American Health Security Act of 2011 - Establishes the State-Based American Health Security Program to provide every U.S. resident who is a U.S. citizen, national, or lawful resident alien with health care services. Requires each participating state to establish a state health security program.
Eliminates benefits under: (1) titles XVIII (Medicare), XIX (Medicaid), and XXI (Children's Health Insurance) (CHIP, formerly known as SCHIP) of the Social Security Act; (2) the Federal Employees Health Benefits Program; and (3) TRICARE.
Repeals provisions of the Patient Protection and Affordable Care Act (PPACA) related to health insurance coverage, including provisions concerning state health insurance exchanges.
Requires each state health security program to prohibit the sale of health insurance in that state that duplicates benefits provided under the program.
Establishes the American Health Security Standards Board to: (1) develop policies, procedures, guidelines and requirements to carry out this Act; (2) establish uniform reporting requirements and quality performance standards; (3) provide for an American Health Security Advisory Council and an Advisory Committee on Health Professional Education; and (4) establish a national health security budget specifying the total federal and state expenditures to be made for covered health care services.
Establishes the American Health Security Quality Council to: (1) review and evaluate practice guidelines, standards of quality, performance measures, and medical review criteria; and (2) develop minimum competence criteria.
Establishes the Office of Primary Care and Prevention Research within the Office of the Director of the National Institutes of Health (NIH).
Creates the American Health Security Trust Fund and appropriates to it specified tax liabilities and current health program receipts, including premium assistance credits under PPACA.
[Congressional Bills 112th Congress]
[From the U.S. Government Publishing Office]
[H.R. 1200 Introduced in House (IH)]
112th CONGRESS
1st Session
H. R. 1200
To provide for health care for every American and to control the cost
and enhance the quality of the health care system.
_______________________________________________________________________
IN THE HOUSE OF REPRESENTATIVES
March 17, 2011
Mr. McDermott introduced the following bill; which was referred to the
Committee on Energy and Commerce, and in addition to the Committees on
Ways and Means, Oversight and Government Reform, Armed Services, and
Education and the Workforce, for a period to be subsequently determined
by the Speaker, in each case for consideration of such provisions as
fall within the jurisdiction of the committee concerned
_______________________________________________________________________
A BILL
To provide for health care for every American and to control the cost
and enhance the quality of the health care system.
Be it enacted by the Senate and House of Representatives of the
United States of America in Congress assembled,
SECTION 1. SHORT TITLE.
This Act may be cited as the ``American Health Security Act of
2011''.
SEC. 2. FINDINGS; SENSE OF THE HOUSE OF REPRESENTATIVES.
(a) Findings.--Congress finds as follows:
(1) The number of uninsured Americans rose by more than
4,000,000 between 2008 and 2009 to a total of 51,000,000, or
more than 1 of every 6 Americans.
(2) Such rise in the number of uninsured Americans was the
largest single-year increase since 1987 and was the result of a
continued decline in private health coverage, primarily in
employer-sponsored insurance.
(3) Small businesses around the country cannot afford to
reinvest in their companies and create new jobs because their
health care bills are going up 10 or 15 percent every year.
(4) American businesses are at an economic disadvantage,
because their health care costs are so much higher than in
other countries. Notably, automobile manufacturers spend more
on health care for an automobile than on steel.
(b) Sense of the House of Representatives Concerning Urgency of a
Medicare-for-All Type Single Payer Health Care System.--It is the sense
of the House of Representatives that the 112th Congress should enact a
Medicare-for-All Single Payer Health Care System to make American
companies more competitive and to stimulate job creation.
(c) Sense of the House of Representatives Concerning the Status of
Health Care.--It is the sense of the House of Representatives that the
112th Congress should recognize and proclaim that health care is a
human right.
SEC. 3. TABLE OF CONTENTS.
The table of contents of this Act is as follows:
Sec. 1. Short title.
Sec. 2. Findings; sense of the House of Representatives.
Sec. 3. 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.
Sec. 107. Repeal of provisions related to the State exchanges.
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.
Sec. 813. Surcharge on high income individuals.
Subtitle C--Other Financing Provisions
Sec. 821. Tax on Securities Transactions.
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.
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.
(a) In General.--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.
(b) State Health Security Programs.--In order for a State to be
eligible to receive payment under section 604, a State shall establish
a State health security program in accordance with this Act.
(c) State Defined.--
(1) In general.--In this Act, subject to paragraph (2), the
term ``State'' means each of the 50 States and the District of
Columbia.
(2) Election.--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 ``State'' under this Act beginning January 1 of
the first year beginning 90 days after the President receives
the notification.
SEC. 102. UNIVERSAL ENTITLEMENT.
(a) In General.--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 ``appropriate State
health security program'' means, with respect to an individual, the
State health security program for the State in which the individual
maintains a primary residence.
(b) Treatment of Certain Nonimmigrants.--
(1) In general.--The American Health Security Standards
Board (in this Act referred to as the ``Board'') 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.
(2) Consideration.--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.
(c) Treatment of Other Individuals.--
(1) By board.--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--
(A) to preserve the public health of communities;
(B) to compensate States for the additional health
care financing burdens created by such individuals; and
(C) to prevent adverse financial and medical
consequences of uncompensated care,
while inhibiting travel and immigration to the United States
for the sole purpose of obtaining health care services.
(2) By states.--Any State health security program may make
individuals described in paragraph (1) eligible for benefits at
the expense of the State.
(d) Lawful Resident Alien Defined.--For purposes of this section,
the term ``lawful resident alien'' 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
Immigration and Nationality Act (8 U.S.C. 1160, 1161, or 1255a).
SEC. 103. ENROLLMENT.
(a) In General.--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--
(1) 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;
(2) provide for the enrollment, as of January 1, 2013, of
all individuals who are eligible to be enrolled as of such
date; and
(3) include a process for the enrollment of individuals
made eligible for health care services under subsections (b)
and (c) of section 102.
(b) Availability of Applications.--Each State health security
program shall make applications for enrollment under the program
available--
(1) at employment and payroll offices of employers located
in the State;
(2) at local offices of the Social Security Administration;
(3) at social services locations;
(4) at out-reach sites (such as provider and practitioner
locations); and
(5) at other locations (including post offices and schools)
accessible to a broad cross-section of individuals eligible to
enroll.
(c) Issuance of Health Security Cards.--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 (to be referred to as a ``smart 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).
SEC. 104. PORTABILITY OF BENEFITS.
(a) In General.--To ensure continuous access to benefits for health
care services covered under this Act, each State health security
program--
(1) 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;
(2) 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
(3) 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:
(A) 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.
(B) 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.
(b) Cross-Border Arrangements.--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.
SEC. 105. EFFECTIVE DATE OF BENEFITS.
Benefits shall first be available under this Act for items and
services furnished on or after January 1, 2013.
SEC. 106. RELATIONSHIP TO EXISTING FEDERAL HEALTH PROGRAMS.
(a) Medicare, Medicaid and State Children's Health Insurance
Program (SCHIP).--
(1) In general.--Notwithstanding any other provision of
law, subject to paragraph (2)--
(A) no benefits shall be available under title
XVIII of the Social Security Act for any item or
service furnished after December 31, 2012;
(B) 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;
(C) 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
(D) 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.
(2) Transition.--In the case of inpatient hospital services
and extended care services during a continuous period of stay
which began before January 1, 2013, 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 Social Security Act, 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.
(b) Federal Employees Health Benefits Program.--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, 2012.
(c) TRICARE.--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, 2012.
(d) Treatment of Benefits for Veterans and Native Americans.--
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.
(e) Treatment of Premium Credits, Cost-Sharing Reductions, and
Small Employer Credits.--
(1) In general.--For each calendar year, the Secretary of
the Treasury shall transfer to the American Health Security
Trust Fund an amount equal to the sum of--
(A) the premium assistance credit amount which
would have been allowable to taxpayers residing in such
State in such calendar year under section 36B of the
Internal Revenue Code of 1986 (relating to refundable
credit for coverage under a qualified health plan), as
added by section 1401 of the Patient Protection and
Affordable Care Act, if such section were in effect for
such year,
(B) the amount of cost-sharing reductions which
would have been required with respect to eligible
insured residing in such State in such calendar year
under section 1402 of the Patient Protection and
Affordable Care Act if such section were in effect for
such year, plus
(C) the amount of tax credits which would have been
allowable to eligible small employers doing business in
such State in such calendar year under section 45R of
the Internal Revenue Code of 1986 if such section were
in effect for such calendar year.
(2) Determination.--The amounts determined under paragraph
(1) shall be estimated by the Secretary of the Treasury in
consultation with the Secretary of Health and Human Services.
SEC. 107. REPEAL OF PROVISIONS RELATED TO THE STATE EXCHANGES.
Title I of the Patient Protection and Affordable Care Act (Public
Law 111-148) (and the amendments made by title I) is repealed.
TITLE II--COMPREHENSIVE BENEFITS, INCLUDING PREVENTIVE BENEFITS AND
BENEFITS FOR LONG-TERM CARE
SEC. 201. COMPREHENSIVE BENEFITS.
(a) In General.--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:
(1) Hospital services.--Inpatient and outpatient hospital
care, including 24-hour-a-day emergency services.
(2) Professional services.--Professional services of health
care practitioners authorized to provide health care services
under State law, including patient education and training in
self-management techniques.
(3) Community-based primary health services.--Community-
based primary health services (as defined in section 202(a)).
(4) Preventive services.--Preventive services (as defined
in section 202(b)).
(5) Long-term, acute, and chronic care services.--
(A) Nursing facility services.
(B) Home health services.
(C) Home and community-based long-term care
services (as defined in section 202(c)) for individuals
described in section 203(a).
(D) Hospice care.
(E) Services in intermediate care facilities for
individuals with an intellectual disability.
(6) Prescription drugs, biologicals, insulin, medical
foods.--
(A) Outpatient prescription drugs and biologics, as
specified by the Board consistent with section 615.
(B) Insulin.
(C) Medical foods (as defined in section 202(e)).
(7) Dental services.--Dental services (as defined in
section 202(h)).
(8) Mental health and substance abuse treatment services.--
Mental health and substance abuse treatment services (as
defined in section 202(f)).
(9) Diagnostic tests.--Diagnostic tests.
(10) Other items and services.--
(A) Outpatient therapy.--Outpatient physical
therapy services, outpatient speech pathology services,
and outpatient occupational therapy services in all
settings.
(B) Durable medical equipment.--Durable medical
equipment.
(C) Home dialysis.--Home dialysis supplies and
equipment.
(D) Ambulance.--Emergency ambulance service.
(E) Prosthetic devices.--Prosthetic devices,
including replacements of such devices.
(F) Additional items and services.--Such other
medical or health care items or services as the Board
may specify.
(b) Prohibition of Balance Billing.--As provided in section 531, no
person may impose a charge for covered services for which benefits are
provided under this Act.
(c) No Duplicate Health Insurance.--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.
(d) State Program May Provide Additional Benefits.--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.
(e) Employers May Provide Additional Benefits.--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.
(f) Taft-Hartley and MEW Benefit Plans.--Notwithstanding any other
provision of law, a health plan may be provided for under a collective
bargaining agreement or a MEWA if such plan is limited to coverage that
is supplemental to the coverage provided for under the State-based
American Health Security Program and available only to employees or
their dependents or to retirees or their dependents.
SEC. 202. DEFINITIONS RELATING TO SERVICES.
(a) Community-Based Primary Health Services.--In this title, the
term ``community-based primary health services'' means ambulatory
health services furnished--
(1) by a rural health clinic;
(2) by a federally qualified health center (as defined in
section 1905(l)(2)(B) of the Social Security Act), and which,
for purposes of this Act, include services furnished by State
and local health agencies;
(3) in a school-based setting;
(4) 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
(5) public and private nonprofit entities receiving Federal
assistance under the Public Health Service Act.
