【跨境合规】美国《健康保险便利和责任法案》（HIPPA）中英对照摘录（三十二）

G 分编 —— 联邦医疗保险相关保险计划的重复保障与协调机制

第 271 条 联邦医疗保险相关保险计划的重复保障与协调机制

(a) 特定健康保险保单不认定为重复保障的处理规则。修订《美国法典》第 42 编第 1395ss (d)(3)(A) 条，即第 1882 (d)(3)(A) 条：

(1) 在第 (iii) 项中，删除 “第 (i) 项”，替换为 “第 (i)(II) 子项”；

(2) 在末尾新增如下内容：

“(iv) 就本分项而言，某健康保险保单（联邦医疗保险补充保单除外），其保险金给付不以被保险人是否享有其他健康保障为前提的，不视为与本编、第十九编或者其他健康保险保单项下的医疗保障构成‘重复保障’；第 (i) 项的 (I)、(III) 子项不适用于该类保单。

(v) 就本分项而言，一份健康保险保单（或非健康保险合同的附加特约）同时满足下列全部条件的，不视为与本编或其他健康保险保单的医疗保障构成‘重复保障’：

(I) 仅提供长期照护、养老院照护、家庭健康照护、社区照护，或上述保障的任意组合；

(II) 对本编或其他保险保单已提供、已给付的服务项目执行保险协调或直接排除赔付；

(III) 对于《1996 年健康保险携带与责任法案》颁布之日起算 90 日期满之后销售、签发的保单，需在保单保障概要中写明前述协调赔付或排除赔付规则。

本项所称‘协调’，针对保单与本编或其他保单医疗保障之间的关系，指依据保单条款，对于本编或其他保单已经覆盖或给付的服务项目，本保单处于次位赔付地位或者直接不予赔付。

(vi)(I) 享有本编 A 部分待遇或已参保 B 部分的自然人，申请购买健康保险保单（第 (III) 子项所列保单除外）的，应当向申请人提供第 (vii) 项所规定的对应保单类型的披露声明。该声明应当作为投保申请文件的一部分，或与投保申请文件一并交付。

(II) 向第 (I) 子项所述自然人签发或销售健康保险保单（第 (III) 子项所列保单除外），但未按规定提供对应披露声明的，行为人依据《美国法典》第 18 编处以罚金，或五年以下有期徒刑，也可罚金并科监禁；除刑事处罚之外或者替代刑事处罚，每发生一次违规，可处以不超过 25000 美元的民事罚款；非保单签发人的其他行为人，每次违规罚款上限为 15000 美元。

(III) 本子项所指保单（不适用 (I)、(II) 子项）为联邦医疗保险补充保单，或者 1995 年 6 月 12 日《联邦公报》第 60 卷 30880 号公告列明、无需提供披露声明的健康保险保单。

(IV) 本条提及经修订的美国全国保险监督官协会示范监管规则（见 (m)(1)(A) 分项），视为已经纳入《1994 年社会保障法修正案》（公法 103‑432）第 171 (m)(2) 条所作修订；同时以第 (vii) 项第 (I) 子项的披露声明，替换原第 16D (2) 条所要求的披露内容。

(vii) 本项所述某类保单的披露声明，采用本法颁布前第 (D) 分项中原定的对应声明文本，并按如下要求修改：

(I) 每份声明的第二行修改为：‘本保单不是联邦医疗保险补充保险’。

(II) 删除每份声明的第三行，替换为：‘联邦医疗保险赔付的部分医疗服务，同样可能触发本保单的保险金给付’。

(III) 不属于第 (V) 子项的声明，删除以‘本保险’开头的加粗文字，直至下一个以‘联邦医疗保险’开头的段落为止。

(IV) 不属于第 (V) 子项的声明，在‘购买本保险前’方框提示文字之前增加：‘本保单给付保险金，不以你是否享有联邦医疗保险或其他保险的保障为前提’。

(V) 同时提供养老院机构照护与非机构照护、仅提供养老院照护、仅提供家庭照护的保单对应的声明，将以‘联邦法律’开头的句子修改为：‘联邦法律要求我们告知你，在部分情形下，本保险会赔付联邦医疗保险也覆盖的部分照护服务’。

(viii)(I) 在遵守第 (II) 子项的前提下，本分条不限制各州对健康保险保单实施监管的权力，包括第 (iv)、(v)、(vi)(III) 项所述保单。

(II) 州政府不得通过成文法、监管规则或其他形式，认定向享有 A 部分待遇或参保 B 部分的自然人销售、签发、续保的下列保单构成与本编或者联邦医疗保险补充保单医疗保障‘重复保障’：第 (iv)、(v)、(vi)(III) 项所述的健康保险保单，或者不属于健康保险合同的附加特约。”

