respect
to a health plan, an individual enrolled under the plan who has an injury or
illness sustained in an automobile accident for which automobile insurance
medical benefits are available.

  (2) Automobile insurance medical benefits. The term "automobile insurance
medical benefits'' means, with respect to an enrollee, the comprehensive
medical benefits for injuries or illnesses sustained in automobile accidents.

  (3) Automobile insurance carrier. The term "automobile insurance carrier''
means an insurance company that underwrites automobile insurance medical
benefits and includes an employer or fund that is financially at risk for the
provision of automobile insurance medical benefits.

  (4) Automobile insurance medical services. The term "automobile insurance
medical services'' means items and services included in automobile insurance
medical benefits and includes items and services (such as rehabilitation
services and long-term care services) commonly used for treatment of injuries
and illnesses sustained in automobile accidents.

PART 1 HEALTH PLAN REQUIREMENTS RELATING TO AUTOMOBILE INSURANCE

SEC. 10101. PROVISION OF AUTOMOBILE INSURANCE MEDICAL BENEFITS THROUGH HEALTH
PLANS.

  (a) In General. An individual entitled to automobile insurance medical
benefits and enrolled in a health plan shall receive automobile insurance
medical services through the provision (or arrangement for the provision) of
such services by the health plan.

  (b) Referral for Specialized Services. Each health plan shall provide for
such referral for automobile insurance medical services as may be necessary to
assure appropriate treatment of injured individuals.

  (c) Exceptions. Subsections (a) and (b) shall not apply in the case of an
individual described in section 1004(b) and making an election described in
such section.

  (d) Alternative Permitted. Subsection (a) shall not be construed as
preventing an injured individual and an automobile insurance carrier from
agreeing that automobile insurance medical services shall be provided other
than by or through the health plan in which the individual is enrolled.

SEC. 10102. PAYMENT BY AUTOMOBILE INSURANCE CARRIER.

  (a) Payment.

  (1) In general. Except as provided in subsection (b), each automobile
insurance carrier that is liable for payment for automobile insurance medical
services furnished by or through a health plan, regardless of whether or not
the services are included in the comprehensive benefit package, shall make
payment for such services.

  (2) Use of regional alliance fee schedule. Such payment shall be made in
accordance with the applicable fee schedule established under section 1322(c)
or section 10111.

  (b) Alternative Payment Methodologies. Subsection (a) shall not apply

  (1) in the case of a regional alliance or participating State that
establishes an alternative payment methodology (such as payment on a
negotiated fee for each case) for payment for automobile insurance medical
services; or

  (2) in the case in which a automobile insurance carrier and the health plan
negotiate alternative payment arrangements.

  (c) Limitation of Liability of Injured Individual. Nothing in this part
shall be construed as requiring an injured individual to make any payment
(including payment of any cost sharing or any amount in excess of the
applicable fee schedule) to any health plan or health care provider for the
receipt of automobile insurance medical services.

PART 2 REQUIREMENT OF PARTICIPATING STATES

SEC. 10111. DEVELOPMENT OF SUPPLEMENTAL SCHEDULE.

  Each participating State shall develop a fee schedule applicable to payment
for automobile insurance medical services for which a fee is not included in
the applicable fee schedule established under section 1322(c).

SEC. 10112. CONSTRUCTION.

  Nothing in this subtitle shall be construed as altering

  (1) the determination of whether or not a person is an injured individual
and entitled to automobile insurance medical benefits under State law,  or

  (2) the scope of items and services available to injured individuals
entitled to automobile insurance medical benefits under State law.

PART 3 APPLICATION OF INFORMATION REQUIREMENTS.

SEC. 10121. APPLICATION OF INFORMATION REQUIREMENTS.

  (a) In General. The provisions of

  (1) part 3 of subtitle B of title V (relating to use of standard forms), and

  (2) section 5101(e)(9) (relating to provision of data on quality),

apply to the provision of automobile insurance medical services in the same
manner as such provisions apply with respect to the provision of services
included in the comprehensive benefit package.

