S 915
112th CONGRESS
1st Session
S. 915
To provide for health care for every American and to control
the cost and enhance the quality of the health care system.
IN THE SENATE OF THE UNITED STATES
May 9, 2011
Mr. SANDERS introduced the following bill; which was read twice and
referred to the Committee on Finance
A BILL
To provide for health care for every American and to control
the cost and enhance the quality of the health care system.
Be it enacted by the Senate and House of Representatives of the
United States of America in Congress assembled,
SECTION 1. SHORT TITLE.
This Act may be cited as the `American Health Security Act of 2011'.
SEC. 2. FINDINGS; SENSE OF THE SENATE.
(a) Findings- Congress finds as follows:
(1) While the United States of America spends on average nearly twice
as much per capita on health care services as the next most costly
nation, the United States ranks 32d among all nations on life expectancy,
and 41st on infant mortality.
(2) The number of uninsured Americans rose by more than 4,000,000
between 2008 and 2009 to a total of 51,000,000, or more than 1 of
every 6 Americans.
(3) This rise in the number of uninsured Americans was the largest
single-year increase since 1987 and was the result of a continued
decline in private health coverage, primarily in employer-sponsored
insurance.
(4) Small businesses around the country cannot afford to reinvest
in their companies and create new jobs because their health care bills
are going up 10 or 15 percent every year.
(5) American businesses are at an economic disadvantage, because their
health care costs are so much higher than in other countries. Notably,
automobile manufacturers spend more on health care per automobile
than on steel.
(b) Sense of the Senate Concerning Urgency of a Medicare-for-All Type
Single Payer Health Care System- It is the sense of the Senate that
the 112th Congress should enact a Medicare-for-All Single Payer Health
Care System to make American companies more competitive and to stimulate
job creation.
(c) Sense of the Senate Concerning the Status of Health Care- It is
the sense of the Senate that the 112th Congress should recognize and
proclaim that health care is a human right.
(d) Sense of the Senate Concerning State Flexibility- It is the sense
of the Senate that in order to provide high quality health care coverage
for all Americans while controlling costs in order to make American
companies more competitive, individual States should be given maximum
flexibility in designing health care programs to improve the individual
experience of care and the health of populations, and to reduce the
per capita costs of care for each State.
(e) Sense of the Senate Concerning a New Health Care System- It is the
sense of the Senate that--
(1) a new single payer health care system should build on achievements
and commitments in the Patient Protection and Affordable Care Act
(Public Law 111-148) and the Health Care and Education Reconciliation
Act of 2010 (Public Law 111-152), to strengthen primary care and public
health, to raise the quality of patient care, to develop new models
of patient care, to develop the capacity of the healthcare workforce,
to increase transparency in the payment of health care system costs,
and to strengthen enforcement against fraud and abuse;
(2) the possibilities of achieving efficiencies through integrated
care are within reach with the spread of electronic support systems,
health information exchanges, and the possibilities for virtual integration
and instant communication; and
(3) policies should be put in place to ensure higher quality, better
prevention, and lower per capita costs, including--
(A) global budget caps on total health care spending;
(B) measurement of and fixed accountability for the health status
and health needs of designated populations;
(C) improved standardized measures of care and per capita costs
across sites and through time that are transparent; and
(D) changes in professional education curricula to ensure that clinicians
are enabled to change and improve their processes of care.
SEC. 3. TABLE OF CONTENTS.
The table of contents of this Act is as follows:
Sec. 2. Findings; sense of the Senate.
Sec. 3. Table of contents.
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.
Sec. 102. Universal entitlement.
Sec. 104. Portability of benefits.
Sec. 105. Effective date of benefits.
Sec. 106. Relationship to existing Federal health programs.
Sec. 107. Repeal of provisions related to the State exchanges.
TITLE II--COMPREHENSIVE BENEFITS, INCLUDING PREVENTIVE BENEFITS AND
BENEFITS FOR LONG-TERM CARE
Sec. 201. Comprehensive benefits.
Sec. 202. Definitions relating to services.
Sec. 203. Special rules for home and community-based long-term care
services.
Sec. 204. Exclusions and limitations.
Sec. 205. Certification; quality review; plans of care.
TITLE III--PROVIDER PARTICIPATION
Sec. 301. Provider participation and standards.
Sec. 302. Qualifications for providers.
Sec. 303. Qualifications for comprehensive health service organizations.
Sec. 304. Limitation on certain physician referrals.
TITLE IV--ADMINISTRATION
Subtitle A--General Administrative Provisions
Sec. 401. American Health Security Standards Board.
Sec. 402. American Health Security Advisory Council.
Sec. 404. State health security programs.
Sec. 405. Complementary conduct of related health programs.
Subtitle B--Control Over Fraud and Abuse
Sec. 411. Application of Federal sanctions to all fraud and abuse
under American Health Security Program.
Sec. 412. Requirements for operation of State health care fraud and
abuse control units.
TITLE V--QUALITY ASSESSMENT
Sec. 501. American Health Security Quality Council.
Sec. 502. Development of certain methodologies, guidelines, and standards.
Sec. 503. State quality review programs.
Sec. 504. Elimination of utilization review programs; transition.
Sec. 505. Application of Center for Medicare and Medicaid Innovation
to American Health Security Program.
TITLE VI--HEALTH SECURITY BUDGET; PAYMENTS; COST CONTAINMENT MEASURES
Subtitle A--Budgeting and Payments to States
Sec. 601. National health security budget.
Sec. 602. Computation of individual and State capitation amounts.
Sec. 603. State health security budgets.
Sec. 604. Federal payments to States.
Sec. 605. Account for health professional education expenditures.
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.
Sec. 612. Payments to health care practitioners based on prospective
fee schedule.
Sec. 613. Payments to comprehensive health service organizations.
Sec. 614. Payments for community-based primary health services.
Sec. 615. Payments for prescription drugs.
Sec. 616. Payments for approved devices and equipment.
Sec. 617. Payments for other items and services.
Sec. 618. Payment incentives for medically underserved areas.
Sec. 619. Authority for alternative payment methodologies.
Subtitle C--Mandatory Assignment and Administrative Provisions
Sec. 631. Mandatory assignment.
Sec. 632. Procedures for reimbursement; appeals.
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.
Sec. 702. Grants for health professions education, nurse education,
and the National Health Service Corps.
Subtitle B--Direct Health Care Delivery
Sec. 711. Set-aside for public health.
Sec. 712. Set-aside for primary health care delivery.
Sec. 713. Primary care service expansion grants.
Subtitle C--Primary Care and Outcomes Research
Sec. 721. Set-aside for outcomes research.
Sec. 722. Office of Primary Care and Prevention Research.
Subtitle D--School-Related Health Services
Sec. 731. Authorizations of appropriations.
Sec. 732. Eligibility for development and operation grants.
Sec. 734. Grants for development of projects.
Sec. 735. Grants for operation of projects.
Sec. 736. Federal administrative costs.
TITLE VIII--FINANCING PROVISIONS; AMERICAN HEALTH SECURITY TRUST FUND
Sec. 800. Amendment of 1986 code; Section 15 not to apply.
Subtitle A--American Health Security Trust Fund
Sec. 801. American Health Security Trust Fund.
Subtitle B--Taxes Based on Income and Wages
Sec. 811. Payroll tax on employers.
Sec. 812. Health care income tax.
Sec. 813. Surcharge on high income individuals.
Subtitle C--Other Financing Provisions
Sec. 821. Tax on Securities Transactions.
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.
Sec. 902. Exemption of State health security programs from ERISA preemption.
Sec. 903. Prohibition of employee benefits duplicative of benefits
under State health security programs; coordination in case of workers'
compensation.
Sec. 904. Repeal of continuation coverage requirements under ERISA
and certain other requirements relating to group health plans.
Sec. 905. Effective date of title.
TITLE X--ADDITIONAL CONFORMING AMENDMENTS
Sec. 1001. Repeal of certain provisions in Internal Revenue Code of
1986.
Sec. 1002. Repeal of certain provisions in the Employee Retirement
Income Security Act of 1974.
Sec. 1003. Repeal of certain provisions in the Public Health Service
Act and related provisions.
Sec. 1004. Effective date of title.
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.
(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.
(b) State Health Security Programs- In order for a State to be eligible
to receive payment under section 604, a State shall establish a State
health security program in accordance with this Act.
(1) IN GENERAL- In this Act, subject to paragraph (2), the term `State'
means each of the 50 States and the District of Columbia.
(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.
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.
(b) Treatment of Certain Nonimmigrants-
(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.
(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.
(c) Treatment of Other Individuals-
(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--
(A) to preserve the public health of communities;
(B) to compensate States for the additional health care financing
burdens created by such individuals; and
(C) to prevent adverse financial and medical consequences of uncompensated
care,
while inhibiting travel and immigration to the United States for the
sole purpose of obtaining health care services.
(2) BY STATES- Any State health security program may make individuals
described in paragraph (1) eligible for benefits at the expense of
the State.
(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).
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--
(1) include a process for the automatic enrollment of individuals
at the time of birth in the United States and at the time of legal
immigration into the United States or other acquisition of lawful
resident status in the United States;
(2) provide for the enrollment, as of January 1, 2013, of all individuals
who are eligible to be enrolled as of such date; and
(3) include a process for the enrollment of individuals made eligible
for health care services under subsections (b) and (c) of section
102.
(b) Availability of Applications- Each State health security program
shall make applications for enrollment under the program available--
(1) at employment and payroll offices of employers located in the
State;
(2) at local offices of the Social Security Administration;
(3) at social services locations;
(4) at out-reach sites (such as provider and practitioner locations,
especially community health centers); and
(5) at other locations (including post offices and schools) accessible
to a broad cross-section of individuals eligible to enroll.
