
From the U.S. Code Online via GPO Access
[wais.access.gpo.gov]
[Laws in effect as of January 23, 2000]
[Document affected by Public Law 106-554 Section 1(a)(6)[618]]
[CITE: 42USC1395ss]

 
                 TITLE 42--THE PUBLIC HEALTH AND WELFARE
 
                       CHAPTER 7--SOCIAL SECURITY
 
        SUBCHAPTER XVIII--HEALTH INSURANCE FOR AGED AND DISABLED
 
                    Part D--Miscellaneous Provisions
 
Sec. 1395ss. Certification of medicare supplemental health 
        insurance policies
        

(a) Submission of policy by insurer

    (1) The Secretary shall establish a procedure whereby medicare 
supplemental policies (as defined in subsection (g)(1) of this section) 
may be certified by the Secretary as meeting minimum standards and 
requirements set forth in subsection (c) of this section. Such procedure 
shall provide an opportunity for any insurer to submit any such policy, 
and such additional data as the Secretary finds necessary, to the 
Secretary for his examination and for his certification thereof as 
meeting the standards and requirements set forth in subsection (c) of 
this section. Subject to subsections (k)(3), (m), and (n) of this 
section, such certification shall remain in effect if the insurer files 
a notarized statement with the Secretary no later than June 30 of each 
year stating that the policy continues to meet such standards and 
requirements and if the insurer submits such additional data as the 
Secretary finds necessary to independently verify the accuracy of such 
notarized statement. Where the Secretary determines such a policy meets 
(or continues to meet) such standards and requirements, he shall 
authorize the insurer to have printed on such policy (but only in 
accordance with such requirements and conditions as the Secretary may 
prescribe) an emblem which the Secretary shall cause to be designed for 
use as an indication that a policy has received the Secretary's 
certification. The Secretary shall provide each State commissioner or 
superintendent of insurance with a list of all the policies which have 
received his certification.
    (2) No medicare supplemental policy may be issued in a State on or 
after the date specified in subsection (p)(1)(C) of this section 
unless--
        (A) the State's regulatory program under subsection (b)(1) of 
    this section provides for the application and enforcement of the 
    standards and requirements set forth in such subsection (including 
    the 1991 NAIC Model Regulation or 1991 Federal Regulation (as the 
    case may be)) by the date specified in subsection (p)(1)(C) of this 
    section; or
        (B) if the State's program does not provide for the application 
    and enforcement of such standards and requirements, the policy has 
    been certified by the Secretary under paragraph (1) as meeting the 
    standards and requirements set forth in subsection (c) of this 
    section (including such applicable standards) by such date.

Any person who issues a medicare supplemental policy, on and after the 
effective date specified in subsection (p)(1)(C) of this section, in 
violation of this paragraph is subject to a civil money penalty of not 
to exceed $25,000 for each such violation. The provisions of section 
1320a-7a of this title (other than the first sentence of subsection (a) 
and other than subsection (b)) shall apply to a civil money penalty 
under the previous sentence in the same manner as such provisions apply 
to a penalty or proceeding under section 1320a-7a(a) of this title.

(b) Standards and requirements; periodic review by Secretary

    (1) Any medicare supplemental policy issued in any State which the 
Secretary determines has established under State law a regulatory 
program that--
        (A) provides for the application and enforcement of standards 
    with respect to such policies equal to or more stringent than the 
    NAIC Model Standards (as defined in subsection (g)(2)(A) of this 
    section), except as otherwise provided by subparagraph (H);
        (B) includes requirements equal to or more stringent than the 
    requirements described in paragraphs (2) through (5) of subsection 
    (c) of this section;
        (C) provides that--
            (i) information with respect to the actual ratio of benefits 
        provided to premiums collected under such policies will be 
        reported to the State on forms conforming to those developed by 
        the National Association of Insurance Commissioners for such 
        purpose, or
            (ii) such ratios will be monitored under the program in an 
        alternative manner approved by the Secretary, and that a copy of 
        each such policy, the most recent premium for each such policy, 
        and a listing of the ratio of benefits provided to premiums 
        collected for the most recent 3-year period for each such policy 
        issued or sold in the State is maintained and made available to 
        interested persons;

        (D) provides for application and enforcement of the standards 
    and requirements described in subparagraphs (A), (B), and (C) to all 
    medicare supplemental policies (as defined in subsection (g)(1) of 
    this section) issued in such State,
        (E) provides the Secretary periodically (but at least annually) 
    with a list containing the name and address of the issuer of each 
    such policy and the name and number of each such policy (including 
    an indication of policies that have been previously approved, newly 
    approved, or withdrawn from approval since the previous list was 
    provided),
        (F) reports to the Secretary on the implementation and 
    enforcement of standards and requirements of this paragraph at 
    intervals established by the Secretary,
        (G) provides for a process for approving or disapproving 
    proposed premium increases with respect to such policies, and 
    establishes a policy for the holding of public hearings prior to 
    approval of a premium increase, and
        (H) in the case of a policy that meets the standards under 
    subparagraph (A) except that benefits under the policy are limited 
    to items and services furnished by certain entities (or reduced 
    benefits are provided when items or services are furnished by other 
    entities), provides for the application of requirements equal to or 
    more stringent than the requirements under subsection (t) of this 
    section,

shall be deemed (subject to subsections (k)(3), (m), and (n) of this 
section, for so long as the Secretary finds that such State regulatory 
program continues to meet the standards and requirements of this 
paragraph) to meet the standards and requirements set forth in 
subsection (c) of this section. Each report required under subparagraph 
(F) shall include information on loss ratios of policies sold in the 
State, frequency and types of instances in which policies approved by 
the State fail to meet the standards and requirements of this paragraph, 
actions taken by the State to bring such policies into compliance, 
information regarding State programs implementing consumer protection 
provisions, and such further information as the Secretary in 
consultation with the National Association of Insurance Commissioners 
may specify.
    (2) The Secretary periodically shall review State regulatory 
programs to determine if they continue to meet the standards and 
requirements specified in paragraph (1). If the Secretary finds that a 
State regulatory program no longer meets the standards and requirements, 
before making a final determination, the Secretary shall provide the 
State an opportunity to adopt such a plan of correction as would permit 
the State regulatory program to continue to meet such standards and 
requirements. If the Secretary makes a final determination that the 
State regulatory program, after such an opportunity, fails to meet such 
standards and requirements, the program shall no longer be considered to 
have in operation a program meeting such standards and requirements.
    (3) Notwithstanding paragraph (1), a medicare supplemental policy 
offered in a State shall not be deemed to meet the standards and 
requirements set forth in subsection (c) of this section, with respect 
to an advertisement (whether through written, radio, or television 
medium) used (or, at a State's option, to be used) for the policy in the 
State, unless the entity issuing the policy provides a copy of each 
advertisement to the Commissioner of Insurance (or comparable officer 
identified by the Secretary) of that State for review or approval to the 
extent it may be required under State law.

(c) Requisite findings

    The Secretary shall certify under this section any medicare 
supplemental policy, or continue certification of such a policy, only if 
he finds that such policy (or, with respect to paragraph (3) or the 
requirement described in subsection (s) of this section, the issuer of 
the policy)--
        (1) meets or exceeds (either in a single policy or, in the case 
    of nonprofit hospital and medical service associations, in one or 
    more policies issued in conjunction with one another) the NAIC Model 
    Standards (except as otherwise provided by subsection (t) of this 
    section);
        (2) meets the requirements of subsection (r) of this section;
        (3)(A) accepts a notice under section 1395u(h)(3)(B) of this 
    title as a claim form for benefits under such policy in lieu of any 
    claim form otherwise required and agrees to make a payment 
    determination on the basis of the information contained in such 
    notice;
        (B) where such a notice is received--
            (i) provides notice to such physician or supplier and the 
        beneficiary of the payment determination under the policy, and
            (ii) provides any payment covered by such policy directly to 
        the participating physician or supplier involved;

        (C) provides each enrollee at the time of enrollment a card 
    listing the policy name and number and a single mailing address to 
    which notices under section 1395u(h)(3)(B) of this title respecting 
    the policy are to be sent;
        (D) agrees to pay any user fees established under section 
    1395u(h)(3)(B) of this title with respect to information transmitted 
    to the issuer of the policy; and
        (E) provides to the Secretary at least annually, for transmittal 
    to carriers, a single mailing address to which notices under section 
    1395u(h)(3)(B) of this title respecting the policy are to be sent;
        (4) may, during a period of not less than 30 days after the 
    policy is issued, be returned for a full refund of any premiums paid 
    (without regard to the manner in which the purchase of the policy 
    was solicited); and
        (5) meets the applicable requirements of subsections (o) through 
    (t) of this section.

(d) Criminal penalties; civil penalties for certain violations

    (1) Whoever knowingly and willfully makes or causes to be made or 
induces or seeks to induce the making of any false statement or 
representation of a material fact with respect to the compliance of any 
policy with the standards and requirements set forth in subsection (c) 
of this section or in regulations promulgated pursuant to such 
subsection, or with respect to the use of the emblem designed by the 
Secretary under subsection (a) of this section, shall be fined under 
title 18 or imprisoned not more than 5 years, or both, and, in addition 
to or in lieu of such a criminal penalty, is subject to a civil money 
penalty of not to exceed $5,000 for each such prohibited act.
    (2) Whoever falsely assumes or pretends to be acting, or 
misrepresents in any way that he is acting, under the authority of or in 
association with, the program of health insurance established by this 
subchapter, or any Federal agency, for the purpose of selling or 
attempting to sell insurance, or in such pretended character demands, or 
obtains money, paper, documents, or anything of value, shall be fined 
under title 18 or imprisoned not more than 5 years, or both, and, in 
addition to or in lieu of such a criminal penalty, is subject to a civil 
money penalty of not to exceed $5,000 for each such prohibited act.
    (3)(A)(i) It is unlawful for a person to sell or issue to an 
individual entitled to benefits under part A of this subchapter or 
enrolled under part B of this subchapter (including an individual 
electing a Medicare+Choice plan under section 1395w-21 of this title)--
        (I) a health insurance policy with knowledge that the policy 
    duplicates health benefits to which the individual is otherwise 
    entitled under this subchapter or subchapter XIX of this chapter,
        (II) in the case of an individual not electing a Medicare+Choice 
    plan \1\ a medicare supplemental policy with knowledge that the 
    individual is entitled to benefits under another medicare 
    supplemental policy or in the case of an individual electing a 
    Medicare+Choice plan, a medicare supplemental policy with knowledge 
    that the policy duplicates health benefits to which the individual 
    is otherwise entitled under the Medicare+Choice plan or under 
    another medicare supplemental policy, or
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    \1\ So in original. Probably should be followed by a comma.
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        (III) a health insurance policy (other than a medicare 
    supplemental policy) with knowledge that the policy duplicates 
    health benefits to which the individual is otherwise entitled, other 
    than benefits to which the individual is entitled under a 
    requirement of State or Federal law.

    (ii) Whoever violates clause (i) shall be fined under title 18 or 
imprisoned not more than 5 years, or both, and, in addition to or in 
lieu of such a criminal penalty, is subject to a civil money penalty of 
not to exceed $25,000 (or $15,000 in the case of a person other than the 
issuer of the policy) for each such prohibited act.
    (iii) A seller (who is not the issuer of a health insurance policy) 
shall not be considered to violate clause (i)(II) with respect to the 
sale of a medicare supplemental policy if the policy is sold in 
compliance with subparagraph (B).
    (iv) For purposes of this subparagraph, a health insurance policy 
(other than a Medicare supplemental policy) providing for benefits which 
are payable to or on behalf of an individual without regard to other 
health benefit coverage of such individual is not considered to 
``duplicate'' any health benefits under this subchapter, under 
subchapter XIX of this chapter, or under a health insurance policy, and 
subclauses (I) and (III) of clause (i) do not apply to such a policy.
    (v) For purposes of this subparagraph, a health insurance policy (or 
a rider to an insurance contract which is not a health insurance policy) 
is not considered to ``duplicate'' health benefits under this subchapter 
or under another health insurance policy if it--
        (I) provides health care benefits only for long-term care, 
    nursing home care, home health care, or community-based care, or any 
    combination thereof,
        (II) coordinates against or excludes items and services 
    available or paid for under this subchapter or under another health 
    insurance policy, and
        (III) for policies sold or issued on or after the end of the 90-
    day period beginning on August 21, 1996, discloses such coordination 
    or exclusion in the policy's outline of coverage.

For purposes of this clause, the terms ``coordinates'' and 
``coordination'' mean, with respect to a policy in relation to health 
benefits under this subchapter or under another health insurance policy, 
that the policy under its terms is secondary to, or excludes from 
payment, items and services to the extent available or paid for under 
this subchapter or under another health insurance policy.
    (vi)(I) An individual entitled to benefits under part A of this 
subchapter or enrolled under part B of this subchapter who is applying 
for a health insurance policy (other than a policy described in 
subclause (III)) shall be furnished a disclosure statement described in 
clause (vii) for the type of policy being applied for. Such statement 
shall be furnished as a part of (or together with) the application for 
such policy.
    (II) Whoever issues or sells a health insurance policy (other than a 
policy described in subclause (III)) to an individual described in 
subclause (I) and fails to furnish the appropriate disclosure statement 
as required under such subclause shall be fined under title 18, or 
imprisoned not more than 5 years, or both, and, in addition to or in 
lieu of such a criminal penalty, is subject to a civil money penalty of 
not to exceed $25,000 (or $15,000 in the case of a person other than the 
issuer of the policy) for each such violation.
    (III) A policy described in this subclause (to which subclauses (I) 
and (II) do not apply) is a Medicare supplemental policy, a policy 
described in clause (v), or a health insurance policy identified under 
60 Federal Register 30880 (June 12, 1995) as a policy not required to 
have a disclosure statement.
    (IV) Any reference in this section to the revised NAIC model 
regulation (referred to in subsection (m)(1)(A) of this section) is 
deemed a reference to such regulation as revised by section 171(m)(2) of 
the Social Security Act Amendments of 1994 (Public Law 103-432) and as 
modified by substituting, for the disclosure required under section 
16D(2), disclosure under subclause (I) of an appropriate disclosure 
statement under clause (vii).
    (vii) The disclosure statement described in this clause for a type 
of policy is the statement specified under subparagraph (D) of this 
paragraph (as in effect before August 21, 1996) for that type of policy, 
as revised as follows:
        (I) In each statement, amend the second line to read as follows:

                                             ``THIS IS NOT MEDICARE 
                                                   SUPPLEMENT

                                                  INSURANCE''.

        (II) In each statement, strike the third line and insert the 
    following: ``Some health care services paid for by Medicare may also 
    trigger the payment of benefits under this policy.''.
        (III) In each statement not described in subclause (V), strike 
    the boldface matter that begins ``This insurance'' and all that 
    follows up to the next paragraph that begins ``Medicare''.
        (IV) In each statement not described in subclause (V), insert 
    before the boxed matter (that states ``Before You Buy This 
    Insurance'') the following: ``This policy must pay benefits without 
    regard to other health benefit coverage to which you may be entitled 
    under Medicare or other insurance.''.
        (V) In a statement relating to policies providing both nursing 
    home and non-institutional coverage, to policies providing nursing 
    home benefits only, or policies providing home care benefits only, 
    amend the sentence that begins ``Federal law'' to read as follows: 
    ``Federal law requires us to inform you that in certain situations 
    this insurance may pay for some care also covered by Medicare.''.

    (viii)(I) Subject to subclause (II), nothing in this subparagraph 
shall restrict or preclude a State's ability to regulate health 
insurance policies, including any health insurance policy that is 
described in clause (iv), (v), or (vi)(III).
    (II) A State may not declare or specify, in statute, regulation, or 
otherwise, that a health insurance policy (other than a Medicare 
supplemental policy) or rider to an insurance contract which is not a 
health insurance policy, that is described in clause (iv), (v), or 
(vi)(III) and that is sold, issued, or renewed to an individual entitled 
to benefits under part A of this subchapter or enrolled under part B of 
this subchapter ``duplicates'' health benefits under this subchapter or 
under a Medicare supplemental policy.
    (B)(i) It is unlawful for a person to issue or sell a medicare 
supplemental policy to an individual entitled to benefits under part A 
of this subchapter or enrolled under part B of this subchapter, whether 
directly, through the mail, or otherwise, unless--
        (I) the person obtains from the individual, as part of the 
    application for the issuance or purchase and on a form described in 
    clause (ii), a written statement signed by the individual stating, 
    to the best of the individual's knowledge, what health insurance 
    policies (including any Medicare+Choice plan) the individual has, 
    from what source, and whether the individual is entitled to any 
    medical assistance under subchapter XIX of this chapter, whether as 
    a qualified medicare beneficiary or otherwise, and
        (II) the written statement is accompanied by a written 
    acknowledgment, signed by the seller of the policy, of the request 
    for and receipt of such statement.

    (ii) The statement required by clause (i) shall be made on a form 
that--
        (I) states in substance that a medicare-eligible individual does 
    not need more than one medicare supplemental policy,
        (II) states in substance that individuals may be eligible for 
    benefits under the State medicaid program under subchapter XIX of 
    this chapter and that such individuals who are entitled to benefits 
    under that program usually do not need a medicare supplemental 
    policy and that benefits and premiums under any such policy shall be 
    suspended upon request of the policyholder during the period (of not 
    longer than 24 months) of entitlement to benefits under such 
    subchapter and may be reinstituted upon loss of such entitlement, 
    and
        (III) states that counseling services may be available in the 
    State to provide advice concerning the purchase of medicare 
    supplemental policies and enrollment under the medicaid program and 
    may provide the telephone number for such services.

