Display Version Introduced in Senate

S 703 ISCommentsClose CommentsPermalink

111th CONGRESSCommentsClose CommentsPermalink

1st SessionCommentsClose CommentsPermalink

S. 703CommentsClose CommentsPermalink

To provide for health care for every American and to control the cost and enhance the quality of the health care system.CommentsClose CommentsPermalink

IN THE SENATE OF THE UNITED STATESCommentsClose CommentsPermalink

March 25, 2009CommentsClose CommentsPermalink

Mr. SANDERS introduced the following bill; which was read twice and referred to the Committee on FinanceCommentsClose CommentsPermalink

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A BILLCommentsClose CommentsPermalink

To provide for health care for every American and to control the cost and enhance the quality of the health care system.CommentsClose CommentsPermalink

Be it enacted by the Senate and House of Representatives of the United States of America in Congress assembled,CommentsClose CommentsPermalink

SECTION 1. SHORT TITLE; TABLE OF CONTENTS.

(a) Short Title- This Act may be cited as the ‘American Health Security Act of 2009’.CommentsClose CommentsPermalink





(b) Table of Contents- The table of contents of this Act is as follows:CommentsClose CommentsPermalink





Sec. 1. Short title; table of contents.CommentsClose CommentsPermalink

TITLE I--ESTABLISHMENT OF A STATE-BASED AMERICAN HEALTH SECURITY PROGRAM; UNIVERSAL ENTITLEMENT; ENROLLMENT

Sec. 101. Establishment of a State-based American Health Security Program.CommentsClose CommentsPermalink





Sec. 102. Universal entitlement.CommentsClose CommentsPermalink





Sec. 103. Enrollment.CommentsClose CommentsPermalink





Sec. 104. Portability of benefits.CommentsClose CommentsPermalink





Sec. 105. Effective date of benefits.CommentsClose CommentsPermalink





Sec. 106. Relationship to existing Federal health programs.CommentsClose CommentsPermalink

TITLE II--COMPREHENSIVE BENEFITS, INCLUDING PREVENTIVE BENEFITS AND BENEFITS FOR LONG-TERM CARE

Sec. 201. Comprehensive benefits.CommentsClose CommentsPermalink





Sec. 202. Definitions relating to services.CommentsClose CommentsPermalink





Sec. 203. Special rules for home and community-based long-term care services.CommentsClose CommentsPermalink





Sec. 204. Exclusions and limitations.CommentsClose CommentsPermalink





Sec. 205. Certification; quality review; plans of care.CommentsClose CommentsPermalink

TITLE III--PROVIDER PARTICIPATION

Sec. 301. Provider participation and standards.CommentsClose CommentsPermalink





Sec. 302. Qualifications for providers.CommentsClose CommentsPermalink





Sec. 303. Qualifications for comprehensive health service organizations.CommentsClose CommentsPermalink





Sec. 304. Limitation on certain physician referrals.CommentsClose CommentsPermalink

TITLE IV--ADMINISTRATION

Subtitle A--General Administrative Provisions

Sec. 401. American Health Security Standards Board.CommentsClose CommentsPermalink





Sec. 402. American Health Security Advisory Council.CommentsClose CommentsPermalink





Sec. 403. Consultation with private entities.CommentsClose CommentsPermalink





Sec. 404. State health security programs.CommentsClose CommentsPermalink





Sec. 405. Complementary conduct of related health programs.CommentsClose CommentsPermalink

Subtitle B--Control Over Fraud and Abuse

Sec. 411. Application of Federal sanctions to all fraud and abuse under American Health Security Program.CommentsClose CommentsPermalink





Sec. 412. Requirements for operation of State health care fraud and abuse control units.CommentsClose CommentsPermalink

TITLE V--QUALITY ASSESSMENT

Sec. 501. American Health Security Quality Council.CommentsClose CommentsPermalink





Sec. 502. Development of certain methodologies, guidelines, and standards.CommentsClose CommentsPermalink





Sec. 503. State quality review programs.CommentsClose CommentsPermalink





Sec. 504. Elimination of utilization review programs; transition.CommentsClose CommentsPermalink

TITLE VI--HEALTH SECURITY BUDGET; PAYMENTS; COST CONTAINMENT MEASURES

Subtitle A--Budgeting and Payments to States

Sec. 601. National health security budget.CommentsClose CommentsPermalink





Sec. 602. Computation of individual and State capitation amounts.CommentsClose CommentsPermalink





Sec. 603. State health security budgets.CommentsClose CommentsPermalink





Sec. 604. Federal payments to States.CommentsClose CommentsPermalink





Sec. 605. Account for health professional education expenditures.CommentsClose CommentsPermalink

Subtitle B--Payments by States to Providers

Sec. 611. Payments to hospitals and other facility-based services for operating expenses on the basis of approved global budgets.CommentsClose CommentsPermalink





Sec. 612. Payments to health care practitioners based on prospective fee schedule.CommentsClose CommentsPermalink





Sec. 613. Payments to comprehensive health service organizations.CommentsClose CommentsPermalink





Sec. 614. Payments for community-based primary health services.CommentsClose CommentsPermalink





Sec. 615. Payments for prescription drugs.CommentsClose CommentsPermalink





Sec. 616. Payments for approved devices and equipment.CommentsClose CommentsPermalink





Sec. 617. Payments for other items and services.CommentsClose CommentsPermalink





Sec. 618. Payment incentives for medically underserved areas.CommentsClose CommentsPermalink





Sec. 619. Authority for alternative payment methodologies.CommentsClose CommentsPermalink

Subtitle C--Mandatory Assignment and Administrative Provisions

Sec. 631. Mandatory assignment.CommentsClose CommentsPermalink





Sec. 632. Procedures for reimbursement; appeals.CommentsClose CommentsPermalink

TITLE VII--PROMOTION OF PRIMARY HEALTH CARE; DEVELOPMENT OF HEALTH SERVICE CAPACITY; PROGRAMS TO ASSIST THE MEDICALLY UNDERSERVED

Subtitle A--Promotion and Expansion of Primary Care Professional Training

Sec. 701. Role of Board; establishment of primary care professional output goals.CommentsClose CommentsPermalink





Sec. 702. Establishment of Advisory Committee on Health Professional Education.CommentsClose CommentsPermalink





Sec. 703. Grants for health professions education, nurse education, and the National Health Service Corps.CommentsClose CommentsPermalink

Subtitle B--Direct Health Care Delivery

Sec. 711. Set-aside for public health.CommentsClose CommentsPermalink





Sec. 712. Set-aside for primary health care delivery.CommentsClose CommentsPermalink





Sec. 713. Primary care service expansion grants.CommentsClose CommentsPermalink

Subtitle C--Primary Care and Outcomes Research

Sec. 721. Set-aside for outcomes research.CommentsClose CommentsPermalink





Sec. 722. Office of Primary Care and Prevention Research.CommentsClose CommentsPermalink

Subtitle D--School-Related Health Services

Sec. 731. Authorizations of appropriations.CommentsClose CommentsPermalink





Sec. 732. Eligibility for development and operation grants.CommentsClose CommentsPermalink





Sec. 733. Preferences.CommentsClose CommentsPermalink





Sec. 734. Grants for development of projects.CommentsClose CommentsPermalink





Sec. 735. Grants for operation of projects.CommentsClose CommentsPermalink





Sec. 736. Federal administrative costs.CommentsClose CommentsPermalink





Sec. 737. Definitions.CommentsClose CommentsPermalink

TITLE VIII--FINANCING PROVISIONS; AMERICAN HEALTH SECURITY TRUST FUND

Sec. 800. Amendment of 1986 code; Section 15 not to apply.CommentsClose CommentsPermalink

Subtitle A--American Health Security Trust Fund

Sec. 801. American Health Security Trust Fund.CommentsClose CommentsPermalink

Subtitle B--Taxes Based on Income and Wages

Sec. 811. Payroll tax on employers.CommentsClose CommentsPermalink





Sec. 812. Health care income tax.CommentsClose CommentsPermalink

TITLE IX--CONFORMING AMENDMENTS TO THE EMPLOYEE RETIREMENT INCOME SECURITY ACT OF 1974

Sec. 901. ERISA inapplicable to health coverage arrangements under State health security programs.CommentsClose CommentsPermalink





Sec. 902. Exemption of State health security programs from ERISA preemption.CommentsClose CommentsPermalink





Sec. 903. Prohibition of employee benefits duplicative of benefits under State health security programs; coordination in case of workers’ compensation.CommentsClose CommentsPermalink





Sec. 904. Repeal of continuation coverage requirements under ERISA and certain other requirements relating to group health plans.CommentsClose CommentsPermalink





Sec. 905. Effective date of title.CommentsClose CommentsPermalink

TITLE X--ADDITIONAL CONFORMING AMENDMENTS

Sec. 1001. Repeal of certain provisions in Internal Revenue Code of 1986.CommentsClose CommentsPermalink





Sec. 1002. Repeal of certain provisions in the Employee Retirement Income Security Act of 1974.CommentsClose CommentsPermalink





Sec. 1003. Repeal of certain provisions in the Public Health Service Act and related provisions.CommentsClose CommentsPermalink





Sec. 1004. Effective date of title.CommentsClose CommentsPermalink

TITLE I--ESTABLISHMENT OF A STATE-BASED AMERICAN HEALTH SECURITY PROGRAM; UNIVERSAL ENTITLEMENT; ENROLLMENTCommentsClose CommentsPermalink

SEC. 101. ESTABLISHMENT OF A STATE-BASED AMERICAN HEALTH SECURITY PROGRAM.

(a) In General- There is hereby established in the United States a State-Based American Health Security Program to be administered by the individual States in accordance with Federal standards specified in, or established under, this Act.CommentsClose CommentsPermalink





(b) State Health Security Programs- In order for a State to be eligible to receive payment under section 604, a State must establish a State health security program in accordance with this Act.CommentsClose CommentsPermalink





(c) State Defined-CommentsClose CommentsPermalink





(1) IN GENERAL- In this Act, subject to paragraph (2), the term ‘State’ means each of the 50 States and the District of Columbia.CommentsClose CommentsPermalink





(2) ELECTION- If the Governor of Puerto Rico, the Virgin Islands, Guam, American Samoa, or the Northern Mariana Islands certifies to the President that the legislature of the Commonwealth or territory has enacted legislation desiring that the Commonwealth or territory be included as a State under the provisions of this Act, such Commonwealth or territory shall be included as a ‘State’ under this Act beginning January 1 of the first year beginning 90 days after the President receives the notification.CommentsClose CommentsPermalink

SEC. 102. UNIVERSAL ENTITLEMENT.

(a) In General- Every individual who is a resident of the United States and is a citizen or national of the United States or lawful resident alien (as defined in subsection (d)) is entitled to benefits for health care services under this Act under the appropriate State health security program. In this section, the term ‘appropriate State health security program’ means, with respect to an individual, the State health security program for the State in which the individual maintains a primary residence.CommentsClose CommentsPermalink





(b) Treatment of Certain Nonimmigrants-CommentsClose CommentsPermalink





(1) IN GENERAL- The American Health Security Standards Board (in this Act referred to as the ‘Board’) may make eligible for benefits for health care services under the appropriate State health security program under this Act such classes of aliens admitted to the United States as nonimmigrants as the Board may provide.CommentsClose CommentsPermalink





(2) CONSIDERATION- In providing for eligibility under paragraph (1), the Board shall consider reciprocity in health care services offered to United States citizens who are nonimmigrants in other foreign states, and such other factors as the Board determines to be appropriate.CommentsClose CommentsPermalink





(c) Treatment of Other Individuals-CommentsClose CommentsPermalink





(1) BY BOARD- The Board also may make eligible for benefits for health care services under the appropriate State health security program under this Act other individuals not described in subsection (a) or (b), and regulate the nature of the eligibility of such individuals, in order--CommentsClose CommentsPermalink





(A) to preserve the public health of communities;CommentsClose CommentsPermalink





(B) to compensate States for the additional health care financing burdens created by such individuals; andCommentsClose CommentsPermalink





(C) to prevent adverse financial and medical consequences of uncompensated care,CommentsClose CommentsPermalink





while inhibiting travel and immigration to the United States for the sole purpose of obtaining health care services.CommentsClose CommentsPermalink





(2) BY STATES- Any State health security program may make individuals described in paragraph (1) eligible for benefits at the expense of the State.CommentsClose CommentsPermalink





(d) Lawful Resident Alien Defined- For purposes of this section, the term ‘lawful resident alien’ means an alien lawfully admitted for permanent residence and any other alien lawfully residing permanently in the United States under color of law, including an alien with lawful temporary resident status under section 210, 210A, or 234A of the Immigration and Nationality Act (8 U.S.C. 1160, 1161, or 1255a).CommentsClose CommentsPermalink

SEC. 103. ENROLLMENT.

(a) In General- Each State health security program shall provide a mechanism for the enrollment of individuals entitled or eligible for benefits under this Act. The mechanism shall--CommentsClose CommentsPermalink





(1) include a process for the automatic enrollment of individuals at the time of birth in the United States and at the time of immigration into the United States or other acquisition of lawful resident status in the United States;CommentsClose CommentsPermalink





(2) provide for the enrollment, as of January 1, 2011, of all individuals who are eligible to be enrolled as of such date; andCommentsClose CommentsPermalink





(3) include a process for the enrollment of individuals made eligible for health care services under subsections (b) and (c) of section 102.CommentsClose CommentsPermalink





(b) Availability of Applications- Each State health security program shall make applications for enrollment under the program available--CommentsClose CommentsPermalink





(1) at employment and payroll offices of employers located in the State;CommentsClose CommentsPermalink





(2) at local offices of the Social Security Administration;CommentsClose CommentsPermalink





(3) at social services locations;CommentsClose CommentsPermalink





(4) at out-reach sites (such as provider and practitioner locations); andCommentsClose CommentsPermalink





(5) at other locations (including post offices and schools) accessible to a broad cross-section of individuals eligible to enroll.CommentsClose CommentsPermalink





(c) Issuance of Health Security Cards- In conjunction with an individual’s enrollment for benefits under this Act, the State health security program shall provide for the issuance of a health security card that shall be used for purposes of identification and processing of claims for benefits under the program. The State health security program may provide for issuance of such cards by employers for purposes of carrying out enrollment pursuant to subsection (a)(2).CommentsClose CommentsPermalink

SEC. 104. PORTABILITY OF BENEFITS.

(a) In General- To ensure continuous access to benefits for health care services covered under this Act, each State health security program--CommentsClose CommentsPermalink





(1) shall not impose any minimum period of residence in the State, or waiting period, in excess of 3 months before residents of the State are entitled to, or eligible for, such benefits under the program;CommentsClose CommentsPermalink





(2) shall provide continuation of payment for covered health care services to individuals who have terminated their residence in the State and established their residence in another State, for the duration of any waiting period imposed in the State of new residency for establishing entitlement to, or eligibility for, such services; andCommentsClose CommentsPermalink





(3) shall provide for the payment for health care services covered under this Act provided to individuals while temporarily absent from the State based on the following principles:CommentsClose CommentsPermalink





(A) Payment for such health care services is at the rate that is approved by the State health security program in the State in which the services are provided, unless the States concerned agree to apportion the cost between them in a different manner.CommentsClose CommentsPermalink





(B) Payment for such health care services provided outside the United States is made on the basis of the amount that would have been paid by the State health security program for similar services rendered in the State, with due regard, in the case of hospital services, to the size of the hospital, standards of service, and other relevant factors.CommentsClose CommentsPermalink





(b) Cross-Border Arrangements- A State health security program for a State may negotiate with such a program in an adjacent State a reciprocal arrangement for the coverage under such other program of health care services to enrollees residing in the border region.CommentsClose CommentsPermalink

SEC. 105. EFFECTIVE DATE OF BENEFITS.

Benefits shall first be available under this Act for items and services furnished on or after January 1, 2011.CommentsClose CommentsPermalink

SEC. 106. RELATIONSHIP TO EXISTING FEDERAL HEALTH PROGRAMS.

(a) Medicare, Medicaid and State Children’s Health Insurance Program (SCHIP)-CommentsClose CommentsPermalink





(1) IN GENERAL- Notwithstanding any other provision of law, subject to paragraph (2)--CommentsClose CommentsPermalink





(A) no benefits shall be available under title XVIII of the Social Security Act for any item or service furnished after December 31, 2010;CommentsClose CommentsPermalink





(B) no individual is entitled to medical assistance under a State plan approved under title XIX of such Act for any item or service furnished after such date;CommentsClose CommentsPermalink





(C) no individual is entitled to medical assistance under an SCHIP plan under title XXI of such Act for any item or service furnished after such date; andCommentsClose CommentsPermalink





(D) no payment shall be made to a State under section 1903(a) or 2105(a) of such Act with respect to medical assistance or child health assistance for any item or service furnished after such date.CommentsClose CommentsPermalink





(2) TRANSITION- In the case of inpatient hospital services and extended care services during a continuous period of stay which began before January 1, 2011, and which had not ended as of such date, for which benefits are provided under title XVIII, under a State plan under title XIX, or a State child health plan under title XXI, of the Social Security Act, the Secretary of Health and Human Services and each State plan, respectively, shall provide for continuation of benefits under such title or plan until the end of the period of stay.CommentsClose CommentsPermalink





(b) Federal Employees Health Benefits Program- No benefits shall be made available under chapter 89 of title 5, United States Code, for any part of a coverage period occurring after December 31, 2010.CommentsClose CommentsPermalink





(c) CHAMPUS- No benefits shall be made available under sections 1079 and 1086 of title 10, United States Code, for items or services furnished after December 31, 2010.CommentsClose CommentsPermalink





(d) Treatment of Benefits for Veterans and Native Americans- Nothing in this Act shall affect the eligibility of veterans for the medical benefits and services provided under title 38, United States Code, or of Indians for the medical benefits and services provided by or through the Indian Health Service.CommentsClose CommentsPermalink

TITLE II--COMPREHENSIVE BENEFITS, INCLUDING PREVENTIVE BENEFITS AND BENEFITS FOR LONG-TERM CARECommentsClose CommentsPermalink

SEC. 201. COMPREHENSIVE BENEFITS.

(a) In General- Subject to the succeeding provisions of this title, individuals enrolled for benefits under this Act are entitled to have payment made under a State health security program for the following items and services if medically necessary or appropriate for the maintenance of health or for the diagnosis, treatment, or rehabilitation of a health condition:CommentsClose CommentsPermalink





(1) HOSPITAL SERVICES- Inpatient and outpatient hospital care, including 24-hour-a-day emergency services.CommentsClose CommentsPermalink





(2) PROFESSIONAL SERVICES- Professional services of health care practitioners authorized to provide health care services under State law, including patient education and training in self-management techniques.CommentsClose CommentsPermalink





(3) COMMUNITY-BASED PRIMARY HEALTH SERVICES- Community-based primary health services (as defined in section 202(a)).CommentsClose CommentsPermalink





(4) PREVENTIVE SERVICES- Preventive services (as defined in section 202(b)).CommentsClose CommentsPermalink





(5) LONG-TERM, ACUTE, AND CHRONIC CARE SERVICES-CommentsClose CommentsPermalink





(A) Nursing facility services.CommentsClose CommentsPermalink





(B) Home health services.CommentsClose CommentsPermalink





(C) Home and community-based long-term care services (as defined in section 202(c)) for individuals described in section 203(a).CommentsClose CommentsPermalink





(D) Hospice care.CommentsClose CommentsPermalink





(E) Services in intermediate care facilities for individuals with mental retardation.CommentsClose CommentsPermalink





(6) PRESCRIPTION DRUGS, BIOLOGICALS, INSULIN, MEDICAL FOODS-CommentsClose CommentsPermalink





(A) Outpatient prescription drugs and biologics, as specified by the Board consistent with section 615.CommentsClose CommentsPermalink





(B) Insulin.CommentsClose CommentsPermalink





(C) Medical foods (as defined in section 202(e)).CommentsClose CommentsPermalink





(7) DENTAL SERVICES- Dental services (as defined in section 202(h)).CommentsClose CommentsPermalink





(8) MENTAL HEALTH AND SUBSTANCE ABUSE TREATMENT SERVICES- Mental health and substance abuse treatment services (as defined in section 202(f)).CommentsClose CommentsPermalink





(9) DIAGNOSTIC TESTS- Diagnostic tests.CommentsClose CommentsPermalink





(10) OTHER ITEMS AND SERVICES-CommentsClose CommentsPermalink





(A) OUTPATIENT THERAPY- Outpatient physical therapy services, outpatient speech pathology services, and outpatient occupational therapy services in all settings.CommentsClose CommentsPermalink





(B) DURABLE MEDICAL EQUIPMENT- Durable medical equipment.CommentsClose CommentsPermalink





(C) HOME DIALYSIS- Home dialysis supplies and equipment.CommentsClose CommentsPermalink





(D) AMBULANCE- Emergency ambulance service.CommentsClose CommentsPermalink





(E) PROSTHETIC DEVICES- Prosthetic devices, including replacements of such devices.CommentsClose CommentsPermalink





(F) ADDITIONAL ITEMS AND SERVICES- Such other medical or health care items or services as the Board may specify.CommentsClose CommentsPermalink





(b) Prohibition of Balance Billing- As provided in section 531, no person may impose a charge for covered services for which benefits are provided under this Act.CommentsClose CommentsPermalink





(c) No Duplicate Health Insurance- Each State health security program shall prohibit the sale of health insurance in the State if payment under the insurance duplicates payment for any items or services for which payment may be made under such a program.CommentsClose CommentsPermalink





(d) State Program May Provide Additional Benefits- Nothing in this Act shall be construed as limiting the benefits that may be made available under a State health security program to residents of the State at the expense of the State.CommentsClose CommentsPermalink





(e) Employers May Provide Additional Benefits- Nothing in this Act shall be construed as limiting the additional benefits that an employer may provide to employees or their dependents, or to former employees or their dependents.CommentsClose CommentsPermalink

SEC. 202. DEFINITIONS RELATING TO SERVICES.

