109th CONGRESS
1st Session
H. R. 15
To provide a program of national health insurance, and for other
purposes.
IN THE HOUSE OF REPRESENTATIVES
January 4, 2005
Mr. DINGELL introduced the following bill; which was referred to the Committee
on Energy and Commerce, and in addition to the Committee on Ways and Means,
for a period to be subsequently determined by the Speaker, in each case for
consideration of such provisions as fall within the jurisdiction of the committee
concerned
A BILL
To provide a program of national health insurance, and for other
purposes.
Be it enacted by the Senate and House of Representatives of the United
States of America in Congress assembled,
SECTION 1. SHORT TITLE; TABLE OF CONTENTS.
(a) Short Title- This Act may be cited as the `National Health Insurance Act'.
(b) Table of Contents- The table of contents of this Act is as follows:
Sec. 1. Short title; table of contents.
Sec. 2. Findings and declaration of purpose.
TITLE I--BENEFITS AND ELIGIBILITY
Sec. 101. Classes of personal health services.
Sec. 102. Availability of benefits.
Sec. 103. How benefits obtained: free choice by patient.
Sec. 104. Eligibility for benefits.
Sec. 105. Provision of benefits for noninsured needy and other individuals.
TITLE II--PARTICIPATION OF PHYSICIANS, DENTISTS, NURSES, HOSPITALS, AND
OTHERS
Sec. 201. Physicians and dentists; specialists.
Sec. 204. Auxiliary services.
Sec. 205. Agreements with individual practitioners, hospitals, and others.
Sec. 206. Agreements with voluntary health insurance and other organizations.
Sec. 207. Provisions common to all agreements.
Sec. 208. Methods of payments for services.
Sec. 209. Amount of payments for services.
Sec. 210. Professional rights and responsibilities.
TITLE III--LOCAL ADMINISTRATION
Sec. 301. Decentralization of administration.
Sec. 302. Local administrative committee or officer.
Sec. 303. Local area committees.
Sec. 304. Local professional committees.
Sec. 305. Methods of administration.
TITLE IV--STATE ADMINISTRATION
Sec. 401. Declaration of policy.
Sec. 402. State plan of operations.
TITLE V--NATIONAL HEALTH INSURANCE BOARD; NATIONAL ADVISORY MEDICAL POLICY
COUNCIL; GENERAL ADMINISTRATIVE PROVISIONS
Sec. 501. National Health Insurance Board.
Sec. 502. Advisory Council.
Sec. 503. Studies, recommendations, and reports.
Sec. 504. Nondisclosure of information.
Sec. 505. Prohibition against discrimination.
TITLE VI--ELIGIBILITY DETERMINATIONS, COMPLAINTS, HEARINGS, AND JUDICIAL
REVIEW
Sec. 601. Determinations as to eligibility for benefits.
Sec. 602. Complaints of eligible individuals and of persons furnishing benefits.
TITLE VII--APPLICATION OF ACT TO INDIVIDUALS COVERED UNDER MEDICARE PROGRAM
Sec. 701. Eligibility; benefits available.
Sec. 702. Study and report.
TITLE VIII--FISCAL PROVISIONS
Sec. 801. Use of Trust Fund.
Sec. 802. Allotment of funds.
Sec. 803. Grants-in-aid for training and education.
TITLE IX--MISCELLANEOUS PROVISIONS
Sec. 902. Effective date.
TITLE X--VALUE ADDED TAX AND NATIONAL HEALTH CARE TRUST FUND
Sec. 1001. Imposition of value added tax.
Sec. 1002. Revenue from value added tax to fund National Health Care Trust
Fund.
TITLE XI--STUDY AND DEVELOPMENT OF COST CONTROL MECHANISMS
Sec. 1101. Development of cost control mechanisms.
SEC. 2. FINDINGS AND DECLARATION OF PURPOSE.
(a) Findings- The Congress finds that--
(1) the health of the Nation's people is the foundation of our Nation's
strength, productivity, and wealth;
(2) the assurance of adequate medical care to all of our people is essential
to the general welfare and to the Nation's security;
(3) since the tremendous advances in medical science in recent years have
necessarily meant great advances in the cost of health services, our archaic
system of paying for medical care--based on public and private charity for
the poor, on unpredictable and often unbearable costs to the otherwise self-supporting,
and on disproportionate charges for the well-to-do--has resulted in the
following conditions:
(A) the inability of the vast majority of our people to meet the shattering
cost of serious or chronic illness;
(B) the inability of most of our people to benefit from modern preventive
medicine; and
(C) wholly inadequate provision for the health needs of our farm families
and agricultural workers;
(4) the conditions described in the preceding paragraph cannot effectively
be remedied under the present system of payment for medical care, or under
any voluntary insurance system; and
(5) a medical dole as an answer to this problem is repugnant to the American
people and would certainly result in a system of state medicine, paid for
from tax funds and rendered by regimented doctors.
(b) Purposes- The Congress declares the purposes of this Act to be to provide
a sound economic foundation for our free system of medicine and to correct
the maldistribution of health personnel and facilities by establishing a system
of prepaid personal health insurance on the principle of social insurance.
SEC. 3. POLICIES OF ACT.
(a) In General- In establishing a system of national health insurance, it
is the policy of this Act that--
(1) those persons and their dependents who are insured under the provisions
of the Act shall be assured full freedom to choose their physicians and
to change their choice as they may desire;
(2) physicians and other professions furnishing services in accordance with
the provisions of this Act shall be assured full freedom in the practice
of their professions, including the right to accept or reject patients except
as this right may be restricted by their own professional ethics or by the
laws of the several States; and
(3) the administration of this Act shall be based upon the American principle
of decentralization.
(b) Administrative Responsibilities- In carrying out these policies, it is
the intention of Congress that the major administrative responsibilities be
placed in the hands of local bodies representing both those who pay for and
receive services and those who render services, and operating within the framework
of plans made by the several States, and approved by the Federal agency; that
the National Health Care Trust Fund created by this Act shall be allotted
equitably among the several States and by the States to their local areas;
that voluntary as well as governmental organizations shall be recognized and
utilized; and that all eligible individuals and their dependents as specified
in this Act shall be entitled to its benefits without discrimination because
of race, color, or creed.
TITLE I--BENEFITS AND ELIGIBILITY
SEC. 101. CLASSES OF PERSONAL HEALTH SERVICES.
(a) Personal Health Services-
(1) IN GENERAL- The personal health services to be made available as benefits
to eligible individuals as provided in this title are the following:
(D) Home-nursing services.
(2) PROVISION OF SERVICES- Each class of services shall be provided by persons
(including individuals, partnerships, corporations, associations, consumer
cooperatives, and other organizations) who are authorized by applicable
State law, and who are qualified under title II, to do so.
(b) Medical Services- Medical services consist of--
(1) general medical services such as can be rendered by a physician engaged
in the general or family practice of medicine, including preventive, diagnostic,
and therapeutic care and periodic medical examinations; and
(2) specialist services rendered by a physician who is a specialist in the
class of services rendered, as defined in section 201.
Such medical services may be rendered at the office, home, hospital, or elsewhere,
as necessary.
(c) Dental Services- Dental services consist of--
(1) general dental services rendered by a dentist engaged in the general
practice of dentistry, including preventive, diagnostic, and therapeutic
care, and periodic dental examinations; and
(2) specialist services rendered by a dentist who is a specialist in the
class of services rendered, as defined in section 201.
Such dental services may be rendered at the office, home, hospital, or elsewhere,
as necessary.
(d) Podiatric Services- Podiatric services consist of those professional services
of a podiatrist who is legally authorized to perform such services in the
State in which the podiatrist practices.
(e) Home-Nursing Services- Home-nursing services consist of nursing care of
the sick rendered in the home by a registered professional nurse or a qualified
practical nurse.
(1) IN GENERAL- Hospital services consist of hospitalization, including
necessary nursing services, and such physician, laboratory, ambulance, and
other services in connection with hospitalization as the National Health
Insurance Board (in this Act referred to as the `Board'), after consultation
with the National Advisory Medical Policy Council (in this Act referred
to as the `Advisory Council'), by regulation designates as essential to
good hospital care, for a maximum of 60 days in any benefit year.
(2) EXCLUSION- Hospital services shall not include hospitalization in a
mental disease hospital or institution, or hospitalization for any day more
than 30 days following the diagnosis of a psychosis.
(3) INCREASE IN MAXIMUM NUMBER OF DAYS- Whenever the Board, after consultation
with the Advisory Council, finds that moneys in the National Health Care
Trust Fund are adequate and that facilities are available, it may by regulation
increase the maximum days of hospitalization in any benefit year.
(g) Auxiliary Services- Auxiliary services consist of such--
(1) chemical, bacteriological, pathological, diagnostic X-ray and related
laboratory services;
(2) X-ray, radium, and related therapy;
(4) services of optometrists;
(5) prescribed drugs which are unusually expensive;
(6) special appliances; and
as the Board, after consultation with the Advisory Council, by regulation
designates as auxiliary services on the basis of its finding that their provision
under this Act is practicable and is essential to good health care.
SEC. 102. AVAILABILITY OF BENEFITS.
