STANDARDS FOR GROUP HEALTH PLAN COVERAGE.

SEC. 4301. STANDARDS FOR GROUP HEALTH PLAN COVERAGE. (a) In General.— Part 6 of subtitle B of title I of the Employee Retirement Income Security Act of 1974 (29 U.S.C. 1161 et seq.) is amended by adding at the end the following new section: 107 STAT. 372 “additional standards for group health plans “Sec. 609. (a) Group Health Plan Coverage Pursuant to Medical Child Support Orders.— “(1) In general.— Each group health plan shall provide benefits in accordance with the applicable requirements of any qualified medical child support order. “(2) Definitions.— For purposes of this subsection— “(A) Qualified medical child support order.— The term ‘qualified medical child support order’ means a medical child support order— “(i) which creates or recognizes the existence of an alternate recipient’s right to, or assigns to an alternate recipient the right to, receive benefits for which a participant or beneficiary is eligible under a group health plan, and “(ii) with respect to which the requirements of paragraphs (3) and (4) are met. “(B) Medical child support order.— The term ‘medical child support order’ means any judgment, decree, or order (including approval of a settlement agreement) issued by a court of competent jurisdiction which— “(i) provides for child support with respect to a child of a participant under a group health plan or provides for health benefit coverage to such a child, is made pursuant to a State domestic relations law (including a community property law), and relates to benefits under such plan, or “(ii) enforces a law relating to medical child support described in section 1908 of the Social Security Act (as added by section 13822 of the Omnibus Budget Reconciliation Act of 1993) with respect to a group health plan. “(C) Alternate recipient.— The term ‘alternate recipient’ means any child of a participant who is recognized under a medical child support order as having a right to enrollment under a group health plan with respect to such participant. “(3) Information to be included in qualified order.— A medical child support order meets the requirements of this paragraph only if such order clearly specifies— “(A) the name and the last known mailing address (if any) of the participant and the name and mailing address of each alternate recipient covered by the order, “(B) a reasonable description of the type of coverage to be provided by the plan to each such alternate recipient, or the manner in which such type of coverage is to be determined, “(C) the period to which such order applies, and “(D) each plan to which such order applies. “(4) Restriction on new types or forms of benefits.— A medical child support order meets the requirements of this paragraph only if such order does not require a plan to provide any type or form of benefit, or any option, not otherwise provided under the plan, except to the extent necessary to meet the requirements of a law relating to medical child support described in section 1908 of the Social Security Act (as added 107 STAT. 373by section 13822 of the Omnibus Budget Reconciliation Act of 1993). “(5) Procedural requirements.— “(A) Timely notifications and determinations.— In the case of any medical child support order received by a group health plan— “(i) the plan administrator shall promptly notify the participant and each alternate recipient of the receipt of such order and the plan’s procedures for determining whether medical child support orders are qualified medical child support orders, and “(ii) within a reasonable period after receipt of such order, the plan administrator shall determine whether such order is a qualified medical child support order and notify the participant and each alternate recipient of such determination. “(B) Establishment of procedures for determining qualified status of orders.— Each group health plan shall establish reasonable procedures to determine whether medical child support orders are qualified medical child support orders and to administer the provision of benefits under such qualified orders. Such procedures— “(i) shall be in writing, “(ii) shall provide for the notification of each person specified in a medical child support order as eligible to receive benefits under the plan (at the address included in the medical child support order) of such procedures promptly upon receipt by the plan of the medical child support order, and “(iii) shall permit an alternate recipient to designate a representative for receipt of copies of notices that are sent to the alternate recipient with respect to a medical child support order. “(6) Actions taken by fiduciaries.— If a plan fiduciary acts in accordance with part 4 of this subtitle in treating a medical child support order as being (or not being) a qualified medical child support order, then the plan’s obligation to the participant and each alternate recipient shall be discharged to the extent of any payment made pursuant to such act of the fiduciary. “(7) Treatment of alternate recipients.— “(A) Treatment as beneficiary generally.— A person who is an alternate recipient under a qualified medical child support order shall be considered a beneficiary under the plan for purposes of any provision of this Act. “(B) Treatment as participant for purposes of reporting and disclosure requirements.— A person who is an alternate recipient under any medical child support order shall be considered a participant under the plan for purposes of the reporting and disclosure requirements of part 1. “(8) Direct provision of benefits provided to alternate recipients.