(a) Community-Based Primary Health Services- In this title, the term ‘community-based primary health services’ means ambulatory health services furnished--CommentsClose CommentsPermalink





(1) by a rural health clinic;CommentsClose CommentsPermalink





(2) by a federally qualified health center (as defined in section 1905(l)(2)(B) of the Social Security Act), and which, for purposes of this Act, include services furnished by State and local health agencies;CommentsClose CommentsPermalink





(3) in a school-based setting;CommentsClose CommentsPermalink





(4) by public educational agencies and other providers of services to children entitled to assistance under the Individuals with Disabilities Education Act for services furnished pursuant to a written Individualized Family Services Plan or Individual Education Plan under such Act; andCommentsClose CommentsPermalink





(5) public and private nonprofit entities receiving Federal assistance under the Public Health Service Act.CommentsClose CommentsPermalink





(b) Preventive Services-CommentsClose CommentsPermalink





(1) IN GENERAL- In this title, the term ‘preventive services’ means items and services--CommentsClose CommentsPermalink





(A) which--CommentsClose CommentsPermalink





(i) are specified in paragraph (2); orCommentsClose CommentsPermalink





(ii) the Board determines to be effective in the maintenance and promotion of health or minimizing the effect of illness, disease, or medical condition; andCommentsClose CommentsPermalink





(B) which are provided consistent with the periodicity schedule established under paragraph (3).CommentsClose CommentsPermalink





(2) SPECIFIED PREVENTIVE SERVICES- The services specified in this paragraph are as follows:CommentsClose CommentsPermalink





(A) Basic immunizations.CommentsClose CommentsPermalink





(B) Prenatal and well-baby care (for infants under 1 year of age).CommentsClose CommentsPermalink





(C) Well-child care (including periodic physical examinations, hearing and vision screening, and developmental screening and examinations) for individuals under 18 years of age.CommentsClose CommentsPermalink





(D) Periodic screening mammography, Pap smears, and colorectal examinations and examinations for prostate cancer.CommentsClose CommentsPermalink





(E) Physical examinations.CommentsClose CommentsPermalink





(F) Family planning services.CommentsClose CommentsPermalink





(G) Routine eye examinations, eyeglasses, and contact lenses.CommentsClose CommentsPermalink





(H) Hearing aids, but only upon a determination of a certified audiologist or physician that a hearing problem exists and is caused by a condition that can be corrected by use of a hearing aid.CommentsClose CommentsPermalink





(3) SCHEDULE- The Board shall establish, in consultation with experts in preventive medicine and public health and taking into consideration those preventive services recommended by the Preventive Services Task Force and published as the Guide to Clinical Preventive Services, a periodicity schedule for the coverage of preventive services under paragraph (1). Such schedule shall take into consideration the cost-effectiveness of appropriate preventive care and shall be revised not less frequently than once every 5 years, in consultation with experts in preventive medicine and public health.CommentsClose CommentsPermalink





(c) Home and Community-Based Long-Term Care Services- In this title, the term ‘home and community-based long-term care services’ means the following services provided to an individual to enable the individual to remain in such individual’s place of residence within the community:CommentsClose CommentsPermalink





(1) Home health aide services.CommentsClose CommentsPermalink





(2) Adult day health care, social day care or psychiatric day care.CommentsClose CommentsPermalink





(3) Medical social work services.CommentsClose CommentsPermalink





(4) Care coordination services, as defined in subsection (g)(1).CommentsClose CommentsPermalink





(5) Respite care, including training for informal caregivers.CommentsClose CommentsPermalink





(6) Personal assistance services, and homemaker services (including meals) incidental to the provision of personal assistance services.CommentsClose CommentsPermalink





(d) Home Health Services-CommentsClose CommentsPermalink





(1) IN GENERAL- The term ‘home health services’ means items and services described in section 1861(m) of the Social Security Act and includes home infusion services.CommentsClose CommentsPermalink





(2) HOME INFUSION SERVICES- The term ‘home infusion services’ includes the nursing, pharmacy, and related services that are necessary to conduct the home infusion of a drug regimen safely and effectively under a plan established and periodically reviewed by a physician and that are provided in compliance with quality assurance requirements established by the Secretary.CommentsClose CommentsPermalink





(e) Medical Foods- In this title, the term ‘medical foods’ means foods which are formulated to be consumed or administered enterally under the supervision of a physician and which are intended for the specific dietary management of a disease or condition for which distinctive nutritional requirements, based on recognized scientific principles, are established by medical evaluation.CommentsClose CommentsPermalink





(f) Mental Health and Substance Abuse Treatment Services-CommentsClose CommentsPermalink





(1) SERVICES DESCRIBED- In this title, the term ‘mental health and substance abuse treatment services’ means the following services related to the prevention, diagnosis, treatment, and rehabilitation of mental illness and promotion of mental health:CommentsClose CommentsPermalink





(A) INPATIENT HOSPITAL SERVICES- Inpatient hospital services furnished primarily for the diagnosis or treatment of mental illness or substance abuse for up to 60 days during a year, reduced by a number of days determined by the Secretary so that the actuarial value of providing such number of days of services under this paragraph to the individual is equal to the actuarial value of the days of inpatient residential services furnished to the individual under subparagraph (B) during the year after such services have been furnished to the individual for 120 days during the year (rounded to the nearest day), but only if (with respect to services furnished to an individual described in section 204(b)(1)) such services are furnished in conformity with the plan of an organized system of care for mental health and substance abuse services in accordance with section 204(b)(2).CommentsClose CommentsPermalink





(B) INTENSIVE RESIDENTIAL SERVICES- Intensive residential services (as defined in paragraph (2)) furnished to an individual for up to 120 days during any calendar year, except that--CommentsClose CommentsPermalink





(i) such services may be furnished to the individual for additional days during the year if necessary for the individual to complete a course of treatment to the extent that the number of days of inpatient hospital services described in subparagraph (A) that may be furnished to the individual during the year (as reduced under such subparagraph) is not less than 15; andCommentsClose CommentsPermalink





(ii) reduced by a number of days determined by the Secretary so that the actuarial value of providing such number of days of services under this paragraph to the individual is equal to the actuarial value of the days of intensive community-based services furnished to the individual under subparagraph (D) during the year after such services have been furnished to the individual for 90 days (or, in the case of services described in subparagraph (D)(ii), for 180 days) during the year (rounded to the nearest day).CommentsClose CommentsPermalink





(C) OUTPATIENT SERVICES- Outpatient treatment services of mental illness or substance abuse (other than intensive community-based services under subparagraph (D)) for an unlimited number of days during any calendar year furnished in accordance with standards established by the Secretary for the management of such services, and, in the case of services furnished to an individual described in section 204(b)(1) who is not an inpatient of a hospital, in conformity with the plan of an organized system of care for mental health and substance abuse services in accordance with section 204(b)(2).CommentsClose CommentsPermalink





(D) INTENSIVE COMMUNITY-BASED SERVICES- Intensive community-based services (as described in paragraph (3))--CommentsClose CommentsPermalink





(i) for an unlimited number of days during any calendar year, in the case of services described in section 1861(ff)(2)(E) that are furnished to an individual who is a seriously mentally ill adult, a seriously emotionally disturbed child, or an adult or child with serious substance abuse disorder (as determined in accordance with criteria established by the Secretary);CommentsClose CommentsPermalink





(ii) in the case of services described in section 1861(ff)(2)(C), for up to 180 days during any calendar year, except that such services may be furnished to the individual for a number of additional days during the year equal to the difference between the total number of days of intensive residential services which the individual may receive during the year under part A (as determined under subparagraph (B)) and the number of days of such services which the individual has received during the year; orCommentsClose CommentsPermalink





(iii) in the case of any other such services, for up to 90 days during any calendar year, except that such services may be furnished to the individual for the number of additional days during the year described in clause (ii).CommentsClose CommentsPermalink





(2) INTENSIVE RESIDENTIAL SERVICES DEFINED-CommentsClose CommentsPermalink





(A) IN GENERAL- Subject to subparagraphs (B) and (C), the term ‘intensive residential services’ means inpatient services provided in any of the following facilities:CommentsClose CommentsPermalink





(i) Residential detoxification centers.CommentsClose CommentsPermalink





(ii) Crisis residential programs or mental illness residential treatment programs.CommentsClose CommentsPermalink





(iii) Therapeutic family or group treatment homes.CommentsClose CommentsPermalink





(iv) Residential centers for substance abuse treatment.CommentsClose CommentsPermalink





(B) REQUIREMENTS FOR FACILITIES- No service may be treated as an intensive residential service under subparagraph (A) unless the facility at which the service is provided--CommentsClose CommentsPermalink





(i) is legally authorized to provide such service under the law of the State (or under a State regulatory mechanism provided by State law) in which the facility is located or is certified to provide such service by an appropriate accreditation entity approved by the State in consultation with the Secretary; andCommentsClose CommentsPermalink





(ii) meets such other requirements as the Secretary may impose to assure the quality of the intensive residential services provided.CommentsClose CommentsPermalink





(C) SERVICES FURNISHED TO AT-RISK CHILDREN- In the case of services furnished to an individual described in section 204(b)(1), no service may be treated as an intensive residential service under this subsection unless the service is furnished in conformity with the plan of an organized system of care for mental health and substance abuse services in accordance with section 204(b)(2).CommentsClose CommentsPermalink





(D) MANAGEMENT STANDARDS- No service may be treated as an intensive residential service under subparagraph (A) unless the service is furnished in accordance with standards established by the Secretary for the management of such services.CommentsClose CommentsPermalink





(3) INTENSIVE COMMUNITY-BASED SERVICES DEFINED-CommentsClose CommentsPermalink





(A) IN GENERAL- The term ‘intensive community-based services’ means the items and services described in subparagraph (B) prescribed by a physician (or, in the case of services furnished to an individual described in section 204(b)(1), by an organized system of care for mental health and substance abuse services in accordance with such section) and provided under a program described in subparagraph (D) under the supervision of a physician (or, to the extent permitted under the law of the State in which the services are furnished, a non-physician mental health professional) pursuant to an individualized, written plan of treatment established and periodically reviewed by a physician (in consultation with appropriate staff participating in such program) which sets forth the physician’s diagnosis, the type, amount, frequency, and duration of the items and services provided under the plan, and the goals for treatment under the plan, but does not include any item or service that is not furnished in accordance with standards established by the Secretary for the management of such services.CommentsClose CommentsPermalink





(B) ITEMS AND SERVICES DESCRIBED- The items and services described in this subparagraph are--CommentsClose CommentsPermalink





(i) partial hospitalization services consisting of the items and services described in subparagraph (C);CommentsClose CommentsPermalink





(ii) psychiatric rehabilitation services;CommentsClose CommentsPermalink





(iii) day treatment services for individuals under 19 years of age;CommentsClose CommentsPermalink





(iv) in-home services;CommentsClose CommentsPermalink





(v) case management services, including collateral services designated as such case management services by the Secretary;CommentsClose CommentsPermalink





(vi) ambulatory detoxification services; andCommentsClose CommentsPermalink





(vii) such other items and services as the Secretary may provide (but in no event to include meals and transportation),CommentsClose CommentsPermalink





that are reasonable and necessary for the diagnosis or active treatment of the individual’s condition, reasonably expected to improve or maintain the individual’s condition and functional level and to prevent relapse or hospitalization, and furnished pursuant to such guidelines relating to frequency and duration of services as the Secretary shall by regulation establish (taking into account accepted norms of medical practice and the reasonable expectation of patient improvement).CommentsClose CommentsPermalink





(C) ITEMS AND SERVICES INCLUDED AS PARTIAL HOSPITALIZATION SERVICES- For purposes of subparagraph (B)(i), partial hospitalization services consist of the following:CommentsClose CommentsPermalink





(i) Individual and group therapy with physicians or psychologists (or other mental health professionals to the extent authorized under State law).CommentsClose CommentsPermalink





(ii) Occupational therapy requiring the skills of a qualified occupational therapist.CommentsClose CommentsPermalink





(iii) Services of social workers, trained psychiatric nurses, behavioral aides, and other staff trained to work with psychiatric patients (to the extent authorized under State law).CommentsClose CommentsPermalink





(iv) Drugs and biologicals furnished for therapeutic purposes (which cannot, as determined in accordance with regulations, be self-administered).CommentsClose CommentsPermalink





(v) Individualized activity therapies that are not primarily recreational or diversionary.CommentsClose CommentsPermalink





(vi) Family counseling (the primary purpose of which is treatment of the individual’s condition).CommentsClose CommentsPermalink





(vii) Patient training and education (to the extent that training and educational activities are closely and clearly related to the individual’s care and treatment).CommentsClose CommentsPermalink





(viii) Diagnostic services.CommentsClose CommentsPermalink





(D) PROGRAMS DESCRIBED- A program described in this subparagraph is a program (whether facility-based or freestanding) which is furnished by an entity--CommentsClose CommentsPermalink





(i) legally authorized to furnish such a program under State law (or the State regulatory mechanism provided by State law) or certified to furnish such a program by an appropriate accreditation entity approved by the State in consultation with the Secretary; andCommentsClose CommentsPermalink





(ii) meeting such other requirements as the Secretary may impose to assure the quality of the intensive community-based services provided.CommentsClose CommentsPermalink





(g) Care Coordination Services-CommentsClose CommentsPermalink





(1) IN GENERAL- In this title, the term ‘care coordination services’ means services provided by care coordinators (as defined in paragraph (2)) to individuals described in paragraph (3) for the coordination and monitoring of home and community-based long term care services to ensure appropriate, cost-effective utilization of such services in a comprehensive and continuous manner, and includes--CommentsClose CommentsPermalink





(A) transition management between inpatient facilities and community-based services, including assisting patients in identifying and gaining access to appropriate ancillary services; andCommentsClose CommentsPermalink





(B) evaluating and recommending appropriate treatment services, in cooperation with patients and other providers and in conjunction with any quality review program or plan of care under section 205.CommentsClose CommentsPermalink





(2) CARE COORDINATOR-CommentsClose CommentsPermalink





(A) IN GENERAL- In this title, the term ‘care coordinator’ means an individual or nonprofit or public agency or organization which the State health security program determines--CommentsClose CommentsPermalink





(i) is capable of performing directly, efficiently, and effectively the duties of a care coordinator described in paragraph (1); andCommentsClose CommentsPermalink





(ii) demonstrates capability in establishing and periodically reviewing and revising plans of care, and in arranging for and monitoring the provision and quality of services under any plan.CommentsClose CommentsPermalink





(B) INDEPENDENCE- State health security programs shall establish safeguards to assure that care coordinators have no financial interest in treatment decisions or placements. Care coordination may not be provided through any structure or mechanism through which quality review is performed.CommentsClose CommentsPermalink





(3) ELIGIBLE INDIVIDUALS- An individual described in this paragraph is an individual described in section 203 (relating to individuals qualifying for long term and chronic care services).CommentsClose CommentsPermalink





(h) Dental Services-CommentsClose CommentsPermalink





(1) IN GENERAL- In this title, subject to subsection (b), the term ‘dental services’ means the following:CommentsClose CommentsPermalink





(A) Emergency dental treatment, including extractions, for bleeding, pain, acute infections, and injuries to the maxillofacial region.CommentsClose CommentsPermalink





(B) Prevention and diagnosis of dental disease, including examinations of the hard and soft tissues of the oral cavity and related structures, radiographs, dental sealants, fluorides, and dental prophylaxis.CommentsClose CommentsPermalink





(C) Treatment of dental disease, including non-cast fillings, periodontal maintenance services, and endodontic services.CommentsClose CommentsPermalink





(D) Space maintenance procedures to prevent orthodontic complications.CommentsClose CommentsPermalink





(E) Orthodontic treatment to prevent severe malocclusions.CommentsClose CommentsPermalink





(F) Full dentures.CommentsClose CommentsPermalink





(G) Medically necessary oral health care.CommentsClose CommentsPermalink





(H) Any items and services for special needs patients that are not described in subparagraphs (A) through (G) and that--CommentsClose CommentsPermalink





(i) are required to provide such patients the items and services described in subparagraphs (A) through (G);CommentsClose CommentsPermalink





(ii) are required to establish oral function (including general anesthesia for individuals with physical or emotional limitations that prevent the provision of dental care without such anesthesia);CommentsClose CommentsPermalink





(iii) consist of orthodontic care for severe dentofacial abnormalities; orCommentsClose CommentsPermalink





(iv) consist of prosthetic dental devices for genetic or birth defects or fitting for such devices.CommentsClose CommentsPermalink





(I) Any dental care for individuals with a seizure disorder that is not described in subparagraphs (A) through (H) and that is required because of an illness, injury, disorder, or other health condition that results from such seizure disorder.CommentsClose CommentsPermalink





(2) LIMITATIONS- Dental services are subject to the following limitations:CommentsClose CommentsPermalink





(A) PREVENTION AND DIAGNOSIS-CommentsClose CommentsPermalink





(i) EXAMINATIONS AND PROPHYLAXIS- The examinations and prophylaxis described in paragraph (1)(B) are covered only consistent with a periodicity schedule established by the Board, which schedule may provide for special treatment of individuals less than 18 years of age and of special needs patients.CommentsClose CommentsPermalink





(ii) DENTAL SEALANTS- The dental sealants described in such paragraph are not covered for individuals 18 years of age or older. Such sealants are covered for individuals less than 10 years of age for protection of the 1st permanent molars. Such sealants are covered for individuals 10 years of age or older for protection of the 2d permanent molars.CommentsClose CommentsPermalink





(B) TREATMENT OF DENTAL DISEASE- Prior to January 1, 2016, the items and services described in paragraph (1)(C) are covered only for individuals less than 18 years of age and special needs patients. On or after such date, such items and services are covered for all individuals enrolled for benefits under this Act, except that endodontic services are not covered for individuals 18 years of age or older.CommentsClose CommentsPermalink





(C) SPACE MAINTENANCE- The items and services described in paragraph (1)(D) are covered only for individuals at least 3 years of age, but less than 13 years of age and--CommentsClose CommentsPermalink





(i) are limited to posterior teeth;CommentsClose CommentsPermalink





(ii) involve maintenance of a space or spaces for permanent posterior teeth that would otherwise be prevented from normal eruption if the space were not maintained; andCommentsClose CommentsPermalink





(iii) do not include a space maintainer that is placed within 6 months of the expected eruption of the permanent posterior tooth concerned.CommentsClose CommentsPermalink





(3) DEFINITIONS- For purposes of this title:CommentsClose CommentsPermalink





(A) MEDICALLY NECESSARY ORAL HEALTH CARE- The term ‘medically necessary oral health care’ means oral health care that is required as a direct result of, or would have a direct impact on, an underlying medical condition. Such term includes oral health care directed toward control or elimination of pain, infection, or reestablishment of oral function.CommentsClose CommentsPermalink





(B) SPECIAL NEEDS PATIENT- The term ‘special needs patient’ includes an individual with a genetic or birth defect, a developmental disability, or an acquired medical disability.CommentsClose CommentsPermalink





(i) Nursing Facility; Nursing Facility Services- Except as may be provided by the Board, the terms ‘nursing facility’ and ‘nursing facility services’ have the meanings given such terms in sections 1919(a) and 1905(f), respectively, of the Social Security Act.CommentsClose CommentsPermalink





(j) Services in Intermediate Care Facilities for Individuals With Mental Retardation- Except as may be provided by the Board--CommentsClose CommentsPermalink





(1) the term ‘intermediate care facility for individuals with mental retardation’ has the meaning specified in section 1905(d) of the Social Security Act (as in effect before the enactment of this Act); andCommentsClose CommentsPermalink





(2) the term ‘services in intermediate care facilities for individuals with mental retardation’ means services described in section 1905(a)(15) of such Act (as so in effect) in an intermediate care facility for individuals with mental retardation to an individual determined to require such services in accordance with standards specified by the Board and comparable to the standards described in section 1902(a)(31)(A) of such Act (as so in effect).CommentsClose CommentsPermalink





(k) Other Terms- Except as may be provided by the Board, the definitions contained in section 1861 of the Social Security Act shall apply.CommentsClose CommentsPermalink

SEC. 203. SPECIAL RULES FOR HOME AND COMMUNITY-BASED LONG-TERM CARE SERVICES.

(a) Qualifying Individuals- For purposes of section 201(a)(5)(C), individuals described in this subsection are the following individuals:CommentsClose CommentsPermalink





(1) ADULTS- Individuals 18 years of age or older determined (in a manner specified by the Board)--CommentsClose CommentsPermalink





(A) to be unable to perform, without the assistance of an individual, at least 2 of the following 5 activities of daily living (or who has a similar level of disability due to cognitive impairment)--CommentsClose CommentsPermalink





(i) bathing;CommentsClose CommentsPermalink





(ii) eating;CommentsClose CommentsPermalink





(iii) dressing;CommentsClose CommentsPermalink





(iv) toileting; andCommentsClose CommentsPermalink





(v) transferring in and out of a bed or in and out of a chair;CommentsClose CommentsPermalink





(B) due to cognitive or mental impairments, to require supervision because the individual behaves in a manner that poses health or safety hazards to himself or herself or others; orCommentsClose CommentsPermalink





(C) due to cognitive or mental impairments, to require queuing to perform activities of daily living.CommentsClose CommentsPermalink





(2) CHILDREN- Individuals under 18 years of age determined (in a manner specified by the Board) to meet such alternative standard of disability for children as the Board develops. Such alternative standard shall be comparable to the standard for adults and appropriate for children.CommentsClose CommentsPermalink





(b) Limit on Services-CommentsClose CommentsPermalink





(1) IN GENERAL- The aggregate expenditures by a State health security program with respect to home and community-based long-term care services in a period (specified by the Board) may not exceed 65 percent (or such alternative ratio as the Board establishes under paragraph (2)) of the average of the amount of payment that would have been made under the program during the period if all the home-based long-term care beneficiaries had been residents of nursing facilities in the same area in which the services were provided.CommentsClose CommentsPermalink





(2) ALTERNATIVE RATIO- The Board may establish for purposes of paragraph (1) an alternative ratio (of payments for home and community-based long term care services to payments for nursing facility services) as the Board determines to be more consistent with the goal of providing cost-effective long-term care in the most appropriate and least restrictive setting.CommentsClose CommentsPermalink

SEC. 204. EXCLUSIONS AND LIMITATIONS.