(b) Preventive Services.--
(1) In general.--In this title, the term ``preventive
services'' means items and services--
(A) which--
(i) are specified in paragraph (2); or
(ii) the Board determines to be effective
in the maintenance and promotion of health or
minimizing the effect of illness, disease, or
medical condition; and
(B) which are provided consistent with the
periodicity schedule established under paragraph (3).
(2) Specified preventive services.--The services specified
in this paragraph are as follows:
(A) Immunizations recommended by the Advisory
Committee on Immunization Practices of the Centers for
Disease Control and Prevention.
(B) Prenatal and well-baby care (for infants under
1 year of age).
(C) Well-child care (including periodic physical
examinations, hearing and vision screening, and
developmental screening and examinations) for
individuals under 18 years of age, including evidence-
informed preventive care and screenings included in the
comprehensive guidelines of the Health Resources and
Services Administration.
(D) Periodic screening mammography, Pap smears, and
colorectal examinations and examinations for prostate
cancer.
(E) Physical examinations.
(F) Family planning services.
(G) Routine eye examinations, eyeglasses, and
contact lenses.
(H) 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.
(I) Evidence-based items or services that have in
effect a rating of ``A'' or ``B'' in the current
recommendations of the United States Preventive
Services Task Force.
(J) With respect to women, such additional
preventive care and screenings not described in
subparagraph (I) that are included in the comprehensive
guidelines of the Health Resources and Services
Administration.
(3) Schedule.--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.
(c) Home and Community-Based Long-Term Care Services.--In this
title, the term ``home and community-based long-term care services''
means the following services provided to an individual to enable the
individual to remain in such individual's place of residence within the
community:
(1) Home health aide services.
(2) Adult day health care, social day care or psychiatric
day care.
(3) Medical social work services.
(4) Care coordination services, as defined in subsection
(g)(1).
(5) Respite care, including training for informal
caregivers.
(6) Personal assistance services, and homemaker services
(including meals) incidental to the provision of personal
assistance services.
(d) Home Health Services.--
(1) In general.--The term ``home health services'' means
items and services described in section 1861(m) of the Social
Security Act and includes home infusion services.
(2) Home infusion services.--The term ``home infusion
services'' 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.
(e) Medical Foods.--In this title, the term ``medical foods'' 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.
(f) Mental Health and Substance Abuse Treatment Services.--
(1) Services described.--In this title, the term ``mental
health and substance abuse treatment services'' means the
following services related to the prevention, diagnosis,
treatment, and rehabilitation of mental illness and promotion
of mental health:
(A) Inpatient hospital services.--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).
(B) Intensive residential services.--Intensive
residential services (as defined in paragraph (2))
furnished to an individual for up to 120 days during
any calendar year, except that--
(i) 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
(ii) 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).
(C) Outpatient services.--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).
(D) Intensive community-based services.--Intensive
community-based services (as described in paragraph
(3))--
(i) for an unlimited number of days during
any calendar year, in the case of services
described in section 1861(ff)(2)(E) of the
Social Security Act (42 U.S.C. 1395x(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);
(ii) in the case of services described in
section 1861(ff)(2)(C) of the Social Security
Act (42 U.S.C. 1395x(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
(iii) 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).
(2) Intensive residential services defined.--
(A) In general.--Subject to subparagraphs (B) and
(C), the term ``intensive residential services'' means
inpatient services provided in any of the following
facilities:
(i) Residential detoxification centers.
(ii) Crisis residential programs or mental
illness residential treatment programs.
(iii) Therapeutic family or group treatment
homes.
(iv) Residential centers for substance
abuse treatment.
(B) Requirements for facilities.--No service may be
treated as an intensive residential service under
subparagraph (A) unless the facility at which the
service is provided--
(i) 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
(ii) meets such other requirements as the
Secretary may impose to ensure the quality of
the intensive residential services provided.
(C) Services furnished to at-risk children.--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).
(D) Management standards.--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.
(3) Intensive community-based services defined.--
(A) In general.--The term ``intensive community-
based services'' 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.
(B) Items and services described.--The items and
services described in this subparagraph are--
(i) partial hospitalization services
consisting of the items and services described
in subparagraph (C);
(ii) psychiatric rehabilitation services;
(iii) day treatment services for
individuals under 19 years of age;
(iv) in-home services;
(v) case management services, including
collateral services designated as such case
management services by the Secretary;
(vi) ambulatory detoxification services;
and
(vii) such other items and services as the
Secretary may provide (but in no event to
include meals and transportation),
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).
(C) Items and services included as partial
hospitalization services.--For purposes of subparagraph
(B)(i), partial hospitalization services consist of the
following:
(i) Individual and group therapy with
physicians or psychologists (or other mental
health professionals to the extent authorized
under State law).
(ii) Occupational therapy requiring the
skills of a qualified occupational therapist.
(iii) 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).
(iv) Drugs and biologicals furnished for
therapeutic purposes (which cannot, as
determined in accordance with regulations, be
self-administered).
(v) Individualized activity therapies that
are not primarily recreational or diversionary.
(vi) Family counseling (the primary purpose
of which is treatment of the individual's
condition).
(vii) Patient training and education (to
the extent that training and educational
activities are closely and clearly related to
the individual's care and treatment).
(viii) Diagnostic services.
(D) Programs described.--A program described in
this subparagraph is a program (whether facility-based
or freestanding) which is furnished by an entity--
(i) 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
(ii) meeting such other requirements as the
Secretary may impose to ensure the quality of
the intensive community-based services
provided.
(g) Care Coordination Services.--
(1) In general.--In this title, the term ``care
coordination services'' 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--
(A) transition management between inpatient
facilities and community-based services, including
assisting patients in identifying and gaining access to
appropriate ancillary services; and
(B) 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.
(2) Care coordinator.--
(A) In general.--In this title, the term ``care
coordinator'' means an individual or nonprofit or
public agency or organization which the State health
security program determines--
(i) is capable of performing directly,
efficiently, and effectively the duties of a
care coordinator described in paragraph (1);
and
(ii) 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.
(B) Independence.--State health security programs
shall establish safeguards to ensure 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.
(3) Eligible individuals.--An individual described in this
paragraph is an individual described in section 203 (relating
to individuals qualifying for long-term and chronic care
services).
(h) Dental Services.--
(1) In general.--In this title, subject to subsection (b),
the term ``dental services'' means the following:
(A) Emergency dental treatment, including
extractions, for bleeding, pain, acute infections, and
injuries to the maxillofacial region.
(B) 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.
(C) Treatment of dental disease, including non-cast
fillings, periodontal maintenance services, and
endodontic services.
(D) Space maintenance procedures to prevent
orthodontic complications.
(E) Orthodontic treatment to prevent severe
malocclusions.
(F) Full dentures.
(G) Medically necessary oral health care.
(H) Any items and services for special needs
patients that are not described in subparagraphs (A)
through (G) and that--
(i) are required to provide such patients
the items and services described in
subparagraphs (A) through (G);
(ii) 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);
(iii) consist of orthodontic care for
severe dentofacial abnormalities; or
(iv) consist of prosthetic dental devices
for genetic or birth defects or fitting for
such devices.
(I) 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.
(2) Limitations.--Dental services are subject to the
following limitations:
(A) Prevention and diagnosis.--
(i) Examinations and prophylaxis.--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.
(ii) Dental sealants.--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.
(B) Treatment of dental disease.--Prior to January
1, 2018, 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.
(C) Space maintenance.--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--
(i) are limited to posterior teeth;
(ii) 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
(iii) do not include a space maintainer
that is placed within 6 months of the expected
eruption of the permanent posterior tooth
concerned.
(3) Definitions.--For purposes of this title:
(A) Medically necessary oral health care.--The term
``medically necessary oral health care'' 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.
(B) Special needs patient.--The term ``special
needs patient'' includes an individual with a genetic
or birth defect, a developmental disability, or an
acquired medical disability.
(i) Nursing Facility; Nursing Facility Services.--Except as may be
provided by the Board, the terms ``nursing facility'' and ``nursing
facility services'' have the meanings given such terms in sections
1919(a) and 1905(f), respectively, of the Social Security Act.
(j) Services in Intermediate Care Facilities for Individuals With
an Intellectual Disability.--Except as may be provided by the Board--
(1) the term ``intermediate care facility for individuals
with an intellectual disability'' has the meaning given the
term ``intermediate care facility for individuals with mental
retardation'' in section 1905(d) of the Social Security Act (as
in effect before the enactment of this Act); and
(2) the term ``services in intermediate care facilities for
individuals with an intellectual disability'' means services
described in section 1905(a)(15) of such Act (as so in effect)
in an intermediate care facility for individuals with an
intellectual disability 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).
(k) Other Terms.--Except as may be provided by the Board, the
definitions contained in section 1861 of the Social Security Act shall
apply.
SEC. 203. SPECIAL RULES FOR HOME AND COMMUNITY-BASED LONG-TERM CARE
SERVICES.
(a) Qualifying Individuals.--For purposes of section 201(a)(5)(C),
individuals described in this subsection are the following individuals:
(1) Adults.--Individuals 18 years of age or older
determined (in a manner specified by the Board)--
(A) 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)--
(i) bathing;
(ii) eating;
(iii) dressing;
(iv) toileting; and
(v) transferring in and out of a bed or in
and out of a chair;
(B) 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
(C) due to cognitive or mental impairments, to
require queuing to perform activities of daily living.
(2) Children.--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.
(b) Limit on Services.--
(1) In general.--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.
(2) Alternative ratio.--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.
SEC. 204. EXCLUSIONS AND LIMITATIONS.
(a) In General.--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).
(b) Special Delivery Requirements for Mental Health and Substance
Abuse Treatment Services Provided to At-Risk Children.--
(1) Requiring services to be provided through organized
systems of care.--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--
(A) the services are provided to an individual less
than 22 years of age;
(B) the individual has a serious emotional
disturbance or a substance abuse disorder; and
(C) 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.
(2) Requirements for system of care.--In this subsection,
an ``organized system of care'' is a community-based service
delivery network, which may consist of public and private
providers, that meets the following requirements:
(A) 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).
(B) 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.
(C) 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.
(D) 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.
(E) 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.
(F) 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.
(c) Treatment of Experimental Services.--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.
(d) Application of Practice Guidelines.--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.
(e) Specific Limitations.--
(1) Limitations on eyeglasses, contact lenses, hearing
aids, and durable medical equipment.--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.
(2) Overlap with preventive services.--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.
(3) Miscellaneous exclusions from covered services.--
Covered services under this Act do not include the following:
(A) Surgery and other procedures (such as
orthodontia) performed solely for cosmetic purposes (as
defined in regulations) and hospital or other services
incident thereto, unless--
(i) required to correct a congenital
anomaly;
(ii) required to restore or correct a part
of the body which has been altered as a result
of accidental injury, disease, or surgery; or
(iii) otherwise determined to be medically
necessary and appropriate under section 201(a).
(B) Personal comfort items or private rooms in
inpatient facilities, unless determined to be medically
necessary and appropriate under section 201(a).
(C) The services of a professional practitioner if
they are furnished in a hospital or other facility
which is not a participating provider.
(f) Nursing Facility Services and Home Health Services.--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.
SEC. 205. CERTIFICATION; QUALITY REVIEW; PLANS OF CARE.
(a) Certifications.--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 Social Security Act, periodic professional certifications of the
kind described in such sections.
(b) Quality Review.--For the 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).
(c) Plan of Care Requirements.--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.
TITLE III--PROVIDER PARTICIPATION
SEC. 301. PROVIDER PARTICIPATION AND STANDARDS.
(a) In General.--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--
(1) is a qualified provider of the services under section
302;
(2) has filed with the State health security program a
participation agreement described in subsection (b); and
(3) meets such other qualifications and conditions as are
established by the Board or the State health security program
under this Act.
(b) Requirements in Participation Agreement.--
(1) In general.--A participation agreement described in
this subsection between a State health security program and a
provider shall provide at least for the following:
(A) 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.
(B) No charge will be made for any covered services
other than for payment authorized by this Act.
