108th CONGRESS
1st Session
S. 1710
To amend title XXVII of the Public Health Service Act and part 7
of subtitle B of title I of the Employee Retirement Income Security Act of
1974 to establish standards for the health quality improvement of children
in managed care plans and other health plans.
IN THE SENATE OF THE UNITED STATES
October 3, 2003
Mr. REED (for himself and Mrs. MURRAY) introduced the following bill; which
was read twice and referred to the Committee on Health, Education, Labor,
and Pensions
A BILL
To amend title XXVII of the Public Health Service Act and part 7
of subtitle B of title I of the Employee Retirement Income Security Act of
1974 to establish standards for the health quality improvement of children
in managed care plans and other health plans.
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 `Children's Health Insurance Accountability Act
of 2003'.
SEC. 2. FINDINGS.
Congress makes the following findings:
(1) Children have health and development needs that are markedly different
than those for the adult population.
(2) Children experience complex and continuing changes during the continuum
from birth to adulthood in which appropriate health care is essential for
optimal development.
(3) The vast majority of work done on development methods to assess the
effectiveness of health care services and the impact of medical care on
patient outcomes and patient satisfaction has been focused on adults.
(4) Health outcome measures need to be age, gender, and developmentally
appropriate to be useful to families and children.
(5) Costly disorders of adulthood often have their origins in childhood,
making early access to effective health services in childhood essential.
(6) More than 200 chronic conditions, disabilities and diseases affect children,
including asthma, diabetes, sickle cell anemia, spina bifida, epilepsy,
autism, cerebral palsy, congenital heart disease, mental retardation, and
cystic fibrosis. These children need the services of specialists who have
in depth knowledge about their particular condition.
(7) Children's patterns of illness, disability and injury differ dramatically
from adults.
SEC. 2. AMENDMENTS TO THE PUBLIC HEALTH SERVICE ACT.
(a) PATIENT PROTECTION STANDARDS- Title XXVII of the Public Health Service
Act is amended--
(1) by redesignating part C as part D; and
(2) by inserting after part B the following:
`Part C--Children's Health Protection Standards
`SEC. 2770. ACCESS TO CARE.
`(a) Access to Appropriate Primary Care Providers-
`(1) IN GENERAL- If a group health plan, or a health insurance issuer in
connection with the provision of health insurance coverage, requires or
provides for an enrollee to designate a participating primary care provider
for a child of such enrollee--
`(A) the plan or issuer shall permit the enrollee to designate a physician
who specializes in pediatrics as the child's primary care provider; and
`(B) if such an enrollee has not designated such a provider for the child,
the plan or issuer shall consider appropriate pediatric expertise in mandatorily
assigning such an enrollee to a primary care provider.
`(2) CONSTRUCTION- Nothing in paragraph (1) shall waive any requirements
of coverage relating to medical necessity or appropriateness with respect
to coverage of services.
`(b) Access to Pediatric Specialty Services-
`(1) Referral to specialty care for children requiring treatment by specialists-
`(A) IN GENERAL- In the case of a child who is covered under a group health
plan, or health insurance coverage offered by a health insurance issuer
and who has a mental or physical condition, disability, or disease of
sufficient seriousness and complexity to require diagnosis, evaluation
or treatment by a specialist, the plan or issuer shall make or provide
for a referral to a specialist who has extensive experience or training,
and is available and accessible to provide the treatment for such condition
or disease, including the choice of a nonprimary care physician specialist
participating in the plan or a referral to a nonparticipating provider
as provided for under subparagraph (D) if such a provider is not available
within the plan.
`(B) SPECIALIST DEFINED- For purposes of this subsection, the term `specialist'
means, with respect to a condition, disability, or disease, a health care
practitioner, facility, or center (such as a center of excellence) that
has extensive pediatric expertise through appropriate training or experience
to provide high quality care in treating the condition, disability or
disease.
`(C) REFERRALS TO PARTICIPATING PROVIDERS- A plan or issuer is not required
under subparagraph (A) to provide for a referral to a specialist that
is not a participating provider, unless the plan or issuer does not have
an appropriate specialist that is available and accessible to treat the
enrollee's condition and that is a participating provider with respect
to such treatment.
