Sec. 211. Expansion of access and choice through individual and small employer membership associations (IMAs)
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The Public Health Service Act , as amended by section 2, is further amended by inserting after title XXX the following new title: For purposes of this title, the terms individual and small employer membership association and IMA mean a legal entity that meets the following requirements: The IMA is an organization operated under the direction of an association (as defined in section 3104(1)). The IMA, in conjunction with those health insurance issuers that offer health benefits coverage through the IMA, makes available health benefits coverage in the manner described in subsection
(b)to all members of the IMA and the dependents of such members (and, in the case of small employers, employees and their dependents) in the manner described in subsection (c)(2) at rates that are established by the health insurance issuer on a policy or product specific basis and that may vary only as permissible under State law. Subject to clause (ii), the IMA may not offer health benefits coverage to a member of an IMA unless the same coverage is offered to all such members of the IMA. Nothing in this title shall be construed as requiring or permitting a health insurance issuer to provide coverage outside the service area of the issuer, as approved under State law, or requiring a health insurance issuer from excluding or limiting the coverage on any individual, subject to the requirement of section 2741. The IMA provides health benefits coverage only through contracts with health insurance issuers and does not assume insurance risk with respect to such coverage. Nothing in this title shall be construed as preventing the establishment and operation of more than one IMA in a geographic area or as limiting the number of IMAs that may operate in any area. The IMA may provide administrative services for members. Such services may include accounting, billing, and enrollment information. Nothing in this subsection shall be construed as preventing an IMA from serving as an administrative service organization to any entity. The IMA files with the Secretary information that demonstrates the IMA’s compliance with the applicable requirements of this title. Any health benefits coverage offered through an IMA shall— be underwritten by a health insurance issuer that— is licensed (or otherwise regulated) under State law, and meets all applicable State standards relating to consumer protection, subject to section 3102(b), and subject to paragraph (2), be approved or otherwise permitted to be offered under State law. The benefits coverage made available through an IMA may include, but is not limited to, any of the following if it meets the other applicable requirements of this title: Coverage through a health maintenance organization. Coverage in connection with a preferred provider organization. Coverage in connection with a licensed provider-sponsored organization. Indemnity coverage through an insurance company. Coverage offered in connection with a contribution into a medical savings account or flexible spending account. Coverage that includes a point-of-service option. Any combination of such types of coverage. Nothing in this title shall be construed as precluding a health insurance issuer offering health benefits coverage through an IMA from establishing premium discounts or rebates for members or from modifying otherwise applicable copayments or deductibles in return for adherence to programs of health promotion and disease prevention so long as such programs are agreed to in advance by the IMA and comply with all other provisions of this title and do not discriminate among similarly situated members. Under rules established to carry out this title, with respect to an individual or small employer who is a member of an IMA, the individual may enroll for health benefits coverage (including coverage for dependents of such individual) or employer may enroll employees for health benefits coverage (including coverage for dependents of such employees) offered by a health insurance issuer through the IMA. Nothing in this paragraph shall preclude an IMA from establishing rules of enrollment and reenrollment of members. Such rules shall be applied consistently to all members within the IMA and shall not be based in any manner on health status-related factors. The contract between an IMA and a health insurance issuer shall provide, with respect to a member enrolled with health benefits coverage offered by the issuer through the IMA, for the payment of the premiums collected by the issuer. State laws insofar as they relate to any of the following are superseded and shall not apply to health benefits coverage made available through an IMA: Benefit requirements for health benefits coverage offered through an IMA, including (but not limited to) requirements relating to coverage of specific providers, specific services or conditions, or the amount, duration, or scope of benefits, but not including requirements to the extent required to implement title XXVII or other Federal law and to the extent the requirement prohibits an exclusion of a specific disease from such coverage. Any other requirements (including limitations on compensation arrangements) that, directly or indirectly, preclude (or have the effect of precluding) the offering of such coverage through an IMA, if the IMA meets the requirements of this title. Any State law or regulation relating to the composition or organization of an IMA is preempted to the extent the law or regulation is inconsistent with the provisions of this title. The Secretary shall administer this title and is authorized to issue such regulations as may be required to carry out this title. Such regulations shall be subject to Congressional review under the provisions of chapter 8 of title 5, United States Code. The Secretary shall incorporate the process of deemed file and use with respect to the information filed under section 3101(a)(5)(A) and shall determine whether information filed by an IMA demonstrates compliance with the applicable requirements of this title. The Secretary shall exercise authority under this title in a manner that fosters and promotes the development of IMAs in order to improve access to health care coverage and services. The Secretary shall submit to Congress a report every 30 months, during the 10-year period beginning on the effective date of the rules promulgated by the Secretary to carry out this title, on the effectiveness of this title in promoting coverage of uninsured individuals. The Secretary may provide for the production of such reports through one or more contracts with appropriate private entities. For purposes of this title: The term association means, with respect to health insurance coverage offered in a State, a legal entity which— has been actively in existence for at least 5 years; has been formed and maintained in good faith for purposes other than obtaining insurance; does not condition membership in the association on any health status-related factor relating to an individual (including an employee of an employer or a dependent of an employee); and does not make health insurance coverage offered through the association available other than in connection with a member of the association. The term dependent , as applied to health insurance coverage offered by a health insurance issuer licensed (or otherwise regulated) in a State, shall have the meaning applied to such term with respect to such coverage under the laws of the State relating to such coverage and such an issuer. Such term may include the spouse and children of the individual involved. The term health benefits coverage has the meaning given the term health insurance coverage in section 2791(b)(1), and does not include excepted benefits (as defined in section 2791(c)). The term health insurance issuer has the meaning given such term in section 2791(b)(2). The term health status-related factor has the meaning given such term in section 2791(d)(9). The terms IMA and individual and small employer membership association are defined in section 3101(a). The term member means, with respect to an IMA, an individual or small employer who is a member of the association to which the IMA is offering coverage. The term small employer has the meaning given such term in section 812(a)(13) of the Employee Retirement and Income Security Act of 1974. .