109 HR 1200 IH: American Health Security Act of 2005 U.S. House of Representatives 2005-03-09 text/xml EN Pursuant to Title 17 Section 105 of the United States Code, this file is not subject to copyright protection and is in the public domain.
I 109th CONGRESS 1st Session H. R. 1200 IN THE HOUSE OF REPRESENTATIVES March 9, 2005 Mr. McDermott (for himself, Mr. Rangel, Mr. Stark, Mr. George Miller of California, Mr. Hinchey, Mr. Dicks, Ms. Woolsey, Mr. Farr, Mr. Weiner, Mr. Rush, Mr. Brown of Ohio, Mr. Kucinich, Mr. Pallone, Ms. Schakowsky, Ms. Lee, Mr. Conyers, Ms. Carson, Ms. Millender-McDonald, Mr. Olver, Mr. Payne, Mr. Berman, Mr. Grijalva, Mrs. Christensen, Ms. Baldwin, Mr. Towns, Mr. Tierney, Mr. Thompson of Mississippi, Mr. Sanders, and Ms. Linda T. Sánchez of California) introduced the following bill; which was referred to the Committee on Energy and Commerce, and in addition to the Committees on Ways and Means, Government Reform, and Armed Services, 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 for health care for every American and to control the cost and enhance the quality of the health care system.
1.
Short title; table of contents
(a)
Short title
This Act may be cited as the American Health Security Act of 2005. (b)
Table of contents
The table of contents of this Act is as follows: Sec. 1. Short title; table of contents Title I—Establishment of a State-based American Health Security Program; universal entitlement; enrollment Sec. 101. Establishment of a State-based American Health Security Program Sec. 102. Universal entitlement Sec. 103. Enrollment Sec. 104. Portability of benefits Sec. 105. Effective date of benefits Sec. 106. Relationship to existing Federal health programs Title II—Comprehensive benefits, including preventive benefits and benefits for long-term care Sec. 201. Comprehensive benefits Sec. 202. Definitions relating to services Sec. 203. Special rules for home and community-based long-term care services Sec. 204. Exclusions and limitations Sec. 205. Certification; quality review; plans of care Title III—Provider participation Sec. 301. Provider participation and standards Sec. 302. Qualifications for providers Sec. 303. Qualifications for comprehensive health service organizations Sec. 304. Limitation on certain physician referrals Title IV—Administration Subtitle A—General administrative provisions Sec. 401. American Health Security Standards Board Sec. 402. American Health Security Advisory Council Sec. 403. Consultation with private entities Sec. 404. State health security programs Sec. 405. Complementary conduct of related health programs Subtitle B—Control over fraud and abuse Sec. 411. Application of Federal sanctions to all fraud and abuse under American Health Security Program Sec. 412. Requirements for operation of State health care fraud and abuse control units Title V—Quality assessment Sec. 501. American Health Security Quality Council Sec. 502. Development of certain methodologies, guidelines, and standards Sec. 503. State quality review programs Sec. 504. Elimination of utilization review programs; transition Title VI—Health security budget; payments; cost containment measures Subtitle A—Budgeting and payments to States Sec. 601. National health security budget Sec. 602. Computation of individual and State capitation amounts Sec. 603. State health security budgets Sec. 604. Federal payments to States Sec. 605. Account for health professional education expenditures Subtitle B—Payments by States to providers Sec. 611. Payments to hospitals and other facility-based services for operating expenses on the basis of approved global budgets Sec. 612. Payments to health care practitioners based on prospective fee schedule Sec. 613. Payments to comprehensive health service organizations Sec. 614. Payments for community-based primary health services Sec. 615. Payments for prescription drugs Sec. 616. Payments for approved devices and equipment Sec. 617. Payments for other items and services Sec. 618. Payment incentives for medically underserved areas Sec. 619. Authority for alternative payment methodologies Subtitle C—Mandatory assignment and administrative provisions Sec. 631. Mandatory assignment Sec. 632. Procedures for reimbursement; appeals Title VII—Promotion of primary health care; development of health service capacity; programs to assist the medically underserved Subtitle A—Promotion and expansion of primary care professional training Sec. 701. Role of Board; establishment of primary care professional output goals Sec. 702. Establishment of Advisory Committee on Health Professional Education Sec. 703. Grants for health professions education, nurse education, and the National Health Service Corps Subtitle B—Direct health care delivery Sec. 711. Setaside for public health Sec. 712. Setaside for primary health care delivery Sec. 713. Primary care service expansion grants Subtitle C—Primary care and outcomes research Sec. 721. Set-aside for outcomes research Sec. 722. Office of Primary Care and Prevention Research Subtitle D—School-related health services Sec. 731. Authorizations of appropriations Sec. 732. Eligibility for development and operation grants Sec. 733. Preferences Sec. 734. Grants for development of projects Sec. 735. Grants for operation of projects Sec. 736. Federal administrative costs Sec. 737. Definitions Title VIII—Financing provisions; American Health Security Trust Fund Sec. 800. Amendment of 1986 code; section 15 not to apply Subtitle A—American Health Security Trust Fund Sec. 801. American Health Security Trust Fund Subtitle B—Taxes based on income and wages Sec. 811. Payroll tax on employers Sec. 812. Health care income tax Subtitle C—Increase in excise taxes on tobacco products Sec. 821. Increase in excise taxes on tobacco products Title IX—Conforming amendments to the Employee Retirement Income Security Act of 1974 Sec. 901. ERISA inapplicable to health coverage arrangements under State health security programs Sec. 902. Exemption of State health security programs from ERISA preemption Sec. 903. Prohibition of employee benefits duplicative of benefits under State health security programs; coordination in case of workers’ compensation Sec. 904. Repeal of continuation coverage requirements under ERISA and certain other requirements relating to group health plans Sec. 905. Effective date of title Title X—Additional conforming amendments Sec. 1001. Repeal of certain provisions in Internal Revenue Code of 1986 Sec. 1002. Repeal of certain provisions in the Employee Retirement Income Security Act of 1974 Sec. 1003. Repeal of certain provisions in the Public Health Service Act and related provisions Sec. 1004. Effective date of title
<enum>I</enum><header>Establishment of a State-based American Health Security Program; universal entitlement; enrollment</header> <section id="H50DB6ED946C744EB94E87DB9EC08609D"><enum>101.</enum><header>Establishment of a State-based American Health Security Program</header> <subsection id="H26293415A56F46268553FFC31D7845D"><enum>(a)</enum><header>In general</header><text>There is hereby established in the United States a State-Based American Health Security Program to be administered by the individual States in accordance with Federal standards specified in, or established under, this Act.</text></subsection> <subsection id="H8E466FB3504D45CE8901AFCD64AC1DC3"><enum>(b)</enum><header>State health security programs</header><text>In order for a State to be eligible to receive payment under section 604, a State must establish a State health security program in accordance with this Act.</text></subsection> <subsection id="H3C910A076B0045A4AC33015C53A19DBB"><enum>(c)</enum><header>State defined</header> <paragraph id="HA3A0B35CC35745B380888EE56F155C62"><enum>(1)</enum><header>In general</header><text>In this Act, subject to paragraph (2), the term <term>State</term> means each of the 50 States and the District of Columbia.</text></paragraph> <paragraph id="H4A97E11DA5084E4F9DE33C3009EDF7AE"><enum>(2)</enum><header>Election</header><text>If the Governor of Puerto Rico, the Virgin Islands, Guam, American Samoa, or the Northern Mariana Islands certifies to the President that the legislature of the Commonwealth or territory has enacted legislation desiring that the Commonwealth or territory be included as a State under the provisions of this Act, such Commonwealth or territory shall be included as a <quote>State</quote> under this Act beginning January 1 of the first year beginning 90 days after the President receives the notification.</text></paragraph></subsection></section> <section id="HAECF395DAC1D44F39F7199DA940450B6"><enum>102.</enum><header>Universal entitlement</header> <subsection id="H8BE22C95882E4B34AFF43FAC7F3F7BC1"><enum>(a)</enum><header>In general</header><text>Every individual who is a resident of the United States and is a citizen or national of the United States or lawful resident alien (as defined in subsection (d)) is entitled to benefits for health care services under this Act under the appropriate State health security program. In this section, the term <term>appropriate State health security program</term> means, with respect to an individual, the State health security program for the State in which the individual maintains a primary residence.</text></subsection> <subsection id="HA7506C55ACAD48A1A17291FA66253866"><enum>(b)</enum><header>Treatment of certain nonimmigrants</header> <paragraph id="H05FA75D56F7F4BA8BC27BEE3001D54F0"><enum>(1)</enum><header>In general</header><text>The American Health Security Standards Board (in this Act referred to as the <quote>Board</quote>) may make eligible for benefits for health care services under the appropriate State health security program under this Act such classes of aliens admitted to the United States as nonimmigrants as the Board may provide.</text></paragraph> <paragraph id="HEE17462F1DBA4A3EB614CEF5F92C8355"><enum>(2)</enum><header>Consideration</header><text>In providing for eligibility under paragraph (1), the Board shall consider reciprocity in health care services offered to United States citizens who are nonimmigrants in other foreign states, and such other factors as the Board determines to be appropriate.</text></paragraph></subsection> <subsection id="H3AB14F20E4F34212B7A1A1C9E46BAC42"><enum>(c)</enum><header>Treatment of other individuals</header> <paragraph id="HF92EEF94447E44688D20D65DC2A5DCE"><enum>(1)</enum><header>By Board</header><text>The Board also may make eligible for benefits for health care services under the appropriate State health security program under this Act other individuals not described in subsection (a) or (b), and regulate the nature of the eligibility of such individuals, in order—</text> <subparagraph id="H5976669D5B6A4C0297D0C15F00D295EA"><enum>(A)</enum><text>to preserve the public health of communities;</text></subparagraph> <subparagraph id="HCD9473FBE4DC4802B71107673015A2EE"><enum>(B)</enum><text>to compensate States for the additional health care financing burdens created by such individuals; and</text></subparagraph> <subparagraph id="H5998C87185B042BFBA6157A7BC66E663"><enum>(C)</enum><text>to prevent adverse financial and medical consequences of uncompensated care,</text></subparagraph><continuation-text continuation-text-level="paragraph">while inhibiting travel and immigration to the United States for the sole purpose of obtaining health care services.</continuation-text></paragraph> <paragraph id="H24F9F3C72E074B80BE8EE5FD69F7024"><enum>(2)</enum><header>By States</header><text>Any State health security program may make individuals described in paragraph (1) eligible for benefits at the expense of the State.</text></paragraph></subsection> <subsection id="HF05B55CED05A4500A4F831346FFFFF32"><enum>(d)</enum><header>Lawful resident alien defined</header><text>For purposes of this section, the term <term>lawful resident alien</term> means an alien lawfully admitted for permanent residence and any other alien lawfully residing permanently in the United States under color of law, including an alien with lawful temporary resident status under section 210, 210A, or 234A of the <act-name parsable-cite="INA">Immigration and Nationality Act</act-name> (<external-xref legal-doc="usc" parsable-cite="usc/8/1160">8 U.S.C. 1160</external-xref>, 1161, or 1255a).</text></subsection></section> <section id="HF149B4069DB74465A4A8009C8B5087ED"><enum>103.</enum><header>Enrollment</header> <subsection id="H267D2F82D51643CB953EED00B9EC00E2"><enum>(a)</enum><header>In general</header><text>Each State health security program shall provide a mechanism for the enrollment of individuals entitled or eligible for benefits under this Act. The mechanism shall—</text> <paragraph id="HFAA78E596A2E4C1A92E024C7145C1F21"><enum>(1)</enum><text>include a process for the automatic enrollment of individuals at the time of birth in the United States and at the time of immigration into the United States or other acquisition of lawful resident status in the United States;</text></paragraph> <paragraph id="HFCADC1BEE82B4F3A829B509954DE92"><enum>(2)</enum><text>provide for the enrollment, as of January 1, 2007, of all individuals who are eligible to be enrolled as of such date; and</text></paragraph> <paragraph id="HD44D370F99F44D4BBBC238DACB04013E"><enum>(3)</enum><text>include a process for the enrollment of individuals made eligible for health care services under subsections (b) and (c) of section 102.</text></paragraph></subsection> <subsection id="HFA27CAAF671147F19160FF005734CD3"><enum>(b)</enum><header>Availability of applications</header><text>Each State health security program shall make applications for enrollment under the program available—</text> <paragraph id="H57333BE5AE154313A9649BE914B58A"><enum>(1)</enum><text>at employment and payroll offices of employers located in the State;</text></paragraph> <paragraph id="H980A201D272D4E3489BD71C99CD6BF56"><enum>(2)</enum><text>at local offices of the Social Security Administration;</text></paragraph> <paragraph id="HB46CFAE455574AD292A844006E5CA51B"><enum>(3)</enum><text>at social services locations;</text></paragraph> <paragraph id="H9AD807867BBA42B3B300A728009E1DF8"><enum>(4)</enum><text>at out-reach sites (such as provider and practitioner locations); and</text></paragraph> <paragraph id="H7A036BAA17924268006E873F3EF48939"><enum>(5)</enum><text>at other locations (including post offices and schools) accessible to a broad cross-section of individuals eligible to enroll.</text></paragraph></subsection> <subsection id="H7A9877925FB3498C9F5CAC006148008B"><enum>(c)</enum><header>Issuance of health security cards</header><text>In conjunction with an individual’s enrollment for benefits under this Act, the State health security program shall provide for the issuance of a health security card that shall be used for purposes of identification and processing of claims for benefits under the program. The State health security program may provide for issuance of such cards by employers for purposes of carrying out enrollment pursuant to subsection (a)(2).</text></subsection></section> <section id="H54C56AC68E6D40488968E4367DF777A6"><enum>104.</enum><header>Portability of benefits</header> <subsection id="HEDF14B7F7F06406A8E09618149FE4863"><enum>(a)</enum><header>In general</header><text>To ensure continuous access to benefits for health care services covered under this Act, each State health security program—</text> <paragraph id="H92C52E2A7F484A3EACC735E3C92522D2"><enum>(1)</enum><text>shall not impose any minimum period of residence in the State, or waiting period, in excess of 3 months before residents of the State are entitled to, or eligible for, such benefits under the program;</text></paragraph> <paragraph id="H633AEB5F07A84CFB89A765C93C64E0E8"><enum>(2)</enum><text>shall provide continuation of payment for covered health care services to individuals who have terminated their residence in the State and established their residence in another State, for the duration of any waiting period imposed in the State of new residency for establishing entitlement to, or eligibility for, such services; and</text></paragraph> <paragraph id="HF05A789034B8433499E52C62ABD8A929"><enum>(3)</enum><text>shall provide for the payment for health care services covered under this Act provided to individuals while temporarily absent from the State based on the following principles:</text> <subparagraph id="HB513BB3ACF2B4959006E3814D6E629C"><enum>(A)</enum><text>Payment for such health care services is at the rate that is approved by the State health security program in the State in which the services are provided, unless the States concerned agree to apportion the cost between them in a different manner.</text></subparagraph> <subparagraph id="H633D78B7D9654A9886CF609389DD9BB"><enum>(B)</enum><text>Payment for such health care services provided outside the United States is made on the basis of the amount that would have been paid by the State health security program for similar services rendered in the State, with due regard, in the case of hospital services, to the size of the hospital, standards of service, and other relevant factors.</text></subparagraph></paragraph></subsection> <subsection id="H3130CB315E164148B000EDBDC9A884"><enum>(b)</enum><header>Cross-border arrangements</header><text>A State health security program for a State may negotiate with such a program in an adjacent State a reciprocal arrangement for the coverage under such other program of health care services to enrollees residing in the border region.</text></subsection></section> <section id="HF8D287A1A98240D1B95F0054A1F92BE"><enum>105.</enum><header>Effective date of benefits</header><text display-inline="no-display-inline">Benefits shall first be available under this Act for items and services furnished on or after January 1, 2007.</text></section> <section id="HF323DEF939D543D0887DB3D7CB107818"><enum>106.</enum><header>Relationship to existing Federal health programs</header> <subsection id="H70BCE40FD15147BAAAA0F3E0EF123397"><enum>(a)</enum><header>Medicare, medicaid and State children’s health insurance program (SCHIP)</header> <paragraph id="HF926B8BDBC5447319060A32736D4449C"><enum>(1)</enum><header>In general</header><text>Notwithstanding any other provision of law, subject to paragraph (2)—</text> <subparagraph id="H1D4A7756288E4A9BB95110B06EACF2C4"><enum>(A)</enum><text>no benefits shall be available under title XVIII of the <act-name parsable-cite="SSA">Social Security Act</act-name> for any item or service furnished after December 31, 2006;</text></subparagraph> <subparagraph id="H4826EFB795B742FA8E00069C031F11B3"><enum>(B)</enum><text>no individual is entitled to medical assistance under a State plan approved under title XIX of such Act for any item or service furnished after such date;</text></subparagraph> <subparagraph id="H1BC1DAC3B0524D25AA73214590A11021"><enum>(C)</enum><text>no individual is entitled to medical assistance under an SCHIP plan under title XXI of such Act for any item or service furnished after such date; and</text></subparagraph> <subparagraph id="H9078FC463F6B4253849DAF9631867118"><enum>(D)</enum><text>no payment shall be made to a State under section 1903(a) or 2105(a) of such Act with respect to medical assistance or child health assistance for any item or service furnished after such date.</text></subparagraph></paragraph> <paragraph id="H2E9312C161094C5100E7055BFB96F5A1"><enum>(2)</enum><header>Transition</header><text>In the case of inpatient hospital services and extended care services during a continuous period of stay which began before January 1, 2007, and which had not ended as of such date, for which benefits are provided under title XVIII, under a State plan under title XIX, or a State child health plan under title XXI, of the <act-name parsable-cite="SSA">Social Security Act</act-name>, the Secretary of Health and Human Services and each State plan, respectively, shall provide for continuation of benefits under such title or plan until the end of the period of stay.</text></paragraph></subsection> <subsection id="H194D6A91272D4A26984DC4624600B3FF"><enum>(b)</enum><header>Federal employees health benefits program</header><text>No benefits shall be made available under <external-xref legal-doc="usc-chapter" parsable-cite="usc-chapter/5/89">chapter 89</external-xref> of title 5, United States Code, for any part of a coverage period occurring after December 31, 2006.</text></subsection> <subsection id="H289BD99C72164F389BC5BEEAFFD6EB03"><enum>(c)</enum><header>CHAMPUS</header><text>No benefits shall be made available under sections <external-xref legal-doc="usc" parsable-cite="usc/10/1079">1079</external-xref> and <external-xref legal-doc="usc" parsable-cite="usc/10/1086">1086</external-xref> of title 10, United States Code, for items or services furnished after December 31, 2006.</text></subsection> <subsection id="HA492BFD6909A496EA1EE09C023B19064"><enum>(d)</enum><header>Treatment of benefits for veterans and native americans</header><text>Nothing in this Act shall affect the eligibility of veterans for the medical benefits and services provided under title 38, United States Code, or of Indians for the medical benefits and services provided by or through the Indian Health Service.</text></subsection></section> <enum>II</enum><header>Comprehensive benefits, including preventive benefits and benefits for long-term care</header> <section id="H03287B83E13F4F18B34FA09E03A22044"><enum>201.</enum><header>Comprehensive benefits</header> <subsection id="HA8FEF01F224C462CB079F3EC004B91B"><enum>(a)</enum><header>In general</header><text>Subject to the succeeding provisions of this title, individuals enrolled for benefits under this Act are entitled to have payment made under a State health security program for the following items and services if medically necessary or appropriate for the maintenance of health or for the diagnosis, treatment, or rehabilitation of a health condition:</text> <paragraph id="H350FDBE7970E45A500DB5E5FE23F3887"><enum>(1)</enum><header>Hospital services</header><text>Inpatient and outpatient hospital care, including 24-hour-a-day emergency services.</text></paragraph> <paragraph id="HD394F98F2B29403AA36836DB9161D359"><enum>(2)</enum><header>Professional services</header><text>Professional services of health care practitioners authorized to provide health care services under State law, including patient education and training in self-management techniques.</text></paragraph> <paragraph id="H0D13199FD591465A9CAA9F6ED2C330B3"><enum>(3)</enum><header>Community-based primary health services</header><text>Community-based primary health services (as defined in section 202(a)).</text></paragraph> <paragraph id="H059F5BCCA9064A3B970438522F474BD7"><enum>(4)</enum><header>Preventive services</header><text>Preventive services (as defined in section 202(b)).</text></paragraph> <paragraph id="HE1686A152B364A7087ADE14C4C608250"><enum>(5)</enum><header>Long-term, acute, and chronic care services</header> <subparagraph id="H65EDD9B2FF0749BFAEE73B51F2905720"><enum>(A)</enum><text>Nursing facility services.</text></subparagraph> <subparagraph id="HDAAA4B7808184BDCA1791728BDEE07"><enum>(B)</enum><text>Home health services.</text></subparagraph> <subparagraph id="HEFF94AC3B8864909BE206017783BFB1F"><enum>(C)</enum><text>Home and community-based long-term care services (as defined in section 202(c)) for individuals described in section 203(a).</text></subparagraph> <subparagraph id="H4767A2A35A034E199BEA00BF57EBD71"><enum>(D)</enum><text>Hospice care.</text></subparagraph> <subparagraph id="H5FEFB045E5224992AB7723FA7056F9D"><enum>(E)</enum><text>Services in intermediate care facilities for individuals with mental retardation.</text></subparagraph></paragraph> <paragraph id="HB232AC0F95C6427893F8F002900A101"><enum>(6)</enum><header>Prescription drugs, biologicals, insulin, medical foods</header> <subparagraph id="H956CB979028A45A2B33C9BD012F2C76D"><enum>(A)</enum><text>Outpatient prescription drugs and biologics, as specified by the Board consistent with section 615.</text></subparagraph> <subparagraph id="H0720CFC48CDB4709B9C8B00D6BDA187"><enum>(B)</enum><text>Insulin.</text></subparagraph> <subparagraph id="H7B5644E350B9436386D26DAF756361A5"><enum>(C)</enum><text>Medical foods (as defined in section 202(e)).</text></subparagraph></paragraph> <paragraph id="H12CB9E13704B4ABBB85BA542BC614DE"><enum>(7)</enum><header>Dental services</header><text>Dental services (as defined in section 202(h)).</text></paragraph> <paragraph id="H0EB20CA6118746AA95DDF855FE3772E4"><enum>(8)</enum><header>Mental health and substance abuse treatment services</header><text>Mental health and substance abuse treatment services (as defined in section 202(f)).</text></paragraph> <paragraph id="HFF0F666902B642FB97F9BDBB864D197"><enum>(9)</enum><header>Diagnostic tests</header><text>Diagnostic tests.</text></paragraph> <paragraph id="H26B52196E4A64FD8A801F0659DC141C9"><enum>(10)</enum><header>Other items and services</header> <subparagraph id="H8D477090548640F981663F00C25B2226"><enum>(A)</enum><header>Outpatient therapy</header><text>Outpatient physical therapy services, outpatient speech pathology services, and outpatient occupational therapy services in all settings.</text></subparagraph> <subparagraph id="HFE534154B87F4655814926097D1250CA"><enum>(B)</enum><header>Durable medical equipment</header><text>Durable medical equipment.</text></subparagraph> <subparagraph id="H7E3F5DEB3FCE4E0AB9A9EF7EF2E2D754"><enum>(C)</enum><header>Home dialysis</header><text>Home dialysis supplies and equipment.</text></subparagraph> <subparagraph id="H826992673ADE4B21AA32FAF9FB5E846F"><enum>(D)</enum><header>Ambulance</header><text>Emergency ambulance service.</text></subparagraph> <subparagraph id="H3205C6B3AEF941E9B18101EAC0E3B1ED"><enum>(E)</enum><header>Prosthetic devices</header><text>Prosthetic devices, including replacements of such devices.</text></subparagraph> <subparagraph id="H366EAFFEA9EE4FFCAEC11829A910F16D"><enum>(F)</enum><header>Additional items and services</header><text>Such other medical or health care items or services as the Board may specify.</text></subparagraph></paragraph></subsection> <subsection id="HF92F7CCA2F774764AAC37E3E271FF0BC"><enum>(b)</enum><header>Cost-sharing</header> <paragraph id="H4AB047D823E34603BB99EEF983FA2949"><enum>(1)</enum><header>In general</header><text>Except as provided in this subsection, there are no deductibles, coinsurance, or copayments applicable to acute care and preventive benefits provided under this title.</text></paragraph> <paragraph id="HA24ECED011864F8B95203FC26ECBFB2C"><enum>(2)</enum><header>Cost-sharing for long-term care services</header> <subparagraph id="H7D2976EAFF864C4AA22400D109FA0520"><enum>(A)</enum><header>In general</header> <clause id="H8FEF98BD149849D000D47D437E041D72"><enum>(i)</enum><text>payments for home and community-based long-term care services are subject to coinsurance of 20 percent; and</text></clause> <clause id="H60041303BED2424CA7AF45C4E7E9BD6"><enum>(ii)</enum><text>payments for nursing facility services are subject to coinsurance of 35 percent.</text></clause></subparagraph> <subparagraph id="HDA7BCAEA5EA943E5B7AB4D5E98B033DF"><enum>(B)</enum><header>Exception</header><text>With respect to the coinsurance established under subparagraph (A)—</text> <clause id="HB24DE7CCC42546008E3900C5A752B486"><enum>(i)</enum><text>such coinsurance shall not apply to an individual with income (as defined by the Secretary) of not more than 100 percent of the income official poverty line applicable to a family of the size involved; and</text></clause> <clause id="H8D4EB468BDC841B6B3B7E6358F871002"><enum>(ii)</enum><text>in the case of an individual with such income that exceeds 100 percent, but is less than 200 percent, of such applicable poverty line, the coinsurance shall be reduced in the same proportion as the proportion of such income is less than 200 percent of such applicable poverty line.</text></clause></subparagraph></paragraph></subsection> <subsection id="H19042CE9925D4AE496F6589D24C7EA52"><enum>(c)</enum><header>Prohibition of balance billing</header><text>As provided in section 531, no person may impose a charge for covered services for which benefits are provided under this Act.</text></subsection> <subsection id="HB67198F8DB4D4AAAB1B85B822CE40887"><enum>(d)</enum><header>No duplicate health insurance</header><text>Each State health security program shall prohibit the sale of health insurance in the State if payment under the insurance duplicates payment for any items or services for which payment may be made under such a program.</text></subsection> <subsection id="H7767904A5BC040D3BCAD03FB77BE7C00"><enum>(e)</enum><header>State program may provide additional benefits</header><text>Nothing in this Act shall be construed as limiting the benefits that may be made available under a State health security program to residents of the State at the expense of the State.</text></subsection> <subsection id="H3E7FD247E17C417B86922DFA7446A9D"><enum>(f)</enum><header>Employers may provide additional benefits</header><text>Nothing in this Act shall be construed as limiting the additional benefits that an employer may provide to employees or their dependents, or to former employees or their dependents.</text></subsection></section> <section id="HD5232E37BB6C404AA29ED786CC26D310"><enum>202.</enum><header>Definitions relating to services</header> <subsection id="H781B6A496FE9415A00BDCEAB533F7389"><enum>(a)</enum><header>Community-based primary health services</header><text>In this title, the term <term>community-based primary health services</term> means ambulatory health services furnished—</text> <paragraph id="H51C4DEC335664119B4CE188CD5F286F6"><enum>(1)</enum><text>by a rural health clinic;</text></paragraph> <paragraph id="HD6A5F005494F41149484FF00E5598256"><enum>(2)</enum><text>by a federally qualified health center (as defined in section 1905(l)(2)(B) of the <act-name parsable-cite="SSA">Social Security Act</act-name>), and which, for purposes of this Act, include services furnished by State and local health agencies;</text></paragraph> <paragraph id="H1DE19CB836954DA8AF52871DB6FCFABF"><enum>(3)</enum><text>in a school-based setting;</text></paragraph> <paragraph id="H8325FAD54F3F48FD883950062700E5AF"><enum>(4)</enum><text>by public educational agencies and other providers of services to children entitled to assistance under the Individuals with Disabilities Education Act for services furnished pursuant to a written Individualized Family Services Plan or Individual Education Plan under such Act; and</text></paragraph> <paragraph id="HFDCFDFA285B749B89F57EB7CEB24B490"><enum>(5)</enum><text>public and private nonprofit entities receiving Federal assistance under the <act-name parsable-cite="PHSA">Public Health Service Act</act-name>.</text></paragraph></subsection> <subsection id="H147A104A13744AA497C9BE00000787DB"><enum>(b)</enum><header>Preventive services</header> <paragraph id="HE8E9778E28D245C6992F3747DB795D05"><enum>(1)</enum><header>In general</header><text>In this title, the term <term>preventive services</term> means items and services—</text> <subparagraph id="H4393226DAEDE41F70032AC5B616242AA"><enum>(A)</enum><text>which—</text> <clause id="H162488A3558E4B509537FD00D5228F7D"><enum>(i)</enum><text>are specified in paragraph (2); or</text></clause> <clause id="HE852FE27E8E34C32AA58D5AEBBEE0076"><enum>(ii)</enum><text>the Board determines to be effective in the maintenance and promotion of health or minimizing the effect of illness, disease, or medical condition; and</text></clause></subparagraph> <subparagraph id="H584FA8423321429EB7C900B7590055FD"><enum>(B)</enum><text>which are provided consistent with the periodicity schedule established under paragraph (3).</text></subparagraph></paragraph> <paragraph id="H3AF7BF272F4147898DB8F713018F6C05"><enum>(2)</enum><header>Specified preventive services</header><text>The services specified in this paragraph are as follows:</text> <subparagraph id="HFC8A0AA84EA64617ACAE380035F6D8F"><enum>(A)</enum><text>Basic immunizations.</text></subparagraph> <subparagraph id="H68449ED4262A49FAB3C08F13ECCA13D"><enum>(B)</enum><text>Prenatal and well-baby care (for infants under 1 year of age).</text></subparagraph> <subparagraph id="HCFB2DEC6C9504CC8004688F11164FD00"><enum>(C)</enum><text>Well-child care (including periodic physical examinations, hearing and vision screening, and developmental screening and examinations) for individuals under 18 years of age.</text></subparagraph> <subparagraph id="H7C7CC04D747E4226BC785671706BE53E"><enum>(D)</enum><text>Periodic screening mammography, Pap smears, and colorectal examinations and examinations for prostate cancer.</text></subparagraph> <subparagraph id="H6FF3C6F6D61D422BBA4BFACC94442E4"><enum>(E)</enum><text>Physical examinations.</text></subparagraph> <subparagraph id="H3964B1A42D354B6DB8CC21F1D1E54E1"><enum>(F)</enum><text>Family planning services.</text></subparagraph> <subparagraph id="H23CE569A40284972001679CB4C592270"><enum>(G)</enum><text>Routine eye examinations, eyeglasses, and contact lenses.</text></subparagraph> <subparagraph id="HD7E174CA08FB477FBE177217C54502A"><enum>(H)</enum><text>Hearing aids, but only upon a determination of a certified audiologist or physician that a hearing problem exists and is caused by a condition that can be corrected by use of a hearing aid.</text></subparagraph></paragraph> <paragraph id="H13A4D285507542E083DAD276F9F9B2D"><enum>(3)</enum><header>Schedule</header><text>The Board shall establish, in consultation with experts in preventive medicine and public health and taking into consideration those preventive services recommended by the Preventive Services Task Force and published as the Guide to Clinical Preventive Services, a periodicity schedule for the coverage of preventive services under paragraph (1). Such schedule shall take into consideration the cost-effectiveness of appropriate preventive care and shall be revised not less frequently than once every 5 years, in consultation with experts in preventive medicine and public health.</text></paragraph></subsection> <subsection id="H370BA8A8509E49458ECB7491D385E58"><enum>(c)</enum><header>Home and community-based long-term care services</header><text>In this title, the term <term>home and community-based long-term care services</term> means the following services provided to an individual to enable the individual to remain in such individual’s place of residence within the community:</text> <paragraph id="HAC0FC17B576B4B0494FB55E701286E09"><enum>(1)</enum><text>Home health aide services.</text></paragraph> <paragraph id="HAFD4B25FE94149559595FCFB41B84091"><enum>(2)</enum><text>Adult day health care, social day care or psychiatric day care.</text></paragraph> <paragraph id="H0BD05838F2684A11008447EB1DE400E1"><enum>(3)</enum><text>Medical social work services.</text></paragraph> <paragraph id="H26B2C54A97134A61B215C931C5B1617E"><enum>(4)</enum><text>Care coordination services, as defined in subsection (g)(1).</text></paragraph> <paragraph id="HB8DFB4A8C8204665002B861553D98FDF"><enum>(5)</enum><text>Respite care, including training for informal caregivers.</text></paragraph> <paragraph id="HFF35551278D041E7A299E069AED42038"><enum>(6)</enum><text>Personal assistance services, and homemaker services (including meals) incidental to the provision of personal assistance services.</text></paragraph></subsection> <subsection id="HD1D5D53FC9D143ABA702BB9407343EDA"><enum>(d)</enum><header>Home health services</header> <paragraph id="H9F516C5BAAA64E80820044F83FED7030"><enum>(1)</enum><header>In general</header><text>The term <term>home health services</term> means items and services described in section 1861(m) of the <act-name parsable-cite="SSA">Social Security Act</act-name> and includes home infusion services.</text></paragraph> <paragraph id="H85C4E7BDFCFF4DD2A9A975CC07BD28E3"><enum>(2)</enum><header>Home infusion services</header><text>The term <term>home infusion services</term> includes the nursing, pharmacy, and related services that are necessary to conduct the home infusion of a drug regimen safely and effectively under a plan established and periodically reviewed by a physician and that are provided in compliance with quality assurance requirements established by the Secretary.</text></paragraph></subsection> <subsection id="HDAC3CD614D724A7593DAE78B00C3B"><enum>(e)</enum><header>Medical foods</header><text>In this title, the term <term>medical foods</term> means foods which are formulated to be consumed or administered enterally under the supervision of a physician and which are intended for the specific dietary management of a disease or condition for which distinctive nutritional requirements, based on recognized scientific principles, are established by medical evaluation.