(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 (to be referred
to as a `smart 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).
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--
(1) shall not impose any minimum period of residence in the State
before residents of the State are entitled to, or eligible for, such
benefits under the program;
(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; and
(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:
(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.
(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.
(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.
SEC. 105. EFFECTIVE DATE OF BENEFITS.
Benefits shall first be available under this Act for items and services
furnished on or after January 1, 2013.
SEC. 106. RELATIONSHIP TO EXISTING FEDERAL HEALTH PROGRAMS.
(a) Medicare, Medicaid and State Children's Health Insurance Program
(SCHIP)-
(1) IN GENERAL- Notwithstanding any other provision of law, subject
to paragraph (2)--
(A) no benefits shall be available under title XVIII of the Social
Security Act for any item or service furnished after December 31,
2012;
(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;
(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; and
(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.
(2) TRANSITION- In the case of inpatient hospital services and extended
care services during a continuous period of stay which began before
January 1, 2013, 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.
(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, 2012.
(c) TRICARE- 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, 2012.
(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.
(e) Treatment of Premium Credits, Cost-Sharing Reductions, and Small
Employer Credits-
(1) IN GENERAL- For each calendar year, the Secretary of the Treasury
shall transfer to the American Health Security Trust Fund an amount
equal to the sum of--
(A) the premium assistance credit amount which would have been allowable
to taxpayers residing in such State in such calendar year under
section 36B of the Internal Revenue Code of 1986 (relating to refundable
credit for coverage under a qualified health plan), as added by
section 1401 of the Patient Protection and Affordable Care Act,
if such section were in effect for such year,
(B) the amount of cost-sharing reductions which would have been
required with respect to eligible insured residing in such State
in such calendar year under section 1402 of the Patient Protection
and Affordable Care Act if such section were in effect for such
year, plus
(C) the amount of tax credits which would have been allowable to
eligible small employers doing business in such State in such calendar
year under section 45R of the Internal Revenue Code of 1986 if such
section were in effect for such calendar year.
(2) DETERMINATION- The amounts determined under paragraph (1) shall
be estimated by the Secretary of the Treasury in consultation with
the Secretary of Health and Human Services.
SEC. 107. REPEAL OF PROVISIONS RELATED TO THE STATE EXCHANGES.
Title I of the Patient Protection and Affordable Care Act (Public Law
111-148) (and the amendments made by title I) is repealed.
TITLE II--COMPREHENSIVE BENEFITS, INCLUDING PREVENTIVE BENEFITS AND
BENEFITS FOR LONG-TERM CARE
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:
(1) HOSPITAL SERVICES- Inpatient and outpatient hospital care, including
24-hour-a-day emergency services.
(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.
(3) COMMUNITY-BASED PRIMARY HEALTH SERVICES- Community-based primary
health services (as defined in section 202(a)).
(4) PREVENTIVE SERVICES- Preventive services (as defined in section
202(b)).
(5) LONG-TERM, ACUTE, AND CHRONIC CARE SERVICES-
(A) Nursing facility services.
(B) Home health services.
(C) Home and community-based long-term care services (as defined
in section 202(c)) for individuals described in section 203(a).
(E) Services in intermediate care facilities for individuals with
an intellectual disability.
(6) PRESCRIPTION DRUGS, BIOLOGICALS, INSULIN, MEDICAL FOODS-
(A) Outpatient prescription drugs and biologics, as specified by
the Board consistent with section 615.
(C) Medical foods (as defined in section 202(e)).
(7) DENTAL SERVICES- Dental services (as defined in section 202(h)).
(8) MENTAL HEALTH AND SUBSTANCE ABUSE TREATMENT SERVICES- Mental health
and substance abuse treatment services (as defined in section 202(f)).
(9) DIAGNOSTIC TESTS- Diagnostic tests.
(10) OTHER ITEMS AND SERVICES-
(A) OUTPATIENT THERAPY- Outpatient physical therapy services, outpatient
speech pathology services, and outpatient occupational therapy services
in all settings.
(B) DURABLE MEDICAL EQUIPMENT- Durable medical equipment.
(C) HOME DIALYSIS- Home dialysis supplies and equipment.
(D) AMBULANCE- Emergency ambulance service.
(E) PROSTHETIC DEVICES- Prosthetic devices, including replacements
of such devices.
(F) ADDITIONAL ITEMS AND SERVICES- Such other medical or health
care items or services as the Board may specify.
(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.
(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.
(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.
(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.
(f) Taft-Hartley and MEW Benefit Plans- Notwithstanding any other provision
of law, a health plan may be provided for under a collective bargaining
agreement or a MEWA if such plan is limited to coverage that is supplemental
to the coverage provided for under the State-based American Health Security
Program and available only to employees or their dependents or to retirees
or their dependents.
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--
(1) by a rural health clinic;
(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;
(3) in a school-based setting;
(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;
and
(5) public and private nonprofit entities receiving Federal assistance
under the Public Health Service Act.
(1) IN GENERAL- In this title, the term `preventive services' means
items and services--
(i) are specified in paragraph (2); or
(ii) the Board determines to be effective in the maintenance and
promotion of health or minimizing the effect of illness, disease,
or medical condition; and
(B) which are provided consistent with the periodicity schedule
established under paragraph (3).
(2) SPECIFIED PREVENTIVE SERVICES- The services specified in this
paragraph are as follows:
(A) Immunizations recommended by the Advisory Committee on Immunization
Practices of the Centers for Disease Control and Prevention.
(B) Prenatal and well-baby care (for infants under 1 year of age).
(C) Well-child care (including periodic physical examinations, hearing
and vision screening, and developmental screening and examinations)
for individuals under 18 years of age, including evidence-informed
preventive care and screenings included in the comprehensive guidelines
of the Health Resources and Services Administration.
(D) Periodic screening mammography, Pap smears, and colorectal examinations
and examinations for prostate cancer.
(E) Physical examinations.
(F) Family planning services.
(G) Routine eye examinations, eyeglasses, and contact lenses.
(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.
(I) Evidence-based items or services that have in effect a rating
of `A' or `B' in the current recommendations of the United States
Preventive Services Task Force.
(J) With respect to women, such additional preventive care and screenings
not described in subparagraph (I) that are included in the comprehensive
guidelines of the Health Resources and Services Administration.
(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.
(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:
(1) Home health aide services.
(2) Adult day health care, social day care or psychiatric day care.
(3) Medical social work services.
(4) Care coordination services, as defined in subsection (g)(1).
(5) Respite care, including training for informal caregivers.
(6) Personal assistance services, and homemaker services (including
meals) incidental to the provision of personal assistance services.
(d) Home Health Services-
(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.
(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.
(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.
(f) Mental Health and Substance Abuse Treatment Services-
(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:
(A) INPATIENT HOSPITAL SERVICES- Inpatient hospital services furnished
primarily for the diagnosis or treatment of mental illness or substance
abuse 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).
(B) INTENSIVE RESIDENTIAL SERVICES- Intensive residential services
(as defined in paragraph (2)).
(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).
(D) INTENSIVE COMMUNITY-BASED SERVICES- Intensive community-based
services (as described in paragraph (3)).
(2) INTENSIVE RESIDENTIAL SERVICES DEFINED-
(A) IN GENERAL- Subject to subparagraphs (B) and (C), the term `intensive
residential services' means inpatient services provided in any of
the following facilities:
(i) Residential detoxification centers.
(ii) Crisis residential programs or mental illness residential
treatment programs.
(iii) Therapeutic family or group treatment homes.
(iv) Residential centers for substance abuse treatment.
(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--
(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; and
(ii) meets such other requirements as the Secretary may impose
to ensure the quality of the intensive residential services provided.
(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).
(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.
(3) INTENSIVE COMMUNITY-BASED SERVICES DEFINED-
(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.
(B) ITEMS AND SERVICES DESCRIBED- The items and services described
in this subparagraph are--
(i) partial hospitalization services consisting of the items and
services described in subparagraph (C);
(ii) psychiatric rehabilitation services;
(iii) day treatment services for individuals under 19 years of
age;
(v) case management services, including collateral services designated
as such case management services by the Secretary;
(vi) ambulatory detoxification services; and
(vii) such other items and services as the Secretary may provide
(but in no event to include meals and transportation),
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).
(C) ITEMS AND SERVICES INCLUDED AS PARTIAL HOSPITALIZATION SERVICES-
For purposes of subparagraph (B)(i), partial hospitalization services
consist of the following:
(i) Individual and group therapy with physicians or psychologists
(or other mental health professionals to the extent authorized
under State law).
(ii) Occupational therapy requiring the skills of a qualified
occupational therapist.
(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).
(iv) Drugs and biologicals furnished for therapeutic purposes
(which cannot, as determined in accordance with regulations, be
self-administered).
(v) Individualized activity therapies that are not primarily recreational
or diversionary.
(vi) Family counseling (the primary purpose of which is treatment
of the individual's condition).
(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).
(viii) Diagnostic services.
(D) PROGRAMS DESCRIBED- A program described in this subparagraph
is a program (whether facility-based or freestanding) which is furnished
by an entity--
(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; and
(ii) meeting such other requirements as the Secretary may impose
to ensure the quality of the intensive community-based services
provided.
(g) Care Coordination Services-
(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
and services offered through medical homes to ensure appropriate,
cost-effective utilization of such services in a comprehensive and
continuous manner, and includes--
(A) transition management between inpatient facilities and community-based
services, including assisting patients in identifying and gaining
access to appropriate ancillary services; and
(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.