(a) General Availability-
(1) IN GENERAL- Medical services, hospital services, and, except as otherwise
provided in subsection (b), all other personal health services specified
in section 101 shall be made available (subject to section 701) as benefits
to eligible individuals in all health-service areas within the United States
as rapidly and as completely as possible having regard for the availability
of the professional and technical personnel and the hospital and other facilities
needed to provide such services.
(2) SURVEYS OF RESOURCES AND NEEDS- To this end the resources and needs
of each State shall be surveyed and a program developed in each State to
assure the maximum participation and use of health personnel and facilities
in the provision of benefits, and to encourage improvement in the number
and distribution of such personnel and facilities throughout the State.
Additional surveys shall be undertaken as required, and the program in the
State from time to time modified on the basis thereof.
(b) Limitation on Availability- If the Board, after consultation with the
Advisory Council, finds that the personnel or facilities or funds that are
or can be made available are inadequate to insure the provision of all services
included as dental, home-nursing, or auxiliary services under section 101,
it may by regulation limit for a specified period the services which may be
provided as benefits, or modify the extent to which, or the circumstances
under which, they will be provided to eligible individuals. Any such restriction
or limitation shall be reduced or withdrawn as rapidly as may be practicable.
In the case of dental services, priority in the reduction or withdrawal of
any such restriction or limitation shall be given to children.
(c) Recommendations- The Board shall have the duty of--
(1) studying and making recommendations as to needed services and facilities
for the care of the chronic sick afflicted with physical ailments, and for
the care of individuals afflicted with mental or nervous diseases, and as
to needed provisions for the prevention of chronic physical diseases and
of mental or nervous diseases; and
(2) making reports from time to time, with recommendations as to legislation,
but the first such report shall be made not later than two years after benefits
under this Act first become available.
SEC. 103. HOW BENEFITS OBTAINED: FREE CHOICE BY PATIENT.
(a) In General- Every individual eligible for personal health services available
under this Act may freely select the physician, dentist, podiatrist, nurse,
medical group, hospital, or other person of the individual's choice to render
such services, and may change such selection if the practitioner, medical
group, hospital, or other person has agreed under title II to furnish the
class of services required and consents to furnish such services to the individual.
(b) Practitioner Services- General medical, dental, and podiatric services
may be obtained by request made by the individual directly to the practitioner
of the individual's choice.
(c) Specialty Services- Specialist, home-nursing, hospital, and auxiliary
services shall be obtained from the specialist, nurse, hospital, or other
person of the individual's choice, whenever the practitioner from whom the
individual is receiving medical or dental services as benefits under this
Act refers the individual for specialist, home-nursing, hospital, or auxiliary
services upon determining that such services are required in the proper care
of the individual's particular case; or whenever, upon request of the individual,
an administrative medical officer, upon a like determination, refers the individual
for such services.
(d) Waiver of Referral- The Board, by regulation, shall dispense with the
necessity of referral in cases of emergency, and may dispense with the necessity
of referral under specified circumstances or as respects specified classes
of services, or both, if it finds, after consultation with the Advisory Council,
that such action will be conducive to the provision of a more adequate amount
and quality of health care and will not unreasonably increase the expenditures
from the National Health Care Trust Fund for such services.
SEC. 104. ELIGIBILITY FOR BENEFITS.
(a) In General- Subject to section 701, every individual shall be eligible
for benefits under this Act throughout any benefit year if the individual--
(1) has received (or, in the case of income from self-employment, has accrued)--
(A) not less than $2,000 in wages during the first four of the last six
calendar quarters preceding the beginning of the benefit year; or
(B) not less than $1,500 in wages in each of six calendar quarters during
the first twelve of the last fourteen calendar quarters preceding the
beginning of the benefit year (not counting as one of such fourteen calendar
quarters any quarter in any part of which the individual was under a total
disability which continued for six months or more);
(2) is entitled, for the first month in the benefit year, to a benefit under
title II of the Social Security Act or to an annuity under subchapter III
(relating to civil service retirement) of chapter 83 of title 5, United
States Code; or
(3) the individual is on the first day of the benefit year a dependent of
an individual who is eligible under paragraph (1) or paragraph (2).
(b) Additional Eligibility- Subject to section 701, every individual, not
eligible therefor under subsection (a), shall be eligible for benefits under
this Act during the remainder of a benefit year, beginning with--
(1) the first day of any calendar quarter in such benefit year, if the individual
has received (or, in the case of income from self-employment, has accrued)
not less than $150 in wages during the first four of the last six calendar
quarters preceding the beginning of such calendar quarter;
(2) the first day of the first month in such benefit year for which the
individual is entitled to a benefit or annuity referred to in subsection
(a)(2); or
(3) the first day in such benefit year on which the is or becomes a dependent
of an individual who is eligible for benefits under subsection (a) (1) or
(2) under paragraph (1) or (2).
(c) Coverage Under Workers' Compensation-
(1) NO COVERAGE- No individual shall be deemed eligible for any personal
health services as a benefit under this Act which are required by reason
of any injury, disease, or disability on account of which any medical, dental,
home-nursing, hospital, or auxiliary service is being received, or upon
application therefor would be received, under a workmen's compensation law
of the United States or of any State, unless equitable reimbursements to
the National Health Care Trust Fund for the provision of such services as
benefits have been made or assured under section 105.
(2) SUBROGATION- In any case in which an individual receives any personal
health service as a benefit under this Act with respect to any such injury,
disease, or disability, for which no reimbursement to the National Health
Care Trust Fund has been made or assured, the United States shall to the
extent permitted by State law be subrogated to all rights of such individual,
or of the person who furnished such service, to be paid or reimbursed, pursuant
to such workmen's compensation law, for the cost of furnishing such service.
SEC. 105. PROVISION OF BENEFITS FOR NONINSURED NEEDY AND OTHER INDIVIDUALS.
(a) In General- Subject to section 701, any or all benefits provided under
this Act to individuals eligible for such benefits may be furnished to individuals
(including the needy) not otherwise eligible therefor, for any period for
which equitable reimbursements to the National Health Care Trust Fund on behalf
of such needy or other individuals have been made, or for which reasonable
assurance of such reimbursements have been given, by public agencies of the
United States, the several States, or any of them or of their political subdivisions,
such reimbursements to be in accordance with agreements and working arrangements
negotiated with such public agencies. Services furnished to such needy or
other individuals as benefits shall be of the same quality, be furnished by
the same methods, and be paid for through the same arrangements, as services
furnished to individuals eligible for benefits under this Act.
(b) Availability of Federal Funds- Federal grants to States under title XIX,
and part A of title IV, of the Social Security Act, and Federal grants to
States for aid or assistance under other provisions of such Act, shall be
available to the States for provision of personal-health services for noninsured
needy individuals in accordance with the provisions of subsection (a).
TITLE II--PARTICIPATION OF PHYSICIANS, DENTISTS, NURSES, HOSPITALS, AND
OTHERS
SEC. 201. PHYSICIANS AND DENTISTS; SPECIALISTS.
(a) Qualifications- Any individual who is a physician, dentist, or podiatrist
legally authorized in a State to render any services included as general medical,
dental, or podiatric services shall be deemed qualified to render such services
in that State as benefits under this Act.
(1) IN GENERAL- Any such individual who is found to possess skill and experience
of a degree and kind sufficient to meet standards established for a class
of specialist services shall be deemed qualified to receive compensation
for specialist services of such class as benefits under this Act.
(2) STANDARDS- The Board, after consultation with the Advisory Council,
shall establish standards as to the special skills and experience required
to qualify an individual to render each such class of specialist services
as benefits under this Act, and to receive compensation for such specialist
services. In establishing such standards and in determining whether individuals
qualify thereunder, standards and certifications developed by professional
agencies shall be utilized as far as is consistent with the purposes of
this Act, and regard shall be had for the varying needs and the available
resources in professional personnel of the States and of local health-service
areas.
SEC. 202. NURSES.
Any individual shall be deemed qualified to render home-nursing services in
a State as benefits under this title if such individual is--
(1) a professional nurse registered in such State; or
(A) who is qualified as such under State standards or requirements, or,
in the absence of State standards or requirements, is found to be qualified
under standards established by the Board after consultation with the Advisory
Council and with nursing agencies; and
(B) who furnishes nursing care under the direction or supervision of the
State health agency, the health agency of a political subdivision of the
State, or an organization supplying and supervising the services of registered
professional nurses in the State.
SEC. 203. HOSPITALS.
Any hospital or other institution shall be deemed qualified to furnish all
or particular classes of hospital services as benefits under this Act if--
(1) it is qualified to furnish such services under State standards or requirements
for the maintenance and operation of hospitals which apply to the class
or classes of services to be furnished; or
(2) in the absence of such State standards or requirements, it is found
to afford professional services, personnel, and equipment adequate to promote
the health and safety of individuals requiring the class or classes of hospital
services to be furnished, according to standards which the Board shall establish
after consultation with the Advisory Council.
SEC. 204. AUXILIARY SERVICES.
Any person (as defined in section 901(1)) who--
(1) is qualified under State standards or requirements to furnish a class
of services included as auxiliary services; or
(2) in the absence of State standards or requirements, is found to be qualified
to furnish a class of such services under standards established for such
class by the Board after consultation with the Advisory Council,
shall be deemed qualified to furnish such class of auxiliary services in that
State as benefits under this Act.
SEC. 205. AGREEMENTS WITH INDIVIDUAL PRACTITIONERS, HOSPITALS, AND OTHERS.
