,,ii #aac? ,,congress #a/ ,session ,s4 #aghb ,,9 ,,! ,,s5ate ,,( ,,! ,,unit$ ,,/ates ,decemb] #i1 #bjac,mr4 ,s&]s introduc$ ! foll[+ bill2 :i* 0 read twice & ref]r$ to ! ,committee on ,f9ance ,a ,,bill ,to provide = heal? c>e = e ,am]ican & to control ! co/ & enhance ! quality ( ! heal? c>e sy/em4 #a4 ,%ort title ,?is ,act may be cit$ z ! ,am]ican ,heal? ,security ,act ( #bjac4 #b4 ,f9d+s2 s5se ( ! ,s5ate 7a7 ,f9d+s ,congress f9ds z foll[s3 7#a7 ,:ile ! ,unit$ ,/ates ( ,am]ica sp5ds on av]age ne>ly twice z mu* p] capita on heal? c>e s]vices z ! next mo/ co/ly nation1 ! ,unit$ ,/ates ranks #cb;d among all nations on life expectancy1 & #da/ on infant mortality4 7#b7 ,! numb] ( un9sur$ ,am]icans held at an unacceptable rate ( #ae4g p]c5t 9 #bjaa1 m ?an #dh1jjj1jjj ,am]icans4 7#c7 ,?is is ! result ( a cont9u$ decl9e 9 private heal? cov]age1 prim>ily 9 employ]-sponsor$ insurance4 7#d7 ,small bus9esses ar\nd ! c\ntry _c af=d to re9ve/ 9 _! companies & create new jobs because _! heal? c>e bills are go+ up #aj or #ae p]c5t e ye>4 7#e7 ,am]ican bus9esses are at an economic disadvantage1 because _! heal? c>e co/s are s mu* high] ?an 9 o!r c\ntries4 ,notably1 automobile manufactur]s sp5d m on heal? c>e p] automobile ?an on /eel4 7b7 ,s5se ( ! ,s5ate conc]n+ urg5cy ( a ,m$ic>e-=-,all type s+le pay] heal? c>e sy/em ,x is ! s5se ( ! ,s5ate t ! #aac? ,congress %\ld enact a ,m$ic>e-=-,all ,s+le ,pay] ,heal? ,c>e ,sy/em to make ,am]ican companies m competitive & to /imulate job creation4 7c7 ,s5se ( ! ,s5ate conc]n+ ! /atus ( heal? c>e ,x is ! s5se ( ! ,s5ate t ! #aac? ,congress %\ld recognize & proclaim t heal? c>e is a human "r4 7d7 ,s5se ( ! ,s5ate conc]n+ ,/ate flexibility ,x is ! s5se ( ! ,s5ate t 9 ord] to provide high quality heal? c>e cov]age = all ,am]icans :ile controll+ co/s 9 ord] to make ,am]ican companies m competitive1 individual ,/ates %\ld be giv5 maximum flexibility 9 design+ heal? c>e programs to improve ! individual exp]i5ce ( c>e & ! heal? ( populations1 & to r$uce ! p] capita co/s ( c>e = ea* ,/ate4 7e7 ,s5se ( ! ,s5ate conc]n+ a new heal? c>e sy/em ,x is ! s5se ( ! ,s5ate t-- 7#a7 a new s+le pay] heal? c>e sy/em %\ld build on a*ievem5ts & commitm5ts 9 ! ,pati5t ,protection & ,af=dable ,c>e ,act 7,public ,law #aaa-adh7 & ! ,heal? ,c>e & ,education ,reconciliation ,act ( #bjaj 7,public ,law #aaa-aeb71 to /r5g!n prim>y c>e & public heal?1 to raise ! quality ( pati5t c>e1 to develop new models ( pati5t c>e1 to develop ! capacity ( ! heal?c>e work=ce1 to increase transp>5cy 9 ! paym5t ( heal? c>e sy/em co/s1 & to /r5g!n en=cem5t aga9/ fraud & abuse2 7#b7 ! possibilities ( a*iev+ effici5cies ?r\gh integrat$ c>e are )9 rea* ) ! spread ( electronic support sy/ems1 heal? in=mation ex*anges1 & ! possibilities = virtual integration & in/ant communication2 & 7#c7 policies %\ld be put 9 place to ensure high] quality1 bett] prev5tion1 & l[] p] capita co/s1 includ+-- 7,a7 global budget caps on total heal? c>e sp5d+2 7,b7 measurem5t ( & fix$ acc\ntability = ! heal? /atus & heal? ne$s ( designat$ populations2 7,c7 improv$ /&>diz$ measures ( c>e & p] capita co/s across sites & ?r\gh "t t are transp>5t2 & 7,d7 *anges 9 pr(essional education curricula to ensure t cl9icians are enabl$ to *ange & improve _! processes ( c>e4 #c4 ,table ( cont5ts ,! table ( cont5ts ( ?is ,act is z foll[s3 ,sec4 #a4 ,%ort title4,sec4 #b4 ,f9d+s2 s5se ( ! ,s5ate4,sec4 #c4 ,table ( cont5ts4,,title ,i--,e/abli%m5t ( a ,/ate-,bas$ ,am]ican ,heal? ,security ,program2 ,univ]sal ,entitlem5t2 ,enrollment,sec4 #aja4 ,e/abli%m5t ( a ,/ate-bas$ ,am]ican ,heal? ,security ,program4,sec4 #ajb4 ,univ]sal entitlem5t4,sec4 #ajc4 ,enrollm5t4,sec4 #ajd4 ,portability ( b5efits4,sec4 #aje4 ,effective date ( b5efits4,sec4 #ajf4 ,relation%ip to exi/+ ,f$]al heal? programs4,sec4 #ajg4 ,repeal ( provisions relat$ to ! ,/ate ex*anges4,,title ,,ii--,compreh5sive ,b5efits1 ,includ+ ,prev5tive ,b5efits & ,b5efits = ,long-,t]m ,care,sec4 #bja4 ,compreh5sive b5efits4,sec4 #bjb4 ,def9itions relat+ to s]vices4,sec4 #bjc4 ,special rules = home & community-bas$ long-t]m c>e s]vices4,sec4 #bjd4 ,exclusions & limitations4,sec4 #bje4 ,c]tification2 quality review2 plans ( c>e4,,title ,,iii--,provid] ,participation,sec4 #cja4 ,provid] p>ticipation & /&>ds4,sec4 #cjb4 ,qualifications = provid]s4,sec4 #cjc4 ,qualifications = compreh5sive heal? s]vice organizations4,sec4 #cjd4 ,limitation on c]ta9 physician ref]rals4,,title ,,iv--,administration,subtitle ,a--,g5]al ,adm9i/rative ,provisions,sec4 #dja4 ,am]ican ,heal? ,security ,/&>ds ,bo>d4,sec4 #djb4 ,am]ican ,heal? ,security ,advisory ,c\ncil4,sec4 #djc4 ,consultation4,sec4 #djd4 ,/ate heal? security programs4,sec4 #dje4 ,complem5t>y conduct ( relat$ heal? programs4,subtitle ,b--,control ov] ,fraud & ,abuse,sec4 #daa4 ,application ( ,f$]al sanctions to all fraud & abuse "u ,am]ican ,heal? ,security ,program4,sec4 #dab4 ,requirem5ts = op]ation ( ,/ate heal? c>e fraud & abuse control units4,,title ,v--,quality ,assessment,sec4 #eja4 ,am]ican ,heal? ,security ,quality ,c\ncil4,sec4 #ejb4 ,developm5t ( c]ta9 me?odologies1 guidel9es1 & /&>ds4,sec4 #ejc4 ,/ate quality review programs4,sec4 #ejd4 ,elim9ation ( utilization review programs2 transition4,sec4 #eje4 ,application ( ,c5t] = ,m$ic>e & ,m$icaid ,innovation to ,am]ican ,heal? ,security ,program4,,title ,,vi--,heal? ,security ,budget2 ,paym5ts2 ,co/ ,conta9m5t ,measures,subtitle ,a--,budget+ & ,paym5ts to ,states,sec4 #fja4 ,national heal? security budget4,sec4 #fjb4 ,computation ( individual & ,/ate capitation am\nts4,sec4 #fjc4 ,/ate heal? security budgets4,sec4 #fjd4 ,f$]al paym5ts to ,/ates4,sec4 #fje4 ,acc\nt = heal? pr(essional education exp5ditures4,subtitle ,b--,paym5ts by ,/ates to ,providers,sec4 #faa4 ,paym5ts to hospitals & o!r facility-bas$ s]vices = op]at+ exp5ses on ! basis ( approv$ global budgets4,sec4 #fab4 ,paym5ts to heal? c>e practition]s bas$ on prospective fee s*$ule4,sec4 #fac4 ,paym5ts to compreh5sive heal? s]vice organizations4,sec4 #fad4 ,paym5ts = community-bas$ prim>y heal? s]vices4,sec4 #fae4 ,paym5ts = prescription drugs4,sec4 #faf4 ,paym5ts = approv$ devices & equipm5t4,sec4 #fag4 ,paym5ts = o!r items & s]vices4,sec4 #fah4 ,paym5t inc5tives = m$ically und]s]v$ areas4,sec4 #fai4 ,au?ority = alt]native paym5t me?odologies4,subtitle ,c--,m&atory assignm5t & adm9i/rative provisions,sec4 #fca4 ,m&atory assignm5t4,sec4 #fcb4 ,proc$ures = reimbursem5t2 appeals4,,title ,,vii--,promotion ( ,prim>y ,heal? ,c>e2 ,developm5t ( ,heal? ,s]vice ,capacity2 ,programs to ,assi/ ! ,m$ically ,underserved,subtitle ,a--,promotion & ,expansion ( ,prim>y ,c>e ,pr(essional ,training,sec4 #gja4 ,role ( ,bo>d2 e/abli%m5t ( prim>y c>e pr(essional output goals4,sec4 #gjb4 ,grants = heal? pr(essions education1 nurse education1 & ! ,national ,heal? ,s]vice ,corps4,subtitle ,b--,direct ,heal? ,c>e ,delivery,sec4 #gaa4 ,set-aside = public heal?4,sec4 #gab4 ,set-aside = prim>y heal? c>e deliv]y4,sec4 #gac4 ,prim>y c>e s]vice expansion grants4,subtitle ,c--,prim>y ,c>e & ,outcomes ,research,sec4 #gba4 ,set-aside = outcomes rese>*4,sec4 #gbb4 ,(fice ( ,prim>y ,c>e & ,prev5tion ,rese>*4,subtitle ,d--,s*ool-,relat$ ,heal? ,services,sec4 #gca4 ,au?orizations ( appropriations4,sec4 #gcb4 ,eligibility = developm5t & op]ation grants4,sec4 #gcc4 ,pref]5ces4,sec4 #gcd4 ,grants = developm5t ( projects4,sec4 #gce4 ,grants = op]ation ( projects4,sec4 #gcf4 ,f$]al adm9i/rative co/s4,sec4 #gcg4 ,def9itions4,,title ,,viii--,f9anc+ ,provisions2 ,am]ican ,heal? ,security ,tru/ ,fund,sec4 #hjj4 ,am5dm5t ( #aihf code2 ,section #ae n to apply4,subtitle ,a--,am]ican ,heal? ,security ,tru/ ,fund,sec4 #hja4 ,am]ican ,heal? ,security ,tru/ ,fund4,subtitle ,b--,taxes ,bas$ on ,income & ,wages,sec4 #haa4 ,payroll tax on employ]s4,sec4 #hab4 ,heal? c>e income tax4,sec4 #hac4 ,sur*>ge on high income individuals4,subtitle ,c--,o!r f9anc+ provisions,sec4 #hba4 ,tax on ,securities ,transactions4,,title ,,ix--,con=m+ ,am5dm5ts to ! ,employee ,retirem5t ,income ,security ,act ( #aigd,sec4 #ija4 ,,erisa inapplicable to heal? cov]age arrangem5ts "u ,/ate heal? security programs4,sec4 #ijb4 ,exemption ( ,/ate heal? security programs f ,,erisa preemption4,sec4 #ijc4 ,prohibition ( employee b5efits duplicative ( b5efits "u ,/ate heal? security programs2 coord9ation 9 case ( work]s' comp5sation4,sec4 #ijd4 ,repeal ( cont9uation cov]age requirem5ts "u ,,erisa & c]ta9 o!r requirem5ts relat+ to gr\p heal? plans4,sec4 #ije4 ,effective date ( title4,,title ,x--,additional ,con=m+ ,amendments,sec4 #ajja4 ,repeal ( c]ta9 provisions 9 ,int]nal ,rev5ue ,code ( #aihf4,sec4 #ajjb4 ,repeal ( c]ta9 provisions 9 ! ,employee ,retirem5t ,income ,security ,act ( #aigd4,sec4 #ajjc4 ,repeal ( c]ta9 provisions 9 ! ,public ,heal? ,s]vice ,act & relat$ provisions4,sec4 #ajjd4 ,effective date ( title4 ,i ,e/abli%m5t ( a ,/ate-,bas$ ,am]ican ,heal? ,security ,program2 ,univ]sal ,entitlem5t2 ,enrollm5t #aja4 ,e/abli%m5t ( a ,/ate-bas$ ,am]ican ,heal? ,security ,program 7a7 ,9 g5]al ,!re is h]eby e/abli%$ 9 ! ,unit$ ,/ates a ,/ate-bas$ ,am]ican ,heal? ,security ,program to be adm9i/]$ by ! individual ,/ates 9 accordance ) ,f$]al /&>ds specifi$ 91 or e/abli%$ "u1 ?is ,act4 7b7 ,/ate heal? security programs ,9 ord] = a ,/ate to be eligible to receive paym5t "u section #fjd1 a ,/ate %all e/abli% a ,/ate heal? security program 9 accordance ) ?is ,act4 7c7 ,/ate def9$ 7#a7 ,9 g5]al ,9 ?is ,act1 subject to p>agraph 7#b71 ! t]m ,/ate means ea* ( ! #ej ,/ates & ! ,di/rict ( ,columbia4 7#b7 ,election ,if ! ,gov]nor ( ,pu]to ,rico1 ! ,virg9 ,isl&s1 ,guam1 ,am]ican ,samoa1 or ! ,nor!rn ,m>iana ,isl&s c]tifies to ! ,presid5t t ! legislature ( ! ,commonweal? or t]ritory has enact$ legislation desir+ t ! ,commonweal? or t]ritory be includ$ z a ,/ate "u ! provisions ( ?is ,act1 su* ,commonweal? or t]ritory %all be includ$ z a ,/ate "u ?is ,act beg9n+ ,janu>y #a ( ! fir/ ye> beg9n+ #ij days aft] ! ,presid5t receives ! notification4 #ajb4 ,univ]sal entitlem5t 7a7 ,9 g5]al ,e individual :o is a resid5t ( ! ,unit$ ,/ates is entitl$ to b5efits = heal? c>e s]vices "u ?is ,act "u ! appropriate ,/ate heal? security program4 ,9 ?is section1 ! t]m appropriate ,/ate heal? security program means1 ) respect to an individual1 ! ,/ate heal? security program = ! ,/ate 9 :i* ! individual ma9ta9s a prim>y resid5ce4 7b7 ,treatm5t ( o!r individuals 7#a7 ,by ,bo>d ,! ,bo>d also may make eligible = b5efits = heal? c>e s]vices "u ! appropriate ,/ate heal? security program "u ?is ,act o!r individuals n describ$ 9 subsection 7a71 & regulate ! nature ( ! eligibility ( su* individuals1 9 ord]-- 7,a7 to pres]ve ! public heal? ( communities2 7,b7 to comp5sate ,/ates = ! additional heal? c>e f9anc+ burd5s creat$ by su* individuals2 & 7,c7 to prev5t adv]se f9ancial & m$ical consequ5ces ( uncomp5sat$ c>e1 :ile inhibit+ travel & immigration to ! ,unit$ ,/ates = ! sole purpose ( obta9+ heal? c>e s]vices4 7#b7 ,by ,/ates ,any ,/ate heal? security program may make individuals describ$ 9 p>agraph 7#a7 eligible = b5efits at ! exp5se ( ! ,/ate4 #ajc4 ,enrollm5t 7a7 ,9 g5]al ,ea* ,/ate heal? security program %all provide a me*anism = ! enrollm5t ( individuals entitl$ or eligible = b5efits "u ?is ,act4 ,! me*anism %all-- 7#a7 include a process = ! automatic enrollm5t ( individuals at ! "t ( bir? 9 ! ,unit$ ,/ates & at ! "t ( legal immigration into ! ,unit$ ,/ates or o!r acquisition ( resid5t /atus 9 ! ,unit$ ,/ates2 7#b7 provide = ! enrollm5t1 z ( ,janu>y #a1 #bjae1 ( all individuals :o are eligible to be enroll$ z ( su* date2 & 7#c7 include a process = ! enrollm5t ( individuals made eligible = heal? c>e s]vices "u subsections 7b7 & 7c7 ( section #ajb4 7b7 ,availability ( applications ,ea* ,/ate heal? security program %all make applications = enrollm5t "u ! program available-- 7#a7 at employm5t & payroll (fices ( employ]s locat$ 9 ! ,/ate2 7#b7 at local (fices ( ! ,social ,security ,adm9i/ration2 7#c7 at social s]vices locations2 7#d7 at out-rea* sites 7su* z provid] & practition] locations1 especially community heal? c5t]s72 & 7#e7 at o!r locations 7includ+ po/ (fices & s*ools7 accessible to a broad cross-section ( individuals eligible to enroll4 7c7 ,issuance ( heal? security c>ds ,9 conjunction ) an individual's enrollm5t = b5efits "u ?is ,act1 ! ,/ate heal? security program %all provide = ! issuance ( a heal? security c>d 7to be ref]r$ to z a sm>t c>d7 t %all be us$ = purposes ( id5tification & process+ ( claims = b5efits "u ! program4 ,! ,/ate heal? security program may provide = issuance ( su* c>ds by employ]s = purposes ( c>ry+ out enrollm5t pursuant to subsection 7a77#b74 #ajd4 ,portability ( b5efits 7a7 ,9 g5]al ,to ensure cont9u\s access to b5efits = heal? c>e s]vices cov]$ "u ?is ,act1 ea* ,/ate heal? security program-- 7#a7 %all n impose any m9imum p]iod ( resid5ce 9 ! ,/ate be=e resid5ts ( ! ,/ate are entitl$ to1 or eligible =1 su* b5efits "u ! program2 7#b7 %all provide cont9uation ( paym5t = cov]$ heal? c>e s]vices to individuals :o h t]m9at$ _! resid5ce 9 ! ,/ate & e/abli%$ _! resid5ce 9 ano!r ,/ate1 = ! duration ( any wait+ p]iod impos$ 9 ! ,/ate ( new resid5cy = e/abli%+ entitlem5t to1 or eligibility =1 su* s]vices2 & 7#c7 %all provide = ! paym5t = heal? c>e s]vices cov]$ "u ?is ,act provid$ to individuals :ile tempor>ily abs5t f ! ,/ate bas$ on ! foll[+ pr9ciples3 7,a7 ,paym5t = su* heal? c>e s]vices is at ! rate t is approv$ by ! ,/ate heal? security program 9 ! ,/ate 9 :i* ! s]vices are provid$1 unless ! ,/ates conc]n$ agree to apportion ! co/ betwe5 !m 9 a diff]5t mann]4 7,b7 ,paym5t = su* heal? c>e s]vices provid$ outside ! ,unit$ ,/ates is made on ! basis ( ! am\nt t w\ld h be5 paid by ! ,/ate heal? security program = simil> s]vices r5d]$ 9 ! ,/ate1 ) due reg>d1 9 ! case ( hospital s]vices1 to ! size ( ! hospital1 /&>ds ( s]vice1 & o!r relevant factors4 7b7 ,cross-,bord] arrangem5ts ,a ,/ate heal? security program = a ,/ate may negotiate ) su* a program 9 an adjac5t ,/ate a reciprocal arrangem5t = ! cov]age "u su* o!r program ( heal? c>e s]vices to enrollees resid+ 9 ! bord] region4 #aje4 ,effective date ( b5efits ,b5efits %all fir/ be available "u ?is ,act = items & s]vices furni%$ on or aft] ,janu>y #a1 #bjae4 #ajf4 ,relation%ip to exi/+ ,f$]al heal? programs 7a7 ,m$ic>e1 m$icaid & ,/ate *ildr5's heal? insurance program 7,,s*ip7 7#a7 ,9 g5]al ,not)/&+ any o!r provision ( law1 subject to p>agraph 7#b7-- 7,a7 no b5efits %all be available "u title ,,xviii ( ! ,social ,security ,act = any item or s]vice furni%$ aft] ,decemb] #ca1 #bjad2 7,b7 no individual is entitl$ to m$ical assi/ance "u a ,/ate plan approv$ "u title ,,xix ( su* ,act = any item or s]vice furni%$ aft] su* date2 7,c7 no individual is entitl$ to m$ical assi/ance "u an ,,s*ip plan "u title ,,xxi ( su* ,act = any item or s]vice furni%$ aft] su* date2 & 7,d7 no paym5t %all be made to a ,/ate "u section #aijc7;a7 or #baje7;a7 ( su* ,act ) respect to m$ical assi/ance or *ild heal? assi/ance = any item or s]vice furni%$ aft] su* date4 7#b7 ,transition ,9 ! case ( inpati5t hospital s]vices & ext5d$ c>e s]vices dur+ a cont9u\s p]iod ( /ay :i* began be=e ,janu>y #a1 #bjae1 & :i* _h n end$ z ( su* date1 = :i* b5efits are provid$ "u title ,,xviii1 "u a ,/ate plan "u title ,,xix1 or a ,/ate *ild heal? plan "u title ,,xxi1 ( ! ,social ,security ,act1 ! ,secret>y ( ,heal? & ,human ,s]vices & ea* ,/ate plan1 respectively1 %all provide = cont9uation ( b5efits "u su* title or plan until ! end ( ! p]iod ( /ay4 7b7 ,f$]al employees heal? b5efits program ,no b5efits %all be made available "u *apt] #hi ( title #e1 ,unit$ ,/ates ,code1 = any "p ( a cov]age p]iod occurr+ aft] ,decemb] #ca1 #bjad4 7c7 ,,tric>e ,no b5efits %all be made available "u sections #ajgi & #ajhf ( title #aj1 ,unit$ ,/ates ,code1 = items or s]vices furni%$ aft] ,decemb] #ca1 #bjad4 7d7 ,treatm5t ( b5efits = vet]ans & native am]icans ,no?+ 9 ?is ,act %all affect ! eligibility ( vet]ans = ! m$ical b5efits & s]vices provid$ "u title #ch1 ,unit$ ,/ates ,code1 or ( ,indians = ! m$ical b5efits & s]vices provid$ by or ?r\gh ! ,indian ,heal? ,s]vice4 7e7 ,treatm5t ( premium cr$its1 co/-,%>+ r$uctions1 & small employ] cr$its 7#a7 ,9 g5]al ,= ea* cal5d> ye>1 ! ,secret>y ( ! ,treasury %all transf] to ! ,am]ican ,heal? ,security ,tru/ ,fund an am\nt equal to ! sum (-- 7,a7 ! premium assi/ance cr$it am\nt :i* w\ld h be5 all[able to taxpay]s resid+ 9 su* ,/ate 9 su* cal5d> ye> "u section #cf;,b ( ! ,int]nal ,rev5ue ,code ( #aihf 7relat+ to refundable cr$it = cov]age "u a qualifi$ heal? plan71 z add$ by section #adja ( ! ,pati5t ,protection & ,af=dable ,c>e ,act1 if su* section 7 9 effect = su* ye>1 7,b7 ! am\nt ( co/-%>+ r$uctions :i* w\ld h be5 requir$ ) respect to eligible insur$ resid+ 9 su* ,/ate 9 su* cal5d> ye> "u section #adjb ( ! ,pati5t ,protection & ,af=dable ,c>e ,act if su* section 7 9 effect = su* ye>1 plus 7,c7 ! am\nt ( tax cr$its :i* w\ld h be5 all[able to eligible small employ]s do+ bus9ess 9 su* ,/ate 9 su* cal5d> ye> "u section #de,r ( ! ,int]nal ,rev5ue ,code ( #aihf if su* section 7 9 effect = su* cal5d> ye>4 7#b7 ,det]m9ation ,! am\nts det]m9$ "u p>agraph 7#a7 %all be e/imat$ by ! ,secret>y ( ! ,treasury 9 consultation ) ! ,secret>y ( ,heal? & ,human ,s]vices4 #ajg4 ,repeal ( provisions relat$ to ! ,/ate ex*anges ,title ,i ( ! ,pati5t ,protection & ,af=dable ,c>e ,act 7,public ,law #aaa-adh7 7& ! am5dm5ts made by title ,i7 is repeal$4 ,,ii ,compreh5sive ,b5efits1 ,includ+ ,prev5tive ,b5efits & ,b5efits = ,long-,t]m ,c>e #bja4 ,compreh5sive b5efits 7a7 ,9 g5]al ,subject to ! succe$+ provisions ( ?is title1 individuals enroll$ = b5efits "u ?is ,act are entitl$ to h paym5t made "u a ,/ate heal? security program = ! foll[+ items & s]vices if m$ically necess>y or appropriate = ! ma9t5ance ( heal? or = ! diagnosis1 treatm5t1 or rehabilitation ( a heal? condition3 7#a7 ,hospital s]vices ,inpati5t & outpati5t hospital c>e1 includ+ #bd-;h\r-a-day em]g5cy s]vices4 7#b7 ,pr(essional s]vices ,pr(essional s]vices ( heal? c>e practition]s au?oriz$ to provide heal? c>e s]vices "u ,/ate law1 includ+ pati5t education & tra9+ 9 self-managem5t te*niques4 7#c7 ,community-bas$ prim>y heal? s]vices ,community-bas$ prim>y heal? s]vices 7z def9$ 9 section #bjb7;a774 7#d7 ,prev5tive s]vices ,prev5tive s]vices 7z def9$ 9 section #bjb7;b774 7#e7 ,long-t]m1 acute1 & *ronic c>e s]vices 7,a7 ,nurs+ facility s]vices4 7,b7 ,home heal? s]vices4 7,c7 ,home & community-bas$ long-t]m c>e s]vices 7z def9$ 9 section #bjb7;c77 = individuals describ$ 9 section #bjc7;a74 7,d7 ,hospice c>e4 7,e7 ,s]vices 9 int]m$iate c>e facilities = individuals ) an intellectual disability4 7#f7 ,prescription drugs1 biologicals1 insul91 m$ical foods 7,a7 ,outpati5t prescription drugs & biologics1 z specifi$ by ! ,bo>d consi/5t ) section #fae4 7,b7 ,insul94 7,c7 ,m$ical foods 7z def9$ 9 section #bjb7;e774 7#g7 ,d5tal s]vices ,d5tal s]vices 7z def9$ 9 section #bjb7;h774 7#h7 ,m5tal heal? & sub/ance abuse treatm5t s]vices ,m5tal heal? & sub/ance abuse treatm5t s]vices 7z def9$ 9 section #bjb7;f774 7#i7 ,diagno/ic te/s ,diagno/ic te/s4 7#aj7 ,o!r items & s]vices 7,a7 ,outpati5t !rapy ,outpati5t physical !rapy s]vices1 outpati5t spee* pa?ology s]vices1 & outpati5t occupational !rapy s]vices 9 all sett+s4 7,b7 ,durable m$ical equipm5t ,durable m$ical equipm5t4 7,c7 ,home dialysis ,home dialysis supplies & equipm5t4 7,d7 ,ambulance ,em]g5cy ambulance s]vice4 7,e7 ,pro/hetic devices ,pro/hetic devices1 includ+ replacem5ts ( su* devices4 7,f7 ,additional items & s]vices ,su* o!r m$ical or heal? c>e items or s]vices z ! ,bo>d may specify4 7b7 ,prohibition ( balance bill+ ,z provid$ 9 section #eca1 no p]son may impose a *>ge = cov]$ s]vices = :i* b5efits are provid$ "u ?is ,act4 7c7 ,no duplicate heal? insurance ,ea* ,/ate heal? security program %all prohibit ! sale ( heal? insurance 9 ! ,/ate if paym5t "u ! insurance duplicates paym5t = any items or s]vices = :i* paym5t may be made "u su* a program4 7d7 ,/ate program may provide additional b5efits ,no?+ 9 ?is ,act %all be con/ru$ z limit+ ! b5efits t may be made available "u a ,/ate heal? security program to resid5ts ( ! ,/ate at ! exp5se ( ! ,/ate4 7e7 ,employ]s may provide additional b5efits ,no?