    (iii)(I) Except as provided in subclauses (II) and (III), if the 
statement required by clause (i) is not obtained or indicates that the 
individual has a medicare supplemental policy or indicates that the 
individual is entitled to any medical assistance under subchapter XIX of 
this chapter, the sale of a medicare supplemental policy shall be 
considered to be a violation of subparagraph (A).
    (II) Subclause (I) shall not apply in the case of an individual who 
has a medicare supplemental policy, if the individual indicates in 
writing, as part of the application for purchase, that the policy being 
purchased replaces such other policy and indicates an intent to 
terminate the policy being replaced when the new policy becomes 
effective and the issuer or seller certifies in writing that such policy 
will not, to the best of the issuer \2\ or seller's knowledge, duplicate 
coverage (taking into account any such replacement).
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    \2\ So in original. Probably should be ``issuer's''.
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    (III) If the statement required by clause (i) is obtained and 
indicates that the individual is entitled to any medical assistance 
under subchapter XIX of this chapter, the sale of the policy is not in 
violation of clause (i) (insofar as such clause relates to such medical 
assistance), if (aa) a State medicaid plan under such subchapter pays 
the premiums for the policy, (bb) in the case of a qualified medicare 
beneficiary described in section 1396d(p)(1) of this title, the policy 
provides for coverage of outpatient prescription drugs, or (cc) the only 
medical assistance to which the individual is entitled under the State 
plan is medicare cost sharing described in section 1396d(p)(3)(A)(ii) of 
this title.
    (iv) Whoever issues or sells a medicare supplemental policy in 
violation of this subparagraph shall be fined under title 18, or 
imprisoned not more than 5 years, or both, and, in addition to or in 
lieu of such a criminal penalty, is subject to a civil money penalty of 
not to exceed $25,000 (or $15,000 in the case of a seller who is not the 
issuer of a policy) for each such violation.
    (C) Subparagraph (A) shall not apply with respect to the sale or 
issuance of a group policy or plan of one or more employers or labor 
organizations, or of the trustees of a fund established by one or more 
employers or labor organizations (or combination thereof), for employees 
or former employees (or combination thereof) or for members or former 
members (or combination thereof) of the labor organizations.
    (4)(A) Whoever knowingly, directly or through his agent, mails or 
causes to be mailed any matter for a prohibited purpose (as determined 
under subparagraph (B)) shall be fined under title 18 or imprisoned not 
more than 5 years, or both, and, in addition to or in lieu of such a 
criminal penalty, is subject to a civil money penalty of not to exceed 
$5,000 for each such prohibited act.
    (B) For purposes of subparagraph (A), a prohibited purpose means the 
advertising, solicitation, or offer for sale of a medicare supplemental 
policy, or the delivery of such a policy, in or into any State in which 
such policy has not been approved by the State commissioner or 
superintendent of insurance.
    (C) Subparagraph (A) shall not apply in the case of a person who 
mails or causes to be mailed a medicare supplemental policy into a State 
if such person has ascertained that the party insured under such policy 
to whom (or on whose behalf) such policy is mailed is located in such 
State on a temporary basis.
    (D) Subparagraph (A) shall not apply in the case of a person who 
mails or causes to be mailed a duplicate copy of a medicare supplemental 
policy previously issued to the party to whom (or on whose behalf) such 
duplicate copy is mailed.
    (E) Subparagraph (A) shall not apply in the case of an issuer who 
mails or causes to be mailed a policy, certificate, or other matter 
solely to comply with the requirements of subsection (q) of this 
section.
    (5) The provisions of section 1320a-7a of this title (other than 
subsections (a) and (b)) shall apply to civil money penalties under 
paragraphs (1), (2), (3)(A), and (4)(A) in the same manner as such 
provisions apply to penalties and proceedings under section 1320a-7a(a) 
of this title.

(e) Dissemination of information

    (1) The Secretary shall provide to all individuals entitled to 
benefits under this subchapter (and, to the extent feasible, to 
individuals about to become so entitled) such information as will permit 
such individuals to evaluate the value of medicare supplemental policies 
to them and the relationship of any such policies to benefits provided 
under this subchapter.
    (2) The Secretary shall--
        (A) inform all individuals entitled to benefits under this 
    subchapter (and, to the extent feasible, individuals about to become 
    so entitled) of--
            (i) the actions and practices that are subject to sanctions 
        under subsection (d) of this section, and
            (ii) the manner in which they may report any such action or 
        practice to an appropriate official of the Department of Health 
        and Human Services (or to an appropriate State official), and

        (B) publish the toll-free telephone number for individuals to 
    report suspected violations of the provisions of such subsection.

    (3) The Secretary shall provide individuals entitled to benefits 
under this subchapter (and, to the extent feasible, individuals about to 
become so entitled) with a listing of the addresses and telephone 
numbers of State and Federal agencies and offices that provide 
information and assistance to individuals with respect to the selection 
of medicare supplemental policies.

(f) Study and evaluation of comparative effectiveness of various State 
        approaches to regulating medicare supplemental policies; report 
        to Congress no later than January 1, 1982; periodic evaluations

    (1)(A) The Secretary shall, in consultation with Federal and State 
regulatory agencies, the National Association of Insurance 
Commissioners, private insurers, and organizations representing 
consumers and the aged, conduct a comprehensive study and evaluation of 
the comparative effectiveness of various State approaches to the 
regulation of medicare supplemental policies in (i) limiting marketing 
and agent abuse, (ii) assuring the dissemination of such information to 
individuals entitled to benefits under this subchapter (and to other 
consumers) as is necessary to permit informed choice, (iii) promoting 
policies which provide reasonable economic benefits for such 
individuals, (iv) reducing the purchase of unnecessary duplicative 
coverage, (v) improving price competition, and (vi) establishing 
effective approved State regulatory programs described in subsection (b) 
of this section.
    (B) Such study shall also address the need for standards or 
certification of health insurance policies, other than medicare 
supplemental policies, sold to individuals eligible for benefits under 
this subchapter.
    (C) The Secretary shall, no later than January 1, 1982, submit a 
report to the Congress on the results of such study and evaluation, 
accompanied by such recommendations as the Secretary finds warranted by 
such results with respect to the need for legislative or administrative 
changes to accomplish the objectives set forth in subparagraphs (A) and 
(B), including the need for a mandatory Federal regulatory program to 
assure the marketing of appropriate types of medicare supplemental 
policies, and such other means as he finds may be appropriate to enhance 
effective State regulation of such policies.
    (2) The Secretary shall submit to the Congress no later than July 1, 
1982, and periodically as may be appropriate thereafter (but not less 
often than once every 2 years), a report evaluating the effectiveness of 
the certification procedure and the criminal penalties established under 
this section, and shall include in such reports an analysis of--
        (A) the impact of such procedure and penalties on the types, 
    market share, value, and cost to individuals entitled to benefits 
    under this subchapter of medicare supplemental policies which have 
    been certified by the Secretary;
        (B) the need for any change in the certification procedure to 
    improve its administration or effectiveness; and
        (C) whether the certification program and criminal penalties 
    should be continued.

    (3) The Secretary shall provide information via a toll-free 
telephone number on medicare supplemental policies (including the 
relationship of State programs under subchapter XIX of this chapter to 
such policies).

(g) Definitions

    (1) For purposes of this section, a medicare supplemental policy is 
a health insurance policy or other health benefit plan offered by a 
private entity to individuals who are entitled to have payment made 
under this subchapter, which provides reimbursement for expenses 
incurred for services and items for which payment may be made under this 
subchapter but which are not reimbursable by reason of the applicability 
of deductibles, coinsurance amounts, or other limitations imposed 
pursuant to this subchapter; but does not include a Medicare+Choice plan 
or any such policy or plan of one or more employers or labor 
organizations, or of the trustees of a fund established by one or more 
employers or labor organizations (or combination thereof), for employees 
or former employees (or combination thereof) or for members or former 
members (or combination thereof) of the labor organizations and does not 
include a policy or plan of an eligible organization (as defined in 
section 1395mm(b) of this title) if the policy or plan provides benefits 
pursuant to a contract under section 1395mm of this title or an approved 
demonstration project described in section 603(c) of the Social Security 
Amendments of 1983, section 2355 of the Deficit Reduction Act of 1984, 
or section 9412(b) of the Omnibus Budget Reconciliation Act of 1986, or 
a policy or plan of an organization if the policy or plan provides 
benefits pursuant to an agreement under section 1395l(a)(1)(A) of this 
title. For purposes of this section, the term ``policy'' includes a 
certificate issued under such policy.
    (2) For purposes of this section:
        (A) The term ``NAIC Model Standards'' means the ``NAIC Model 
    Regulation to Implement the Individual Accident and Sickness 
    Insurance Minimum Standards Act'', adopted by the National 
    Association of Insurance Commissioners on June 6, 1979, as it 
    applies to medicare supplement \3\ policies.
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    \3\ So in original. Probably should be ``supplemental''.
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        (B) The term ``State with an approved regulatory program'' means 
    a State for which the Secretary has made a determination under 
    subsection (b)(1) of this section.
        (C) The State in which a policy is issued means--
            (i) in the case of an individual policy, the State in which 
        the policyholder resides; and
            (ii) in the case of a group policy, the State in which the 
        holder of the master policy resides.

(h) Rules and regulations

    The Secretary shall prescribe such regulations as may be necessary 
for the effective, efficient, and equitable administration of the 
certification procedure established under this section. The Secretary 
shall first issue final regulations to implement the certification 
procedure established under subsection (a) of this section not later 
than March 1, 1981.

(i) Commencement of certification program

    (1) No medicare supplemental policy shall be certified and no such 
policy may be issued bearing the emblem authorized by the Secretary 
under subsection (a) of this section until July 1, 1982. On and after 
such date policies certified by the Secretary may bear such emblem, 
including policies which were issued prior to such date and were 
subsequently certified, and insurers may notify holders of such 
certified policies issued prior to such date using such emblem in the 
notification.
    (2)(A) The Secretary shall not implement the certification program 
established under subsection (a) of this section with respect to 
policies issued in a State unless the Panel makes a finding that such 
State cannot be expected to have established, by July 1, 1982, an 
approved State regulatory program meeting the standards and requirements 
of subsection (b)(1) of this section. If the Panel makes such a finding, 
the Secretary shall implement such program under subsection (a) of this 
section with respect to medicare supplemental policies issued in such 
State, until such time as the Panel determines that such State has a 
program that meets the standards and requirements of subsection (b)(1) 
of this section.
    (B) Any finding by the Panel under subparagraph (A) shall be 
transmitted in writing, not later than January 1, 1982, to the Committee 
on Finance of the Senate and to the Committee on Energy and Commerce and 
the Committee on Ways and Means of the House of Representatives and 
shall not become effective until 60 days after the date of its 
transmittal to the Committees of the Congress under this subparagraph. 
In counting such days, days on which either House is not in session 
because of an adjournment sine die or an adjournment of more than three 
days to a day certain are excluded in the computation.

(j) State regulation of policies issued in other States

    Nothing in this section shall be construed so as to affect the right 
of any State to regulate medicare supplemental policies which, under the 
provisions of this section, are considered to be issued in another 
State.

(k) Amended NAIC Model Regulation or Federal model standards applicable; 
        effective date; medicare supplemental policy and State 
        regulatory program meeting applicable standards

    (1)(A) If, within the 90-day period beginning on July 1, 1988, the 
National Association of Insurance Commissioners (in this subsection 
referred to as the ``Association'') amends the NAIC Model Regulation 
adopted on June 6, 1979 (as it relates to medicare supplemental 
policies), with respect to matters such as minimum benefit standards, 
loss ratios, disclosure requirements, and replacement requirements and 
provisions otherwise necessary to reflect the changes in law made by the 
Medicare Catastrophic Coverage Act of 1988, except as provided in 
subsection (m) of this section, subsection (g)(2)(A) of this section 
shall be applied in a State, effective on and after the date specified 
in subparagraph (B), as if the reference to the Model Regulation adopted 
on June 6, 1979, were a reference to the Model Regulation as amended by 
the Association in accordance with this paragraph (in this subsection 
and subsection (l) of this section referred to as the ``amended NAIC 
Model Regulation'').
    (B) The date specified in this subparagraph for a State is the 
earlier of the date the State adopts standards equal to or more 
stringent than the amended NAIC Model Regulation or 1 year after the 
date the Association first adopts such amended Regulation.
    (2)(A) If the Association does not amend the NAIC Model Regulation 
within the 90-day period specified in paragraph (1)(A), the Secretary 
shall promulgate, not later than 60 days after the end of such period, 
Federal model standards (in this subsection and subsection (l) of this 
section referred to as ``Federal model standards'') for medicare 
supplemental policies to reflect the changes in law made by the Medicare 
Catastrophic Coverage Act of 1988, and subsection (g)(2)(A) of this 
section shall be applied in a State, effective on and after the date 
specified in subparagraph (B), as if the reference to the Model 
Regulation adopted on June 6, 1979, were a reference to Federal model 
standards.
    (B) The date specified in this subparagraph for a State is the 
earlier of the date the State adopts standards equal to or more 
stringent than the Federal model standards or 1 year after the date the 
Secretary first promulgates such standards.
    (3) Notwithstanding any other provision of this section (except as 
provided in subsections (l), (m), and (n) of this section)--
        (A) no medicare supplemental policy may be certified by the 
    Secretary pursuant to subsection (a) of this section,
        (B) no certification made pursuant to subsection (a) of this 
    section shall remain in effect, and
        (C) no State regulatory program shall be found to meet (or to 
    continue to meet) the requirements of subsection (b)(1)(A) of this 
    section,

unless such policy meets (or such program provides for the application 
of standards equal to or more stringent than) the standards set forth in 
the amended NAIC Model Regulation or the Federal model standards (as the 
case may be) by the date specified in paragraph (1)(B) or (2)(B) (as the 
case may be).

(l) Transitional compliance with NAIC Model Transition Regulation; 
        ``qualifying medicare supplemental policy'' and ``NAIC Model 
        Transition Regulation'' defined

    (1) Until the date specified in paragraph (3), in the case of a 
qualifying medicare supplemental policy described in paragraph (2) 
issued--
        (A) before January 1, 1989, the policy is deemed to remain in 
    compliance with this section if the insurer issuing the policy 
    complies with the NAIC Model Transition Regulation (including giving 
    notices to subscribers and filing for premium adjustments with the 
    State as described in section 5.B. of such Regulation) by January 1, 
    1989; or
        (B) on or after January 1, 1989, the policy is deemed to be in 
    compliance with this section if the insurer issuing the policy 
    complies with the NAIC Model Transition Regulation before the date 
    of the sale of the policy.

    (2) In paragraph (1), the term ``qualifying medicare supplemental 
policy'' means a medicare supplemental policy--
        (A) issued in a State which--
            (i) has not adopted standards equal to or more stringent 
        than the NAIC Model Transition Regulation by January 1, 1989, 
        and
            (ii) has not adopted standards equal to or more stringent 
        than the amended NAIC Model Regulation (or Federal model 
        standards) by January 1, 1989; and

        (B) which has been issued in compliance with this section (as in 
    effect on June 1, 1988).

    (3)(A) The date specified in this paragraph is the earlier of--
        (i) the first date a State adopts, after January 1, 1989, 
    standards equal to or more stringent than the NAIC Model Transition 
    Regulation or equal to or more stringent than the amended NAIC Model 
    Regulation (or Federal model standards), as the case may be, or
        (ii) the later of (I) the date specified in subsection (k)(1)(B) 
    or (k)(2)(B) of this section (as the case may be), or (II) the date 
    specified in subparagraph (B).

    (B) In the case of a State which the Secretary identifies as--
        (i) requiring State legislation (other than legislation 
    appropriating funds) in order for medicare supplemental policies to 
    meet standards described in subparagraph (A)(i), but
        (ii) having a legislature which is not scheduled to meet in 1989 
    in a legislative session in which such legislation may be 
    considered,

the date specified in this subparagraph is the first day of the first 
calendar quarter beginning after the close of the first legislative 
session of the State legislature that begins on or after January 1, 
1989, and in which legislation described in clause (i) may be 
considered. For purposes of the previous sentence, in the case of a 
State that has a 2-year legislative session, each year of such session 
shall be deemed to be a separate regular session of the State 
legislature.
    (4) In the case of a medicare supplemental policy in effect on 
January 1, 1989, and offered in a State which, as of such date--
        (A) has adopted standards equal to or more stringent than the 
    amended NAIC Model Regulation (or Federal model standards), but
        (B) does not have in effect standards equal to or more stringent 
    than the NAIC Model Transition Regulation (or otherwise requiring 
    notice substantially the same as the notice required in section 5.B. 
    of such Regulation),

the policy shall not be deemed to meet the standards in subsection (c) 
of this section unless each individual who is entitled to benefits under 
this subchapter and is a policyholder under such policy on January 1, 
1989, is sent such a notice in any appropriate form by not later than 
January 31, 1989, that explains--
        (A) the improved benefits under this subchapter contained in the 
    Medicare Catastrophic Coverage Act of 1988, and
        (B) how these improvements affect the benefits contained in the 
    policies and the premium for the policy.