— Any payment for benefits made by a group health plan pursuant to a medical child support order in reimbursement for expenses paid by an alternate recipient or an alternate recipient’s custodial parent or legal guardian shall 107 STAT. 374be made to the alternate recipient or the alternate recipient’s custodial parent or legal guardian. “(b) Rights of States with Respect to Group Health Plans Where Participants or Beneficiaries Thereunder Are Eligible for Medicaid Benefits.— “(1) Compliance by plans with assignment of rights.— A group health plan shall provide that payment for benefits with respect to a participant under the plan will be made in accordance with any assignment of rights made by or on behalf of such participant or a beneficiary of the participant as required by a State plan for medical assistance approved under title XIX of the Social Security Act pursuant to section 1912(a)(1)(A) of such Act (as in effect on the date of the enactment of the Omnibus Budget Reconciliation Act of 1993). “(2) Enrollment and provision of benefits without regard to medicaid eligibility.— A group health plan shall provide that, in enrolling an individual as a participant or beneficiary or in determining or making any payments for benefits of an individual as a participant or beneficiary, the fact that the individual is eligible for or is provided medical assistance under a State plan for medical assistance approved under title XIX of the Social Security Act will not be taken into account. “(3) Acquisition by states of rights of third parties.— A group health plan shall provide that, to the extent that payment has been made under a State plan for medical assistance approved under title XIX of the Social Security Act in any case in which a group health plan has a legal liability to make payment for items or services constituting such assistance, payment for benefits under the plan will be made in accordance with any State law which provides that the State has acquired the rights with respect to a participant to such payment for such items or services. “(c) Group Health Plan Coverage of Dependent Children in Cases of Adoption.— “(1) Coverage effective upon placement for adoption.— In any case in which a group health plan provides coverage for dependent children of participants or beneficiaries, such plan shall provide benefits to dependent children placed with participants or beneficiaries for adoption under the same terms and conditions as apply in the case of dependent children who are natural children of participants or beneficiaries under the plan, irrespective of whether the adoption has become final. “(2) Restrictions based on preexisting conditions at time of placement for adoption prohibited.— A group health plan may not restrict coverage under the plan of any dependent child adopted by a participant or beneficiary, or placed with a participant or beneficiary for adoption, solely on the basis of a preexisting condition of such child at the time that such child would otherwise become eligible for coverage under the plan, if the adoption or placement for adoption occurs while the participant or beneficiary is eligible for coverage under the plan. “(3) Definitions.— For purposes of this subsection— “(A) Child.— The term ‘child’ means, in connection with any adoption, or placement for adoption, of the child, an 107 STAT. 375individual who has not attained age 18 as of the date of such adoption or placement for adoption. “(B) Placement for adoption.— The term ‘placement’, or being ‘placed’, for adoption, in connection with any placement for adoption of a child with any person, means the assumption and retention by such person of a legal obligation for total or partial support of such child in anticipation of adoption of such child. The child’s placement with such person terminates upon the termination of such legal obligation. “(d) Continued Coverage of Costs of a Pediatric Vaccine Under Group Health Plans.— A group health plan may not reduce its coverage of the costs of pediatric vaccines (as defined under section 1928(h)(6) of the Social Security Act as amended by section 13830 of the Omnibus Budget Reconciliation Act of 1993) below the coverage it provided as of May 1, 1993. “(e) Regulations.— Any regulations prescribed under this section shall be prescribed by the Secretary of Labor, in consultation with the Secretary of Health and Human Services.”. (b) Conforming Amendments to ERISA To Ensure Compliance With Medicare and Medicaid Coverage Data Bank Requirements.— (1) Reports to data bank.— Section 101 of the Employee Retirement Income Security Act of 1974 (29 U.S.C. 1021) is amended— (A) by redesignating subsection (f) as subsection (g); and (B) by inserting after subsection (e) the following new subsection: “(f) Information Necessary To Comply With Medicare and Medicaid Coverage Data Bank Requirements.— “(1) Provision of information by group health plan upon request of employer.— “(A) In general.— An employer shall comply with the applicable requirements of section 1144 of the Social Security Act (as added by section 13581 of the Omnibus Budget Reconciliation Act of 1993). Upon the request of an employer maintaining a group health plan, any plan sponsor, plan administrator, insurer, third-party administrator, or other person who maintains under the plan the information necessary to enable the employer to comply with the applicable requirements of section 1144 of the Social Security Act shall, in such form and manner as may be prescribed in regulations of the Secretary (in consultation with the Secretary of Health and Human Services), provide such information (not inconsistent with paragraph (2))— “(i) in the case of a request by an employer described in subparagraph (B) and a plan that is not a multiemployer plan or a component of an arrangement described in subparagraph (C), to the Medicare and Medicaid Coverage Data Bank; “(ii) in the case of a plan that is a multiemployer plan or is a component of an arrangement described in subparagraph (C), to the employer or to such Data Bank, at the option of the plan; and “(iii) in any other case, to the employer or to such Data Bank, at the option of the employer. 