</text></subsection> <subsection id="H5E7AD491A6C146ABA22BB32F626F2207"><enum>(f)</enum><header>Mental health and substance abuse treatment services</header> <paragraph id="H63DEDC6DA6F64C37837B9535D3BC10E2"><enum>(1)</enum><header>Services described</header><text>In this title, the term <term>mental health and substance abuse treatment services</term> means the following services related to the prevention, diagnosis, treatment, and rehabilitation of mental illness and promotion of mental health:</text> <subparagraph id="HB5F3E29397C94AE0B4F3C865BAD4FF43"><enum>(A)</enum><header>Inpatient hospital services</header><text>Inpatient hospital services furnished primarily for the diagnosis or treatment of mental illness or substance abuse for up to 60 days during a year, reduced by a number of days determined by the Secretary so that the actuarial value of providing such number of days of services under this paragraph to the individual is equal to the actuarial value of the days of inpatient residential services furnished to the individual under subparagraph (B) during the year after such services have been furnished to the individual for 120 days during the year (rounded to the nearest day), but only if (with respect to services furnished to an individual described in section 204(b)(1)) such services are furnished in conformity with the plan of an organized system of care for mental health and substance abuse services in accordance with section 204(b)(2).</text></subparagraph> <subparagraph id="HBF1483030BB84E9CB0541FB8EF84E039"><enum>(B)</enum><header>Intensive residential services</header><text>Intensive residential services (as defined in paragraph (2)) furnished to an individual for up to 120 days during any calendar year, except that—</text> <clause id="H9C8B541806564CD094D508BCB414711F"><enum>(i)</enum><text>such services may be furnished to the individual for additional days during the year if necessary for the individual to complete a course of treatment to the extent that the number of days of inpatient hospital services described in subparagraph (A) that may be furnished to the individual during the year (as reduced under such subparagraph) is not less than 15; and</text></clause> <clause id="HF00AC28779E24398B9398991A9518FA9"><enum>(ii)</enum><text>reduced by a number of days determined by the Secretary so that the actuarial value of providing such number of days of services under this paragraph to the individual is equal to the actuarial value of the days of intensive community-based services furnished to the individual under subparagraph (D) during the year after such services have been furnished to the individual for 90 days (or, in the case of services described in subparagraph (D)(ii), for 180 days) during the year (rounded to the nearest day).</text></clause></subparagraph> <subparagraph id="H8C3900E5CBA74D8FBDED59C13ECDFDCA"><enum>(C)</enum><header>Outpatient services</header><text>Outpatient treatment services of mental illness or substance abuse (other than intensive community-based services under subparagraph (D)) for an unlimited number of days during any calendar year furnished in accordance with standards established by the Secretary for the management of such services, and, in the case of services furnished to an individual described in section 204(b)(1) who is not an inpatient of a hospital, in conformity with the plan of an organized system of care for mental health and substance abuse services in accordance with section 204(b)(2).</text></subparagraph> <subparagraph id="HDA99D89A5AA641D2A8DAF5F676BE56C1"><enum>(D)</enum><header>Intensive community-based services</header><text>Intensive community-based services (as described in paragraph (3))—</text> <clause id="H230CE5FEF3064515BB7D3E19F774E4FB"><enum>(i)</enum><text>for an unlimited number of days during any calendar year, in the case of services described in section 1861(ff)(2)(E) that are furnished to an individual who is a seriously mentally ill adult, a seriously emotionally disturbed child, or an adult or child with serious substance abuse disorder (as determined in accordance with criteria established by the Secretary);</text></clause> <clause id="H0980AF036F32400C9CB064E37E537615"><enum>(ii)</enum><text>in the case of services described in section 1861(ff)(2)(C), for up to 180 days during any calendar year, except that such services may be furnished to the individual for a number of additional days during the year equal to the difference between the total number of days of intensive residential services which the individual may receive during the year under part A (as determined under subparagraph (B)) and the number of days of such services which the individual has received during the year; or</text></clause> <clause id="HE664DC147D5E4F7CA98368018FFA96AF"><enum>(iii)</enum><text>in the case of any other such services, for up to 90 days during any calendar year, except that such services may be furnished to the individual for the number of additional days during the year described in clause (ii).</text></clause></subparagraph></paragraph> <paragraph id="HA0E75C9ED8B14A5BB77CB824FBC1BE57"><enum>(2)</enum><header>Intensive residential services defined</header> <subparagraph id="H0BCDBA11C932466BA04CDF04B23DF46C"><enum>(A)</enum><header>In general</header><text>Subject to subparagraphs (B) and (C), the term <term>intensive residential services</term> means inpatient services provided in any of the following facilities:</text> <clause id="H5B7A553C250B45E0807782C3514FA996"><enum>(i)</enum><text>Residential detoxification centers.</text></clause> <clause id="HC30954BE78C44D5AB35777CFA6D518D8"><enum>(ii)</enum><text>Crisis residential programs or mental illness residential treatment programs.</text></clause> <clause id="HD24C469CB2664697AEC06B9F921647FF"><enum>(iii)</enum><text>Therapeutic family or group treatment homes.</text></clause> <clause id="H91C49C4BC80344CD803000BB368ED2BA"><enum>(iv)</enum><text>Residential centers for substance abuse treatment.</text></clause></subparagraph> <subparagraph id="H46345E8515BD45F98557865F9D8DA4E3"><enum>(B)</enum><header>Requirements for facilities</header><text>No service may be treated as an intensive residential service under subparagraph (A) unless the facility at which the service is provided—</text> <clause id="HF2E24CE381674DCBACC614A05483F983"><enum>(i)</enum><text>is legally authorized to provide such service under the law of the State (or under a State regulatory mechanism provided by State law) in which the facility is located or is certified to provide such service by an appropriate accreditation entity approved by the State in consultation with the Secretary; and</text></clause> <clause id="H845D5C0240A9406F003300D76BB588E1"><enum>(ii)</enum><text>meets such other requirements as the Secretary may impose to assure the quality of the intensive residential services provided.</text></clause></subparagraph> <subparagraph id="HDD5A47EB249D407CBCED7DA1842382DE"><enum>(C)</enum><header>Services furnished to at-risk children</header><text>In the case of services furnished to an individual described in section 204(b)(1), no service may be treated as an intensive residential service under this subsection unless the service is furnished in conformity with the plan of an organized system of care for mental health and substance abuse services in accordance with section 204(b)(2).</text></subparagraph> <subparagraph id="H0D5BDA469F4C4B548FCAD05FBE003E54"><enum>(D)</enum><header>Management standards</header><text>No service may be treated as an intensive residential service under subparagraph (A) unless the service is furnished in accordance with standards established by the Secretary for the management of such services.</text></subparagraph></paragraph> <paragraph id="H8A9C227E10FF4A83BD54176000C4A191"><enum>(3)</enum><header>Intensive community-based services defined</header> <subparagraph id="H1E32755E6E7C43F08E0000BEEAC66600"><enum>(A)</enum><header>In general</header><text>The term <term>intensive community-based services</term> means the items and services described in subparagraph (B) prescribed by a physician (or, in the case of services furnished to an individual described in section 204(b)(1), by an organized system of care for mental health and substance abuse services in accordance with such section) and provided under a program described in subparagraph (D) under the supervision of a physician (or, to the extent permitted under the law of the State in which the services are furnished, a non-physician mental health professional) pursuant to an individualized, written plan of treatment established and periodically reviewed by a physician (in consultation with appropriate staff participating in such program) which sets forth the physician’s diagnosis, the type, amount, frequency, and duration of the items and services provided under the plan, and the goals for treatment under the plan, but does not include any item or service that is not furnished in accordance with standards established by the Secretary for the management of such services.</text></subparagraph> <subparagraph id="H0C9260A6A79F4969BE61A9CA9B6B47E2"><enum>(B)</enum><header>Items and services described</header><text>The items and services described in this subparagraph are—</text> <clause id="H15F2EA42E40948929BB7191519BF3E16"><enum>(i)</enum><text>partial hospitalization services consisting of the items and services described in subparagraph (C);</text></clause> <clause id="HDA049B9E37DF4D85975CEE8B308F00DA"><enum>(ii)</enum><text>psychiatric rehabilitation services;</text></clause> <clause id="H66D50D6C55F245AB90AFA7623CA26913"><enum>(iii)</enum><text>day treatment services for individuals under 19 years of age;</text></clause> <clause id="H9D25C58E3CC9450EB06F13AA15FCE9E6"><enum>(iv)</enum><text>in-home services;</text></clause> <clause id="H0ABD072AB3B34618AC75F9C3A2FE7D31"><enum>(v)</enum><text>case management services, including collateral services designated as such case management services by the Secretary;</text></clause> <clause id="HA7EFE770AA64449783AEBA446225368E"><enum>(vi)</enum><text>ambulatory detoxification services; and</text></clause> <clause id="H957B1B35DB144A7BAB886844C6E5E886"><enum>(vii)</enum><text>such other items and services as the Secretary may provide (but in no event to include meals and transportation),</text></clause><continuation-text continuation-text-level="subparagraph">that are reasonable and necessary for the diagnosis or active treatment of the individual’s condition, reasonably expected to improve or maintain the individual’s condition and functional level and to prevent relapse or hospitalization, and furnished pursuant to such guidelines relating to frequency and duration of services as the Secretary shall by regulation establish (taking into account accepted norms of medical practice and the reasonable expectation of patient improvement).</continuation-text></subparagraph> <subparagraph id="H1DFC05AD66CF4ED7867B4FF3A9CD6356"><enum>(C)</enum><header>Items and services included as partial hospitalization services</header><text>For purposes of subparagraph (B)(i), partial hospitalization services consist of the following:</text> <clause id="H3ED331F14BBD4C0C9E5F28332100B22C"><enum>(i)</enum><text>Individual and group therapy with physicians or psychologists (or other mental health professionals to the extent authorized under State law).</text></clause> <clause id="HFF26D4471743408088363229AFF51D45"><enum>(ii)</enum><text>Occupational therapy requiring the skills of a qualified occupational therapist.</text></clause> <clause id="H6A5277471A7946F28517E79887925126"><enum>(iii)</enum><text>Services of social workers, trained psychiatric nurses, behavioral aides, and other staff trained to work with psychiatric patients (to the extent authorized under State law).</text></clause> <clause id="H17AF0A8BB97D455580A08600FBE2ADCF"><enum>(iv)</enum><text>Drugs and biologicals furnished for therapeutic purposes (which cannot, as determined in accordance with regulations, be self-administered).</text></clause> <clause id="HB9A353A9C38C4CA4AD569980A800243B"><enum>(v)</enum><text>Individualized activity therapies that are not primarily recreational or diversionary.</text></clause> <clause id="HAE506704316046C0B4AAC9D8FFEF21A1"><enum>(vi)</enum><text>Family counseling (the primary purpose of which is treatment of the individual’s condition).</text></clause> <clause id="H6B0DA6BDFD764505AA4F1C899B458B54"><enum>(vii)</enum><text>Patient training and education (to the extent that training and educational activities are closely and clearly related to the individual’s care and treatment).</text></clause> <clause id="HF1702C56FF8544FBBAE69871EA10FAF2"><enum>(viii)</enum><text>Diagnostic services.</text></clause></subparagraph> <subparagraph id="H6705A50BF0384423883547D3D4F7DBBF"><enum>(D)</enum><header>Programs described</header><text>A program described in this subparagraph is a program (whether facility-based or freestanding) which is furnished by an entity—</text> <clause id="H5D6C0C6E571447E28CA5706FEA8A6F8"><enum>(i)</enum><text>legally authorized to furnish such a program under State law (or the State regulatory mechanism provided by State law) or certified to furnish such a program by an appropriate accreditation entity approved by the State in consultation with the Secretary; and</text></clause> <clause id="H6D72B83ED28B4ED3913FB4F77E2CCB2C"><enum>(ii)</enum><text>meeting such other requirements as the Secretary may impose to assure the quality of the intensive community-based services provided.</text></clause></subparagraph></paragraph></subsection> <subsection id="H553750FE01C942F18F842900B133009E"><enum>(g)</enum><header>Care coordination services</header> <paragraph id="HA170BD5C8E5D4C65AD574709D095936"><enum>(1)</enum><header>In general</header><text>In this title, the term <term>care coordination services</term> means services provided by care coordinators (as defined in paragraph (2)) to individuals described in paragraph (3) for the coordination and monitoring of home and community-based long term care services to ensure appropriate, cost-effective utilization of such services in a comprehensive and continuous manner, and includes—</text> <subparagraph id="HA6A92A7419854D4C8BE04094C732E99E"><enum>(A)</enum><text>transition management between inpatient facilities and community-based services, including assisting patients in identifying and gaining access to appropriate ancillary services; and</text></subparagraph> <subparagraph id="H5CB879E3965F472AB32505C7095466BB"><enum>(B)</enum><text>evaluating and recommending appropriate treatment services, in cooperation with patients and other providers and in conjunction with any quality review program or plan of care under section 205.</text></subparagraph></paragraph> <paragraph id="H851BBC225D4342589FFE8403AA833FA2"><enum>(2)</enum><header>Care coordinator</header> <subparagraph id="H8B3AD31861A147CA00B1031FAE720701"><enum>(A)</enum><header>In general</header><text>In this title, the term <term>care coordinator</term> means an individual or nonprofit or public agency or organization which the State health security program determines—</text> <clause id="HADD9F3DE3D3843478B83EDAD683BE983"><enum>(i)</enum><text>is capable of performing directly, efficiently, and effectively the duties of a care coordinator described in paragraph (1); and</text></clause> <clause id="H5A29CF156CDD46A592043665A7AC9D10"><enum>(ii)</enum><text>demonstrates capability in establishing and periodically reviewing and revising plans of care, and in arranging for and monitoring the provision and quality of services under any plan.</text></clause></subparagraph> <subparagraph id="HD20189F2837C4720B3B7C2DE93F4835E"><enum>(B)</enum><header>Independence</header><text>State health security programs shall establish safeguards to assure that care coordinators have no financial interest in treatment decisions or placements. Care coordination may not be provided through any structure or mechanism through which quality review is performed.</text></subparagraph></paragraph> <paragraph id="H07544822B01C453FB096B89300340986"><enum>(3)</enum><header>Eligible individuals</header><text>An individual described in this paragraph is an individual described in section 203 (relating to individuals qualifying for long term and chronic care services).</text></paragraph></subsection> <subsection id="H7E15C653059846C5A736DDA26BB561C"><enum>(h)</enum><header>Dental services</header> <paragraph id="HAE9A9ECA0F0E466AA0F3102DF0146BB1"><enum>(1)</enum><header>In general</header><text>In this title, subject to subsection (b), the term <term>dental services</term> means the following:</text> <subparagraph id="H61E32FBF95964F5E9401DFD6F6408189"><enum>(A)</enum><text>Emergency dental treatment, including extractions, for bleeding, pain, acute infections, and injuries to the maxillofacial region.</text></subparagraph> <subparagraph id="HBFD4994CED4748B584CD45F6A71237C1"><enum>(B)</enum><text>Prevention and diagnosis of dental disease, including examinations of the hard and soft tissues of the oral cavity and related structures, radiographs, dental sealants, fluorides, and dental prophylaxis.</text></subparagraph> <subparagraph id="H5F20D4E20FD84B629E1D6F1E892E9D14"><enum>(C)</enum><text>Treatment of dental disease, including non-cast fillings, periodontal maintenance services, and endodontic services.</text></subparagraph> <subparagraph id="HB7039E7C17C647CCA12C94FECB74A225"><enum>(D)</enum><text>Space maintenance procedures to prevent orthodontic complications.</text></subparagraph> <subparagraph id="H975A3A3740F6409DAABB173D00B6D74"><enum>(E)</enum><text>Orthodontic treatment to prevent severe malocclusions.</text></subparagraph> <subparagraph id="HCF8487807D39455C81BAB21CF9001C72"><enum>(F)</enum><text>Full dentures.</text></subparagraph> <subparagraph id="H697B5912068B44E2B883EBF3E36F239B"><enum>(G)</enum><text>Medically necessary oral health care.</text></subparagraph> <subparagraph id="H62F77F10030546D99921B8A0635CD3BB"><enum>(H)</enum><text>Any items and services for special needs patients that are not described in subparagraphs (A) through (G) and that—</text> <clause id="H3999B35446794DAC938CF904A4AD2D05"><enum>(i)</enum><text>are required to provide such patients the items and services described in subparagraphs (A) through (G);</text></clause> <clause id="H97F1EF3804D645F4BA4E98C862182095"><enum>(ii)</enum><text>are required to establish oral function (including general anesthesia for individuals with physical or emotional limitations that prevent the provision of dental care without such anesthesia);</text></clause> <clause id="HCD7874600127468DBE5E0001E87015D1"><enum>(iii)</enum><text>consist of orthodontic care for severe dentofacial abnormalities; or</text></clause> <clause id="H23D8B8F0CC4F48560035E3001397A362"><enum>(iv)</enum><text>consist of prosthetic dental devices for genetic or birth defects or fitting for such devices.</text> <subclause indent="up2" id="H4551CE3024204F8D997ED819AE78DADB"><enum>(I)</enum><text>Any dental care for individuals with a seizure disorder that is not described in subparagraphs (A) through (H) and that is required because of an illness, injury, disorder, or other health condition that results from such seizure disorder.</text></subclause></clause></subparagraph></paragraph> <paragraph id="H97711AE754DC443D9B1FA0BB7B28B209"><enum>(2)</enum><header>Limitations</header><text>Dental services are subject to the following limitations:</text> <subparagraph id="H9A2391627ED64E50ABFA6F3EC8D81C3"><enum>(A)</enum><header>Prevention and diagnosis</header> <clause id="HB2E52A743EED4ABC8CD051924799B300"><enum>(i)</enum><header>Examinations and prophylaxis</header><text>The examinations and prophylaxis described in paragraph (1)(B) are covered only consistent with a periodicity schedule established by the Board, which schedule may provide for special treatment of individuals less than 18 years of age and of special needs patients.</text></clause> <clause id="HC2A231F9378247CC8971CAE9EB5F808B"><enum>(ii)</enum><header>Dental sealants</header><text>The dental sealants described in such paragraph are not covered for individuals 18 years of age or older. Such sealants are covered for individuals less than 10 years of age for protection of the 1st permanent molars. Such sealants are covered for individuals 10 years of age or older for protection of the 2d permanent molars.</text></clause></subparagraph> <subparagraph id="H551DB3079D3E42F28DE64878078F2E06"><enum>(B)</enum><header>Treatment of dental disease</header><text>Prior to January 1, 2012, the items and services described in paragraph (1)(C) are covered only for individuals less than 18 years of age and special needs patients. On or after such date, such items and services are covered for all individuals enrolled for benefits under this Act, except that endodontic services are not covered for individuals 18 years of age or older.</text></subparagraph> <subparagraph id="H2F88194B48B943C198C79803240110B4"><enum>(C)</enum><header>Space maintenance</header><text>The items and services described in paragraph (1)(D) are covered only for individuals at least 3 years of age, but less than 13 years of age and—</text> <clause id="H45A6A15A03D04DABA1C96E10F1CC97C"><enum>(i)</enum><text>are limited to posterior teeth;</text></clause> <clause id="H2360589ABDCD4F5492970070BAD96670"><enum>(ii)</enum><text>involve maintenance of a space or spaces for permanent posterior teeth that would otherwise be prevented from normal eruption if the space were not maintained; and</text></clause> <clause id="H2DCEEA13DDE64DE5B3C2AA19859BBA20"><enum>(iii)</enum><text>do not include a space maintainer that is placed within 6 months of the expected eruption of the permanent posterior tooth concerned.</text></clause></subparagraph> <subparagraph id="HA07D48D0D33A422D8EC04549FBD41F05"><enum>(D)</enum><header>Orthodontic treatment</header><text>Prior to January 1, 2012, the items and services described in paragraph (1)(E) are covered only for individuals at least 6 years of age, but less than 12 years of age, who have severe dentofacial abnormalities. On or after such date, such items and services are covered only for individuals at least 6 years of age, but less than 12 years of age.</text></subparagraph> <subparagraph id="H917E81138D1C4A359B9C8CE5EEEE579"><enum>(E)</enum><header>Dentures</header><text>Prior to January 1, 2012, the dentures described in paragraph (1)(F) are not covered, except for special needs patients. On or after such date, dentures are covered for an individual consistent with a periodicity schedule established by the Board, except that the limitation of periodicity provided in such schedule shall not apply to a special needs patient.</text></subparagraph></paragraph> <paragraph id="H9DAA193EF278415E8B2B8CAB52EAA370"><enum>(3)</enum><header>Definitions</header><text>For purposes of this title:</text> <subparagraph id="H4C60A3776C6A4E26AE49772C2159BCB7"><enum>(A)</enum><header>Medically necessary oral health care</header><text>The term <term>medically necessary oral health care</term> means oral health care that is required as a direct result of, or would have a direct impact on, an underlying medical condition. Such term includes oral health care directed toward control or elimination of pain, infection, or reestablishment of oral function.</text></subparagraph> <subparagraph id="H4A9223622CB44629AE8141BE91FF84AD"><enum>(B)</enum><header>Special needs patient</header><text>The term <term>special needs patient</term> includes an individual with a genetic or birth defect, a developmental disability, or an acquired medical disability.</text></subparagraph></paragraph></subsection> <subsection id="HF41EC1CF39ED436E9F68838390CFD2E8"><enum>(i)</enum><header>Nursing facility; nursing facility services</header><text>Except as may be provided by the Board, the terms <term>nursing facility</term> and <term>nursing facility services</term> have the meanings given such terms in sections 1919(a) and 1905(f), respectively, of the <act-name parsable-cite="SSA">Social Security Act</act-name>.</text></subsection> <subsection id="H23C1EEF1B9E34459864488BD00BAA1AA"><enum>(j)</enum><header>Services in intermediate care facilities for individuals with mental retardation</header><text>Except as may be provided by the Board—</text> <paragraph id="H03B0F089814E469487DD5272FE4DF61E"><enum>(1)</enum><text>the term <term>intermediate care facility for individuals with mental retardation</term> has the meaning specified in section 1905(d) of the <act-name parsable-cite="SSA">Social Security Act</act-name> (as in effect before the enactment of this Act); and</text></paragraph> <paragraph id="H7FAB3688C919425784C08210BACBC57"><enum>(2)</enum><text>the term <term>services in intermediate care facilities for individuals with mental retardation</term> means services described in section 1905(a)(15) of such Act (as so in effect) in an intermediate care facility for individuals with mental retardation to an individual determined to require such services in accordance with standards specified by the Board and comparable to the standards described in section 1902(a)(31)(A) of such Act (as so in effect).</text></paragraph></subsection> <subsection id="HA220A3A6977946989B1C9BB4D9960096"><enum>(k)</enum><header>Other terms</header><text>Except as may be provided by the Board, the definitions contained in section 1861 of the <act-name parsable-cite="SSA">Social Security Act</act-name> shall apply.</text></subsection></section> <section id="HF7D350D979C04E5692DBD4B07670002E"><enum>203.</enum><header>Special rules for home and community-based long-term care services</header> <subsection id="H3AA377DC0F104494AA497C001F495736"><enum>(a)</enum><header>Qualifying individuals</header><text>For purposes of section 201(a)(5)(C), individuals described in this subsection are the following individuals:</text> <paragraph id="HACAD7D478D834BC1AA6B714100AF9C33"><enum>(1)</enum><header>Adults</header><text>Individuals 18 years of age or older determined (in a manner specified by the Board)—</text> <subparagraph id="HDB042BD733B241FD96579BDC3D376D04"><enum>(A)</enum><text>to be unable to perform, without the assistance of an individual, at least 2 of the following 5 activities of daily living (or who has a similar level of disability due to cognitive impairment)—</text> <clause id="HF22D25C4A28A4F04A9B4C269754909E8"><enum>(i)</enum><text>bathing;</text></clause> <clause id="H16911DD9E4BA4E2E81FA7F439280ED8D"><enum>(ii)</enum><text>eating;</text></clause> <clause id="HE2EC736009604374B6E040E3DB321BE4"><enum>(iii)</enum><text>dressing;</text></clause> <clause id="HAEE88A128A204E4488D94419B71B1115"><enum>(iv)</enum><text>toileting; and</text></clause> <clause id="H840A1944B7774BC08C93F9D49DC74F9"><enum>(v)</enum><text>transferring in and out of a bed or in and out of a chair;</text></clause></subparagraph> <subparagraph id="H3289C0EA6CB1451095E2FE17E622B7F6"><enum>(B)</enum><text>due to cognitive or mental impairments, to require supervision because the individual behaves in a manner that poses health or safety hazards to himself or herself or others; or</text></subparagraph> <subparagraph id="H1D7E9992BFCE4442ADD8956EF25DE8BE"><enum>(C)</enum><text>due to cognitive or mental impairments, to require queuing to perform activities of daily living.</text></subparagraph></paragraph> <paragraph id="H3A404E1C9C39416C8E19B94E3552C412"><enum>(2)</enum><header>Children</header><text>Individuals under 18 years of age determined (in a manner specified by the Board) to meet such alternative standard of disability for children as the Board develops. Such alternative standard shall be comparable to the standard for adults and appropriate for children.</text></paragraph></subsection> <subsection id="HE43229986B344827001BC251D7818FF5"><enum>(b)</enum><header>Limit on services</header> <paragraph id="H0706F20355034FB5B4F8B3324EC80E2"><enum>(1)</enum><header>In general</header><text>The aggregate expenditures by a State health security program with respect to home and community-based long-term care services in a period (specified by the Board) may not exceed 65 percent (or such alternative ratio as the Board establishes under paragraph (2)) of the average of the amount of payment that would have been made under the program during the period if all the home-based long-term care beneficiaries had been residents of nursing facilities in the same area in which the services were provided.</text></paragraph> <paragraph id="H0E5B0D81D1BE4DC1BC6815A1F1597B10"><enum>(2)</enum><header>Alternative ratio</header><text>The Board may establish for purposes of paragraph (1) an alternative ratio (of payments for home and community-based long term care services to payments for nursing facility services) as the Board determines to be more consistent with the goal of providing cost-effective long-term care in the most appropriate and least restrictive setting.</text></paragraph></subsection></section> <section id="H3BEBD864DADA4E50AFF2D62B76A79665"><enum>204.</enum><header>Exclusions and limitations</header> <subsection id="HC1B349B3467544DF8700BE9F193FED1"><enum>(a)</enum><header>In general</header><text>Subject to section 201(e), benefits for service are not available under this Act unless the services meet the standards specified in section 201(a).</text></subsection> <subsection id="H90DD29A9BB6F42AFA527D52493A54818"><enum>(b)</enum><header>Special delivery requirements for mental health and substance abuse treatment services provided to At-risk children</header> <paragraph id="H3A19E2D672524C63B039F6451B903F54"><enum>(1)</enum><header>Requiring services to be provided through organized systems of care</header><text>A State health security program shall ensure that mental health services and substance abuse treatment services are furnished through an organized system of care, as described in paragraph (2), if—</text> <subparagraph id="HD6C7FCC978624BA1952B606220D5D82"><enum>(A)</enum><text>the services are provided to an individual less than 22 years of age;</text></subparagraph> <subparagraph id="H74CC5E622DFB4BE3881F70A99070EC58"><enum>(B)</enum><text>the individual has a serious emotional disturbance or a substance abuse disorder; and</text></subparagraph> <subparagraph id="HFB447D8E3D3F4C1D8569FA33BAD4E041"><enum>(C)</enum><text>the individual is, or is at imminent risk of being, subject to the authority of, or in need of the services of, at least 1 public agency that serves the needs of children, including an agency involved with child welfare, special education, juvenile justice, or criminal justice.</text></subparagraph></paragraph> <paragraph id="H2125BFC2851F475CB9E8659BFC3961F3"><enum>(2)</enum><header>Requirements for system of care</header><text>In this subsection, an <quote>organized system of care</quote> is a community-based service delivery network, which may consist of public and private providers, that meets the following requirements:</text> <subparagraph id="H1598A0279B864A56BDFBF411D09CA3A4"><enum>(A)</enum><text>The system has established linkages with existing mental health services and substance abuse treatment service delivery programs in the plan service area (or is in the process of developing or operating a system with appropriate public agencies in the area to coordinate the delivery of such services to individuals in the area).</text></subparagraph> <subparagraph id="H78887A19F5664F44BA24B3126B8F46A4"><enum>(B)</enum><text>The system provides for the participation and coordination of multiple agencies and providers that serve the needs of children in the area, including agencies and providers involved with child welfare, education, juvenile justice, criminal justice, health care, mental health, and substance abuse prevention and treatment.</text></subparagraph> <subparagraph id="HEC5C9FE8B8674E2782D59FBA33A89412"><enum>(C)</enum><text>The system provides for the involvement of the families of children to whom mental health services and substance abuse treatment services are provided in the planning of treatment and the delivery of services.</text></subparagraph> <subparagraph id="H8F9AF30012BE4DA5914828E9B24C39B7"><enum>(D)</enum><text>The system provides for the development and implementation of individualized treatment plans by multidisciplinary and multiagency teams, which are recognized and followed by the applicable agencies and providers in the area.</text></subparagraph> <subparagraph id="H8813AA84981342B7AA57708E15001968"><enum>(E)</enum><text>The system ensures the delivery and coordination of the range of mental health services and substance abuse treatment services required by individuals under 22 years of age who have a serious emotional disturbance or a substance abuse disorder.</text></subparagraph> <subparagraph id="H58FFA3041A80474ABFAC0081856FA927"><enum>(F)</enum><text>The system provides for the management of the individualized treatment plans described in subparagraph (D) and for a flexible response to changes in treatment needs over time.</text></subparagraph></paragraph></subsection> <subsection id="HB6CDC1BDDA634A5EB129EA5863C5A7F4"><enum>(c)</enum><header>Treatment of experimental services</header><text>In applying subsection (a), the Board shall make national coverage determinations with respect to those services that are experimental in nature. Such determinations shall be made consistent with a process that provides for input from representatives of health care professionals and patients and public comment.</text></subsection> <subsection id="HDC9CF9A4076846C7B1F5D90926DF992B"><enum>(d)</enum><header>Application of practice guidelines</header><text>In the case of services for which the American Health Security Quality Council (established under section 501) has recognized a national practice guideline, the services are considered to meet the standards specified in section 201(a) if they have been provided in accordance with such guideline or in accordance with such guidelines as are provided by the State health security program consistent with title V. For purposes of this subsection, a service shall be considered to have been provided in accordance with a practice guideline if the health care provider providing the service exercised appropriate professional discretion to deviate from the guideline in a manner authorized or anticipated by the guideline.</text></subsection> <subsection id="H1E960CE17AD8428F952921CABBAA8C67"><enum>(e)</enum><header>Specific limitations</header> <paragraph id="H1C19D251510845A3B6851E5C5D03037C"><enum>(1)</enum><header>Limitations on eyeglasses, contact lenses, hearing aids, and durable medical equipment</header><text>Subject to section 201(e), the Board may impose such limits relating to the costs and frequency of replacement of eyeglasses, contact lenses, hearing aids, and durable medical equipment to which individuals enrolled for benefits under this Act are entitled to have payment made under a State health security program as the Board deems appropriate.</text></paragraph> <paragraph id="HA86693BC93BC42CBB17F604606C8245E"><enum>(2)</enum><header>Overlap with preventive services</header><text>The coverage of services described in section 201(a) (other than paragraph (3)) which also are preventive services are required to be covered only to the extent that they are required to be covered as preventive services.</text></paragraph> <paragraph id="H90E8D2957EDA41BC93E6C2384DB93375"><enum>(3)</enum><header>Miscellaneous exclusions from covered services</header><text>Covered services under this Act do not include the following:</text> <subparagraph id="HC97A4B9558334CF7B4E2EBDDAF104755"><enum>(A)</enum><text>Surgery and other procedures (such as orthodontia) performed solely for cosmetic purposes (as defined in regulations) and hospital or other services incident thereto, unless—</text> <clause id="H75137097BB164FDF9C2369A53FEDBED"><enum>(i)</enum><text>required to correct a congenital anomaly;</text></clause> <clause id="H4403FD0892D1404683E44B3D6219E2DE"><enum>(ii)</enum><text>required to restore or correct a part of the body which has been altered as a result of accidental injury, disease, or surgery; or</text></clause> <clause id="H63FCB0D05A42472F9893DBA9A01F328C"><enum>(iii)</enum><text>otherwise determined to be medically necessary and appropriate under section 201(a).</text></clause></subparagraph> <subparagraph id="HD0094F20011246879100BCCF1C37C400"><enum>(B)</enum><text>Personal comfort items or private rooms in inpatient facilities, unless determined to be medically necessary and appropriate under section 201(a).</text></subparagraph> <subparagraph id="HC82DFC5FCAB44A53835C9593D5903D78"><enum>(C)</enum><text>The services of a professional practitioner if they are furnished in a hospital or other facility which is not a participating provider.</text></subparagraph></paragraph></subsection> <subsection id="HBD98C5C375B04881941EF92903FAD251"><enum>(f)</enum><header>Nursing facility services and home health services</header><text>Nursing facility services and home health services (other than post-hospital services, as defined by the Board) furnished to an individual who is not described in section 203(a) are not covered services unless the services are determined to meet the standards specified in section 201(a) and, with respect to nursing facility services, to be provided in the least restrictive and most appropriate setting.