(a) In General- Subject to section 201(e), benefits for service are not available under this Act unless the services meet the standards specified in section 201(a).CommentsClose CommentsPermalink





(b) Special Delivery Requirements for Mental Health and Substance Abuse Treatment Services Provided to At-Risk Children-CommentsClose CommentsPermalink





(1) REQUIRING SERVICES TO BE PROVIDED THROUGH ORGANIZED SYSTEMS OF CARE- A State health security program shall ensure that mental health services and substance abuse treatment services are furnished through an organized system of care, as described in paragraph (2), if--CommentsClose CommentsPermalink





(A) the services are provided to an individual less than 22 years of age;CommentsClose CommentsPermalink





(B) the individual has a serious emotional disturbance or a substance abuse disorder; andCommentsClose CommentsPermalink





(C) the individual is, or is at imminent risk of being, subject to the authority of, or in need of the services of, at least 1 public agency that serves the needs of children, including an agency involved with child welfare, special education, juvenile justice, or criminal justice.CommentsClose CommentsPermalink





(2) REQUIREMENTS FOR SYSTEM OF CARE- In this subsection, an ‘organized system of care’ is a community-based service delivery network, which may consist of public and private providers, that meets the following requirements:CommentsClose CommentsPermalink





(A) The system has established linkages with existing mental health services and substance abuse treatment service delivery programs in the plan service area (or is in the process of developing or operating a system with appropriate public agencies in the area to coordinate the delivery of such services to individuals in the area).CommentsClose CommentsPermalink





(B) The system provides for the participation and coordination of multiple agencies and providers that serve the needs of children in the area, including agencies and providers involved with child welfare, education, juvenile justice, criminal justice, health care, mental health, and substance abuse prevention and treatment.CommentsClose CommentsPermalink





(C) The system provides for the involvement of the families of children to whom mental health services and substance abuse treatment services are provided in the planning of treatment and the delivery of services.CommentsClose CommentsPermalink





(D) The system provides for the development and implementation of individualized treatment plans by multidisciplinary and multiagency teams, which are recognized and followed by the applicable agencies and providers in the area.CommentsClose CommentsPermalink





(E) The system ensures the delivery and coordination of the range of mental health services and substance abuse treatment services required by individuals under 22 years of age who have a serious emotional disturbance or a substance abuse disorder.CommentsClose CommentsPermalink





(F) The system provides for the management of the individualized treatment plans described in subparagraph (D) and for a flexible response to changes in treatment needs over time.CommentsClose CommentsPermalink





(c) Treatment of Experimental Services- In applying subsection (a), the Board shall make national coverage determinations with respect to those services that are experimental in nature. Such determinations shall be made consistent with a process that provides for input from representatives of health care professionals and patients and public comment.CommentsClose CommentsPermalink





(d) Application of Practice Guidelines- In the case of services for which the American Health Security Quality Council (established under section 501) has recognized a national practice guideline, the services are considered to meet the standards specified in section 201(a) if they have been provided in accordance with such guideline or in accordance with such guidelines as are provided by the State health security program consistent with title V. For purposes of this subsection, a service shall be considered to have been provided in accordance with a practice guideline if the health care provider providing the service exercised appropriate professional discretion to deviate from the guideline in a manner authorized or anticipated by the guideline.CommentsClose CommentsPermalink





(e) Specific Limitations-CommentsClose CommentsPermalink





(1) LIMITATIONS ON EYEGLASSES, CONTACT LENSES, HEARING AIDS, AND DURABLE MEDICAL EQUIPMENT- Subject to section 201(e), the Board may impose such limits relating to the costs and frequency of replacement of eyeglasses, contact lenses, hearing aids, and durable medical equipment to which individuals enrolled for benefits under this Act are entitled to have payment made under a State health security program as the Board deems appropriate.CommentsClose CommentsPermalink





(2) OVERLAP WITH PREVENTIVE SERVICES- The coverage of services described in section 201(a) (other than paragraph (3)) which also are preventive services are required to be covered only to the extent that they are required to be covered as preventive services.CommentsClose CommentsPermalink





(3) MISCELLANEOUS EXCLUSIONS FROM COVERED SERVICES- Covered services under this Act do not include the following:CommentsClose CommentsPermalink





(A) Surgery and other procedures (such as orthodontia) performed solely for cosmetic purposes (as defined in regulations) and hospital or other services incident thereto, unless--CommentsClose CommentsPermalink





(i) required to correct a congenital anomaly;CommentsClose CommentsPermalink





(ii) required to restore or correct a part of the body which has been altered as a result of accidental injury, disease, or surgery; orCommentsClose CommentsPermalink





(iii) otherwise determined to be medically necessary and appropriate under section 201(a).CommentsClose CommentsPermalink





(B) Personal comfort items or private rooms in inpatient facilities, unless determined to be medically necessary and appropriate under section 201(a).CommentsClose CommentsPermalink





(C) The services of a professional practitioner if they are furnished in a hospital or other facility which is not a participating provider.CommentsClose CommentsPermalink





(f) Nursing Facility Services and Home Health Services- Nursing facility services and home health services (other than post-hospital services, as defined by the Board) furnished to an individual who is not described in section 203(a) are not covered services unless the services are determined to meet the standards specified in section 201(a) and, with respect to nursing facility services, to be provided in the least restrictive and most appropriate setting.CommentsClose CommentsPermalink

SEC. 205. CERTIFICATION; QUALITY REVIEW; PLANS OF CARE.

(a) Certifications- State health security programs may require, as a condition of payment for institutional health care services and other services of the type described in such sections 1814(a) and 1835(a) of the Social Security Act, periodic professional certifications of the kind described in such sections.CommentsClose CommentsPermalink





(b) Quality Review- For requirement that each State health security program establish a quality review program that meets the requirements for such a program under title V, see section 404(b)(1)(H).CommentsClose CommentsPermalink





(c) Plan of Care Requirements- A State health security program may require, consistent with standards established by the Board, that payment for services exceeding specified levels or duration be provided only as consistent with a plan of care or treatment formulated by one or more providers of the services or other qualified professionals. Such a plan may include, consistent with subsection (b), case management at specified intervals as a further condition of payment for services.CommentsClose CommentsPermalink

TITLE III--PROVIDER PARTICIPATIONCommentsClose CommentsPermalink

SEC. 301. PROVIDER PARTICIPATION AND STANDARDS.

(a) In General- An individual or other entity furnishing any covered service under a State health security program under this Act is not a qualified provider unless the individual or entity--CommentsClose CommentsPermalink





(1) is a qualified provider of the services under section 302;CommentsClose CommentsPermalink





(2) has filed with the State health security program a participation agreement described in subsection (b); andCommentsClose CommentsPermalink





(3) meets such other qualifications and conditions as are established by the Board or the State health security program under this Act.CommentsClose CommentsPermalink





(b) Requirements in Participation Agreement-CommentsClose CommentsPermalink





(1) IN GENERAL- A participation agreement described in this subsection between a State health security program and a provider shall provide at least for the following:CommentsClose CommentsPermalink





(A) Services to eligible persons will be furnished by the provider without discrimination on the ground of race, national origin, income, religion, age, sex or sexual orientation, disability, handicapping condition, or (subject to the professional qualifications of the provider) illness. Nothing in this subparagraph shall be construed as requiring the provision of a type or class of services which services are outside the scope of the provider’s normal practice.CommentsClose CommentsPermalink





(B) No charge will be made for any covered services other than for payment authorized by this Act.CommentsClose CommentsPermalink





(C) The provider agrees to furnish such information as may be reasonably required by the Board or a State health security program, in accordance with uniform reporting standards established under section 401(g)(1), for--CommentsClose CommentsPermalink





(i) quality review by designated entities;CommentsClose CommentsPermalink





(ii) the making of payments under this Act (including the examination of records as may be necessary for the verification of information on which payments are based);CommentsClose CommentsPermalink





(iii) statistical or other studies required for the implementation of this Act; andCommentsClose CommentsPermalink





(iv) such other purposes as the Board or State may specify.CommentsClose CommentsPermalink





(D) The provider agrees not to bill the program for any services for which benefits are not available because of section 204(d).CommentsClose CommentsPermalink





(E) In the case of a provider that is not an individual, the provider agrees not to employ or use for the provision of health services any individual or other provider who or which has had a participation agreement under this subsection terminated for cause.CommentsClose CommentsPermalink





(F) In the case of a provider paid under a fee-for-service basis under section 612, the provider agrees to submit bills and any required supporting documentation relating to the provision of covered services within 30 days (or such shorter period as a State health security program may require) after the date of providing such services.CommentsClose CommentsPermalink





(2) TERMINATION OF PARTICIPATION AGREEMENTS-CommentsClose CommentsPermalink





(A) IN GENERAL- Participation agreements may be terminated, with appropriate notice--CommentsClose CommentsPermalink





(i) by the Board or a State health security program for failure to meet the requirements of this title; orCommentsClose CommentsPermalink





(ii) by a provider.CommentsClose CommentsPermalink





(B) TERMINATION PROCESS- Providers shall be provided notice and a reasonable opportunity to correct deficiencies before the Board or a State health security program terminates an agreement unless a more immediate termination is required for public safety or similar reasons.CommentsClose CommentsPermalink

SEC. 302. QUALIFICATIONS FOR PROVIDERS.

(a) In General- A health care provider is considered to be qualified to provide covered services if the provider is licensed or certified and meets--CommentsClose CommentsPermalink





(1) all the requirements of State law to provide such services;CommentsClose CommentsPermalink





(2) applicable requirements of Federal law to provide such services; andCommentsClose CommentsPermalink





(3) any applicable standards established under subsection (b).CommentsClose CommentsPermalink





(b) Minimum Provider Standards-CommentsClose CommentsPermalink





(1) IN GENERAL- The Board shall establish, evaluate, and update national minimum standards to assure the quality of services provided under this Act and to monitor efforts by State health security programs to assure the quality of such services. A State health security program may also establish additional minimum standards which providers must meet.CommentsClose CommentsPermalink





(2) NATIONAL MINIMUM STANDARDS- The national minimum standards under paragraph (1) shall be established for institutional providers of services, individual health care practitioners, and comprehensive health service organizations. Except as the Board may specify in order to carry out this title, a hospital, nursing facility, or other institutional provider of services shall meet standards for such a facility under the medicare program under title XVIII of the Social Security Act. Such standards also may include, where appropriate, elements relating to--CommentsClose CommentsPermalink





(A) adequacy and quality of facilities;CommentsClose CommentsPermalink





(B) training and competence of personnel (including continuing education requirements);CommentsClose CommentsPermalink





(C) comprehensiveness of service;CommentsClose CommentsPermalink





(D) continuity of service;CommentsClose CommentsPermalink





(E) patient satisfaction (including waiting time and access to services); andCommentsClose CommentsPermalink





(F) performance standards (including organization, facilities, structure of services, efficiency of operation, and outcome in palliation, improvement of health, stabilization, cure, or rehabilitation).CommentsClose CommentsPermalink





(3) TRANSITION IN APPLICATION- If the Board provides for additional requirements for providers under this subsection, any such additional requirement shall be implemented in a manner that provides for a reasonable period during which a previously qualified provider is permitted to meet such an additional requirement.CommentsClose CommentsPermalink





(4) EXCHANGE OF INFORMATION- The Board shall provide for an exchange, at least annually, among State health security programs of information with respect to quality assurance and cost containment.CommentsClose CommentsPermalink

SEC. 303. QUALIFICATIONS FOR COMPREHENSIVE HEALTH SERVICE ORGANIZATIONS.

(a) In General- For purposes of this Act, a comprehensive health service organization (in this section referred to as a ‘CHSO’) is a public or private organization which, in return for a capitated payment amount, undertakes to furnish, arrange for the provision of, or provide payment with respect to--CommentsClose CommentsPermalink





(1) a full range of health services (as identified by the Board), including at least hospital services and physicians services; andCommentsClose CommentsPermalink





(2) out-of-area coverage in the case of urgently needed services;CommentsClose CommentsPermalink





to an identified population which is living in or near a specified service area and which enrolls voluntarily in the organization.CommentsClose CommentsPermalink





(b) Enrollment-CommentsClose CommentsPermalink





(1) IN GENERAL- All eligible persons living in or near the specified service area of a CHSO are eligible to enroll in the organization; except that the number of enrollees may be limited to avoid overtaxing the resources of the organization.CommentsClose CommentsPermalink





(2) MINIMUM ENROLLMENT PERIOD- Subject to paragraph (3), the minimum period of enrollment with a CHSO shall be twelve months, unless the enrolled individual becomes ineligible to enroll with the organization.CommentsClose CommentsPermalink





(3) WITHDRAWAL FOR CAUSE- Each CHSO shall permit an enrolled individual to disenroll from the organization for cause at any time.CommentsClose CommentsPermalink





(c) Requirements for CHSOs-CommentsClose CommentsPermalink





(1) ACCESSIBLE SERVICES- Each CHSO, to the maximum extent feasible, shall make all services readily and promptly accessible to enrollees who live in the specified service area.CommentsClose CommentsPermalink





(2) CONTINUITY OF CARE- Each CHSO shall furnish services in such manner as to provide continuity of care and (when services are furnished by different providers) shall provide ready referral of patients to such services and at such times as may be medically appropriate.CommentsClose CommentsPermalink





(3) BOARD OF DIRECTORS- In the case of a CHSO that is a private organization--CommentsClose CommentsPermalink





(A) CONSUMER REPRESENTATION- At least one-third of the members of the CHSO’s board of directors must be consumer members with no direct or indirect, personal or family financial relationship to the organization.CommentsClose CommentsPermalink





(B) PROVIDER REPRESENTATION- The CHSO’s board of directors must include at least one member who represents health care providers.CommentsClose CommentsPermalink





(4) PATIENT GRIEVANCE PROGRAM- Each CHSO must have in effect a patient grievance program and must conduct regularly surveys of the satisfaction of members with services provided by or through the organization.CommentsClose CommentsPermalink





(5) MEDICAL STANDARDS- Each CHSO must provide that a committee or committees of health care practitioners associated with the organization will promulgate medical standards, oversee the professional aspects of the delivery of care, perform the functions of a pharmacy and drug therapeutics committee, and monitor and review the quality of all health services (including drugs, education, and preventive services).CommentsClose CommentsPermalink





(6) PREMIUMS- Premiums or other charges by a CHSO for any services not paid for under this Act must be reasonable.CommentsClose CommentsPermalink





(7) UTILIZATION AND BONUS INFORMATION- Each CHSO must--CommentsClose CommentsPermalink





(A) comply with the requirements of section 1876(i)(8) of the Social Security Act (relating to prohibiting physician incentive plans that provide specific inducements to reduce or limit medically necessary services); andCommentsClose CommentsPermalink





(B) make available to its membership utilization information and data regarding financial performance, including bonus or incentive payment arrangements to practitioners.CommentsClose CommentsPermalink





(8) PROVISION OF SERVICES TO ENROLLEES AT INSTITUTIONS OPERATING UNDER GLOBAL BUDGETS- The organization shall arrange to reimburse for hospital services and other facility-based services (as identified by the Board) for services provided to members of the organization in accordance with the global operating budget of the hospital or facility approved under section 611.CommentsClose CommentsPermalink





(9) BROAD MARKETING- Each CHSO must provide for the marketing of its services (including dissemination of marketing materials) to potential enrollees in a manner that is designed to enroll individuals representative of the different population groups and geographic areas included within its service area and meets such requirements as the Board or a State health security program may specify.CommentsClose CommentsPermalink





(10) ADDITIONAL REQUIREMENTS- Each CHSO must meet--CommentsClose CommentsPermalink





(A) such requirements relating to minimum enrollment;CommentsClose CommentsPermalink





(B) such requirements relating to financial solvency;CommentsClose CommentsPermalink





(C) such requirements relating to quality and availability of care; andCommentsClose CommentsPermalink





(D) such other requirements,CommentsClose CommentsPermalink





as the Board or a State health security program may specify.CommentsClose CommentsPermalink





(d) Provision of Emergency Services to Nonenrollees- A CHSO may furnish emergency services to persons who are not enrolled in the organization. Payment for such services, if they are covered services to eligible persons, shall be made to the organization unless the organization requests that it be made to the individual provider who furnished the services.CommentsClose CommentsPermalink

SEC. 304. LIMITATION ON CERTAIN PHYSICIAN REFERRALS.

(a) Application to American Health Security Program- Section 1877 of the Social Security Act, as amended by subsections (b) and (c), shall apply under this Act in the same manner as it applies under title XVIII of the Social Security Act; except that in applying such section under this Act any references in such section to the Secretary or title XVIII of the Social Security Act are deemed references to the Board and the American Health Security Program under this Act, respectively.CommentsClose CommentsPermalink





(b) Expansion of Prohibition to Certain Additional Designated Services- Section 1877(h)(6) of the Social Security Act (42 U.S.C. 1395nn(h)(6)) is amended by adding at the end the following:CommentsClose CommentsPermalink





‘(M) Ambulance services.CommentsClose CommentsPermalink





‘(N) Home infusion therapy services.’.CommentsClose CommentsPermalink





(c) Conforming Amendments- Section 1877 of such Act is further amended--CommentsClose CommentsPermalink





(1) in subsection (a)(1)(A), by striking ‘for which payment otherwise may be made under this title’ and inserting ‘for which a charge is imposed’;CommentsClose CommentsPermalink





(2) in subsection (a)(1)(B), by striking ‘under this title’;CommentsClose CommentsPermalink





(3) by amending paragraph (1) of subsection (g) to read as follows:CommentsClose CommentsPermalink





‘(1) DENIAL OF PAYMENT- No payment may be made under a State health security program for a designated health service for which a claim is presented in violation of subsection (a)(1)(B). No individual, third party payor, or other entity is liable for payment for designated health services for which a claim is presented in violation of such subsection.’; andCommentsClose CommentsPermalink





(4) in subsection (g)(3), by striking ‘for which payment may not be made under paragraph (1)’ and inserting ‘for which such a claim may not be presented under subsection (a)(1)’.CommentsClose CommentsPermalink

TITLE IV--ADMINISTRATIONCommentsClose CommentsPermalink

Subtitle A--General Administrative ProvisionsCommentsClose CommentsPermalink

SEC. 401. AMERICAN HEALTH SECURITY STANDARDS BOARD.

(a) Establishment- There is hereby established an American Health Security Standards Board.CommentsClose CommentsPermalink





(b) Appointment and Terms of Members-CommentsClose CommentsPermalink





(1) IN GENERAL- The Board shall be composed of--CommentsClose CommentsPermalink





(A) the Secretary of Health and Human Services; andCommentsClose CommentsPermalink





(B) 6 other individuals (described in paragraph (2)) appointed by the President with the advice and consent of the Senate.CommentsClose CommentsPermalink





The President shall first nominate individuals under subparagraph (B) on a timely basis so as to provide for the operation of the Board by not later than January 1, 2010.CommentsClose CommentsPermalink





(2) SELECTION OF APPOINTED MEMBERS- With respect to the individuals appointed under paragraph (1)(B):CommentsClose CommentsPermalink





(A) They shall be chosen on the basis of backgrounds in health policy, health economics, the healing professions, and the administration of health care institutions.CommentsClose CommentsPermalink





(B) They shall provide a balanced point of view with respect to the various health care interests and at least 2 of them shall represent the interests of individual consumers.CommentsClose CommentsPermalink





(C) Not more than 3 of them shall be from the same political party.CommentsClose CommentsPermalink





(D) To the greatest extent feasible, they shall represent the various geographic regions of the United States and shall reflect the racial, ethnic, and gender composition of the population of the United States.CommentsClose CommentsPermalink





(3) TERMS OF APPOINTED MEMBERS- Individuals appointed under paragraph (1)(B) shall serve for a term of 6 years, except that the terms of 5 of the individuals initially appointed shall be, as designated by the President at the time of their appointment, for 1, 2, 3, 4, and 5 years. During a term of membership on the Board, no member shall engage in any other business, vocation or employment.CommentsClose CommentsPermalink





(c) Vacancies-CommentsClose CommentsPermalink





(1) IN GENERAL- The President shall fill any vacancy in the membership of the Board in the same manner as the original appointment. The vacancy shall not affect the power of the remaining members to execute the duties of the Board.CommentsClose CommentsPermalink





(2) VACANCY APPOINTMENTS- Any member appointed to fill a vacancy shall serve for the remainder of the term for which the predecessor of the member was appointed.CommentsClose CommentsPermalink





(3) REAPPOINTMENT- The President may reappoint an appointed member of the Board for a second term in the same manner as the original appointment. A member who has served for 2 consecutive 6-year terms shall not be eligible for reappointment until 2 years after the member has ceased to serve.CommentsClose CommentsPermalink





(4) REMOVAL FOR CAUSE- Upon confirmation, members of the Board may not be removed except by the President for cause.CommentsClose CommentsPermalink





(d) Chair- The President shall designate 1 of the members of the Board, other than the Secretary, to serve at the will of the President as Chair of the Board.CommentsClose CommentsPermalink





(e) Compensation- Members of the Board (other than the Secretary) shall be entitled to compensation at a level equivalent to level II of the Executive Schedule, in accordance with section 5313 of title 5, United States Code.CommentsClose CommentsPermalink





(f) General Duties of the Board-CommentsClose CommentsPermalink





(1) IN GENERAL- The Board shall develop policies, procedures, guidelines, and requirements to carry out this Act, including those related to--CommentsClose CommentsPermalink





(A) eligibility;CommentsClose CommentsPermalink





(B) enrollment;CommentsClose CommentsPermalink





(C) benefits;CommentsClose CommentsPermalink





(D) provider participation standards and qualifications, as defined in title III;CommentsClose CommentsPermalink





(E) national and State funding levels;CommentsClose CommentsPermalink





(F) methods for determining amounts of payments to providers of covered services, consistent with subtitle B of title VI;CommentsClose CommentsPermalink





(G) the determination of medical necessity and appropriateness with respect to coverage of certain services;CommentsClose CommentsPermalink





(H) assisting State health security programs with planning for capital expenditures and service delivery;CommentsClose CommentsPermalink





(I) planning for health professional education funding (as specified in title VI);CommentsClose CommentsPermalink





(J) allocating funds provided under title VII; andCommentsClose CommentsPermalink





(K) encouraging States to develop regional planning mechanisms (described in section 404(a)(3)).CommentsClose CommentsPermalink





(2) REGULATIONS- Regulations authorized by this Act shall be issued by the Board in accordance with the provisions of section 553 of title 5, United States Code.CommentsClose CommentsPermalink





(g) Uniform Reporting Standards; Annual Report; Studies-CommentsClose CommentsPermalink





(1) UNIFORM REPORTING STANDARDS-CommentsClose CommentsPermalink





(A) IN GENERAL- The Board shall establish uniform reporting requirements and standards to ensure an adequate national data base regarding health services practitioners, services and finances of State health security programs, approved plans, providers, and the costs of facilities and practitioners providing services. Such standards shall include, to the maximum extent feasible, health outcome measures.CommentsClose CommentsPermalink





(B) REPORTS- The Board shall analyze regularly information reported to it, and to State health security programs pursuant to such requirements and standards.CommentsClose CommentsPermalink





(2) ANNUAL REPORT- Beginning January 1, of the second year beginning after the date of the enactment of this Act, the Board shall annually report to Congress on the following:CommentsClose CommentsPermalink





(A) The status of implementation of the Act.CommentsClose CommentsPermalink





(B) Enrollment under this Act.CommentsClose CommentsPermalink





(C) Benefits under this Act.CommentsClose CommentsPermalink





(D) Expenditures and financing under this Act.CommentsClose CommentsPermalink





(E) Cost-containment measures and achievements under this Act.CommentsClose CommentsPermalink





(F) Quality assurance.CommentsClose CommentsPermalink





(G) Health care utilization patterns, including any changes attributable to the program.CommentsClose CommentsPermalink