Any individual (or, in the case of hospital or auxiliary services, any person)
qualified under this title to furnish any class or classes of personal health
services as benefits may enter into an agreement with the State agency which
in accordance with title IV has assumed responsibility for the administration
in the State of benefits under this Act (in this Act referred to as the `State
agency'), to furnish such class or classes of services as benefits to individuals
eligible therefor under this Act.
SEC. 206. AGREEMENTS WITH VOLUNTARY HEALTH INSURANCE AND OTHER ORGANIZATIONS.
(a) In General- In the provision of personal health services, it shall be
the policy to utilize individuals or organizations qualified under this title
to render such services, including--
(1) any organized group of individuals;
(2) any partnership, association, or consumer cooperative;
(3) any hospital or any hospital and its staff; or
(4) any organization operating a voluntary health-service insurance plan
or other voluntary health-service plan.
(b) Authorization- The State agency is authorized to enter into an agreement
with any organization referred to in subsection (a) for the provision of personal
health services under this Act. Any such organization, whether or not it enters
into an agreement with the State agency on its own behalf, shall be permitted
to act as agent for individuals or other persons in negotiating or in carrying
out agreements with the State agency for rendering personal health services
under this Act.
(c) Qualification of Providers- Any agreement under this section shall provide
that each class of personal health services will be furnished only by individuals
(or, in the case of hospital or auxiliary benefits, by persons, as defined
in section 901(1)) who are qualified under this title to render such class
of services and each of whom has agreed or has authorized an agreement to
be made on the individual's behalf with the State agency that the individual
will furnish such services in accordance with this Act and with regulations
prescribed thereunder. Each such individual or person shall be responsible,
both to the State agency and (in accordance with applicable State law) to
individuals eligible for personal health services as benefits, for carrying
out such agreement made by the individual or person or on behalf of the individual
or person.
SEC. 207. PROVISIONS COMMON TO ALL AGREEMENTS.
(a) In General- Each agreement made under this title shall--
(1) specify the class or classes of services to be furnished or provided
pursuant to its terms;
(2) contain an undertaking to comply with this Act and with regulations
prescribed thereunder;
(3) be made upon terms and conditions consistent with the efficient and
economical administration of this Act; and
(4) continue in force for such period and be terminable upon such notice
as may be agreed upon.
(b) Term- No agreement under section 206, and no designation of an agent,
shall for more than one year preclude any individual or person qualified to
furnish personal health services from exercising such rights as the individual
or person would otherwise have under this title--
(1) to negotiate and enter into an agreement directly with the State agency;
(2) to designate another agent for such negotiation; or
(3) to participate in another agreement under section 206.
(c) Non Exclusive Agreements- No agreement made under this title shall confer
upon any individual or other person, or any group or other organization, the
right of furnishing or providing personal health services as benefits, to
the exclusion in whole or in part of other individuals, persons, groups, or
organizations qualified to furnish or provide such services.
(1) IN GENERAL- If the State agency after investigation finds that an individual
or other person under agreement to furnish or provide personal health services
as benefits is no longer qualified to furnish or provide such services,
or has committed a substantial breach of the agreement, it shall notify
such person of its findings, together with the reasons therefor, and in
the absence of a request for a hearing by such person under title VI, or
in the event of a final decision sustaining its findings after any hearing
and further review provided under title VI, may terminate the agreement
and withdraw the person's name from the list published pursuant to title
III.
(2) LIMITATION ON SUBSEQUENT AGREEMENTS- After an agreement has been so
terminated, no new agreement shall be entered into with such person under
this Act unless and until such person gives reasonable assurances to the
State agency of the person's ability and willingness to discharge all obligations
and responsibilities under a new agreement satisfactorily in accordance
with its provisions.
SEC. 208. METHODS OF PAYMENTS FOR SERVICES.
(a) Professional Services- Agreements for the furnishing of medical, dental,
or podiatric services (other than specialist services) as benefits under this
Act shall provide for payment--
(1) on the basis of fees for services rendered as benefits, according to
a fee schedule;
(2) on a per capita basis, the amount being according to the number of individuals
eligible for benefits who are on the practitioner's list;
(3) on a salary basis, whole time or part time; or
(4) on such combinations or modifications of these bases, including separate
provision for travel and related expenses, as may be approved by the State
agency;
according in each health-service area as the majority of the medical practitioners
or of the dental practitioners, respectively, under agreement to furnish such
services shall elect. Provision shall be made for another method or methods
of payment (from among the methods listed in this subsection) to those medical
practitioners or to those dental practitioners who do not elect the method
of such majority, when it is found that such alternative method of making
payments contributes to carrying out the provisions of section 305 or otherwise
promotes the efficient and economical provision of medical or dental services
in the area.
(b) Specialist Services- Agreements for the furnishing of specialist services
as benefits under this Act may provide for payments on the basis of fee for
service, per case, per session, per capita, on salary (whole time or part
time), or other basis, or combination thereof.
(c) Treatment of Groups- Any of the methods of making payments from among
the methods listed in subsection (a) or subsection (b) may be used in making
payments to groups or practitioners or organizations or other agencies which
undertake to provide specialist services as well as general medical or general
dental services.
(1) USE OF REASONABLE COSTS- Agreements for the furnishing of hospital services
as benefits under this Act shall provide for payment on the basis of the
reasonable costs of hospitalization furnished as benefits.
(2) MAXIMUM RATES- The Board, after consultation with the Advisory Council
and with representatives of interested hospital organizations, may by regulation
prescribe maximum rates for hospitalization furnished as benefits under
this Act, and such maximum rates may be varied according to classes of localities
or types of service.
(3) PAYMENT BASIS- Payments to hospitals shall be based on the least expensive
multiple-bed accommodations available in the hospital unless the patient's
condition makes the use of private accommodations essential for the patient's
proper medical care.
(4) ADDITIONAL CHARGES- An agreement made for furnishing such services shall
not affect the right of the hospital or other person with whom the agreement
is made to require payments from patients with respect to the additional
cost of more expensive facilities occupied at the request of the patient,
or with respect to services not included as benefits under this Act.
(e) Home-Nursing Services and Auxiliary Services- Agreements for the furnishing
of home-nursing services or auxiliary services as benefits under this Act
shall provide for payment in accordance with such methods as the State agency
may approve from among those set forth in regulations prescribed pursuant
to this Act.
(f) Pro-Rating Certain Per Capita Payments- In any health-service area where
agreements for the furnishing of general medical or general dental services
provide for payment only on a per capita basis, the per capita payments with
respect to those individuals residing in the area who have failed to select
a practitioner or other person to furnish such services to them shall be made
on a pro rata basis among the practitioners and other persons under agreement
to furnish such services in the area.
SEC. 209. AMOUNT OF PAYMENTS FOR SERVICES.
(a) Consideration of Local Conditions-
(1) IN GENERAL- Rates or amounts of payment for particular services or classes
of services furnished as benefits under this Act shall be adapted to take
account of relevant regional, State, or local conditions and practices.
(2) PROFESSIONAL SERVICES- In arriving at the payments to be made for services
of general medical and dental practitioners, specialists, professional and
practical nurses, or other practitioners, regard shall be had for the annual
income or its equivalent which the payments will provide, and consideration
shall be given to degree of specialization, and to the skill, experience,
and responsibility involved in rendering the services.
(3) ADEQUACY- Such payments, together with the other terms and conditions
of the agreements made under this title, shall be adequate to provide professional
and financial incentives to practitioners to advance in their professions
and to practice in localities where their services are most needed, to encourage
high standards in the quality of services furnished, to give assistance
in their use of opportunities for postgraduate study, and to allow for adequate
vacation.
(b) Equivalence in Choice of Payment Methods- The rates and amounts of payments
fixed under the different methods of payments specified in subsections (a),
(b), (c), and (e) of section 208, and the methods of making payments, shall
assure reasonably equivalent awards for practitioners selecting different
methods of payment, in consideration of the value of the services they render.
(c) Limitations on Maximum Number of Patients- Maximum limits upon the number
of eligible individuals with respect to whom any person may undertake to render
services in any local health-service area may be fixed by the local administrative
committee or local administrative officer of that health-service area only
on the basis of a recommendation of the professional committee in that area
that such limitation is necessary to maintain high standards in the quality
of medical, dental, or other services furnished as benefits. Any such limits
shall take account of professional needs and practices and shall provide suitable
exceptions for emergency and temporary situations.
(d) Treatment of Groups- The making of an agreement under section 206 with
a group or other organization shall not operate to increase the payments to
be made pursuant to any such agreement over the amounts which, in the absence
of such group or organization would be payable for the same services pursuant
to agreements made under section 205 directly with the person or persons who
furnish the services.
SEC. 210. PROFESSIONAL RIGHTS AND RESPONSIBILITIES.
(a) Termination Arrangements- Any person who enters into an agreement under
this title may terminate such agreement after reasonable notice and after
suitable arrangements are made to fulfill professional obligations to eligible
individuals.
(b) Freedom of Practice- Every physician, dentist, or nurse agreeing to render
services as benefits under this Act shall be free to practice such professional's
profession in the locality of the professional's own choosing, consistent
with the requirements of the laws of the States.
(c) Freedom in Acceptance of Patients- Every physician, dentist, nurse, hospital,
or other person entering into an agreement under this title shall be free
to the extent consistent with applicable State law and customary professional
ethics to accept or reject as a patient any individual requesting the professional's
services.
