1.Short title; table of
contents
(a)This Act may be cited as the American Health Security Act of
2009
.
(b)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. Set-aside for public health.
Sec. 712. Set-aside 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.
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="HAC6FA5F9B74A4820AD6F811E4F048D2E"><enum>101.</enum><header>Establishment
of a State-based American Health Security Program</header>
<subsection id="HCF30B09335764D32AA7935B20641747D"><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="HBFCEC178217448C5A060A2F324DF0035"><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="H9F42AFFEAB00463785CAB27DCE430267"><enum>(c)</enum><header>State
defined</header>
<paragraph id="H12B204C4CDA24E689D49F99596CE050"><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="H205B8D13DAA248B2851E65A10407F404"><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="H939B79EC8EF947B20010FA7CB9996D59"><enum>102.</enum><header>Universal
entitlement</header>
<subsection id="H97CB601BE7FC4C668244C8976D37DADA"><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="H56005D261534431195CAFCD9B353EBA5"><enum>(b)</enum><header>Treatment of
certain nonimmigrants</header>
<paragraph id="HA1F3A72414714C2DBAE26FB9C8A6DD86"><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="H3153596795AD475F923504C7FC2EAFA"><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="H9F627B511D024D50A13D4CC276FEF00"><enum>(c)</enum><header>Treatment of
other individuals</header>
<paragraph id="HB36BB13D77454FCE8C554C56A5CB5216"><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="HA35668E8B5B948FCAF01A0C2869D2EF4"><enum>(A)</enum><text>to preserve the
public health of communities;</text>
</subparagraph><subparagraph id="HF14FC84FFCF44A4BBE179B104E24C7A8"><enum>(B)</enum><text>to compensate
States for the additional health care financing burdens created by such
individuals; and</text>
</subparagraph><subparagraph id="H6CAC8D48456C40AE8B35C0448946C5A1"><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="H102D820588774C8EBDB9BBA009623D59"><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="H65AE01C55E56476F87006B2600A7D323"><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> (8 U.S.C. 1160, 1161, or 1255a).</text>
</subsection></section><section id="H1302AB7BE382450400005C87D3FBEE14"><enum>103.</enum><header>Enrollment</header>
<subsection id="H9E9B37014DE54CFF99F618A2002E4B22"><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="HFB88AAEE7A9340FABCE42935104F53F7"><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="HF429D63A66B94281B3C8696F5DAAAF39"><enum>(2)</enum><text>provide for the
enrollment, as of January 1, 2011, of all individuals who are eligible to be
enrolled as of such date; and</text>
</paragraph><paragraph id="H6A15C1D0791043BD9801E1E548B2835E"><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="HF7907EACBDD74670B331839CE9DC3DBB"><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="HBE85B21D7E184B59A6C3EC09FAE149D5"><enum>(1)</enum><text>at employment and
payroll offices of employers located in the State;</text>
</paragraph><paragraph id="HF25B4E670917412EB4B7A801A891878E"><enum>(2)</enum><text>at local offices
of the Social Security Administration;</text>
</paragraph><paragraph id="H67B6B17D1A6441F4997E4DF662D28D7E"><enum>(3)</enum><text>at social services
locations;</text>
</paragraph><paragraph id="HE5B88A9539C842C2839131A9C5BA76CE"><enum>(4)</enum><text>at out-reach sites
(such as provider and practitioner locations); and</text>
</paragraph><paragraph id="H71F7C095BB12477E00323438C29BE01F"><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="HD7772FD858324C3EBB83CFAF0000FC0"><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="HB367747DB4394E188B4F67CE5197FBF8"><enum>104.</enum><header>Portability of
benefits</header>
<subsection id="HE50E52EC5DA64C0B8B9C725C3B5BF092"><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="HE1768FCF1398477AB069F40646899B18"><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="H0C0763BE398A4A40A3730890BDFF3B00"><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="H855B94FACA35439D97F328848B9CB018"><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="HFFDE989496EB4FB88557DF87595E7742"><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="HB9983CE823944A4886ADC629A5001510"><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="H09FDB88B63C14EEDA68317538130B0D8"><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="H6FEAA73496A34018A05C065C68D06CDF"><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, 2011.</text>
</section><section id="H716D5A92DD3E4EEC8294E50014006911"><enum>106.</enum><header>Relationship to
existing Federal health programs</header>
<subsection id="HD8B67150A4D041C5B73214E4D834B2BC"><enum>(a)</enum><header>Medicare,
medicaid and State children’s health insurance program (SCHIP)</header>
<paragraph id="HC8CF162F7C664CF9AF34909651F9C822"><enum>(1)</enum><header>In
general</header><text>Notwithstanding any other provision of law, subject to
paragraph (2)—</text>
<subparagraph id="H7AE0D69979F344328B74B8F7A46B93E7"><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,
2010;</text>
</subparagraph><subparagraph id="H39156FE251C047BE82A6E83E6CEE8E21"><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="HBFB85B3982E74ECD90BD2546E3554392"><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="H62C79A5C1FF24A8B004CE6896CE0A861"><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="HDA305DB6425C48F0BDFD9F38F7114B10"><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, 2011, 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="HC3A91012790446A7AB83ED82F7830926"><enum>(b)</enum><header>Federal
employees health benefits program</header><text>No benefits shall be made
available under chapter 89 of title 5, United States Code, for any part of a
coverage period occurring after December 31, 2010.</text>
</subsection><subsection id="H9703460D00FA4343B328A5009FBAE52B"><enum>(c)</enum><header>CHAMPUS</header><text>No
benefits shall be made available under sections 1079 and 1086 of title 10,
United States Code, for items or services furnished after December 31,
2010.</text>
</subsection><subsection id="H2860BCFF70D9489CA3CAA00FEA45C79"><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="H3311927E289F4EBFAF00CFF3997DB4E6"><enum>201.</enum><header>Comprehensive
benefits</header>
<subsection id="HC3CB6A0E3D4B4BF988008DA5FAF037D5"><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="HB0730973BB7D4501A7EE76D4488CFA78"><enum>(1)</enum><header>Hospital
services</header><text>Inpatient and outpatient hospital care, including
24-hour-a-day emergency services.</text>
</paragraph><paragraph id="H1AA07BB6B5854CBFA3FDA32421DE9575"><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="HF83DE46AF04F4B7F9D6EC1CC5B71F21"><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="H7D7194BE35F34A4385B55144F31F1C71"><enum>(4)</enum><header>Preventive
services</header><text>Preventive services (as defined in section
202(b)).</text>
</paragraph><paragraph id="H83ADF767FEB24539BD32F200AEDD7E00"><enum>(5)</enum><header>Long-term,
acute, and chronic care services</header>
<subparagraph id="HFE5A071B54914122A4BEE7055BBC2C6"><enum>(A)</enum><text>Nursing facility
services.</text>
</subparagraph><subparagraph id="H8B580278E3A54AC2A1C6CCE45700C945"><enum>(B)</enum><text>Home health
services.</text>
</subparagraph><subparagraph id="HB362B44F7B234D9DB49FE1049C0D944"><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="H119850504B5F449A80302983C1C9B04E"><enum>(D)</enum><text>Hospice
care.</text>
</subparagraph><subparagraph id="H4C95E2C28BA2462695002DB8E3FDE07C"><enum>(E)</enum><text>Services in
intermediate care facilities for individuals with mental retardation.</text>
</subparagraph></paragraph><paragraph id="HE0EF115D5ED744C48914D9C8F8073DEB"><enum>(6)</enum><header>Prescription
drugs, biologicals, insulin, medical foods</header>
<subparagraph id="H2DC6CC8174DF4CAB8DEA6D828B19F9DA"><enum>(A)</enum><text>Outpatient
prescription drugs and biologics, as specified by the Board consistent with
section 615.</text>
</subparagraph><subparagraph id="H3CFCB6AEAC6F4883B686EC4281CA4E87"><enum>(B)</enum><text>Insulin.</text>
</subparagraph><subparagraph id="HD2C1F26B004C49DCB9C0006C1EBB739D"><enum>(C)</enum><text>Medical foods (as
defined in section 202(e)).</text>
</subparagraph></paragraph><paragraph id="HA1E6E0FA17C94A5FBFDDCFF5491E7FB0"><enum>(7)</enum><header>Dental
services</header><text>Dental services (as defined in section 202(h)).</text>
</paragraph><paragraph id="HBD908D2BBE8746DE81156C5895D60029"><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="HB5B600532AA0498582FEE4977F423B5D"><enum>(9)</enum><header>Diagnostic
tests</header><text>Diagnostic tests.</text>
</paragraph><paragraph id="H5414409DBD074813AFBBC2ED1EC7989"><enum>(10)</enum><header>Other items and
services</header>
<subparagraph id="H3AF5AEB076C04E11AAA1D2B89C70D4DE"><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="H45FD2FB4D6014BF98C75D121ED6715BC"><enum>(B)</enum><header>Durable medical
equipment</header><text>Durable medical equipment.</text>
</subparagraph><subparagraph id="H832954A0E06C4D608D94E684E573859B"><enum>(C)</enum><header>Home
dialysis</header><text>Home dialysis supplies and equipment.</text>
</subparagraph><subparagraph id="H3FAC7291F4D94BE7953D5DE85C376944"><enum>(D)</enum><header>Ambulance</header><text>Emergency
ambulance service.</text>
</subparagraph><subparagraph id="HD28FBA31F76248CAA252D2677C00E7D4"><enum>(E)</enum><header>Prosthetic
devices</header><text>Prosthetic devices, including replacements of such
devices.</text>
</subparagraph><subparagraph id="H9C4815AAD474430C856038D07200E9D3"><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="H11B284992D2E41E5902F52C0BFFE2115"><enum>(b)</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="H5991559BD034459398030542F89E705B"><enum>(c)</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="HC42663C3AC264C959D839F5FBC74FB34"><enum>(d)</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="HED4AD31B4EED4D388DE0F9201B57B584"><enum>(e)</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="H368CEA65CBED405FB7B2FC503820456"><enum>202.</enum><header>Definitions
relating to services</header>
<subsection id="H210A1479933241A99EFD27E5D5FCF0EE"><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="H597EA1B1ACD14C81BD6D41FDA6C8B32"><enum>(1)</enum><text>by
a rural health clinic;</text>
</paragraph><paragraph id="H3621E8FEFBC44A64A1A99FD0A58465AE"><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="H70C1D68FCC794047B42949F13CE198B0"><enum>(3)</enum><text>in a school-based
setting;</text>
</paragraph><paragraph id="H30440030AF534385BEB998ECD0535918"><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="H13AC489B78664BE5B14FAB56C76DDC"><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="HFB0026B1D2954D60A28C402117E71352"><enum>(b)</enum><header>Preventive
services</header>
<paragraph id="HE3217DA4C4BF4BA78CD7009DFCB351D6"><enum>(1)</enum><header>In
general</header><text>In this title, the term <term>preventive services</term>
means items and services—</text>
<subparagraph id="HA11081CABF214818B562F0CD2DA00CB"><enum>(A)</enum><text>which—</text>
<clause id="HDE245B2319434FCCB6D03E75249C8E54"><enum>(i)</enum><text>are
specified in paragraph (2); or</text>
</clause><clause id="HEA1C0580AAC54777B4824CC9C9FCE405"><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="H5646408D54BC475A9D40ECD6F8D260F9"><enum>(B)</enum><text>which are provided
consistent with the periodicity schedule established under paragraph
(3).</text>
</subparagraph></paragraph><paragraph id="H4010EC2AF6154A63A236F17B5140B8BB"><enum>(2)</enum><header>Specified
preventive services</header><text>The services specified in this paragraph are
as follows:</text>
<subparagraph id="H0CD909B521F1432E00DFD66A8AE736D"><enum>(A)</enum><text>Basic
immunizations.</text>
</subparagraph><subparagraph id="H7DF0A1F6407D438C91C7E868AA941CB0"><enum>(B)</enum><text>Prenatal and
well-baby care (for infants under 1 year of age).</text>
</subparagraph><subparagraph id="HCFEDA7BD61614D6F9F008097E85324C5"><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="H47951C663B7A44038C11D1F638B37615"><enum>(D)</enum><text>Periodic screening
mammography, Pap smears, and colorectal examinations and examinations for
prostate cancer.</text>
</subparagraph><subparagraph id="H5F6130EFC9504F8A9D313FD0DC7045FD"><enum>(E)</enum><text>Physical
examinations.</text>
</subparagraph><subparagraph id="HCBD7156C3E4042B8959F86AA042E5DBA"><enum>(F)</enum><text>Family planning
services.</text>
</subparagraph><subparagraph id="HD65C447CF70A4AA88450D7B7E5C31CBA"><enum>(G)</enum><text>Routine eye
examinations, eyeglasses, and contact lenses.</text>
</subparagraph><subparagraph id="H585803A80D5240E5A2E330012F5452BB"><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="H30A49037E3884F57A0169D8626069CF0"><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="H71F99FCEA0304B34A153471DD21FDBA0"><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="H0AE38C5C20A94CB8B0211E0999F31BD4"><enum>(1)</enum><text>Home health aide
services.</text>
</paragraph><paragraph id="H6111A0CB60834D76A48C88E290EBD002"><enum>(2)</enum><text>Adult day health
care, social day care or psychiatric day care.</text>
</paragraph><paragraph id="HC9B0F88AB0FD46F8A2BD573136E7CE3"><enum>(3)</enum><text>Medical social work
services.</text>
</paragraph><paragraph id="H8E83D95A816D43C58D0281E6C27C4AC"><enum>(4)</enum><text>Care coordination
services, as defined in subsection (g)(1).</text>
</paragraph><paragraph id="HC8E1910DDB9445788DCE4BF53F731D01"><enum>(5)</enum><text>Respite care,
including training for informal caregivers.</text>
</paragraph><paragraph id="HA8F7E70FA0AB45059414EE95DDBF5E6E"><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="H621D179BD353484EA94C73CDF6658EFB"><enum>(d)</enum><header>Home health
services</header>
<paragraph id="H3FD03A38240D4E8B8D2639D6C1CE1C1"><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="H411B625D1D004758925B23B908E385CA"><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="H46FB50F5C64244ECA473989032266812"><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="HF72F2B528BA74141B9A47271001BFB10"><enum>(f)</enum><header>Mental health
and substance abuse treatment services</header>
<paragraph id="HBAC4A83CA868404EA24F7EEFCCEBE171"><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="HA4A13FCD1DE04E689D839FB9884E8BCB"><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="HB71B321AFA1443E28BEF6C309EA6D459"><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="H2F4477BFD15547268D6ED6DAEF2899B"><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="HB65527F1F2FF43DDB76239DFB43B9315"><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="HDB764A42B3D7428A95D3BAB30A342F"><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="H55E28AAC03E244BE93BC2BB8078DD6F"><enum>(D)</enum><header>Intensive
community-based services</header><text>Intensive community-based services (as
described in paragraph (3))—</text>
<clause id="H86537CD9248A497BA29234D6A9D4C3A2"><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="HC0352EE629584172A7A006C37E59E87"><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="H8666CF73FEC84488BAD886DC07358920"><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="H9217C57B016F4E3A8C1622FBADBFD900"><enum>(2)</enum><header>Intensive
residential services defined</header>
<subparagraph id="H0A102B56232541AC939BD7053E002BBD"><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="H74112E32BD504030952C761F9DDDA9E6"><enum>(i)</enum><text>Residential
detoxification centers.</text>
</clause><clause id="H91232000B55446E2B09F829BC1A58645"><enum>(ii)</enum><text>Crisis
residential programs or mental illness residential treatment programs.</text>
</clause><clause id="HCDF25FBB2A9C4F0AB85789C0F03DDBCB"><enum>(iii)</enum><text>Therapeutic
family or group treatment homes.</text>
</clause><clause id="HD58DA8264058406EAACDA218F09B821"><enum>(iv)</enum><text>Residential
centers for substance abuse treatment.</text>