(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--
(i) is capable of performing directly, efficiently, and effectively
the duties of a care coordinator described in paragraph (1); and
(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.
(B) INDEPENDENCE- State health security programs shall establish
safeguards to ensure 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.
(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).
(1) IN GENERAL- In this title, subject to subsection (b), the term
`dental services' means the following:
(A) Emergency dental treatment, including extractions, for bleeding,
pain, acute infections, and injuries to the maxillofacial region.
(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.
(C) Treatment of dental disease, including non-cast fillings, periodontal
maintenance services, and endodontic services.
(D) Space maintenance procedures to prevent orthodontic complications.
(E) Orthodontic treatment to prevent severe malocclusions.
(G) Medically necessary oral health care.
(H) Any items and services for special needs patients that are not
described in subparagraphs (A) through (G) and that--
(i) are required to provide such patients the items and services
described in subparagraphs (A) through (G);
(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);
(iii) consist of orthodontic care for severe dentofacial abnormalities;
or
(iv) consist of prosthetic dental devices for genetic or birth
defects or fitting for such devices.
(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.
(2) LIMITATIONS- Dental services are subject to the following limitations:
(A) PREVENTION AND DIAGNOSIS-
(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.
(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.
(B) TREATMENT OF DENTAL DISEASE- Prior to January 1, 2018, 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.
(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--
(i) are limited to posterior teeth;
(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; and
(iii) do not include a space maintainer that is placed within
6 months of the expected eruption of the permanent posterior tooth
concerned.
(3) DEFINITIONS- For purposes of this title:
(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.
(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.
(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.
(j) Services in Intermediate Care Facilities for Individuals With an
Intellectual Disability- Except as may be provided by the Board--
(1) the term `intermediate care facility for individuals with an intellectual
disability' has the meaning given the term `intermediate care facility
for individuals with mental retardation' in section 1905(d) of the
Social Security Act (as in effect before the enactment of this Act);
and
(2) the term `services in intermediate care facilities for individuals
with an intellectual disability' means services described in section
1905(a)(15) of such Act (as so in effect) in an intermediate care
facility for individuals with an intellectual disability 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).
(k) Other Terms- Except as may be provided by the Board, the definitions
contained in section 1861 of the Social Security Act shall apply.
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:
(1) ADULTS- Individuals 18 years of age or older determined (in a
manner specified by the Board)--
(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)--
(v) transferring in and out of a bed or in and out of a chair;
(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; or
(C) due to cognitive or mental impairments, to require queuing to
perform activities of daily living.
(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.
(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.
(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.
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).
(b) Special Delivery Requirements for Mental Health and Substance Abuse
Treatment Services Provided to At-Risk Children-
(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--
(A) the services are provided to an individual less than 22 years
of age;
(B) the individual has a serious emotional disturbance or a substance
abuse disorder; and
(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.
(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:
(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).
(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.
(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.
(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.
(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.
(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.
(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.
(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.
(e) Specific Limitations-
(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.
(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.
(3) MISCELLANEOUS EXCLUSIONS FROM COVERED SERVICES- Covered services
under this Act do not include the following:
(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--
(i) required to correct a congenital anomaly;
(ii) required to restore or correct a part of the body which has
been altered as a result of accidental injury, disease, or surgery;
or
(iii) otherwise determined to be medically necessary and appropriate
under section 201(a).
(B) Personal comfort items or private rooms in inpatient facilities,
unless determined to be medically necessary and appropriate under
section 201(a).
(C) The services of a professional practitioner if they are furnished
in a hospital or other facility which is not a participating provider.
(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.
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.
(b) Quality Review- For the 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).
(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.
TITLE III--PROVIDER PARTICIPATION
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--
(1) is a qualified provider of the services under section 302;
(2) has filed with the State health security program a participation
agreement described in subsection (b); and
(3) meets such other qualifications and conditions as are established
by the Board or the State health security program under this Act.
(b) Requirements in Participation Agreement-
(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:
(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.
(B) No charge will be made for any covered services other than for
payment authorized by this Act.
(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--
(i) quality review by designated entities;
(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);
(iii) statistical or other studies required for the implementation
of this Act; and
(iv) such other purposes as the Board or State may specify.
(D) The provider agrees not to bill the program for any services
for which benefits are not available because of section 204(d).
(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.
(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.
(2) TERMINATION OF PARTICIPATION AGREEMENTS-
(A) IN GENERAL- Participation agreements may be terminated, with
appropriate notice--
(i) by the Board or a State health security program for failure
to meet the requirements of this title; or
(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.
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--
(1) all the requirements of State law to provide such services;
(2) applicable requirements of Federal law to provide such services;
and
(3) any applicable standards established under subsection (b).
(b) Minimum Provider Standards-
(1) IN GENERAL- The Board shall establish, evaluate, and update national
minimum standards to ensure the quality of services provided under
this Act and to monitor efforts by State health security programs
to ensure the quality of such services. A State health security program
may also establish additional minimum standards which providers shall
meet.
(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
(42 U.S.C. 1395 et seq.). Such standards also may include, where appropriate,
elements relating to--
(A) adequacy and quality of facilities;
(B) training and competence of personnel (including continuing education
requirements);
(C) comprehensiveness of service;
(D) continuity of service;
(E) patient satisfaction (including waiting time and access to services);
and
(F) performance standards (including organization, facilities, structure
of services, efficiency of operation, and outcome in palliation,
improvement of health, stabilization, cure, or rehabilitation).
(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.
(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.
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--
(1) a full range of health services (as identified by the Board),
including at least hospital services and physicians services; and
(2) out-of-area coverage in the case of urgently needed services;
to an identified population which is living in or near a specified service
area and which enrolls voluntarily in the organization.
(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.
(2) MINIMUM ENROLLMENT PERIOD- Subject to paragraph (3), the minimum
period of enrollment with a CHSO shall be 1 year, unless the enrolled
individual becomes ineligible to enroll with the organization.
(3) WITHDRAWAL FOR CAUSE- Each CHSO shall permit an enrolled individual
to disenroll from the organization for cause at any time.
(c) Requirements for CHSOs-
(1) ACCESSIBLE SERVICES- Each CHSO shall make all health services
readily and promptly accessible to enrollees who live in the specified
service area.
(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.
(3) BOARD OF DIRECTORS- In the case of a CHSO that is a private organization--
(A) CONSUMER REPRESENTATION- At least one-third of the members of
the CHSO's board of directors shall be consumer members with no
direct or indirect, personal or family financial relationship to
the organization.
(B) PROVIDER REPRESENTATION- The CHSO's board of directors shall
include at least one member who represents health care providers.
(4) PATIENT GRIEVANCE PROGRAM- Each CHSO shall have in effect a patient
grievance program and shall conduct regularly surveys of the satisfaction
of members with services provided by or through the organization.
(5) MEDICAL STANDARDS- Each CHSO shall 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).
(6) QUALITY AND OTHER REPORTING REQUIREMENTS-
(A) IN GENERAL- The Board shall determine appropriate measures to
assess the quality of care furnished by the CHSO, such as measures
of--
(i) clinical processes and outcomes;
(ii) patient and, where practicable, caregiver experience of care;
and
(iii) utilization (such as rates of hospital admissions for ambulatory
care sensitive conditions).
(B) OTHER DUTIES- The CHSO shall--
(i) define processes to promote evidence-based medicine and patient
engagement, report on quality and cost measures, and coordinate
care, such as through the use of telehealth, remote patient monitoring,
and other such enabling technologies; and
(ii) demonstrate to the Board that the CHSO meets patient-centeredness
criteria specified by the Board, such as the use of patient and
caregiver assessments or the use of individualized care plans.
(C) REPORTING REQUIREMENTS- A CHSO shall submit data in a form and
manner specified by the Board on measures the Board determines necessary
for the CHSO to report to the State Health Security Program in order
to evaluate the quality of care furnished by the CHSO. Such data
may include care transitions across health care settings, including
hospital discharge planning and post-hospital discharge follow-up
by CHSO professionals, as the Board determines appropriate.
(D) QUALITY PERFORMANCE STANDARDS- The Board shall establish quality
performance standards to assess the quality of care furnished by
CHSOs and shall seek to improve the quality of care furnished by
CHSOs over time by specifying higher standards, new measures, or
both for purposes of assessing such quality of care.
(7) PREMIUMS- Premiums or other charges by a CHSO for any services
not paid for under this Act shall be reasonable.
(8) UTILIZATION AND BONUS INFORMATION- Each CHSO shall--
(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); and
(B) make available to its membership utilization information and
data regarding financial performance, including bonus or incentive
payment arrangements to practitioners.
(9) 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.
(10) BROAD MARKETING- Each CHSO shall 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.
(11) ADDITIONAL REQUIREMENTS- Each CHSO shall meet--
(A) such requirements relating to minimum enrollment;
(B) such requirements relating to financial solvency;
(C) such requirements relating to quality and availability of care;
and
(D) such other requirements,
as the Board or a State health security program may specify.
(d) Provision of Emergency Services to Nonenrollees- A CHSO may furnish
emergency services to persons who are not enrolled in the organization.
Payment by the State Health Security Program 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.
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.
(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:
`(N) Home infusion therapy services.'.
(c) Conforming Amendments- Section 1877 of such Act is further amended--
(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';
(2) in subsection (a)(1)(B), by striking `under this title';
(3) by amending paragraph (1) of subsection (g) to read as follows:
`(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.'; and
(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)'.