    (5) In this subsection, the term ``NAIC Model Transition 
Regulation'' refers to the standards contained in the ``Model Regulation 
to Implement Transitional Requirements for the Conversion of Medicare 
Supplement Insurance Benefits and Premiums to Conform to Medicare 
Program Revisions'' (as adopted by the National Association of Insurance 
Commissioners in September 1987).

(m) Revision of amended NAIC Model Regulation and amended Federal model 
        standards; effective dates; medicare supplemental policy and 
        State regulatory program meeting applicable standards

    (1)(A) If, within the 90-day period beginning on December 13, 1989, 
the National Association of Insurance Commissioners (in this subsection 
and subsection (n) of this section referred to as the ``Association'') 
revises the amended NAIC Model Regulation (referred to in subsection 
(k)(1)(A) of this section and adopted on September 20, 1988) to improve 
such regulation and otherwise to reflect the changes in law made by the 
Medicare Catastrophic Coverage Repeal Act of 1989, subsection (g)(2)(A) 
of this section shall be applied in a State, effective on and after the 
date specified in subparagraph (B), as if the reference to the Model 
Regulation adopted on June 6, 1979, were a reference to the amended NAIC 
Model Regulation (referred to in subsection (k)(1)(A) of this section) 
as revised by the Association in accordance with this paragraph (in this 
subsection and subsection (n) of this section referred to as the 
``revised NAIC Model Regulation'').
    (B) The date specified in this subparagraph for a State is the 
earlier of the date the State adopts standards equal to or more 
stringent than the revised NAIC Model Regulation or 1 year after the 
date the Association first adopts such revised Regulation.
    (2)(A) If the Association does not revise the amended NAIC Model 
Regulation, within the 90-day period specified in paragraph (1)(A), the 
Secretary shall promulgate, not later than 60 days after the end of such 
period, revised Federal model standards (in this subsection and 
subsection (n) of this section referred to as ``revised Federal model 
standards'') for medicare supplemental policies to improve such 
standards and otherwise to reflect the changes in law made by the 
Medicare Catastrophic Coverage Repeal Act of 1989, subsection (g)(2)(A) 
of this section shall be applied in a State, effective on and after the 
date specified in subparagraph (B), as if the reference to the Model 
Regulation adopted on June 6, 1979, were a reference to the revised 
Federal model standards.
    (B) The date specified in this subparagraph for a State is the 
earlier of the date the State adopts standards equal to or more 
stringent than the revised Federal model standards or 1 year after the 
date the Secretary first promulgates such standards.
    (3) Notwithstanding any other provision of this section (except as 
provided in subsection (n) of this section)--
        (A) no medicare supplemental policy may be certified by the 
    Secretary pursuant to subsection (a) of this section,
        (B) no certification made pursuant to subsection (a) of this 
    section shall remain in effect, and
        (C) no State regulatory program shall be found to meet (or to 
    continue to meet) the requirements of subsection (b)(1)(A) of this 
    section,

unless such policy meets (or such program provides for the application 
of standards equal to or more stringent than) the standards set forth in 
the revised NAIC Model Regulation or the revised Federal model standards 
(as the case may be) by the date specified in paragraph (1)(B) or (2)(B) 
(as the case may be).

(n) Transition compliance with revision of NAIC Model Regulation and 
        Federal model standards

    (1) Until the date specified in paragraph (4), in the case of a 
qualifying medicare supplemental policy described in paragraph (3) 
issued in a State--
        (A) before the transition deadline, the policy is deemed to 
    remain in compliance with the standards described in subsection 
    (b)(1)(A) of this section only if the insurer issuing the policy 
    complies with the transition provision described in paragraph (2), 
    or
        (B) on or after the transition deadline, the policy is deemed to 
    be in compliance with the standards described in subsection 
    (b)(1)(A) of this section only if the insurer issuing the policy 
    complies with the revised NAIC Model Regulation or the revised 
    Federal model standards (as the case may be) before the date of the 
    sale of the policy.

In this paragraph, the term ``transition deadline'' means 1 year after 
the date the Association adopts the revised NAIC Model Regulation or 1 
year after the date the Secretary promulgates revised Federal model 
standards (as the case may be).
    (2) The transition provision described in this paragraph is--
        (A) such transition provision as the Association provides, by 
    not later than December 15, 1989, so as to provide for an 
    appropriate transition (i) to restore benefit provisions which are 
    no longer duplicative as a result of the changes in benefits under 
    this subchapter made by the Medicare Catastrophic Coverage Repeal 
    Act of 1989 and (ii) to eliminate the requirement of payment for the 
    first 8 days of coinsurance for extended care services, or
        (B) if the Association does not provide for a transition 
    provision by the date described in subparagraph (A), such transition 
    provision as the Secretary shall provide, by January 1, 1990, so as 
    to provide for an appropriate transition described in subparagraph 
    (A).

    (3) In paragraph (1), the term ``qualifying medicare supplemental 
policy'' means a medicare supplemental policy which has been issued in 
compliance with this section as in effect on the date before December 
13, 1989.
    (4)(A) The date specified in this paragraph for a policy issued in a 
State is--
        (i) the first date a State adopts, after December 13, 1989, 
    standards equal to or more stringent than the revised NAIC Model 
    Regulation (or revised Federal model standards), as the case may be, 
    or
        (ii) the date specified in subparagraph (B),

whichever is earlier.
    (B) In the case of a State which the Secretary identifies, in 
consultation with the Association, as--
        (i) requiring State legislation (other than legislation 
    appropriating funds) in order for medicare supplemental policies to 
    meet standards described in subparagraph (A)(i), but
        (ii) having a legislature which is not scheduled to meet in 1990 
    in a legislative session in which such legislation may be 
    considered,

the date specified in this subparagraph is the first day of the first 
calendar quarter beginning after the close of the first legislative 
session of the State legislature that begins on or after January 1, 
1990. For purposes of the previous sentence, in the case of a State that 
has a 2-year legislative session, each year of such session shall be 
deemed to be a separate regular session of the State legislature.
    (5) In the case of a medicare supplemental policy in effect on 
January 1, 1990, the policy shall not be deemed to meet the standards in 
subsection (c) of this section unless each individual who is entitled to 
benefits under this subchapter and is a policyholder or certificate 
holder under such policy on such date is sent a notice in an appropriate 
form by not later than January 31, 1990, that explains--
        (A) the changes in benefits under this subchapter effected by 
    the Medicare Catastrophic Coverage Repeal Act of 1989, and
        (B) how these changes may affect the benefits contained in such 
    policy and the premium for the policy.

    (6)(A) Except as provided in subparagraph (B), in the case of an 
individual who had in effect, as of December 31, 1988, a medicare 
supplemental policy with an insurer (as a policyholder or, in the case 
of a group policy, as a certificate holder) and the individual 
terminated coverage under such policy before December 13, 1989, no 
medicare supplemental policy of the insurer shall be deemed to meet the 
standards in subsection (c) of this section unless the insurer--
        (i) provides written notice, no earlier than December 15, 1989, 
    and no later than January 30, 1990, to the policyholder or 
    certificate holder (at the most recent available address) of the 
    offer described in clause (ii), and
        (ii) offers the individual, during a period of at least 60 days 
    beginning not later than February 1, 1990, reinstitution of coverage 
    (with coverage effective as of January 1, 1990), under the terms 
    which (I) do not provide for any waiting period with respect to 
    treatment of pre-existing conditions, (II) provides for coverage 
    which is substantially equivalent to coverage in effect before the 
    date of such termination, and (III) provides for classification of 
    premiums on which terms are at least as favorable to the 
    policyholder or certificate holder as the premium classification 
    terms that would have applied to the policyholder or certificate 
    holder had the coverage never terminated.

    (B) An insurer is not required to make the offer under subparagraph 
(A)(ii) in the case of an individual who is a policyholder or 
certificate holder in another medicare supplemental policy as of 
December 13, 1989, if (as of January 1, 1990) the individual is not 
subject to a waiting period with respect to treatment of a pre-existing 
condition under such other policy.

(o) Requirements of group benefits; core group benefits; uniform outline 
        of coverage

    The requirements of this subsection are as follows:
        (1) Each medicare supplemental policy shall provide for coverage 
    of a group of benefits consistent with subsection (p) of this 
    section.
        (2) If the medicare supplemental policy provides for coverage of 
    a group of benefits other than the core group of basic benefits 
    described in subsection (p)(2)(B) of this section, the issuer of the 
    policy must make available to the individual a medicare supplemental 
    policy with only such core group of basic benefits.
        (3) The issuer of the policy has provided, before the sale of 
    the policy, an outline of coverage that uses uniform language and 
    format (including layout and print size) that facilitates comparison 
    among medicare supplemental policies and comparison with medicare 
    benefits.

(p) Standards for group benefits

    (1)(A) If, within 9 months after November 5, 1990, the National 
Association of Insurance Commissioners (in this subsection referred to 
as the ``Association'') changes the revised NAIC Model Regulation 
(described in subsection (m) of this section) to incorporate--
        (i) limitations on the groups or packages of benefits that may 
    be offered under a medicare supplemental policy consistent with 
    paragraphs (2) and (3) of this subsection,
        (ii) uniform language and definitions to be used with respect to 
    such benefits,
        (iii) uniform format to be used in the policy with respect to 
    such benefits, and
        (iv) other standards to meet the additional requirements imposed 
    by the amendments made by the Omnibus Budget Reconciliation Act of 
    1990,

subsection (g)(2)(A) of this section shall be applied in each State, 
effective for policies issued to policyholders on and after the date 
specified in subparagraph (C), as if the reference to the Model 
Regulation adopted on June 6, 1979, were a reference to the revised NAIC 
Model Regulation as changed under this subparagraph (such changed 
regulation referred to in this section as the ``1991 NAIC Model 
Regulation'').
    (B) If the Association does not make the changes in the revised NAIC 
Model Regulation within the 9-month period specified in subparagraph 
(A), the Secretary shall promulgate, not later than 9 months after the 
end of such period, a regulation and subsection (g)(2)(A) of this 
section shall be applied in each State, effective for policies issued to 
policyholders on and after the date specified in subparagraph (C), as if 
the reference to the Model Regulation adopted on June 6, 1979, were a 
reference to the revised NAIC Model Regulation as changed by the 
Secretary under this subparagraph (such changed regulation referred to 
in this section as the ``1991 Federal Regulation'').
    (C)(i) Subject to clause (ii), the date specified in this 
subparagraph for a State is the date the State adopts the 1991 NAIC 
Model Regulation or 1991 Federal Regulation or 1 year after the date the 
Association or the Secretary first adopts such standards, whichever is 
earlier.
    (ii) In the case of a State which the Secretary identifies, in 
consultation with the Association, as--
        (I) requiring State legislation (other than legislation 
    appropriating funds) in order for medicare supplemental policies to 
    meet the 1991 NAIC Model Regulation or 1991 Federal Regulation, but
        (II) having a legislature which is not scheduled to meet in 1992 
    in a legislative session in which such legislation may be 
    considered,

the date specified in this subparagraph is the first day of the first 
calendar quarter beginning after the close of the first legislative 
session of the State legislature that begins on or after January 1, 
1992. For purposes of the previous sentence, in the case of a State that 
has a 2-year legislative session, each year of such session shall be 
deemed to be a separate regular session of the State legislature.
    (D) In promulgating standards under this paragraph, the Association 
or Secretary shall consult with a working group composed of 
representatives of issuers of medicare supplemental policies, consumer 
groups, medicare beneficiaries, and other qualified individuals. Such 
representatives shall be selected in a manner so as to assure balanced 
representation among the interested groups.
    (E) If benefits (including deductibles and coinsurance) under this 
subchapter are changed and the Secretary determines, in consultation 
with the Association, that changes in the 1991 NAIC Model Regulation or 
1991 Federal Regulation are needed to reflect such changes, the 
preceding provisions of this paragraph shall apply to the modification 
of standards previously established in the same manner as they applied 
to the original establishment of such standards.
    (2) The benefits under the 1991 NAIC Model Regulation or 1991 
Federal Regulation shall provide--
        (A) for such groups or packages of benefits as may be 
    appropriate taking into account the considerations specified in 
    paragraph (3) and the requirements of the succeeding subparagraphs;
        (B) for identification of a core group of basic benefits common 
    to all policies,\4\ and
---------------------------------------------------------------------------
    \4\ So in original. The comma probably should be a semicolon.
---------------------------------------------------------------------------
        (C) that, subject to paragraph (4)(B), the total number of 
    different benefit packages (counting the core group of basic 
    benefits described in subparagraph (B) and each other combination of 
    benefits that may be offered as a separate benefit package) that may 
    be established in all the States and by all issuers shall not exceed 
    10 plus the 2 plans described in paragraph (11)(A).

    (3) The benefits under paragraph (2) shall, to the extent possible--
        (A) provide for benefits that offer consumers the ability to 
    purchase the benefits that are available in the market as of 
    November 5, 1990; and
        (B) balance the objectives of (i) simplifying the market to 
    facilitate comparisons among policies, (ii) avoiding adverse 
    selection, (iii) providing consumer choice, (iv) providing market 
    stability, and (v) promoting competition.

    (4)(A)(i) Except as provided in subparagraph (B) or paragraph (6), 
no State with a regulatory program approved under subsection (b)(1) of 
this section may provide for or permit the grouping of benefits (or 
language or format with respect to such benefits) under a medicare 
supplemental policy unless such grouping meets the applicable 1991 NAIC 
Model Regulation or 1991 Federal Regulation.
    (ii) Except as provided in subparagraph (B), the Secretary may not 
provide for or permit the grouping of benefits (or language or format 
with respect to such benefits) under a medicare supplemental policy 
seeking approval by the Secretary unless such grouping meets the 
applicable 1991 NAIC Model Regulation or 1991 Federal Regulation.
    (B) With the approval of the State (in the case of a policy issued 
in a State with an approved regulatory program) or the Secretary (in the 
case of any other policy), the issuer of a medicare supplemental policy 
may offer new or innovative benefits in addition to the benefits 
provided in a policy that otherwise complies with the applicable 1991 
NAIC Model Regulation or 1991 Federal Regulation. Any such new or 
innovative benefits may include benefits that are not otherwise 
available and are cost-effective and shall be offered in a manner which 
is consistent with the goal of simplification of medicare supplemental 
policies.
    (5)(A) Except as provided in subparagraph (B), this subsection shall 
not be construed as preventing a State from restricting the groups of 
benefits that may be offered in medicare supplemental policies in the 
State.
    (B) A State with a regulatory program approved under subsection 
(b)(1) of this section may not restrict under subparagraph (A) the 
offering of a medicare supplemental policy consisting only of the core 
group of benefits described in paragraph (2)(B).
    (6) The Secretary may waive the application of standards described 
in clauses (i) through (iii) of paragraph (1)(A) in those States that on 
November 5, 1990, had in place an alternative simplification program.
    (7) This subsection shall not be construed as preventing an issuer 
of a medicare supplemental policy who otherwise meets the requirements 
of this section from providing, through an arrangement with a vendor, 
for discounts from that vendor to policyholders or certificateholders 
for the purchase of items or services not covered under its medicare 
supplemental policies.
    (8) Any person who sells or issues a medicare supplemental policy, 
on and after the effective date specified in paragraph (1)(C) (but 
subject to paragraph (10)), in violation of the applicable 1991 NAIC 
Model Regulation or 1991 Federal Regulation insofar as such regulation 
relates to the requirements of subsection (o) or (q) of this section or 
clause (i), (ii), or (iii) of paragraph (1)(A) is subject to a civil 
money penalty of not to exceed $25,000 (or $15,000 in the case of a 
seller who is not an issuer of a policy) for each such violation. The 
provisions of section 1320a-7a of this title (other than the first 
sentence of subsection (a) and other than subsection (b)) shall apply to 
a civil money penalty under the previous sentence in the same manner as 
such provisions apply to a penalty or proceeding under section 1320a-
7a(a) of this title.
    (9)(A) Anyone who sells a medicare supplemental policy to an 
individual shall make available for sale to the individual a medicare 
supplemental policy with only the core group of basic benefits 
(described in paragraph (2)(B)).
    (B) Anyone who sells a medicare supplemental policy to an individual 
shall provide the individual, before the sale of the policy, an outline 
of coverage which describes the benefits under the policy. Such outline 
shall be on a standard form approved by the State regulatory program or 
the Secretary (as the case may be) consistent with the 1991 NAIC Model 
Regulation or 1991 Federal Regulation under this subsection.
    (C) Whoever sells a medicare supplemental policy in violation of 
this paragraph is subject to a civil money penalty of not to exceed 
$25,000 (or $15,000 in the case of a seller who is not the issuer of the 
policy) for each such violation. The provisions of section 1320a-7a of 
this title (other than the first sentence of subsection (a) and other 
than subsection (b)) shall apply to a civil money penalty under the 
previous sentence in the same manner as such provisions apply to a 
penalty or proceeding under section 1320a-7a(a) of this title.
    (D) Subject to paragraph (10), this paragraph shall apply to sales 
of policies occurring on or after the effective date specified in 
paragraph (1)(C).
    (10) No penalty may be imposed under paragraph (8) or (9) in the 
case of a seller who is not the issuer of a policy until the Secretary 
has published a list of the groups of benefit packages that may be sold 
or issued consistent with paragraph (1)(A)(i).
    (11)(A) For purposes of paragraph (2), the benefit packages 
described in this subparagraph are as follows:
        (i) The benefit package classified as ``F'' under the standards 
    established by such paragraph, except that it has a high deductible 
    feature.
        (ii) The benefit package classified as ``J'' under the standards 
    established by such paragraph, except that it has a high deductible 
    feature.