</text></subsection></section> <section id="H624629A6CA5549FFADF76956CC377107"><enum>205.</enum><header>Certification; quality review; plans of care</header> <subsection id="H5420B4CF7C1543D5BAD62BCC68B7B7C2"><enum>(a)</enum><header>Certifications</header><text>State health security programs may require, as a condition of payment for institutional health care services and other services of the type described in such sections 1814(a) and 1835(a) of the <act-name parsable-cite="SSA">Social Security Act</act-name>, periodic professional certifications of the kind described in such sections.</text></subsection> <subsection id="H2F2A9F481F0B48B6BDF9F66E54E7E8C7"><enum>(b)</enum><header>Quality review</header><text>For requirement that each State health security program establish a quality review program that meets the requirements for such a program under title V, see section 404(b)(1)(H).</text></subsection> <subsection id="HD18D8F70998F43C9A2A3AD19F663EEE"><enum>(c)</enum><header>Plan of care requirements</header><text>A State health security program may require, consistent with standards established by the Board, that payment for services exceeding specified levels or duration be provided only as consistent with a plan of care or treatment formulated by one or more providers of the services or other qualified professionals. Such a plan may include, consistent with subsection (b), case management at specified intervals as a further condition of payment for services.</text></subsection></section> <enum>III</enum><header>Provider participation</header> <section id="H8DEF9314401F47B2A049667CED97E949"><enum>301.</enum><header>Provider participation and standards</header> <subsection id="H28D0EA2A48C64C58BDA61EBC1243A9E2"><enum>(a)</enum><header>In general</header><text>An individual or other entity furnishing any covered service under a State health security program under this Act is not a qualified provider unless the individual or entity—</text> <paragraph id="H45655653FBDB4602AC80D759D72CE679"><enum>(1)</enum><text>is a qualified provider of the services under section 302;</text></paragraph> <paragraph id="HB813CE5BE0444875B2A18C1C40D6EA46"><enum>(2)</enum><text>has filed with the State health security program a participation agreement described in subsection (b); and</text></paragraph> <paragraph id="H16438DD100B7427EA31F71E7C4B11673"><enum>(3)</enum><text>meets such other qualifications and conditions as are established by the Board or the State health security program under this Act.</text></paragraph></subsection> <subsection id="H1ECAEC19FBBB4403B828B295C310A38C"><enum>(b)</enum><header>Requirements in participation agreement</header> <paragraph id="H4441056FB59346C1A2B00B6093D9BAE"><enum>(1)</enum><header>In general</header><text>A participation agreement described in this subsection between a State health security program and a provider shall provide at least for the following:</text> <subparagraph id="HDE1494E7E53B4AFB81A49BD7E162F336"><enum>(A)</enum><text>Services to eligible persons will be furnished by the provider without discrimination on the ground of race, national origin, income, religion, age, sex or sexual orientation, disability, handicapping condition, or (subject to the professional qualifications of the provider) illness. Nothing in this subparagraph shall be construed as requiring the provision of a type or class of services which services are outside the scope of the provider’s normal practice.</text></subparagraph> <subparagraph id="H938F9C1BDADA4EC48834A0A2751D4110"><enum>(B)</enum><text>No charge will be made for any covered services other than for payment authorized by this Act.</text></subparagraph> <subparagraph id="HC37EFECD1AFC4C25BDE044808E1F3000"><enum>(C)</enum><text>The provider agrees to furnish such information as may be reasonably required by the Board or a State health security program, in accordance with uniform reporting standards established under section 401(g)(1), for—</text> <clause id="H02AA5D5003E34C2E8125A13B83A5F55"><enum>(i)</enum><text>quality review by designated entities;</text></clause> <clause id="H0C66835C1EDE45B5A4BEF4CAC121CE38"><enum>(ii)</enum><text>the making of payments under this Act (including the examination of records as may be necessary for the verification of information on which payments are based);</text></clause> <clause id="H3E9B799E0DBC4E8E985340F0D7718D6"><enum>(iii)</enum><text>statistical or other studies required for the implementation of this Act; and</text></clause> <clause id="H14619742DC6448CC007676AAB24942C5"><enum>(iv)</enum><text>such other purposes as the Board or State may specify.</text></clause></subparagraph> <subparagraph id="HB7DEC5577A404BD1B2AF884175C42C4E"><enum>(D)</enum><text>The provider agrees not to bill the program for any services for which benefits are not available because of section 204(d).</text></subparagraph> <subparagraph id="HB76921B8B9A547C49B87186F2067302D"><enum>(E)</enum><text>In the case of a provider that is not an individual, the provider agrees not to employ or use for the provision of health services any individual or other provider who or which has had a participation agreement under this subsection terminated for cause.</text></subparagraph> <subparagraph id="HA3AE1463CA44426A9E33B1CFFE030975"><enum>(F)</enum><text>In the case of a provider paid under a fee-for-service basis under section 612, the provider agrees to submit bills and any required supporting documentation relating to the provision of covered services within 30 days (or such shorter period as a State health security program may require) after the date of providing such services.</text></subparagraph></paragraph> <paragraph id="H1F77E2B851364A3F94AFEFDA108D0000"><enum>(2)</enum><header>Termination of participation agreements</header> <subparagraph id="H052DD9EB8F424DCA8B442483B5FE2850"><enum>(A)</enum><header>In general</header><text>Participation agreements may be terminated, with appropriate notice—</text> <clause id="H85698B0F8C7A477DB0F6A51E3B28AA"><enum>(i)</enum><text>by the Board or a State health security program for failure to meet the requirements of this title; or</text></clause> <clause id="H3EA9434DA5A7480C837143916728F01"><enum>(ii)</enum><text>by a provider.</text></clause></subparagraph> <subparagraph id="HD440224D786840138762BABEDF47AE36"><enum>(B)</enum><header>Termination process</header><text>Providers shall be provided notice and a reasonable opportunity to correct deficiencies before the Board or a State health security program terminates an agreement unless a more immediate termination is required for public safety or similar reasons.</text></subparagraph></paragraph></subsection></section> <section id="HAAF1FD6420C44FA0A6EAAE35D90050E2"><enum>302.</enum><header>Qualifications for providers</header> <subsection id="H92EB8566A5144D88AF2EF9A37357E22C"><enum>(a)</enum><header>In general</header><text>A health care provider is considered to be qualified to provide covered services if the provider is licensed or certified and meets—</text> <paragraph id="H5625F2833DFB44FBAEBEB509B700ACF8"><enum>(1)</enum><text>all the requirements of State law to provide such services;</text></paragraph> <paragraph id="HFFD66E964332451A8623B576DE00AF8F"><enum>(2)</enum><text>applicable requirements of Federal law to provide such services; and</text></paragraph> <paragraph id="H8C85515FCEC94D2087C892AC2625D23E"><enum>(3)</enum><text>any applicable standards established under subsection (b).</text></paragraph></subsection> <subsection id="H106588232A4546C2A155A7A4F17552B3"><enum>(b)</enum><header>Minimum provider standards</header> <paragraph id="HCB418EBD595040929184117E25818BEB"><enum>(1)</enum><header>In general</header><text>The Board shall establish, evaluate, and update national minimum standards to assure the quality of services provided under this Act and to monitor efforts by State health security programs to assure the quality of such services. A State health security program may also establish additional minimum standards which providers must meet.</text></paragraph> <paragraph id="HC987C72367624F5880E7D9429F8DC489"><enum>(2)</enum><header>National minimum standards</header><text>The national minimum standards under paragraph (1) shall be established for institutional providers of services, individual health care practitioners, and comprehensive health service organizations. Except as the Board may specify in order to carry out this title, a hospital, nursing facility, or other institutional provider of services shall meet standards for such a facility under the medicare program under title XVIII of the <act-name parsable-cite="SSA">Social Security Act</act-name>. Such standards also may include, where appropriate, elements relating to—</text> <subparagraph id="HD5CBD72BDA404867835976B3CFA20087"><enum>(A)</enum><text>adequacy and quality of facilities;</text></subparagraph> <subparagraph id="HF6FFA51CD6FE4652A06BDBC779848B77"><enum>(B)</enum><text>training and competence of personnel (including continuing education requirements);</text></subparagraph> <subparagraph id="H2FF8AE9746C3400DB48DA18E44D8B9F6"><enum>(C)</enum><text>comprehensiveness of service;</text></subparagraph> <subparagraph id="H9FB7DE934537464E9BE424EB3249ADCE"><enum>(D)</enum><text>continuity of service;</text></subparagraph> <subparagraph id="H3A689F0ED80A4123BEED2BC0DA629F41"><enum>(E)</enum><text>patient satisfaction (including waiting time and access to services); and</text></subparagraph> <subparagraph id="HCC442F40324B42099BE8408B80CDF4C"><enum>(F)</enum><text>performance standards (including organization, facilities, structure of services, efficiency of operation, and outcome in palliation, improvement of health, stabilization, cure, or rehabilitation).</text></subparagraph></paragraph> <paragraph id="HBBAC9F5AF6EB4D0099F716D3B06D6AE"><enum>(3)</enum><header>Transition in application</header><text>If the Board provides for additional requirements for providers under this subsection, any such additional requirement shall be implemented in a manner that provides for a reasonable period during which a previously qualified provider is permitted to meet such an additional requirement.</text></paragraph> <paragraph id="H87A27E161A5C41DCB0EF8E69BE9CDE85"><enum>(4)</enum><header>Exchange of information</header><text>The Board shall provide for an exchange, at least annually, among State health security programs of information with respect to quality assurance and cost containment.</text></paragraph></subsection></section> <section id="HBD1CBCD26D42459C870089874985CE7D"><enum>303.</enum><header>Qualifications for comprehensive health service organizations</header> <subsection id="H6A019713C2E4436E9237E7F4F1009700"><enum>(a)</enum><header>In general</header><text>For purposes of this Act, a comprehensive health service organization (in this section referred to as a <quote>CHSO</quote>) is a public or private organization which, in return for a capitated payment amount, undertakes to furnish, arrange for the provision of, or provide payment with respect to—</text> <paragraph id="HDEA803D19E964BE0BC1587F09D6CBC49"><enum>(1)</enum><text>a full range of health services (as identified by the Board), including at least hospital services and physicians services; and</text></paragraph> <paragraph id="H1E85943F684F4ED2ABE6D62F2C92F99E"><enum>(2)</enum><text>out-of-area coverage in the case of urgently needed services;</text></paragraph><continuation-text continuation-text-level="subsection">to an identified population which is living in or near a specified service area and which enrolls voluntarily in the organization.</continuation-text></subsection> <subsection id="H8B87101A00CD4E40A78812DA6C8872E6"><enum>(b)</enum><header>Enrollment</header> <paragraph id="H35A0BA6FD02549038366F8D6ED2938CB"><enum>(1)</enum><header>In general</header><text>All eligible persons living in or near the specified service area of a CHSO are eligible to enroll in the organization; except that the number of enrollees may be limited to avoid overtaxing the resources of the organization.</text></paragraph> <paragraph id="HFED3D6FA0DC7497D9006932EF0075D8"><enum>(2)</enum><header>Minimum enrollment period</header><text>Subject to paragraph (3), the minimum period of enrollment with a CHSO shall be twelve months, unless the enrolled individual becomes ineligible to enroll with the organization.</text></paragraph> <paragraph id="H9869C1D908054CE394E8A4AED5507EB1"><enum>(3)</enum><header>Withdrawal for cause</header><text>Each CHSO shall permit an enrolled individual to disenroll from the organization for cause at any time.</text></paragraph></subsection> <subsection id="HAEA94015CC2C437ABCABB1C7F30949F6"><enum>(c)</enum><header>Requirements for CHSOs</header> <paragraph id="HFDAB5028B31F4DAB91D83F1FDEDA9390"><enum>(1)</enum><header>Accessible services</header><text>Each CHSO, to the maximum extent feasible, shall make all services readily and promptly accessible to enrollees who live in the specified service area.</text></paragraph> <paragraph id="HC6211ED75D044A67B55F00558EC776B3"><enum>(2)</enum><header>Continuity of care</header><text>Each CHSO shall furnish services in such manner as to provide continuity of care and (when services are furnished by different providers) shall provide ready referral of patients to such services and at such times as may be medically appropriate.</text></paragraph> <paragraph id="H8C7F1909919F4CCFB9942601527EFD92"><enum>(3)</enum><header>Board of directors</header><text>In the case of a CHSO that is a private organization—</text> <subparagraph id="H4F34F1DE84214BC092ED1517D3DFC233"><enum>(A)</enum><header>Consumer representation</header><text>At least one-third of the members of the CHSO’s board of directors must be consumer members with no direct or indirect, personal or family financial relationship to the organization.</text></subparagraph> <subparagraph id="H587CA66960204D7F9456F6E55051C2F7"><enum>(B)</enum><header>Provider representation</header><text>The CHSO’s board of directors must include at least one member who represents health care providers.</text></subparagraph></paragraph> <paragraph id="H3035DCAF8AC24E5DA630324D5132946D"><enum>(4)</enum><header>Patient grievance program</header><text>Each CHSO must have in effect a patient grievance program and must conduct regularly surveys of the satisfaction of members with services provided by or through the organization.</text></paragraph> <paragraph id="H9D2C8548552E4B33A7CFF479E1929388"><enum>(5)</enum><header>Medical standards</header><text>Each CHSO must provide that a committee or committees of health care practitioners associated with the organization will promulgate medical standards, oversee the professional aspects of the delivery of care, perform the functions of a pharmacy and drug therapeutics committee, and monitor and review the quality of all health services (including drugs, education, and preventive services).</text></paragraph> <paragraph id="H72D2C8AC32634D0FBCA0F40000D5A51B"><enum>(6)</enum><header>Premiums</header><text>Premiums or other charges by a CHSO for any services not paid for under this Act must be reasonable.</text></paragraph> <paragraph id="H59D241EC5035423D88B800241EECC23E"><enum>(7)</enum><header>Utilization and bonus information</header><text>Each CHSO must—</text> <subparagraph id="HDEB493C717E3483993CD24262C87D0E3"><enum>(A)</enum><text>comply with the requirements of section 1876(i)(8) of the <act-name parsable-cite="SSA">Social Security Act</act-name> (relating to prohibiting physician incentive plans that provide specific inducements to reduce or limit medically necessary services); and</text></subparagraph> <subparagraph id="HDFE84D06915D4EA1BCB8A96170015F9C"><enum>(B)</enum><text>make available to its membership utilization information and data regarding financial performance, including bonus or incentive payment arrangements to practitioners.</text></subparagraph></paragraph> <paragraph id="H2E4B2FBC9B9446738BB9085F448F73C6"><enum>(8)</enum><header>Provision of services to enrollees at institutions operating under global budgets</header><text>The organization shall arrange to reimburse for hospital services and other facility-based services (as identified by the Board) for services provided to members of the organization in accordance with the global operating budget of the hospital or facility approved under section 611.</text></paragraph> <paragraph id="H19E65E9B0E6D4D8DA8AF69C785719C6C"><enum>(9)</enum><header>Broad marketing</header><text>Each CHSO must provide for the marketing of its services (including dissemination of marketing materials) to potential enrollees in a manner that is designed to enroll individuals representative of the different population groups and geographic areas included within its service area and meets such requirements as the Board or a State health security program may specify.</text></paragraph> <paragraph id="H9139CBE681A54916ABC6A5C99D58F4B7"><enum>(10)</enum><header>Additional requirements</header><text>Each CHSO must meet—</text> <subparagraph id="HBD6B0AEC7D344573AD4144CD9F7BD190"><enum>(A)</enum><text>such requirements relating to minimum enrollment;</text></subparagraph> <subparagraph id="H2873A0CCFFAC42C8AC953E94BCF54005"><enum>(B)</enum><text>such requirements relating to financial solvency;</text></subparagraph> <subparagraph id="HE605B49D14D34856980471458B62194E"><enum>(C)</enum><text>such requirements relating to quality and availability of care; and</text></subparagraph> <subparagraph id="H08E85E614D304AE8A032EEF178FE6EF4"><enum>(D)</enum><text>such other requirements,</text></subparagraph><continuation-text continuation-text-level="paragraph">as the Board or a State health security program may specify.</continuation-text></paragraph></subsection> <subsection id="H3D61861CBABC4F5B9D12C37D1FEEA570"><enum>(d)</enum><header>Provision of emergency services to nonenrollees</header><text>A CHSO may furnish emergency services to persons who are not enrolled in the organization. Payment for such services, if they are covered services to eligible persons, shall be made to the organization unless the organization requests that it be made to the individual provider who furnished the services.</text></subsection></section> <section id="H980D1FC7684B476A851693488076C1A9"><enum>304.</enum><header>Limitation on certain physician referrals</header> <subsection id="H4ABA9F3B064E4C95AAF041393BDEF1E"><enum>(a)</enum><header>Application to American Health Security Program</header><text>Section 1877 of the <act-name parsable-cite="SSA">Social Security Act</act-name>, as amended by subsections (b) and (c), shall apply under this Act in the same manner as it applies under title XVIII of the <act-name parsable-cite="SSA">Social Security Act</act-name>; except that in applying such section under this Act any references in such section to the Secretary or title XVIII of the <act-name parsable-cite="SSA">Social Security Act</act-name> are deemed references to the Board and the American Health Security Program under this Act, respectively.</text></subsection> <subsection id="HCB2C4290F1504FA2A4216DFF4CF26FA9"><enum>(b)</enum><header>Expansion of prohibition to certain additional designated services</header><text>Section 1877(h)(6) of the <act-name parsable-cite="SSA">Social Security Act</act-name> (<external-xref legal-doc="usc" parsable-cite="usc/42/1395nn">42 U.S.C. 1395nn(h)(6)</external-xref>) is amended by adding at the end the following:</text> <quoted-block act-name="Social Security Act" id="H8E1C1C834CF24868B0EB11A367D7DA02"> <subparagraph id="H31A0937341284DAA8D62C3AB1E8968F4"><enum>(L)</enum><text>Ambulance services.</text></subparagraph> <subparagraph id="H3CDA78FE40E54584AC05224BF1A5CD75"><enum>(M)</enum><text>Home infusion therapy services.</text></subparagraph><after-quoted-block>.</after-quoted-block></quoted-block></subsection> <subsection id="H3CAEF19B349546E19D60062C2D04AD9F"><enum>(c)</enum><header>Conforming amendments</header><text>Section 1877 of such Act is further amended—</text> <paragraph id="HFD677B7C5474460187C76BA597F05370"><enum>(1)</enum><text>in subsection (a)(1)(A), by striking <quote>for which payment otherwise may be made under this title</quote> and inserting <quote>for which a charge is imposed</quote>;</text></paragraph> <paragraph id="H76A38B164AFD4394A7247C949D00BB64"><enum>(2)</enum><text>in subsection (a)(1)(B), by striking <quote>under this title</quote>;</text></paragraph> <paragraph id="HF9F960A9B5AD4FD0865BB2EFCA509449"><enum>(3)</enum><text>by amending paragraph (1) of subsection (g) to read as follows:</text> <quoted-block id="H7AA7F6FD3BE24E7A9C90A559439649B9"> <paragraph id="H5303B6EC364F41F5007708D80061653B"><enum>(1)</enum><header>Denial of payment</header><text>No payment may be made under a State health security program for a designated health service for which a claim is presented in violation of subsection (a)(1)(B). No individual, third party payor, or other entity is liable for payment for designated health services for which a claim is presented in violation of such subsection.</text></paragraph><after-quoted-block>; and</after-quoted-block></quoted-block></paragraph> <paragraph id="H62747DDA72E445508FE3A32C4863973"><enum>(4)</enum><text>in subsection (g)(3), by striking <quote>for which payment may not be made under paragraph (1)</quote> and inserting <quote>for which such a claim may not be presented under subsection (a)(1)</quote>.</text></paragraph></subsection></section> <enum>IV</enum><header>Administration</header> <subtitle id="H33948D0871684CA4B2F8A7E8BE33FE3"><enum>A</enum><header>General administrative provisions</header> <section id="H56B53866F52A4F0495C4003CC41EDD2D"><enum>401.</enum><header>American Health Security Standards Board</header> <subsection id="HE38FF450D8AA40F0BED54D1B445BE14"><enum>(a)</enum><header>Establishment</header><text>There is hereby established an American Health Security Standards Board.</text></subsection> <subsection id="HC46508FE8A8146A4AE053833D10058CA"><enum>(b)</enum><header>Appointment and terms of members</header> <paragraph id="HEFD6B147E55E46A1BB07F686B39E22C7"><enum>(1)</enum><header>In general</header><text>The Board shall be composed of—</text> <subparagraph id="H9ED9BD07303144A4B9A83DA8B6257726"><enum>(A)</enum><text>the Secretary of Health and Human Services; and</text></subparagraph> <subparagraph id="HF0DE7D4890314108A6823E5CD28F0053"><enum>(B)</enum><text>6 other individuals (described in paragraph (2)) appointed by the President with the advice and consent of the Senate.</text></subparagraph><continuation-text continuation-text-level="paragraph">The President shall first nominate individuals under subparagraph (B) on a timely basis so as to provide for the operation of the Board by not later than January 1, 2006.</continuation-text></paragraph> <paragraph id="HE42DF3423FEE4393A1B2A5D792F8BBE8"><enum>(2)</enum><header>Selection of appointed members</header><text>With respect to the individuals appointed under paragraph (1)(B):</text> <subparagraph id="HC327AF7A984247499563E3D735452BB1"><enum>(A)</enum><text>They shall be chosen on the basis of backgrounds in health policy, health economics, the healing professions, and the administration of health care institutions.</text></subparagraph> <subparagraph id="HDFD0FCD9DABB482CB6572094E764348B"><enum>(B)</enum><text>They shall provide a balanced point of view with respect to the various health care interests and at least 2 of them shall represent the interests of individual consumers.</text></subparagraph> <subparagraph id="H0010127A2DBA4C6A8D17EFE976851F8"><enum>(C)</enum><text>Not more than 3 of them shall be from the same political party.</text></subparagraph> <subparagraph id="HDD045BDE5F5E41639F8711379ECDBC9C"><enum>(D)</enum><text>To the greatest extent feasible, they shall represent the various geographic regions of the United States and shall reflect the racial, ethnic, and gender composition of the population of the United States.</text></subparagraph></paragraph> <paragraph id="HF392E206C3EE4E2AAF00D68B334039D9"><enum>(3)</enum><header>Terms of appointed members</header><text>Individuals appointed under paragraph (1)(B) shall serve for a term of 6 years, except that the terms of 5 of the individuals initially appointed shall be, as designated by the President at the time of their appointment, for 1, 2, 3, 4, and 5 years. During a term of membership on the Board, no member shall engage in any other business, vocation or employment.</text></paragraph></subsection> <subsection id="HD4A028EFC3314FAF9C578664CCB0EE2E"><enum>(c)</enum><header>Vacancies</header> <paragraph id="H115234AF05284B2AA7F55E69CBE9C33F"><enum>(1)</enum><header>In general</header><text>The President shall fill any vacancy in the membership of the Board in the same manner as the original appointment. The vacancy shall not affect the power of the remaining members to execute the duties of the Board.</text></paragraph> <paragraph id="HC89EA6A4BF7D45A7B4AA9000230717C1"><enum>(2)</enum><header>Vacancy appointments</header><text>Any member appointed to fill a vacancy shall serve for the remainder of the term for which the predecessor of the member was appointed.</text></paragraph> <paragraph id="H4735F0D3681F4ADFAD00A948E55B0145"><enum>(3)</enum><header>Reappointment</header><text>The President may reappoint an appointed member of the Board for a second term in the same manner as the original appointment. A member who has served for 2 consecutive 6-year terms shall not be eligible for reappointment until 2 years after the member has ceased to serve.</text></paragraph> <paragraph id="H4679AF1902E54982B38B3950274BBF85"><enum>(4)</enum><header>Removal for cause</header><text>Upon confirmation, members of the Board may not be removed except by the President for cause.</text></paragraph></subsection> <subsection id="H35D0D7035FEB474D87E62C2E643C6926"><enum>(d)</enum><header>Chair</header><text>The President shall designate 1 of the members of the Board, other than the Secretary, to serve at the will of the President as Chair of the Board.</text></subsection> <subsection id="HBFF94E9B746A491DBAEF4152662D6730"><enum>(e)</enum><header>Compensation</header><text>Members of the Board (other than the Secretary) shall be entitled to compensation at a level equivalent to level II of the Executive Schedule, in accordance with <external-xref legal-doc="usc" parsable-cite="usc/5/5313">section 5313</external-xref> of title 5, United States Code.</text></subsection> <subsection id="H460DBE60014A4C338B40941191CCABB0"><enum>(f)</enum><header>General duties of the Board</header> <paragraph id="H9D699C3D41A9456B9D57583875CCFCE6"><enum>(1)</enum><header>In general</header><text>The Board shall develop policies, procedures, guidelines, and requirements to carry out this Act, including those related to—</text> <subparagraph id="H3B3E73BE18A34EBD84C0E06EB6C3F58"><enum>(A)</enum><text>eligibility;</text></subparagraph> <subparagraph id="H373B9A4972BA4F83B5E208B458F83200"><enum>(B)</enum><text>enrollment;</text></subparagraph> <subparagraph id="HDB0179B2260A427C00E6E3FDBAE7D988"><enum>(C)</enum><text>benefits;</text></subparagraph> <subparagraph id="HF00456896D724AF59C2DE2A42B88AF96"><enum>(D)</enum><text>provider participation standards and qualifications, as defined in title III;</text></subparagraph> <subparagraph id="H8E02F46D7D6343779EB0713670CA5D99"><enum>(E)</enum><text>national and State funding levels;</text></subparagraph> <subparagraph id="HF95B422CEDFC4CA5A78379003BE19D5"><enum>(F)</enum><text>methods for determining amounts of payments to providers of covered services, consistent with subtitle B of title VI;</text></subparagraph> <subparagraph id="H2AC8230945D84466ADD6A94E883D2EE6"><enum>(G)</enum><text>the determination of medical necessity and appropriateness with respect to coverage of certain services;</text></subparagraph> <subparagraph id="HBFF381D83505480DA4DB68A3A9009429"><enum>(H)</enum><text>assisting State health security programs with planning for capital expenditures and service delivery;</text></subparagraph> <subparagraph id="HFFF3893A7A3D42FC9641D89D089777D0"><enum>(I)</enum><text>planning for health professional education funding (as specified in title VI);</text></subparagraph> <subparagraph id="H7D76610C4FC049F79411E64300240091"><enum>(J)</enum><text>allocating funds provided under title VII; and</text></subparagraph> <subparagraph id="H5DA803C757024206B3D19565764D4D4"><enum>(K)</enum><text>encouraging States to develop regional planning mechanisms (described in section 404(a)(3)).</text></subparagraph></paragraph> <paragraph id="H0F5FEC06A5004216BFBF8475AE549047"><enum>(2)</enum><header>Regulations</header><text>Regulations authorized by this Act shall be issued by the Board in accordance with the provisions of <external-xref legal-doc="usc" parsable-cite="usc/5/553">section 553</external-xref> of title 5, United States Code.</text></paragraph></subsection> <subsection id="H3FB4E830F91E4E3FBDD9F2F958BBD1F"><enum>(g)</enum><header>Uniform reporting standards; annual report; studies</header> <paragraph id="HA2365FD911164C0AA1A371E3D1155B00"><enum>(1)</enum><header>Uniform reporting standards</header> <subparagraph id="HF853ED5CEE8A40C20030FC2458D5FA5"><enum>(A)</enum><header>In general</header><text>The Board shall establish uniform reporting requirements and standards to ensure an adequate national data base regarding health services practitioners, services and finances of State health security programs, approved plans, providers, and the costs of facilities and practitioners providing services. Such standards shall include, to the maximum extent feasible, health outcome measures.</text></subparagraph> <subparagraph id="H080B783F041A4B1200D79B203B44D0A4"><enum>(B)</enum><header>Reports</header><text>The Board shall analyze regularly information reported to it, and to State health security programs pursuant to such requirements and standards.</text></subparagraph></paragraph> <paragraph id="H44462F1CB4C048AB8DD43153B7E637CD"><enum>(2)</enum><header>Annual report</header><text>Beginning January 1, of the second year beginning after the date of the enactment of this Act, the Board shall annually report to Congress on the following:</text> <subparagraph id="HAE005D2307E04FEDBC78727931E8BAD5"><enum>(A)</enum><text>The status of implementation of the Act.</text></subparagraph> <subparagraph id="HF06A6CBFC8FC4E978E591C26EC4CCADD"><enum>(B)</enum><text>Enrollment under this Act.</text></subparagraph> <subparagraph id="HEC05530D0CF840609500E5EEE686983B"><enum>(C)</enum><text>Benefits under this Act.</text></subparagraph> <subparagraph id="H8A943242FB9B434FB55DB86120673314"><enum>(D)</enum><text>Expenditures and financing under this Act.</text></subparagraph> <subparagraph id="HE08C494BE4BC4029AF334BA2F656522E"><enum>(E)</enum><text>Cost-containment measures and achievements under this Act.</text></subparagraph> <subparagraph id="HB1AF039ED3FC4A4CB3FC3556FF5300D6"><enum>(F)</enum><text>Quality assurance.</text></subparagraph> <subparagraph id="HC73B53C9AD744D69A39BF231866200B1"><enum>(G)</enum><text>Health care utilization patterns, including any changes attributable to the program.</text></subparagraph> <subparagraph id="H91511527F0C54B5BBA8F1EAE7C54FA50"><enum>(H)</enum><text>Long-range plans and goals for the delivery of health services.</text></subparagraph> <subparagraph id="H4022FEF672F040539D2D61958DA6B300"><enum>(I)</enum><text>Differences in the health status of the populations of the different States, including income and racial characteristics.</text></subparagraph> <subparagraph id="HDA8E1C57403E43B09E297723C9C6E7BF"><enum>(J)</enum><text>Necessary changes in the education of health personnel.</text></subparagraph> <subparagraph id="H30DDEBA6178B44FE98206118B1D5E2D3"><enum>(K)</enum><text>Plans for improving service to medically underserved populations.</text></subparagraph> <subparagraph id="H6E6A58335C78464DBC886FBB186600AC"><enum>(L)</enum><text>Transition problems as a result of implementation of this Act.</text></subparagraph> <subparagraph id="H5357CBC2CA674F6F9989CFABD49DEB6F"><enum>(M)</enum><text>Opportunities for improvements under this Act.</text></subparagraph></paragraph> <paragraph id="HCF2C90EE900E418400E8A989A2DE5EDE"><enum>(3)</enum><header>Statistical analyses and other studies</header><text>The Board may, either directly or by contract—</text> <subparagraph id="H9B585F3CAB70477FAC8101ECEC4E1C3"><enum>(A)</enum><text>make statistical and other studies, on a nationwide, regional, state, or local basis, of any aspect of the operation of this Act, including studies of the effect of the Act upon the health of the people of the United States and the effect of comprehensive health services upon the health of persons receiving such services;</text></subparagraph> <subparagraph id="H0F400059D8F2473A8878002E9CFE369F"><enum>(B)</enum><text>develop and test methods of providing through payment for services or otherwise, additional incentives for adherence by providers to standards of adequacy, access, and quality; methods of consumer and peer review and peer control of the utilization of drugs, of laboratory services, and of other services; and methods of consumer and peer review of the quality of services;</text></subparagraph> <subparagraph id="H31387CAB449949F3834B62E4A2B59635"><enum>(C)</enum><text>develop and test, for use by the Board, records and information retrieval systems and budget systems for health services administration, and develop and test model systems for use by providers of services;</text></subparagraph> <subparagraph id="H6220ADF1D07C49730043EB8E899C3CA9"><enum>(D)</enum><text>develop and test, for use by providers of services, records and information retrieval systems useful in the furnishing of preventive or diagnostic services;</text></subparagraph> <subparagraph id="HAC0D6FFCCC0E41D1903CF263949D9CFD"><enum>(E)</enum><text>develop, in collaboration with the pharmaceutical profession, and test, improved administrative practices or improved methods for the reimbursement of independent pharmacies for the cost of furnishing drugs as a covered service; and</text></subparagraph> <subparagraph id="HA674C09214B041D7AD2FA14E7CE2FD00"><enum>(F)</enum><text>make such other studies as it may consider necessary or promising for the evaluation, or for the improvement, of the operation of this Act.</text></subparagraph></paragraph> <paragraph id="H1915A54937A34FBDA19E3945E8C1B2F1"><enum>(4)</enum><header>Report on use of existing Federal health care facilities</header><text>Not later than 1 year after the date of the enactment of this Act, the Board shall recommend to the Congress one or more proposals for the treatment of health care facilities of the Federal Government.</text></paragraph></subsection> <subsection id="H48BD0967D90E4B57B86EC9097C50D2CB"><enum>(h)</enum><header>Executive Director</header> <paragraph id="H2F4510E792EA4CAC8FE2AE791FB036DE"><enum>(1)</enum><header>Appointment</header><text>There is hereby established the position of Executive Director of the Board. The Director shall be appointed by the Board and shall serve as secretary to the Board and perform such duties in the administration of this title as the Board may assign.</text></paragraph> <paragraph id="H2502D593606742988B965968ECFC846F"><enum>(2)</enum><header>Delegation</header><text>The Board is authorized to delegate to the Director or to any other officer or employee of the Board or, with the approval of the Secretary of Health and Human Services (and subject to reimbursement of identifiable costs), to any other officer or employee of the Department of Health and Human Services, any of its functions or duties under this Act other than—</text> <subparagraph id="H5D943BFA0CAA4A909E963887117FBB5B"><enum>(A)</enum><text>the issuance of regulations; or</text></subparagraph> <subparagraph id="HD2E01A5585A14296BFE767E903DBD604"><enum>(B)</enum><text>the determination of the availability of funds and their allocation to implement this Act.</text></subparagraph></paragraph> <paragraph id="HC29B4BE5328C429A841F3B00C9D6631E"><enum>(3)</enum><header>Compensation</header><text>The Executive Director of the Board shall be entitled to compensation at a level equivalent to level III of the Executive Schedule, in accordance with <external-xref legal-doc="usc" parsable-cite="usc/5/5314">section 5314</external-xref> of title 5, United States Code.