107 STAT. 376 “(B) Employer described.— An employer is described in this subparagraph for any calendar year if such employer normally employed fewer than 50 employees on a typical business day during such calendar year. “(C) Arrangement described.— An arrangement described in this subparagraph is any arrangement in which two or more employers contribute for the purpose of providing group health plan coverage for employees. “(2) Information not required to be provided.— Any plan sponsor, plan administrator, insurer, third-party administrator, or other person described in paragraph (1)(A) (other than the employer) that maintains the information under the plan shall not provide to an employer in order to satisfy the requirements of section 1144 of the Social Security Act, and shall not provide to the Data Bank under such section, information that pertains in any way to— “(A) the health status of a participant, or of the participant’s spouse, dependent child, or other beneficiary, “(B) the cost of coverage provided to any participant or beneficiary, or “(C) any limitations on such coverage specific to any participant or beneficiary. “(3) Regulations.— The Secretary may, in consultation with the Secretary of Health and Human Services, prescribe such regulations as are necessary to carry out this subsection.”. (c) Conforming Amendments.— (1) Civil actions.— Section 502(a) of such Act (29 U.S.C. 1132(a)) is amended— (A) in paragraph (5), by striking “or” at the end; (B) in paragraph (6), by striking the period and inserting a semicolon; and (C) by adding at the end the following new paragraphs: “(7) by a State to enforce compliance with a qualified medical child support order (as defined in section 609(a)(2)(A)); or “(8) by the Secretary, or by an employer or other person referred to in section 101(f)(1), (A) to enjoin any act or practice which violates subsection (f) of section 101, or (B) to obtain appropriate equitable relief (i) to redress such violation or (ii) to enforce such subsection.”. (2) Civil penalty.— Section 502(c) of such Act (29 U.S.C. 1132(c)) is amended by adding at the end the following new paragraph: “(4) The Secretary may assess a civil penalty of not more than $1,000 for each violation by any person of section 101(f)(1). For purposes of this paragraph, each violation described in subparagraph (A) with respect to any single participant, and each violation described in subparagraph (B) with respect to any single participant or beneficiary, shall be treated as a separate violation. The Secretary and the Secretary of Health and Human Services shall maintain such ongoing consultation as may be necessary and appropriate to coordinate enforcement under this subsection with enforcement under section 1144(c)(8) of the Social Security Act.”. (3) Jurisdiction.— Section 502(e)(1) of such Act (29 U.S.C. 1132(e)(1)) is amended— 107 STAT. 377 (A) in the first sentence, by striking “or fiduciary” and inserting “fiduciary, or any person referred to in section 101(f)(1)”; and (B) in the second sentence, by striking “subsection (a)(1)(B)” and inserting “paragraphs (1)(B) and (7) of subsection (a)”. (4) Effect on other laws.— Section 514 of such Act (29 U.S.C. 1144) is amended— (A) in subsection (b)(7)(D), by inserting “, qualified medical child support orders (within the meaning of section 609(a)(2)(A)), and the provisions of law referred to in section 609(a)(2)(B)(ii) to the extent enforced by qualified medical child support orders” before the period; and (B) by striking subsection (b)(8) and inserting the following: “(8) Subsection (a) of this section shall not be construed to preclude any State cause of action— “(A) with respect to which the State exercises its acquired rights under section 609(b)(3) with respect to a group health plan (as defined in section 607(1)), or “(B) for recoupment of payment with respect to items or services pursuant to a State plan for medical assistance approved under title XIX of the Social Security Act which would not have been payable if such acquired rights had been executed before payment with respect to such items or services by the group health plan.”; (5) Clerical amendments.— (A) The heading for part 6 of subtitle B of title I of such Act is amended to read as follows: “Part 6— Group Health Plans”. (B) The table of contents in section 1 of such Act is amended— (i) by striking the item relating to the heading for part 6 of subtitle B of title I and inserting the following: “Past 6—Group Health Plans”; and (ii) by inserting after the item relating to section 608 the following new item: “Sec. 609. Additional standards for group health plans.”. (d) Effective Date.— (1) In general.— The amendments made by this section shall take effect on the date of the enactment of this Act. (2) Plan amendments not required until January 1, 1994.— Any amendment to a plan required to be made by an amendment made by this section shall not be required to be made before the first plan year beginning on or after January 1, 1994, if— (A) during the period after the date before the date of the enactment of this Act and before such first plan year, the plan is operated in accordance with the requirements of the amendments made by this section, and 107 STAT. 378 (B) such plan amendment applies retroactively to the period after the date before the date of the enactment of this Act and before such first plan year. A plan shall not be treated as failing to be operated in accordance with the provisions of the plan merely because it operates in accordance with this paragraph.