,i #aacth ,,congress #ast ,session ,h4 ,r4 #abjj ,,in ,,the ,,house ,,of ,,representatives ,march #ad1 #bjac ,mr4 ,mc,dermott introduced the following bill2 which was referred to the ,committee on ,energy and ,commerce1 and in addition to the ,committees on ,ways and ,means1 ,oversight and ,government ,reform1 ,armed ,services1 and ,education and the ,workforce1 for a period to be subsequently determined by the ,speaker1 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 system4 #a4 ,short title ,this ,act may be cited as the ,american ,health ,security ,act of #bjac4 #b4 ,sense of the ,house of ,representatives concerning the status of health care ,it is the sense of the ,house of ,representatives that the #aacth ,congress should recognize and proclaim that health care is a human right4 #c4 ,table of contents ,the table of contents of this ,act is as follows3 ,sec4 #a4 ,short title4 ,sec4 #b4 ,sense of the ,house of ,representatives concerning the status of health care4 ,sec4 #c4 ,table of contents4 ,title ,i--,establishment of a ,state-,based ,american ,health ,security ,program2 ,universal ,entitlement2 ,enrollment ,sec4 #aja4 ,establishment of a ,state-,based ,american ,health ,security ,program4 ,sec4 #ajb4 ,universal entitlement4 ,sec4 #ajc4 ,enrollment4 ,sec4 #ajd4 ,portability of benefits4 ,sec4 #aje4 ,effective date of benefits4 ,sec4 #ajf4 ,relationship to existing ,federal health programs4 ,title ,,ii--,comprehensive ,benefits1 ,including ,preventive ,benefits and ,benefits for ,long-,term ,care ,sec4 #bja4 ,comprehensive benefits4 ,sec4 #bjb4 ,definitions relating to services4 ,sec4 #bjc4 ,special rules for home and community-based long-term care services4 ,sec4 #bjd4 ,exclusions and limitations4 ,sec4 #bje4 ,certification2 quality review2 plans of care4 ,title ,,iii--,provider ,participation ,sec4 #cja4 ,provider participation and standards4 ,sec4 #cjb4 ,qualifications for providers4 ,sec4 #cjc4 ,qualifications for comprehensive health service organizations4 ,sec4 #cjd4 ,limitation on certain physician referrals4 ,title ,,iv--,administration ,subtitle ,a--,general ,administrative ,provisions ,sec4 #dja4 ,american ,health ,security ,standards ,board4 ,sec4 #djb4 ,american ,health ,security ,advisory ,council4 ,sec4 #djc4 ,consultation with private entities4 ,sec4 #djd4 ,state health security programs4 ,sec4 #dje4 ,complementary conduct of related health programs4 ,subtitle ,b--,control over ,fraud and ,abuse ,sec4 #daa4 ,application of ,federal sanctions to all fraud and abuse under ,american ,health ,security ,program4 ,sec4 #dab4 ,requirements for operation of ,state health care fraud and abuse control units4 ,title ,v--,quality ,assessment ,sec4 #eja4 ,american ,health ,security ,quality ,council4 ,sec4 #ejb4 ,development of certain methodologies1 guidelines1 and standards4 ,sec4 #ejc4 ,state quality review programs4 ,sec4 #ejd4 ,elimination of utilization review programs2 transition4 ,title ,,vi--,health ,security ,budget2 ,payments2 ,cost ,containment ,measures ,subtitle ,a--,budgeting and ,payments to ,states ,sec4 #fja4 ,national health security budget4 ,sec4 #fjb4 ,computation of individual and ,state capitation amounts4 ,sec4 #fjc4 ,state health security budgets4 ,sec4 #fjd4 ,federal payments to ,states4 ,sec4 #fje4 ,account for health professional education expenditures4 ,subtitle ,b--,payments by ,states to ,providers ,sec4 #faa4 ,payments to hospitals and other facility-based services for operating expenses on the basis of approved global budgets4 ,sec4 #fab4 ,payments to health care practitioners based on prospective fee schedule4 ,sec4 #fac4 ,payments to comprehensive health service organizations4 ,sec4 #fad4 ,payments for community-,based primary health services4 ,sec4 #fae4 ,payments for prescription drugs4 ,sec4 #faf4 ,payments for approved devices and equipment4 ,sec4 #fag4 ,payments for other items and services4 ,sec4 #fah4 ,payment incentives for medically underserved areas4 ,sec4 #fai4 ,authority for alternative payment methodologies4 ,subtitle ,c--,mandatory assignment and administrative provisions ,sec4 #fca4 ,mandatory assignment4 ,sec4 #fcb4 ,procedures for reimbursement2 appeals4 ,title ,,vii--,promotion of ,primary ,health ,care2 ,development of ,health ,service ,capacity2 ,programs to ,assist the ,medically ,underserved ,subtitle ,a--,promotion and ,expansion of ,primary ,care ,professional ,training ,sec4 #gja4 ,role of ,board2 establishment of primary care professional output goals4 ,sec4 #gjb4 ,establishment of ,advisory ,committee on ,health ,professional ,education4 ,sec4 #gjc4 ,grants for health professions education1 nurse education1 and the ,national ,health ,service ,corps4 ,subtitle ,b--,direct ,health ,care ,delivery ,sec4 #gaa4 ,set-aside for public health4 ,sec4 #gab4 ,set-aside for primary health care delivery4 ,sec4 #gac4 ,primary care service expansion grants4 ,subtitle ,c--,primary ,care and ,outcomes ,research ,sec4 #gba4 ,set-aside for outcomes research4 ,sec4 #gbb4 ,office of ,primary ,care and ,prevention ,research4 ,subtitle ,d--,school-,related ,health ,services ,sec4 #gca4 ,authorizations of appropriations4 ,sec4 #gcb4 ,eligibility for development and operation grants4 ,sec4 #gcc4 ,preferences4 ,sec4 #gcd4 ,grants for development of projects4 ,sec4 #gce4 ,grants for operation of projects4 ,sec4 #gcf4 ,federal administrative costs4 ,sec4 #gcg4 ,definitions4 ,title ,,viii--,financing ,provisions2 ,american ,health ,security ,trust ,fund ,sec4 #hjj4 ,amendment of #aihf code2 ,section #ae not to apply4 ,subtitle ,a--,american ,health ,security ,trust ,fund ,sec4 #hja4 ,american ,health ,security ,trust ,fund4 ,subtitle ,b--,taxes ,based on ,income and ,wages ,sec4 #haa4 ,payroll tax on employers4 ,sec4 #hab4 ,health care income tax4 ,sec4 #hac4 ,surcharge on high income individuals4 ,subtitle ,c--,other financing provisions ,sec4 #hba4 ,tax on ,securities ,transactions4 ,title ,,ix--,conforming ,amendments to the ,employee ,retirement ,income ,security ,act of #aigd ,sec4 #ija4 ,,erisa inapplicable to health coverage arrangements under ,state health security programs4 ,sec4 #ijb4 ,exemption of ,state health security programs from ,,erisa preemption4 ,sec4 #ijc4 ,prohibition of employee benefits duplicative of benefits under ,state health security programs2 coordination in case of workers' compensation4 ,sec4 #ijd4 ,repeal of continuation coverage requirements under ,,erisa and certain other requirements relating to group health plans4 ,sec4 #ije4 ,effective date of title4 ,title ,x--,additional ,conforming ,amendments ,sec4 #ajja4 ,repeal of certain provisions in ,internal ,revenue ,code of #aihf4 ,sec4 #ajjb4 ,repeal of certain provisions in the ,employee ,retirement ,income ,security ,act of #aigd4 ,sec4 #ajjc4 ,repeal of certain provisions in the ,public ,health ,service ,act and related provisions4 ,sec4 #ajjd4 ,effective date of title4 ,i ,establishment of a ,state-,based ,american ,health ,security ,program2 ,universal ,entitlement2 ,enrollment #aja4 ,establishment of a ,state-,based ,american ,health ,security ,program 7a7 ,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 in1 or established under1 this ,act4 7b7 ,state health security programs ,in order for a ,state to be eligible to receive payment under section #fjd1 a ,state shall establish a ,state health security program in accordance with this ,act4 7c7 ,state defined 7#a7 ,in general ,in this ,act1 subject to paragraph 7#b71 the term ,state means each of the #ej ,states and the ,district of ,columbia4 7#b7 ,election ,if the ,governor of ,puerto ,rico1 the ,virgin ,islands1 ,guam1 ,american ,samoa1 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 ,act1 such ,commonwealth or territory shall be included as a ,state under this ,act beginning ,january #a of the first year beginning #ij days after the ,president receives the notification4 #ajb4 ,universal entitlement 7a7 ,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 7as defined in subsection 7d77 is entitled to benefits for health care services under this ,act under the appropriate ,state health security program4 ,in this section1 the term appropriate ,state health security program means1 with respect to an individual1 the ,state health security program for the ,state in which the individual maintains a primary residence4 7b7 ,treatment of certain nonimmigrants 7#a7 ,in general ,the ,american ,health ,security ,standards ,board 7in this ,act referred to as the ,board7 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 provide4 7#b7 ,consideration ,in providing for eligibility under paragraph 7#a71 the ,board shall consider reciprocity in health care services offered to ,united ,states citizens who are nonimmigrants in other foreign states1 and such other factors as the ,board determines to be appropriate4 7c7 ,treatment of other individuals 7#a7 ,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 7a7 or 7b71 and regulate the nature of the eligibility of such individuals1 in order-- 7,a7 to preserve the public health of communities2 7,b7 to compensate ,states for the additional health care financing burdens created by such individuals2 and 7,c7 to prevent adverse financial and medical consequences of uncompensated care1 while inhibiting travel and immigration to the ,united ,states for the sole purpose of obtaining health care services4 7#b7 ,by ,states ,any ,state health security program may make individuals described in paragraph 7#a7 eligible for benefits at the expense of the ,state4 7d7 ,lawful resident alien defined ,for purposes of this section1 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 law1 including an alien with lawful temporary resident status under section #baj1 #baj;,a1 or #bcd;,a of the ,immigration and ,nationality ,act 7#h ,u4,s4,c4 #aafj1 #aafa1 or #abee;a74 #ajc4 ,enrollment 7a7 ,in general ,each ,state health security program shall provide a mechanism for the enrollment of individuals entitled or eligible for benefits under this ,act4 ,the mechanism shall-- 7#a7 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 ,states2 7#b7 provide for the enrollment1 as of ,january #a1 #bjae1 of all individuals who are eligible to be enrolled as of such date2 and 7#c7 include a process for the enrollment of individuals made eligible for health care services under subsections 7b7 and 7c7 of section #ajb4 7b7 ,availability of applications ,each ,state health security program shall make applications for enrollment under the program available-- 7#a7 at employment and payroll offices of employers located in the ,state2 7#b7 at local offices of the ,social ,security ,administration2 7#c7 at social services locations2 7#d7 at out-reach sites 7such as provider and practitioner locations72 and 7#e7 at other locations 7including post offices and schools7 accessible to a broad cross-section of individuals eligible to enroll4 7c7 ,issuance of health security cards ,in conjunction with an individual's enrollment for benefits under this ,act1 the ,state health security program shall provide for the issuance of a health security card 7to be referred to as a smart card7 that shall be used for purposes of identification and processing of claims for benefits under the program4 ,the ,state health security program may provide for issuance of such cards by employers for purposes of carrying out enrollment pursuant to subsection 7a77#b74 #ajd4 ,portability of benefits 7a7 ,in general ,to ensure continuous access to benefits for health care services covered under this ,act1 each ,state health security program-- 7#a7 shall not impose any minimum period of residence in the ,state1 or waiting period1 in excess of #c months before residents of the ,state are entitled to1 or eligible for1 such benefits under the program2 7#b7 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 ,state1 for the duration of any waiting period imposed in the ,state of new residency for establishing entitlement to1 or eligibility for1 such services2 and 7#c7 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 principles3 7,a7 ,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 provided1 unless the ,states concerned agree to apportion the cost between them in a different manner4 7,b7 ,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 ,state1 with due regard1 in the case of hospital services1 to the size of the hospital1 standards of service1 and other relevant factors4 7b7 ,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 region4 #aje4 ,effective date of benefits ,benefits shall first be available under this ,act for items and services furnished on or after ,january #a1 #bjae4 #ajf4 ,relationship to existing ,federal health programs 7a7 ,medicare1 medicaid and ,state children's health insurance program 7,,schip7 7#a7 ,in general ,notwithstanding any other provision of law1 subject to paragraph 7#b7-- 7,a7 no benefits shall be available under title ,,xviii of the ,social ,security ,act for any item or service furnished after ,december #ca1 #bjad2 7,b7 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 date2 7,c7 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 date2 and 7,d7 no payment shall be made to a ,state under section #aijc7;a7 or #baje7;a7 of such ,act with respect to medical assistance or child health assistance for any item or service furnished after such date4 7#b7 ,transition ,in the case of inpatient hospital services and extended care services during a continuous period of stay which began before ,january #a1 #bjae1 and which had not ended as of such date1 for which benefits are provided under title ,,xviii1 under a ,state plan under title ,,xix1 or a ,state child health plan under title ,,xxi1 of the ,social ,security ,act1 the ,secretary of ,health and ,human ,services and each ,state plan1 respectively1 shall provide for continuation of benefits under such title or plan until the end of the period of stay4 7b7 ,federal employees health benefits program ,no benefits shall be made available under chapter #hi of title #e1 ,united ,states ,code1 for any part of a coverage period occurring after ,december #ca1 #bjad4 7c7 ,,tricare ,no benefits shall be made available under sections #ajgi and #ajhf of title #aj1 ,united ,states ,code1 for items or services furnished after ,december #ca1 #bjad4 7d7 ,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 #ch1 ,united ,states ,code1 or of ,indians for the medical benefits and services provided by or through the ,indian ,health ,service4 7e7 ,treatment of premium credits1 cost-,sharing reductions1 and small employer credits 7#a7 ,in general ,for each calendar year1 the ,secretary of the ,treasury shall transfer to the ,american ,health ,security ,trust ,fund an amount equal to the sum of-- 7,a7 the premium assistance credit amount which would have been allowable to taxpayers residing in such ,state in such calendar year under section #cf;,b of the ,internal ,revenue ,code of #aihf 7relating to refundable credit for coverage under a qualified health plan71 as added by section #adja of the ,patient ,protection and ,affordable ,care ,act1 if such section were in effect for such year1 7,b7 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 #adjb of the ,patient ,protection and ,affordable ,care ,act if such section were in effect for such year1 plus 7,c7 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 #de,r of the ,internal ,revenue ,code of #aihf if such section were in effect for such calendar year4 7#b7 ,determination ,the amounts determined under paragraph 7#a7 shall be estimated by the ,secretary of the ,treasury in consultation with the ,secretary of ,health and ,human ,services4 ,,ii ,comprehensive ,benefits1 ,including ,preventive ,benefits and ,benefits for ,long-,term ,care #bja4 ,comprehensive benefits 7a7 ,in general ,subject to the succeeding provisions of this title1 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 diagnosis1 treatment1 or rehabilitation of a health condition3 7#a7 ,hospital services ,inpatient and outpatient hospital care1 including #bd-;hour-a-day emergency services4 7#b7 ,professional services ,professional services of health care practitioners authorized to provide health care services under ,state law1 including patient education and training in self-management techniques4 7#c7 ,community-based primary health services ,community-based primary health services 7as defined in section #bjb7;a774 7#d7 ,preventive services ,preventive services 7as defined in section #bjb7;b774 7#e7 ,long-term1 acute1 and chronic care services 7,a7 ,nursing facility services4 7,b7 ,home health services4 7,c7 ,home and community-based long-term care services 7as defined in section #bjb7;c77 for individuals described in section #bjc7;a74 7,d7 ,hospice care4 7,e7 ,services in intermediate care facilities for individuals with an intellectual disability4 7#f7 ,prescription drugs1 biologicals1 insulin1 medical foods 7,a7 ,outpatient prescription drugs and biologics1 as specified by the ,board consistent with section #fae4 7,b7 ,insulin4 7,c7 ,medical foods 7as defined in section #bjb7;e774 7#g7 ,dental services ,dental services 7as defined in section #bjb7;h774 7#h7 ,mental health and substance abuse treatment services ,mental health and substance abuse treatment services 7as defined in section #bjb7;f774 7#i7 ,diagnostic tests ,diagnostic tests4 7#aj7 ,other items and services 7,a7 ,outpatient therapy ,outpatient physical therapy services1 outpatient speech pathology services1 and outpatient occupational therapy services in all settings4 7,b7 ,durable medical equipment ,durable medical equipment4 7,c7 ,home dialysis ,home dialysis supplies and equipment4 7,d7 ,ambulance ,emergency ambulance service4 7,e7 ,prosthetic devices ,prosthetic devices1 including replacements of such devices4 7,f7 ,additional items and services ,such other medical or health care items or services as the ,board may specify4 7b7 ,prohibition of balance billing ,as provided in section #eca1 no person may impose a charge for covered services for which benefits are provided under this ,act4 7c7 ,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 program4 7d7 ,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 ,state4 7e7 ,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 dependents1 or to former employees or their dependents4 7f7 ,taft-,hartley and ,,mew benefit plans ,notwithstanding any other provision of law1 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 dependents4 #bjb4 ,definitions relating to services 7a7 ,community-,based primary health services ,in this title1 the term community-based primary health services means ambulatory health services furnished-- 7#a7 by a rural health clinic2 7#b7 by a federally qualified health center 7as defined in section #aije7l77#b77;,b7 of the ,social ,security ,act71 and which1 for purposes of this ,act1 include services furnished by ,state and local health agencies2 7#c7 in a school-based setting2 7#d7 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 ,act2 and 7#e7 public and private nonprofit entities receiving ,federal assistance under the ,public ,health ,service ,act4 7b7 ,preventive services 7#a7 ,in general ,in this title1 the term preventive services means items and services-- 7,a7 which-- 7i7 are specified in paragraph 7#b72 or 7ii7 the ,board determines to be effective in the maintenance and promotion of health or minimizing the effect of illness1 disease1 or medical condition2 and 7,b7 which are provided consistent with the periodicity schedule established under paragraph 7#c74 7#b7 ,specified preventive services ,the services specified in this paragraph are as follows3 7,a7 ,immunizations recommended by the ,advisory ,committee on ,immunization ,practices of the ,centers for ,disease ,control and ,prevention4 7,b7 ,prenatal and well-baby care 7for infants under #a year of age74 7,c7 ,well-child care 7including periodic physical examinations1 hearing and vision screening1 and developmental screening and examinations7 for individuals under #ah years of age1 including evidence-informed preventive care and screenings included in the comprehensive guidelines of the ,health ,resources and ,services ,administration4 7,d7 ,periodic screening mammography1 ,pap smears1 and colorectal examinations and examinations for prostate cancer4 7,e7 ,physical examinations4 7,f7 ,family planning services4 7,g7 ,routine eye examinations1 eyeglasses1 and contact lenses4 7,h7 ,hearing aids1 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 aid4 7,i7 ,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 ,force4 7,j7 ,with respect to women1 such additional preventive care and screenings not described in subparagraph 7,i7 that are included in the comprehensive guidelines of the ,health ,resources and ,services ,administration4 7#c7 ,schedule ,the ,board shall establish1 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 ,services1 a periodicity schedule for the coverage of preventive services under paragraph 7#a74 ,such schedule shall take into consideration the cost-effectiveness of appropriate preventive care and shall be revised not less frequently than once every #e years1 in consultation with experts in preventive medicine and public health4 7c7 ,home and community-,based long-,term care services ,in this title1 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 community3 7#a7 ,home health aide services4 7#b7 ,adult day health care1 social day care or psychiatric day care4 7#c7 ,medical social work services4 7#d7 ,care coordination services1 as defined in subsection 7g77#a74 7#e7 ,respite care1 including training for informal caregivers4 7#f7 ,personal assistance services1 and homemaker services 7including meals7 incidental to the provision of personal assistance services4 7d7 ,home health services 7#a7 ,in general ,the term home health services means items and services described in section #ahfa7m7 of the ,social ,security ,act and includes home infusion services4 7#b7 ,home infusion services ,the term home