+ 9 ?is ,act %all be con/ru$ z limit+ ! additional b5efits t an employ] may provide to employees or _! dep5d5ts1 or to =m] employees or _! dep5d5ts4 7f7 ,taft-,h>tley & ,,mew b5efit plans ,not)/&+ any o!r provision ( law1 a heal? plan may be provid$ = "u a collective b>ga9+ agreem5t or a ,,mewa if su* plan is limit$ to cov]age t is supplem5tal to ! cov]age provid$ = "u ! ,/ate-bas$ ,am]ican ,heal? ,security ,program & available only to employees or _! dep5d5ts or to retirees or _! dep5d5ts4 #bjb4 ,def9itions relat+ to s]vices 7a7 ,community-,bas$ prim>y heal? s]vices ,9 ?is title1 ! t]m community-bas$ prim>y heal? s]vices means ambulatory heal? s]vices furni%$-- 7#a7 by a rural heal? cl9ic2 7#b7 by a f$]ally qualifi$ heal? c5t] 7z def9$ 9 section #aije7l77#b77;,b7 ( ! ,social ,security ,act71 & :i*1 = purposes ( ?is ,act1 include s]vices furni%$ by ,/ate & local heal? ag5cies2 7#c7 9 a s*ool-bas$ sett+2 7#d7 by public educational ag5cies & o!r provid]s ( s]vices to *ildr5 entitl$ to assi/ance "u ! ,individuals ) ,disabilities ,education ,act = s]vices furni%$ pursuant to a writt5 ,individualiz$ ,family ,s]vices ,plan or ,individual ,education ,plan "u su* ,act2 & 7#e7 public & private nonpr(it entities receiv+ ,f$]al assi/ance "u ! ,public ,heal? ,s]vice ,act4 7b7 ,prev5tive s]vices 7#a7 ,9 g5]al ,9 ?is title1 ! t]m prev5tive s]vices means items & s]vices-- 7,a7 :i*-- 7i7 are specifi$ 9 p>agraph 7#b72 or 7ii7 ! ,bo>d det]m9es to be effective 9 ! ma9t5ance & promotion ( heal? or m9imiz+ ! effect ( illness1 disease1 or m$ical condition2 & 7,b7 :i* are provid$ consi/5t ) ! p]iodicity s*$ule e/abli%$ "u p>agraph 7#c74 7#b7 ,specifi$ prev5tive s]vices ,! s]vices specifi$ 9 ?is p>agraph are z foll[s3 7,a7 ,immunizations recomm5d$ by ! ,advisory ,committee on ,immunization ,practices ( ! ,c5t]s = ,disease ,control & ,prev5tion4 7,b7 ,pr5atal & well-baby c>e 7= infants "u #a ye> ( age74 7,c7 ,well-*ild c>e 7includ+ p]iodic physical exam9ations1 he>+ & vision scre5+1 & developm5tal scre5+ & exam9ations7 = individuals "u #ah ye>s ( age1 includ+ evid5ce-in=m$ prev5tive c>e & scre5+s includ$ 9 ! compreh5sive guidel9es ( ! ,heal? ,res\rces & ,s]vices ,adm9i/ration4 7,d7 ,p]iodic scre5+ mammography1 ,pap sme>s1 & colorectal exam9ations & exam9ations = pro/ate canc]4 7,e7 ,physical exam9ations4 7,f7 ,family plann+ s]vices4 7,g7 ,r\t9e eye exam9ations1 eyeglasses1 & contact l5ses4 7,h7 ,he>+ aids1 b only ^u a det]m9ation ( a c]tifi$ audiologi/ or physician t a he>+ problem exi/s & is caus$ by a condition t c be correct$ by use ( a he>+ aid4 7,i7 ,evid5ce-bas$ items or s]vices t h 9 effect a rat+ ( ,a or ,b 9 ! curr5t recomm5dations ( ! ,unit$ ,/ates ,prev5tive ,s]vices ,task ,=ce4 7,j7 ,) respect to wom51 su* additional prev5tive c>e & scre5+s n describ$ 9 subp>agraph 7,i7 t are includ$ 9 ! compreh5sive guidel9es ( ! ,heal? ,res\rces & ,s]vices ,adm9i/ration4 7#c7 ,s*$ule ,! ,bo>d %all e/abli%1 9 consultation ) exp]ts 9 prev5tive m$ic9e & public heal? & tak+ into consid]ation ^? prev5tive s]vices recomm5d$ by ! ,prev5tive ,s]vices ,task ,=ce & publi%$ z ! ,guide to ,cl9ical ,prev5tive ,s]vices1 a p]iodicity s*$ule = ! cov]age ( prev5tive s]vices "u p>agraph 7#a74 ,su* s*$ule %all take into consid]ation ! co/-effectiv5ess ( appropriate prev5tive c>e & %all be revis$ n less frequ5tly ?an once e #e ye>s1 9 consultation ) exp]ts 9 prev5tive m$ic9e & public heal?4 7c7 ,home & community-,bas$ long-,t]m c>e s]vices ,9 ?is title1 ! t]m home & community-bas$ long-t]m c>e s]vices means ! foll[+ s]vices provid$ to an individual to enable ! individual to rema9 9 su* individual's place ( resid5ce )9 ! community3 7#a7 ,home heal? aide s]vices4 7#b7 ,adult day heal? c>e1 social day c>e or psy*iatric day c>e4 7#c7 ,m$ical social "w s]vices4 7#d7 ,c>e coord9ation s]vices1 z def9$ 9 subsection 7g77#a74 7#e7 ,respite c>e1 includ+ tra9+ = in=mal c>egiv]s4 7#f7 ,p]sonal assi/ance s]vices1 & homemak] s]vices 7includ+ meals7 incid5tal to ! provision ( p]sonal assi/ance s]vices4 7d7 ,home heal? s]vices 7#a7 ,9 g5]al ,! t]m home heal? s]vices means items & s]vices describ$ 9 section #ahfa7m7 ( ! ,social ,security ,act & includes home infusion s]vices4 7#b7 ,home infusion s]vices ,! t]m home infusion s]vices includes ! nurs+1 ph>macy1 & relat$ s]vices t are necess>y to conduct ! home infusion ( a drug regim5 safely & effectively "u a plan e/abli%$ & p]iodically review$ by a physician & t are provid$ 9 compliance ) quality assurance requirem5ts e/abli%$ by ! ,secret>y4 7e7 ,m$ical foods ,9 ?is title1 ! t]m m$ical foods means foods :i* are =mulat$ to be consum$ or adm9i/]$ ent]ally "u ! sup]vision ( a physician & :i* are int5d$ = ! specific diet>y managem5t ( a disease or condition = :i* di/9ctive nutritional requirem5ts1 bas$ on recogniz$ sci5tific pr9ciples1 are e/abli%$ by m$ical evaluation4 7f7 ,m5tal heal? & sub/ance abuse treatm5t s]vices 7#a7 ,s]vices describ$ ,9 ?is title1 ! t]m m5tal heal? & sub/ance abuse treatm5t s]vices means ! foll[+ s]vices relat$ to ! prev5tion1 diagnosis1 treatm5t1 & rehabilitation ( m5tal illness & promotion ( m5tal heal?3 7,a7 ,inpati5t hospital s]vices ,inpati5t hospital s]vices furni%$ prim>ily = ! diagnosis or treatm5t ( m5tal illness or sub/ance abuse if 7) respect to s]vices furni%$ to an individual describ$ 9 section #bjd7;b77#a77 su* s]vices are furni%$ 9 con=mity ) ! plan ( an organiz$ sy/em ( c>e = m5tal heal? & sub/ance abuse s]vices 9 accordance ) section #bjd7;b77#b74 7,b7 ,int5sive resid5tial s]vices ,int5sive resid5tial s]vices 7z def9$ 9 p>agraph 7#b774 7,c7 ,outpati5t s]vices ,outpati5t treatm5t s]vices ( m5tal illness or sub/ance abuse 7o!r ?an int5sive community-bas$ s]vices "u subp>agraph 7,d77 = an unlimit$ numb] ( days dur+ any cal5d> ye> furni%$ 9 accordance ) /&>ds e/abli%$ by ! ,secret>y = ! managem5t ( su* s]vices1 &1 9 ! case ( s]vices furni%$ to an individual describ$ 9 section #bjd7;b77#a7 :o is n an inpati5t ( a hospital1 9 con=mity ) ! plan ( an organiz$ sy/em ( c>e = m5tal heal? & sub/ance abuse s]vices 9 accordance ) section #bjd7;b77#b74 7,d7 ,int5sive community-bas$ s]vices ,int5sive community-bas$ s]vices 7z describ$ 9 p>agraph 7#c774 7#b7 ,int5sive resid5tial s]vices def9$ 7,a7 ,9 g5]al ,subject to subp>agraphs 7,b7 & 7,c71 ! t]m int5sive resid5tial s]vices means inpati5t s]vices provid$ 9 any ( ! foll[+ facilities3 7i7 ,resid5tial detoxification c5t]s4 7ii7 ,crisis resid5tial programs or m5tal illness resid5tial treatm5t programs4 7iii7 ,!rapeutic family or gr\p treatm5t homes4 7iv7 ,resid5tial c5t]s = sub/ance abuse treatm5t4 7,b7 ,requirem5ts = facilities ,no s]vice may be treat$ z an int5sive resid5tial s]vice "u subp>agraph 7,a7 unless ! facility at :i* ! s]vice is provid$-- 7i7 is legally au?oriz$ to provide su* s]vice "u ! law ( ! ,/ate 7or "u a ,/ate regulatory me*anism provid$ by ,/ate law7 9 :i* ! facility is locat$ or is c]tifi$ to provide su* s]vice by an appropriate accr$itation entity approv$ by ! ,/ate 9 consultation ) ! ,secret>y2 & 7ii7 meets su* o!r requirem5ts z ! ,secret>y may impose to ensure ! quality ( ! int5sive resid5tial s]vices provid$4 7,c7 ,s]vices furni%$ to at-risk *ildr5 ,9 ! case ( s]vices furni%$ to an individual describ$ 9 section #bjd7;b77#a71 no s]vice may be treat$ z an int5sive resid5tial s]vice "u ?is subsection unless ! s]vice is furni%$ 9 con=mity ) ! plan ( an organiz$ sy/em ( c>e = m5tal heal? & sub/ance abuse s]vices 9 accordance ) section #bjd7;b77#b74 7,d7 ,managem5t /&>ds ,no s]vice may be treat$ z an int5sive resid5tial s]vice "u subp>agraph 7,a7 unless ! s]vice is furni%$ 9 accordance ) /&>ds e/abli%$ by ! ,secret>y = ! managem5t ( su* s]vices4 7#c7 ,int5sive community-bas$ s]vices def9$ 7,a7 ,9 g5]al ,! t]m int5sive community-bas$ s]vices means ! items & s]vices describ$ 9 subp>agraph 7,b7 prescrib$ by a physician 7or1 9 ! case ( s]vices furni%$ to an individual describ$ 9 section #bjd7;b77#a71 by an organiz$ sy/em ( c>e = m5tal heal? & sub/ance abuse s]vices 9 accordance ) su* section7 & provid$ "u a program describ$ 9 subp>agraph 7,d7 "u ! sup]vision ( a physician 7or1 to ! ext5t p]mitt$ "u ! law ( ! ,/ate 9 :i* ! s]vices are furni%$1 a non-physician m5tal heal? pr(essional7 pursuant to an individualiz$1 writt5 plan ( treatm5t e/abli%$ & p]iodically review$ by a physician 79 consultation ) appropriate /aff p>ticipat+ 9 su* program7 :i* sets =? ! physician's diagnosis1 ! type1 am\nt1 frequ5cy1 & duration ( ! items & s]vices provid$ "u ! plan1 & ! goals = treatm5t "u ! plan1 b does n include any item or s]vice t is n furni%$ 9 accordance ) /&>ds e/abli%$ by ! ,secret>y = ! managem5t ( su* s]vices4 7,b7 ,items & s]vices describ$ ,! items & s]vices describ$ 9 ?is subp>agraph are-- 7i7 p>tial hospitalization s]vices consi/+ ( ! items & s]vices describ$ 9 subp>agraph 7,c72 7ii7 psy*iatric rehabilitation s]vices2 7iii7 day treatm5t s]vices = individuals "u #ai ye>s ( age2 7iv7 9-home s]vices2 7v7 case managem5t s]vices1 includ+ collat]al s]vices designat$ z su* case managem5t s]vices by ! ,secret>y2 7vi7 ambulatory detoxification s]vices2 & 7vii7 su* o!r items & s]vices z ! ,secret>y may provide 7b 9 no ev5t to include meals & transportation71 t are reasonable & necess>y = ! diagnosis or active treatm5t ( ! individual's condition1 reasonably expect$ to improve or ma9ta9 ! individual's condition & functional level & to prev5t relapse or hospitalization1 & furni%$ pursuant to su* guidel9es relat+ to frequ5cy & duration ( s]vices z ! ,secret>y %all by regulation e/abli% 7tak+ into acc\nt accept$ norms ( m$ical practice & ! reasonable expectation ( pati5t improvem5t74 7,c7 ,items & s]vices includ$ z p>tial hospitalization s]vices ,= purposes ( subp>agraph 7,b77i71 p>tial hospitalization s]vices consi/ ( ! foll[+3 7i7 ,individual & gr\p !rapy ) physicians or psy*ologi/s 7or o!r m5tal heal? pr(essionals to ! ext5t au?oriz$ "u ,/ate law74 7ii7 ,occupational !rapy requir+ ! skills ( a qualifi$ occupational !rapi/4 7iii7 ,s]vices ( social work]s1 tra9$ psy*iatric nurses1 behavioral aides1 & o!r /aff tra9$ to "w ) psy*iatric pati5ts 7to ! ext5t au?oriz$ "u ,/ate law74 7iv7 ,drugs & biologicals furni%$ = !rapeutic purposes 7:i* _c1 z det]m9$ 9 accordance ) regulations1 be self-adm9i/]$74 7v7 ,individualiz$ activity !rapies t are n prim>ily recreational or div]sion>y4 7vi7 ,family c\nsel+ 7! prim>y purpose ( :i* is treatm5t ( ! individual's condition74 7vii7 ,pati5t tra9+ & education 7to ! ext5t t tra9+ & educational activities are closely & cle>ly relat$ to ! individual's c>e & treatm5t74 7viii7 ,diagno/ic s]vices4 7,d7 ,programs describ$ ,a program describ$ 9 ?is subp>agraph is a program 7:e!r facility-bas$ or free/&+7 :i* is furni%$ by an entity-- 7i7 legally au?oriz$ to furni% su* a program "u ,/ate law 7or ! ,/ate regulatory me*anism provid$ by ,/ate law7 or c]tifi$ to furni% su* a program by an appropriate accr$itation entity approv$ by ! ,/ate 9 consultation ) ! ,secret>y2 & 7ii7 meet+ su* o!r requirem5ts z ! ,secret>y may impose to ensure ! quality ( ! int5sive community-bas$ s]vices provid$4 7g7 ,c>e coord9ation s]vices 7#a7 ,9 g5]al ,9 ?is title1 ! t]m c>e coord9ation s]vices means s]vices provid$ by c>e coord9ators 7z def9$ 9 p>agraph 7#b77 to individuals describ$ 9 p>agraph 7#c7 = ! coord9ation & monitor+ ( home & community-bas$ long-t]m c>e s]vices & s]vices (f]$ ?r\gh m$ical homes to ensure appropriate1 co/-effective utilization ( su* s]vices 9 a compreh5sive & cont9u\s mann]1 & includes-- 7,a7 transition managem5t betwe5 inpati5t facilities & community-bas$ s]vices1 includ+ assi/+ pati5ts 9 id5tify+ & ga9+ access to appropriate ancill>y s]vices2 & 7,b7 evaluat+ & recomm5d+ appropriate treatm5t s]vices1 9 coop]ation ) pati5ts & o!r provid]s & 9 conjunction ) any quality review program or plan ( c>e "u section #bje4 7#b7 ,c>e coord9ator 7,a7 ,9 g5]al ,9 ?is title1 ! t]m c>e coord9ator means an individual or nonpr(it or public ag5cy or organization :i* ! ,/ate heal? security program det]m9es-- 7i7 is capable ( p]=m+ directly1 effici5tly1 & effectively ! duties ( a c>e coord9ator describ$ 9 p>agraph 7#a72 & 7ii7 demon/rates capability 9 e/abli%+ & p]iodically review+ & revis+ plans ( c>e1 & 9 arrang+ = & monitor+ ! provision & quality ( s]vices "u any plan4 7,b7 ,indep5d5ce ,/ate heal? security programs %all e/abli% safegu>ds to ensure t c>e coord9ators h no f9ancial int]e/ 9 treatm5t decisions or placem5ts4 ,c>e coord9ation may n be provid$ ?r\gh any /ructure or me*anism ?r\gh :i* quality review is p]=m$4 7#c7 ,eligible individuals ,an individual describ$ 9 ?is p>agraph is an individual describ$ 9 section #bjc 7relat+ to individuals qualify+ = long-t]m & *ronic c>e s]vices74 7h7 ,d5tal s]vices 7#a7 ,9 g5]al ,9 ?is title1 subject to subsection 7b71 ! t]m d5tal s]vices means ! foll[+3 7,a7 ,em]g5cy d5tal treatm5t1 includ+ extractions1 = ble$+1 pa91 acute infections1 & injuries to ! maxill(acial region4 7,b7 ,prev5tion & diagnosis ( d5tal disease1 includ+ exam9ations ( ! h>d & s(t tissues ( ! oral cavity & relat$ /ructures1 radiographs1 d5tal sealants1 fluorides1 & d5tal prophylaxis4 7,c7 ,treatm5t ( d5tal disease1 includ+ non-ca/ fill+s1 p]iodontal ma9t5ance s]vices1 & endodontic s]vices4 7,d7 ,space ma9t5ance proc$ures to prev5t or?odontic complications4 7,e7 ,or?odontic treatm5t to prev5t sev]e malocclusions4 7,f7 ,full d5tures4 7,g7 ,m$ically necess>y oral heal? c>e4 7,h7 ,any items & s]vices = special ne$s pati5ts t are n describ$ 9 subp>agraphs 7,a7 ?r\gh 7,g7 & t-- 7i7 are requir$ to provide su* pati5ts ! items & s]vices describ$ 9 subp>agraphs 7,a7 ?r\gh 7,g72 7ii7 are requir$ to e/abli% oral function 7includ+ g5]al ane/hesia = individuals ) physical or emotional limitations t prev5t ! provision ( d5tal c>e )\t su* ane/hesia72 7iii7 consi/ ( or?odontic c>e = sev]e d5t(acial abnormalities2 or 7iv7 consi/ ( pro/hetic d5tal devices = g5etic or bir? defects or fitt+ = su* devices4 7,i7 ,any d5tal c>e = individuals ) a seizure disord] t is n describ$ 9 subp>agraphs 7,a7 ?r\gh 7,h7 & t is requir$ because ( an illness1 injury1 disord]1 or o!r heal? condition t results f su* seizure disord]4 7#b7 ,limitations ,d5tal s]vices are subject to ! foll[+ limitations3 7,a7 ,prev5tion & diagnosis 7i7 ,exam9ations & prophylaxis ,! exam9ations & prophylaxis describ$ 9 p>agraph 7#a77;,b7 are cov]$ only consi/5t ) a p]iodicity s*$ule e/abli%$ by ! ,bo>d1 :i* s*$ule may provide = special treatm5t ( individuals less ?an #ah ye>s ( age & ( special ne$s pati5ts4 7ii7 ,d5tal sealants ,! d5tal sealants describ$ 9 su* p>agraph are n cov]$ = individuals #ah ye>s ( age or old]4 ,su* sealants are cov]$ = individuals less ?an #aj ye>s ( age = protection ( ! #a/ p]man5t mol>s4 ,su* sealants are cov]$ = individuals #aj ye>s ( age or old] = protection ( ! #b;d p]man5t mol>s4 7,b7 ,treatm5t ( d5tal disease ,prior to ,janu>y #a1 #bjbj1 ! items & s]vices describ$ 9 p>agraph 7#a77;,c7 are cov]$ only = individuals less ?an #ah ye>s ( age & special ne$s pati5ts4 ,on or aft] su* date1 su* items & s]vices are cov]$ = all individuals enroll$ = b5efits "u ?is ,act1 except t endodontic s]vices are n cov]$ = individuals #ah ye>s ( age or old]4 7,c7 ,space ma9t5ance ,! items & s]vices describ$ 9 p>agraph 7#a77;,d7 are cov]$ only = individuals at lea/ #c ye>s ( age1 b less ?an #ac ye>s ( age &-- 7i7 are limit$ to po/]ior tee?2 7ii7 involve ma9t5ance ( a space or spaces = p]man5t po/]ior tee? t w\ld o!rwise be prev5t$ f normal eruption if ! space 7 n ma9ta9$2 & 7iii7 d n include a space ma9ta9] t is plac$ )9 #f mon?s ( ! expect$ eruption ( ! p]man5t po/]ior too? conc]n$4 7#c7 ,def9itions ,= purposes ( ?is title3 7,a7 ,m$ically necess>y oral heal? c>e ,! t]m m$ically necess>y oral heal? c>e means oral heal? c>e t is requir$ z a direct result (1 or w\ld h a direct impact on1 an und]ly+ m$ical condition4 ,su* t]m includes oral heal? c>e direct$ t[>d control or elim9ation ( pa91 infection1 or ree/abli%m5t ( oral function4 7,b7 ,special ne$s pati5t ,! t]m special ne$s pati5t includes an individual ) a g5etic or bir? defect1 a developm5tal disability1 or an acquir$ m$ical disability4 7i7 ,nurs+ facility2 nurs+ facility s]vices ,except z may be provid$ by ! ,bo>d1 ! t]ms nurs+ facility & nurs+ facility s]vices h ! mean+s giv5 su* t]ms 9 sections #aiai7;a7 & #aije7;f71 respectively1 ( ! ,social ,security ,act4 7j7 ,s]vices 9 int]m$iate c>e facilities = individuals ) an intellectual disability ,except z may be provid$ by ! ,bo>d-- 7#a7 ! t]m int]m$iate c>e facility = individuals ) an intellectual disability has ! mean+ giv5 ! t]m int]m$iate c>e facility = individuals ) m5tal ret>dation 9 section #aije7;d7 ( ! ,social ,security ,act 7z 9 effect be=e ! enactm5t ( ?is ,act72 & 7#b7 ! t]m s]vices 9 int]m$iate c>e facilities = individuals ) an intellectual disability means s]vices describ$ 9 section #aije7;a77#ae7 ( su* ,act 7z s 9 effect7 9 an int]m$iate c>e facility = individuals ) an intellectual disability to an individual det]m9$ to require su* s]vices 9 accordance ) /&>ds specifi$ by ! ,bo>d & comp>able to ! /&>ds describ$ 9 section #aijb7;a77#ca77;,a7 ( su* ,act 7z s 9 effect74 7k7 ,o!r t]ms ,except z may be provid$ by ! ,bo>d1 ! def9itions conta9$ 9 section #ahfa ( ! ,social ,security ,act %all apply4 #bjc4 ,special rules = home & community-bas$ long-t]m c>e s]vices 7a7 ,qualify+ individuals ,= purposes ( section #bja7;a77#e77;,c71 individuals describ$ 9 ?is subsection are ! foll[+ individuals3 7#a7 ,adults ,individuals #ah ye>s ( age or old] det]m9$ 79 a mann] specifi$ by ! ,bo>d7-- 7,a7 to be unable to p]=m1 )\t ! assi/ance ( an individual1 at lea/ #b ( ! foll[+ #e activities ( daily liv+ 7or :o has a simil> level ( disability due to cognitive impairm5t7-- 7i7 ba?+2 7ii7 eat+2 7iii7 dress+2 7iv7 toilet+2 & 7v7 transf]r+ 9 & out ( a b$ or 9 & out ( a *air2 7,b7 due to cognitive or m5tal impairm5ts1 to require sup]vision because ! individual behaves 9 a mann] t poses heal? or safety haz>ds to himself or h]self or o!rs2 or 7,c7 due to cognitive or m5tal impairm5ts1 to require queu+ to p]=m activities ( daily liv+4 7#b7 ,*ildr5 ,individuals "u #ah ye>s ( age det]m9$ 79 a mann] specifi$ by ! ,bo>d7 to meet su* alt]native /&>d ( disability = *ildr5 z ! ,bo>d develops4 ,su* alt]native /&>d %all be comp>able to ! /&>d = adults & appropriate = *ildr54 7b7 ,limit on s]vices 7#a7 ,9 g5]al ,! aggregate exp5ditures by a ,/ate heal? security program ) respect to home & community-bas$ long-t]m c>e s]vices 9 a p]iod 7specifi$ by ! ,bo>d7 may n exce$ #fe p]c5t 7or su* alt]native ratio z ! ,bo>d e/abli%es "u p>agraph 7#b77 ( ! av]age ( ! am\nt ( paym5t t w\ld h be5 made "u ! program dur+ ! p]iod if all ! home-bas$ long-t]m c>e b5efici>ies _h be5 resid5ts ( nurs+ facilities 9 ! same area 9 :i* ! s]vices 7 provid$4 7#b7 ,alt]native ratio ,! ,bo>d may e/abli% = purposes ( p>agraph 7#a7 an alt]native ratio 7( paym5ts = home & community-bas$ long-t]m c>e s]vices to paym5ts = nurs+ facility s]vices7 z ! ,bo>d det]m9es to be m consi/5t ) ! goal ( provid+ co/-effective long-t]m c>e 9 ! mo/ appropriate & lea/ re/rictive sett+4 #bjd4 ,exclusions & limitations 7a7 ,9 g5]al ,subject to section #bja7;e71 b5efits = s]vice are n available "u ?is ,act unless ! s]vices meet ! /&>ds specifi$ 9 section #bja7;a74 7b7 ,special deliv]y requirem5ts = m5tal heal? & sub/ance abuse treatm5t s]vices provid$ to ,at-,risk *ildr5 7#a7 ,requir+ s]vices to be provid$ ?r\gh organiz$ sy/ems ( c>e ,a ,/ate heal? security program %all ensure t m5tal heal? s]vices & sub/ance abuse treatm5t s]vices are furni%$ ?r\gh an organiz$ sy/em ( c>e1 z describ$ 9 p>agraph 7#b71 if-- 7,a7 ! s]vices are provid$ to an individual less ?an #bb ye>s ( age2 7,b7 ! individual has a s]i\s emotional di/urbance or a sub/ance abuse disord]2 & 7,c7 ! individual is1 or is at imm95t risk ( be+1 subject to ! au?ority (1 or 9 ne$ ( ! s]vices (1 at lea/ #a public ag5cy t s]ves ! ne$s ( *ildr51 includ+ an ag5cy involv$ ) *ild welf>e1 special education1 juv5ile ju/ice1 or crim9al ju/ice4 7#b7 ,requirem5ts = sy/em ( c>e ,9 ?is subsection1 an organiz$ sy/em ( c>e is a community-bas$ s]vice deliv]y network1 :i* may consi/ ( public & private provid]s1 t meets ! foll[+ requirem5ts3 7,a7 ,! sy/em has e/abli%$ l9kages ) exi/+ m5tal heal? s]vices & sub/ance abuse treatm5t s]vice deliv]y programs 9 ! plan s]vice area 7or is 9 ! process ( develop+ or op]at+ a sy/em ) appropriate public ag5cies 9 ! area to coord9ate ! deliv]y ( su* s]vices to individuals 9 ! area74 7,b7 ,! sy/em provides = ! p>ticipation & coord9ation ( multiple ag5cies & provid]s t s]ve ! ne$s ( *ildr5 9 ! area1 includ+ ag5cies & provid]s involv$ ) *ild welf>e1 education1 juv5ile ju/ice1 crim9al ju/ice1 heal? c>e1 m5tal heal?1 & sub/ance abuse prev5tion & treatm5t4 7,c7 ,! sy/em provides = ! involvem5t ( ! families ( *ildr5 to :om m5tal