`(D) TREATMENT OF NONPARTICIPATING PROVIDERS- If a plan or issuer refers
a child enrollee to a nonparticipating specialist, services provided pursuant
to the referral shall be provided at no additional cost to the enrollee
beyond what the enrollee would otherwise pay for
services received by such a specialist that is a participating provider.
`(E) SPECIALISTS AS PRIMARY CARE PROVIDERS- A plan or issuer shall have
in place a procedure under which a child who is covered under health insurance
coverage provided by the plan or issuer who has a condition or disease
that requires specialized medical care over a prolonged period of time
shall receive a referral to a pediatric specialist affiliated with the
plan, or if not available within the plan, to a nonparticipating provider
for such condition and such specialist may be responsible for and capable
of providing and coordinating the child's primary and specialty care.
`(A) IN GENERAL- A group health plan, or health insurance issuer in connection
with the provision of health insurance coverage of a child, shall have
a procedure by which a child who has a condition, disability, or disease
that requires ongoing care from a specialist may request and obtain a
standing referral to such specialist for treatment of such condition.
If the primary care provider in consultation with the medical director
of the plan or issuer and the specialist (if any), determines that such
a standing referral is appropriate, the plan or issuer shall authorize
such a referral to such a specialist. Such standing referral shall be
consistent with a treatment plan.
`(B) TREATMENT PLANS- A group health plan, or health insurance issuer,
with the participation of the family and the health care providers of
the child, shall develop a treatment plan for a child who requires ongoing
care that covers a specified period of time (but in no event less than
a 6-month period). Services provided for under the treatment plan shall
not require additional approvals or referrals through a gatekeeper.
`(C) TERMS OF REFERRAL- The provisions of subparagraph (C) and (D) of
paragraph (1) shall apply with respect to referrals under subparagraph
(A) in the same manner as they apply to referrals under paragraph (1)(A).
`(c) ADEQUACY OF ACCESS- For purposes of subsections (a) and (b), a group
health plan or health insurance issuer in connection with health insurance
coverage shall ensure that a sufficient number, distribution, and variety
of qualified participating health care providers are available so as to ensure
that all covered health care services, including specialty services, are available
and accessible to all enrollees in a timely manner.
`(d) COVERAGE OF EMERGENCY SERVICES-
`(1) IN GENERAL- If a group health plan, or health insurance coverage offered
by a health insurance issuer, provides any benefits for children with respect
to emergency services (as defined in paragraph (2)(A)), the plan or issuer
shall cover emergency services furnished under the plan or coverage--
`(A) without the need for any prior authorization determination;
`(B) whether or not the physician or provider furnishing such services
is a participating physician or provider with respect to such services;
and
`(C) without regard to any other term or condition of such coverage (other
than exclusion of benefits, or an affiliation or waiting period, permitted
under section 2701).
`(2) DEFINITIONS- In this subsection:
`(A) EMERGENCY MEDICAL CONDITION BASED ON PRUDENT LAYPERSON STANDARD-
The term `emergency medical condition' means a medical condition manifesting
itself by acute symptoms of sufficient severity (including severe pain)
such that a prudent layperson, who possesses an average knowledge of health
and medicine, could reasonably expect the absence of immediate medical
attention to result in a condition described in clause (i), (ii), or (iii)
of section 1867(e)(1)(A) of the Social Security Act.
`(B) EMERGENCY SERVICES- The term `emergency services' means--
`(i) a medical screening examination (as required under section 1867
of the Social Security Act) that is within the capability of the emergency
department of a hospital, including ancillary services routinely available
to the emergency department to evaluate an emergency medical condition
(as defined in subparagraph (A)); and
`(ii) within the capabilities of the staff and facilities available
at the hospital, such further medical examination and treatment as are
required under section 1867 of such Act to stabilize the patient.
`(3) REIMBURSEMENT FOR MAINTENANCE CARE AND POST-STABILIZATION CARE- A group
health plan, and health insurance issuer offering health insurance coverage,
shall provide, in covering services other than emergency services, for reimbursement
with respect to services which are otherwise covered and which are provided
to an enrollee other than through the plan or issuer if the services are
maintenance care or post-stabilization care covered under the guidelines
established under section 1852(d) of the Social Security Act (relating to
promoting efficient and timely coordination of appropriate maintenance and
post-stabilization care of an enrollee after an enrollee has been determined
to be stable).
