[Congressional Bills 105th Congress]
[From the U.S. Government Publishing Office]
[H.R. 356 Introduced in House (IH)]







105th CONGRESS
  1st Session
                                H. R. 356

To improve health status in medically disadvantaged communities through 
          comprehensive community-based managed care programs.


_______________________________________________________________________


                    IN THE HOUSE OF REPRESENTATIVES

                            January 7, 1997

  Mr. Towns introduced the following bill; which was referred to the 
                         Committee on Commerce

_______________________________________________________________________

                                 A BILL


 
To improve health status in medically disadvantaged communities through 
          comprehensive community-based managed care programs.

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

SECTION 1. SHORT TITLE.

    This Act may be cited as the ``Comprehensive Health Access District 
Act''.

SEC. 2. DEFINITIONS.

    (a) Comprehensive Health Access District.--The term ``comprehensive 
health access district'' means a community in which unemployment and 
the percentage of residents with incomes below the poverty line are 
greater than the national average, and in which a majority of the 
following conditions occur at rates greater than the national average:
            (1) Infant mortality and low birth-weight babies.
            (2) Proportion of children below the age of 5 who have not 
        received age-appropriate routine child-hood immunizations.
            (3) Hospitalization for preventable illnesses and 
        conditions that may be managed successfully on an outpatient 
        basis, such as otitis media, diabetes, and hypertension.
            (4) Emergency room visits for nonemergency conditions.
            (5) Accidental injury.
            (6) Incidence of tuberculosis, acquired immune deficiency 
        syndrome, Black Lung disease, or cancer.
            (7) Incidence of violent crimes.
    (b) Comprehensive Community-Based Health Access Plan.--The term 
``comprehensive community-based health access plan'' (hereafter in this 
Act referred to as a ``health access plan'') means an entity that 
provides health care services on a prepaid, capitated basis or any 
other risk basis and that the Secretary has certified meets the 
requirements contained in section 5 of this Act.
    (c) Secretary.--The term ``Secretary'' means the Secretary of 
Health and Human Services.

SEC. 3. MEDICAID STATE PLAN REQUIREMENTS FOR COMPREHENSIVE HEALTH 
              ACCESS DISTRICTS.

    Section 1902(a) of the Social Security Act (42 U.S.C. 1396a(a)) is 
amended by adding after paragraph (62) the following new paragraph:
            ``(63) provide that each comprehensive health access 
        district located within the State is served by a comprehensive 
        community-based health access district plan.''

SEC. 4. HEALTH ALLIANCE OBLIGATIONS WITH RESPECT TO COMPREHENSIVE 
              HEALTH ACCESS DISTRICTS.

    Each Health Alliance or other health insurance purchasing 
cooperative created as a result of the enactment of comprehensive 
health care reform legislation that receives premiums on behalf of 
persons formerly insured under title XIX of the Social Security Act and 
whose boundaries encompass a comprehensive health access district shall 
insure that a least one comprehensive community-based health access 
plan is available to persons living in such district.

SEC 5. COMPREHENSIVE COMMUNITY-BASED HEALTH ACCESS PLANS.