infusion services includes the nursing1 pharmacy1 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 ,secretary4 7e7 ,medical foods ,in this title1 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 requirements1 based on recognized scientific principles1 are established by medical evaluation4 7f7 ,mental health and substance abuse treatment services 7#a7 ,services described ,in this title1 the term mental health and substance abuse treatment services means the following services related to the prevention1 diagnosis1 treatment1 and rehabilitation of mental illness and promotion of mental health3 7,a7 ,inpatient hospital services ,inpatient hospital services furnished primarily for the diagnosis or treatment of mental illness or substance abuse for up to #fj days during a year1 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 7,b7 during the year after such services have been furnished to the individual for #abj days during the year 7rounded to the nearest day71 but only if 7with respect to services furnished to an individual described in section #bjd7;b77#a77 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 #bjd7;b77#b74 7,b7 ,intensive residential services ,intensive residential services 7as defined in paragraph 7#b77 furnished to an individual for up to #abj days during any calendar year1 except that-- 7i7 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 7,a7 that may be furnished to the individual during the year 7as reduced under such subparagraph7 is not less than #ae2 and 7ii7 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 7,d7 during the year after such services have been furnished to the individual for #ij days 7or1 in the case of services described in subparagraph 7,d77ii71 for #ahj days7 during the year 7rounded to the nearest day74 7,c7 ,outpatient services ,outpatient treatment services of mental illness or substance abuse 7other than intensive community-based services under subparagraph 7,d77 for an unlimited number of days during any calendar year furnished in accordance with standards established by the ,secretary for the management of such services1 and1 in the case of services furnished to an individual described in section #bjd7;b77#a7 who is not an inpatient of a hospital1 in conformity with the plan of an organized system of care for mental health and substance abuse services in accordance with section #bjd7;b77#b74 7,d7 ,intensive community-based services ,intensive community-based services 7as described in paragraph 7#c77-- 7i7 for an unlimited number of days during any calendar year1 in the case of services described in section #ahfa7;ff77#b77;,e7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciex7ff77#b77;,e77 that are furnished to an individual who is a seriously mentally ill adult1 a seriously emotionally disturbed child1 or an adult or child with serious substance abuse disorder 7as determined in accordance with criteria established by the ,secretary72 7ii7 in the case of services described in section #ahfa7;ff77#b77;,c7 of the ,social ,security ,act 7#db ,u4,s4,c4 #aciex7ff77#b77;,c771 for up to #ahj days during any calendar year1 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 7as determined under subparagraph 7,b77 and the number of days of such services which the individual has received during the year2 or 7iii7 in the case of any other such services1 for up to #ij days during any calendar year1 except that such services may be furnished to the individual for the number of additional days during the year described in clause 7ii74 7#b7 ,intensive residential services defined 7,a7 ,in general ,subject to subparagraphs 7,b7 and 7,c71 the term intensive residential services means inpatient services provided in any of the following facilities3 7i7 ,residential detoxification centers4 7ii7 ,crisis residential programs or mental illness residential treatment programs4 7iii7 ,therapeutic family or group treatment homes4 7iv7 ,residential centers for substance abuse treatment4 7,b7 ,requirements for facilities ,no service may be treated as an intensive residential service under subparagraph 7,a7 unless the facility at which the service is provided-- 7i7 is legally authorized to provide such service under the law of the ,state 7or under a ,state regulatory mechanism provided by ,state law7 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 ,secretary2 and 7ii7 meets such other requirements as the ,secretary may impose to ensure the quality of the intensive residential services provided4 7,c7 ,services furnished to at-risk children ,in the case of services furnished to an individual described in section #bjd7;b77#a71 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 #bjd7;b77#b74 7,d7 ,management standards ,no service may be treated as an intensive residential service under subparagraph 7,a7 unless the service is furnished in accordance with standards established by the ,secretary for the management of such services4 7#c7 ,intensive community-based services defined 7,a7 ,in general ,the term intensive community-based services means the items and services described in subparagraph 7,b7 prescribed by a physician 7or1 in the case of services furnished to an individual described in section #bjd7;b77#a71 by an organized system of care for mental health and substance abuse services in accordance with such section7 and provided under a program described in subparagraph 7,d7 under the supervision of a physician 7or1 to the extent permitted under the law of the ,state in which the services are furnished1 a non-physician mental health professional7 pursuant to an individualized1 written plan of treatment established and periodically reviewed by a physician 7in consultation with appropriate staff participating in such program7 which sets forth the physician's diagnosis1 the type1 amount1 frequency1 and duration of the items and services provided under the plan1 and the goals for treatment under the plan1 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 services4 7,b7 ,items and services described ,the items and services described in this subparagraph are-- 7i7 partial hospitalization services consisting of the items and services described in subparagraph 7,c72 7ii7 psychiatric rehabilitation services2 7iii7 day treatment services for individuals under #ai years of age2 7iv7 in-home services2 7v7 case management services1 including collateral services designated as such case management services by the ,secretary2 7vi7 ambulatory detoxification services2 and 7vii7 such other items and services as the ,secretary may provide 7but in no event to include meals and transportation71 that are reasonable and necessary for the diagnosis or active treatment of the individual's condition1 reasonably expected to improve or maintain the individual's condition and functional level and to prevent relapse or hospitalization1 and furnished pursuant to such guidelines relating to frequency and duration of services as the ,secretary shall by regulation establish 7taking into account accepted norms of medical practice and the reasonable expectation of patient improvement74 7,c7 ,items and services included as partial hospitalization services ,for purposes of subparagraph 7,b77i71 partial hospitalization services consist of the following3 7i7 ,individual and group therapy with physicians or psychologists 7or other mental health professionals to the extent authorized under ,state law74 7ii7 ,occupational therapy requiring the skills of a qualified occupational therapist4 7iii7 ,services of social workers1 trained psychiatric nurses1 behavioral aides1 and other staff trained to work with psychiatric patients 7to the extent authorized under ,state law74 7iv7 ,drugs and biologicals furnished for therapeutic purposes 7which cannot1 as determined in accordance with regulations1 be self-administered74 7v7 ,individualized activity therapies that are not primarily recreational or diversionary4 7vi7 ,family counseling 7the primary purpose of which is treatment of the individual's condition74 7vii7 ,patient training and education 7to the extent that training and educational activities are closely and clearly related to the individual's care and treatment74 7viii7 ,diagnostic services4 7,d7 ,programs described ,a program described in this subparagraph is a program 7whether facility-based or freestanding7 which is furnished by an entity-- 7i7 legally authorized to furnish such a program under ,state law 7or the ,state regulatory mechanism provided by ,state law7 or certified to furnish such a program by an appropriate accreditation entity approved by the ,state in consultation with the ,secretary2 and 7ii7 meeting such other requirements as the ,secretary may impose to ensure the quality of the intensive community-based services provided4 7g7 ,care coordination services 7#a7 ,in general ,in this title1 the term care coordination services means services provided by care coordinators 7as defined in paragraph 7#b77 to individuals described in paragraph 7#c7 for the coordination and monitoring of home and community-based long-term care services to ensure appropriate1 cost-effective utilization of such services in a comprehensive and continuous manner1 and includes-- 7,a7 transition management between inpatient facilities and community-based services1 including assisting patients in identifying and gaining access to appropriate ancillary services2 and 7,b7 evaluating and recommending appropriate treatment services1 in cooperation with patients and other providers and in conjunction with any quality review program or plan of care under section #bje4 7#b7 ,care coordinator 7,a7 ,in general ,in this title1 the term care coordinator means an individual or nonprofit or public agency or organization which the ,state health security program determines-- 7i7 is capable of performing directly1 efficiently1 and effectively the duties of a care coordinator described in paragraph 7#a72 and 7ii7 demonstrates capability in establishing and periodically reviewing and revising plans of care1 and in arranging for and monitoring the provision and quality of services under any plan4 7,b7 ,independence ,state health security programs shall establish safeguards to ensure that care coordinators have no financial interest in treatment decisions or placements4 ,care coordination may not be provided through any structure or mechanism through which quality review is performed4 7#c7 ,eligible individuals ,an individual described in this paragraph is an individual described in section #bjc 7relating to individuals qualifying for long-term and chronic care services74 7h7 ,dental services 7#a7 ,in general ,in this title1 subject to subsection 7b71 the term dental services means the following3 7,a7 ,emergency dental treatment1 including extractions1 for bleeding1 pain1 acute infections1 and injuries to the maxillofacial region4 7,b7 ,prevention and diagnosis of dental disease1 including examinations of the hard and soft tissues of the oral cavity and related structures1 radiographs1 dental sealants1 fluorides1 and dental prophylaxis4 7,c7 ,treatment of dental disease1 including non-cast fillings1 periodontal maintenance services1 and endodontic services4 7,d7 ,space maintenance procedures to prevent orthodontic complications4 7,e7 ,orthodontic treatment to prevent severe malocclusions4 7,f7 ,full dentures4 7,g7 ,medically necessary oral health care4 7,h7 ,any items and services for special needs patients that are not described in subparagraphs 7,a7 through 7,g7 and that-- 7i7 are required to provide such patients the items and services described in subparagraphs 7,a7 through 7,g72 7ii7 are required to establish oral function 7including general anesthesia for individuals with physical or emotional limitations that prevent the provision of dental care without such anesthesia72 7iii7 consist of orthodontic care for severe dentofacial abnormalities2 or 7iv7 consist of prosthetic dental devices for genetic or birth defects or fitting for such devices4 7,i7 ,any dental care for individuals with a seizure disorder that is not described in subparagraphs 7,a7 through 7,h7 and that is required because of an illness1 injury1 disorder1 or other health condition that results from such seizure disorder4 7#b7 ,limitations ,dental services are subject to the following limitations3 7,a7 ,prevention and diagnosis 7i7 ,examinations and prophylaxis ,the examinations and prophylaxis described in paragraph 7#a77;,b7 are covered only consistent with a periodicity schedule established by the ,board1 which schedule may provide for special treatment of individuals less than #ah years of age and of special needs patients4 7ii7 ,dental sealants ,the dental sealants described in such paragraph are not covered for individuals #ah years of age or older4 ,such sealants are covered for individuals less than #aj years of age for protection of the #ast permanent molars4 ,such sealants are covered for individuals #aj years of age or older for protection of the #b;d permanent molars4 7,b7 ,treatment of dental disease ,prior to ,january #a1 #bjbj1 the items and services described in paragraph 7#a77;,c7 are covered only for individuals less than #ah years of age and special needs patients4 ,on or after such date1 such items and services are covered for all individuals enrolled for benefits under this ,act1 except that endodontic services are not covered for individuals #ah years of age or older4 7,c7 ,space maintenance ,the items and services described in paragraph 7#a77;,d7 are covered only for individuals at least #c years of age1 but less than #ac years of age and-- 7i7 are limited to posterior teeth2 7ii7 involve maintenance of a space or spaces for permanent posterior teeth that would otherwise be prevented from normal eruption if the space were not maintained2 and 7iii7 do not include a space maintainer that is placed within #f months of the expected eruption of the permanent posterior tooth concerned4 7#c7 ,definitions ,for purposes of this title3 7,a7 ,medically necessary oral health care ,the term medically necessary oral health care means oral health care that is required as a direct result of1 or would have a direct impact on1 an underlying medical condition4 ,such term includes oral health care directed toward control or elimination of pain1 infection1 or reestablishment of oral function4 7,b7 ,special needs patient ,the term special needs patient includes an individual with a genetic or birth defect1 a developmental disability1 or an acquired medical disability4 7i7 ,nursing facility2 nursing facility services ,except as may be provided by the ,board1 the terms nursing facility and nursing facility services have the meanings given such terms in sections #aiai7;a7 and #aije7;f71 respectively1 of the ,social ,security ,act4 7j7 ,services in intermediate care facilities for individuals with an intellectual disability ,except as may be provided by the ,board-- 7#a7 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 #aije7;d7 of the ,social ,security ,act 7as in effect before the enactment of this ,act72 and 7#b7 the term services in intermediate care facilities for individuals with an intellectual disability means services described in section #aije7;a77#ae7 of such ,act 7as so in effect7 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 #aijb7;a77#ca77;,a7 of such ,act 7as so in effect74 7k7 ,other terms ,except as may be provided by the ,board1 the definitions contained in section #ahfa of the ,social ,security ,act shall apply4 #bjc4 ,special rules for home and community-based long-term care services 7a7 ,qualifying individuals ,for purposes of section #bja7;a77#e77;,c71 individuals described in this subsection are the following individuals3 7#a7 ,adults ,individuals #ah years of age or older determined 7in a manner specified by the ,board7-- 7,a7 to be unable to perform1 without the assistance of an individual1 at least #b of the following #e activities of daily living 7or who has a similar level of disability due to cognitive impairment7-- 7i7 bathing2 7ii7 eating2 7iii7 dressing2 7iv7 toileting2 and 7v7 transferring in and out of a bed or in and out of a chair2 7,b7 due to cognitive or mental impairments1 to require supervision because the individual behaves in a manner that poses health or safety hazards to himself or herself or others2 or 7,c7 due to cognitive or mental impairments1 to require queuing to perform activities of daily living4 7#b7 ,children ,individuals under #ah years of age determined 7in a manner specified by the ,board7 to meet such alternative standard of disability for children as the ,board develops4 ,such alternative standard shall be comparable to the standard for adults and appropriate for children4 7b7 ,limit on services 7#a7 ,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 7specified by the ,board7 may not exceed #fe percent 7or such alternative ratio as the ,board establishes under paragraph 7#b77 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 provided4 7#b7 ,alternative ratio ,the ,board may establish for purposes of paragraph 7#a7 an alternative ratio 7of payments for home and community-based long-term care services to payments for nursing facility services7 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 setting4 #bjd4 ,exclusions and limitations 7a7 ,in general ,subject to section #bja7;e71 benefits for service are not available under this ,act unless the services meet the standards specified in section #bja7;a74 7b7 ,special delivery requirements for mental health and substance abuse treatment services provided to ,at-,risk children 7#a7 ,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 care1 as described in paragraph 7#b71 if-- 7,a7 the services are provided to an individual less than #bb years of age2 7,b7 the individual has a serious emotional disturbance or a substance abuse disorder2 and 7,c7 the individual is1 or is at imminent risk of being1 subject to the authority of1 or in need of the services of1 at least #a public agency that serves the needs of children1 including an agency involved with child welfare1 special education1 juvenile justice1 or criminal justice4 7#b7 ,requirements for system of care ,in this subsection1 an organized system of care is a community-based service delivery network1 which may consist of public and private providers1 that meets the following requirements3 7,a7 ,the system has established linkages with existing mental health services and substance abuse treatment service delivery programs in the plan service area 7or 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 area74 7,b7 ,the system provides for the participation and coordination of multiple agencies and providers that serve the needs of children in the area1 including agencies and providers involved with child welfare1 education1 juvenile justice1 criminal justice1 health care1 mental health1 and substance abuse prevention and treatment4 7,c7 ,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 services4 7,d7 ,the system provides for the development and implementation of individualized treatment plans by multidisciplinary and multiagency teams1 which are recognized and followed by the applicable agencies and providers in the area4 7,e7 ,the system ensures the delivery and coordination of the range of mental health services and substance abuse treatment services required by individuals under #bb years of age who have a serious emotional disturbance or a substance abuse disorder4 7,f7 ,the system provides for the management of the individualized treatment plans described in subparagraph 7,d7 and for a flexible response to changes in treatment needs over time4 7c7 ,treatment of experimental services ,in applying subsection 7a71 the ,board shall make national coverage determinations with respect to those services that are experimental in nature4 ,such determinations shall be made consistent with a process that provides for input from representatives of health care professionals and patients and public comment4 7d7 ,application of practice guidelines ,in the case of services for which the ,american ,health ,security ,quality ,council 7established under section #eja7 has recognized a national practice guideline1 the services are considered to meet the standards specified in section #bja7;a7 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 ,v4 ,for purposes of this subsection1 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 guideline4 7e7 ,specific limitations 7#a7 ,limitations on eyeglasses1 contact lenses1 hearing aids1 and durable medical equipment ,subject to section #bja7;e71 the ,board may impose such limits relating to the costs and frequency of replacement of eyeglasses1 contact lenses1 hearing aids1 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 appropriate4 7#b7 ,overlap with preventive services ,the coverage of services described in section #bja7;a7 7other than paragraph 7#c77 which also are preventive services are required to be covered only to the extent that they are required to be covered as preventive services4 7#c7 ,miscellaneous exclusions from covered services ,covered services under this ,act do not include the following3 7,a7 ,surgery and other procedures 7such as orthodontia7 performed solely for cosmetic purposes 7as defined in regulations7 and hospital or other services incident thereto1 unless-- 7i7 required to correct a congenital anomaly2 7ii7 required to restore or correct a part of the body which has been altered as a result of accidental injury1 disease1 or surgery2 or 7iii7 otherwise determined to be medically necessary and appropriate under section #bja7;a74 7,b7 ,personal comfort items or private rooms in inpatient facilities1 unless determined to be medically necessary and appropriate under section #bja7;a74 7,c7 ,the services of a professional practitioner if they are furnished in a hospital or other facility which is not a participating provider4 7f7 ,nursing facility services and home health services ,nursing facility services and