</text></paragraph></subsection> <subsection id="H52ACC3B5B67C4E3BAB956FAF13996419"><enum>(i)</enum><header>Inspector General</header><text>The Inspector General Act of 1978 (5 U.S.C. App.) is amended—</text> <paragraph id="HF50915B2B3014D49AD0400B04EB59EA"><enum>(1)</enum><text>in section 11(1), by inserting after <quote>Corporation;</quote> the first place it appears the following: <quote>the Chair of the American Health Security Standards Board;</quote>;</text></paragraph> <paragraph id="HB43BCC1743474C9CB394CCA2EF34044E"><enum>(2)</enum><text>in section 11(2), by inserting after <quote>Resolution Trust Corporation,</quote> the following: <quote>the American Health Security Standards Board,</quote>; and</text></paragraph> <paragraph id="HA3147BF7B1BF4E8CAA1B27DFA9638E1F"><enum>(3)</enum><text>by inserting before section 9 the following:</text> <quoted-block style="traditional" id="H01AB7D4B3AF14FDAB68DB96050CEA200"> <section id="H6423C29F038544B48C6DC8F58E13B89D" display-inline="no-display-inline"><enum>8L.</enum><header>Special provisions concerning American Health Security Standards Board</header><text display-inline="yes-display-inline">The Inspector General of the American Health Security Standards Board, in addition to the other authorities vested by this Act, shall have the same authority, with respect to the Board and the American Health Security Program under this Act, as the Inspector General for the Department of Health and Human Services has with respect to the Secretary of Health and Human Services and the medicare and medicaid programs, respectively.</text></section><after-quoted-block>.</after-quoted-block></quoted-block></paragraph></subsection> <subsection id="H0051536F60904FCFB2CC70F45DC3527D"><enum>(j)</enum><header>Staff</header><text>The Board shall employ such staff as the Board may deem necessary.</text></subsection> <subsection id="H31AEC8D1612F483C9BE2EA2CA3EBB1F4"><enum>(k)</enum><header>Access to information</header><text>The Secretary of Health and Human Services shall make available to the Board all information available from sources within the Department or from other sources, pertaining to the duties of the Board.</text></subsection></section> <section id="HB9D62723388B4D2194001DAF340403F5"><enum>402.</enum><header>American Health Security Advisory Council</header> <subsection id="H5608FCA66D0442D5BC879DF8E309FE02"><enum>(a)</enum><header>In general</header><text>The Board shall provide for an American Health Security Advisory Council (in this section referred to as the <quote>Council</quote>) to advise the Board on its activities.</text></subsection> <subsection id="H40291B54C68246D6A1E07003A8A41388"><enum>(b)</enum><header>Membership</header><text>The Council shall be composed of—</text> <paragraph id="HB6E253DA5AD5485D81E879BE4C4D1880"><enum>(1)</enum><text>the Chair of the Board, who shall serve as Chair of the Council; and</text></paragraph> <paragraph id="HF28E1094D794456ABB99D5742BA33020"><enum>(2)</enum><text>twenty members, not otherwise in the employ of the United States, appointed by the Board without regard to the provisions of title 5, United States Code, governing appointments in the competitive service.</text></paragraph><continuation-text continuation-text-level="subsection">The appointed members shall include, in accordance with subsection (e), individuals who are representative of State health security programs, public health professionals, providers of health services, and of individuals (who shall constitute a majority of the Council) who are representative of consumers of such services, including a balanced representation of employers, unions, consumer organizations, and population groups with special health care needs. To the greatest extent feasible, the membership of the Council shall represent the various geographic regions of the United States and shall reflect the racial, ethnic, and gender composition of the population of the United States.</continuation-text></subsection> <subsection id="H865D227421B04BD8BA7E3EB8C5007142"><enum>(c)</enum><header>Terms of members</header><text>Each appointed member shall hold office for a term of 4 years, except that—</text> <paragraph id="H21B9AAD1E4AD49F7A761F06D6F2EACE"><enum>(1)</enum><text>any member appointed to fill a vacancy occurring during the term for which the member’s predecessor was appointed shall be appointed for the remainder of that term; and</text></paragraph> <paragraph id="HB54454C5DF13459A9189F850569337CF"><enum>(2)</enum><text>the terms of the members first taking office shall expire, as designated by the Board at the time of appointment, 5 at the end of the first year, 5 at the end of the second year, 5 at the end of the third year, and 5 at the end of the fourth year after the date of enactment of this Act.</text></paragraph></subsection> <subsection id="H558CECDFD7434A198799B709DFA6826E"><enum>(d)</enum><header>Vacancies</header> <paragraph id="HCCE828CB2C56489DB448AFFD89037C08"><enum>(1)</enum><header>In general</header><text>The Board shall fill any vacancy in the membership of the Council in the same manner as the original appointment. The vacancy shall not affect the power of the remaining members to execute the duties of the Council.</text></paragraph> <paragraph id="H04718075AEF643358C3CA57F342F685F"><enum>(2)</enum><header>Vacancy appointments</header><text>Any member appointed to fill a vacancy shall serve for the remainder of the term for which the predecessor of the member was appointed.</text></paragraph> <paragraph id="H5C49CF21DE0E44ABA374731331545B06"><enum>(3)</enum><header>Reappointment</header><text>The Board may reappoint an appointed member of the Council for a second term in the same manner as the original appointment.</text></paragraph></subsection> <subsection id="HB8A3C59FFC1343D4B4D258DE70B3AD10"><enum>(e)</enum><header>Qualifications</header> <paragraph id="HBD9BC3A2F4034517A8E413358778D2FF"><enum>(1)</enum><header>Public health representatives</header><text>Members of the Council who are representative of State health security programs and public health professionals shall be individuals who have extensive experience in the financing and delivery of care under public health programs.</text></paragraph> <paragraph id="H55B4BB5BB5C94C4100121D02A0A50070"><enum>(2)</enum><header>Providers</header><text>Members of the Council who are representative of providers of health care shall be individuals who are outstanding in fields related to medical, hospital, or other health activities, or who are representative of organizations or associations of professional health practitioners.</text></paragraph> <paragraph id="HE7E31896B650401F89A44FFB374BE1C0"><enum>(3)</enum><header>Consumers</header><text>Members who are representative of consumers of such care shall be individuals, not engaged in and having no financial interest in the furnishing of health services, who are familiar with the needs of various segments of the population for personal health services and are experienced in dealing with problems associated with the consumption of such services.</text></paragraph></subsection> <subsection id="H6D312604F06B454C8C95A14ED8FE2B46"><enum>(f)</enum><header>Duties</header> <paragraph id="H701143E7E468486B91BE0037A9C626E6"><enum>(1)</enum><header>In general</header><text>It shall be the duty of the Council—</text> <subparagraph id="H68C30460C5ED419CBFECBC5D6CD8B72"><enum>(A)</enum><text>to advise the Board on matters of general policy in the administration of this Act, in the formulation of regulations, and in the performance of the Board’s duties under section 401; and</text></subparagraph> <subparagraph id="H2704B53341F541EA9CCCC4C786555BA"><enum>(B)</enum><text>to study the operation of this Act and the utilization of health services under it, with a view to recommending any changes in the administration of the Act or in its provisions which may appear desirable.</text></subparagraph></paragraph> <paragraph id="H0E6E023891014484B6EFF861F69BA8D"><enum>(2)</enum><header>Report</header><text>The Council shall make an annual report to the Board on the performance of its functions, including any recommendations it may have with respect thereto, and the Board shall promptly transmit the report to the Congress, together with a report by the Board on any recommendations of the Council that have not been followed.</text></paragraph></subsection> <subsection id="H7BDDE22362554F4D89D38EA670007248"><enum>(g)</enum><header>Staff</header><text>The Council, its members, and any committees of the Council shall be provided with such secretarial, clerical, or other assistance as may be authorized by the Board for carrying out their respective functions.</text></subsection> <subsection id="H350E81EE528A42249B29E7C1BC0177F6"><enum>(h)</enum><header>Meetings</header><text>The Council shall meet as frequently as the Board deems necessary, but not less than 4 times each year. Upon request by 7 or more members it shall be the duty of the Chair to call a meeting of the Council.</text></subsection> <subsection id="H87BDE8FCBCC24DB18D5787FA58B69BF0"><enum>(i)</enum><header>Compensation</header><text>Members of the Council shall be reimbursed by the Board for travel and per diem in lieu of subsistence expenses during the performance of duties of the Board in accordance with subchapter I of <external-xref legal-doc="usc-chapter" parsable-cite="usc-chapter/5/57">chapter 57</external-xref> of title 5, United States Code.</text></subsection> <subsection id="H0E86E482D5F941228E83B43F4C6F43A0"><enum>(j)</enum><header>FACA not applicable</header><text>The provisions of the <act-name parsable-cite="FACA">Federal Advisory Committee Act</act-name> shall not apply to the Council.</text></subsection></section> <section id="HE70C1FD6CBF84349B3CF0011E6DFFD8C"><enum>403.</enum><header>Consultation with private entities</header><text display-inline="no-display-inline">The Secretary and the Board shall consult with private entities, such as professional societies, national associations, nationally recognized associations of experts, medical schools and academic health centers, consumer groups, and labor and business organizations in the formulation of guidelines, regulations, policy initiatives, and information gathering to assure the broadest and most informed input in the administration of this Act. Nothing in this Act shall prevent the Secretary from adopting guidelines developed by such a private entity if, in the Secretary’s and Board’s judgment, such guidelines are generally accepted as reasonable and prudent and consistent with this Act.</text></section> <section id="H336751D677C74080A4E394008C5049BC"><enum>404.</enum><header>State health security programs</header> <subsection id="H37DD627DC5E94994A997259EDB6EE793"><enum>(a)</enum><header>Submission of plans</header> <paragraph id="H1CB6D7424287440AA4319B06A1CF0A"><enum>(1)</enum><header>In general</header><text>Each State shall submit to the Board a plan for a State health security program for providing for health care services to the residents of the State in accordance with this Act.</text></paragraph> <paragraph id="H9C23742BEF8C4C2F9395012625A62B17"><enum>(2)</enum><header>Regional programs</header><text>A State may join with 1 or more neighboring States to submit to the Board a plan for a regional health security program instead of separate State health security programs.</text></paragraph> <paragraph id="HDFD306B94E2E429DAE35F5002B65EC6F"><enum>(3)</enum><header>Regional planning mechanisms</header><text>The Board shall provide incentives for States to develop regional planning mechanisms to promote the rational distribution of, adequate access to, and efficient use of, tertiary care facilities, equipment, and services.</text></paragraph></subsection> <subsection id="H305FD531829E4363AE6E6F68E62E30BE"><enum>(b)</enum><header>Review and approval of plans</header> <paragraph id="H776D8A85F09E45BA9FE5545D5FA76B12"><enum>(1)</enum><header>In general</header><text>The Board shall review plans submitted under subsection (a) and determine whether such plans meet the requirements for approval. The Board shall not approve such a plan unless it finds that the plan (or State law) provides, consistent with the provisions of this Act, for the following:</text> <subparagraph id="HC476E6A4EB6A4325B72150A2F9002962"><enum>(A)</enum><text>Payment for required health services for eligible individuals in the State in accordance with this Act.</text></subparagraph> <subparagraph id="H5AEC5BB7D5AE4ADEBCD8A2009DFD4214"><enum>(B)</enum><text>Adequate administration, including the designation of a single State agency responsible for the administration (or supervision of the administration) of the program.</text></subparagraph> <subparagraph id="H4CBEEE700FE24BE09155283D6FEF4B8F"><enum>(C)</enum><text>The establishment of a State health security budget.</text></subparagraph> <subparagraph id="H0FF716DB49144C4CAF41A1A45D9DCD08"><enum>(D)</enum><text>Establishment of payment methodologies (consistent with subtitle B of title VII).</text></subparagraph> <subparagraph id="H84A95BA03CED411792B5D1E5B857FC93"><enum>(E)</enum><text>Assurances that individuals have the freedom to choose practitioners and other health care providers for services covered under this Act.</text></subparagraph> <subparagraph id="HD63BB27B7B5A4E0BAD212064B12942E1"><enum>(F)</enum><text>A procedure for carrying out long-term regional management and planning functions with respect to the delivery and distribution of health care services that—</text> <clause id="H2EEF566CF907470C99001B3151759EB0"><enum>(i)</enum><text>ensures participation of consumers of health services and providers of health services; and</text></clause> <clause id="HA8FC98FC185E4B2EBCFB3500AC7F1CC8"><enum>(ii)</enum><text>gives priority to the most acute shortages and maldistributions of health personnel and facilities and the most serious deficiencies in the delivery of covered services and to the means for the speedy alleviation of these shortcomings.</text></clause></subparagraph> <subparagraph id="HDABB2CE0D5604F8A8E4998B6288DD6D"><enum>(G)</enum><text>The licensure and regulation of all health providers and facilities to ensure compliance with Federal and State laws and to promote quality of care.</text></subparagraph> <subparagraph id="H1511AA2198FA4C05A3FDFD00E6462661"><enum>(H)</enum><text>Establishment of a quality review system in accordance with section 503.</text></subparagraph> <subparagraph id="HBE36D7A4B18040B99E008C8120986FBE"><enum>(I)</enum><text>Establishment of an independent ombudsman for consumers to register complaints about the organization and administration of the State health security program and to help resolve complaints and disputes between consumers and providers.</text></subparagraph> <subparagraph id="H18228827DF964F6D8B6F68A0FE302F90"><enum>(J)</enum><text>Publication of an annual report on the operation of the State health security program, which report shall include information on cost, progress towards achieving full enrollment, public access to health services, quality review, health outcomes, health professional training, and the needs of medically underserved populations.</text></subparagraph> <subparagraph id="HD5555FA851B84B29BA51435839CA2573"><enum>(K)</enum><text>Provision of a fraud and abuse prevention and control unit that the Inspector General determines meets the requirements of section 412(a).</text></subparagraph> <subparagraph id="H86ABF0ADFD384DC5AA31EEAB1DC0041"><enum>(L)</enum><text>Prohibit payment in cases of prohibited physician referrals under section 304.</text></subparagraph></paragraph> <paragraph id="H4C44739AC044490B9835C8FDED7459EE"><enum>(2)</enum><header>Consequences of failure to comply</header><text>If the Board finds that a State plan submitted under paragraph (1) does not meet the requirements for approval under this section or that a State health security program or specific portion of such program, the plan for which was previously approved, no longer meets such requirements, the Board shall provide notice to the State of such failure and that unless corrective action is taken within a period specified by the Board, the Board shall place the State health security program (or specific portions of such program) in receivership under the jurisdiction of the Board.</text></paragraph></subsection> <subsection id="HEE95113DF046475D8F00F9A5F6C1E413"><enum>(c)</enum><header>State Health Security Advisory Councils</header> <paragraph id="H72D14375FEAB43859270831733AEDE"><enum>(1)</enum><header>In general</header><text>For each State, the Governor shall provide for appointment of a State Health Security Advisory Council to advise and make recommendations to the Governor and State with respect to the implementation of the State health security program in the State.</text></paragraph> <paragraph id="HF37D5CA89A9740398EB739CC00592609"><enum>(2)</enum><header>Membership</header><text>Each State Health Security Advisory Council shall be composed of at least 11 individuals. The appointed members shall include individuals who are representative of the State health security program, public health professionals, providers of health services, and of individuals (who shall constitute a majority) who are representative of consumers of such services, including a balanced representation of employers, unions and consumer organizations. To the greatest extent feasible, the membership of each State Health Security Advisory Council shall represent the various geographic regions of the State and shall reflect the racial, ethnic, and gender composition of the population of the State.</text></paragraph> <paragraph id="H163BDBC6D1A84478AB9B5C912B602C85"><enum>(3)</enum><header>Duties</header> <subparagraph id="H9C40E40F7E234A2E8BFBEBD9A1B61BE"><enum>(A)</enum><header>In general</header><text>Each State Health Security Advisory Council shall review, and submit comments to the Governor concerning the implementation of the State health security program in the State.</text></subparagraph> <subparagraph id="H8FE35CE6993C49FDA4E6D96578F1321C"><enum>(B)</enum><header>Assistance</header><text>Each State Health Security Advisory Council shall provide assistance and technical support to community organizations and public and private non-profit agencies submitting applications for funding under appropriate State and Federal public health programs, with particular emphasis placed on assisting those applicants with broad consumer representation.</text></subparagraph></paragraph></subsection> <subsection id="H9C612EB6B9504991A55D6824F4A39F6E"><enum>(d)</enum><header>State use of fiscal agents</header> <paragraph id="HC86AC5F014DC4A16A39F3B30E79D1D7B"><enum>(1)</enum><header>In general</header><text>Each State health security program, using competitive bidding procedures, may enter into such contracts with qualified entities, such as voluntary associations, as the State determines to be appropriate to process claims and to perform other related functions of fiscal agents under the State health security program.</text></paragraph> <paragraph id="HDF51CAEF106D40AEA682F96245BC269C"><enum>(2)</enum><header>Restriction</header><text>Except as the Board may provide for good cause shown, in no case may more than 1 contract described in paragraph (1) be entered into under a State health security program.</text></paragraph></subsection></section> <section id="H91A797057AC54D1EA8C2E196ACAE8B25"><enum>405.</enum><header>Complementary conduct of related health programs</header><text display-inline="no-display-inline">In performing functions with respect to health personnel education and training, health research, environmental health, disability insurance, vocational rehabilitation, the regulation of food and drugs, and all other matters pertaining to health, the Secretary of Health and Human Services shall direct all activities of the Department of Health and Human Services toward contributions to the health of the people complementary to this Act.</text></section></subtitle> <subtitle id="H599DC470175849B58228295C9855A4CB"><enum>B</enum><header>Control over fraud and abuse</header> <section id="HEBE008D82C89443EA6C66B2298941B44"><enum>411.</enum><header>Application of Federal sanctions to all fraud and abuse under American Health Security Program</header><text display-inline="no-display-inline">The following sections of the <act-name parsable-cite="SSA">Social Security Act</act-name> shall apply to State health security programs in the same manner as they apply to State medical assistance plans under title XIX of such Act (except that in applying such provisions any reference to the Secretary is deemed a reference to the Board):</text> <paragraph id="H25AB91CDF96C4178926800046709B027"><enum>(1)</enum><text>Section 1128 (relating to exclusion of individuals and entities).</text></paragraph> <paragraph id="HF62B4D3A08D448E48E00D4D00DC30FF"><enum>(2)</enum><text>Section 1128A (civil monetary penalties).</text></paragraph> <paragraph id="HFD34255A45E44597B1D15664B0C54D70"><enum>(3)</enum><text>Section 1128B (criminal penalties).</text></paragraph> <paragraph id="HB8B6F761463943D798CB202073683209"><enum>(4)</enum><text>Section 1124 (relating to disclosure of ownership and related information).</text></paragraph> <paragraph id="H426E457A49ED43B9A2841C1127DA5C89"><enum>(5)</enum><text>Section 1126 (relating to disclosure of certain owners).</text></paragraph></section> <section id="H9C18A807908A43ABBAB82177E4FBB41"><enum>412.</enum><header>Requirements for operation of State health care fraud and abuse control units</header> <subsection id="H1D2E66B5FC0B413A9306D6D9966CFF66"><enum>(a)</enum><header>Requirement</header><text>In order to meet the requirement of section 404(b)(1)(K), each State health security program must establish and maintain a health care fraud and abuse control unit (in this section referred to as a <quote>fraud unit</quote>) that meets requirements of this section and other requirements of the Board. Such a unit may be a State medicaid fraud control unit (described in section 1903(q) of the <act-name parsable-cite="SSA">Social Security Act</act-name>).</text></subsection> <subsection id="H018EE02AF53B470CA7CC6B425EC7D054"><enum>(b)</enum><header>Structure of unit</header><text>The fraud unit must—</text> <paragraph id="H1587E6FBB768498787DA3C482C58B0EA"><enum>(1)</enum><text>be a single identifiable entity of the State government;</text></paragraph> <paragraph id="H103FD12FB34D4F6FAC230056A75FE843"><enum>(2)</enum><text>be separate and distinct from the State agency with principal responsibility for the administration of the State health security program; and</text></paragraph> <paragraph id="H9B9C3C4019464113BFD72D705C003E3B"><enum>(3)</enum><text>meet 1 of the following requirements:</text> <subparagraph id="H98DB18A5AC4E473B972DF2FD19330F6"><enum>(A)</enum><text>It must be a unit of the office of the State Attorney General or of another department of State government which possesses statewide authority to prosecute individuals for criminal violations.</text></subparagraph> <subparagraph id="H3D9E928FE6CC48CDBFCE2332C6CE628F"><enum>(B)</enum><text>If it is in a State the constitution of which does not provide for the criminal prosecution of individuals by a statewide authority and has formal procedures, approved by the Board, that—</text> <clause id="HAB1F6959F63D486D93E2C21EDEC1CEA0"><enum>(i)</enum><text>assure its referral of suspected criminal violations relating to the State health insurance plan to the appropriate authority or authorities in the States for prosecution; and</text></clause> <clause id="HAE562FEDB60F47B3B35DF7943044B51F"><enum>(ii)</enum><text>assure its assistance of, and coordination with, such authority or authorities in such prosecutions.</text></clause></subparagraph> <subparagraph id="H186C837B2F934A3280922F060754CA8D"><enum>(C)</enum><text>It must have a formal working relationship with the office of the State Attorney General and have formal procedures (including procedures for its referral of suspected criminal violations to such office) which are approved by the Board and which provide effective coordination of activities between the fraud unit and such office with respect to the detection, investigation, and prosecution of suspected criminal violations relating to the State health insurance plan.</text></subparagraph></paragraph></subsection> <subsection id="HFAADCED0B25E4D9D8F098D459C484F6D"><enum>(c)</enum><header>Functions</header><text>The fraud unit must—</text> <paragraph id="H823E198D3050477DB4294DA89D598041"><enum>(1)</enum><text>have the function of conducting a statewide program for the investigation and prosecution of violations of all applicable State laws regarding any and all aspects of fraud in connection with any aspect of the provision of health care services and activities of providers of such services under the State health security program;</text></paragraph> <paragraph id="HBE8098ED46F54B369900897B33D04801"><enum>(2)</enum><text>have procedures for reviewing complaints of the abuse and neglect of patients of providers and facilities that receive payments under the State health security program, and, where appropriate, for acting upon such complaints under the criminal laws of the State or for referring them to other State agencies for action; and</text></paragraph> <paragraph id="HC59FA428EAA042049C63D4C900B0CC04"><enum>(3)</enum><text>provide for the collection, or referral for collection to a single State agency, of overpayments that are made under the State health security program to providers and that are discovered by the fraud unit in carrying out its activities.</text></paragraph></subsection> <subsection id="H478F21040EDD4E3C87A210ED6275B8BF"><enum>(d)</enum><header>Resources</header><text>The fraud unit must—</text> <paragraph id="HD05F094DAACE4F1C9B45379B66B15427"><enum>(1)</enum><text>employ such auditors, attorneys, investigators, and other necessary personnel;</text></paragraph> <paragraph id="H4D4C0AE6911C47C2BFFEEAE57D67D081"><enum>(2)</enum><text>be organized in such a manner; and</text></paragraph> <paragraph id="H1EE70ECFCB13443BBD47CD7CDC5DED31"><enum>(3)</enum><text>provide sufficient resources (as specified by the Board),</text></paragraph><continuation-text continuation-text-level="subsection">as is necessary to promote the effective and efficient conduct of the unit’s activities.</continuation-text></subsection> <subsection id="H2023155915924ED88C40E0AE2FAC2DA5"><enum>(e)</enum><header>Cooperative agreements</header><text>The fraud unit must have cooperative agreements (as specified by the Board) with—</text> <paragraph id="H6DD328AE544341D1AE41268D68C572E8"><enum>(1)</enum><text>similar fraud units in other States;</text></paragraph> <paragraph id="H32174B6A47264BBF8B6D568E08A16F00"><enum>(2)</enum><text>the Inspector General; and</text></paragraph> <paragraph id="HC1CA532FCDE348D29D2112EFC2464F05"><enum>(3)</enum><text>the Attorney General of the United States.</text></paragraph></subsection> <subsection id="H423B26A16FC9449DAB38EACBA4D3C33D"><enum>(f)</enum><header>Reports</header><text>The fraud unit must submit to the Inspector General an application and annual reports containing such information as the Inspector General determines to be necessary to determine whether the unit meets the previous requirements of this section.</text></subsection></section></subtitle> <enum>V</enum><header>Quality assessment</header> <section id="H00C27E2CE09E4C3691239F44E83079E1"><enum>501.</enum><header>American Health Security Quality Council</header> <subsection id="H32AEDA5D7446456CA6C6003EBB27FDD1"><enum>(a)</enum><header>Establishment</header><text>There is hereby established an American Health Security Quality Council (in this title referred to as the <quote>Council</quote>).</text></subsection> <subsection id="H47B94229529E4D309F400200D97BB947"><enum>(b)</enum><header>Duties of the Council</header><text>The Council shall perform the following duties:</text> <paragraph id="H97A4C6182EA84D0798A22C20DEC8AF01"><enum>(1)</enum><header>Practice guidelines</header><text>The Council shall review and evaluate each practice guideline developed under part B of title IX of the <act-name parsable-cite="PHSA">Public Health Service Act</act-name>. The Council shall determine whether the guideline should be recognized as a national practice guideline to be used under section 204(d) for purposes of determining payments under a State health security program.</text></paragraph> <paragraph id="H03669A14F3BB4E71A2A91877E94B4286"><enum>(2)</enum><header>Standards of quality, performance measures, and medical review criteria</header><text>The Council shall review and evaluate each standard of quality, performance measure, and medical review criterion developed under part B of title IX of the <act-name parsable-cite="PHSA">Public Health Service Act</act-name>. The Council shall determine whether the standard, measure, or criterion is appropriate for use in assessing or reviewing the quality of services provided by State health security programs, health care institutions, or health care professionals.</text></paragraph> <paragraph id="H4BC878A585334D9B895033D8A24595C5"><enum>(3)</enum><header>Criteria for entities conducting quality reviews</header><text>The Council shall develop minimum criteria for competence for entities that can qualify to conduct ongoing and continuous external quality review for State quality review programs under section 503. Such criteria shall require such an entity to be administratively independent of the individual or board that administers the State health security program and shall ensure that such entities do not provide financial incentives to reviewers to favor one pattern of practice over another. The Council shall ensure coordination and reporting by such entities to assure national consistency in quality standards.</text></paragraph> <paragraph id="H12A812B6E2D2482485E1BE6CA75E5C"><enum>(4)</enum><header>Reporting</header><text>The Council shall report to the Board annually on the conduct of activities under such title and shall report to the Board annually specifically on findings from outcomes research and development of practice guidelines that may affect the Board’s determination of coverage of services under section 401(f)(1)(G).</text></paragraph> <paragraph id="H0C4243E1F7CC413F8C616B8897A7A800"><enum>(5)</enum><header>Other functions</header><text>The Council shall perform the functions of the Council described in section 502.</text></paragraph></subsection> <subsection id="H2964CBB92FBB4B318165CD66E46B02A2"><enum>(c)</enum><header>Appointment and terms of members</header> <paragraph id="H1F758D3A326042F59825C583097287B2"><enum>(1)</enum><header>In general</header><text>The Council shall be composed of 10 members appointed by the President. The President shall first appoint individuals on a timely basis so as to provide for the operation of the Council by not later than January 1, 2006.</text></paragraph> <paragraph id="HA73460F42C7341CB934E34EB2C55B745"><enum>(2)</enum><header>Selection of members</header><text>Each member of the Council shall be a member of a health profession. Five members of the Council shall be physicians. Individuals shall be appointed to the Council on the basis of national reputations for clinical and academic excellence. To the greatest extent feasible, the membership of the Council shall represent the various geographic regions of the United States and shall reflect the racial, ethnic, and gender composition of the population of the United States.</text></paragraph> <paragraph id="H9F14EC44F956499D9D01EE9135DD82B6"><enum>(3)</enum><header>Terms of members</header><text>Individuals appointed to the Council shall serve for a term of 5 years, except that the terms of 4 of the individuals initially appointed shall be, as designated by the President at the time of their appointment, for 1, 2, 3, and 4 years.</text></paragraph></subsection> <subsection id="H719B01B831584A2C97D7000023AAA6D3"><enum>(d)</enum><header>Vacancies</header> <paragraph id="H654B5F4D5DDA47CEB5F97DCDB1021F8"><enum>(1)</enum><header>In general</header><text>The President shall fill any vacancy in the membership of the Council in the same manner as the original appointment. The vacancy shall not affect the power of the remaining members to execute the duties of the Council.</text></paragraph> <paragraph id="HC95DC602014A43FBBF07D1564DBC8861"><enum>(2)</enum><header>Vacancy appointments</header><text>Any member appointed to fill a vacancy shall serve for the remainder of the term for which the predecessor of the member was appointed.</text></paragraph> <paragraph id="H8ADAC483510A4C1FBE1BB8D070E6B28F"><enum>(3)</enum><header>Reappointment</header><text>The President may reappoint a member of the Council for a second term in the same manner as the original appointment. A member who has served for 2 consecutive 5-year terms shall not be eligible for reappointment until 2 years after the member has ceased to serve.</text></paragraph></subsection> <subsection id="HE7606C97A93B49A7B9A13718E424B5E"><enum>(e)</enum><header>Chair</header><text>The President shall designate 1 of the members of the Council to serve at the will of the President as Chair of the Council.</text></subsection> <subsection id="H953B091FCB8341518495DB6C35AE004B"><enum>(f)</enum><header>Compensation</header><text>Members of the Council who are not employees of the Federal Government shall be entitled to compensation at a level equivalent to level II of the Executive Schedule, in accordance with <external-xref legal-doc="usc" parsable-cite="usc/5/5313">section 5313</external-xref> of title 5, United States Code.</text></subsection></section> <section id="H0EEC07989EE5419F99F31001204ECE7E"><enum>502.</enum><header>Development of certain methodologies, guidelines, and standards</header> <subsection id="HD101A258780D488996D7FFB445B4DAF8"><enum>(a)</enum><header>Profiling of patterns of practice; identification of outliers</header><text>The Council shall adopt methodologies for profiling the patterns of practice of health care professionals and for identifying outliers (as defined in subsection (e)).</text></subsection> <subsection id="HF7F895D15FFC4568BCEEE3D808997281"><enum>(b)</enum><header>Centers of excellence</header><text>The Council shall develop guidelines for certain medical procedures designated by the Board to be performed only at tertiary care centers which can meet standards for frequency of procedure performance and intensity of support mechanisms that are consistent with the high probability of desired patient outcome. Reimbursement under this Act for such a designated procedure may only be provided if the procedure was performed at a center that meets such standards.</text></subsection> <subsection id="HDA99D54F92384A869E82E9F4433E07DF"><enum>(c)</enum><header>Remedial actions</header><text>The Council shall develop standards for education and sanctions with respect to outliers so as to assure the quality of health care services provided under this Act. The Council shall develop criteria for referral of providers to the State licensing board if education proves ineffective in correcting provider practice behavior.</text></subsection> <subsection id="H659F1DECED5B453C8C28B225DFFBA8D1"><enum>(d)</enum><header>Dissemination</header><text>The Council shall disseminate to the State—</text> <paragraph id="HBCAE913836C84CC7A0A0F3E2DDF6521B"><enum>(1)</enum><text>the methodologies adopted under subsection (a);</text></paragraph> <paragraph id="H4E011548C8B74F4AB6A973AC326F71A0"><enum>(2)</enum><text>the guidelines developed under subsection (b); and</text></paragraph> <paragraph id="H0A79C03E39D9429E8DAFE0C9CE3DE278"><enum>(3)</enum><text>the standards developed under subsection (c);</text></paragraph><continuation-text continuation-text-level="subsection">for use by the States under section 503.</continuation-text></subsection> <subsection id="H45A64E0DFECB4EF5BD04744E1E0007DA"><enum>(e)</enum><header>Outlier defined</header><text>In this title, the term <term>outlier</term> means a health care provider whose pattern of practice, relative to applicable practice guidelines, suggests deficiencies in the quality of health care services being provided.</text></subsection></section> <section id="H79EC8D79157C4A91A9D0926EC305E87C"><enum>503.</enum><header>State quality review programs</header> <subsection id="H31027EE139074795AE9C2602CE9442F9"><enum>(a)</enum><header>Requirement</header><text>In order to meet the requirement of section 404(b)(1)(H), each State health security program shall establish 1 or more qualified entities to conduct quality reviews of persons providing covered services under the program, in accordance with standards established under subsection (b)(1) (except as provided in subsection (b)(2)) and subsection (d).</text></subsection> <subsection id="H36BB0B0BB0A04ADD9425561BD393C5A6"><enum>(b)</enum><header>Federal standards</header> <paragraph id="H9B5E11BE3EBF4941B3A5164EFEE2808"><enum>(1)</enum><header>In general</header><text>The Council shall establish standards with respect to—</text> <subparagraph id="HA8915A2488724C4A9014BCB09EFBD8F9"><enum>(A)</enum><text>the adoption of practice guidelines (whether developed by the Federal Government or other entities);</text></subparagraph> <subparagraph id="HB13289D36EA84E0BB7006348713B4C42"><enum>(B)</enum><text>the identification of outliers (consistent with methodologies adopted under section 502(a));</text></subparagraph> <subparagraph id="H2D0D1178C3FC460AB77464C292F654D4"><enum>(C)</enum><text>the development of remedial programs and monitoring for outliers; and</text></subparagraph> <subparagraph id="HDE4A1102B4F946039189E3E6BE2059DE"><enum>(D)</enum><text>the application of sanctions (consistent with the standards developed under section 502(c)).