    To be certified as a comprehensive community-based health access 
plan, an entity must meet all of the following requirements:
            (a) Organizational requirements.--A health access plan 
        must--
                    (1) be a public or private organization, organized 
                under the laws of any State;
                    (2) locate its primary place of business in the 
                comprehensive health access district it serves;
                    (3) give preference in hiring to otherwise 
                qualified individuals who live within the comprehensive 
                health access district; and
                    (4) have made adequate provision against the risk 
                of insolvency, which provision is satisfactory to the 
                State and which assures that individuals enrolled in a 
                plan are in no case liable for debt of the plan in case 
                of the plan's insolvency. Provisions against the risk 
                of insolvency may include--
                            (A) escrow or similar arrangements to 
                        ensure that funds for the payment of providers 
                        are available only for such payments and cannot 
                        be otherwise used by the plan;
                            (B) reinsurance purchased by the plan of an 
                        amount which is reasonably adequate to insure 
                        against unexpected costs;
                            (C) a demonstration of financial viability, 
                        as evidenced by the plan's obtaining a 
                        significant amount of reinsurance, line of 
                        credit, or performance bond; or
                            (D) such other mechanisms and requirements 
                        as the State finds appropriate.
            (b) Service requirements.--
                    (1) Basic benefits.--A health access plan shall 
                provide, either directly or through arrangements with 
                providers, the following basic benefits:
                            (A) Hospital services, including inpatient, 
                        outpatient and 24-hour emergency services.
                            (B) Emergency and ambulatory medical and 
                        surgical services.
                            (C) Physicians' services.
                            (D) Medical care other than physicians' 
                        services recognized under State law and 
                        furnished by licensed practitioners within the 
                        scope of their practice as defined by State 
                        law.
                            (E) Dental services.
                            (F) Vision services.
                             (G) Preventive health care services 
                        (including children's eye and ear examinations 
                        to determine the need for vision and hearing 
                        correction, well child services, immunizations 
                        against vaccine-preventable diseases, and 
                        screening for elevated blood lead levels).
                             (H) Outpatient laboratory, radiology, and 
                        diagnostic services.
                             (I) Ambulance services.
                             (J) Mental health and substance abuse 
                        services.
                             (K) Family planning services and services 
                        for pregnant women.
                             (L) Outpatient prescription drugs and 
                        biologicals.
                     (2) Community-based health services.--In addition 
                to providing the services described in paragraph 
                (b)(1), a health access plan shall--
                             (A) identify the most frequent causes of 
                        morbidity and mortality in the comprehensive 
                        health access district (such as acquired immune 
                        deficiency syndrome, tuberculosis, mental 
                        illness, substance abuse and addiction, 
                        childhood developmental disorders (particularly 
                        those caused by children's exposure to 
                        violence), asthma, teen pregnancy, unhealthy 
                        behaviors (such as smoking and high-fat diets), 
                        and lead poisoning); and
                             (B) design and implement programs of 
                        prevention, early intervention, or treatment 
                        intended to ameliorate or eliminate the factors 
                        identified in subparagraph (b)(2)(A).
                     (3) Coordination of services.--In addition to 
                providing the services described in paragraphs (b)(1) 
                and (b)(2), a health access plan must promote its 
                enrollees' access to social, educational or economic 
                services (such as child day care, nutritional services, 
                vocational training, and adult literacy programs).
             (c) Service network requirements.--
                     (1) Basic service network.--A health access plan 
                shall enter into arrangements with a sufficient number 
                and variety of providers to guarantee that--
                             (A) the plan's enrollees have access to 
                        the services described in subsection 4(b); and
                             (B) the provider network takes into 
                        account and is representative of the cultural 
                        identity and diversity of the community being 
                        served.
                    (2) Traditional community providers.--A health 
                access plan shall, to the extent feasible, draw upon 
                health care providers currently serving the community, 
                including community health centers (as defined in 
                section 330(a) of the Public Health Service Act) and 
                hospitals operated by units of local government, in 
                developing its service network.
                    (3) Development of new health resources.--A health 
                access plan shall develop new health resources in the 
                community (such as schoolbased clinics, mobile 
                screening programs, and clinics based in public 
                housing) to meet needs that are not met by existing 
                community resources.
            (d) Access standards.--A health access plan shall insure 
        that each individual enrolled in it--
                    (1) is linked with the primary care physician 
                within the health access plan's provider network of the 
                individual's choice and has access to that doctor on a 
                24-hour a day, 7-day a week basis;
                    (2) has round-the-clock telephone access to a 
                central program office for information purposes as well 
                as to voice grievances; and
                    (3) has access to interpreter services as necessary 
                (where a significant proportion of the population in 
                the community health access district is non-English 
                speaking, the health access plan shall insure that a 
                corresponding proportion of its health care providers 
                have multilingual capability).
            (e) Quality assurance standards.--A health access plan 
        shall establish and maintain a quality assurance program that 
        includes at least the following activities:
                    (1) Treatment standards.--A health access plan 
                shall establish--
                            (A) minimum standards for treating patients 
                        that participating providers must satisfy;
                            (B) a program of ongoing medical record 
                        reviews and other provider audits to insure 
                        compliance with the plan's treatment standards; 
                        and
                            (C) a system of sanctions to insure that 
                        providers who do not comply with the plan's 
                        treatment standards will be penalized and, if 
                        found to be repeatedly out of compliance, 
                        terminated from participation in the health 
                        access plan service network.
                    (2) Data collection.--A health access plan shall 
                monitor morbidity and mortality within the 
                comprehensive health access district and identify the 
                leading causes of death and disease.
                    (3) Member surveys.--A health access plan shall 
                survey its enrollees on a regular basis to determine 
                their satisfaction with the quality of services 
                received.
                    (4) Independent quality audits.--A health access 
                plan shall be evaluated on a regular basis by an 
                independent health care accrediting organization.
            (f) Effective grievance procedures.--A health access plan 
        must provide for effective procedures for hearing and resolving 
        grievances between the plan and individuals enrolled in the 
        plan.
            (g) Confidentiality of enrollee records.--
                    (1) A health access plan shall ensure that 
                information concerning its enrollees is protected from 
                unauthorized disclosure by the plan, its employees or 
                its providers.
                    (2) To promote the coordination of benefits to 
                health plan enrollees, a health access plan may 
                disclose information about its enrollees to the extent 
                necessary to facilitate the enrollee's receipt of 
                services and assistance from other entities.