</clause></subparagraph><subparagraph id="H24F115FD1B3B4FEC835D26244C24A75B"><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="H4C9084954DF0468ABBE8D7C5A13FB010"><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="H388A287DEF2840A597D2FFD69B3B5533"><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="HBE08D9605024481B919E2C4360E495E1"><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="H0D853CEC053A4FC5A9143E14355B532B"><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="HAB73509683B041DF99F8897FD32F1F2C"><enum>(3)</enum><header>Intensive
community-based services defined</header>
<subparagraph id="H81BC4E8F3BDF47F5A5A1BE7616003B8F"><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="H04C97FBAF0574523A3826986E1E99197"><enum>(B)</enum><header>Items and
services described</header><text>The items and services described in this
subparagraph are—</text>
<clause id="H0CA99CA283174A8DA9A3BBF6F383FC6"><enum>(i)</enum><text>partial
hospitalization services consisting of the items and services described in
subparagraph (C);</text>
</clause><clause id="H74F356B2FDE04A6397C4334D9916F491"><enum>(ii)</enum><text>psychiatric
rehabilitation services;</text>
</clause><clause id="HAD1CEFBA28B14815B200B619EF7CB059"><enum>(iii)</enum><text>day treatment
services for individuals under 19 years of age;</text>
</clause><clause id="H671BD9F7A30D44039C00CB3EF600E9B8"><enum>(iv)</enum><text>in-home
services;</text>
</clause><clause id="HCC64C4F237074D1F9F2591DD0632DD5E"><enum>(v)</enum><text>case
management services, including collateral services designated as such case
management services by the Secretary;</text>
</clause><clause id="HC6C8314E4062418BAE9291A71E697254"><enum>(vi)</enum><text>ambulatory
detoxification services; and</text>
</clause><clause id="HE38E37A7DF7C4F5DAAD4126D1B8B455E"><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="H54A428C23BD147F89C97EB31D6D7753E"><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="HEFB24085BA0A4EDBA0BD93BBF14A500"><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="H9828501712A04CE2A7EAFEC3071D41CE"><enum>(ii)</enum><text>Occupational
therapy requiring the skills of a qualified occupational therapist.</text>
</clause><clause id="HD61934EE475B4E89A967127D1750E8A3"><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="H332EB082414F4C8CB585E35F441FA55"><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="HA24EE649451943A3B5AC5CDDD3FFCC5E"><enum>(v)</enum><text>Individualized
activity therapies that are not primarily recreational or diversionary.</text>
</clause><clause id="HA9790F1D242C4866A6679721A1839B1F"><enum>(vi)</enum><text>Family counseling
(the primary purpose of which is treatment of the individual’s
condition).</text>
</clause><clause id="H2DDD3C5D4B75404792AA8300AF0017B5"><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="HD0EF1D7147154EBCAE8BE500849BDE9"><enum>(viii)</enum><text>Diagnostic
services.</text>
</clause></subparagraph><subparagraph id="H4C415F981B624C77A248CEC125E444FD"><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="H3405FA1557AB46A7AA1710499CA0C746"><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="HF2F9FBDD2AB04572009539BA4B9C19D"><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="H53A8B85CDB474D6EA7B5F4DE23DF8C49"><enum>(g)</enum><header>Care
coordination services</header>
<paragraph id="H433459B44C2F419BAC56AE008FFE3911"><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="HC00571909B744E1ABC3C5D972D32518E"><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="H12D53778E82E4999909C5540DBCFD596"><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="H69D9966FFBA44C149257CBD3CACD4620"><enum>(2)</enum><header>Care
coordinator</header>
<subparagraph id="HCEC220D8DB184028990092F2702BCFC2"><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="H6F70CD7C88CD4B2C8039A18C3B076C6C"><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="HEC0666DEB3CB4791BE00B0E94BB89B48"><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="H67C84A3B02674C2BB0748168444365B4"><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="HF1DE5EA273C941E4A2503D00B9B184B3"><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="H31630FEA9F3442348959E4A86B9058AB"><enum>(h)</enum><header>Dental
services</header>
<paragraph id="H5C7A9763C21E4A41AB44B31D6FC317E8"><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="HC4986CEEDF144B22BF996DE575E352D6"><enum>(A)</enum><text>Emergency dental
treatment, including extractions, for bleeding, pain, acute infections, and
injuries to the maxillofacial region.</text>
</subparagraph><subparagraph id="HD1DDCB0633AC4BA3A803CDC100474E7F"><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="H0BBEEFB972524B4BBDFCE16D56D34600"><enum>(C)</enum><text>Treatment of
dental disease, including non-cast fillings, periodontal maintenance services,
and endodontic services.</text>
</subparagraph><subparagraph id="HF047D776ADC941A28373CF86EB2F6CC6"><enum>(D)</enum><text>Space maintenance
procedures to prevent orthodontic complications.</text>
</subparagraph><subparagraph id="H2BFB59EB13B54F2D007E85989800E0F3"><enum>(E)</enum><text>Orthodontic
treatment to prevent severe malocclusions.</text>
</subparagraph><subparagraph id="HD99C597580C247CAA25577C301749998"><enum>(F)</enum><text>Full
dentures.</text>
</subparagraph><subparagraph id="HD5488BBB398445AD8F7512769BC960B"><enum>(G)</enum><text>Medically necessary
oral health care.</text>
</subparagraph><subparagraph id="HD20A5735B2BE405F87A35FD5A148CA1C"><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="H9186BA40260D4B809421174B9449737F"><enum>(i)</enum><text>are
required to provide such patients the items and services described in
subparagraphs (A) through (G);</text>
</clause><clause id="HE699D6D9FD8E457C833D905E73A5E82F"><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="HFEA5F3AAD108473A943229BBD133D2CF"><enum>(iii)</enum><text>consist of
orthodontic care for severe dentofacial abnormalities; or</text>
</clause><clause id="HA33EA76126D94CD9A2BB66DD43277405"><enum>(iv)</enum><text>consist of
prosthetic dental devices for genetic or birth defects or fitting for such
devices.</text>
<subclause id="HE790CC9F58974F30A0ECF156AE8EA804" indent="up2"><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="H4106D95B773D4B5CB3AF70D2C2064027"><enum>(2)</enum><header>Limitations</header><text>Dental
services are subject to the following limitations:</text>
<subparagraph id="HBAF8E30288314105AB861E0029E15088"><enum>(A)</enum><header>Prevention and
diagnosis</header>
<clause id="H7E836E55B98A4BB39B8B28C35E7977F"><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="HCA318DA3B4264DD78B633EC817B235F4"><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="H4827ED95FC1D4F5CBA00ABD064629571"><enum>(B)</enum><header>Treatment of
dental disease</header><text>Prior to January 1, 2016, 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="HB99CFB0F86B240C6B94C3F005B6CD624"><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="H52803FB6E5134838885493090064125B"><enum>(i)</enum><text>are
limited to posterior teeth;</text>
</clause><clause id="H0640C694D69D42FD858462652389E010"><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="H3C4B0F45297E4F3AB79474BD439B14BA"><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></paragraph><paragraph id="H1AF09DC8CCC84DA0B7427C631ED6BBA4"><enum>(3)</enum><header>Definitions</header><text>For
purposes of this title:</text>
<subparagraph id="H91B521DBE6CB453FA2753367DBDB300"><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="H45C341F8DD4B48239BCDEB7004CF1B5"><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="H2F6EAE0B1C724ECBBFCE74A58C198668"><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="H4C41C454D17E4B0CA1E081F4B2B4AF48"><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="H0BF4A48C7872490A8DF4BC3D4C5DAE87"><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="H5AEB8440561046DE95C44C675446A19B"><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="H01AB5417E6D64FA0A4B2113577D00004"><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="H1A3C7D0B804D4B1CACE5A50422BFBC6"><enum>203.</enum><header>Special rules
for home and community-based long-term care services</header>
<subsection id="HDC36025285B045AC809C2FEEF2AED14E"><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="H14B7F3D3561E404C84BF300A25D097C"><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="H5E5352DB4D6A428FA2B1442DE21DEEAC"><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="HADA4CDC01B6348639C5FE7EA16570698"><enum>(i)</enum><text>bathing;</text>
</clause><clause id="H520A82125DF24F9088960327AC47A1B1"><enum>(ii)</enum><text>eating;</text>
</clause><clause id="HE71BB443E5AC48569B7EDD2D00D891AD"><enum>(iii)</enum><text>dressing;</text>
</clause><clause id="H72B893A0163B417C845F6E1B7D10D700"><enum>(iv)</enum><text>toileting;
and</text>
</clause><clause id="H823CD8D188794CDDBBBFFBB207C527B2"><enum>(v)</enum><text>transferring in
and out of a bed or in and out of a chair;</text>
</clause></subparagraph><subparagraph id="HA1E35222144E4E4DBA5259A6375E9B1C"><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="HF5F1AC4E32F14DD49F3EFCA2D57DB3F4"><enum>(C)</enum><text>due to cognitive
or mental impairments, to require queuing to perform activities of daily
living.</text>
</subparagraph></paragraph><paragraph id="HD28F8AFC9A6E483BA20060B5EB43C58"><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="HE7D82BBCD6F641C099BB2000E445BCA9"><enum>(b)</enum><header>Limit on
services</header>
<paragraph id="H63606F00711B4E468FE275D2C4BE13B4"><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="HEAA55007CAAD43DA8B66555600832DA1"><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="HA7B2539C129B4B27B54ED72021C443B"><enum>204.</enum><header>Exclusions and
limitations</header>
<subsection id="HEAFE97F909D646D9B67BE85441EE10A2"><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="HDF6EAA7B4A4A400681BADF047951E6FF"><enum>(b)</enum><header>Special delivery
requirements for mental health and substance abuse treatment services provided
to At-risk children</header>
<paragraph id="HF23338D9C4A74DBDB04137BB002951B9"><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="HFD9C24FD12154107A2D0925849B5D89C"><enum>(A)</enum><text>the services are
provided to an individual less than 22 years of age;</text>
</subparagraph><subparagraph id="H78031203383F42D1A637A6B800CED9C1"><enum>(B)</enum><text>the individual has
a serious emotional disturbance or a substance abuse disorder; and</text>
</subparagraph><subparagraph id="HE901BEBAB1614B239D7982034DB37C62"><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="HCFC86C0EEE834DAA9C9E1B23CE33A3DE"><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="HBB0A418516E94032B052EF7E2D775B29"><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="HFEE4C2C5C1AB480EB37688B2112EB523"><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="HAE92774DAFAD4EA0A75419C183EB8DC2"><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="H58F03CD3CC1944E591CC8FBE46B0060"><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="HC280A3DEE72340ACB073CC312F203DB9"><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="H49A4ADF42B9F4503B1DE05220009CFC9"><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="H546BA192583941759FD98DEED97C2DDE"><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="H9BAA75CCE4C1402FB66056492BCA635D"><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="H7EFD9E4F5D674E7683F595D0C067092E"><enum>(e)</enum><header>Specific
limitations</header>
<paragraph id="H42261098B58B4336B40057C44F74E3D4"><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="H3CB62F72497342B6A5B5347AFEF7CF"><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="HD8CF243007D941CA80B645AC2B44FB84"><enum>(3)</enum><header>Miscellaneous
exclusions from covered services</header><text>Covered services under this Act
do not include the following:</text>
<subparagraph id="H3B45C01E08B34BFC9B8BC875C1D900F5"><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="H338AB0694F3D4BB98EDC6F8B4F9083F2"><enum>(i)</enum><text>required to
correct a congenital anomaly;</text>
</clause><clause id="HC752C2D3411249DF8320F14CE13F4104"><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="HD24F8B9A2C7B4FD09F5F4D2D2222DE69"><enum>(iii)</enum><text>otherwise
determined to be medically necessary and appropriate under section
201(a).</text>
</clause></subparagraph><subparagraph id="H0AB2677651284B28BC206290C99DAC17"><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="HB5EB3A4F001A46418914DDB2AAD006B"><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="HCC942D1E2B8C48F294708411151E354C"><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="HC7DC6B9BF0B04CE995CA3D996D70F3D6"><enum>205.</enum><header>Certification;
quality review; plans of care</header>
<subsection id="H64C1368A98D549F1813FB285FA5E7C75"><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="H69EC82086002491EAE61EC73C54045C8"><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="H715AE0114F0B4BB1B6D2003574E7EF8E"><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="HE2C2CFC16DA6418F98E79D9BF94813D"><enum>301.</enum><header>Provider
participation and standards</header>
<subsection id="H408E114460AC4A148E1E1ECDBC9984B0"><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="H198FC81DB4C54630A981FACFB0BD6C76"><enum>(1)</enum><text>is a qualified
provider of the services under section 302;</text>
</paragraph><paragraph id="HD034DF76E9FA450BAACE3308F064AC35"><enum>(2)</enum><text>has filed with the
State health security program a participation agreement described in subsection
(b); and</text>
</paragraph><paragraph id="H48FED2768F7545B790B3778CD688EA8B"><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="H52838A992A6A4307AC09962581463897"><enum>(b)</enum><header>Requirements in
participation agreement</header>
<paragraph id="H04840D7BA36A403FA76FB9602F28ABF7"><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="H0591CF44898146F58914E98CB200B017"><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="H424FE161BA3E425E96941BDB40016D3"><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="HD17142EB97FD4B47A71BCA689272067B"><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="HED981F2C64F447F6A461A81D18090970"><enum>(i)</enum><text>quality review by
designated entities;</text>
</clause><clause id="H39DE87B7FCE24AF8BCF1FEDF00F100ED"><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="H46B08595481649A1976D780679E13E61"><enum>(iii)</enum><text>statistical or
other studies required for the implementation of this Act; and</text>
</clause><clause id="H1A0B5337FC484F3F91E26D477071CF30"><enum>(iv)</enum><text>such other
purposes as the Board or State may specify.</text>
</clause></subparagraph><subparagraph id="HCC59819F579242E10081834DD49B71E0"><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="H5C92AACABAF34179ADCEEC817580F502"><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="H1179201603BC49EDA7DB429072003235"><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="H5EA75AAD639A4770BC284EF65784CF75"><enum>(2)</enum><header>Termination of
participation agreements</header>
<subparagraph id="H3671E82A4A4F4C4ABA1F250600C7A334"><enum>(A)</enum><header>In
general</header><text>Participation agreements may be terminated, with
appropriate notice—</text>
<clause id="H41C81F5272A14A5B88BE88DA51008D36"><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="H5A586F2E31F64373B651FE37C4AB9C26"><enum>(ii)</enum><text>by
a provider.</text>
</clause></subparagraph><subparagraph id="HE07DEF7CFD0B440F9480B8F5FBBB274D"><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="H6B10770BAADD4123B6C91FAF489E76AF"><enum>302.</enum><header>Qualifications
for providers</header>
<subsection id="HF1315ED6E4DC4C648D6708A718A5E011"><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="H1165D2DC4F4F488382BA4F42BD1C9189"><enum>(1)</enum><text>all the
requirements of State law to provide such services;</text>
</paragraph><paragraph id="H1FFB7D3936B343B4B4887B96321FC052"><enum>(2)</enum><text>applicable
requirements of Federal law to provide such services; and</text>
</paragraph><paragraph id="HF270AA405B374635AAF85E074F76E8C"><enum>(3)</enum><text>any applicable
standards established under subsection (b).</text>
</paragraph></subsection><subsection id="H334D3BF8BD6E4CFEA65B288B591DB8FB"><enum>(b)</enum><header>Minimum provider
standards</header>