    (B) For purposes of subparagraph (A), a high deductible feature is 
one which--
        (i) requires the beneficiary of the policy to pay annual out-of-
    pocket expenses (other than premiums) in the amount specified in 
    subparagraph (C) before the policy begins payment of benefits, and
        (ii) covers 100 percent of covered out-of-pocket expenses once 
    such deductible has been satisfied in a year.

    (C) The amount specified in this subparagraph--
        (i) for 1998 and 1999 is $1,500, and
        (ii) for a subsequent year, is the amount specified in this 
    subparagraph for the previous year increased by the percentage 
    increase in the Consumer Price Index for all urban consumers (all 
    items; U.S. city average) for the 12-month period ending with August 
    of the preceding year.

If any amount determined under clause (ii) is not a multiple of $10, it 
shall be rounded to the nearest multiple of $10.

(q) Guaranteed renewal of policies; termination; suspension

    The requirements of this subsection are as follows:
        (1) Each medicare supplemental policy shall be guaranteed 
    renewable and--
            (A) the issuer may not cancel or nonrenew the policy solely 
        on the ground of health status of the individual; and
            (B) the issuer shall not cancel or nonrenew the policy for 
        any reason other than nonpayment of premium or material 
        misrepresentation.

        (2) If the medicare supplemental policy is terminated by the 
    group policyholder and is not replaced as provided under paragraph 
    (4), the issuer shall offer certificateholders an individual 
    medicare supplemental policy which (at the option of the 
    certificateholder)--
            (A) provides for continuation of the benefits contained in 
        the group policy, or
            (B) provides for such benefits as otherwise meets \5\ the 
        requirements of this section.
---------------------------------------------------------------------------
    \5\ So in original. Probably should be ``meet''.

        (3) If an individual is a certificateholder in a group medicare 
    supplemental policy and the individual terminates membership in the 
    group, the issuer shall--
            (A) offer the certificateholder the conversion opportunity 
        described in paragraph (2), or
            (B) at the option of the group policyholder, offer the 
        certificateholder continuation of coverage under the group 
        policy.

        (4) If a group medicare supplemental policy is replaced by 
    another group medicare supplemental policy purchased by the same 
    policyholder, issuer \6\ of the replacement policy shall offer 
    coverage to all persons covered under the old group policy on its 
    date of termination. Coverage under the new group policy shall not 
    result in any exclusion for preexisting conditions that would have 
    been covered under the group policy being replaced.
---------------------------------------------------------------------------
    \6\ So in original. Probably should be preceded by ``the''.
---------------------------------------------------------------------------
        (5)(A) Each medicare supplemental policy shall provide that 
    benefits and premiums under the policy shall be suspended at the 
    request of the policyholder for the period (not to exceed 24 months) 
    in which the policyholder has applied for and is determined to be 
    entitled to medical assistance under subchapter XIX of this chapter, 
    but only if the policyholder notifies the issuer of such policy 
    within 90 days after the date the individual becomes entitled to 
    such assistance. If such suspension occurs and if the policyholder 
    or certificate holder loses entitlement to such medical assistance, 
    such policy shall be automatically reinstituted (effective as of the 
    date of termination of such entitlement) under terms described in 
    subsection (n)(6)(A)(ii) of this section as of the termination of 
    such entitlement if the policyholder provides notice of loss of such 
    entitlement within 90 days after the date of such loss.
        (B) Nothing in this section shall be construed as affecting the 
    authority of a State, under subchapter XIX of this chapter, to 
    purchase a medicare supplemental policy for an individual otherwise 
    entitled to assistance under such subchapter.
        (C) Any person who issues a medicare supplemental policy and 
    fails to comply with the requirements of this paragraph or paragraph 
    (6) is subject to a civil money penalty of not to exceed $25,000 for 
    each such violation. The provisions of section 1320a-7a of this 
    title (other than the first sentence of subsection (a) and other 
    than subsection (b)) shall apply to a civil money penalty under the 
    previous sentence in the same manner as such provisions apply to a 
    penalty or proceeding under section 1320a-7a(a) of this title.
        (6) Each medicare supplemental policy shall provide that 
    benefits and premiums under the policy shall be suspended at the 
    request of the policyholder if the policyholder is entitled to 
    benefits under section 426(b) of this title and is covered under a 
    group health plan (as defined in section 1395y(b)(1)(A)(v) of this 
    title). If such suspension occurs and if the policyholder or 
    certificate holder loses coverage under the group health plan, such 
    policy shall be automatically reinstituted (effective as of the date 
    of such loss of coverage) under terms described in subsection 
    (n)(6)(A)(ii) of this section as of the loss of such coverage if the 
    policyholder provides notice of loss of such coverage within 90 days 
    after the date of such loss.

(r) Required ratio of aggregate benefits to aggregate premiums

    (1) A medicare supplemental policy may not be issued or renewed (or 
otherwise provide coverage after the date described in subsection 
(p)(1)(C) of this section) in any State unless--
        (A) the policy can be expected for periods after the effective 
    date of these provisions (as estimated for the entire period for 
    which rates are computed to provide coverage, on the basis of 
    incurred claims experience and earned premiums for such periods and 
    in accordance with a uniform methodology, including uniform 
    reporting standards, developed by the National Association of 
    Insurance Commissioners) to return to policyholders in the form of 
    aggregate benefits provided under the policy, at least 75 percent of 
    the aggregate amount of premiums collected in the case of group 
    policies and at least 65 percent in the case of individual policies; 
    and
        (B) the issuer of the policy provides for the issuance of a 
    proportional refund, or a credit against future premiums of a 
    proportional amount, based on the premium paid and in accordance 
    with paragraph (2), of the amount of premiums received necessary to 
    assure that the ratio of aggregate benefits provided to the 
    aggregate premiums collected (net of such refunds or credits) 
    complies with the expectation required under subparagraph (A), 
    treating policies of the same type as a single policy for each 
    standard package.

For purposes of applying subparagraph (A) only, policies issued as a 
result of solicitations of individuals through the mails or by mass 
media advertising (including both print and broadcast advertising) shall 
be deemed to be individual policies. For the purpose of calculating the 
refund or credit required under paragraph (1)(B) for a policy issued 
before the date specified in subsection (p)(1)(C) of this section, the 
refund or credit calculation shall be based on the aggregate benefits 
provided and premiums collected under all such policies issued by an 
insurer in a State (separated as to individual and group policies) and 
shall be based only on aggregate benefits provided and premiums 
collected under such policies after the date specified in section 
171(m)(4) of the Social Security Act Amendments of 1994.
    (2)(A) Paragraph (1)(B) shall be applied with respect to each type 
of policy by standard package. Paragraph (1)(B) shall not apply to a 
policy until 12 months following issue. The Comptroller General, in 
consultation with the National Association of Insurance Commissioners, 
shall submit to Congress a report containing recommendations on 
adjustment in the percentages under paragraph (1)(A) that may be 
appropriate. In the case of a policy issued before the date specified in 
subsection (p)(1)(C) of this section, paragraph (1)(B) shall not apply 
until 1 year after the date specified in section 171(m)(4) of the Social 
Security Act Amendments of 1994.
    (B) A refund or credit required under paragraph (1)(B) shall be made 
to each policyholder insured under the applicable policy as of the last 
day of the year involved.
    (C) Such a refund or credit shall include interest from the end of 
the calendar year involved until the date of the refund or credit at a 
rate as specified by the Secretary for this purpose from time to time 
which is not less than the average rate of interest for 13-week Treasury 
notes.
    (D) For purposes of this paragraph and paragraph (1)(B), refunds or 
credits against premiums due shall be made, with respect to a calendar 
year, not later than the third quarter of the succeeding calendar year.
    (3) The provisions of this subsection do not preempt a State from 
requiring a higher percentage than that specified in paragraph (1)(A).
    (4) The Secretary shall submit in October of each year (beginning 
with 1993) a report to the Committees on Energy and Commerce and Ways 
and Means of the House of Representatives and the Committee on Finance 
of the Senate on loss ratios under medicare supplemental policies and 
the use of sanctions, such as a required rebate or credit or the 
disallowance of premium increases, for policies that fail to meet the 
requirements of this subsection (relating to loss ratios). Such report 
shall include a list of the policies that failed to comply with such 
loss ratio requirements or other requirements of this section.
    (5)(A) The Comptroller General shall periodically, not less often 
than once every 3 years, perform audits with respect to the compliance 
of medicare supplemental policies with the loss ratio requirements of 
this subsection and shall report the results of such audits to the State 
involved and to the Secretary.
    (B) The Secretary may independently perform such compliance audits.
    (6)(A) A person who fails to provide refunds or credits as required 
in paragraph (1)(B) is subject to a civil money penalty of not to exceed 
$25,000 for each policy issued for which such failure occurred. The 
provisions of section 1320a-7a of this title (other than the first 
sentence of subsection (a) and other than subsection (b)) shall apply to 
a civil money penalty under the previous sentence in the same manner as 
such provisions apply to a penalty or proceeding under section 1320a-
7a(a) of this title.
    (B) Each issuer of a policy subject to the requirements of paragraph 
(1)(B) shall be liable to the policyholder or, in the case of a group 
policy, to the certificate holder for credits required under such 
paragraph.

(s) Coverage for pre-existing conditions

    (1) If a medicare supplemental policy replaces another medicare 
supplemental policy, the issuer of the replacing policy shall waive any 
time periods applicable to preexisting conditions, waiting period, 
elimination periods and probationary periods in the new medicare 
supplemental policy for similar benefits to the extent such time was 
spent under the original policy.
    (2)(A) The issuer of a medicare supplemental policy may not deny or 
condition the issuance or effectiveness of a medicare supplemental 
policy, or discriminate in the pricing of the policy, because of health 
status, claims experience, receipt of health care, or medical condition 
in the case of an individual for whom an application is submitted prior 
to or during the 6 month period beginning with the first month as of the 
first day on which the individual is 65 years of age or older and is 
enrolled for benefits under part B of this subchapter.
    (B) Subject to subparagraphs (C) and (D), subparagraph (A) shall not 
be construed as preventing the exclusion of benefits under a policy, 
during its first 6 months, based on a pre-existing condition for which 
the policyholder received treatment or was otherwise diagnosed during 
the 6 months before the policy became effective.
    (C) If a medicare supplemental policy or certificate replaces 
another such policy or certificate which has been in effect for 6 months 
or longer, the replacing policy may not provide any time period 
applicable to pre-existing conditions, waiting periods, elimination 
periods, and probationary periods in the new policy or certificate for 
similar benefits.
    (D) In the case of a policy issued during the 6-month period 
described in subparagraph (A) to an individual who is 65 years of age or 
older as of the date of issuance and who as of the date of the 
application for enrollment has a continuous period of creditable 
coverage (as defined in section 300gg(c) of this title) of--
        (i) at least 6 months, the policy may not exclude benefits based 
    on a pre-existing condition; or
        (ii) less than 6 months, if the policy excludes benefits based 
    on a preexisting condition, the policy shall reduce the period of 
    any preexisting condition exclusion by the aggregate of the periods 
    of creditable coverage (if any, as so defined) applicable to the 
    individual as of the enrollment date.

The Secretary shall specify the manner of the reduction under clause 
(ii), based upon the rules used by the Secretary in carrying out section 
300gg(a)(3) of this title.
    (3)(A) The issuer of a medicare supplemental policy--
        (i) may not deny or condition the issuance or effectiveness of a 
    medicare supplemental policy described in subparagraph (C) that is 
    offered and is available for issuance to new enrollees by such 
    issuer;
        (ii) may not discriminate in the pricing of such policy, because 
    of health status, claims experience, receipt of health care, or 
    medical condition; and
        (iii) may not impose an exclusion of benefits based on a pre-
    existing \9\ condition under such policy,

in the case of an individual described in subparagraph (B) who, subject 
to subparagraph (E), seeks to enroll under the policy not later than 63 
days after the date of the termination of enrollment described in such 
subparagraph and who submits evidence of the date of termination or 
disenrollment along with the application for such medicare supplemental 
policy.
    (B) An individual described in this subparagraph is an individual 
described in any of the following clauses:
        (i) The individual is enrolled under an employee welfare benefit 
    plan that provides health benefits that supplement the benefits 
    under this subchapter and the plan terminates or ceases to provide 
    all such supplemental health benefits to the individual.
        (ii) The individual is enrolled with a Medicare+Choice 
    organization under a Medicare+Choice plan under part C of this 
    subchapter, and there are circumstances permitting discontinuance of 
    the individual's election of the plan under the first sentence of 
    section 1395w-21(e)(4) of this title or the individual is 65 years 
    of age or older and is enrolled with a PACE provider under section 
    1395eee of this title, and there are circumstances that would permit 
    the discontinuance of the individual's enrollment with such provider 
    under circumstances that are similar to the circumstances that would 
    permit discontinuance of the individual's election under the first 
    sentence of such section if such individual were enrolled in a 
    Medicare+Choice plan.
        (iii) The individual is enrolled with an eligible organization 
    under a contract under section 1395mm of this title, a similar 
    organization operating under demonstration project authority, 
    effective for periods before April 1, 1999, with an organization 
    under an agreement under section 1395l(a)(1)(A) of this title, or 
    with an organization under a policy described in subsection (t) of 
    this section, and such enrollment ceases under the same 
    circumstances that would permit discontinuance of an individual's 
    election of coverage under the first sentence of section 1395w-
    21(e)(4) of this title and, in the case of a policy described in 
    subsection (t) of this section, there is no provision under 
    applicable State law for the continuation or conversion of coverage 
    under such policy.
        (iv) The individual is enrolled under a medicare supplemental 
    policy under this section and such enrollment ceases because--
            (I) of the bankruptcy or insolvency of the issuer or because 
        of other involuntary termination of coverage or enrollment under 
        such policy and there is no provision under applicable State law 
        for the continuation or conversion of such coverage;
            (II) the issuer of the policy substantially violated a 
        material provision of the policy; or
            (III) the issuer (or an agent or other entity acting on the 
        issuer's behalf) materially misrepresented the policy's 
        provisions in marketing the policy to the individual.

        (v) The individual--
            (I) was enrolled under a medicare supplemental policy under 
        this section,
            (II) subsequently terminates such enrollment and enrolls, 
        for the first time, with any Medicare+Choice organization under 
        a Medicare+Choice plan under part C of this subchapter, any 
        eligible organization under a contract under section 1395mm of 
        this title, any similar organization operating under 
        demonstration project authority, any PACE provider under section 
        1395eee of this title, or any policy described in subsection (t) 
        of this section, and
            (III) the subsequent enrollment under subclause (II) is 
        terminated by the enrollee during any period within the first 12 
        months of such enrollment (during which the enrollee is 
        permitted to terminate such subsequent enrollment under section 
        1395w-21(e) of this title).

        (vi) The individual, upon first becoming eligible for benefits 
    under part A of this subchapter at age 65, enrolls in a Medicare+
    Choice plan under part C of this subchapter or in a PACE program 
    under section 1395eee of this title, and disenrolls from such plan 
    or such program by not later than 12 months after the effective date 
    of such enrollment.

    (C)(i) Subject to clauses (ii) and (iii), a medicare supplemental 
policy described in this subparagraph is a medicare supplemental policy 
which has a benefit package classified as ``A'', ``B'', ``C'', or ``F'' 
under the standards established under subsection (p)(2) of this section.
    (ii) Only for purposes of an individual described in subparagraph 
(B)(v), a medicare supplemental policy described in this subparagraph is 
the same medicare supplemental policy referred to in such subparagraph 
in which the individual was most recently previously enrolled, if 
available from the same issuer, or, if not so available, a policy 
described in clause (i).
    (iii) Only for purposes of an individual described in subparagraph 
(B)(vi), a medicare supplemental policy described in this subparagraph 
shall include any medicare supplemental policy.
    (iv) For purposes of applying this paragraph in the case of a State 
that provides for offering of benefit packages other than under the 
classification referred to in clause (i), the references to benefit 
packages in such clause are deemed references to comparable benefit 
packages offered in such State.
    (D) At the time of an event described in subparagraph (B) because of 
which an individual ceases enrollment or loses coverage or benefits 
under a contract or agreement, policy, or plan, the organization that 
offers the contract or agreement, the insurer offering the policy, or 
the administrator of the plan, respectively, shall notify the individual 
of the rights of the individual under this paragraph, and obligations of 
issuers of medicare supplemental policies, under subparagraph (A).
    (E)(i) An individual described in subparagraph (B)(ii) may elect to 
apply subparagraph (A) by substituting, for the date of termination of 
enrollment, the date on which the individual was notified by the 
Medicare+Choice organization of the impending termination or 
discontinuance of the Medicare+Choice plan it offers in the area in 
which the individual resides, but only if the individual disenrolls from 
the plan as a result of such notification.
    (ii) In the case of an individual making such an election, the 
issuer involved shall accept the application of the individual submitted 
before the date of termination of enrollment, but the coverage under 
subparagraph (A) shall only become effective upon termination of 
coverage under the Medicare+Choice plan involved.
    (4) Any issuer of a medicare supplemental policy that fails to meet 
the requirements of this subsection is subject to a civil money penalty 
of not to exceed $5,000 for each such failure. The provisions of section 
1320a-7a of this title (other than the first sentence of subsection (a) 
and other than subsection (b)) shall apply to a civil money penalty 
under the previous sentence in the same manner as such provisions apply 
to a penalty or proceeding under section 1320a-7a(a) of this title.