home health services 7other than post-hospital services1 as defined by the ,board7 furnished to an individual who is not described in section #bjc7;a7 are not covered services unless the services are determined to meet the standards specified in section #bja7;a7 and1 with respect to nursing facility services1 to be provided in the least restrictive and most appropriate setting4 #bje4 ,certification2 quality review2 plans of care 7a7 ,certifications ,state health security programs may require1 as a condition of payment for institutional health care services and other services of the type described in such sections #ahad7;a7 and #ahce7;a7 of the ,social ,security ,act1 periodic professional certifications of the kind described in such sections4 7b7 ,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 ,v1 see section #djd7;b77#a77;,h74 7c7 ,plan of care requirements ,a ,state health security program may require1 consistent with standards established by the ,board1 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 professionals4 ,such a plan may include1 consistent with subsection 7b71 case management at specified intervals as a further condition of payment for services4 ,,iii ,provider ,participation #cja4 ,provider participation and standards 7a7 ,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-- 7#a7 is a qualified provider of the services under section #cjb2 7#b7 has filed with the ,state health security program a participation agreement described in subsection 7b72 and 7#c7 meets such other qualifications and conditions as are established by the ,board or the ,state health security program under this ,act4 7b7 ,requirements in participation agreement 7#a7 ,in general ,a participation agreement described in this subsection between a ,state health security program and a provider shall provide at least for the following3 7,a7 ,services to eligible persons will be furnished by the provider without discrimination on the ground of race1 national origin1 income1 religion1 age1 sex or sexual orientation1 disability1 handicapping condition1 or 7subject to the professional qualifications of the provider7 illness4 ,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 practice4 7,b7 ,no charge will be made for any covered services other than for payment authorized by this ,act4 7,c7 ,the provider agrees to furnish such information as may be reasonably required by the ,board or a ,state health security program1 in accordance with uniform reporting standards established under section #dja7;g77#a71 for-- 7i7 quality review by designated entities2 7ii7 the making of payments under this ,act 7including the examination of records as may be necessary for the verification of information on which payments are based72 7iii7 statistical or other studies required for the implementation of this ,act2 and 7iv7 such other purposes as the ,board or ,state may specify4 7,d7 ,the provider agrees not to bill the program for any services for which benefits are not available because of section #bjd7;d74 7,e7 ,in the case of a provider that is not an individual1 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 cause4 7,f7 ,in the case of a provider paid under a fee-for-service basis under section #fab1 the provider agrees to submit bills and any required supporting documentation relating to the provision of covered services within #cj days 7or such shorter period as a ,state health security program may require7 after the date of providing such services4 7#b7 ,termination of participation agreements 7,a7 ,in general ,participation agreements may be terminated1 with appropriate notice-- 7i7 by the ,board or a ,state health security program for failure to meet the requirements of this title2 or 7ii7 by a provider4 7,b7 ,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 reasons4 #cjb4 ,qualifications for providers 7a7 ,in general ,a health care provider is considered to be qualified to provide covered services if the provider is licensed or certified and meets-- 7#a7 all the requirements of ,state law to provide such services2 7#b7 applicable requirements of ,federal law to provide such services2 and 7#c7 any applicable standards established under subsection 7b74 7b7 ,minimum provider standards 7#a7 ,in general ,the ,board shall establish1 evaluate1 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 services4 ,a ,state health security program may also establish additional minimum standards which providers shall meet4 7#b7 ,national minimum standards ,the national minimum standards under paragraph 7#a7 shall be established for institutional providers of services1 individual health care practitioners1 and comprehensive health service organizations4 ,except as the ,board may specify in order to carry out this title1 a hospital1 nursing facility1 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 7#db ,u4,s4,c4 #acie et seq474 ,such standards also may include1 where appropriate1 elements relating to-- 7,a7 adequacy and quality of facilities2 7,b7 training and competence of personnel 7including continuing education requirements72 7,c7 comprehensiveness of service2 7,d7 continuity of service2 7,e7 patient satisfaction 7including waiting time and access to services72 and 7,f7 performance standards 7including organization1 facilities1 structure of services1 efficiency of operation1 and outcome in palliation1 improvement of health1 stabilization1 cure1 or rehabilitation74 7#c7 ,transition in application ,if the ,board provides for additional requirements for providers under this subsection1 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 requirement4 7#d7 ,exchange of information ,the ,board shall provide for an exchange1 at least annually1 among ,state health security programs of information with respect to quality assurance and cost containment4 #cjc4 ,qualifications for comprehensive health service organizations 7a7 ,in general ,for purposes of this ,act1 a comprehensive health service organization 7in this section referred to as a ,,chso7 is a public or private organization which1 in return for a capitated payment amount1 undertakes to furnish1 arrange for the provision of1 or provide payment with respect to-- 7#a7 a full range of health services 7as identified by the ,board71 including at least hospital services and physicians services2 and 7#b7 out-of-area coverage in the case of urgently needed services2 to an identified population which is living in or near a specified service area and which enrolls voluntarily in the organization4 7b7 ,enrollment 7#a7 ,in general ,all eligible persons living in or near the specified service area of a ,,chso are eligible to enroll in the organization2 except that the number of enrollees may be limited to avoid overtaxing the resources of the organization4 7#b7 ,minimum enrollment period ,subject to paragraph 7#c71 the minimum period of enrollment with a ,,chso shall be #a year1 unless the enrolled individual becomes ineligible to enroll with the organization4 7#c7 ,withdrawal for cause ,each ,,chso shall permit an enrolled individual to disenroll from the organization for cause at any time4 7c7 ,requirements for ,c,h,s,os 7#a7 ,accessible services ,each ,,chso1 to the maximum extent feasible1 shall make all health services readily and promptly accessible to enrollees who live in the specified service area4 7#b7 ,continuity of care ,each ,,chso shall furnish services in such manner as to provide continuity of care and 7when services are furnished by different providers7 shall provide ready referral of patients to such services and at such times as may be medically appropriate4 7#c7 ,board of directors ,in the case of a ,,chso that is a private organization-- 7,a7 ,consumer representation ,at least one-third of the members of the ,,chso's board of directors shall be consumer members with no direct or indirect1 personal or family financial relationship to the organization4 7,b7 ,provider representation ,the ,,chso's board of directors shall include at least one member who represents health care providers4 7#d7 ,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 organization4 7#e7 ,medical standards ,each ,,chso shall provide that a committee or committees of health care practitioners associated with the organization will promulgate medical standards1 oversee the professional aspects of the delivery of care1 perform the functions of a pharmacy and drug therapeutics committee1 and monitor and review the quality of all health services 7including drugs1 education1 and preventive services74 7#f7 ,quality and other reporting requirements 7,a7 ,in general ,the ,board shall determine appropriate measures to assess the quality of care furnished by the ,,chso1 such as measures of-- 7i7 clinical processes and outcomes2 7ii7 patient and1 where practicable1 caregiver experience of care2 and 7iii7 utilization 7such as rates of hospital admissions for ambulatory care sensitive conditions74 7,b7 ,other duties ,the ,,chso shall-- 7i7 define processes to promote evidence-based medicine and patient engagement1 report on quality and cost measures1 and coordinate care1 such as through the use of telehealth1 remote patient monitoring1 and other such enabling technologies2 and 7ii7 demonstrate to the ,board that the ,,chso meets patient-centeredness criteria specified by the ,board1 such as the use of patient and caregiver assessments or the use of individualized care plans4 7,c7 ,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 ,,chso4 ,such data may include care transitions across health care settings1 including hospital discharge planning and post-hospital discharge follow-up by ,,chso professionals1 as the ,board determines appropriate4 7,d7 ,quality performance standards ,the ,board shall establish quality performance standards to assess the quality of care furnished by ,c,h,s,os and shall seek to improve the quality of care furnished by ,c,h,s,os over time by specifying higher standards1 new measures1 or both for purposes of assessing such quality of care4 7#g7 ,premiums ,premiums or other charges by a ,,chso for any services not paid for under this ,act shall be reasonable4 7#h7 ,utilization and bonus information ,each ,,chso shall-- 7,a7 comply with the requirements of section #ahgf7;i77#h7 of the ,social ,security ,act 7relating to prohibiting physician incentive plans that provide specific inducements to reduce or limit medically necessary services72 and 7,b7 make available to its membership utilization information and data regarding financial performance1 including bonus or incentive payment arrangements to practitioners4 7#i7 ,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 7as identified by the ,board7 for services provided to members of the organization in accordance with the global operating budget of the hospital or facility approved under section #faa4 7#aj7 ,broad marketing ,each ,,chso shall provide for the marketing of its services 7including dissemination of marketing materials7 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 specify4 7#aa7 ,additional requirements ,each ,,chso shall meet-- 7,a7 such requirements relating to minimum enrollment2 7,b7 such requirements relating to financial solvency2 7,c7 such requirements relating to quality and availability of care2 and 7,d7 such other requirements1 as the ,board or a ,state health security program may specify4 7d7 ,provision of emergency services to nonenrollees ,a ,,chso may furnish emergency services to persons who are not enrolled in the organization4 ,payment for such services1 if they are covered services to eligible persons1 shall be made to the organization unless the organization requests that it be made to the individual provider who furnished the services4 #cjd4 ,limitation on certain physician referrals 7a7 ,application to ,american ,health ,security ,program ,section #ahgg of the ,social ,security ,act1 as amended by subsections 7b7 and 7c71 shall apply under this ,act in the same manner as it applies under title ,,xviii of the ,social ,security ,act2 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 ,act1 respectively4 7b7 ,expansion of prohibition to certain additional designated services ,section #ahgg7;h77#f7 of the ,social ,security ,act 7#db ,u4,s4,c4 #acienn7h77#f77 is amended by adding at the end the following3 7,m7 ,ambulance services4 7,n7 ,home infusion therapy services4 4 7c7 ,conforming amendments ,section #ahgg of such ,act is further amended-- 7#a7 in subsection 7a77#a77;,a71 by striking for which payment otherwise may be made under this title and inserting for which a charge is imposed2 7#b7 in subsection 7a77#a77;,b71 by striking under this title2 7#c7 by amending paragraph 7#a7 of subsection 7g7 to read as follows3 7#a7 ,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 7a77#a77;,b74 ,no individual1 third-party payor1 or other entity is liable for payment for designated health services for which a claim is presented in violation of such subsection4 2 and 7#d7 in subsection 7g77#c71 by striking for which payment may not be made under paragraph 7#a7 and inserting for which such a claim may not be presented under subsection 7a77#a74 ,,iv ,administration ,a ,general ,administrative ,provisions #dja4 ,american ,health ,security ,standards ,board 7a7 ,establishment ,there is hereby established an ,american ,health ,security ,standards ,board4 7b7 ,appointment and terms of members 7#a7 ,in general ,the ,board shall be composed of-- 7,a7 the ,secretary of ,health and ,human ,services2 and 7,b7 #f other individuals 7described in paragraph 7#b77 appointed by the ,president with the advice and consent of the ,senate4 ,the ,president shall first nominate individuals under subparagraph 7,b7 on a timely basis so as to provide for the operation of the ,board by not later than ,january #a1 #bjad4 7#b7 ,selection of appointed members ,with respect to the individuals appointed under paragraph 7#a77;,b73 7,a7 ,the members shall be chosen on the basis of backgrounds in health policy1 health economics1 the healing professions1 and the administration of health care institutions4 7,b7 ,the members shall provide a balanced point of view with respect to the various health care interests and at least #b of them shall represent the interests of individual consumers4 7,c7 ,at least #a member shall have a nursing background4 7,d7 ,not more than #c members shall be from the same political party4 7,e7 ,to the greatest extent feasible1 the members shall represent the various geographic regions of the ,united ,states and shall reflect the racial1 ethnic1 and gender composition of the population of the ,united ,states4 7#c7 ,terms of appointed members ,individuals appointed under paragraph 7#a77;,b7 shall serve for a term of #f years1 except that the terms of #e of the individuals initially appointed shall be1 as designated by the ,president at the time of their appointment1 for #a1 #b1 #c1 #d1 and #e years4 ,during a term of membership on the ,board1 no member shall engage in any other business1 vocation or employment4 7c7 ,vacancies 7#a7 ,in general ,the ,president shall fill any vacancy in the membership of the ,board in the same manner as the original appointment4 ,the vacancy shall not affect the power of the remaining members to execute the duties of the ,board4 7#b7 ,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 appointed4 7#c7 ,reappointment ,the ,president may reappoint an appointed member of the ,board for a second term in the same manner as the original appointment4 ,a member who has served for #b consecutive #f-year terms shall not be eligible for reappointment until #b years after the member has ceased to serve4 7#d7 ,removal for cause ,upon confirmation1 members of the ,board may not be removed except by the ,president for cause4 7d7 ,chair ,the ,president shall designate #a of the members of the ,board1 other than the ,secretary1 to serve at the will of the ,president as ,chair of the ,board4 7e7 ,compensation ,members of the ,board 7other than the ,secretary7 shall be entitled to compensation at a level equivalent to level ,,ii of the ,executive ,schedule1 in accordance with section #ecac of title #e1 ,united ,states ,code4 7f7 ,general duties of the ,board 7#a7 ,in general ,the ,board shall develop policies1 procedures1 guidelines1 and requirements to carry out this ,act1 including those related to-- 7,a7 eligibility2 7,b7 enrollment2 7,c7 benefits2 7,d7 provider participation standards and qualifications1 as defined in title ,,iii2 7,e7 national and ,state funding levels2 7,f7 methods for determining amounts of payments to providers of covered services1 consistent with subtitle ,b of title ,,vi2 7,g7 the determination of medical necessity and appropriateness with respect to coverage of certain services2 7,h7 assisting ,state health security programs with planning for capital expenditures and service delivery2 7,i7 planning for health professional education funding 7as specified in title ,,vi72 7,j7 allocating funds provided under title ,,vii2 and 7,k7 encouraging ,states to develop regional planning mechanisms 7described in section #djd7;a77#c774 7#b7 ,regulations ,regulations authorized by this ,act shall be issued by the ,board in accordance with the provisions of section #eec of title #e1 ,united ,states ,code4 7g7 ,uniform reporting standards2 annual report2 studies 7#a7 ,uniform reporting standards 7,a7 ,in general ,the ,board shall establish uniform reporting requirements and standards to ensure an adequate national data base regarding health services practitioners1 services and finances of ,state health security programs1 approved plans1 providers1 and the costs of facilities and practitioners providing services4 ,such standards shall include1 to the maximum extent feasible1 health outcome measures4 7,b7 ,reports ,the ,board shall analyze regularly information reported to it1 and to ,state health security programs pursuant to such requirements and standards4 7#b7 ,annual report ,beginning ,january #a1 of the second year beginning after the date of the enactment of this ,act1 the ,board shall annually report to ,congress on the following3 7,a7 ,the status of implementation of the ,act4 7,b7 ,enrollment under this ,act4 7,c7 ,benefits under this ,act4 7,d7 ,expenditures and financing under this ,act4 7,e7 ,cost-containment measures and achievements under this ,act4 7,f7 ,quality assurance4 7,g7 ,health care utilization patterns1 including any changes attributable to the program4 7,h7 ,long-range plans and goals for the delivery of health services4 7,i7 ,differences in the health status of the populations of the different ,states1 including income and racial characteristics4 7,j7 ,necessary changes in the education of health personnel4 7,k7 ,plans for improving service to medically underserved populations4 7,l7 ,transition problems as a result of implementation of this ,act4 7,m7 ,opportunities for improvements under this ,act4 7#c7 ,statistical analyses and other studies ,the ,board may1 either directly or by contract-- 7,a7 make statistical and other studies1 on a nationwide1 regional1 ,state1 or local basis1 of any aspect of the operation of this ,act1 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 services2 7,b7 develop and test methods of providing through payment for services or otherwise1 additional incentives for adherence by providers to standards of adequacy1 access1 and quality2 methods of consumer and peer review and peer control of the utilization of drugs1 of laboratory services1 and of other services2 and methods of consumer and peer review of the quality of services2 7,c7 develop and test1 for use by the ,board1 records and information retrieval systems and budget systems for health services administration1 and develop and test model systems for use by providers of services2 7,d7 develop and test1 for use by providers of services1 records and information retrieval systems useful in the furnishing of preventive or diagnostic services2 7,e7 develop1 in collaboration with the pharmaceutical profession1 and test1 improved administrative practices or improved methods for the reimbursement of independent pharmacies for the cost of furnishing drugs as a covered service2 and 7,f7 make such other studies as it may consider necessary or promising for the evaluation1 or for the improvement1 of the operation of this ,act4 7#d7 ,report on use of existing ,federal health care facilities ,not later than #a year after the date of the enactment of this ,act1 the ,board shall recommend to ,congress one or more proposals for the treatment of health care facilities of the ,federal ,government4 7h7 ,executive ,director 7#a7 ,appointment ,there is hereby established the position of ,executive ,director of the ,board4 ,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 assign4 7#b7 ,delegation ,the ,board is authorized to delegate to the ,director or to any other officer or employee of the ,board or1 with the approval of the ,secretary of ,health and ,human ,services 7and subject to reimbursement of identifiable costs71 to any other officer or employee of the ,department of ,health and ,human ,services1 any of its functions or duties under this ,act other than-- 7,a7 the issuance of regulations2 or 7,b7 the determination of the availability of funds and their allocation to implement this ,act4 7#c7 ,compensation ,the ,executive ,director of the ,board shall be entitled to compensation at a level equivalent to level ,,iii of the ,executive ,schedule1 in accordance with section #ecad of title #e1 ,united ,states ,code4 7i7 ,inspector ,general ,the ,inspector ,general ,act of #aigh 7#e ,u4,s4,c4 ,app47 is amended-- 7#a7 in section #ab7a71 by inserting after ,corporation2 the first place it appears the following3 the ,chair of the ,american ,health ,security ,standards ,board22 7#b7 in section #ab7b71 by inserting after ,resolution ,trust ,corporation1 the following3 the ,american ,health ,security ,standards ,board12 and 7#c7 by inserting before section #i the following3 #h,m4 ,special provisions concerning ,american ,health ,security ,standards ,board ,the ,inspector ,general of the ,american ,health ,security ,standards ,board1 in addition to the other authorities vested by this ,act1 shall have the same authority1 with respect to the ,board and the ,american ,health ,security ,program under this ,act1 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 programs1 respectively4 4 7j7 ,staff ,the ,board shall employ such staff as the ,board may deem necessary4 7k7 ,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 sources1 pertaining to the duties of the ,board4 #djb4 ,american ,health ,security ,advisory ,council 7a7 ,in general ,the ,board shall provide for an ,american ,health ,security ,advisory ,council 7in this section referred to as the ,council7 to advise the ,board on its activities4 7b7 ,membership ,the ,council shall be composed of-- 7#a7 the ,chair of the ,board1 who shall serve as ,chair of the ,council2 and 7#b7 #bj members1 not otherwise in the employ of the ,united ,states1 appointed by the ,board without regard to the provisions of title #e1 ,united ,states ,code1 governing appointments in the competitive service4 ,the appointed members shall include1 in accordance with subsection 7e71 individuals who are representative of ,state health security programs1 public health professionals1 providers of health services1 and of individuals 7who shall constitute a majority of the ,council7 who are representative of consumers of such services1 including a balanced representation of employers1 unions1 consumer organizations1 and population groups with special health care needs4 ,to the greatest extent feasible1 the membership of the ,council shall represent the various geographic regions of the ,united ,states and shall reflect the racial1 ethnic1 and gender composition of the population of the ,united ,states4 7c7 ,terms of members ,each appointed member shall hold office for a term of #d years1 except that-- 7#a7 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 term2 and 7#b7 the terms of the members first taking office shall expire1 as designated by the ,board at the time of appointment1 at the end of the first year with respect to #e members1 at the end of the second year with respect to #e members1 at the end of the third year with respect to #e members1 and at the end of the fourth year with respect to #e members after the date of enactment of this ,act4 7d7 ,vacancies 7#a7 ,in general ,the ,board shall fill any vacancy in the membership of the ,council in the same manner as the original appointment4 ,the vacancy shall not affect the power of the remaining members to execute the duties of the ,council4 7#b7 ,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 appointed4 7#c7 ,reappointment ,the ,board may reappoint an appointed member of the ,council for a second term in the same manner as the original appointment4 7e7 ,qualifications 7#a7 ,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 programs4 7#b7 ,providers ,members of the ,council who are representative of providers of health care shall be individuals who are outstanding in fields related to medical1 hospital1 or other health activities1 or who are representative of organizations or associations of professional health practitioners4 7#c7 ,consumers ,members who are representative of consumers of such care shall be individuals1 not engaged in and having no financial interest in the furnishing of health services1 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 services4 7f7 ,duties 7#a7 ,in general ,it shall be the duty of the ,council-- 7,a7 to advise the ,board on matters of general policy in the administration of this ,act1 in the formulation of regulations1 and in the performance of the ,board's duties under section #dja2 and 7,b7 to study the operation of this ,act and the utilization of health services under it1 with a view to recommending any changes in the administration of the ,act or in its provisions which may appear desirable4 7#b7 ,report ,the ,council shall make an annual report to the ,board on the performance of its functions1 including any recommendations it may have with respect thereto1 and the ,board shall promptly transmit the report to the ,congress1 together with a report by the ,board on any recommendations of the ,council that have not been followed4 7g7 ,staff ,the ,council1 its members1 and any committees of the ,council shall be provided with such secretarial1 clerical1 or other assistance as may be authorized by the ,board for carrying out their respective functions4 7h7 ,meetings ,the ,council shall meet as frequently as the ,board deems necessary1 but not less than #d times each year4 ,upon request by #g or more members it shall be the duty of the ,chair to call a meeting of the ,council4 7i7 ,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 #eg of title #e1 ,united ,states ,code4 7j7 ,,faca not applicable ,the provisions of the ,federal ,advisory ,committee ,act shall not apply to the ,council4 #djc4 ,consultation with private entities ,the ,secretary and the ,board shall consult with private entities1 such as professional societies1 national associations1 nationally recognized associations of experts1 medical schools and academic health centers1 consumer groups1 and labor and business organizations in the formulation of guidelines1 regulations1 policy initiatives1 and information gathering to ensure the broadest and most informed input in the administration of this ,act4 ,nothing in this ,act shall prevent the ,secretary from adopting guidelines developed by such a private entity if1 in the ,secretary's and ,board's judgment1 such guidelines are generally accepted as reasonable and prudent and consistent with this ,act4 #djd4 ,state health security programs 7a7 ,submission of plans 7#a7 ,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 ,act4 7#b7 ,regional programs ,a ,state may join with #a or more neighboring ,states to submit to the ,board a plan for a regional health security program instead of separate ,state health security programs4 7#c7 ,regional planning mechanisms ,the ,board shall provide incentives for ,states to develop regional planning mechanisms to promote the rational distribution of1 adequate access to1 and efficient use of1 tertiary care facilities1 equipment1 and services4 7#d7 ,states that fail to submit a plan ,in the case of a ,state that fails to submit a plan as required under this subsection1 the ,american ,health ,security ,standards ,board ,authority shall develop a plan for a ,state health security program in such ,state4 7b7 ,review and approval of plans 7#a7 ,in general ,the ,board shall review plans submitted under subsection 7a7 and determine whether such plans meet the requirements for approval4 ,the ,board shall not approve such a plan unless it finds that the plan 7or ,state law7 provides1 consistent with the provisions of this ,act1 for the following3 7,a7 ,payment for required health services for eligible individuals in the ,state in accordance with this ,act4 7,b7 ,adequate administration1 including the designation of a single ,state agency responsible for the administration 7or supervision of the administration7 of the program4 7,c7 ,the establishment of a ,state health security budget4 7,d7 ,establishment of payment methodologies 7consistent with subtitle ,b of title ,,vii74 7,e7 ,assurances that individuals have the freedom to choose practitioners and other health care providers for services covered under this ,act4 7,f7 ,a procedure for carrying out long-term regional management and planning functions with respect to the delivery and distribution of health care services that-- 7i7 ensures participation of consumers of health services and providers of health services2 and 7ii7 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 shortcomings4 7,g7 ,the licensure and regulation of all health providers and facilities to ensure compliance with ,federal and ,state laws and to promote quality of care4 7,h7 ,establishment of a quality review system in accordance with section #ejc4 7,i7 ,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 providers4 7,j7 ,publication of an annual report on the operation of the ,state health security program1 which report shall include information on cost1 progress towards achieving full enrollment1 public access to health services1 quality review1 health outcomes1 health professional training1 and the needs of medically underserved populations4 7,k7 ,provision of a fraud and abuse prevention and control unit that the ,inspector ,general determines meets the requirements of section #dab7;a74 7,l7 ,prohibit payment in cases of prohibited physician referrals under section #cjd4 7#b7 ,consequences of failure to comply ,if the ,board finds that a ,state plan submitted under paragraph 7#a7 does not meet the requirements for approval under this section or that a ,state health security program or specific portion of such program1 the plan for which was previously approved1 no longer meets such requirements1 the ,board shall provide notice to the ,state of such failure and that unless corrective action is taken within a period specified by the ,board1 the ,board shall place the ,state health security program 7or specific portions of such program7 in receivership under the jurisdiction of the ,board4 7c7 ,state ,health ,security ,advisory ,councils 7#a7 ,in general ,for each ,state1 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 ,state4 7#b7 ,membership ,each ,state ,health ,security ,advisory ,council shall be composed of at least #aa individuals4 ,the appointed members shall include individuals who are representative of the ,state health security program1 public health professionals1 providers of health services1 and of individuals 7who shall constitute a majority7 who are representative of consumers of such services1 including a balanced representation of employers1 unions and consumer organizations4 ,to the greatest extent feasible1 the membership of each ,state ,health ,security ,advisory ,council shall represent the various geographic regions of the ,state and shall reflect the racial1 ethnic1 and gender composition of the population of the ,state4 7#c7 ,duties 7,a7 ,in general ,each ,state ,health ,security ,advisory ,council shall review1 and submit comments to the ,governor concerning the implementation of the ,state health security program in the ,state4 7,b7 ,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 programs1 with particular emphasis placed on assisting those applicants with broad consumer representation4 7d7 ,state use of fiscal agents 7#a7 ,in general ,each ,state health security program1 using competitive bidding procedures1 may enter into such contracts with qualified entities1 such as voluntary associations1 as the ,state determines to be appropriate to process claims and to perform other related functions of fiscal agents under the ,state health security program4 7#b7 ,restriction ,except as the ,board may provide for good cause shown1 in no case may more than #a contract described in paragraph 7#a7 be entered into under a ,state health security program4 #dje4 ,complementary conduct of related health programs ,in performing functions with respect to health personnel education and training1 health research1 environmental health1 disability insurance1 vocational rehabilitation1 the regulation of food and drugs1 and all other matters pertaining to health1 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 ,act4 ,b ,control over ,fraud and ,abuse #daa4 ,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 7except that in applying such provisions any reference to the ,secretary is deemed a reference to the ,board73 7#a7 ,section #aabh 7relating to exclusion of individuals and entities74 7#b7 ,section #aabh;,a 7civil monetary penalties74 7#c7 ,section #aabh;,b 7criminal penalties74 7#d7 ,section #aabd 7relating to disclosure of ownership and related information74 7#e7 ,section #aabf 7relating to disclosure of certain owners74 #dab4 ,requirements for operation of ,state health care fraud and abuse control units 7a7 ,requirement ,in order to meet the requirement of section #djd7;b77#a77,k71 each ,state health security program shall establish and maintain a health care fraud and abuse control unit 7in this section referred to as a fraud unit7 that meets requirements of this section and other requirements of the ,board4 ,such a unit may be a ,state medicaid fraud control unit 7described in section #aijc7q7 of the ,social ,security ,act74 7b7 ,structure of unit ,the fraud unit shall-- 7#a7 be a single identifiable entity of the ,state government2 7#b7 be separate and distinct from the ,state agency with principal responsibility for the administration of the ,state health security program2 and 7#c7 meet one of the following requirements3 7,a7 ,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 violations4 7,b7 ,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 procedures1 approved by the ,board1 that-- 7i7 assure its referral of suspected criminal violations relating to the ,state health insurance plan to the appropriate authority or authorities in the ,states for prosecution2 and 7ii7 assure its assistance of1 and coordination with1 such authority or authorities in such prosecutions4 7,c7 ,it shall have a formal working relationship with the office of the ,state ,attorney ,general and have formal procedures 7including procedures for its referral of suspected criminal violations to such office7 which are approved by the ,board and which provide effective coordination of activities between the fraud unit and such office with respect to the detection1 investigation1 and prosecution of suspected criminal violations relating to the ,state health insurance plan4 7c7 ,functions ,the fraud unit shall-- 7#a7 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 program2 7#b7 have procedures for reviewing complaints of the abuse and neglect of patients of providers and facilities that receive payments under the ,state health security program1 and1 where appropriate1 for acting upon such complaints under the criminal laws of the ,state or for referring them to other ,state agencies for action2 and 7#c7 provide for the collection1 or referral for collection to a single ,state agency1 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 activities4 7d7 ,resources ,the fraud unit shall-- 7#a7 employ such auditors1 attorneys1 investigators1 and other necessary personnel2 7#b7 be organized in such a manner2 and 7#c7 provide sufficient resources 7as specified by the ,board71 as is necessary to promote the effective and efficient conduct of the unit's activities4 7e7 ,cooperative agreements ,the fraud unit shall have cooperative agreements 7as specified by the ,board7 with-- 7#a7 similar fraud units in other ,states2 7#b7 the ,inspector ,general2 and 7#c7 the ,attorney ,general of the ,united ,states4 7f7 ,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 section4 ,v ,quality ,assessment #eja4 ,american ,health ,security ,quality ,council 7a7 ,establishment ,there is hereby established an ,american ,health ,security ,quality ,council 7in this title referred to as the ,council74 7b7 ,duties of the ,council ,the ,council shall perform the following duties3 7#a7 ,practice guidelines ,the ,council shall review and evaluate each practice guideline developed under part ,b of title ,,ix of the ,public ,health ,service ,act4 ,the ,council shall determine whether the guideline should be recognized as a national practice guideline to be used under section #bjd7;d7 for purposes of determining payments under a ,state health security program4 7#b7 ,standards of quality1 performance measures1 and medical review criteria ,the ,council shall review and evaluate each standard of quality1 performance measure1 and medical review criterion developed under part ,b of title ,,ix of the ,public ,health ,service ,act4 ,the ,council shall determine whether the standard1 measure1 or criterion is appropriate for use in assessing or reviewing the quality of services provided by ,state health security programs1 health care institutions1 or health care professionals4 7#c7 ,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 #ejc4 ,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 another4 ,the ,council shall ensure coordination and reporting by such entities to ensure national consistency in quality standards4 7#d7 ,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 #dja7;f77#a77;,g74 7#e7 ,other functions ,the ,council shall perform the functions of the ,council described in section #ejb4 7c7 ,appointment and terms of members 7#a7 ,in general ,the ,council shall be composed of #aj members appointed by the ,president4 ,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 #a1 #bjad4 7#b7 ,selection of members ,each member of the ,council shall be a member of a health profession4 ,five members of the ,council shall be physicians4 ,individuals shall be appointed to the ,council on the basis of national reputations for clinical and academic excellence4 ,to the greatest extent feasible1 the membership of the ,council shall represent the various geographic regions of the ,united ,states and shall reflect the racial1 ethnic1 and gender composition of the population of the ,united ,states4 7#c7 ,terms of members ,individuals appointed to the ,council shall serve for a term of #e years1 except that the terms of #d of the individuals initially appointed shall be1 as designated by the ,president at the time of their appointment1 for #a1 #b1 #c1 and #d years4 7d7 ,vacancies 7#a7 ,in general ,the ,president shall fill any vacancy in the membership of the ,council in the same manner as the original appointment4 ,the vacancy shall not affect the power of the remaining members to execute the duties of the ,council4 7#b7 ,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 appointed4 7#c7 ,reappointment ,the ,president may reappoint a member of the ,council for a second term in the same manner as the original appointment4 ,a member who has served for #b consecutive #e-year terms shall not be eligible for reappointment until #b years after the member has ceased to serve4 7e7 ,chair ,the ,president shall designate #a of the members of the ,council to serve at the will of the ,president as ,chair of the ,council4 7f7 ,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 ,schedule1 in accordance with section #ecac of title #e1 ,united ,states ,code4 #ejb4 ,development of certain methodologies1 guidelines1 and standards 7a7 ,profiling of patterns of practice2 identification of outliers ,the ,council shall adopt methodologies for profiling the patterns of practice of health care professionals and for identifying outliers 7as defined in subsection 7e774 7b7 ,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 outcome4 ,reimbursement under this ,act for such a designated procedure may only be provided if the procedure was performed at a center that meets such standards4 7c7 ,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 ,act4 ,the ,council shall develop criteria for referral of providers to the ,state licensing board if education proves ineffective in correcting provider practice behavior4 7d7 ,dissemination ,the ,council shall disseminate to the ,state-- 7#a7 the methodologies adopted under subsection 7a72 7#b7 the guidelines developed under subsection 7b72 and 7#c7 the standards developed under subsection 7c72 for use by the ,states under section #ejc4 7e7 ,outlier defined ,in this title1 the term outlier means a health care provider whose pattern of practice1 relative to applicable practice guidelines1 suggests deficiencies in the quality of health care services being provided4 #ejc4 ,state quality review programs 7a7 ,requirement ,in order to meet the requirement of section #djd7;b77#a77;,h71 each ,state health security program shall establish #a or more qualified entities to conduct quality reviews of persons providing covered services under the program1 in accordance with standards established under subsection 7b77#a7 7except as provided in subsection 7b77#b77 and subsection 7d74 7b7 ,federal standards 7#a7 ,in general ,the ,council shall establish standards with respect to-- 7,a7 the adoption of practice guidelines 7whether developed by the ,federal ,government or other entities72 7,b7 the identification of outliers 7consistent with methodologies adopted under section #ejb7;a772 7,c7 the development of remedial programs and monitoring for outliers2 and 7,d7 the application of sanctions 7consistent with the standards developed under section #ejb7;c774 7#b7 ,state discretion ,a ,state may apply under subsection 7a7 standards other than those established under paragraph 7#a7 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 7#a74 ,positive improvements in quality shall be documented by reductions in the variations of clinical care process and improvement in patient outcomes4 7c7 ,qualifications ,an entity is not qualified to conduct quality reviews under subsection 7a7 unless the entity satisfies the criteria for competence for such entities developed by the ,council under section #eja7;b77#c74 7d7 ,internal quality review ,nothing in this section shall preclude an institutional provider from establishing its own internal quality review and enhancement programs4 #ejd4 ,elimination of utilization review programs2 transition 7a7 ,intent ,it is the intention of this title to replace by ,january #a1 #bjag1 random utilization controls with a systematic review of patterns of practice that compromise the quality of care4 7b7 ,superseding case reviews 7#a7 ,in general ,subject to the succeeding provisions of this subsection1 the program of quality review provided under the previous sections of this title supersede all existing ,federal requirements for utilization review programs1 including requirements for random case-by-case reviews and programs requiring pre-certification of medical