<paragraph id="H47F2EBF7F1B34AA2BBB7284F77EF4E60"><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="H87A71BA044BF4ADEB416AB55795DE682"><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="HDFC65505EC3F4E569CF546BF6F698E2C"><enum>(A)</enum><text>adequacy and
quality of facilities;</text>
</subparagraph><subparagraph id="H4ABCD1F8C4BC4AE69DFFB7D6AED4D82B"><enum>(B)</enum><text>training and
competence of personnel (including continuing education requirements);</text>
</subparagraph><subparagraph id="H3EBF87F2C12743DDBBA37BD184297E23"><enum>(C)</enum><text>comprehensiveness
of service;</text>
</subparagraph><subparagraph id="H0F66F1BF4F284B19BDC821D466D61F76"><enum>(D)</enum><text>continuity of
service;</text>
</subparagraph><subparagraph id="H90D4A8885F6047FC9615E9DE1B6E3865"><enum>(E)</enum><text>patient
satisfaction (including waiting time and access to services); and</text>
</subparagraph><subparagraph id="H621888A881FD40F79F596401E37E43E"><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="HD538D4F69C9C4FB09623CA7B9FCB8C21"><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="H94158A42429746669D966B6F017B8192"><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="H23623E19FA3F4636B21561FB25BA355C"><enum>303.</enum><header>Qualifications
for comprehensive health service organizations</header>
<subsection id="H36F9AE4068874D0CBE00E0D300B782EB"><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="HE0ACFB5F799A495890228597D1BA14F4"><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="HE7893C33F771495BB14FF95BB08224E5"><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="H490B5B4E544249CB9FFACD5C86965B80"><enum>(b)</enum><header>Enrollment</header>
<paragraph id="HED8F4CE0FA85417E8E75FEF8B5537D52"><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="H6D60B87E10EA46EE8B57DCC770906648"><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="H6F353577D2E3462C84F46EC61DBE9026"><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="H7D093C71216B4B52B8D01E410125D234"><enum>(c)</enum><header>Requirements for
CHSOs</header>
<paragraph id="H4B4087B917554D8288D890FC4235019E"><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="H3A57BFB6EF424B9EAB9774F3E68C934C"><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="H0CD385BA74B54FB98DEBC00038385F11"><enum>(3)</enum><header>Board of
directors</header><text>In the case of a CHSO that is a private
organization—</text>
<subparagraph id="HED538B8517A34D6EBF0027DD0089ABB0"><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="HDE929715C91A4D62887740AB6666985F"><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="H790DDC144ABF4389A4AAF4028BB58C7"><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="H58B3DBA87C8646D7B7B1DCA0EEE0055"><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="H5E4D7CE811BD49F299C6E72DA8F6E6"><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="H1C7579A9E17846F9A0EF0243DC603D16"><enum>(7)</enum><header>Utilization and
bonus information</header><text>Each CHSO must—</text>
<subparagraph id="H4F170F5239894C0599028C36AE5B2FC4"><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="HA249B0AAA3BE4B7DA1AA8DDE55E27C02"><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="HD665E89BEAE1444591E29528D31C5119"><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="H7D1F8673B6D84A5F8B35DF734076D123"><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="HDEC48B0939FD4C29B13149B963FD4D60"><enum>(10)</enum><header>Additional
requirements</header><text>Each CHSO must meet—</text>
<subparagraph id="H0F97B61079F2420FBA006DE33E002738"><enum>(A)</enum><text>such requirements
relating to minimum enrollment;</text>
</subparagraph><subparagraph id="HD5A65B388C09422ABBA6000167596F1B"><enum>(B)</enum><text>such requirements
relating to financial solvency;</text>
</subparagraph><subparagraph id="H79BAC533F4F94C88915E2498C19C46C9"><enum>(C)</enum><text>such requirements
relating to quality and availability of care; and</text>
</subparagraph><subparagraph id="HA8B8E5C1A66C48ADBA1273CA6806AA8F"><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="HFA6BFA9E92334B3AA35B74A3C1DFEF59"><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="H207E9C0EB0194148AF17D1CDDA3CB358"><enum>304.</enum><header>Limitation on
certain physician referrals</header>
<subsection id="HD720673E94BB4210841700DD8404ED5C"><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="HC95EB6260079406A8390C02075D89D86"><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>
(42 U.S.C. 1395nn(h)(6)) is amended by adding at the end the following:</text>
<quoted-block act-name="Social Security Act" id="H3F315717FE594EEF8C787BB3D4C5BCF4">
<subparagraph id="HFDD013A9D038400BB03691D1C821C23D"><enum>(M)</enum><text>Ambulance
services.</text>
</subparagraph><subparagraph id="HC55E10AD036B45CFB72044B80030E7DA"><enum>(N)</enum><text>Home infusion
therapy
services.</text>
</subparagraph><after-quoted-block>.</after-quoted-block></quoted-block>
</subsection><subsection id="H66F4410CA87642F99543A19661B5A399"><enum>(c)</enum><header>Conforming
amendments</header><text>Section 1877 of such Act is further amended—</text>
<paragraph id="H957B491E7D55437BB81CBA1AEDF1421"><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="H5A3885DFD9974C1287B1BA01DF52D132"><enum>(2)</enum><text>in subsection
(a)(1)(B), by striking <quote>under this title</quote>;</text>
</paragraph><paragraph id="H37F8F29A509C47C0B5D89D5035D56B90"><enum>(3)</enum><text>by amending
paragraph (1) of subsection (g) to read as follows:</text>
<quoted-block id="H0DF90DD280C2495A9063F3787315F12D">
<paragraph id="H3B6671CFCF6A4FDD98066DFBD551E816"><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="H5AC7E56F2F704D629F74B18A03478C8"><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="HBD26202892C54A6EA1A7D39CB5C7B9FF"><enum>A</enum><header>General
Administrative Provisions</header>
<section id="HC9450E897C8C4891973186BFB54C005E"><enum>401.</enum><header>American Health
Security Standards Board</header>
<subsection id="HAB6083DFC98A4449BCBF23F0F07983B3"><enum>(a)</enum><header>Establishment</header><text>There
is hereby established an American Health Security Standards Board.</text>
</subsection><subsection id="H655E1268FDE84A61ABB300D23674CBD0"><enum>(b)</enum><header>Appointment and
terms of members</header>
<paragraph id="H3C85AFEA633D4E0FBC1F101279C33740"><enum>(1)</enum><header>In
general</header><text>The Board shall be composed of—</text>
<subparagraph id="H7CE31864D8E44F2FA87687D9F2898F46"><enum>(A)</enum><text>the Secretary of
Health and Human Services; and</text>
</subparagraph><subparagraph id="HF7DE732B1F294E339438977ECDFFBF00"><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, 2010.</continuation-text></paragraph><paragraph id="H88C30FA7EF674D688F77E585E602BA2C"><enum>(2)</enum><header>Selection of
appointed members</header><text>With respect to the individuals appointed under
paragraph (1)(B):</text>
<subparagraph id="H8048EC2B307A4859A0007BBC03A19889"><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="H5D5AE58CF3194EA1829CCAF465FCDD2"><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="H78DA10D1922C48DCBA9861BEC73994C3"><enum>(C)</enum><text>Not more than 3 of
them shall be from the same political party.</text>
</subparagraph><subparagraph id="HE20C975CE311444BB9024E68DCAAA79F"><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="H4068ABD583FF45AA88356D4910FA24A0"><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="H9F289D383C414CC2A95111285D51CBF3"><enum>(c)</enum><header>Vacancies</header>
<paragraph id="H20BE25D7E17F45ACAFD6CD701DDC2020"><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="H1FDA1852DD214262963B92BA69C4B7D"><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="H61612BA7CE78480381701BBA979C88F5"><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="HD929F8E9ECEC40FABEC450E900167B70"><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="H5BC27A8E06644CC389B8CEDAC556E4FC"><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="H6A9181DE5BA44C549830FBBE592D835F"><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
section 5313 of title 5, United States Code.</text>
</subsection><subsection id="H67181CAD3AB445A0B726AA9E2BD84143"><enum>(f)</enum><header>General duties
of the Board</header>
<paragraph id="H1ACF0622058B482DB4D230001DA9BEDA"><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="H21C1D850F86E432096EE7DF496F237B2"><enum>(A)</enum><text>eligibility;</text>
</subparagraph><subparagraph id="H12E9CD6852A54C5F9620E7DF73B185DC"><enum>(B)</enum><text>enrollment;</text>
</subparagraph><subparagraph id="H78BF377352DB4DF1AAAA87AFEB6C00B9"><enum>(C)</enum><text>benefits;</text>
</subparagraph><subparagraph id="HCE2D00E099B74C28B1E4E6F6C7C1CF4"><enum>(D)</enum><text>provider
participation standards and qualifications, as defined in title III;</text>
</subparagraph><subparagraph id="H28659381BC5C4D97B47C027F432EC391"><enum>(E)</enum><text>national and State
funding levels;</text>
</subparagraph><subparagraph id="H59444375F3C8426A9CCEAA8E7DAFB281"><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="HB2A05A67291947138FA1CBEF281D4991"><enum>(G)</enum><text>the determination
of medical necessity and appropriateness with respect to coverage of certain
services;</text>
</subparagraph><subparagraph id="H2741F9F5FF37407800C6289DB92021E"><enum>(H)</enum><text>assisting State
health security programs with planning for capital expenditures and service
delivery;</text>
</subparagraph><subparagraph id="H78D9EB4E5A314379A49B63C18FE1BC2"><enum>(I)</enum><text>planning for health
professional education funding (as specified in title VI);</text>
</subparagraph><subparagraph id="H49F2E69CAF5C403083D703C11626D179"><enum>(J)</enum><text>allocating funds
provided under title VII; and</text>
</subparagraph><subparagraph id="H7158E80FC78B4EF79E2FBBAE81A506B0"><enum>(K)</enum><text>encouraging States
to develop regional planning mechanisms (described in section
404(a)(3)).</text>
</subparagraph></paragraph><paragraph id="H6FBA066C2754497FB28E20AB52E89CF9"><enum>(2)</enum><header>Regulations</header><text>Regulations
authorized by this Act shall be issued by the Board in accordance with the
provisions of section 553 of title 5, United States Code.</text>
</paragraph></subsection><subsection id="H99FAC238B5184BD5A36F00F7252D954D"><enum>(g)</enum><header>Uniform
reporting standards; annual report; studies</header>
<paragraph id="H0E2365BD9765477EB200FB99CA24D786"><enum>(1)</enum><header>Uniform
reporting standards</header>
<subparagraph id="H9CAFF487BD5848E9ACEEF1D809664973"><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="H5D637088A8CB412EB234610631D5EC5F"><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="HA10D53544E2D423BAAA612EE6FFA6C16"><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="H991110FAF65B4DC8B0BA873DA26211B"><enum>(A)</enum><text>The status of
implementation of the Act.</text>
</subparagraph><subparagraph id="H18B403ED9ACD43E0832FF229B814F3B"><enum>(B)</enum><text>Enrollment under
this Act.</text>
</subparagraph><subparagraph id="HCC5D0E094A4F4192BBBFDABD11260071"><enum>(C)</enum><text>Benefits under
this Act.</text>
</subparagraph><subparagraph id="H632E71D3419C414AA2357F6E7500F15F"><enum>(D)</enum><text>Expenditures and
financing under this Act.</text>
</subparagraph><subparagraph id="HD3A00A0B587648D6AA6825C113EF1D46"><enum>(E)</enum><text>Cost-containment
measures and achievements under this Act.</text>
</subparagraph><subparagraph id="H30F80BCCB3804A378715FF007E60B353"><enum>(F)</enum><text>Quality
assurance.</text>
</subparagraph><subparagraph id="H33580AA148174E91ADA7E41625F4362"><enum>(G)</enum><text>Health care
utilization patterns, including any changes attributable to the program.</text>
</subparagraph><subparagraph id="H857C0502EC584768A2B8901DBF8DC0B0"><enum>(H)</enum><text>Long-range plans
and goals for the delivery of health services.</text>
</subparagraph><subparagraph id="H971CC461EF9948208E7CBD4B5D3200EE"><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="HE5E9567481064EC19C66FAB49AA69EC"><enum>(J)</enum><text>Necessary changes
in the education of health personnel.</text>
</subparagraph><subparagraph id="H962B6CC3C35C4A54B50757AA6B00ABAC"><enum>(K)</enum><text>Plans for
improving service to medically underserved populations.</text>
</subparagraph><subparagraph id="H098748A56B5348849DC34EC99D3B5132"><enum>(L)</enum><text>Transition
problems as a result of implementation of this Act.</text>
</subparagraph><subparagraph id="H8C265C5665CD4ACEB0D008075873124"><enum>(M)</enum><text>Opportunities for
improvements under this Act.</text>
</subparagraph></paragraph><paragraph id="H48B6962D4A7E4DF5B0B3ADCB18AD8811"><enum>(3)</enum><header>Statistical
analyses and other studies</header><text>The Board may, either directly or by
contract—</text>
<subparagraph id="H211A58BCB3EA4ECE9033C9881EE41BC7"><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="H1688A7F4206741E3AB4601E605006460"><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="H59C644BA782D401989E9FF16C2EE1B"><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="HB7876155CB054DBC9346C63A37E2AF"><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="H6EDAB3ACB56A48E0A8112B63B31FE7BC"><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="HABC04EAB0AB2469BAAA236B863EDF978"><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="H1F0CDAD50B3A4870BAC24C9BEAE26B"><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="H03CED063F317433D9FF892C63D014396"><enum>(h)</enum><header>Executive
Director</header>
<paragraph id="HC17A8ED34A794B80A00062CC1E7E1444"><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="HAB062652A9F4455B84EFC04C1153A999"><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="H2973245CC9D14195AB14F50795F6BCA1"><enum>(A)</enum><text>the issuance of
regulations; or</text>
</subparagraph><subparagraph id="H39CAF7410C3E4977A731001600C29BFF"><enum>(B)</enum><text>the determination
of the availability of funds and their allocation to implement this Act.</text>
</subparagraph></paragraph><paragraph id="H356F3D48255049BAAC92233BC3DBCB35"><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 section
5314 of title 5, United States Code.</text>
</paragraph></subsection><subsection id="H302FB4AA052940E8A410325C5804E4DF"><enum>(i)</enum><header>Inspector
General</header><text>The Inspector General Act of 1978 (5 U.S.C. App.) is
amended—</text>
<paragraph id="HC35996B994FC4D61AA005C4F2DC840EA"><enum>(1)</enum><text>in section 12(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="HAB998A5D7C9F41B68DB100D7BE50303D"><enum>(2)</enum><text>in section 12(2),
by inserting after <quote>Resolution Trust Corporation,</quote> the following:
<quote>the American Health Security Standards Board,</quote>; and</text>
</paragraph><paragraph id="HE7F78326B2F44F3EB82812002B7739C6"><enum>(3)</enum><text>by inserting
before section 9 the following:</text>
<quoted-block id="HF6948CE3D8EE4C0B8179E667FA26CE34" style="traditional">
<section display-inline="no-display-inline" id="H598C629FB1D743F1976200CCFDF30024"><enum>8M.</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="H1DC04C44F2CB4DE0AA5307FAB74135CD"><enum>(j)</enum><header>Staff</header><text>The
Board shall employ such staff as the Board may deem necessary.</text>
</subsection><subsection id="HACC122BF260F4CB99E8859CB8EFE747D"><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="H0A0CDD9634F44FC095C74B98893B9FDC"><enum>402.</enum><header>American Health
Security Advisory Council</header>
<subsection id="H665117A5DB7E4A69AA76A376D2E3EBC2"><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="HAF0BFF83B6FE4BC297DADBD4585800AE"><enum>(b)</enum><header>Membership</header><text>The
Council shall be composed of—</text>
<paragraph id="H73311C0ED3BD4EDFBB63C86176C66B9"><enum>(1)</enum><text>the Chair of the
Board, who shall serve as Chair of the Council; and</text>
</paragraph><paragraph id="H3EED5DC6E14E41E39D00A061DAE4EB49"><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="HA54DA8F726B64F0B8503AC18001F5D61"><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="HDD12F3629034439A822432AB6394DD2E"><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="H16C40CBF101F455D8BD7016766CDE2F9"><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="H5622CE22AA3D417899E97C00BF1C1837"><enum>(d)</enum><header>Vacancies</header>