TITLE IV--ADMINISTRATION
Subtitle A--General Administrative Provisions
SEC. 401. AMERICAN HEALTH SECURITY STANDARDS BOARD.
(a) Establishment- There is hereby established an American Health Security
Standards Board.
(b) Appointment and Terms of Members-
(1) IN GENERAL- The Board shall be composed of--
(A) the Secretary of Health and Human Services; and
(B) 6 other individuals (described in paragraph (2)) appointed by
the President with the advice and consent of the Senate.
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, 2012.
(2) SELECTION OF APPOINTED MEMBERS- With respect to the individuals
appointed under paragraph (1)(B):
(A) The members shall be chosen on the basis of backgrounds in health
policy, health economics, the health professions, and the administration
of health care institutions.
(B) The members 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.
(C) At least 1 member shall have a nursing background.
(D) Not more than 3 members shall be from the same political party.
(E) To the greatest extent feasible, the members 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.
(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.
(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.
(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.
(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.
(4) REMOVAL FOR CAUSE- Upon confirmation, members of the Board may
not be removed except by the President for cause.
(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.
(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.
(f) General Duties of the Board-
(1) IN GENERAL- The Board shall develop policies, procedures, guidelines,
and requirements to carry out this Act, including those related to--
(D) provider participation standards and qualifications, as defined
in title III;
(F) national and State funding levels;
(G) methods for determining amounts of payments to providers of
covered services, consistent with subtitle B of title VI;
(H) the determination of medical necessity and appropriateness with
respect to coverage of certain services;
(I) assisting State health security programs with planning for capital
expenditures and service delivery;
(J) planning for health professional education funding (as specified
in title VI);
(K) allocating funds provided under title VII; and
(L) encouraging States to develop regional planning mechanisms (described
in section 404(a)(3)).
(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.
(g) Uniform Reporting Standards; Annual Report; Studies-
(1) UNIFORM REPORTING STANDARDS-
(A) IN GENERAL- The Board shall establish uniform State reporting
requirements and national 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.
(B) REPORTS- The Board shall analyze regularly information reported
to it, and to State health security programs pursuant to such requirements
and standards.
(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:
(A) The status of implementation of the Act.
(B) Enrollment under this Act.
(C) Benefits under this Act.
(D) Expenditures and financing under this Act.
(E) Cost-containment measures and achievements under this Act.
(G) Health care utilization patterns, including any changes attributable
to the program.
(H) Long-range plans and goals for the delivery of health services.
(I) Differences in the health status of the populations of the different
States, including income and racial characteristics.
(J) Necessary changes in the education of health personnel.
(K) Plans for improving service to medically underserved populations.
(L) Transition problems as a result of implementation of this Act.
(M) Opportunities for improvements under this Act.
(3) STATISTICAL ANALYSES AND OTHER STUDIES- The Board may, either
directly or by contract--
(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;
(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;
(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;
(D) develop and test, for use by providers of services, records
and information retrieval systems useful in the furnishing of preventive
or diagnostic services;
(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; and
(F) conduct or solicit other studies as it may consider necessary
or promising for the evaluation, or for the improvement, of the
operation of this Act.
(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 Congress one or more proposals for the treatment
of health care facilities of the Federal Government.
(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.
(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--
(A) the issuance of regulations; or
(B) the determination of the availability of funds and their allocation
to implement this Act.
(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.
(i) Inspector General- The Inspector General Act of 1978 (5 U.S.C. App.)
is amended--
(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;';
(2) in section 12(2), by inserting after `Resolution Trust Corporation,'
the following: `the American Health Security Standards Board,'; and
(3) by inserting before section 9 the following:
`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.'.
(j) Staff- The Board shall employ such staff as the Board may deem necessary.
(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.
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.
(b) Membership- The Council shall be composed of--
(1) the Chair of the Board, who shall serve as Chair of the Council;
and
(2) 20 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.
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.
(c) Terms of Members- Each appointed member shall hold office for a
term of 4 years, except that--
(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; and
(2) the terms of the members first taking office shall expire, as
designated by the Board at the time of appointment, at the end of
the first year with respect to 5 members, at the end of the second
year with respect to 5 members, at the end of the third year with
respect to 5 members, and at the end of the fourth year with respect
to 5 members after the date of enactment of this Act.
(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.
(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.
(3) REAPPOINTMENT- The Board may reappoint an appointed member of
the Council for a second term in the same manner as the original appointment.
(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.
(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.
(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.
(1) IN GENERAL- It shall be the duty of the Council--
(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; and
(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.
(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.
(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.
(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.
(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.
(j) FACA Not Applicable- The provisions of the Federal Advisory Committee
Act shall not apply to the Council.
SEC. 403. CONSULTATION.
The Secretary and the Board shall consult with Federal agencies and
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 ensure 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.
SEC. 404. STATE HEALTH SECURITY PROGRAMS.
(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.
(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.
(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.
(4) STATES THAT FAIL TO SUBMIT A PLAN- In the case of a State that
fails to submit a plan as required under this subsection, the American
Health Security Standards Board Authority shall develop a plan for
a State health security program in such State.
(b) Review and Approval of Plans-
(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:
(A) Payment for required health services for eligible individuals
in the State in accordance with this Act.
(B) Adequate administration, including the designation of a single
State agency responsible for the administration (or supervision
of the administration) of the program.
(C) The establishment of a State health security budget.
(D) Establishment of payment methodologies (consistent with subtitle
B of title VII).
(E) Assurances that individuals have the freedom to choose practitioners
and other health care providers for services covered under this
Act.
(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--
(i) ensures participation of consumers of health services and
providers of health services; and
(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.
(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.
(H) Establishment of a quality review system in accordance with
section 503.
(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.
(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, the needs of medically underserved populations, and the
information required in the annual report under section 401(g)(2).
(K) Provision of a fraud and abuse prevention and control unit that
the Inspector General determines meets the requirements of section
412(a).
(L) Prohibit payment in cases of prohibited physician referrals
under section 304.
(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.
(c) State Health Security Advisory Councils-
(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.
(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.
(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.
(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.
(d) State Use of Fiscal Agents-
(1) IN GENERAL- Each State health security program, using competitive
bidding procedures, may enter into such contracts with qualified entities,
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.
(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.
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.
Subtitle B--Control Over Fraud and Abuse
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):
(1) Section 1128 (relating to exclusion of individuals and entities).
(2) Section 1128A (civil monetary penalties).
(3) Section 1128B (criminal penalties).
(4) Section 1124 (relating to disclosure of ownership and related
information).
(5) Section 1126 (relating to disclosure of certain owners).
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 shall 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).
(b) Structure of Unit- The fraud unit shall--
(1) be a single identifiable entity of the State government;
(2) be separate and distinct from the State agency with principal
responsibility for the administration of the State health security
program; and
(3) meet 1 of the following requirements:
(A) It shall 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.
(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--
(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; and
(ii) assure its assistance of, and coordination with, such authority
or authorities in such prosecutions.
(C) It shall 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.
(c) Functions- The fraud unit shall--
(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;
(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; and
(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.
(d) Resources- The fraud unit shall--
(1) employ such auditors, attorneys, investigators, and other necessary
personnel;
(2) be organized in such a manner; and
(3) provide sufficient resources (as specified by the Board),
as is necessary to promote the effective and efficient conduct of the
unit's activities.
(e) Cooperative Agreements- The fraud unit shall have cooperative agreements
(as specified by the Board) with--
(1) similar fraud units in other States;
(2) the Inspector General; and
(3) the Attorney General of the United States.
(f) Reports- The fraud unit shall 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.
TITLE V--QUALITY ASSESSMENT
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').
(b) Duties of the Council- The Council shall perform the following duties:
(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.
(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.
(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 ensure national consistency in quality standards.
(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).
(5) OTHER FUNCTIONS- The Council shall perform the functions of the
Council described in section 502.
(c) Appointment and Terms of Members-
(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, 2012.
(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.
(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.
(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.
(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.
(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.
(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.
(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.
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)).
(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.
(c) Remedial Actions- The Council shall develop standards for education
and sanctions with respect to outliers so as to ensure 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.
(d) Dissemination- The Council shall disseminate to the State--
(1) the methodologies adopted under subsection (a);
(2) the guidelines developed under subsection (b); and
(3) the standards developed under subsection (c);
for use by the States under section 503.
(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.
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).
(1) IN GENERAL- The Council shall establish standards with respect
to--
(A) the adoption of practice guidelines (whether developed by the
Federal Government or other entities);
(B) the identification of outliers (consistent with methodologies
adopted under section 502(a));
(C) the development of remedial programs and monitoring for outliers;
and
(D) the application of sanctions (consistent with the standards
developed under section 502(c)).
(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.
(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).
(d) Internal Quality Review- Nothing in this section shall preclude
an institutional provider from establishing its own internal quality
review and enhancement programs.
SEC. 504. ELIMINATION OF UTILIZATION REVIEW PROGRAMS; TRANSITION.
(a) Intent- It is the intention of this title to replace by January
1, 2015, random utilization controls with a systematic review of patterns
of practice that compromise the quality of care.
(b) Superseding Case Reviews-
(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.
(2) TRANSITION- Before January 1, 2015, 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.
(3) CONSTRUCTION- Nothing in this subsection shall be construed--
(A) as precluding the case-by-case review of the provision of care--
(i) in individual incidents where the quality of care has significantly
deviated from acceptable standards of practice; and
(ii) with respect to a provider who has been determined to be
an outlier; or
(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.
SEC. 505. APPLICATION OF CENTER FOR MEDICARE AND MEDICAID INNOVATION
TO AMERICAN HEALTH SECURITY PROGRAM.