`(e) PROHIBITION ON FINANCIAL BARRIERS- A health insurance issuer in connection
with the provision of health insurance coverage may not impose any cost sharing
for pediatric specialty services provided under such coverage to enrollee
children in amounts that exceed the cost-sharing required for other specialty
care under such coverage.
`(f) CHILDREN WITH SPECIAL HEALTH CARE NEEDS- A health insurance issuer in
connection with the provision of health insurance coverage shall ensure that
such coverage provides special consideration for the provision of services
to enrollee children with special health care needs. Appropriate procedures
shall be implemented to provide care for children with special health care
needs. The development of such procedures shall include participation by the
families of such children.
`(g) DEFINITIONS- In this part:
`(1) CHILD- The term `child' means an individual who is under 19 years of
age.
`(2) CHILDREN WITH SPECIAL HEALTH CARE NEEDS- The term `children with special
health care needs' means those children who have or are at elevated risk
for chronic physical, developmental, behavioral or emotional conditions
and who also require health and related services of a type and amount not
usually required by children.
`SEC. 2771. CONTINUITY OF CARE.
`(a) IN GENERAL- If a contract between a health insurance issuer, in connection
with the provision of health insurance coverage, and a health care provider
is terminated (other than by the issuer for failure to meet applicable quality
standards or for fraud) and an enrollee is undergoing a course of treatment
from the provider at the time of such termination, the issuer shall--
`(1) notify the enrollee of such termination, and
`(2) subject to subsection (c), permit the enrollee to continue the course
of treatment with the provider during a transitional period (provided under
subsection (b)).
`(b) TRANSITIONAL PERIOD-
`(1) IN GENERAL- Except as provided in paragraphs (2) through (4), the transitional
period under this subsection shall extend for at least--
`(A) 60 days from the date of the notice to the enrollee of the provider's
termination in the case of a primary care provider, or
`(B) 120 days from such date in the case of another provider.
`(2) INSTITUTIONAL CARE- The transitional period under this subsection for
institutional or inpatient care from a provider shall extend until the discharge
or termination of the period of institutionalization and shall include reasonable
follow-up care related to the institutionalization and shall also include
institutional care scheduled prior to the date of termination of the provider
status.
`(A) an enrollee has entered the second trimester of pregnancy at the
time of a provider's termination of participation, and
`(B) the provider was treating the pregnancy before date of the termination,
the transitional period under this subsection with respect to provider's
treatment of the pregnancy shall extend through the provision of post-partum
care directly related to the delivery.
`(i) an enrollee was determined to be terminally ill (as defined in
subparagraph (B)) at the time of a provider's termination of participation,
and
`(ii) the provider was treating the terminal illness before the date
of termination,
the transitional period under this subsection shall extend for the remainder
of the enrollee's life for care directly related to the treatment of the
terminal illness.
`(B) DEFINITION- In subparagraph (A), an enrollee is considered to be
`terminally ill' if the enrollee has a medical prognosis that the enrollee's
life expectancy is 6 months or less.
`(c) PERMISSIBLE TERMS AND CONDITIONS- An issuer may condition coverage of
continued treatment by a provider under subsection (a)(2) upon the provider
agreeing to the following terms and conditions:
`(1) The provider agrees to continue to accept reimbursement from the issuer
at the rates applicable prior to the start of the transitional period as
payment in full.
`(2) The provider agrees to adhere to the issuer's quality assurance standards
and to provide to the issuer necessary medical information related to the
care provided.
`(3) The provider agrees otherwise to adhere to the issuer's policies and
procedures, including procedures regarding referrals and obtaining prior
authorization and providing services pursuant to a treatment plan approved
by the issuer.
`SEC. 2772. CONTINUOUS QUALITY IMPROVEMENT.
`(a) IN GENERAL- A health insurance issuer that offers health insurance coverage
for children shall establish and maintain an ongoing, internal quality assurance
program that at a minimum meets the requirements of subsection (b).
