National Health Plan Act

National Health Plan Act - Sets forth the following three major structural elements of a National Health Plan established by this Act for the benefit of individuals who live or work in the United States: (1) health insurance required to be provided by all employers to employees and their families; (2) Healthcare, a Federal health insurance program for the aged, disabled, poor, and for other individuals who cannot obtain health insurance elsewhere; and (3) health systems reform, designed to enhance competition in the health care system, reduce excess capacity in hospitals, and improve access to essential health resources.

Title I: Protection Against Medical Expenses - Replaces title XVIII (Medicare) of the Social Security Act with a National Health Plan. Provides coverage under the Plan for the following items and services when reasonable and needed to diagnose, treat, or aid in rehabilitation from disease, injury, or malformation: (1) inpatient hospital items and services; (2) inpatient skilled nursing items and services; (3) home health items and services; (4) physician's services; (5) outpatient physical therapy services; (6) health care practitioner items and services; (7) x-ray, radium, and radioactive isotope therapy services; (8) certain ambulance services; (9) chiropractor's services; and (10) the following items as specified by a physician: certain supplies furnished as an incident to a physician's professional services, diagnostic tests, x-ray, radium, and radioactive isotope therapy items, devices used for the reduction of fractures or dislocations, durable medical equipment, non-dental prosthetic devices, colostomy care supplies, blood, body organs, allergen extracts, portable devices for monitoring cardiac failure and portable respirators, dialysis items for chronic renal disease, and braces for the leg, arm, neck, and back. Provides coverage under the Plan for the following items and services when reasonable and needed for the maintenance of good health: (1) family planning items and services; (2) immunizations; (3) items and services related to pregnancy, to delivery, to care of a child for one year after birth, or to care of a women through 60 days after termination of pregnancy; (4) items and services for entitled individuals under 18 as prescribed by the Secretary of Health, Education, and Welfare; and (5) dental, vision, and hearing items and services for certain eligible individuals under 18.

Excludes the following items and services from coverage under the Plan: (1) items and services needed solely to diagnose, treat, or aid in rehabilitation from disease, accident, or malformation in relation to teeth or structures directly supporting teeth, other than oral surgery in case of accident or malformation; (2) eyeglasses, eye examinations for the purpose of prescribing, fitting, or changing eyeglasses, and procedures performed to determine the refractive state of the eyes; (3) hearing aids or examinations for hearing aids, except for certain eligible individuals under 18; (4) personal comfort items that are not supplied to all patients of an entity or are not found to promote higher quality care; (5) cosmetic surgery, except as required for the prompt repair of accidental injury or for improvement of a malformed body member; (6) items and services furnished to an individual by an immediate relative or a member of the individual's household; (7) items and services for the treatment of flat foot conditions, the treatment of subluxations of the foot, or routine foot care; (8) surgery performed by an uncertified physician; (9) diagnostic tests for environmental or occupational diseases; (10) elective surgery; (11) items and services that a physician has not certified; (12) custodial care; and (13) items and services furnished by the Veterans' Administration to a disabled veteran for a military service-connected disability.

Requires every employer to provide coverage under a qualified plan or under Healthcare for each employee family member, unless an individual is covered under a qualified plan or under Healthcare with another employer and chooses not to accept coverage. Requires every employer not providing coverage under Healthcare to employee family members in a geographic area to designate one qualified plan as the employer's primary plan in that geographic area. Requires every employer to offer a health benefit, whether or not part of a qualified plan, to each employee family member in a geographic area if the employer offers that health benefit to any other employee family member in that geographic area.

Requires every employer to provide for the payment of required premiums on behalf of employee family members to the entity administering a qualified plan, or, to the Secretary if coverage is under Healthcare.