</text></subparagraph></paragraph> <paragraph id="H3B46F467E03243A580A4356F048CF0BC"><enum>(2)</enum><header>State discretion</header><text>A State may apply under subsection (a) standards other than those established under paragraph (1) so long as the State demonstrates to the satisfaction of the Council on an annual basis that the standards applied have been as efficacious in promoting and achieving improved quality of care as the application of the standards established under paragraph (1). Positive improvements in quality shall be documented by reductions in the variations of clinical care process and improvement in patient outcomes.</text></paragraph></subsection> <subsection id="H27FF737E06054EE887B3330006FCECD8"><enum>(c)</enum><header>Qualifications</header><text>An entity is not qualified to conduct quality reviews under subsection (a) unless the entity satisfies the criteria for competence for such entities developed by the Council under section 501(b)(3).</text></subsection> <subsection id="HD81FFDFA020E47E8A69D648FA3A4E612"><enum>(d)</enum><header>Internal quality review</header><text>Nothing in this section shall preclude an institutional provider from establishing its own internal quality review and enhancement programs.</text></subsection></section> <section id="HA6BCE084EFAF48B085556DD5B6EC4AA"><enum>504.</enum><header>Elimination of utilization review programs; transition</header> <subsection id="H94B2EB6321C9488DBC04FEE8E97900BD"><enum>(a)</enum><header>Intent</header><text>It is the intention of this title to replace by January 1, 2009, random utilization controls with a systematic review of patterns of practice that compromise the quality of care.</text></subsection> <subsection id="HB307B3A545154F7EBE116F20C88C51B9"><enum>(b)</enum><header>Superseding case reviews</header> <paragraph id="H315731F7F9B7494DB3E8E3005549163F"><enum>(1)</enum><header>In general</header><text>Subject to the succeeding provisions of this subsection, the program of quality review provided under the previous sections of this title supersede all existing Federal requirements for utilization review programs, including requirements for random case-by-case reviews and programs requiring pre-certification of medical procedures on a case-by-case basis.</text></paragraph> <paragraph id="H3672D80A3BB0419AA4EC99B4B5BB5F00"><enum>(2)</enum><header>Transition</header><text>Before January 1, 2009, the Board and the States may employ existing utilization review standards and mechanisms as may be necessary to effect the transition to pattern of practice-based reviews.</text></paragraph> <paragraph id="H49DFD951751E4D578C6467782785FB89"><enum>(3)</enum><header>Construction</header><text>Nothing in this subsection shall be construed—</text> <subparagraph id="H574424E452D54967A80928C72D7F817B"><enum>(A)</enum><text>as precluding the case-by-case review of the provision of care—</text> <clause id="H5067B9DAB92B44608B6329B4577D00BD"><enum>(i)</enum><text>in individual incidents where the quality of care has significantly deviated from acceptable standards of practice; and</text></clause> <clause id="HEAA78CA0F1264589846FBCBD27DE0031"><enum>(ii)</enum><text>with respect to a provider who has been determined to be an outlier; or</text></clause></subparagraph> <subparagraph id="H55DD425D209E4679B467DF3C38C2B200"><enum>(B)</enum><text>as precluding the case management of catastrophic, mental health, or substance abuse cases or long-term care where such management is necessary to achieve appropriate, cost-effective, and beneficial comprehensive medical care, as provided for in section 204.</text></subparagraph></paragraph></subsection></section> <enum>VI</enum><header>Health security budget; payments; cost containment measures</header> <subtitle id="H1D6EFF1D6FFB4EA0BA6FB04B3B58A608"><enum>A</enum><header>Budgeting and payments to States</header> <section id="H7EC7D915454E4AD6BC449536F32E53F3"><enum>601.</enum><header>National health security budget</header> <subsection id="H099475A4329E446486B733C1699D3BF4"><enum>(a)</enum><header>National health security budget</header> <paragraph id="HD31A3382DCAA4B0EA204E815B4001DD4"><enum>(1)</enum><header>In general</header><text>By not later than September 1 before the beginning of each year (beginning with 2006), the Board shall establish a national health security budget, which—</text> <subparagraph id="HF3A3A66F46DA45FD9D0060AD474FB943"><enum>(A)</enum><text>specifies the total expenditures (including expenditures for administrative costs) to be made by the Federal Government and the States for covered health care services under this Act; and</text></subparagraph> <subparagraph id="HBDC54A2AE26142E893DD8CFD481E70FA"><enum>(B)</enum><text>allocates those expenditures among the States consistent with section 604.</text></subparagraph><continuation-text continuation-text-level="paragraph">Pursuant to subsection (b), such budget for a year shall not exceed the budget for the preceding year increased by the percentage increase in gross domestic product.</continuation-text></paragraph> <paragraph id="H4052C3CBB207463EA5B97D299BC1CF"><enum>(2)</enum><header>Division OF budget into components</header><text>The national health security budget shall consist of at least 4 components:</text> <subparagraph id="H690223F80DED42A2B4F4BEB85D3117C6"><enum>(A)</enum><text>A component for quality assessment activities (described in title V).</text></subparagraph> <subparagraph id="H88B997D7EB8B4AE59E239640BD00B291"><enum>(B)</enum><text>A component for health professional education expenditures.</text></subparagraph> <subparagraph id="H4481AE04C4004A4FBB9DA16075423B4E"><enum>(C)</enum><text>A component for administrative costs.</text></subparagraph> <subparagraph id="H00DB3E98D2E9414FB0EBF81E7B0A478"><enum>(D)</enum><text>A component (in this title referred to as the <quote>operating component</quote>) for operating and other expenditures not described in subparagraphs (A) through (C), consisting of amounts not included in the other components. A State may provide for the allocation of this component between capital expenditures and other expenditures.</text></subparagraph></paragraph> <paragraph id="HB18960057B074D4C9FCFEC8E22C6DF51"><enum>(3)</enum><header>Allocation among components</header><text>Taking into account the State health security budgets established and submitted under section 603, the Board shall allocate the national health security budget among the components in a manner that—</text> <subparagraph id="H552573A8D77B41F5AC35A614F6AF57D7"><enum>(A)</enum><text>assures a fair allocation for quality assessment activities (consistent with the national health security spending growth limit); and</text></subparagraph> <subparagraph id="H306A7891DBBF4AC7BB3DE0C1A6CFCAD8"><enum>(B)</enum><text>assures that the health professional education expenditure component is sufficient to provide for the amount of health professional education expenditures sufficient to meet the need for covered health care services (consistent with the national health security spending growth limit under subsection (b)(2)).</text></subparagraph></paragraph></subsection> <subsection id="HA3D9DE8485AC473DB08EA66740A588D9"><enum>(b)</enum><header>Basis for total expenditures</header> <paragraph id="H7EC87FF8488F499894A025D267E671C3"><enum>(1)</enum><header>In general</header><text>The total expenditures specified in such budget shall be the sum of the capitation amounts computed under section 602(a) and the amount of Federal administrative expenditures needed to carry out this Act.</text></paragraph> <paragraph id="H15055755E0714315813F67CD0000D292"><enum>(2)</enum><header>National health security spending growth limit</header><text>For purposes of this subtitle, the national health security spending growth limit described in this paragraph for a year is (A) zero, or, if greater, (B) the average annual percentage increase in the gross domestic product (in current dollars) during the 3-year period beginning with the first quarter of the fourth previous year to the first quarter of the previous year minus the percentage increase (if any) in the number of eligible individuals residing in any State the United States from the first quarter of the second previous year to the first quarter of the previous year.</text></paragraph></subsection> <subsection id="H3096D29153E74292A33C0033D47E1989"><enum>(c)</enum><header>Definitions</header><text>In this title:</text> <paragraph id="H2BC01C42CDE94ED18B4C52009CA75E4F"><enum>(1)</enum><header>Capital expenditures</header><text>The term <term>capital expenditures</term> means expenses for the purchase, lease, construction, or renovation of capital facilities and for equipment and includes return on equity capital.</text></paragraph> <paragraph id="HB306768445634F8280A4088D020089E1"><enum>(2)</enum><header>Health professional education expenditures</header><text>The term <term>health professional education expenditures</term> means expenditures in hospitals and other health care facilities to cover costs associated with teaching and related research activities.</text></paragraph></subsection></section> <section id="HB9D48E930A604A4AA274EB59BE6610B1"><enum>602.</enum><header>Computation of individual and State capitation amounts</header> <subsection id="HA1427D8C9FFF44C18F9B29B884E2BC"><enum>(a)</enum><header>Capitation amounts</header> <paragraph id="H4F3559DD46BE40998343ECF869E3E13F"><enum>(1)</enum><header>Individual capitation amounts</header><text>In establishing the national health security budget under section 601(a) and in computing the national average per capita cost under subsection (b) for each year, the Board shall establish a method for computing the capitation amount for each eligible individual residing in each State. The capitation amount for an eligible individual in a State classified within a risk group (established under subsection (d)(2)) is the product of—</text> <subparagraph id="HA8483A79A9724B8795B1E6937C9C2692"><enum>(A)</enum><text>a national average per capita cost for all covered health care services (computed under subsection (b));</text></subparagraph> <subparagraph id="HC22D1D71DFAA4410BCDD32A7ACA7A648"><enum>(B)</enum><text>the State adjustment factor (established under subsection (c)) for the State; and</text></subparagraph> <subparagraph id="H3E4115867A6342E59FEAC1D00331180"><enum>(C)</enum><text>the risk adjustment factor (established under subsection (d)) for the risk group.</text></subparagraph></paragraph> <paragraph id="HF9780F8EBB0F435D968DE172A107C9BC"><enum>(2)</enum><header>State capitation amount</header> <subparagraph id="HA071B2AA25C74E748979CAA7E3B61EAD"><enum>(A)</enum><header>In general</header><text>For purposes of this title, the term <term>State capitation amount</term> means, for a State for a year, the sum of the capitation amounts computed under paragraph (1) for all the residents of the State in the year, as estimated by the Board before the beginning of the year involved.</text></subparagraph> <subparagraph id="H30CAC351F66E4E7D8B70C2C669DDE59C"><enum>(B)</enum><header>Use of statistical model</header><text>The Board may provide for the computation of State capitation amounts based on statistical models that fairly reflect the elements that comprise the State capitation amount described in subparagraph (A).</text></subparagraph> <subparagraph id="H7D4F13EBCA9546DE8700F42244EDF876"><enum>(C)</enum><header>Population information</header><text>The Bureau of the Census shall assist the Board in determining the number, place of residence, and risk group classification of eligible individuals.</text></subparagraph></paragraph></subsection> <subsection id="H2609B21A6F5643B400699EEB347553E2"><enum>(b)</enum><header>Computation of national average per capita cost</header> <paragraph id="HD7DCF1C6E3CB4619B5A6A123232BDBE3"><enum>(1)</enum><header>For 2006</header><text>For 2006, the national average per capita cost under this paragraph is equal to—</text> <subparagraph id="HE02E38D1612647A4ABC31E47ABA148AA"><enum>(A)</enum><text>the average per capita health care expenditures in the United States in 2004 (as estimated by the Board);</text></subparagraph> <subparagraph id="HB7A024D2C88F4C069072920039515562"><enum>(B)</enum><text>increased to 2005 by the Board’s estimate of the actual amount of such per capita expenditures during 2005; and</text></subparagraph> <subparagraph id="H30DEFF03E9384930B4AE79AC42AF7876"><enum>(C)</enum><text>updated to 2006 by the national health security spending growth limit specified in section 601(b)(2) for 2006.</text></subparagraph></paragraph> <paragraph id="HB513C5DC417A46B1A7C488CEB1D51553"><enum>(2)</enum><header>For succeeding years</header><text>For each succeeding year, the national average per capita cost under this subsection is equal to the national average per capita cost computed under this subsection for the previous year increased by the national health security spending growth limit (specified in section 601(b)(2)) for the year involved.</text></paragraph></subsection> <subsection id="H207A314111544A1D9C78AD68B0C0562D"><enum>(c)</enum><header>State adjustment factors</header> <paragraph id="H16DCDE42825243F684E1BF90D7EC568"><enum>(1)</enum><header>In general</header><text>Subject to the succeeding paragraphs of this subsection, the Board shall develop for each State a factor to adjust the national average per capita costs to reflect differences between the State and the United States in—</text> <subparagraph id="H7942FD2205D24F5388BE1932B255E0A6"><enum>(A)</enum><text>average labor and nonlabor costs that are necessary to provide covered health services;</text></subparagraph> <subparagraph id="H87281F07ADF44FF194D1BA322F1B00B7"><enum>(B)</enum><text>any social, environmental, or geographic condition affecting health status or the need for health care services, to the extent such a condition is not taken into account in the establishment of risk groups under subsection (d);</text></subparagraph> <subparagraph id="H96AC67D99C4A4B9D8DA90038B7209E1"><enum>(C)</enum><text>the geographic distribution of the State’s population, particularly the proportion of the population residing in medically underserved areas, to the extent such a condition is not taken into account in the establishment of risk groups under subsection (d); and</text></subparagraph> <subparagraph id="H9BD65212FE514EB6865D79E8C3CA1D98"><enum>(D)</enum><text>any other factor relating to operating costs required to assure equitable distribution of funds among the States.</text></subparagraph></paragraph> <paragraph id="HA02B8D7659A844C180DE1BBF98157DDF"><enum>(2)</enum><header>Modification of health professional education component</header><text>With respect to the portion of the national health security budget allocated to expenditures for health professional education, the Board shall modify the State adjustment factors so as to take into account—</text> <subparagraph id="H5EEC294C89D14D7EB423FBA954BF37C3"><enum>(A)</enum><text>differences among States in health professional education programs in operation as of the date of the enactment of this Act; and</text></subparagraph> <subparagraph id="H87297BBFDF064149A1B01C6F9E8FEAAC"><enum>(B)</enum><text>differences among States in their relative need for expenditures for health professional education, taking into account the health professional education expenditures proposed in State health security budgets under section 603(a).</text></subparagraph></paragraph> <paragraph id="H505B01835CC04FDA837F80EECE1E6639"><enum>(3)</enum><header>Budget neutrality</header><text>The State adjustment factors, as modified under paragraph (2), shall be applied under this subsection in a manner that results in neither an increase nor a decrease in the total amount of the Federal contributions to all State health security programs under subsection (b) as a result of the application of such factors.</text></paragraph> <paragraph id="H603D26E04F5446C500F646C4C6840684"><enum>(4)</enum><header>Phase-in</header><text>In applying State adjustment factors under this subsection during the 5-year period beginning with 2006, the Board shall phase-in, over such period, the use of factors described in paragraph (1) in a manner so that the adjustment factor for a State is based on a blend of such factors and a factor that reflects the relative actual average per capita costs of health services of the different States as of the time of enactment of this Act.</text></paragraph> <paragraph id="H0802E637810E45679BEAF7F0365760B9"><enum>(5)</enum><header>Periodic adjustment</header><text>In establishing the national health security budget before the beginning of each year, the Board shall provide for appropriate adjustments in the State adjustment factors under this subsection.</text></paragraph></subsection> <subsection id="HC807AEF086C2410DA3A00FCD8B3A269"><enum>(d)</enum><header>Adjustments for risk group classification</header> <paragraph id="HEFEA623EA69D403EABD76FE673DF50E"><enum>(1)</enum><header>In general</header><text>The Board shall develop an adjustment factor to the national average per capita costs computed under subsection (b) for individuals classified in each risk group (as designated under paragraph (2)) to reflect the difference between the average national average per capita costs and the national average per capita cost for individuals classified in the risk group.</text></paragraph> <paragraph id="H78FDEB898D544CF0AE70F5FD4CE10916"><enum>(2)</enum><header>Risk groups</header><text>The Board shall designate a series of risk groups, determined by age, health indicators, and other factors that represent distinct patterns of health care services utilization and costs.</text></paragraph> <paragraph id="H93339BB5CE2A4D3099AA88CA48485562"><enum>(3)</enum><header>Periodic adjustment</header><text>In establishing the national health security budget before the beginning of each year, the Board shall provide for appropriate adjustments in the risk adjustment factors under this subsection.</text></paragraph></subsection></section> <section id="H81A57195E73D471798CC09E5E6850015"><enum>603.</enum><header>State health security budgets</header> <subsection id="HF99F0BEA4B43448EB9D6CD91F7BDA37"><enum>(a)</enum><header>Establishment and submission of budgets</header> <paragraph id="HEB0A692490864C419CEA2428A1DC51E"><enum>(1)</enum><header>In general</header><text>Each State health security program shall establish and submit to the Board for each year a proposed and a final State health security budget, which specifies the following:</text> <subparagraph id="HF52CCA34307A4813ACAD8C35BCEB5BBA"><enum>(A)</enum><text>The total expenditures (including expenditures for administrative costs) to be made under the program in the State for covered health care services under this Act, consistent with subsection (b), broken down as follows:</text> <clause id="HD3571F9326834F599FC700AFD79CECDE"><enum>(i)</enum><text>By the 4 components (described in section 601(a)(2)), consistent with subsection (b).</text></clause> <clause id="HF97AC5988CF74AEAB58F57D9DE332FD0"><enum>(ii)</enum><text>Within the operating component—</text> <subclause id="H03BEB347D5D54B80ABBD7367882500B2"><enum>(I)</enum><text>expenditures for operating costs of hospitals and other facility-based services in the State;</text></subclause> <subclause id="H22E12E25160B4E0B8B7B5DD6EFAC13FC"><enum>(II)</enum><text>expenditures for payment to comprehensive health service organizations;</text></subclause> <subclause id="H7B3EAA3832F649E4B292CC610023472F"><enum>(III)</enum><text>expenditures for payment of services provided by health care practitioners; and</text></subclause> <subclause id="HCBCCB4E5DB884EF08678E65FB4610621"><enum>(IV)</enum><text>expenditures for other covered items and services.</text></subclause><continuation-text continuation-text-level="clause">Amounts included in the operating component include amounts that may be used by providers for capital expenditures.</continuation-text></clause></subparagraph> <subparagraph id="H35EB1AE96B504E699681465513AA057E"><enum>(B)</enum><text>The total revenues required to meet the State health security expenditures.</text></subparagraph></paragraph> <paragraph id="H736D35E06EC142148BAD017B14923CF3"><enum>(2)</enum><header>Proposed budget deadline</header><text>The proposed budget for a year shall be submitted under paragraph (1) not later than June 1 before the year.</text></paragraph> <paragraph id="HE19F669D472640C9AE4428D4E6E4CDBD"><enum>(3)</enum><header>Final budget</header><text>The final budget for a year shall—</text> <subparagraph id="H899B3814C9584CA888C1DA009C225451"><enum>(A)</enum><text>be established and submitted under paragraph (1) not later than October 1 before the year, and</text></subparagraph> <subparagraph id="HF43E9225C4E340D7915DBD9094C27943"><enum>(B)</enum><text>take into account the amounts established under the national health security budget under section 601 for the year.</text></subparagraph></paragraph> <paragraph id="H4D9D8309AA624C839903364FDAF7BF6"><enum>(4)</enum><header>Adjustment in allocations permitted</header> <subparagraph id="HB941AB1DA8514B7AA13794EBC2EB7B7"><enum>(A)</enum><header>In general</header><text>Subject to subparagraphs (B) and (C), in the case of a final budget, a State may change the allocation of amounts among components.</text></subparagraph> <subparagraph id="H6346CE8298F845A296B64DF7A7DD6817"><enum>(B)</enum><header>Notice</header><text>No such change may be made unless the State has provided prior notice of the change to the Board.</text></subparagraph> <subparagraph id="H4EB9B5A95F3A4F7985D42B6D10B066F5"><enum>(C)</enum><header>Denial</header><text>Such a change may not be made if the Board, within such time period as the Board specifies, disapproves such change.</text></subparagraph></paragraph></subsection> <subsection id="HBBCE04FDE78A4A8294099697A8238300"><enum>(b)</enum><header>Expenditure limits</header> <paragraph id="HFCAEAFB219414E16855B388C62CD95B5"><enum>(1)</enum><header>In general</header><text>The total expenditures specified in each State health security budget under subsection (a)(1) shall take into account Federal contributions made under section 604.</text></paragraph> <paragraph id="HF142DAC5E4F142F382DC3E7B760377C5"><enum>(2)</enum><header>Limit on claims processing and billing expenditures</header><text>Each State health security budget shall provide that State administrative expenditures, including expenditures for claims processing and billing, shall not exceed 3 percent of the total expenditures under the State health security program, unless the Board determines, on a case-by-case basis, that additional administrative expenditures would improve health care quality and cost effectiveness.</text></paragraph> <paragraph id="H89EA755F5C6941FFA6B34D00D0FF1F"><enum>(3)</enum><header>Worker assistance</header><text>A State health security program may provide that, for budgets for years before 2009, up to 1 percent of the budget may be used for purposes of programs providing assistance to workers who are currently performing functions in the administration of the health insurance system and who may experience economic dislocation as a result of the implementation of the program.</text></paragraph></subsection> <subsection id="HDA1883BF80D14ED3A2801C635C33F5A3"><enum>(c)</enum><header>Approval process for capital expenditures permitted</header><text>Nothing in this title shall be construed as preventing a State health security program from providing for a process for the approval of capital expenditures based on information derived from regional planning agencies.</text></subsection></section> <section id="HC7379F45508A47CDA5F84C47809E71D1"><enum>604.</enum><header>Federal payments to States</header> <subsection id="H6C443283F3324DC5A47D20DEC9430007"><enum>(a)</enum><header>In general</header><text>Each State with an approved State health security program is entitled to receive, from amounts in the American Health Security Trust Fund, on a monthly basis each year, of an amount equal to one-twelfth of the product of—</text> <paragraph id="H51BA8E20BF5049ECA6CF9F5E4432003B"><enum>(1)</enum><text>the State capitation amount (computed under section 602(a)(2)) for the State for the year; and</text></paragraph> <paragraph id="H49337093D57E44EEA2148FD41EB187B3"><enum>(2)</enum><text>the Federal contribution percentage (established under subsection (b)).</text></paragraph></subsection> <subsection id="H4D93B6A44FEE441084980095B062ED52"><enum>(b)</enum><header>Federal contribution percentage</header><text>The Board shall establish a formula for the establishment of a Federal contribution percentage for each State. Such formula shall take into consideration a State’s per capita income and revenue capacity and such other relevant economic indicators as the Board determines to be appropriate. In addition, during the 5-year period beginning with 2006, the Board may provide for a transition adjustment to the formula in order to take into account current expenditures by the State (and local governments thereof) for health services covered under the State health security program. The weighted-average Federal contribution percentage for all States shall equal 86 percent and in no event shall such percentage be less than 81 percent nor more than 91 percent.</text></subsection> <subsection id="H5A51A90590C844B7A8421300743599E0"><enum>(c)</enum><header>Use of payments</header><text>All payments made under this section may only be used to carry out the State health security program.</text></subsection> <subsection id="H0C8C3AA841BD42A898B3ADC9554D3BA5"><enum>(d)</enum><header>Effect of spending excess or surplus</header> <paragraph id="H0D539E1C697E4D3891DB1E9FAB16F161"><enum>(1)</enum><header>Spending excess</header><text>If a State exceeds it’s budget in a given year, the State shall continue to fund covered health services from its own revenues.</text></paragraph> <paragraph id="HF161C2C96A2E42A9999F6049A10403B2"><enum>(2)</enum><header>Surplus</header><text>If a State provides all covered health services for less than the budgeted amount for a year, it may retain its Federal payment for that year for uses consistent with this Act.</text></paragraph></subsection></section> <section id="H550FE05B13674FD7B28312EC00248BA3"><enum>605.</enum><header>Account for health professional education expenditures</header> <subsection id="HB8F2154DB62341DC9C48C8A3A2926104"><enum>(a)</enum><header>Separate account</header><text>Each State health security program shall—</text> <paragraph id="H3E54702471104C9495C6723E4857D360"><enum>(1)</enum><text>include a separate account for health professional education expenditures; and</text></paragraph> <paragraph id="HD0B121FDD0D8423C928E65FFB29CCC70"><enum>(2)</enum><text>specify the general manner, consistent with subsection (b), in which such expenditures are to be distributed among different types of institutions and the different areas of the State.</text></paragraph></subsection> <subsection id="H5867AF96DDA343608129E29C4CA02CA"><enum>(b)</enum><header>Distribution rules</header><text>The distribution of funds to hospitals and other health care facilities from the account must conform to the following principles:</text> <paragraph id="H67DF6F8D660842FAB8013DE3557F03CC"><enum>(1)</enum><text>The disbursement of funds must be consistent with achievement of the national and program goals (specified in section 701(b)) within the State health security program and the distribution of funds from the account must be conditioned upon the receipt of such reports as the Board may require in order to monitor compliance with such goals.</text></paragraph> <paragraph id="HB34125C9ED1749458FB2C8C5FDC846F"><enum>(2)</enum><text>The distribution of funds from the account must take into account the potentially higher costs of placing health professional students in clinical education programs in health professional shortage areas.</text></paragraph></subsection></section></subtitle> <subtitle id="H40416E7762194430B4334D8521FC27BA"><enum>B</enum><header>Payments by States to providers</header> <section id="H6DD5C9E5168C474E00A93069310001CD"><enum>611.</enum><header>Payments to hospitals and other facility-based services for operating expenses on the basis of approved global budgets</header> <subsection id="HFDBC806A0477499E9F008E70EC600E9"><enum>(a)</enum><header>Direct payment under global budget</header><text>Payment for operating expenses for institutional and facility-based care, including hospital services and nursing facility services, under State health security programs shall be made directly to each institution or facility by each State health security program under an annual prospective global budget approved under the program. Such a budget shall include payment for outpatient care and non-facility-based care that is furnished by or through the facility. In the case of a hospital that is wholly owned (or controlled) by a comprehensive health service organization that is paid under section 614 on the basis of a global budget, the global budget of the organization shall include the budget for the hospital.</text></subsection> <subsection id="H4F826F9F90114350973100005F7F73CA"><enum>(b)</enum><text>Annual Negotiations; Budget Approval—</text> <paragraph id="H02E3CBD23000415AB02170CFB8942E75"><enum>(1)</enum><header>In general</header><text>The prospective global budget for an institution or facility shall—</text> <subparagraph id="H11AB82ADBE2446E7BD5B36871BFDB31C"><enum>(A)</enum><text>be developed through annual negotiations between—</text> <clause id="HADCBACD8229041EB96E62FBAFF4CD00"><enum>(i)</enum><text>a panel of individuals who are appointed by the Governor of the State and who represent consumers, labor, business, and the State government; and</text></clause> <clause id="HE6743FFBCA5143738BA200B70148A186"><enum>(ii)</enum><text>the institution or facility; and</text></clause></subparagraph> <subparagraph id="H118E8E6D553740B19D6F3992AA0453CF"><enum>(B)</enum><text>be based on a nationally uniform system of cost accounting established under standards of the Board.</text></subparagraph></paragraph> <paragraph id="H5AA67C6167F64C91A50051AA000024F6"><enum>(2)</enum><header>Considerations</header><text>In developing a budget through negotiations, there shall be taken into account at least the following:</text> <subparagraph id="H4FAC540934FB48DA94A4DF5DBE64F75"><enum>(A)</enum><text>With respect to inpatient hospital services, the number, and classification by diagnosis-related group, of discharges.</text></subparagraph> <subparagraph id="HE60AB1277CC741BB9887F6A9F75040B0"><enum>(B)</enum><text>An institution’s or facility’s past expenditures.</text></subparagraph> <subparagraph id="H8BB04E1701714C2A91F3BBC19E16ABB"><enum>(C)</enum><text>The extent to which debt service for capital expenditures has been included in the proposed operating budget.</text></subparagraph> <subparagraph id="H5034EA4030264D9A831DEAA443DACE2D"><enum>(D)</enum><text>The extent to which capital expenditures are financed directly or indirectly through reductions in direct care to patients, including (but not limited to) reductions in registered nursing staffing patterns or changes in emergency room or primary care services or availability.</text></subparagraph> <subparagraph id="H0D6CBB1BB62B47A78932DFCC5B2DEDE"><enum>(E)</enum><text>Change in the consumer price index and other price indices.</text></subparagraph> <subparagraph id="HCA891AF24EC44CA5AC6EB1A516BDE12D"><enum>(F)</enum><text>The cost of reasonable compensation to health care practitioners;</text></subparagraph> <subparagraph id="H6CE004DCC05A4ACB873C5125102D37DA"><enum>(G)</enum><text>The compensation level of the institution’s or facility’s work force.</text></subparagraph> <subparagraph id="H50A45F5330164A38A38F7F000074A141"><enum>(H)</enum><text>The extent to which the institution or facility is providing health care services to meet the needs of residents in the area served by the institution or facility, including the institution’s or facility’s occupancy level.</text></subparagraph> <subparagraph id="H0E69E682799D41169F5FD65DCA200B9"><enum>(I)</enum><text>The institution’s or facility’s previous financial and clinical performance, based on utilization and outcomes data provided under this Act.</text></subparagraph> <subparagraph id="H87AFF4B47B184BADA1E107C7172471BD"><enum>(J)</enum><text>The type of institution or facility, including whether the institution or facility is part of a clinical education program or serves a health professional education, research or other training purpose.</text></subparagraph> <subparagraph id="H4EAC23D8AADE4DB30001B875921DA1E"><enum>(K)</enum><text>Technological advances or changes.</text></subparagraph> <subparagraph id="H2EBAFEEBE74648379003FAB414709DC7"><enum>(L)</enum><text>Costs of the institution or facility associated with meeting Federal and State regulations.</text></subparagraph> <subparagraph id="HC1FC94802CE04A63A57501532B4519A5"><enum>(M)</enum><text>The costs associated with necessary public outreach activities.</text></subparagraph> <subparagraph id="H504E7F93E253421CB3ECFB826D556D28"><enum>(N)</enum><text>In the case of a for-profit facility, a reasonable rate of return on equity capital, independent of those operating expenses necessary to fulfill the objectives of this Act.</text></subparagraph> <subparagraph id="H62E95A4028494931935113CFCC9CFC75"><enum>(O)</enum><text>Incentives to facilities that maintain costs below previous reasonable budgeted levels without reducing the care provided.</text></subparagraph> <subparagraph id="H8902A7FBC44048038243D08C74B67141"><enum>(P)</enum><text>With respect to facilities that provide mental health services and substance abuse treatment services, any additional costs involved in the treatment of dually diagnosed individuals.</text></subparagraph><continuation-text continuation-text-level="paragraph">The portion of such a budget that relates to expenditures for health professional education shall be consistent with the State health security budget for such expenditures.</continuation-text></paragraph> <paragraph id="HF3E170A2BE0C4113B40817BAC1D5E11B"><enum>(3)</enum><header>Provision of required information; diagnosis-related group</header><text>No budget for an institution or facility for a year may be approved unless the institution or facility has submitted on a timely basis to the State health security program such information as the program or the Board shall specify, including in the case of hospitals information on discharges classified by diagnosis-related group.</text></paragraph></subsection> <subsection id="H3AF4D3F1049A4C1A84A122DF068E0077"><enum>(c)</enum><header>Adjustments in approved budgets</header> <paragraph id="H767653218E4D47C8ACAE5D355498E25"><enum>(1)</enum><header>Adjustments to global budgets that contract with comprehensive health service organizations</header><text>Each State health security program shall develop an administrative mechanism for reducing operating funds to institutions or facilities in proportion to payments made to such institutions or facilities for services contracted for by a comprehensive health service organization.</text></paragraph> <paragraph id="HF78CC14677F14B66A5CC4646D9455560"><enum>(2)</enum><header>Amendments</header><text>In accordance with standards established by the Board, an operating and capital budget approved under this section for a year may be amended before, during, or after the year if there is a substantial change in any of the factors relevant to budget approval.</text></paragraph></subsection> <subsection id="H2465C085C0734C3782706FCA216C2B08"><enum>(d)</enum><header>Donations permissible</header><text>The States health security programs may permit institutions and facilities to raise funds from private sources to pay for newly constructed facilities, major renovations, and equipment. The expenditure of such funds, whether for operating or capital expenditures, does not obligate the State health security program to provide for continued support for such expenditures unless included in an approved global budget.</text></subsection></section> <section id="H079AEE4F3E414C6A83177636C64BABBB"><enum>612.</enum><header>Payments to health care practitioners based on prospective fee schedule</header> <subsection id="HE4031EC6475B4FF10045A692CBB3A6DD"><enum>(a)</enum><header>Fee for service</header> <paragraph id="H36ADEE06C686491CB530D4AEB6BE3CD"><enum>(1)</enum><header>In general</header><text>Every independent health care practitioner is entitled to be paid, for the provision of covered health services under the State health security program, a fee for each billable covered service.