procedures on a case-by-case basis4 7#b7 ,transition ,before ,january #a1 #bjag1 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 reviews4 7#c7 ,construction ,nothing in this subsection shall be construed-- 7,a7 as precluding the case-by-case review of the provision of care-- 7i7 in individual incidents where the quality of care has significantly deviated from acceptable standards of practice2 and 7ii7 with respect to a provider who has been determined to be an outlier2 or 7,b7 as precluding the case management of catastrophic1 mental health1 or substance abuse cases or long-term care where such management is necessary to achieve appropriate1 cost-effective1 and beneficial comprehensive medical care1 as provided for in section #bjd4 ,,vi ,health ,security ,budget2 ,payments2 ,cost ,containment ,measures ,a ,budgeting and ,payments to ,states #fja4 ,national health security budget 7a7 ,national health security budget 7#a7 ,in general ,by not later than ,september #a before the beginning of each year 7beginning with #bjad71 the ,board shall establish a national health security budget1 which-- 7,a7 specifies the total expenditures 7including expenditures for administrative costs7 to be made by the ,federal ,government and the ,states for covered health care services under this ,act2 and 7,b7 allocates those expenditures among the ,states consistent with section #fjd4 ,pursuant to subsection 7b71 such budget for a year shall not exceed the budget for the preceding year increased by the percentage increase in gross domestic product4 7#b7 ,division of budget into components ,the national health security budget shall consist of at least #d components3 7,a7 ,a component for quality assessment activities 7described in title ,v74 7,b7 ,a component for health professional education expenditures4 7,c7 ,a component for administrative costs4 7,d7 ,a component for operating and other expenditures not described in subparagraphs 7,a7 through 7,c7 7in this title referred to as the operating component71 consisting of amounts not included in the other components4 ,a ,state may provide for the allocation of this component between capital expenditures and other expenditures4 7#c7 ,allocation among components ,taking into account the ,state health security budgets established and submitted under section #fjc1 the ,board shall allocate the national health security budget among the components in a manner that-- 7,a7 assures a fair allocation for quality assessment activities 7consistent with the national health security spending growth limit72 and 7,b7 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 7consistent with the national health security spending growth limit under subsection 7b77#b774 7b7 ,basis for total expenditures 7#a7 ,in general ,the total expenditures specified in such budget shall be the sum of the capitation amounts computed under section #fjb7;a7 and the amount of ,federal administrative expenditures needed to carry out this ,act4 7#b7 ,national health security spending growth limit ,for purposes of this subtitle1 the national health security spending growth limit described in this paragraph for a year is 7,a7 zero1 or1 if greater1 7,b7 the average annual percentage increase in the gross domestic product 7in current dollars7 during the #c-year period beginning with the first quarter of the fourth previous year to the first quarter of the previous year minus the percentage increase 7if any7 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 year4 7c7 ,definitions ,in this title3 7#a7 ,capital expenditures ,the term capital expenditures means expenses for the purchase1 lease1 construction1 or renovation of capital facilities and for equipment and includes return on equity capital4 7#b7 ,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 activities4 #fjb4 ,computation of individual and ,state capitation amounts 7a7 ,capitation amounts 7#a7 ,individual capitation amounts ,in establishing the national health security budget under section #fja7;a7 and in computing the national average per capita cost under subsection 7b7 for each year1 the ,board shall establish a method for computing the capitation amount for each eligible individual residing in each ,state4 ,the capitation amount for an eligible individual in a ,state classified within a risk group 7established under subsection 7d77#b77 is the product of-- 7,a7 a national average per capita cost for all covered health care services 7computed under subsection 7b772 7,b7 the ,state adjustment factor 7established under subsection 7c77 for the ,state2 and 7,c7 the risk adjustment factor 7established under subsection 7d77 for the risk group4 7#b7 ,state capitation amount 7,a7 ,in general ,for purposes of this title1 the term ,state capitation amount means1 for a ,state for a year1 the sum of the capitation amounts computed under paragraph 7#a7 for all the residents of the ,state in the year1 as estimated by the ,board before the beginning of the year involved4 7,b7 ,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 7,a74 7,c7 ,population information ,the ,bureau of the ,census shall assist the ,board in determining the number1 place of residence1 and risk group classification of eligible individuals4 7b7 ,computation of national average per capita cost 7#a7 ,for #bjad ,for #bjad1 the national average per capita cost under this paragraph is equal to-- 7,a7 the average per capita health care expenditures in the ,united ,states in #bjab 7as estimated by the ,board72 7,b7 increased to #bjac by the ,board's estimate of the actual amount of such per capita expenditures during #bjac2 and 7,c7 updated to #bjad by the national health security spending growth limit specified in section #fja7;b77#b7 for #bjad4 7#b7 ,for succeeding years ,for each succeeding year1 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 7specified in section #fja7;b77#b77 for the year involved4 7c7 ,state adjustment factors 7#a7 ,in general ,subject to the succeeding paragraphs of this subsection1 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-- 7,a7 average labor and nonlabor costs that are necessary to provide covered health services2 7,b7 any social1 environmental1 or geographic condition affecting health status or the need for health care services1 to the extent such a condition is not taken into account in the establishment of risk groups under subsection 7d72 7,c7 the geographic distribution of the ,state's population1 particularly the proportion of the population residing in medically underserved areas1 to the extent such a condition is not taken into account in the establishment of risk groups under subsection 7d72 and 7,d7 any other factor relating to operating costs required to ensure equitable distribution of funds among the ,states4 7#b7 ,modification of health professional education component ,with respect to the portion of the national health security budget allocated to expenditures for health professional education1 the ,board shall modify the ,state adjustment factors so as to take into account-- 7,a7 differences among ,states in health professional education programs in operation as of the date of the enactment of this ,act2 and 7,b7 differences among ,states in their relative need for expenditures for health professional education1 taking into account the health professional education expenditures proposed in ,state health security budgets under section #fjc7;a74 7#c7 ,budget neutrality ,the ,state adjustment factors1 as modified under paragraph 7#b71 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 7b7 as a result of the application of such factors4 7#d7 ,phase-in ,in applying ,state adjustment factors under this subsection during the #e-year period beginning with #bjad1 the ,board shall phase-in1 over such period1 the use of factors described in paragraph 7#a7 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 ,act4 7#e7 ,periodic adjustment ,in establishing the national health security budget before the beginning of each year1 the ,board shall provide for appropriate adjustments in the ,state adjustment factors under this subsection4 7d7 ,adjustments for risk group classification 7#a7 ,in general ,the ,board shall develop an adjustment factor to the national average per capita costs computed under subsection 7b7 for individuals classified in each risk group 7as designated under paragraph 7#b77 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 group4 7#b7 ,risk groups ,the ,board shall designate a series of risk groups1 determined by age1 health indicators1 and other factors that represent distinct patterns of health care services utilization and costs4 7#c7 ,periodic adjustment ,in establishing the national health security budget before the beginning of each year1 the ,board shall provide for appropriate adjustments in the risk adjustment factors under this subsection4 #fjc4 ,state health security budgets 7a7 ,establishment and submission of budgets 7#a7 ,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 budget1 which specifies the following3 7,a7 ,the total expenditures 7including expenditures for administrative costs7 to be made under the program in the ,state for covered health care services under this ,act1 consistent with subsection 7b71 broken down as follows3 7i7 ,by the #d components 7described in section #fja7;a77#b771 consistent with subsection 7b74 7ii7 ,within the operating component-- 7,i7 expenditures for operating costs of hospitals and other facility-based services in the ,state2 7,,ii7 expenditures for payment to comprehensive health service organizations2 7,,iii7 expenditures for payment of services provided by health care practitioners2 and 7,,iv7 expenditures for other covered items and services4 ,amounts included in the operating component include amounts that may be used by providers for capital expenditures4 7,b7 ,the total revenues required to meet the ,state health security expenditures4 7#b7 ,proposed budget deadline ,the proposed budget for a year shall be submitted under paragraph 7#a7 not later than ,june #a before the year4 7#c7 ,final budget ,the final budget for a year shall-- 7,a7 be established and submitted under paragraph 7#a7 not later than ,october #a before the year1 and 7,b7 take into account the amounts established under the national health security budget under section #fja for the year4 7#d7 ,adjustment in allocations permitted 7,a7 ,in general ,subject to subparagraphs 7,b7 and 7,c71 in the case of a final budget1 a ,state may change the allocation of amounts among components4 7,b7 ,notice ,no such change may be made unless the ,state has provided prior notice of the change to the ,board4 7,c7 ,denial ,such a change may not be made if the ,board1 within such time period as the ,board specifies1 disapproves such change4 7b7 ,expenditure limits 7#a7 ,in general ,the total expenditures specified in each ,state health security budget under subsection 7a77#a7 shall take into account ,federal contributions made under section #fjd4 7#b7 ,limit on claims processing and billing expenditures ,each ,state health security budget shall provide that ,state administrative expenditures1 including expenditures for claims processing and billing1 shall not exceed #c percent of the total expenditures under the ,state health security program1 unless the ,board determines1 on a case-by-case basis1 that additional administrative expenditures would improve health care quality and cost effectiveness4 7#c7 ,worker assistance ,a ,state health security program may provide that1 for budgets for years before #bjag1 up to #a 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 program4 7c7 ,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 agencies4 #fjd4 ,federal payments to ,states 7a7 ,in general ,each ,state with an approved ,state health security program is entitled to receive1 from amounts in the ,american ,health ,security ,trust ,fund1 on a monthly basis each year1 of an amount equal to one-twelfth of the product of-- 7#a7 the ,state capitation amount 7computed under section #fjb7;a77#b77 for the ,state for the year2 and 7#b7 the ,federal contribution percentage 7established under subsection 7b774 7b7 ,federal contribution percentage ,the ,board shall establish a formula for the establishment of a ,federal contribution percentage for each ,state4 ,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 appropriate4 ,in addition1 during the #e-year period beginning with #bjad1 the ,board may provide for a transition adjustment to the formula in order to take into account current expenditures by the ,state 7and local governments thereof7 for health services covered under the ,state health security program4 ,the weighted-average ,federal contribution percentage for all ,states shall equal #hf percent and in no event shall such percentage be less than #ha percent nor more than #ia percent4 7c7 ,use of payments ,all payments made under this section may only be used to carry out the ,state health security program4 7d7 ,effect of spending excess or surplus 7#a7 ,spending excess ,if a ,state exceeds its budget in a given year1 the ,state shall continue to fund covered health services from its own revenues4 7#b7 ,surplus ,if a ,state provides all covered health services for less than the budgeted amount for a year1 it may retain its ,federal payment for that year for uses consistent with this ,act4 #fje4 ,account for health professional education expenditures 7a7 ,separate account ,each ,state health security program shall-- 7#a7 include a separate account for health professional education expenditures2 and 7#b7 specify the general manner1 consistent with subsection 7b71 in which such expenditures are to be distributed among different types of institutions and the different areas of the ,state4 7b7 ,distribution rules ,the distribution of funds to hospitals and other health care facilities from the account shall conform to the following principles3 7#a7 ,the disbursement of funds shall be consistent with achievement of the national and program goals 7specified in section #gja7;b77 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 goals4 7#b7 ,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 areas4 ,b ,payments by ,states to ,providers #faa4 ,payments to hospitals and other facility-based services for operating expenses on the basis of approved global budgets 7a7 ,direct payment under global budget ,payment for operating expenses for institutional and facility-based care1 including hospital services and nursing facility services1 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 program4 ,such a budget shall include payment for outpatient care and non-facility-based care that is furnished by or through the facility4 ,in the case of a hospital that is wholly owned 7or controlled7 by a comprehensive health service organization that is paid under section #fad on the basis of a global budget1 the global budget of the organization shall include the budget for the hospital4 7b7 ,annual negotiations2 budget approval 7#a7 ,in general ,the prospective global budget for an institution or facility shall-- 7,a7 be developed through annual negotiations between-- 7i7 a panel of individuals who are appointed by the ,governor of the ,state and who represent consumers1 labor1 business1 and the ,state government2 and 7ii7 the institution or facility2 and 7,b7 be based on a nationally uniform system of cost accounting established under standards of the ,board4 7#b7 ,considerations ,in developing a budget through negotiations1 there shall be taken into account at least the following3 7,a7 ,with respect to inpatient hospital services1 the number1 and classification by diagnosis-related group1 of discharges4 7,b7 ,an institution's or facility's past expenditures4 7,c7 ,the extent to which debt service for capital expenditures has been included in the proposed operating budget4 7,d7 ,the extent to which capital expenditures are financed directly or indirectly through reductions in direct care to patients1 including reductions in registered nursing staffing patterns or changes in emergency room or primary care services or availability4 7,e7 ,change in the consumer price index and other price indices4 7,f7 ,the cost of reasonable compensation to health care practitioners4 7,g7 ,the compensation level of the institution's or facility's work force4 7,h7 ,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 facility1 including the institution's or facility's occupancy level4 7,i7 ,the institution's or facility's previous financial and clinical performance1 based on utilization and outcomes data provided under this ,act4 7,j7 ,the type of institution or facility1 including whether the institution or facility is part of a clinical education program or serves a health professional education1 research or other training purpose4 7,k7 ,technological advances or changes4 7,l7 ,costs of the institution or facility associated with meeting ,federal and ,state regulations4 7,m7 ,the costs associated with necessary public outreach activities4 7,n7 ,in the case of a for-profit facility1 a reasonable rate of return on equity capital1 independent of those operating expenses necessary to fulfill the objectives of this ,act4 7,o7 ,incentives to facilities that maintain costs below previous reasonable budgeted levels without reducing the care provided4 7,p7 ,with respect to facilities that provide mental health services and substance abuse treatment services1 any additional costs involved in the treatment of dually diagnosed individuals4 ,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 expenditures4 7#c7 ,provision of required information2 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 specify1 including in the case of hospitals information on discharges classified by diagnosis-related group4 7c7 ,adjustments in approved budgets 7#a7 ,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 organization4 7#b7 ,amendments ,in accordance with standards established by the ,board1 an operating and capital budget approved under this section for a year may be amended before1 during1 or after the year if there is a substantial change in any of the factors relevant to budget approval4 7d7 ,donations permissible ,the ,states health security programs may permit institutions and facilities to raise funds from private sources to pay for newly constructed facilities1 major renovations1 and equipment4 ,the expenditure of such funds1 whether for operating or capital expenditures1 does not obligate the ,state health security program to provide for continued support for such expenditures unless included in an approved global budget4 #fab4 ,payments to health care practitioners based on prospective fee schedule 7a7 ,fee for service 7#a7 ,in general ,every independent health care practitioner is entitled to be paid1 for the provision of covered health services under the ,state health security program1 a fee for each billable covered service4 7#b7 ,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 7such as all outpatient procedures for treatment of a condition7 or for a basic group of services 7such as primary care services7 furnished to an individual over a period of time1 in order to encourage continuity and efficiency in the provision of services4 ,such methodologies shall be designed to ensure a high quality of care4 7#c7 ,billing deadlines2 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 7which had been previously specified7 within #cj days after the date the service was provided4 ,such a program may require that bills for services for which payment may be made under this section1 or for any class of such services1 be submitted electronically4 7b7 ,payment rates based on negotiated prospective fee schedules ,with respect to any payment method for a class of services of practitioners1 the ,state health security program shall establish1 on a prospective basis1 a payment schedule4 ,the ,state health security program may establish such a schedule after negotiations with organizations representing the practitioners involved4 ,such fee schedules shall be designed to provide incentives for practitioners to choose primary care medicine1 including general internal medicine1 family medicine1 gynecology1 and pediatrics1 over medical specialization4 ,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 expenditures4 7c7 ,billable covered service defined ,in this section1 the term billable covered service means a service covered under section #bja for which a practitioner is entitled to compensation by payment of a fee determined under this section4 #fac4 ,payments to comprehensive health service organizations 7a7 ,in general ,payment under a ,state health security program to a comprehensive health service organization to its enrollees shall be determined by the ,state-- 7#a7 based on a global budget described in section #faa2 or 7#b7 based on the basic capitation amount described in subsection 7b7 for each of its enrollees4 7b7 ,basic capitation amount 7#a7 ,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 enrollee1 based on actuarial characteristics 7as defined by the ,state health security program74 7#b7 ,adjustment for special health needs ,the ,state health security program shall adjust such average amounts to take into account the special health needs1 including a disproportionate number of medically underserved individuals1 of populations served by the organization4 7#c7 ,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 #cjc7;a74 #fad4 ,payments for community-,based primary health services 7a7 ,in general ,in the case of community-based primary health services1 subject to subsection 7b71 payments under a ,state health security program shall-- 7#a7 be based on a global budget described in section #faa2 7#b7 be based on the basic primary care capitation amount described in subsection 7c7 for each individual enrolled with the provider of such services2 or 7#c7 be made on a fee-for-service basis under section #fab4 7b7 ,payment adjustment ,payments