`(b) REQUIREMENTS- The internal quality assurance program of an issuer under
subsection (a) shall--
`(1) establish and measure a set of health care, functional assessments,
structure, processes and outcomes, and quality indicators that are unique
to children and based on nationally accepted standards or guidelines of
care;
`(2) maintain written protocols consistent with recognized clinical guidelines
or current consensus on the pediatric field, to be used for purposes of
internal utilization review, with periodic updating and evaluation by pediatric
specialists to determine effectiveness in controlling utilization;
`(3) provide for peer review by health care professionals of the structure,
processes, and outcomes related to the provision of health services, including
pediatric review of pediatric cases;
`(4) include in member satisfaction surveys, questions on child and family
satisfaction and experience of care, including care to children with special
needs;
`(5) monitor and evaluate the continuity of care with respect to children;
`(6) include pediatric measures that are directed at meeting the needs of
at-risk children and
children with chronic conditions, disabilities and severe illnesses;
`(7) maintain written guidelines to ensure the availability of medications
appropriate to children;
`(8) use focused studies of care received by children with certain types
of chronic conditions and disabilities and focused studies of specialized
services used by children with chronic conditions and disabilities;
`(9) monitor access to pediatric specialty services; and
`(10) monitor child health care professional satisfaction.
`(c) UTILIZATION REVIEW ACTIVITIES-
`(1) COMPLIANCE WITH REQUIREMENTS-
`(A) IN GENERAL- A health insurance issuer that offers health insurance
coverage for children shall conduct utilization review activities in connection
with the provision of such coverage only in accordance with a utilization
review program that meets at a minimum the requirements of this subsection.
`(B) DEFINITIONS- In this subsection:
`(i) CLINICAL PEERS- The term `clinical peer' means, with respect to
a review, a physician or other health care professional who holds a
non-restricted license in a State and in the same or similar specialty
as typically manages the pediatric medical condition, procedure, or
treatment under review.
`(ii) HEALTH CARE PROFESSIONAL- The term `health care professional'
means a physician or other health care practitioner licensed or certified
under State law to provide health care services and who is operating
within the scope of such licensure or certification.
`(iii) UTILIZATION REVIEW- The terms `utilization review' and `utilization
review activities' mean procedures used to monitor or evaluate the clinical
necessity, appropriateness, efficacy, or efficiency of health care services,
procedures or settings for children, and includes prospective review,
concurrent review, second opinions, case management, discharge planning,
or retrospective review specific to children.
`(2) WRITTEN POLICIES AND CRITERIA-
`(A) WRITTEN POLICIES- A utilization review program shall be conducted
consistent with written policies and procedures that govern all aspects
of the program.
`(B) USE OF WRITTEN CRITERIA- A utilization review program shall utilize
written clinical review criteria specific to children and developed pursuant
to the program with the input of appropriate physicians, including pediatricians,
nonprimary care pediatric specialists, and other child health professionals.
`(C) ADMINISTRATION BY HEALTH CARE PROFESSIONALS- A utilization review
program shall be administered by qualified health care professionals,
including health care professionals with pediatric expertise who shall
oversee review decisions.
`(3) USE OF QUALIFIED, INDEPENDENT PERSONNEL-
`(A) IN GENERAL- A utilization review program shall provide for the conduct
of utilization review activities only through personnel who are qualified
and, to the extent required, who have received appropriate pediatric or
child health training in the conduct of such activities under the program.
`(B) PEER REVIEW OF ADVERSE CLINICAL DETERMINATIONS- A utilization review
program shall provide that clinical peers shall evaluate the clinical
appropriateness of adverse clinical determinations and divergent clinical
options.
`SEC. 2773. APPEALS AND GRIEVANCE MECHANISMS FOR CHILDREN.
`(a) INTERNAL APPEALS PROCESS- A health insurance issuer in connection with
the provision of health insurance coverage for children shall establish and
maintain a system to provide for the resolution of complaints and appeals
regarding all aspects of such coverage. Such a system shall include an expedited
procedure for appeals on behalf of a child enrollee in situations in which
the time frame of a standard appeal would jeopardize the life, health, or
development of the child.
`(b) EXTERNAL APPEALS PROCESS- A health insurance issuer in connection with
the provision of health insurance coverage for children shall provide for
an independent external review process that meets the following requirements:
`(1) External appeal activities shall be conducted through clinical peers,
a physician or other health care professional who is appropriately credentialed
in pediatrics with the same or similar specialty and typically manages the
condition, procedure, or treatment under review or appeal.
`(2) External appeal activities shall be conducted through an entity that
has sufficient pediatric expertise, including subspeciality expertise, and
staffing to conduct external appeal activities on a timely basis.