heal? s]vices & sub/ance abuse treatm5t s]vices are provid$ 9 ! plann+ ( treatm5t & ! deliv]y ( s]vices4 7,d7 ,! sy/em provides = ! developm5t & implem5tation ( individualiz$ treatm5t plans by multidiscipl9>y & multiag5cy teams1 :i* are recogniz$ & foll[$ by ! applicable ag5cies & provid]s 9 ! area4 7,e7 ,! sy/em ensures ! deliv]y & coord9ation ( ! range ( m5tal heal? s]vices & sub/ance abuse treatm5t s]vices requir$ by individuals "u #bb ye>s ( age :o h a s]i\s emotional di/urbance or a sub/ance abuse disord]4 7,f7 ,! sy/em provides = ! managem5t ( ! individualiz$ treatm5t plans describ$ 9 subp>agraph 7,d7 & = a flexible response to *anges 9 treatm5t ne$s ov] "t4 7c7 ,treatm5t ( exp]im5tal s]vices ,9 apply+ subsection 7a71 ! ,bo>d %all make national cov]age det]m9ations ) respect to ^? s]vices t are exp]im5tal 9 nature4 ,su* det]m9ations %all be made consi/5t ) a process t provides = input f repres5tatives ( heal? c>e pr(essionals & pati5ts & public comm5t4 7d7 ,application ( practice guidel9es ,9 ! case ( s]vices = :i* ! ,am]ican ,heal? ,security ,quality ,c\ncil 7e/abli%$ "u section #eja7 has recogniz$ a national practice guidel9e1 ! s]vices are consid]$ to meet ! /&>ds specifi$ 9 section #bja7;a7 if !y h be5 provid$ 9 accordance ) su* guidel9e or 9 accordance ) su* guidel9es z are provid$ by ! ,/ate heal? security program consi/5t ) title ,v4 ,= purposes ( ?is subsection1 a s]vice %all be consid]$ to h be5 provid$ 9 accordance ) a practice guidel9e if ! heal? c>e provid] provid+ ! s]vice ex]cis$ appropriate pr(essional discretion to deviate f ! guidel9e 9 a mann] au?oriz$ or anticipat$ by ! guidel9e4 7e7 ,specific limitations 7#a7 ,limitations on eyeglasses1 contact l5ses1 he>+ aids1 & durable m$ical equipm5t ,subject to section #bja7;e71 ! ,bo>d may impose su* limits relat+ to ! co/s & frequ5cy ( replacem5t ( eyeglasses1 contact l5ses1 he>+ aids1 & durable m$ical equipm5t to :i* individuals enroll$ = b5efits "u ?is ,act are entitl$ to h paym5t made "u a ,/ate heal? security program z ! ,bo>d deems appropriate4 7#b7 ,ov]lap ) prev5tive s]vices ,! cov]age ( s]vices describ$ 9 section #bja7;a7 7o!r ?an p>agraph 7#c77 :i* also are prev5tive s]vices are requir$ to be cov]$ only to ! ext5t t !y are requir$ to be cov]$ z prev5tive s]vices4 7#c7 ,miscellane\s exclusions f cov]$ s]vices ,cov]$ s]vices "u ?is ,act d n include ! foll[+3 7,a7 ,surg]y & o!r proc$ures 7su* z or?odontia7 p]=m$ solely = cosmetic purposes 7z def9$ 9 regulations7 & hospital or o!r s]vices incid5t !reto1 unless-- 7i7 requir$ to correct a cong5ital anomaly2 7ii7 requir$ to re/ore or correct a "p ( ! body :i* has be5 alt]$ z a result ( accid5tal injury1 disease1 or surg]y2 or 7iii7 o!rwise det]m9$ to be m$ically necess>y & appropriate "u section #bja7;a74 7,b7 ,p]sonal com=t items or private rooms 9 inpati5t facilities1 unless det]m9$ to be m$ically necess>y & appropriate "u section #bja7;a74 7,c7 ,! s]vices ( a pr(essional practition] if !y are furni%$ 9 a hospital or o!r facility :i* is n a p>ticipat+ provid]4 7f7 ,nurs+ facility s]vices & home heal? s]vices ,nurs+ facility s]vices & home heal? s]vices 7o!r ?an po/-hospital s]vices1 z def9$ by ! ,bo>d7 furni%$ to an individual :o is n describ$ 9 section #bjc7;a7 are n cov]$ s]vices unless ! s]vices are det]m9$ to meet ! /&>ds specifi$ 9 section #bja7;a7 &1 ) respect to nurs+ facility s]vices1 to be provid$ 9 ! lea/ re/rictive & mo/ appropriate sett+4 #bje4 ,c]tification2 quality review2 plans ( c>e 7a7 ,c]tifications ,/ate heal? security programs may require1 z a condition ( paym5t = in/itutional heal? c>e s]vices & o!r s]vices ( ! type describ$ 9 su* sections #ahad7;a7 & #ahce7;a7 ( ! ,social ,security ,act1 p]iodic pr(essional c]tifications ( ! k9d describ$ 9 su* sections4 7b7 ,quality review ,= ! requirem5t t ea* ,/ate heal? security program e/abli% a quality review program t meets ! requirem5ts = su* a program "u title ,v1 see section #djd7;b77#a77;,h74 7c7 ,plan ( c>e requirem5ts ,a ,/ate heal? security program may require1 consi/5t ) /&>ds e/abli%$ by ! ,bo>d1 t paym5t = s]vices exce$+ specifi$ levels or duration be provid$ only z consi/5t ) a plan ( c>e or treatm5t =mulat$ by "o or m provid]s ( ! s]vices or o!r qualifi$ pr(essionals4 ,su* a plan may include1 consi/5t ) subsection 7b71 case managem5t at specifi$ int]vals z a fur!r condition ( paym5t = s]vices4 ,,iii ,provid] ,p>ticipation #cja4 ,provid] p>ticipation & /&>ds 7a7 ,9 g5]al ,an individual or o!r entity furni%+ any cov]$ s]vice "u a ,/ate heal? security program "u ?is ,act is n a qualifi$ provid] unless ! individual or entity-- 7#a7 is a qualifi$ provid] ( ! s]vices "u section #cjb2 7#b7 has fil$ ) ! ,/ate heal? security program a p>ticipation agreem5t describ$ 9 subsection 7b72 & 7#c7 meets su* o!r qualifications & conditions z are e/abli%$ by ! ,bo>d or ! ,/ate heal? security program "u ?is ,act4 7b7 ,requirem5ts 9 p>ticipation agreem5t 7#a7 ,9 g5]al ,a p>ticipation agreem5t describ$ 9 ?is subsection betwe5 a ,/ate heal? security program & a provid] %all provide at lea/ = ! foll[+3 7,a7 ,s]vices to eligible p]sons w be furni%$ by ! provid] )\t discrim9ation on ! gr\nd ( race1 national orig91 income1 religion1 age1 sex or sexual ori5tation1 disability1 h&icapp+ condition1 or 7subject to ! pr(essional qualifications ( ! provid]7 illness4 ,no?+ 9 ?is subp>agraph %all be con/ru$ z requir+ ! provision ( a type or class ( s]vices :i* s]vices are outside ! scope ( ! provid]'s normal practice4 7,b7 ,no *>ge w be made = any cov]$ s]vices o!r ?an = paym5t au?oriz$ by ?is ,act4 7,c7 ,! provid] agrees to furni% su* in=mation z may be reasonably requir$ by ! ,bo>d or a ,/ate heal? security program1 9 accordance ) uni=m report+ /&>ds e/abli%$ "u section #dja7;g77#a71 =-- 7i7 quality review by designat$ entities2 7ii7 ! mak+ ( paym5ts "u ?is ,act 7includ+ ! exam9ation ( records z may be necess>y = ! v]ification ( in=mation on :i* paym5ts are bas$72 7iii7 /ati/ical or o!r /udies requir$ = ! implem5tation ( ?is ,act2 & 7iv7 su* o!r purposes z ! ,bo>d or ,/ate may specify4 7,d7 ,! provid] agrees n to bill ! program = any s]vices = :i* b5efits are n available because ( section #bjd7;d74 7,e7 ,9 ! case ( a provid] t is n an individual1 ! provid] agrees n to employ or use = ! provision ( heal? s]vices any individual or o!r provid] :o or :i* has _h a p>ticipation agreem5t "u ?is subsection t]m9at$ = cause4 7,f7 ,9 ! case ( a provid] paid "u a fee-=-s]vice basis "u section #fab1 ! provid] agrees to submit bills & any requir$ support+ docum5tation relat+ to ! provision ( cov]$ s]vices )9 #cj days 7or su* %ort] p]iod z a ,/ate heal? security program may require7 aft] ! date ( provid+ su* s]vices4 7#b7 ,t]m9ation ( p>ticipation agreem5ts 7,a7 ,9 g5]al ,p>ticipation agreem5ts may be t]m9at$1 ) appropriate notice-- 7i7 by ! ,bo>d or a ,/ate heal? security program = failure to meet ! requirem5ts ( ?is title2 or 7ii7 by a provid]4 7,b7 ,t]m9ation process ,provid]s %all be provid$ notice & a reasonable opportunity to correct defici5cies be=e ! ,bo>d or a ,/ate heal? security program t]m9ates an agreem5t unless a m imm$iate t]m9ation is requir$ = public safety or simil> reasons4 #cjb4 ,qualifications = provid]s 7a7 ,9 g5]al ,a heal? c>e provid] is consid]$ to be qualifi$ to provide cov]$ s]vices if ! provid] is lic5s$ or c]tifi$ & meets-- 7#a7 all ! requirem5ts ( ,/ate law to provide su* s]vices2 & 7#b7 applicable requirem5ts ( ,f$]al law to provide su* s]vices4 7b7 ,m9imum provid] /&>ds 7#a7 ,9 g5]al ,! ,bo>d %all e/abli%1 evaluate1 & update national m9imum /&>ds to ensure ! quality ( s]vices provid$ "u ?is ,act & to monitor ef=ts by ,/ate heal? security programs to ensure ! quality ( su* s]vices4 ,a ,/ate heal? security program may also e/abli% additional m9imum /&>ds :i* provid]s %all meet4 7#b7 ,national m9imum /&>ds ,! national m9imum /&>ds "u p>agraph 7#a7 %all be e/abli%$ = in/itutional provid]s ( s]vices1 individual heal? c>e practition]s1 & compreh5sive heal? s]vice organizations4 ,except z ! ,bo>d may specify 9 ord] to c>ry out ?is title1 a hospital1 nurs+ facility1 or o!r in/itutional provid] ( s]vices %all meet /&>ds = su* a facility "u ! m$ic>e program "u title ,,xviii ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acie et seq474 ,su* /&>ds also may include1 :]e appropriate1 elem5ts relat+ to-- 7,a7 adequacy & quality ( facilities2 7,b7 tra9+ & compet5ce ( p]sonnel 7includ+ cont9u+ education requirem5ts72 7,c7 compreh5siv5ess ( s]vice2 7,d7 cont9uity ( s]vice2 7,e7 pati5t satisfaction 7includ+ wait+ "t & access to s]vices72 & 7,f7 p]=mance /&>ds 7includ+ organization1 facilities1 /ructure ( s]vices1 effici5cy ( op]ation1 & outcome 9 palliation1 improvem5t ( heal?1 /abilization1 cure1 or rehabilitation74 7#c7 ,transition 9 application ,if ! ,bo>d provides = additional requirem5ts = provid]s "u ?is subsection1 any su* additional requirem5t %all be implem5t$ 9 a mann] t provides = a reasonable p]iod dur+ :i* a previ\sly qualifi$ provid] is p]mitt$ to meet su* an additional requirem5t4 7#d7 ,ex*ange ( in=mation ,! ,bo>d %all provide = an ex*ange1 at lea/ annually1 among ,/ate heal? security programs ( in=mation ) respect to quality assurance & co/ conta9m5t4 #cjc4 ,qualifications = compreh5sive heal? s]vice organizations 7a7 ,9 g5]al ,= purposes ( ?is ,act1 a compreh5sive heal? s]vice organization 79 ?is section ref]r$ to z a ,,*so7 is a public or private non-pr(it organization t deliv]s c>e 9 its own facilities & employs cl9icians on a sal>i$ basis1 :i*1 9 return = a capitat$ paym5t am\nt or global budget1 und]takes to furni%1 arrange = ! provision (1 or provide paym5t ) respect to-- 7#a7 a full range ( heal? s]vices 7z id5tifi$ by ! ,bo>d71 includ+ at lea/ hospital s]vices & physicians s]vices2 & 7#b7 out-(-area cov]age 9 ! case ( urg5tly ne$$ s]vices2 to an id5tifi$ population :i* is liv+ 9 or ne> a specifi$ s]vice area & :i* enrolls volunt>ily 9 ! organization4 7b7 ,enrollm5t 7#a7 ,9 g5]al ,all eligible p]sons liv+ 9 or ne> ! specifi$ s]vice area ( a ,,*so are eligible to enroll 9 ! organization2 except t ! numb] ( enrollees may be limit$ to avoid ov]tax+ ! res\rces ( ! organization4 7#b7 ,m9imum enrollm5t p]iod ,subject to p>agraph 7#c71 ! m9imum p]iod ( enrollm5t ) a ,,*so %all be #a ye>1 unless ! enroll$ individual becomes ineligible to enroll ) ! organization4 7#c7 ,)drawal = cause ,ea* ,,*so %all p]mit an enroll$ individual to dis5roll f ! organization = cause at any "t4 7c7 ,requirem5ts = ,c,h,s,os 7#a7 ,accessible s]vices ,ea* ,,*so %all make all heal? s]vices readily & promptly accessible to enrollees :o live 9 ! specifi$ s]vice area4 7#b7 ,cont9uity ( c>e ,ea* ,,*so %all furni% s]vices 9 su* mann] z to provide cont9uity ( c>e & 7:5 s]vices are furni%$ by diff]5t provid]s7 %all provide ready ref]ral ( pati5ts to su* s]vices & at su* times z may be m$ically appropriate4 7#c7 ,bo>d ( directors ,9 ! case ( a ,,*so t is a private organization-- 7,a7 ,consum] repres5tation ,at lea/ "o-?ird ( ! memb]s ( ! ,,*so's bo>d ( directors %all be consum] memb]s ) no direct or indirect1 p]sonal or family f9ancial relation%ip to ! organization4 7,b7 ,provid] repres5tation ,! ,,*so's bo>d ( directors %all include at lea/ "o memb] :o repres5ts heal? c>e provid]s4 7#d7 ,pati5t grievance program ,ea* ,,*so %all h 9 effect a pati5t grievance program & %all conduct regul>ly surveys ( ! satisfaction ( memb]s ) s]vices provid$ by or ?r\gh ! organization4 7#e7 ,m$ical /&>ds ,ea* ,,*so %all provide t a committee or committees ( heal? c>e practition]s associat$ ) ! organization w promulgate m$ical /&>ds1 ov]see ! pr(essional aspects ( ! deliv]y ( c>e1 p]=m ! functions ( a ph>macy & drug !rapeutics committee1 & monitor & review ! quality ( all heal? s]vices 7includ+ drugs1 education1 & prev5tive s]vices74 7#f7 ,quality & o!r report+ requirem5ts 7,a7 ,9 g5]al ,! ,bo>d %all det]m9e appropriate measures to assess ! quality ( c>e furni%$ by ! ,,*so1 su* z measures (-- 7i7 cl9ical processes & outcomes2 7ii7 pati5t &1 :]e practicable1 c>egiv] exp]i5ce ( c>e2 & 7iii7 utilization 7su* z rates ( hospital admissions = ambulatory c>e s5sitive conditions74 7,b7 ,o!r duties ,! ,,*so %all-- 7i7 def9e processes to promote evid5ce-bas$ m$ic9e & pati5t engagem5t1 report on quality & co/ measures1 & coord9ate c>e1 su* z ?r\gh ! use ( teleheal?1 remote pati5t monitor+1 & o!r su* enabl+ te*nologies2 & 7ii7 demon/rate to ! ,bo>d t ! ,,*so meets pati5t-c5t]$ness crit]ia specifi$ by ! ,bo>d1 su* z ! use ( pati5t & c>egiv] assessm5ts or ! use ( individualiz$ c>e plans4 7,c7 ,report+ requirem5ts ,a ,,*so %all submit data 9 a =m & mann] specifi$ by ! ,bo>d on measures ! ,bo>d det]m9es necess>y = ! ,,*so to report to ! ,/ate ,heal? ,security ,program 9 ord] to evaluate ! quality ( c>e furni%$ by ! ,,*so4 ,su* data may include c>e transitions across heal? c>e sett+s1 includ+ hospital dis*>ge plann+ & po/-hospital dis*>ge foll[-up by ,,*so pr(essionals1 z ! ,bo>d det]m9es appropriate4 7,d7 ,quality p]=mance /&>ds ,! ,bo>d %all e/abli% quality p]=mance /&>ds to assess ! quality ( c>e furni%$ by ,c,h,s,os & %all seek to improve ! quality ( c>e furni%$ by ,c,h,s,os ov] "t by specify+ high] /&>ds1 new measures1 or bo? = purposes ( assess+ su* quality ( c>e4 7#g7 ,premiums ,premiums or o!r *>ges by a ,,*so = any s]vices n paid = "u ?is ,act %all be reasonable4 7#h7 ,utilization & bonus in=mation ,ea* ,,*so %all-- 7,a7 comply ) ! requirem5ts ( section #ahgf7;i77#h7 ( ! ,social ,security ,act 7relat+ to prohibit+ physician inc5tive plans t provide specific inducem5ts to r$uce or limit m$ically necess>y s]vices72 & 7,b7 make available to its memb]%ip utilization in=mation & data reg>d+ f9ancial p]=mance1 includ+ bonus or inc5tive paym5t arrangem5ts to practition]s4 7#i7 ,provision ( s]vices to enrollees at in/itutions op]at+ "u global budgets ,! organization %all arrange to reimburse = hospital s]vices & o!r facility-bas$ s]vices 7z id5tifi$ by ! ,bo>d7 = s]vices provid$ to memb]s ( ! organization 9 accordance ) ! global op]at+ budget ( ! hospital or facility approv$ "u section #faa4 7#aj7 ,broad m>ket+ ,ea* ,,*so %all provide = ! m>ket+ ( its s]vices 7includ+ dissem9ation ( m>ket+ mat]ials7 to pot5tial enrollees 9 a mann] t is design$ to enroll individuals repres5tative ( ! diff]5t population gr\ps & geographic areas includ$ )9 its s]vice area & meets su* requirem5ts z ! ,bo>d or a ,/ate heal? security program may specify4 7#aa7 ,additional requirem5ts ,ea* ,,*so %all meet-- 7,a7 su* requirem5ts relat+ to m9imum enrollm5t2 7,b7 su* requirem5ts relat+ to f9ancial solv5cy2 7,c7 su* requirem5ts relat+ to quality & availability ( c>e2 & 7,d7 su* o!r requirem5ts1 z ! ,bo>d or a ,/ate heal? security program may specify4 7d7 ,provision ( em]g5cy s]vices to non5rollees ,a ,,*so may furni% em]g5cy s]vices to p]sons :o are n enroll$ 9 ! organization4 ,paym5t by ! ,/ate ,heal? ,security ,program = su* s]vices1 if !y are cov]$ s]vices to eligible p]sons1 %all be made to ! organization unless ! organization reque/s t x be made to ! individual provid] :o furni%$ ! s]vices4 #cjd4 ,limitation on c]ta9 physician ref]rals 7a7 ,application to ,am]ican ,heal? ,security ,program ,section #ahgg ( ! ,social ,security ,act1 z am5d$ by subsections 7b7 & 7c71 %all apply "u ?is ,act 9 ! same mann] z x applies "u title ,,xviii ( ! ,social ,security ,act2 except t 9 apply+ su* section "u ?is ,act any ref]5ces 9 su* section to ! ,secret>y or title ,,xviii ( ! ,social ,security ,act are deem$ ref]5ces to ! ,bo>d & ! ,am]ican ,heal? ,security ,program "u ?is ,act1 respectively4 7b7 ,expansion ( prohibition to c]ta9 additional designat$ s]vices ,section #ahgg7;h77#f7 ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acienn7h77#f77 is am5d$ by add+ at ! end ! foll[+3 7,m7 ,ambulance s]vices4 7,n7 ,home infusion !rapy s]vices4 4 7c7 ,con=m+ am5dm5ts ,section #ahgg ( su* ,act is fur!r am5d$-- 7#a7 9 subsection 7a77#a77;,a71 by /rik+ = :i* paym5t o!rwise may be made "u ?is title & ins]t+ = :i* a *>ge is impos$2 7#b7 9 subsection 7a77#a77;,b71 by /rik+ "u ?is title2 7#c7 by am5d+ p>agraph 7#a7 ( subsection 7g7 to read z foll[s3 7#a7 ,d5ial ( paym5t ,no paym5t may be made "u a ,/ate heal? security program = a designat$ heal? s]vice = :i* a claim is pres5t$ 9 violation ( subsection 7a77#a77;,b74 ,no individual1 ?ird p>ty payor1 or o!r entity is liable = paym5t = designat$ heal? s]vices = :i* a claim is pres5t$ 9 violation ( su* subsection4 2 & 7#d7 9 subsection 7g77#c71 by /rik+ = :i* paym5t may n be made "u p>agraph 7#a7 & ins]t+ = :i* su* a claim may n be pres5t$ "u subsection 7a77#a74 ,,iv ,adm9i/ration ,a ,g5]al ,adm9i/rative ,provisions #dja4 ,am]ican ,heal? ,security ,/&>ds ,bo>d 7a7 ,e/abli%m5t ,!re is h]eby e/abli%$ an ,am]ican ,heal? ,security ,/&>ds ,bo>d4 7b7 ,appo9tm5t & t]ms ( memb]s 7#a7 ,9 g5]al ,! ,bo>d %all be compos$ (-- 7,a7 ! ,secret>y ( ,heal? & ,human ,s]vices2 & 7,b7 #f o!r individuals 7describ$ 9 p>agraph 7#b77 appo9t$ by ! ,presid5t ) ! advice & cons5t ( ! ,s5ate4 ,! ,presid5t %all fir/ nom9ate individuals "u subp>agraph 7,b7 on a timely basis s z to provide = ! op]ation ( ! ,bo>d by n lat] ?an ,janu>y #a1 #bjae4 7#b7 ,selection ( appo9t$ memb]s ,) respect to ! individuals appo9t$ "u p>agraph 7#a77;,b73 7,a7 ,! memb]s %all be *os5 on ! basis ( backgr\nds 9 heal? policy1 heal? economics1 ! heal? pr(essions1 & ! adm9i/ration ( heal? c>e in/itutions4 7,b7 ,! memb]s %all provide a balanc$ po9t ( view ) respect to ! v>i\s heal? c>e int]e/s & at lea/ #b ( !m %all repres5t ! int]e/s ( individual pati5ts4 7,c7 ,at lea/ #a memb] %all h a nurs+ backgr\nd4 7,d7 ,n m ?an #c memb]s %all be f ! same political p>ty4 7,e7 ,to ! greate/ ext5t feasible1 ! memb]s %all repres5t ! v>i\s geographic regions ( ! ,unit$ ,/ates & %all reflect ! racial1 e?nic1 & g5d] composition ( ! population ( ! ,unit$ ,/ates4 7#c7 ,t]ms ( appo9t$ memb]s ,individuals appo9t$ "u p>agraph 7#a77;,b7 %all s]ve = a t]m ( #f ye>s1 except t ! t]ms ( #e ( ! individuals initially appo9t$ %all be1 z designat$ by ! ,presid5t at ! "t ( _! appo9tm5t1 = #a1 #b1 #c1 #d1 & #e ye>s4 ,dur+ a t]m ( memb]%ip on ! ,bo>d1 no memb] %all engage 9 any o!r bus9ess1 vocation or employm5t4 7c7 ,vacancies 7#a7 ,9 g5]al ,! ,presid5t %all fill any vacancy 9 ! memb]%ip ( ! ,bo>d 9 ! same mann] z ! orig9al appo9tm5t4 ,! vacancy %all n affect ! p[] ( ! rema9+ memb]s to execute ! duties ( ! ,bo>d4 7#b7 ,vacancy appo9tm5ts ,any memb] appo9t$ to fill a vacancy %all s]ve = ! rema9d] ( ! t]m = :i* ! pr$ecessor ( ! memb] 0 appo9t$4 7#c7 ,reappo9tm5t ,! ,presid5t may reappo9t an appo9t$ memb] ( ! ,bo>d = a second t]m 9 ! same mann] z ! orig9al appo9tm5t4 ,a memb] :o has s]v$ = #b consecutive #f-ye> t]ms %all n be eligible = reappo9tm5t until #b ye>s aft] ! memb] has ceas$ to s]ve4 7#d7 ,removal = cause ,^u confirmation1 memb]s ( ! ,bo>d may n be remov$ except by ! ,presid5t = cause4 7d7 ,*air ,! ,presid5t %all designate #a ( ! memb]s ( ! ,bo>d1 o!r ?an ! ,secret>y1 to s]ve at ! w ( ! ,presid5t z ,*air ( ! ,bo>d4 7e7 ,comp5sation ,memb]s ( ! ,bo>d 7o!r ?an ! ,secret>y7 %all be entitl$ to comp5sation at a level equival5t to level ,,ii ( ! ,executive ,s*$ule1 9 accordance ) section #ecac ( title #e1 ,unit$ ,/ates ,code4 7f7 ,g5]al duties ( ! ,bo>d 7#a7 ,9 g5]al ,! ,bo>d %all develop policies1 proc$ures1 guidel9es1 & requirem5ts to c>ry out ?is ,act1 includ+ ^? relat$ to-- 7,a7 eligibility2 7,b7 enrollm5t2 7,c7 b5efits2 7,d7 provid] p>ticipation /&>ds & qualifications1 z def9$ 9 title ,,iii2 7,e7 ,c,h,s,os2 7,f7 national & ,/ate fund+ levels2 7,g7 me?ods = det]m9+ am\nts ( paym5ts to provid]s ( cov]$ s]vices1 consi/5t ) subtitle ,b ( title ,,vi2 7,h7 ! det]m9ation ( m$ical necessity & appropriat5ess ) respect to cov]age ( c]ta9 s]vices2 7,i7 assi/+ ,/ate heal? security programs ) plann+ = capital exp5ditures & s]vice deliv]y2 7,j7 plann+ = heal? pr(essional education fund+ 7z specifi$ 9 title ,,vi72 7,k7 allocat+ funds provid$ "u title ,,vii2 & 7,l7 enc\rag+ ,/ates to develop regional plann+ me*anisms 7describ$ 9 section #djd7;a77#c774 7#b7 ,regulations ,regulations au?oriz$ by ?is ,act %all be issu$ by ! ,bo>d 9 accordance ) ! provisions ( section #eec ( title #e1 ,unit$ ,/ates ,code4 7g7 ,uni=m report+ /&>ds2 annual report2 /udies 7#a7 ,uni=m report+ /&>ds 7,a7 ,9 g5]al ,! ,bo>d %all e/abli% uni=m ,/ate report+ requirem5ts & national /&>ds to ensure an adequate national data base reg>d+ heal? s]vices practition]s1 s]vices & f9ances ( ,/ate heal? security programs1 approv$ plans1 provid]s1 & ! co/s ( facilities & practition]s provid+ s]vices4 ,su* /&>ds %all include1 to ! maximum ext5t feasible1 heal? outcome measures4 7,b7 ,reports ,! ,bo>d %all analyze regul>ly in=mation report$ to x1 & to ,/ate heal? security programs pursuant to su* requirem5ts & /&>ds4 7#b7 ,annual report ,beg9n+ ,janu>y #a1 ( ! second ye> beg9n+ aft] ! date ( ! enactm5t ( ?is ,act1 ! ,bo>d %all annually report to ,congress on ! foll[+3 7,a7 ,! /atus ( implem5tation ( ! ,act4 7,b7 ,enrollm5t "u ?is ,act4 7,c7 ,b5efits "u ?is ,act4 7,d7 ,exp5ditures & f9anc+ "u ?is ,act4 7,e7 ,co/-conta9m5t measures & a*ievem5ts "u ?is ,act4 7,f7 ,quality assurance4 7,g7 ,heal? c>e utilization patt]ns1 includ+ any *anges attributable to ! program4 7,h7 ,long-range plans & goals = ! deliv]y ( heal? s]vices4 7,i7 ,diff]5ces 9 ! heal? /atus ( ! populations ( ! diff]5t ,/ates1 includ+ income & racial *>act]i/ics4 7,j7 ,necess>y *anges 9 ! education ( heal? p]sonnel4 7,k7 ,plans = improv+ s]vice to m$ically und]s]v$ populations4 7,l7 ,transition problems z a result ( implem5tation ( ?is ,act4 7,m7 ,opportunities = improvem5ts "u ?is ,act4 7#c7 ,/ati/ical analyses & o!r /udies ,! ,bo>d may1 ei!r directly or by contract-- 7,a7 make /ati/ical & o!r /udies1 on a nationwide1 regional1 ,/ate1 or local basis1 ( any aspect ( ! op]ation ( ?is ,act1 includ+ /udies ( ! effect ( ! ,act ^u ! heal? ( ! p ( ! ,unit$ ,/ates & ! effect ( compreh5sive heal? s]vices ^u ! heal? ( p]sons receiv+ su* s]vices2 7,b7 develop & te/ me?ods ( provid+ ?r\gh paym5t = s]vices or o!rwise1 additional inc5tives = adh]5ce by provid]s to /&>ds ( adequacy1 access1 & quality2 me?ods ( consum] & pe] review & pe] control ( ! utilization ( drugs1 ( laboratory s]vices1 & ( o!r s]vices2 & me?ods ( consum] & pe] review ( ! quality ( s]vices2 7,c7 develop & te/1 = use by ! ,bo>d1 records & in=mation retrieval sy/ems & budget sy/ems = heal? s]vices adm9i/ration1 & develop & te/ model sy/ems = use by provid]s ( s]vices2 7,d7 develop & te/1 = use by provid]s ( s]vices1 records & in=mation retrieval sy/ems useful 9 ! furni%+ ( prev5tive or diagno/ic s]vices2 7,e7 develop1 9 collaboration ) ! ph>maceutical pr(ession1 & te/1 improv$ adm9i/rative practices or improv$ me?ods = ! reimbursem5t ( indep5d5t ph>macies = ! co/ ( furni%+ drugs z a cov]$ s]vice2 & 7,f7 conduct or solicit o!r /udies z x may consid] necess>y or promis+ = ! evaluation1 or = ! improvem5t1 ( ! op]ation ( ?is ,act4 7#d7 ,report on use ( exi/+ ,f$]al heal? c>e facilities ,n lat] ?an #a ye> aft] ! date ( ! enactm5t ( ?is ,act1 ! ,bo>d %all recomm5d to ,congress "o or m proposals = ! treatm5t ( heal? c>e facilities ( ! ,f$]al ,gov]nm5t4 7h7 ,executive ,director 7#a7 ,appo9tm5t ,!re is h]eby e/abli%$ ! position ( ,executive ,director ( ! ,bo>d4 ,! ,director %all be appo9t$ by ! ,bo>d & %all s]ve z secret>y to ! ,bo>d & p]=m su* duties 9 ! adm9i/ration ( ?is title z ! ,bo>d may assign4 7#b7 ,delegation ,! ,bo>d is au?oriz$ to delegate to ! ,director or to any o!r (fic] or employee ( ! ,bo>d or1 ) ! approval ( ! ,secret>y ( ,heal? & ,human ,s]vices 7& subject to reimbursem5t ( id5tifiable co/s71 to any o!r (fic] or employee ( ! ,dep>tm5t ( ,heal? & ,human ,s]vices1 any ( its functions or duties "u ?is ,act o!r ?an-- 7,a7 ! issuance ( regulations2 or 7,b7 ! det]m9ation ( ! availability ( funds & _! allocation to implem5t ?is ,act4 7#c7 ,comp5sation ,! ,executive ,director ( ! ,bo>d %all be entitl$ to comp5sation at a level equival5t to level ,,iii ( ! ,executive ,s*$ule1 9 accordance ) section #ecad ( title #e1 ,unit$ ,/ates ,code4 7i7 ,inspector ,g5]al ,! ,inspector ,g5]al ,act ( #aigh 7#e ,u4,s4,c4 ,app47 is am5d$-- 7#a7 9 section #ab7a71 by ins]t+ aft] ,corporation2 ! fir/ place x appe>s ! foll[+3 ! ,*air ( ! ,am]ican ,heal? ,security ,/&>ds ,bo>d22 7#b7 9 section #ab7b71 by ins]t+ aft] ,resolution ,tru/ ,corporation1 ! foll[+3 ! ,am]ican ,heal? ,security ,/&>ds ,bo>d12 & 7#c7 by ins]t+ be=e section #i ! foll[+3 #h,m4 ,special provisions conc]n+ ,am]ican ,heal? ,security ,/&>ds ,bo>d ,! ,inspector ,g5]al ( ! ,am]ican ,heal? ,security ,/&>ds ,bo>d1 9 addition to ! o!r au?orities ve/$ by ?is ,act1 %all h ! same au?ority1 ) respect to ! ,bo>d & ! ,am]ican ,heal? ,security ,program "u ?is ,act1 z ! ,inspector ,g5]al = ! ,dep>tm5t ( ,heal? & ,human ,s]vices has ) respect to ! ,secret>y ( ,heal? & ,human ,s]vices & ! m$ic>e & m$icaid programs1 respectively4 4 7j7 ,/aff ,! ,bo>d %all employ su* /aff z ! ,bo>d may deem necess>y4 7k7 ,access to in=mation ,! ,secret>y ( ,heal? & ,human ,s]vices %all make available to ! ,bo>d all in=mation available f s\rces )9 ! ,dep>tm5t or f o!r s\rces1 p]ta9+ to ! duties ( ! ,bo>d4 #djb4 ,am]ican ,heal? ,security ,advisory ,c\ncil 7a7 ,9 g5]al ,! ,bo>d %all provide = an ,am]ican ,heal? ,security ,advisory ,c\ncil 79 ?is section ref]r$ to z ! ,c\ncil7 to advise ! ,bo>d on its activities4 7b7 ,memb]%ip ,! ,c\ncil %all be compos$ (-- 7#a7 ! ,*air ( ! ,bo>d1 :o %all s]ve z ,*air ( ! ,c\ncil2 & 7#b7 #bj memb]s1 n o!rwise 9 ! employ ( ! ,unit$ ,/ates1 appo9t$ by ! ,bo>d )\t reg>d to ! provisions ( title #e1 ,unit$ ,/ates ,code1 gov]n+ appo9tm5ts 9 ! competitive s]vice4 ,! appo9t$ memb]s %all include1 9 accordance ) subsection 7e71 individuals :o are repres5tative ( ,/ate heal? security programs1 public heal? pr(essionals1 provid]s ( heal? s]vices1 & ( individuals 7:o %all con/itute a majority ( ! ,c\ncil7 :o are repres5tative ( consum]s ( su* s]vices1 includ+ a balanc$ repres5tation ( employ]s1 unions1 consum] organizations1 & population gr\ps ) special heal? c>e ne$s4 ,to ! greate/ ext5t feasible1 ! memb]%ip ( ! ,c\ncil %all repres5t ! v>i\s geographic regions ( ! ,unit$ ,/ates & %all reflect ! racial1 e?nic1 & g5d] composition ( ! population ( ! ,unit$ ,/ates4 7c7 ,t]ms ( memb]s ,ea* appo9t$ memb] %all hold (fice = a t]m ( #d ye>s1 except t-- 7#a7 any memb] appo9t$ to fill a vacancy occurr+ dur+ ! t]m = :i* ! memb]'s pr$ecessor 0 appo9t$ %all be appo9t$ = ! rema9d] ( t t]m2 & 7#b7 ! t]ms ( ! memb]s fir/ tak+ (fice %all expire1 z designat$ by ! ,bo>d at ! "t ( appo9tm5t1 at ! end ( ! fir/ ye> ) respect to #e memb]s1 at ! end ( ! second ye> ) respect to #e memb]s1 at ! end ( ! ?ird ye> ) respect to #e memb]s1 & at ! end ( ! f\r? ye> ) respect to #e memb]s aft] ! date ( enactm5t ( ?is ,act4 7d7 ,vacancies 7#a7 ,9 g5]al ,! ,bo>d %all fill any vacancy 9 ! memb]%ip ( ! ,c\ncil 9 ! same mann] z ! orig9al appo9tm5t4 ,! vacancy %all n affect ! p[] ( ! rema9+ memb]s to execute ! duties ( ! ,c\ncil4 7#b7 ,vacancy appo9tm5ts ,any memb] appo9t$ to fill a vacancy %all s]ve = ! rema9d] ( ! t]m = :i* ! pr$ecessor ( ! memb] 0 appo9t$4 7#c7 ,reappo9tm5t ,! ,bo>d may reappo9t an appo9t$ memb] ( ! ,c\ncil = a second t]m 9 ! same mann] z ! orig9al appo9tm5t4 7e7 ,qualifications 7#a7 ,public heal? repres5tatives ,memb]s ( ! ,c\ncil :o are repres5tative ( ,/ate heal? security programs & public heal? pr(essionals %all be individuals :o h ext5sive exp]i5ce 9 ! f9anc+ & deliv]y ( c>e "u public heal? programs4 7#b7 ,provid]s ,memb]s ( ! ,c\ncil :o are repres5tative ( provid]s ( heal? c>e %all be individuals :o are out/&+ 9 fields relat$ to m$ical1 hospital1 or o!r heal? activities1 or :o are repres5tative ( organizations or associations ( pr(essional heal? practition]s4 7#c7 ,consum]s ,memb]s :o are repres5tative ( consum]s ( su* c>e %all be individuals1 n engag$ 9 & hav+ no f9ancial int]e/ 9 ! furni%+ ( heal? s]vices1 :o are famili> ) ! ne$s ( v>i\s segm5ts ( ! population = p]sonal heal? s]vices & are exp]i5c$ 9 deal+ ) problems associat$ ) ! consumption ( su* s]vices4 7f7 ,duties 7#a7 ,9 g5]al ,x %all be ! duty ( ! ,c\ncil-- 7,a7 to advise ! ,bo>d on matt]s ( g5]al policy 9 ! adm9i/ration ( ?is ,act1 9 ! =mulation ( regulations1 & 9 ! p]=mance ( ! ,bo>d's duties "u section #dja2 & 7,b7 to /udy ! op]ation ( ?is ,act & ! utilization ( heal? s]vices "u x1 ) a view to recomm5d+ any *anges 9 ! adm9i/ration ( ! ,act or 9 its provisions :i* may appe> desirable4 7#b7 ,report ,! ,c\ncil %all make an annual report to ! ,bo>d on ! p]=mance ( its functions1 includ+ any recomm5dations x may h ) respect !reto1 & ! ,bo>d %all promptly transmit ! report to ! ,congress1 toge!r ) a report by ! ,bo>d on any recomm5dations ( ! ,c\ncil t h n be5 foll[$4 7g7 ,/aff ,! ,c\ncil1 its memb]s1 & any committees ( ! ,c\ncil %all be provid$ ) su* secret>ial1 cl]ical1 or o!r assi/ance z may be au?oriz$ by ! ,bo>d = c>ry+ out _! respective functions4 7h7 ,meet+s ,! ,c\ncil %all meet z frequ5tly z ! ,bo>d deems necess>y1 b n less ?an #d times ea* ye>4 ,^u reque/ by #g or m memb]s x %all be ! duty ( ! ,*air to call a meet+ ( ! ,c\ncil4 7i7 ,comp5sation ,memb]s ( ! ,c\ncil %all be reimburs$ by ! ,bo>d = travel & p] diem 9 lieu ( subsi/5ce exp5ses dur+ ! p]=mance ( duties ( ! ,bo>d 9 accordance ) sub*apt] ,i ( *apt] #eg ( title #e1 ,unit$ ,/ates ,code4 7j7 ,,faca n applicable ,! provisions ( ! ,f$]al ,advisory ,committee ,act %all n apply to ! ,c\ncil4 #djc4 ,consultation ,! ,secret>y & ! ,bo>d %all consult ) ,f$]al ag5cies & private entities1 su* z pr(essional societies1 national associations1 nationally recogniz$ associations ( exp]ts1 m$ical s*ools & academic heal? c5t]s1 consum] gr\ps1 & labor & bus9ess organizations 9 ! =mulation ( guidel9es1 regulations1 policy initiatives1 & in=mation ga!r+ to ensure ! broade/ & mo/ in=m$ input 9 ! adm9i/ration ( ?is ,act4 ,no?+ 9 ?is ,act %all prev5t ! ,secret>y f adopt+ guidel9es develop$ by su* a private entity if1 9 ! ,secret>y's & ,bo>d's judgm5t1 su* guidel9es are g5]ally accept$ z reasonable & prud5t & consi/5t ) ?is ,act4 #djd4 ,/ate heal? security programs 7a7 ,submission ( plans 7#a7 ,9 g5]al ,ea* ,/ate %all submit to ! ,bo>d a plan = a ,/ate heal? security program = provid+ = heal? c>e s]vices to ! resid5ts ( ! ,/ate 9 accordance ) ?is ,act4 7#b7 ,regional programs ,a ,/ate may jo9 ) #a or m neighbor+ ,/ates to submit to ! ,bo>d a plan = a regional heal? security program in/ead ( sep>ate ,/ate heal? security programs4 7#c7 ,regional plann+ me*anisms ,! ,bo>d %all provide inc5tives = ,/ates to develop regional plann+ me*anisms to promote ! rational di/ribution (1 adequate access to1 & effici5t use (1 t]ti>y c>e facilities1 equipm5t1 & s]vices4 7#d7 ,/ates t fail to submit a plan ,9 ! case ( a ,/ate t fails to submit a plan z requir$ "u ?is subsection1 ! ,am]ican ,heal? ,security ,/&>ds ,bo>d ,au?ority %all develop a plan = a ,/ate heal? security program 9 su* ,/ate4 7b7 ,review & approval ( plans 7#a7 ,9 g5]al ,! ,bo>d %all review plans submitt$ "u subsection 7a7 & det]m9e :e!r su* plans meet ! requirem5ts = approval4 ,! ,bo>d %all n approve su* a plan unless x f9ds t ! plan 7or ,/ate law7 provides1 consi/5t ) ! provisions ( ?is ,act1 = ! foll[+3 7,a7 ,paym5t = requir$ heal? s]vices = eligible individuals 9 ! ,/ate 9 accordance ) ?is ,act4 7,b7 ,adequate adm9i/ration1 includ+ ! designation ( a s+le ,/ate ag5cy responsible = ! adm9i/ration 7or sup]vision ( ! adm9i/ration7 ( ! program4 7,c7 ,! e/abli%m5t ( a ,/ate heal? security budget4 7,d7 ,e/abli%m5t ( paym5t me?odologies 7consi/5t ) subtitle ,b ( title ,,vii74 7,e7 ,assurances t individuals h ! fre$om to *oose practition]s & o!r heal? c>e provid]s = s]vices cov]$ "u ?is ,act4 7,f7 ,a proc$ure = c>ry+ out long-t]m regional managem5t & plann+ functions ) respect to ! deliv]y & di/ribution ( heal? c>e s]vices t-- 7i7 ensures p>ticipation ( consum]s ( heal? s]vices & provid]s ( heal? s]vices2 & 7ii7 gives priority to ! mo/ acute %ortages & maldi/ributions ( heal? p]sonnel & facilities & ! mo/ s]i\s defici5cies 9 ! deliv]y ( cov]$ s]vices & to ! means = ! spe$y alleviation ( ^! %ortcom+s4 7,g7 ,! lic5sure & regulation ( all heal? provid]s & facilities to ensure compliance ) ,f$]al & ,/ate laws & to promote quality ( c>e4 7,h7 ,e/abli%m5t ( a quality review sy/em 9 accordance ) section #ejc4 7,i7 ,e/abli%m5t ( an indep5d5t ombudsman = consum]s to regi/] compla9ts ab\t ! organization & adm9i/ration ( ! ,/ate heal? security program & to help resolve compla9ts & disputes betwe5 consum]s & provid]s4 7,j7 ,publication ( an annual report on ! op]ation ( ! ,/ate heal? security program1 :i* report %all include in=mation on co/1 progress t[>ds a*iev+ full enrollm5t1 public access to heal? s]vices1 quality review1 heal? outcomes1 heal? pr(essional tra9+1 ! ne$s ( m$ically und]s]v$ populations1 & ! in=mation requir$ 9 ! annual report "u section #dja7;g77#b74 7,k7 ,provision ( a fraud & abuse prev5tion & control unit t ! ,inspector ,g5]al det]m9es meets ! requirem5ts ( section #dab7;a74 7,l7 ,prohibit paym5t 9 cases ( prohibit$ physician ref]rals "u section #cjd4 7#b7 ,consequ5ces ( failure to comply ,if ! ,bo>d f9ds t a ,/ate plan submitt$ "u p>agraph 7#a7 does n meet ! requirem5ts = approval "u ?is section or t a ,/ate heal? security program or specific portion ( su* program1 ! plan = :i* 0 previ\sly approv$1 no long] meets su* requirem5ts1 ! ,bo>d %all provide notice to ! ,/ate ( su* failure & t unless corrective action is tak5 )9 a p]iod specifi$ by ! ,bo>d1 ! ,bo>d %all place ! ,/ate heal? security program 7or specific portions ( su* program7 9 receiv]%ip "u ! jurisdiction ( ! ,bo>d4 7c7 ,/ate ,heal? ,security ,advisory ,c\ncils 7#a7 ,9 g5]al ,= ea* ,/ate1 ! ,gov]nor %all provide = appo9tm5t ( a ,/ate ,heal? ,security ,advisory ,c\ncil to advise & make recomm5dations to ! ,gov]nor & ,/ate ) respect to ! implem5tation ( ! ,/ate heal? security program 9 ! ,/ate4 7#b7 ,memb]%ip ,ea* ,/ate ,heal? ,security ,advisory ,c\ncil %all be compos$ ( at lea/ #aa individuals4 ,! appo9t$ memb]s %all include individuals :o are repres5tative ( ! ,/ate heal? security program1 public heal? pr(essionals1 provid]s ( heal? s]vices1 & ( individuals 7:o %all con/itute a majority7 :o are repres5tative ( consum]s ( su* s]vices1 includ+ a balanc$ repres5tation ( employ]s1 unions & consum] organizations4 ,to ! greate/ ext5t feasible1 ! memb]%ip ( ea* ,/ate ,heal? ,security ,advisory ,c\ncil %all repres5t ! v>i\s geographic regions ( ! ,/ate & %all reflect ! racial1 e?nic1 & g5d] composition ( ! population ( ! ,/ate4 7#c7 ,duties 7,a7 ,9 g5]al ,ea* ,/ate ,heal? ,security ,advisory ,c\ncil %all review1 & submit comm5ts to ! ,gov]nor conc]n+ ! implem5tation ( ! ,/ate heal? security program 9 ! ,/ate4 7,b7 ,assi/ance ,ea* ,/ate ,heal? ,security ,advisory ,c\ncil %all provide assi/ance & te*nical support to community organizations & public & private non-pr(it ag5cies submitt+ applications = fund+ "u appropriate ,/ate & ,f$]al public heal? programs1 ) p>ticul> emphasis plac$ on assi/+ ^? applicants ) broad consum] repres5tation4 7d7 ,/ate use ( fiscal ag5ts 7#a7 ,9 g5]al ,ea* ,/ate heal? security program1 us+ competitive bidd+ proc$ures1 may ent] into su* contracts ) qualifi$ entities1 z ! ,/ate det]m9es to be appropriate to process claims & to p]=m o!r relat$ functions ( fiscal ag5ts "u ! ,/ate heal? security program4 7#b7 ,re/riction ,except z ! ,bo>d may provide = good cause %[n1 9 no case may m ?an #a contract describ$ 9 p>agraph 7#a7 be ent]$ into "u a ,/ate heal? security program4 #dje4 ,complem5t>y conduct ( relat$ heal? programs ,9 p]=m+ functions ) respect to heal? p]sonnel education & tra9+1 heal? rese>*1 environm5tal heal?1 disability insurance1 vocational rehabilitation1 ! regulation ( food & drugs1 & all o!r matt]s p]ta9+ to heal?1 ! ,secret>y ( ,heal? & ,human ,s]vices %all direct all activities ( ! ,dep>tm5t ( ,heal? & ,human ,s]vices t[>d contributions to ! heal? ( ! p complem5t>y to ?is ,act4 ,b ,control ov] ,fraud & ,abuse #daa4 ,application ( ,f$]al sanctions to all fraud & abuse "u ,am]ican ,heal? ,security ,program ,! foll[+ sections ( ! ,social ,security ,act %all apply to ,/ate heal? security programs 9 ! same mann] z !y apply to ,/ate m$ical assi/ance plans "u title ,,xix ( su* ,act 7except t 9 apply+ su* provisions any ref]5ce to ! ,secret>y is deem$ a ref]5ce to ! ,bo>d73 7#a7 ,section #aabh 7relat+ to exclusion ( individuals & entities74 7#b7 ,section #aabh;,a 7civil monet>y p5alties74 7#c7 ,section #aabh;,b 7crim9al p5alties74 7#d7 ,section #aabd 7relat+ to disclosure ( own]%ip & relat$ in=mation74 7#e7 ,section #aabf 7relat+ to disclosure ( c]ta9 own]s74 #dab4 ,requirem5ts = op]ation ( ,/ate heal? c>e fraud & abuse control units 7a7 ,requirem5t ,9 ord] to meet ! requirem5t ( section #djd7;b77#a77,k71 ea* ,/ate heal? security program %all e/abli% & ma9ta9 a heal? c>e fraud & abuse control unit 79 ?is section ref]r$ to z a fraud unit7 t meets requirem5ts ( ?is section & o!r requirem5ts ( ! ,bo>d4 ,su* a unit may be a ,/ate m$icaid fraud control unit 7describ$ 9 section #aijc7q7 ( ! ,social ,security ,act74 7b7 ,/ructure ( unit ,! fraud unit %all-- 7#a7 be a s+le id5tifiable entity ( ! ,/ate gov]nm5t2 7#b7 be sep>ate & di/9ct f ! ,/ate ag5cy ) pr9cipal responsibility = ! adm9i/ration ( ! ,/ate heal? security program2 & 7#c7 meet #a ( ! foll[+ requirem5ts3 7,a7 ,x %all be a unit ( ! (fice ( ! ,/ate ,attorney ,g5]al or ( ano!r dep>tm5t ( ,/ate gov]nm5t :i* possesses /atewide au?ority to prosecute individuals = crim9al violations4 7,b7 ,if x is 9 a ,/ate ! con/itution ( :i* does n provide = ! crim9al prosecution ( individuals by a /atewide au?ority & has =mal proc$ures1 approv$ by ! ,bo>d1 t-- 7i7 assure its ref]ral ( suspect$ crim9al violations relat+ to ! ,/ate heal? insurance plan to ! appropriate au?ority or au?orities 9 ! ,/ates = prosecution2 & 7ii7 assure its assi/ance (1 & coord9ation )1 su* au?ority or au?orities 9 su* prosecutions4 7,c7 ,x %all h a =mal work+ relation%ip ) ! (fice ( ! ,/ate ,attorney ,g5]al & h =mal proc$ures 7includ+ proc$ures = its ref]ral ( suspect$ crim9al violations to su* (fice7 :i* are approv$ by ! ,bo>d & :i* provide effective coord9ation ( activities betwe5 ! fraud unit & su* (fice ) respect to ! detection1 inve/igation1 & prosecution ( suspect$ crim9al violations relat+ to ! ,/ate heal? insurance plan4 7c7 ,functions ,! fraud unit %all-- 7#a7 h ! function ( conduct+ a /atewide program = ! inve/igation & prosecution ( violations ( all applicable ,/ate laws reg>d+ any & all aspects ( fraud 9 connection ) any aspect ( ! provision ( heal? c>e s]vices & activities ( provid]s ( su* s]vices "u ! ,/ate heal? security program2 7#b7 h proc$ures = review+ compla9ts ( ! abuse & neglect ( pati5ts ( provid]s & facilities t receive paym5ts "u ! ,/ate heal? security program1 &1 :]e appropriate1 = act+ ^u su* compla9ts "u ! crim9al laws ( ! ,/ate or = ref]r+ !m to o!r ,/ate ag5cies = action2 & 7#c7 provide = ! collection1 or ref]ral = collection to a s+le ,/ate ag5cy1 ( ov]paym5ts t are made "u ! ,/ate heal? security program to provid]s & t are discov]$ by ! fraud unit 9 c>ry+ out its activities4 7d7 ,res\rces ,! fraud unit %all-- 7#a7 employ su* auditors1 attorneys1 inve/igators1 & o!r necess>y p]sonnel2 7#b7 be organiz$ 9 su* a mann]2 & 7#c7 provide suffici5t res\rces 7z specifi$ by ! ,bo>d71 z is necess>y to promote ! effective & effici5t conduct ( ! unit's activities4 7e7 ,coop]ative agreem5ts ,! fraud unit %all h coop]ative agreem5ts 7z specifi$ by ! ,bo>d7 )-- 7#a7 simil> fraud units 9 o!r ,/ates2 7#b7 ! ,inspector ,g5]al2 & 7#c7 ! ,attorney ,g5]al ( ! ,unit$ ,/ates4 7f7 ,reports ,! fraud unit %all submit to ! ,inspector ,g5]al an application & annual reports conta9+ su* in=mation z ! ,inspector ,g5]al det]m9es to be necess>y to det]m9e :e!r ! unit meets ! previ\s requirem5ts ( ?is section4 ,v ,quality ,assessm5t #eja4 ,am]ican ,heal? ,security ,quality ,c\ncil 7a7 ,e/abli%m5t ,!re is h]eby e/abli%$ an ,am]ican ,heal? ,security ,quality ,c\ncil 79 ?is title ref]r$ to z ! ,c\ncil74 7b7 ,duties ( ! ,c\ncil ,! ,c\ncil %all p]=m ! foll[+ duties3 7#a7 ,practice guidel9es ,! ,c\ncil %all review & evaluate ea* practice guidel9e develop$ "u "p ,b ( title ,,ix ( ! ,public ,heal? ,s]vice ,act4 ,! ,c\ncil %all det]m9e :e!r ! guidel9e %\ld be recogniz$ z a national practice guidel9e to be us$ "u section #bjd7;d7 = purposes ( det]m9+ paym5ts "u a ,/ate heal? security program4 7#b7 ,/&>ds ( quality1 p]=mance measures1 & m$ical review crit]ia ,! ,c\ncil %all review & evaluate ea* /&>d ( quality1 p]=mance measure1 & m$ical review crit]ion develop$ "u "p ,b ( title ,,ix ( ! ,public ,heal? ,s]vice ,act4 ,! ,c\ncil %all det]m9e :e!r ! /&>d1 measure1 or crit]ion is appropriate = use 9 assess+ or review+ ! quality ( s]vices provid$ by ,/ate heal? security programs1 heal? c>e in/itutions1 or heal? c>e pr(essionals4 7#c7 ,crit]ia = entities conduct+ quality reviews ,! ,c\ncil %all develop m9imum crit]ia = compet5ce = entities t c qualify