SEC. 6. DESIGNATION OF COMPREHENSIVE HEALTH ACCESS DISTRICTS AND 
              CERTIFICATION OF COMPREHENSIVE COMMUNITY-BASED HEALTH 
              ACCESS PLANS.

    The Secretary shall designate a community that meets the criteria 
set forth in section 2(a) of this Act a comprehensive health access 
district and shall certify an entity that meets the criteria set forth 
in section 5 of this Act as a comprehensive health access plan. Each 
such certification and designation shall be reviewed every five years. 
The Secretary may delegate all or part of the certification function to 
the State in which the health access plan operates.

SEC. 7. NATIONAL HEALTH OUTCOMES RESEARCH AND EVALUATION.

    (a) Provision of Information.--In order to evaluate the performance 
of health access plans in improving the health status of persons living 
in comprehensive health access districts, each health access plan shall 
provide the Secretary, at a time and in a manner specified by the 
Secretary, at least the following information:
            (1) Information on the characteristics of enrollees that 
        may affect their need for or use of health services.
            (2) Information on the types of treatments and services and 
        outcomes of treatments with respect to the clinical health, 
        functional status and well-being of enrollees.
            (3) Information on enrollee satisfaction.
            (4) Information on health care expenditures, volume and 
        prices of procedures, and use of specialized services.
    (b) Analysis of Information.--The Secretary shall analyze the 
information reported by health access plans in order to report to 
Congress, the plans and the public, no less than annually, on the 
following:
            (1) The health status of persons living in comprehensive 
        health access district (particularly those indicators listed in 
        section 2(a) of this Act).
            (2) The level and rate of expenditures by health access 
        plans on medical services and other programs to improve health 
        status.
            (3) The effectiveness of health access plans in improving 
        health outcomes (particularly outcomes related to health 
        indicators listed in section 2(a) of this Act).
    (c) Research.--
            (1) The Secretary shall examine the relationship between 
        socioeconomic factors and health status and, based on his 
        findings, suggest interventions appropriate to comprehensive 
        health access districts.
            (2) The Secretary may contract with non-governmental 
        entities to perform this research. Persons undertaking this 
        work shall have access to the information provided by the 
        health access plans to the Secretary.

SEC. 8. CHANGES TO THE MEDICAID STATUTE TO FACILITATE STATE CONTRACTS 
              WITH COMPREHENSIVE COMMUNITY-BASED HEALTH ACCESS PLANS.

    (a) Section 1903(m)(2) of the Social Security Act (42 U.S.C. 
1396b(m)(2)) is amended by adding after subparagraph (H) the following 
new subparagraph:
            ``(I) Clause (ii) of subparagraph (A) does not apply to any 
        entity certified as a comprehensive health access plan pursuant 
        to section 6 of the Comprehensive Health Access District Act.''
    (b) This amendment shall apply to payments for medical assistance 
for calendar quarters beginning on or after July 1, 1996.

SEC. 9. REGULATIONS AND EFFECTIVE DATE.

    (a) The Secretary shall promulgate regulations necessary to 
implement this Act.
    (b) This Act shall take effect on July 1, 1998, without regard to 
whether or not final regulations to carry out this Act have been 
promulgated by such date.
                                 <all>