`(3) Such a review process shall include an expedited procedure for appeals
on behalf of a child enrollee in which the time frame of a standard appeal
would jeopardize the life, health, or development of the child.
`SEC. 2774. ACCOUNTABILITY THROUGH DISTRIBUTION OF INFORMATION.
`(a) IN GENERAL- A health insurance issuer in connection with the provision
of health insurance coverage for children shall submit to enrollees (and prospective
enrollees), and make available to the public, in writing the health-related
information described in subsection (b).
`(b) INFORMATION- The information to be provided under subsection (a) shall
include a report of measures
of structures, processes, and outcomes regarding each health insurance product
offered to participants and dependents in a manner that is separate for both
the adult and child enrollees, using measures that are specific to each group.'.
(b) APPLICATION TO GROUP HEALTH INSURANCE COVERAGE-
(1) IN GENERAL- Subpart 2 of part A of title XXVII of the Public Health
Service Act (42 U.S.C. 300gg-4 et seq.) is amended by adding at the end
the following:
`SEC. 2707. CHILDREN'S HEALTH ACCOUNTABILITY STANDARDS.
`(a) IN GENERAL- Each health insurance issuer shall comply with children's
health accountability requirement under part C with respect to group health
insurance coverage it offers.
`(b) ASSURING COORDINATION- The Secretary of Health and Human Services and
the Secretary of Labor shall ensure, through the execution of an interagency
memorandum of understanding between such Secretaries, that--
`(1) regulations, rulings, and interpretations issued by such Secretaries
relating to the same matter over which such Secretaries have responsibility
under part C (and this section) and section 714 of the Employee Retirement
Income Security Act of 1974 are administered so as to have the same effect
at all times; and
`(2) coordination of policies relating to enforcing the same requirements
through such Secretaries in order to have a coordinated enforcement strategy
that avoids duplication of enforcement efforts and assigns priorities in
enforcement.'.
(2) CONFORMING AMENDMENT- Section 2792 of the Public Health Service Act
(42 U.S.C. 300gg-92) is amended by inserting `and section 2707(b)' after
`of 1996'.
(c) APPLICATION TO INDIVIDUAL HEALTH INSURANCE COVERAGE- Part B of title XXVII
of the Public Health Service Act (42 U.S.C. 300gg-41 et seq.) is amended by
inserting after section 2752 the following:
`SEC. 2753. CHILDREN'S HEALTH ACCOUNTABILITY STANDARDS.
`Each health insurance issuer shall comply with children's health accountability
requirements under part C with respect to individual health insurance coverage
it offers.'.
(d) Modification of Preemption Standards-
(1) GROUP HEALTH INSURANCE COVERAGE- Section 2723 of the Public Health Service
Act (42 U.S.C. 300gg-23) is amended--
(A) in subsection (a)(1), by striking `subsection (b)' and inserting `subsection
(b) and (c)';
(B) by redesignating subsections (c) and (d) as subsections (d) and (e),
respectively; and
(C) by inserting after subsection (b) the following new subsection:
`(c) SPECIAL RULES IN CASE OF CHILDREN'S HEALTH ACCOUNTABILITY REQUIREMENTS-
Subject to subsection (a)(2), the provisions of section 2707 and part C, and
part D insofar as it applies to section 2707 or part C, shall not prevent
a State from establishing requirements relating to the subject matter of such
provisions so long as such requirements are at least as stringent on health
insurance issuers as the requirements imposed under such provisions.'.
(2) INDIVIDUAL HEALTH INSURANCE COVERAGE- Section 2762 of the Public Health
Service Act (42 U.S.C. 300gg-62) is amended--
(A) in subsection (a), by striking `subsection (b), nothing in this part'
and inserting `subsections (b) and (c)'; and
(B) by adding at the end the following new subsection:
`(c) SPECIAL RULES IN CASE OF CHILDREN'S HEALTH ACCOUNTABILITY REQUIREMENTS-
Subject to subsection (b), the provisions of section 2753 and part C, and
part D insofar as it applies to section 2753 or part C, shall not prevent
a State from establishing requirements relating to the subject matter of such
provisions so long as such requirements are at least as stringent on health
insurance issuers as the requirements imposed under such section.'.