under subsection 7a7 may include1 consistent with the budgets developed under this title-- 7#a7 an additional amount1 as set by the ,state health security program1 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 disease1 and for whom the cost of such care is otherwise uncompensated2 7#b7 an additional amount1 as set by the ,state health security program1 to cover the reasonable costs incurred by a provider that furnishes case management services 7as defined in section #aiae7;g77#b7 of the ,social ,security ,act71 transportation services1 and translation services2 and 7#c7 an additional amount1 as set by the ,state health security program1 to cover the costs incurred by a provider in conducting health professional education programs in connection with the provision of such services4 7c7 ,basic primary care capitation amount 7#a7 ,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 enrollee1 based on actuarial characteristics 7as defined by the ,state health security program74 7#b7 ,adjustment for special health needs ,the ,state health security program shall adjust such average amounts to take into account the special health needs1 including a disproportionate number of medically underserved individuals1 of populations served by the provider4 7#c7 ,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 provider4 7d7 ,community-,based primary health services defined ,in this section1 the term community-based primary health services has the meaning given such term in section #bjb7;a74 #fae4 ,payments for prescription drugs 7a7 ,establishment of list 7#a7 ,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 ,act4 7#b7 ,exclusions ,the ,board may exclude reimbursement under this ,act for ineffective1 unsafe1 or over-priced products where better alternatives are determined to be available4 7b7 ,prices ,for each such listed prescription drug or biological covered under this ,act1 for insulin1 and for medical foods1 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 thereof4 ,the ,board may conduct negotiations1 on behalf of ,state health security programs1 with product manufacturers and distributors in determining the applicable product price or prices4 7c7 ,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 7not in excess of the applicable product price established under subsection 7b77 plus a dispensing fee4 ,in accordance with standards established by the ,board1 each ,state health security program1 after consultation with representatives of the pharmaceutical profession1 shall establish schedules of dispensing fees1 designed to afford reasonable compensation to independent pharmacies after taking into account variations in their cost of operation resulting from regional differences1 differences in the volume of prescription drugs dispensed1 differences in services provided1 the need to maintain expenditures within the budgets established under this title1 and other relevant factors4 #faf4 ,payments for approved devices and equipment 7a7 ,establishment of list ,the ,board shall establish a list of approved durable medical equipment and therapeutic devices and equipment 7including eyeglasses1 hearing aids1 and prosthetic appliances71 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 ,act4 7b7 ,considerations and conditions ,in establishing the list under subsection 7a71 the ,board shall take into consideration the efficacy1 safety1 and cost of each item contained on such list1 and shall attach to any item such conditions as the ,board determines appropriate with respect to the circumstances under which1 or the frequency with which1 the item may be prescribed4 7c7 ,prices ,for each such listed item covered under this ,act1 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 thereof4 ,the ,board may conduct negotiations1 on behalf of ,state health security programs1 with equipment and device manufacturers and distributors in determining the applicable product price or prices4 7d7 ,exclusions ,the ,board may exclude from coverage under this ,act ineffective1 unsafe1 or overpriced products where better alternatives are determined to be available4 #fag4 ,payments for other items and services ,in the case of payment for other covered health services1 the amount of payment under a ,state health security program shall be established by the program-- 7#a7 in accordance with payment methodologies which are specified by the ,board1 after consultation with the ,american ,health ,security ,advisory ,council1 or methodologies established by the ,state under section #fbj2 and 7#b7 consistent with the ,state health security budget4 #fah4 ,payment incentives for medically underserved areas 7a7 ,model payment methodologies ,in addition to the payment amounts otherwise provided in this title1 the ,board shall establish model payment methodologies and other incentives that promote the provision of covered health care services in medically underserved areas1 particularly in rural and inner-city underserved areas4 7b7 ,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 incentives1 consistent with the ,state health security budget1 to encourage the provision of medically necessary and appropriate services in underserved areas4 #fai4 ,authority for alternative payment methodologies ,a ,state health security program1 as part of its plan under section #djd7;a71 may use a payment methodology other than a methodology required under this subtitle so long as-- 7#a7 such payment methodology does not affect the entitlement of individuals to coverage1 the weighting of fee schedules to encourage an increase in the number of primary care providers1 the ability of individuals to choose among qualified providers1 the benefits covered under the program1 or the compliance of the program with the ,state health security budget under subtitle ,a2 and 7#b7 the program submits periodic reports to the ,board showing the operation and effectiveness of the alternative methodology1 in order for the ,board to evaluate the appropriateness of applying the alternative methodology to other ,states4 ,c ,mandatory assignment and administrative provisions #fca4 ,mandatory assignment 7a7 ,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 ,act4 7b7 ,enforcement ,if an entity knowingly and willfully bills for an item or service or accepts payment in violation of subsection 7a71 the ,board may apply sanctions against the entity in the same manner as sanctions could have been imposed under section #ahdb7;j77#b7 of the ,social ,security ,act for a violation of section #ahdb7;j77#a7 of such ,act4 ,such sanctions are in addition to any sanctions that a ,state may impose under its ,state health security program4 #fcb4 ,procedures for reimbursement2 appeals 7a7 ,procedures for reimbursement ,in accordance with standards issued by the ,board1 a ,state health security program shall establish a timely and administratively simple procedure to ensure payment within #fj days of the date of submission of clean claims by providers under this ,act4 7b7 ,appeals process ,each ,state health security program shall establish an appeals process to handle all grievances pertaining to payment to providers under this title4 ,,vii ,promotion of ,primary ,health ,care2 ,development of ,health ,service ,capacity2 ,programs to ,assist the ,medically ,underserved ,a ,promotion and ,expansion of ,primary ,care ,professional ,training #gja4 ,role of ,board2 establishment of primary care professional output goals 7a7 ,in general ,the ,board is responsible for-- 7#a7 coordinating health professional education policies and goals1 in consultation with the ,secretary of ,health and ,human ,services 7in this title referred to as the ,secretary71 to achieve the national goals specified in subsection 7b72 7#b7 overseeing the health professional education expenditures of the ,state health security programs from the account established under section #fjb7;c72 7#c7 developing and maintaining1 in cooperation with the ,secretary1 a system to monitor the number and specialties of individuals through their health professional education1 any postgraduate training1 and professional practice2 and 7#d7 developing1 coordinating1 and promoting other policies that expand the number of primary care practitioners4 7b7 ,national goals ,the national goals specified in this subsection are as follows3 7#a7 ,graduate medical education ,by not later than #e years after the date of the enactment of this ,act1 at least #ej percent of the residents in medical residency education programs 7as defined in subsection 7e77#a77 are primary care residents 7as defined in subsection 7e77#c774 7#b7 ,midlevel primary care practitioners ,to ensure an adequate supply of primary care practitioners1 there shall be a number1 specified by the ,board1 of midlevel primary care practitioners 7as defined in subsection 7e77#b77 employed in the health care system as of ,january #a1 #bjag4 7#c7 ,dentistry ,to ensure an adequate supply of dental care practitioners1 there shall be a number1 specified by the ,board1 of dentists 7as defined in subsection 7e77#a77 employed in the health care system as of ,january #a1 #bjag4 7c7 ,method for attainment of national goal for graduate medical education2 program goals 7#a7 ,in general ,the ,board shall establish a method of applying the national goal in subsection 7b77#a7 to program goals for each medical residency education program or to medical residency education consortia4 7#b7 ,consideration ,the program goals under paragraph 7#a7 shall be based on the distribution of medical schools and other teaching facilities within each ,state health security program1 and the number of positions for graduate medical education4 7#c7 ,medical residency education consortium ,in this subsection1 the term medical residency education consortium means a consortium of medical residency education programs in a contiguous geographic area 7which may be an interstate area7 if the consortium-- 7,a7 includes at least #a medical school with a teaching hospital and related teaching settings2 and 7,b7 has an affiliation with qualified community-based primary health service providers described in section #bjb7;a7 and with at least #a comprehensive health service organization established under section #cjc4 7#d7 ,enforcement through ,state health security budgets ,the ,board shall develop a formula for reducing payments to ,state health security programs 7that provide for payments to a medical residency education program7 that failed to meet the goal for the program established under this subsection4 7d7 ,method for attainment of national goal for midlevel primary care practitioners ,to assist in attaining the national goal identified in subsection 7b77#b71 the ,board shall-- 7#a7 advise the ,public ,health ,service on allocations of funding under titles ,,vii and ,,viii of the ,public ,health ,service ,act1 the ,national ,health ,service ,corps1 and other programs in order to increase the supply of midlevel primary care practitioners2 and 7#b7 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 practitioners4 7e7 ,definitions ,in this title3 7#a7 ,dentist ,the term dentist means a practitioner who performs the evaluation1 diagnosis1 prevention or treatment 7nonsurgical1 surgical1 or related procedures7 of diseases1 disorders or conditions of the oral cavity1 maxillofacial area or the adjacent and associated structures and their impact on the human body1 within the scope of his or her education1 training and experience1 in accordance with the ethics of the profession and applicable law4 7#b7 ,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 physician1 and includes the medical school supervising the program and includes the hospital or other facility in which the program is operated4 7#c7 ,midlevel primary care practitioner ,the term midlevel primary care practitioner means a clinical nurse practitioner1 certified nurse midwife1 physician assistance1 or other nonphysician practitioner1 specified by the ,board1 as authorized to practice under ,state law4 7#d7 ,primary care resident ,the term primary care resident means 7in accordance with criteria established by the ,board7 a resident being trained in a distinct program of family practice medicine1 general practice1 general internal medicine1 or general pediatrics4 #gjb4 ,establishment of ,advisory ,committee on ,health ,professional ,education 7a7 ,in general ,the ,board shall provide for an ,advisory ,committee on ,health ,professional ,education 7in this section referred to as the ,committee7 to advise the ,board on its activities under section #gja4 7b7 ,membership ,the ,committee shall be composed of-- 7#a7 the ,chair of the ,board1 who shall serve as ,chair of the ,committee2 and 7#b7 #ab members1 not otherwise in the employ of the ,united ,states1 appointed by the ,board without regard to the provisions of title #e1 ,united ,states ,code1 governing appointments in the competitive service4 ,the appointed members shall provide a balanced point of view with respect to health professional education1 primary care disciplines1 and health care policy and shall include individuals who are representative of medical schools1 other health professional schools1 residency programs1 primary care practitioners1 teaching hospitals1 professional associations1 public health organizations1 ,state health security programs1 and consumers4 7c7 ,terms of members ,each appointed member shall hold office for a term of #e years1 except that-- 7#a7 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 term2 and 7#b7 the terms of the members first taking office shall expire1 as designated by the ,board at the time of appointment1 #b at the end of the second year1 #b at the end of the third year1 #b at the end of the fourth year1 and #c at the end of the fifth year after the date of enactment of this ,act4 7d7 ,vacancies 7#a7 ,in general ,the ,board shall fill any vacancy in the membership of the ,committee in the same manner as the original appointment4 ,the vacancy shall not affect the power of the remaining members to execute the duties of the ,committee4 7#b7 ,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 appointed4 7#c7 ,reappointment ,the ,board may reappoint an appointed member of the ,committee for a second term in the same manner as the original appointment4 7e7 ,duties ,it shall be the duty of the ,committee to advise the ,board concerning graduate medical education policies under this title4 7f7 ,staff ,the ,committee1 its members1 and any committees of the ,committee shall be provided with such secretarial1 clerical1 or other assistance as may be authorized by the ,board for carrying out their respective functions4 7g7 ,meetings ,the ,committee shall meet as frequently as the ,board deems necessary1 but not less than #d times each year4 ,upon request by #d or more members it shall be the duty of the ,chair to call a meeting of the ,committee4 7h7 ,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 #eg of title #e1 ,united ,states ,code4 7i7 ,,faca not applicable ,the provisions of the ,federal ,advisory ,committee ,act shall not apply to the ,committee4 #gjc4 ,grants for health professions education1 nurse education1 and the ,national ,health ,service ,corps 7a7 ,transfers to ,public ,health ,service 7#a7 ,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 ,,iii1 title ,,vii1 and title ,,viii of the ,public ,health ,service ,act for the support of the ,national ,health ,service ,corps1 health professions education1 and nursing education1 including education of clinical nurse practitioners1 certified registered nurse anesthetists1 certified nurse midwives1 and physician assistants4 7#b7 ,fiscal year #bjah and subsequent years ,the amount transferred for the support of the ,national ,health ,service ,corps for fiscal year #bjah and each subsequent fiscal year shall be equal to the amount transferred for the preceding fiscal year adjusted by the product of-- 7,a7 one plus the average percentage increase in the costs of health professions education during the prior fiscal year2 and 7,b7 one plus the average percentage change in the number of individuals residing in health professions shortage areas designated under section #ccc during the prior fiscal year1 relative to the number of individuals residing in such areas during the previous fiscal year4 7b7 ,range of funds ,the amount of transfers under subsection 7a7 for any fiscal year for title ,,vii and ,,viii shall be an amount 7specified by the ,board each year7 not less than #c_/ajj percent and not to exceed #d_/ajj percent of the amounts the ,board estimates will be expended from the ,trust ,fund in the fiscal year4 7c7 ,funds supplemental to other funds ,the funds provided under this section with respect to provision of services are in addition to1 and not in replacement of1 funds made available under the provisions referred to in subsection 7a7 and shall be administered in accordance with the terms of such provisions4 ,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 #bjab4 ,b ,direct ,health ,care ,delivery #gaa4 ,set-aside for public health 7a7 ,transfers to ,public ,health ,service ,from the amounts provided under subsection 7c71 the ,board shall make transfers from the ,american ,health ,security ,trust ,fund to the ,public ,health ,service for the following purposes 7other than payment for services covered under title ,,ii73 7#a7 ,for payments to ,states under the maternal and child health block grants under title ,v of the ,social ,security ,act 7#db ,u4,s4,c4 #gja et seq474 7#b7 ,for prevention and treatment of tuberculosis under section #cag of the ,public ,health ,service ,act 7#db ,u4,s4,c4 #bdg;b74 7#c7 ,for the prevention and treatment of sexually transmitted diseases under section #cah of the ,public ,health ,service ,act 7#db ,u4,s4,c4 #bdg;c74 7#d7 ,preventive health block grants under part ,a of title ,,xix of the ,public ,health ,service ,act 7#db ,u4,s4,c4 #cjjw et seq474 7#e7 ,grants to ,states for community mental health services under subpart ,i of part ,b of title ,,xix of the ,public ,health ,service ,act 7#db ,u4,s4,c4 #cjjx et seq474 7#f7 ,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 7#db ,u4,s4,c4 #cjjx-#ba et seq474 7#g7 ,grants for ,,hiv health care services under parts ,a1 ,b1 and ,c of title ,,xxvi of the ,public ,health ,service ,act 7#db ,u4,s4,c4 #cjj;ff-#aa et seq474 7#h7 ,public health formula grants described in subsection 7d74 7b7 ,range of funds ,the amount of transfers under subsection 7a7 for any fiscal year shall be an amount 7specified by the ,board each year7 not less than #a_/aj percent and not to exceed #ad_/ajj percent of the amounts the ,board estimates will be expended from the ,trust ,fund in the fiscal year4 7c7 ,funds supplemental to other funds ,the funds provided under this section with respect to provision of services are in addition to1 and not in replacement of1 funds made available under the programs referred to in subsection 7a7 and shall be administered in accordance with the terms of such programs4 7d7 ,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 ,state4 ,such reports shall include the following3 7#a7 ,a comparison of the measures of the ,state and local public health system compared to relevant objectives set forth in ,healthy ,people #bjbj or subsequent national objectives set by the ,secretary4 7#b7 ,a description of health status measures to be improved within the ,state 7at the ,state and local levels7 through expanded public health functions and health promotion and disease prevention programs4 7#c7 ,measurable outcomes and process objectives for improving health status1 and a report on outcomes from the previous year4 7#d7 ,information regarding how ,federal funding has improved population-based prevention activities and programs4 7#e7 ,a description of the core public health functions to be carried out at the local level4 7#f7 ,a description of the relationship between the ,state's public health system1 community-based health promotion and disease prevention providers1 and the ,state health security program4 7e7 ,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 #bjab4 7f7 ,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 pollutants1 occupational hazards1 harmful products1 and poor health outcomes4 ,such functions include the following3 7#a7 ,data collection1 analysis1 and assessment of public health data1 vital statistics1 and personal health data to assess community health status and outcomes reporting4 ,this function includes the acquisition and installation of hardware and software1 and personnel training and technical assistance to operate and support automated and integrated information systems4 7#b7 ,activities to protect the environment and to ensure the safety of housing1 workplaces1 food1 and water4 7#c7 ,investigation and control of adverse health conditions1 and threats to the health status of individuals and the community4 ,this function includes the identification and control of outbreaks of infectious disease1 patterns of chronic disease and injury1 and cooperative activities to reduce the levels of violence4 7#d7 ,health promotion and disease prevention activities for which there is a significant need and a high priority of the ,public ,health ,service4 7#e7 ,the provision of public health laboratory services to complement private clinical laboratory services1 including-- 7,a7 screening tests for metabolic diseases in newborns2 7,b7 toxicology assessments of blood lead levels and other environmental toxins2 7,c7 tuberculosis and other diseases requiring partner notification2 and 7,d7 testing for infectious and food-borne diseases4 7#f7 ,training and education for the public health professions4 7#g7 ,research on effective and cost-effective public health practices4 ,this function includes the development1 testing1 evaluation1 and publication of results of new prevention and public health control interventions4 7#h7 ,integration and coordination of the prevention programs and services of