Section 1115A of the Social Security Act (42 U.S.C. 1315a) is amended
by adding at the end the following new subsection:
`(h) Application to American Health Security Program- Notwithstanding
any other provision of law (including the preceding provisions of this
section), on and after January 1, 2013, the duties described in this
section shall be adapted to apply to the American Health Security Program
under the American Health Security Act of 2011. For purposes of carrying
out the preceding sentence, effective on such date, the following rules
shall apply:
`(1) There is created, in consultation with the American Health Security
Standards Board established under section 401 of the American Health
Security Act of 2011, within the Department of Health and Human Services
a Center for American Health Security Innovation (in this subsection
referred to as the `Center') to carry out this subsection. The purpose
of the Center is to accelerate the implementation of new models of
care under the American Health Security Program that would improve
patient care, improve population health, and lower costs in a manner
consistent with the requirements of such Program.
`(2) Any references in this section to the `Secretary' or the `Centers
for Medicare & Medicaid Services' are deemed references to the
`American Health Security Standards Board'.
`(3) Any references in this section to title XVIII, XIX, or XXI of
this Act are deemed references to the American Health Security Program.
`(4) Any references in this section to the `Chief Actuary of the Centers
for Medicare & Medicaid Services' are deemed references to the
`Chief Actuary of the Department of Health and Human Services'.
`(5) Any references in this section to the `Center for Medicare and
Medicaid Innovation' or the `CMI' are deemed references to the Center
for American Health Security Innovation.
`(6) For purposes of carrying out this subsection, the American Health
Security Standards Board shall provide for the transfer, from the
American Health Security Trust Fund under section 801 of the American
Health Security Act of 2011, of such sums as the Board determines
necessary, to the Center.'.
TITLE VI--HEALTH SECURITY BUDGET; PAYMENTS; COST CONTAINMENT MEASURES
Subtitle A--Budgeting and Payments to States
SEC. 601. NATIONAL HEALTH SECURITY BUDGET.
(a) National Health Security Budget-
(1) IN GENERAL- By not later than September 1 before the beginning
of each year (beginning with 2012), the Board shall establish a national
health security budget, which--
(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; and
(B) allocates those expenditures among the States consistent with
section 604.
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.
(2) DIVISION OF BUDGET INTO COMPONENTS- In addition to the cost of
covered health services, the national health security budget shall
consist of at least 4 components:
(A) A component for quality assessment activities (described in
title V).
(B) A component for health professional education expenditures.
(C) A component for administrative costs.
(D) A component for operating and other expenditures not described
in subparagraphs (A) through (C) (in this title referred to as the
`operating component'), 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.
(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--
(A) assures a fair allocation for quality assessment activities
(consistent with the national health security spending growth limit);
and
(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)).
(b) Basis for Total Expenditures-
(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.
(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.
(c) Definitions- In this title:
(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.
(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.
SEC. 602. COMPUTATION OF INDIVIDUAL AND STATE CAPITATION AMOUNTS.
(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--
(A) a national average per capita cost for all covered health care
services (computed under subsection (b));
(B) the State adjustment factor (established under subsection (c))
for the State; and
(C) the risk adjustment factor (established under subsection (d))
for the risk group.
(2) STATE CAPITATION AMOUNT-
(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.
(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).
(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.
(b) Computation of National Average Per Capita Cost-
(1) FOR 2012- For 2012, the national average per capita cost under
this paragraph is equal to--
(A) the average per capita health care expenditures in the United
States in 2010 (as estimated by the Board);
(B) increased to 2011 by the Board's estimate of the actual amount
of such per capita expenditures during 2011; and
(C) updated to 2012 by the national health security spending growth
limit specified in section 601(b)(2) for 2012.
(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
adjusted by the national health security spending growth limit (specified
in section 601(b)(2)) for the year involved.
(c) State Adjustment Factors-
(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--
(A) average labor and nonlabor costs that are necessary to provide
covered health services;
(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);
(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); and
(D) any other factor relating to operating costs required to ensure
equitable distribution of funds among the States.
(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--
(A) differences among States in health professional education programs
in operation as of the date of the enactment of this Act; and
(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).
(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.
(4) PHASE-IN- In applying State adjustment factors under this subsection
during the 5-year period beginning with 2012, 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.
(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.
(d) Adjustments for Risk Group Classification-
(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.
(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.
(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.
SEC. 603. STATE HEALTH SECURITY BUDGETS.
(a) Establishment and Submission of Budgets-
(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:
(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:
(i) By the 4 components (described in section 601(a)(2)), consistent
with subsection (b).
(ii) Within the operating component--
(I) expenditures for operating costs of hospitals and other
facility-based services in the State;
(II) expenditures for payment to comprehensive health service
organizations;
(III) expenditures for payment of services provided by health
care practitioners; and
(IV) expenditures for other covered items and services.
Amounts included in the operating component include amounts that
may be used by providers for capital expenditures.
(B) The total revenues required to meet the State health security
expenditures.
(2) PROPOSED BUDGET DEADLINE- The proposed budget for a year shall
be submitted under paragraph (1) not later than June 1 before the
year.
(3) FINAL BUDGET- The final budget for a year shall--
(A) be established and submitted under paragraph (1) not later than
October 1 before the year, and
(B) take into account the amounts established under the national
health security budget under section 601 for the year.
(4) ADJUSTMENT IN ALLOCATIONS PERMITTED-
(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.
(B) NOTICE- No such change may be made unless the State has provided
prior notice of the change to the Board.
(C) DENIAL- Such a change may not be made if the Board, within such
time period as the Board specifies, disapproves such change.
(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.
(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.
(3) WORKER ASSISTANCE- A State health security program may provide
that, for budgets for years before 2015, 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.
(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.
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--
(1) the State capitation amount (computed under section 602(a)(2))
for the State for the year; and
(2) the Federal contribution percentage (established under subsection
(b)).
(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 2012, 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.
(c) Use of Payments- All payments made under this section may only be
used to carry out the State health security program.
(d) Effect of Spending Excess or Surplus-
(1) SPENDING EXCESS- If a State exceeds its budget in a given year,
the State shall continue to fund covered health services from its
own revenues.
(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.
SEC. 605. ACCOUNT FOR HEALTH PROFESSIONAL EDUCATION EXPENDITURES.
(a) Separate Account- Each State health security program shall--
(1) include a separate account for health professional education expenditures;
and
(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.
(b) Distribution Rules- The distribution of funds to hospitals and other
health care facilities from the account shall conform to the following
principles:
(1) The disbursement of funds shall 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 shall be conditioned upon the receipt of such reports
as the Board may require in order to monitor compliance with such
goals.
(2) The distribution of funds from the account shall take into account
the potentially higher costs of placing health professional students
in clinical education programs in health professional shortage areas.
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.
(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.
(b) Annual Negotiations; Budget Approval-
(1) IN GENERAL- The prospective global budget for an institution or
facility shall--
(A) be developed through annual negotiations between--
(i) a panel of individuals who are appointed by the Governor of
the State and who represent consumers, labor, business, and the
State government; and
(ii) the institution or facility; and
(B) be based on a nationally uniform system of cost accounting established
under standards of the Board.
(2) CONSIDERATIONS- In developing a budget through negotiations, there
shall be taken into account at least the following:
(A) With respect to inpatient hospital services, the number, and
classification by diagnosis-related group, of discharges.
(B) An institution's or facility's past expenditures.
(C) The extent to which debt service for capital expenditures has
been included in the proposed operating budget.
(D) The extent to which capital expenditures are financed directly
or indirectly through reductions in direct care to patients, including
reductions in registered nursing staffing patterns or changes in
emergency room or primary care services or availability.
(E) Change in the consumer price index and other price indices.
(F) The cost of reasonable compensation to health care practitioners.
(G) The compensation level of the institution's or facility's work
force.
(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.
(I) The institution's or facility's previous financial and clinical
performance, based on utilization and outcomes data provided under
this Act.
(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.
(K) Technological advances or changes.
(L) Costs of the institution or facility associated with meeting
Federal and State regulations.
(M) The costs associated with necessary public outreach activities.
(N) Incentives to facilities that maintain costs below previous
reasonable budgeted levels without reducing the care provided.
(O) 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.
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.
(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.
(c) Adjustments in Approved Budgets-
(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.
(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.
(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.
SEC. 612. PAYMENTS TO HEALTH CARE PRACTITIONERS BASED ON PROSPECTIVE
FEE SCHEDULE.
(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.
(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.
(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.
(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, family medicine, gynecology, 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.
(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.
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--
(1) based on a global budget described in section 611; or
(2) based on the basic capitation amount described in subsection (b)
for each of its enrollees.
(b) Basic Capitation Amount-
(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).
(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.
(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).
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--
(1) be based on a global budget described in section 611;
(2) be based on the basic primary care capitation amount described
in subsection (c) for each individual enrolled with the provider of
such services; or
(3) be made on a fee-for-service basis under section 612.
(b) Payment Adjustment- Payments under subsection (a) may include, consistent
with the budgets developed under this title--
(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;
(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;
and
(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.
(c) Basic Primary Care Capitation Amount-
(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).
(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.
(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.
(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).
SEC. 615. PAYMENTS FOR PRESCRIPTION DRUGS.
(a) Establishment of List-
(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.
(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.
(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.
(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.
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.
(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.
(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.
(d) Exclusions- The Board may exclude from coverage under this Act ineffective,
unsafe, or overpriced products where better alternatives are determined
to be available.
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--
(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;
and
(2) consistent with the State health security budget.
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.
(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.
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--
(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; and
(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.