(C) 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--
(i) quality review by designated entities;
(ii) 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);
(iii) statistical or other studies required
for the implementation of this Act; and
(iv) such other purposes as the Board or
State may specify.
(D) The provider agrees not to bill the program for
any services for which benefits are not available
because of section 204(d).
(E) 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.
(F) 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.
(2) Termination of participation agreements.--
(A) In general.--Participation agreements may be
terminated, with appropriate notice--
(i) by the Board or a State health security
program for failure to meet the requirements of
this title; or
(ii) by a provider.
(B) Termination process.--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.
SEC. 302. QUALIFICATIONS FOR PROVIDERS.
(a) In General.--A health care provider is considered to be
qualified to provide covered services if the provider is licensed or
certified and meets--
(1) all the requirements of State law to provide such
services;
(2) applicable requirements of Federal law to provide such
services; and
(3) any applicable standards established under subsection
(b).
(b) Minimum Provider Standards.--
(1) In general.--The Board shall establish, evaluate, and
update national minimum standards to ensure the quality of
services provided under this Act and to monitor efforts by
State health security programs to ensure the quality of such
services. A State health security program may also establish
additional minimum standards which providers shall meet.
(2) National minimum standards.--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 Social
Security Act (42 U.S.C. 1395 et seq.). Such standards also may
include, where appropriate, elements relating to--
(A) adequacy and quality of facilities;
(B) training and competence of personnel (including
continuing education requirements);
(C) comprehensiveness of service;
(D) continuity of service;
(E) patient satisfaction (including waiting time
and access to services); and
(F) performance standards (including organization,
facilities, structure of services, efficiency of
operation, and outcome in palliation, improvement of
health, stabilization, cure, or rehabilitation).
(3) Transition in application.--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.
(4) Exchange of information.--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.
SEC. 303. QUALIFICATIONS FOR COMPREHENSIVE HEALTH SERVICE
ORGANIZATIONS.
(a) In General.--For purposes of this Act, a comprehensive health
service organization (in this section referred to as a ``CHSO'') 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--
(1) a full range of health services (as identified by the
Board), including at least hospital services and physicians
services; and
(2) out-of-area coverage in the case of urgently needed
services;
to an identified population which is living in or near a specified
service area and which enrolls voluntarily in the organization.
(b) Enrollment.--
(1) In general.--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.
(2) Minimum enrollment period.--Subject to paragraph (3),
the minimum period of enrollment with a CHSO shall be 1 year,
unless the enrolled individual becomes ineligible to enroll
with the organization.
(3) Withdrawal for cause.--Each CHSO shall permit an
enrolled individual to disenroll from the organization for
cause at any time.
(c) Requirements for CHSOs.--
(1) Accessible services.--Each CHSO, to the maximum extent
feasible, shall make all health services readily and promptly
accessible to enrollees who live in the specified service area.
(2) Continuity of care.--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.
(3) Board of directors.--In the case of a CHSO that is a
private organization--
(A) Consumer representation.--At least one-third of
the members of the CHSO's board of directors shall be
consumer members with no direct or indirect, personal
or family financial relationship to the organization.
(B) Provider representation.--The CHSO's board of
directors shall include at least one member who
represents health care providers.
(4) Patient grievance program.--Each CHSO shall have in
effect a patient grievance program and shall conduct regularly
surveys of the satisfaction of members with services provided
by or through the organization.
(5) Medical standards.--Each CHSO shall 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).
(6) Quality and other reporting requirements.--
(A) In general.--The Board shall determine
appropriate measures to assess the quality of care
furnished by the CHSO, such as measures of--
(i) clinical processes and outcomes;
(ii) patient and, where practicable,
caregiver experience of care; and
(iii) utilization (such as rates of
hospital admissions for ambulatory care
sensitive conditions).
(B) Other duties.--The CHSO shall--
(i) define processes to promote evidence-
based medicine and patient engagement, report
on quality and cost measures, and coordinate
care, such as through the use of telehealth,
remote patient monitoring, and other such
enabling technologies; and
(ii) demonstrate to the Board that the CHSO
meets patient-centeredness criteria specified
by the Board, such as the use of patient and
caregiver assessments or the use of
individualized care plans.
(C) Reporting requirements.--A CHSO shall submit
data in a form and manner specified by the Board on
measures the Board determines necessary in order to
evaluate the quality of care furnished by the CHSO.
Such data may include care transitions across health
care settings, including hospital discharge planning
and post-hospital discharge follow-up by CHSO
professionals, as the Board determines appropriate.
(D) Quality performance standards.--The Board shall
establish quality performance standards to assess the
quality of care furnished by CHSOs and shall seek to
improve the quality of care furnished by CHSOs over
time by specifying higher standards, new measures, or
both for purposes of assessing such quality of care.
(7) Premiums.--Premiums or other charges by a CHSO for any
services not paid for under this Act shall be reasonable.
(8) Utilization and bonus information.--Each CHSO shall--
(A) comply with the requirements of section
1876(i)(8) of the Social Security Act (relating to
prohibiting physician incentive plans that provide
specific inducements to reduce or limit medically
necessary services); and
(B) make available to its membership utilization
information and data regarding financial performance,
including bonus or incentive payment arrangements to
practitioners.
(9) Provision of services to enrollees at institutions
operating under global budgets.--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.
(10) Broad marketing.--Each CHSO shall 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.
(11) Additional requirements.--Each CHSO shall meet--
(A) such requirements relating to minimum
enrollment;
(B) such requirements relating to financial
solvency;
(C) such requirements relating to quality and
availability of care; and
(D) such other requirements,
as the Board or a State health security program may specify.
(d) Provision of Emergency Services to Nonenrollees.--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.
SEC. 304. LIMITATION ON CERTAIN PHYSICIAN REFERRALS.
(a) Application to American Health Security Program.--Section 1877
of the Social Security Act, as amended by subsections (b) and (c),
shall apply under this Act in the same manner as it applies under title
XVIII of the Social Security Act; except that in applying such section
under this Act any references in such section to the Secretary or title
XVIII of the Social Security Act are deemed references to the Board and
the American Health Security Program under this Act, respectively.
(b) Expansion of Prohibition to Certain Additional Designated
Services.--Section 1877(h)(6) of the Social Security Act (42 U.S.C.
1395nn(h)(6)) is amended by adding at the end the following:
``(M) Ambulance services.
``(N) Home infusion therapy services.''.
(c) Conforming Amendments.--Section 1877 of such Act is further
amended--
(1) in subsection (a)(1)(A), by striking ``for which
payment otherwise may be made under this title'' and inserting
``for which a charge is imposed'';
(2) in subsection (a)(1)(B), by striking ``under this
title'';
(3) by amending paragraph (1) of subsection (g) to read as
follows:
``(1) Denial of payment.--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.''; and
(4) in subsection (g)(3), by striking ``for which payment
may not be made under paragraph (1)'' and inserting ``for which
such a claim may not be presented under subsection (a)(1)''.
TITLE IV--ADMINISTRATION
Subtitle A--General Administrative Provisions
SEC. 401. AMERICAN HEALTH SECURITY STANDARDS BOARD.
(a) Establishment.--There is hereby established an American Health
Security Standards Board.
(b) Appointment and Terms of Members.--
(1) In general.--The Board shall be composed of--
(A) the Secretary of Health and Human Services; and
(B) 6 other individuals (described in paragraph
(2)) appointed by the President with the advice and
consent of the Senate.
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, 2012.
(2) Selection of appointed members.--With respect to the
individuals appointed under paragraph (1)(B):
(A) The members shall be chosen on the basis of
backgrounds in health policy, health economics, the
healing professions, and the administration of health
care institutions.
(B) The members 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.
(C) At least 1 member shall have a nursing
background.
(D) Not more than 3 members shall be from the same
political party.
(E) To the greatest extent feasible, the members
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.
(3) Terms of appointed members.--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.
(c) Vacancies.--
(1) In general.--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.
(2) Vacancy appointments.--Any member appointed to fill a
vacancy shall serve for the remainder of the term for which the
predecessor of the member was appointed.
(3) Reappointment.--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.
(4) Removal for cause.--Upon confirmation, members of the
Board may not be removed except by the President for cause.
(d) Chair.--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.
(e) Compensation.--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.
(f) General Duties of the Board.--
(1) In general.--The Board shall develop policies,
procedures, guidelines, and requirements to carry out this Act,
including those related to--
(A) eligibility;
(B) enrollment;
(C) benefits;
(D) provider participation standards and
qualifications, as defined in title III;
(E) national and State funding levels;
(F) methods for determining amounts of payments to
providers of covered services, consistent with subtitle
B of title VI;
(G) the determination of medical necessity and
appropriateness with respect to coverage of certain
services;
(H) assisting State health security programs with
planning for capital expenditures and service delivery;
(I) planning for health professional education
funding (as specified in title VI);
(J) allocating funds provided under title VII; and
(K) encouraging States to develop regional planning
mechanisms (described in section 404(a)(3)).
(2) Regulations.--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.
(g) Uniform Reporting Standards; Annual Report; Studies.--
(1) Uniform reporting standards.--
(A) In general.--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.
(B) Reports.--The Board shall analyze regularly
information reported to it, and to State health
security programs pursuant to such requirements and
standards.
(2) Annual report.--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:
(A) The status of implementation of the Act.
(B) Enrollment under this Act.
(C) Benefits under this Act.
(D) Expenditures and financing under this Act.
(E) Cost-containment measures and achievements
under this Act.
(F) Quality assurance.
(G) Health care utilization patterns, including any
changes attributable to the program.
(H) Long-range plans and goals for the delivery of
health services.
(I) Differences in the health status of the
populations of the different States, including income
and racial characteristics.
(J) Necessary changes in the education of health
personnel.
(K) Plans for improving service to medically
underserved populations.
(L) Transition problems as a result of
implementation of this Act.
(M) Opportunities for improvements under this Act.
(3) Statistical analyses and other studies.--The Board may,
either directly or by contract--
(A) 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;
(B) 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;
(C) 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;
(D) develop and test, for use by providers of
services, records and information retrieval systems
useful in the furnishing of preventive or diagnostic
services;
(E) 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
(F) make such other studies as it may consider
necessary or promising for the evaluation, or for the
improvement, of the operation of this Act.
(4) Report on use of existing federal health care
facilities.--Not later than 1 year after the date of the
enactment of this Act, the Board shall recommend to Congress
one or more proposals for the treatment of health care
facilities of the Federal Government.
(h) Executive Director.--
(1) Appointment.--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.
(2) Delegation.--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--
(A) the issuance of regulations; or
(B) the determination of the availability of funds
and their allocation to implement this Act.
(3) Compensation.--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.
(i) Inspector General.--The Inspector General Act of 1978 (5 U.S.C.
App.) is amended--
(1) in section 12(1), by inserting after ``Corporation;''
the first place it appears the following: ``the Chair of the
American Health Security Standards Board;'';
(2) in section 12(2), by inserting after ``Resolution Trust
Corporation,'' the following: ``the American Health Security
Standards Board,''; and
(3) by inserting before section 9 the following:
``special provisions concerning american health security standards
board
``Sec. 8M. 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.''.
(j) Staff.--The Board shall employ such staff as the Board may deem
necessary.
(k) Access to Information.--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.
SEC. 402. AMERICAN HEALTH SECURITY ADVISORY COUNCIL.
(a) In General.--The Board shall provide for an American Health
Security Advisory Council (in this section referred to as the
``Council'') to advise the Board on its activities.
(b) Membership.--The Council shall be composed of--
(1) the Chair of the Board, who shall serve as Chair of the
Council; and
(2) 20 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.
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.
(c) Terms of Members.--Each appointed member shall hold office for
a term of 4 years, except that--
(1) 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
(2) the terms of the members first taking office shall
expire, as designated by the Board at the time of appointment,
at the end of the first year with respect to 5 members, at the
end of the second year with respect to 5 members, at the end of
the third year with respect to 5 members, and at the end of the
fourth year with respect to 5 members after the date of
enactment of this Act.