community-based providers1 local and ,state health departments1 and other sectors of ,state and local government that affect health4 #gab4 ,set-aside for primary health care delivery 7a7 ,transfers to ,section #ccj program of the ,public ,health ,service ,act 7#a7 ,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 #ccj of the ,public ,health ,service ,act 7#db ,u4,s4,c4 #bed;b74 7#b7 ,fiscal year #bjah and subsequent years ,the amount transferred for fiscal year #bjah and each subsequent fiscal year shall be equal to the amount transferred for the preceding fiscal year adjusted by the product of-- 7,a7 one plus the average percentage increase in costs incurred per patient served by entities receiving funding under such section2 and 7,b7 one plus the average percentage increase in the total number of patients served by entities receiving funding under such section4 7b7 ,transfers to ,public ,health ,service ,from the amounts provided under subsection 7d71 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 7as added by section #gac of this ,act74 7c7 ,range of funds ,the amount of transfers under subsection 7b7 for any fiscal year shall be an amount 7specified by the ,board each year7 not less than #f_/ajj percent and not to exceed #a_/aj percent of the amounts the ,board estimates will be expended from the ,trust ,fund in the fiscal year4 7d7 ,funds supplemental to other funds ,the funds provided under this section with respect to provision of services are in addition to1 and not in replacement of1 funds made available under the sections #cdj;,a1 #ajja1 and #bfee of the ,public ,health ,service ,act4 ,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 #bjab4 #gac4 ,primary care service expansion grants 7a7 ,in general ,part ,d of title ,,iii of the ,public ,health ,service ,act 7#db ,u4,s4,c4 #bed;b et seq47 is amended by adding at the end the following new subpart3 ,,xiii ,primary care expansion #cdj;,j4 ,expanding primary care delivery capacity in urban and rural areas 7a7 ,grants for primary care centers ,from the amounts described in subsection 7c71 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 7as defined in section #ccj7;b77#c77 in urban and rural areas and to deliver primary care services to such populations in such areas4 ,the funds provided under such a grant may be used for the same purposes for which a grant may be made under subsection 7c71 7e71 7f71 7g71 7h71 or 7i7 of section #ccj4 7b7 ,process of awarding grants ,the provisions of subsection 7k77#a7 of section #ccj shall apply to a grant under this section in the same manner as they apply to a grant under the corresponding subsection of such section4 ,the provisions of subsection 7r77#b77;,a7 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 section4 7c7 ,funding as set-,aside from ,trust ,fund ,funds in the ,american ,health ,security ,trust ,fund 7established under section #hja of the act7 shall be available to carry out this section4 7d7 ,primary care center defined ,in this section1 the term primary care center means-- 7#a7 a health center 7as defined in section #ccj7;a77#a772 7#b7 an entity qualified to receive a grant under section #ccj1 #ajja1 or #bfea2 or 7#c7 a ,federally-qualified health center 7as defined in section #aije7l77#b77;,b7 of the ,social ,security ,act74 4 7b7 ,technical amendments ,part ,d of title ,,iii of the ,public ,health ,service ,act 7#db ,u4,s4,c4 #bed;b et seq47 is amended-- 7#a7 by redesignating subpart ,,xi1 as added by section #ajccc of the ,patient ,protection and ,affordable ,care ,act 7,public ,law #aaa-adh71 as subpart ,,xii2 and 7#b7 by redesignating section #cdj;,h of the ,public ,health ,service ,act 7#db ,u4,s4,c4 #bef;i71 as added by section #ajccc of the ,patient ,protection and ,affordable ,care ,act 7,public ,law #aaa-adh71 as section #cdj;,i4 ,c ,primary ,care and ,outcomes ,research #gba4 ,set-aside for outcomes research 7a7 ,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 7#db ,u4,s4,c4 #bii et seq47 for the purpose of carrying out activities under such title4 ,the ,secretary shall assure that there is a special emphasis placed on pediatric outcomes research4 7b7 ,range of funds ,the amount of transfers under subsection 7a7 for any fiscal year shall be an amount 7specified by the ,board each year7 not less than #a_/ajj percent and not to exceed #b_/ajj percent of the amounts the ,board estimates will be expended from the ,trust ,fund in the fiscal year4 7c7 ,funds supplemental to other funds ,the funds provided under this section with respect to provision of services are in addition to1 and not in replacement of1 funds made available to the ,agency for ,healthcare ,research and ,quality under section #idg of the ,public ,health ,service ,act 7#db ,u4,s4,c4 #bii;c-#f74 ,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 #bjab4 7d7 ,conforming amendment ,section #idg7;b7 of the ,public ,health ,service ,act 7#db ,u4,s4,c4 #bii;c-#f7;b77 is amended by inserting after of the fiscal years #bjja through #bjje the following3 and of fiscal year #bjad and each subsequent year4 #gbb4 ,office of ,primary ,care and ,prevention ,research 7a7 ,in general ,title ,,iv of the ,public ,health ,service ,act is amended-- 7#a7 by redesignating parts ,g through ,i as parts ,h through ,j1 respectively2 and 7#b7 by inserting after part ,f 7#db ,u4,s4,c4 #bhg;d et seq47 the following new part3 ,g ,research on primary care and prevention #dhf;,e4 ,office of ,primary ,care and ,prevention ,research 7a7 ,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 7in this part referred to as the ,office74 ,the ,office shall be headed by a director1 who shall be appointed by the ,director of ,,nih4 7b7 ,purpose ,the ,director of the ,office shall-- 7#a7 identify projects of research on primary care and prevention1 for children as well as adults1 that should be conducted or supported by the national research institutes1 with particular emphasis on-- 7,a7 clinical patient care1 with special emphasis on pediatric clinical care and diagnosis2 7,b7 diagnostic effectiveness2 7,c7 primary care education2 7,d7 health and family planning services2 7,e7 medical effectiveness outcomes of primary care procedures and interventions2 and 7,f7 the use of multidisciplinary teams of health care practitioners2 7#b7 identify multidisciplinary research related to primary care and prevention that should be so conducted2 7#c7 promote coordination and collaboration among entities conducting research identified under any of paragraphs 7#a7 and 7#b72 7#d7 encourage the conduct of such research by entities receiving funds from the national research institutes2 7#e7 recommend an agenda for conducting and supporting such research2 7#f7 promote the sufficient allocation of the resources of the national research institutes for conducting and supporting such research2 and 7#g7 prepare the report required under section #dhf;,g4 7c7 ,primary care and prevention research defined ,for purposes of this part1 the term primary care and prevention research means research on improvement of the practice of family medicine1 general internal medicine1 and general pediatrics1 and includes research relating to-- 7#a7 obstetrics and gynecology1 dentistry1 or mental health or substance abuse treatment when provided by a primary care physician or other primary care practitioner2 and 7#b7 primary care provided by multidisciplinary teams4 #dhf;,f4 ,national data system and clearinghouse on primary care and prevention research 7a7 ,data system ,the ,director of ,,nih1 in consultation with the ,director of the ,office1 shall establish a data system for the collection1 storage1 analysis1 retrieval1 and dissemination of information regarding primary care and prevention research that is conducted or supported by the national research institutes4 ,information from the data system shall be available through information systems available to health care professionals and providers1 researchers1 and members of the public4 7b7 ,clearinghouse ,the ,director of ,,nih1 in consultation with the ,director of the ,office and with the ,national ,library of ,medicine1 shall establish1 maintain1 and operate a program to provide1 and encourage the use of1 information on research and prevention activities of the national research institutes that relate to primary care and prevention research4 #dhf;,g4 ,biennial report 7a7 ,in general ,with respect to primary care and prevention research1 the ,director of the ,office shall1 not later than #a year after the date of the enactment of this part1 and biennially thereafter1 prepare a report-- 7#a7 describing and evaluating the progress made during the preceding #b fiscal years in research and treatment conducted or supported by the ,national ,institutes of ,health2 7#b7 summarizing and analyzing expenditures made by the agencies of such ,institutes 7and by such ,office7 during the preceding #b fiscal years2 and 7#c7 making such recommendations for legislative and administrative initiatives as the ,director of the ,office determines to be appropriate4 7b7 ,inclusion in biennial report of ,director of ,,nih ,the ,director of the ,office shall submit each report prepared under subsection 7a7 to the ,director of ,,nih for inclusion in the report submitted to the ,president and the ,congress under section #djc4 #dhf;,h4 ,authorization of appropriations ,for the ,office of ,primary ,care and ,prevention ,research1 there are authorized to be appropriated #aej1jjj1jjj for fiscal year #bjad1 #ahj1jjj1jjj for fiscal year #bjae1 and #baf1jjj1jjj for fiscal year #bjaf4 4 7b7 ,requirement of sufficient allocation of resources of ,institutes ,section #djb7;b7 of the ,public ,health ,service ,act 7#db ,u4,s4,c4 #bhb7;b77 is amended-- 7#a7 in paragraph 7#bc71 by striking and after the semicolon at the end2 7#b7 in paragraph 7#bd71 by striking the period at the end and inserting 2 and2 and 7#c7 by inserting after paragraph 7#bd7 the following new paragraph3 7#be7 after consultation with the ,director of the ,office of ,primary ,care and ,prevention ,research1 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 #dhf;,e7b74 4 ,d ,school-,related ,health ,services #gca4 ,authorizations of appropriations 7a7 ,funding for school-,related health services ,for the purpose of carrying out this subtitle1 there are authorized to be appropriated #ajj1jjj1jjj for fiscal year #bjaf1 #bge1jjj1jjj for fiscal year #bjag1 #cej1jjj1jjj for fiscal year #bjah1 and #djj1jjj1jjj for each of the fiscal years #bjai and #bjbj4 7b7 ,relation to other funds ,the authorizations of appropriations established in subsection 7a7 are in addition to any other authorizations of appropriations that are available for the purpose described in such subsection4 #gcb4 ,eligibility for development and operation grants 7a7 ,in general ,entities eligible to apply for and receive grants under section #gcd or #gce are the following3 7#a7 ,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 ,state4 7#b7 ,local community partnerships in ,states in which health agencies have not applied4 7b7 ,local community partnerships 7#a7 ,in general ,a local community partnership under subsection 7a77#b7 is an entity that1 at a minimum1 includes-- 7,a7 a local health care provider with experience in delivering services to school-aged children2 7,b7 one or more local public schools2 and 7,c7 at least one 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-risk4 7#b7 ,participation ,a partnership described in paragraph 7#a7 shall1 to the maximum extent feasible1 involve broad based community participation from parents and adolescent children to be served1 health and social service providers1 teachers and other public school and school board personnel1 development and service organizations for adolescent children1 and interested business leaders4 ,such participation may be evidenced through an expanded partnership1 or an advisory board to such partnership4 7c7 ,definitions regarding children ,for purposes of this subtitle3 7#a7 ,the term adolescent children means school-aged children who are adolescents4 7#b7 ,the term school-aged children means individuals who are between the ages of #d and #ai 7inclusive74 #gcc4 ,preferences 7a7 ,in general ,in making grants under sections #gcd and #gce1 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 children1 as measured by indicators of community health including the following3 7#a7 ,high levels of poverty4 7#b7 ,the presence of a medically underserved population4 7#c7 ,the presence of a health professional shortage area4 7#d7 ,high rates of indicators of health risk among school-aged children1 including a high proportion of such children receiving services through the ,individuals with ,disabilities ,education ,act1 adolescent pregnancy1 sexually transmitted disease 7including infection with the human immunodeficiency virus71 preventable disease1 communicable disease1 intentional and unintentional injuries1 community and gang violence1 unemployment among adolescent children1 juvenile justice involvement1 and high rates of drug and alcohol exposure4 7b7 ,linkage to community health centers ,in making grants under sections #gcd and #gce1 the ,secretary shall give preference to applicants that demonstrate a linkage to community health centers4 #gcd4 ,grants for development of projects 7a7 ,in general ,the ,secretary may make grants to ,state health agencies or to local community partnerships to develop school health service sites4 7b7 ,use of funds ,a project for which a grant may be made under subsection 7a7 may include the cost of the following3 7#a7 ,planning for the provision of school health services4 7#b7 ,recruitment1 compensation1 and training of health and administrative staff4 7#c7 ,the development of agreements1 and the acquisition and development of equipment and information services1 necessary to support information exchange between school health service sites and health plans1 health providers1 and other entities authorized to collect information under this ,act4 7#d7 ,other activities necessary to assume operational status4 7c7 ,application for grant 7#a7 ,in general ,applicants shall submit applications in a form and manner prescribed by the ,secretary4 7#b7 ,applications by ,state health agencies 7,a7 ,in the case of applicants that are ,state health agencies1 the application shall contain assurances that the ,state health agency is applying for funds-- 7i7 on behalf of at least one local community partnership2 and 7ii7 on behalf of at least one other community identified by the ,state as in need of the services funded under this subtitle but without a local community partnership4 7,b7 ,in the case of the communities identified in applications submitted by ,state health agencies that do not yet have local community partnerships 7including the community identified under subparagraph 7,a77ii771 the ,state shall describe the steps that will be taken to aid the communities in developing a local community partnership4 7,c7 ,a ,state applying on behalf of local community partnerships and other communities may retain not more than #aj percent of grants awarded under this subtitle for administrative costs4 7d7 ,contents of application ,in order to receive a grant under this section1 an applicant shall include in the application the following information3 7#a7 ,an assessment of the need for school health services in the communities to be served1 using the latest available health data and health goals and objectives established by the ,secretary4 7#b7 ,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 risk4 7#c7 ,an explanation of how the applicant will integrate its services with those of other health and social service programs within the community4 7#d7 ,a description of a quality assurance program which complies with standards that the ,secretary may prescribe4 7e7 ,number of grants ,not more than one planning grant may be made to a single applicant4 ,a planning grant may not exceed #b years in duration4 #gce4 ,grants for operation of projects 7a7 ,in general ,the ,secretary may make grants to ,state health agencies or to local community partnerships for the cost of operating school health service sites4 7b7 ,use of grant ,the costs for which a grant may be made under this section include the following3 7#a7 ,the cost of furnishing health services that are not otherwise covered under this ,act or by any other public or private insurer4 7#b7 ,the cost of furnishing services whose purpose is to increase the capacity of individuals to utilize available health services1 including transportation1 community and patient outreach1 patient education1 translation services1 and such other services as the ,secretary determines to be appropriate in carrying out such purpose4 7#c7 ,training1 recruitment and compensation of health professionals and other staff4 7#d7 ,outreach services to school-aged children who are at risk and to the parents of such children4 7#e7 ,linkage of individuals to health plans1 community health services and social services4 7#f7 ,other activities deemed necessary by the ,secretary4 7c7 ,application for grant ,applicants shall submit applications in a form and manner prescribed by the ,secretary4 ,in order to receive a grant under this section1 an applicant shall include in the application the following information3 7#a7 ,a description of the services to be furnished by the applicant4 7#b7 ,the amounts and sources of funding that the applicant will expend1 including estimates of the amount of payments the applicant will receive from sources other than the grant4 7#c7 ,such other information as the ,secretary determines to be appropriate4 7d7 ,additional contents of application ,in order to receive a grant under this section1 an applicant shall meet the following conditions3 7#a7 ,the applicant furnishes the following services3 7,a7 ,diagnosis and treatment of simple illnesses and minor injuries4 7,b7 ,preventive health services1 including health screenings4 7,c7 ,services provided for the purpose described in subsection 7b77#b74 7,d7 ,referrals and followups in situations involving illness or injury4 7,e7 ,health and social services1 counseling services1 and necessary referrals1 including referrals regarding mental health and substance abuse4 7,f7 ,such other services as the ,secretary determines to be appropriate4 7#b7 ,the applicant is a participating provider in the ,state's program for medical assistance under title ,,xix of the ,social ,security ,act4 7#c7 ,the applicant does not impose charges on students or their families for services 7including collection of any cost-sharing for services under the comprehensive benefit package that otherwise would be required74 7#d7 ,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 area1 and that1 to the maximum extent possible1 barriers to access to services of the applicant are removed 7including barriers resulting from the area's physical characteristics1 its economic1 social and cultural grouping1 the health care utilization patterns of such children1 and available transportation74 7#e7 ,in the case of an applicant which serves a population that includes a substantial proportion of individuals of limited ,english speaking ability1 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 individuals4 7#f7 ,the applicant will provide non-,federal contributions toward the cost of the project in an amount determined by the ,secretary4 7#g7 ,the applicant will operate a quality assurance program consistent with section #gcd7;d74 7e7 ,duration of grant ,a grant under this section shall be for a period determined by the ,secretary4 7f7 ,reports ,a recipient of funding under this section shall provide such reports and information as are required in regulations of the ,secretary4 #gcf4 ,federal administrative costs ,of the amounts made available under section #gca1 the ,secretary may reserve not more than #e percent for administrative expenses regarding this subtitle4 #gcg4 ,definitions ,for purposes of this subtitle3 7#a7 ,the term adolescent children has the meaning given such term in section #gcb7;c74 7#b7 ,the term at risk means at-risk with respect to health4 7#c7 ,the term community health center has the meaning given such term in section #ccj of the ,public ,health ,service ,act4 7#d7 ,the term health professional shortage area means a health professional shortage area designated under section #ccb of the ,public ,health ,service ,act4 7#e7 ,the term medically underserved population has the meaning given such term in section #ccj of the ,public ,health ,service ,act4 7#f7 ,the term school-aged children has the meaning given such term in section #gcb7;c74 ,,viii ,financing ,provisions2 ,american ,health ,security ,trust ,fund #hjj4 ,amendment of #aihf code2 ,section #ae not to apply 7a7 ,amendment of #aihf ,code ,except as otherwise expressly provided1 whenever in this title an amendment or repeal is expressed in terms of an amendment to1 or repeal of1 a section or other provision1 the reference shall be considered to be made to a section or other provision of the ,internal ,revenue ,code of #aihf4 7b7 ,section #ae 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 #ae of the ,internal ,revenue ,code of #aihf4 ,a ,american ,health ,security ,trust ,fund #hja4 ,american ,health ,security ,trust ,fund 7a7 ,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 7in this section referred to as the ,trust ,fund74 ,the ,trust ,fund shall consist of such gifts and bequests as may be made and such amounts as may be deposited in1 or appropriated to1 such ,trust ,fund as provided in this ,act4 7b7 ,appropriations into ,trust ,fund 7#a7 ,taxes ,there are hereby appropriated to the ,trust ,fund for each fiscal year 7beginning with fiscal year #bjae71 out of any moneys in the ,treasury not otherwise appropriated1 amounts equivalent to #ajj percent of the aggregate increase in tax liabilities under the ,internal ,revenue ,code of #aihf which is attributable to the application of the amendments