Prohibits an employer requiring any employee covered under the employer's primary plan or under Healthcare from contributing more than 25 percent of the premium payments for his or her family members attributable to the minimum benefits required by a plan under this Act. Provides that the employer's total share of premium or other payments for health benefits provided to an employee's family in a geographic area shall be equal to the employer's share of premium payments under the primary plan or Healthcare for a family of the same size and composition in that geographic area. Requires a plan, in order to be certified by the Secretary as qualified, to, among other things: (1) be administered by an entity certified by the Secretary; (2) cover at a minimum the items and services covered by the National Health Plan; (3) provide for rates of payment under the plan for items and services such that the rates in the aggregate insure access to items and services; (4) provide a certain level of quality of items and services; (5) provide specified rates of payment; and (6) prohibit total coinsurance and deductibles for items and services covered by the National Health Plan for the family members of any employee from exceeding $2,500 subject to certain adjustments and stipulations.

Provides that services prescribed by a health maintenance organization (HMO) shall be considered a qualified plan.

Directs the Secretary to certify an entity as a plan administrator only if it meets specified criteria pertaining to: (1) the privacy of medical records; (2) the availability of certain information concerning the plan; (3) access to records; (4) grievance procedures; (5) the purchase of additional insurance; (6) premiums; (7) solvency; and (8) control of the entity.

Establishes in the Treasury a Health Reinsurance Fund to make reinsurance available and to be used for any Federal insolvency program.

Directs the Secretary to report to Congress on the adequacy of State programs for assuring the solvency of health insurers. Authorizes the Secretary to establish a Federal insolvency program for any State that does not have an adequate program for assuring the solvency of health insurers.

Directs the Secretary to establish an Insurance Standards Advisory Board to advise the Secretary with respect to: (1) standards for qualified plans; (2) implementation of the certification process; (3) appeals from plans or administrators denied certification; and (4) other matters as requested by the Secretary.

Directs the Secretary to pay to any employer whose premium payments for the required minimum benefits exceed five percent of his or her payroll the difference between those payments and five percent of the payroll, if such payments are reasonable in relation to the benefits provided.

Sets forth civil penalties for employers who fail to provide coverage and make premium payments as required by this Act.

Entitles the following individuals to Healthcare: (1) individuals age 65 or older who are entitled to benefits under title II (Old Age, Survivors and Disability Insurance) of the Social Security Act or are qualified to receive railroad retirement benefits; (2) disabled individuals entitled to benefits under title II or the Railroad Retirement Act; (3) every individual who is fully or currently insured under title II or the Railroad Retirement Act or is the spouse or dependent child of such individual and certain individuals who have end stage renal disease (ESRD); (4) kidney donors; (5) family members of U.S. citizens and aliens admitted for permanent residence; (6) individuals covered by a Healthcare employer agreement; (7) individuals and family members of individuals who are at or below 55 percent of the poverty level, as reduced according to this Act; (8) individuals eligible under title XIX (Medicaid) of the Act whose income, reduced as provided for in this Act, does not exceed specified levels; and (9) individuals eligible for assistance under titles I (Old-Age and Medical Assistance), X (Aid to the Blind), XIV (Aid to the Permanently and Totally Disabled), IV (part A, Aid to Families with Dependent Children), or XVI (Supplemental Security Income) of the Act and who are residents of States which, if eligible, participate in Medicaid.

Provides that an individual required to make Healthcare premium payments shall cease to be entitled to Healthcare benefits if the individual: (1) files notice that he or she no longer wishes to participate in Healthcare; or (2) fails to make a required payment.

Provides that the Secretary shall make payments for items and services furnished to individuals covered by the National Health Plan. Prohibits payments for: (1) more than 100 days of inpatient skilled nursing items and services annually; (2) more than 30 days annually of inpatient hospital items and services for a mental or nervous condition, alcoholism, or drug abuse; (3) more than $1,000 annually for outpatient items and services related to a mental or nervous condition, alcoholism, or drug abuse; and (4) more than 200 home health visits annually.