(d) Vacancies.--
(1) In general.--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.
(2) Vacancy appointments.--Any member appointed to fill a
vacancy shall serve for the remainder of the term for which the
predecessor of the member was appointed.
(3) Reappointment.--The Board may reappoint an appointed
member of the Council for a second term in the same manner as
the original appointment.
(e) Qualifications.--
(1) Public health representatives.--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.
(2) Providers.--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.
(3) Consumers.--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.
(f) Duties.--
(1) In general.--It shall be the duty of the Council--
(A) 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
(B) 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.
(2) Report.--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.
(g) Staff.--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.
(h) Meetings.--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.
(i) Compensation.--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.
(j) FACA Not Applicable.--The provisions of the Federal Advisory
Committee Act shall not apply to the Council.
SEC. 403. CONSULTATION WITH PRIVATE ENTITIES.
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 ensure 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.
SEC. 404. STATE HEALTH SECURITY PROGRAMS.
(a) Submission of Plans.--
(1) In general.--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.
(2) Regional programs.--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.
(3) Regional planning mechanisms.--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.
(4) States that fail to submit a plan.--In the case of a
State that fails to submit a plan as required under this
subsection, the American Health Security Standards Board
Authority shall develop a plan for a State health security
program in such State.
(b) Review and Approval of Plans.--
(1) In general.--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:
(A) Payment for required health services for
eligible individuals in the State in accordance with
this Act.
(B) Adequate administration, including the
designation of a single State agency responsible for
the administration (or supervision of the
administration) of the program.
(C) The establishment of a State health security
budget.
(D) Establishment of payment methodologies
(consistent with subtitle B of title VII).
(E) Assurances that individuals have the freedom to
choose practitioners and other health care providers
for services covered under this Act.
(F) A procedure for carrying out long-term regional
management and planning functions with respect to the
delivery and distribution of health care services
that--
(i) ensures participation of consumers of
health services and providers of health
services; and
(ii) 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.
(G) The licensure and regulation of all health
providers and facilities to ensure compliance with
Federal and State laws and to promote quality of care.
(H) Establishment of a quality review system in
accordance with section 503.
(I) 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.
(J) 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.
(K) Provision of a fraud and abuse prevention and
control unit that the Inspector General determines
meets the requirements of section 412(a).
(L) Prohibit payment in cases of prohibited
physician referrals under section 304.
(2) Consequences of failure to comply.--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.
(c) State Health Security Advisory Councils.--
(1) In general.--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.
(2) Membership.--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.
(3) Duties.--
(A) In general.--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.
(B) Assistance.--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.
(d) State Use of Fiscal Agents.--
(1) In general.--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.
(2) Restriction.--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.
SEC. 405. COMPLEMENTARY CONDUCT OF RELATED HEALTH PROGRAMS.
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.
Subtitle B--Control Over Fraud and Abuse
SEC. 411. APPLICATION OF FEDERAL SANCTIONS TO ALL FRAUD AND ABUSE UNDER
AMERICAN HEALTH SECURITY PROGRAM.
The following sections of the Social Security Act 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):
(1) Section 1128 (relating to exclusion of individuals and
entities).
(2) Section 1128A (civil monetary penalties).
(3) Section 1128B (criminal penalties).
(4) Section 1124 (relating to disclosure of ownership and
related information).
(5) Section 1126 (relating to disclosure of certain
owners).
SEC. 412. REQUIREMENTS FOR OPERATION OF STATE HEALTH CARE FRAUD AND
ABUSE CONTROL UNITS.
(a) Requirement.--In order to meet the requirement of section
404(b)(1)(K), each State health security program shall establish and
maintain a health care fraud and abuse control unit (in this section
referred to as a ``fraud unit'') 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 Social
Security Act).
(b) Structure of Unit.--The fraud unit shall--
(1) be a single identifiable entity of the State
government;
(2) be separate and distinct from the State agency with
principal responsibility for the administration of the State
health security program; and
(3) meet 1 of the following requirements:
(A) It shall 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.
(B) 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--
(i) 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
(ii) assure its assistance of, and
coordination with, such authority or
authorities in such prosecutions.
(C) It shall 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.
(c) Functions.--The fraud unit shall--
(1) 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;
(2) 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
(3) 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.
(d) Resources.--The fraud unit shall--
(1) employ such auditors, attorneys, investigators, and
other necessary personnel;
(2) be organized in such a manner; and
(3) provide sufficient resources (as specified by the
Board),
as is necessary to promote the effective and efficient conduct of the
unit's activities.
(e) Cooperative Agreements.--The fraud unit shall have cooperative
agreements (as specified by the Board) with--
(1) similar fraud units in other States;
(2) the Inspector General; and
(3) the Attorney General of the United States.
(f) Reports.--The fraud unit shall 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.
TITLE V--QUALITY ASSESSMENT
SEC. 501. AMERICAN HEALTH SECURITY QUALITY COUNCIL.
(a) Establishment.--There is hereby established an American Health
Security Quality Council (in this title referred to as the
``Council'').
(b) Duties of the Council.--The Council shall perform the following
duties:
(1) Practice guidelines.--The Council shall review and
evaluate each practice guideline developed under part B of
title IX of the Public Health Service Act. 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.
(2) Standards of quality, performance measures, and medical
review criteria.--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 Public
Health Service Act. 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.
(3) Criteria for entities conducting quality reviews.--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 ensure national consistency in quality standards.
(4) Reporting.--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).
(5) Other functions.--The Council shall perform the
functions of the Council described in section 502.
(c) Appointment and Terms of Members.--
(1) In general.--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, 2012.
(2) Selection of members.--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.
(3) Terms of members.--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.
(d) Vacancies.--
(1) In general.--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.
(2) Vacancy appointments.--Any member appointed to fill a
vacancy shall serve for the remainder of the term for which the
predecessor of the member was appointed.
(3) Reappointment.--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.
(e) Chair.--The President shall designate 1 of the members of the
Council to serve at the will of the President as Chair of the Council.
(f) Compensation.--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.
SEC. 502. DEVELOPMENT OF CERTAIN METHODOLOGIES, GUIDELINES, AND
STANDARDS.
(a) Profiling of Patterns of Practice; Identification of
Outliers.--The Council shall adopt methodologies for profiling the
patterns of practice of health care professionals and for identifying
outliers (as defined in subsection (e)).
(b) Centers of Excellence.--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.
(c) Remedial Actions.--The Council shall develop standards for
education and sanctions with respect to outliers so as to ensure 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.
(d) Dissemination.--The Council shall disseminate to the State--
(1) the methodologies adopted under subsection (a);
(2) the guidelines developed under subsection (b); and
(3) the standards developed under subsection (c);
for use by the States under section 503.
(e) Outlier Defined.--In this title, the term ``outlier'' 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.
SEC. 503. STATE QUALITY REVIEW PROGRAMS.
(a) Requirement.--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).
(b) Federal Standards.--
(1) In general.--The Council shall establish standards with
respect to--
(A) the adoption of practice guidelines (whether
developed by the Federal Government or other entities);
(B) the identification of outliers (consistent with
methodologies adopted under section 502(a));
(C) the development of remedial programs and
monitoring for outliers; and
(D) the application of sanctions (consistent with
the standards developed under section 502(c)).
(2) State discretion.--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.
(c) Qualifications.--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).
(d) Internal Quality Review.--Nothing in this section shall
preclude an institutional provider from establishing its own internal
quality review and enhancement programs.
SEC. 504. ELIMINATION OF UTILIZATION REVIEW PROGRAMS; TRANSITION.
(a) Intent.--It is the intention of this title to replace by
January 1, 2015, random utilization controls with a systematic review
of patterns of practice that compromise the quality of care.
(b) Superseding Case Reviews.--
(1) In general.--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.
(2) Transition.--Before January 1, 2015, 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.
(3) Construction.--Nothing in this subsection shall be
construed--
(A) as precluding the case-by-case review of the
provision of care--
(i) in individual incidents where the
quality of care has significantly deviated from
acceptable standards of practice; and
(ii) with respect to a provider who has
been determined to be an outlier; or
(B) 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.
TITLE VI--HEALTH SECURITY BUDGET; PAYMENTS; COST CONTAINMENT MEASURES
Subtitle A--Budgeting and Payments to States
SEC. 601. NATIONAL HEALTH SECURITY BUDGET.
(a) National Health Security Budget.--
(1) In general.--By not later than September 1 before the
beginning of each year (beginning with 2012), the Board shall
establish a national health security budget, which--
(A) 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
(B) allocates those expenditures among the States
consistent with section 604.
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.
(2) Division of budget into components.--The national
health security budget shall consist of at least 4 components:
(A) A component for quality assessment activities
(described in title V).
(B) A component for health professional education
expenditures.
(C) A component for administrative costs.
(D) A component for operating and other
expenditures not described in subparagraphs (A) through
(C) (in this title referred to as the ``operating
component''), 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.
(3) Allocation among components.--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--
(A) assures a fair allocation for quality
assessment activities (consistent with the national
health security spending growth limit); and
(B) 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)).
(b) Basis for Total Expenditures.--
(1) In general.--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.
(2) National health security spending growth limit.--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.
(c) Definitions.--In this title:
(1) Capital expenditures.--The term ``capital
expenditures'' means expenses for the purchase, lease,
construction, or renovation of capital facilities and for
equipment and includes return on equity capital.
(2) Health professional education expenditures.--The term
``health professional education expenditures'' means
expenditures in hospitals and other health care facilities to
cover costs associated with teaching and related research
activities.
SEC. 602. COMPUTATION OF INDIVIDUAL AND STATE CAPITATION AMOUNTS.
(a) Capitation Amounts.--
(1) Individual capitation amounts.--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--
(A) a national average per capita cost for all
covered health care services (computed under subsection
(b));
(B) the State adjustment factor (established under
subsection (c)) for the State; and
(C) the risk adjustment factor (established under
subsection (d)) for the risk group.
(2) State capitation amount.--
(A) In general.--For purposes of this title, the
term ``State capitation amount'' 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.
(B) Use of statistical model.--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).
(C) Population information.--The Bureau of the
Census shall assist the Board in determining the
number, place of residence, and risk group
classification of eligible individuals.
(b) Computation of National Average Per Capita Cost.--
(1) For 2012.--For 2012, the national average per capita
cost under this paragraph is equal to--
(A) the average per capita health care expenditures
in the United States in 2010 (as estimated by the
Board);
(B) increased to 2011 by the Board's estimate of
the actual amount of such per capita expenditures
during 2011; and
(C) updated to 2012 by the national health security
spending growth limit specified in section 601(b)(2)
for 2012.
(2) For succeeding years.--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.
(c) State Adjustment Factors.--
(1) In general.--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--
(A) average labor and nonlabor costs that are
necessary to provide covered health services;
(B) 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);
(C) 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
(D) any other factor relating to operating costs
required to ensure equitable distribution of funds
among the States.
(2) Modification of health professional education
component.--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--
(A) differences among States in health professional
education programs in operation as of the date of the
enactment of this Act; and
(B) 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).
(3) Budget neutrality.--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.
(4) Phase-in.--In applying State adjustment factors under
this subsection during the 5-year period beginning with 2012,
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.
(5) Periodic adjustment.--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.
(d) Adjustments for Risk Group Classification.--
(1) In general.--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.
(2) Risk groups.--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.
(3) Periodic adjustment.--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.
SEC. 603. STATE HEALTH SECURITY BUDGETS.
(a) Establishment and Submission of Budgets.--
(1) In general.--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:
(A) 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:
(i) By the 4 components (described in
section 601(a)(2)), consistent with subsection
(b).
(ii) Within the operating component--
(I) expenditures for operating
costs of hospitals and other facility-
based services in the State;
(II) expenditures for payment to
comprehensive health service
organizations;
(III) expenditures for payment of
services provided by health care
practitioners; and
(IV) expenditures for other covered
items and services.