<paragraph id="H49943CC3A23B45559E5B6D24108CDAFB"><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="H8B77D85D0EFA4B008E2B4E183DBD34EC"><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="HCAAABDB60F1E4C7A8F8CFBC80124415E"><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="H4EBDD9AFE3644E3EBBDDA4D3997EDF18"><enum>(e)</enum><header>Qualifications</header>
<paragraph id="H35A92380B339400CA702BA77273112C1"><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="H4BEEA90A8A714869BEEDC8304EA4F55F"><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="H6087AD63986A4EEC86B3B1E5C2D009B"><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="HA93837B22BBE4ED697902827600904E"><enum>(f)</enum><header>Duties</header>
<paragraph id="H7CBD671C63654E6F847F26C883E7C071"><enum>(1)</enum><header>In
general</header><text>It shall be the duty of the Council—</text>
<subparagraph id="H4CA8F5432C24452388F3C1995BEB828D"><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="H94FF645EE142486D802FAB52A0280908"><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="HA0F51F93A23B49779D155E367100F734"><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="H6368A6F8B77F4D749D13142B655B0515"><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="HA629DC41318C4B4B9D439B68ACE97F9"><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="H0692D313A08D4E64A13E3433267565F7"><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 chapter 57 of title 5, United States
Code.</text>
</subsection><subsection id="H284D21D85B5F46838FF8C6478155E2C"><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="H1FA94F6944B047C5B76F665EFCDC962"><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="H43B5099DBB844AC3943B94DCBDBEF572"><enum>404.</enum><header>State health
security programs</header>
<subsection id="H6751864459D245B78B3E3DC2F29FEC89"><enum>(a)</enum><header>Submission of
plans</header>
<paragraph id="H0A7DC9A465AE41F3832B180667B6BDB"><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="HAD7D8B7329764B46A533C3FFF5B38E00"><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="H2F11AE4D45364A24BF094E54AAF79C3"><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="HF8C28BA006864694A4C895FE28311CAE"><enum>(b)</enum><header>Review and
approval of plans</header>
<paragraph id="HC3D8BEE502224D03B1192C61AF2B2AF"><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="HD44AD6D5C4E942E2A6A3A09CF454BAF3"><enum>(A)</enum><text>Payment for
required health services for eligible individuals in the State in accordance
with this Act.</text>
</subparagraph><subparagraph id="HE6FC4A07BABF4C3B9C377B533B376C06"><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="H51BED24852EE4A0BAA2C7530CF9618C0"><enum>(C)</enum><text>The establishment
of a State health security budget.</text>
</subparagraph><subparagraph id="H189536BA7F12454E912501E490E64356"><enum>(D)</enum><text>Establishment of
payment methodologies (consistent with subtitle B of title VII).</text>
</subparagraph><subparagraph id="HFD776119F05647748D4823E1F1EE6E1"><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="HD625798C4B45409D9821CABDB5B52E32"><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="H6763839920E0452998DF88715C234164"><enum>(i)</enum><text>ensures
participation of consumers of health services and providers of health services;
and</text>
</clause><clause id="HBCCC4BB87D8F4D84822CD3BADBA9576F"><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="H76FF7D82FC9946E786BB068B3E7BC977"><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="H20971815562049B384F05B9F00EC03DF"><enum>(H)</enum><text>Establishment of a
quality review system in accordance with section 503.</text>
</subparagraph><subparagraph id="HFF8D3B56FA1E41CF8724D49855F072AF"><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="HFFCD3CD0716B485FA8FFF8905000C414"><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="H837E0E2E4E1048F2AA63314350C0005B"><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="H6B3ADA44C7E64F338DD955FAAEE6F87"><enum>(L)</enum><text>Prohibit payment in
cases of prohibited physician referrals under section 304.</text>
</subparagraph></paragraph><paragraph id="HE9766327BB424A4482F9877866E37500"><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="HFA979205E4E24D998F8FA5BF8D8D0146"><enum>(c)</enum><header>State Health
Security Advisory Councils</header>
<paragraph id="H411E97F4701B44238FBAB74BD0BE15BF"><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="H1CAC4B79B31346AAA2B3EADE05A2DF8"><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="H219C8D0FD53743F3B280C93F6D623951"><enum>(3)</enum><header>Duties</header>
<subparagraph id="H0854259EFF0840FEA812878DF9EFDF3F"><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="HCBFAB2FA32F74C0484DF467057C2A004"><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="HA36A757586304ADF9D4090DBDD3D85B5"><enum>(d)</enum><header>State use of
fiscal agents</header>
<paragraph id="HDA82516342F642ABBFB14292717056B9"><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="HAA5A023F03BE40C99D008BDEFD78279"><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="H8AE7652743D143A58BDBBC57C02DC7E2"><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="H25FF84BA42F742239323EDB32BE586D"><enum>B</enum><header>Control over Fraud
and Abuse</header>
<section id="H7CF1880DA9304DEFA17DF31233EC79F2"><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="H5FA255333E264865B3B7BEF37497C813"><enum>(1)</enum><text>Section 1128
(relating to exclusion of individuals and entities).</text>
</paragraph><paragraph id="HD40D1C9CFAA54D6984A072CDDC001B65"><enum>(2)</enum><text>Section 1128A
(civil monetary penalties).</text>
</paragraph><paragraph id="HB1DB7ED705F1437ABDEA055BCEA9E78"><enum>(3)</enum><text>Section 1128B
(criminal penalties).</text>
</paragraph><paragraph id="H795D2CC1FFA2409F8208D6CEC4DE8200"><enum>(4)</enum><text>Section 1124
(relating to disclosure of ownership and related information).</text>
</paragraph><paragraph id="HD47B44074D51490AA5B1F5B598D00C5"><enum>(5)</enum><text>Section 1126
(relating to disclosure of certain owners).</text>
</paragraph></section><section id="HCBDBA374480D43F100DC3F2EB948880"><enum>412.</enum><header>Requirements for
operation of State health care fraud and abuse control units</header>
<subsection id="HB7E7295F148F4EB8B975F3DD3BDCC042"><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="H73752C05F2C4451B95511476FEAF4BE"><enum>(b)</enum><header>Structure of
unit</header><text>The fraud unit must—</text>
<paragraph id="HCD8C6D5DCEBA4BD596B5485702AB5E37"><enum>(1)</enum><text>be a single
identifiable entity of the State government;</text>
</paragraph><paragraph id="H8D9C5410047A4BDA85C65975862EB244"><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="HBB3E7B8D058F4BE9B50394CDEB7C89FE"><enum>(3)</enum><text>meet 1 of the
following requirements:</text>
<subparagraph id="H254A399D9B284559AE38BDE6B7008F26"><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="H6572D7AAF1234CF1AD6D2D836E17BD9"><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="H6D8D94BF0982452495244F725951188F"><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="HB49AD4151C994391A1BC33E6F0FCF71"><enum>(ii)</enum><text>assure its
assistance of, and coordination with, such authority or authorities in such
prosecutions.</text>
</clause></subparagraph><subparagraph id="H7CF93AEE0A804C2CA260A5E4D44B6B02"><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="H9DCBC81007DB45648233251692EEBC79"><enum>(c)</enum><header>Functions</header><text>The
fraud unit must—</text>
<paragraph id="HDED57E31C8214D178420D715AB2B085"><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="H93162B2F1C7C498CA02FE7B75EA4B2D3"><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="H4DC5FA89EEB748398F52FA5F57F9F6F3"><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="HFE20AA4495794662920700D903F087D1"><enum>(d)</enum><header>Resources</header><text>The
fraud unit must—</text>
<paragraph id="HCBFDA345D4F64A61BEC9FBC00030D06D"><enum>(1)</enum><text>employ such
auditors, attorneys, investigators, and other necessary personnel;</text>
</paragraph><paragraph id="HA9CDC20E3D0F4B6FAF85005D6B58A1CC"><enum>(2)</enum><text>be organized in
such a manner; and</text>
</paragraph><paragraph id="HB490AC0B822F4970A269A6F3FA6D98B9"><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="HFEF396BD18B94922A41B59637C219484"><enum>(e)</enum><header>Cooperative
agreements</header><text>The fraud unit must have cooperative agreements (as
specified by the Board) with—</text>
<paragraph id="H11E6401787E24CB68092C49E8081CAE8"><enum>(1)</enum><text>similar fraud
units in other States;</text>
</paragraph><paragraph id="H4C0C30C2F4FB4DFBB13E26423020EE0"><enum>(2)</enum><text>the Inspector
General; and</text>
</paragraph><paragraph id="H43D37618CD064B89ACC784C5C8FD8CD5"><enum>(3)</enum><text>the Attorney
General of the United States.</text>
</paragraph></subsection><subsection id="H47B3C8223752456EA78944E2F048007D"><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="HF5426386F756496790108CD0EB547D3C"><enum>501.</enum><header>American Health
Security Quality Council</header>
<subsection id="H23409C7A478E4C66A3F8B8D75925367E"><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="H16993A8234D646C3B924669C637EDB24"><enum>(b)</enum><header>Duties of the
Council</header><text>The Council shall perform the following duties:</text>
<paragraph id="H00B9BE84EC9A49BDA9007B95A7E7AAB6"><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="H5993FE4814644AAAA4B8BC9FE76F23BC"><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="H6E3B73ABEAB44F1584683D669922B264"><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="H9FF1E39F02CA490281A8D395ACE83990"><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="H84D48DCE1CDB41DB9EA7E7E7F5746972"><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="HAFCEC9A3385A455B8616B57D62AD5CF3"><enum>(c)</enum><header>Appointment and
terms of members</header>
<paragraph id="H74BAB4E1A4F14818A8DB7CB3F151B13"><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,
2010.</text>
</paragraph><paragraph id="HB3E62603B4EE4A3FA7ADCB5BA78E3890"><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="H8D1A312189B94DF98038A75C7BD8B889"><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="HC5A5C3C7D64F460187E5CF0806BBC07"><enum>(d)</enum><header>Vacancies</header>
<paragraph id="HCFA3B8410320490CA46D5B17004D059D"><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="H19A61B53703E4C5EA1EAA2B51D7E6CFE"><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="H8426B6ACFE84485F006402ECC9EF8C9"><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="H9FC3640FAAFE4827BF3F620038BEC14E"><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="HE2EC199F67D24EC99B9746A37E00DCD"><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 section 5313 of title 5, United States
Code.</text>
</subsection></section><section id="H473335FD69514B49A21F470053E668A3"><enum>502.</enum><header>Development of
certain methodologies, guidelines, and standards</header>
<subsection id="HFDD8E494B712482DBEA316066864F171"><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="H06DB5EA842484DB5AC00C01B43B91071"><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="HF2BFC65D21084DB895DBAD67A323981D"><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="HF9761CDCD6864C00A7AAA9EA284F66A3"><enum>(d)</enum><header>Dissemination</header><text>The
Council shall disseminate to the State—</text>
<paragraph id="H5A59D9E3BC0D4C528C97E2113E028751"><enum>(1)</enum><text>the methodologies
adopted under subsection (a);</text>
</paragraph><paragraph id="HB2E8790039C5405181624BF604130191"><enum>(2)</enum><text>the guidelines
developed under subsection (b); and</text>
</paragraph><paragraph id="H4DB7874285A940068253F58CF8F5AFEE"><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="H07898AF70A444A8396004BA2CB28405C"><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="H6C39F324A90B42CE81172575D2AA37A4"><enum>503.</enum><header>State quality
review programs</header>
<subsection id="HF7F806604FD94367A9AEF03DAC33E63"><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="H0E27DCEE7B3744AC8596FEFD00322835"><enum>(b)</enum><header>Federal
standards</header>
<paragraph id="HCCA4C5B78E164E878ED002987DF64CD"><enum>(1)</enum><header>In
general</header><text>The Council shall establish standards with respect
to—</text>
<subparagraph id="HF691BE98E8624484AAFE1B8373FF4D"><enum>(A)</enum><text>the adoption of
practice guidelines (whether developed by the Federal Government or other
entities);</text>
</subparagraph><subparagraph id="HBB485B8D137B41918C83079B645CE442"><enum>(B)</enum><text>the identification
of outliers (consistent with methodologies adopted under section
502(a));</text>
</subparagraph><subparagraph id="H077624EB9C314CEB84B2C9F015DE0517"><enum>(C)</enum><text>the development of
remedial programs and monitoring for outliers; and</text>
</subparagraph><subparagraph id="H88E159E1FDB948278B002E526B47B6CB"><enum>(D)</enum><text>the application of
sanctions (consistent with the standards developed under section
502(c)).</text>
</subparagraph></paragraph><paragraph id="H70097C5F4F284F0B8DC5C4D1BDC193C"><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="HC1B524E111E94607ADFBDAE1412961BE"><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="HF9BD6B1BD2FA4E2787008BBCB3C16000"><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="H9F7A41C3E35A49E78513FF331FD0A95E"><enum>504.</enum><header>Elimination of
utilization review programs; transition</header>
<subsection id="HB2EB9AE721114048983E82B147D91169"><enum>(a)</enum><header>Intent</header><text>It
is the intention of this title to replace by January 1, 2013, random
utilization controls with a systematic review of patterns of practice that
compromise the quality of care.</text>
</subsection><subsection id="H80BFA404DAB54EEBB2E8325F8DF612CA"><enum>(b)</enum><header>Superseding case
reviews</header>
<paragraph id="H8C1BF677548843EF92BF778C83B57DAC"><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="HF49FC7175A5B478A8863253006F7AC45"><enum>(2)</enum><header>Transition</header><text>Before
January 1, 2013, 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="H5D5A6F3F74264B6300419ED241DB671D"><enum>(3)</enum><header>Construction</header><text>Nothing
in this subsection shall be construed—</text>
<subparagraph id="H4F2604290BC742E6B181560136B9F616"><enum>(A)</enum><text>as precluding the
case-by-case review of the provision of care—</text>
<clause id="H1BF8276BAF0C47CF00E1FE18E06E7BFB"><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="H3B4353FA69F147EB9B17B3ED89A1A0A1"><enum>(ii)</enum><text>with respect to a
provider who has been determined to be an outlier; or</text>
</clause></subparagraph><subparagraph id="H4FD98731727B4F9BAD7BA95B00E93EDE"><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="H277AEBEFBAAC442C8938CC31F3003212"><enum>A</enum><header>Budgeting and
Payments to States</header>
<section id="H669DF534F0B84FEA8D0985A7DFEB58F8"><enum>601.</enum><header>National health
security budget</header>
<subsection id="HB019738F5365452AA9C9104F57328E88"><enum>(a)</enum><header>National health
security budget</header>
<paragraph id="H394D29646D3748DEA93D9D4669251802"><enum>(1)</enum><header>In
general</header><text>By not later than September 1 before the beginning of
each year (beginning with 2010), the Board shall establish a national health
security budget, which—</text>
<subparagraph id="HCC1794FBBBE1470383FF07A07670D384"><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="H21E434EADCC1400ABC80D3009FABF220"><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="H9E197A68235C4346B0E87159CAA55FF3"><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="HA0D1A857DF1E4FB2AF7F7B56B77FBB48"><enum>(A)</enum><text>A component for
quality assessment activities (described in title V).</text>
</subparagraph><subparagraph id="H80E4B2214AE54A18ACA2569E15082D89"><enum>(B)</enum><text>A component for
health professional education expenditures.</text>
</subparagraph><subparagraph id="H0F60A72D2D444D77B28B1D78DB03E246"><enum>(C)</enum><text>A component for
administrative costs.</text>