(t) Medicare select policies

    (1) If a medicare supplemental policy meets the 1991 NAIC Model 
Regulation or 1991 Federal Regulation and otherwise complies with the 
requirements of this section except that benefits under the policy are 
restricted to items and services furnished by certain entities (or 
reduced benefits are provided when items or services are furnished by 
other entities), the policy shall nevertheless be treated as meeting 
those standards if--
        (A) full benefits are provided for items and services furnished 
    through a network of entities which have entered into contracts or 
    agreements with the issuer of the policy;
        (B) full benefits are provided for items and services furnished 
    by other entities if the services are medically necessary and 
    immediately required because of an unforeseen illness, injury, or 
    condition and it is not reasonable given the circumstances to obtain 
    the services through the network;
        (C) the network offers sufficient access;
        (D) the issuer of the policy has arrangements for an ongoing 
    quality assurance program for items and services furnished through 
    the network;
        (E)(i) the issuer of the policy provides to each enrollee at the 
    time of enrollment an explanation of (I) the restrictions on payment 
    under the policy for services furnished other than by or through the 
    network, (II) out of area coverage under the policy, (III) the 
    policy's coverage of emergency services and urgently needed care, 
    and (IV) the availability of a policy through the entity that meets 
    the standards in the 1991 NAIC Model Regulation or 1991 Federal 
    Regulation without reference to this subsection and the premium 
    charged for such policy, and
        (ii) each enrollee prior to enrollment acknowledges receipt of 
    the explanation provided under clause (i); and
        (F) the issuer of the policy makes available to individuals, in 
    addition to the policy described in this subsection, any policy 
    (otherwise offered by the issuer to individuals in the State) that 
    meets the standards in the 1991 NAIC Model Regulation or 1991 
    Federal Regulation and other requirements of this section without 
    reference to this subsection.

    (2) If the Secretary determines that an issuer of a policy approved 
under paragraph (1)--
        (A) fails substantially to provide medically necessary items and 
    services to enrollees seeking such items and services through the 
    issuer's network, if the failure has adversely affected (or has 
    substantial likelihood of adversely affecting) the individual,
        (B) imposes premiums on enrollees in excess of the premiums 
    approved by the State,
        (C) acts to expel an enrollee for reasons other than nonpayment 
    of premiums, or
        (D) does not provide the explanation required under paragraph 
    (1)(E)(i) or does not obtain the acknowledgment required under 
    paragraph (1)(E)(ii),

the issuer is subject to a civil money penalty in an amount not to 
exceed $25,000 for each such violation. The provisions of section 1320a-
7a of this title (other than the first sentence of subsection (a) and 
other than subsection (b)) shall apply to a civil money penalty under 
the previous sentence in the same manner as such provisions apply to a 
penalty or proceeding under section 1320a-7a(a) of this title.
    (3) The Secretary may enter into a contract with an entity whose 
policy has been certified under paragraph (1) or has been approved by a 
State under subsection (b)(1)(H) of this section to determine whether 
items and services (furnished to individuals entitled to benefits under 
this subchapter and under that policy) are not allowable under section 
1395y(a)(1) of this title. Payments to the entity shall be in such 
amounts as the Secretary may determine, taking into account estimated 
savings under contracts with carriers and fiscal intermediaries and 
other factors that the Secretary finds appropriate. Paragraph (1), the 
first sentence of paragraph (2)(A), paragraph (2)(B), paragraph (3)(C), 
paragraph (3)(D), and paragraph (3)(E) of section 1395u(b) of this title 
shall apply to the entity.

(u) Additional rules relating to individuals enrolled in MSA plans and 
        in private fee-for-service plans

    (1) It is unlawful for a person to sell or issue a policy described 
in paragraph (2) to an individual with knowledge that the individual has 
in effect under section 1395w-21 of this title an election of an MSA 
plan or a Medicare+Choice private fee-for-service plan.
    (2)(A) A policy described in this subparagraph is a health insurance 
policy (other than a policy described in subparagraph (B)) that provides 
for coverage of expenses that are otherwise required to be counted 
toward meeting the annual deductible amount provided under the MSA plan.
    (B) A policy described in this subparagraph is any of the following:
        (i) A policy that provides coverage (whether through insurance 
    or otherwise) for accidents, disability, dental care, vision care, 
    or long-term care.
        (ii) A policy of insurance to which substantially all of the 
    coverage relates to--
            (I) liabilities incurred under workers' compensation laws,
            (II) tort liabilities,
            (III) liabilities relating to ownership or use of property, 
        or
            (IV) such other similar liabilities as the Secretary may 
        specify by regulations.

        (iii) A policy of insurance that provides coverage for a 
    specified disease or illness.
        (iv) A policy of insurance that pays a fixed amount per day (or 
    other period) of hospitalization.

(Aug. 14, 1935, ch. 531, title XVIII, Sec. 1882, as added Pub. L. 96-
265, title V, Sec. 507(a), June 9, 1980, 94 Stat. 476; amended H. Res. 
549, Mar. 25, 1980; Pub. L. 100-93, Sec. 13, Aug. 18, 1987, 101 Stat. 
697; Pub. L. 100-203, title IV, Sec. 4081(b), Dec. 22, 1987, 101 Stat. 
1330-127; Pub. L. 100-360, title II, Sec. 221(a)-(f), title IV, 
Secs. 411(i)(1)(B), (C), 428(b), July 1, 1988, 102 Stat. 742-746, 788, 
817; Pub. L. 101-234, title II, Sec. 203(a)(1), Dec. 13, 1989, 103 Stat. 
1982; Pub. L. 101-508, title IV, Secs. 4207(k)(1), formerly 4027(k)(1), 
4351, formerly 4351(a), 4352, 4353(a)-(d)(1), 4354(a), (b), 4355(a)-(c), 
4356(a), 4357(a), 4358(a), (b)(1), (2), Nov. 5, 1990, 104 Stat. 1388-
124, 1388-125, 1388-129, 1388-130, 1388-132, 1388-134 to 1388-137; Pub. 
L. 103-432, title I, Secs. 160(d)(4), 171(a)-(d)(3)(B), (4), (e)(1), 
(2), (f)(1), (g), (h)(1), (j)(2), (k), Oct. 31, 1994, 108 Stat. 4444-
4451; Pub. L. 104-191, title II, Sec. 271(a), (b), Aug. 21, 1996, 110 
Stat. 2034-2036; Pub. L. 105-33, title IV, Secs. 4002(j)(2), 4003, 
4031(a)-(c), 4032(a), Aug. 5, 1997, 111 Stat. 330, 355, 357, 359; Pub. 
L. 105-362, title VI, Sec. 601(b)(6), Nov. 10, 1998, 112 Stat. 3286; 
Pub. L. 106-113, div. B, Sec. 1000(a)(6) [title III, Sec. 321(k)(13), 
(14), title V, Secs. 501(a)(2), 536(a)], Nov. 29, 1999, 113 Stat. 1536, 
1501A-368, 1501A-378, 1501A-390; Pub. L. 106-170, title II, Sec. 205(a), 
Dec. 17, 1999, 113 Stat. 1899.)

                       References in Text

    Parts A and B of this subchapter, referred to in subsecs. 
(d)(3)(A)(i), (vi)(I), (viii)(II), (B)(i) and (s)(2)(A), (3)(B)(vi), are 
classified to sections 1395c et seq. and 1395j et seq., respectively, of 
this title.
    Section 171(m) of the Social Security Act Amendments of 1994, 
referred to in subsecs. (d)(3)(A)(vi)(IV) and (r)(1), (2)(A), is section 
171(m) of Pub. L. 103-432, title I, Oct. 31, 1994, 108 Stat. 4452, which 
is set out as a note below.
    Section 603(c) of the Social Security Amendments of 1983, referred 
to in subsec. (g)(1), is section 603(c) of Pub. L. 98-21, title VI, Apr. 
20, 1983, 97 Stat. 168, which was not classified to the Code, and was 
repealed by Pub. L. 105-33, title IV, Sec. 4803(d), Aug. 5, 1997, 111 
Stat. 550, subject to transition provisions.
    Section 2355 of the Deficit Reduction Act of 1984, referred to in 
subsec. (g)(1), is section 2355 of Pub. L. 98-369, div. B, title III, 
July 18, 1984, 98 Stat. 1103, which is not classified to the Code.
    Section 9412(b) of the Omnibus Budget Reconciliation Act of 1986, 
referred to in subsec. (g)(1), is section 9412(b) of Pub. L. 99-509, 
title IX, Oct. 21, 1986, 100 Stat. 2062, which was not classified to the 
Code, and was repealed by Pub. L. 105-33, title IV, Sec. 4803(d), Aug. 
5, 1997, 111 Stat. 550, subject to transition provisions.
    The Medicare Catastrophic Coverage Act of 1988, referred to in 
subsecs. (k)(1)(A), (2)(A) and (l)(4)(A), is Pub. L. 100-360, July 1, 
1988, 102 Stat. 683, as amended. For complete classification of this Act 
to the Code, see Short Title of 1988 Amendment note set out under 
section 1305 of this title and Tables.
    The Medicare Catastrophic Coverage Repeal Act of 1989, referred to 
in subsecs. (m)(1)(A), (2)(A) and (n)(2)(A), (5)(A), is Pub. L. 101-234, 
Dec. 13, 1989, 103 Stat. 1979. For complete classification of this Act 
to the Code, see Short Title of 1989 Amendment note set out under 
section 1305 of this title and Tables.
    The Omnibus Budget Reconciliation Act of 1990, referred to in 
subsec. (p)(1)(A)(iv), is Pub. L. 101-508, Nov. 5, 1990, 104 Stat. 1388. 
For complete classification of this Act to the Code, see Tables.
    Part C of this subchapter, referred to in subsec. (s)(3)(B)(ii), 
(v)(II), (vi), is classified to section 1395w-21 et seq. of this title.