(d) Freedom From Supervision or Control- No supervision or control over the
details of administration or operation, or over the selection, tenure, or
compensation of personnel, shall be exercised under the authority of this
Act over any hospital which has agreed to furnish personal health services
as benefits.
TITLE III--LOCAL ADMINISTRATION
SEC. 301. DECENTRALIZATION OF ADMINISTRATION.
(a) In General- In order that personal health-service benefits may be made
available promptly and in a manner best adapted to local practices, conditions,
and needs, responsibility for administration of the benefits provided under
this Act in the several local health-service areas shall be decentralized
as fully as practicable to local administrative committees or local administrative
officers, acting with the advice and assistance, as provided in this title,
of local professional committees and, in the case of local administrative
officers, the advice and assistance of local area committees.
(b) Designation of Health-Service Areas- The health-service areas of a State
shall be those so designated in the State plan of operations.
SEC. 302. LOCAL ADMINISTRATIVE COMMITTEE OR OFFICER.
(a) In General- The local administrative agency for each local health-service
area may, as determined by the State, be either--
(1) a local administrative committee established in accordance with section
303, which shall act through a local executive officer; or
(2) a local administrative officer, who shall act with the advice and assistance
of a local advisory committee established in accordance with section 303.
(b) Arrangements for Services- The local administrative committee or officer,
with the advice and assistance of such local professional committees as may
from time to time be established, shall arrange for the furnishing of personal
health-service benefits to eligible individuals in the area and to that end
shall--
(1) publish, and make readily available to eligible individuals in the area,
lists of the names of all persons who have agreed to furnish personal health
services in the area, together with the class or classes of services which
each has undertaken to furnish;
(2) disseminate pertinent information concerning the rights and privileges
under this Act of eligible individuals and of persons qualified to furnish
personal health services as benefits;
(3) maintain effective relationships with physicians, dentists, nurses,
hospitals, and other persons who have entered into agreements to furnish
personal health services in the area, in order to facilitate the furnishing
of such services in accordance with such agreements, to assure full and
prompt payment to such persons for services so furnished, and to enlist
their full cooperation in the administration of benefits under this Act
in the area;
(4) receive and, to the extent possible in the local area, adjust any complaints
which may be made concerning the administration of benefits under this Act
in the area;
(5) perform such other duties (including the making of payments to persons
furnishing personal health services in the area) as may be assigned by the
State agency; and
(6) take or initiate such other administrative action as the committee or
officer finds will best carry out, within the area, the provisions of this
Act, and best effectuate its purposes.
SEC. 303. LOCAL AREA COMMITTEES.
(1) IN GENERAL- A local area committee shall be established in each health-service
area.
(2) FUNCTIONS- If designated by the State as a local administrative committee,
the local area committee shall perform the functions specified in section
302 and shall formulate policies for the administration of benefits under
this Act in the area. If designated as an advisory committee, it shall advise
and assist in the performance of such functions and the formulation of such
policies. The committee, whether administrative or advisory, shall--
(A) participate in the solution of problems affecting the administration
of such benefits;
(B) promote impartiality and freedom from political influence in such
administration;
(C) perform related functions to the end that administration in the area
may be responsive to the wishes and needs of persons furnishing and receiving
benefits in the area, be adapted to local practices and resources; and
(D) provide adequate and high quality personal health services to all
eligible individuals.
(b) Composition- Each local area committee shall consist of not less than
8 nor more than 16 members. The members shall be so selected that--
(1) a majority of the committee shall be representative of the interests
of individuals in the area who are eligible for benefits; and
(2) the remaining members shall be chosen from the several professions,
hospitals, and other organizations in the area by whom such benefits will
be provided.
(1) IN GENERAL- The local area committee shall meet--
(A) as often as may be necessary, and whenever one-third or more of the
members request a meeting; and
(B) in the case of a local administrative committee, not less frequently
than once each month, and, in the case of a local advisory committee,
not less frequently than once in each quarter of the year.
(2) ANNUAL PUBLIC MEETING- At least one meeting of the committee each year
shall be open to the public, notice of which shall be published and at which
any person in the area may participate.
(3) ANNUAL STATEWIDE MEETINGS-
(A) ADMINISTRATIVE OFFICERS- At least once each year there shall be a
statewide meeting of local administrative officers and representatives
of local administrative committees.
(B) LOCAL ADVISORY COMMITTEES- At least once in each year there shall
be a statewide meeting of representatives of all local advisory committees
in the State, and any reports or recommendations made at such meeting
shall on the request of such meeting be transmitted through the State
agency to the Board.
SEC. 304. LOCAL PROFESSIONAL COMMITTEES.
(a) Establishment- Local committees representative of the persons furnishing
personal health services in the area shall be established in each health-service
area.
(b) Functions- Each local professional committee shall assist the local administrative
committee and its executive officer, or the local administrative officer and
the local advisory committee, as the case may be, in--
(1) the preservation of the customary freedom and responsibility (under
applicable State law) of practitioners in the exercise of professional judgment
as to the care of patients; and
(2) in the solution of technical problems concerning the participation of
professional personnel, hospitals, and other qualified persons in the provision
of personal health services as benefits, and to advise the local administrative
or executive officer and the local area committee regarding matters of professional
practice or conduct arising in connection with the performance of agreements
for the provision of such services.
(c) Meetings- Such local committees shall meet on call of the local administrative
committee or officer, as the case may be, or upon their own motion. The members
of any such local professional committee may be professional members of the
local area committee or other professional persons or both.
SEC. 305. METHODS OF ADMINISTRATION.
(a) In General- In each health-service area the methods of administration
shall be such as to--
(1) insure the prompt and efficient care of individuals entitled to personal
health services as benefits;
(2) promote personal relationships between physician and patients;
(3) promote coordination among and between general practitioners, specialists,
those who furnish auxiliary services, nurses, and hospitals, in the furnishing
of services under this Act, between them and public-health centers and agencies,
and educational service, research, and other related agencies or institutions,
and between preventive, diagnostic, and curative services, public and private;
(4) aid in the prevention of disease, disability, and premature death;
(5) encourage improvement in the number and distribution of professional
personnel and facilities; and
(6) insure the provision of adequate service with the greatest economy consistent
with high standards of quality.
(b) Appointment- Local administrative officers shall be appointed by the State
agency or the head thereof, in accordance with the merit system provided for
in the State plan of operations. Local administrative committees shall be
appointed by such agency or the head thereof, from individuals residing in
the respective health-service areas, and the executive officers of such committees
shall be appointed by the committees in accordance with the merit system.
The local health-service areas shall be those so designated in such plan.
Members of local advisory committees and of local professional committees
shall be selected in accordance with methods set forth in such plan.
(c) Compliance With Provisions- In exercising their functions and discharging
their responsibilities under this Act, local administrative officers and communities,
local advisory committees, and local professional committees shall observe
the provisions of this Act, and of regulations prescribed thereunder, and
of any regulations, standards, and procedures prescribed by the State agency.
TITLE IV--STATE ADMINISTRATION
SEC. 401. DECLARATION OF POLICY.
It is the intent of Congress that the benefits provided under this Act be
administered wherever possible by the several States, in accordance with plans
of operations submitted and approved as provided in this title, and in each
State insofar as feasible by the same State agency which administers, or supervises
the administration of, the State's general public health and maternal and
child health programs.
SEC. 402. STATE PLAN OF OPERATIONS.
(a) In General- Any State desiring to assume responsibility for the administration
in the State of the personal health-service benefits provided under this Act
to all individuals in the State who are eligible for such benefits, may do
so for the period beginning October 1, 2006 (when benefits first become available
under this Act), or for the period beginning October 1 of any succeeding year,
if it has undertaken, through its legislature, to administer such benefits
in accordance with the provisions of this Act and with the provisions of regulations
and standards prescribed thereunder, and, at least 12 months in advance, has
submitted and had approved a State plan of operations which provides for the
following:
(1) The plan must designate as the sole agency for the statewide administration
of benefits under this Act a single State agency duly authorized under the
law of the State to administer such benefits within the State in accordance
with the provisions of this Act, the provisions of regulations and standards
prescribed thereunder, and the provisions of the State plan.
(2) The plan must provide for the designation of a State advisory committee
which shall include members who are familiar with the needs for personal
health services in urban and rural areas, and who are representative of
the interests of individuals in the State who are eligible for benefits,
such members to constitute a majority, and members chosen from the several
professions, hospitals, and other organizations in the State by whom such
benefits will be provided, to advise the State agency in carrying out the
administration of such benefits in the State.
(3) The plan must provide for the decentralized administration of this Act
in the State in accordance with title III for the designation of local health-service
areas, and for such methods of selecting the members of local advisory committees
and of local professional committees as are calculated to insure representation
of the nature set forth in sections 303 and 304, respectively.
(4) The plan must provide for such methods of administration, including
methods relating to the establishment and maintenance of personnel standards
on a merit basis (except that the Board shall exercise no authority with
respect to the selection, tenure of office, or compensation of any individual
employed in accordance with such methods), as are found by the Board to
be necessary for the proper and efficient administration of such benefits
in the State.