(H) Long-range plans and goals for the delivery of health services.CommentsClose CommentsPermalink





(I) Differences in the health status of the populations of the different States, including income and racial characteristics.CommentsClose CommentsPermalink





(J) Necessary changes in the education of health personnel.CommentsClose CommentsPermalink





(K) Plans for improving service to medically underserved populations.CommentsClose CommentsPermalink





(L) Transition problems as a result of implementation of this Act.CommentsClose CommentsPermalink





(M) Opportunities for improvements under this Act.CommentsClose CommentsPermalink





(3) STATISTICAL ANALYSES AND OTHER STUDIES- The Board may, either directly or by contract--CommentsClose CommentsPermalink





(A) make statistical and other studies, on a nationwide, regional, state, or local basis, of any aspect of the operation of this Act, including studies of the effect of the Act upon the health of the people of the United States and the effect of comprehensive health services upon the health of persons receiving such services;CommentsClose CommentsPermalink





(B) develop and test methods of providing through payment for services or otherwise, additional incentives for adherence by providers to standards of adequacy, access, and quality; methods of consumer and peer review and peer control of the utilization of drugs, of laboratory services, and of other services; and methods of consumer and peer review of the quality of services;CommentsClose CommentsPermalink





(C) develop and test, for use by the Board, records and information retrieval systems and budget systems for health services administration, and develop and test model systems for use by providers of services;CommentsClose CommentsPermalink





(D) develop and test, for use by providers of services, records and information retrieval systems useful in the furnishing of preventive or diagnostic services;CommentsClose CommentsPermalink





(E) develop, in collaboration with the pharmaceutical profession, and test, improved administrative practices or improved methods for the reimbursement of independent pharmacies for the cost of furnishing drugs as a covered service; andCommentsClose CommentsPermalink





(F) make such other studies as it may consider necessary or promising for the evaluation, or for the improvement, of the operation of this Act.CommentsClose CommentsPermalink





(4) REPORT ON USE OF EXISTING FEDERAL HEALTH CARE FACILITIES- Not later than 1 year after the date of the enactment of this Act, the Board shall recommend to the Congress one or more proposals for the treatment of health care facilities of the Federal Government.CommentsClose CommentsPermalink





(h) Executive Director-CommentsClose CommentsPermalink





(1) APPOINTMENT- There is hereby established the position of Executive Director of the Board. The Director shall be appointed by the Board and shall serve as secretary to the Board and perform such duties in the administration of this title as the Board may assign.CommentsClose CommentsPermalink





(2) DELEGATION- The Board is authorized to delegate to the Director or to any other officer or employee of the Board or, with the approval of the Secretary of Health and Human Services (and subject to reimbursement of identifiable costs), to any other officer or employee of the Department of Health and Human Services, any of its functions or duties under this Act other than--CommentsClose CommentsPermalink





(A) the issuance of regulations; orCommentsClose CommentsPermalink





(B) the determination of the availability of funds and their allocation to implement this Act.CommentsClose CommentsPermalink





(3) COMPENSATION- The Executive Director of the Board shall be entitled to compensation at a level equivalent to level III of the Executive Schedule, in accordance with section 5314 of title 5, United States Code.CommentsClose CommentsPermalink





(i) Inspector General- The Inspector General Act of 1978 (5 U.S.C. App.) is amended--CommentsClose CommentsPermalink





(1) in section 12(1), by inserting after ‘Corporation;’ the first place it appears the following: ‘the Chair of the American Health Security Standards Board;’;CommentsClose CommentsPermalink





(2) in section 12(2), by inserting after ‘Resolution Trust Corporation,’ the following: ‘the American Health Security Standards Board,’; andCommentsClose CommentsPermalink





(3) by inserting before section 9 the following:CommentsClose CommentsPermalink

‘SPECIAL PROVISIONS CONCERNING AMERICAN HEALTH SECURITY STANDARDS BOARD

‘Sec. 8M. The Inspector General of the American Health Security Standards Board, in addition to the other authorities vested by this Act, shall have the same authority, with respect to the Board and the American Health Security Program under this Act, as the Inspector General for the Department of Health and Human Services has with respect to the Secretary of Health and Human Services and the medicare and medicaid programs, respectively.’.CommentsClose CommentsPermalink





(j) Staff- The Board shall employ such staff as the Board may deem necessary.CommentsClose CommentsPermalink





(k) Access to Information- The Secretary of Health and Human Services shall make available to the Board all information available from sources within the Department or from other sources, pertaining to the duties of the Board.CommentsClose CommentsPermalink

SEC. 402. AMERICAN HEALTH SECURITY ADVISORY COUNCIL.

(a) In General- The Board shall provide for an American Health Security Advisory Council (in this section referred to as the ‘Council’) to advise the Board on its activities.CommentsClose CommentsPermalink





(b) Membership- The Council shall be composed of--CommentsClose CommentsPermalink





(1) the Chair of the Board, who shall serve as Chair of the Council; andCommentsClose CommentsPermalink





(2) twenty members, not otherwise in the employ of the United States, appointed by the Board without regard to the provisions of title 5, United States Code, governing appointments in the competitive service.CommentsClose CommentsPermalink





The appointed members shall include, in accordance with subsection (e), individuals who are representative of State health security programs, public health professionals, providers of health services, and of individuals (who shall constitute a majority of the Council) who are representative of consumers of such services, including a balanced representation of employers, unions, consumer organizations, and population groups with special health care needs. To the greatest extent feasible, the membership of the Council shall represent the various geographic regions of the United States and shall reflect the racial, ethnic, and gender composition of the population of the United States.CommentsClose CommentsPermalink





(c) Terms of Members- Each appointed member shall hold office for a term of 4 years, except that--CommentsClose CommentsPermalink





(1) any member appointed to fill a vacancy occurring during the term for which the member’s predecessor was appointed shall be appointed for the remainder of that term; andCommentsClose CommentsPermalink





(2) the terms of the members first taking office shall expire, as designated by the Board at the time of appointment, 5 at the end of the first year, 5 at the end of the second year, 5 at the end of the third year, and 5 at the end of the fourth year after the date of enactment of this Act.CommentsClose CommentsPermalink





(d) Vacancies-CommentsClose CommentsPermalink





(1) IN GENERAL- The Board shall fill any vacancy in the membership of the Council in the same manner as the original appointment. The vacancy shall not affect the power of the remaining members to execute the duties of the Council.CommentsClose CommentsPermalink





(2) VACANCY APPOINTMENTS- Any member appointed to fill a vacancy shall serve for the remainder of the term for which the predecessor of the member was appointed.CommentsClose CommentsPermalink





(3) REAPPOINTMENT- The Board may reappoint an appointed member of the Council for a second term in the same manner as the original appointment.CommentsClose CommentsPermalink





(e) Qualifications-CommentsClose CommentsPermalink





(1) PUBLIC HEALTH REPRESENTATIVES- Members of the Council who are representative of State health security programs and public health professionals shall be individuals who have extensive experience in the financing and delivery of care under public health programs.CommentsClose CommentsPermalink





(2) PROVIDERS- Members of the Council who are representative of providers of health care shall be individuals who are outstanding in fields related to medical, hospital, or other health activities, or who are representative of organizations or associations of professional health practitioners.CommentsClose CommentsPermalink





(3) CONSUMERS- Members who are representative of consumers of such care shall be individuals, not engaged in and having no financial interest in the furnishing of health services, who are familiar with the needs of various segments of the population for personal health services and are experienced in dealing with problems associated with the consumption of such services.CommentsClose CommentsPermalink





(f) Duties-CommentsClose CommentsPermalink





(1) IN GENERAL- It shall be the duty of the Council--CommentsClose CommentsPermalink





(A) to advise the Board on matters of general policy in the administration of this Act, in the formulation of regulations, and in the performance of the Board’s duties under section 401; andCommentsClose CommentsPermalink





(B) to study the operation of this Act and the utilization of health services under it, with a view to recommending any changes in the administration of the Act or in its provisions which may appear desirable.CommentsClose CommentsPermalink





(2) REPORT- The Council shall make an annual report to the Board on the performance of its functions, including any recommendations it may have with respect thereto, and the Board shall promptly transmit the report to the Congress, together with a report by the Board on any recommendations of the Council that have not been followed.CommentsClose CommentsPermalink





(g) Staff- The Council, its members, and any committees of the Council shall be provided with such secretarial, clerical, or other assistance as may be authorized by the Board for carrying out their respective functions.CommentsClose CommentsPermalink





(h) Meetings- The Council shall meet as frequently as the Board deems necessary, but not less than 4 times each year. Upon request by 7 or more members it shall be the duty of the Chair to call a meeting of the Council.CommentsClose CommentsPermalink





(i) Compensation- Members of the Council shall be reimbursed by the Board for travel and per diem in lieu of subsistence expenses during the performance of duties of the Board in accordance with subchapter I of chapter 57 of title 5, United States Code.CommentsClose CommentsPermalink





(j) FACA Not Applicable- The provisions of the Federal Advisory Committee Act shall not apply to the Council.CommentsClose CommentsPermalink

SEC. 403. CONSULTATION WITH PRIVATE ENTITIES.

The Secretary and the Board shall consult with private entities, such as professional societies, national associations, nationally recognized associations of experts, medical schools and academic health centers, consumer groups, and labor and business organizations in the formulation of guidelines, regulations, policy initiatives, and information gathering to assure the broadest and most informed input in the administration of this Act. Nothing in this Act shall prevent the Secretary from adopting guidelines developed by such a private entity if, in the Secretary’s and Board’s judgment, such guidelines are generally accepted as reasonable and prudent and consistent with this Act.CommentsClose CommentsPermalink

SEC. 404. STATE HEALTH SECURITY PROGRAMS.

(a) Submission of Plans-CommentsClose CommentsPermalink





(1) IN GENERAL- Each State shall submit to the Board a plan for a State health security program for providing for health care services to the residents of the State in accordance with this Act.CommentsClose CommentsPermalink





(2) REGIONAL PROGRAMS- A State may join with 1 or more neighboring States to submit to the Board a plan for a regional health security program instead of separate State health security programs.CommentsClose CommentsPermalink





(3) REGIONAL PLANNING MECHANISMS- The Board shall provide incentives for States to develop regional planning mechanisms to promote the rational distribution of, adequate access to, and efficient use of, tertiary care facilities, equipment, and services.CommentsClose CommentsPermalink





(b) Review and Approval of Plans-CommentsClose CommentsPermalink





(1) IN GENERAL- The Board shall review plans submitted under subsection (a) and determine whether such plans meet the requirements for approval. The Board shall not approve such a plan unless it finds that the plan (or State law) provides, consistent with the provisions of this Act, for the following:CommentsClose CommentsPermalink





(A) Payment for required health services for eligible individuals in the State in accordance with this Act.CommentsClose CommentsPermalink





(B) Adequate administration, including the designation of a single State agency responsible for the administration (or supervision of the administration) of the program.CommentsClose CommentsPermalink





(C) The establishment of a State health security budget.CommentsClose CommentsPermalink





(D) Establishment of payment methodologies (consistent with subtitle B of title VII).CommentsClose CommentsPermalink





(E) Assurances that individuals have the freedom to choose practitioners and other health care providers for services covered under this Act.CommentsClose CommentsPermalink





(F) A procedure for carrying out long-term regional management and planning functions with respect to the delivery and distribution of health care services that--CommentsClose CommentsPermalink





(i) ensures participation of consumers of health services and providers of health services; andCommentsClose CommentsPermalink





(ii) gives priority to the most acute shortages and maldistributions of health personnel and facilities and the most serious deficiencies in the delivery of covered services and to the means for the speedy alleviation of these shortcomings.CommentsClose CommentsPermalink





(G) The licensure and regulation of all health providers and facilities to ensure compliance with Federal and State laws and to promote quality of care.CommentsClose CommentsPermalink





(H) Establishment of a quality review system in accordance with section 503.CommentsClose CommentsPermalink





(I) Establishment of an independent ombudsman for consumers to register complaints about the organization and administration of the State health security program and to help resolve complaints and disputes between consumers and providers.CommentsClose CommentsPermalink





(J) Publication of an annual report on the operation of the State health security program, which report shall include information on cost, progress towards achieving full enrollment, public access to health services, quality review, health outcomes, health professional training, and the needs of medically underserved populations.CommentsClose CommentsPermalink





(K) Provision of a fraud and abuse prevention and control unit that the Inspector General determines meets the requirements of section 412(a).CommentsClose CommentsPermalink





(L) Prohibit payment in cases of prohibited physician referrals under section 304.CommentsClose CommentsPermalink





(2) CONSEQUENCES OF FAILURE TO COMPLY- If the Board finds that a State plan submitted under paragraph (1) does not meet the requirements for approval under this section or that a State health security program or specific portion of such program, the plan for which was previously approved, no longer meets such requirements, the Board shall provide notice to the State of such failure and that unless corrective action is taken within a period specified by the Board, the Board shall place the State health security program (or specific portions of such program) in receivership under the jurisdiction of the Board.CommentsClose CommentsPermalink





(c) State Health Security Advisory Councils-CommentsClose CommentsPermalink





(1) IN GENERAL- For each State, the Governor shall provide for appointment of a State Health Security Advisory Council to advise and make recommendations to the Governor and State with respect to the implementation of the State health security program in the State.CommentsClose CommentsPermalink





(2) MEMBERSHIP- Each State Health Security Advisory Council shall be composed of at least 11 individuals. The appointed members shall include individuals who are representative of the State health security program, public health professionals, providers of health services, and of individuals (who shall constitute a majority) who are representative of consumers of such services, including a balanced representation of employers, unions and consumer organizations. To the greatest extent feasible, the membership of each State Health Security Advisory Council shall represent the various geographic regions of the State and shall reflect the racial, ethnic, and gender composition of the population of the State.CommentsClose CommentsPermalink





(3) DUTIES-CommentsClose CommentsPermalink





(A) IN GENERAL- Each State Health Security Advisory Council shall review, and submit comments to the Governor concerning the implementation of the State health security program in the State.CommentsClose CommentsPermalink





(B) ASSISTANCE- Each State Health Security Advisory Council shall provide assistance and technical support to community organizations and public and private non-profit agencies submitting applications for funding under appropriate State and Federal public health programs, with particular emphasis placed on assisting those applicants with broad consumer representation.CommentsClose CommentsPermalink





(d) State Use of Fiscal Agents-CommentsClose CommentsPermalink





(1) IN GENERAL- Each State health security program, using competitive bidding procedures, may enter into such contracts with qualified entities, such as voluntary associations, as the State determines to be appropriate to process claims and to perform other related functions of fiscal agents under the State health security program.CommentsClose CommentsPermalink





(2) RESTRICTION- Except as the Board may provide for good cause shown, in no case may more than 1 contract described in paragraph (1) be entered into under a State health security program.CommentsClose CommentsPermalink

SEC. 405. COMPLEMENTARY CONDUCT OF RELATED HEALTH PROGRAMS.

In performing functions with respect to health personnel education and training, health research, environmental health, disability insurance, vocational rehabilitation, the regulation of food and drugs, and all other matters pertaining to health, the Secretary of Health and Human Services shall direct all activities of the Department of Health and Human Services toward contributions to the health of the people complementary to this Act.CommentsClose CommentsPermalink

Subtitle B--Control Over Fraud and AbuseCommentsClose CommentsPermalink

SEC. 411. APPLICATION OF FEDERAL SANCTIONS TO ALL FRAUD AND ABUSE UNDER AMERICAN HEALTH SECURITY PROGRAM.

The following sections of the Social Security Act shall apply to State health security programs in the same manner as they apply to State medical assistance plans under title XIX of such Act (except that in applying such provisions any reference to the Secretary is deemed a reference to the Board):CommentsClose CommentsPermalink





(1) Section 1128 (relating to exclusion of individuals and entities).CommentsClose CommentsPermalink





(2) Section 1128A (civil monetary penalties).CommentsClose CommentsPermalink





(3) Section 1128B (criminal penalties).CommentsClose CommentsPermalink





(4) Section 1124 (relating to disclosure of ownership and related information).CommentsClose CommentsPermalink





(5) Section 1126 (relating to disclosure of certain owners).CommentsClose CommentsPermalink

SEC. 412. REQUIREMENTS FOR OPERATION OF STATE HEALTH CARE FRAUD AND ABUSE CONTROL UNITS.

(a) Requirement- In order to meet the requirement of section 404(b)(1)(K), each State health security program must establish and maintain a health care fraud and abuse control unit (in this section referred to as a ‘fraud unit’) that meets requirements of this section and other requirements of the Board. Such a unit may be a State medicaid fraud control unit (described in section 1903(q) of the Social Security Act).CommentsClose CommentsPermalink





(b) Structure of Unit- The fraud unit must--CommentsClose CommentsPermalink





(1) be a single identifiable entity of the State government;CommentsClose CommentsPermalink





(2) be separate and distinct from the State agency with principal responsibility for the administration of the State health security program; andCommentsClose CommentsPermalink





(3) meet 1 of the following requirements:CommentsClose CommentsPermalink





(A) It must be a unit of the office of the State Attorney General or of another department of State government which possesses statewide authority to prosecute individuals for criminal violations.CommentsClose CommentsPermalink





(B) If it is in a State the constitution of which does not provide for the criminal prosecution of individuals by a statewide authority and has formal procedures, approved by the Board, that--CommentsClose CommentsPermalink





(i) assure its referral of suspected criminal violations relating to the State health insurance plan to the appropriate authority or authorities in the States for prosecution; andCommentsClose CommentsPermalink





(ii) assure its assistance of, and coordination with, such authority or authorities in such prosecutions.CommentsClose CommentsPermalink





(C) It must have a formal working relationship with the office of the State Attorney General and have formal procedures (including procedures for its referral of suspected criminal violations to such office) which are approved by the Board and which provide effective coordination of activities between the fraud unit and such office with respect to the detection, investigation, and prosecution of suspected criminal violations relating to the State health insurance plan.CommentsClose CommentsPermalink





(c) Functions- The fraud unit must--CommentsClose CommentsPermalink





(1) have the function of conducting a statewide program for the investigation and prosecution of violations of all applicable State laws regarding any and all aspects of fraud in connection with any aspect of the provision of health care services and activities of providers of such services under the State health security program;CommentsClose CommentsPermalink





(2) have procedures for reviewing complaints of the abuse and neglect of patients of providers and facilities that receive payments under the State health security program, and, where appropriate, for acting upon such complaints under the criminal laws of the State or for referring them to other State agencies for action; andCommentsClose CommentsPermalink





(3) provide for the collection, or referral for collection to a single State agency, of overpayments that are made under the State health security program to providers and that are discovered by the fraud unit in carrying out its activities.CommentsClose CommentsPermalink





(d) Resources- The fraud unit must--CommentsClose CommentsPermalink





(1) employ such auditors, attorneys, investigators, and other necessary personnel;CommentsClose CommentsPermalink





(2) be organized in such a manner; andCommentsClose CommentsPermalink





(3) provide sufficient resources (as specified by the Board),CommentsClose CommentsPermalink





as is necessary to promote the effective and efficient conduct of the unit’s activities.CommentsClose CommentsPermalink





(e) Cooperative Agreements- The fraud unit must have cooperative agreements (as specified by the Board) with--CommentsClose CommentsPermalink





(1) similar fraud units in other States;CommentsClose CommentsPermalink





(2) the Inspector General; andCommentsClose CommentsPermalink





(3) the Attorney General of the United States.CommentsClose CommentsPermalink





(f) Reports- The fraud unit must submit to the Inspector General an application and annual reports containing such information as the Inspector General determines to be necessary to determine whether the unit meets the previous requirements of this section.CommentsClose CommentsPermalink

TITLE V--QUALITY ASSESSMENTCommentsClose CommentsPermalink

SEC. 501. AMERICAN HEALTH SECURITY QUALITY COUNCIL.

(a) Establishment- There is hereby established an American Health Security Quality Council (in this title referred to as the ‘Council’).CommentsClose CommentsPermalink





(b) Duties of the Council- The Council shall perform the following duties:CommentsClose CommentsPermalink





(1) PRACTICE GUIDELINES- The Council shall review and evaluate each practice guideline developed under part B of title IX of the Public Health Service Act. The Council shall determine whether the guideline should be recognized as a national practice guideline to be used under section 204(d) for purposes of determining payments under a State health security program.CommentsClose CommentsPermalink





(2) STANDARDS OF QUALITY, PERFORMANCE MEASURES, AND MEDICAL REVIEW CRITERIA- The Council shall review and evaluate each standard of quality, performance measure, and medical review criterion developed under part B of title IX of the Public Health Service Act. The Council shall determine whether the standard, measure, or criterion is appropriate for use in assessing or reviewing the quality of services provided by State health security programs, health care institutions, or health care professionals.CommentsClose CommentsPermalink





(3) CRITERIA FOR ENTITIES CONDUCTING QUALITY REVIEWS- The Council shall develop minimum criteria for competence for entities that can qualify to conduct ongoing and continuous external quality review for State quality review programs under section 503. Such criteria shall require such an entity to be administratively independent of the individual or board that administers the State health security program and shall ensure that such entities do not provide financial incentives to reviewers to favor one pattern of practice over another. The Council shall ensure coordination and reporting by such entities to assure national consistency in quality standards.CommentsClose CommentsPermalink





(4) REPORTING- The Council shall report to the Board annually on the conduct of activities under such title and shall report to the Board annually specifically on findings from outcomes research and development of practice guidelines that may affect the Board’s determination of coverage of services under section 401(f)(1)(G).CommentsClose CommentsPermalink





(5) OTHER FUNCTIONS- The Council shall perform the functions of the Council described in section 502.CommentsClose CommentsPermalink





(c) Appointment and Terms of Members-CommentsClose CommentsPermalink





(1) IN GENERAL- The Council shall be composed of 10 members appointed by the President. The President shall first appoint individuals on a timely basis so as to provide for the operation of the Council by not later than January 1, 2010.CommentsClose CommentsPermalink





(2) SELECTION OF MEMBERS- Each member of the Council shall be a member of a health profession. Five members of the Council shall be physicians. Individuals shall be appointed to the Council on the basis of national reputations for clinical and academic excellence. To the greatest extent feasible, the membership of the Council shall represent the various geographic regions of the United States and shall reflect the racial, ethnic, and gender composition of the population of the United States.CommentsClose CommentsPermalink





(3) TERMS OF MEMBERS- Individuals appointed to the Council shall serve for a term of 5 years, except that the terms of 4 of the individuals initially appointed shall be, as designated by the President at the time of their appointment, for 1, 2, 3, and 4 years.CommentsClose CommentsPermalink





(d) Vacancies-CommentsClose CommentsPermalink





(1) IN GENERAL- The President shall fill any vacancy in the membership of the Council in the same manner as the original appointment. The vacancy shall not affect the power of the remaining members to execute the duties of the Council.CommentsClose CommentsPermalink





(2) VACANCY APPOINTMENTS- Any member appointed to fill a vacancy shall serve for the remainder of the term for which the predecessor of the member was appointed.CommentsClose CommentsPermalink





(3) REAPPOINTMENT- The President may reappoint a member of the Council for a second term in the same manner as the original appointment. A member who has served for 2 consecutive 5-year terms shall not be eligible for reappointment until 2 years after the member has ceased to serve.CommentsClose CommentsPermalink





(e) Chair- The President shall designate 1 of the members of the Council to serve at the will of the President as Chair of the Council.CommentsClose CommentsPermalink





(f) Compensation- Members of the Council who are not employees of the Federal Government shall be entitled to compensation at a level equivalent to level II of the Executive Schedule, in accordance with section 5313 of title 5, United States Code.CommentsClose CommentsPermalink

SEC. 502. DEVELOPMENT OF CERTAIN METHODOLOGIES, GUIDELINES, AND STANDARDS.