                               Amendments

    1999--Subsec. (g)(1). Pub. L. 106-113, Sec. 1000(a)(6) [title III, 
Sec. 321(k)(13)], struck out ``or'' after ``; but does not include''.
    Subsec. (q)(5)(C). Pub. L. 106-170, Sec. 205(a)(1), inserted ``or 
paragraph (6)'' after ``this paragraph''.
    Subsec. (q)(6). Pub. L. 106-170, Sec. 205(a)(2), added par. (6).
    Subsec. (s)(2)(D). Pub. L. 106-113, Sec. 1000(a)(6) [title III, 
Sec. 321(k)(14)], inserted ``section'' after ``(as defined in'' in 
introductory provisions.
    Subsec. (s)(3)(A). Pub. L. 106-113, Sec. 1000(a)(6) [title V, 
Sec. 501(a)(2)(A)], inserted ``, subject to subparagraph (E),'' after 
``in the case of an individual described in subparagraph (B) who'' in 
concluding provisions.
    Subsec. (s)(3)(B)(ii). Pub. L. 106-113, Sec. 1000(a)(6) [title V, 
Sec. 536(a)(1)], inserted before period at end ``or the individual is 65 
years of age or older and is enrolled with a PACE provider under section 
1395eee of this title, and there are circumstances that would permit the 
discontinuance of the individual's enrollment with such provider under 
circumstances that are similar to the circumstances that would permit 
discontinuance of the individual's election under the first sentence of 
such section if such individual were enrolled in a Medicare+Choice 
plan''.
    Subsec. (s)(3)(B)(v)(II). Pub. L. 106-113, Sec. 1000(a)(6) [title V, 
Sec. 536(a)(2)], inserted ``any PACE provider under section 1395eee of 
this title,'' after ``demonstration project authority,''.
    Subsec. (s)(3)(B)(vi). Pub. L. 106-113, Sec. 1000(a)(6) [title V, 
Sec. 536(a)(3)], inserted ``or in a PACE program under section 1395eee 
of this title'' after ``part C of this subchapter'' and substituted 
``such plan or such program'' for ``such plan''.
    Subsec. (s)(3)(E). Pub. L. 106-113, Sec. 1000(a)(6) [title V, 
Sec. 501(a)(2)(B)], added subpar. (E).
    1998--Subsec. (l)(6). Pub. L. 105-362 struck out par. (6) which read 
as follows: ``The Secretary shall report to the Congress in March 1989 
and in July 1990 on actions States have taken in adopting standards 
equal to or more stringent than the NAIC Model Transition Regulation or 
the amended NAIC Model Regulation (or Federal model standards).''
    1997--Subsec. (d)(3)(A)(i). Pub. L. 105-33, Sec. 4003(a)(1)(A), 
inserted ``(including an individual electing a Medicare+Choice plan 
under section 1395w-21 of this title)'' after ``part B of this 
subchapter'' in introductory provisions.
    Subsec. (d)(3)(A)(i)(II). Pub. L. 105-33, Sec. 4003(a)(1)(B), 
inserted ``in the case of an individual not electing a Medicare+Choice 
plan'' after ``(II)'' and inserted ``or in the case of an individual 
electing a Medicare+Choice plan, a medicare supplemental policy with 
knowledge that the policy duplicates health benefits to which the 
individual is otherwise entitled under the Medicare+
Choice plan or under another medicare supplemental policy'' before comma 
at end.
    Subsec. (d)(3)(A)(vi)(III). Pub. L. 105-33, Sec. 4031(c), inserted 
``, a policy described in clause (v),'' after ``Medicare supplemental 
policy''.
    Subsec. (d)(3)(B)(i)(I). Pub. L. 105-33, Sec. 4003(a)(2), inserted 
``(including any Medicare+Choice plan)'' after ``health insurance 
policies''.
    Subsec. (g)(1). Pub. L. 105-33, Sec. 4003(a)(3), inserted ``or a 
Medicare+Choice plan or'' after ``does not include'' the first place 
appearing.
    Pub. L. 105-33, Sec. 4002(j)(2), struck out ``, during the period 
beginning on the date specified in subsection (p)(1)(C) of this section 
and ending on December 31, 1995,'' after ``Omnibus Budget Reconciliation 
Act of 1986, or''.
    Subsec. (p)(2)(C). Pub. L. 105-33, Sec. 4032(a)(1), inserted before 
period at end ``plus the 2 plans described in paragraph (11)(A)''.
    Subsec. (p)(11). Pub. L. 105-33, Sec. 4032(a)(2), added par. (11).
    Subsec. (s)(2)(B). Pub. L. 105-33, Sec. 4031(b)(1), substituted 
``subparagraphs (C) and (D)'' for ``subparagraph (C)''.
    Subsec. (s)(2)(D). Pub. L. 105-33, Sec. 4031(b)(2), added subpar. 
(D).
    Subsec. (s)(3). Pub. L. 105-33, Sec. 4031(a)(3), added par. (3). 
Former par. (3) redesignated (4).
    Pub. L. 105-33, Sec. 4031(a)(1), (2), substituted ``requirements of 
this subsection'' for ``requirements of paragraphs (1) and (2)'' and 
redesignated par. (3) as (4).
    Subsec. (s)(4). Pub. L. 105-33, Sec. 4031(a)(2), redesignated par. 
(3) as (4).
    Subsec. (u). Pub. L. 105-33, Sec. 4003(b), added subsec. (u).
    1996--Subsec. (d)(3)(A)(iii). Pub. L. 104-191, Sec. 271(a)(1), 
substituted ``clause (i)(II)'' for ``clause (i)''.
    Subsec. (d)(3)(A)(iv) to (viii). Pub. L. 104-191, Sec. 271(a)(2), 
added cls. (iv) to (viii).
    Subsec. (d)(3)(C). Pub. L. 104-191, Sec. 271(b)(1), substituted 
``with respect to'' for ``with respect to (i)'' and struck out before 
period at end ``, (ii) the sale or issuance of a policy or plan 
described in subparagraph (A)(i)(I) (other than a medicare supplemental 
policy to an individual entitled to any medical assistance under 
subchapter XIX of this chapter) under which all the benefits are fully 
payable directly to or on behalf of the individual without regard to 
other health benefit coverage of the individual but only if (for 
policies sold or issued more than 60 days after the date the statements 
are published or promulgated under subparagraph (D)) there is disclosed 
in a prominent manner as part of (or together with) the application the 
applicable statement (specified under subparagraph (D)) of the extent to 
which benefits payable under the policy or plan duplicate benefits under 
this subchapter, or (iii) the sale or issuance of a policy or plan 
described in subparagraph (A)(i)(III) under which all the benefits are 
fully payable directly to or on behalf of the individual without regard 
to other health benefit coverage of the individual''.
    Subsec. (d)(3)(D). Pub. L. 104-191, Sec. 271(b)(2), struck out 
subpar. (D) which provided for development of statements for various 
types of health insurance policies sold or issued to persons entitled to 
health benefits under this subchapter regarding extent to which benefits 
payable under those policies duplicate benefits under this subchapter.
    1994--Subsec. (a)(2). Pub. L. 103-432, Sec. 171(c)(1)(B), in closing 
provisions substituted ``on and after the effective date specified in 
subsection (p)(1)(C) of this section'' for ``after the effective date of 
the NAIC or Federal standards with respect to the policy''.
    Subsec. (a)(2)(A). Pub. L. 103-432, Sec. 171(c)(1)(A), substituted 
``1991 NAIC Model Regulation or 1991 Federal Regulation'' for ``NAIC 
standards or the Federal standards''.
    Subsec. (b)(1). Pub. L. 103-432, Sec. 171(e)(2), substituted 
``subparagraph (F)'' for ``subsection (F)'' in last sentence.
    Pub. L. 103-432, Sec. 171(c)(4), substituted ``the Secretary 
determines'' for ``the the Secretary determines'' in introductory 
provisions.
    Pub. L. 103-432, Sec. 171(c)(2), in last sentence substituted ``Each 
report'' for ``The report'', ``fail to meet the standards and 
requirements'' for ``fail to meet the standards'', ``compliance, 
information regarding'' for ``compliance, and information regarding'', 
and ``Commissioners may specify'' for ``Commissioners, may specify''.
    Subsecs. (b)(1)(B), (c)(5). Pub. L. 103-432, Sec. 171(a)(1), made 
technical amendment to Pub. L. 101-508, Sec. 4351. See 1990 Amendment 
notes below.
    Subsec. (d)(3)(A). Pub. L. 103-432, Sec. 171(d)(1)(D), struck out at 
end ``This subsection shall not apply to such a seller until such date 
as the Secretary publishes a list of the standardized benefit packages 
that may be offered consistent with subsection (p) of this section.''
    Pub. L. 103-432, Sec. 171(d)(1)(C), designated third sentence as cl. 
(iii), substituted ``clause (i) with respect to the sale of a medicare 
supplemental policy'' for ``the previous sentence'', and struck out 
``and the statement under such subparagraph indicates on its face that 
the sale of the policy will not duplicate health benefits to which the 
individual is otherwise entitled'' after ``compliance with subparagraph 
(B)''.
    Pub. L. 103-432, Sec. 171(d)(1)(B), designated second sentence as 
cl. (ii) and substituted ``Whoever violates clause (i)'' for ``Whoever 
violates the previous sentence''.
    Pub. L. 103-432, Sec. 171(d)(1)(A), designated first sentence as cl. 
(i) and amended it generally. Prior to amendment, first sentence read as 
follows: ``It is unlawful for a person to sell or issue a health 
insurance policy to an individual entitled to benefits under part A of 
this subchapter or enrolled under part B of this subchapter, with 
knowledge that such policy duplicates health benefits to which such 
individual is otherwise entitled, other than benefits to which he is 
entitled under a requirement of State or Federal law (other than this 
subchapter or subchapter XIX of this chapter).''
    Subsec. (d)(3)(B)(ii)(II). Pub. L. 103-432, Sec. 171(d)(2)(A), 
struck out ``65 years of age or older'' before ``may be eligible''.
    Subsec. (d)(3)(B)(iii)(I). Pub. L. 103-432, Sec. 171(d)(2)(B), (C), 
substituted ``has a medicare supplemental policy'' for ``has another 
medicare supplemental policy'' and ``sale of a medicare supplemental 
policy'' for ``sale of such a policy''.
    Subsec. (d)(3)(B)(iii)(II). Pub. L. 103-432, Sec. 171(d)(2)(D), 
substituted ``has a medicare supplemental policy'' for ``has another 
policy''.
    Subsec. (d)(3)(B)(iii)(III). Pub. L. 103-432, Sec. 171(d)(2)(E), 
amended subcl. (III) generally. Prior to amendment, subcl. (III) read as 
follows: ``Subclause (I) also shall not apply if a State medicaid plan 
under subchapter XIX of this chapter pays the premiums for the policy, 
or pays less than an individual's (who is described in section 
1396d(p)(1) of this title) full liability for medicare cost sharing as 
defined in section 1396d(p)(3)(A) of this title.''
    Subsec. (d)(3)(C). Pub. L. 103-432, Sec. 171(d)(3)(A), substituted 
``(i) the sale or issuance of a group policy'' for ``the selling of a 
group policy'' and added cls. (ii) and (iii).
    Subsec. (d)(3)(D). Pub. L. 103-432, Sec. 171(d)(3)(B), added subpar. 
(D).
    Subsec. (d)(4)(D). Pub. L. 103-432, Sec. 171(k)(1), struck out 
before period at end ``, if such policy expires not more than 12 months 
after the date on which the duplicate copy is mailed''.
    Subsec. (d)(4)(E). Pub. L. 103-432, Sec. 171(k)(2), added subpar. 
(E).
    Subsec. (f)(3). Pub. L. 103-432, Sec. 171(j)(2), added par. (3).
    Subsec. (g)(1). Pub. L. 103-432, Sec. 171(f)(1), substituted ``an 
eligible organization (as defined in section 1395mm(b) of this title) if 
the policy or plan provides benefits pursuant to a contract under 
section 1395mm of this title or an approved demonstration project 
described in section 603(c) of the Social Security Amendments of 1983, 
section 2355 of the Deficit Reduction Act of 1984, or section 9412(b) of 
the Omnibus Budget Reconciliation Act of 1986, or, during the period 
beginning on the date specified in subsection (p)(1)(C) of this section 
and ending on December 31, 1995, a policy or plan of an organization if 
the policy or plan provides benefits pursuant to an agreement under 
section 1395l(a)(1)(A) of this title'' for ``a health maintenance 
organization or other direct service organization which offers benefits 
under this subchapter, including such services under a contract under 
under section 1395mm of this title or an agreement under section 1395l 
of this title.''
    Subsec. (g)(2)(B). Pub. L. 103-432, Sec. 171(c)(3), substituted 
``Secretary'' for ``Panel''.
    Subsec. (o). Pub. L. 103-432, Sec. 171(a)(1), made technical 
amendment to Pub. L. 101-508, Sec. 4351. See 1990 Amendment note below.
    Subsec. (p). Pub. L. 103-432, Sec. 171(a)(1), made technical 
amendment to Pub. L. 101-508, Sec. 4351. See 1990 Amendment note below.
    Subsec. (p)(1)(A). Pub. L. 103-432, Sec. 171(a)(2)(A), in 
introductory provisions, substituted ``changes the revised NAIC Model 
Regulation (described in subsection (m) of this section) to 
incorporate'' for ``promulgates'', and in closing provisions, struck out 
``(such limitations, language, definitions, format, and standards 
referred to collectively in this subsection as `NAIC standards'),'' 
before ``subsection (g)(2)(A) of this section'' and substituted ``were a 
reference to the revised NAIC Model Regulation as changed under this 
subparagraph (such changed regulation referred to in this section as the 
`1991 NAIC Model Regulation')'' for ``included a reference to the NAIC 
standards''.
    Subsec. (p)(1)(B). Pub. L. 103-432, Sec. 171(a)(2)(B), substituted 
``make the changes in the revised NAIC Model Regulation'' for 
``promulgate NAIC standards'', ``a regulation'' for ``limitations, 
language, definitions, format, and standards described in clauses (i) 
through (iv) of such subparagraph (in this subsection referred to 
collectively as `Federal standards')'', and ``were a reference to the 
revised NAIC Model Regulation as changed by the Secretary under this 
subparagraph (such changed regulation referred to in this section as the 
`1991 Federal Regulation')'' for ``included a reference to the Federal 
standards''.
    Subsec. (p)(1)(C)(i). Pub. L. 103-432, Sec. 171(a)(2)(C), 
substituted ``1991 NAIC Model Regulation or 1991 Federal Regulation'' 
for ``NAIC standards or the Federal standards''.
    Subsec. (p)(1)(C)(ii)(I), (E). Pub. L. 103-432, Sec. 171(a)(2)(D), 
substituted ``1991 NAIC Model Regulation or 1991 Federal Regulation'' 
for ``NAIC or Federal standards''.
    Subsec. (p)(2). Pub. L. 103-432, Sec. 171(a)(2)(D), substituted 
``1991 NAIC Model Regulation or 1991 Federal Regulation'' for ``NAIC or 
Federal standards'' in introductory provisions.
    Subsec. (p)(2)(C). Pub. L. 103-432, Sec. 171(a)(2)(E), substituted 
``paragraph (4)(B)'' for ``paragraph (5)(B)''.
    Subsec. (p)(4). Pub. L. 103-432, Sec. 171(a)(2)(G), substituted 
``applicable 1991 NAIC Model Regulation or 1991 Federal Regulation'' for 
``applicable standards'' wherever appearing.
    Subsec. (p)(4)(A)(i). Pub. L. 103-432, Sec. 171(a)(2)(F), inserted 
``or paragraph (6)'' after ``subparagraph (B)''.
    Subsec. (p)(6). Pub. L. 103-432, Sec. 171(a)(2)(H), substituted 
``described in clauses (i) through (iii) of paragraph (1)(A)'' for ``in 
regard to the limitation of benefits described in paragraph (4)''.
    Subsec. (p)(7). Pub. L. 103-432, Sec. 171(a)(2)(I), substituted 
``policyholders'' for ``policyholder''.
    Subsec. (p)(8). Pub. L. 103-432, Sec. 171(a)(2)(J), substituted ``on 
and after the effective date specified in paragraph (1)(C) (but subject 
to paragraph (10)), in violation of the applicable 1991 NAIC Model 
Regulation or 1991 Federal Regulation insofar as such regulation relates 
to the requirements of subsection (o) or (q) of this section or clause 
(i), (ii), or (iii) of paragraph (1)(A)'' for ``after the effective date 
of the NAIC or Federal standards with respect to the policy, in 
violation of the previous requirements of this subsection''.
    Subsec. (p)(9)(B). Pub. L. 103-432, Sec. 171(a)(2)(D), substituted 
``1991 NAIC Model Regulation or 1991 Federal Regulation'' for ``NAIC or 
Federal standards''.
    Subsec. (p)(9)(D). Pub. L. 103-432, Sec. 171(a)(2)(K), added subpar. 
(D).
    Subsec. (p)(10). Pub. L. 103-432, Sec. 171(a)(2)(L), substituted 
``consistent with paragraph (1)(A)(i)'' for ``consistent with this 
subsection''.
    Subsec. (q)(2). Pub. L. 103-432, Sec. 171(b)(1), substituted 
``paragraph (4)'' for ``paragraph (2)''.
    Subsec. (q)(4). Pub. L. 103-432, Sec. 171(b)(2), substituted 
``issuer of the replacement policy'' for ``the succeeding issuer''.
    Subsec. (q)(5)(A), (B). Pub. L. 103-432, Sec. 171(d)(4), made 
technical amendment to the reference to subchapter XIX of this chapter 
to correct reference to corresponding provision of original act.
    Subsec. (r)(1). Pub. L. 103-432, Sec. 171(e)(1)(A), (E), in 
introductory provisions substituted ``or renewed (or otherwise provide 
coverage after the date described in subsection (p)(1)(C) of this 
section)'' for ``or sold'' and inserted at end of closing provisions 
``For the purpose of calculating the refund or credit required under 
paragraph (1)(B) for a policy issued before the date specified in 
subsection (p)(1)(C) of this section, the refund or credit calculation 
shall be based on the aggregate benefits provided and premiums collected 
under all such policies issued by an insurer in a State (separated as to 
individual and group policies) and shall be based only on aggregate 
benefits provided and premiums collected under such policies after the 
date specified in section 171(m)(4) of the Social Security Act 
Amendments of 1994.''
    Subsec. (r)(1)(A). Pub. L. 103-432, Sec. 171(e)(1)(C), substituted 
``Commissioners)'' for ``Commissioners,''.
    Pub. L. 103-432, Sec. 171(e)(1)(B), inserted ``for periods after the 
effective date of these provisions'' after ``the policy can be 
expected''.
    Subsec. (r)(1)(B). Pub. L. 103-432, Sec. 171(e)(1)(D), inserted 
before period at end ``, treating policies of the same type as a single 
policy for each standard package''.
    Subsec. (r)(2)(A). Pub. L. 103-432, Sec. 171(e)(1)(F)-(I), 
substituted ``by standard package'' for ``by policy number'' in first 
sentence and ``until 12 months following issue'' for ``with respect to 
the first 2 years in which it is in effect'' in second sentence, struck 
out ``in order to apply paragraph (1)(B) to the first 2 years in which 
policies are effective'' after ``may be appropriate'' in third sentence, 
and inserted at end ``In the case of a policy issued before the date 
specified in subsection (p)(1)(C) of this section, paragraph (1)(B) 
shall not apply until 1 year after the date specified in section 
171(m)(4) of the Social Security Act Amendments of 1994.''
    Subsec. (r)(2)(C), (D). Pub. L. 103-432, Sec. 171(e)(1)(J), 
substituted ``calendar year'' for ``policy year'' wherever appearing.
    Subsec. (r)(4). Pub. L. 103-432, Sec. 171(e)(1)(K), substituted 
``October'' for ``February'', ``disallowance'' for ``disllowance'', 
``loss ratios'' for ``loss-ratios'' in two places, and ``loss ratio'' 
for ``loss-ratio''.
    Subsec. (r)(6)(A). Pub. L. 103-432, Sec. 171(e)(1)(L), substituted 
``fails to provide refunds or credits as required in paragraph (1)(B)'' 
for ``issues a policy in violation of the loss ratio requirements of 
this subsection'' and ``policy issued for which such failure occurred'' 
for ``such violation''.
    Subsec. (r)(6)(B). Pub. L. 103-432, Sec. 171(e)(1)(M), substituted 
``to the policyholder or, in the case of a group policy, to the 
certificate holder'' for ``to policyholders''.
    Subsec. (s)(2)(A). Pub. L. 103-432, Sec. 171(g)(1), (2), substituted 
``in the case of an individual for whom an application is submitted 
prior to or'' for ``for which an application is submitted'' and ``as of 
the first day on which the individual is 65 years of age or older and is 
enrolled for benefits under part B'' for ``in which the individual (who 
is 65 years of age or older) first is enrolled for benefits under part 
B''.
    Subsec. (s)(2)(B). Pub. L. 103-432, Sec. 171(g)(3), substituted 
``before the policy became effective'' for ``before it became 
effective''.
    Subsec. (t)(1). Pub. L. 103-432, Sec. 171(h)(1)(A), (B), substituted 
``If a medicare supplemental policy meets the 1991 NAIC Model Regulation 
or 1991 Federal Regulation'' for ``If a policy meets the NAIC Model 
Standards''.
    Subsec. (t)(1)(A). Pub. L. 103-432, Sec. 171(h)(1)(C), inserted ``or 
agreements'' after ``contracts''.
    Subsec. (t)(1)(E)(i), (F). Pub. L. 103-432, Sec. 171(h)(1)(D), 
substituted ``standards in the 1991 NAIC Model Regulation or 1991 
Federal Regulation'' for ``NAIC standards''.
    Subsec. (t)(2). Pub. L. 103-432, Sec. 171(h)(1)(E), inserted ``the 
issuer'' before ``is subject to a civil money penalty'' in concluding 
provisions.
    1990--Pub. L. 101-508, Sec. 4353(a)(1), struck out ``Voluntary'' at 
beginning of section catchline.
    Subsec. (a). Pub. L. 101-508, Sec. 4353(a)(2), designated existing 
provisions as par. (1) and added par. (2).
    Pub. L. 101-508, Sec. 4207(k)(1), formerly Sec. 4027(k)(1), as 
renumbered by Pub. L. 103-432, Sec. 160(d)(4), struck out ``(k)(4),'' 
after ``subsections (k)(3),'' in third sentence.
    Subsec. (b)(1). Pub. L. 101-508, Sec. 4353(c)(5), inserted at end 
``The report required under subsection (F) shall include information on 
loss ratios of policies sold in the State, frequency and types of 
instances in which policies approved by the State fail to meet the 
standards of this paragraph, actions taken by the State to bring such 
policies into compliance, and information regarding State programs 
implementing consumer protection provisions, and such further 
information as the Secretary in consultation with the National 
Association of Insurance Commissioners, may specify.''
    Pub. L. 101-508, Sec. 4353(b)(1), (2), substituted ``the Secretary'' 
for ``Supplemental Health Insurance Panel (established under paragraph 
(2))'' in introductory provisions and for ``the Panel'' in concluding 
provisions.
    Pub. L. 101-508, Sec. 4207(k)(1), formerly Sec. 4027(k)(1), as 
renumbered by Pub. L. 103-432, Sec. 160(d)(4), which directed the 
amendment of third sentence of par. (1) by striking out ``(k)(4),'' was 
executed by making the deletion after ``subsections (k)(3),'' in 
concluding provisions to reflect the probable intent of Congress.
    Subsec. (b)(1)(A). Pub. L. 101-508, Sec. 4358(b)(2)(A), inserted 
before semicolon at end ``, except as otherwise provided by subparagraph 
(H)''.
    Pub. L. 101-508, Sec. 4353(b)(3), inserted ``and enforcement'' after 
``application''.
    Subsec. (b)(1)(B). Pub. L. 101-508, Sec. 4351(1), formerly 
Sec. 4351(a)(1), as renumbered and amended by Pub. L. 103-432, 
Sec. 171(a)(1), substituted ``through (5)'' for ``through (4)''.
    Subsec. (b)(1)(C). Pub. L. 101-508, Sec. 4355(b), substituted for 
semicolon at end ``, and that a copy of each such policy, the most 
recent premium for each such policy, and a listing of the ratio of 
benefits provided to premiums collected for the most recent 3-year 
period for each such policy issued or sold in the State is maintained 
and made available to interested persons;''.
    Subsec. (b)(1)(D). Pub. L. 101-508, Sec. 4353(b)(3), inserted ``and 
enforcement'' after ``application''.
    Subsec. (b)(1)(F). Pub. L. 101-508, Sec. 4353(c)(1)-(3), added 
subpar. (F).
    Subsec. (b)(1)(G). Pub. L. 101-508, Sec. 4355(c), which directed 
amendment of par. (1) by adding at the end thereof a new subpar. (G), 
was executed by adding the new subpar. (G) immediately after subpar. (F) 
to reflect the probable intent of Congress.
    Subsec. (b)(1)(H). Pub. L. 101-508, Sec. 4358(b)(2)(B)-(D), added 
subpar. (H).
    Subsec. (b)(2). Pub. L. 101-508, Sec. 4353(b)(4), amended par. (2) 
generally. Prior to amendment, par. (2) read as follows:
    ``(A) There is hereby established a panel (hereinafter in this 
section referred to as the `Panel') to be known as the Supplemental 
Health Insurance Panel. The Panel shall consist of the Secretary, who 
shall serve as the Chairman, and four State commissioners or 
superintendents of insurance, who shall be appointed by the Secretary 
and serve at his pleasure. Such members shall first be appointed not 
later than December 31, 1980.
    ``(B) A majority of the members of the Panel shall constitute a 
quorum, but a lesser number may conduct hearings.
    ``(C) The Secretary shall provide such technical, secretarial, 
clerical, and other assistance as the Panel may require.
    ``(D) There are authorized to be appropriated such sums as may be 
necessary to carry out this paragraph.
    ``(E) Members of the Panel shall be allowed, while away from their 
homes or regular places of business in the performance of services for 
the Panel, travel expenses (including per diem in lieu of subsistence) 
in the same manner as persons employed intermittently in the Government 
service are allowed expenses under section 5703 of title 5.''
    Subsec. (c). Pub. L. 101-508, Sec. 4357(a)(1), inserted ``or the 
requirement described in subsection (s) of this section'' after 
``paragraph (3)'' in introductory provisions.
    Pub. L. 101-508, Sec. 4355(a)(2), struck out at end ``For purposes 
of paragraph (2), policies issued as a result of solicitations of 
individuals through the mails or by mass media advertising (including 
both print and broadcast advertising) shall be deemed to be individual 
policies.''
    Subsec. (c)(1). Pub. L. 101-508, Sec. 4358(b)(1), inserted before 
semicolon at end ``(except as otherwise provided by subsection (t) of 
this section)''.
    Subsec. (c)(2). Pub. L. 101-508, Sec. 4355(a)(1), amended par. (2) 
generally. Prior to amendment, par. (2) read as follows: ``can be 
expected (as estimated for the entire period for which rates are 
computed to provide coverage, on the basis of incurred claims experience 
and earned premiums for such period and in accordance with accepted 
actuarial principles and practices) to return to policyholders in the 
form of aggregate benefits provided under the policy, at least 75 
percent of the aggregate amount of premiums collected in the case of 
group policies and at least 60 percent of the aggregate amount of 
premiums collected in the case of individual policies;''.
    Subsec. (c)(5). Pub. L. 101-508, Sec. 4351(2), formerly 
Sec. 4351(a)(2), as renumbered and amended by Pub. L. 103-432, 
Sec. 171(a)(1), added par. (5).
    Subsec. (d)(3)(A). Pub. L. 101-508, Sec. 4354(a)(1), substituted 
``It is unlawful for a person to sell or issue'' for ``Whoever knowingly 
sells'', ``duplicates health benefits'' for ``substantially duplicates 
health benefits'', ``. Whoever violates the previous sentence shall be 
fined'' for ``, shall be fined'', ``(other than this subchapter or 
subchapter XIX of this chapter)'' for ``(other than this subchapter)'', 
and ``$25,000 (or $15,000 in the case of a person other than the issuer 
of the policy)'' for ``$5,000'' and inserted at end ``A seller (who is 
not the issuer of a health insurance policy) shall not be considered to 
violate the previous sentence if the policy is sold in compliance with 
subparagraph (B) and the statement under such subparagraph indicates on 
its face that the sale of the policy will not duplicate health benefits 
to which the individual is otherwise entitled. This subsection shall not 
apply to such a seller until such date as the Secretary publishes a list 
of the standardized benefit packages that may be offered consistent with 
subsection (p) of this section.''
    Subsec. (d)(3)(B). Pub. L. 101-508, Sec. 4354(a)(2), amended subpar. 
(B) generally. Prior to amendment, subpar. (B) read as follows: ``For 
purposes of this paragraph, benefits which are payable to or on behalf 
of an individual without regard to other health benefit coverage of such 
individual, shall not be considered as duplicative.''
    Subsec. (d)(4)(B). Pub. L. 101-508, Sec. 4353(d)(1), struck out at 
end ``For purposes of this paragraph, a medicare supplemental policy 
shall be deemed to be approved by the commissioner or superintendent of 
insurance of a State if--
        ``(i) the policy has been certified by the Secretary pursuant to 
    subsection (c) of this section or was issued in a State with an 
    approved regulatory program (as defined in subsection (g)(2)(B) of 
    this section);
        ``(ii) the policy has been approved by the commissioners or 
    superintendents of insurance in States in which more than 30 percent 
    of such policies are sold; or
        ``(iii) the State has in effect a law which the commissioner or 
    superintendent of insurance of the State has determined gives him 
    the authority to review, and to approve, or effectively bar from 
    sale in the State, such policy;
except that such a policy shall not be deemed to be approved by a State 
commissioner or superintendent of insurance if the State notifies the 
Secretary that such policy has been submitted for approval to the State 
and has been specifically disapproved by such State after providing 
appropriate notice and opportunity for hearing pursuant to the 
procedures (if any) of the State.''
    Subsec. (g)(1). Pub. L. 101-508, Sec. 4356(a), inserted before 
period at end of first sentence ``and does not include a policy or plan 
of a health maintenance organization or other direct service 
organization which offers benefits under this subchapter, including such 
services under a contract under under section 1395mm of this title or an 
agreement under section 1395l of this title''.
    Subsecs. (o), (p). Pub. L. 101-508, Sec. 4351(3), formerly 
Sec. 4351(a)(3), as renumbered and amended by Pub. L. 103-432, 
Sec. 171(a)(1), added subsecs. (o) and (p).
    Subsec. (q). Pub. L. 101-508, Sec. 4352, added subsec. (q).
    Subsec. (q)(5). Pub. L. 101-508, Sec. 4354(b), added par. (5).
    Subsec. (r). Pub. L. 101-508, Sec. 4355(a)(3), added subsec. (r).
    Subsec. (s). Pub. L. 101-508, Sec. 4357(a)(2), added subsec. (s).
    Subsec. (t). Pub. L. 101-508, Sec. 4358(a), added subsec. (t).
    1989--Subsecs. (a), (b)(1). Pub. L. 101-234, Sec. 203(a)(1)(A), 
substituted ``subsections (k)(3), (k)(4), (m), and (n) of this section'' 
for ``subsection (k)(3) of this section''.
    Subsec. (k)(1)(A). Pub. L. 101-234, Sec. 203(a)(1)(B)(i), inserted 
``except as provided in subsection (m) of this section,'' before 
``subsection (g)(2)(A)''.
    Subsec. (k)(3). Pub. L. 101-234, Sec. 203(a)(1)(B)(ii), substituted 
``subsections (l), (m), and (n) of this section'' for ``subsection (l) 
of this section''.
    Subsecs. (m), (n). Pub. L. 101-234, Sec. 203(a)(1)(C), added 
subsecs. (m) and (n).
    1988--Subsec. (a). Pub. L. 100-360, Sec. 221(d)(1), substituted 
``Subject to subsection (k)(3) of this section, such'' for ``Such''.
    Subsec. (b)(1). Pub. L. 100-360, Sec. 221(d)(2), substituted 
``(subject to subsection (k)(3) of this section, for so long as'' for 
``(for so long as'' in concluding provisions.
    Subsec. (b)(1)(B). Pub. L. 100-360, Sec. 221(a)(1), substituted 
``through (4)'' for ``and (3)''.
    Subsec. (b)(1)(C). Pub. L. 100-360, Sec. 221(b)(2), (3), added 
subpar. (C). Former subpar. (C) redesignated (D).
    Pub. L. 100-360, Sec. 221(b)(1), substituted ``(A), (B), and (C)'' 
for ``(A) and (B)''.
    Subsec. (b)(1)(D), (E). Pub. L. 100-360, Sec. 221(b)(2), 
redesignated former subpars. (C) and (D) as (D) and (E), respectively.
    Subsec. (b)(2)(A). Pub. L. 100-360, Sec. 221(f), substituted 
``appointed by the Secretary'' for ``appointed by the President''.
    Subsec. (b)(3). Pub. L. 100-360, Sec. 221(e), added par. (3).
    Subsec. (c). Pub. L. 100-360, Sec. 411(i)(1)(B), added Pub. L. 100-
203, Sec. 4081(b)(2)(A), see 1987 Amendment note below.
    Subsec. (c)(3). Pub. L. 100-360, Sec. 411(i)(1)(B), redesignated 
Pub. L. 100-203, Sec. 4081(b)(2)(B)-(D), see 1987 Amendment note below.
    Subsec. (c)(3)(A). Pub. L. 100-360, Sec. 411(i)(1)(C)(i), 
substituted ``claim form'' for ``claims form'' in two places and ``such 
notice'' for ``such claims form''.
    Subsec. (c)(3)(B)(i). Pub. L. 100-360, Sec. 411(i)(1)(C)(ii), 
inserted ``under the policy'' after ``payment determination''.
    Subsec. (c)(3)(B)(ii). Pub. L. 100-360, Sec. 411(i)(1)(C)(iii), 
substituted ``payment covered by such policy'' for ``appropriate 
payment''.
    Subsec. (c)(4). Pub. L. 100-360, Sec. 221(a)(2), added par. (4).
    Subsec. (d). Pub. L. 100-360, Sec. 428(b)(1), substituted ``shall be 
fined under title 18 or imprisoned not more than 5 years, or both, and, 
in addition to or in lieu of such a criminal penalty, is subject to a 
civil money penalty of not to exceed $5,000 for each such prohibited 
act'' for ``shall be guilty of a felony and upon conviction thereof 
shall be fined not more than $25,000 or imprisoned for not more than 5 
years, or both'' in pars. (1), (2), (3)(A), and (4)(A).
    Subsec. (d)(5). Pub. L. 100-360, Sec. 428(b)(2), added par. (5).
    Subsec. (e). Pub. L. 100-360, Sec. 221(c), designated existing 
provision as par. (1) and added pars. (2) and (3).
    Subsecs. (k), (l). Pub. L. 100-360, Sec. 221(d)(3), added subsecs. 
(k) and (l).
    1987--Subsec. (b)(1)(B). Pub. L. 100-203, Sec. 4081(b)(1)(A), 
amended subpar. (B) generally. Prior to amendment, subpar. (B) read as 
follows: ``includes a requirement equal to or more stringent than the 
requirement described in subsection (c)(2) of this section; and''.
    Subsec. (b)(1)(D). Pub. L. 100-203, Sec. 4081(b)(1)(B), (C), added 
subpar. (D).
    Subsec. (c). Pub. L. 100-203, Sec. 4081(b)(2)(A), as added by Pub. 
L. 100-360, Sec. 411(i)(1)(B), inserted ``(or, with respect to paragraph 
(3), the issuer of the policy)'' in introductory provisions.
    Subsec. (c)(3). Pub. L. 100-203, Sec. 4081(b)(2)(B)-(D), formerly 
Sec. 4081(b)(2), as redesignated by Pub. L. 100-360, Sec. 411(i)(1)(B), 
added par. (3).
    Subsec. (d)(1). Pub. L. 100-93 substituted ``knowingly and 
willfully'' for ``knowingly or willfully''.