(5) The plan must provide for the making of surveys of the resources and
needs of the State, in accordance with section 102(a), and sets forth a
program for the administration of such benefits in the State which gives
reasonable assurance (A) that maximum use will be made of all available
health personnel and facilities desiring to participate in the provision
of benefits to eligible individuals, (B) that funds allotted to the State
for the several classes of benefits will be allocated in such manner as
to give reasonable assurance of the availability of services in all health-service
areas in the State, and (C) that any maldistribution or other inadequacies
in the health personnel or facilities available for such purpose, or in
the quality of the services rendered, will be progressively improved as
rapidly as may be practicable.
(6) The plan must provide that the State agency will make such reports in
such form and containing such information as the Board may from time to
time reasonably require, and give the Board, upon demand, access to the
records upon which such information is based.
(7) The plan must provide that all Federal funds paid to the State agency
for purposes of carrying out this Act in the State shall be properly safeguarded
and expended solely for the purposes for which paid, and must provide for
the repayment by the State to the United States of any such funds lost by
the State agency or diverted from the purposes for which paid.
(8) The plan must provide for cooperation, including where necessary entering
into working agreements (with any appropriate transfer of funds), with other
public agencies of the State or of its political subdivisions concerned
with programs related to the purposes of this Act, and with appropriate
agencies of other States or of the United States administering this Act,
or benefits under this Act, in other States.
(b) Approval- The Board shall approve any State plan and any modification
thereof submitted by the State which it finds complies with the provisions
of subsection (a). No change in a State plan shall be required within one
year after initial approval thereof, or within one year after any change thereafter
required therein, by reason of any change in the regulations or standards
prescribed pursuant to this Act, except with the consent of the State or in
accordance with further action by Congress.
(c) Notice of Disapproval- In the event of its disapproval of any plan or
any modification therein submitted by a State pursuant to this title, the
Board shall notify the State of such disapproval and shall, upon request of
the State, afford it reasonable notice and opportunity for a hearing on such
disapproval.
(d) Fallback Administration-
(1) NOTICE TO GOVERNOR- If a State has not prior to October 1, 2006, submitted
and had approved a plan of operations, the Board shall notify the Governor
of the State that the Board will be required to administer this Act in the
State, commencing October 1, 2006.
(2) PUBLICATION OF NOTICE- The Board shall provide for the publication of
such notice in at least two newspapers of general circulation in the State.
(3) CONTINUED ADMINISTRATION- If within 60 days after such notification
to the Governor the State has not submitted an approvable plan, the Board
shall continue such administration until one year after the submission and
approval of a plan of operations in accordance with this section.
(4) WAIVER- The Board may waive the requirement that a State plan must be
submitted and approved one year prior to commencement of State administration
if it is satisfied in a particular case that the substitution of a shorter
preparatory period will not prejudice the interests of eligible individuals
in the State.
(1) NOTICE- Whenever the Board, after reasonable notice and opportunity
for hearing to the State, finds that the State, having submitted and had
approved a plan of operations under this title--
(A) is not complying substantially with the provisions of such plan, or
with the provisions of this Act or any regulations or standards prescribed
thereunder, or
(B) has withdrawn its plan or failed to change it when and as required
by a change in this Act or in regulations prescribed thereunder,
the Board shall notify the Governor of the State of such findings, together
with its reasons therefor and a statement concerning the effect of such
findings under this Act, and shall provide for the publication of such notice
in at least two newspapers of general circulation in the State.
(2) BOARD ASSUMPTION OF RESPONSIBILITY- If within 60 days following such
a notice the State has not taken appropriate action to bring its plan or
its administration thereof into conformity with this Act and regulations
and standards thereunder, the Board shall immediately assume responsibility
for the administration of this Act in the State and shall administer the
same in such State for so long thereafter as the State fails to give reasonable
assurances of substantial compliance or fails to submit an approvable plan,
as the case may be.
(f) Board Authority- In any State in which the Board has assumed responsibility
for the administration of benefits under this Act as provided in subsections
(d) and (e), the Board shall have and discharge all authority and duties,
in accordance with the provisions of this Act, which it finds necessary for
that purpose, and the term `State agency' wherever used in title II or title
III shall be deemed to refer to the Board.
(g) Additional State-Funded Services- Nothing in this Act shall preclude any
State or any political subdivision thereof, whether or not the State has assumed
responsibility for the administration of benefits under this Act, from furnishing,
with funds available from sources other than the National Health Care Trust
Fund, any additional health services to individuals who are eligible for benefits
under this Act or any or all health services to individuals who are not so
eligible.
TITLE V--NATIONAL HEALTH INSURANCE BOARD; NATIONAL ADVISORY MEDICAL POLICY
COUNCIL; GENERAL ADMINISTRATIVE PROVISIONS
SEC. 501. NATIONAL HEALTH INSURANCE BOARD.
(1) IN GENERAL- There is hereby established in the Department of Health
and Human Services a National Health Insurance Board.
(2) COMPOSITION- The Board shall be composed of 5 members, three of whom
shall be appointed by the President by and with the advice and consent of
the Senate, and the other two of whom shall be the Surgeon General of the
Public Health Service and the Administrator of Social Security. At least
one of the appointed members shall be a doctor of medicine licensed to practice
medicine or surgery in one of the States.
(3) NO OTHER EMPLOYMENT- During an appointment member's term of membership
on the Board, the member shall not shall engage in any other business, vocation,
or employment.
(4) COMPENSATION- Each appointed member shall receive a salary at an annual
rate of basic pay, established by the President, which is not less than
the annual rate of basic pay for positions at level V of the Executive Schedule
and which is not greater than the annual rate of basic pay for positions
at level IV of the Executive Schedule.
(5) TERM- Each appointed member shall hold office for a term of six years,
except that--
(A) any member appointed to fill a vacancy occurring prior to the expiration
of the term for which the member's predecessor was appointed shall be
appointed for the remainder of such term; and
(B) the terms of office of the members first taking office after the date
of the enactment of this Act shall expire, as designated by the President
at the time of appointment, one at the end of two years, one at the end
of four years, and one at the end of six years, after the date of the
enactment of this Act.
(6) DESIGNATION OF CHAIRMAN- The President shall designate one of the appointed
members as the Chairman of the Board.
(1) SUPERVISION- All functions of the Board shall be administered by the
Board under the direction and supervision of the Secretary of Health and
Human Services. The board shall perform such functions as it finds necessary
to carry out the provisions of this Act, and shall make all regulations
and standards specifically authorized to be made in this Act and such other
regulations not inconsistent with this Act as may be necessary.
(2) DELEGATION- The Board may delegate to any of its members, officers,
or employees, or with the approval of the Secretary to any other officer
or employee of the Department of Health and Human Services, such of its
powers or duties, except that of making regulations, as it may consider
necessary and proper to carry out the provisions of this Act.
(3) CONTRACT AUTHORITY- The Board may also enter into agreements for the
furnishing or provision of personal health services under this Act without
regard to the provisions of title 5, United States Code, pertaining to the
appointment, status, or compensation of Federal employees, or pertaining
to contracts for personal services, and without regard to section 3709 of
the Revised Statutes (41 U.S.C. 5), and any person rendering services pursuant
to an agreement so made shall not by reason thereof be deemed to be an employee
of the United States.
(c) Use of Executive Agencies- In administering the provisions of this Act,
the Board is authorized to utilize the services and facilities of any executive
department or other agency of the United States in accordance with an agreement
with the head thereof. Payment for such services and facilities shall be made
in advance or by way of reimbursement, as may be agreed upon with the head
of the executive department or other agency furnishing them.
(1) IN GENERAL- Personnel of the Board shall be appointed by the Secretary
upon recommendation of the Board.
(2) DETAILING OF EMPLOYEES TO BOARD- The Secretary is authorized to detail
to the Board, upon its request, any officer or employee of the Department
of Health and Human Services, and in the Secretary's discretion to reimburse,
from funds available for the administration of this Act, the appropriation
from which the salary or, in the case of commissioned officers of the Public
Health Service, the pay and allowances of such officer or employee are paid.
(e) Detailing of Board Employees- Upon the request of any State agency administering
a State plan of operations pursuant to title IV, or upon the request of any
State desiring to prepare and submit a plan of operations, any officer or
employee of the Board (including any officer or employee detailed to the Board
pursuant to subsection (d)) may be detailed by the Board to assist in the
administration, or in the preparation, of such State plan of operations. The
funds available for the Federal administration of this Act may, in the discretion
of the Secretary, be reimbursed from funds allotted to the State pursuant
to section 802 and available for State administration, for the salary (or
for the pay and allowances) of any officer or employee so detailed.
SEC. 502. ADVISORY COUNCIL.
(1) IN GENERAL- There is hereby established a National Advisory Medical
Policy Council.
(2) COMPOSITION- The Council shall consist of the Chairman of the Board,
who shall serve as Chairman of the Advisory Council ex officio, and 16 members
appointed by the Secretary of Health and Human Services. At least 8 of the
16 appointed members shall be individuals who are familiar with the need
for personal health services in urban or rural areas and who are representative
of the interests of individuals eligible for benefits under this Act, and
at least 6 of the members shall be individuals who are outstanding in the
medical or other professions concerned with the provision of services provided
as benefits under this Act and who are representative of the individuals,
organizations, and other persons by whom personal health services will be
provided.