(a) Profiling of Patterns of Practice; Identification of Outliers- The Council shall adopt methodologies for profiling the patterns of practice of health care professionals and for identifying outliers (as defined in subsection (e)).CommentsClose CommentsPermalink





(b) Centers of Excellence- The Council shall develop guidelines for certain medical procedures designated by the Board to be performed only at tertiary care centers which can meet standards for frequency of procedure performance and intensity of support mechanisms that are consistent with the high probability of desired patient outcome. Reimbursement under this Act for such a designated procedure may only be provided if the procedure was performed at a center that meets such standards.CommentsClose CommentsPermalink





(c) Remedial Actions- The Council shall develop standards for education and sanctions with respect to outliers so as to assure the quality of health care services provided under this Act. The Council shall develop criteria for referral of providers to the State licensing board if education proves ineffective in correcting provider practice behavior.CommentsClose CommentsPermalink





(d) Dissemination- The Council shall disseminate to the State--CommentsClose CommentsPermalink





(1) the methodologies adopted under subsection (a);CommentsClose CommentsPermalink





(2) the guidelines developed under subsection (b); andCommentsClose CommentsPermalink





(3) the standards developed under subsection (c);CommentsClose CommentsPermalink





for use by the States under section 503.CommentsClose CommentsPermalink





(e) Outlier Defined- In this title, the term ‘outlier’ means a health care provider whose pattern of practice, relative to applicable practice guidelines, suggests deficiencies in the quality of health care services being provided.CommentsClose CommentsPermalink

SEC. 503. STATE QUALITY REVIEW PROGRAMS.

(a) Requirement- In order to meet the requirement of section 404(b)(1)(H), each State health security program shall establish 1 or more qualified entities to conduct quality reviews of persons providing covered services under the program, in accordance with standards established under subsection (b)(1) (except as provided in subsection (b)(2)) and subsection (d).CommentsClose CommentsPermalink





(b) Federal Standards-CommentsClose CommentsPermalink





(1) IN GENERAL- The Council shall establish standards with respect to--CommentsClose CommentsPermalink





(A) the adoption of practice guidelines (whether developed by the Federal Government or other entities);CommentsClose CommentsPermalink





(B) the identification of outliers (consistent with methodologies adopted under section 502(a));CommentsClose CommentsPermalink





(C) the development of remedial programs and monitoring for outliers; andCommentsClose CommentsPermalink





(D) the application of sanctions (consistent with the standards developed under section 502(c)).CommentsClose CommentsPermalink





(2) STATE DISCRETION- A State may apply under subsection (a) standards other than those established under paragraph (1) so long as the State demonstrates to the satisfaction of the Council on an annual basis that the standards applied have been as efficacious in promoting and achieving improved quality of care as the application of the standards established under paragraph (1). Positive improvements in quality shall be documented by reductions in the variations of clinical care process and improvement in patient outcomes.CommentsClose CommentsPermalink





(c) Qualifications- An entity is not qualified to conduct quality reviews under subsection (a) unless the entity satisfies the criteria for competence for such entities developed by the Council under section 501(b)(3).CommentsClose CommentsPermalink





(d) Internal Quality Review- Nothing in this section shall preclude an institutional provider from establishing its own internal quality review and enhancement programs.CommentsClose CommentsPermalink

SEC. 504. ELIMINATION OF UTILIZATION REVIEW PROGRAMS; TRANSITION.

(a) Intent- It is the intention of this title to replace by January 1, 2013, random utilization controls with a systematic review of patterns of practice that compromise the quality of care.CommentsClose CommentsPermalink





(b) Superseding Case Reviews-CommentsClose CommentsPermalink





(1) IN GENERAL- Subject to the succeeding provisions of this subsection, the program of quality review provided under the previous sections of this title supersede all existing Federal requirements for utilization review programs, including requirements for random case-by-case reviews and programs requiring pre-certification of medical procedures on a case-by-case basis.CommentsClose CommentsPermalink





(2) TRANSITION- Before January 1, 2013, the Board and the States may employ existing utilization review standards and mechanisms as may be necessary to effect the transition to pattern of practice-based reviews.CommentsClose CommentsPermalink





(3) CONSTRUCTION- Nothing in this subsection shall be construed--CommentsClose CommentsPermalink





(A) as precluding the case-by-case review of the provision of care--CommentsClose CommentsPermalink





(i) in individual incidents where the quality of care has significantly deviated from acceptable standards of practice; andCommentsClose CommentsPermalink





(ii) with respect to a provider who has been determined to be an outlier; orCommentsClose CommentsPermalink





(B) as precluding the case management of catastrophic, mental health, or substance abuse cases or long-term care where such management is necessary to achieve appropriate, cost-effective, and beneficial comprehensive medical care, as provided for in section 204.CommentsClose CommentsPermalink

TITLE VI--HEALTH SECURITY BUDGET; PAYMENTS; COST CONTAINMENT MEASURESCommentsClose CommentsPermalink

Subtitle A--Budgeting and Payments to StatesCommentsClose CommentsPermalink

SEC. 601. NATIONAL HEALTH SECURITY BUDGET.

(a) National Health Security Budget-CommentsClose CommentsPermalink





(1) IN GENERAL- By not later than September 1 before the beginning of each year (beginning with 2010), the Board shall establish a national health security budget, which--CommentsClose CommentsPermalink





(A) specifies the total expenditures (including expenditures for administrative costs) to be made by the Federal Government and the States for covered health care services under this Act; andCommentsClose CommentsPermalink





(B) allocates those expenditures among the States consistent with section 604.CommentsClose CommentsPermalink





Pursuant to subsection (b), such budget for a year shall not exceed the budget for the preceding year increased by the percentage increase in gross domestic product.CommentsClose CommentsPermalink





(2) DIVISION OF BUDGET INTO COMPONENTS- The national health security budget shall consist of at least 4 components:CommentsClose CommentsPermalink





(A) A component for quality assessment activities (described in title V).CommentsClose CommentsPermalink





(B) A component for health professional education expenditures.CommentsClose CommentsPermalink





(C) A component for administrative costs.CommentsClose CommentsPermalink





(D) A component (in this title referred to as the ‘operating component’) for operating and other expenditures not described in subparagraphs (A) through (C), consisting of amounts not included in the other components. A State may provide for the allocation of this component between capital expenditures and other expenditures.CommentsClose CommentsPermalink





(3) ALLOCATION AMONG COMPONENTS- Taking into account the State health security budgets established and submitted under section 603, the Board shall allocate the national health security budget among the components in a manner that--CommentsClose CommentsPermalink





(A) assures a fair allocation for quality assessment activities (consistent with the national health security spending growth limit); andCommentsClose CommentsPermalink





(B) assures that the health professional education expenditure component is sufficient to provide for the amount of health professional education expenditures sufficient to meet the need for covered health care services (consistent with the national health security spending growth limit under subsection (b)(2)).CommentsClose CommentsPermalink





(b) Basis for Total Expenditures-CommentsClose CommentsPermalink





(1) IN GENERAL- The total expenditures specified in such budget shall be the sum of the capitation amounts computed under section 602(a) and the amount of Federal administrative expenditures needed to carry out this Act.CommentsClose CommentsPermalink





(2) NATIONAL HEALTH SECURITY SPENDING GROWTH LIMIT- For purposes of this subtitle, the national health security spending growth limit described in this paragraph for a year is (A) zero, or, if greater, (B) the average annual percentage increase in the gross domestic product (in current dollars) during the 3-year period beginning with the first quarter of the fourth previous year to the first quarter of the previous year minus the percentage increase (if any) in the number of eligible individuals residing in any State the United States from the first quarter of the second previous year to the first quarter of the previous year.CommentsClose CommentsPermalink





(c) Definitions- In this title:CommentsClose CommentsPermalink





(1) CAPITAL EXPENDITURES- The term ‘capital expenditures’ means expenses for the purchase, lease, construction, or renovation of capital facilities and for equipment and includes return on equity capital.CommentsClose CommentsPermalink





(2) HEALTH PROFESSIONAL EDUCATION EXPENDITURES- The term ‘health professional education expenditures’ means expenditures in hospitals and other health care facilities to cover costs associated with teaching and related research activities.CommentsClose CommentsPermalink

SEC. 602. COMPUTATION OF INDIVIDUAL AND STATE CAPITATION AMOUNTS.

(a) Capitation Amounts-CommentsClose CommentsPermalink





(1) INDIVIDUAL CAPITATION AMOUNTS- In establishing the national health security budget under section 601(a) and in computing the national average per capita cost under subsection (b) for each year, the Board shall establish a method for computing the capitation amount for each eligible individual residing in each State. The capitation amount for an eligible individual in a State classified within a risk group (established under subsection (d)(2)) is the product of--CommentsClose CommentsPermalink





(A) a national average per capita cost for all covered health care services (computed under subsection (b));CommentsClose CommentsPermalink





(B) the State adjustment factor (established under subsection (c)) for the State; andCommentsClose CommentsPermalink





(C) the risk adjustment factor (established under subsection (d)) for the risk group.CommentsClose CommentsPermalink





(2) STATE CAPITATION AMOUNT-CommentsClose CommentsPermalink





(A) IN GENERAL- For purposes of this title, the term ‘State capitation amount’ means, for a State for a year, the sum of the capitation amounts computed under paragraph (1) for all the residents of the State in the year, as estimated by the Board before the beginning of the year involved.CommentsClose CommentsPermalink





(B) USE OF STATISTICAL MODEL- The Board may provide for the computation of State capitation amounts based on statistical models that fairly reflect the elements that comprise the State capitation amount described in subparagraph (A).CommentsClose CommentsPermalink





(C) POPULATION INFORMATION- The Bureau of the Census shall assist the Board in determining the number, place of residence, and risk group classification of eligible individuals.CommentsClose CommentsPermalink





(b) Computation of National Average Per Capita Cost-CommentsClose CommentsPermalink





(1) FOR 2010- For 2010, the national average per capita cost under this paragraph is equal to--CommentsClose CommentsPermalink





(A) the average per capita health care expenditures in the United States in 2008 (as estimated by the Board);CommentsClose CommentsPermalink





(B) increased to 2009 by the Board’s estimate of the actual amount of such per capita expenditures during 2009; andCommentsClose CommentsPermalink





(C) updated to 2010 by the national health security spending growth limit specified in section 601(b)(2) for 2010.CommentsClose CommentsPermalink





(2) FOR SUCCEEDING YEARS- For each succeeding year, the national average per capita cost under this subsection is equal to the national average per capita cost computed under this subsection for the previous year increased by the national health security spending growth limit (specified in section 601(b)(2)) for the year involved.CommentsClose CommentsPermalink





(c) State Adjustment Factors-CommentsClose CommentsPermalink





(1) IN GENERAL- Subject to the succeeding paragraphs of this subsection, the Board shall develop for each State a factor to adjust the national average per capita costs to reflect differences between the State and the United States in--CommentsClose CommentsPermalink





(A) average labor and nonlabor costs that are necessary to provide covered health services;CommentsClose CommentsPermalink





(B) any social, environmental, or geographic condition affecting health status or the need for health care services, to the extent such a condition is not taken into account in the establishment of risk groups under subsection (d);CommentsClose CommentsPermalink





(C) the geographic distribution of the State’s population, particularly the proportion of the population residing in medically underserved areas, to the extent such a condition is not taken into account in the establishment of risk groups under subsection (d); andCommentsClose CommentsPermalink





(D) any other factor relating to operating costs required to assure equitable distribution of funds among the States.CommentsClose CommentsPermalink





(2) MODIFICATION OF HEALTH PROFESSIONAL EDUCATION COMPONENT- With respect to the portion of the national health security budget allocated to expenditures for health professional education, the Board shall modify the State adjustment factors so as to take into account--CommentsClose CommentsPermalink





(A) differences among States in health professional education programs in operation as of the date of the enactment of this Act; andCommentsClose CommentsPermalink





(B) differences among States in their relative need for expenditures for health professional education, taking into account the health professional education expenditures proposed in State health security budgets under section 603(a).CommentsClose CommentsPermalink





(3) BUDGET NEUTRALITY- The State adjustment factors, as modified under paragraph (2), shall be applied under this subsection in a manner that results in neither an increase nor a decrease in the total amount of the Federal contributions to all State health security programs under subsection (b) as a result of the application of such factors.CommentsClose CommentsPermalink





(4) PHASE-IN- In applying State adjustment factors under this subsection during the 5-year period beginning with 2010, the Board shall phase-in, over such period, the use of factors described in paragraph (1) in a manner so that the adjustment factor for a State is based on a blend of such factors and a factor that reflects the relative actual average per capita costs of health services of the different States as of the time of enactment of this Act.CommentsClose CommentsPermalink





(5) PERIODIC ADJUSTMENT- In establishing the national health security budget before the beginning of each year, the Board shall provide for appropriate adjustments in the State adjustment factors under this subsection.CommentsClose CommentsPermalink





(d) Adjustments for Risk Group Classification-CommentsClose CommentsPermalink





(1) IN GENERAL- The Board shall develop an adjustment factor to the national average per capita costs computed under subsection (b) for individuals classified in each risk group (as designated under paragraph (2)) to reflect the difference between the average national average per capita costs and the national average per capita cost for individuals classified in the risk group.CommentsClose CommentsPermalink





(2) RISK GROUPS- The Board shall designate a series of risk groups, determined by age, health indicators, and other factors that represent distinct patterns of health care services utilization and costs.CommentsClose CommentsPermalink





(3) PERIODIC ADJUSTMENT- In establishing the national health security budget before the beginning of each year, the Board shall provide for appropriate adjustments in the risk adjustment factors under this subsection.CommentsClose CommentsPermalink

SEC. 603. STATE HEALTH SECURITY BUDGETS.

(a) Establishment and Submission of Budgets-CommentsClose CommentsPermalink





(1) IN GENERAL- Each State health security program shall establish and submit to the Board for each year a proposed and a final State health security budget, which specifies the following:CommentsClose CommentsPermalink





(A) The total expenditures (including expenditures for administrative costs) to be made under the program in the State for covered health care services under this Act, consistent with subsection (b), broken down as follows:CommentsClose CommentsPermalink





(i) By the 4 components (described in section 601(a)(2)), consistent with subsection (b).CommentsClose CommentsPermalink





(ii) Within the operating component--CommentsClose CommentsPermalink





(I) expenditures for operating costs of hospitals and other facility-based services in the State;CommentsClose CommentsPermalink





(II) expenditures for payment to comprehensive health service organizations;CommentsClose CommentsPermalink





(III) expenditures for payment of services provided by health care practitioners; andCommentsClose CommentsPermalink





(IV) expenditures for other covered items and services.CommentsClose CommentsPermalink





Amounts included in the operating component include amounts that may be used by providers for capital expenditures.CommentsClose CommentsPermalink





(B) The total revenues required to meet the State health security expenditures.CommentsClose CommentsPermalink





(2) PROPOSED BUDGET DEADLINE- The proposed budget for a year shall be submitted under paragraph (1) not later than June 1 before the year.CommentsClose CommentsPermalink





(3) FINAL BUDGET- The final budget for a year shall--CommentsClose CommentsPermalink





(A) be established and submitted under paragraph (1) not later than October 1 before the year, andCommentsClose CommentsPermalink





(B) take into account the amounts established under the national health security budget under section 601 for the year.CommentsClose CommentsPermalink





(4) ADJUSTMENT IN ALLOCATIONS PERMITTED-CommentsClose CommentsPermalink





(A) IN GENERAL- Subject to subparagraphs (B) and (C), in the case of a final budget, a State may change the allocation of amounts among components.CommentsClose CommentsPermalink





(B) NOTICE- No such change may be made unless the State has provided prior notice of the change to the Board.CommentsClose CommentsPermalink





(C) DENIAL- Such a change may not be made if the Board, within such time period as the Board specifies, disapproves such change.CommentsClose CommentsPermalink





(b) Expenditure Limits-CommentsClose CommentsPermalink





(1) IN GENERAL- The total expenditures specified in each State health security budget under subsection (a)(1) shall take into account Federal contributions made under section 604.CommentsClose CommentsPermalink





(2) LIMIT ON CLAIMS PROCESSING AND BILLING EXPENDITURES- Each State health security budget shall provide that State administrative expenditures, including expenditures for claims processing and billing, shall not exceed 3 percent of the total expenditures under the State health security program, unless the Board determines, on a case-by-case basis, that additional administrative expenditures would improve health care quality and cost effectiveness.CommentsClose CommentsPermalink





(3) WORKER ASSISTANCE- A State health security program may provide that, for budgets for years before 2013, up to 1 percent of the budget may be used for purposes of programs providing assistance to workers who are currently performing functions in the administration of the health insurance system and who may experience economic dislocation as a result of the implementation of the program.CommentsClose CommentsPermalink





(c) Approval Process for Capital Expenditures Permitted- Nothing in this title shall be construed as preventing a State health security program from providing for a process for the approval of capital expenditures based on information derived from regional planning agencies.CommentsClose CommentsPermalink

SEC. 604. FEDERAL PAYMENTS TO STATES.

(a) In General- Each State with an approved State health security program is entitled to receive, from amounts in the American Health Security Trust Fund, on a monthly basis each year, of an amount equal to one-twelfth of the product of--CommentsClose CommentsPermalink





(1) the State capitation amount (computed under section 602(a)(2)) for the State for the year; andCommentsClose CommentsPermalink





(2) the Federal contribution percentage (established under subsection (b)).CommentsClose CommentsPermalink





(b) Federal Contribution Percentage- The Board shall establish a formula for the establishment of a Federal contribution percentage for each State. Such formula shall take into consideration a State’s per capita income and revenue capacity and such other relevant economic indicators as the Board determines to be appropriate. In addition, during the 5-year period beginning with 2010, the Board may provide for a transition adjustment to the formula in order to take into account current expenditures by the State (and local governments thereof) for health services covered under the State health security program. The weighted-average Federal contribution percentage for all States shall equal 86 percent and in no event shall such percentage be less than 81 percent nor more than 91 percent.CommentsClose CommentsPermalink





(c) Use of Payments- All payments made under this section may only be used to carry out the State health security program.CommentsClose CommentsPermalink





(d) Effect of Spending Excess or Surplus-CommentsClose CommentsPermalink





(1) SPENDING EXCESS- If a State exceeds it’s budget in a given year, the State shall continue to fund covered health services from its own revenues.CommentsClose CommentsPermalink





(2) SURPLUS- If a State provides all covered health services for less than the budgeted amount for a year, it may retain its Federal payment for that year for uses consistent with this Act.CommentsClose CommentsPermalink

SEC. 605. ACCOUNT FOR HEALTH PROFESSIONAL EDUCATION EXPENDITURES.

(a) Separate Account- Each State health security program shall--CommentsClose CommentsPermalink





(1) include a separate account for health professional education expenditures; andCommentsClose CommentsPermalink





(2) specify the general manner, consistent with subsection (b), in which such expenditures are to be distributed among different types of institutions and the different areas of the State.CommentsClose CommentsPermalink





(b) Distribution Rules- The distribution of funds to hospitals and other health care facilities from the account must conform to the following principles:CommentsClose CommentsPermalink





(1) The disbursement of funds must be consistent with achievement of the national and program goals (specified in section 701(b)) within the State health security program and the distribution of funds from the account must be conditioned upon the receipt of such reports as the Board may require in order to monitor compliance with such goals.CommentsClose CommentsPermalink





(2) The distribution of funds from the account must take into account the potentially higher costs of placing health professional students in clinical education programs in health professional shortage areas.CommentsClose CommentsPermalink

Subtitle B--Payments by States to ProvidersCommentsClose CommentsPermalink

SEC. 611. PAYMENTS TO HOSPITALS AND OTHER FACILITY-BASED SERVICES FOR OPERATING EXPENSES ON THE BASIS OF APPROVED GLOBAL BUDGETS.