Amounts included in the operating component
include amounts that may be used by providers
for capital expenditures.
(B) The total revenues required to meet the State
health security expenditures.
(2) Proposed budget deadline.--The proposed budget for a
year shall be submitted under paragraph (1) not later than June
1 before the year.
(3) Final budget.--The final budget for a year shall--
(A) be established and submitted under paragraph
(1) not later than October 1 before the year, and
(B) take into account the amounts established under
the national health security budget under section 601
for the year.
(4) Adjustment in allocations permitted.--
(A) In general.--Subject to subparagraphs (B) and
(C), in the case of a final budget, a State may change
the allocation of amounts among components.
(B) Notice.--No such change may be made unless the
State has provided prior notice of the change to the
Board.
(C) Denial.--Such a change may not be made if the
Board, within such time period as the Board specifies,
disapproves such change.
(b) Expenditure Limits.--
(1) In general.--The total expenditures specified in each
State health security budget under subsection (a)(1) shall take
into account Federal contributions made under section 604.
(2) Limit on claims processing and billing expenditures.--
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.
(3) Worker assistance.--A State health security program may
provide that, for budgets for years before 2015, 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.
(c) Approval Process for Capital Expenditures Permitted.--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.
SEC. 604. FEDERAL PAYMENTS TO STATES.
(a) In General.--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--
(1) the State capitation amount (computed under section
602(a)(2)) for the State for the year; and
(2) the Federal contribution percentage (established under
subsection (b)).
(b) Federal Contribution Percentage.--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 2012, 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.
(c) Use of Payments.--All payments made under this section may only
be used to carry out the State health security program.
(d) Effect of Spending Excess or Surplus.--
(1) Spending excess.--If a State exceeds its budget in a
given year, the State shall continue to fund covered health
services from its own revenues.
(2) Surplus.--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.
SEC. 605. ACCOUNT FOR HEALTH PROFESSIONAL EDUCATION EXPENDITURES.
(a) Separate Account.--Each State health security program shall--
(1) include a separate account for health professional
education expenditures; and
(2) 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.
(b) Distribution Rules.--The distribution of funds to hospitals and
other health care facilities from the account shall conform to the
following principles:
(1) The disbursement of funds shall 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 shall be conditioned
upon the receipt of such reports as the Board may require in
order to monitor compliance with such goals.
(2) The distribution of funds from the account shall take
into account the potentially higher costs of placing health
professional students in clinical education programs in health
professional shortage areas.
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.
(a) Direct Payment Under Global Budget.--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.
(b) Annual Negotiations; Budget Approval.--
(1) In general.--The prospective global budget for an
institution or facility shall--
(A) be developed through annual negotiations
between--
(i) a panel of individuals who are
appointed by the Governor of the State and who
represent consumers, labor, business, and the
State government; and
(ii) the institution or facility; and
(B) be based on a nationally uniform system of cost
accounting established under standards of the Board.
(2) Considerations.--In developing a budget through
negotiations, there shall be taken into account at least the
following:
(A) With respect to inpatient hospital services,
the number, and classification by diagnosis-related
group, of discharges.
(B) An institution's or facility's past
expenditures.
(C) The extent to which debt service for capital
expenditures has been included in the proposed
operating budget.
(D) The extent to which capital expenditures are
financed directly or indirectly through reductions in
direct care to patients, including reductions in
registered nursing staffing patterns or changes in
emergency room or primary care services or
availability.
(E) Change in the consumer price index and other
price indices.
(F) The cost of reasonable compensation to health
care practitioners.
(G) The compensation level of the institution's or
facility's work force.
(H) 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.
(I) The institution's or facility's previous
financial and clinical performance, based on
utilization and outcomes data provided under this Act.
(J) 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.
(K) Technological advances or changes.
(L) Costs of the institution or facility associated
with meeting Federal and State regulations.
(M) The costs associated with necessary public
outreach activities.
(N) 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.
(O) Incentives to facilities that maintain costs
below previous reasonable budgeted levels without
reducing the care provided.
(P) 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.
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.
(3) Provision of required information; diagnosis-related
group.--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.
(c) Adjustments in Approved Budgets.--
(1) Adjustments to global budgets that contract with
comprehensive health service organizations.--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.
(2) Amendments.--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.
(d) Donations Permissible.--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.
SEC. 612. PAYMENTS TO HEALTH CARE PRACTITIONERS BASED ON PROSPECTIVE
FEE SCHEDULE.
(a) Fee for Service.--
(1) In general.--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.
(2) Global fee payment methodologies.--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.
(3) Billing deadlines; electronic billing.--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.
(b) Payment Rates Based on Negotiated Prospective Fee Schedules.--
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,
family medicine, gynecology, 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.
(c) Billable Covered Service Defined.--In this section, the term
``billable covered service'' means a service covered under section 201
for which a practitioner is entitled to compensation by payment of a
fee determined under this section.
SEC. 613. PAYMENTS TO COMPREHENSIVE HEALTH SERVICE ORGANIZATIONS.
(a) In General.--Payment under a State health security program to a
comprehensive health service organization to its enrollees shall be
determined by the State--
(1) based on a global budget described in section 611; or
(2) based on the basic capitation amount described in
subsection (b) for each of its enrollees.
(b) Basic Capitation Amount.--
(1) In general.--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).
(2) Adjustment for special health needs.--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.
(3) Adjustment for services not provided.--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).
SEC. 614. PAYMENTS FOR COMMUNITY-BASED PRIMARY HEALTH SERVICES.
(a) In General.--In the case of community-based primary health
services, subject to subsection (b), payments under a State health
security program shall--
(1) be based on a global budget described in section 611;
(2) be based on the basic primary care capitation amount
described in subsection (c) for each individual enrolled with
the provider of such services; or
(3) be made on a fee-for-service basis under section 612.
(b) Payment Adjustment.--Payments under subsection (a) may include,
consistent with the budgets developed under this title--
(1) 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;
(2) 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 Social Security Act), transportation
services, and translation services; and
(3) 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.
(c) Basic Primary Care Capitation Amount.--
(1) In general.--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).
(2) Adjustment for special health needs.--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.
(3) Adjustment for services not provided.--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.
(d) Community-Based Primary Health Services Defined.--In this
section, the term ``community-based primary health services'' has the
meaning given such term in section 202(a).
SEC. 615. PAYMENTS FOR PRESCRIPTION DRUGS.
(a) Establishment of List.--
(1) In general.--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.
(2) Exclusions.--The Board may exclude reimbursement under
this Act for ineffective, unsafe, or over-priced products where
better alternatives are determined to be available.
(b) Prices.--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.
(c) Charges by Independent Pharmacies.--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.
SEC. 616. PAYMENTS FOR APPROVED DEVICES AND EQUIPMENT.
(a) Establishment of List.--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.
(b) Considerations and Conditions.--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.
(c) Prices.--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.
(d) Exclusions.--The Board may exclude from coverage under this Act
ineffective, unsafe, or overpriced products where better alternatives
are determined to be available.
SEC. 617. PAYMENTS FOR OTHER ITEMS AND SERVICES.
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--
(1) 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
(2) consistent with the State health security budget.
SEC. 618. PAYMENT INCENTIVES FOR MEDICALLY UNDERSERVED AREAS.
(a) Model Payment Methodologies.--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.
(b) Construction.--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.
SEC. 619. AUTHORITY FOR ALTERNATIVE PAYMENT METHODOLOGIES.
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--
(1) 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
(2) 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.
Subtitle C--Mandatory Assignment and Administrative Provisions
SEC. 631. MANDATORY ASSIGNMENT.
(a) No Balance Billing.--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.
(b) Enforcement.--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
Social Security Act 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.
SEC. 632. PROCEDURES FOR REIMBURSEMENT; APPEALS.
(a) Procedures for Reimbursement.--In accordance with standards
issued by the Board, a State health security program shall establish a
timely and administratively simple procedure to ensure payment within
60 days of the date of submission of clean claims by providers under
this Act.
(b) Appeals Process.--Each State health security program shall
establish an appeals process to handle all grievances pertaining to
payment to providers under this title.
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.
(a) In General.--The Board is responsible for--
(1) coordinating health professional education policies and
goals, in consultation with the Secretary of Health and Human
Services (in this title referred to as the ``Secretary''), to
achieve the national goals specified in subsection (b);
(2) overseeing the health professional education
expenditures of the State health security programs from the
account established under section 602(c);
(3) 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
(4) developing, coordinating, and promoting other policies
that expand the number of primary care practitioners.
(b) National Goals.--The national goals specified in this
subsection are as follows:
(1) Graduate medical education.--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)).
(2) Midlevel primary care practitioners.--To ensure 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, 2015.
(3) Dentistry.--To ensure 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, 2015.
(c) Method for Attainment of National Goal for Graduate Medical
Education; Program Goals.--
(1) In general.--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.
(2) Consideration.--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.
(3) Medical residency education consortium.--In this
subsection, the term ``medical residency education consortium''
means a consortium of medical residency education programs in a
contiguous geographic area (which may be an interstate area) if
the consortium--
(A) includes at least 1 medical school with a
teaching hospital and related teaching settings; and
(B) 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.
(4) Enforcement through state health security budgets.--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.
(d) Method for Attainment of National Goal for Midlevel Primary
Care Practitioners.--To assist in attaining the national goal
identified in subsection (b)(2), the Board shall--
(1) advise the Public Health Service on allocations of
funding under titles VII and VIII of the Public Health Service
Act, the National Health Service Corps, and other programs in
order to increase the supply of midlevel primary care
practitioners; and
(2) 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.
(e) Definitions.--In this title:
(1) Dentist.--The term ``dentist'' 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.
(2) Medical residency education program.--The term
``medical residency education program'' 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.
(3) Midlevel primary care practitioner.--The term
``midlevel primary care practitioner'' 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.
(4) Primary care resident.--The term ``primary care
resident'' 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.
SEC. 702. ESTABLISHMENT OF ADVISORY COMMITTEE ON HEALTH PROFESSIONAL
EDUCATION.
(a) In General.--The Board shall provide for an Advisory Committee
on Health Professional Education (in this section referred to as the
``Committee'') to advise the Board on its activities under section 701.
(b) Membership.--The Committee shall be composed of--
(1) the Chair of the Board, who shall serve as Chair of the
Committee; and
(2) 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.
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.
(c) Terms of Members.--Each appointed member shall hold office for
a term of 5 years, except that--
(1) 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
(2) 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.
(d) Vacancies.--
(1) In general.--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.
(2) Vacancy appointments.--Any member appointed to fill a
vacancy shall serve for the remainder of the term for which the
predecessor of the member was appointed.
(3) Reappointment.--The Board may reappoint an appointed
member of the Committee for a second term in the same manner as
the original appointment.
(e) Duties.--It shall be the duty of the Committee to advise the
Board concerning graduate medical education policies under this title.
(f) Staff.--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.
(g) Meetings.--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.
(h) Compensation.--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.
(i) FACA Not Applicable.--The provisions of the Federal Advisory
Committee Act shall not apply to the Committee.
SEC. 703. GRANTS FOR HEALTH PROFESSIONS EDUCATION, NURSE EDUCATION, AND
THE NATIONAL HEALTH SERVICE CORPS.
(a) Transfers to Public Health Service.--
(1) In general.--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 Public Health Service Act 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.
(2) Fiscal year 2016 and subsequent years.--The amount
transferred for the support of the National Health Service
Corps for fiscal year 2016 and each subsequent fiscal year
shall be equal to the amount transferred for the preceding
fiscal year adjusted by the product of--
(A) one plus the average percentage increase in the
costs of health professions education during the prior
fiscal year; and
(B) 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.
(b) Range of Funds.--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 \3/100\ percent and
not to exceed \4/100\ percent of the amounts the Board estimates will
be expended from the Trust Fund in the fiscal year.
(c) Funds Supplemental to Other Funds.--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
2010.
Subtitle B--Direct Health Care Delivery
SEC. 711. SET-ASIDE FOR PUBLIC HEALTH.