SEC. 3. AMENDMENTS TO THE EMPLOYEE RETIREMENT INCOME SECURITY ACT OF 1974.
(a) IN GENERAL- Subpart B of part 7 of subtitle B of title I of (29 U.S.C.
1185 et seq.) is amended by adding at the end the following:
`SEC. 714. CHILDREN'S HEALTH ACCOUNTABILITY STANDARDS.
`(a) IN GENERAL- Subject to subsection (b), the provisions of part C of title
XXVII of the Public Health Service Act shall apply under this subpart and
part to a group health plan (and group health insurance coverage offered in
connection with a group health plan) as if such part were incorporated in
this section.
`(b) APPLICATION- In applying subsection (a) under this subpart and part,
any reference in such part C--
`(1) to health insurance coverage is deemed to be a reference only to group
health insurance coverage offered in connection with a group health plan
and to also be a reference to coverage under a group health plan;
`(2) to a health insurance issuer is deemed to be a reference only to such
an issuer in relation to group health insurance coverage or, with respect
to a group health plan, to the plan;
`(3) to the Secretary is deemed to be a reference to the Secretary of Labor;
`(4) to an applicable State authority is deemed to be a reference to the
Secretary of Labor; and
`(5) to an enrollee with respect to health insurance coverage is deemed
to include a reference to a participant or beneficiary with respect to a
group health plan.'.
(b) MODIFICATION OF PREEMPTION STANDARDS- Section 731 of the Employee Retirement
Income Security Act of 1974 (42 U.S.C. 1191) is amended--
(1) in subsection (a)(1), by striking `subsection (b)' and inserting `subsections
(b) and (c)';
(2) by redesignating subsections (c) and (d) as subsections (d) and (e),
respectively; and
(3) by inserting after subsection (b) the following new subsection:
`(c) SPECIAL RULES IN CASE OF PATIENT ACCOUNTABILITY REQUIREMENTS- Subject
to subsection (a)(2), the provisions of section 714, shall not prevent a State
from establishing requirements relating to the subject matter of such provisions
so long as such requirements are at least as stringent on group health plans
and health insurance issuers in connection with group health insurance coverage
as the requirements imposed under such provisions.'.
(c) CONFORMING AMENDMENTS-
(1) Section 732(a) of the Employee Retirement Income Security Act of 1974
(29 U.S.C. 1185(a)) is amended by striking `section 711' and inserting `sections
711 and 714'.
(2) The table of contents in section 1 of the Employee Retirement Income
Security Act of 1974 is amended by inserting after the item relating to
section 713 the following new item:
`Sec. 714. Children's health accountability standards.'.
SEC. 4. STUDIES.
(a) BY SECRETARY- Not later than 1 year after the date of enactment of this
Act, the Secretary of Health and Human Services shall conduct a study, and
prepare and submit to Congress a report, concerning--
(1) the unique characteristics of patterns of illness, disability, and injury
in children;
(2) the development of measures of quality of care and outcomes related
to the health care of children; and
(3) the access of children to primary mental health services and the coordination
of managed behavioral health services.
(1) MANAGED CARE- Not later than 1 year after the date of enactment of this
Act, the General Accounting Office shall conduct a study, and prepare and
submit to the Committee on Health, Education, Labor, and Pensions of the
Senate and the Committee on Commerce of the House of Representatives a report,
concerning--
(A) an assessment of the structure and performance of non-governmental
health plans, medicaid managed care organizations, plans under title XIX
of the Social Security Act (42 U.S.C. 1396 et seq.), and the program under
title XXI of the Social Security Act (42 U.S.C. 1397aa et seq.) serving
the needs of children with special health care needs;
(B) an assessment of the structure and performance of non-governmental
plans in serving the needs of children as compared to medicaid managed
care organizations under title XIX of the Social Security Act (42 U.S.C.
1396 et seq.); and
(C) the emphasis that private managed care health plans place on primary
care and the control of services as it relates to care and services provided
to children with special health care needs.
(2) PLAN SURVEY- Not later than 1 year after the date of enactment of this
Act, the General Accounting Office shall prepare and submit to the Committee
on Health, Education, Labor, and Pensions of the Senate and the Committee
on Commerce of the House of Representatives a report that contains a survey
of health plan activities that address the unique health needs of adolescents,
including quality measures for adolescents and innovative practice arrangement.
END