</text></paragraph> <paragraph id="HE86C70BA99154F6BBF348FBEFE163BA3"><enum>(2)</enum><header>Global fee payment methodologies</header><text>The Board shall establish models and encourage State health security programs to implement alternative payment methodologies that incorporate global fees for related services (such as all outpatient procedures for treatment of a condition) or for a basic group of services (such as primary care services) furnished to an individual over a period of time, in order to encourage continuity and efficiency in the provision of services. Such methodologies shall be designed to ensure a high quality of care.</text></paragraph> <paragraph id="HAFADC93752F249F18CB4039486298051"><enum>(3)</enum><header>Billing deadlines; electronic billing</header><text>A State health security program may deny payment for any service of an independent health care practitioner for which it did not receive a bill and appropriate supporting documentation (which had been previously specified) within 30 days after the date the service was provided. Such a program may require that bills for services for which payment may be made under this section, or for any class of such services, be submitted electronically.</text></paragraph></subsection> <subsection id="H7F647FA4FC3C4641B5E9EC0643CE7FF"><enum>(b)</enum><header>Payment rates based on negotiated prospective fee schedules</header><text>With respect to any payment method for a class of services of practitioners, the State health security program shall establish, on a prospective basis, a payment schedule. The State health security program may establish such a schedule after negotiations with organizations representing the practitioners involved. Such fee schedules shall be designed to provide incentives for practitioners to choose primary care medicine, including general internal medicine and pediatrics, over medical specialization. Nothing in this section shall be construed as preventing a State from adjusting the payment schedule amounts on a quarterly or other periodic basis depending on whether expenditures under the schedule will exceed the budgeted amount with respect to such expenditures.</text></subsection> <subsection id="H79896423FB7F4CDF84A12FB1ADC97FE3"><enum>(c)</enum><header>Billable covered service defined</header><text>In this section, the term <term>billable covered service</term> means a service covered under section 201 for which a practitioner is entitled to compensation by payment of a fee determined under this section.</text></subsection></section> <section id="HC141F8AA604C41918D50E102B9DEB69F"><enum>613.</enum><header>Payments to comprehensive health service organizations</header> <subsection id="H0B2101ADE0664284B02BBE212736CF49"><enum>(a)</enum><header>In general</header><text>Payment under a State health security program to a comprehensive health service organization to its enrollees shall be determined by the State—</text> <paragraph id="HF43572C2D280479EBA2E5200FF353920"><enum>(1)</enum><text>based on a global budget described in section 611; or</text></paragraph> <paragraph id="H1FCB2FD0F4E547A781004878DAF4007C"><enum>(2)</enum><text>based on the basic capitation amount described in subsection (b) for each of its enrollees.</text></paragraph></subsection> <subsection id="H62792B336A594CF493AFE7B274971B00"><enum>(b)</enum><header>Basic capitation amount</header> <paragraph id="H9497A938073A4263A86029113DCDE8C1"><enum>(1)</enum><header>In general</header><text>The basic capitation amount described in this subsection for an enrollee shall be determined by the State health security program on the basis of the average amount of expenditures that is estimated would be made under the State health security program for covered health care services for an enrollee, based on actuarial characteristics (as defined by the State health security program).</text></paragraph> <paragraph id="H42DCF4EFED3049488DC60765A84E5494"><enum>(2)</enum><header>Adjustment for special health needs</header><text>The State health security program shall adjust such average amounts to take into account the special health needs, including a disproportionate number of medically underserved individuals, of populations served by the organization.</text></paragraph> <paragraph id="H50660457D348497A949110B068B950A2"><enum>(3)</enum><header>Adjustment for services not provided</header><text>The State health security program shall adjust such average amounts to take into account the cost of covered health care services that are not provided by the comprehensive health service organization under section 303(a).</text></paragraph></subsection></section> <section id="HCC1E1E29194E40FC910707FEF27B44F2"><enum>614.</enum><header>Payments for community-based primary health services</header> <subsection id="HF22D01E0AD3544ECA8F3682C82F3DE09"><enum>(a)</enum><header>In general</header><text>In the case of community-based primary health services, subject to subsection (b), payments under a State health security program shall—</text> <paragraph id="H1F9984088B0347DEABAE21539DDAE092"><enum>(1)</enum><text>be based on a global budget described in section 611;</text></paragraph> <paragraph id="H952A4015373A44329DD3DA55B1A79BF9"><enum>(2)</enum><text>be based on the basic primary care capitation amount described in subsection (c) for each individual enrolled with the provider of such services; or</text></paragraph> <paragraph id="H957F61F13E594502A4B130000F1C200"><enum>(3)</enum><text>be made on a fee-for-service basis under section 612.</text></paragraph></subsection> <subsection id="H7D7991F0D438484F8564FFA334DE1D45"><enum>(b)</enum><header>Payment adjustment</header><text>Payments under subsection (a) may include, consistent with the budgets developed under this title—</text> <paragraph id="HFBAD6185258F4CB782821620D55332D8"><enum>(1)</enum><text>an additional amount, as set by the State health security program, to cover the costs incurred by a provider which serves persons not covered by this Act whose health care is essential to overall community health and the control of communicable disease, and for whom the cost of such care is otherwise uncompensated;</text></paragraph> <paragraph id="H8E34648388134057858EEC6CDF612168"><enum>(2)</enum><text>an additional amount, as set by the State health security program, to cover the reasonable costs incurred by a provider that furnishes case management services (as defined in section 1915(g)(2) of the <act-name parsable-cite="SSA">Social Security Act</act-name>), transportation services, and translation services; and</text></paragraph> <paragraph id="H880EBD46ED6843B889CE7C34C247EB3E"><enum>(3)</enum><text>an additional amount, as set by the State health security program, to cover the costs incurred by a provider in conducting health professional education programs in connection with the provision of such services.</text></paragraph></subsection> <subsection id="H3C3780FD97F148E7A9D106E429778429"><enum>(c)</enum><header>Basic primary care capitation amount</header> <paragraph id="HCDCB9B1F639E43B18FE9A558DEC7DB"><enum>(1)</enum><header>In general</header><text>The basic primary care capitation amount described in this subsection for an enrollee with a provider of community-based primary health services shall be determined by the State health security program on the basis of the average amount of expenditures that is estimated would be made under the State health security program for such an enrollee, based on actuarial characteristics (as defined by the State health security program).</text></paragraph> <paragraph id="H20C59381014B413AB48D7F20B4C63BB6"><enum>(2)</enum><header>Adjustment for special health needs</header><text>The State health security program shall adjust such average amounts to take into account the special health needs, including a disproportionate number of medically underserved individuals, of populations served by the provider.</text></paragraph> <paragraph id="H766F126B58C64662AB99D051120438C5"><enum>(3)</enum><header>Adjustment for services not provided</header><text>The State health security program shall adjust such average amounts to take into account the cost of community-based primary health services that are not provided by the provider.</text></paragraph></subsection> <subsection id="H8F2616F9E6A74F5F84704B07604ED357"><enum>(d)</enum><header>Community-based primary health services defined</header><text>In this section, the term <term>community-based primary health services</term> has the meaning given such term in section 202(a).</text></subsection></section> <section id="H7D8AF34F1A5F4182A5A601FA2F781DD3"><enum>615.</enum><header>Payments for prescription drugs</header> <subsection id="HA0632F38CFA140EFB1FE089680776873"><enum>(a)</enum><header>Establishment of list</header> <paragraph id="H1D8DC420D8404AB696E8442D3A4201"><enum>(1)</enum><header>In general</header><text>The Board shall establish a list of approved prescription drugs and biologicals that the Board determines are necessary for the maintenance or restoration of health or of employability or self-management and eligible for coverage under this Act.</text></paragraph> <paragraph id="H54D129DA36C04C8F85A311A17BD7E6CB"><enum>(2)</enum><header>Exclusions</header><text>The Board may exclude reimbursement under this Act for ineffective, unsafe, or over-priced products where better alternatives are determined to be available.</text></paragraph></subsection> <subsection id="H4350A436F4804E29AAFF6CC3886D2B13"><enum>(b)</enum><header>Prices</header><text>For each such listed prescription drug or biological covered under this Act, for insulin, and for medical foods, the Board shall from time to time determine a product price or prices which shall constitute the maximum to be recognized under this Act as the cost of a drug to a provider thereof. The Board may conduct negotiations, on behalf of State health security programs, with product manufacturers and distributors in determining the applicable product price or prices.</text></subsection> <subsection id="H129374ADACFF47F0996FB3B48F6F6034"><enum>(c)</enum><header>Charges by independent pharmacies</header><text>Each State health security program shall provide for payment for a prescription drug or biological or insulin furnished by an independent pharmacy based on the drug’s cost to the pharmacy (not in excess of the applicable product price established under subsection (b)) plus a dispensing fee. In accordance with standards established by the Board, each State health security program, after consultation with representatives of the pharmaceutical profession, shall establish schedules of dispensing fees, designed to afford reasonable compensation to independent pharmacies after taking into account variations in their cost of operation resulting from regional differences, differences in the volume of prescription drugs dispensed, differences in services provided, the need to maintain expenditures within the budgets established under this title, and other relevant factors.</text></subsection></section> <section id="H14C5AA4B662943C681A7A8ED1C40445E"><enum>616.</enum><header>Payments for approved devices and equipment</header> <subsection id="HEE4CC8F154CC41B19653AA78A9FA94C"><enum>(a)</enum><header>Establishment of list</header><text>The Board shall establish a list of approved durable medical equipment and therapeutic devices and equipment (including eyeglasses, hearing aids, and prosthetic appliances), that the Board determines are necessary for the maintenance or restoration of health or of employability or self-management and eligible for coverage under this Act.</text></subsection> <subsection id="HFB51351C506E438AA162AFEC79868CC"><enum>(b)</enum><header>Considerations and conditions</header><text>In establishing the list under subsection (a), the Board shall take into consideration the efficacy, safety, and cost of each item contained on such list, and shall attach to any item such conditions as the Board determines appropriate with respect to the circumstances under which, or the frequency with which, the item may be prescribed.</text></subsection> <subsection id="H6C38D17932764DDF8D12FC03859841BA"><enum>(c)</enum><header>Prices</header><text>For each such listed item covered under this Act, the Board shall from time to time determine a product price or prices which shall constitute the maximum to be recognized under this Act as the cost of the item to a provider thereof. The Board may conduct negotiations, on behalf of State health security programs, with equipment and device manufacturers and distributors in determining the applicable product price or prices.</text></subsection> <subsection id="H14BC8E45E378468582849EBC75C0DD4B"><enum>(d)</enum><header>Exclusions</header><text>The Board may exclude from coverage under this Act ineffective, unsafe, or overpriced products where better alternatives are determined to be available.</text></subsection></section> <section id="HEEA9147F7E1D4DFEB8E4D5DF8FEFE0AD"><enum>617.</enum><header>Payments for other items and services</header><text display-inline="no-display-inline">In the case of payment for other covered health services, the amount of payment under a State health security program shall be established by the program—</text> <paragraph id="H422A51FA5FB24974AB365EE83BEFA597"><enum>(1)</enum><text>in accordance with payment methodologies which are specified by the Board, after consultation with the American Health Security Advisory Council, or methodologies established by the State under section 620; and</text></paragraph> <paragraph id="H01484DEE6C3F4B41867247205B78AC6B"><enum>(2)</enum><text>consistent with the State health security budget.</text></paragraph></section> <section id="H505DC385F3624F8BBD8B7650EE383E88"><enum>618.</enum><header>Payment incentives for medically underserved areas</header> <subsection id="HDABEF47472314559B148E8A924E482CC"><enum>(a)</enum><header>Model payment methodologies</header><text>In addition to the payment amounts otherwise provided in this title, the Board shall establish model payment methodologies and other incentives that promote the provision of covered health care services in medically underserved areas, particularly in rural and inner-city underserved areas.</text></subsection> <subsection id="HA929842436144BAA82789C6B6C146275"><enum>(b)</enum><header>Construction</header><text>Nothing in this title shall be construed as limiting the authority of State health security programs to increase payment amounts or otherwise provide additional incentives, consistent with the State health security budget, to encourage the provision of medically necessary and appropriate services in underserved areas.</text></subsection></section> <section id="H446F6927C6A344B4BE7C0745D065012B"><enum>619.</enum><header>Authority for alternative payment methodologies</header><text display-inline="no-display-inline">A State health security program, as part of its plan under section 404(a), may use a payment methodology other than a methodology required under this subtitle so long as—</text> <paragraph id="H23ED5C630E7845E7AF2DF19E6EEDF2F6"><enum>(1)</enum><text>such payment methodology does not affect the entitlement of individuals to coverage, the weighting of fee schedules to encourage an increase in the number of primary care providers, the ability of individuals to choose among qualified providers, the benefits covered under the program, or the compliance of the program with the State health security budget under subtitle A; and</text></paragraph> <paragraph id="H7026EA2DC8994F33AB71788E84D3C000"><enum>(2)</enum><text>the program submits periodic reports to the Board showing the operation and effectiveness of the alternative methodology, in order for the Board to evaluate the appropriateness of applying the alternative methodology to other States.</text></paragraph></section></subtitle> <subtitle id="H975C3EDD0B4942A3AFD035F5CF2D3867"><enum>C</enum><header>Mandatory assignment and administrative provisions</header> <section id="H87805BDA6CFD448AA0BBD0D5DA5C3B5D"><enum>631.</enum><header>Mandatory assignment</header> <subsection id="H161E1952346E4A23B09F4BC0FCFC7DAB"><enum>(a)</enum><header>No balance billing</header><text>Payments for benefits under this Act shall constitute payment in full for such benefits and the entity furnishing an item or service for which payment is made under this Act shall accept such payment as payment in full for the item or service and may not accept any payment or impose any charge for any such item or service other than accepting payment from the State health security program in accordance with this Act.</text></subsection> <subsection id="H87D0F49226244B429E0756EAD9512B54"><enum>(b)</enum><header>Enforcement</header><text>If an entity knowingly and willfully bills for an item or service or accepts payment in violation of subsection (a), the Board may apply sanctions against the entity in the same manner as sanctions could have been imposed under section 1842(j)(2) of the <act-name parsable-cite="SSA">Social Security Act</act-name> for a violation of section 1842(j)(1) of such Act. Such sanctions are in addition to any sanctions that a State may impose under its State health security program.</text></subsection></section> <section id="HAC8155F0F1024377B64F1CFDE162402F"><enum>632.</enum><header>Procedures for reimbursement; appeals</header> <subsection id="HF912F77E842C47448E4760BBA05A6F0"><enum>(a)</enum><header>Procedures for reimbursement</header><text>In accordance with standards issued by the Board, a State health security program shall establish a timely and administratively simple procedure to assure payment within 60 days of the date of submission of clean claims by providers under this Act.</text></subsection> <subsection id="HB2E7A08762FF4CD396AF16F8EC51E504"><enum>(b)</enum><header>Appeals process</header><text>Each State health security program shall establish an appeals process to handle all grievances pertaining to payment to providers under this title.</text></subsection></section></subtitle> <enum>VII</enum><header>Promotion of primary health care; development of health service capacity; programs to assist the medically underserved</header> <subtitle id="H42AF00EDC81548B5A9EA32B5CB3103DE"><enum>A</enum><header>Promotion and expansion of primary care professional training</header> <section id="HB8522E75CCAD47B88EBE5DFF2ED337DA"><enum>701.</enum><header>Role of Board; establishment of primary care professional output goals</header> <subsection id="HC2BF26F57453453CBC353CE1FC1F5428"><enum>(a)</enum><header>In general</header><text>The Board is responsible for—</text> <paragraph id="H4C26B3ED16BD42B38700E2EE97099453"><enum>(1)</enum><text>coordinating health professional education policies and goals, in consultation with the Secretary of Health and Human Services (in this title referred to as the <quote>Secretary</quote>), to achieve the national goals specified in subsection (b);</text></paragraph> <paragraph id="H0C0D55DD64004B32B20231001EE39B08"><enum>(2)</enum><text>overseeing the health professional education expenditures of the State health security programs from the account established under section 602(c);</text></paragraph> <paragraph id="H4841D5FD1B8843C6993CD0E5CEBF4D5B"><enum>(3)</enum><text>developing and maintaining, in cooperation with the Secretary, a system to monitor the number and specialties of individuals through their health professional education, any postgraduate training, and professional practice; and</text></paragraph> <paragraph id="H46FAAA735F694FE9989448CBA00094EF"><enum>(4)</enum><text>developing, coordinating, and promoting other policies that expand the number of primary care practitioners.</text></paragraph></subsection> <subsection id="H329B92CE24DA49519D57EA6D09420046"><enum>(b)</enum><header>National goals</header><text>The national goals specified in this subsection are as follows:</text> <paragraph id="H8E49A4ABFBF5433F0064D1ECA1CC73F5"><enum>(1)</enum><header>Graduate medical education</header><text>By not later than 5 years after the date of the enactment of this Act, at least 50 percent of the residents in medical residency education programs (as defined in subsection (e)(1)) are primary care residents (as defined in subsection (e)(3)).</text></paragraph> <paragraph id="H603B7CFD4C284B6C9543B9B06F8E2FD2"><enum>(2)</enum><header>Midlevel primary care practitioners</header><text>To assure an adequate supply of primary care practitioners, there shall be a number, specified by the Board, of midlevel primary care practitioners (as defined in subsection (e)(2)) employed in the health care system as of January 1, 2009.</text></paragraph></subsection> <subsection id="H72AE80404ECE4D93A038EE4170D79BD"><enum>(c)</enum><header>Method for attainment of national goal for graduate medical education; program goals</header> <paragraph id="H7C09F08E188844D29CC65CF7A925E66"><enum>(1)</enum><header>In general</header><text>The Board shall establish a method of applying the national goal in subsection (b)(1) to program goals for each medical residency education program or to medical residency education consortia.</text></paragraph> <paragraph id="HFDC693A5A24E4BCD00392B49A07B5E1D"><enum>(2)</enum><header>Consideration</header><text>The program goals under paragraph (1) shall be based on the distribution of medical schools and other teaching facilities within each State health security program, and the number of positions for graduate medical education.</text></paragraph> <paragraph id="HD985B26F3E894339006194C53E95BF78"><enum>(3)</enum><header>Medical residency education consortium</header><text>In this subsection, the term <term>medical residency education consortium</term> means a consortium of medical residency education programs in a contiguous geographic area (which may be an interstate area) if the consortium—</text> <subparagraph id="H50F949FE95874B1695D8554F67B15897"><enum>(A)</enum><text>includes at least 1 medical school with a teaching hospital and related teaching settings; and</text></subparagraph> <subparagraph id="H805EC864AA54422E95CAD080629DC56"><enum>(B)</enum><text>has an affiliation with qualified community-based primary health service providers described in section 202(a) and with at least 1 comprehensive health service organization established under section 303.</text></subparagraph></paragraph> <paragraph id="HED7BC443C25D429CB50058B81E48E38F"><enum>(4)</enum><header>Enforcement through State health security budgets</header><text>The Board shall develop a formula for reducing payments to State health security programs (that provide for payments to a medical residency education program) that failed to meet the goal for the program established under this subsection.</text></paragraph></subsection> <subsection id="H1B45FFBF52CC4E2E9D4D2EE7481000FA"><enum>(d)</enum><header>Method for attainment of national goal for midlevel primary care practitioners</header><text>To assist in attaining the national goal identified in subsection (b)(2), the Board shall—</text> <paragraph id="H1416E3329CA24BD39549E52305EE1A7"><enum>(1)</enum><text>advise the Public Health Service on allocations of funding under titles VII and VIII of the <act-name parsable-cite="PHSA">Public Health Service Act</act-name>, the National Health Service Corps, and other programs in order to increase the supply of midlevel primary care practitioners; and</text></paragraph> <paragraph id="H95E112FED7EF4AE88E3D38D800E0802B"><enum>(2)</enum><text>commission a study of the potential benefits and disadvantages of expanding the scope of practice authorized under State laws for any class of midlevel primary care practitioners.</text></paragraph></subsection> <subsection id="H437EAF8EAE394C03BFE5579F5C850086"><enum>(e)</enum><header>Definitions</header><text>In this title:</text> <paragraph id="HB40334B01D0F452ABC16E84C58D4476B"><enum>(1)</enum><header>Medical residency education program</header><text>The term <term>medical residency education program</term> means a program that provides education and training to graduates of medical schools in order to meet requirements for licensing and certification as a physician, and includes the medical school supervising the program and includes the hospital or other facility in which the program is operated.</text></paragraph> <paragraph id="H06186C44367447F8BAD5D9447F7C78DE"><enum>(2)</enum><header>Midlevel primary care practitioner</header><text>The term <term>midlevel primary care practitioner</term> means a clinical nurse practitioner, certified nurse midwife, physician assistance, or other nonphysician practitioner, specified by the Board, as authorized to practice under State law.</text></paragraph> <paragraph id="H50EC0C80EC2649A2AAA6854C07DFA68E"><enum>(3)</enum><header>Primary care resident</header><text>The term <term>primary care resident</term> means (in accordance with criteria established by the Board) a resident being trained in a distinct program of family practice medicine, general practice, general internal medicine, or general pediatrics.</text></paragraph></subsection></section> <section id="H31626B9D2DEE403195EAB5973BDB8740"><enum>702.</enum><header>Establishment of Advisory Committee on Health Professional Education</header> <subsection id="H2465CE59B2F4405A9000C3F996793D5E"><enum>(a)</enum><header>In general</header><text>The Board shall provide for an Advisory Committee on Health Professional Education (in this section referred to as the <quote>Committee</quote>) to advise the Board on its activities under section 701.</text></subsection> <subsection id="H9F17F32FC1D9475582D57ECABCCD131D"><enum>(b)</enum><header>Membership</header><text>The Committee shall be composed of—</text> <paragraph id="H308EFFFA483F4F8797D8B50917C045BC"><enum>(1)</enum><text>the Chair of the Board, who shall serve as Chair of the Committee; and</text></paragraph> <paragraph id="HA36B5394769F480A9D246FC818F800F5"><enum>(2)</enum><text>12 members, not otherwise in the employ of the United States, appointed by the Board without regard to the provisions of title 5, United States Code, governing appointments in the competitive service.</text></paragraph><continuation-text continuation-text-level="subsection">The appointed members shall provide a balanced point of view with respect to health professional education, primary care disciplines, and health care policy and shall include individuals who are representative of medical schools, other health professional schools, residency programs, primary care practitioners, teaching hospitals, professional associations, public health organizations, State health security programs, and consumers.</continuation-text></subsection> <subsection id="HAF28165373B34AA4885CB166B1414D8"><enum>(c)</enum><header>Terms of members</header><text>Each appointed member shall hold office for a term of 5 years, except that—</text> <paragraph id="H49B4F5F70CCD4DD4BFF14B996CAE6B7E"><enum>(1)</enum><text>any member appointed to fill a vacancy occurring during the term for which the member’s predecessor was appointed shall be appointed for the remainder of that term; and</text></paragraph> <paragraph id="HFE960B5FFAF54B718657FE7B870000CB"><enum>(2)</enum><text>the terms of the members first taking office shall expire, as designated by the Board at the time of appointment, 2 at the end of the second year, 2 at the end of the third year, 2 at the end of the fourth year, and 3 at the end of the fifth year after the date of enactment of this Act.</text></paragraph></subsection> <subsection id="H3A58315BB1CB4B4193E64E080004B87C"><enum>(d)</enum><header>Vacancies</header> <paragraph id="HC3A15B32DA4844E1A1D49C009709EA9F"><enum>(1)</enum><header>In general</header><text>The Board shall fill any vacancy in the membership of the Committee in the same manner as the original appointment. The vacancy shall not affect the power of the remaining members to execute the duties of the Committee.</text></paragraph> <paragraph id="H7A03845F0FC14756A7908ED1E8E7E4CA"><enum>(2)</enum><header>Vacancy appointments</header><text>Any member appointed to fill a vacancy shall serve for the remainder of the term for which the predecessor of the member was appointed.</text></paragraph> <paragraph id="H1ABD56A0ED4A4B319145ED00F58C9082"><enum>(3)</enum><header>Reappointment</header><text>The Board may reappoint an appointed member of the Committee for a second term in the same manner as the original appointment.</text></paragraph></subsection> <subsection id="HB7962593DFEA48D5B56F98C870E8AFD9"><enum>(e)</enum><header>Duties</header><text>It shall be the duty of the Committee to advise the Board concerning graduate medical education policies under this title.</text></subsection> <subsection id="HB5BAD8432AF44F88B7392E7C01B9A316"><enum>(f)</enum><header>Staff</header><text>The Committee, its members, and any committees of the Committee shall be provided with such secretarial, clerical, or other assistance as may be authorized by the Board for carrying out their respective functions.</text></subsection> <subsection id="HC4381CB7E741460B921366C96800E6F1"><enum>(g)</enum><header>Meetings</header><text>The Committee shall meet as frequently as the Board deems necessary, but not less than 4 times each year. Upon request by 4 or more members it shall be the duty of the Chair to call a meeting of the Committee.</text></subsection> <subsection id="H46AAEDDD80264E1B963F84AD80D00925"><enum>(h)</enum><header>Compensation</header><text>Members of the Committee shall be reimbursed by the Board for travel and per diem in lieu of subsistence expenses during the performance of duties of the Board in accordance with subchapter I of <external-xref legal-doc="usc-chapter" parsable-cite="usc-chapter/5/57">chapter 57</external-xref> of title 5, United States Code.</text></subsection> <subsection id="H45EF55C11D4946ABAFFDF709F1CFF455"><enum>(i)</enum><header>FACA not applicable</header><text>The provisions of the <act-name parsable-cite="FACA">Federal Advisory Committee Act</act-name> shall not apply to the Committee.</text></subsection></section> <section id="HD60B3AF445F343FFB05236DC1B9F79B0"><enum>703.</enum><header>Grants for health professions education, nurse education, and the National Health Service Corps</header> <subsection id="H7687CBFCFA904A1DA200F554EF82158E"><enum>(a)</enum><header>Transfers to Public Health Service</header><text>From the amounts provided under subsection (c), the Board shall make transfers from the American Health Security Trust Fund to the Public Health Service under subpart II of part D of title III, title VII, and title VIII of the <act-name parsable-cite="PHSA">Public Health Service Act</act-name> for the support of the National Health Service Corps, health professions education, and nursing education, including education of clinical nurse practitioners, certified registered nurse anesthetists, certified nurse midwives, and physician assistants. Of the amounts so transferred in each year, not less than 50 percent shall be expended for the support of the National Health Service Corps.</text></subsection> <subsection id="HCB61DAC81561459FA7001E36F3009756"><enum>(b)</enum><header>Range of funds</header><text>The amount of transfers under subsection (a) for any fiscal year shall be an amount (specified by the Board each year) not less than <fraction>4/100</fraction> percent and not to exceed \6/100\ percent of the amounts the Board estimates will be expended from the Trust Fund in the fiscal year.</text></subsection> <subsection id="H1F3B81B44A7D44B8A9AF81873542E700"><enum>(c)</enum><header>Funds supplemental to other funds</header><text>The funds provided under this section with respect to provision of services are in addition to, and not in replacement of, funds made available under the provisions referred to in subsection (a) and shall be administered in accordance with the terms of such provisions. The Board shall make no transfer of funds under this section for any fiscal year for which the total appropriations for the programs authorized by such provisions are less than the total amount appropriated for such programs in fiscal year 2004.</text></subsection></section></subtitle> <subtitle id="H6D7EF676EB224DD6B795B5D4A6993994"><enum>B</enum><header>Direct health care delivery</header> <section id="H622A891A36BC4660BD25CFFECFB9B82"><enum>711.</enum><header>Setaside for public health</header> <subsection id="HA017E0657B094A9E892091BDBF004E38"><enum>(a)</enum><header>Transfers to Public Health Service</header><text>From the amounts provided under subsection (c), the Board shall make transfers from the American Health Security Trust Fund to the Public Health Service for the following purposes (other than payment for services covered under title II):</text> <paragraph id="H74F10770CFB04A6A844FCF6C1EC50281"><enum>(1)</enum><text>For payments to States under the maternal and child health block grants under title V of the <act-name parsable-cite="SSA">Social Security Act</act-name>.</text></paragraph> <paragraph id="H9337B52774704C74BDF85EE486E9D0EE"><enum>(2)</enum><text>For prevention and treatment of tuberculosis under section 317 of the <act-name parsable-cite="PHSA">Public Health Service Act</act-name>.</text></paragraph> <paragraph id="HB2CD285A6C6141D3AD6286E86C1825E"><enum>(3)</enum><text>For the prevention and treatment of sexually transmitted diseases under section 318 of the <act-name parsable-cite="PHSA">Public Health Service Act</act-name>.</text></paragraph> <paragraph id="H9BF136FA5B2344C0AFEFC1FA5C71FE5C"><enum>(4)</enum><text>Preventive health block grants under part A of title XIX of the <act-name parsable-cite="PHSA">Public Health Service Act</act-name>.</text></paragraph> <paragraph id="H85BBDF6EFF3F4CE78852B0B4D73F3435"><enum>(5)</enum><text>Grants to States for community mental health services under subpart I of part B of title XIX of the <act-name parsable-cite="PHSA">Public Health Service Act</act-name>.</text></paragraph> <paragraph id="HC3F7B86EE77947F0B5AF76A1F7C3F5C1"><enum>(6)</enum><text>Grants to States for prevention and treatment of substance abuse under subpart II of part B of title XIX of the <act-name parsable-cite="PHSA">Public Health Service Act</act-name>.</text></paragraph> <paragraph id="HBA8E9EFF067643EE89CBF0645C576211"><enum>(7)</enum><text>Grants for HIV health care services under parts A, B, and C of title XXVI of the <act-name parsable-cite="PHSA">Public Health Service Act</act-name>.</text></paragraph> <paragraph id="HB55E2FDB865E4CFE8BE4BA49FB24D3"><enum>(8)</enum><text>Public health formula grants described in subsection (d).</text></paragraph></subsection> <subsection id="H8B520380FA2F4199955332F379AC4017"><enum>(b)</enum><header>Range of funds</header><text>The amount of transfers under subsection (a) for any fiscal year shall be an amount (specified by the Board each year) not less than <fraction>1/10</fraction> percent and not to exceed \14/100\ percent of the amounts the Board estimates will be expended from the Trust Fund in the fiscal year.</text></subsection> <subsection id="H7465B4FBD4D5493C96BC684369D12772"><enum>(c)</enum><header>Funds supplemental to other funds</header><text>The funds provided under this section with respect to provision of services are in addition to, and not in replacement of, funds made available under the programs referred to in subsection (a) and shall be administered in accordance with the terms of such programs.</text></subsection> <subsection id="HB56539A79B0E416700DD007FECA185B"><enum>(d)</enum><header>Required reports on health status</header><text>The Secretary shall require each State receiving funds under this section to submit annual reports to the Secretary on the health status of the population and measurable objectives for improving the health of the public in the State. Such reports shall include the following:</text> <paragraph id="HEB29A25913E14ABAB99DA222E85DF6D6"><enum>(1)</enum><text>A comparison of the measures of the State and local public health system compared to relevant objectives set forth in <quote>Healthy People 2000</quote> or subsequent national objectives set by the Secretary.</text></paragraph> <paragraph id="H2E2E4777B7C44632896DF7915D4FF8AB"><enum>(2)</enum><text>A description of health status measures to be improved within the State (at the State and local levels) through expanded public health functions and health promotion and disease prevention programs.</text></paragraph> <paragraph id="H337C8DB8009146B0B98C6D82E5567999"><enum>(3)</enum><text>Measurable outcomes and process objectives for improving health status, and a report on outcomes from the previous year.</text></paragraph> <paragraph id="H352788CED57940168565BA2E3D2E592C"><enum>(4)</enum><text>Information regarding how Federal funding has improved population-based prevention activities and programs.</text></paragraph> <paragraph id="H071C6EADDE3C466A972771C67E19D369"><enum>(5)</enum><text>A description of the core public health functions to be carried out at the local level.