(a) Transfers to Public Health Service.--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):
(1) For payments to States under the maternal and child
health block grants under title V of the Social Security Act
(42 U.S.C. 701 et seq.).
(2) For prevention and treatment of tuberculosis under
section 317 of the Public Health Service Act (42 U.S.C. 247b).
(3) For the prevention and treatment of sexually
transmitted diseases under section 318 of the Public Health
Service Act (42 U.S.C. 247c).
(4) Preventive health block grants under part A of title
XIX of the Public Health Service Act (42 U.S.C. 300w et seq.).
(5) Grants to States for community mental health services
under subpart I of part B of title XIX of the Public Health
Service Act (42 U.S.C. 300x et seq.).
(6) Grants to States for prevention and treatment of
substance abuse under subpart II of part B of title XIX of the
Public Health Service Act (42 U.S.C. 300x-21 et seq.).
(7) Grants for HIV health care services under parts A, B,
and C of title XXVI of the Public Health Service Act (42 U.S.C.
300ff-11 et seq.).
(8) Public health formula grants described in subsection
(d).
(b) Range of Funds.--The amount of transfers under subsection (a)
for any fiscal year shall be an amount (specified by the Board each
year) not less than \1/10\ percent and not to exceed \14/100\ percent
of the amounts the Board estimates will be expended from the Trust Fund
in the fiscal year.
(c) Funds Supplemental to Other Funds.--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.
(d) Required Reports on Health Status.--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:
(1) A comparison of the measures of the State and local
public health system compared to relevant objectives set forth
in ``Healthy People 2020'' or subsequent national objectives
set by the Secretary.
(2) 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.
(3) Measurable outcomes and process objectives for
improving health status, and a report on outcomes from the
previous year.
(4) Information regarding how Federal funding has improved
population-based prevention activities and programs.
(5) A description of the core public health functions to be
carried out at the local level.
(6) 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.
(e) Limitation on Fund Transfers.--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 2010.
(f) Public Health Formula Grants.--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:
(1) 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.
(2) Activities to protect the environment and to ensure the
safety of housing, workplaces, food, and water.
(3) 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.
(4) Health promotion and disease prevention activities for
which there is a significant need and a high priority of the
Public Health Service.
(5) The provision of public health laboratory services to
complement private clinical laboratory services, including--
(A) screening tests for metabolic diseases in
newborns;
(B) toxicology assessments of blood lead levels and
other environmental toxins;
(C) tuberculosis and other diseases requiring
partner notification; and
(D) testing for infectious and food-borne diseases.
(6) Training and education for the public health
professions.
(7) 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.
(8) 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.
SEC. 712. SET-ASIDE FOR PRIMARY HEALTH CARE DELIVERY.
(a) Transfers to Section 330 Program of the Public Health Service
Act.--
(1) In general.--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).
(2) Fiscal year 2016 and subsequent years.--The amount
transferred for fiscal year 2016 and each subsequent fiscal
year shall be equal to the amount transferred for the preceding
fiscal year adjusted by the product of--
(A) one plus the average percentage increase in
costs incurred per patient served by entities receiving
funding under such section; and
(B) one plus the average percentage increase in the
total number of patients served by entities receiving
funding under such section.
(b) Transfers to Public Health Service.--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 Public Health Service Act (as added by section 713 of
this Act).
(c) Range of Funds.--The amount of transfers under subsection (b)
for any fiscal year shall be an amount (specified by the Board each
year) not less than \6/100\ percent and not to exceed \1/10\ percent of
the amounts the Board estimates will be expended from the Trust Fund in
the fiscal year.
(d) Funds Supplemental to Other Funds.--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 Public Health Service Act. 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 2010.
SEC. 713. PRIMARY CARE SERVICE EXPANSION GRANTS.
(a) In General.--Part D of title III of the Public Health Service
Act (42 U.S.C. 254b et seq.) is amended by adding at the end the
following new subpart:
``Subpart XIII--Primary Care Expansion
``SEC. 340J. EXPANDING PRIMARY CARE DELIVERY CAPACITY IN URBAN AND
RURAL AREAS.
``(a) Grants for Primary Care Centers.--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.
``(b) Process of Awarding Grants.--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.
``(c) Funding as Set-Aside From Trust Fund.--Funds in the American
Health Security Trust Fund (established under section 801 of the act)
shall be available to carry out this section.
``(d) Primary Care Center Defined.--In this section, the term
`primary care center' means--
``(1) a health center (as defined in section 330(a)(1));
``(2) an entity qualified to receive a grant under section
330, 1001, or 2651; or
``(3) a Federally-qualified health center (as defined in
section 1905(l)(2)(B) of the Social Security Act).''.
(b) Technical Amendments.--Part D of title III of the Public Health
Service Act (42 U.S.C. 254b et seq.) is amended--
(1) by redesignating subpart XI, as added by section 10333
of the Patient Protection and Affordable Care Act (Public Law
111-148), as subpart XII; and
(2) by redesignating section 340H of the Public Health
Service Act (42 U.S.C. 256i), as added by section 10333 of the
Patient Protection and Affordable Care Act (Public Law 111-
148), as section 340I.
Subtitle C--Primary Care and Outcomes Research
SEC. 721. SET-ASIDE FOR OUTCOMES RESEARCH.
(a) Grants for Outcomes Research.--The Board shall make transfers
from the American Health Security Trust Fund to the Agency for
Healthcare Research and Quality under title IX of the Public Health
Service Act (42 U.S.C. 299 et seq.) 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.
(b) Range of Funds.--The amount of transfers under subsection (a)
for any fiscal year shall be an amount (specified by the Board each
year) not less than \1/100\ percent and not to exceed \2/100\ percent
of the amounts the Board estimates will be expended from the Trust Fund
in the fiscal year.
(c) Funds Supplemental to Other Funds.--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
Healthcare Research and Quality under section 947 of the Public Health
Service Act (42 U.S.C. 299c-6). 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 2010.
(d) Conforming Amendment.--Section 947(b) of the Public Health
Service Act (42 U.S.C. 299c-6(b)) is amended by inserting after ``of
the fiscal years 2001 through 2005'' the following: ``and of fiscal
year 2012 and each subsequent year''.
SEC. 722. OFFICE OF PRIMARY CARE AND PREVENTION RESEARCH.
(a) In General.--Title IV of the Public Health Service Act is
amended--
(1) by redesignating parts G through I as parts H through
J, respectively; and
(2) by inserting after part F the following new part:
``PART G--RESEARCH ON PRIMARY CARE AND PREVENTION
``SEC. 486E. OFFICE OF PRIMARY CARE AND PREVENTION RESEARCH.
``(a) Establishment.--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 `Office'). The
Office shall be headed by a director, who shall be appointed by the
Director of NIH.
``(b) Purpose.--The Director of the Office shall--
``(1) 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--
``(A) clinical patient care, with special emphasis
on pediatric clinical care and diagnosis;
``(B) diagnostic effectiveness;
``(C) primary care education;
``(D) health and family planning services;
``(E) medical effectiveness outcomes of primary
care procedures and interventions; and
``(F) the use of multidisciplinary teams of health
care practitioners;
``(2) identify multidisciplinary research related to
primary care and prevention that should be so conducted;
``(3) promote coordination and collaboration among entities
conducting research identified under any of paragraphs (1) and
(2);
``(4) encourage the conduct of such research by entities
receiving funds from the national research institutes;
``(5) recommend an agenda for conducting and supporting
such research;
``(6) promote the sufficient allocation of the resources of
the national research institutes for conducting and supporting
such research; and
``(7) prepare the report required under section 486G.
``(c) Primary Care and Prevention Research Defined.--For purposes
of this part, the term `primary care and prevention research' means
research on improvement of the practice of family medicine, general
internal medicine, and general pediatrics, and includes research
relating to--
``(1) obstetrics and gynecology, dentistry, or mental
health or substance abuse treatment when provided by a primary
care physician or other primary care practitioner; and
``(2) primary care provided by multidisciplinary teams.
``SEC. 486F. NATIONAL DATA SYSTEM AND CLEARINGHOUSE ON PRIMARY CARE AND
PREVENTION RESEARCH.
``(a) Data System.--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.
``(b) Clearinghouse.--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.
``SEC. 486G. BIENNIAL REPORT.
``(a) In General.--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--
``(1) 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;
``(2) summarizing and analyzing expenditures made by the
agencies of such Institutes (and by such Office) during the
preceding 2 fiscal years; and
``(3) making such recommendations for legislative and
administrative initiatives as the Director of the Office
determines to be appropriate.
``(b) Inclusion in Biennial Report of Director of NIH.--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.
``SEC. 486H. AUTHORIZATION OF APPROPRIATIONS.
``For the Office of Primary Care and Prevention Research, there are
authorized to be appropriated $150,000,000 for fiscal year 2012,
$180,000,000 for fiscal year 2013, and $216,000,000 for fiscal year
2014.''.
(b) Requirement of Sufficient Allocation of Resources of
Institutes.--Section 402(b) of the Public Health Service Act (42 U.S.C.
282(b)) is amended--
(1) in paragraph (23), by striking ``and'' after the
semicolon at the end;
(2) in paragraph (24), by striking the period at the end
and inserting ``; and''; and
(3) by inserting after paragraph (24) the following new
paragraph:
``(25) 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).''.
Subtitle D--School-Related Health Services
SEC. 731. AUTHORIZATIONS OF APPROPRIATIONS.
(a) Funding for School-Related Health Services.--For the purpose of
carrying out this subtitle, there are authorized to be appropriated
$100,000,000 for fiscal year 2014, $275,000,000 for fiscal year 2015,
$350,000,000 for fiscal year 2016, and $400,000,000 for each of the
fiscal years 2017 and 2018.
(b) Relation to Other Funds.--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.
SEC. 732. ELIGIBILITY FOR DEVELOPMENT AND OPERATION GRANTS.
(a) In General.--Entities eligible to apply for and receive grants
under section 734 or 735 are the following:
(1) 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.
(2) Local community partnerships in States in which health
agencies have not applied.
(b) Local Community Partnerships.--
(1) In general.--A local community partnership under
subsection (a)(2) is an entity that, at a minimum, includes--
(A) a local health care provider with experience in
delivering services to school-aged children;
(B) 1 or more local public schools; and
(C) 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.
(2) Participation.--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.
(c) Definitions Regarding Children.--For purposes of this subtitle:
(1) The term ``adolescent children'' means school-aged
children who are adolescents.
(2) The term ``school-aged children'' means individuals who
are between the ages of 4 and 19 (inclusive).
SEC. 733. PREFERENCES.
(a) In General.--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:
(1) High levels of poverty.
(2) The presence of a medically underserved population.
(3) The presence of a health professional shortage area.
(4) 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.
(b) Linkage to Community Health Centers.--In making grants under
sections 734 and 735, the Secretary shall give preference to applicants
that demonstrate a linkage to community health centers.
SEC. 734. GRANTS FOR DEVELOPMENT OF PROJECTS.
(a) In General.--The Secretary may make grants to State health
agencies or to local community partnerships to develop school health
service sites.
(b) Use of Funds.--A project for which a grant may be made under
subsection (a) may include the cost of the following:
(1) Planning for the provision of school health services.
(2) Recruitment, compensation, and training of health and
administrative staff.
(3) 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.
(4) Other activities necessary to assume operational
status.
(c) Application for Grant.--
(1) In general.--Applicants shall submit applications in a
form and manner prescribed by the Secretary.
(2) Applications by state health agencies.--
(A) In the case of applicants that are State health
agencies, the application shall contain assurances that
the State health agency is applying for funds--
(i) on behalf of at least 1 local community
partnership; and
(ii) 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.
(B) 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.
(C) 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.
(d) Contents of Application.--In order to receive a grant under
this section, an applicant shall include in the application the
following information:
(1) 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.
(2) 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.
(3) An explanation of how the applicant will integrate its
services with those of other health and social service programs
within the community.