to conduct ongo+ & cont9u\s ext]nal quality review = ,/ate quality review programs "u section #ejc4 ,su* crit]ia %all require su* an entity to be adm9i/ratively indep5d5t ( ! individual or bo>d t adm9i/]s ! ,/ate heal? security program & %all ensure t su* entities d n provide f9ancial inc5tives to review]s to favor "o patt]n ( practice ov] ano!r4 ,! ,c\ncil %all ensure coord9ation & report+ by su* entities to ensure national consi/5cy 9 quality /&>ds4 7#d7 ,report+ ,! ,c\ncil %all report to ! ,bo>d annually on ! conduct ( activities "u su* title & %all report to ! ,bo>d annually specifically on f9d+s f outcomes rese>* & developm5t ( practice guidel9es t may affect ! ,bo>d's det]m9ation ( cov]age ( s]vices "u section #dja7;f77#a77;,g74 7#e7 ,o!r functions ,! ,c\ncil %all p]=m ! functions ( ! ,c\ncil describ$ 9 section #ejb4 7c7 ,appo9tm5t & t]ms ( memb]s 7#a7 ,9 g5]al ,! ,c\ncil %all be compos$ ( #aj memb]s appo9t$ by ! ,presid5t4 ,! ,presid5t %all fir/ appo9t individuals on a timely basis s z to provide = ! op]ation ( ! ,c\ncil by n lat] ?an ,janu>y #a1 #bjab4 7#b7 ,selection ( memb]s ,ea* memb] ( ! ,c\ncil %all be a memb] ( a heal? pr(ession4 ,five memb]s ( ! ,c\ncil %all be physicians4 ,individuals %all be appo9t$ to ! ,c\ncil on ! basis ( national reputations = cl9ical & academic excell5ce4 ,to ! greate/ ext5t feasible1 ! memb]%ip ( ! ,c\ncil %all repres5t ! v>i\s geographic regions ( ! ,unit$ ,/ates & %all reflect ! racial1 e?nic1 & g5d] composition ( ! population ( ! ,unit$ ,/ates4 7#c7 ,t]ms ( memb]s ,individuals appo9t$ to ! ,c\ncil %all s]ve = a t]m ( #e ye>s1 except t ! t]ms ( #d ( ! individuals initially appo9t$ %all be1 z designat$ by ! ,presid5t at ! "t ( _! appo9tm5t1 = #a1 #b1 #c1 & #d ye>s4 7d7 ,vacancies 7#a7 ,9 g5]al ,! ,presid5t %all fill any vacancy 9 ! memb]%ip ( ! ,c\ncil 9 ! same mann] z ! orig9al appo9tm5t4 ,! vacancy %all n affect ! p[] ( ! rema9+ memb]s to execute ! duties ( ! ,c\ncil4 7#b7 ,vacancy appo9tm5ts ,any memb] appo9t$ to fill a vacancy %all s]ve = ! rema9d] ( ! t]m = :i* ! pr$ecessor ( ! memb] 0 appo9t$4 7#c7 ,reappo9tm5t ,! ,presid5t may reappo9t a memb] ( ! ,c\ncil = a second t]m 9 ! same mann] z ! orig9al appo9tm5t4 ,a memb] :o has s]v$ = #b consecutive #e-ye> t]ms %all n be eligible = reappo9tm5t until #b ye>s aft] ! memb] has ceas$ to s]ve4 7e7 ,*air ,! ,presid5t %all designate #a ( ! memb]s ( ! ,c\ncil to s]ve at ! w ( ! ,presid5t z ,*air ( ! ,c\ncil4 7f7 ,comp5sation ,memb]s ( ! ,c\ncil :o are n employees ( ! ,f$]al ,gov]nm5t %all be entitl$ to comp5sation at a level equival5t to level ,,ii ( ! ,executive ,s*$ule1 9 accordance ) section #ecac ( title #e1 ,unit$ ,/ates ,code4 #ejb4 ,developm5t ( c]ta9 me?odologies1 guidel9es1 & /&>ds 7a7 ,pr(il+ ( patt]ns ( practice2 id5tification ( outli]s ,! ,c\ncil %all adopt me?odologies = pr(il+ ! patt]ns ( practice ( heal? c>e pr(essionals & = id5tify+ outli]s 7z def9$ 9 subsection 7e774 7b7 ,c5t]s ( excell5ce ,! ,c\ncil %all develop guidel9es = c]ta9 m$ical proc$ures designat$ by ! ,bo>d to be p]=m$ only at t]ti>y c>e c5t]s :i* c meet /&>ds = frequ5cy ( proc$ure p]=mance & int5sity ( support me*anisms t are consi/5t ) ! high probability ( desir$ pati5t outcome4 ,reimbursem5t "u ?is ,act = su* a designat$ proc$ure may only be provid$ if ! proc$ure 0 p]=m$ at a c5t] t meets su* /&>ds4 7c7 ,rem$ial actions ,! ,c\ncil %all develop /&>ds = education & sanctions ) respect to outli]s s z to ensure ! quality ( heal? c>e s]vices provid$ "u ?is ,act4 ,! ,c\ncil %all develop crit]ia = ref]ral ( provid]s to ! ,/ate lic5s+ bo>d if education proves ineffective 9 correct+ provid] practice behavior4 7d7 ,dissem9ation ,! ,c\ncil %all dissem9ate to ! ,/ate-- 7#a7 ! me?odologies adopt$ "u subsection 7a72 7#b7 ! guidel9es develop$ "u subsection 7b72 & 7#c7 ! /&>ds develop$ "u subsection 7c72 = use by ! ,/ates "u section #ejc4 7e7 ,outli] def9$ ,9 ?is title1 ! t]m outli] means a heal? c>e provid] ^: patt]n ( practice1 relative to applicable practice guidel9es1 sugge/s defici5cies 9 ! quality ( heal? c>e s]vices be+ provid$4 #ejc4 ,/ate quality review programs 7a7 ,requirem5t ,9 ord] to meet ! requirem5t ( section #djd7;b77#a77;,h71 ea* ,/ate heal? security program %all e/abli% #a or m qualifi$ entities to conduct quality reviews ( p]sons provid+ cov]$ s]vices "u ! program1 9 accordance ) /&>ds e/abli%$ "u subsection 7b77#a7 7except z provid$ 9 subsection 7b77#b77 & subsection 7d74 7b7 ,f$]al /&>ds 7#a7 ,9 g5]al ,! ,c\ncil %all e/abli% /&>ds ) respect to-- 7,a7 ! adoption ( practice guidel9es 7:e!r develop$ by ! ,f$]al ,gov]nm5t or o!r entities72 7,b7 ! id5tification ( outli]s 7consi/5t ) me?odologies adopt$ "u section #ejb7;a772 7,c7 ! developm5t ( rem$ial programs & monitor+ = outli]s2 & 7,d7 ! application ( sanctions 7consi/5t ) ! /&>ds develop$ "u section #ejb7;c774 7#b7 ,/ate discretion ,a ,/ate may apply "u subsection 7a7 /&>ds o!r ?an ^? e/abli%$ "u p>agraph 7#a7 s long z ! ,/ate demon/rates to ! satisfaction ( ! ,c\ncil on an annual basis t ! /&>ds appli$ h be5 z efficaci\s 9 promot+ & a*iev+ improv$ quality ( c>e z ! application ( ! /&>ds e/abli%$ "u p>agraph 7#a74 ,positive improvem5ts 9 quality %all be docum5t$ by r$uctions 9 ! v>iations ( cl9ical c>e process & improvem5t 9 pati5t outcomes4 7c7 ,qualifications ,an entity is n qualifi$ to conduct quality reviews "u subsection 7a7 unless ! entity satisfies ! crit]ia = compet5ce = su* entities develop$ by ! ,c\ncil "u section #eja7;b77#c74 7d7 ,int]nal quality review ,no?+ 9 ?is section %all preclude an in/itutional provid] f e/abli%+ its own int]nal quality review & enhancem5t programs4 #ejd4 ,elim9ation ( utilization review programs2 transition 7a7 ,int5t ,x is ! int5tion ( ?is title to replace by ,janu>y #a1 #bjag1 r&om utilization controls ) a sy/ematic review ( patt]ns ( practice t compromise ! quality ( c>e4 7b7 ,sup]s$+ case reviews 7#a7 ,9 g5]al ,subject to ! succe$+ provisions ( ?is subsection1 ! program ( quality review provid$ "u ! previ\s sections ( ?is title sup]s$e all exi/+ ,f$]al requirem5ts = utilization review programs1 includ+ requirem5ts = r&om case-by-case reviews & programs requir+ pre-c]tification ( m$ical proc$ures on a case-by-case basis4 7#b7 ,transition ,be=e ,janu>y #a1 #bjag1 ! ,bo>d & ! ,/ates may employ exi/+ utilization review /&>ds & me*anisms z may be necess>y to effect ! transition to patt]n ( practice-bas$ reviews4 7#c7 ,con/ruction ,no?+ 9 ?is subsection %all be con/ru$-- 7,a7 z preclud+ ! case-by-case review ( ! provision ( c>e-- 7i7 9 individual incid5ts :]e ! quality ( c>e has significantly deviat$ f acceptable /&>ds ( practice2 & 7ii7 ) respect to a provid] :o has be5 det]m9$ to be an outli]2 or 7,b7 z preclud+ ! case managem5t ( cata/rophic1 m5tal heal?1 or sub/ance abuse cases or long-t]m c>e :]e su* managem5t is necess>y to a*ieve appropriate1 co/-effective1 & b5eficial compreh5sive m$ical c>e1 z provid$ = 9 section #bjd4 #eje4 ,application ( ,c5t] = ,m$ic>e & ,m$icaid ,innovation to ,am]ican ,heal? ,security ,program ,section #aaae;,a ( ! ,social ,security ,act 7#db ,u4,s4,c4 #acae;a7 is am5d$ by add+ at ! end ! foll[+ new subsection3 7h7 ,application to ,am]ican ,heal? ,security ,program ,not)/&+ any o!r provision ( law 7includ+ ! prec$+ provisions ( ?is section71 on & aft] ,janu>y #a1 #bjae1 ! duties describ$ 9 ?is section %all be adapt$ to apply to ! ,am]ican ,heal? ,security ,program "u ! ,am]ican ,heal? ,security ,act ( #bjac4 ,= purposes ( c>ry+ out ! prec$+ s5t5ce1 effective on su* date1 ! foll[+ rules %all apply3 7#a7 ,!re is creat$1 9 consultation ) ! ,am]ican ,heal? ,security ,/&>ds ,bo>d e/abli%$ "u section #dja ( ! ,am]ican ,heal? ,security ,act ( #bjac1 )9 ! ,dep>tm5t ( ,heal? & ,human ,s]vices a ,c5t] = ,am]ican ,heal? ,security ,innovation 79 ?is subsection ref]r$ to z ! ,c5t]7 to c>ry out ?is subsection4 ,! purpose ( ! ,c5t] is to accel]ate ! implem5tation ( new models ( c>e "u ! ,am]ican ,heal? ,security ,program t w\ld improve pati5t c>e1 improve population heal?1 & l[] co/s 9 a mann] consi/5t ) ! requirem5ts ( su* ,program4 7#b7 ,any ref]5ces 9 ?is section to ! ,secret>y or ! ,c5t]s = ,m$ic>e ,m$icaid ,s]vices are deem$ ref]5ces to ! ,am]ican ,heal? ,security ,/&>ds ,bo>d4 7#c7 ,any ref]5ces 9 ?is section to title ,,xviii1 ,,xix1 or ,,xxi ( ?is ,act are deem$ ref]5ces to ! ,am]ican ,heal? ,security ,program4 7#d7 ,any ref]5ces 9 ?is section to ! ,*ief ,actu>y ( ! ,c5t]s = ,m$ic>e ,m$icaid ,s]vices are deem$ ref]5ces to ! ,*ief ,actu>y ( ! ,dep>tm5t ( ,heal? & ,human ,s]vices4 7#e7 ,any ref]5ces 9 ?is section to ! ,c5t] = ,m$ic>e & ,m$icaid ,innovation or ! ,,cmi are deem$ ref]5ces to ! ,c5t] = ,am]ican ,heal? ,security ,innovation4 7#f7 ,= purposes ( c>ry+ out ?is subsection1 ! ,am]ican ,heal? ,security ,/&>ds ,bo>d %all provide = ! transf]1 f ! ,am]ican ,heal? ,security ,tru/ ,fund "u section #hja ( ! ,am]ican ,heal? ,security ,act ( #bjac1 ( su* sums z ! ,bo>d det]m9es necess>y1 to ! ,c5t]4 4 ,,vi ,heal? ,security ,budget2 ,paym5ts2 ,co/ ,conta9m5t ,measures ,a ,budget+ & ,paym5ts to ,/ates #fja4 ,national heal? security budget 7a7 ,national heal? security budget 7#a7 ,9 g5]al ,by n lat] ?an ,septemb] #a be=e ! beg9n+ ( ea* ye> 7beg9n+ ) #bjab71 ! ,bo>d %all e/abli% a national heal? security budget1 :i*-- 7,a7 specifies ! total exp5ditures 7includ+ exp5ditures = adm9i/rative co/s7 to be made by ! ,f$]al ,gov]nm5t & ! ,/ates = cov]$ heal? c>e s]vices "u ?is ,act2 & 7,b7 allocates ^? exp5ditures among ! ,/ates consi/5t ) section #fjd4 ,pursuant to subsection 7b71 su* budget = a ye> %all n exce$ ! budget = ! prec$+ ye> increas$ by ! p]c5tage increase 9 gross dome/ic product4 7#b7 ,division ,,( budget into compon5ts ,9 addition to ! co/ ( cov]$ heal? s]vices1 ! national heal? security budget %all consi/ ( at lea/ #d compon5ts3 7,a7 ,a compon5t = quality assessm5t activities 7describ$ 9 title ,v74 7,b7 ,a compon5t = heal? pr(essional education exp5ditures4 7,c7 ,a compon5t = adm9i/rative co/s4 7,d7 ,a compon5t = op]at+ & o!r exp5ditures n describ$ 9 subp>agraphs 7,a7 ?r\gh 7,c7 79 ?is title ref]r$ to z ! op]at+ compon5t71 consi/+ ( am\nts n includ$ 9 ! o!r compon5ts4 ,a ,/ate may provide = ! allocation ( ?is compon5t betwe5 capital exp5ditures & o!r exp5ditures4 7#c7 ,allocation among compon5ts ,tak+ into acc\nt ! ,/ate heal? security budgets e/abli%$ & submitt$ "u section #fjc1 ! ,bo>d %all allocate ! national heal? security budget among ! compon5ts 9 a mann] t-- 7,a7 assures a fair allocation = quality assessm5t activities 7consi/5t ) ! national heal? security sp5d+ gr[? limit72 & 7,b7 assures t ! heal? pr(essional education exp5diture compon5t is suffici5t to provide = ! am\nt ( heal? pr(essional education exp5ditures suffici5t to meet ! ne$ = cov]$ heal? c>e s]vices 7consi/5t ) ! national heal? security sp5d+ gr[? limit "u subsection 7b77#b774 7b7 ,basis = total exp5ditures 7#a7 ,9 g5]al ,! total exp5ditures specifi$ 9 su* budget %all be ! sum ( ! capitation am\nts comput$ "u section #fjb7;a7 & ! am\nt ( ,f$]al adm9i/rative exp5ditures ne$$ to c>ry out ?is ,act4 7#b7 ,national heal? security sp5d+ gr[? limit ,= purposes ( ?is subtitle1 ! national heal? security sp5d+ gr[? limit describ$ 9 ?is p>agraph = a ye> is 7,a7 z]o1 or1 if great]1 7,b7 ! av]age annual p]c5tage increase 9 ! gross dome/ic product 79 curr5t doll>s7 dur+ ! #c-ye> p]iod beg9n+ ) ! fir/ qu>t] ( ! f\r? previ\s ye> to ! fir/ qu>t] ( ! previ\s ye> m9us ! p]c5tage increase 7if any7 9 ! numb] ( eligible individuals resid+ 9 any ,/ate ! ,unit$ ,/ates f ! fir/ qu>t] ( ! second previ\s ye> to ! fir/ qu>t] ( ! previ\s ye>4 7c7 ,def9itions ,9 ?is title3 7#a7 ,capital exp5ditures ,! t]m capital exp5ditures means exp5ses = ! pur*ase1 lease1 con/ruction1 or r5ovation ( capital facilities & = equipm5t & includes return on equity capital4 7#b7 ,heal? pr(essional education exp5ditures ,! t]m heal? pr(essional education exp5ditures means exp5ditures 9 hospitals & o!r heal? c>e facilities to cov] co/s associat$ ) tea*+ & relat$ rese>* activities4 #fjb4 ,computation ( individual & ,/ate capitation am\nts 7a7 ,capitation am\nts 7#a7 ,individual capitation am\nts ,9 e/abli%+ ! national heal? security budget "u section #fja7;a7 & 9 comput+ ! national av]age p] capita co/ "u subsection 7b7 = ea* ye>1 ! ,bo>d %all e/abli% a me?od = comput+ ! capitation am\nt = ea* eligible individual resid+ 9 ea* ,/ate4 ,! capitation am\nt = an eligible individual 9 a ,/ate classifi$ )9 a risk gr\p 7e/abli%$ "u subsection 7d77#b77 is ! product (-- 7,a7 a national av]age p] capita co/ = all cov]$ heal? c>e s]vices 7comput$ "u subsection 7b772 7,b7 ! ,/ate adju/m5t factor 7e/abli%$ "u subsection 7c77 = ! ,/ate2 & 7,c7 ! risk adju/m5t factor 7e/abli%$ "u subsection 7d77 = ! risk gr\p4 7#b7 ,/ate capitation am\nt 7,a7 ,9 g5]al ,= purposes ( ?is title1 ! t]m ,/ate capitation am\nt means1 = a ,/ate = a ye>1 ! sum ( ! capitation am\nts comput$ "u p>agraph 7#a7 = all ! resid5ts ( ! ,/ate 9 ! ye>1 z e/imat$ by ! ,bo>d be=e ! beg9n+ ( ! ye> involv$4 7,b7 ,use ( /ati/ical model ,! ,bo>d may provide = ! computation ( ,/ate capitation am\nts bas$ on /ati/ical models t fairly reflect ! elem5ts t comprise ! ,/ate capitation am\nt describ$ 9 subp>agraph 7,a74 7,c7 ,population in=mation ,! ,bureau ( ! ,c5sus %all assi/ ! ,bo>d 9 det]m9+ ! numb]1 place ( resid5ce1 & risk gr\p classification ( eligible individuals4 7b7 ,computation ( national av]age p] capita co/ 7#a7 ,= #bjad ,= #bjad1 ! national av]age p] capita co/ "u ?is p>agraph is equal to-- 7,a7 ! av]age p] capita heal? c>e exp5ditures 9 ! ,unit$ ,/ates 9 #bjab 7z e/imat$ by ! ,bo>d72 7,b7 increas$ to #bjac by ! ,bo>d's e/imate ( ! actual am\nt ( su* p] capita exp5ditures dur+ #bjac2 & 7,c7 updat$ to #bjad by ! national heal? security sp5d+ gr[? limit specifi$ 9 section #fja7;b77#b7 = #bjad4 7#b7 ,= succe$+ ye>s ,= ea* succe$+ ye>1 ! national av]age p] capita co/ "u ?is subsection is equal to ! national av]age p] capita co/ comput$ "u ?is subsection = ! previ\s ye> adju/$ by ! national heal? security sp5d+ gr[? limit 7specifi$ 9 section #fja7;b77#b77 = ! ye> involv$4 7c7 ,/ate adju/m5t factors 7#a7 ,9 g5]al ,subject to ! succe$+ p>agraphs ( ?is subsection1 ! ,bo>d %all develop = ea* ,/ate a factor to adju/ ! national av]age p] capita co/s to reflect diff]5ces betwe5 ! ,/ate & ! ,unit$ ,/ates 9-- 7,a7 av]age labor & nonlabor co/s t are necess>y to provide cov]$ heal? s]vices2 7,b7 any social1 environm5tal1 or geographic condition affect+ heal? /atus or ! ne$ = heal? c>e s]vices1 to ! ext5t su* a condition is n tak5 into acc\nt 9 ! e/abli%m5t ( risk gr\ps "u subsection 7d72 7,c7 ! geographic di/ribution ( ! ,/ate's population1 p>ticul>ly ! proportion ( ! population resid+ 9 m$ically und]s]v$ areas1 to ! ext5t su* a condition is n tak5 into acc\nt 9 ! e/abli%m5t ( risk gr\ps "u subsection 7d72 & 7,d7 any o!r factor relat+ to op]at+ co/s requir$ to ensure equitable di/ribution ( funds among ! ,/ates4 7#b7 ,modification ( heal? pr(essional education compon5t ,) respect to ! portion ( ! national heal? security budget allocat$ to exp5ditures = heal? pr(essional education1 ! ,bo>d %all modify ! ,/ate adju/m5t factors s z to take into acc\nt-- 7,a7 diff]5ces among ,/ates 9 heal? pr(essional education programs 9 op]ation z ( ! date ( ! enactm5t ( ?is ,act2 & 7,b7 diff]5ces among ,/ates 9 _! relative ne$ = exp5ditures = heal? pr(essional education1 tak+ into acc\nt ! heal? pr(essional education exp5ditures propos$ 9 ,/ate heal? security budgets "u section #fjc7;a74 7#c7 ,budget neutrality ,! ,/ate adju/m5t factors1 z modifi$ "u p>agraph 7#b71 %all be appli$ "u ?is subsection 9 a mann] t results 9 nei!r an increase nor a decrease 9 ! total am\nt ( ! ,f$]al contributions to all ,/ate heal? security programs "u subsection 7b7 z a result ( ! application ( su* factors4 7#d7 ,phase-9 ,9 apply+ ,/ate adju/m5t factors "u ?is subsection dur+ ! #e-ye> p]iod beg9n+ ) #bjad1 ! ,bo>d %all phase-91 ov] su* p]iod1 ! use ( factors describ$ 9 p>agraph 7#a7 9 a mann] s t ! adju/m5t factor = a ,/ate is bas$ on a bl5d ( su* factors & a factor t reflects ! relative actual av]age p] capita co/s ( heal? s]vices ( ! diff]5t ,/ates z ( ! "t ( enactm5t ( ?is ,act4 7#e7 ,p]iodic adju/m5t ,9 e/abli%+ ! national heal? security budget be=e ! beg9n+ ( ea* ye>1 ! ,bo>d %all provide = appropriate adju/m5ts 9 ! ,/ate adju/m5t factors "u ?is subsection4 7d7 ,adju/m5ts = risk gr\p classification 7#a7 ,9 g5]al ,! ,bo>d %all develop an adju/m5t factor to ! national av]age p] capita co/s comput$ "u subsection 7b7 = individuals classifi$ 9 ea* risk gr\p 7z designat$ "u p>agraph 7#b77 to reflect ! diff]5ce betwe5 ! av]age national av]age p] capita co/s & ! national av]age p] capita co/ = individuals classifi$ 9 ! risk gr\p4 7#b7 ,risk gr\ps ,! ,bo>d %all designate a s]ies ( risk gr\ps1 det]m9$ by age1 heal? indicators1 & o!r factors t repres5t di/9ct patt]ns ( heal? c>e s]vices utilization & co/s4 7#c7 ,p]iodic adju/m5t ,9 e/abli%+ ! national heal? security budget be=e ! beg9n+ ( ea* ye>1 ! ,bo>d %all provide = appropriate adju/m5ts 9 ! risk adju/m5t factors "u ?is subsection4 #fjc4 ,/ate heal? security budgets 7a7 ,e/abli%m5t & submission ( budgets 7#a7 ,9 g5]al ,ea* ,/ate heal? security program %all e/abli% & submit to ! ,bo>d = ea* ye> a propos$ & a f9al ,/ate heal? security budget1 :i* specifies ! foll[+3 7,a7 ,! total exp5ditures 7includ+ exp5ditures = adm9i/rative co/s7 to be made "u ! program 9 ! ,/ate = cov]$ heal? c>e s]vices "u ?is ,act1 consi/5t ) subsection 7b71 brok5 d[n z foll[s3 7i7 ,by ! #d compon5ts 7describ$ 9 section #fja7;a77#b771 consi/5t ) subsection 7b74 7ii7 ,)9 ! op]at+ compon5t-- 7,i7 exp5ditures = op]at+ co/s ( hospitals & o!r facility-bas$ s]vices 9 ! ,/ate2 7,,ii7 exp5ditures = paym5t to compreh5sive heal? s]vice organizations2 7,,iii7 exp5ditures = paym5t ( s]vices provid$ by heal? c>e practition]s2 & 7,,iv7 exp5ditures = o!r cov]$ items & s]vices4 ,funds "u ?is ,act t are appropriat$ = op]ations %all n be us$ = capital exp5ditures1 & funds "u ?is ,act t are appropriat$ = capital exp5ditures %all n be us$ = op]ations4 7,b7 ,! total rev5ues requir$ to meet ! ,/ate heal? security exp5ditures4 7#b7 ,propos$ budget deadl9e ,! propos$ budget = a ye> %all be submitt$ "u p>agraph 7#a7 n lat] ?an ,june #a be=e ! ye>4 7#c7 ,f9al budget ,! f9al budget = a ye> %all-- 7,a7 be e/abli%$ & submitt$ "u p>agraph 7#a7 n lat] ?an ,octob] #a be=e ! ye>1 & 7,b7 take into acc\nt ! am\nts e/abli%$ "u ! national heal? security budget "u section #fja = ! ye>4 7#d7 ,adju/m5t 9 allocations p]mitt$ 7,a7 ,9 g5]al ,subject to subp>agraphs 7,b7 & 7,c71 9 ! case ( a f9al budget1 a ,/ate may *ange ! allocation ( am\nts among compon5ts4 7,b7 ,notice ,no su* *ange may be made unless ! ,/ate has provid$ prior notice ( ! *ange to ! ,bo>d4 7,c7 ,d5ial ,su* a *ange may n be made if ! ,bo>d1 )9 su* "t p]iod z ! ,bo>d specifies1 disapproves su* *ange4 7b7 ,exp5diture limits 7#a7 ,9 g5]al ,! total exp5ditures specifi$ 9 ea* ,/ate heal? security budget "u subsection 7a77#a7 %all take into acc\nt ,f$]al contributions made "u section #fjd4 7#b7 ,limit on claims process+ & bill+ exp5ditures ,ea* ,/ate heal? security budget %all provide t ,/ate adm9i/rative exp5ditures1 includ+ exp5ditures = claims process+ & bill+1 %all n exce$ #c p]c5t ( ! total exp5ditures "u ! ,/ate heal? security program1 unless ! ,bo>d det]m9es1 on a case-by-case basis1 t additional adm9i/rative exp5ditures w\ld improve heal? c>e quality & co/ effectiv5ess4 7#c7 ,work] assi/ance ,a ,/ate heal? security program may provide t1 = budgets = ye>s be=e #bjag1 up to #a p]c5t ( ! budget may be us$ = purposes ( programs provid+ assi/ance to work]s :o are curr5tly p]=m+ functions 9 ! adm9i/ration ( ! heal? insurance sy/em & :o may exp]i5ce economic dislocation z a result ( ! implem5tation ( ! program4 7c7 ,approval process = capital exp5ditures p]mitt$ ,no?