(3) TERM- Each appointed member shall hold office for a term of 4 years,
except that any member appointed to fill a vacancy occurring prior to the
expiration of the term for which the member's predecessor was appointed
shall be appointed for the remainder of that term, and the terms of the
members first taking office shall expire, as designated by the Secretary
at the time of appointment, four at the end of the first year, four at the
end of the second year, four at the end of the third year, and four at the
end of the fourth year after the date of appointment.
(4) TECHNICAL AND PROFESSIONAL ADVISORY COMMITTEES- The Advisory Council
is authorized to appoint such special advisory technical or professional
committees as may be useful in carrying out its functions, and the members
of such committees may be members of the Advisory Council, or other persons,
or both.
(5) COMPENSATION- Appointed Advisory Council members and members of technical
or professional committees, while serving on business of the Council (inclusive
of traveltime), shall receive compensation at rates fixed by the Secretary,
but not exceeding $200 per day, and shall be entitled to receive actual
and necessary traveling expenses and per diem in lieu of subsistence while
so serving away from their places of residence.
(6) SUPPORT SERVICES- The Advisory Council, its appointed members, and its
committees, shall be provided with such secretarial, clerical, or other
assistance as may be provided by the Congress for carrying out their respective
functions.
(7) MEETINGS- The Advisory Council shall meet as frequently as the Board
deems necessary, but not less than twice each year. Upon request by six
or more members, it shall be the duty of the Chairman to call a meeting
of the Council.
(b) Functions- The Advisory Council shall advise the Board with reference
to matters of general policy and administration arising in connection with
the making of regulations, the establishment of professional standards, and
the performance of its other duties under this Act.
(c) Indefinite Duration- Section 14 of the Federal Advisory Committee Act
shall not apply to the Advisory Council.
SEC. 503. STUDIES, RECOMMENDATIONS, AND REPORTS.
(a) In General- The Board shall have the duty of studying and making recommendations
as to the most effective methods of providing health services, and as to legislation
and matters of administrative policy concerning health and related subjects.
(b) Annual Reports- At the beginning of each regular session of Congress,
it shall make a full report to Congress of the administration of this Act,
including a report with regard to the adequacy of its financial provisions
contained in this Act and of appropriations made pursuant thereto, the methods
of allotment of funds among the States, and related matters. Such report shall
include a record of consultations with the Advisory Council, recommendations
of the Advisory Council, and comments thereon.
SEC. 504. NONDISCLOSURE OF INFORMATION.
(a) Confidentiality- Information concerning an individual, obtained from the
individual or from any physician, dentist, nurse, or hospital, or from any
other person pursuant to or as a result of the administration of this Act,
shall be held confidential (except for statistical purposes) and shall not
be disclosed or be open to public inspection in any manner revealing the identity
of the individual or other person from whom the information was obtained or
to whom the information pertains, except as may be necessary for the proper
administration of this Act or of other laws, State or Federal.
(b) Penalty- Any person who shall violate any provision of subsection (a)
shall be deemed guilty of a misdemeanor and, upon conviction thereof, shall
be punished by a fine not exceeding $50,000 or by imprisonment not exceeding
one year, or both.
SEC. 505. PROHIBITION AGAINST DISCRIMINATION.
In carrying out the provisions of this Act there shall be no discrimination
on account of race, creed, or color. Personal health services shall be made
available as benefits to all eligible individuals, and all persons qualified
under title II to enter into agreements to furnish or provide such services
shall be permitted to do so.
TITLE VI--ELIGIBILITY DETERMINATIONS, COMPLAINTS, HEARINGS, AND JUDICIAL
REVIEW
SEC. 601. DETERMINATIONS AS TO ELIGIBILITY FOR BENEFITS.
(a) In General- The Secretary of Health and Human Services through such units
of the Department of Health and Human Services as the Secretary may determine,
shall upon the Secretary's own initiative or upon application of any individual
make determinations as to the eligibility of individuals for benefits under
this Act. Whenever requested by any individual determined by the Secretary
not to be eligible for benefits for any period, or by a dependent of any such
individual, the Secretary shall give such individual or such dependent reasonable
notice and opportunity for a hearing with respect to such determination and
on the basis of the evidence adduced at the hearing shall affirm, modify,
or reverse the Secretary's determination.
(1) IN GENERAL- In carrying out the Secretary's responsibility under this
section, the Secretary shall have all the powers and duties conferred upon
the Secretary under sections 205 and 206 of the Social Security Act. Such
powers and duties shall be subject to the same limitations and rights of
judicial review as are contained in section 205 of such Act.
(2) CIVIL SERVICE ELIGIBILITY DETERMINATIONS- Eligibility for benefits under
this title based on entitlement to an annuity under subchapter III (relating
to civil service retirement) of chapter 83 of title 5, United States Code,
shall be determined on the basis of certification by the Office of Personnel
Management.
(c) Role of States- Nothing in title IV shall be deemed to require or authorize
any assumption by the State agency, designated in accordance with an approved
State plan of operations approved under such title, of any of the Secretary's
responsibilities under this section, but the Secretary may utilize existing
facilities and services of any such agency on the basis of mutual agreements
with such agency.
SEC. 602. COMPLAINTS OF ELIGIBLE INDIVIDUALS AND OF PERSONS FURNISHING BENEFITS.
(1) FILING- Any eligible individual aggrieved by reason of the individual's
failure to receive any personal health-service benefits to which the believes
entitled, or dissatisfied with any service rendered the individual as a
personal health-service benefit, and any person who has entered into an
agreement to furnish services as personal health-service benefits and who
is aggrieved by the failure or alleged failure of a local or other administrative
officer or a local administrative committee to carry out the agreement in
accordance with its terms, may make a complaint to the local administrative
officer or local executive officer in the area in which the action or inaction
complained of occurred, or to such other officer as may be provided in regulations.
(2) RESPONSE- If the officer to whom such complaint is made finds, after
investigation, that the complaint is well founded, the officer shall promptly--
(A) take such steps as may be necessary and appropriate to correct the
action or inaction complained of; and
(B) notify the individual or other person making the complaint of the
officer's disposition thereof.
(3) HEARING- Any such individual or other person dissatisfied with the action
taken may in writing request a hearing thereon and shall be afforded opportunity
for the same pursuant to subsection (b).
(1) IN GENERAL- Provision shall be made for the establishment of necessary
and sufficient impartial tribunals to afford hearings to individuals and
other persons entitled thereto under subsection (a), or section 207(d),
and for further review of the findings, conclusions, and recommendations
of such tribunals, in accordance with regulations made by the Board, after
consultation with the Advisory Council.
(2) SPECIFIC SUBJECTS- With respect to any complaint involving--
(A) matters or questions of professional practice or conduct, the hearing
body shall contain competent and disinterested professional representation;
and
(B) only matters or questions of professional practice or conduct, the
hearing body shall consist exclusively of such professional persons.
(c) Powers of Board- In administering this section in any State which has
not assumed responsibility for the administration of benefits under this Act
as provided in title IV, the Board (subject to the provisions of section 501(b))
shall, insofar as they are applicable to its functions under this Act, have
all the powers and duties conferred upon the Secretary by sections 205 and
206 of the Social Security Act. Such powers and duties shall be subject to
the limitations and rights of judicial review contained in section 205 of
such Act.
(d) Judicial Review- In any State which has assumed responsibility for the
administration of benefits under this Act as provided in title IV the powers
and duties of the State agency shall be subject to such rights of judicial
review in the courts of the State as the law of the State may provide; subject,
however, to review by the Supreme Court of the United States in such cases
and in such manner as is provided in section 1257 of title 28 of the United
States Code.
TITLE VII--APPLICATION OF ACT TO INDIVIDUALS COVERED UNDER MEDICARE PROGRAM
SEC. 701. ELIGIBILITY; BENEFITS AVAILABLE.
(a) Limitation to Supplementary Benefits-
(1) IN GENERAL- In the case of any individual who is entitled to hospital
insurance benefits under part A of title XVIII of the Social Security Act,
or to supplementary medical insurance benefits under the insurance program
established by part B of such title, during any benefit year or part thereof
in which the individual is otherwise eligible for benefits under this Act
in accordance with section 104 or would otherwise be furnished such benefits
in accordance with section 105, the personal health services (specified
in section 101) which may be made available to the individual as benefits
under this Act shall be limited to those services (otherwise available to
the individual in accordance with section 102) for which the individual
is ineligible under part A or B of such title XVIII.
(2) TREATMENT- For purposes of paragraph (1), an individual shall be considered
ineligible under part A or B of such title XVIII if no payment is or can
be made to the individual or on the individual's behalf thereunder with
respect to the item or service involved, whether because the individual
is not entitled to benefits under whichever such part is applicable, because
no payment is provided under either such part for the item or service involved,
or because the individual has exhausted entitlement to have payment made
thereunder for items or services of the type involved. An individual shall
also be considered ineligible under part A or B of such title XVIII with
respect to any item or service (for which the individual is otherwise entitled
to have payment made thereunder) to the extent that payment is not made
with respect to such item or service because of the application of the deductible
and coinsurance provisions of sections 1813 and 1833 of the Social Security
Act.
(b) Regulations- The Board, after consultation with the Advisory Council,
shall prescribe such regulations as may be necessary or appropriate to insure,
in the case of individuals whose benefits under this Act are limited under
subsection (a), that the combination of benefits under this Act and title
XVIII of the Social Security Act will effectively carry out (without duplication
of benefits) the purpose of this Act.