(4) A description of a quality assurance program which
complies with standards that the Secretary may prescribe.
(e) Number of Grants.--Not more than 1 planning grant may be made
to a single applicant. A planning grant may not exceed 2 years in
duration.
SEC. 735. GRANTS FOR OPERATION OF PROJECTS.
(a) In General.--The Secretary may make grants to State health
agencies or to local community partnerships for the cost of operating
school health service sites.
(b) Use of Grant.--The costs for which a grant may be made under
this section include the following:
(1) The cost of furnishing health services that are not
otherwise covered under this Act or by any other public or
private insurer.
(2) 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.
(3) Training, recruitment and compensation of health
professionals and other staff.
(4) Outreach services to school-aged children who are at
risk and to the parents of such children.
(5) Linkage of individuals to health plans, community
health services and social services.
(6) Other activities deemed necessary by the Secretary.
(c) Application for Grant.--Applicants shall submit applications in
a form and manner prescribed by the Secretary. In order to receive a
grant under this section, an applicant shall include in the application
the following information:
(1) A description of the services to be furnished by the
applicant.
(2) 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.
(3) Such other information as the Secretary determines to
be appropriate.
(d) Additional Contents of Application.--In order to receive a
grant under this section, an applicant shall meet the following
conditions:
(1) The applicant furnishes the following services:
(A) Diagnosis and treatment of simple illnesses and
minor injuries.
(B) Preventive health services, including health
screenings.
(C) Services provided for the purpose described in
subsection (b)(2).
(D) Referrals and followups in situations involving
illness or injury.
(E) Health and social services, counseling
services, and necessary referrals, including referrals
regarding mental health and substance abuse.
(F) Such other services as the Secretary determines
to be appropriate.
(2) The applicant is a participating provider in the
State's program for medical assistance under title XIX of the
Social Security Act.
(3) 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).
(4) 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).
(5) 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.
(6) The applicant will provide non-Federal contributions
toward the cost of the project in an amount determined by the
Secretary.
(7) The applicant will operate a quality assurance program
consistent with section 734(d).
(e) Duration of Grant.--A grant under this section shall be for a
period determined by the Secretary.
(f) Reports.--A recipient of funding under this section shall
provide such reports and information as are required in regulations of
the Secretary.
SEC. 736. FEDERAL ADMINISTRATIVE COSTS.
Of the amounts made available under section 731, the Secretary may
reserve not more than 5 percent for administrative expenses regarding
this subtitle.
SEC. 737. DEFINITIONS.
For purposes of this subtitle:
(1) The term ``adolescent children'' has the meaning given
such term in section 732(c).
(2) The term ``at risk'' means at-risk with respect to
health.
(3) The term ``community health center'' has the meaning
given such term in section 330 of the Public Health Service
Act.
(4) The term ``health professional shortage area'' means a
health professional shortage area designated under section 332
of the Public Health Service Act.
(5) The term ``medically underserved population'' has the
meaning given such term in section 330 of the Public Health
Service Act.
(6) The term ``school-aged children'' has the meaning given
such term in section 732(c).
TITLE VIII--FINANCING PROVISIONS; AMERICAN HEALTH SECURITY TRUST FUND
SEC. 800. AMENDMENT OF 1986 CODE; SECTION 15 NOT TO APPLY.
(a) Amendment of 1986 Code.--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.
(b) Section 15 Not To Apply.--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.
Subtitle A--American Health Security Trust Fund
SEC. 801. AMERICAN HEALTH SECURITY TRUST FUND.
(a) In General.--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 ``Trust
Fund''). 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.
(b) Appropriations Into Trust Fund.--
(1) Taxes.--There are hereby appropriated to the Trust Fund
for each fiscal year (beginning with fiscal year 2013), 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.
(2) Current program receipts.--Notwithstanding any other
provision of law, there are hereby appropriated to the Trust
Fund for each fiscal year (beginning with fiscal year 2013) the
amounts that would otherwise have been appropriated to carry
out the following programs:
(A) The Medicare program, under parts A, B, and D
of title XVIII of the Social Security Act (other than
amounts attributable to any premiums under such parts).
(B) The Medicaid program, under State plans
approved under title XIX of such Act.
(C) The Federal employees health benefit program,
under chapter 89 of title 5, United States Code.
(D) The TRICARE program (formerly known as the
CHAMPUS program), under chapter 55 of title 10, United
States Code.
(E) The maternal and child health program (under
title V of the Social Security Act), vocational
rehabilitation programs, programs for drug abuse and
mental health services under the Public Health Service
Act, 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.
(c) Incorporation of Provisions.--The provisions of subsections (b)
through (i) of section 1817 of the Social Security Act 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.
(d) Transfer of Funds.--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.
Subtitle B--Taxes Based on Income and Wages
SEC. 811. PAYROLL TAX ON EMPLOYERS.
(a) In General.--Section 3111 (relating to tax on employers) is
amended by redesignating subsections (c) and (d) as subsection (d) and
(e), respectively, and by inserting after subsection (b) the following
new subsection:
``(c) Health Care.--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 6.7 percent of the wages (as
defined in section 3121(a)) paid by him with respect to employment (as
defined in section 3121(b)).''.
(b) Self-Employment Income.--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:
``(c) Health Care.--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 6.7 percent of the amount of the self-
employment income for such taxable year.''.
(c) Comparable Taxes for Railroad Services.--
(1) Tax on employers.--Section 3221 is amended by
redesignating subsections (c) and (d) as subsections (d) and
(e), respectively, and by inserting after subsection (b) the
following new subsection:
``(c) Health Care.--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 6.7 percent of the compensation
paid by such employer for services rendered to such employer.''.
(2) Tax on employee representatives.--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:
``(c) Health Care.--In addition to other taxes, there is hereby
imposed on the income of each employee representative a tax equal to
6.7 percent of the compensation received during the calendar year by
such employee representative for services rendered by such employee
representative.''.
(3) No applicable base.--Subparagraph (A) of section
3231(e)(2) is amended by adding at the end thereof the
following new clause:
``(iv) Health care taxes.--Clause (i) shall
not apply to the taxes imposed by sections
3221(c) and 3211(c).''.
(4) Technical amendment.--
(A) Subsection (d) of section 3211, as redesignated
by paragraph (2), is amended by striking ``and (b)''
and inserting ``, (b), and (c)''.
(B) Subsection (d) of section 3221, as redesignated
by paragraph (1), is amended by striking ``and (b)''
and inserting ``, (b), and (c)''.
(d) Effective Date.--The amendments made by this section shall
apply to remuneration paid after December 31, 2012.
SEC. 812. HEALTH CARE INCOME TAX.
(a) General Rule.--Subchapter A of chapter 1 (relating to
determination of tax liability) is amended by adding at the end thereof
the following new part:
``PART VIII--HEALTH CARE RELATED TAXES
``subpart a.--health care income tax on individuals
``Subpart A--Health Care Income Tax on Individuals
``Sec. 59B. Health care income tax.
``SEC. 59B. HEALTH CARE INCOME TAX.
``(a) Imposition of Tax.--In the case of an individual, there is
hereby imposed on the taxable income of the taxpayer for the taxable
year a tax (in addition to any other tax imposed by this subtitle)
determined in accordance with the following tables:
``(1) Married individuals filing joint returns and
surviving spouses.--In the case of any taxpayer making a joint
return under section 6013 or a surviving spouse (as defined in
section 2(a)), the following table shall apply:
``If taxable income is: The tax is:
Not over $250,000..............
2.2% of taxable income.
Over $250,000 but not over
$400,000.
$5,500, plus 3.2% of the excess
over $250,000.
Over $400,000 but not over
$600,000.
$10,300, plus 4.2% of the
excess over $400,000.
Over $600,000..................
$18,700, plus 5.2% of the
excess over $600,000.
``(2) Other taxpayers.--In the case of any taxpayer not
described in paragraph (1), the following table shall apply:
``If taxable income is: The tax is:
Not over $200,000..............
2.2% of taxable income.
Over $200,000 but not over
$400,000.
$4,400, plus 3.2% of the excess
over $200,000.
Over $400,000 but not over
$600,000.
$10,800, plus 4.2% of the
excess over $400,000.
Over $600,000..................
$19,200, plus 5.2% of the
excess over $600,000.
``(b) Inflation Adjustment.--
``(1) In general.--In the case of any taxable year
beginning after 2013, each of the dollar amounts set forth in
the tables in subsection (a) shall be increased by an amount
equal to--
``(A) such dollar amount, multiplied by
``(B) the cost-of-living adjustment determined
under section 1(f)(3) for such calendar year by
substituting `calendar year 2012' for `calendar year
1992' in subparagraph (B) thereof.
``(2) Rounding.--If the amount as adjusted under paragraph
(1) is not a multiple of $1,000, such amount shall be rounded
to the next lowest multiple of $1,000.
``(c) No Credits Against Tax; No Effect on Minimum Tax.--The tax
imposed by this section shall not be treated as a tax imposed by this
chapter for purposes of determining--
``(1) the amount of any credit allowable under this
chapter, or
``(2) the amount of the minimum tax imposed by section 55.
``(d) Special Rules.--
``(1) Tax to be withheld, etc.--For purposes of this title,
the tax imposed by this section shall be treated as imposed by
section 1.
``(2) Reimbursement of tax by employer not includible in
gross income.--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.
``(3) Other rules.--The rules of section 59A(d) shall apply
to the tax imposed by this section.''.
(b) Clerical Amendment.--The table of parts for subchapter A of
chapter 1 is amended by adding at the end the following new item:
``Part VIII--Health Care Related Taxes''.
(c) Effective Date.--The amendments made by this section shall
apply to taxable years beginning after December 31, 2012.
SEC. 813. SURCHARGE ON HIGH INCOME INDIVIDUALS.
(a) In General.--Part VIII of subchapter A of chapter 1, as added
by this title, is amended by adding at the end the following new
subpart:
``Subpart B--Surcharge on High Income Individuals
``Sec. 59C. Surcharge on high income individuals.
``SEC. 59C. SURCHARGE ON HIGH INCOME INDIVIDUALS.
``(a) General Rule.--In the case of a taxpayer other than a
corporation, there is hereby imposed (in addition to any other tax
imposed by this subtitle) a tax equal to 5.4 percent of so much of the
modified adjusted gross income of the taxpayer as exceeds $1,000,000.
``(b) Taxpayers Not Making a Joint Return.--In the case of any
taxpayer other than a taxpayer making a joint return under section 6013
or a surviving spouse (as defined in section 2(a)), subsection (a)
shall be applied by substituting `$500,000' for `$1,000,000'.
``(c) Modified Adjusted Gross Income.--For purposes of this
section, the term `modified adjusted gross income' means adjusted gross
income reduced by any deduction (not taken into account in determining
adjusted gross income) allowed for investment interest (as defined in
section 163(d)). In the case of an estate or trust, adjusted gross
income shall be determined as provided in section 67(e).
``(d) Special Rules.--
``(1) Nonresident alien.--In the case of a nonresident
alien individual, only amounts taken into account in connection
with the tax imposed under section 871(b) shall be taken into
account under this section.
``(2) Citizens and residents living abroad.--The dollar
amount in effect under subsection (a) (after the application of
subsection (b)) shall be decreased by the excess of--
``(A) the amounts excluded from the taxpayer's
gross income under section 911, over
``(B) the amounts of any deductions or exclusions
disallowed under section 911(d)(6) with respect to the
amounts described in subparagraph (A).
``(3) Charitable trusts.--Subsection (a) shall not apply to
a trust all the unexpired interests in which are devoted to one
or more of the purposes described in section 170(c)(2)(B).
``(4) Not treated as tax imposed by this chapter for
certain purposes.--The tax imposed under this section shall not
be treated as tax imposed by this chapter for purposes of
determining the amount of any credit under this chapter or for
purposes of section 55.''.
(b) Clerical Amendment.--The table of subparts for part VIII of
subchapter A of chapter 1, as added by this title, is amended by
inserting after the item relating to subpart A the following new item:
``subpart b. surcharge on high income individuals''.