  (b) Rules. The Secretary of Labor shall promulgate rules to clarify the
responsibilities of health plans and automobile insurance carriers in carrying
out the provisions referred to in subsection (a).

Title X, Subtitle C

Subtitle C COMMISSION ON INTEGRATION OF HEALTH BENEFITS

SEC. 10201. COMMISSION.

  (a) Establishment. There is hereby created a Commission on Integration of
Health Benefits (in this section referred to as the "Commission'').

  (b) Composition.

  (1) In general. The Commission shall consist of 15 members appointed jointly
by the Secretary of Health and Human Services and the Secretary of Labor.

  (2) No compensation except travel expenses. Members of the Commission shall
serve without compensation, but the Secretaries shall provide that each member
shall receive travel expenses, including per diem in lieu of subsistence, in
accordance with sections 5702 and 5703 of title 5, United States Code.

  (c) Duties. The Commission shall study the feasibility and appropriateness
of transferring financial responsibility for all medical benefits (including
those currently covered under workers compensation and automobile insurance)
to health plans.

  (d) Staff Support. The Secretaries shall provide staff support for the
Commission.

  (e) Report. The Commission shall submit a report on its work to the
President by not later than July 1, 1995. If such report recommends the
integration of financial responsibility for all medical benefits in health
plans, such report shall provide for a detailed plan as to how (and when) such
an integration should be effected under this Act.

  (f) Termination. The Commission shall terminate 90 days after the date of
submission of its report under subsection (e).

  (g) Authorization of Appropriations. There are authorized to be appropriated
such sums as may be necessary to carry out this section.

Title X, Subtitle D

Subtitle D Federal Employees' Compensation Act

SEC. 10301. APPLICATION OF POLICY.

  (a) In General. Chapter 81 of title 5, United States Code, known as the
Federal Employees' Compensation Act shall be interpreted and administered
consistent with the provisions of subtitle A.

  (b) Construction. In applying subsection (a), subtitle A shall be applied as
if the following modifications had been made in subtitle A:

  (1) Any reference in section 10000, section 10001(c)(2)(C), section
10012(b), or section 10014 to a State law is deemed to include a reference to
chapter 81 of title 5, United States Code.

  (2) The term "workers compensation carrier'' includes the Employees
Compensation Fund (established under section 8147 of title 5, United States
Code).

Title X, Subtitle E

Subtitle E Davis-Bacon Act and Service Contract Act

SEC. 10401. COVERAGE OF BENEFITS UNDER HEALTH SECURITY ACT.

  (a) Davis-Bacon Act. Subsection (b)(2) of the first section of the Davis
Bacon Act (40 U.S.C. 276a(b)(2)) is amended in the matter following
subparagraph (B) by inserting after "local law'' the following: "(other than
benefits provided pursuant to the Health Security Act)''.

  (b) Service Contract Act of 1965. The second sentence of section 2(a)(2) of
the Service Contract Act of 1965 (41 U.S.C. 351(a)(2)) is amended by inserting
after "local law'' the following: "(other than benefits provided pursuant to
the Health Security Act)''.

Title X, Subtitle F

Subtitle F Effective Dates

SEC. 10501. REGIONAL ALLIANCES.

  The provisions of subtitles A and B of this title apply to regional
alliances, and regional alliance health plans, in a State 2 years after the
State's first year (as defined in section 1902(17)).

SEC. 10502. CORPORATE ALLIANCES.

  The provisions of subtitles A and B of this title apply to corporate
alliances, and corporate alliance health plans, on the date under section
10501 that such subtitles apply to regional alliances, and regional alliance
health plans, in the State.

SEC. 10503. FEDERAL REQUIREMENTS.

  The provisions of subtitle D of this title shall take effect on January 1,
1998.