</subparagraph><subparagraph id="H23432594FBA14B8F800028804195B8DD"><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="H9AA25BFA23D74BD39454F3C54644292E"><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="H85186E533D2A492CA0C7F0A448A076F3"><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="H89485EC09023455C9EB53CFFFCD4270"><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="HDDB26F329DF04DA3B18059A2AD9B707C"><enum>(b)</enum><header>Basis for total
expenditures</header>
<paragraph id="HBDAA0CC3CDBB43DB873E5E178E002682"><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="H86CFB0509C2D4A618434604D2BB14B92"><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="H6C939B6925B649E2897975EF4B22904F"><enum>(c)</enum><header>Definitions</header><text>In
this title:</text>
<paragraph id="H4F521EF69627428E006DCA7641C49CC"><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="H50157390253A45D4B212CAFDCA24357"><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="H38709115475B46B18C3BED503FDACC77"><enum>602.</enum><header>Computation of
individual and State capitation amounts</header>
<subsection id="H56C0821DD40541FA8FACF39FE114876"><enum>(a)</enum><header>Capitation
amounts</header>
<paragraph id="H58E30B91931C4E9682F4B81942576C85"><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="HF09C41425A5947FF8F2C014F47BBDEA4"><enum>(A)</enum><text>a national average
per capita cost for all covered health care services (computed under subsection
(b));</text>
</subparagraph><subparagraph id="H91A2D3826B684499AC4B62E30834FC88"><enum>(B)</enum><text>the State
adjustment factor (established under subsection (c)) for the State; and</text>
</subparagraph><subparagraph id="HD9B934EE221A40C088A2B61739CF5EEF"><enum>(C)</enum><text>the risk
adjustment factor (established under subsection (d)) for the risk group.</text>
</subparagraph></paragraph><paragraph id="H2D3993D0F6A34B9C94CFBBD8909B590"><enum>(2)</enum><header>State capitation
amount</header>
<subparagraph id="H0811B0E8953F4DF38D7F67DE13B6069D"><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="H189564F417204ABE9266F9400E2C7CF"><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="H48DBA6BCD01F427B8D2415FE20794AD"><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="H1B0EAB74144C4EC8A1FAC4BBDEF12C47"><enum>(b)</enum><header>Computation of
national average per capita cost</header>
<paragraph id="H07854C6B7DE341378E85EFC600AFF2B"><enum>(1)</enum><header>For
2010</header><text>For 2010, the national average per capita cost under this
paragraph is equal to—</text>
<subparagraph id="H60F159B4CF4B4A4E89E9FD4263D3A79B"><enum>(A)</enum><text>the average per
capita health care expenditures in the United States in 2008 (as estimated by
the Board);</text>
</subparagraph><subparagraph id="H0D66BBF68DE84B61B1EEA300EDA422DC"><enum>(B)</enum><text>increased to 2009
by the Board’s estimate of the actual amount of such per capita expenditures
during 2009; and</text>
</subparagraph><subparagraph id="H328E616D613545A39F007F1051E745DD"><enum>(C)</enum><text>updated to 2010 by
the national health security spending growth limit specified in section
601(b)(2) for 2010.</text>
</subparagraph></paragraph><paragraph id="HDF0D121B1EE74F9FA2432EE7DDB68DF0"><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="H262A829E8AD74DB1A3ED1BE9CAEDE47F"><enum>(c)</enum><header>State adjustment
factors</header>
<paragraph id="H08907FAB602346E49E007F4FAA438105"><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="H3916C6380C38456B9373FF89B049E703"><enum>(A)</enum><text>average labor and
nonlabor costs that are necessary to provide covered health services;</text>
</subparagraph><subparagraph id="HD5C4DAF364DE4301A6E950345C8789D9"><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="HACF82DE2941F4EFD9EF02EC96553499"><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="H2B2C2F7440C449C0BD2ED2D6B4A89C00"><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="H5BD8A127FC3F455DB75EB0DC24EC8F00"><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="HA55E2B5A4E9F4FC69482A17E7174FFD0"><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="H9779BE6FB4694103ABDC5900825772FA"><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="HB65DFADC94684617A902A46D2E3E32D4"><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="H98403478535341B1A0F5E73BDCD58242"><enum>(4)</enum><header>Phase-in</header><text>In
applying State adjustment factors under this subsection during the 5-year
period beginning with 2010, 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="HD605282529FD4DE39DB32DE7EB5FF82"><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="H5FEECE877EC344A6B9A5CBEB5947B362"><enum>(d)</enum><header>Adjustments for
risk group classification</header>
<paragraph id="HDBC8C8CD13B8401D98A3359C474CD9FD"><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="H7F43FE9A8FFD41F385B0A6A87927AEA5"><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="HA873532CF0C048A39FFE7EFC5B788073"><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="HEF632688BF5A47E0AF9FA84805ABA260"><enum>603.</enum><header>State health
security budgets</header>
<subsection id="HD2937E7AD1F746CD91281C43B079DD74"><enum>(a)</enum><header>Establishment
and submission of budgets</header>
<paragraph id="H68F656BE99544C17BDBEC210FEED3597"><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="H18D74057A4774C10B14CB8D9F51891DF"><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="HB7F32F3FA96E4BC382F646A762C0568"><enum>(i)</enum><text>By
the 4 components (described in section 601(a)(2)), consistent with subsection
(b).</text>
</clause><clause id="H7A8E128700E34BC28415B7DA9D6CACBC"><enum>(ii)</enum><text>Within the
operating component—</text>
<subclause id="H363B3992575F44A5BD34974508E60600"><enum>(I)</enum><text>expenditures for
operating costs of hospitals and other facility-based services in the
State;</text>
</subclause><subclause id="H440E26316D564372A81C28D3C7B8BE47"><enum>(II)</enum><text>expenditures for
payment to comprehensive health service organizations;</text>
</subclause><subclause id="HDE76F5CB56174AFE80FACA8D1E27CABA"><enum>(III)</enum><text>expenditures for
payment of services provided by health care practitioners; and</text>
</subclause><subclause id="HB51CC21B3E7A43C58171B2ACDFD6FE0"><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="HA38AEA70A71E404F824C04EFDB48BB3F"><enum>(B)</enum><text>The total revenues
required to meet the State health security expenditures.</text>
</subparagraph></paragraph><paragraph id="HA5AAFCAF9B424379A1B73FF2F08FCA50"><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="H1A57E3EF030D4D97A06DBCC5CDA4A09E"><enum>(3)</enum><header>Final
budget</header><text>The final budget for a year shall—</text>
<subparagraph id="H56603E2DE06C4FC2835FDB1F1E88336C"><enum>(A)</enum><text>be established and
submitted under paragraph (1) not later than October 1 before the year,
and</text>
</subparagraph><subparagraph id="H85C3B1AE98B64BBBA5DD057BFB984C4E"><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="H5FBCB5A756E44BC3B4F56D36DE685687"><enum>(4)</enum><header>Adjustment in
allocations permitted</header>
<subparagraph id="HBA0325C8A35A4FE1BAE1B16C00F470CD"><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="H6F7B4DD58D1648619723E1D922F6CFCD"><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="H7C398552798D4C8A838F5CC9F4B1FF5"><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="HF06D21E49CFC42079DC3ECF830F6E501"><enum>(b)</enum><header>Expenditure
limits</header>
<paragraph id="H37E79477DD60433FB4DA4184A590628E"><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="H26B330634EB644AEAC8EDB99AF000086"><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="H0E36CF16A07D40DBBE9906AD8CCDF239"><enum>(3)</enum><header>Worker
assistance</header><text>A State health security program may provide that, for
budgets for years before 2013, 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="H3563EF75DE81480281D3816EA6BBF18"><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="H44F0CCAA886B46DBBF64AC306E10ACF"><enum>604.</enum><header>Federal payments
to States</header>
<subsection id="H91F8B37028C04E5690C6EE6E073F9CFE"><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="H956C3DC67E974B828FA48B996BE16B45"><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="H9DE2A6748B88432DA6789BE70054E0A8"><enum>(2)</enum><text>the Federal
contribution percentage (established under subsection (b)).</text>
</paragraph></subsection><subsection id="H1F9ADD0990FF4FB5BD49DB54B1CC53C9"><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 2010, 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="H0904D6C7400D4491B8ACF65820A31DB9"><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="HA4CB9EA1B4B6464EAE003E990009A2EC"><enum>(d)</enum><header>Effect of
spending excess or surplus</header>
<paragraph id="H26914A9400A9411C9B8C52D44204D64E"><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="HF11975F0636B449DB072A7DDB7861F4C"><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="H9A425870B7D94217BA94078E99111D81"><enum>605.</enum><header>Account for
health professional education expenditures</header>
<subsection id="H8FFEF02C89A84907856986E3C36BAC72"><enum>(a)</enum><header>Separate
account</header><text>Each State health security program shall—</text>
<paragraph id="H272927732732417491EAFEAB9164EE7F"><enum>(1)</enum><text>include a separate
account for health professional education expenditures; and</text>
</paragraph><paragraph id="H1FF9CBCEAAEC452196D1BBC77471C1F"><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="H1B7F8BBF0E394944A30924BFC97EA2EF"><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="H2B68D6B122D24497B7DCFFAB8569A306"><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="H05BF611F0ED943CFA348DE8D00F57793"><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="HADF60CD8ECF340948E2C97C4F91D8B92"><enum>B</enum><header>Payments by States
to Providers</header>
<section id="H76015382F6384964A64580F696C00AB"><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="HA594B7DAF1B14415BC11489804EB00F6"><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="HCA06EC0D88D149F79B9ECBF56B411B30"><enum>(b)</enum><header>Annual
negotiations; budget approval</header>
<paragraph id="H77B8E0CF3AAC4D04955F03253400E815"><enum>(1)</enum><header>In
general</header><text>The prospective global budget for an institution or
facility shall—</text>
<subparagraph id="H6018B3E04AA44701BE225808CF02230"><enum>(A)</enum><text>be developed
through annual negotiations between—</text>
<clause id="HADDD3833985548A988D1868525E93F74"><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="H603BE70AFAD84938A7F31074DE77008"><enum>(ii)</enum><text>the
institution or facility; and</text>
</clause></subparagraph><subparagraph id="H59385FD6FCFC4B5C8D47D4651E378FD1"><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="H7FDF2350C84E43C68F6329DCEACEC4A7"><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="H4900609E73D448C38D18FCC357EBD9D0"><enum>(A)</enum><text>With respect to
inpatient hospital services, the number, and classification by
diagnosis-related group, of discharges.</text>
</subparagraph><subparagraph id="HBC08087463514B6AAF95F8C2D025001E"><enum>(B)</enum><text>An institution’s
or facility’s past expenditures.</text>
</subparagraph><subparagraph id="H0635D6B304B040F598E673EE00673F57"><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="H33AC31209E104DBCA0AA8CC733BF1152"><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="H248682E0E1CC48BBADE558A17E06AADF"><enum>(E)</enum><text>Change in the
consumer price index and other price indices.</text>
</subparagraph><subparagraph id="H70BAE67F27E14E4A84AEFDD35029A7F0"><enum>(F)</enum><text>The cost of
reasonable compensation to health care practitioners.</text>
</subparagraph><subparagraph id="HA119F05F8FE841D5B1A2D35F0E90723"><enum>(G)</enum><text>The compensation
level of the institution’s or facility’s work force.</text>
</subparagraph><subparagraph id="H3E4CD6ED278646B0808D28A56465C287"><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="H1F9812B81D164E578B25529C8783CF5D"><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="H3F74282F15944E63BFC6D16C852475CB"><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="H987D60F78D7F46458DDC19977E27E586"><enum>(K)</enum><text>Technological
advances or changes.</text>
</subparagraph><subparagraph id="H231806FF5997493CA8A9B4DDF8B44EA6"><enum>(L)</enum><text>Costs of the
institution or facility associated with meeting Federal and State
regulations.</text>
</subparagraph><subparagraph id="H6C0BFC8E5758436EAF0043D0B1CC0285"><enum>(M)</enum><text>The costs
associated with necessary public outreach activities.</text>
</subparagraph><subparagraph id="HC9B67FD796EC4D9F8680F626009460B"><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="H2E86BA5A6ED444D1BA05AA121BD72860"><enum>(O)</enum><text>Incentives to
facilities that maintain costs below previous reasonable budgeted levels
without reducing the care provided.</text>
</subparagraph><subparagraph id="H94235972258C475AACB36BA302909154"><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="H982ED909BEDD4131ABCFA300BD905BCB"><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="H293AD6A5941446DCAF551DF3E026CA00"><enum>(c)</enum><header>Adjustments in
approved budgets</header>
<paragraph id="H01F55653C9444ABDAB00E47D5EBCC466"><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="HE1E11E2C75374A2594274F51E573AE1E"><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="HE132F03A28834ED7B2D371C9421ED002"><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="HFF461D1F88864E0CBFA4C1F3C163B548"><enum>612.</enum><header>Payments to
health care practitioners based on prospective fee schedule</header>
<subsection id="HAC7EE5B5923D462699B1FC00F9B5449"><enum>(a)</enum><header>Fee for
service</header>
<paragraph id="H1CA913C32ECD410CB95D434F2E530431"><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="H3EE12160E997428F9C40D06066A18892"><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="H4B22A9D15D6F43D4AD2262B627EA6062"><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="HA0E3E21355C8413B82DFA101DCC274FA"><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="H95983E17878148F49500BD9CD9333420"><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="H0DA07A1C86AD4366989FA6E555076077"><enum>613.</enum><header>Payments to
comprehensive health service organizations</header>
<subsection id="H40AA14E8172145C59416ACBFD9F1AA64"><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="H098073EA8D4541B20039088532007B6D"><enum>(1)</enum><text>based on a global
budget described in section 611; or</text>
</paragraph><paragraph id="HDCA97596CD1543260065343DBD265327"><enum>(2)</enum><text>based on the basic
capitation amount described in subsection (b) for each of its enrollees.</text>
</paragraph></subsection><subsection id="HB6E2BC6A886E48A500EB0E300A4CB65"><enum>(b)</enum><header>Basic capitation
amount</header>
<paragraph id="H98E07B19739D479CA51803F3DD0072E2"><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="H9BF8C22BF034444FB4E71C9C00A15DF9"><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="H2BC4CF41C2784E379EEB73E2FF29F670"><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="H850BDA43648F47A49230B1B43E517961"><enum>614.</enum><header>Payments for
community-based primary health services</header>
<subsection id="HCD629435E7C547B1A9508E314465C235"><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="H6C8EA3842A1944F2A1DED63E853BF8CA"><enum>(1)</enum><text>be based on a
global budget described in section 611;</text>
</paragraph><paragraph id="H5A8FC7CC37D943E397ADE9867D478E2F"><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="H75B7E9C25A6B4CF5001C62E9CFDC7BAA"><enum>(3)</enum><text>be made on a
fee-for-service basis under section 612.</text>
</paragraph></subsection><subsection id="HBD99DEDDFBFC4C3383941EBBE649FC2"><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="HAD9E256BDE4246FBBCFF2D362C8BC1D0"><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="H1C770BC7A7034AEB9F1EB2C88CD369E1"><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="H8763C7787AD24EF9B509DD45C77E625E"><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="H7FCF1D40909640D9A735FC71B00E4DE"><enum>(c)</enum><header>Basic primary
care capitation amount</header>