                         Change of Name

    Committee on Interstate and Foreign Commerce of House of 
Representatives changed to Committee on Energy and Commerce of House of 
Representatives immediately prior to noon on Jan. 3, 1981, by House 
Resolution No. 549, Ninety-sixth Congress, Mar. 25, 1980. Committee on 
Energy and Commerce of House of Representatives treated as referring to 
Committee on Commerce of House of Representatives by section 1(a) of 
Pub. L. 104-14, set out as a note preceding section 21 of Title 2, The 
Congress.


                    Effective Date of 1999 Amendments

    Pub. L. 106-170, title II, Sec. 205(b), Dec. 17, 1999, 113 Stat. 
1900, provided that: ``The amendments made by subsection (a) [amending 
this section] apply with respect to requests made after the date of the 
enactment of this Act [Dec. 17, 1999].''
    Amendment by section 1000(a)(6) [title III, Sec. 321(k)(13), (14)] 
of Pub. L. 106-113 effective as if included in the enactment of the 
Balanced Budget Act of 1997, Pub. L. 105-33, except as otherwise 
provided, see section 1000(a)(6) [title III, Sec. 321(m)] of Pub. L. 
106-113, set out as a note under section 1395d of this title.
    Amendment by section 1000(a)(6) [title V, Sec. 501(a)(2)] of Pub. L. 
106-113 applicable to notices of impending terminations or 
discontinuances made on or after Nov. 29, 1999, see section 1000(a)(6) 
[title V, Sec. 501(d)(1)] of Pub. L. 106-113, set out as a note under 
section 1395w-21 of this title.
    Pub. L. 106-113, div. B, Sec. 1000(a)(6) [title V, Sec. 536(b)], 
Nov. 29, 1999, 113 Stat. 1536, 1501A-391, provided that: ``The 
amendments made by this section [amending this section] shall apply to 
terminations or discontinuances made on or after the date of the 
enactment of this Act [Nov. 29, 1999].''


                    Effective Date of 1997 Amendment

    Section 4002(j)(2) of Pub. L. 105-33 provided that the amendment 
made by that section is effective Jan. 1, 1999.
    Section 4031(d) of Pub. L. 105-33 provided that:
    ``(1) Guaranteed issue.--The amendment made by subsection (a) 
[amending this section] shall take effect on July 1, 1998.
    ``(2) Limit on preexisting condition exclusions.--The amendment made 
by subsection (b) [amending this section] shall apply to policies issued 
on or after July 1, 1998.
    ``(3) Conforming amendment.--The amendment made by subsection (c) 
[amending this section] shall be effective as if included in the 
enactment of the Health Insurance Portability and Accountability Act of 
1996 [Pub. L. 104-191].''
    Section 4032(b) of Pub. L. 105-33 provided that:
    ``(1) In general.--The amendments made by subsection (a) [amending 
this section] shall take effect the date of the enactment of this Act 
[Aug. 5, 1997].
    ``(2) Transition.--The provisions of section 4031(e) [set out as a 
note below] shall apply with respect to this section in the same manner 
as they apply to section 4031 [amending this section and enacting 
provisions set out as notes below].''


                    Effective Date of 1996 Amendment

    Section 271(d) of Pub. L. 104-191 provided that:
    ``(1) Except as provided in this subsection, the amendment made by 
subsection (a) [amending this section] shall be effective as if included 
in the enactment of section 4354 of the Omnibus Budget Reconciliation 
Act of 1990 [Pub. L. 101-508].
    ``(2)(A) Clause (vi) of section 1882(d)(3)(A) of the Social Security 
Act [subsec. (d)(3)(A)(vi) of this section], as added by subsection (a), 
shall only apply to individuals applying for--
        ``(i) a health insurance policy described in section 
    1882(d)(3)(A)(iv) of such Act (as added by subsection (a)), after 
    the date of the enactment of this Act [Aug. 21, 1996], or
        ``(ii) another health insurance policy after the end of the 30-
    day period beginning on the date of the enactment of this Act.
    ``(B) A seller or issuer of a health insurance policy may 
substitute, for the disclosure statement described in clause (vii) of 
such section, the statement specified under section 1882(d)(3)(D) of the 
Social Security Act (as in effect before the date of the enactment of 
this Act), without the revision specified in such clause.''


                    Effective Date of 1994 Amendment

    Section 171(l) of Pub. L. 103-432 provided that: ``The amendments 
made by this section [amending this section and sections 1320c-3, 1395b-
2, and 1395b-4 of this title, repealing section 1395zz of this title, 
and enacting and amending provisions set out as notes below] shall be 
effective as if included in the enactment of OBRA-1990 [Pub. L. 101-
508]; except that--
        ``(1) the amendments made by subsection (d)(1) [amending this 
    section] shall take effect on the date of the enactment of this Act 
    [Oct. 31, 1994], but no penalty shall be imposed under section 
    1882(d)(3)(A) of the Social Security Act [subsec. (d)(3)(A) of this 
    section] (for an action occurring after the effective date of the 
    amendments made by section 4354 of OBRA-1990 [see section 4354(c) of 
    Pub. L. 101-508, set out as an Effective Date of 1990 Amendment note 
    below] and before the date of the enactment of this Act) with 
    respect to the sale or issuance of a policy which is not unlawful 
    under section 1882(d)(3)(A)(i)(II) of the Social Security Act 
    [subsec. (d)(3)(A)(i)(II) of this section] (as amended by this 
    section);
        ``(2) the amendments made by subsection (d)(2)(A) [amending this 
    section] and by subparagraphs (A), (B), and (E) of subsection (e)(1) 
    [amending this section] shall be effective on the date specified in 
    subsection (m)(4) [set out as a note below]; and
        ``(3) the amendment made by subsection (g)(2) [amending this 
    section] shall take effect on January 1, 1995, and shall apply to 
    individuals who attain 65 years of age or older on or after the 
    effective date of section 1882(s)(2) of the Social Security Act 
    [subsec. (s)(2) of this section, for effective date see section 
    4357(b) of Pub. L. 101-508, set out as an Effective Date of 1990 
    Amendment note below] (and, in the case of individuals who attained 
    65 years of age after such effective date and before January 1, 
    1995, and who were not covered under such section before January 1, 
    1995, the 6-month period specified in that section shall begin 
    January 1, 1995).''