+ 9 ?is title %all be con/ru$ z prev5t+ a ,/ate heal? security program f provid+ = a process = ! approval ( capital exp5ditures bas$ on in=mation d]iv$ f regional plann+ ag5cies4 #fjd4 ,f$]al paym5ts to ,/ates 7a7 ,9 g5]al ,ea* ,/ate ) an approv$ ,/ate heal? security program is entitl$ to receive1 f am\nts 9 ! ,am]ican ,heal? ,security ,tru/ ,fund1 on a mon?ly basis ea* ye>1 ( an am\nt equal to "o-twelf? ( ! product (-- 7#a7 ! ,/ate capitation am\nt 7comput$ "u section #fjb7;a77#b77 = ! ,/ate = ! ye>2 & 7#b7 ! ,f$]al contribution p]c5tage 7e/abli%$ "u subsection 7b774 7b7 ,f$]al contribution p]c5tage ,! ,bo>d %all e/abli% a =mula = ! e/abli%m5t ( a ,f$]al contribution p]c5tage = ea* ,/ate4 ,su* =mula %all take into consid]ation a ,/ate's p] capita income & rev5ue capacity & su* o!r relevant economic indicators z ! ,bo>d det]m9es to be appropriate4 ,9 addition1 dur+ ! #e-ye> p]iod beg9n+ ) #bjab1 ! ,bo>d may provide = a transition adju/m5t to ! =mula 9 ord] to take into acc\nt curr5t exp5ditures by ! ,/ate 7& local gov]nm5ts !re(7 = heal? s]vices cov]$ "u ! ,/ate heal? security program4 ,! weight$-av]age ,f$]al contribution p]c5tage = all ,/ates %all equal #hf p]c5t & 9 no ev5t %all su* p]c5tage be less ?an #ha p]c5t nor m ?an #ia p]c5t4 7c7 ,use ( paym5ts ,all paym5ts made "u ?is section may only be us$ to c>ry out ! ,/ate heal? security program4 7d7 ,effect ( sp5d+ excess or surplus 7#a7 ,sp5d+ excess ,if a ,/ate exce$s its budget 9 a giv5 ye>1 ! ,/ate %all cont9ue to fund cov]$ heal? s]vices f its own rev5ues4 7#b7 ,surplus ,if a ,/ate provides all cov]$ heal? s]vices = less ?an ! budget$ am\nt = a ye>1 x may reta9 its ,f$]al paym5t = t ye> = uses consi/5t ) ?is ,act4 #fje4 ,acc\nt = heal? pr(essional education exp5ditures 7a7 ,sep>ate acc\nt ,ea* ,/ate heal? security program %all-- 7#a7 include a sep>ate acc\nt = heal? pr(essional education exp5ditures2 & 7#b7 specify ! g5]al mann]1 consi/5t ) subsection 7b71 9 :i* su* exp5ditures are to be di/ribut$ among diff]5t types ( in/itutions & ! diff]5t areas ( ! ,/ate4 7b7 ,di/ribution rules ,! di/ribution ( funds to hospitals & o!r heal? c>e facilities f ! acc\nt %all con=m to ! foll[+ pr9ciples3 7#a7 ,! disbursem5t ( funds %all be consi/5t ) a*ievem5t ( ! national & program goals 7specifi$ 9 section #gja7;b77 )9 ! ,/ate heal? security program & ! di/ribution ( funds f ! acc\nt %all be condition$ ^u ! receipt ( su* reports z ! ,bo>d may require 9 ord] to monitor compliance ) su* goals4 7#b7 ,! di/ribution ( funds f ! acc\nt %all take into acc\nt ! pot5tially high] co/s ( plac+ heal? pr(essional /ud5ts 9 cl9ical education programs 9 heal? pr(essional %ortage areas4 ,b ,paym5ts by ,/ates to ,provid]s #faa4 ,paym5ts to hospitals & o!r facility-bas$ s]vices = op]at+ exp5ses on ! basis ( approv$ global budgets 7a7 ,direct paym5t "u global budget ,paym5t = op]at+ exp5ses = in/itutional & facility-bas$ c>e1 includ+ hospital s]vices & nurs+ facility s]vices1 "u ,/ate heal? security programs %all be made directly to ea* in/itution or facility by ea* ,/ate heal? security program "u an annual prospective global budget approv$ "u ! program4 ,su* a budget %all include paym5t = outpati5t c>e & non-facility-bas$ c>e t is furni%$ by or ?r\gh ! facility4 ,9 ! case ( a hospital t is :olly own$ 7or controll$7 by a compreh5sive heal? s]vice organization t is paid "u section #fad on ! basis ( a global budget1 ! global budget ( ! organization %all include ! budget = ! hospital4 7b7 ,annual negotiations2 budget approval 7#a7 ,9 g5]al ,! prospective global budget = an in/itution or facility %all-- 7,a7 be develop$ ?r\gh annual negotiations betwe5-- 7i7 a panel ( individuals :o are appo9t$ by ! ,gov]nor ( ! ,/ate & :o repres5t consum]s1 labor1 bus9ess1 & ! ,/ate gov]nm5t2 & 7ii7 ! in/itution or facility2 & 7,b7 be bas$ on a nationally uni=m sy/em ( co/ acc\nt+ e/abli%$ "u /&>ds ( ! ,bo>d4 7#b7 ,consid]ations ,9 develop+ a budget ?r\gh negotiations1 !re %all be tak5 into acc\nt at lea/ ! foll[+3 7,a7 ,) respect to inpati5t hospital s]vices1 ! numb]1 & classification by diagnosis-relat$ gr\p1 ( dis*>ges4 7,b7 ,an in/itution's or facility's pa/ exp5ditures4 7,c7 ,! ext5t to :i* debt s]vice = capital exp5ditures has be5 includ$ 9 ! propos$ op]at+ budget4 7,d7 ,! ext5t to :i* capital exp5ditures are f9anc$ directly or indirectly ?r\gh r$uctions 9 direct c>e to pati5ts1 includ+ r$uctions 9 regi/]$ nurs+ /aff+ patt]ns or *anges 9 em]g5cy room or prim>y c>e s]vices or availability4 7,e7 ,*ange 9 ! consum] price index & o!r price indices4 7,f7 ,! co/ ( reasonable comp5sation to heal? c>e practition]s4 7,g7 ,! comp5sation level ( ! in/itution's or facility's work=ce4 7,h7 ,! ext5t to :i* ! in/itution or facility is provid+ heal? c>e s]vices to meet ! ne$s ( resid5ts 9 ! area s]v$ by ! in/itution or facility1 includ+ ! in/itution's or facility's occupancy level4 7,i7 ,! in/itution's or facility's previ\s f9ancial & cl9ical p]=mance1 bas$ on utilization & outcomes data provid$ "u ?is ,act4 7,j7 ,! type ( in/itution or facility1 includ+ :e!r ! in/itution or facility is "p ( a cl9ical education program or s]ves a heal? pr(essional education1 rese>* or o!r tra9+ purpose4 7,k7 ,te*nological advances or *anges4 7,l7 ,co/s ( ! in/itution or facility associat$ ) meet+ ,f$]al & ,/ate regulations4 7,m7 ,! co/s associat$ ) necess>y public outrea* activities4 7,n7 ,inc5tives to facilities t ma9ta9 co/s bel[ previ\s reasonable budget$ levels )\t r$uc+ ! c>e provid$4 7,o7 ,) respect to facilities t provide m5tal heal? s]vices & sub/ance abuse treatm5t s]vices1 any additional co/s involv$ 9 ! treatm5t ( dually diagnos$ individuals4 ,! portion ( su* a budget t relates to exp5ditures = heal? pr(essional education %all be consi/5t ) ! ,/ate heal? security budget = su* exp5ditures4 7#c7 ,provision ( requir$ in=mation2 diagnosis-relat$ gr\p ,no budget = an in/itution or facility = a ye> may be approv$ unless ! in/itution or facility has submitt$ on a timely basis to ! ,/ate heal? security program su* in=mation z ! program or ! ,bo>d %all specify1 includ+ 9 ! case ( hospitals in=mation on dis*>ges classifi$ by diagnosis-relat$ gr\p4 7c7 ,adju/m5ts 9 approv$ budgets 7#a7 ,adju/m5ts to global budgets t contract ) compreh5sive heal? s]vice organizations ,ea* ,/ate heal? security program %all develop an adm9i/rative me*anism = r$uc+ op]at+ funds to in/itutions or facilities 9 proportion to paym5ts made to su* in/itutions or facilities = s]vices contract$ = by a compreh5sive heal? s]vice organization4 7#b7 ,am5dm5ts ,9 accordance ) /&>ds e/abli%$ by ! ,bo>d1 an op]at+ & capital budget approv$ "u ?is section = a ye> may be am5d$ be=e1 dur+1 or aft] ! ye> if !re is a sub/antial *ange 9 any ( ! factors relevant to budget approval4 7d7 ,donations p]missible ,! ,/ates heal? security programs may p]mit in/itutions & facilities to raise funds f private s\rces to pay = newly con/ruct$ facilities1 major r5ovations1 & equipm5t4 ,! exp5diture ( su* funds1 :e!r = op]at+ or capital exp5ditures1 does n obligate ! ,/ate heal? security program to provide = cont9u$ support = su* exp5ditures unless includ$ 9 an approv$ global budget4 #fab4 ,paym5ts to heal? c>e practition]s bas$ on prospective fee s*$ule 7a7 ,fee = s]vice 7#a7 ,9 g5]al ,e indep5d5t heal? c>e practition] is entitl$ to be paid1 = ! provision ( cov]$ heal? s]vices "u ! ,/ate heal? security program1 a fee = ea* billable cov]$ s]vice4 7#b7 ,global fee paym5t me?odologies ,! ,bo>d %all e/abli% models & enc\rage ,/ate heal? security programs to implem5t alt]native paym5t me?odologies t incorporate global fees = relat$ s]vices 7su* z all outpati5t proc$ures = treatm5t ( a condition7 or = a basic gr\p ( s]vices 7su* z prim>y c>e s]vices7 furni%$ to an individual ov] a p]iod ( "t1 9 ord] to enc\rage cont9uity & effici5cy 9 ! provision ( s]vices4 ,su* me?odologies %all be design$ to ensure a high quality ( c>e4 7#c7 ,bill+ deadl9es2 electronic bill+ ,a ,/ate heal? security program may d5y paym5t = any s]vice ( an indep5d5t heal? c>e practition] = :i* x did n receive a bill & appropriate support+ docum5tation 7:i* _h be5 previ\sly specifi$7 )9 #cj days aft] ! date ! s]vice 0 provid$4 ,su* a program may require t bills = s]vices = :i* paym5t may be made "u ?is section1 or = any class ( su* s]vices1 be submitt$ electronically4 7b7 ,paym5t rates bas$ on negotiat$ prospective fee s*$ules ,) respect to any paym5t me?od = a class ( s]vices ( practition]s1 ! ,/ate heal? security program %all e/abli%1 on a prospective basis1 a paym5t s*$ule4 ,! ,/ate heal? security program may e/abli% su* a s*$ule aft] negotiations ) organizations repres5t+ ! practition]s involv$4 ,su* fee s*$ules %all be design$ to provide inc5tives = practition]s to *oose prim>y c>e m$ic9e1 includ+ g5]al int]nal m$ic9e1 family m$ic9e1 gynecology1 & p$iatrics1 ov] m$ical specialization4 ,no?+ 9 ?is section %all be con/ru$ z prev5t+ a ,/ate f adju/+ ! paym5t s*$ule am\nts on a qu>t]ly or o!r p]iodic basis dep5d+ on :e!r exp5ditures "u ! s*$ule w exce$ ! budget$ am\nt ) respect to su* exp5ditures4 7c7 ,billable cov]$ s]vice def9$ ,9 ?is section1 ! t]m billable cov]$ s]vice means a s]vice cov]$ "u section #bja = :i* a practition] is entitl$ to comp5sation by paym5t ( a fee det]m9$ "u ?is section4 #fac4 ,paym5ts to compreh5sive heal? s]vice organizations 7a7 ,9 g5]al ,paym5t "u a ,/ate heal? security program to a compreh5sive heal? s]vice organization to its enrollees %all be det]m9$ by ! ,/ate-- 7#a7 bas$ on a global budget describ$ 9 section #faa2 or 7#b7 bas$ on ! basic capitation am\nt describ$ 9 subsection 7b7 = ea* ( its enrollees4 7b7 ,basic capitation am\nt 7#a7 ,9 g5]al ,! basic capitation am\nt describ$ 9 ?is subsection = an enrollee %all be det]m9$ by ! ,/ate heal? security program on ! basis ( ! av]age am\nt ( exp5ditures t is e/imat$ w\ld be made "u ! ,/ate heal? security program = cov]$ heal? c>e s]vices = an enrollee1 bas$ on actu>ial *>act]i/ics 7z def9$ by ! ,/ate heal? security program74 7#b7 ,adju/m5t = special heal? ne$s ,! ,/ate heal? security program %all adju/ su* av]age am\nts to take into acc\nt ! special heal? ne$s1 includ+ a disproportionate numb] ( m$ically und]s]v$ individuals1 ( populations s]v$ by ! organization4 7#c7 ,adju/m5t = s]vices n provid$ ,! ,/ate heal? security program %all adju/ su* av]age am\nts to take into acc\nt ! co/ ( cov]$ heal? c>e s]vices t are n provid$ by ! compreh5sive heal? s]vice organization "u section #cjc7;a74 #fad4 ,paym5ts = community-bas$ prim>y heal? s]vices 7a7 ,9 g5]al ,9 ! case ( community-bas$ prim>y heal? s]vices1 subject to subsection 7b71 paym5ts "u a ,/ate heal? security program %all-- 7#a7 be bas$ on a global budget describ$ 9 section #faa2 7#b7 be bas$ on ! basic prim>y c>e capitation am\nt describ$ 9 subsection 7c7 = ea* individual enroll$ ) ! provid] ( su* s]vices2 or 7#c7 be made on a fee-=-s]vice basis "u section #fab4 7b7 ,paym5t adju/m5t ,paym5ts "u subsection 7a7 may include1 consi/5t ) ! budgets develop$ "u ?is title-- 7#a7 an additional am\nt1 z set by ! ,/ate heal? security program1 to cov] ! co/s incurr$ by a provid] :i* s]ves p]sons n cov]$ by ?is ,act ^: heal? c>e is ess5tial to ov]all community heal? & ! control ( communicable disease1 & = :om ! co/ ( su* c>e is o!rwise uncomp5sat$2 7#b7 an additional am\nt1 z set by ! ,/ate heal? security program1 to cov] ! reasonable co/s incurr$ by a provid] t furni%es case managem5t s]vices 7z def9$ 9 section #aiae7;g77#b7 ( ! ,social ,security ,act71 transportation s]vices1 & translation s]vices2 & 7#c7 an additional am\nt1 z set by ! ,/ate heal? security program1 to cov] ! co/s incurr$ by a provid] 9 conduct+ heal? pr(essional education programs 9 connection ) ! provision ( su* s]vices4 7c7 ,basic prim>y c>e capitation am\nt 7#a7 ,9 g5]al ,! basic prim>y c>e capitation am\nt describ$ 9 ?is subsection = an enrollee ) a provid] ( community-bas$ prim>y heal? s]vices %all be det]m9$ by ! ,/ate heal? security program on ! basis ( ! av]age am\nt ( exp5ditures t is e/imat$ w\ld be made "u ! ,/ate heal? security program = su* an enrollee1 bas$ on actu>ial *>act]i/ics 7z def9$ by ! ,/ate heal? security program74 7#b7 ,adju/m5t = special heal? ne$s ,! ,/ate heal? security program %all adju/ su* av]age am\nts to take into acc\nt ! special heal? ne$s1 includ+ a disproportionate numb] ( m$ically und]s]v$ individuals1 ( populations s]v$ by ! provid]4 7#c7 ,adju/m5t = s]vices n provid$ ,! ,/ate heal? security program %all adju/ su* av]age am\nts to take into acc\nt ! co/ ( community-bas$ prim>y heal? s]vices t are n provid$ by ! provid]4 7d7 ,community-,bas$ prim>y heal? s]vices def9$ ,9 ?is section1 ! t]m community-bas$ prim>y heal? s]vices has ! mean+ giv5 su* t]m 9 section #bjb7;a74 #fae4 ,paym5ts = prescription drugs 7a7 ,e/abli%m5t ( li/ 7#a7 ,9 g5]al ,! ,bo>d %all e/abli% a li/ ( approv$ prescription drugs & biologicals t ! ,bo>d det]m9es are necess>y = ! ma9t5ance or re/oration ( heal? or ( employability or self-managem5t & eligible = cov]age "u ?is ,act4 7#b7 ,exclusions ,! ,bo>d may exclude reimbursem5t "u ?is ,act = ineffective1 unsafe1 or ov]-pric$ products :]e bett] alt]natives are det]m9$ to be available4 7b7 ,prices ,= ea* su* li/$ prescription drug or biological cov]$ "u ?is ,act1 = insul91 & = m$ical foods1 ! ,bo>d %all f "t to "t det]m9e a product price or prices :i* %all con/itute ! maximum to be recogniz$ "u ?is ,act z ! co/ ( a drug to a provid] !re(4 ,! ,bo>d may conduct negotiations1 on behalf ( ,/ate heal? security programs1 ) product manufactur]s & di/ributors 9 det]m9+ ! applicable product price or prices4 7c7 ,*>ges by indep5d5t ph>macies ,ea* ,/ate heal? security program %all provide = paym5t = a prescription drug or biological or insul9 furni%$ by an indep5d5t ph>macy bas$ on ! drug's co/ to ! ph>macy 7n 9 excess ( ! applicable product price e/abli%$ "u subsection 7b77 plus a disp5s+ fee4 ,9 accordance ) /&>ds e/abli%$ by ! ,bo>d1 ea* ,/ate heal? security program1 aft] consultation ) repres5tatives ( ! ph>maceutical pr(ession1 %all e/abli% s*$ules ( disp5s+ fees1 design$ to af=d reasonable comp5sation to indep5d5t ph>macies aft] tak+ into acc\nt v>iations 9 _! co/ ( op]ation result+ f regional diff]5ces1 diff]5ces 9 ! volume ( prescription drugs disp5s$1 diff]5ces 9 s]vices provid$1 ! ne$ to ma9ta9 exp5ditures )9 ! budgets e/abli%$ "u ?is title1 & o!r relevant factors4 #faf4 ,paym5ts = approv$ devices & equipm5t 7a7 ,e/abli%m5t ( li/ ,! ,bo>d %all e/abli% a li/ ( approv$ durable m$ical equipm5t & !rapeutic devices & equipm5t 7includ+ eyeglasses1 he>+ aids1 & pro/hetic appliances71 t ! ,bo>d det]m9es are necess>y = ! ma9t5ance or re/oration ( heal? or ( employability or self-managem5t & eligible = cov]age "u ?is ,act4 7b7 ,consid]ations & conditions ,9 e/abli%+ ! li/ "u subsection 7a71 ! ,bo>d %all take into consid]ation ! efficacy1 safety1 & co/ ( ea* item conta9$ on su* li/1 & %all atta* to any item su* conditions z ! ,bo>d det]m9es appropriate ) respect to ! circum/ances "u :i*1 or ! frequ5cy ) :i*1 ! item may be prescrib$4 7c7 ,prices ,= ea* su* li/$ item cov]$ "u ?is ,act1 ! ,bo>d %all f "t to "t det]m9e a product price or prices :i* %all con/itute ! maximum to be recogniz$ "u ?is ,act z ! co/ ( ! item to a provid] !re(4 ,! ,bo>d may conduct negotiations1 on behalf ( ,/ate heal? security programs1 ) equipm5t & device manufactur]s & di/ributors 9 det]m9+ ! applicable product price or prices4 7d7 ,exclusions ,! ,bo>d may exclude f cov]age "u ?is ,act ineffective1 unsafe1 or ov]pric$ products :]e bett] alt]natives are det]m9$ to be available4 #fag4 ,paym5ts = o!r items & s]vices ,9 ! case ( paym5t = o!r cov]$ heal? s]vices1 ! am\nt ( paym5t "u a ,/ate heal? security program %all be e/abli%$ by ! program-- 7#a7 9 accordance ) paym5t me?odologies :i* are specifi$ by ! ,bo>d1 aft] consultation ) ! ,am]ican ,heal? ,security ,advisory ,c\ncil1 or me?odologies e/abli%$ by ! ,/ate "u section #fbj2 & 7#b7 consi/5t ) ! ,/ate heal? security budget4 #fah4 ,paym5t inc5tives = m$ically und]s]v$ areas 7a7 ,model paym5t me?odologies ,9 addition to ! paym5t am\nts o!rwise provid$ 9 ?is title1 ! ,bo>d %all e/abli% model paym5t me?odologies & o!r inc5tives t promote ! provision ( cov]$ heal? c>e s]vices 9 m$ically und]s]v$ areas1 p>ticul>ly 9 rural & inn]-city und]s]v$ areas4 7b7 ,con/ruction ,no?+ 9 ?is title %all be con/ru$ z limit+ ! au?ority ( ,/ate heal? security programs to increase paym5t am\nts or o!rwise provide additional inc5tives1 consi/5t ) ! ,/ate heal? security budget1 to enc\rage ! provision ( m$ically necess>y & appropriate s]vices 9 und]s]v$ areas4 #fai4 ,au?ority = alt]native paym5t me?odologies ,a ,/ate heal? security program1 z "p ( its plan "u section #djd7;a71 may use a paym5t me?odology o!r ?an a me?odology requir$ "u ?is subtitle s long z-- 7#a7 su* paym5t me?odology does n affect ! entitlem5t ( individuals to cov]age1 ! weight+ ( fee s*$ules to enc\rage an increase 9 ! numb] ( prim>y c>e provid]s1 ! ability ( individuals to *oose among qualifi$ provid]s1 ! b5efits cov]$ "u ! program1 or ! compliance ( ! program ) ! ,/ate heal? security budget "u subtitle ,a2 & 7#b7 ! program submits p]iodic reports to ! ,bo>d %[+ ! op]ation & effectiv5ess ( ! alt]native me?odology1 9 ord] = ! ,bo>d to evaluate ! appropriat5ess ( apply+ ! alt]native me?odology to o!r ,/ates4 ,c ,m&atory assignm5t & adm9i/rative provisions #fca4 ,m&atory assignm5t 7a7 ,no balance bill+ ,paym5ts = b5efits "u ?is ,act %all con/itute paym5t 9 full = su* b5efits & ! entity furni%+ an item or s]vice = :i* paym5t is made "u ?is ,act %all accept su* paym5t z paym5t 9 full = ! item or s]vice & may n accept any paym5t or impose any *>ge = any su* item or s]vice o!r ?an accept+ paym5t f ! ,/ate heal? security program 9 accordance ) ?is ,act4 7b7 ,en=cem5t ,if an entity kn[+ly & willfully bills = an item or s]vice or accepts paym5t 9 violation ( subsection 7a71 ! ,bo>d may apply sanctions aga9/ ! entity 9 ! same mann] z sanctions c\ld h be5 impos$ "u section #ahdb7;j77#b7 ( ! ,social ,security ,act = a violation ( section #ahdb7;j77#a7 ( su* ,act4 ,su* sanctions are 9 addition to any sanctions t a ,/ate may impose "u its ,/ate heal? security program4 #fcb4 ,proc$ures = reimbursem5t2 appeals 7a7 ,proc$ures = reimbursem5t ,9 accordance ) /&>ds issu$ by ! ,bo>d1 a ,/ate heal? security program %all e/abli% a timely & adm9i/ratively simple proc$ure to ensure paym5t )9 #fj days ( ! date ( submission ( clean claims by provid]s "u ?is ,act4 7b7 ,appeals process ,ea* ,/ate heal? security program %all e/abli% an appeals process to h&le all grievances p]ta9+ to paym5t to provid]s "u ?is title4 ,,vii ,promotion ( ,prim>y ,heal? ,c>e2 ,developm5t ( ,heal? ,s]vice ,capacity2 ,programs to ,assi/ ! ,m$ically ,und]s]v$ ,a ,promotion & ,expansion ( ,prim>y ,c>e ,pr(essional ,tra9+ #gja4 ,role ( ,bo>d2 e/abli%m5t ( prim>y c>e pr(essional output goals 7a7 ,9 g5]al ,! ,bo>d is responsible =-- 7#a7 coord9at+ heal? pr(essional education policies & goals1 9 consultation ) ! ,secret>y ( ,heal? & ,human ,s]vices 79 ?is title ref]r$ to z ! ,secret>y71 to a*ieve ! national goals specifi$ 9 subsection 7b72 7#b7 ov]see+ ! heal? pr(essional education exp5ditures ( ! ,/ate heal? security programs f ! acc\nt e/abli%$ "u section #fjb7;c72 7#c7 develop+ & ma9ta9+1 9 coop]ation ) ! ,secret>y1 a sy/em to monitor ! numb] & specialties ( individuals ?r\gh _! heal? pr(essional education1 any po/graduate tra9+1 & pr(essional practice2 7#d7 develop+1 coord9at+1 & promot+ o!r policies t exp& ! numb] ( prim>y c>e practition]s1 regi/]$ nurses1 midlevel practition]s1 & d5ti/s2 & 7#e7 recomm5d+ ! appropriate tra9+1 education1 & pati5t advocacy enhancem5ts ( prim>y c>e heal? pr(essionals1 includ+ regi/]$ nurses1 to a*ieve uni=m high quality c>e & pati5t safety4 7b7 ,national goals ,! national goals specifi$ 9 ?is subsection are z foll[s3 7#a7 ,graduate m$ical education ,by n lat] ?an #e ye>s aft] ! date ( ! enactm5t ( ?is ,act1 at lea/ #ej p]c5t ( ! resid5ts 9 m$ical resid5cy education programs 7z def9$ 9 subsection 7e77#b77 are prim>y c>e resid5ts 7z def9$ 9 subsection 7e77#d774 7#b7 ,regi/]$ nurses ,to ensure an adequate supply ( regi/]$ nurses1 !re %all be a numb]1 specifi$ by ! ,bo>d1 ( regi/]$ nurses employ$ 9 ! heal? c>e sy/em z ( ,janu>y #a1 #bjag4 7#c7 ,midlevel prim>y c>e practition]s ,to ensure an adequate supply ( prim>y c>e practition]s1 !re %all be a numb]1 specifi$ by ! ,bo>d1 ( midlevel prim>y c>e practition]s 7z def9$ 9 subsection 7e77#c77 employ$ 9 ! heal? c>e sy/em z ( ,janu>y #a1 #bjag4 7#d7 ,d5ti/ry ,to ensure an adequate supply ( d5tal c>e practition]s1 !re %all be a numb]1 specifi$ by ! ,bo>d1 ( d5ti/s 7z def9$ 9 subsection 7e77#a77 employ$ 9 ! heal? c>e sy/em z ( ,janu>y #a1 #bjag4 7c7 ,me?od = atta9m5t ( national goal = graduate m$ical education2 program goals 7#a7 ,9 g5]al ,! ,bo>d1 9 consultation ) ! ,national ,heal? ,c>e ,work=ce ,commission1 %all e/abli% a me?od ( apply+ ! national goal 9 subsection 7b77#a7 to program goals = ea* m$ical resid5cy education program or to m$ical resid5cy education consortia4 7#b7 ,consid]ation ,! program goals "u p>agraph 7#a7 %all be bas$ on ! di/ribution ( m$ical s*ools & o!r