(c) No Impact on Dependents- The limitation under subsection (a) of an individual's
benefits under this Act shall not be construed as affecting the eligibility
of the individual's dependents for such benefits in accordance with subsection
(a)(3) or (b)(3) of section 104.
SEC. 702. STUDY AND REPORT.
(a) Study- As soon as practicable after the date of the enactment of this
Act, the Secretary of Health and Human Services shall undertake and carry
out a full and complete study of the interrelationship of the program of national
health insurance under this Act and the program of health insurance under
title XVIII of the Social Security Act, in order to determine the way in which
the latter program may be most effectively and equitably transferred to and
incorporated in the program under this Act.
(b) Considerations- In conducting such study, the Secretary shall give particular
attention to the transitional problems which would result from such a transfer,
and shall consider in detail (with respect to each such program)--
(1) the benefits provided;
(2) the standards of eligibility therefor;
(3) the standards and qualifications for participation by providers of services
of various types;
(4) the methods of administration;
(5) the costs and methods of financing; and
(6) any other matters which might assist in making such determination and
in insuring that all desirable features of the program under title XVIII
of the Social Security Act will to the maximum extent feasible be preserved
with respect to the individuals covered by that program (and, in appropriate
cases, included in the program under this Act for all individuals who are
eligible thereunder, without regard to any transfer).
(c) Report- The Secretary shall submit to the President and the Congress,
no later than one year after the date of the enactment of this Act, a complete
report of the study conducted under this section together with the Secretary's
findings as to the most effective and equitable way in which the transfer
under consideration could be effected and detailed recommendations for legislative,
administrative, and other actions to accomplish it.
TITLE VIII--FISCAL PROVISIONS
SEC. 801. USE OF TRUST FUND.
(a) Availability of Funds- Funds in the National Health Care Trust Fund shall
be available for all expenditures necessary or appropriate to carry out this
Act; except that (subject to the provisions of section 802(g)) only so much
of such funds shall be available for salaries or other administrative expenses
of any department or agency of the United States as may be authorized in annual
or other appropriation Acts.
(b) Deposit of Reimbursements- Sums received as reimbursements to the National
Health Care Trust Fund pursuant to section 104(c) or section 105, or by virtue
of subrogation pursuant to section 104(c), shall be deposited in the National
Health Care Trust Fund and shall be available in accordance with the provisions
of subsection (a).
SEC. 802. ALLOTMENT OF FUNDS.
(a) For Classes of Services-
(1) IN GENERAL- The Board, after consultation with the Advisory Council,
shall determine, as far in advance of the beginning of each fiscal year
as is possible, the sums which shall be available from the Trust Fund for
provision during the fiscal year of all classes, and of each of the five
classes, of personal health-service benefits specified in section 101(a).
(2) CONSIDERATIONS- Such sums shall be determined, after taking into consideration
the estimated amount which will be in the Trust Fund at the beginning of
the fiscal year and the anticipated income of the National Health Care Trust
Fund thereafter, with a view--
(A) to maintaining as nearly as practicable a uniform rate of expenditure
for personal health-service benefits in successive fiscal years, except
for appropriated allowance on account of anticipated increase in the personnel
and facilities available to furnish personal health-service benefits and
on account of reduction or withdrawal of restrictions or limitations pursuant
to section 102(b); and
(B) to establishing and maintaining a reserve in the Trust Fund adequate
to meet emergency demands in accordance with subsection (d) and adequate
to maintain the rate of expenditure or to permit its gradual reduction
if the income of the Trust Fund should fall below the income which had
been anticipated.
(b) Initial State Allotments-
(1) IN GENERAL- In accordance with regulations prescribed after consultation
with the State agencies, the Board, prior to the beginning of each fiscal
year shall allot to the several States, for the fiscal years 2006, 2007,
and 2008, 90 percent, and for each fiscal year thereafter 95 percent of
each sum determined pursuant to subsection (a).
(2) BASIS OF ALLOTMENTS- Such regulations shall provide for allotments on
the basis of--
(A) the population in the several States eligible for benefits under this
Act;
(B) professional and other personnel, hospitals, and other facilities,
and supplies and commodities, to be available in the several States in
the provision of such benefits; and
(C) the cost of reasonable and equitable compensation to such personnel
and facilities and for such supplies and commodities.
(3) OPERATION OF ALLOTMENTS- Such allotments shall operate, to the maximum
extent possible, both to assure provision to eligible individuals of adequate
personal health-service benefits in all States and all local health-service
areas, and also to increase the adequacy of services where personnel and
facilities are below the national average.
(c) Allotment of Remainder to States-
(1) IN GENERAL- From time to time during each fiscal year, the Board shall
allot to the several States the remaining 10 percent or the remaining 5
percent, as the case may be, of each sum determined pursuant to subsection
(a).
(2) CONSIDERATIONS- In making allotments under this subsection, the Board
shall take into consideration the factors specified in subsection (b), but
shall, in addition, give special consideration to the extent of which allotments
under subsection (b) have proved to be insufficient to permit provision
of reasonably adequate benefits under this Act.
(d) Emergency Allotments- In addition to the sums determined pursuant to subsection
(a) to be available for the provision of personal health-service benefits,
the Board, after consultation with the Advisory Council, is authorized to
make emergency allotments from the National Health Care Trust Fund if it finds
that a disaster, epidemic, or other cause has substantially increased the
volume of personal health-service benefits required in any part of the United
States over the volume anticipated when the determinations pursuant to subsection
(a) were made. Allotments pursuant to this subsection shall be made to such
State or States, for such class or classes of personal health-service benefits,
and in such amounts, as the Board may find necessary to meet the emergency.
(e) Payment From Allotments- The Board shall from time to time determine the
amounts to be paid to each State from its allotments under this section, and
shall certify to the Secretary of the Treasury the amounts so determined.
The Secretary shall thereupon, and prior to audit or settlement by the General
Accounting Office, pay to the State the amounts so certified.
(1) IN GENERAL- Funds paid to a State for any class of personal health-service
benefits shall be used exclusively for the provision of benefits of that
class, except that the administrative costs of the State in administering
personal health-service benefits under this Act may be met from the allotments
to the State.
(2) LIMITATION ON ADMINISTRATIVE COSTS- Such administrative costs, which
in any fiscal year shall not exceed 5 percent of the aggregate allotments
to the State for such fiscal year, shall be apportioned as between the several
allotments in accordance with the costs of administering the respective
classes of benefits. Such apportionment may be made in such manner, and
by such sampling, statistical, or other methods, as may be agreed upon between
the Board and the State agency.
(g) Board Assumption of Responsibility- In any case in which the Board has
assumed responsibility for the administration in a State of benefits under
this Act in accordance with section 402 (d) or (e), all allotments or balances
of allotments to such State shall be available for expenditure by the Board
for the provision of personal health-service benefits in that State, and (until
the Congress shall make funds available therefor pursuant to section 801(a))
for the costs of administration of such benefits in such State. Expenditures
authorized pursuant to section 801(a) for such costs of administration shall
be charged against allotments to such State.
SEC. 803. GRANTS-IN-AID FOR TRAINING AND EDUCATION.
(a) Authority- For the purpose of increasing the availability of training
and education for professional and technical personnel engaged or undertaking
to engage in the provision or administration of personal health services as
benefits under this Act, and to carry out the policies of section 209(a),
the Board is authorized to make grants--
(1) to public or nonprofit institutions or agencies engaging in undergraduate
or postgraduate professional, technical, or administration education or
training, for the cost (in whole or in part) of courses or projects which
the Board finds, after consultation with the Advisory Council and appropriate
Federal departments and agencies, (A) cannot be carried out without financial
assistance under this section, and (B) show promise of making valuable contributions
to the education, training, or retraining of professional or technical personnel
engaged or undertaking to engage in the provision or administration of benefits,
or
(2) to individuals who are professional or technical persons engaged or
who undertake to engage in the provision of personal health-service benefits,
or who are engaged or undertake to engage in the administration of such
benefits, for maintenance (in whole or in part) while in attendance at courses
or projects assisted under paragraph (1) or approved by the Board for similar
training or education, and for costs of necessary travel.
(b) Payment Under Grants- Such grants, in such amounts and for payment at
such times as are approved by the Board, shall be certified for payment to
the Secretary of the Treasury, who shall pay them from the National Health
Care Trust Fund to the designated individuals, institutions, or agencies.
(c) Availability of Funds- For the purposes of this section there shall be
available for the fiscal year 2006 the sum of $5,000,000, for the fiscal year
2006 the sum of $5,000,000, and for each fiscal year thereafter an amount
not to exceed one-half of 1 percent of the amount expended for benefits under
this Act in the last preceding calendar year.
TITLE IX--MISCELLANEOUS PROVISIONS
SEC. 901. DEFINITIONS.