</text></paragraph> <paragraph id="HE5ED68E61A2E4C3AB68FA1238793E647"><enum>(6)</enum><text>A description of the relationship between the State’s public health system, community-based health promotion and disease prevention providers, and the State health security program.</text></paragraph></subsection> <subsection id="H6BF0C02C919E4ACE97E614DE2884C95F"><enum>(e)</enum><header>Limitation on fund transfers</header><text>The Board shall make no transfer of funds under this section for any fiscal year for which the total appropriations for such programs are less than the total amount appropriated for such programs in fiscal year 2004.</text></subsection> <subsection id="HEE785D42AA9D4BF293CB3B5C24189626"><enum>(f)</enum><header>Public health formula grants</header><text>The Secretary shall provide stable funds to States through formula grants for the purpose of carrying out core public health functions to monitor and protect the health of communities from communicable diseases and exposure to toxic environmental pollutants, occupational hazards, harmful products, and poor health outcomes. Such functions include the following:</text> <paragraph id="HE43656F0FBF94DC29E182DE7E79EA928"><enum>(1)</enum><text>Data collection, analysis, and assessment of public health data, vital statistics, and personal health data to assess community health status and outcomes reporting. This function includes the acquisition and installation of hardware and software, and personnel training and technical assistance to operate and support automated and integrated information systems.</text></paragraph> <paragraph id="H28027BCE449B4DB1939C22414653CCBD"><enum>(2)</enum><text>Activities to protect the environment and to assure the safety of housing, workplaces, food, and water.</text></paragraph> <paragraph id="HDEDF9D9923A045E29FADCAB079C3F4DB"><enum>(3)</enum><text>Investigation and control of adverse health conditions, and threats to the health status of individuals and the community. This function includes the identification and control of outbreaks of infectious disease, patterns of chronic disease and injury, and cooperative activities to reduce the levels of violence.</text></paragraph> <paragraph id="H2D33C5CF65534805005500D14B5E6E8C"><enum>(4)</enum><text>Health promotion and disease prevention activities for which there is a significant need and a high priority of the Public Health Service.</text></paragraph> <paragraph id="HB0655BA44A8147B7B35493359E479956"><enum>(5)</enum><text>The provision of public health laboratory services to complement private clinical laboratory services, including—</text> <subparagraph id="HD426B25F66874AF8AE684FD265C2E659"><enum>(A)</enum><text>screening tests for metabolic diseases in newborns;</text></subparagraph> <subparagraph id="H1814ED3DF50B48A0ACCDEF094FE62364"><enum>(B)</enum><text>toxicology assessments of blood lead levels and other environmental toxins;</text></subparagraph> <subparagraph id="HAED4077BDCDC48B4B2F57915EC3E7600"><enum>(C)</enum><text>tuberculosis and other diseases requiring partner notification; and</text></subparagraph> <subparagraph id="HC0CAF176DF04424BAFDE5575F469A728"><enum>(D)</enum><text>testing for infectious and food-borne diseases.</text></subparagraph></paragraph> <paragraph id="H0CBB95B463A74B39A731F336CB4086B0"><enum>(6)</enum><text>Training and education for the public health professions.</text></paragraph> <paragraph id="H6593A5BFD2254E039201C23CA2CB85CB"><enum>(7)</enum><text>Research on effective and cost-effective public health practices. This function includes the development, testing, evaluation, and publication of results of new prevention and public health control interventions.</text></paragraph> <paragraph id="H1CDD5B5FD58547DE88F054EF60B2CAEA"><enum>(8)</enum><text>Integration and coordination of the prevention programs and services of community-based providers, local and State health departments, and other sectors of State and local government that affect health.</text></paragraph></subsection></section> <section id="HAC773C028EFD45F2BA2CF45DE8C6EF83"><enum>712.</enum><header>Setaside for primary health care delivery</header> <subsection id="H1C0CBBDB860747709215AF8E49A8247"><enum>(a)</enum><header>Transfers to Public Health Service</header><text>From the amounts provided under subsection (c), the Board shall make transfers from the American Health Security Trust Fund to the Public Health Service for the program of primary care service expansion grants under subpart V of part D of title III of the <act-name parsable-cite="PHSA">Public Health Service Act</act-name> (as added by section 713 of this Act).</text></subsection> <subsection id="H1D5D1AF17F594B4C82D52231CE02029F"><enum>(b)</enum><header>Range of funds</header><text>The amount of transfers under subsection (a) for any fiscal year shall be an amount (specified by the Board each year) not less than <fraction>6/100</fraction> percent and not to exceed \1/10\ percent of the amounts the Board estimates will be expended from the Trust Fund in the fiscal year.</text></subsection> <subsection id="H2EC0A03F7CAA4368B3966FDD8CDFB323"><enum>(c)</enum><header>Funds supplemental to other funds</header><text>The funds provided under this section with respect to provision of services are in addition to, and not in replacement of, funds made available under the sections 329, 330, 340, 340A, 1001, and 2655 of the <act-name parsable-cite="PHSA">Public Health Service Act</act-name>. The Board shall make no transfer of funds under this section for any fiscal year for which the total appropriations for such sections are less than the total amount appropriated under such sections in fiscal year 2004.</text></subsection></section> <section id="HE0E94F3700C9412A9227F991CE00C933"><enum>713.</enum><header>Primary care service expansion grants</header><text display-inline="no-display-inline">Part D of title III of the <act-name parsable-cite="PHSA">Public Health Service Act</act-name> (<external-xref legal-doc="usc" parsable-cite="usc/42/254b">42 U.S.C. 254b et seq.</external-xref>) is amended by adding at the end thereof the following new subpart:</text> <quoted-block act-name="Public Health Service Act" id="H0B650AD6B01A41E381965440F0897900"> <subpart id="HB302CBFBB7C34D44954CB7A34D09882C"><enum>XI</enum><header>Primary care expansion</header> <section id="HFB7D51C2119845D7A8151B8FEB0004A0"><enum>340H.</enum><header>Expanding primary care delivery capacity in urban and rural areas</header> <subsection id="H470C448E5D3140ED9517AEDFC91E5470"><enum>(a)</enum><header>Grants for primary care centers</header><text>From the amounts described in subsection (c), the American Health Security Standards Board shall make grants to public and nonprofit private entities for projects to plan and develop primary care centers which will serve medically underserved populations (as defined in section 330(b)(3)) in urban and rural areas and to deliver primary care services to such populations in such areas. The funds provided under such a grant may be used for the same purposes for which a grant may be made under subsection (c), (e), (f), (g), (h), or (i) of section 330.</text></subsection> <subsection id="H93ADFE769E5F4B4A88186C2D8B171D04"><enum>(b)</enum><header>Process of awarding grants</header><text>The provisions of subsection (k)(1) of section 330 shall apply to a grant under this section in the same manner as they apply to a grant under the corresponding subsection of such section. The provisions of subsection (r)(2)(A) of such section shall apply to grants for projects to plan and develop primary care centers under this section in the same manner as they apply to grants under such section.</text></subsection> <subsection id="H5549D64DA2F940D69191A311034BF342"><enum>(c)</enum><header>Funding as set-aside from Trust Fund</header><text>Funding to carry out this section is provided from the American Health Security Trust Fund in accordance with section 912 of the <short-title>American Health Security Act of 2005</short-title>.</text></subsection> <subsection id="H21B2D186CE7C4876A11BC28EA808D013"><enum>(d)</enum><header>Primary care center defined</header><text>In this section, the term <term>primary care center</term> means—</text> <paragraph id="H4CAAC75015D14D5B878EB5F5A4C1DE1"><enum>(1)</enum><text>a health center (as defined in section 330(1));</text></paragraph> <paragraph id="H7A3AAC6767EC4E4D8EF2B354E3AB936B"><enum>(2)</enum><text>an entity qualified to receive a grant under section 330, 1001 or 2655; or</text></paragraph> <paragraph id="HF5552EAEB0014405B3D5CAC299FE400"><enum>(3)</enum><text>a federally qualified health center (as defined in section 1905(l)(2)(B) of the <act-name parsable-cite="SSA">Social Security Act</act-name>).</text></paragraph></subsection></section></subpart><after-quoted-block>.</after-quoted-block></quoted-block></section></subtitle> <subtitle id="HB1F2CE8088FF46439609755837F324C4"><enum>C</enum><header>Primary care and outcomes research</header> <section id="H0349115DF45C4DE9B062E46EEEFF1767"><enum>721.</enum><header>Set-aside for outcomes research</header> <subsection id="HDD1B3C87ED1C416F9B257D2209E861D5"><enum>(a)</enum><header>Grants for outcomes research</header><text>The Board shall make transfers from the American Health Security Trust Fund to the Agency for Health Care Policy and Research under title IX of the <act-name parsable-cite="PHSA">Public Health Service Act</act-name> for the purpose of carrying out activities under such title. The Secretary shall assure that there is a special emphasis placed on pediatric outcomes research.</text></subsection> <subsection id="HEB72139FB7FA4B6396943410D123CA9"><enum>(b)</enum><header>Range of funds</header><text>The amount of transfers under subsection (a) for any fiscal year shall be an amount (specified by the Board each year) not less than <fraction>1/100</fraction> percent and not to exceed \2/100\ percent of the amounts the Board estimates will be expended from the Trust Fund in the fiscal year.</text></subsection> <subsection id="H09E960D0A4444EC788027EDA75E45225"><enum>(c)</enum><header>Funds supplemental to other funds</header><text>The funds provided under this section with respect to provision of services are in addition to, and not in replacement of, funds made available to the Agency for Health Care Policy and Research under section 926 of the <act-name parsable-cite="PHSA">Public Health Service Act</act-name>. The Board shall make no transfer of funds under this section for any fiscal year for which the total appropriations under such section are less than the total amount appropriated under such section and title in fiscal year 2004.</text></subsection> <subsection id="HA555CC9B7C5D48DCAEB9D5D6683F4F2D"><enum>(d)</enum><header>Conforming amendment</header><text>Section 927(b) of the <act-name parsable-cite="PHSA">Public Health Service Act</act-name> (<external-xref legal-doc="usc" parsable-cite="usc/42/299c-6">42 U.S.C. 299c–6(b)</external-xref>) is amended by striking <quote>of the fiscal years 2001 through 2005</quote> and inserting <quote>subsequent fiscal year</quote>.</text></subsection></section> <section id="HBFAB4EE9D9A5448190DC3D6D6EF7AE12"><enum>722.</enum><header>Office of Primary Care and Prevention Research</header> <subsection id="H79583CF62247428AAC00C001121DF3CD"><enum>(a)</enum><header>In general</header><text>Title IV of the <act-name parsable-cite="PHSA">Public Health Service Act</act-name> is amended—</text> <paragraph id="H6397D94386F9494B9900B8CF6D59CCF"><enum>(1)</enum><text>by redesignating parts G through I as parts H through J, respectively; and</text></paragraph> <paragraph id="HC09458296EED44C4ADA606F063152890"><enum>(2)</enum><text>by inserting after part F the following new part:</text> <quoted-block id="H58F75EE738CF4009BC3C5D181FE5A55E"> <part id="H7588865620604D699945B018485D5100"><enum>G</enum><header>Research on primary care and prevention</header> <section id="H2F1C0B5F913B44AFAD94A3E7FDD4DC5B"><enum>486E.</enum><header>Office of Primary Care and Prevention Research</header> <subsection id="H794EF1C8C6C5432281E4433C0083AB01"><enum>(a)</enum><header>Establishment</header><text>There is established within the Office of the Director of NIH an office to be known as the Office of Primary Care and Prevention Research (in this part referred to as the <quote>Office</quote>). The Office shall be headed by a director, who shall be appointed by the Director of NIH.</text></subsection> <subsection id="H5D8A4FD9DF5D4F498D5749C900F38DBE"><enum>(b)</enum><header>Purpose</header><text>The Director of the Office shall—</text> <paragraph id="H7AE40E70279C47A191D40028BEDBF0A0"><enum>(1)</enum><text>identify projects of research on primary care and prevention, for children as well as adults, that should be conducted or supported by the national research institutes, with particular emphasis on—</text> <subparagraph id="HD145207F71AE46C7B2C6CDEDF5B95CE"><enum>(A)</enum><text>clinical patient care, with special emphasis on pediatric clinical care and diagnosis;</text></subparagraph> <subparagraph id="HE66915C286F74B04B5912C8C06EC4FE8"><enum>(B)</enum><text>diagnostic effectiveness;</text></subparagraph> <subparagraph id="HDBA48946D68D4AB49CCC00007148DF9"><enum>(C)</enum><text>primary care education;</text></subparagraph> <subparagraph id="H2793307B5CE84299A7CB8AF35000640"><enum>(D)</enum><text>health and family planning services;</text></subparagraph> <subparagraph id="H0C2E0B8808A94FD79E121DBD2E38C4CB"><enum>(E)</enum><text>medical effectiveness outcomes of primary care procedures and interventions; and</text></subparagraph> <subparagraph id="HE608EA40B2604723B058B3DFB94C9B6E"><enum>(F)</enum><text>the use of multidisciplinary teams of health care practitioners;</text></subparagraph></paragraph> <paragraph id="HE942E60863554471A8351B08D67FEBE"><enum>(2)</enum><text>identify multidisciplinary research related to primary care and prevention that should be so conducted;</text></paragraph> <paragraph id="H058DE5D5C2574497AA00C6001005DD9D"><enum>(3)</enum><text>promote coordination and collaboration among entities conducting research identified under any of paragraphs (1) and (2);</text></paragraph> <paragraph id="H8E8F65850A8643F0BA272B1236D3B14"><enum>(4)</enum><text>encourage the conduct of such research by entities receiving funds from the national research institutes;</text></paragraph> <paragraph id="HE55AA39EC3114797A48DECAB0057C988"><enum>(5)</enum><text>recommend an agenda for conducting and supporting such research;</text></paragraph> <paragraph id="H64A961C8FF3F4BAD8176FA21536CB6D7"><enum>(6)</enum><text>promote the sufficient allocation of the resources of the national research institutes for conducting and supporting such research; and</text></paragraph> <paragraph id="H05949ED344CE487DB0D4048377A2EE38"><enum>(7)</enum><text>prepare the report required in section 486G.</text></paragraph></subsection> <subsection id="H7A4A69E008CC47A289F025DB0058BF84"><enum>(c)</enum><header>Primary care and prevention research defined</header><text>For purposes of this part, the term <term>primary care and prevention research</term> means research on improvement of the practice of family medicine, general internal medicine, and general pediatrics, and includes research relating to—</text> <paragraph id="HA4F5F785D8FD4A38B3C6007B4E4E00E4"><enum>(1)</enum><text>obstetrics and gynecology, dentistry, or mental health or substance abuse treatment when provided by a primary care physician or other primary care practitioner; and</text></paragraph> <paragraph id="HAEA9D262230442828F4F19805CDB3FE5"><enum>(2)</enum><text>primary care provided by multidisciplinary teams.</text></paragraph></subsection></section> <section id="H5BE4D2E6689C499B8972E03DD1501007"><enum>486F.</enum><header>National data system and clearinghouse on primary care and prevention research</header> <subsection id="H4C01417C2DDF4C05B5A446E51716F12D"><enum>(a)</enum><header>Data system</header><text>The Director of NIH, in consultation with the Director of the Office, shall establish a data system for the collection, storage, analysis, retrieval, and dissemination of information regarding primary care and prevention research that is conducted or supported by the national research institutes. Information from the data system shall be available through information systems available to health care professionals and providers, researchers, and members of the public.</text></subsection> <subsection id="H9A2C4F053A2C473EB29B48D04E33196"><enum>(b)</enum><header>Clearinghouse</header><text>The Director of NIH, in consultation with the Director of the Office and with the National Library of Medicine, shall establish, maintain, and operate a program to provide, and encourage the use of, information on research and prevention activities of the national research institutes that relate to primary care and prevention research.</text></subsection></section> <section id="H5C3184AAF06544F0B0004C3CD05EADDE"><enum>486G.</enum><header>Biennial report</header> <subsection id="H28570B86B0EF44F1AAC37765BCBE4400"><enum>(a)</enum><header>In general</header><text>With respect to primary care and prevention research, the Director of the Office shall, not later than 1 year after the date of the enactment of this part, and biennially thereafter, prepare a report—</text> <paragraph id="H1C087CFD8A89422E00B5168AB1397DC"><enum>(1)</enum><text>describing and evaluating the progress made during the preceding 2 fiscal years in research and treatment conducted or supported by the National Institutes of Health;</text></paragraph> <paragraph id="H4C848880CB3042A7A0922E7E9740541B"><enum>(2)</enum><text>summarizing and analyzing expenditures made by the agencies of such Institutes (and by such Office) during the preceding 2 fiscal years; and</text></paragraph> <paragraph id="HF83FD33FEF1A45BAB9A147C1E876AF2C"><enum>(3)</enum><text>making such recommendations for legislative and administrative initiatives as the Director of the Office determines to be appropriate.</text></paragraph></subsection> <subsection id="H52E9EF06B0C34CD083A503D77EAF4000"><enum>(b)</enum><header>Inclusion in biennial report of Director of NIH</header><text>The Director of the Office shall submit each report prepared under subsection (a) to the Director of NIH for inclusion in the report submitted to the President and the Congress under section 403.</text></subsection></section> <section id="H16FCCF48C5AF4E9CBE4C1D24A6181FA"><enum>486H.</enum><header>Authorization of appropriations</header><text display-inline="no-display-inline">For the Office of Primary Care and Prevention Research, there are authorized to be appropriated $150,000,000 for fiscal year 2006, $180,000,000 for fiscal year 2007, and $216,000,000 for fiscal year 2008.</text></section></part><after-quoted-block>.</after-quoted-block></quoted-block></paragraph></subsection> <subsection id="HFAE6F15989DA4C748DBF8ADC379B642"><enum>(b)</enum><header>Requirement of sufficient allocation of resources of Institutes</header><text>Section 402(b) of the <act-name parsable-cite="PHSA">Public Health Service Act</act-name> (<external-xref legal-doc="usc" parsable-cite="usc/42/282">42 U.S.C. 282(b)</external-xref>) is amended—</text> <paragraph id="H60A13602D77445D1B7C8EA9FBB8F0FA"><enum>(1)</enum><text>in paragraph (13), by striking <quote>and</quote> after the semicolon at the end;</text></paragraph> <paragraph id="H846EE2F2E1C745739FDAEFB7BDC1FA"><enum>(2)</enum><text>in paragraph (14), by striking the period at the end and inserting <quote>; and</quote>; and</text></paragraph> <paragraph id="HA9E8D6B11B8F4D7AA0DE11E573009CE1"><enum>(3)</enum><text>by inserting after paragraph (14) the following new paragraph:</text> <quoted-block id="HFB4C47840C1C4D84A2009BB633DF27C6"> <paragraph id="H42B4735EB2B24B83B09C1DD29FFF2540"><enum>(15)</enum><text>after consultation with the Director of the Office of Primary Care and Prevention Research, shall ensure that resources of the National Institutes of Health are sufficiently allocated for projects on primary care and prevention research that are identified under section 486E(b).</text></paragraph><after-quoted-block>.</after-quoted-block></quoted-block></paragraph></subsection></section></subtitle> <subtitle id="H90EA0144935842A500A5F323A951CD6D"><enum>D</enum><header>School-related health services</header> <section id="H233B1862DEE5410882F7F87F132EE923"><enum>731.</enum><header>Authorizations of appropriations</header> <subsection id="H3479D1C7DBD3474BB23FF9DAF400AF7E"><enum>(a)</enum><header>Funding for school-related health services</header><text>For the purpose of carrying out this subtitle, there are authorized to be appropriated $100,000,000 for fiscal year 2008, $275,000,000 for fiscal year 2009, $350,000,000 for fiscal year 2010, and $400,000,000 for each of the fiscal years 2011 and 2012.</text></subsection> <subsection id="HA49066AB429D454CBE3C82C754EE4EBA"><enum>(b)</enum><header>Relation to other funds</header><text>The authorizations of appropriations established in subsection (a) are in addition to any other authorizations of appropriations that are available for the purpose described in such subsection.</text></subsection></section> <section id="H7C9C2D73114F4823968D422141003BA4"><enum>732.</enum><header>Eligibility for development and operation grants</header> <subsection id="H1EF31038986A46AAA24636D4836FFCE8"><enum>(a)</enum><header>In general</header><text>Entities eligible to apply for and receive grants under section 734 or 735 are the following:</text> <paragraph id="HF7DA9792E64049599BC67F00C5D4973E"><enum>(1)</enum><text>State health agencies that apply on behalf of local community partnerships and other communities in need of health services for school-aged children within the State.</text></paragraph> <paragraph id="H4F904A21983642C4BEC47EAE1118DDF8"><enum>(2)</enum><text>Local community partnerships in States in which health agencies have not applied.</text></paragraph></subsection> <subsection id="H07E9C2CC96704F208735009BEC5F31AB"><enum>(b)</enum><header>Local community partnerships</header> <paragraph id="HAFF1126E7C4141949700B700DE560596"><enum>(1)</enum><header>In general</header><text>A local community partnership under subsection (a)(2) is an entity that, at a minimum, includes—</text> <subparagraph id="HCF36621076864D57AFE37884E34EB14C"><enum>(A)</enum><text>a local health care provider with experience in delivering services to school-aged children;</text></subparagraph> <subparagraph id="H806E8E870F934A419F3FCC08C65C98CD"><enum>(B)</enum><text>1 or more local public schools; and</text></subparagraph> <subparagraph id="H7CB20FAFACCD445996C16D0136C659EA"><enum>(C)</enum><text>at least 1 community based organization located in the community to be served that has a history of providing services to school-aged children in the community who are at-risk.</text></subparagraph></paragraph> <paragraph id="H57DC0280A50348C79B665494F3E7D7F5"><enum>(2)</enum><header>Participation</header><text>A partnership described in paragraph (1) shall, to the maximum extent feasible, involve broad based community participation from parents and adolescent children to be served, health and social service providers, teachers and other public school and school board personnel, development and service organizations for adolescent children, and interested business leaders. Such participation may be evidenced through an expanded partnership, or an advisory board to such partnership.</text></paragraph></subsection> <subsection id="H26A51F0D08344CB2B7F221443F373610"><enum>(c)</enum><header>Definitions regarding children</header><text>For purposes of this subtitle:</text> <paragraph id="HA7C89154D5C441278162FFA3095587F4"><enum>(1)</enum><text>The term <term>adolescent children</term> means school-aged children who are adolescents.</text></paragraph> <paragraph id="HEE4B94ADFCEF414D85EB1FB800BC51AD"><enum>(2)</enum><text>The term <term>school-aged children</term> means individuals who are between the ages of 4 and 19 (inclusive).</text></paragraph></subsection></section> <section id="H6CE5155411F3443189667E22681DFFAB"><enum>733.</enum><header>Preferences</header> <subsection id="HA08CEFC2D091437285857160E6AEB1B7"><enum>(a)</enum><header>In general</header><text>In making grants under sections 734 and 735, the Secretary shall give preference to applicants whose communities to be served show the most substantial level of need for such services among school-aged children, as measured by indicators of community health including the following:</text> <paragraph id="H4770D77C49FC4A5F8D60E1237E09193D"><enum>(1)</enum><text>High levels of poverty.</text></paragraph> <paragraph id="HA259754DE40D4ECFAD06607FD1DB2FB4"><enum>(2)</enum><text>The presence of a medically underserved population.</text></paragraph> <paragraph id="H5AD53546283D43789E2108766190DA12"><enum>(3)</enum><text>The presence of a health professional shortage area.</text></paragraph> <paragraph id="HFCCF940477CC4C30B6FFE8F1DC1E12DD"><enum>(4)</enum><text>High rates of indicators of health risk among school-aged children, including a high proportion of such children receiving services through the Individuals with Disabilities Education Act, adolescent pregnancy, sexually transmitted disease (including infection with the human immunodeficiency virus), preventable disease, communicable disease, intentional and unintentional injuries, community and gang violence, unemployment among adolescent children, juvenile justice involvement, and high rates of drug and alcohol exposure.</text></paragraph></subsection> <subsection id="H0B4C9C549EFE4A5391E0A7E2C93E8CAB"><enum>(b)</enum><header>Linkage to community health centers</header><text>In making grants under sections 734 and 735, the Secretary shall give preference to applicants that demonstrate a linkage to community health centers.</text></subsection></section> <section id="H13AC0B0954B148258D343D1F57F52DE"><enum>734.</enum><header>Grants for development of projects</header> <subsection id="H581AEBCC7BC84B54A8D7BAAA201EFA4C"><enum>(a)</enum><header>In general</header><text>The Secretary may make grants to State health agencies or to local community partnerships to develop school health service sites.</text></subsection> <subsection id="HD0DC72930C8B4DC49200D1B07B324600"><enum>(b)</enum><header>Use of funds</header><text>A project for which a grant may be made under subsection (a) may include but not be limited to the cost of the following:</text> <paragraph id="HE7A5BE608A56459098BB3BC1556BBA1F"><enum>(1)</enum><text>Planning for the provision of school health services.</text></paragraph> <paragraph id="H89DCF1D4BE3046A58E1B9E0048D2077F"><enum>(2)</enum><text>Recruitment, compensation, and training of health and administrative staff.</text></paragraph> <paragraph id="HB12D249C782E4CF19F12F77D31DC18EE"><enum>(3)</enum><text>The development of agreements, and the acquisition and development of equipment and information services, necessary to support information exchange between school health service sites and health plans, health providers, and other entities authorized to collect information under this Act.</text></paragraph> <paragraph id="H2154266D6FE6451BA0C5A9BA1F494796"><enum>(4)</enum><text>Other activities necessary to assume operational status.</text></paragraph></subsection> <subsection id="HC0D87ACAF6584D76A067E28ECDA96640"><enum>(c)</enum><header>Application for grant</header> <paragraph id="HCDB7AF5152B2430681C202C4D64EC5F"><enum>(1)</enum><header>In general</header><text>Applicants shall submit applications in a form and manner prescribed by the Secretary.</text></paragraph> <paragraph id="HE7BDBE67E28D429388C191DDDF064B6"><enum>(2)</enum><header>Applications by State health agencies</header> <subparagraph id="H523E1DDD668D41A19B9EDE11E4D66B1D"><enum>(A)</enum><text>In the case of applicants that are State health agencies, the application shall contain assurances that the State health agency is applying for funds—</text> <clause id="H3425526057A0498AA76C4519126125A4"><enum>(i)</enum><text>on behalf of at least 1 local community partnership; and</text></clause> <clause id="H3AD3EF8428CA43D69083D108B461F7D7"><enum>(ii)</enum><text>on behalf of at least 1 other community identified by the State as in need of the services funded under this subtitle but without a local community partnership.</text></clause></subparagraph> <subparagraph id="H16088FE9471A40A9A01E3364C119F6E7"><enum>(B)</enum><text>In the case of the communities identified in applications submitted by State health agencies that do not yet have local community partnerships (including the community identified under subparagraph (A)(ii)), the State shall describe the steps that will be taken to aid the communities in developing a local community partnership.</text></subparagraph> <subparagraph id="H412EC71E6E534B07AA681C80F25B8086"><enum>(C)</enum><text>A State applying on behalf of local community partnerships and other communities may retain not more than 10 percent of grants awarded under this subtitle for administrative costs.</text></subparagraph></paragraph></subsection> <subsection id="H5302D24672E145078322CB8E1C7D7111"><enum>(d)</enum><header>Contents of application</header><text>In order to receive a grant under this section, an applicant must include in the application the following information:</text> <paragraph id="H70F82713D78044CA9B69DA2F9891523E"><enum>(1)</enum><text>An assessment of the need for school health services in the communities to be served, using the latest available health data and health goals and objectives established by the Secretary.</text></paragraph> <paragraph id="HB8BC162940C645BAAC3C00D1591012E"><enum>(2)</enum><text>A description of how the applicant will design the proposed school health services to reach the maximum number of school-aged children who are at risk.</text></paragraph> <paragraph id="H1C173677DA4A420186A35055A11BB32"><enum>(3)</enum><text>An explanation of how the applicant will integrate its services with those of other health and social service programs within the community.</text></paragraph> <paragraph id="H185996600EA64A4BB3542BD8AF0000E7"><enum>(4)</enum><text>A description of a quality assurance program which complies with standards that the Secretary may prescribe.</text></paragraph></subsection> <subsection id="HF0BCFEC5549F4980B9B4E7ECD51BE456"><enum>(e)</enum><header>Number of grants</header><text>Not more than 1 planning grant may be made to a single applicant. A planning grant may not exceed 2 years in duration.</text></subsection></section> <section id="H3E683188F8094258975D7D9649EA7FC1"><enum>735.</enum><header>Grants for operation of projects</header> <subsection id="H199FA4D9C151453A87AA7A475667DD5"><enum>(a)</enum><header>In general</header><text>The Secretary may make grants to State health agencies or to local community partnerships for the cost of operating school health service sites.</text></subsection> <subsection id="H9C60A9D303C54D7AB25E8F9C6E3DBFC7"><enum>(b)</enum><header>Use of grant</header><text>The costs for which a grant may be made under this section include but are not limited to the following:</text> <paragraph id="HB1CEF8A5EBB842BEB9A0693498CEC5EE"><enum>(1)</enum><text>The cost of furnishing health services that are not otherwise covered under this Act or by any other public or private insurer.</text></paragraph> <paragraph id="HC0650EC5D85C40C892F8E8BECEB26874"><enum>(2)</enum><text>The cost of furnishing services whose purpose is to increase the capacity of individuals to utilize available health services, including transportation, community and patient outreach, patient education, translation services, and such other services as the Secretary determines to be appropriate in carrying out such purpose.</text></paragraph> <paragraph id="H1934A079E66B4A65A7B4C3D6F94EA2DB"><enum>(3)</enum><text>Training, recruitment and compensation of health professionals and other staff.</text></paragraph> <paragraph id="HF773D0BD29CD4588AE9E54409634B631"><enum>(4)</enum><text>Outreach services to school-aged children who are at risk and to the parents of such children.</text></paragraph> <paragraph id="H09AA4B7804A64CF9B89162343BB5E800"><enum>(5)</enum><text>Linkage of individuals to health plans, community health services and social services.</text></paragraph> <paragraph id="H6A516C68D8B541EF86C0A4D7E8F5FC19"><enum>(6)</enum><text>Other activities deemed necessary by the Secretary.</text></paragraph></subsection> <subsection id="H3CF99178473A45E5B48CC13CF30663AD"><enum>(c)</enum><header>Application for grant</header><text>Applicants shall submit applications in a form and manner prescribed by the Secretary. In order to receive a grant under this section, an applicant must include in the application the following information:</text> <paragraph id="HD938D448CE4049D19F956C1F24A1F4BA"><enum>(1)</enum><text>A description of the services to be furnished by the applicant.</text></paragraph> <paragraph id="H6900EB3D5C364163AAB85C1383AC7B29"><enum>(2)</enum><text>The amounts and sources of funding that the applicant will expend, including estimates of the amount of payments the applicant will receive from sources other than the grant.</text></paragraph> <paragraph id="HEADEA8F75FDA4784B6C0C734ED6294FC"><enum>(3)</enum><text>Such other information as the Secretary determines to be appropriate.</text></paragraph></subsection> <subsection id="HB1C12EE44581472CB258C8F4347565A6"><enum>(d)</enum><header>Additional contents of application</header><text>In order to receive a grant under this section, an applicant must meet the following conditions:</text> <paragraph id="H8ABB5CC5EE0C41FEBCC9CF2C082B8100"><enum>(1)</enum><text>The applicant furnishes the following services:</text> <subparagraph id="HB5C5B1AC784243DDB26EA8F8007E07E0"><enum>(A)</enum><text>Diagnosis and treatment of simple illnesses and minor injuries.</text></subparagraph> <subparagraph id="H735B51EB76484A04BAEA93E5F72F7DD7"><enum>(B)</enum><text>Preventive health services, including health screenings.</text></subparagraph> <subparagraph id="HA659033B11A844EFAD1975FC79CF1ECA"><enum>(C)</enum><text>Services provided for the purpose described in subsection (b)(2).</text></subparagraph> <subparagraph id="H93ED5AC5BFD7494FB1DA20D73E241BEA"><enum>(D)</enum><text>Referrals and followups in situations involving illness or injury.</text></subparagraph> <subparagraph id="HBCCBC6B6C1C04F4CAAB1585FB3F7BC60"><enum>(E)</enum><text>Health and social services, counseling services, and necessary referrals, including referrals regarding mental health and substance abuse.</text></subparagraph> <subparagraph id="HCA282E20CAA543C7A4CE37F9A04DBDA7"><enum>(F)</enum><text>Such other services as the Secretary determines to be appropriate.</text></subparagraph></paragraph> <paragraph id="H3BEC517E2274437F93F8C3D37094F216"><enum>(2)</enum><text>The applicant is a participating provider in the State’s program for medical assistance under title XIX of the <act-name parsable-cite="SSA">Social Security Act</act-name>.</text></paragraph> <paragraph id="H9478BEAF968F4BB1896B2D5242357BA9"><enum>(3)</enum><text>The applicant does not impose charges on students or their families for services (including collection of any cost-sharing for services under the comprehensive benefit package that otherwise would be required).</text></paragraph> <paragraph id="H4D440B7ECA3243EFB187EE86E6A5EEB5"><enum>(4)</enum><text>The applicant has reviewed and will periodically review the needs of the population served by the applicant in order to ensure that its services are accessible to the maximum number of school-aged children in the area, and that, to the maximum extent possible, barriers to access to services of the applicant are removed (including barriers resulting from the area’s physical characteristics, its economic, social and cultural grouping, the health care utilization patterns of such children, and available transportation).</text></paragraph> <paragraph id="H298AA064E63648CD9CA514872F4E9627"><enum>(5)</enum><text>In the case of an applicant which serves a population that includes a substantial proportion of individuals of limited English speaking ability, the applicant has developed a plan to meet the needs of such population to the extent practicable in the language and cultural context most appropriate to such individuals.</text></paragraph> <paragraph id="H2EB8DA6B2C154EC096C5219E7937E3BC"><enum>(6)</enum><text>The applicant will provide non-Federal contributions toward the cost of the project in an amount determined by the Secretary.</text></paragraph> <paragraph id="H0F60550A22D54D19868FE86F3EA01564"><enum>(7)</enum><text>The applicant will operate a quality assurance program consistent with section 734(d).</text></paragraph></subsection> <subsection id="H032902C966D4447B9915D0895030CC65"><enum>(e)</enum><header>Duration of grant</header><text>A grant under this section shall be for a period determined by the Secretary.