Subtitle C--Mandatory Assignment and Administrative Provisions
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.
(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.
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 ensure payment within 60 days
of the date of submission of clean claims by providers under this Act.
(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.
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.
(a) In General- The Board is responsible for--
(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);
(2) overseeing the health professional education expenditures of the
State health security programs from the account established under
section 602(c);
(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;
(4) developing, coordinating, and promoting other policies that expand
the number of primary care practitioners, registered nurses, midlevel
practitioners, and dentists; and
(5) recommending the appropriate training, education, and patient
advocacy enhancements of primary care health professionals, including
registered nurses, to achieve uniform high quality care and patient
safety.
(b) National Goals- The national goals specified in this subsection
are as follows:
(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)(2)) are primary care residents (as defined in subsection (e)(4)).
(2) REGISTERED NURSES- To ensure an adequate supply of registered
nurses, there shall be a number, specified by the Board, of registered
nurses employed in the health care system as of January 1, 2015.
(3) MIDLEVEL PRIMARY CARE PRACTITIONERS- To ensure 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)(3)) employed in the health care system as of January
1, 2015.
(4) DENTISTRY- To ensure 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, 2015.
(c) Method for Attainment of National Goal for Graduate Medical Education;
Program Goals-
(1) IN GENERAL- The Board, in consultation with the National Health
Care Workforce Commission, 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.
(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.
(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--
(A) includes at least 1 medical school with a teaching hospital
and related teaching settings; and
(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.
(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.
(d) Method for Attainment of National Goal for Midlevel Primary Care
Practitioners- To assist in attaining the national goal identified in
subsection (b)(3), the Board, in consultation with the National Health
Care Workforce Commission, shall--
(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; and
(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.
(e) Definitions- In this title:
(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.
(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.
(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.
(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.
SEC. 702. 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.
(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 of the amounts the
Board estimates will be expended from the Trust Fund in the fiscal year.
(c) Maintenance- 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 the provisions referred to in subsection (a)
are less than the total amount appropriated for such programs in fiscal
year 2010.
Subtitle B--Direct Health Care Delivery
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):
(1) For payments to States under the maternal and child health block
grants under title V of the Social Security Act (42 U.S.C. 701 et
seq.).
(2) For prevention and treatment of tuberculosis under section 317
of the Public Health Service Act (42 U.S.C. 247b).
(3) For the prevention and treatment of sexually transmitted diseases
under section 318 of the Public Health Service Act (42 U.S.C. 247c).
(4) Preventive health block grants under part A of title XIX of the
Public Health Service Act (42 U.S.C. 300w et seq.).
(5) Grants to States for community mental health services under subpart
I of part B of title XIX of the Public Health Service Act (42 U.S.C.
300x et seq.).
(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 (42 U.S.C. 300x-21 et seq.).
(7) Grants for HIV health care services under parts A, B, and C of
title XXVI of the Public Health Service Act (42 U.S.C. 300ff-11 et
seq.).
(8) Public health formula grants described in subsection (d).
(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.
(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.
(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:
(1) A comparison of the measures of the State and local public health
system compared to relevant objectives set forth in `Healthy People
2020' or subsequent national objectives set by the Secretary.
(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.
(3) Measurable outcomes and process objectives for improving health
status, and a report on outcomes from the previous year.
(4) Information regarding how Federal funding has improved population-based
prevention activities and programs.
(5) A description of the core public health functions to be carried
out at the local level.
(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.
(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 2010.
(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:
(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.
(2) Activities to protect the environment and to ensure the safety
of housing, workplaces, food, and water.
(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.
(4) Health promotion and disease prevention activities for which there
is a significant need and a high priority of the Public Health Service.
(5) The provision of public health laboratory services to complement
private clinical laboratory services, including--
(A) screening tests for metabolic diseases in newborns;
(B) toxicology assessments of blood lead levels and other environmental
toxins;
(C) tuberculosis and other diseases requiring partner notification;
and
(D) testing for infectious and food-borne diseases.
(6) Training and education for the public health professions.
(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.
(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.
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).
(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).
(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 of the amounts the Board estimates will
be expended from the Trust Fund in the fiscal year.
(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 2010.
SEC. 713. PRIMARY CARE SERVICE EXPANSION GRANTS.
(a) In General- 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 the following
new subpart:
`Subpart XIII--Primary Care Expansion
`SEC. 340J. 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.
`(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.
`(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.
`(d) Primary Care Center Defined- In this section, the term `primary
care center' means--
`(1) a health center (as defined in section 330(a)(1));
`(2) an entity qualified to receive a grant under section 330, 1001,
or 2651; or
`(3) a Federally-qualified health center (as defined in section 1905(l)(2)(B)
of the Social Security Act).'.
(b) Technical Amendments- Part D of title III of the Public Health Service
Act (42 U.S.C. 254b et seq.) is amended--
(1) by redesignating subpart XI, as added by section 10333 of the
Patient Protection and Affordable Care Act (Public Law 111-148), as
subpart XII; and
(2) by redesignating section 340H of the Public Health Service Act
(42 U.S.C. 256i), as added by section 10333 of the Patient Protection
and Affordable Care Act (Public Law 111-148), as section 340I.
Subtitle C--Primary Care and Outcomes Research
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 Healthcare
Research and Quality under title IX of the Public Health Service Act
(42 U.S.C. 299 et seq.) 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.
(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.
(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 Healthcare
Research and Quality under section 947 of the Public Health Service
Act (42 U.S.C. 299c-6). 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 2010.
(d) Conforming Amendment- Section 947(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 2012 and
each subsequent year'.
SEC. 722. OFFICE OF PRIMARY CARE AND PREVENTION RESEARCH.
(a) In General- Title IV of the Public Health Service Act is amended--
(1) by redesignating parts G through I as parts H through J, respectively;
and
(2) by inserting after part F the following new part:
`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.
`(b) Purpose- The Director of the Office shall--
`(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--
`(A) clinical patient care, with special emphasis on pediatric clinical
care and diagnosis;
`(B) diagnostic effectiveness;
`(C) primary care education;
`(D) health and family planning services;
`(E) medical effectiveness outcomes of primary care procedures and
interventions; and
`(F) the use of multidisciplinary teams of health care practitioners;
`(2) identify multidisciplinary research related to primary care and
prevention that should be so conducted;
`(3) promote coordination and collaboration among entities conducting
research identified under any of paragraphs (1) and (2);
`(4) encourage the conduct of such research by entities receiving
funds from the national research institutes;
`(5) recommend an agenda for conducting and supporting such research;
`(6) promote the sufficient allocation of the resources of the national
research institutes for conducting and supporting such research; and
`(7) prepare the report required under section 486G.
`(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--
`(1) obstetrics and gynecology, dentistry, or mental health or substance
abuse treatment when provided by a primary care physician or other
primary care practitioner; and
`(2) primary care provided by multidisciplinary teams.
`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.
`(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.
`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--
`(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;
`(2) summarizing and analyzing expenditures made by the agencies of
such Institutes (and by such Office) during the preceding 2 fiscal
years; and
`(3) making such recommendations for legislative and administrative
initiatives as the Director of the Office determines to be appropriate.
`(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.
`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 2012, $180,000,000 for
fiscal year 2013, and $216,000,000 for fiscal year 2014.'.
(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--
(1) in paragraph (23), by striking `and' after the semicolon at the
end;
(2) in paragraph (24), by striking the period at the end and inserting
`; and'; and
(3) by inserting after paragraph (24) the following new paragraph:
`(25) 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).'.
Subtitle D--School-Related Health Services
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 2014, $275,000,000 for fiscal year 2015, $350,000,000
for fiscal year 2016, and $400,000,000 for each of the fiscal years
2017 and 2018.
(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.
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:
(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.
(2) Local community partnerships in States in which health agencies
have not applied.
(b) Local Community Partnerships-
(1) IN GENERAL- A local community partnership under subsection (a)(2)
is an entity that, at a minimum, includes--
(A) a local health care provider with experience in delivering services
to school-aged children;
(B) 1 or more local public schools; and
(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.
(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.
(c) Definitions Regarding Children- For purposes of this subtitle:
(1) The term `adolescent children' means school-aged children who
are adolescents.
(2) The term `school-aged children' means individuals who are between
the ages of 4 and 19 (inclusive).
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:
(1) High levels of poverty.
(2) The presence of a medically underserved population.
(3) The presence of a health professional shortage area.
(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.
(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.
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.
(b) Use of Funds- A project for which a grant may be made under subsection
(a) may include the cost of the following:
(1) Planning for the provision of school health services.
(2) Recruitment, compensation, and training of health and administrative
staff.
(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.
(4) Other activities necessary to assume operational status.
(c) Application for Grant-
(1) IN GENERAL- Applicants shall submit applications in a form and
manner prescribed by the Secretary.
(2) APPLICATIONS BY STATE HEALTH AGENCIES-
(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--
(i) on behalf of at least 1 local community partnership; and
(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.
(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.
(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.
(d) Contents of Application- In order to receive a grant under this
section, an applicant shall include in the application the following
information:
(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.
(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.
(3) An explanation of how the applicant will integrate its services
with those of other health and social service programs within the
community.
(4) A description of a quality assurance program which complies with
standards that the Secretary may prescribe.
(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.
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.
(b) Use of Grant- The costs for which a grant may be made under this
section include the following:
(1) The cost of furnishing health services that are not otherwise
covered under this Act or by any other public or private insurer.
(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.
(3) Training, recruitment and compensation of health professionals
and other staff.
(4) Outreach services to school-aged children who are at risk and
to the parents of such children.