(1) WAGES- The term `wages' means the sum of the following items, excluding
any amount in excess of the applicable contribution and benefit base (as
determined under section 230 of the Social Security Act with respect to
the hospital insurance tax) which is received (or, in the case of income
from self-employment, accrued) by any individual during any calendar year--
(A) all remuneration for employment, including the cash value of all remuneration
paid in any medium other than cash; except that such term does not include--
(i) the amount of any payment made to, or on behalf of, an employee
under a plan or system established by an employer which makes provision
for the employer's employees generally or for a class or classes of
the employer's employees (including any amount paid by an employer for
insurance or annuities, or into a fund to provide for any such payment),
on account of retirement, or sickness or accident disability, or medical
and hospitalization expenses in connection with sickness or accident
disability, or death; provided, in the case of a death benefit, that
the employee (I) has not the option to receive, instead of provision
for such death benefit, any part of such payment or, if such death benefit
is insured, any part of the premiums (or contributions to premiums)
paid by the employee's employer, and (II) has not the right, under the
provisions of the plan or system or policy of insurance providing for
such death benefit, to assign such benefit, or to receive a cash consideration
in lieu of such benefit either upon the employee's withdrawal from the
plan or system providing for such benefit or upon termination of such
plan or system or policy of insurance or of the employee's employment
with such employer;
(ii) the payment by an employer (without deductions from the remuneration
of the employee) of any social-insurance taxes or contributions imposed
upon an employee; or
(iii) the value of services exchanged for other services for which there
is no payment other than the exchange; and
(B) all net income from farm, business, professional, or other self-employment.
(2) EMPLOYMENT- The term `employment' means any service of whatever nature
performed by an employee for the person employing the employee, irrespective
of the citizenship or residence of either, within United States, or on or
in connection with an American vessel or an American civil aircraft under
a contract of service which is entered into within the United States or
during the performance of which the vessel or aircraft touches at a port
or airport in the United States, if the employee is employed on and in connection
with such vessel or aircraft when outside the United States, except--
(A) service on active duty in the Armed Forces of the United States;
(B) service performed in the employ of a State or any political subdivision
thereof, or any instrumentality of any one or more of the foregoing which
is wholly owned by one or more States or political subdivisions;
(C) casual labor not in the course of the employer's trade or business;
(D) service performed by an employee on or in connection with a vessel
not an American vessel, or an aircraft not an American aircraft, if the
employee is employed on and in connection with such vessel or aircraft
when outside the United States;
(E) service performed by a duly ordained or duly commissioned or licensed
minister of any church in the regular exercise of the minister's ministry
and service performed by a regular member of a religious order in the
exercise of duties required by such order;
(F) service performed by an individual as an employee or employee representative
as defined in section 1 of the Railroad Retirement Act of 1937 or section
1 of the Railroad Retirement Act of 1974;
(G) service performance in any calendar quarter in the employ of any organization
exempt from income tax under section 501 of the Internal Revenue Code
of 1986 if--
(i) the remuneration for such services does not exceed $150; or
(ii) such service is in connection with the collection of dues or premiums
for a fraternal beneficiary society, order, or association, and is performed
away from the home office or is ritualistic service in connection with
any such society, order, or association; or
(iii) such service is performed by a student who is enrolled and is
regularly attending classes at a school, college, or university;
(H) service performed in the employ of a foreign government (including
service as a consular or other officer or employee or a nondiplomatic
representative);
(I) service performed in the employ of an instrumentality wholly owned
by a foreign government, if--
(i) the service is of a character similar to that performed in foreign
countries by employees of the United States Government or of an instrumentality
thereof; and
(ii) the Secretary of State shall certify to the Secretary of Health
and Human Services that the foreign government, with respect to whose
instrumentality and employees thereof exemption is claimed, grants an
equivalent exemption with respect to similar service performed in the
foreign country by employees of the United States Government and of
instrumentalities thereof; and
(J) service performed in the employ of an international organization entitled
to enjoy privileges, exemptions, and immunities as an international organization
under the International Organizations Immunities Act.
(3) In any case in which an individual has received wages equal to the applicable
contribution and benefit base (as determined under section 230 of the Social
Security Act), in a calendar year, not less than $500 of such wages shall
be deemed, for the purpose of section 104(a), to have been received by the
individual in the quarter during which the first of such wages were in fact
received by the individual and in each quarter of such calendar year thereafter.
(4) BENEFIT YEAR- The term `benefit year' means a period commencing on July
1 of any year and ending on June 30 of the succeeding year.
(5) QUARTER- The term `quarter' and the term `calendar quarter' mean a period
of three calendar months ending on March 31, June 30, September 30, or December
31.
(6) EMPLOYEE- The term `employee' includes (in addition to any individual
who is a servant under the law of master and servant) any individual who
performs service, of whatever nature, for a person, unless the service is
performed by the individual in pursuit of the individual's own independently
established business. The term `employee' also includes an officer of a
corporation.
(7) AMERICAN VESSEL- The term `American vessel' means any vessel documented
or numbered under the laws of the United States; and includes any vessel
which is neither documented nor numbered under the laws of any foreign country,
if its crew is employed solely by one or more citizens or residents of the
United States or corporations organized under the laws of the United States
or of any State.
(8) AMERICAN AIRCRAFT- The term `American aircraft' means an aircraft registered
under the laws of the United States.
(9) STATE- The term `State' includes the District of Columbia.
(10) UNITED STATES- The term `United States', when used in a geographic
sense, means the several States, as defined in paragraph (9).
(11) DEPENDENT- The term `dependent' means--
(A) an unmarried child (including a stepchild, adopted, or foster child)
of an individual, who is under the age of 18, or who is under a total
disability which has continued for a period of not less than six consecutive
calendar months and is living with such individual or receiving regular
support from the individual;
(B) a wife of an individual living with such individual or receiving regular
support from the individual;
(C) a husband who is under a total disability which has continued for
a period of not less than six consecutive calendar months, and is living
with or receiving regular and substantial support from such individual;
and
(D) a parent who is living with or receiving regular and substantial support
from such individual.
(12) PERSON- The term `person' means an individual, a trust or estate, a
partnership, a corporation, an association, a consumer cooperative, or other
organization.
SEC. 902. EFFECTIVE DATE.
The effective date of this Act shall be the date of its enactment, but personal
health services shall first become available as benefits in accordance with
this Act on October 1, 2006.
TITLE X--VALUE ADDED TAX AND NATIONAL HEALTH CARE TRUST FUND
SEC. 1001. IMPOSITION OF VALUE ADDED TAX.
(a) In General- Subtitle D of the Internal Revenue Code of 1986 (relating
to miscellaneous excise taxes) is amended by inserting before chapter 31 the
following new chapter:
`CHAPTER 30--VALUE ADDED TAX
`SUBCHAPTER A. IMPOSITION OF TAX
`SUBCHAPTER B. TAXABLE TRANSACTION
`SUBCHAPTER C. TAXABLE AMOUNT; RATE OF TAX FOR CERTAIN TRANSACTIONS; CREDIT
AGAINST TAX
`SUBCHAPTER D. ADMINISTRATION
`SUBCHAPTER E. DEFINITIONS AND SPECIAL RULES; TREATMENT OF CERTAIN TRANSACTIONS
`Subchapter A--Imposition of Tax
`Sec. 3901. Imposition of tax.
`SEC. 3901. IMPOSITION OF TAX.
`(a) General Rule- A tax is hereby imposed on each taxable transaction.
`(b) Amount of Tax- Except as otherwise provided in this chapter, the amount
of the tax shall be 5 percent of the taxable amount.
`Subchapter B--Taxable Transaction
`Sec. 3903. Taxable transaction.
`Sec. 3904. Commercial-type transaction.
`Sec. 3905. Taxable person.
`Sec. 3906. Transactions in the United States.
`Sec. 3907. Rules relating to other terms used in section 3903.
`SEC. 3903. TAXABLE TRANSACTION.
`For purposes of this chapter, the term `taxable transaction' means--
`(1) the sale of property in the United States,
`(2) the performance of services in the United States, and
`(3) the importing of property into the United States,
by a taxable person in a commercial-type transaction.
`SEC. 3904. COMMERCIAL-TYPE TRANSACTION.
`(a) General Rule- For purposes of this chapter, the term `commercial-type
transaction' means a transaction engaged in by--
`(2) any person (other than a corporation) in connection with a business.
`(b) Sales and Leases of Real Property; Imports- For purposes of this chapter--
`(1) IN GENERAL- The term `commercial-type transaction' includes--
`(A) any sale or leasing of real property, and
`(B) any importing of property,
whether or not such transaction is described in subsection (a).
`(2) CERTAIN IMPORTED ARTICLES- Notwithstanding paragraph (1)(B), the importing
of an article which is free of duty under part 2 of schedule 8 of the Tariff
Schedules of the United States shall not be treated as a commercial-type
transaction unless such transaction is described in subsection (a).
`SEC. 3905. TAXABLE PERSON.
`(a) General Rule- Except as otherwise provided in this chapter, for purposes
of this chapter, the term `taxable person' means a person who engages in a
business or in a commercial-type transaction.
`(b) Treatment of Employees, Etc- For purposes of this chapter, an employee
shall not be treated as a taxable person with respect to activities engaged
in as an employee.
`SEC. 3906. TRANSACTIONS IN THE UNITED STATES.
`(a) Sales of Property- For purposes of this chapter--
`(1) IN GENERAL- Except as provided in paragraph (2), the sale of property
shall be treated as occurring where delivery takes place.
`(2) REAL PROPERTY- The sale of real property shall be treated as occurring
where the real property is located.
`(b) Performance of Service- For purposes of this chapter--
`(1) IN GENERAL- Except as otherwise provided in this subsection, a service
shall be treated as occurring where it is pe