<paragraph id="H742362290E09425F8BC9E47F0966E039"><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="HC5ECA4A02B69401981C7752F7825FB83"><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="H52B617529D2E474080AD68F21CE5FD9C"><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="HE2E1DADA3FFB44569722B4983539F338"><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="HCA2ADC84815A4A71B1A5FC8C01A45DDF"><enum>615.</enum><header>Payments for
prescription drugs</header>
<subsection id="H55DC58BAAB0C4911A256B9D549AC4DFD"><enum>(a)</enum><header>Establishment of
list</header>
<paragraph id="HE3454C23A98A40159293A9C865614669"><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="H9C8F47E491C04AD492E990B514DE00C4"><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="HD269640EA30546F9BFFF10AB468EF7A3"><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="H5EED4B861F774CF08353004543535917"><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="H49CC04460DF04FB9A4E0746DD7CB05F6"><enum>616.</enum><header>Payments for
approved devices and equipment</header>
<subsection id="H100E9413D7494C46AD21051CAB7F3C6D"><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="HFF22108D27DD40DD9800F900BA3B4557"><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="HFA8BBB20CDB8482193C07100DDDC0042"><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="HDF10B930B8934312ACD8072C9E76DD01"><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="HD9BA2B2C51874D998B7E55B1D27403FD"><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="HD22369D1CF1D4E81BEBD778F93F090DF"><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="H0B51EC3C4ABE46C2BFB38F06002B90BF"><enum>(2)</enum><text>consistent with
the State health security budget.</text>
</paragraph></section><section id="H2A5EDC11DDCA4667BE206E9CD912428D"><enum>618.</enum><header>Payment
incentives for medically underserved areas</header>
<subsection id="H912C1C3379374AA283E5621BBCE31771"><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="HA1A8517C97A34B15AEA88BF01BAB016"><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="H73358143CF704C9280953569C5B800EF"><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="H32CF2AB9D238418F8042C6A86147B13F"><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="HE73B87B1D09E419900B138D5B74BAAD"><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="H3E1183A50014481AB4A86651EF78F2F"><enum>C</enum><header>Mandatory
assignment and administrative provisions</header>
<section id="HF234D4B0BE8944BBBD36D7A2672EAF83"><enum>631.</enum><header>Mandatory
assignment</header>
<subsection id="H28CE05A4C39445C59031E0DBD8F032C6"><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="H35893A1BE04F4FAEA9B0E57053190331"><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="H0A13A32A9A60426792933F27DBECE03"><enum>632.</enum><header>Procedures for
reimbursement; appeals</header>
<subsection id="H228C8218DB5D40FF8444B7251215C708"><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="H0F0296FD274A4BCF90AEF2FD0841F09"><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="H1E9AF88E2C404AC4BF889634F996B2CC"><enum>A</enum><header>Promotion and
Expansion of Primary Care Professional Training</header>
<section id="H337116CA18684F8EAFB8B34479A1BE10"><enum>701.</enum><header>Role of Board;
establishment of primary care professional output goals</header>
<subsection id="H5AB73DCCB48B463E81888D99AA95DF4F"><enum>(a)</enum><header>In
general</header><text>The Board is responsible for—</text>
<paragraph id="H54A579EA9D7349CB81546D029D818D2F"><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="H07F54CA3178F4B0E9E3165EC58920AB"><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="H3A5EAC721337481F8903A22198AAC552"><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="H32038EAAE8674D98B775AB56593D5BE"><enum>(4)</enum><text>developing,
coordinating, and promoting other policies that expand the number of primary
care practitioners.</text>
</paragraph></subsection><subsection id="H353EA4FD5ACB48E69B27E7CC70E3AAAA"><enum>(b)</enum><header>National
goals</header><text>The national goals specified in this subsection are as
follows:</text>
<paragraph id="H5D722A08FA2B4AAEBBC09FB349851EA2"><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="HD5DCE4821241483D8415E7E46F44C96"><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, 2013.</text>
</paragraph><paragraph id="id30CDF05A18B845868A8813A91DC11AAD"><enum>(3)</enum><header>Dentistry</header><text>To
assure an adequate supply of dental care practitioners, there shall be a
number, specified by the Board, of dentists (as defined in subsection (e)(1))
employed in the health care system as of January 1, 2013.</text>
</paragraph></subsection><subsection id="H160969C18D0F489BB6C609F2C257F1EE"><enum>(c)</enum><header>Method for
attainment of national goal for graduate medical education; program
goals</header>
<paragraph id="H27869529BA594A05A2B80000067FA7D4"><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="HC6FB000955824BB2BA843192D0CC78DA"><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="H3D78C90FAFC04221A859D47DB6F9CCA3"><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="HC8A9F35BB93B4988BFBB43D68CCCBAE7"><enum>(A)</enum><text>includes at least
1 medical school with a teaching hospital and related teaching settings;
and</text>
</subparagraph><subparagraph id="HDC3D56C151B64495BFB653B1EF9B7B7E"><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="HC86CB5B02B004EE0B7498F962EFED48E"><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="HA095D3CAC708406DA24222D16D4F2B73"><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="HB2CE004437004BCE80935B8C3CF5301F"><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="HF6D2D243D112465AAC4E8F7CF6E63CEF"><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="H75A94E56EBE14018B98972E843A71EAE"><enum>(e)</enum><header>Definitions</header><text>In
this title:</text>
<paragraph id="idABA324577C05435E99A65F94EF69F610"><enum>(1)</enum><header>Dentist</header><text>The
term <term>dentist</term> means a practitioner who performs the evaluation,
diagnosis, prevention or treatment (nonsurgical, surgical or related
procedures) of diseases, disorders or conditions of the oral cavity,
maxillofacial area or the adjacent and associated structures and their impact
on the human body, within the scope of his or her education, training and
experience, in accordance with the ethics of the profession and applicable
law.</text>
</paragraph><paragraph id="HBF69F45CBC364A91817BA3DA06B93EA0"><enum>(2)</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="H9169AEFC53274DA3A2EAAB7436AE094B"><enum>(3)</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="HA5CB589BD2A74FA69DE8901EF63FD"><enum>(4)</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="HBD5B6B3A50CC4BF6AD4BC875979536F"><enum>702.</enum><header>Establishment of
Advisory Committee on Health Professional Education</header>
<subsection id="H663D335A8E8B44909CB963F227F071C5"><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="HE5C4C5A1D5A84F62B8C4E8B4B91B3FBD"><enum>(b)</enum><header>Membership</header><text>The
Committee shall be composed of—</text>
<paragraph id="HB4FDF5EF08234C35A5132F347604C1CA"><enum>(1)</enum><text>the Chair of the
Board, who shall serve as Chair of the Committee; and</text>
</paragraph><paragraph id="H3AA045ACCFC7461D9B2F03FC40510001"><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="H6DBD1576D5FD4189B0A53A89D17DCB2"><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="H07A2E48D35BE46598C4E037914BB1348"><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="HB069929245F64F73BE00B15DD020D1DB"><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="H0F308420CDEC448F8DE6C74115162400"><enum>(d)</enum><header>Vacancies</header>
<paragraph id="HC72E962259E24A499C6BB2009ECF58A5"><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="HECA8625F0AB14F84BBDAC3E061C00EB"><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="H2E09903067D34F929B2403157B2BA11"><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="H197C77E15ABD4B4EABA22FC6F022B428"><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="HFB314B9D16A34A3BAE1C72751DDAA4E0"><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="H3B74DE4441F94F70AA76EA98277000F1"><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="H9959061468834582888547BD83F8234E"><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 chapter 57 of title 5, United States
Code.</text>
</subsection><subsection id="HE65436809E544C4D95835EAD93D1D6"><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="H6F7C5255E4144F48A022FAE6766290E6"><enum>703.</enum><header>Grants for
health professions education, nurse education, and the National Health Service
Corps</header>
<subsection id="H15EA35942CED42469E85B65DE4BA4543"><enum>(a)</enum><header>Transfers to
Public Health Service</header><text>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. The amounts transferred for the support of the National
Health Service Corps shall be in the following amounts for the fiscal year
indicated:</text>
<paragraph id="idB8A7FD7710C84858869C8E0E367D092B"><enum>(1)</enum><text>For fiscal year
2010, $320,461,632.</text>
</paragraph><paragraph id="idACFFE206A8924F2CA130AC3F8B96518B"><enum>(2)</enum><text>For fiscal year
2011, $414,095,394.</text>
</paragraph><paragraph id="idE6085C4A309E4883A741466DE4EAF2AD"><enum>(3)</enum><text>For fiscal year
2012, $535,087,442.</text>
</paragraph><paragraph id="id255465BAF5D64D55BF143C3E73ED63A5"><enum>(4)</enum><text>For fiscal year
2013, $691,431,432.</text>
</paragraph><paragraph id="id4C64BB3444DC40FCB0C2B077C235D407"><enum>(5)</enum><text>For fiscal year
2014, $893,456,433.</text>
</paragraph><paragraph id="id3C984F5BB05246B2887582BED9FF8029"><enum>(6)</enum><text>For fiscal year
2015, $1,154,510,336.</text>
</paragraph><paragraph id="id997CD235701C4AB0885CEA0B38C97651"><enum>(7)</enum><text>For fiscal year
2016, and each subsequent fiscal year, the amount transferred for the preceding
fiscal year adjusted by the product of—</text>
<subparagraph id="id068783C797CB48C4A5405E0A08BBF068"><enum>(A)</enum><text>one plus the
average percentage increase in the costs of health professions education during
the prior fiscal year; and</text>
</subparagraph><subparagraph id="idCF8034F86DF24936A6B5079BEB04678C"><enum>(B)</enum><text>one plus the
average percentage change in the number of individuals residing in health
professions shortage areas designated under section 333 during the prior fiscal
year, relative to the number of individuals residing in such areas during the
previous fiscal year.</text>
</subparagraph></paragraph></subsection><subsection id="H99B976F49D384836BA5897D53E46A0DC"><enum>(b)</enum><header>Range of
funds</header><text>The amount of transfers under subsection (a) for any fiscal
year for title VII and VIII shall be an amount (specified by the Board each
year) not less than <fraction>3/100</fraction> percent and not to exceed
<fraction>4/100</fraction> percent of the amounts the Board estimates will be
expended from the Trust Fund in the fiscal year.</text>
</subsection><subsection id="H86C2323927FF4C9E865592B02C004282"><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 2009.</text>
</subsection></section></subtitle><subtitle id="HD91F6595AAD1463C9D8F864CFB96C0C7"><enum>B</enum><header>Direct Health Care
Delivery</header>
<section id="H71AEEC6564384BE4986C37006D51251D"><enum>711.</enum><header>Set-aside for
public health</header>
<subsection id="HF6E2D42F9046481AB6E948189184167"><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="H3D95D8025CF44986AA708E2321001000"><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="HCBD6E8EA22D44CD08B691F49F1608442"><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="HD46A6489BDFF4184858C001042B47BB7"><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="H4892111C7BD843BF81C6C93678303D1D"><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="H306D9A26D42248C194163F29B175F037"><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="H43B720D3721A4C45B6C1051700F79E99"><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="HB2B6DD8C033F4C7CBBC24D21364500C7"><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="H433A7862EA724ED69DF81193363B6050"><enum>(8)</enum><text>Public health
formula grants described in subsection (d).</text>
</paragraph></subsection><subsection id="H00726522809E421C81FA55A8C363CB91"><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 <fraction>14/100</fraction>
percent of the amounts the Board estimates will be expended from the Trust Fund
in the fiscal year.</text>
</subsection><subsection id="H72421B02971C4EAA9B179552EEF76EBA"><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="HB8DB03094D024E06B8677760325B8590"><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="H7EE8D168130546C1B3E109B3EFFD5D7"><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="HFF6CCF5AF1EC4A51A5F5C5DAFACB004E"><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="HBBDA8AE377724A31B44D22DA06957C00"><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="H375D7D44A6074717B01D6FBF0088D6DA"><enum>(4)</enum><text>Information
regarding how Federal funding has improved population-based prevention
activities and programs.</text>
</paragraph><paragraph id="H14D5FDB920EC4B01B7614FFF1255975E"><enum>(5)</enum><text>A
description of the core public health functions to be carried out at the local
level.</text>
</paragraph><paragraph id="H13FD2C4CD9A34A53A621C332B04AEC"><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="HB5844A6AFE8F434EA4BD1020AA9E8BE3"><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 2008.</text>
</subsection><subsection id="H0175E34EC6C440A3A392DF1C685616A8"><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="H0F1A40FF15BD461E98CEC29E7F1E7D3"><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="HE260B80DC3BE486AA5E0AA26757122EC"><enum>(2)</enum><text>Activities to
protect the environment and to assure the safety of housing, workplaces, food,
and water.</text>
</paragraph><paragraph id="H4C5149EDDD6C4E8CB24309BE007CD027"><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="H0C3D8774F75B4BA3001333882F6CC77F"><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="H046B64615DF94445B5BD9388E1606F83"><enum>(5)</enum><text>The provision of
public health laboratory services to complement private clinical laboratory
services, including—</text>
<subparagraph id="H4D74585F259B46AA8258415700EC75B7"><enum>(A)</enum><text>screening tests
for metabolic diseases in newborns;</text>
</subparagraph><subparagraph id="HD4D4C57D230C4E9EAE9433A0D2360028"><enum>(B)</enum><text>toxicology
assessments of blood lead levels and other environmental toxins;</text>
</subparagraph><subparagraph id="H9455A79701DC4188A9AE67BA8E39B37F"><enum>(C)</enum><text>tuberculosis and
other diseases requiring partner notification; and</text>
</subparagraph><subparagraph id="H80557247C65145F4B1AB4D96E0004CD1"><enum>(D)</enum><text>testing for
infectious and food-borne diseases.</text>
</subparagraph></paragraph><paragraph id="H796D7A375EA94499AE15622F47E8AAC5"><enum>(6)</enum><text>Training and
education for the public health professions.</text>
</paragraph><paragraph id="H59E465DD51B6412AA1A061A6D900A101"><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="HCC1BA25D8B064ABA8CADD2D8355BCFE6"><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="HF4924302214F4A8F8F61B45791F79B51"><enum>712.</enum><header>Set-aside for
primary health care delivery</header>
<subsection id="idB4B7AC95A35740109F9E8D0A63FD2E15"><enum>(a)</enum><header>Transfers to
Section 330 program of the Public Health Service Act</header><text>The Board
shall make transfers from the American Health Security Trust Fund to the Public
Health Service for the program authorized under section 330 of the Public
Health Service Act (42 U.S.C. 254b) in the following amounts for the fiscal
year indicated:</text>
<paragraph id="id09BBA259A1204BDF8E057A4CB746FB25"><enum>(1)</enum><text>For fiscal year
2010, $2,988,821,592.</text>
</paragraph><paragraph id="idEF985BD6EFB4438F9D3E44D91DBEBDBA"><enum>(2)</enum><text>For fiscal year
2011, $3,862,107,440.</text>
</paragraph><paragraph id="idA2764585894142DCA25E51AEDC7C6E2D"><enum>(3)</enum><text>For fiscal year
2012, $4,990,553,440.</text>
</paragraph><paragraph id="id964C812DBAA14294929AEE28EEE7E682"><enum>(4)</enum><text>For fiscal year