                    Effective Date of 1990 Amendment

    Section 4353(d)(2) of Pub. L. 101-508 provided that: ``The amendment 
made by paragraph (1) [amending this section] shall apply to policies 
mailed, or caused to be mailed, on and after July 1, 1991.''
    Section 4354(c) of Pub. L. 101-508 provided that: ``The amendments 
made by this section [amending this section] shall apply to policies 
issued or sold more than 1 year after the date of the enactment of this 
Act [Nov. 5, 1990].''
    Section 4355(d) of Pub. L. 101-508, as amended by Pub. L. 103-432, 
title I, Sec. 171(e)(3), Oct. 31, 1994, 108 Stat. 4449, provided that: 
``The amendments made by this section [amending this section] shall 
apply to policies issued or renewed (or otherwise providing coverage 
after the date described in section 1882(p)(1)(C) of the Social Security 
Act [subsec. (p)(1)(C) of this section]) on or after the date specified 
in section 1882(p)(1)(C) of the Social Security Act.''
    Section 4356(b) of Pub. L. 101-508, as amended by Pub. L. 103-432, 
title I, Sec. 171(f)(2), Oct. 31, 1994, 108 Stat. 4449, provided that: 
``The amendment made by subsection (a) [amending this section] shall 
take effect on the date specified in section 1882(p)(1)(C) of the Social 
Security Act [subsec. (p)(1)(C) of this section].''
    Section 4357(b) of Pub. L. 101-508 provided that: ``The amendments 
made by subsection (a) [amending this section] shall take effect 1 year 
after the date of the enactment of this Act [Nov. 5, 1990].''
    Amendment by section 4358(a), (b)(1), (2) of Pub. L. 101-508 only 
applicable in 15 States (as determined by Secretary of Health and Human 
Services) and such other States as elect such amendment to apply to 
them, and during the 6\1/2\-year period beginning with 1992, with such 
amendment to remain in effect beyond the 6\1/2\-year period unless the 
Secretary makes certain determinations, see section 4358(c) of Pub. L. 
101-508, as amended, set out as a note under section 1320c-3 of this 
title.


                    Effective Date of 1989 Amendment

    Section 203(e) of Pub. L. 101-234 provided that: ``The provisions of 
this section [amending this section, enacting provisions set out as 
notes under sections 1395b-2 and 1395mm of this title, and amending 
provisions set out as a note under this section] shall take effect 
January 1, 1990, except that the amendment made by subsection (d) 
[amending provisions set out as an Effective Date of 1988 Amendment note 
under this section] shall be effective as if included in the enactment 
of MCCA [Pub. L. 100-360].''


                    Effective Date of 1988 Amendment

    Section 221(g) of Pub. L. 100-360, as amended by Pub. L. 100-485, 
title VI, Sec. 608(d)(12), Oct. 13, 1988, 102 Stat. 2415; Pub. L. 101-
234, title II, Sec. 203(d), Dec. 13, 1989, 103 Stat. 1985, provided 
that:
    ``(1) Except as provided in paragraphs (2) and (3), the amendments 
made by this section [amending this section] shall take effect on the 
date of the enactment of this Act [July 1, 1988].
    ``(2) The amendments made by subsections (a) and (b) [amending this 
section] shall become effective on the date specified in subsection 
(k)(1)(B) or (k)(2)(B) of section 1882 of the Social Security Act 
[subsec. (k)(1)(B) or (k)(2)(B) of this section] (as added by subsection 
(d) of this section).
    ``(3) The amendment made by subsection (e) [amending this section] 
shall apply to medicare supplemental policies as of January 1, 1989, 
with respect to advertising used on or after such date.
    ``(4) The Secretary of Health and Human Services shall provide for 
the reappointment of members to the Supplemental Health Insurance Panel 
(under section 1882(b)(2) of the Social Security Act [subsec. (b)(2) of 
this section]) by not later than 90 days after the date of the enactment 
of this Act [July 1, 1988].''
    Except as specifically provided in section 411 of Pub. L. 100-360, 
amendment by section 411(i)(1)(B), (C) of Pub. L. 100-360, as it relates 
to a provision in the Omnibus Budget Reconciliation Act of 1987, Pub. L. 
100-203, effective as if included in the enactment of that provision in 
Pub. L. 100-203, see section 411(a) of Pub. L. 100-360, set out as a 
Reference to OBRA; Effective Date note under section 106 of Title 1, 
General Provisions.
    Amendment by section 428(b) of Pub. L. 100-360 effective July 1, 
1988, and applicable only with respect to violations occurring on or 
after such date, see section 428(c) of Pub. L. 100-360, set out as an 
Effective Date note under section 1320b-10 of this title.


                    Effective Date of 1987 Amendments

    Section 4081(c)(2) of Pub. L. 100-203, as amended by Pub. L. 100-
360, title IV, Sec. 411(i)(1)(D), (E), July 1, 1988, 102 Stat. 788; Pub. 
L. 100-485, title VI, Sec. 608(d)(24)(A), Oct. 13, 1988, 102 Stat. 2421, 
provided that:
    ``(A) The amendments made by subsection (b) [amending this section] 
shall apply to medicare supplemental policies as of January 1, 1989 (or, 
if applicable, the date established under subparagraph (B)).
    ``(B) In the case of a State which the Secretary of Health and Human 
Services identifies as--
        ``(i) requiring State legislation (other than legislation 
    appropriating funds) in order for medicare supplemental policies to 
    be changed to meet the requirements of section 1882(c)(3) of the 
    Social Security Act [subsec. (c)(3) of this section], and
        ``(ii) having a legislature which is not scheduled to meet in 
    1988 in a legislative session in which such legislation may be 
    considered or which has not enacted such legislation before July 1, 
    1988,
the date specified in this subparagraph is the first day of the first 
calendar quarter beginning after the close of the first legislative 
session of the State legislature that begins on or after January 1, 
1989, and in which legislation described in clause (i) may be 
considered.''
    Amendment by Pub. L. 100-93 effective at end of fourteen-day period 
beginning Aug. 18, 1987, and inapplicable to administrative proceedings 
commenced before end of such period, see section 15(a) of Pub. L. 100-
93, set out as a note under section 1320a-7 of this title.


                             Effective Date

    Section 507(b) of Pub. L. 96-265 provided that: ``The amendment made 
by this section [enacting this section] shall become effective on the 
date of the enactment of this Act [June 9, 1980], except that the 
provisions of paragraph (4) of section 1882(d) of the Social Security 
Act [subsec. (d)(4) of this section] (as added by this section) shall 
become effective on July 1, 1982.''


                        Study of Medigap Policies

    Pub. L. 106-113, div. B, Sec. 1000(a)(6) [title V, Sec. 553(a)], 
Nov. 29, 1999, 113 Stat. 1536, 1501A-393, provided that:
    ``(1) In general.--The Comptroller General of the United States (in 
this section referred to as the `Comptroller General') shall conduct a 
study of the issues described in paragraph (2) regarding medicare 
supplemental policies described in section 1882(g)(1) of the Social 
Security Act (42 U.S.C. 1395ss(g)(1)).
    ``(2) Issues to be studied.--The issues described in this paragraph 
are the following:
        ``(A) The level of coverage provided by each type of medicare 
    supplemental policy.
        ``(B) The current enrollment levels in each type of medicare 
    supplemental policy.
        ``(C) The availability of each type of medicare supplemental 
    policy to medicare beneficiaries over age 65\1/2\.
        ``(D) The number and type of medicare supplemental policies 
    offered in each State.
        ``(E) The average out-of-pocket costs (including premiums) per 
    beneficiary under each type of medicare supplemental policy.
    ``(2)[(3)] Report.--Not later than July 31, 2001, the Comptroller 
General shall submit a report to Congress on the results of the study 
conducted under this subsection, together with any recommendations for 
legislation that the Comptroller General determines to be appropriate as 
a result of such study.''


 Conforming Benefits to Changes in Terminology for Hospital Outpatient 
                         Department Cost Sharing

    Section 4031(f) of Pub. L. 105-33 provided that: ``For purposes of 
apply [sic] section 1882 of the Social Security Act (42 U.S.C. 1395ss) 
and regulations referred to in subsection (e) [set out as a note above], 
copayment amounts provided under section 1833(t)(5) of such Act [section 
1395l(t)(5) of this title] with respect to hospital outpatient 
department services shall be treated under medicare supplemental 
policies in the same manner as coinsurance with respect to such 
services.''


                          Transition Provisions

    Section 4031(e) of Pub. L. 105-33 provided that:
    ``(1) In general.--If the Secretary of Health and Human Services 
identifies a State as requiring a change to its statutes or regulations 
to conform its regulatory program to the changes made by this section 
[amending this section], the State regulatory program shall not be 
considered to be out of compliance with the requirements of section 1882 
of the Social Security Act [this section] due solely to failure to make 
such change until the date specified in paragraph (4).
    ``(2) NAIC standards.--If, within 9 months after the date of the 
enactment of this Act [Aug. 5, 1997], the National Association of 
Insurance Commissioners (in this subsection referred to as the `NAIC') 
modifies its NAIC Model Regulation relating to section 1882 of the 
Social Security Act [this section] (referred to in such section as the 
1991 NAIC Model Regulation, as modified pursuant to section 171(m)(2) of 
the Social Security Act Amendments of 1994 (Public Law 103-432) [set out 
as a note below] and as modified pursuant to section 
1882(d)(3)(A)(vi)(IV) of the Social Security Act [subsec. 
(d)(3)(A)(vi)(IV) of this section], as added by section 271(a) of the 
Health Insurance Portability and Accountability Act of 1996 (Public Law 
104-191) to conform to the amendments made by this section [amending 
this section], such revised regulation incorporating the modifications 
shall be considered to be the applicable NAIC model regulation 
(including the revised NAIC model regulation and the 1991 NAIC Model 
Regulation) for the purposes of such section.
    ``(3) Secretary standards.--If the NAIC does not make the 
modifications described in paragraph (2) within the period specified in 
such paragraph, the Secretary of Health and Human Services shall make 
the modifications described in such paragraph and such revised 
regulation incorporating the modifications shall be considered to be the 
appropriate Regulation for the purposes of such section.
    ``(4) Date specified.--
        ``(A) In general.--Subject to subparagraph (B), the date 
    specified in this paragraph for a State is the earlier of--
            ``(i) the date the State changes its statutes or regulations 
        to conform its regulatory program to the changes made by this 
        section, or
            ``(ii) 1 year after the date the NAIC or the Secretary first 
        makes the modifications under paragraph (2) or (3), 
        respectively.
        ``(B) Additional legislative action required.--In the case of a 
    State which the Secretary identifies as--
            ``(i) requiring State legislation (other than legislation 
        appropriating funds) to conform its regulatory program to the 
        changes made in this section, but
            ``(ii) having a legislature which is not scheduled to meet 
        in 1999 in a legislative session in which such legislation may 
        be considered,
    the date specified in this paragraph is the first day of the first 
    calendar quarter beginning after the close of the first legislative 
    session of the State legislature that begins on or after July 1, 
    1999. For purposes of the previous sentence, in the case of a State 
    that has a 2-year legislative session, each year of such session 
    shall be deemed to be a separate regular session of the State 
    legislature.''
    Section 271(c) of Pub. L. 104-191 provided that:
    ``(1) No penalties.--Subject to paragraph (3), no criminal or civil 
money penalty may be imposed under section 1882(d)(3)(A) of the Social 
Security Act [subsec. (d)(3)(A) of this section] for any act or omission 
that occurred during the transition period (as defined in paragraph (4)) 
and that relates to any health insurance policy that is described in 
clause (iv) or (v) of such section (as amended by subsection (a)).
    ``(2) Limitation on legal action.--Subject to paragraph (3), no 
legal action shall be brought or continued in any Federal or State court 
insofar as such action--
        ``(A) includes a cause of action which arose, or which is based 
    on or evidenced by any act or omission which occurred, during the 
    transition period; and
        ``(B) relates to the application of section 1882(d)(3)(A) of the 
    Social Security Act to any act or omission with respect to the sale, 
    issuance, or renewal of any health insurance policy that is 
    described in clause (iv) or (v) of such section (as amended by 
    subsection (a)).
    ``(3) Disclosure condition.--In the case of a policy described in 
clause (iv) of section 1882(d)(3)(A) of the Social Security Act that is 
sold or issued on or after the effective date of statements under 
section 171(d)(3)(C) of the Social Security Act Amendments of 1994 [Pub. 
L. 103-432, set out below] and before the end of the 30-day period 
beginning on the date of the enactment of this Act [Aug. 21, 1996], 
paragraphs (1) and (2) shall only apply if disclosure was made in 
accordance with section 1882(d)(3)(C)(ii) of the Social Security Act (as 
in effect before the date of the enactment of this Act).
    ``(4) Transition period.--In this subsection, the term `transition 
period' means the period beginning on November 5, 1991, and ending on 
the date of the enactment of this Act.''


                 Applicability of Disclosure Requirement

    Section 171(d)(3)(C) of Pub. L. 103-432 provided that: ``The 
requirement of a disclosure under section 1882(d)(3)(C)(ii) of the 
Social Security Act [subsec. (d)(3)(C)(ii) of this section] shall not 
apply to an application made for a policy or plan before 60 days after 
the date the Secretary of Health and Human Services publishes or 
promulgates all the statements under section 1882(d)(3)(D) of such 
Act.''


                        State Regulatory Programs

    Section 171(m) of Pub. L. 103-432 provided that:
    ``(1) In general.--If the Secretary of Health and Human Services 
identifies a State as requiring a change to its statutes or regulations 
to conform its regulatory program to the changes made by this section 
[amending this section and sections 1320c-3, 1395b-2, and 1395b-4 of 
this title, repealing section 1395zz of this title, and enacting and 
amending provisions set out as notes under this section], the State 
regulatory program shall not be considered to be out of compliance with 
the requirements of section 1882 of the Social Security Act [this 
section] due solely to failure to make such change until the date 
specified in paragraph (4).
    ``(2) NAIC standards.--If, within 6 months after the date of the 
enactment of this Act [Oct. 31, 1994], the National Association of 
Insurance Commissioners (in this subsection referred to as the `NAIC') 
modifies its 1991 NAIC Model Regulation (adopted in July 1991) to 
conform to the amendments made by this section and to delete from 
section 15C the exception which begins with `unless', such revised 
regulation incorporating the modifications shall be considered to be the 
1991 Regulation for the purposes of section 1882 of the Social Security 
Act.
    ``(3) Secretary standards.--If the NAIC does not make the 
modifications described in paragraph (2) within the period specified in 
such paragraph, the Secretary of Health and Human Services shall make 
the modifications described in such paragraph and such revised 
regulation incorporating the modifications shall be considered to be the 
1991 Regulation for the purposes of section 1882 of the Social Security 
Act.
    ``(4) Date specified.--
        ``(A) In general.--Subject to subparagraph (B), the date 
    specified in this paragraph for a State is the earlier of--
            ``(i) the date the State changes its statutes or regulations 
        to conform its regulatory program to the changes made by this 
        section, or
            ``(ii) 1 year after the date the NAIC or the Secretary first 
        makes the modifications under paragraph (2) or (3), 
        respectively.
        ``(B) Additional legislative action required.--In the case of a 
    State which the Secretary identifies as--
            ``(i) requiring State legislation (other than legislation 
        appropriating funds) to conform its regulatory program to the 
        changes made in this section, but
            ``(ii) having a legislature which is not scheduled to meet 
        in 1996 in a legislative session in which such legislation may 
        be considered,
    the date specified in this paragraph is the first day of the first 
    calendar quarter beginning after the close of the first legislative 
    session of the State legislature that begins on or after January 1, 
    1996. For purposes of the previous sentence, in the case of a State 
    that has a 2-year legislative session, each year of such session 
    shall be deemed to be a separate regular session of the State 
    legislature.''


                      Evaluation of 1990 Amendments

    Section 4358(d) of Pub. L. 101-508 provided that: ``The Secretary of 
Health and Human Services shall conduct an evaluation of the amendments 
made by this section [amending this section and section 1320c-3 of this 
title] and shall report to Congress on such evaluation by not later than 
January 1, 1995.''

                  Section Referred to in Other Sections

    This section is referred to in sections 300gg-91, 1320c-3, 1320d, 
1395a, 1395b-3, 1395b-4, 1395u, 1395w-21, 1395w-22, 3058k of this title; 
title 10 section 1108; title 26 section 9832; title 29 section 1191b.