(5) Linkage of individuals to health plans, community health services
and social services.
(6) Other activities deemed necessary by the Secretary.
(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 shall include in the application the
following information:
(1) A description of the services to be furnished by the applicant.
(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.
(3) Such other information as the Secretary determines to be appropriate.
(d) Additional Contents of Application- In order to receive a grant
under this section, an applicant shall meet the following conditions:
(1) The applicant furnishes the following services:
(A) Diagnosis and treatment of simple illnesses and minor injuries.
(B) Preventive health services, including health screenings.
(C) Services provided for the purpose described in subsection (b)(2).
(D) Referrals and followups in situations involving illness or injury.
(E) Health and social services, counseling services, and necessary
referrals, including referrals regarding mental health and substance
abuse and oral health services.
(F) Such other services as the Secretary determines to be appropriate.
(2) The applicant is a participating provider in the State's program
for medical assistance under title XIX of the Social Security Act.
(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).
(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).
(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.
(6) The applicant will provide non-Federal contributions toward the
cost of the project in an amount determined by the Secretary.
(7) The applicant will operate a quality assurance program consistent
with section 734(d).
(e) Duration of Grant- A grant under this section shall be for a period
determined by the Secretary.
(f) Reports- A recipient of funding under this section shall provide
such reports and information as are required in regulations of the Secretary.
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.
SEC. 737. DEFINITIONS.
For purposes of this subtitle:
(1) The term `adolescent children' has the meaning given such term
in section 732(c).
(2) The term `at risk' means at-risk with respect to health.
(3) The term `community health center' has the meaning given such
term in section 330 of the Public Health Service Act.
(4) The term `health professional shortage area' means a health professional
shortage area designated under section 332 of the Public Health Service
Act.
(5) The term `medically underserved population' has the meaning given
such term in section 330 of the Public Health Service Act.
(6) The term `school-aged children' has the meaning given such term
in section 732(c).
TITLE VIII--FINANCING PROVISIONS; AMERICAN HEALTH SECURITY TRUST FUND
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.
(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.
Subtitle A--American Health Security Trust Fund
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.
(b) Appropriations Into Trust Fund-
(1) TAXES- There are hereby appropriated to the Trust Fund for each
fiscal year (beginning with fiscal year 2013), 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.
(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 2013) the amounts that would otherwise
have been appropriated to carry out the following programs:
(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).
(B) The Medicaid program, under State plans approved under title
XIX of such Act.
(C) The Federal employees health benefit program, under chapter
89 of title 5, United States Code.
(D) The TRICARE program (formerly known as the CHAMPUS program),
under chapter 55 of title 10, United States Code.
(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.
(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.
(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.
Subtitle B--Taxes Based on Income and Wages
SEC. 811. PAYROLL TAX ON EMPLOYERS.
(a) In General- Section 3111 (relating to tax on employers) is amended
by redesignating subsections (c) and (d) as subsection (d) and (e),
respectively, and by inserting after subsection (b) the following new
subsection:
`(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 6.7 percent of the wages (as defined in section
3121(a)) paid by him with respect to employment (as defined in section
3121(b)).'.
(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:
`(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 6.7 percent of the amount of the self-employment income
for such taxable year.'.
(c) Comparable Taxes for Railroad Services-
(1) TAX ON EMPLOYERS- Section 3221 is amended by redesignating subsections
(c) and (d) as subsections (d) and (e), respectively, and by inserting
after subsection (b) the following new subsection:
`(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 6.7 percent of the compensation paid by such
employer for services rendered to such employer.'.
(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:
`(c) Health Care- In addition to other taxes, there is hereby imposed
on the income of each employee representative a tax equal to 6.7 percent
of the compensation received during the calendar year by such employee
representative for services rendered by such employee representative.'.
(3) NO APPLICABLE BASE- Subparagraph (A) of section 3231(e)(2) is
amended by adding at the end thereof the following new clause:
`(iv) HEALTH CARE TAXES- Clause (i) shall not apply to the taxes
imposed by sections 3221(c) and 3211(c).'.
(A) Subsection (d) of section 3211, as redesignated by paragraph
(2), is amended by striking `and (b)' and inserting `, (b), and
(c)'.
(B) Subsection (d) of section 3221, as redesignated by paragraph
(1), is amended by striking `and (b)' and inserting `, (b), and
(c)'.
(d) Effective Date- The amendments made by this section shall apply
to remuneration paid after December 31, 2012.
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:
`PART VIII--HEALTH CARE RELATED TAXES
`subpart a- health care income tax on individuals.
`Subpart A--Health Care Income Tax on Individuals
`Sec. 59B. Health care income tax.
`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 the applicable amount with respect to the taxpayer for the
taxable year.
`(b) Applicable Amount- For purposes of this section--
`(1) IN GENERAL- In the case of a taxpayer not described in paragraph
(2), the applicable amount with respect to any taxable year shall
be determined in accordance with the following table:
`If taxable income is:
The applicable amount is:
Not over $200,000
2.2% of taxable income
Over $200,000 but not over $400,000
$4,400, plus 3.2% of the excess over $200,000
Over $400,000 but not over $600,000
$10,800, plus 4.2% of the excess over $400,000
Over $600,000
$19,200, plus 5.2% of the excess over $600,000.
`(2) JOINT RETURNS AND SURVIVING SPOUSES- In the case of a joint return
or a surviving spouse (as defined in section 2(a)), the applicable
amount with respect to any taxable year shall be determined in accordance
with the following table:
`If taxable income is:
The applicable amount is:
Not over $250,000
2.2% of taxable income
Over $250,000 but not over $400,000
$5,500, plus 3.2% of the excess over $250,000
Over $400,000 but not over $600,000
$10,300, plus 4.2% of the excess over $400,000
Over $600,000
$18,700, plus 5.2% of the excess over $600,000.
`(3) INFLATION ADJUSTMENT-
`(A) IN GENERAL- In the case of any taxable year beginning after
2013, each of the dollar amounts in the tables contained in paragraphs
(1) and (2) shall be increased by an amount equal to--
`(i) such dollar amount, multiplied by
`(ii) the cost-of-living adjustment determined under section 1(f)(3)
for the calendar year in which the taxable year begins, determined
by substituting `calendar year 2012' for `calendar year 1992'
in subparagraph (B) thereof.
`(B) ROUNDING- If any amount after adjustment under subparagraph
(A) is not a multiple of $1,000, such amount shall be rounded to
the next lowest multiple of $1,000.
`(c) 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--
`(1) the amount of any credit allowable under this chapter, or
`(2) the amount of the minimum tax imposed by section 55.
`(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.
`(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.
`(3) OTHER RULES- The rules of section 59A(d) shall apply to the tax
imposed by this section.'.
(b) Clerical Amendment- The table of parts for subchapter A of chapter
1 is amended by adding at the end the following new item:
`Part VIII--Health Care Related Taxes'.
(c) Effective Date- The amendments made by this section shall apply
to taxable years beginning after December 31, 2012.
SEC. 813. SURCHARGE ON HIGH INCOME INDIVIDUALS.
(a) In General- Part VIII of subchapter A of chapter 1, as added by
this title, is amended by adding at the end the following new subpart:
`Subpart B--Surcharge on High Income Individuals
`Sec. 59C. Surcharge on high income individuals.
`SEC. 59C. SURCHARGE ON HIGH INCOME INDIVIDUALS.
`(a) General Rule- In the case of a taxpayer other than a corporation,
there is hereby imposed (in addition to any other tax imposed by this
subtitle) a tax equal to 5.4 percent of so much of the modified adjusted
gross income of the taxpayer as exceeds $1,000,000.
`(b) Taxpayers Not Making a Joint Return- In the case of any taxpayer
other than a taxpayer making a joint return under section 6013 or a
surviving spouse (as defined in section 2(a)), subsection (a) shall
be applied by substituting `$500,000' for `$1,000,000'.
`(c) Modified Adjusted Gross Income- For purposes of this section, the
term `modified adjusted gross income' means adjusted gross income reduced
by any deduction (not taken into account in determining adjusted gross
income) allowed for investment interest (as defined in section 163(d)).
In the case of an estate or trust, adjusted gross income shall be determined
as provided in section 67(e).
`(1) NONRESIDENT ALIEN- In the case of a nonresident alien individual,
only amounts taken into account in connection with the tax imposed
under section 871(b) shall be taken into account under this section.
`(2) CITIZENS AND RESIDENTS LIVING ABROAD- The dollar amount in effect
under subsection (a) (after the application of subsection (b)) shall
be decreased by the excess of--
`(A) the amounts excluded from the taxpayer's gross income under
section 911, over
`(B) the amounts of any deductions or exclusions disallowed under
section 911(d)(6) with respect to the amounts described in subparagraph
(A).
`(3) CHARITABLE TRUSTS- Subsection (a) shall not apply to a trust
all the unexpired interests in which are devoted to one or more of
the purposes described in section 170(c)(2)(B).
`(4) NOT TREATED AS TAX IMPOSED BY THIS CHAPTER FOR CERTAIN PURPOSES-
The tax imposed under this section shall not be treated as tax imposed
by this chapter for purposes of determining the amount of any credit
under this chapter or for purposes of section 55.'.
(b) Clerical Amendment- The table of subparts for part VIII of subchapter
A of chapter 1, as added by this title, is amended by inserting after
the item relating to subpart A the following new item:
`subpart b. surcharge on high income individuals.'.
(c) Section 15 Not to Apply- The amendment made by subsection (a) shall
not be treated as a change in a rate of tax for purposes of section
15 of the Internal Revenue Code of 1986.