2013, $6,448,713,307.</text>
</paragraph><paragraph id="id2A248CB1939A48ACA25A536B7C37B4A8"><enum>(5)</enum><text>For fiscal year
2014, $7,332,924,155.</text>
</paragraph><paragraph id="id08121AD74C4E4DDAA74B2528413E31BF"><enum>(6)</enum><text>For fiscal year
2015, $8,332,924,155.</text>
</paragraph><paragraph id="id70446D493B324FAC9344DD4E1C92DE61"><enum>(7)</enum><text>For fiscal year
2016 and each subsequent fiscal year, the amount transferred for the preceding
fiscal year adjusted by the product of—</text>
<subparagraph id="id2B468A6E3B4B46A49501B1D4312D817F"><enum>(A)</enum><text>one plus the
average percentage increase in costs incurred per patient served by entities
receiving funding under such section; and</text>
</subparagraph><subparagraph id="id6DE72786F573458DB8ACF2FF24BB2A6B"><enum>(B)</enum><text>one plus the
average percentage increase in the total number of patients served by entities
receiving funding under such section.</text>
</subparagraph></paragraph></subsection><subsection id="HE29DE38CA1D84F0792C789004BCEF608"><enum>(b)</enum><header>Transfers to
Public Health Service</header><text>From the amounts provided under subsection
(d), 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="HB860AA6BE5FF44779B75F8A9EDAA0037"><enum>(c)</enum><header>Range of
funds</header><text>The amount of transfers under subsection (b) 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 <fraction>1/10</fraction>
percent of the amounts the Board estimates will be expended from the Trust Fund
in the fiscal year.</text>
</subsection><subsection id="HBBAF071D428249D1B02E7B505E7140C"><enum>(d)</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 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 2008.</text>
</subsection></section><section id="H9CB8E1A1FF384436880000ED87CD2E97"><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> (42 U.S.C. 254b et seq.) is amended by adding at the end thereof
the following new subpart:</text>
<quoted-block act-name="Public Health Service Act" id="H1327751F0EC44546BCB9CC59CD886B">
<subpart id="H091BDA5203514D8881B5008D4EE52630"><enum>XI</enum><header>Primary care
expansion</header>
<section id="H7A7993679E5F4FBB83DCB1FCF65D7983"><enum>340H.</enum><header>Expanding
primary care delivery capacity in urban and rural areas</header>
<subsection id="H402335D9996F42568F16358036CDFF09"><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="H7BCC5EB85907416D9200555C01F48A4"><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="H9C09964E303C42148713E7351EB4B854"><enum>(c)</enum><header>Funding as
set-aside from Trust Fund</header><text>Funds in the American Health Security
Trust Fund (established under section 801 of the act) shall be available to
carry out this section.</text>
</subsection><subsection id="H5F7FE21AB1FF47C5A451FA61C5788563"><enum>(d)</enum><header>Primary care
center defined</header><text>In this section, the term <term>primary care
center</term> means—</text>
<paragraph id="HACDDB89EDF324A96883EEA7861F9260"><enum>(1)</enum><text>a health center (as
defined in section 330(a)(1));</text>
</paragraph><paragraph id="H1848F8FD029D41A5A35D94F836003BAC"><enum>(2)</enum><text>an entity
qualified to receive a grant under section 330, 1001, or 2651; or</text>
</paragraph><paragraph id="H804407C677FD4B9C89613D18EBD8A952"><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="HEFB71B94255147D6A33C5742F1C400D0"><enum>C</enum><header>Primary Care and
Outcomes Research</header>
<section id="H6CB78FD564FE484C974235925D499C16"><enum>721.</enum><header>Set-aside for
outcomes research</header>
<subsection id="HBA743B71F36A4E408F4642DA128783C0"><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="HB82AADAAA8B3453D85FBB45F21D69435"><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 <fraction>2/100</fraction>
percent of the amounts the Board estimates will be expended from the Trust Fund
in the fiscal year.</text>
</subsection><subsection id="H775872281C0C4DC1B271FEFBBBC562C"><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 937 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 2008.</text>
</subsection><subsection id="H5C6F6E9A929D4E2BA8DAAD2BF4E8E3FC"><enum>(d)</enum><header>Conforming
amendment</header><text>Section 937(b) of the <act-name parsable-cite="PHSA">Public Health Service Act</act-name> (42 U.S.C. 299c–6(b))
is amended by inserting after <quote>of the fiscal years 2001 through
2005</quote> the following: <quote>and of fiscal year 2010 and each subsequent
year</quote>.</text>
</subsection></section><section id="H47D3017BBB034B7EB71200093F04C41E"><enum>722.</enum><header>Office of
Primary Care and Prevention Research</header>
<subsection id="HB9C202BA3F8943FCBF73C6C49BD61BCE"><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="H52AEC611AA7D426282BF968D4896C711"><enum>(1)</enum><text>by redesignating
parts G through I as parts H through J, respectively; and</text>
</paragraph><paragraph id="H366A18A1A5DB498C97B2007C3478EA6E"><enum>(2)</enum><text>by inserting after
part F the following new part:</text>
<quoted-block id="H9022B896CC1443C0B972AB08C4A738AE">
<part id="HCDDEDC4192F5456CA310CE82D56F5EEC"><enum>G</enum><header>Research on
primary care and prevention</header>
<section id="H35285820EDA5486CB678F79107A699F"><enum>486E.</enum><header>Office of
Primary Care and Prevention Research</header>
<subsection id="HD1239987CE8F4125867EF9F6EA579259"><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="HCABEB1A3E4944989A8384031E25D1F2C"><enum>(b)</enum><header>Purpose</header><text>The
Director of the Office shall—</text>
<paragraph id="HD7DE4756E3D845588CEE1088F1ACC126"><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="HD02134F883E249A49F5BA281D39F0068"><enum>(A)</enum><text>clinical patient
care, with special emphasis on pediatric clinical care and diagnosis;</text>
</subparagraph><subparagraph id="HE79357F9034240EEBA1FBC8F5FEB8B02"><enum>(B)</enum><text>diagnostic
effectiveness;</text>
</subparagraph><subparagraph id="HFC36AB3583DF47038591E1D92FB5B166"><enum>(C)</enum><text>primary care
education;</text>
</subparagraph><subparagraph id="H9D847125564E439D9BD5EC576F73D3A1"><enum>(D)</enum><text>health and family
planning services;</text>
</subparagraph><subparagraph id="H8DDD3F2046104A5892B697E015D7890"><enum>(E)</enum><text>medical
effectiveness outcomes of primary care procedures and interventions; and</text>
</subparagraph><subparagraph id="H17E02E65024448B0ABC5CFCF474B1F7C"><enum>(F)</enum><text>the use of
multidisciplinary teams of health care practitioners;</text>
</subparagraph></paragraph><paragraph id="H56021E6E0C844F7995775FFCFDA6A6CB"><enum>(2)</enum><text>identify
multidisciplinary research related to primary care and prevention that should
be so conducted;</text>
</paragraph><paragraph id="HF2C38E05E89E4512B541C74172F2A00"><enum>(3)</enum><text>promote
coordination and collaboration among entities conducting research identified
under any of paragraphs (1) and (2);</text>
</paragraph><paragraph id="HCA249335ABE74EF0B3DA9CDDDBAF91BB"><enum>(4)</enum><text>encourage the
conduct of such research by entities receiving funds from the national research
institutes;</text>
</paragraph><paragraph id="HDFE8773D64B4476EA41C00D56F718B"><enum>(5)</enum><text>recommend an agenda
for conducting and supporting such research;</text>
</paragraph><paragraph id="HA06605BD74324816BEAB129E814F3659"><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="H6F00FDD66F1345BD968EB07DD7607941"><enum>(7)</enum><text>prepare the report
required in section 486G.</text>
</paragraph></subsection><subsection id="H5E473E5168404705A14650842F3302AC"><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="H74FDF916758E4499BB117499ECBD30FF"><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="H7BAFF05D0C064C6AA118EFE5574FF900"><enum>(2)</enum><text>primary care
provided by multidisciplinary teams.</text>
</paragraph></subsection></section><section id="H7D7C541C4A0F47939600CB233FDCC493"><enum>486F.</enum><header>National data
system and clearinghouse on primary care and prevention research</header>
<subsection id="HF3FA8E5A943743FC97FD81F95182DFDD"><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="H701EBD370F1F4F05AE7E765C00E95001"><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="HC9478FA2CBB14A3F911C5FE2910500D4"><enum>486G.</enum><header>Biennial
report</header>
<subsection id="HB97E5307676B48A3BD1CB4AEEBB047A7"><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="HB9A6A3509286498A99316CF6422D07FF"><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="H7842EB4549974F36B0E592E38D5D6981"><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="H7915C758FEB34DD6AE00CC08F2D3BC21"><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="H60AD891F640442F195717FD40095393B"><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="HB24D92456DEB4950A937D5988D67731C"><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 2010, $180,000,000 for fiscal year
2011, and $216,000,000 for fiscal year
2012.</text>
</section></part><after-quoted-block>.</after-quoted-block></quoted-block>
</paragraph></subsection><subsection id="HCEE28BF93DA24ED2863C4381764E759B"><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> (42
U.S.C. 282(b)) is amended—</text>
<paragraph id="HE4FA7B12238B4341A862E7A463E75215"><enum>(1)</enum><text>in paragraph (22),
by striking <quote>and</quote> after the semicolon at the end;</text>
</paragraph><paragraph id="HD8CEBFEF61B94C9AA814C06FFD8724D5"><enum>(2)</enum><text>in paragraph (23),
by striking the period at the end and inserting <quote>; and</quote>;
and</text>
</paragraph><paragraph id="H3B0C0BD283AC498EA63193C53EE07EF2"><enum>(3)</enum><text>by inserting after
paragraph (23) the following new paragraph:</text>
<quoted-block id="H3459AAFCD55B4CA6BB07A057004D5377">
<paragraph id="H5BC9CE8905AB459DA8B3F640A02101FA"><enum>(24)</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="H52400034FB8D4CDCB3A4EDC2F29BA8E0"><enum>D</enum><header>School-Related
Health Services</header>
<section id="HA482CFF813F34CDE89580104DDB11795"><enum>731.</enum><header>Authorizations
of appropriations</header>
<subsection id="HBDF98CEAA07C4507ACA360BCE4C55919"><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 2012, $275,000,000 for fiscal year 2013, $350,000,000 for fiscal year
2014, and $400,000,000 for each of the fiscal years 2015 and 2016.</text>
</subsection><subsection id="H043F3981A4B64749828B46EAB0D9FE83"><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="H1B73A404D72B415F9CF557421B2DBC24"><enum>732.</enum><header>Eligibility for
development and operation grants</header>
<subsection id="HF47AFFA181B44CAEB88C557E8B0106E6"><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="H1DC70B8C46D24BC485C801A62345D241"><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="HFFBDA1C3848E46A88B2027517D5EF03E"><enum>(2)</enum><text>Local community
partnerships in States in which health agencies have not applied.</text>
</paragraph></subsection><subsection id="HF0FCA825D27A4E5FB0EA14CD7CAA47EE"><enum>(b)</enum><header>Local community
partnerships</header>
<paragraph id="HE4664CA2F83F4929A580E4FECF2E24D0"><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="H0B34E27A2AA246EB9E7950CE2F6900A4"><enum>(A)</enum><text>a local health
care provider with experience in delivering services to school-aged
children;</text>
</subparagraph><subparagraph id="H4D171DCE9CB2404F8BC6F3E36DEA2E8C"><enum>(B)</enum><text>1 or more local
public schools; and</text>
</subparagraph><subparagraph id="HB13664886B654CD6B7B1028F25A2D145"><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="H2801D0B7C05D44F0B2E35749C957E2D0"><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="H6F032A0BA0F14215005320D199FDCA00"><enum>(c)</enum><header>Definitions
regarding children</header><text>For purposes of this subtitle:</text>
<paragraph id="H6DEEC17960C5463AB2060491F4E6E649"><enum>(1)</enum><text>The term
<term>adolescent children</term> means school-aged children who are
adolescents.</text>
</paragraph><paragraph id="HDF9469A7F2974B90A5FFD1EC66D0703C"><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="H39A56B543D8046F10035A8DDF7F0E7F5"><enum>733.</enum><header>Preferences</header>
<subsection id="H961942B01DCA43F39FA202006EAD9FC2"><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="HFE1E27FC11594C6F9B13F7E7BAA5E0F6"><enum>(1)</enum><text>High levels of
poverty.</text>
</paragraph><paragraph id="HFB26BFE289D8494EA4C0FBFD2C506855"><enum>(2)</enum><text>The presence of a
medically underserved population.</text>
</paragraph><paragraph id="H48C145200C9447DEB9551882983F7F3B"><enum>(3)</enum><text>The presence of a
health professional shortage area.</text>
</paragraph><paragraph id="H399372E12D7640078CBC07CA2CC8053F"><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="HE89AEAED9A7A460A83D1378FABAD696"><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="H25CDB19FC1134F51A111613ED5CE7882"><enum>734.</enum><header>Grants for
development of projects</header>
<subsection id="H4127057CF7D64B8DB28EFD3906900562"><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="HF478AEC28E154BD984E45DB58CC85364"><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="H504FBF0479A24047BED9BCBF800EADC"><enum>(1)</enum><text>Planning for the
provision of school health services.</text>
</paragraph><paragraph id="HF26D221C0516490AA4C3ACEC25B393E0"><enum>(2)</enum><text>Recruitment,
compensation, and training of health and administrative staff.</text>
</paragraph><paragraph id="H8ECE6B22EA7547C788763FDB7005052F"><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="H313E19FA4E2644568E66FB9C4B9DADB1"><enum>(4)</enum><text>Other activities
necessary to assume operational status.</text>
</paragraph></subsection><subsection id="H4E0ABFE4BFC74FF6B9D8C12CA3184B7C"><enum>(c)</enum><header>Application for
grant</header>
<paragraph id="H6509995B0FCC4635823B13FB56D543E5"><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="HC7371B2429FA464F9648B621E4DA50F9"><enum>(2)</enum><header>Applications by
State health agencies</header>
<subparagraph id="H286EFB9CB6524AC488B59536F94BDBD8"><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="HB9891F5A4FD247DDB4428C17AB506EEB"><enum>(i)</enum><text>on
behalf of at least 1 local community partnership; and</text>
</clause><clause id="HC0955C3B4E224D4788DFDFB732F07296"><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="H453851F689D447FA00C176384D58C26E"><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="H487A00C2DA1D4A158157DB72E9173ED2"><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="HE05B6B21E9C94309988F9757D49D00FB"><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="H50C864695A05433CA656F2E4A5061BEF"><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="H47C46FCFF7EE4D5AB2A807E03B7F436E"><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="HEC83EBE143A24367BDA2C3F254CE3271"><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="H5CF91B6C52D8477AADC7139CA700B00"><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="H5385907E71664EDD8BC9CD06A5E36399"><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="H79815442688C43F9ABF6B19B2B66897F"><enum>735.</enum><header>Grants for
operation of projects</header>
<subsection id="H8E9F6329C29F4D9DB402B5751453E934"><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="H7688CCA5B1F84332A33C32748C48DA00"><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="H3280A3F268C24C3792E6376BD74C00EE"><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="H56C99B54A455423580C16E94E600B98E"><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="HA7EBE7E6B2F94C9B8286EC0062E8A76B"><enum>(3)</enum><text>Training,
recruitment and compensation of health professionals and other staff.</text>
</paragraph><paragraph id="H3E8D4E78F08141CBA9B976CE006680F7"><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="HBD232801C56343AF9FB3D6BCE5BB3C98"><enum>(5)</enum><text>Linkage of
individuals to health plans, community health services and social
services.</text>
</paragraph><paragraph id="HF6B27A189BBC4AC2B9589C8900C6B97B"><enum>(6)</enum><text>Other activities
deemed necessary by the Secretary.</text>
</paragraph></subsection><subsection id="H06B2CE487D974DF1BFB1EDE97FD5D201"><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="HEE463BDD66984275BDD3D527ADE6E5D3"><enum>(1)</enum><text>A