(b) 配套条文修订。修订《美国法典》第 42 编第 1395ss (d)(3) 条，即第 1882 (d)(3) 条：

(1) 在 (C) 分项中：

(A) 删除 “就 (i) 项而言”，替换为 “就”；

(B) 删除 “,(ii) 销售” 之后全部内容直至末尾句号；

(2) 删除原 (D) 分项。

(c) 过渡条款。

(1) 不予处罚。在遵守第 (3) 款的前提下，对于发生在第 (4) 款定义的过渡期内，且涉及 (a) 款修订后第 1882 (d)(3)(A) 条第 (iv)、(v) 项保单的作为或不作为，不得依据该条施加刑事处罚或者民事罚款。

(2) 诉讼限制。在遵守第 (3) 款的前提下，联邦、州法院不得受理或继续审理满足下列两项条件的诉讼：

(A) 诉讼请求权产生于过渡期，或者以过渡期内发生的作为、不作为作为依据或证据；并且

(B) 诉讼涉及将第 1882 (d)(3)(A) 条适用于该条第 (iv)、(v) 项保单销售、签发、续保相关的作为或不作为。

(3) 披露的适用前提。对于《1994 年社会保障法修正案》第 171 (d)(3)(C) 条项下声明生效之后、本法颁布之日起算 30 日届满之前签发销售的、第 1882 (d)(3)(A) 条第 (iv) 项所述保单，第 (1)、(2) 款仅在已经按照本法生效前版本的第 1882 (d)(3)(C)(ii) 条完成披露的情形下方可适用。

(4) 过渡期定义。本款所称 “过渡期”，指自 1991 年 11 月 5 日起至本法颁布之日止的期间。

(d) 生效日期。

(1) 除本款另有规定外，(a) 款作出的修订，效力视同写入《1990 年综合预算协调法案》第 4354 条的立法文本。

(2)(A) (a) 款新增的第 1882 (d)(3)(A) 条第 (vi) 项，仅适用于下列申请人：

(i) 在本法颁布之后，申请购买修订后第 1882 (d)(3)(A)(iv) 项所述保单的个人；或者

(ii) 在本法颁布之日起算 30 日届满之后，申请购买其他健康保险保单的个人。

(B) 保单销售方、签发方可以使用本法生效前版本《社会保障法》第 1882 (d)(3)(D) 条规定的原有声明，替代第 (vii) 项所要求的、经过修订的披露声明。

Subtitle G—Duplication and Coordination of Medicare‑Related Plans

SEC. 271. DUPLICATION AND COORDINATION OF MEDICARE‑RELATED PLANS.

(a) TREATMENT OF CERTAIN HEALTH INSURANCE POLICIES AS NONDUPLICATIVE.—Section 1882(d)(3)(A) (42 U.S.C. 1395ss(d)(3)(A)) is amended—

(1) in clause (iii), by striking ‘‘clause (i)’’ and inserting ‘‘clause (i)(II)’’; and

(2) by adding at the end the following:

‘‘(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 title, under title XIX, 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 title 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 title 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 the date of enactment of the Health Insurance Portability and Accountability Act of 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 title 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 title or under another health insurance policy.

‘‘(vi)(I) An individual entitled to benefits under part A or enrolled under part B of this title 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, United States Code, 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 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)) 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 the date of the enactment of the Health Insurance Portability and Accountability Act of 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 or enrolled under part B ‘duplicates’ health benefits under this title or under a Medicare supplemental policy.’’.

(b) CONFORMING AMENDMENTS.—Section 1882(d)(3) (42 U.S.C. 1395ss(d)(3)) is amended—

(1) in subparagraph (C)—

(A) by striking ‘‘with respect to (i)’’ and inserting ‘‘with respect to’’, and

(B) by striking ‘‘, (ii) the sale’’ and all that follows up to the period at the end; and

(2) by striking subparagraph (D).

(c) TRANSITIONAL PROVISION.—

(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 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 and before the end of the 30‑day period beginning on the date of the enactment of this Act, 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.

(d) EFFECTIVE DATE.—

(1) Except as provided in this subsection, the amendment made by subsection (a) shall be effective as if included in the enactment of section 4354 of the Omnibus Budget Reconciliation Act of 1990.

(2)(A) Clause (vi) of section 1882(d)(3)(A) of the Social Security Act, 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, 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.