(d) Effective Date- The amendments made by this section shall apply
to taxable years beginning after December 31, 2012.
Subtitle C--Other Financing Provisions
SEC. 821. TAX ON SECURITIES TRANSACTIONS.
(a) In General- Chapter 36 is amended by inserting after subchapter
B the following new subchapter:
`Subchapter C--Tax on Securities Transactions
`Sec. 4475. Tax on securities transactions.
`SEC. 4475. TAX ON SECURITIES TRANSACTIONS.
`(a) Imposition of Tax- There is hereby imposed a tax on each covered
transaction with respect to any security.
`(1) IN GENERAL- Except as otherwise provided in this subsection,
the rate of such tax shall be equal to 0.02 percent of the fair market
value of the security.
`(2) SWAPS- In the case of a security described in subsection (d)(1)(D),
the rate of such tax shall be equal to 0.02 percent of the fair market
value of the underlying property with respect to, or the notional
principal amount of, the security-based swap involved in such transaction.
`(3) SHORT-TERM DEBT INSTRUMENTS- In the case of a covered transaction
with respect to a security described in subsection (d)(1)(C) which
has a fixed maturity date not more than 1 year from the date of issue,
the rate of such tax shall be equal to 0.02 percent of the fair market
value of such security.
`(c) Covered Transaction- For purposes of this section, the term `covered
transaction' means--
`(1) except as provided in paragraph (2), any purchase if--
`(A) such purchase occurs on a trading facility located in the United
States, or
`(B) the purchaser or seller is a United States person, or
`(2) any transaction with respect to a security described in subsection
(d)(1)(D), if any party with rights under such security is a United
States person or if such transaction is facilitated by a United States
person, including a trading facility located in the United States
or a broker.
`(d) Security and Other Definitions- For purposes of this section--
`(1) IN GENERAL- The term `security' has the meaning given such term
by section 2(a)(1) of the Securities Act of 1933 (15 U.S.C. 77b(a)(1)).
`(2) SECURITY-BASED SWAP- The term `security-based swap' means any
option, forward contract, short position, notional principal contract,
credit default swap, or any similar financial instrument.
`(3) SPECIFIED INDEX- The term `specified index' means any 1 or more
of any combination of--
`(A) a fixed rate, price, or amount, or
`(B) a variable rate, price, or amount,
which is based on any current objectively determinable information
which is not within the control of any of the parties to the contract
or instrument and is not unique to any of the parties' circumstances.
`(e) Exceptions to Imposition of Tax-
`(1) EXCEPTION FOR INITIAL ISSUES- No tax shall be imposed under subsection
(a) on any covered transaction with respect to the initial issuance
of any security described in subparagraph (A), (B), or (C) of subsection
(d)(1).
`(2) EXCEPTION FOR RETIREMENT ACCOUNTS, ETC- No tax shall be imposed
under subsection (a) on any covered transaction with respect to any
security which is held in any plan, account, or arrangement described
in section 220, 223, 401(a), 403(a), 403(b), 408, 408A, 529, or 530
(including assets held in a segregated asset account described in
section 817 as part of any such plan, account, or arrangement).
`(3) EXCEPTION FOR CERTAIN MUTUAL FUND TRANSACTIONS- No tax shall
be imposed under subsection (a) on any covered transaction--
`(A) with respect to the purchase of any interest in a regulated
investment company (as defined in section 851) which issues only
stock which is redeemable on the demand of the stock holder,
`(B) by a regulated investment company (as so defined) which is
100 percent owned by 1 or more plans, accounts, or arrangements
described in paragraph (2), and
`(C) to the extent such tax is properly allocable to any class of
shares of a regulated investment company (as so defined) which is
100 percent owned by 1 or more plans, accounts, or arrangements
described in paragraph (2).
`(1) IN GENERAL- The tax imposed by this section shall be paid by--
`(A) in the case of a transaction which occurs on a trading facility
located in the United States, such trading facility,
`(B) in the case of a transaction not described in subparagraph
(A) which is executed by a broker, such broker,
`(C) in the case of a transaction not described in subparagraph
(A) or (B), with respect to a security described in section (d)(1)(D),
the party identified by the Secretary, or
`(D) in any other case, the purchaser with respect to the transaction.
`(2) WITHHOLDING IF PURCHASER IS NOT A UNITED STATES PERSON- See section
1447 for withholding by seller if purchaser is a foreign person.
`(g) Administration- The Secretary shall carry out this section in consultation
with the Securities and Exchange Commission and the Commodity Futures
Trading Commission.
`(h) Guidance; Regulations- The Secretary shall--
`(1) provide guidance regarding such information reporting concerning
covered transactions as the Secretary deems appropriate, and
`(2) prescribe such regulations as are necessary or appropriate to
prevent avoidance of the purposes of this section, including the use
of non-United States persons in such transactions or the improper
allocation of taxes to classes of shares described in subsection (e)(3)(C).'.
(b) Credit for First $100,000 of Stock Transactions Per Year- Subpart
C of part IV of subchapter A of chapter 1 is amended by inserting after
section 36A the following new section:
`SEC. 36B. CREDIT FOR SECURITIES TRANSACTION TAXES.
`(a) Allowance of Credit- In the case of any purchaser with respect
to a covered transaction, there shall be allowed as a credit against
the tax imposed by this subtitle for the taxable year an amount equal
to the lesser of--
`(1) the aggregate amount of tax imposed under section 4475 on covered
transactions during the taxable year with respect to which the taxpayer
is the purchaser, or
`(2) $250 ($500 in the case of a joint return).
`(b) Aggregation Rule- For purposes of this section, all persons treated
as a single employer under subsection (a) or (b) of section 52, or subsection
(m) or (o) of section 414, shall be treated as one taxpayer.
`(c) Definitions- For purposes of this section, any term used in this
section which is also used in section 4475 shall have the same meaning
as when used in section 4475.'.
(c) Withholding- Subchapter A of chapter 3 is amended by adding at the
end the following new section:
`SEC. 1447. WITHHOLDING ON SECURITIES TRANSACTIONS.
`(a) In General- In the case of any outbound securities transaction,
the transferor shall deduct and withhold a tax equal to the tax imposed
under section 4475 with respect to such transaction.
`(b) Outbound Securities Transaction- For purposes of this section,
the term `outbound securities transaction' means any covered transaction
to which section 4475(a) applies if--
`(1) such transaction does not occur on a trading facility located
in the United States, and
`(2) the purchaser with respect to such transaction in not a United
States person.'.
(d) Conforming Amendments-
(1) Section 6211(b)(4)(A) is amended by inserting `36B,' after `36A,'.
(2) Section 1324(b)(2) of title 31, United States Code, is amended
by inserting `36B,' after `36A,'.
(3) The table of subchapters for chapter 36 is amended by inserting
after the item relating to subchapter B the following new item:
`Subchapter C. Tax on securities transactions.'.
(4) The table of sections for subchapter A of chapter 3 is amended
by adding at the end the following new item:
`Sec. 1447. Withholding on securities transactions.'.
(5) The table of sections for subpart C of part IV of subchapter A
of chapter 1 is amended by inserting after the item relating to section
36A the following new item:
`Sec. 36B. Credit for securities transaction taxes.'.
(e) Effective Date- The amendments made by this section shall apply
to transactions occurring more than 180 days after the date of the enactment
of this Act.
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.
Section 4 of the Employee Retirement Income Security Act of 1974 (29
U.S.C. 1003) is amended--
(1) in subsection (a), by striking `(b) or (c)' and inserting `(b),
(c), or (d)'; and
(2) by adding at the end the following new subsection:
`(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 2011.'.
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:
`(10) 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 2011.'.
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:
`PROHIBITION OF EMPLOYEE BENEFITS DUPLICATIVE OF STATE HEALTH SECURITY
PROGRAM BENEFITS; COORDINATION IN CASE OF WORKERS' COMPENSATION
`Sec. 522. (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 2011.
`(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.
`(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.
`(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.
`(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.'.
(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 522(b) (relating to reimbursement of State
health security plans by workers compensation carriers).'.
(c) Clerical Amendment- The table of contents in section 1 of such Act
is amended by inserting after the item relating to section 521 the following
new items:
`Sec. 522. Prohibition of employee benefits duplicative of state health
security program benefits; coordination in case of workers' compensation.'.
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.
(b) Conforming Amendments-
(1) Section 502(a) of such Act (29 U.S.C. 1132(a)) is amended--
(A) by striking paragraph (7); and
(B) by redesignating paragraphs (8), (9), and (10) as paragraphs
(7), (8), and (9), respectively.
(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,'.
(3) Section 514(b) of such Act (29 U.S.C. 1144(b)) is amended--
(A) in paragraph (7), by striking `section 206(d)(3)(B)(i)),' and
all that follows and inserting `section 206(d)(3)(B)(i)).'; and
(B) by striking paragraph (8).
(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.
SEC. 905. EFFECTIVE DATE OF TITLE.
The amendments made by this title shall take effect January 1, 2014.
TITLE X--ADDITIONAL CONFORMING AMENDMENTS
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.
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.
(b) Conforming Amendment- Section 514(b) of such Act (29 U.S.C. 1144(b))
is amended by striking paragraph (9).
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.
(b) Additional Amendments-
(1) Section 1301(b) of such Act (42 U.S.C. 300e(b)) is amended by
striking paragraph (6).
(2) Sections 104 and 191 of the Health Insurance Portability and Accountability
Act of 1996 are repealed.
SEC. 1004. EFFECTIVE DATE OF TITLE.
The amendments made by this title shall take effect January 1, 2015.
END
