110th 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, 2007
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, 2008 (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, 2008,
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, 2008.
(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 2008, 2009,
and 2010, 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 2008 the sum of $5,000,000, for the fiscal
year 2009 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;