(a) Direct Payment Under Global Budget- Payment for operating expenses for institutional and facility-based care, including hospital services and nursing facility services, under State health security programs shall be made directly to each institution or facility by each State health security program under an annual prospective global budget approved under the program. Such a budget shall include payment for outpatient care and non-facility-based care that is furnished by or through the facility. In the case of a hospital that is wholly owned (or controlled) by a comprehensive health service organization that is paid under section 614 on the basis of a global budget, the global budget of the organization shall include the budget for the hospital.CommentsClose CommentsPermalink





(b) Annual Negotiations; Budget Approval-CommentsClose CommentsPermalink





(1) IN GENERAL- The prospective global budget for an institution or facility shall--CommentsClose CommentsPermalink





(A) be developed through annual negotiations between--CommentsClose CommentsPermalink





(i) a panel of individuals who are appointed by the Governor of the State and who represent consumers, labor, business, and the State government; andCommentsClose CommentsPermalink





(ii) the institution or facility; andCommentsClose CommentsPermalink





(B) be based on a nationally uniform system of cost accounting established under standards of the Board.CommentsClose CommentsPermalink





(2) CONSIDERATIONS- In developing a budget through negotiations, there shall be taken into account at least the following:CommentsClose CommentsPermalink





(A) With respect to inpatient hospital services, the number, and classification by diagnosis-related group, of discharges.CommentsClose CommentsPermalink





(B) An institution’s or facility’s past expenditures.CommentsClose CommentsPermalink





(C) The extent to which debt service for capital expenditures has been included in the proposed operating budget.CommentsClose CommentsPermalink





(D) The extent to which capital expenditures are financed directly or indirectly through reductions in direct care to patients, including (but not limited to) reductions in registered nursing staffing patterns or changes in emergency room or primary care services or availability.CommentsClose CommentsPermalink





(E) Change in the consumer price index and other price indices.CommentsClose CommentsPermalink





(F) The cost of reasonable compensation to health care practitioners.CommentsClose CommentsPermalink





(G) The compensation level of the institution’s or facility’s work force.CommentsClose CommentsPermalink





(H) The extent to which the institution or facility is providing health care services to meet the needs of residents in the area served by the institution or facility, including the institution’s or facility’s occupancy level.CommentsClose CommentsPermalink





(I) The institution’s or facility’s previous financial and clinical performance, based on utilization and outcomes data provided under this Act.CommentsClose CommentsPermalink





(J) The type of institution or facility, including whether the institution or facility is part of a clinical education program or serves a health professional education, research or other training purpose.CommentsClose CommentsPermalink





(K) Technological advances or changes.CommentsClose CommentsPermalink





(L) Costs of the institution or facility associated with meeting Federal and State regulations.CommentsClose CommentsPermalink





(M) The costs associated with necessary public outreach activities.CommentsClose CommentsPermalink





(N) In the case of a for-profit facility, a reasonable rate of return on equity capital, independent of those operating expenses necessary to fulfill the objectives of this Act.CommentsClose CommentsPermalink





(O) Incentives to facilities that maintain costs below previous reasonable budgeted levels without reducing the care provided.CommentsClose CommentsPermalink





(P) With respect to facilities that provide mental health services and substance abuse treatment services, any additional costs involved in the treatment of dually diagnosed individuals.CommentsClose CommentsPermalink





The portion of such a budget that relates to expenditures for health professional education shall be consistent with the State health security budget for such expenditures.CommentsClose CommentsPermalink





(3) PROVISION OF REQUIRED INFORMATION; DIAGNOSIS-RELATED GROUP- No budget for an institution or facility for a year may be approved unless the institution or facility has submitted on a timely basis to the State health security program such information as the program or the Board shall specify, including in the case of hospitals information on discharges classified by diagnosis-related group.CommentsClose CommentsPermalink





(c) Adjustments in Approved Budgets-CommentsClose CommentsPermalink





(1) ADJUSTMENTS TO GLOBAL BUDGETS THAT CONTRACT WITH COMPREHENSIVE HEALTH SERVICE ORGANIZATIONS- Each State health security program shall develop an administrative mechanism for reducing operating funds to institutions or facilities in proportion to payments made to such institutions or facilities for services contracted for by a comprehensive health service organization.CommentsClose CommentsPermalink





(2) AMENDMENTS- In accordance with standards established by the Board, an operating and capital budget approved under this section for a year may be amended before, during, or after the year if there is a substantial change in any of the factors relevant to budget approval.CommentsClose CommentsPermalink





(d) Donations Permissible- The States health security programs may permit institutions and facilities to raise funds from private sources to pay for newly constructed facilities, major renovations, and equipment. The expenditure of such funds, whether for operating or capital expenditures, does not obligate the State health security program to provide for continued support for such expenditures unless included in an approved global budget.CommentsClose CommentsPermalink

SEC. 612. PAYMENTS TO HEALTH CARE PRACTITIONERS BASED ON PROSPECTIVE FEE SCHEDULE.

(a) Fee for Service-CommentsClose CommentsPermalink





(1) IN GENERAL- Every independent health care practitioner is entitled to be paid, for the provision of covered health services under the State health security program, a fee for each billable covered service.CommentsClose CommentsPermalink





(2) GLOBAL FEE PAYMENT METHODOLOGIES- The Board shall establish models and encourage State health security programs to implement alternative payment methodologies that incorporate global fees for related services (such as all outpatient procedures for treatment of a condition) or for a basic group of services (such as primary care services) furnished to an individual over a period of time, in order to encourage continuity and efficiency in the provision of services. Such methodologies shall be designed to ensure a high quality of care.CommentsClose CommentsPermalink





(3) BILLING DEADLINES; ELECTRONIC BILLING- A State health security program may deny payment for any service of an independent health care practitioner for which it did not receive a bill and appropriate supporting documentation (which had been previously specified) within 30 days after the date the service was provided. Such a program may require that bills for services for which payment may be made under this section, or for any class of such services, be submitted electronically.CommentsClose CommentsPermalink





(b) Payment Rates Based on Negotiated Prospective Fee Schedules- With respect to any payment method for a class of services of practitioners, the State health security program shall establish, on a prospective basis, a payment schedule. The State health security program may establish such a schedule after negotiations with organizations representing the practitioners involved. Such fee schedules shall be designed to provide incentives for practitioners to choose primary care medicine, including general internal medicine and pediatrics, over medical specialization. Nothing in this section shall be construed as preventing a State from adjusting the payment schedule amounts on a quarterly or other periodic basis depending on whether expenditures under the schedule will exceed the budgeted amount with respect to such expenditures.CommentsClose CommentsPermalink





(c) Billable Covered Service Defined- In this section, the term ‘billable covered service’ means a service covered under section 201 for which a practitioner is entitled to compensation by payment of a fee determined under this section.CommentsClose CommentsPermalink

SEC. 613. PAYMENTS TO COMPREHENSIVE HEALTH SERVICE ORGANIZATIONS.

(a) In General- Payment under a State health security program to a comprehensive health service organization to its enrollees shall be determined by the State--CommentsClose CommentsPermalink





(1) based on a global budget described in section 611; orCommentsClose CommentsPermalink





(2) based on the basic capitation amount described in subsection (b) for each of its enrollees.CommentsClose CommentsPermalink





(b) Basic Capitation Amount-CommentsClose CommentsPermalink





(1) IN GENERAL- The basic capitation amount described in this subsection for an enrollee shall be determined by the State health security program on the basis of the average amount of expenditures that is estimated would be made under the State health security program for covered health care services for an enrollee, based on actuarial characteristics (as defined by the State health security program).CommentsClose CommentsPermalink





(2) ADJUSTMENT FOR SPECIAL HEALTH NEEDS- The State health security program shall adjust such average amounts to take into account the special health needs, including a disproportionate number of medically underserved individuals, of populations served by the organization.CommentsClose CommentsPermalink





(3) ADJUSTMENT FOR SERVICES NOT PROVIDED- The State health security program shall adjust such average amounts to take into account the cost of covered health care services that are not provided by the comprehensive health service organization under section 303(a).CommentsClose CommentsPermalink

SEC. 614. PAYMENTS FOR COMMUNITY-BASED PRIMARY HEALTH SERVICES.

(a) In General- In the case of community-based primary health services, subject to subsection (b), payments under a State health security program shall--CommentsClose CommentsPermalink





(1) be based on a global budget described in section 611;CommentsClose CommentsPermalink





(2) be based on the basic primary care capitation amount described in subsection (c) for each individual enrolled with the provider of such services; orCommentsClose CommentsPermalink





(3) be made on a fee-for-service basis under section 612.CommentsClose CommentsPermalink





(b) Payment Adjustment- Payments under subsection (a) may include, consistent with the budgets developed under this title--CommentsClose CommentsPermalink





(1) an additional amount, as set by the State health security program, to cover the costs incurred by a provider which serves persons not covered by this Act whose health care is essential to overall community health and the control of communicable disease, and for whom the cost of such care is otherwise uncompensated;CommentsClose CommentsPermalink





(2) an additional amount, as set by the State health security program, to cover the reasonable costs incurred by a provider that furnishes case management services (as defined in section 1915(g)(2) of the Social Security Act), transportation services, and translation services; andCommentsClose CommentsPermalink





(3) an additional amount, as set by the State health security program, to cover the costs incurred by a provider in conducting health professional education programs in connection with the provision of such services.CommentsClose CommentsPermalink





(c) Basic Primary Care Capitation Amount-CommentsClose CommentsPermalink





(1) IN GENERAL- The basic primary care capitation amount described in this subsection for an enrollee with a provider of community-based primary health services shall be determined by the State health security program on the basis of the average amount of expenditures that is estimated would be made under the State health security program for such an enrollee, based on actuarial characteristics (as defined by the State health security program).CommentsClose CommentsPermalink





(2) ADJUSTMENT FOR SPECIAL HEALTH NEEDS- The State health security program shall adjust such average amounts to take into account the special health needs, including a disproportionate number of medically underserved individuals, of populations served by the provider.CommentsClose CommentsPermalink





(3) ADJUSTMENT FOR SERVICES NOT PROVIDED- The State health security program shall adjust such average amounts to take into account the cost of community-based primary health services that are not provided by the provider.CommentsClose CommentsPermalink





(d) Community-Based Primary Health Services Defined- In this section, the term ‘community-based primary health services’ has the meaning given such term in section 202(a).CommentsClose CommentsPermalink

SEC. 615. PAYMENTS FOR PRESCRIPTION DRUGS.

(a) Establishment of List-CommentsClose CommentsPermalink





(1) IN GENERAL- The Board shall establish a list of approved prescription drugs and biologicals that the Board determines are necessary for the maintenance or restoration of health or of employability or self-management and eligible for coverage under this Act.CommentsClose CommentsPermalink





(2) EXCLUSIONS- The Board may exclude reimbursement under this Act for ineffective, unsafe, or over-priced products where better alternatives are determined to be available.CommentsClose CommentsPermalink





(b) Prices- For each such listed prescription drug or biological covered under this Act, for insulin, and for medical foods, the Board shall from time to time determine a product price or prices which shall constitute the maximum to be recognized under this Act as the cost of a drug to a provider thereof. The Board may conduct negotiations, on behalf of State health security programs, with product manufacturers and distributors in determining the applicable product price or prices.CommentsClose CommentsPermalink





(c) Charges by Independent Pharmacies- Each State health security program shall provide for payment for a prescription drug or biological or insulin furnished by an independent pharmacy based on the drug’s cost to the pharmacy (not in excess of the applicable product price established under subsection (b)) plus a dispensing fee. In accordance with standards established by the Board, each State health security program, after consultation with representatives of the pharmaceutical profession, shall establish schedules of dispensing fees, designed to afford reasonable compensation to independent pharmacies after taking into account variations in their cost of operation resulting from regional differences, differences in the volume of prescription drugs dispensed, differences in services provided, the need to maintain expenditures within the budgets established under this title, and other relevant factors.CommentsClose CommentsPermalink

SEC. 616. PAYMENTS FOR APPROVED DEVICES AND EQUIPMENT.

(a) Establishment of List- The Board shall establish a list of approved durable medical equipment and therapeutic devices and equipment (including eyeglasses, hearing aids, and prosthetic appliances), that the Board determines are necessary for the maintenance or restoration of health or of employability or self-management and eligible for coverage under this Act.CommentsClose CommentsPermalink





(b) Considerations and Conditions- In establishing the list under subsection (a), the Board shall take into consideration the efficacy, safety, and cost of each item contained on such list, and shall attach to any item such conditions as the Board determines appropriate with respect to the circumstances under which, or the frequency with which, the item may be prescribed.CommentsClose CommentsPermalink





(c) Prices- For each such listed item covered under this Act, the Board shall from time to time determine a product price or prices which shall constitute the maximum to be recognized under this Act as the cost of the item to a provider thereof. The Board may conduct negotiations, on behalf of State health security programs, with equipment and device manufacturers and distributors in determining the applicable product price or prices.CommentsClose CommentsPermalink





(d) Exclusions- The Board may exclude from coverage under this Act ineffective, unsafe, or overpriced products where better alternatives are determined to be available.CommentsClose CommentsPermalink

SEC. 617. PAYMENTS FOR OTHER ITEMS AND SERVICES.

In the case of payment for other covered health services, the amount of payment under a State health security program shall be established by the program--CommentsClose CommentsPermalink





(1) in accordance with payment methodologies which are specified by the Board, after consultation with the American Health Security Advisory Council, or methodologies established by the State under section 620; andCommentsClose CommentsPermalink





(2) consistent with the State health security budget.CommentsClose CommentsPermalink

SEC. 618. PAYMENT INCENTIVES FOR MEDICALLY UNDERSERVED AREAS.

(a) Model Payment Methodologies- In addition to the payment amounts otherwise provided in this title, the Board shall establish model payment methodologies and other incentives that promote the provision of covered health care services in medically underserved areas, particularly in rural and inner-city underserved areas.CommentsClose CommentsPermalink





(b) Construction- Nothing in this title shall be construed as limiting the authority of State health security programs to increase payment amounts or otherwise provide additional incentives, consistent with the State health security budget, to encourage the provision of medically necessary and appropriate services in underserved areas.CommentsClose CommentsPermalink

SEC. 619. AUTHORITY FOR ALTERNATIVE PAYMENT METHODOLOGIES.

A State health security program, as part of its plan under section 404(a), may use a payment methodology other than a methodology required under this subtitle so long as--CommentsClose CommentsPermalink





(1) such payment methodology does not affect the entitlement of individuals to coverage, the weighting of fee schedules to encourage an increase in the number of primary care providers, the ability of individuals to choose among qualified providers, the benefits covered under the program, or the compliance of the program with the State health security budget under subtitle A; andCommentsClose CommentsPermalink





(2) the program submits periodic reports to the Board showing the operation and effectiveness of the alternative methodology, in order for the Board to evaluate the appropriateness of applying the alternative methodology to other States.CommentsClose CommentsPermalink

Subtitle C--Mandatory Assignment and Administrative ProvisionsCommentsClose CommentsPermalink

SEC. 631. MANDATORY ASSIGNMENT.

(a) No Balance Billing- Payments for benefits under this Act shall constitute payment in full for such benefits and the entity furnishing an item or service for which payment is made under this Act shall accept such payment as payment in full for the item or service and may not accept any payment or impose any charge for any such item or service other than accepting payment from the State health security program in accordance with this Act.CommentsClose CommentsPermalink





(b) Enforcement- If an entity knowingly and willfully bills for an item or service or accepts payment in violation of subsection (a), the Board may apply sanctions against the entity in the same manner as sanctions could have been imposed under section 1842(j)(2) of the Social Security Act for a violation of section 1842(j)(1) of such Act. Such sanctions are in addition to any sanctions that a State may impose under its State health security program.CommentsClose CommentsPermalink

SEC. 632. PROCEDURES FOR REIMBURSEMENT; APPEALS.

(a) Procedures for Reimbursement- In accordance with standards issued by the Board, a State health security program shall establish a timely and administratively simple procedure to assure payment within 60 days of the date of submission of clean claims by providers under this Act.CommentsClose CommentsPermalink





(b) Appeals Process- Each State health security program shall establish an appeals process to handle all grievances pertaining to payment to providers under this title.CommentsClose CommentsPermalink

TITLE VII--PROMOTION OF PRIMARY HEALTH CARE; DEVELOPMENT OF HEALTH SERVICE CAPACITY; PROGRAMS TO ASSIST THE MEDICALLY UNDERSERVEDCommentsClose CommentsPermalink

Subtitle A--Promotion and Expansion of Primary Care Professional TrainingCommentsClose CommentsPermalink

SEC. 701. ROLE OF BOARD; ESTABLISHMENT OF PRIMARY CARE PROFESSIONAL OUTPUT GOALS.

(a) In General- The Board is responsible for--CommentsClose CommentsPermalink





(1) coordinating health professional education policies and goals, in consultation with the Secretary of Health and Human Services (in this title referred to as the ‘Secretary’), to achieve the national goals specified in subsection (b);CommentsClose CommentsPermalink





(2) overseeing the health professional education expenditures of the State health security programs from the account established under section 602(c);CommentsClose CommentsPermalink





(3) developing and maintaining, in cooperation with the Secretary, a system to monitor the number and specialties of individuals through their health professional education, any postgraduate training, and professional practice; andCommentsClose CommentsPermalink





(4) developing, coordinating, and promoting other policies that expand the number of primary care practitioners.CommentsClose CommentsPermalink





(b) National Goals- The national goals specified in this subsection are as follows:CommentsClose CommentsPermalink





(1) GRADUATE MEDICAL EDUCATION- By not later than 5 years after the date of the enactment of this Act, at least 50 percent of the residents in medical residency education programs (as defined in subsection (e)(1)) are primary care residents (as defined in subsection (e)(3)).CommentsClose CommentsPermalink





(2) MIDLEVEL PRIMARY CARE PRACTITIONERS- To assure an adequate supply of primary care practitioners, there shall be a number, specified by the Board, of midlevel primary care practitioners (as defined in subsection (e)(2)) employed in the health care system as of January 1, 2013.CommentsClose CommentsPermalink





(3) DENTISTRY- To assure an adequate supply of dental care practitioners, there shall be a number, specified by the Board, of dentists (as defined in subsection (e)(1)) employed in the health care system as of January 1, 2013.CommentsClose CommentsPermalink





(c) Method for Attainment of National Goal for Graduate Medical Education; Program Goals-CommentsClose CommentsPermalink





(1) IN GENERAL- The Board shall establish a method of applying the national goal in subsection (b)(1) to program goals for each medical residency education program or to medical residency education consortia.CommentsClose CommentsPermalink





(2) CONSIDERATION- The program goals under paragraph (1) shall be based on the distribution of medical schools and other teaching facilities within each State health security program, and the number of positions for graduate medical education.CommentsClose CommentsPermalink





(3) MEDICAL RESIDENCY EDUCATION CONSORTIUM- In this subsection, the term ‘medical residency education consortium’ means a consortium of medical residency education programs in a contiguous geographic area (which may be an interstate area) if the consortium--CommentsClose CommentsPermalink





(A) includes at least 1 medical school with a teaching hospital and related teaching settings; andCommentsClose CommentsPermalink





(B) has an affiliation with qualified community-based primary health service providers described in section 202(a) and with at least 1 comprehensive health service organization established under section 303.CommentsClose CommentsPermalink





(4) ENFORCEMENT THROUGH STATE HEALTH SECURITY BUDGETS- The Board shall develop a formula for reducing payments to State health security programs (that provide for payments to a medical residency education program) that failed to meet the goal for the program established under this subsection.CommentsClose CommentsPermalink





(d) Method for Attainment of National Goal for Midlevel Primary Care Practitioners- To assist in attaining the national goal identified in subsection (b)(2), the Board shall--CommentsClose CommentsPermalink





(1) advise the Public Health Service on allocations of funding under titles VII and VIII of the Public Health Service Act, the National Health Service Corps, and other programs in order to increase the supply of midlevel primary care practitioners; andCommentsClose CommentsPermalink





(2) commission a study of the potential benefits and disadvantages of expanding the scope of practice authorized under State laws for any class of midlevel primary care practitioners.CommentsClose CommentsPermalink





(e) Definitions- In this title:CommentsClose CommentsPermalink





(1) DENTIST- The term ‘dentist’ means a practitioner who performs the evaluation, diagnosis, prevention or treatment (nonsurgical, surgical or related procedures) of diseases, disorders or conditions of the oral cavity, maxillofacial area or the adjacent and associated structures and their impact on the human body, within the scope of his or her education, training and experience, in accordance with the ethics of the profession and applicable law.CommentsClose CommentsPermalink





(2) MEDICAL RESIDENCY EDUCATION PROGRAM- The term ‘medical residency education program’ means a program that provides education and training to graduates of medical schools in order to meet requirements for licensing and certification as a physician, and includes the medical school supervising the program and includes the hospital or other facility in which the program is operated.CommentsClose CommentsPermalink





(3) MIDLEVEL PRIMARY CARE PRACTITIONER- The term ‘midlevel primary care practitioner’ means a clinical nurse practitioner, certified nurse midwife, physician assistance, or other nonphysician practitioner, specified by the Board, as authorized to practice under State law.CommentsClose CommentsPermalink





(4) PRIMARY CARE RESIDENT- The term ‘primary care resident’ means (in accordance with criteria established by the Board) a resident being trained in a distinct program of family practice medicine, general practice, general internal medicine, or general pediatrics.CommentsClose CommentsPermalink

SEC. 702. ESTABLISHMENT OF ADVISORY COMMITTEE ON HEALTH PROFESSIONAL EDUCATION.

(a) In General- The Board shall provide for an Advisory Committee on Health Professional Education (in this section referred to as the ‘Committee’) to advise the Board on its activities under section 701.CommentsClose CommentsPermalink





(b) Membership- The Committee shall be composed of--CommentsClose CommentsPermalink





(1) the Chair of the Board, who shall serve as Chair of the Committee; andCommentsClose CommentsPermalink





(2) 12 members, not otherwise in the employ of the United States, appointed by the Board without regard to the provisions of title 5, United States Code, governing appointments in the competitive service.CommentsClose CommentsPermalink





The appointed members shall provide a balanced point of view with respect to health professional education, primary care disciplines, and health care policy and shall include individuals who are representative of medical schools, other health professional schools, residency programs, primary care practitioners, teaching hospitals, professional associations, public health organizations, State health security programs, and consumers.CommentsClose CommentsPermalink





(c) Terms of Members- Each appointed member shall hold office for a term of 5 years, except that--CommentsClose CommentsPermalink





(1) any member appointed to fill a vacancy occurring during the term for which the member’s predecessor was appointed shall be appointed for the remainder of that term; andCommentsClose CommentsPermalink





(2) the terms of the members first taking office shall expire, as designated by the Board at the time of appointment, 2 at the end of the second year, 2 at the end of the third year, 2 at the end of the fourth year, and 3 at the end of the fifth year after the date of enactment of this Act.CommentsClose CommentsPermalink





(d) Vacancies-CommentsClose CommentsPermalink





(1) IN GENERAL- The Board shall fill any vacancy in the membership of the Committee in the same manner as the original appointment. The vacancy shall not affect the power of the remaining members to execute the duties of the Committee.CommentsClose CommentsPermalink





(2) VACANCY APPOINTMENTS- Any member appointed to fill a vacancy shall serve for the remainder of the term for which the predecessor of the member was appointed.CommentsClose CommentsPermalink





(3) REAPPOINTMENT- The Board may reappoint an appointed member of the Committee for a second term in the same manner as the original appointment.CommentsClose CommentsPermalink





(e) Duties- It shall be the duty of the Committee to advise the Board concerning graduate medical education policies under this title.CommentsClose CommentsPermalink





(f) Staff- The Committee, its members, and any committees of the Committee shall be provided with such secretarial, clerical, or other assistance as may be authorized by the Board for carrying out their respective functions.CommentsClose CommentsPermalink





(g) Meetings- The Committee shall meet as frequently as the Board deems necessary, but not less than 4 times each year. Upon request by 4 or more members it shall be the duty of the Chair to call a meeting of the Committee.CommentsClose CommentsPermalink





(h) Compensation- Members of the Committee shall be reimbursed by the Board for travel and per diem in lieu of subsistence expenses during the performance of duties of the Board in accordance with subchapter I of chapter 57 of title 5, United States Code.CommentsClose CommentsPermalink





(i) FACA Not Applicable- The provisions of the Federal Advisory Committee Act shall not apply to the Committee.CommentsClose CommentsPermalink

SEC. 703. GRANTS FOR HEALTH PROFESSIONS EDUCATION, NURSE EDUCATION, AND THE NATIONAL HEALTH SERVICE CORPS.