made by this title4 ,the amounts appropriated by the preceding sentence shall be transferred from time to time 7but not less frequently than monthly7 from the general fund in the ,treasury to the ,trust ,fund1 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 ,treasury2 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 transferred4 7#b7 ,current program receipts ,notwithstanding any other provision of law1 there are hereby appropriated to the ,trust ,fund for each fiscal year 7beginning with fiscal year #bjae7 the amounts that would otherwise have been appropriated to carry out the following programs3 7,a7 ,the ,medicare program1 under parts ,a1 ,b1 and ,d of title ,,xviii of the ,social ,security ,act 7other than amounts attributable to any premiums under such parts74 7,b7 ,the ,medicaid program1 under ,state plans approved under title ,,xix of such ,act4 7,c7 ,the ,federal employees health benefit program1 under chapter #hi of title #e1 ,united ,states ,code4 7,d7 ,the ,,tricare program 7formerly known as the ,,champus program71 under chapter #ee of title #aj1 ,united ,states ,code4 7,e7 ,the maternal and child health program 7under title ,v of the ,social ,security ,act71 vocational rehabilitation programs1 programs for drug abuse and mental health services under the ,public ,health ,service ,act1 programs providing general hospital or medical assistance1 and any other ,federal program identified by the ,board1 in consultation with the ,secretary of the ,treasury1 to the extent the programs provide for payment for health services the payment of which may be made under this ,act4 7c7 ,incorporation of provisions ,the provisions of subsections 7b7 through 7i7 of section #ahag 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 ,act1 except that the ,american ,health ,security ,standards ,board shall constitute the ,board of ,trustees of the ,trust ,fund4 7d7 ,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 completed1 shall be transferred into the ,american ,health ,security ,trust ,fund4 ,b ,taxes ,based on ,income and ,wages #haa4 ,payroll tax on employers 7a7 ,in general ,section #caaa 7relating to tax on employers7 is amended by redesignating subsections 7c7 and 7d7 as subsection 7d7 and 7e71 respectively1 and by inserting after subsection 7b7 the following new subsection3 7c7 ,health care ,in addition to other taxes1 there is hereby imposed on every employer an excise tax1 with respect to having individuals in his employ1 equal to #f4g percent of the wages 7as defined in section #caba7;a77 paid by him with respect to employment 7as defined in section #caba7;b774 4 7b7 ,self-,employment income ,section #adja 7relating to rate of tax on self-employment income7 is amended by redesignating subsection 7c7 as subsection 7d7 and inserting after subsection 7b7 the following new subsection3 7c7 ,health care ,in addition to other taxes1 there shall be imposed for each taxable year1 on the self-employment income of every individual1 a tax equal to #f4g percent of the amount of the self-employment income for such taxable year4 4 7c7 ,comparable taxes for railroad services 7#a7 ,tax on employers ,section #cbba is amended by redesignating subsections 7c7 and 7d7 as subsections 7d7 and 7e71 respectively1 and by inserting after subsection 7b7 the following new subsection3 7c7 ,health care ,in addition to other taxes1 there is hereby imposed on every employer an excise tax1 with respect to having individuals in his employ1 equal to #f4g percent of the compensation paid by such employer for services rendered to such employer4 4 7#b7 ,tax on employee representatives ,section #cbaa 7relating to tax on employee representatives7 is amended by redesignating subsection 7c7 as subsection 7d7 and inserting after subsection 7b7 the following new paragraph3 7c7 ,health care ,in addition to other taxes1 there is hereby imposed on the income of each employee representative a tax equal to #f4g percent of the compensation received during the calendar year by such employee representative for services rendered by such employee representative4 4 7#c7 ,no applicable base ,subparagraph 7,a7 of section #cbca7;e77#b7 is amended by adding at the end thereof the following new clause3 7iv7 ,health care taxes ,clause 7i7 shall not apply to the taxes imposed by sections #cbba7;c7 and #cbaa7;c74 4 7#d7 ,technical amendment 7,a7 ,subsection 7d7 of section #cbaa1 as redesignated by paragraph 7#b71 is amended by striking and 7b7 and inserting 1 7b71 and 7c74 7,b7 ,subsection 7d7 of section #cbba1 as redesignated by paragraph 7#a71 is amended by striking and 7b7 and inserting 1 7b71 and 7c74 7d7 ,effective date ,the amendments made by this section shall apply to remuneration paid after ,december #ca1 #bjad4 #hab4 ,health care income tax 7a7 ,general rule ,subchapter ,a of chapter #a 7relating to determination of tax liability7 is amended by adding at the end thereof the following new part3 ,,viii ,health care related taxes ,subpart ,a4--,health care income tax on individuals ,a ,health care income tax on individuals ,sec4 #ei;,b4 ,health care income tax4 #ei;,b4 ,health care income tax 7a7 ,imposition of tax ,in the case of an individual1 there is hereby imposed on the taxable income of the taxpayer for the taxable year a tax 7in addition to any other tax imposed by this subtitle7 determined in accordance with the following tables3 7#a7 ,married individuals filing joint returns and surviving spouses ,in the case of any taxpayer making a joint return under section #fjac or a surviving spouse 7as defined in section #b7;a771 the following table shall apply3 ,if taxable income is3,the tax is3 ,not over #bej1jjjb4b of taxable income4 ,over #bej1jjj but not over #djj1jjje1ejj1 plus #c4b of the excess over #bej1jjj4 ,over #djj1jjj but not over #fjj1jjjaj1cjj1 plus #d4b of the excess over #djj1jjj4 ,over #fjj1jjjah1gjj1 plus #e4b of the excess over #fjj1jjj4 7#b7 ,other taxpayers ,in the case of any taxpayer not described in paragraph 7#a71 the following table shall apply3 ,if taxable income is3,the tax is3 ,not over #bjj1jjjb4b of taxable income4 ,over #bjj1jjj but not over #djj1jjjd1djj1 plus #c4b of the excess over #bjj1jjj4 ,over #djj1jjj but not over #fjj1jjjaj1hjj1 plus #d4b of the excess over #djj1jjj4 ,over #fjj1jjjai1bjj1 plus #e4b of the excess over #fjj1jjj4 7b7 ,inflation adjustment 7#a7 ,in general ,in the case of any taxable year beginning after #bjae1 each of the dollar amounts set forth in the tables in subsection 7a7 shall be increased by an amount equal to-- 7,a7 such dollar amount1 multiplied by 7,b7 the cost-of-living adjustment determined under section #a7;f77#c7 for such calendar year by substituting calendar year #bjad for calendar year #aiib in subparagraph 7,b7 thereof4 7#b7 ,rounding ,if the amount as adjusted under paragraph 7#a7 is not a multiple of #a1jjj1 such amount shall be rounded to the next lowest multiple of #a1jjj4 7c7 ,no credits against tax2 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-- 7#a7 the amount of any credit allowable under this chapter1 or 7#b7 the amount of the minimum tax imposed by section #ee4 7d7 ,special rules 7#a7 ,tax to be withheld1 etc ,for purposes of this title1 the tax imposed by this section shall be treated as imposed by section #a4 7#b7 ,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 section4 7#c7 ,other rules ,the rules of section #ei;,a7d7 shall apply to the tax imposed by this section4 4 7b7 ,clerical amendment ,the table of parts for subchapter ,a of chapter #a is amended by adding at the end the following new item3 ,part ,,viii--,health care related taxes 4 7c7 ,effective date ,the amendments made by this section shall apply to taxable years beginning after ,december #ca1 #bjad4 #hac4 ,surcharge on high income individuals 7a7 ,in general ,part ,,viii of subchapter ,a of chapter #a1 as added by this title1 is amended by adding at the end the following new subpart3 ,b ,surcharge on high income individuals ,sec4 #ei;,c4 ,surcharge on high income individuals4 #ei;,c4 ,surcharge on high income individuals 7a7 ,general rule ,in the case of a taxpayer other than a corporation1 there is hereby imposed 7in addition to any other tax imposed by this subtitle7 a tax equal to #e4d percent of so much of the modified adjusted gross income of the taxpayer as exceeds #a1jjj1jjj4 7b7 ,taxpayers not making a joint return ,in the case of any taxpayer other than a taxpayer making a joint return under section #fjac or a surviving spouse 7as defined in section #b7;a771 subsection 7a7 shall be applied by substituting #ejj1jjj for #a1jjj1jjj4 7c7 ,modified adjusted gross income ,for purposes of this section1 the term modified adjusted gross income means adjusted gross income reduced by any deduction 7not taken into account in determining adjusted gross income7 allowed for investment interest 7as defined in section #afc7;d774 ,in the case of an estate or trust1 adjusted gross income shall be determined as provided in section #fg7;e74 7d7 ,special rules 7#a7 ,nonresident alien ,in the case of a nonresident alien individual1 only amounts taken into account in connection with the tax imposed under section #hga7;b7 shall be taken into account under this section4 7#b7 ,citizens and residents living abroad ,the dollar amount in effect under subsection 7a7 7after the application of subsection 7b77 shall be decreased by the excess of-- 7,a7 the amounts excluded from the taxpayer's gross income under section #iaa1 over 7,b7 the amounts of any deductions or exclusions disallowed under section #iaa7;d77#f7 with respect to the amounts described in subparagraph 7,a74 7#c7 ,charitable trusts ,subsection 7a7 shall not apply to a trust all the unexpired interests in which are devoted to one or more of the purposes described in section #agj7;c77#b77;,b74 7#d7 ,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 #ee4 4 7b7 ,clerical amendment ,the table of subparts for part ,,viii of subchapter ,a of chapter #a1 as added by this title1 is amended by inserting after the item relating to subpart ,a the following new item3 ,subpart ,b4 ,surcharge on high income individuals 4 7c7 ,section #ae not ,to apply ,the amendment made by subsection 7a7 shall not be treated as a change in a rate of tax for purposes of section #ae of the ,internal ,revenue ,code of #aihf4 7d7 ,effective date ,the amendments made by this section shall apply to taxable years beginning after ,december #ca1 #bjad4 ,c ,other financing provisions #hba4 ,tax on ,securities ,transactions 7a7 ,in general ,chapter #cf is amended by inserting after subchapter ,b the following new subchapter3 ,c ,tax on ,securities ,transactions ,sec4 #ddge4 ,tax on securities transactions4 #ddge4 ,tax on securities transactions 7a7 ,imposition of tax 7#a7 ,stocks ,there is hereby imposed a tax on each covered transaction in a stock contract of #j4be percent of the value of the instruments involved in such transaction4 7#b7 ,futures ,there is hereby imposed a tax on each covered transaction in a futures contract of #j4jb percent of the value of the instruments involved in such transaction4 7#c7 ,swaps ,there is hereby imposed a tax on each covered transaction in a swaps contract of #j4jb percent of the value of the instruments involved in such transaction4 7#d7 ,credit default swaps ,there is hereby imposed a tax on each covered transaction in a credit default swaps contract of #j4jb percent of the value of the instruments involved in such transaction4 7#e7 ,options ,there is hereby imposed a tax on each covered transaction in an options contract with respect to a transaction described in paragraph 7#a71 7#b71 7#c71 or 7#d7 of-- 7,a7 the rate imposed with respect to such underlying transaction under paragraph 7#a71 7#b71 7#c71 or 7#d7 7as the case may be71 multiplied by 7,b7 the premium paid on such option4 7b7 ,exception for retirement accounts1 etc ,no tax shall be imposed under subsection 7a7 with respect to any stock contract1 futures contract1 swaps contract1 credit default swap1 or options contract which is held in any plan1 account1 or arrangement described in section #bbj1 #bbc1 #dja7;a71 #djc7;a71 #djc7;b71 #djh1 #djh;,a1 #ebi1 or #ecj4 7c7 ,exception for interests in mutual funds ,no tax shall be imposed under subsection 7a7 with respect to the purchase or sale of any interest in a regulated investment company 7as defined in section #hea7 or of any derivative of such an interest4 7d7 ,by whom paid 7#a7 ,in general ,the tax imposed by this section shall be paid by-- 7,a7 in the case of a transaction which occurs on a trading facility located in the ,united ,states1 such trading facility1 or 7,b7 in any other case1 the purchaser with respect to the transaction4 7#b7 ,withholding if buyer is not a ,united ,states person ,see section #addg for withholding by seller if buyer is a foreign person4 7e7 ,covered transaction ,the term covered transaction means any purchase or sale if-- 7#a7 such purchase or sale occurs on a trading facility located in the ,united ,states1 or 7#b7 the purchaser or seller is a ,united ,states person4 7f7 ,administration ,the ,secretary shall carry out this section in consultation with the ,securities and ,exchange ,commission and the ,commodity ,futures ,trading ,commission4 4 7b7 ,credit for first #ajj1jjj of stock transactions per year ,subpart ,c of part ,,iv of subchapter ,a of chapter #a is amended by inserting after section #cf;,a the following new section3 #cf;,b4 ,credit for securities transaction taxes 7a7 ,allowance of credit ,in the case of any purchaser with respect to a covered transaction1 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-- 7#a7 the aggregate amount of tax imposed under section #ddge on covered transactions during the taxable year with respect to which the taxpayer is the purchaser1 or 7#b7 #bej 7#ejj in the case of a joint return74 7b7 ,aggregation rule ,for purposes of this section1 all persons treated as a single employer under subsection 7a7 or 7b7 of section #eb1 or subsection 7m7 or 7o7 of section #dad1 shall be treated as one taxpayer4 7c7 ,definitions ,for purposes of this section1 any term used in this section which is also used in section #ddge shall have the same meaning as when used in section #ddge4 4 7c7 ,withholding ,subchapter ,a of chapter #c is amended by adding at the end the following new section3 #addg4 ,withholding on securities transactions 7a7 ,in general ,in the case of any outbound securities transaction1 the transferor shall deduct and withhold a tax equal to the tax imposed under section #ddge with respect to such transaction4 7b7 ,outbound securities transaction ,for purposes of this section1 the term outbound securities transaction means any covered transaction to which section #ddge7;a7 applies if-- 7#a7 such transaction does not occur on a trading facility located in the ,united ,states1 and 7#b7 the purchaser with respect to such transaction is not a ,united ,states person4 4 7d7 ,conforming amendments 7#a7 ,section #fbaa7;b77#d77;,a7 is amended by inserting #cf;,b1 after #cf;,a14 7#b7 ,section #acbd7;b77#b7 of title #ca1 ,united ,states ,code1 is amended by inserting #cf;,b1 after #cf;,a14 7#c7 ,the table of subchapters for chapter #cf is amended by inserting after the item relating to subchapter ,b the following new item3 ,subchapter ,c4 ,tax on securities transactions 4 7#d7 ,the table of sections for subchapter ,a of chapter #c is amended by adding at the end the following new item3 ,sec4 #addg4 ,withholding on securities transactions4 4 7#e7 ,the table of sections for subpart ,c of part ,,iv of subchapter ,a of chapter #a is amended by inserting after the item relating to section #cf;,a the following new item3 ,sec4 #cf;,b4 ,credit for securities transaction taxes4 4 7e7 ,effective date ,the amendments made by this section shall apply to transactions occurring more than #ahj days after the date of the enactment of this ,act4 ,,ix ,conforming ,amendments to the ,employee ,retirement ,income ,security ,act of #aigd #ija4 ,,erisa inapplicable to health coverage arrangements under ,state health security programs ,section #d of the ,employee ,retirement ,income ,security ,act of #aigd 7#bi ,u4,s4,c4 #ajjc7 is amended-- 7#a7 in subsection 7a71 by striking 7b7 or 7c7 and inserting 7b71 7c71 or 7d72 and 7#b7 by adding at the end the following new subsection3 7d7 ,the provisions of this title shall not apply to any arrangement forming a part of a ,state health security program established pursuant to section #aja7;b7 of the ,american ,health ,security ,act of #bjac4 4 #ijb4 ,exemption of ,state health security programs from ,,erisa preemption ,section #ead7;b7 of the ,employee ,retirement ,income ,security ,act of #aigd 7#bi ,u4,s4,c4 #aadd7;b77 7as amended by sections #ijd7;b77#c77;,b7 and #ajjb7;b7 of this ,act7 is amended by adding at the end the following new paragraph3 7#aj7 ,subsection 7a7 of this section shall not apply to ,state health security programs established pursuant to section #aja7;b7 of the ,american ,health ,security ,act of #bjac4 4 #ijc4 ,prohibition of employee benefits duplicative of benefits under ,state health security programs2 coordination in case of workers' compensation 7a7 ,in general ,part #e of subtitle ,b of title ,i of the ,employee ,retirement ,income ,security ,act of #aigd 7#bi ,u4,s4,c4 #aaca et seq47 is amended by adding at the end the following new section3 #ebb4 ,prohibition of employee benefits duplicative of ,state health security program benefits2 coordination in case of workers' compensation 7a7 ,subject to subsection 7b71 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 #aja7;b7 of the ,american ,health ,security ,act of #bjac4 7b7 7#a7 ,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 services4 7#b7 ,in this subsection3 7,a7 ,the term workers compensation carrier means an insurance company that underwrites workers compensation medical benefits with respect to one or more employers and includes an employer or fund that is financially at risk for the provision of workers compensation medical benefits4 7,b7 ,the term workers compensation medical benefits means1 with respect to an enrollee who is an employee subject to the workers compensation laws of a ,state1 the comprehensive medical benefits for work-related injuries and illnesses provided for under such laws with respect to such an employee4 7,c7 ,the term workers compensation services means items and services included in workers compensation medical benefits and includes items and services 7including rehabilitation services and long-term-care services7 commonly used for treatment of work-related injuries and illnesses4 4 7b7 ,conforming amendment ,section #d7;b7 of such ,act 7#bi ,u4,s4,c4 #ajjc7;b77 is amended by adding at the end the following3 ,paragraph 7#c7 shall apply subject to section #ebb7;b7 7relating to reimbursement of ,state health security plans by workers compensation carriers744 7c7 ,clerical amendment ,the table of contents in section #a of such ,act is amended by inserting after the item relating to section #eba the following new items3 ,sec4 #ebb4 ,prohibition of employee benefits duplicative of ,state health security program benefits2 coordination in case of workers' compensation4 4 #ijd4 ,repeal of continuation coverage requirements under ,,erisa and certain other requirements relating to group health plans 7a7 ,in general ,part #f of subtitle ,b of title ,i of the ,employee ,retirement ,income ,security ,act of #aigd 7#bi ,u4,s4,c4 #aafa et seq47 is repealed4 7b7 ,conforming amendments 7#a7 ,section #ejb7;a7 of such ,act 7#bi ,u4,s4,c4 #aacb7;a77 is amended-- 7,a7 by striking paragraph 7#g72 and 7,b7 by redesignating paragraphs 7#h71 7#i71 and 7#aj7 as paragraphs 7#g71 7#h71 and 7#i71 respectively4 7#b7 ,section #ejb7;c77#a7 of such ,act 7#bi ,u4,s4,c4 #aacb7;c77#a77 is amended by striking paragraph 7#a7 or 7#d7 of section #fjf14 7#c7 ,section #ead7;b7 of such ,act 7#bi ,u4,s4,c4 #aadd7;b77 is amended-- 7,a7 in paragraph 7#g71 by striking section #bjf7;d77#c77;,b77i771 and all that follows and inserting section #bjf7;d77#c77;,b77i7742 and 7,b7 by striking paragraph 7#h74 7#d7 ,the table of contents in section #a of the ,employee ,retirement ,income ,security ,act of #aigd is amended by striking the items relating to part #f of subtitle ,b of title ,i of such ,act4 #ije4 ,effective date of title ,the amendments made by this title shall take effect ,january #a1 #bjaf4 ,x ,additional ,conforming ,amendments #ajja4 ,repeal of certain provisions in ,internal ,revenue ,code of #aihf ,the provisions of titles ,,iii and ,,iv of the ,health ,insurance ,portability and ,accountability ,act of #aiif1 other than subtitles ,d and ,h of title ,,iii and section #cdb1 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 enacted4 #ajjb4 ,repeal of certain provisions in the ,employee ,retirement ,income ,security ,act of #aigd 7a7 ,in general ,part #g of subtitle ,b of title ,i of the ,employee ,retirement ,income ,security ,act of #aigd 7#bi ,u4,s4,c4 #aaha et seq47 is repealed and the items relating to such part in the table of contents in section #a of such ,act are repealed4 7b7 ,conforming amendment ,section #ead7;b7 of such ,act 7#bi ,u4,s4,c4 #aadd7;b77 is amended by striking paragraph 7#i74 #ajjc4 ,repeal of certain provisions in the ,public ,health ,service ,act and related provisions 7a7 ,in general ,titles ,,xxii and ,,xxvii of the ,public ,health ,service ,act 7#db ,u4,s4,c4 #cjj;bb-#a et seq41 #cjj;gg et seq47 are repealed4 7b7 ,certain ,,ppaca provisions ,title ,i of the ,patient ,protection and ,affordable ,care ,act 7,public ,law #aaa-adh7 7and the amendments made by such title7 is repealed4 7c7 ,additional amendments 7#a7 ,section #acja7;b7 of such ,act 7#db ,u4,s4,c4 #cjj;e7b77 is amended by striking paragraph 7#f74 7#b7 ,sections #ajd and #aia of the ,health ,insurance ,portability and ,accountability ,act of #aiif are repealed4 #ajjd4 ,effective date of title ,the amendments made by this title shall take effect ,january #a1 #bjag4