Sets the monthly premium for individuals age 65 and older, disabled individuals, railroad retirement beneficiaries, and certain other individuals at $8.70, to be indexed from 1980 to the cost of health care. Limits premiums, coinsurance, and deductibles for this group, after 1983, to $1,250 indexed from 1980 to take into account the increase in per capita expenses for health. Provides that individuals eligible for Healthcare because of low-income shall not be subject to any premium, coinsurance, or deductible. Provides that the premium for any citizen or alien admitted for permanent residence seeking coverage under the Plan and who is not otherwise covered through an employer plan or Healthcare shall be set by the Secretary using a community rating system. Limits out of pocket expenses for this group to $2,500. Provides that the premium paid by an employer with more than nine employees shall be five percent of the payroll for employees covered by an agreement under this Act.

Provides that premiums for individuals receiving payments under title II of the Act or the Railroad Retirement Act shall be deducted from such payments.

Establishes the Healthcare Trust Fund. Appropriates to the Fund employer, employee, and self-employment Hospital Insurance taxes collected pursuant to the Internal Revenue Code. Establishes the Board of Trustees of the Trust Fund to be composed of the Secretary of the Treasury, the Secretary of Labor, and the Secretary of Health, Education, and Welfare, all ex officio. Directs the Board of Trustees to: (1) hold the Trust Fund; (2) report to Congress concerning the status of the Trust Fund; and (3) review the general policies followed in managing the Trust Fund, and recommend changes in such policies.

Requires each State with an approved Medicaid plan to participate in the costs of services provided for by this Act. Directs each State to pay, for fiscal years 1983 and 1984, an amount equal to 90 percent of its Medicaid payments to the Healthcare Trust Fund, and as according to a specified formula for each succeeding year.

Prohibits Federal funding to a State for programs under titles V (Maternal and Child Health) and XX (Grants to States for Services) of the Act or for any program for delivery of health care services under the Public Health Service Act if such State is eligible to participate in Medicaid but does not participate.

Directs the Secretary to pay for inpatient hospital items and services and for the services of a hospital based physician on the basis of reasonable cost; inpatient skilled nursing items and services and for home health items and services on the basis of reasonable cost or on the basis of prospectively set rates, outpatient services on the basis of a prospectively set, all-inclusive rate per visit, physician's services on the basis of a fee schedule, and for all other covered items and services on such basis as the Secretary of Health, Education, and Welfare finds reasonable.

Authorizes the Secretary to enter into contracts with public and private entities to provide for the administration of benefits under this Act with maximum efficiency and convenience.

Directs the Secretary to determine annually a per capita rate of payment for each class of individuals entitled to benefits under this Act and who are enrolled pursuant to this Act with an HMO. Directs the Secretary to define classes of members based on such factors as age, sex, institutional status, disability status and place of residence, and cost sharing requirements. Provides a rate for each class equal to 95 percent of the adjusted average per capita cost for that class. Defines the term "adjusted average per capita cost" to mean the average per capita amount that the Secretary estimates would be payable for services furnished under the program established by this Act, if the services were to be furnished by other than an HMO.

Provides that every individual entitled to benefits under this Act shall be eligible to enroll with an HMO with which the Secretary has contracted to provide services.

Sets limits on an HMO's premium rate and the actuarial value of its other charges for individuals enrolled under this Act.

Authorizes the Secretary to contract with any HMO that can provide the benefits required by this Act.

Permits a provider to obtain a hearing with respect to a claim for payment with a Provider Reimbursement Review Board which the Secretary shall establish if: (1) the reimbursement offered a provider is not satisfactory or a timely determination is not made as to the amount of reimbursement due; (2) the amount in controversy is $10,000 or more; and (3) the provider requests a hearing within 180 days after a reimbursement determination has been made.