(a) Transfers to Public Health Service- The Board shall make transfers from the American Health Security Trust Fund to the Public Health Service under subpart II of part D of title III, title VII, and title VIII of the Public Health Service Act for the support of the National Health Service Corps, health professions education, and nursing education, including education of clinical nurse practitioners, certified registered nurse anesthetists, certified nurse midwives, and physician assistants. The amounts transferred for the support of the National Health Service Corps shall be in the following amounts for the fiscal year indicated:CommentsClose CommentsPermalink





(1) For fiscal year 2010, $320,461,632.CommentsClose CommentsPermalink





(2) For fiscal year 2011, $414,095,394.CommentsClose CommentsPermalink





(3) For fiscal year 2012, $535,087,442.CommentsClose CommentsPermalink





(4) For fiscal year 2013, $691,431,432.CommentsClose CommentsPermalink





(5) For fiscal year 2014, $893,456,433.CommentsClose CommentsPermalink





(6) For fiscal year 2015, $1,154,510,336.CommentsClose CommentsPermalink





(7) For fiscal year 2016, and each subsequent fiscal year, the amount transferred for the preceding fiscal year adjusted by the product of--CommentsClose CommentsPermalink





(A) one plus the average percentage increase in the costs of health professions education during the prior fiscal year; andCommentsClose CommentsPermalink





(B) one plus the average percentage change in the number of individuals residing in health professions shortage areas designated under section 333 during the prior fiscal year, relative to the number of individuals residing in such areas during the previous fiscal year.CommentsClose CommentsPermalink





(b) Range of Funds- The amount of transfers under subsection (a) for any fiscal year for title VII and VIII shall be an amount (specified by the Board each year) not less than 3/100 percent and not to exceed 4/100 percent of the amounts the Board estimates will be expended from the Trust Fund in the fiscal year.CommentsClose CommentsPermalink





(c) Funds Supplemental to Other Funds- The funds provided under this section with respect to provision of services are in addition to, and not in replacement of, funds made available under the provisions referred to in subsection (a) and shall be administered in accordance with the terms of such provisions. The Board shall make no transfer of funds under this section for any fiscal year for which the total appropriations for the programs authorized by such provisions are less than the total amount appropriated for such programs in fiscal year 2009.CommentsClose CommentsPermalink

Subtitle B--Direct Health Care DeliveryCommentsClose CommentsPermalink

SEC. 711. SET-ASIDE FOR PUBLIC HEALTH.

(a) Transfers to Public Health Service- From the amounts provided under subsection (c), the Board shall make transfers from the American Health Security Trust Fund to the Public Health Service for the following purposes (other than payment for services covered under title II):CommentsClose CommentsPermalink





(1) For payments to States under the maternal and child health block grants under title V of the Social Security Act.CommentsClose CommentsPermalink





(2) For prevention and treatment of tuberculosis under section 317 of the Public Health Service Act.CommentsClose CommentsPermalink





(3) For the prevention and treatment of sexually transmitted diseases under section 318 of the Public Health Service Act.CommentsClose CommentsPermalink





(4) Preventive health block grants under part A of title XIX of the Public Health Service Act.CommentsClose CommentsPermalink





(5) Grants to States for community mental health services under subpart I of part B of title XIX of the Public Health Service Act.CommentsClose CommentsPermalink





(6) Grants to States for prevention and treatment of substance abuse under subpart II of part B of title XIX of the Public Health Service Act.CommentsClose CommentsPermalink





(7) Grants for HIV health care services under parts A, B, and C of title XXVI of the Public Health Service Act.CommentsClose CommentsPermalink





(8) Public health formula grants described in subsection (d).CommentsClose CommentsPermalink





(b) Range of Funds- The amount of transfers under subsection (a) for any fiscal year shall be an amount (specified by the Board each year) not less than 1/10 percent and not to exceed 14/100 percent of the amounts the Board estimates will be expended from the Trust Fund in the fiscal year.CommentsClose CommentsPermalink





(c) Funds Supplemental to Other Funds- The funds provided under this section with respect to provision of services are in addition to, and not in replacement of, funds made available under the programs referred to in subsection (a) and shall be administered in accordance with the terms of such programs.CommentsClose CommentsPermalink





(d) Required Reports on Health Status- The Secretary shall require each State receiving funds under this section to submit annual reports to the Secretary on the health status of the population and measurable objectives for improving the health of the public in the State. Such reports shall include the following:CommentsClose CommentsPermalink





(1) A comparison of the measures of the State and local public health system compared to relevant objectives set forth in ‘Healthy People 2000’ or subsequent national objectives set by the Secretary.CommentsClose CommentsPermalink





(2) A description of health status measures to be improved within the State (at the State and local levels) through expanded public health functions and health promotion and disease prevention programs.CommentsClose CommentsPermalink





(3) Measurable outcomes and process objectives for improving health status, and a report on outcomes from the previous year.CommentsClose CommentsPermalink





(4) Information regarding how Federal funding has improved population-based prevention activities and programs.CommentsClose CommentsPermalink





(5) A description of the core public health functions to be carried out at the local level.CommentsClose CommentsPermalink





(6) A description of the relationship between the State’s public health system, community-based health promotion and disease prevention providers, and the State health security program.CommentsClose CommentsPermalink





(e) Limitation on Fund Transfers- The Board shall make no transfer of funds under this section for any fiscal year for which the total appropriations for such programs are less than the total amount appropriated for such programs in fiscal year 2008.CommentsClose CommentsPermalink





(f) Public Health Formula Grants- The Secretary shall provide stable funds to States through formula grants for the purpose of carrying out core public health functions to monitor and protect the health of communities from communicable diseases and exposure to toxic environmental pollutants, occupational hazards, harmful products, and poor health outcomes. Such functions include the following:CommentsClose CommentsPermalink





(1) Data collection, analysis, and assessment of public health data, vital statistics, and personal health data to assess community health status and outcomes reporting. This function includes the acquisition and installation of hardware and software, and personnel training and technical assistance to operate and support automated and integrated information systems.CommentsClose CommentsPermalink





(2) Activities to protect the environment and to assure the safety of housing, workplaces, food, and water.CommentsClose CommentsPermalink





(3) Investigation and control of adverse health conditions, and threats to the health status of individuals and the community. This function includes the identification and control of outbreaks of infectious disease, patterns of chronic disease and injury, and cooperative activities to reduce the levels of violence.CommentsClose CommentsPermalink





(4) Health promotion and disease prevention activities for which there is a significant need and a high priority of the Public Health Service.CommentsClose CommentsPermalink





(5) The provision of public health laboratory services to complement private clinical laboratory services, including--CommentsClose CommentsPermalink





(A) screening tests for metabolic diseases in newborns;CommentsClose CommentsPermalink





(B) toxicology assessments of blood lead levels and other environmental toxins;CommentsClose CommentsPermalink





(C) tuberculosis and other diseases requiring partner notification; andCommentsClose CommentsPermalink





(D) testing for infectious and food-borne diseases.CommentsClose CommentsPermalink





(6) Training and education for the public health professions.CommentsClose CommentsPermalink





(7) Research on effective and cost-effective public health practices. This function includes the development, testing, evaluation, and publication of results of new prevention and public health control interventions.CommentsClose CommentsPermalink





(8) Integration and coordination of the prevention programs and services of community-based providers, local and State health departments, and other sectors of State and local government that affect health.CommentsClose CommentsPermalink

SEC. 712. SET-ASIDE FOR PRIMARY HEALTH CARE DELIVERY.

(a) Transfers to Section 330 Program of the Public Health Service Act- The Board shall make transfers from the American Health Security Trust Fund to the Public Health Service for the program authorized under section 330 of the Public Health Service Act (42 U.S.C. 254b) in the following amounts for the fiscal year indicated:CommentsClose CommentsPermalink





(1) For fiscal year 2010, $2,988,821,592.CommentsClose CommentsPermalink





(2) For fiscal year 2011, $3,862,107,440.CommentsClose CommentsPermalink





(3) For fiscal year 2012, $4,990,553,440.CommentsClose CommentsPermalink





(4) For fiscal year 2013, $6,448,713,307.CommentsClose CommentsPermalink





(5) For fiscal year 2014, $7,332,924,155.CommentsClose CommentsPermalink





(6) For fiscal year 2015, $8,332,924,155.CommentsClose CommentsPermalink





(7) For fiscal year 2016 and each subsequent fiscal year, the amount transferred for the preceding fiscal year adjusted by the product of--CommentsClose CommentsPermalink





(A) one plus the average percentage increase in costs incurred per patient served by entities receiving funding under such section; andCommentsClose CommentsPermalink





(B) one plus the average percentage increase in the total number of patients served by entities receiving funding under such section.CommentsClose CommentsPermalink





(b) Transfers to Public Health Service- From the amounts provided under subsection (d), the Board shall make transfers from the American Health Security Trust Fund to the Public Health Service for the program of primary care service expansion grants under subpart V of part D of title III of the Public Health Service Act (as added by section 713 of this Act).CommentsClose CommentsPermalink





(c) Range of Funds- The amount of transfers under subsection (b) for any fiscal year shall be an amount (specified by the Board each year) not less than 6/100 percent and not to exceed 1/10 percent of the amounts the Board estimates will be expended from the Trust Fund in the fiscal year.CommentsClose CommentsPermalink





(d) Funds Supplemental to Other Funds- The funds provided under this section with respect to provision of services are in addition to, and not in replacement of, funds made available under the sections 340A, 1001, and 2655 of the Public Health Service Act. The Board shall make no transfer of funds under this section for any fiscal year for which the total appropriations for such sections are less than the total amount appropriated under such sections in fiscal year 2008.CommentsClose CommentsPermalink

SEC. 713. PRIMARY CARE SERVICE EXPANSION GRANTS.

Part D of title III of the Public Health Service Act (42 U.S.C. 254b et seq.) is amended by adding at the end thereof the following new subpart:CommentsClose CommentsPermalink

‘Subpart XI--Primary Care Expansion

‘SEC. 340H. EXPANDING PRIMARY CARE DELIVERY CAPACITY IN URBAN AND RURAL AREAS.

‘(a) Grants for Primary Care Centers- From the amounts described in subsection (c), the American Health Security Standards Board shall make grants to public and nonprofit private entities for projects to plan and develop primary care centers which will serve medically underserved populations (as defined in section 330(b)(3)) in urban and rural areas and to deliver primary care services to such populations in such areas. The funds provided under such a grant may be used for the same purposes for which a grant may be made under subsection (c), (e), (f), (g), (h), or (i) of section 330.CommentsClose CommentsPermalink





‘(b) Process of Awarding Grants- The provisions of subsection (k)(1) of section 330 shall apply to a grant under this section in the same manner as they apply to a grant under the corresponding subsection of such section. The provisions of subsection (r)(2)(A) of such section shall apply to grants for projects to plan and develop primary care centers under this section in the same manner as they apply to grants under such section.CommentsClose CommentsPermalink





‘(c) Funding as Set-Aside From Trust Fund- Funds in the American Health Security Trust Fund (established under section 801 of the act) shall be available to carry out this section.CommentsClose CommentsPermalink





‘(d) Primary Care Center Defined- In this section, the term ‘primary care center’ means--CommentsClose CommentsPermalink





‘(1) a health center (as defined in section 330(a)(1));CommentsClose CommentsPermalink





‘(2) an entity qualified to receive a grant under section 330, 1001, or 2651; orCommentsClose CommentsPermalink





‘(3) a Federally-qualified health center (as defined in section 1905(l)(2)(B) of the Social Security Act).’.CommentsClose CommentsPermalink

Subtitle C--Primary Care and Outcomes ResearchCommentsClose CommentsPermalink

SEC. 721. SET-ASIDE FOR OUTCOMES RESEARCH.

(a) Grants for Outcomes Research- The Board shall make transfers from the American Health Security Trust Fund to the Agency for Health Care Policy and Research under title IX of the Public Health Service Act for the purpose of carrying out activities under such title. The Secretary shall assure that there is a special emphasis placed on pediatric outcomes research.CommentsClose CommentsPermalink





(b) Range of Funds- The amount of transfers under subsection (a) for any fiscal year shall be an amount (specified by the Board each year) not less than 1/100 percent and not to exceed 2/100 percent of the amounts the Board estimates will be expended from the Trust Fund in the fiscal year.CommentsClose CommentsPermalink





(c) Funds Supplemental to Other Funds- The funds provided under this section with respect to provision of services are in addition to, and not in replacement of, funds made available to the Agency for Health Care Policy and Research under 937 of the Public Health Service Act. The Board shall make no transfer of funds under this section for any fiscal year for which the total appropriations under such section are less than the total amount appropriated under such section and title in fiscal year 2008.CommentsClose CommentsPermalink





(d) Conforming Amendment- Section 937(b) of the Public Health Service Act (42 U.S.C. 299c-6(b)) is amended by inserting after ‘of the fiscal years 2001 through 2005’ the following: ‘and of fiscal year 2010 and each subsequent year’.CommentsClose CommentsPermalink

SEC. 722. OFFICE OF PRIMARY CARE AND PREVENTION RESEARCH.

(a) In General- Title IV of the Public Health Service Act is amended--CommentsClose CommentsPermalink





(1) by redesignating parts G through I as parts H through J, respectively; andCommentsClose CommentsPermalink





(2) by inserting after part F the following new part:CommentsClose CommentsPermalink

‘PART G--RESEARCH ON PRIMARY CARE AND PREVENTION

‘SEC. 486E. OFFICE OF PRIMARY CARE AND PREVENTION RESEARCH.

‘(a) Establishment- There is established within the Office of the Director of NIH an office to be known as the Office of Primary Care and Prevention Research (in this part referred to as the ‘Office’). The Office shall be headed by a director, who shall be appointed by the Director of NIH.CommentsClose CommentsPermalink





‘(b) Purpose- The Director of the Office shall--CommentsClose CommentsPermalink





‘(1) identify projects of research on primary care and prevention, for children as well as adults, that should be conducted or supported by the national research institutes, with particular emphasis on--CommentsClose CommentsPermalink





‘(A) clinical patient care, with special emphasis on pediatric clinical care and diagnosis;CommentsClose CommentsPermalink





‘(B) diagnostic effectiveness;CommentsClose CommentsPermalink





‘(C) primary care education;CommentsClose CommentsPermalink





‘(D) health and family planning services;CommentsClose CommentsPermalink





‘(E) medical effectiveness outcomes of primary care procedures and interventions; andCommentsClose CommentsPermalink





‘(F) the use of multidisciplinary teams of health care practitioners;CommentsClose CommentsPermalink





‘(2) identify multidisciplinary research related to primary care and prevention that should be so conducted;CommentsClose CommentsPermalink





‘(3) promote coordination and collaboration among entities conducting research identified under any of paragraphs (1) and (2);CommentsClose CommentsPermalink





‘(4) encourage the conduct of such research by entities receiving funds from the national research institutes;CommentsClose CommentsPermalink





‘(5) recommend an agenda for conducting and supporting such research;CommentsClose CommentsPermalink





‘(6) promote the sufficient allocation of the resources of the national research institutes for conducting and supporting such research; andCommentsClose CommentsPermalink





‘(7) prepare the report required in section 486G.CommentsClose CommentsPermalink





‘(c) Primary Care and Prevention Research Defined- For purposes of this part, the term ‘primary care and prevention research’ means research on improvement of the practice of family medicine, general internal medicine, and general pediatrics, and includes research relating to--CommentsClose CommentsPermalink





‘(1) obstetrics and gynecology, dentistry, or mental health or substance abuse treatment when provided by a primary care physician or other primary care practitioner; andCommentsClose CommentsPermalink





‘(2) primary care provided by multidisciplinary teams.CommentsClose CommentsPermalink

‘SEC. 486F. NATIONAL DATA SYSTEM AND CLEARINGHOUSE ON PRIMARY CARE AND PREVENTION RESEARCH.

‘(a) Data System- The Director of NIH, in consultation with the Director of the Office, shall establish a data system for the collection, storage, analysis, retrieval, and dissemination of information regarding primary care and prevention research that is conducted or supported by the national research institutes. Information from the data system shall be available through information systems available to health care professionals and providers, researchers, and members of the public.CommentsClose CommentsPermalink





‘(b) Clearinghouse- The Director of NIH, in consultation with the Director of the Office and with the National Library of Medicine, shall establish, maintain, and operate a program to provide, and encourage the use of, information on research and prevention activities of the national research institutes that relate to primary care and prevention research.CommentsClose CommentsPermalink

‘SEC. 486G. BIENNIAL REPORT.

‘(a) In General- With respect to primary care and prevention research, the Director of the Office shall, not later than 1 year after the date of the enactment of this part, and biennially thereafter, prepare a report--CommentsClose CommentsPermalink





‘(1) describing and evaluating the progress made during the preceding 2 fiscal years in research and treatment conducted or supported by the National Institutes of Health;CommentsClose CommentsPermalink





‘(2) summarizing and analyzing expenditures made by the agencies of such Institutes (and by such Office) during the preceding 2 fiscal years; andCommentsClose CommentsPermalink





‘(3) making such recommendations for legislative and administrative initiatives as the Director of the Office determines to be appropriate.CommentsClose CommentsPermalink





‘(b) Inclusion in Biennial Report of Director of NIH- The Director of the Office shall submit each report prepared under subsection (a) to the Director of NIH for inclusion in the report submitted to the President and the Congress under section 403.CommentsClose CommentsPermalink

‘SEC. 486H. AUTHORIZATION OF APPROPRIATIONS.

‘For the Office of Primary Care and Prevention Research, there are authorized to be appropriated $150,000,000 for fiscal year 2010, $180,000,000 for fiscal year 2011, and $216,000,000 for fiscal year 2012.’.CommentsClose CommentsPermalink





(b) Requirement of Sufficient Allocation of Resources of Institutes- Section 402(b) of the Public Health Service Act (42 U.S.C. 282(b)) is amended--CommentsClose CommentsPermalink





(1) in paragraph (22), by striking ‘and’ after the semicolon at the end;CommentsClose CommentsPermalink





(2) in paragraph (23), by striking the period at the end and inserting ‘; and’; andCommentsClose CommentsPermalink





(3) by inserting after paragraph (23) the following new paragraph:CommentsClose CommentsPermalink





‘(24) after consultation with the Director of the Office of Primary Care and Prevention Research, shall ensure that resources of the National Institutes of Health are sufficiently allocated for projects on primary care and prevention research that are identified under section 486E(b).’.CommentsClose CommentsPermalink

Subtitle D--School-Related Health ServicesCommentsClose CommentsPermalink

SEC. 731. AUTHORIZATIONS OF APPROPRIATIONS.

(a) Funding for School-Related Health Services- For the purpose of carrying out this subtitle, there are authorized to be appropriated $100,000,000 for fiscal year 2012, $275,000,000 for fiscal year 2013, $350,000,000 for fiscal year 2014, and $400,000,000 for each of the fiscal years 2015 and 2016.CommentsClose CommentsPermalink





(b) Relation to Other Funds- The authorizations of appropriations established in subsection (a) are in addition to any other authorizations of appropriations that are available for the purpose described in such subsection.CommentsClose CommentsPermalink

SEC. 732. ELIGIBILITY FOR DEVELOPMENT AND OPERATION GRANTS.

(a) In General- Entities eligible to apply for and receive grants under section 734 or 735 are the following:CommentsClose CommentsPermalink





(1) State health agencies that apply on behalf of local community partnerships and other communities in need of health services for school-aged children within the State.CommentsClose CommentsPermalink





(2) Local community partnerships in States in which health agencies have not applied.CommentsClose CommentsPermalink





(b) Local Community Partnerships-CommentsClose CommentsPermalink





(1) IN GENERAL- A local community partnership under subsection (a)(2) is an entity that, at a minimum, includes--CommentsClose CommentsPermalink





(A) a local health care provider with experience in delivering services to school-aged children;CommentsClose CommentsPermalink





(B) 1 or more local public schools; andCommentsClose CommentsPermalink





(C) at least 1 community based organization located in the community to be served that has a history of providing services to school-aged children in the community who are at-risk.CommentsClose CommentsPermalink





(2) PARTICIPATION- A partnership described in paragraph (1) shall, to the maximum extent feasible, involve broad based community participation from parents and adolescent children to be served, health and social service providers, teachers and other public school and school board personnel, development and service organizations for adolescent children, and interested business leaders. Such participation may be evidenced through an expanded partnership, or an advisory board to such partnership.CommentsClose CommentsPermalink





(c) Definitions Regarding Children- For purposes of this subtitle:CommentsClose CommentsPermalink





(1) The term ‘adolescent children’ means school-aged children who are adolescents.CommentsClose CommentsPermalink





(2) The term ‘school-aged children’ means individuals who are between the ages of 4 and 19 (inclusive).CommentsClose CommentsPermalink

SEC. 733. PREFERENCES.

(a) In General- In making grants under sections 734 and 735, the Secretary shall give preference to applicants whose communities to be served show the most substantial level of need for such services among school-aged children, as measured by indicators of community health including the following:CommentsClose CommentsPermalink





(1) High levels of poverty.CommentsClose CommentsPermalink





(2) The presence of a medically underserved population.CommentsClose CommentsPermalink





(3) The presence of a health professional shortage area.CommentsClose CommentsPermalink





(4) High rates of indicators of health risk among school-aged children, including a high proportion of such children receiving services through the Individuals with Disabilities Education Act, adolescent pregnancy, sexually transmitted disease (including infection with the human immunodeficiency virus), preventable disease, communicable disease, intentional and unintentional injuries, community and gang violence, unemployment among adolescent children, juvenile justice involvement, and high rates of drug and alcohol exposure.CommentsClose CommentsPermalink





(b) Linkage to Community Health Centers- In making grants under sections 734 and 735, the Secretary shall give preference to applicants that demonstrate a linkage to community health centers.CommentsClose CommentsPermalink

SEC. 734. GRANTS FOR DEVELOPMENT OF PROJECTS.