(c) Section 15 Not To Apply.--The amendment made by subsection (a)
shall not be treated as a change in a rate of tax for purposes of
section 15 of the Internal Revenue Code of 1986.
(d) Effective Date.--The amendments made by this section shall
apply to taxable years beginning after December 31, 2012.
Subtitle C--Other Financing Provisions
SEC. 821. TAX ON SECURITIES TRANSACTIONS.
(a) In General.--Chapter 36 is amended by inserting after
subchapter B the following new subchapter:
``Subchapter C--Tax on Securities Transactions
``Sec. 4475. Tax on securities transactions.
``SEC. 4475. TAX ON SECURITIES TRANSACTIONS.
``(a) Imposition of Tax.--
``(1) Stocks.--There is hereby imposed a tax on each
covered transaction in a stock contract of 0.25 percent of the
value of the instruments involved in such transaction.
``(2) Futures.--There is hereby imposed a tax on each
covered transaction in a futures contract of 0.02 percent of
the value of the instruments involved in such transaction.
``(3) Swaps.--There is hereby imposed a tax on each covered
transaction in a swaps contract of 0.02 percent of the value of
the instruments involved in such transaction.
``(4) Credit default swaps.--There is hereby imposed a tax
on each covered transaction in a credit default swaps contract
of 0.02 percent of the value of the instruments involved in
such transaction.
``(5) Options.--There is hereby imposed a tax on each
covered transaction in an options contract with respect to a
transaction described in paragraph (1), (2), (3), or (4) of--
``(A) the rate imposed with respect to such
underlying transaction under paragraph (1), (2), (3),
or (4) (as the case may be), multiplied by
``(B) the premium paid on such option.
``(b) Exception for Retirement Accounts, etc.--No tax shall be
imposed under subsection (a) with respect to any stock contract,
futures contract, swaps contract, credit default swap, or options
contract which is held in any plan, account, or arrangement described
in section 220, 223, 401(a), 403(a), 403(b), 408, 408A, 529, or 530.
``(c) Exception for Interests in Mutual Funds.--No tax shall be
imposed under subsection (a) with respect to the purchase or sale of
any interest in a regulated investment company (as defined in section
851) or of any derivative of such an interest.
``(d) By Whom Paid.--
``(1) In general.--The tax imposed by this section shall be
paid by--
``(A) in the case of a transaction which occurs on
a trading facility located in the United States, such
trading facility, or
``(B) in any other case, the purchaser with respect
to the transaction.
``(2) Withholding if buyer is not a united states person.--
See section 1447 for withholding by seller if buyer is a
foreign person.
``(e) Covered Transaction.--The term `covered transaction' means
any purchase or sale if--
``(1) such purchase or sale occurs on a trading facility
located in the United States, or
``(2) the purchaser or seller is a United States person.
``(f) Administration.--The Secretary shall carry out this section
in consultation with the Securities and Exchange Commission and the
Commodity Futures Trading Commission.''.
(b) Credit for First $100,000 of Stock Transactions Per Year.--
Subpart C of part IV of subchapter A of chapter 1 is amended by
inserting after section 36A the following new section:
``SEC. 36B. CREDIT FOR SECURITIES TRANSACTION TAXES.
``(a) Allowance of Credit.--In the case of any purchaser with
respect to a covered transaction, there shall be allowed as a credit
against the tax imposed by this subtitle for the taxable year an amount
equal to the lesser of--
``(1) the aggregate amount of tax imposed under section
4475 on covered transactions during the taxable year with
respect to which the taxpayer is the purchaser, or
``(2) $250 ($500 in the case of a joint return).
``(b) Aggregation Rule.--For purposes of this section, all persons
treated as a single employer under subsection (a) or (b) of section 52,
or subsection (m) or (o) of section 414, shall be treated as one
taxpayer.
``(c) Definitions.--For purposes of this section, any term used in
this section which is also used in section 4475 shall have the same
meaning as when used in section 4475.''.
(c) Withholding.--Subchapter A of chapter 3 is amended by adding at
the end the following new section:
``SEC. 1447. WITHHOLDING ON SECURITIES TRANSACTIONS.
``(a) In General.--In the case of any outbound securities
transaction, the transferor shall deduct and withhold a tax equal to
the tax imposed under section 4475 with respect to such transaction.
``(b) Outbound Securities Transaction.--For purposes of this
section, the term `outbound securities transaction' means any covered
transaction to which section 4475(a) applies if--
``(1) such transaction does not occur on a trading facility
located in the United States, and
``(2) the purchaser with respect to such transaction is not
a United States person.''.
(d) Conforming Amendments.--
(1) Section 6211(b)(4)(A) is amended by inserting ``36B,''
after ``36A,''.
(2) Section 1324(b)(2) of title 31, United States Code, is
amended by inserting ``36B,'' after ``36A,''.
(3) The table of subchapters for chapter 36 is amended by
inserting after the item relating to subchapter B the following
new item:
``Subchapter C. Tax on securities transactions''.
(4) The table of sections for subchapter A of chapter 3 is
amended by adding at the end the following new item:
``Sec. 1447. Withholding on securities transactions.''.
(5) The table of sections for subpart C of part IV of
subchapter A of chapter 1 is amended by inserting after the
item relating to section 36A the following new item:
``Sec. 36B. Credit for securities transaction taxes.''.
(e) Effective Date.--The amendments made by this section shall
apply to transactions occurring more than 180 days after the date of
the enactment of this Act.
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.
Section 4 of the Employee Retirement Income Security Act of 1974
(29 U.S.C. 1003) is amended--
(1) in subsection (a), by striking ``(b) or (c)'' and
inserting ``(b), (c), or (d)''; and
(2) by adding at the end the following new subsection:
``(d) 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 American Health Security
Act of 2011.''.
SEC. 902. EXEMPTION OF STATE HEALTH SECURITY PROGRAMS FROM ERISA
PREEMPTION.
Section 514(b) of the Employee Retirement Income Security Act of
1974 (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:
``(10) Subsection (a) of this section shall not apply to State
health security programs established pursuant to section 101(b) of the
American Health Security Act of 2011.''.
SEC. 903. PROHIBITION OF EMPLOYEE BENEFITS DUPLICATIVE OF BENEFITS
UNDER STATE HEALTH SECURITY PROGRAMS; COORDINATION IN
CASE OF WORKERS' COMPENSATION.
(a) In General.--Part 5 of subtitle B of title I of the Employee
Retirement Income Security Act of 1974 is amended by adding at the end
the following new section:
``prohibition of employee benefits duplicative of state health security
program benefits; coordination in case of workers' compensation
``Sec. 522. (a) 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 American Health
Security Act of 2011.
``(b)(1) 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.
``(2) In this subsection:
``(A) The term `workers compensation carrier' 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.
``(B) The term `workers compensation medical benefits'
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.
``(C) The term `workers compensation services' 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.''.
(b) Conforming Amendment.--Section 4(b) of such Act (29 U.S.C.
1003(b)) is amended by adding at the end the following: ``Paragraph (3)
shall apply subject to section 522(b) (relating to reimbursement of
State health security plans by workers compensation carriers).''.
(c) Clerical Amendment.--The table of contents in section 1 of such
Act is amended by inserting after the item relating to section 521 the
following new items:
``Sec. 522. Prohibition of employee benefits duplicative of state
health security program benefits;
coordination in case of workers'
compensation.''.
SEC. 904. REPEAL OF CONTINUATION COVERAGE REQUIREMENTS UNDER ERISA AND
CERTAIN OTHER REQUIREMENTS RELATING TO GROUP HEALTH
PLANS.
(a) In General.--Part 6 of subtitle B of title I of the Employee
Retirement Income Security Act of 1974 (29 U.S.C. 1161 et seq.) is
repealed.
(b) Conforming Amendments.--
(1) Section 502(a) of such Act (29 U.S.C. 1132(a)) is
amended--
(A) by striking paragraph (7); and
(B) by redesignating paragraphs (8), (9), and (10)
as paragraphs (7), (8), and (9), respectively.
(2) Section 502(c)(1) of such Act (29 U.S.C. 1132(c)(1)) is
amended by striking ``paragraph (1) or (4) of section 606,''.
(3) Section 514(b) of such Act (29 U.S.C. 1144(b)) is
amended--
(A) in paragraph (7), by striking ``section
206(d)(3)(B)(i)),'' and all that follows and inserting
``section 206(d)(3)(B)(i)).''; and
(B) by striking paragraph (8).
(4) The table of contents in section 1 of the Employee
Retirement Income Security Act of 1974 is amended by striking
the items relating to part 6 of subtitle B of title I of such
Act.
SEC. 905. EFFECTIVE DATE OF TITLE.
The amendments made by this title shall take effect January 1,
2014.
TITLE X--ADDITIONAL CONFORMING AMENDMENTS
SEC. 1001. REPEAL OF CERTAIN PROVISIONS IN INTERNAL REVENUE CODE OF
1986.
The provisions of titles III and IV of the Health Insurance
Portability and Accountability Act of 1996, 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.
SEC. 1002. REPEAL OF CERTAIN PROVISIONS IN THE EMPLOYEE RETIREMENT
INCOME SECURITY ACT OF 1974.
(a) In General.--Part 7 of subtitle B of title I of the Employee
Retirement Income Security Act of 1974 is repealed and the items
relating to such part in the table of contents in section 1 of such Act
are repealed.
(b) Conforming Amendment.--Section 514(b) of such Act (29 U.S.C.
1144(b)) is amended by striking paragraph (9).
SEC. 1003. REPEAL OF CERTAIN PROVISIONS IN THE PUBLIC HEALTH SERVICE
ACT AND RELATED PROVISIONS.
(a) In General.--Titles XXII and XXVII of the Public Health Service
Act are repealed.
(b) Additional Amendments.--
(1) Section 1301(b) of such Act (42 U.S.C. 300e(b)) is
amended by striking paragraph (6).
(2) Sections 104 and 191 of the Health Insurance
Portability and Accountability Act of 1996 are repealed.
SEC. 1004. EFFECTIVE DATE OF TITLE.
The amendments made by this title shall take effect January 1,
2015.
<all>
Introduced in House
Introduced in House
Sponsor introductory remarks on measure. (CR E518)
Referred to the Committee on Energy and Commerce, and in addition to the Committees on Ways and Means, Oversight and Government Reform, Armed Services, and Education and the Workforce, for a period to be subsequently determined by the Speaker, in each case for consideration of such provisions as fall within the jurisdiction of the committee concerned.
Referred to the Committee on Energy and Commerce, and in addition to the Committees on Ways and Means, Oversight and Government Reform, Armed Services, and Education and the Workforce, for a period to be subsequently determined by the Speaker, in each case for consideration of such provisions as fall within the jurisdiction of the committee concerned.
Referred to the Committee on Energy and Commerce, and in addition to the Committees on Ways and Means, Oversight and Government Reform, Armed Services, and Education and the Workforce, for a period to be subsequently determined by the Speaker, in each case for consideration of such provisions as fall within the jurisdiction of the committee concerned.
Referred to the Committee on Energy and Commerce, and in addition to the Committees on Ways and Means, Oversight and Government Reform, Armed Services, and Education and the Workforce, for a period to be subsequently determined by the Speaker, in each case for consideration of such provisions as fall within the jurisdiction of the committee concerned.
Referred to the Committee on Energy and Commerce, and in addition to the Committees on Ways and Means, Oversight and Government Reform, Armed Services, and Education and the Workforce, for a period to be subsequently determined by the Speaker, in each case for consideration of such provisions as fall within the jurisdiction of the committee concerned.
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Referred to the Subcommittee on Health.
Referred to the Subcommittee on Federal Workforce, U.S. Postal Service, and Labor Policy.
Referred to the Subcommittee on Health, Employment, Labor, and Pensions.
Referred to the Subcommittee on Health.
Referred to the Subcommittee on Military Personnel.