Directs the Secretary to establish procedures to assure that: (1) all individuals have an opportunity to apply for the benefits provided by this Act; (2) determinations of eligibility are made promptly; and (3) individuals determined ineligible for benefits or certain items and services are granted a fair hearing concerning such determination. Requires a provider to be certified by the Secretary in order to participate in the programs established by this Act. Sets forth general requirements for certification as a provider of items and services covered under this Act. Sets forth further requirements which must be met to be certified as a provider of the following specific items and services: (1) inpatient hospital items and services; (2) inpatient hospital items and services furnished to an individual with a mental or nervous condition, alcoholism, or drug abuse; (3) inpatient skilled nursing items and services; and (4) home health items and services. Requires every provider to have in effect a specified agreement with the Secretary pertaining to payment for items and services, filing information and reports with the Secretary, non-discrimination, certification requirements, and termination of the agreement. Authorizes the Secretary to revoke the certification of a provider which no longer meets the requirements of this Act, or to impose other sanctions as appropriate.

Authorizes the Secretary to define various kinds of health care practitioners other than physicians and to certify an individual as a qualified health care practitioner of a certain kind.

Sets forth the definitions of terms used in this Act.

Provides for penalties of up to $25,000, or imprisonment for up to five years, or both for any individual seeking to obtain benefits or payments under this Act by fraud or abuse.

Authorizes the Secretary to prescribe regulations to carry out this Act.

Directs the Secretary to conduct studies on and to report to Congress concerning: (1) the health care of the American people including studies of the adequacy of existing personnel and facilities for health care, efficient and economic alternatives to inpatient hospital care, and the various effects of deductions and coinsurance; and (2) the operation and administration of the insurance programs established under this Act.

Makes conforming amendments to the Medicaid program including redefining "medical assistance" and eligibility requirements. Repeals provisions of title XIX under which certain SSI recipients are not required to be covered under a State's Medicaid plan.

Amends the Internal Revenue Code to permit a deduction for medical expenses for those medical expenses which exceed ten percent of adjusted gross income. Increases the earned income tax credit.

Includes as members of the National Professional Standards Review Council one dentist, one registered nurse, one health care practitioner not a physician, one individual representative of insurance companies operated for profit, one individual of representative of nonprofit insurance companies, one individual representative of employers self-funded with respect to the provision of employee health benefits, and one individual representative of health maintenance organizations.

Amends title XIII (Health Maintenance Organizations) of the Public Health Service Act to require employers to offer membership in an HMO serving an area in which at least 25 of the employer's employees reside.

Authorizes the Secretary to waive compliance with the requirements of titles X, XVIII, and XIX of the Act to the extent necessary to conduct specified experiments or demonstration projects.

Provides for the transfer of funds in the Medicare trust funds to the Healthcare Trust Fund.

Title II: Health System Reform - Amends title XV (National Health Planning and Development) of the Public Health Service Act to direct the Secretary to annually set a national limit for certificates and reports of need to be issued for major increases in hospital capital stock. Sets the limit at $3,000,000,000 to be increased to reflect a rise in construction prices and adjusted further to reflect population changes. Defines a "major increase in hospital capital stock" as the establishment of a new hospital or an acquisition or improvement by an existing hospital that exceeds $150,000 in value, would increase the number of short term non-federal hospital beds, or would substantially change institutional health services offered.

Stipulates that a certificate of need authorizing new short term non-federal hospital beds in a health service area where the number of such beds per 1,000 persons in the area exceeds the bed limit for that area may only be issued if two existing beds would be eliminated for each new bed established.

Requires a certificate of need authorizing a major increase in hospital capital stock to specify the maximum dollar amount authorized. Prohibits the total value of such certificates issued in a State from exceeding the State's total allocation from the national limit, with certain adjustments. Permits exceptions to meet an emergency situation or if needed to assist in serving individuals from other States.

Amends part A of title XI (General Provisions) of the Social Security Act to increase by a factor of ten the reduction in Federal payments under titles V, XVIII, and XIX of the Act for an increase in health care facility capital stock or a change in health care facility bed function made without an appropriate certificate of need.

Directs the Secretary to allocate to each State a maximum dollar amount for: (1) all major increases in hospital stock in the State; (2) increases that will not result in an increase in the number of short term non-federal hospital beds; and (3) for other increases.