(a) In General- The Secretary may make grants to State health agencies or to local community partnerships to develop school health service sites.CommentsClose CommentsPermalink





(b) Use of Funds- A project for which a grant may be made under subsection (a) may include but not be limited to the cost of the following:CommentsClose CommentsPermalink





(1) Planning for the provision of school health services.CommentsClose CommentsPermalink





(2) Recruitment, compensation, and training of health and administrative staff.CommentsClose CommentsPermalink





(3) The development of agreements, and the acquisition and development of equipment and information services, necessary to support information exchange between school health service sites and health plans, health providers, and other entities authorized to collect information under this Act.CommentsClose CommentsPermalink





(4) Other activities necessary to assume operational status.CommentsClose CommentsPermalink





(c) Application for Grant-CommentsClose CommentsPermalink





(1) IN GENERAL- Applicants shall submit applications in a form and manner prescribed by the Secretary.CommentsClose CommentsPermalink





(2) APPLICATIONS BY STATE HEALTH AGENCIES-CommentsClose CommentsPermalink





(A) In the case of applicants that are State health agencies, the application shall contain assurances that the State health agency is applying for funds--CommentsClose CommentsPermalink





(i) on behalf of at least 1 local community partnership; andCommentsClose CommentsPermalink





(ii) on behalf of at least 1 other community identified by the State as in need of the services funded under this subtitle but without a local community partnership.CommentsClose CommentsPermalink





(B) In the case of the communities identified in applications submitted by State health agencies that do not yet have local community partnerships (including the community identified under subparagraph (A)(ii)), the State shall describe the steps that will be taken to aid the communities in developing a local community partnership.CommentsClose CommentsPermalink





(C) A State applying on behalf of local community partnerships and other communities may retain not more than 10 percent of grants awarded under this subtitle for administrative costs.CommentsClose CommentsPermalink





(d) Contents of Application- In order to receive a grant under this section, an applicant must include in the application the following information:CommentsClose CommentsPermalink





(1) An assessment of the need for school health services in the communities to be served, using the latest available health data and health goals and objectives established by the Secretary.CommentsClose CommentsPermalink





(2) A description of how the applicant will design the proposed school health services to reach the maximum number of school-aged children who are at risk.CommentsClose CommentsPermalink





(3) An explanation of how the applicant will integrate its services with those of other health and social service programs within the community.CommentsClose CommentsPermalink





(4) A description of a quality assurance program which complies with standards that the Secretary may prescribe.CommentsClose CommentsPermalink





(e) Number of Grants- Not more than 1 planning grant may be made to a single applicant. A planning grant may not exceed 2 years in duration.CommentsClose CommentsPermalink

SEC. 735. GRANTS FOR OPERATION OF PROJECTS.

(a) In General- The Secretary may make grants to State health agencies or to local community partnerships for the cost of operating school health service sites.CommentsClose CommentsPermalink





(b) Use of Grant- The costs for which a grant may be made under this section include but are not limited to the following:CommentsClose CommentsPermalink





(1) The cost of furnishing health services that are not otherwise covered under this Act or by any other public or private insurer.CommentsClose CommentsPermalink





(2) The cost of furnishing services whose purpose is to increase the capacity of individuals to utilize available health services, including transportation, community and patient outreach, patient education, translation services, and such other services as the Secretary determines to be appropriate in carrying out such purpose.CommentsClose CommentsPermalink





(3) Training, recruitment and compensation of health professionals and other staff.CommentsClose CommentsPermalink





(4) Outreach services to school-aged children who are at risk and to the parents of such children.CommentsClose CommentsPermalink





(5) Linkage of individuals to health plans, community health services and social services.CommentsClose CommentsPermalink





(6) Other activities deemed necessary by the Secretary.CommentsClose CommentsPermalink





(c) Application for Grant- Applicants shall submit applications in a form and manner prescribed by the Secretary. In order to receive a grant under this section, an applicant must include in the application the following information:CommentsClose CommentsPermalink





(1) A description of the services to be furnished by the applicant.CommentsClose CommentsPermalink





(2) The amounts and sources of funding that the applicant will expend, including estimates of the amount of payments the applicant will receive from sources other than the grant.CommentsClose CommentsPermalink





(3) Such other information as the Secretary determines to be appropriate.CommentsClose CommentsPermalink





(d) Additional Contents of Application- In order to receive a grant under this section, an applicant must meet the following conditions:CommentsClose CommentsPermalink





(1) The applicant furnishes the following services:CommentsClose CommentsPermalink





(A) Diagnosis and treatment of simple illnesses and minor injuries.CommentsClose CommentsPermalink





(B) Preventive health services, including health screenings.CommentsClose CommentsPermalink





(C) Services provided for the purpose described in subsection (b)(2).CommentsClose CommentsPermalink





(D) Referrals and followups in situations involving illness or injury.CommentsClose CommentsPermalink





(E) Health and social services, counseling services, and necessary referrals, including referrals regarding mental health and substance abuse.CommentsClose CommentsPermalink





(F) Such other services as the Secretary determines to be appropriate.CommentsClose CommentsPermalink





(2) The applicant is a participating provider in the State’s program for medical assistance under title XIX of the Social Security Act.CommentsClose CommentsPermalink





(3) The applicant does not impose charges on students or their families for services (including collection of any cost-sharing for services under the comprehensive benefit package that otherwise would be required).CommentsClose CommentsPermalink





(4) The applicant has reviewed and will periodically review the needs of the population served by the applicant in order to ensure that its services are accessible to the maximum number of school-aged children in the area, and that, to the maximum extent possible, barriers to access to services of the applicant are removed (including barriers resulting from the area’s physical characteristics, its economic, social and cultural grouping, the health care utilization patterns of such children, and available transportation).CommentsClose CommentsPermalink





(5) In the case of an applicant which serves a population that includes a substantial proportion of individuals of limited English speaking ability, the applicant has developed a plan to meet the needs of such population to the extent practicable in the language and cultural context most appropriate to such individuals.CommentsClose CommentsPermalink





(6) The applicant will provide non-Federal contributions toward the cost of the project in an amount determined by the Secretary.CommentsClose CommentsPermalink





(7) The applicant will operate a quality assurance program consistent with section 734(d).CommentsClose CommentsPermalink





(e) Duration of Grant- A grant under this section shall be for a period determined by the Secretary.CommentsClose CommentsPermalink





(f) Reports- A recipient of funding under this section shall provide such reports and information as are required in regulations of the Secretary.CommentsClose CommentsPermalink

SEC. 736. FEDERAL ADMINISTRATIVE COSTS.

Of the amounts made available under section 731, the Secretary may reserve not more than 5 percent for administrative expenses regarding this subtitle.CommentsClose CommentsPermalink

SEC. 737. DEFINITIONS.

For purposes of this subtitle:CommentsClose CommentsPermalink





(1) The term ‘adolescent children’ has the meaning given such term in section 732(c).CommentsClose CommentsPermalink





(2) The term ‘at risk’ means at-risk with respect to health.CommentsClose CommentsPermalink





(3) The term ‘community health center’ has the meaning given such term in section 330 of the Public Health Service Act.CommentsClose CommentsPermalink





(4) The term ‘health professional shortage area’ means a health professional shortage area designated under section 332 of the Public Health Service Act.CommentsClose CommentsPermalink





(5) The term ‘medically underserved population’ has the meaning given such term in section 330 of the Public Health Service Act.CommentsClose CommentsPermalink





(6) The term ‘school-aged children’ has the meaning given such term in section 732(c).CommentsClose CommentsPermalink

TITLE VIII--FINANCING PROVISIONS; AMERICAN HEALTH SECURITY TRUST FUNDCommentsClose CommentsPermalink

SEC. 800. AMENDMENT OF 1986 CODE; SECTION 15 NOT TO APPLY.

(a) Amendment of 1986 Code- Except as otherwise expressly provided, whenever in this title an amendment or repeal is expressed in terms of an amendment to, or repeal of, a section or other provision, the reference shall be considered to be made to a section or other provision of the Internal Revenue Code of 1986.CommentsClose CommentsPermalink





(b) Section 15 Not To Apply- The amendments made by subtitle B shall not be treated as a change in a rate of tax for purposes of section 15 of the Internal Revenue Code of 1986.CommentsClose CommentsPermalink

Subtitle A--American Health Security Trust FundCommentsClose CommentsPermalink

SEC. 801. AMERICAN HEALTH SECURITY TRUST FUND.

(a) In General- There is hereby created on the books of the Treasury of the United States a trust fund to be known as the American Health Security Trust Fund (in this section referred to as the ‘Trust Fund’). The Trust Fund shall consist of such gifts and bequests as may be made and such amounts as may be deposited in, or appropriated to, such Trust Fund as provided in this Act.CommentsClose CommentsPermalink





(b) Appropriations Into Trust Fund-CommentsClose CommentsPermalink





(1) TAXES- There are hereby appropriated to the Trust Fund for each fiscal year (beginning with fiscal year 2011), out of any moneys in the Treasury not otherwise appropriated, amounts equivalent to 100 percent of the aggregate increase in tax liabilities under the Internal Revenue Code of 1986 which is attributable to the application of the amendments made by this title. The amounts appropriated by the preceding sentence shall be transferred from time to time (but not less frequently than monthly) from the general fund in the Treasury to the Trust Fund, such amounts to be determined on the basis of estimates by the Secretary of the Treasury of the taxes paid to or deposited into the Treasury; and proper adjustments shall be made in amounts subsequently transferred to the extent prior estimates were in excess of or were less than the amounts that should have been so transferred.CommentsClose CommentsPermalink





(2) CURRENT PROGRAM RECEIPTS- Notwithstanding any other provision of law, there are hereby appropriated to the Trust Fund for each fiscal year (beginning with fiscal year 2011) the amounts that would otherwise have been appropriated to carry out the following programs:CommentsClose CommentsPermalink





(A) The medicare program, under parts A, B, and D of title XVIII of the Social Security Act (other than amounts attributable to any premiums under such parts).CommentsClose CommentsPermalink





(B) The medicaid program, under State plans approved under title XIX of such Act.CommentsClose CommentsPermalink





(C) The Federal employees health benefit program, under chapter 89 of title 5, United States Code.CommentsClose CommentsPermalink





(D) The TRICARE program (formerly known as the CHAMPUS program), under chapter 55 of title 10, United States Code.CommentsClose CommentsPermalink





(E) The maternal and child health program (under title V of the Social Security Act), vocational rehabilitation programs, programs for drug abuse and mental health services under the Public Health Service Act, programs providing general hospital or medical assistance, and any other Federal program identified by the Board, in consultation with the Secretary of the Treasury, to the extent the programs provide for payment for health services the payment of which may be made under this Act.CommentsClose CommentsPermalink





(c) Incorporation of Provisions- The provisions of subsections (b) through (i) of section 1817 of the Social Security Act shall apply to the Trust Fund under this Act in the same manner as they applied to the Federal Hospital Insurance Trust Fund under part A of title XVIII of such Act, except that the American Health Security Standards Board shall constitute the Board of Trustees of the Trust Fund.CommentsClose CommentsPermalink





(d) Transfer of Funds- Any amounts remaining in the Federal Hospital Insurance Trust Fund or the Federal Supplementary Medical Insurance Trust Fund after the settlement of claims for payments under title XVIII have been completed, shall be transferred into the American Health Security Trust Fund.CommentsClose CommentsPermalink

Subtitle B--Taxes Based on Income and WagesCommentsClose CommentsPermalink

SEC. 811. PAYROLL TAX ON EMPLOYERS.

(a) In General- Section 3111 (relating to tax on employers) is amended by redesignating subsection (c) as subsection (d) and inserting after subsection (b) the following new subsection:CommentsClose CommentsPermalink





‘(c) Health Care- In addition to other taxes, there is hereby imposed on every employer an excise tax, with respect to having individuals in his employ, equal to 8.7 percent of the wages (as defined in section 3121(a)) paid by him with respect to employment (as defined in section 3121(b)).’.CommentsClose CommentsPermalink





(b) Self-Employment Income- Section 1401 (relating to rate of tax on self-employment income) is amended by redesignating subsection (c) as subsection (d) and inserting after subsection (b) the following new subsection:CommentsClose CommentsPermalink





‘(c) Health Care- In addition to other taxes, there shall be imposed for each taxable year, on the self-employment income of every individual, a tax equal to 8.7 percent of the amount of the self-employment income for such taxable year.’.CommentsClose CommentsPermalink





(c) Comparable Taxes for Railroad Services-CommentsClose CommentsPermalink





(1) TAX ON EMPLOYERS- Section 3221 is amended by redesignating subsection (c) as subsections (d) and inserting after subsection (b) the following new subsection:CommentsClose CommentsPermalink





‘(c) Health Care- In addition to other taxes, there is hereby imposed on every employer an excise tax, with respect to having individuals in his employ, equal to 8.7 percent of the compensation paid by such employer for services rendered to such employer.’.CommentsClose CommentsPermalink





(2) TAX ON EMPLOYEE REPRESENTATIVES- Section 3211 (relating to tax on employee representatives) is amended by redesignating subsection (c) as subsection (d) and inserting after subsection (b) the following new paragraph:CommentsClose CommentsPermalink





‘(c) Health Care- In addition to other taxes, there is hereby imposed on the income of each employee representative a tax equal to 8.7 percent of the compensation received during the calendar year by such employee representative for services rendered by such employee representative.’.CommentsClose CommentsPermalink





(3) NO APPLICABLE BASE- Subparagraph (A) of section 3231(e)(2) is amended by adding at the end thereof the following new clause:CommentsClose CommentsPermalink





‘(iv) HEALTH CARE TAXES- Clause (i) shall not apply to the taxes imposed by sections 3221(c) and 3211(c).’.CommentsClose CommentsPermalink





(4) TECHNICAL AMENDMENT-CommentsClose CommentsPermalink





(A) Subsection (d) of section 3211, as redesignated by paragraph (2), is amended by striking ‘and (b)’ and inserting ‘, (b), and (c)’.CommentsClose CommentsPermalink





(B) Subsection (d) of section 3221, as redesignated by paragraph (1), is amended by striking ‘and (b)’ and inserting ‘, (b), and (c)’.CommentsClose CommentsPermalink





(d) Effective Date- The amendments made by this section shall apply to remuneration paid after December 31, 2010.CommentsClose CommentsPermalink

SEC. 812. HEALTH CARE INCOME TAX.

(a) General Rule- Subchapter A of chapter 1 (relating to determination of tax liability) is amended by adding at the end thereof the following new part:CommentsClose CommentsPermalink

‘PART VIII--HEALTH CARE INCOME TAX ON INDIVIDUALS

‘Sec. 59B. Health care income tax.CommentsClose CommentsPermalink

‘SEC. 59B. HEALTH CARE INCOME TAX.

‘(a) Imposition of Tax- In the case of an individual, there is hereby imposed a tax (in addition to any other tax imposed by this subtitle) equal to 2.2 percent of the taxable income of the taxpayer for the taxable year.CommentsClose CommentsPermalink





‘(b) No Credits Against Tax; No Effect on Minimum Tax- The tax imposed by this section shall not be treated as a tax imposed by this chapter for purposes of determining--CommentsClose CommentsPermalink





‘(1) the amount of any credit allowable under this chapter, orCommentsClose CommentsPermalink





‘(2) the amount of the minimum tax imposed by section 55.CommentsClose CommentsPermalink





‘(c) Special Rules-CommentsClose CommentsPermalink





‘(1) TAX TO BE WITHHELD, ETC- For purposes of this title, the tax imposed by this section shall be treated as imposed by section 1.CommentsClose CommentsPermalink





‘(2) REIMBURSEMENT OF TAX BY EMPLOYER NOT INCLUDIBLE IN GROSS INCOME- The gross income of an employee shall not include any payment by his employer to reimburse the employee for the tax paid by the employee under this section.CommentsClose CommentsPermalink





‘(3) OTHER RULES- The rules of section 59A(d) shall apply to the tax imposed by this section.’.CommentsClose CommentsPermalink





(b) Clerical Amendment- The table of parts for subchapter A of chapter 1 is amended by adding at the end the following new item:CommentsClose CommentsPermalink

‘Part VIII--Health Care Income Tax on Individuals’.

(c) Effective Date- The amendments made by this section shall apply to taxable years beginning after December 31, 2010.CommentsClose CommentsPermalink

TITLE IX--CONFORMING AMENDMENTS TO THE EMPLOYEE RETIREMENT INCOME SECURITY ACT OF 1974CommentsClose CommentsPermalink

SEC. 901. ERISA INAPPLICABLE TO HEALTH COVERAGE ARRANGEMENTS UNDER STATE HEALTH SECURITY PROGRAMS.

Section 4 of the Employee Retirement Income Security Act of 1974 (29 U.S.C. 1003) is amended--CommentsClose CommentsPermalink





(1) in subsection (a), by striking ‘(b) or (c)’ and inserting ‘(b), (c), or (d)’; andCommentsClose CommentsPermalink





(2) by adding at the end the following new subsection:CommentsClose CommentsPermalink





‘(d) The provisions of this title shall not apply to any arrangement forming a part of a State health security program established pursuant to section 101(b) of the American Health Security Act of 2009.’.CommentsClose CommentsPermalink

SEC. 902. EXEMPTION OF STATE HEALTH SECURITY PROGRAMS FROM ERISA PREEMPTION.

Section 514(b) of the Employee Retirement Income Security Act of 1974 (29 U.S.C. 1144(b)) (as amended by sections 904(b)(3)(B) and 1002(b) of this Act) is amended by adding at the end the following new paragraph:CommentsClose CommentsPermalink





‘(8) Subsection (a) of this section shall not apply to State health security programs established pursuant to section 101(b) of the American Health Security Act of 2009.’.CommentsClose CommentsPermalink

SEC. 903. PROHIBITION OF EMPLOYEE BENEFITS DUPLICATIVE OF BENEFITS UNDER STATE HEALTH SECURITY PROGRAMS; COORDINATION IN CASE OF WORKERS’ COMPENSATION.

(a) In General- Part 5 of subtitle B of title I of the Employee Retirement Income Security Act of 1974 is amended by adding at the end the following new section:CommentsClose CommentsPermalink

‘PROHIBITION OF EMPLOYEE BENEFITS DUPLICATIVE OF STATE HEALTH SECURITY PROGRAM BENEFITS; COORDINATION IN CASE OF WORKERS’ COMPENSATION

‘Sec. 519. (a) Subject to subsection (b), no employee benefit plan may provide benefits which duplicate payment for any items or services for which payment may be made under a State health security program established pursuant to section 101(b) of the American Health Security Act of 2009.CommentsClose CommentsPermalink





‘(b)(1) Each workers compensation carrier that is liable for payment for workers compensation services furnished in a State shall reimburse the State health security plan for the State in which the services are furnished for the cost of such services.CommentsClose CommentsPermalink





‘(2) In this subsection:CommentsClose CommentsPermalink





‘(A) The term ‘workers compensation carrier’ means an insurance company that underwrites workers compensation medical benefits with respect to 1 or more employers and includes an employer or fund that is financially at risk for the provision of workers compensation medical benefits.CommentsClose CommentsPermalink





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





‘(C) The term ‘workers compensation services’ means items and services included in workers compensation medical benefits and includes items and services (including rehabilitation services and long-term-care services) commonly used for treatment of work-related injuries and illnesses.’.CommentsClose CommentsPermalink





(b) Conforming Amendment- Section 4(b) of such Act (29 U.S.C. 1003(b)) is amended by adding at the end the following: ‘Paragraph (3) shall apply subject to section 519(b) (relating to reimbursement of State health security plans by workers compensation carriers).’.CommentsClose CommentsPermalink





(c) Clerical Amendment- The table of contents in section 1 of such Act is amended by inserting after the item relating to section 518 the following new items:CommentsClose CommentsPermalink





‘Sec. 519. Prohibition of employee benefits duplicative of state health security program benefits; coordination in case of workers’ compensation.’.CommentsClose CommentsPermalink

SEC. 904. REPEAL OF CONTINUATION COVERAGE REQUIREMENTS UNDER ERISA AND CERTAIN OTHER REQUIREMENTS RELATING TO GROUP HEALTH PLANS.

(a) In General- Part 6 of subtitle B of title I of the Employee Retirement Income Security Act of 1974 (29 U.S.C. 1161 et seq.) is repealed.CommentsClose CommentsPermalink





(b) Conforming Amendments-CommentsClose CommentsPermalink





(1) Section 502(a) of such Act (29 U.S.C. 1132(a)) is amended--CommentsClose CommentsPermalink





(A) by striking paragraph (7); andCommentsClose CommentsPermalink





(B) by redesignating paragraphs (8), (9), and (10) as paragraphs (7), (8), and (9), respectively.CommentsClose CommentsPermalink





(2) Section 502(c)(1) of such Act (29 U.S.C. 1132(c)(1)) is amended by striking ‘paragraph (1) or (4) of section 606,’.CommentsClose CommentsPermalink





(3) Section 514(b) of such Act (29 U.S.C. 1144(b)) is amended--CommentsClose CommentsPermalink





(A) in paragraph (7), by striking ‘section 206(d)(3)(B)(i)),’ and all that follows and inserting ‘section 206(d)(3)(B)(i)).’; andCommentsClose CommentsPermalink





(B) by striking paragraph (8).CommentsClose CommentsPermalink





(4) The table of contents in section 1 of the Employee Retirement Income Security Act of 1974 is amended by striking the items relating to part 6 of subtitle B of title I of such Act.CommentsClose CommentsPermalink

SEC. 905. EFFECTIVE DATE OF TITLE.

The amendments made by this title shall take effect January 1, 2012.CommentsClose CommentsPermalink

TITLE X--ADDITIONAL CONFORMING AMENDMENTSCommentsClose CommentsPermalink

SEC. 1001. REPEAL OF CERTAIN PROVISIONS IN INTERNAL REVENUE CODE OF 1986.

The provisions of titles III and IV of the Health Insurance Portability and Accountability Act of 1996, other than subtitles D and H of title III and section 342, are repealed and the provisions of law that were amended or repealed by such provisions are hereby restored as if such provisions had not been enacted.CommentsClose CommentsPermalink

SEC. 1002. REPEAL OF CERTAIN PROVISIONS IN THE EMPLOYEE RETIREMENT INCOME SECURITY ACT OF 1974.

(a) In General- Part 7 of subtitle B of title I of the Employee Retirement Income Security Act of 1974 is repealed and the items relating to such part in the table of contents in section 1 of such Act are repealed.CommentsClose CommentsPermalink





(b) Conforming Amendment- Section 514(b) of such Act (29 U.S.C. 1144(b)) is amended by striking paragraph (9).CommentsClose CommentsPermalink

SEC. 1003. REPEAL OF CERTAIN PROVISIONS IN THE PUBLIC HEALTH SERVICE ACT AND RELATED PROVISIONS.

(a) In General- Titles XXII and XXVII of the Public Health Service Act are repealed.CommentsClose CommentsPermalink





(b) Additional Amendments-CommentsClose CommentsPermalink





(1) Section 1301(b) of such Act (42 U.S.C. 300e(b)) is amended by striking paragraph (6).CommentsClose CommentsPermalink





(2) Sections 104 and 191 of the Health Insurance Portability and Accountability Act of 1996 are repealed.CommentsClose CommentsPermalink

SEC. 1004. EFFECTIVE DATE OF TITLE.

The amendments made by this title shall take effect January 1, 2013.CommentsClose CommentsPermalink