description of the services to be furnished by the applicant.</text>
</paragraph><paragraph id="HD4E0619AEB0D4F89B31EF9EAE0D2E00"><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="H8ACAB45F195E43D0A75000793DF90DA"><enum>(3)</enum><text>Such other
information as the Secretary determines to be appropriate.</text>
</paragraph></subsection><subsection id="HA7DE115189A046D8AB7E079E92DEF00"><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="HD77F2C8707BD468285784C9139A7B47"><enum>(1)</enum><text>The applicant
furnishes the following services:</text>
<subparagraph id="H86C33D89D5E84897852995A2F0D4E083"><enum>(A)</enum><text>Diagnosis and
treatment of simple illnesses and minor injuries.</text>
</subparagraph><subparagraph id="HF9013BB04E594A468418149548C12D7B"><enum>(B)</enum><text>Preventive health
services, including health screenings.</text>
</subparagraph><subparagraph id="H9518AF466123456EACE722E4353DADF"><enum>(C)</enum><text>Services provided
for the purpose described in subsection (b)(2).</text>
</subparagraph><subparagraph id="H4982B41564A64AEFBD96FC7E75CC4B28"><enum>(D)</enum><text>Referrals and
followups in situations involving illness or injury.</text>
</subparagraph><subparagraph id="H564D0CD4768D4CF5A483A0C76757BC6D"><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="H0BEDB9C207DA4B91839247A514C37D1D"><enum>(F)</enum><text>Such other
services as the Secretary determines to be appropriate.</text>
</subparagraph></paragraph><paragraph id="HC01C68361FB748A7A153E82C9B8E56CB"><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="H7C07C7F91D854D12B497205540DBA890"><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="HCABF838150624964B1AEAE398814164D"><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="H1D15D3ED08EC4B619D1C4E1B42D7D133"><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="H208275916F8B44E28FAC829F3054901F"><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="H844B838E92C240BDB7BD09E520B64F31"><enum>(7)</enum><text>The applicant will
operate a quality assurance program consistent with section 734(d).</text>
</paragraph></subsection><subsection id="H6071DD21327643D0A470D407784600F9"><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="HD1AB7D3848424389A3C1E08B002032B1"><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="H97FAADF0BE68465FBE1925001DA25491"><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="H1DDE177A9D214F7DBD00087106D37CA"><enum>737.</enum><header>Definitions</header><text display-inline="no-display-inline">For purposes of this subtitle:</text>
<paragraph id="H1615A539B46748249D12914FA7A41EBF"><enum>(1)</enum><text>The term
<term>adolescent children</term> has the meaning given such term in section
732(c).</text>
</paragraph><paragraph id="HE63FA3B7BA404207BC1362F8F6F58F72"><enum>(2)</enum><text>The term <term>at
risk</term> means at-risk with respect to health.</text>
</paragraph><paragraph id="H6FAFFB6E338748C0A882623B01171118"><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="H3DD1734EF1904B308C445D09327FE5BC"><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="HA9DC548198F2489DB81C460272FFC7EB"><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="H4C7C6B57026440C19155397979FF61B4"><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="HD34435073F6B461BA5EA3B99B1095B73"><enum>800.</enum><header>Amendment of
1986 code; Section 15 not to apply</header>
<subsection id="HF5A910FD0EF9439BA44733A456DC7162"><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="HA417C074BB3D4EF1AF42C8542BE9A8F3"><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 section 15 of the Internal Revenue
Code of 1986.</text>
</subsection></section><subtitle id="H207373521B724876BE707010D515B19E"><enum>A</enum><header>American Health
Security Trust Fund</header>
<section id="H6AC9818C6A3B4F04AEC39814947BBEF9"><enum>801.</enum><header>American Health
Security Trust Fund</header>
<subsection id="H91C9599DB4504A0F97A34107290628C0"><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="HA26C95D47C9948DAA3359D237F035EF7"><enum>(b)</enum><header>Appropriations
into Trust Fund</header>
<paragraph id="H6EED1295C3474AFAAC004214C63DB04"><enum>(1)</enum><header>Taxes</header><text>There
are hereby appropriated to the Trust Fund for each fiscal year (beginning with
fiscal year 2011), 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="HC9489E1B01194DBDB5F100484029D434"><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 2011) the amounts that would otherwise have been appropriated to
carry out the following programs:</text>
<subparagraph id="HF19A591CFF3C474498F5CB358F8D5217"><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="H35722D6B76FD43648742619CE7CD54C2"><enum>(B)</enum><text>The medicaid
program, under State plans approved under title XIX of such Act.</text>
</subparagraph><subparagraph id="HA83CF35A82B749B99C5EACE2730586B"><enum>(C)</enum><text>The Federal
employees health benefit program, under chapter 89 of title 5, United States
Code.</text>
</subparagraph><subparagraph id="H682EAD1B15984DC7887564BBE4B50258"><enum>(D)</enum><text>The TRICARE
program (formerly known as the CHAMPUS program), under chapter 55 of title 10,
United States Code.</text>
</subparagraph><subparagraph id="HEB0C03FE18D3473296ED63F9FB5B37E"><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="H0672897DE4B64DC38DBB818CFCFEEAA9"><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="H9D60FEA540944D449936F17D6744009E"><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="H6BB7AB77393B4A2193A2FA959EF71332"><enum>B</enum><header>Taxes Based on
Income and Wages</header>
<section id="H493586D9833947C4A4BB184CA1B9E6B3"><enum>811.</enum><header>Payroll tax on
employers</header>
<subsection id="H8C06642305174280805985A64F3EA14B"><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="H37DF4DBCBB3C499285E200558C5B590">
<subsection id="H94CA7AE5B1EC435F91543D007E6237BB"><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="H84E34BFD9B404E85B630F01945D06FE4"><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="H5E74299702904365AA5ED7CED1C52F82">
<subsection id="HA80918996C684246A45FB2965808017C"><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="HE2B0009408A645CC9B5D6F09AC6BBF86"><enum>(c)</enum><header>Comparable taxes
for railroad services</header>
<paragraph id="H0BACDF93988641FDBE7D2F70A949BBE5"><enum>(1)</enum><header>Tax on
employers</header><text>Section 3221 is amended by redesignating subsection (c)
as subsections (d) and inserting after subsection (b) the following new
subsection:</text>
<quoted-block id="H7A860340FF0245FBBA5C254009A8E7B7">
<subsection id="H92AB4AFF186043D98FA4FC400B10415"><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="HC75B56948B294AF4956E97BF5FFC6F94"><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="H53D88D84B7D041FBA850673740AC00E9">
<subsection id="H5C180F65C9A64CEF870739726EEAFA89"><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="HF72A36758D7546B4832611E5EFB6143C"><enum>(3)</enum><header>No applicable
base</header><text>Subparagraph (A) of section 3231(e)(2) is amended by adding
at the end thereof the following new clause:</text>
<quoted-block id="H323D8B18FCA54EB781CE96D46DD4DEF">
<clause id="H917F49C991DA40888E8396EB74008D2E"><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="HBA7417A7723644F8BB9D65E0D5B3482D"><enum>(4)</enum><header>Technical
amendment</header>
<subparagraph id="HD9145935E4884A69B21C1D7DC4B76B72"><enum>(A)</enum><text>Subsection (d) of
section 3211, as redesignated by paragraph (2), is amended by striking
<quote>and (b)</quote> and inserting <quote>, (b), and (c)</quote>.</text>
</subparagraph><subparagraph id="H8A959A8182EA4785B648E71ED99BDE3D"><enum>(B)</enum><text>Subsection (d) of
section 3221, 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="H14196C710E4244C5AEA8B8F529B34535"><enum>(d)</enum><header>Effective
date</header><text>The amendments made by this section shall apply to
remuneration paid after December 31, 2010.</text>
</subsection></section><section id="HFBDCE6D9AD1C489A97F718FB5256733E"><enum>812.</enum><header>Health care
income tax</header>
<subsection id="H8DEC903AB6014F5EA986289C87EBE540"><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="H15DC03FA241A403400BF3BC4CB470018">
<part id="HEED63E37BB354739A5FDE2BBBCF0681"><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="H4F09FBDD765A48C8B559372F861C48D7"><enum>59B.</enum><header>Health care
income tax</header>
<subsection id="H1A069EE2547849BB00632E403E5FCA13"><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="HD486E62718474F7991005BE7AD4D24C5"><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="HF85DB9C2619944D2AB00917430712FD2"><enum>(1)</enum><text>the amount of any
credit allowable under this chapter, or</text>
</paragraph><paragraph id="H827750F28D61478CBAD8C7003392AB58"><enum>(2)</enum><text>the amount of the
minimum tax imposed by section 55.</text>
</paragraph></subsection><subsection id="H68F2465258F94B8D8111A5C16C8DE3BD"><enum>(c)</enum><header>Special
rules</header>
<paragraph id="HD0320D7DC7E64B0BB9AFD5FEDA331E43"><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="HF3E92B7379004289AE332C00DD062500"><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="H65CF7AE16B1742AE8399D03033ADB72C"><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="H55FE47977A2D4B7E8E00A5F8F71F38F3"><enum>(b)</enum><header>Clerical
amendment</header><text>The table of parts for subchapter A of chapter 1 is
amended by adding at the end the following new item:</text>
<quoted-block id="H57590E8179F14CC280921E0000B889CE" style="OLC">
<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="H60C6EA8EE67D4394A0A6C899CFD6194B"><enum>(c)</enum><header>Effective
date</header><text>The amendments made by this section shall apply to taxable
years beginning after December 31, 2010.</text>
</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="HB846B054F32C41E09C4406F2BB09F6B8"><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> (29 U.S.C. 1003) is amended—</text>
<paragraph id="H4A04DE87434140D3B9E18EF7FB0077E7"><enum>(1)</enum><text>in subsection (a),
by striking <quote>(b) or (c)</quote> and inserting <quote>(b), (c), or
(d)</quote>; and</text>
</paragraph><paragraph id="H634C6FBC2EAD4223BFA13BE1A65977E8"><enum>(2)</enum><text>by adding at the
end the following new subsection:</text>
<quoted-block id="HD166DE4F43414ABE8D59F2EBA205878F">
<subsection id="H6C099DD1F71E40EC91917BCD10A8251B"><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
2009</short-title>.</text>
</subsection><after-quoted-block>.</after-quoted-block></quoted-block>
</paragraph></section><section id="H75A54B4C0C6E498EA91F2504736F4E39"><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> (29 U.S.C. 1144(b)) (as amended by sections 904(b)(3)(B) and
1002(b) of this Act) is amended by adding at the end the following new
paragraph:</text>
<quoted-block act-name="Employee Retirement Income Security Act of 1974" id="HDFB985E946A04D7893842E36C97B1C6E">
<paragraph id="HFDEC0F147EAC4C909F0040CDCCA76CDC" indent="up1"><enum>(8)</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
2009</short-title>.</text>
</paragraph><after-quoted-block>.</after-quoted-block></quoted-block>
</section><section id="HCC873964FE3248BD855706995FB7DC4C"><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="H61A395C3AEEB4A4DA788C6006DFFCEF1"><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 act-name="Employee Retirement Income Security Act of 1974" id="HE628EA26122A4D9BBDCD154C00F7AD51" style="traditional">
<section id="H944DD023E3F04A2A88F3E6585BBB5CD8"><enum>519.</enum><header>Prohibition of employee benefits duplicative of State health
security program benefits; coordination in case of workers’
compensation</header><subsection commented="no" display-inline="yes-display-inline" id="H2FEE21CFFFCD4489A4CC55159453252D"><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
2009</short-title>.</text>
</subsection><subsection id="H9114353138214DE18E03C62B00E477B0"><enum>(b)</enum><paragraph commented="no" display-inline="yes-display-inline" id="H9AC736106BEC47AF9D4CB2EE35C563B"><enum>(1)</enum><text>Each workers compensation
carrier that is liable 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 id="HC971305AE981406684007FC8AFCC43DA" indent="up1"><enum>(2)</enum><text>In this subsection:</text>
<subparagraph id="H0BBFCA6944EF4CC08B5700DFD900104C"><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="HC05D6004BB3A423E8600F0B43DADE810"><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="HE47E6EAC482C4FE8B35639781826969F"><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="H35AAFF3970024FC5A66E6F35007C99AB"><enum>(b)</enum><header>Conforming
amendment</header><text>Section 4(b) of such Act (29 U.S.C. 1003(b)) is amended
by adding at the end the following: <quote>Paragraph (3) shall apply subject to
section 519(b) (relating to reimbursement of State health security plans by
workers compensation carriers).</quote>.</text>
</subsection><subsection id="H7EAD601FD30B4BA59983E288044894FD"><enum>(c)</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 id="H833EDEB018E840B189ECC199628C9FA9" style="USC">
<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="H6D561D9AF5A44FC295D849FBB14DC94"><enum>904.</enum><header>Repeal of
continuation coverage requirements under ERISA and certain other requirements
relating to group health plans</header>
<subsection id="H97C43EB313A047DFBB3BF14CD1829C12"><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> (29 U.S.C. 1161 et seq.) is repealed.</text>
</subsection><subsection id="H34D759F78FE74D47975F4F3D7D385F1D"><enum>(b)</enum><header>Conforming
amendments</header>
<paragraph id="HCFA6CB756E0D40688B75094900E987FB"><enum>(1)</enum><text>Section 502(a) of
such Act (29 U.S.C. 1132(a)) is amended—</text>
<subparagraph id="H45FD986040BB42F9AE19D189299EBB3D"><enum>(A)</enum><text>by striking
paragraph (7); and</text>
</subparagraph><subparagraph id="H23B0A782CE844A5A86DD54C0C2BDB3D"><enum>(B)</enum><text>by redesignating
paragraphs (8), (9), and (10) as paragraphs (7), (8), and (9),
respectively.</text>
</subparagraph></paragraph><paragraph id="H3C28F250879B49FA8F56BCD98B9618BC"><enum>(2)</enum><text>Section 502(c)(1)
of such Act (29 U.S.C. 1132(c)(1)) is amended by striking <quote>paragraph (1)
or (4) of section 606,</quote>.</text>
</paragraph><paragraph id="H037FE3239AFE4AB9A3D3AD472DDB7225"><enum>(3)</enum><text>Section 514(b) of
such Act (29 U.S.C. 1144(b)) is amended—</text>
<subparagraph id="H8CF8722A651B4445969B50ECB77634BD"><enum>(A)</enum><text>in paragraph (7),
by striking <quote>section 206(d)(3)(B)(i)),</quote> and all that follows and
inserting <quote>section 206(d)(3)(B)(i)).</quote>; and</text>
</subparagraph><subparagraph id="H514B389A610B4F3400BCABAF649D7EC"><enum>(B)</enum><text>by striking
paragraph (8).</text>
</subparagraph></paragraph><paragraph id="H2D7E890ECA754E5B8792EA6489A22BF"><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="H2928824113964197BC7C54DA4F438D01"><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, 2012.</text>
</section><enum>X</enum><header>Additional
Conforming Amendments</header>
<section id="HD2382E98225246ADA5D188B1C01F305C"><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="H8DC9AD97E9594DCBAE8FDB8594E77FEA"><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="H92007FCF0A2A44C9B59767DDAB40FD29"><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="H10D832DD01C241CE945BBFB25FE5B910"><enum>(b)</enum><header>Conforming
amendment</header><text>Section 514(b) of such Act (29 U.S.C. 1144(b)) is
amended by striking paragraph (9).</text>
</subsection></section><section id="HE4A90DB90C184388BBE505096D284210"><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="H14CC42983D124E43AC54F7C400CD44D9"><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="H19ED4D2987D74D698C5D45EF0027623E"><enum>(b)</enum><header>Additional
amendments</header>
<paragraph id="H42496BBDE17B463B00DFBAF27D917890"><enum>(1)</enum><text>Section 1301(b) of
such Act (42 U.S.C. 300e(b)) is amended by striking paragraph (6).</text>
</paragraph><paragraph id="HD4583B4EB57C4085BEE8A4369F6BD700"><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="H3BA07F137C324DADA67396D6FE31F4D5"><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, 2013.</text>
</section>