</text></subsection> <subsection id="HE0C58421346D4755BB2727534799D59F"><enum>(f)</enum><header>Reports</header><text>A recipient of funding under this section shall provide such reports and information as are required in regulations of the Secretary.</text></subsection></section> <section id="HAA84006404E24E71B13B37C2B74400EB"><enum>736.</enum><header>Federal administrative costs</header><text display-inline="no-display-inline">Of the amounts made available under section 731, the Secretary may reserve not more than 5 percent for administrative expenses regarding this subtitle.</text></section> <section id="HD04EE06D51FB4536B800F56D00198918"><enum>737.</enum><header>Definitions</header><text display-inline="no-display-inline">For purposes of this subtitle:</text> <paragraph id="H078D386C043A402B9D71824026DAEA29"><enum>(1)</enum><text>The term <term>adolescent children</term> has the meaning given such term in section 732(c).</text></paragraph> <paragraph id="HDB9126402F5A4BD498008C528D292D46"><enum>(2)</enum><text>The term <term>at risk</term> means at-risk with respect to health.</text></paragraph> <paragraph id="H3D2148486B9C44C0AFCD6CA441E43CF2"><enum>(3)</enum><text>The term <term>community health center</term> has the meaning given such term in section 330 of the <act-name parsable-cite="PHSA">Public Health Service Act</act-name>.</text></paragraph> <paragraph id="HA93F1D2E77C0416BAA8B3D828BA2138F"><enum>(4)</enum><text>The term <term>health professional shortage area</term> means a health professional shortage area designated under section 332 of the <act-name parsable-cite="PHSA">Public Health Service Act</act-name>.</text></paragraph> <paragraph id="HDE2EF9CD969A46C684D9E00198BD6083"><enum>(5)</enum><text>The term <term>medically underserved population</term> has the meaning given such term in section 330 of the <act-name parsable-cite="PHSA">Public Health Service Act</act-name>.</text></paragraph> <paragraph id="HD7C36CE829F945458CC84D2E3E1EA5DB"><enum>(6)</enum><text>The term <term>school-aged children</term> has the meaning given such term in section 732(c).</text></paragraph></section></subtitle> <enum>VIII</enum><header>Financing provisions; American Health Security Trust Fund</header> <section id="H4E9340A0A4A14D878C9F5206C282CFD"><enum>800.</enum><header>Amendment of 1986 code; Section 15 not to apply</header> <subsection id="H5BA7E5A9F6014473A90777732D5288D"><enum>(a)</enum><header>Amendment of 1986 Code</header><text>Except as otherwise expressly provided, whenever in this title an amendment or repeal is expressed in terms of an amendment to, or repeal of, a section or other provision, the reference shall be considered to be made to a section or other provision of the Internal Revenue Code of 1986.</text></subsection> <subsection id="HA5050E29704C40C2BB9FC97C09339078"><enum>(b)</enum><header>Section 15 not to apply</header><text>The amendments made by subtitle B shall not be treated as a change in a rate of tax for purposes of <external-xref legal-doc="usc" parsable-cite="usc/26/15">section 15</external-xref> of the Internal Revenue Code of 1986.</text></subsection></section> <subtitle id="H6B8245AED5D6449A9825BB31DEEABB3B"><enum>A</enum><header>American Health Security Trust Fund</header> <section id="H099643D6E760486CB18B59E999ABD9B9"><enum>801.</enum><header>American Health Security Trust Fund</header> <subsection id="HD457FD8F8CC546FE8EA714ABD7F07C00"><enum>(a)</enum><header>In general</header><text>There is hereby created on the books of the Treasury of the United States a trust fund to be known as the American Health Security Trust Fund (in this section referred to as the <quote>Trust Fund</quote>). The Trust Fund shall consist of such gifts and bequests as may be made and such amounts as may be deposited in, or appropriated to, such Trust Fund as provided in this Act.</text></subsection> <subsection id="H1ED380894AAE4391A6088DB0042634A0"><enum>(b)</enum><header>Appropriations into Trust Fund</header> <paragraph id="HB7FC3E38038347A08F79FEF06256505D"><enum>(1)</enum><header>Taxes</header><text>There are hereby appropriated to the Trust Fund for each fiscal year (beginning with fiscal year 2006), out of any moneys in the Treasury not otherwise appropriated, amounts equivalent to 100 percent of the aggregate increase in tax liabilities under the Internal Revenue Code of 1986 which is attributable to the application of the amendments made by this title. The amounts appropriated by the preceding sentence shall be transferred from time to time (but not less frequently than monthly) from the general fund in the Treasury to the Trust Fund, such amounts to be determined on the basis of estimates by the Secretary of the Treasury of the taxes paid to or deposited into the Treasury; and proper adjustments shall be made in amounts subsequently transferred to the extent prior estimates were in excess of or were less than the amounts that should have been so transferred.</text></paragraph> <paragraph id="HDC855E015D4C482C95EB53EFDEC7F82B"><enum>(2)</enum><header>Current program receipts</header><text>Notwithstanding any other provision of law, there are hereby appropriated to the Trust Fund for each fiscal year (beginning with fiscal year 2006) the amounts that would otherwise have been appropriated to carry out the following programs:</text> <subparagraph id="H412B297FD06E4203A8AEDFE72DF4E87B"><enum>(A)</enum><text>The medicare program, under parts A, B, and D of title XVIII of the <act-name parsable-cite="SSA">Social Security Act</act-name> (other than amounts attributable to any premiums under such parts).</text></subparagraph> <subparagraph id="H477D47BE70314BEB98CADE6B17E9E95B"><enum>(B)</enum><text>The medicaid program, under State plans approved under title XIX of such Act.</text></subparagraph> <subparagraph id="H1DED788E46CF4BBCB306340198591864"><enum>(C)</enum><text>The Federal employees health benefit program, under <external-xref legal-doc="usc-chapter" parsable-cite="usc-chapter/5/89">chapter 89</external-xref> of title 5, United States Code.</text></subparagraph> <subparagraph id="H7FA95ABF993B46F991ADA43C81CFC95"><enum>(D)</enum><text>The TRICARE program (formerly known as the CHAMPUS program), under <external-xref legal-doc="usc-chapter" parsable-cite="usc-chapter/10/55">chapter 55</external-xref> of title 10, United States Code.</text></subparagraph> <subparagraph id="HDB97FC01AA4E449FA9A280F5024390CB"><enum>(E)</enum><text>The maternal and child health program (under title V of the <act-name parsable-cite="SSA">Social Security Act</act-name>), vocational rehabilitation programs, programs for drug abuse and mental health services under the <act-name parsable-cite="PHSA">Public Health Service Act</act-name>, programs providing general hospital or medical assistance, and any other Federal program identified by the Board, in consultation with the Secretary of the Treasury, to the extent the programs provide for payment for health services the payment of which may be made under this Act.</text></subparagraph></paragraph></subsection> <subsection id="HD8643FA7D9EC4A8CB8DC5DC78300CBC1"><enum>(c)</enum><header>Incorporation of provisions</header><text>The provisions of subsections (b) through (i) of section 1817 of the <act-name parsable-cite="SSA">Social Security Act</act-name> shall apply to the Trust Fund under this Act in the same manner as they applied to the Federal Hospital Insurance Trust Fund under part A of title XVIII of such Act, except that the American Health Security Standards Board shall constitute the Board of Trustees of the Trust Fund.</text></subsection> <subsection id="H1749A32E855F4E458C8DF1269FA9C36E"><enum>(d)</enum><header>Transfer of funds</header><text>Any amounts remaining in the Federal Hospital Insurance Trust Fund or the Federal Supplementary Medical Insurance Trust Fund after the settlement of claims for payments under title XVIII have been completed, shall be transferred into the American Health Security Trust Fund.</text></subsection></section></subtitle> <subtitle id="H07730B5A17184AAD99EBA566F28E7B41"><enum>B</enum><header>Taxes based on income and wages</header> <section id="H7940968FD631462FA024229DFC33FC13"><enum>811.</enum><header>Payroll tax on employers</header> <subsection id="H38477ECCACC2471B8D131B07795778FB"><enum>(a)</enum><header>In general</header><text>Section 3111 (relating to tax on employers) is amended by redesignating subsection (c) as subsection (d) and inserting after subsection (b) the following new subsection:</text> <quoted-block id="HB5D0FAF97EB042D0B341B6A6FF709BB"> <subsection id="H672EA1897F9645AA924D73ADA8CB01"><enum>(c)</enum><header>Health care</header><text>In addition to other taxes, there is hereby imposed on every employer an excise tax, with respect to having individuals in his employ, equal to 8.7 percent of the wages (as defined in section 3121(a)) paid by him with respect to employment (as defined in section 3121(b)).</text></subsection><after-quoted-block></after-quoted-block></quoted-block></subsection> <subsection id="HAE9FECCD590A47CCBBD400CADE4E511D"><enum>(b)</enum><header>Self-employment income</header><text>Section 1401 (relating to rate of tax on self-employment income) is amended by redesignating subsection (c) as subsection (d) and inserting after subsection (b) the following new subsection:</text> <quoted-block id="HA0AD00B8EEE24884BAEFA6B7E84FD1E3"> <subsection id="HC703B4572A3D47028E9DF81F95123527"><enum>(c)</enum><header>Health care</header><text>In addition to other taxes, there shall be imposed for each taxable year, on the self-employment income of every individual, a tax equal to 8.7 percent of the amount of the self-employment income for such taxable year.</text></subsection><after-quoted-block></after-quoted-block></quoted-block></subsection> <subsection id="H31A967F58D4B441F97E24223182482F6"><enum>(c)</enum><header>Comparable taxes for railroad services</header> <paragraph id="H79FFF50B1AD74784AB04AAF5409271"><enum>(1)</enum><header>Tax on employers</header><text><external-xref legal-doc="usc" parsable-cite="usc/26/3221">Section 3221</external-xref> is amended by redesignating subsection (c) as subsections (d) and inserting after subsection (b) the following new subsection:</text> <quoted-block id="H7B079F8BFD4540CD00AFFEA8FF686B89"> <subsection id="H61D8D1D7FE3D41A190D3B439E6C7D959"><enum>(c)</enum><header>Health care</header><text>In addition to other taxes, there is hereby imposed on every employer an excise tax, with respect to having individuals in his employ, equal to 8.7 percent of the compensation paid by such employer for services rendered to such employer.</text></subsection><after-quoted-block></after-quoted-block></quoted-block></paragraph> <paragraph id="H065D9C8718DF4C2189F31DB2C4517F2E"><enum>(2)</enum><header>Tax on employee representatives</header><text>Section 3211 (relating to tax on employee representatives) is amended by redesignating subsection (c) as subsection (d) and inserting after subsection (b) the following new paragraph:</text> <quoted-block id="H2BFC08EE682E403AAB8CA32DDA91FDA6"> <subsection id="H51074882CF1D491E9C2E9F4F21E14399"><enum>(c)</enum><header>Health care</header><text>In addition to other taxes, there is hereby imposed on the income of each employee representative a tax equal to 8.7 percent of the compensation received during the calendar year by such employee representative for services rendered by such employee representative.</text></subsection><after-quoted-block></after-quoted-block></quoted-block></paragraph> <paragraph id="H364049DE56F648C1BA4E27F500BE198D"><enum>(3)</enum><header>No applicable base</header><text>Subparagraph (A) of <external-xref legal-doc="usc" parsable-cite="usc/26/3231">section 3231(e)(2)</external-xref> is amended by adding at the end thereof the following new clause:</text> <quoted-block id="H1F9806DA020D448FB8B67D28C5F845AF"> <clause id="H2F9947D7934A44FFB6F047CC6483E300"><enum>(iv)</enum><header>Health care taxes</header><text>Clause (i) shall not apply to the taxes imposed by sections 3221(c) and 3211(c).</text></clause><after-quoted-block></after-quoted-block></quoted-block></paragraph> <paragraph id="HC7214CE34EED42D483CE97D8DE3695F1"><enum>(4)</enum><header>Technical amendment</header> <subparagraph id="H8039D1C8744049E8988EFEF1DE901752"><enum>(A)</enum><text>Subsection (d) of <external-xref legal-doc="usc" parsable-cite="usc/26/3211">section 3211</external-xref>, as redesignated by paragraph (2), is amended by striking <quote>and (b)</quote> and inserting <quote>, (b), and (c)</quote>.</text></subparagraph> <subparagraph id="HEC2DC82963C44AF1BFAFACAF527F75AF"><enum>(B)</enum><text>Subsection (d) of <external-xref legal-doc="usc" parsable-cite="usc/26/3221">section 3221</external-xref>, as redesignated by paragraph (1), is amended by striking <quote>and (b)</quote> and inserting <quote>, (b), and (c)</quote>.</text></subparagraph></paragraph></subsection> <subsection id="H26B005113092412AADF83102CF85F477"><enum>(d)</enum><header>Effective date</header><text>The amendments made by this section shall apply to remuneration paid after December 31, 2006.</text></subsection></section> <section id="H071B55C86948486E9D05001D8BE080A4"><enum>812.</enum><header>Health care income tax</header> <subsection id="H65D2D93C841B4B45803DEE00D9898826"><enum>(a)</enum><header>General rule</header><text>Subchapter A of chapter 1 (relating to determination of tax liability) is amended by adding at the end thereof the following new part:</text> <quoted-block id="HF349A767ABC24808006F7F186E4C50C"> <part id="HD955E48EEF3F4D59A9B8F61667381EFF"><enum>VIII</enum><header>Health care income tax on individuals</header> <toc regeneration="no-regeneration"> <toc-entry level="section">Sec. 59B. Health care income tax</toc-entry></toc> <section id="H0E27361516B0441A9D3706293D478159"><enum>59B.</enum><header>Health care income tax</header> <subsection id="HE9DF980F6C414A1A9E00E60975BC40E9"><enum>(a)</enum><header>Imposition of tax</header><text>In the case of an individual, there is hereby imposed a tax (in addition to any other tax imposed by this subtitle) equal to 2.2 percent of the taxable income of the taxpayer for the taxable year.</text></subsection> <subsection id="HFF8919F51B33441CA255009F00000483"><enum>(b)</enum><header>No credits against tax; no effect on minimum tax</header><text>The tax imposed by this section shall not be treated as a tax imposed by this chapter for purposes of determining—</text> <paragraph id="HB5EFF181B3B7441BABE2165DA76BDF79"><enum>(1)</enum><text>the amount of any credit allowable under this chapter, or</text></paragraph> <paragraph id="HCB24283A5C25441CA6FD73721D4821E"><enum>(2)</enum><text>the amount of the minimum tax imposed by section 55.</text></paragraph></subsection> <subsection id="HBBC0156911474FFAB44402B26C62EE9B"><enum>(c)</enum><header>Special rules</header> <paragraph id="HBA26AEEA01284B9AAD113B649419DE97"><enum>(1)</enum><header>Tax to be withheld, etc</header><text>For purposes of this title, the tax imposed by this section shall be treated as imposed by section 1.</text></paragraph> <paragraph id="H5F1D326C1C4F4EE8BCB6DA3C57B15C67"><enum>(2)</enum><header>Reimbursement of tax by employer not includible in gross income</header><text>The gross income of an employee shall not include any payment by his employer to reimburse the employee for the tax paid by the employee under this section.</text></paragraph> <paragraph id="HC1B3C77B89E84662A390E12B00AADFCA"><enum>(3)</enum><header>Other rules</header><text>The rules of section 59A(d) shall apply to the tax imposed by this section.</text></paragraph></subsection></section></part><after-quoted-block></after-quoted-block></quoted-block></subsection> <subsection id="H99C52A25570042A6ACC9D7D9CB894B7"><enum>(b)</enum><header>Clerical amendment</header><text>The table of parts for subchapter A of <external-xref legal-doc="usc-chapter" parsable-cite="usc-chapter/26/1">chapter 1</external-xref> is amended by adding at the end the following new item:</text> <quoted-block style="OLC" id="H0CC9A8769E6745DEA245FFB9D300EB00"> <toc regeneration="no-regeneration"> <toc-entry level="part">Part VIII. Health Care Income Tax on Individuals</toc-entry></toc><after-quoted-block>.</after-quoted-block></quoted-block></subsection> <subsection id="H8F9E0FF3463E40CBB6948F7B144C7FDA"><enum>(c)</enum><header>Effective date</header><text>The amendments made by this section shall apply to taxable years beginning after December 31, 2006.</text></subsection></section></subtitle> <subtitle id="H1EC0C9847C29434E8EE5E977606AC3F"><enum>C</enum><header>Increase in excise taxes on tobacco products</header> <section id="H1E839654049140A4BE11E14E7BF75892"><enum>821.</enum><header>Increase in excise taxes on tobacco products</header> <subsection id="H30B42932B3D740E49F7460C2CEB380E7"><enum>(a)</enum><header>Cigarettes</header><text>Subsection (b) of <external-xref legal-doc="usc" parsable-cite="usc/26/5701">section 5701</external-xref> is amended—</text> <paragraph id="HD08F7302F34E4F8CB741F07F1066BB5B"><enum>(1)</enum><text>by striking <quote>$19.50 per thousand ($17 per thousand on cigarettes removed during 2000 or 2001)</quote> in paragraph (1) and inserting <quote>$22.50 per thousand</quote>, and</text></paragraph> <paragraph id="H94DC4F56EAD549AD93703BF872B177C6"><enum>(2)</enum><text>by striking <quote>$40.95 per thousand ($35.70 per thousand on cigarettes removed during 2000 or 2001)</quote> in paragraph (2) and inserting <quote>$47.25 per thousand</quote>.</text></paragraph></subsection> <subsection id="HE09910CA391F43E190D6B228725CBB04"><enum>(b)</enum><header>Cigars</header><text>Subsection (a) of <external-xref legal-doc="usc" parsable-cite="usc/26/5701">section 5701</external-xref> is amended—</text> <paragraph id="H107160C3BD224579AF35B26E20DDFD2B"><enum>(1)</enum><text>in paragraph (1), by striking <quote>$1.828 cents per thousand ($1.594 per thousand on cigars removed during 2000 or 2001)</quote> in paragraph (1) and inserting <quote>$2.11 per thousand</quote>, and</text></paragraph> <paragraph id="H9CC25C688B4040BA8FFF00007FDC011B"><enum>(2)</enum><text>in paragraph (2) by striking <quote>equal to</quote> and all that follows in such paragraph and inserting <quote>equal to 23.91 percent of the price for which sold but not more than $56.25 per thousand.</quote></text></paragraph></subsection> <subsection id="HF668BBE425DA43688286F815B9C998C3"><enum>(c)</enum><header>Cigarette papers</header><text>Subsection (c) of <external-xref legal-doc="usc" parsable-cite="usc/26/5701">section 5701</external-xref> is amended by striking <quote>1.22 cents (1.06 cents on cigarette papers removed during 2000 or 2001)</quote> and inserting <quote>1.41 cents</quote>.</text></subsection> <subsection id="H08E81E0F40CC417FB931148EBDFA3729"><enum>(d)</enum><header>Cigarette tubes</header><text>Subsection (d) of <external-xref legal-doc="usc" parsable-cite="usc/26/5701">section 5701</external-xref> is amended by striking <quote>2.44 cents (2.13 cents on cigarette tubes removed during 2000 or 2001)</quote> and inserting <quote>2.81 cents</quote>.</text></subsection> <subsection id="H3B5CB78476854699A0CE4E7EB2470007"><enum>(e)</enum><header>Smokeless tobacco</header><text>Subsection (e) of <external-xref legal-doc="usc" parsable-cite="usc/26/5701">section 5701</external-xref> is amended—</text> <paragraph id="HB197FCC5233B4E79AC5FE08266565D06"><enum>(1)</enum><text>by striking <quote>58.5 cents (51 cents on snuff removed during 2000 or 2001)</quote> in paragraph (1) and inserting <quote>67.5 cents</quote>, and</text></paragraph> <paragraph id="H1E1D5BF228BE42A59B826709FCF3803"><enum>(2)</enum><text>by striking <quote>19.5 cents (17 cents on chewing tobacco removed during 2000 or 2001)</quote> in paragraph (2) and inserting <quote>22.5 cents</quote>.</text></paragraph></subsection> <subsection id="H5DAFEB0159884502A69E0172B493DA34"><enum>(f)</enum><header>Pipe tobacco</header><text>Subsection (f) of <external-xref legal-doc="usc" parsable-cite="usc/26/5701">section 5701</external-xref> is amended by striking <quote>$1.0969 cents (95.67 cents on pipe tobacco removed during 2000 or 2001)</quote> and inserting <quote>$1.27</quote>.</text></subsection> <subsection id="H8598B31670A649F9BA393264EEAD2D39"><enum>(g)</enum><header>Effective date</header><text>The amendments made by this section shall apply to articles removed (as defined in <external-xref legal-doc="usc" parsable-cite="usc/26/5702">section 5702(k)</external-xref> of the Internal Revenue Code of 1986) after December 31, 2006.</text></subsection> <subsection id="H0436D20D9B5C422E960011ACB15195C"><enum>(h)</enum><header>Floor stocks taxes</header> <paragraph id="H36980B82A455421D878CD87E26668B93"><enum>(1)</enum><header>Imposition of tax</header><text>On tobacco products and cigarette papers and tubes manufactured in or imported into the United States which are removed before January 1, 2007, and held on such date for sale by any person, there is hereby imposed a tax in an amount equal to the excess of—</text> <subparagraph id="H7372CB4240894A608C4BE47D3EAAFFE1"><enum>(A)</enum><text>the tax which would be imposed under <external-xref legal-doc="usc" parsable-cite="usc/26/5701">section 5701</external-xref> of the Internal Revenue Code of 1986 on the article if the article had been removed on such date, over</text></subparagraph> <subparagraph id="H2F71535951B04730A087A3703859AA67"><enum>(B)</enum><text>the prior tax (if any) imposed under section 5701 or 7652 of such Code on such article.</text></subparagraph></paragraph> <paragraph id="HD6A8398FDFBB491B9864FAF3A2A2B541"><enum>(2)</enum><header>Authority to exempt cigarettes held in vending machines</header><text>To the extent provided in regulations prescribed by the Secretary, no tax shall be imposed by paragraph (1) on cigarettes held for retail sale on January 1, 2007, by any person in any vending machine. If the Secretary provides such a benefit with respect to any person, the Secretary may reduce the $500 amount in paragraph (3) with respect to such person.</text></paragraph> <paragraph id="HECB8C7657E4C4467B7B6DDED7389D775"><enum>(3)</enum><header>Credit against tax</header><text>Each person shall be allowed as a credit against the taxes imposed by paragraph (1) an amount equal to $500. Such credit shall not exceed the amount of taxes imposed by paragraph (1) for which such person is liable.</text></paragraph> <paragraph id="H3E12ACF38BE04EAAB37E19998C724E04"><enum>(4)</enum><header>Liability for tax and method of payment</header> <subparagraph id="H8AA8441CB4A64A1A8C7EEB90095ECD99"><enum>(A)</enum><header>Liability for tax</header><text>A person holding any article on January 1, 2007, to which any tax imposed by paragraph (1) applies shall be liable for such tax.</text></subparagraph> <subparagraph id="H3B6E66C3DCD249B096CD627761CDBDF0"><enum>(B)</enum><header>Method of payment</header><text>The tax imposed by paragraph (1) shall be paid in such manner as the Secretary shall prescribe by regulations.</text></subparagraph> <subparagraph id="H8B9ADD69D540464A8BBFEE007C5ED87C"><enum>(C)</enum><header>Time for payment</header><text>The tax imposed by paragraph (1) shall be paid on or before July 31, 2007.</text></subparagraph></paragraph> <paragraph id="H716C7457FBF8422B9700B3875339E25C"><enum>(5)</enum><header>Articles in foreign trade zones</header><text>Notwithstanding the Act of June 18, 1934 (48 Stat. 998, <external-xref legal-doc="usc" parsable-cite="usc/19/81a">19 U.S.C. 81a</external-xref>) and any other provision of law, any article which is located in a foreign trade zone on January 1, 2007, shall be subject to the tax imposed by paragraph (1) if—</text> <subparagraph id="HECDD7FE7381245E89C7BD749026B9903"><enum>(A)</enum><text>internal revenue taxes have been determined, or customs duties liquidated, with respect to such article before such date pursuant to a request made under the 1st proviso of section 3(a) of such Act, or</text></subparagraph> <subparagraph id="HA203823F99114B588E44151FE0D77641"><enum>(B)</enum><text>such article is held on such date under the supervision of a customs officer pursuant to the 2d proviso of such section 3(a).</text></subparagraph></paragraph> <paragraph id="HD04688AA82794E37B104439B0000C45B"><enum>(6)</enum><header>Definitions</header><text>For purposes of this subsection—</text> <subparagraph id="H3541378BF2F5444CB5278B3BC7F2107"><enum>(A)</enum><header>In general</header><text>Terms used in this subsection which are also used in <external-xref legal-doc="usc" parsable-cite="usc/26/5702">section 5702</external-xref> of the Internal Revenue Code of 1986 shall have the respective meanings such terms have in such section.</text></subparagraph> <subparagraph id="H82025F1BA22A4697A3C4D477CE6FA79E"><enum>(B)</enum><header>Secretary</header><text>The term <term>Secretary</term> means the Secretary of the Treasury or his delegate.</text></subparagraph></paragraph> <paragraph id="H634A8FC8D4C8446F8942CD2D948C2F67"><enum>(7)</enum><header>Controlled groups</header><text>Rules similar to the rules of section 5061(e)(3) of such Code shall apply for purposes of this subsection.</text></paragraph> <paragraph id="HE2CF1CE748E04D789EEE8C13B73C1FB0"><enum>(8)</enum><header>Other laws applicable</header><text>All provisions of law, including penalties, applicable with respect to the taxes imposed by section 5701 of such Code shall, insofar as applicable and not inconsistent with the provisions of this subsection, apply to the floor stocks taxes imposed by paragraph (1), to the same extent as if such taxes were imposed by such section 5701. The Secretary may treat any person who bore the ultimate burden of the tax imposed by paragraph (1) as the person to whom a credit or refund under such provisions may be allowed or made.</text></paragraph></subsection></section></subtitle> <enum>IX</enum><header>Conforming amendments to the <act-name parsable-cite="ERISA">Employee Retirement Income Security Act of 1974</act-name></header> <section id="H468B75C7677F40FB92884624EF5406"><enum>901.</enum><header>ERISA inapplicable to health coverage arrangements under State health security programs</header><text display-inline="no-display-inline">Section 4 of the <act-name parsable-cite="ERISA">Employee Retirement Income Security Act of 1974</act-name> (<external-xref legal-doc="usc" parsable-cite="usc/29/1003">29 U.S.C. 1003</external-xref>) is amended—</text> <paragraph id="HE67FA6116ECA4F91AB372E5E236D303D"><enum>(1)</enum><text>in subsection (a), by striking <quote>or (c)</quote> and inserting <quote>(c), or (d)</quote>; and</text></paragraph> <paragraph id="HB3349D45356E40F8BCA089A76060E4A"><enum>(2)</enum><text>by adding at the end the following new subsection:</text> <quoted-block id="HFE817D5BCDF54FC7BAE1A4001E1DF0A"> <subsection id="H06305EB7312E4D9EBC62EC77118D13F3"><enum>(d)</enum><text>The provisions of this title shall not apply to any arrangement forming a part of a State health security program established pursuant to section 101(b) of the <short-title>American Health Security Act of 2005</short-title>.</text></subsection><after-quoted-block>.</after-quoted-block></quoted-block></paragraph></section> <section id="HE28CEA764D854BE8A6B0D1529CEB9C00"><enum>902.</enum><header>Exemption of State health security programs from ERISA preemption</header><text display-inline="no-display-inline">Section 514(b) of the <act-name parsable-cite="ERISA">Employee Retirement Income Security Act of 1974</act-name> (<external-xref legal-doc="usc" parsable-cite="usc/29/1144">29 U.S.C. 1144(b)</external-xref>) is amended by adding at the end the following new paragraph:</text> <quoted-block act-name="Employee Retirement Income Security Act of 1974" id="HE3455D47C277413EB200BBB0AA97741D"> <paragraph id="H24D9CDE483B24085814D789C06AFC40"><enum>(10)</enum><text>Subsection (a) of this section shall not apply to State health security programs established pursuant to section 101(b) of the <short-title>American Health Security Act of 2005</short-title>.</text></paragraph><after-quoted-block>.</after-quoted-block></quoted-block></section> <section id="H86AE2F18C6BC471EA600B3B1F0BF4F61"><enum>903.</enum><header>Prohibition of employee benefits duplicative of benefits under State health security programs; coordination in case of workers’ compensation</header> <subsection id="H509851B4F6964FC6915E37013E124F63"><enum>(a)</enum><header>In general</header><text>Part 5 of subtitle B of title I of the <act-name parsable-cite="ERISA">Employee Retirement Income Security Act of 1974</act-name> is amended by adding at the end the following new section:</text> <quoted-block style="traditional" act-name="Employee Retirement Income Security Act of 1974" id="H835A4B9493A9483DA6CBBF1E9F5E3F21"> <section id="HA58EEBF4572C4AC3A5E020AAFE2492F3"><enum>519.</enum><header>Prohibition of employee benefits duplicative of State health security program benefits; coordination in case of workers’ compensation</header> <subsection display-inline="yes-display-inline" id="H4FF5466DF5C44318B8C3B2BE054F4162"><enum>(a)</enum><text>Subject to subsection (b), no employee benefit plan may provide benefits which duplicate payment for any items or services for which payment may be made under a State health security program established pursuant to section 101(b) of the <short-title>American Health Security Act of 2005</short-title>.</text></subsection> <subsection id="HDEEE3D6E9DD54AB98400659F00CAB403"><enum>(b)</enum> <paragraph display-inline="yes-display-inline" id="HC4D3A098B86A4A69A7C1B7ED51D6EE96"><enum>(1)</enum><text>Each workers compensation carrier that is liable (or would be liable but for the enactment of the <short-title>American Health Security Act of 2005</short-title>) for payment for workers compensation services furnished in a State shall reimburse the State health security plan for the State in which the services are furnished for the cost of such services.</text></paragraph> <paragraph indent="up1" id="H7230798797E24958B4E7A89DFF443B14"><enum>(2)</enum><text>In this subsection:</text> <subparagraph id="H97411CFD7F7D4E438F7FCAACAC3C1D79"><enum>(A)</enum><text>The term <term>workers compensation carrier</term> means an insurance company that underwrites workers compensation medical benefits with respect to 1 or more employers and includes an employer or fund that is financially at risk for the provision of workers compensation medical benefits.</text></subparagraph> <subparagraph id="H70C053FFB9B2424D8E725951C3A8CB9"><enum>(B)</enum><text>The term <term>workers compensation medical benefits</term> means, with respect to an enrollee who is an employee subject to the workers compensation laws of a State, the comprehensive medical benefits for work-related injuries and illnesses provided for under such laws with respect to such an employee.</text></subparagraph> <subparagraph id="H92117FCF76FC49EBA4249555325E5203"><enum>(C)</enum><text>The term <term>workers compensation services</term> means items and services included in workers compensation medical benefits and includes items and services (including rehabilitation services and long-term-care services) commonly used for treatment of work-related injuries and illnesses.</text></subparagraph></paragraph></subsection></section><after-quoted-block>.</after-quoted-block></quoted-block></subsection> <subsection id="H0680172B8E7D47378497A946693D8389"><enum>(b)</enum><header>Clerical amendment</header><text>The table of contents in section 1 of such Act is amended by inserting after the item relating to section 518 the following new items:</text> <quoted-block style="USC" id="H762DCBBC769943918D00F4A3F26CA8D9"> <toc regeneration="no-regeneration"> <toc-entry level="section">Sec. 519. Prohibition of employee benefits duplicative of state health security program benefits; coordination in case of workers’ compensation</toc-entry></toc><after-quoted-block>.</after-quoted-block></quoted-block></subsection></section> <section id="HB1D77DA2E88D4D3C850000AC417AAFF"><enum>904.</enum><header>Repeal of continuation coverage requirements under ERISA and certain other requirements relating to group health plans</header> <subsection id="HE2C7A6554A46473385898B00F04242CB"><enum>(a)</enum><header>In general</header><text>Part 6 of subtitle B of title I of the <act-name parsable-cite="ERISA">Employee Retirement Income Security Act of 1974</act-name> (<external-xref legal-doc="usc" parsable-cite="usc/29/1161">29 U.S.C. 1161 et seq.</external-xref>) is repealed.</text></subsection> <subsection id="H702ECFFB71354063A56C66C9F582F549"><enum>(b)</enum><header>Conforming amendments</header> <paragraph id="H479CBCD0FAA7467600386346BEEDAE85"><enum>(1)</enum><text>Section 502(a) of such Act (<external-xref legal-doc="usc" parsable-cite="usc/29/1132">29 U.S.C. 1132(a)</external-xref>) is amended—</text> <subparagraph id="HB14A16579839433D92B2E477397E1668"><enum>(A)</enum><text>by striking paragraph (7); and</text></subparagraph> <subparagraph id="H6D5D833BBD5F4D2B94B4DE12D719F51D"><enum>(B)</enum><text>by redesignating paragraphs (8) and (9) as paragraphs (7) and (8), respectively.</text></subparagraph></paragraph> <paragraph id="H90A3E93C2B1D4369B28229CCC298CC6"><enum>(2)</enum><text>Section 502(c)(1) of such Act (<external-xref legal-doc="usc" parsable-cite="usc/29/1132">29 U.S.C. 1132(c)(1)</external-xref>) is amended by striking <quote>paragraph (1) or (4) of section 606 or</quote>.</text></paragraph> <paragraph id="H63A316CB469E421EB20300DCFA4BE361"><enum>(3)</enum><text>Section 4301(c)(4) of the <act-name parsable-cite="OBRA93">Omnibus Budget Reconciliation Act of 1993</act-name> (<external-xref legal-doc="public-law" parsable-cite="pl/103/66">Public Law 103–66</external-xref>; 107 Stat. 377) and the amendments made thereby are repealed.</text></paragraph> <paragraph id="HBE346F4CD5BC447A9F203C1844A8E8C7"><enum>(4)</enum><text>The table of contents in section 1 of the <act-name parsable-cite="ERISA">Employee Retirement Income Security Act of 1974</act-name> is amended by striking the items relating to part 6 of subtitle B of title I of such Act.</text></paragraph></subsection></section> <section id="HE7F3671F00E74217B834436F84006569"><enum>905.</enum><header>Effective date of title</header><text display-inline="no-display-inline">The amendments made by this title shall take effect January 1, 2007.</text></section> <enum>X</enum><header>Additional conforming amendments</header> <section id="HE475BE7D7389441882FAA1F119DE2D06"><enum>1001.</enum><header>Repeal of certain provisions in Internal Revenue Code of 1986</header><text display-inline="no-display-inline">The provisions of titles III and IV of the <act-name parsable-cite="HIPAA">Health Insurance Portability and Accountability Act of 1996</act-name>, other than subtitles D and H of title III and section 342, are repealed and the provisions of law that were amended or repealed by such provisions are hereby restored as if such provisions had not been enacted.</text></section> <section id="HF0FE33C590FC4773A1E89FFB60C50030"><enum>1002.</enum><header>Repeal of certain provisions in the <act-name parsable-cite="ERISA">Employee Retirement Income Security Act of 1974</act-name></header> <subsection id="HD30FA6A58FFE4C80B3118D0033823C70"><enum>(a)</enum><header>In general</header><text>Part 7 of subtitle B of title I of the <act-name parsable-cite="ERISA">Employee Retirement Income Security Act of 1974</act-name> is repealed and the items relating to such part in the table of contents in section 1 of such Act are repealed.</text></subsection> <subsection id="H1474066E5CB140F9AC5B9DF8A888B225"><enum>(b)</enum><header>Conforming amendment</header><text>Section 514(b) of such Act (<external-xref legal-doc="usc" parsable-cite="usc/29/1144">29 U.S.C. 1144(b)</external-xref>) is amended by striking paragraph (9).</text></subsection></section> <section id="H8BF7E26AEB2A4C259F3467A8FA8C31E9"><enum>1003.</enum><header>Repeal of certain provisions in the <act-name parsable-cite="PHSA">Public Health Service Act</act-name> and related provisions</header> <subsection id="HAC3D882216614CE690611373D63B45A8"><enum>(a)</enum><header>In general</header><text>Titles XXII and XXVII of the <act-name parsable-cite="PHSA">Public Health Service Act</act-name> are repealed.</text></subsection> <subsection id="H05D245E2224B44FCA5814F5200038BF7"><enum>(b)</enum><header>Additional amendments</header> <paragraph id="H18DE10C7F13F4BD7A594B8596F6C7BE0"><enum>(1)</enum><text>Section 1301(b) of such Act (<external-xref legal-doc="usc" parsable-cite="usc/42/300e">42 U.S.C. 300e(b)</external-xref>) is amended by striking paragraph (6).</text></paragraph> <paragraph id="H5F710A6057944D4AB9470094D77EE202"><enum>(2)</enum><text>Sections 104 and 191 of the <act-name parsable-cite="HIPAA">Health Insurance Portability and Accountability Act of 1996</act-name> are repealed.</text></paragraph></subsection></section> <section id="H398A2178699048EB80BA253B9C4BDD00"><enum>1004.</enum><header>Effective date of title</header><text display-inline="no-display-inline">The amendments made by this title shall take effect January 1, 2007.</text></section>