tea*+ facilities )9 ea* ,/ate heal? security program1 & ! numb] ( positions = graduate m$ical education4 7#c7 ,m$ical resid5cy education consortium ,9 ?is subsection1 ! t]m m$ical resid5cy education consortium means a consortium ( m$ical resid5cy education programs 9 a contigu\s geographic area 7:i* may be an int]/ate area7 if ! consortium-- 7,a7 includes at lea/ #a m$ical s*ool ) a tea*+ hospital & relat$ tea*+ sett+s2 & 7,b7 has an affiliation ) qualifi$ community-bas$ prim>y heal? s]vice provid]s describ$ 9 section #bjb7;a7 & ) at lea/ #a compreh5sive heal? s]vice organization e/abli%$ "u section #cjc4 7#d7 ,en=cem5t ?r\gh ,/ate heal? security budgets ,! ,bo>d %all develop a =mula = r$uc+ paym5ts to ,/ate heal? security programs 7t provide = paym5ts to a m$ical resid5cy education program7 t fail$ to meet ! goal = ! program e/abli%$ "u ?is subsection4 7d7 ,me?od = atta9m5t ( national goal = midlevel prim>y c>e practition]s ,to assi/ 9 atta9+ ! national goal id5tifi$ 9 subsection 7b77#c71 ! ,bo>d1 9 consultation ) ! ,national ,heal? ,c>e ,work=ce ,commission1 %all-- 7#a7 advise ! ,public ,heal? ,s]vice on allocations ( fund+ "u titles ,,vii & ,,viii ( ! ,public ,heal? ,s]vice ,act1 ! ,national ,heal? ,s]vice ,corps1 & o!r programs 9 ord] to increase ! supply ( midlevel prim>y c>e practition]s2 & 7#b7 commission a /udy ( ! pot5tial b5efits & disadvantages ( exp&+ ! scope ( practice au?oriz$ "u ,/ate laws = any class ( midlevel prim>y c>e practition]s4 7e7 ,def9itions ,9 ?is title3 7#a7 ,d5ti/ ,! t]m d5ti/ means a practition] :o p]=ms ! evaluation1 diagnosis1 prev5tion or treatm5t 7nonsurgical1 surgical1 or relat$ proc$ures7 ( diseases1 disord]s or conditions ( ! oral cavity1 maxill(acial area or ! adjac5t & associat$ /ructures & _! impact on ! human body1 )9 ! scope ( 8 or h] education1 tra9+ & exp]i5ce1 9 accordance ) ! e?ics ( ! pr(ession & applicable law4 7#b7 ,m$ical resid5cy education program ,! t]m m$ical resid5cy education program means a program t provides education & tra9+ to graduates ( m$ical s*ools 9 ord] to meet requirem5ts = lic5s+ & c]tification z a physician1 & includes ! m$ical s*ool sup]vis+ ! program & includes ! hospital or o!r facility 9 :i* ! program is op]at$4 7#c7 ,midlevel prim>y c>e practition] ,! t]m midlevel prim>y c>e practition] means a cl9ical nurse practition]1 c]tifi$ nurse midwife1 physician assi/ance1 or o!r nonphysician practition]1 specifi$ by ! ,bo>d1 z au?oriz$ to practice "u ,/ate law4 7#d7 ,prim>y c>e resid5t ,! t]m prim>y c>e resid5t means 79 accordance ) crit]ia e/abli%$ by ! ,bo>d7 a resid5t be+ tra9$ 9 a di/9ct program ( family practice m$ic9e1 g5]al practice1 g5]al int]nal m$ic9e1 or g5]al p$iatrics4 #gjb4 ,grants = heal? pr(essions education1 nurse education1 & ! ,national ,heal? ,s]vice ,corps 7a7 ,transf]s to ,public ,heal? ,s]vice ,! ,bo>d %all make transf]s f ! ,am]ican ,heal? ,security ,tru/ ,fund to ! ,public ,heal? ,s]vice "u subp>t ,,ii ( "p ,d ( title ,,iii1 title ,,vii1 & title ,,viii ( ! ,public ,heal? ,s]vice ,act = ! support ( ! ,national ,heal? ,s]vice ,corps1 heal? pr(essions education1 & nurs+ education1 includ+ education ( cl9ical nurse practition]s1 c]tifi$ regi/]$ nurse ane/heti/s1 c]tifi$ nurse midwives1 & physician assi/ants4 7b7 ,range ( funds ,! am\nt ( transf]s "u subsection 7a7 = any fiscal ye> = title ,,vii & ,,viii %all be an am\nt 7specifi$ by ! ,bo>d ea* ye>7 n less ?an #c_/ajj p]c5t ( ! am\nts ! ,bo>d e/imates w be exp5d$ f ! ,tru/ ,fund 9 ! fiscal ye>4 7c7 ,ma9t5ance ,! ,bo>d %all make no transf] ( funds "u ?is section = any fiscal ye> = :i* ! total appropriations = ! programs au?oriz$ by ! provisions ref]r$ to 9 subsection 7a7 are less ?an ! total am\nt appropriat$ = su* programs 9 fiscal ye> #bjaj4 ,b ,direct ,heal? ,c>e ,deliv]y #gaa4 ,set-aside = public heal? 7a7 ,transf]s to ,public ,heal? ,s]vice ,f ! am\nts provid$ "u subsection 7c71 ! ,bo>d %all make transf]s f ! ,am]ican ,heal? ,security ,tru/ ,fund to ! ,public ,heal? ,s]vice = ! foll[+ purposes 7o!r ?an paym5t = s]vices cov]$ "u title ,,ii73 7#a7 ,= paym5ts to ,/ates "u ! mat]nal & *ild heal? block grants "u title ,v ( ! ,social ,security ,act 7#db ,u4,s4,c4 #gja et seq474 7#b7 ,= prev5tion & treatm5t ( tub]culosis "u section #cag ( ! ,public ,heal? ,s]vice ,act 7#db ,u4,s4,c4 #bdg;b74 7#c7 ,= ! prev5tion & treatm5t ( sexually transmitt$ diseases "u section #cah ( ! ,public ,heal? ,s]vice ,act 7#db ,u4,s4,c4 #bdg;c74 7#d7 ,prev5tive heal? block grants "u "p ,a ( title ,,xix ( ! ,public ,heal? ,s]vice ,act 7#db ,u4,s4,c4 #cjjw et seq474 7#e7 ,grants to ,/ates = community m5tal heal? s]vices "u subp>t ,i ( "p ,b ( title ,,xix ( ! ,public ,heal? ,s]vice ,act 7#db ,u4,s4,c4 #cjjx et seq474 7#f7 ,grants to ,/ates = prev5tion & treatm5t ( sub/ance abuse "u subp>t ,,ii ( "p ,b ( title ,,xix ( ! ,public ,heal? ,s]vice ,act 7#db ,u4,s4,c4 #cjjx-#ba et seq474 7#g7 ,grants = ,,hiv heal? c>e s]vices "u p>ts ,a1 ,b1 & ,c ( title ,,xxvi ( ! ,public ,heal? ,s]vice ,act 7#db ,u4,s4,c4 #cjj;ff-#aa et seq474 7#h7 ,public heal? =mula grants describ$ 9 subsection 7d74 7b7 ,range ( funds ,! am\nt ( transf]s "u subsection 7a7 = any fiscal ye> %all be an am\nt 7specifi$ by ! ,bo>d ea* ye>7 n less ?an #a_/aj p]c5t & n to exce$ #ad_/ajj p]c5t ( ! am\nts ! ,bo>d e/imates w be exp5d$ f ! ,tru/ ,fund 9 ! fiscal ye>4 7c7 ,funds supplem5tal to o!r funds ,! funds provid$ "u ?is section ) respect to provision ( s]vices are 9 addition to1 & n 9 replacem5t (1 funds made available "u ! programs ref]r$ to 9 subsection 7a7 & %all be adm9i/]$ 9 accordance ) ! t]ms ( su* programs4 7d7 ,requir$ reports on heal? /atus ,! ,secret>y %all require ea* ,/ate receiv+ funds "u ?is section to submit annual reports to ! ,secret>y on ! heal? /atus ( ! population & measurable objectives = improv+ ! heal? ( ! public 9 ! ,/ate4 ,su* reports %all include ! foll[+3 7#a7 ,a comp>ison ( ! measures ( ! ,/ate & local public heal? sy/em comp>$ to relevant objectives set =? 9 ,heal?y ,p #bjbj or subsequ5t national objectives set by ! ,secret>y4 7#b7 ,a description ( heal? /atus measures to be improv$ )9 ! ,/ate 7at ! ,/ate & local levels7 ?r\gh exp&$ public heal? functions & heal? promotion & disease prev5tion programs4 7#c7 ,measurable outcomes & process objectives = improv+ heal? /atus1 & a report on outcomes f ! previ\s ye>4 7#d7 ,in=mation reg>d+ h[ ,f$]al fund+ has improv$ population-bas$ prev5tion activities & programs4 7#e7 ,a description ( ! core public heal? functions to be c>ri$ out at ! local level4 7#f7 ,a description ( ! relation%ip betwe5 ! ,/ate's public heal? sy/em1 community-bas$ heal? promotion & disease prev5tion provid]s1 & ! ,/ate heal? security program4 7e7 ,limitation on fund transf]s ,! ,bo>d %all make no transf] ( funds "u ?is section = any fiscal ye> = :i* ! total appropriations = su* programs are less ?an ! total am\nt appropriat$ = su* programs 9 fiscal ye> #bjaj4 7f7 ,public heal? =mula grants ,! ,secret>y %all provide /able funds to ,/ates ?r\gh =mula grants = ! purpose ( c>ry+ out core public heal? functions to monitor & protect ! heal? ( communities f communicable diseases & exposure to toxic environm5tal pollutants1 occupational haz>ds1 h>mful products1 & poor heal? outcomes4 ,su* functions include ! foll[+3 7#a7 ,data collection1 analysis1 & assessm5t ( public heal? data1 vital /ati/ics1 & p]sonal heal? data to assess community heal? /atus & outcomes report+4 ,?is function includes ! acquisition & in/allation ( h>dw>e & s(tw>e1 & p]sonnel tra9+ & te*nical assi/ance to op]ate & support automat$ & integrat$ in=mation sy/ems4 7#b7 ,activities to protect ! environm5t & to ensure ! safety ( h\s+1 workplaces1 food1 & wat]4 7#c7 ,inve/igation & control ( adv]se heal? conditions1 & ?reats to ! heal? /atus ( individuals & ! community4 ,?is function includes ! id5tification & control ( outbreaks ( infecti\s disease1 patt]ns ( *ronic disease & injury1 & coop]ative activities to r$uce ! levels ( viol5ce4 7#d7 ,heal? promotion & disease prev5tion activities = :i* !re is a significant ne$ & a high priority ( ! ,public ,heal? ,s]vice4 7#e7 ,! provision ( public heal? laboratory s]vices to complem5t private cl9ical laboratory s]vices1 includ+-- 7,a7 scre5+ te/s = metabolic diseases 9 newborns2 7,b7 toxicology assessm5ts ( blood lead levels & o!r environm5tal tox9s2 7,c7 tub]culosis & o!r diseases requir+ p>tn] notification2 & 7,d7 te/+ = infecti\s & food-borne diseases4 7#f7 ,tra9+ & education = ! public heal? pr(essions4 7#g7 ,rese>* on effective & co/-effective public heal? practices4 ,?is function includes ! developm5t1 te/+1 evaluation1 & publication ( results ( new prev5tion & public heal? control int]v5tions4 7#h7 ,integration & coord9ation ( ! prev5tion programs & s]vices ( community-bas$ provid]s1 local & ,/ate heal? dep>tm5ts1 & o!r sectors ( ,/ate & local gov]nm5t t affect heal?4 #gab4 ,set-aside = prim>y heal? c>e deliv]y 7a7 ,transf]s to ,section #ccj program ( ! ,public ,heal? ,s]vice ,act ,! ,bo>d %all make transf]s f ! ,am]ican ,heal? ,security ,tru/ ,fund to ! ,public ,heal? ,s]vice = ! program au?oriz$ "u section #ccj ( ! ,public ,heal? ,s]vice ,act 7#db ,u4,s4,c4 #bed;b74 7b7 ,transf]s to ,public ,heal? ,s]vice ,f ! am\nts provid$ "u subsection 7d71 ! ,bo>d %all make transf]s f ! ,am]ican ,heal? ,security ,tru/ ,fund to ! ,public ,heal? ,s]vice = ! program ( prim>y c>e s]vice expansion grants "u subp>t ,v ( "p ,d ( title ,,iii ( ! ,public ,heal? ,s]vice ,act 7z add$ by section #gac ( ?is ,act74 7c7 ,range ( funds ,! am\nt ( transf]s "u subsection 7b7 = any fiscal ye> %all be an am\nt 7specifi$ by ! ,bo>d ea* ye>7 n less ?an #f_/ajj p]c5t ( ! am\nts ! ,bo>d e/imates w be exp5d$ f ! ,tru/ ,fund 9 ! fiscal ye>4 7d7 ,funds supplem5tal to o!r funds ,! funds provid$ "u ?is section ) respect to provision ( s]vices are 9 addition to1 & n 9 replacem5t (1 funds made available "u ! sections #cdj;,a1 #ajja1 & #bfee ( ! ,public ,heal? ,s]vice ,act4 ,! ,bo>d %all make no transf] ( funds "u ?is section = any fiscal ye> = :i* ! total appropriations = su* sections are less ?an ! total am\nt appropriat$ "u su* sections 9 fiscal ye> #bjaj4 #gac4 ,prim>y c>e s]vice expansion grants 7a7 ,9 g5]al ,"p ,d ( title ,,iii ( ! ,public ,heal? ,s]vice ,act 7#db ,u4,s4,c4 #bed;b et seq47 is am5d$ by add+ at ! end ! foll[+ new subp>t3 ,,xiii ,prim>y c>e expansion #cdj;,j4 ,exp&+ prim>y c>e deliv]y capacity 9 urban & rural areas 7a7 ,grants = prim>y c>e c5t]s ,f ! am\nts describ$ 9 subsection 7c71 ! ,am]ican ,heal? ,security ,/&>ds ,bo>d %all make grants to public & nonpr(it private entities = projects to plan & develop prim>y c>e c5t]s :i* w s]ve m$ically und]s]v$ populations 7z def9$ 9 section #ccj7;b77#c77 9 urban & rural areas & to deliv] prim>y c>e s]vices to su* populations 9 su* areas4 ,! funds provid$ "u su* a grant may be us$ = ! same purposes = :i* a grant may be made "u subsection 7c71 7e71 7f71 7g71 7h71 or 7i7 ( section #ccj4 7b7 ,process ( aw>d+ grants ,! provisions ( subsection 7k77#a7 ( section #ccj %all apply to a grant "u ?is section 9 ! same mann] z !y apply to a grant "u ! correspond+ subsection ( su* section4 ,! provisions ( subsection 7r77#b77;,a7 ( su* section %all apply to grants = projects to plan & develop prim>y c>e c5t]s "u ?is section 9 ! same mann] z !y apply to grants "u su* section4 7c7 ,fund+ z set-,aside f ,tru/ ,fund ,funds 9 ! ,am]ican ,heal? ,security ,tru/ ,fund 7e/abli%$ "u section #hja ( ! ,act7 %all be available to c>ry out ?is section4 7d7 ,prim>y c>e c5t] def9$ ,9 ?is section1 ! t]m prim>y c>e c5t] means-- 7#a7 a heal? c5t] 7z def9$ 9 section #ccj7;a77#a772 7#b7 an entity qualifi$ to receive a grant "u section #ccj1 #ajja1 or #bfea2 or 7#c7 a ,f$]ally-qualifi$ heal? c5t] 7z def9$ 9 section #aije7l77#b77;,b7 ( ! ,social ,security ,act74 4 7b7 ,te*nical am5dm5ts ,"p ,d ( title ,,iii ( ! ,public ,heal? ,s]vice ,act 7#db ,u4,s4,c4 #bed;b et seq47 is am5d$-- 7#a7 by r$esignat+ subp>t ,,xi1 z add$ by section #ajccc ( ! ,pati5t ,protection & ,af=dable ,c>e ,act 7,public ,law #aaa-adh71 z subp>t ,,xii2 & 7#b7 by r$esignat+ section #cdj;,h ( ! ,public ,heal? ,s]vice ,act 7#db ,u4,s4,c4 #bef;i71 z add$ by section #ajccc ( ! ,pati5t ,protection & ,af=dable ,c>e ,act 7,public ,law #aaa-adh71 z section #cdj;,i4 ,c ,prim>y ,c>e & ,outcomes ,rese>* #gba4 ,set-aside = outcomes rese>* 7a7 ,grants = outcomes rese>* ,! ,bo>d %all make transf]s f ! ,am]ican ,heal? ,security ,tru/ ,fund to ! ,ag5cy = ,heal?c>e ,rese>* & ,quality "u title ,,ix ( ! ,public ,heal? ,s]vice ,act 7#db ,u4,s4,c4 #bii et seq47 = ! purpose ( c>ry+ out activities "u su* title4 ,! ,secret>y %all assure t !re is a special emphasis plac$ on p$iatric outcomes rese>*4 7b7 ,range ( funds ,! am\nt ( transf]s "u subsection 7a7 = any fiscal ye> %all be an am\nt 7specifi$ by ! ,bo>d ea* ye>7 n less ?an #a_/ajj p]c5t & n to exce$ #b_/ajj p]c5t ( ! am\nts ! ,bo>d e/imates w be exp5d$ f ! ,tru/ ,fund 9 ! fiscal ye>4 7c7 ,funds supplem5tal to o!r funds ,! funds provid$ "u ?is section ) respect to provision ( s]vices are 9 addition to1 & n 9 replacem5t (1 funds made available to ! ,ag5cy = ,heal?c>e ,rese>* & ,quality "u section #idg ( ! ,public ,heal? ,s]vice ,act 7#db ,u4,s4,c4 #bii;c-#f74 ,! ,bo>d %all make no transf] ( funds "u ?is section = any fiscal ye> = :i* ! total appropriations "u su* section are less ?an ! total am\nt appropriat$ "u su* section & title 9 fiscal ye> #bjaj4 7d7 ,con=m+ am5dm5t ,section #idg7;b7 ( ! ,public ,heal? ,s]vice ,act 7#db ,u4,s4,c4 #bii;c-#f7;b77 is am5d$ by ins]t+ aft] ( ! fiscal ye>s #bjja ?r\gh #bjje ! foll[+3 & ( fiscal ye> #bjab & ea* subsequ5t ye>4 #gbb4 ,(fice ( ,prim>y ,c>e & ,prev5tion ,rese>* 7a7 ,9 g5]al ,title ,,iv ( ! ,public ,heal? ,s]vice ,act is am5d$-- 7#a7 by r$esignat+ p>ts ,g ?r\gh ,i z p>ts ,h ?r\gh ,j1 respectively2 & 7#b7 by ins]t+ aft] "p ,f ! foll[+ new "p3 ,g ,rese>* on prim>y c>e & prev5tion #dhf;,e4 ,(fice ( ,prim>y ,c>e & ,prev5tion ,rese>* 7a7 ,e/abli%m5t ,!re is e/abli%$ )9 ! ,(fice ( ! ,director ( ,,nih an (fice to be kn[n z ! ,(fice ( ,prim>y ,c>e & ,prev5tion ,rese>* 79 ?is "p ref]r$ to z ! ,(fice74 ,! ,(fice %all be head$ by a director1 :o %all be appo9t$ by ! ,director ( ,,nih4 7b7 ,purpose ,! ,director ( ! ,(fice %all-- 7#a7 id5tify projects ( rese>* on prim>y c>e & prev5tion1 = *ildr5 z well z adults1 t %\ld be conduct$ or support$ by ! national rese>* in/itutes1 ) p>ticul> emphasis on-- 7,a7 cl9ical pati5t c>e1 ) special emphasis on p$iatric cl9ical c>e & diagnosis2 7,b7 diagno/ic effectiv5ess2 7,c7 prim>y c>e education2 7,d7 heal? & family plann+ s]vices2 7,e7 m$ical effectiv5ess outcomes ( prim>y c>e proc$ures & int]v5tions2 & 7,f7 ! use ( multidiscipl9>y teams ( heal? c>e practition]s2 7#b7 id5tify multidiscipl9>y rese>* relat$ to prim>y c>e & prev5tion t %\ld be s conduct$2 7#c7 promote coord9ation & collaboration among entities conduct+ rese>* id5tifi$ "u any ( p>agraphs 7#a7 & 7#b72 7#d7 enc\rage ! conduct ( su* rese>* by entities receiv+ funds f ! national rese>* in/itutes2 7#e7 recomm5d an ag5da = conduct+ & support+ su* rese>*2 7#f7 promote ! suffici5t allocation ( ! res\rces ( ! national rese>* in/itutes = conduct+ & support+ su* rese>*2 & 7#g7 prep>e ! report requir$ "u section #dhf;,g4 7c7 ,prim>y c>e & prev5tion rese>* def9$ ,= purposes ( ?is "p1 ! t]m prim>y c>e & prev5tion rese>* means rese>* on improvem5t ( ! practice ( family m$ic9e1 g5]al int]nal m$ic9e1 & g5]al p$iatrics1 & includes rese>* relat+ to-- 7#a7 ob/etrics & gynecology1 d5ti/ry1 or m5tal heal? or sub/ance abuse treatm5t :5 provid$ by a prim>y c>e physician or o!r prim>y c>e practition]2 & 7#b7 prim>y c>e provid$ by multidiscipl9>y teams4 #dhf;,f4 ,national data sy/em & cle>+h\se on prim>y c>e & prev5tion rese>* 7a7 ,data sy/em ,! ,director ( ,,nih1 9 consultation ) ! ,director ( ! ,(fice1 %all e/abli% a data sy/em = ! collection1 /orage1 analysis1 retrieval1 & dissem9ation ( in=mation reg>d+ prim>y c>e & prev5tion rese>* t is conduct$ or support$ by ! national rese>* in/itutes4 ,in=mation f ! data sy/em %all be available ?r\gh in=mation sy/ems available to heal? c>e pr(essionals & provid]s1 rese>*]s1 & memb]s ( ! public4 7b7 ,cle>+h\se ,! ,director ( ,,nih1 9 consultation ) ! ,director ( ! ,(fice & ) ! ,national ,libr>y ( ,m$ic9e1 %all e/abli%1 ma9ta91 & op]ate a program to provide1 & enc\rage ! use (1 in=mation on rese>* & prev5tion activities ( ! national rese>* in/itutes t relate to prim>y c>e & prev5tion rese>*4 #dhf;,g4 ,bi5nial report 7a7 ,9 g5]al ,) respect to prim>y c>e & prev5tion rese>*1 ! ,director ( ! ,(fice %all1 n lat] ?an #a ye> aft] ! date ( ! enactm5t ( ?is "p1 & bi5nially !reaft]1 prep>e a report-- 7#a7 describ+ & evaluat+ ! progress made dur+ ! prec$+ #b fiscal ye>s 9 rese>* & treatm5t conduct$ or support$ by ! ,national ,in/itutes ( ,heal?2 7#b7 summ>iz+ & analyz+ exp5ditures made by ! ag5cies ( su* ,in/itutes 7& by su* ,(fice7 dur+ ! prec$+ #b fiscal ye>s2 & 7#c7 mak+ su* recomm5dations = legislative & adm9i/rative initiatives z ! ,director ( ! ,(fice det]m9es to be appropriate4 7b7 ,inclusion 9 bi5nial report ( ,director ( ,,nih ,! ,director ( ! ,(fice %all submit ea* report prep>$ "u subsection 7a7 to ! ,director ( ,,nih = inclusion 9 ! report submitt$ to ! ,presid5t & ! ,congress "u section #djc4 #dhf;,h4 ,au?orization ( appropriations ,= ! ,(fice ( ,prim>y ,c>e & ,prev5tion ,rese>*1 !re are au?oriz$ to be appropriat$ #aej1jjj1jjj = fiscal ye> #bjad1 #ahj1jjj1jjj = fiscal ye> #bjae1 & #baf1jjj1jjj = fiscal ye> #bjaf4 4 7b7 ,requirem5t ( suffici5t allocation ( res\rces ( ,in/itutes ,section #djb7;b7 ( ! ,public ,heal? ,s]vice ,act 7#db ,u4,s4,c4 #bhb7;b77 is am5d$-- 7#a7 9 p>agraph 7#bc71 by /rik+ & aft] ! semicolon at ! end2 7#b7 9 p>agraph 7#bd71 by /rik+ ! p]iod at ! end & ins]t+ 2 &2 & 7#c7 by ins]t+ aft] p>agraph 7#bd7 ! foll[+ new p>agraph3 7#be7 aft] consultation ) ! ,director ( ! ,(fice ( ,prim>y ,c>e & ,prev5tion ,rese>*1 %all ensure t res\rces ( ! ,national ,in/itutes ( ,heal? are suffici5tly allocat$ = projects on prim>y c>e & prev5tion rese>* t are id5tifi$ "u section #dhf;,e7b74 4 ,d ,s*ool-,relat$ ,heal? ,s]vices #gca4 ,au?orizations ( appropriations 7a7 ,fund+ = s*ool-,relat$ heal? s]vices ,= ! purpose ( c>ry+ out ?is subtitle1 !re are au?oriz$ to be appropriat$ #ajj1jjj1jjj = fiscal ye> #bjaf1 #bge1jjj1jjj = fiscal ye> #bjag1 #cej1jjj1jjj = fiscal ye> #bjah1 & #djj1jjj1jjj = ea* ( ! fiscal ye>s #bjai & #bjbj4 7b7 ,relation to o!r funds ,! au?orizations ( appropriations e/abli%$ 9 subsection 7a7 are 9 addition to any o!r au?orizations ( appropriations t are available = ! purpose describ$ 9 su* subsection4 #gcb4 ,eligibility = developm5t & op]ation grants 7a7 ,9 g5]al ,entities eligible to apply = & receive grants "u section #gcd or #gce are ! foll[+3 7#a7 ,/ate heal? ag5cies t apply on behalf ( local community p>tn]%ips & o!r communities 9 ne$ ( heal? s]vices = s*ool-ag$ *ildr5 )9 ! ,/ate4 7#b7 ,local community p>tn]%ips 9 ,/ates 9 :i* heal? ag5cies h n appli$4 7b7 ,local community p>tn]%ips 7#a7 ,9 g5]al ,a local community p>tn]%ip "u subsection 7a77#b7 is an entity t1 at a m9imum1 includes-- 7,a7 a local heal? c>e provid] ) exp]i5ce 9 deliv]+ s]vices to s*ool-ag$ *ildr52 7,b7 #a or m local public s*ools2 & 7,c7 at lea/ #a community bas$ organization locat$ 9 ! community to be s]v$ t has a hi/ory ( provid+ s]vices to s*ool-ag$ *ildr5 9 ! community :o are at-risk4 7#b7 ,p>ticipation ,a p>tn]%ip describ$ 9 p>agraph 7#a7 %all1 to ! maximum ext5t feasible1 involve broad bas$ community p>ticipation f p>5ts & adolesc5t *ildr5 to be s]v$1 heal? & social s]vice provid]s1 tea*]s & o!r public s*ool & s*ool bo>d p]sonnel1 developm5t & s]vice organizations = adolesc5t *ildr51 & int]e/$ bus9ess lead]s4 ,su* p>ticipation may be evid5c$ ?r\gh an exp&$ p>tn]%ip1 or an advisory bo>d to su* p>tn]%ip4 7c7 ,def9itions reg>d+ *ildr5 ,= purposes ( ?is subtitle3 7#a7 ,! t]m adolesc5t *ildr5 means s*ool-ag$ *ildr5 :o are adolesc5ts4 7#b7 ,! t]m s*ool-ag$ *ildr5 means individuals :o are betwe5 ! ages ( #d & #ai 7inclusive74 #gcc4 ,pref]5ces 7a7 ,9 g5]al ,9 mak+ grants "u sections #gcd & #gce1 ! ,secret>y %all give pref]5ce to applicants ^: communities to be s]v$ %[ ! mo/ sub/antial level ( ne$ = su* s]vices among s*ool-ag$ *ildr51 z measur$ by indicators ( community heal? includ+ ! foll[+3 7#a7 ,high levels ( pov]ty4 7#b7 ,! pres5ce ( a m$ically und]s]v$ population4 7#c7 ,! pres5ce ( a heal? pr(essional %ortage area4 7#d7 ,high rates ( indicators ( heal? risk among s*ool-ag$ *ildr51 includ+ a high proportion ( su* *ildr5 receiv+ s]vices ?r\gh ! ,individuals ) ,disabilities ,education ,act1 adolesc5t pregnancy1 sexually transmitt$ disease 7includ+ infection ) ! human immunodefici5cy virus71 prev5table disease1 communicable disease1 int5tional & un9t5tional injuries1 community & gang viol5ce1 unemploym5t among adolesc5t *ildr51 juv5ile ju/ice involvem5t1 & high rates ( drug & alcohol exposure4 7b7 ,l9kage to community heal? c5t]s ,9 mak+ grants "u sections #gcd & #gce1 ! ,secret>y %all give pref]5ce to applicants t demon/rate a l9kage to community heal? c5t]s4 #gcd4 ,grants = developm5t ( projects 7a7 ,9 g5]al ,! ,secret>y may make grants to ,/ate heal? ag5cies or to local community p>tn]%ips to develop s*ool heal? s]vice sites4 7b7 ,use ( funds ,a project = :i* a grant may be made "u subsection 7a7 may include ! co/ ( ! foll[+3 7#a7 ,plann+ = ! provision ( s*ool heal? s]vices4 7#b7 ,recruitm5t1 comp5sation1 & tra9+ ( heal? & adm9i/rative /aff4 7#c7 ,! developm5t ( agreem5ts1 & ! acquisition & developm5t ( equipm5t & in=mation s]vices1 necess>y to support in=mation ex*ange betwe5 s*ool heal? s]vice sites & heal? plans1 heal? provid]s1 & o!r entities au?oriz$ to collect in=mation "u ?is ,act4 7#d7 ,o!r activities necess>y to assume op]ational /atus4 7c7 ,application = grant 7#a7 ,9 g5]al ,applicants %all submit applications 9 a =m & mann] prescrib$ by ! ,secret>y4 7#b7 ,applications by ,/ate heal? ag5cies 7,a7 ,9 ! case ( applicants t are ,/ate heal? ag5cies1 ! application %all conta9 assurances t ! ,/ate heal? ag5cy is apply+ = funds-- 7i7 on behalf ( at lea/ #a local community p>tn]%ip2 & 7ii7 on behalf ( at lea/ #a o!r community id5tifi$ by ! ,/ate z 9 ne$ ( ! s]vices fund$ "u ?is subtitle b )\t a local community p>tn]%ip4 7,b7 ,9 ! case ( ! communities id5tifi$ 9 applications submitt$ by ,/ate heal? ag5cies t d n yet h local community p>tn]%ips 7includ+ ! community id5tifi$ "u subp>agraph 7,a77ii771 ! ,/ate %all describe ! /eps t w be tak5 to aid ! communities 9 develop+ a local community p>tn]%ip4 7,c7 ,a ,/ate apply+ on behalf ( local community p>tn]%ips & o!r communities may reta9 n m ?an #aj p]c5t ( grants aw>d$ "u ?is subtitle = adm9i/rative co/s4 7d7 ,cont5ts ( application ,9 ord] to receive a grant "u ?is section1 an applicant %all include 9 ! application ! foll[+ in=mation3 7#a7 ,an assessm5t ( ! ne$ = s*ool heal? s]vices 9 ! communities to be s]v$1 us+ ! late/ available heal? data & heal? goals & objectives e/abli%$ by ! ,secret>y4 7#b7 ,a description ( h[ ! applicant w design ! propos$ s*ool heal? s]vices to rea* ! maximum numb] ( s*ool-ag$ *ildr5 :o are at risk4 7#c7 ,an explanation ( h[ ! applicant w integrate its s]vices ) ^? ( o!r heal? & social s]vice programs )9 ! community4 7#d7 ,a description ( a quality assurance program :i* complies ) /&>ds t ! ,secret>y may prescribe4 7e7 ,numb] ( grants ,n m ?an #a plann+ grant may be made to a s+le applicant4 ,a plann+ grant may n exce$ #b ye>s 9 duration4 #gce4 ,grants = op]ation ( projects 7a7 ,9 g5]al ,! ,secret>y may make grants to ,/ate heal? ag5cies or to local community p>tn]%ips = ! co/ ( op]at+ s*ool heal? s]vice sites4 7b7 ,use ( grant ,! co/s = :i* a grant may be made "u ?is section include ! foll[+3 7#a7 ,! co/ ( furni%+ heal? s]vices t are n o!rwise cov]$ "u ?is ,act or by any o!r public or private insur]4 7#b7 ,! co/ ( furni%+ s]vices ^: purpose is to increase ! capacity ( individuals to utilize available heal? s]vices1 includ+ transportation1 community & pati5t outrea*1 pati5t education1 translation s]vices1 & su* o!r s]vices z ! ,secret>y det]m9es to be appropriate 9 c>ry+ out su* purpose4 7#c7 ,tra9+1 recruitm5t & comp5sation ( heal? pr(essionals & o!r /aff4 7#d7 ,outrea* s]vices to s*ool-ag$ *ildr5 :o are at risk & to ! p>5ts ( su* *ildr54 7#e7 ,l9kage ( individuals to heal? plans1 community heal? s]vices & social s]vices4 7#f7 ,o!r activities deem$ necess>y by ! ,secret>y4 7c7 ,application = grant ,applicants %all submit applications 9 a =m & mann] prescrib$ by ! ,secret>y4 ,9 ord] to receive a grant "u ?is section1 an applicant %all include 9 ! application ! foll[+ in=mation3 7#a7 ,a description ( ! s]vices to be furni%$ by ! applicant4 7#b7 ,! am\nts & s\rces ( fund+ t ! applicant w exp5d1 includ+ e/imates ( ! am\nt ( paym5ts ! applicant w receive f s\rces o!r ?an ! grant4 7#c7 ,su* o!r in=mation z ! ,secret>y det]m9es to be appropriate4 7d7 ,additional cont5ts ( application ,9 ord] to receive a grant "u ?is section1 an applicant %all meet ! foll[+ conditions3 7#a7 ,! applicant furni%es ! foll[+ s]vices3 7,a7 ,diagnosis & treatm5t ( simple illnesses & m9or injuries4 7,b7 ,prev5tive heal? s]vices1 includ+ heal? scre5+s4 7,c7 ,s]vices provid$ = ! purpose describ$ 9 subsection 7b77#b74 7,d7 ,ref]rals & foll[ups 9 situations involv+ illness or injury4 7,e7 ,heal? & social s]vices1 c\nsel+ s]vices1 & necess>y ref]rals1 includ+ ref]rals reg>d+ m5tal heal? & sub/ance abuse & oral heal? s]vices4 7,f7 ,su* o!r s]vices z ! ,secret>y det]m9es to be appropriate4 7#b7 ,! applicant is a p>ticipat+ provid] 9 ! ,/ate's program = m$ical assi/ance "u title ,,xix ( ! ,social ,security ,act4 7#c7 ,! applicant does n impose *>ges on /ud5ts or _! families = s]vices 7includ+ collection ( any co/-%>+ = s]vices "u ! compreh5sive b5efit package t o!rwise w\ld be requir$74 7#d7 ,! applicant has review$ & w p]iodically review ! ne$s ( ! population s]v$ by ! applicant 9 ord] to ensure t its s]vices are accessible to ! maximum numb] ( s*ool-ag$ *ildr5 9 ! area1 & t1 to ! maximum ext5t possible1 b>ri]s to access to s]vices ( ! applicant are remov$ 7includ+ b>ri]s result+ f ! area's physical *>act]i/ics1 its economic1 social & cultural gr\p+1 ! heal? c>e utilization patt]ns ( su* *ildr51 & available transportation74 7#e7 ,9 ! case ( an applicant :i* s]ves a population t includes a sub/antial proportion ( individuals ( limit$ ,engli% speak+ ability1 ! applicant has develop$ a plan to meet ! ne$s ( su* population to ! ext5t practicable 9 ! language & cultural context mo/ appropriate to su* individuals4 7#f7 ,! applicant w provide non-,f$]al contributions t[>d ! co/ ( ! project 9 an am\nt det]m9$ by ! ,secret>y4 7#g7 ,! applicant w op]ate a quality assurance program consi/5t ) section #gcd7;d74 7e7 ,duration ( grant ,a grant "u ?is section %all be = a p]iod det]m9$ by ! ,secret>y4 7f7 ,reports ,a recipi5t ( fund+ "u ?is section %all provide su* reports & in=mation z are requir$ 9 regulations ( ! ,secret>y4 #gcf4 ,f$]al adm9i/rative co/s ,( ! am\nts made available "u section #gca1 ! ,secret>y may res]ve n m ?an #e p]c5t = adm9i/rative exp5ses reg>d+ ?is subtitle4 #gcg4 ,def9itions ,= purposes ( ?is subtitle3 7#a7 ,! t]m adolesc5t *ildr5 has ! mean+ giv5 su* t]m 9 section #gcb7;c74 7#b7 ,! t]m at risk means at-risk ) respect to heal?4 7#c7 ,! t]m community heal? c5t] has ! mean+ giv5 su* t]m 9 section #ccj ( ! ,public ,heal? ,s]vice ,act4 7#d7 ,! t]m heal? pr(essional %ortage area means a heal? pr(essional %ortage area designat$ "u section #ccb ( ! ,public ,heal? ,s]vice ,act4 7#e7 ,! t]m m$ically und]s]v$ population has ! mean+ giv5 su* t]m 9 section #ccj ( ! ,public ,heal? ,s]vice ,act4 7#f7 ,! t]m s*ool-ag$ *ildr5 has ! mean+ giv5 su* t]m 9 section #gcb7;c74 ,,viii ,f9anc+ ,provisions2 ,am]ican ,heal? ,security ,tru/ ,fund #hjj4 ,am5dm5t ( #aihf code2 ,section #ae n to apply 7a7 ,am5dm5t ( #aihf ,code ,except z o!rwise expressly provid$1 :5ev] 9 ?is title an am5dm5t or repeal is express$ 9 t]ms ( an am5dm5t to1 or repeal (1 a section or o!r provision1 ! ref]5ce %all be consid]$ to be made to a section or o!r provision ( ! ,int]nal ,rev5ue ,code ( #aihf4 7b7 ,section #ae n ,to apply ,! am5dm5ts made by subtitle ,b %all n be treat$ z a *ange 9 a rate ( tax = purposes ( section #ae ( ! ,int]nal ,rev5ue ,code ( #aihf4 ,a ,am]ican ,heal? ,security ,tru/ ,fund #hja4 ,am]ican ,heal? ,security ,tru/ ,fund 7a7 ,9 g5]al ,!re is h]eby creat$ on ! books ( ! ,treasury ( ! ,unit$ ,/ates a tru/ fund to be kn[n z ! ,am]ican ,heal? ,security ,tru/ ,fund 79 ?is section ref]r$ to z ! ,tru/ ,fund74 ,! ,tru/ ,fund %all consi/ ( su* gifts & beque/s z may be made & su* am\nts z may be deposit$ 91 or appropriat$ to1 su* ,tru/ ,fund z provid$ 9 ?is ,act4 7b7 ,appropriations into ,tru/ ,fund 7#a7 ,taxes ,!re are h]eby appropriat$ to ! ,tru/ ,fund = ea* fiscal ye> 7beg9n+ ) fiscal ye> #bjae71 out ( any moneys 9 ! ,treasury n o!rwise appropriat$1 am\nts equival5t to #ajj p]c5t ( ! aggregate increase 9 tax liabilities "u ! ,int]nal ,rev5ue ,code ( #aihf :i* is attributable to ! application ( ! am5dm5ts made by ?is title4 ,! am\nts appropriat$ by ! prec$+ s5t5ce %all be transf]r$ f "t to "t 7b n less frequ5tly ?an mon?ly7 f ! g5]al fund 9 ! ,treasury to ! ,tru/ ,fund1 su* am\nts to be det]m9$ on ! basis ( e/imates by ! ,secret>y ( ! ,treasury ( ! taxes paid to or deposit$ into ! ,treasury2 & prop] adju/m5ts %all be made 9 am\nts subsequ5tly transf]r$ to ! ext5t prior e/imates 7 9 excess ( or 7 less ?an ! am\nts t %\ld h be5 s transf]r$4 7#b7 ,curr5t program receipts ,not)/&+ any o!r provision ( law1 !re are h]eby appropriat$ to ! ,tru/ ,fund = ea* fiscal ye> 7beg9n+ ) fiscal ye> #bjae7 ! am\nts t w\ld o!rwise h be5 appropriat$ to c>ry out ! foll[+ programs3 7,a7 ,! ,m$ic>e program1 "u p>ts ,a1 ,b1 & ,d ( title ,,xviii ( ! ,social ,security ,act 7o!r ?an am\nts attributable to any premiums "u su* p>ts74 7,b7 ,! ,m$icaid program1 "u ,/ate plans approv$ "u title ,,xix ( su* ,act4 7,c7 ,! ,f$]al employees heal? b5efit program1 "u *apt] #hi ( title #e1 ,unit$ ,/ates ,code4 7,d7 ,! ,,tric>e program 7=m]ly kn[n z ! ,,*ampus program71 "u *apt] #ee ( title #aj1 ,unit$ ,/ates ,code4 7,e7 ,! mat]nal & *ild heal? program 7"u title ,v ( ! ,social ,security ,act71 vocational rehabilitation programs1 programs = drug abuse & m5tal heal? s]vices "u ! ,public ,heal? ,s]vice ,act1 programs provid+ g5]al hospital or m$ical assi/ance1 & any o!r ,f$]al program id5tifi$ by ! ,bo>d1 9 consultation ) ! ,secret>y ( ! ,treasury1 to ! ext5t ! programs provide = paym5t = heal? s]vices ! paym5t ( :i* may be made "u ?is ,act4 7c7 ,incorporation ( provisions ,! provisions ( subsections 7b7 ?r\gh 7i7 ( section #ahag ( ! ,social ,security ,act %all apply to ! ,tru/ ,fund "u ?is ,act 9 ! same mann] z !y appli$ to ! ,f$]al ,hospital ,insurance ,tru/ ,fund "u "p ,a ( title ,,xviii ( su* ,act1 except t ! ,am]ican ,heal? ,security ,/&>ds ,bo>d %all con/itute ! ,bo>d ( ,tru/ees ( ! ,tru/ ,fund4 7d7 ,transf] ( funds ,any am\nts rema9+ 9 ! ,f$]al ,hospital ,insurance ,tru/ ,fund or ! ,f$]al ,supplem5t>y ,m$ical ,insurance ,tru/ ,fund aft] ! settlem5t ( claims = paym5ts "u title ,,xviii h be5 complet$1 %all be transf]r$ into ! ,am]ican ,heal? ,security ,tru/ ,fund4 ,b ,taxes ,bas$ on ,income & ,wages #haa4 ,payroll tax on employ]s 7a7 ,9 g5]al ,section #caaa 7relat+ to tax on employ]s7 is am5d$ by r$esignat+ subsections 7c71 7d71 & 7e7 z subsections 7d71 7e71 & 7f71 respectively1 & by ins]t+ aft] subsection 7b7 ! foll[+ new subsection3 7c7 ,heal? c>e ,9 addition to o!r taxes1 !re is h]eby impos$ on e employ] an excise tax1 ) respect to hav+ individuals 9 8 employ1 equal to #f4g p]c5t ( ! wages 7z def9$ 9 section #caba7;a77 paid by him ) respect to employm5t 7z def9$ 9 section #caba7;b774 4 7b7 ,self-,employm5t income ,section #adja 7relat+ to rate ( tax on self-employm5t income7 is am5d$ by r$esignat+ subsection 7c7 z subsection 7d7 & ins]t+ aft] subsection 7b7 ! foll[+ new subsection3 7c7 ,heal? c>e ,9 addition to o!r taxes1 !re %all be impos$ = ea* taxable ye>1 on ! self-employm5t income ( e individual1 a tax equal to #f4g p]c5t ( ! am\nt ( ! self-employm5t income = su* taxable ye>4 4 7c7 ,comp>able taxes = railroad s]vices 7#a7 ,tax on employ]s ,section #cbba is am5d$ by r$esignat+ subsections 7c7 & 7d7 z subsections 7d7 & 7e71 respectively1 & by ins]t+ aft] subsection 7b7 ! foll[+ new subsection3 7c7 ,heal? c>e ,9 addition to o!r taxes1 !re is h]eby impos$ on e employ] an excise tax1 ) respect to hav+ individuals 9 8 employ1 equal to #f4g p]c5t ( ! comp5sation paid by su* employ] = s]vices r5d]$ to su* employ]4 4 7#b7 ,tax on employee repres5tatives ,section #cbaa 7relat+ to tax on employee repres5tatives7 is am5d$ by r$esignat+ subsection 7c7 z subsection 7d7 & ins]t+ aft] subsection 7b7 ! foll[+ new p>agraph3 7c7 ,heal? c>e ,9 addition to o!r taxes1 !re is h]eby impos$ on ! income ( ea* employee repres5tative a tax equal to #f4g p]c5t ( ! comp5sation receiv$ dur+ ! cal5d> ye> by su* employee repres5tative = s]vices r5d]$ by su* employee repres5tative4 4 7#c7 ,no applicable base ,subp>agraph 7,a7 ( section #cbca7;e77#b7 is am5d$ by add+ at ! end !re( ! foll[+ new clause3 7iv7 ,heal? c>e taxes ,clause 7i7 %all n apply to ! taxes impos$ by sections #cbba7;c7 & #cbaa7;c74 4 7#d7 ,te*nical am5dm5ts 7,a7 ,subsection 7d7 ( section #cbaa1 z r$esignat$ by p>agraph 7#b71 is am5d$ by /rik+ & 7b7 & ins]t+ 1 7b71 & 7c74 7,b7 ,subsection 7d7 ( section #cbba1 z r$esignat$ by p>agraph 7#a71 is am5d$ by /rik+ & 7b7 & ins]t+ 1 7b71 & 7c74 7d7 ,con=m+ am5dm5ts 7#a7 ,p>agraph 7#e7 ( section #ea7;c7 is am5d$-- 7,a7 by /rik+ #caaa7;d77#c7 & ins]t+ #caaa7;e77#c71 & 7,b7 by /rik+ #caaa7;d7 bo? places x appe>s & ins]t+ #caaa7;e74 7#b7 ,p>agraph 7#b7 ( section #eb7;c7 is am5d$ by /rik+ #caaa7;e7 & ins]t+ #caaa7;f74 7#c7 ,p>agraph 7#e7 ( section #caba7z7 is am5d$ by /rik+ #caaa7;c7 & ins]t+ #caaa7;d74 7#d7 ,! fif? s5t5ce ( subsection 7a7 ( section #fjea is am5d$ by /rik+ #caaa7;c7 & ins]t+ #caaa7;d74 7e7 ,effective date ,! am5dm5ts made by ?is section %all apply to remun]ation paid aft] ,decemb] #ca1 #bjad4 #hab4 ,heal? c>e income tax 7a7 ,g5]al rule ,sub*apt] ,a ( *apt] #a 7relat+ to det]m9ation ( tax liability7 is am5d$ by add+ at ! end !re( ! foll[+ new "p3 ,,viii ,heal? c>e relat$ taxes ,subp>t ,a--,heal? c>e income tax on individuals ,a ,heal? c>e income tax on individuals ,sec4 #ei;,b4 ,heal? c>e income tax4 #ei;,b4 ,heal? c>e income tax 7a7 ,imposition ( tax ,9 ! case ( an individual1 !re is h]eby impos$ a tax 79 addition to any o!r tax impos$ by ?is subtitle7 equal to ! applicable am\nt ) respect to ! taxpay] = ! taxable ye>4 7b7 ,applicable am\nt ,= purposes ( ?is section-- 7#a7 ,9 g5]al ,9 ! case ( a taxpay] n describ$ 9 p>agraph 7#b71 ! applicable am\nt ) respect to any taxable ye> %all be det]m9$ 9 accordance ) ! foll[+ table3 ,if taxable income is3,! applicable am\nt is3,n ov] #bjj1jjjb4b ( taxable income,over #bjj1jjj b n ov] #djj1jjjd1djj1 plus #c4b ( ! excess ov] #bjj1jjj,ov] #djj1jjj b n ov] #fjj1jjjaj1hjj1 plus #d4b ( ! excess ov] #djj1jjj,ov] #fjj1jjjai1bjj1 plus #e4b ( ! excess ov] #fjj1jjj4 7#b7 ,jo9t returns & surviv+ sp\ses ,9 ! case ( a jo9t return or a surviv+ sp\se 7z def9$ 9 section #b7;a771 ! applicable am\nt ) respect to any taxable ye> %all be det]m9$ 9 accordance ) ! foll[+ table3 ,if taxable income is3,! applicable am\nt is3,n ov] #bej1jjjb4b ( taxable income,over #bej1jjj b n ov] #djj1jjje1ejj1 plus #c4b ( ! excess ov] #bej1jjj,ov] #djj1jjj b n ov] #fjj1jjjaj1cjj1 plus #d4b ( ! excess ov] #djj1jjj,ov] #fjj1jjjah1gjj1 plus #e4b ( ! excess ov] #fjj1jjj4 7#c7 ,inflation adju/m5t 7,a7 ,9 g5]al ,9 ! case ( any taxable ye> beg9n+ aft] #bjae1 ea* ( ! doll> am\nts 9 ! tables conta9$ 9 p>agraphs 7#a7 & 7#b7 %all be increas$ by an am\nt equal to-- 7i7 su* doll> am\nt1 multipli$ by 7ii7 ! co/-(-liv+ adju/m5t det]m9$ "u section #a7;f77#c7 = ! cal5d> ye> 9 :i* ! taxable ye> beg9s1 det]m9$ by sub/itut+ cal5d> ye> #bjad = cal5d> ye> #aiib 9 subp>agraph 7,b7 !re(4 7,b7 ,r\nd+ ,if any am\nt aft] adju/m5t "u subp>agraph 7,a7 is n a multiple ( #a1jjj1 su* am\nt %all be r\nd$ to ! next l[e/ multiple ( #a1jjj4 7c7 ,no cr$its aga9/ tax2 no effect on m9imum tax ,! tax impos$ by ?is section %all n be treat$ z a tax impos$ by ?is *apt] = purposes ( det]m9+-- 7#a7 ! am\nt ( any cr$it all[able "u ?is *apt]1 or 7#b7 ! am\nt ( ! m9imum tax impos$ by section #ee4 7d7 ,special rules 7#a7 ,tax to be )held1 etc ,= purposes ( ?is title1 ! tax impos$ by ?is section %all be treat$ z impos$ by section #a4 7#b7 ,reimbursem5t ( tax by employ] n includible 9 gross income ,! gross income ( an employee %all n include any paym5t by 8 employ] to reimburse ! employee = ! tax paid by ! employee "u ?is section4 7#c7 ,o!r rules ,! rules ( section #ei;,a7d7 %all apply to ! tax impos$ by ?is section4 4 7b7 ,cl]ical am5dm5t ,! table ( p>ts = sub*apt] ,a ( *apt] #a is am5d$ by add+ at ! end ! foll[+ new item3 ,"p ,,viii--,heal? c>e relat$ taxes 4 7c7 ,effective date ,! am5dm5ts made by ?is section %all apply to taxable ye>s beg9n+ aft] ,decemb] #ca1 #bjad4 #hac4 ,sur*>ge on high income individuals 7a7 ,9 g5]al ,"p ,,viii ( sub*apt] ,a ( *apt] #a1 z add$ by ?is title1 is am5d$ by add+ at ! end ! foll[+ new subp>t3 ,b ,sur*>ge on high income individuals ,sec4 #ei;,c4 ,sur*>ge on high income individuals4 #ei;,c4 ,sur*>ge on high income individuals 7a7 ,g5]al rule ,9 ! case ( a taxpay] o!r ?an a corporation1 !re is h]eby impos$ 79 addition to any o!r tax impos$ by ?is subtitle7 a tax equal to #e4d p]c5t ( s mu* ( ! modifi$ adju/$ gross income ( ! taxpay] z exce$s #a1jjj1jjj4 7b7 ,taxpay]s n mak+ a jo9t return ,9 ! case ( any taxpay] o!r ?an a taxpay] mak+ a jo9t return "u section #fjac or a surviv+ sp\se 7z def9$ 9 section #b7;a771 subsection 7a7 %all be appli$ by sub/itut+ #ejj1jjj = #a1jjj1jjj4 7c7 ,modifi$ adju/$ gross income ,= purposes ( ?is section1 ! t]m modifi$ adju/$ gross income means adju/$ gross income r$uc$ by any d$uction 7n tak5 into acc\nt 9 det]m9+ adju/$ gross income7 all[$ = inve/m5t int]e/ 7z def9$ 9 section #afc7;d774 ,9 ! case ( an e/ate or tru/1 adju/$ gross income %all be det]m9$ z provid$ 9 section #fg7;e74 7d7 ,special rules 7#a7 ,nonresid5t ali5 ,9 ! case ( a nonresid5t ali5 individual1 only am\nts tak5 into acc\nt 9 connection ) ! tax impos$ "u section #hga7;b7 %all be tak5 into acc\nt "u ?is section4 7#b7 ,citiz5s & resid5ts liv+ abroad ,! doll> am\nt 9 effect "u subsection 7a7 7aft] ! application ( subsection 7b77 %all be decreas$ by ! excess (-- 7,a7 ! am\nts exclud$ f ! taxpay]'s gross income "u section #iaa1 ov] 7,b7 ! am\nts ( any d$uctions or exclusions disall[$ "u section #iaa7;d77#f7 ) respect to ! am\nts describ$ 9 subp>agraph 7,a74 7#c7 ,*>itable tru/s ,subsection 7a7 %all n apply to a tru/ all ! unexpir$ int]e/s 9 :i* are devot$ to "o or m ( ! purposes describ$ 9 section #agj7;c77#b77;,b74 7#d7 ,n treat$ z tax impos$ by ?is *apt] = c]ta9 purposes ,! tax impos$ "u ?is section %all n be treat$ z tax impos$ by ?is *apt] = purposes ( det]m9+ ! am\nt ( any cr$it "u ?is *apt] or = purposes ( section #ee4 4 7b7 ,cl]ical am5dm5t ,! table ( subp>ts = "p ,,viii ( sub*apt] ,a ( *apt] #a1 z add$ by ?is title1 is am5d$ by ins]t+ aft] ! item relat+ to subp>t ,a ! foll[+ new item3 ,subp>t ,b--,sur*>ge on high income individuals 4 7c7 ,section #ae n ,to apply ,! am5dm5t made by subsection 7a7 %all n be treat$ z a *ange 9 a rate ( tax = purposes ( section #ae ( ! ,int]nal ,rev5ue ,code ( #aihf4 7d7 ,effective date ,! am5dm5ts made by ?is section %all apply to taxable ye>s beg9n+ aft] ,decemb] #ca1 #bjad4 ,c ,o!r f9anc+ provisions #hba4 ,tax on ,securities ,transactions 7a7 ,9 g5]al ,*apt] #cf is am5d$ by ins]t+ aft] sub*apt] ,b ! foll[+ new sub*apt]3 ,c ,tax on ,securities ,transactions ,sec4 #ddge4 ,tax on securities transactions4 #ddge4 ,tax on securities transactions 7a7 ,imposition ( tax ,!re is h]eby impos$ a tax on ea* cov]$ transaction ) respect to any security4 7b7 ,rate ( tax 7#a7 ,9 g5]al ,except z o!rwise provid$ 9 ?is subsection1 ! rate ( su* tax %all be equal to #j4jb p]c5t ( ! fair m>ket value ( ! security4 7#b7 ,swaps ,9 ! case ( a security describ$ 9 subsection 7d77#a77;,d71 ! rate ( su* tax %all be equal to #j4jb p]c5t ( ! fair m>ket value ( ! und]ly+ prop]ty ) respect to1 or ! notional pr9cipal am\nt (1 ! d]ivative f9ancial in/rum5t involv$ 9 su* transaction4 7#c7 ,%ort-t]m debt in/rum5ts ,9 ! case ( a cov]$ transaction ) respect to a security describ$ 9 subsection 7d77#a77;,c7 :i* has a fix$ maturity date n m ?an #a ye> f ! date ( issue1 ! rate ( su* tax %all be equal to #j4jb p]c5t ( ! fair m>ket value ( su* security4 7c7 ,cov]$ transaction ,= purposes ( ?is section1 ! t]m cov]$ transaction means-- 7#a7 except z provid$ 9 p>agraph 7#b71 any pur*ase if-- 7,a7 su* pur*ase occurs on a trad+ facility locat$ 9 ! ,unit$ ,/ates1 or 7,b7 ! pur*as] or sell] is a ,unit$ ,/ates p]son1 or 7#b7 any transaction ) respect to a security describ$ 9 subsection 7d77#a77;,d71 if any p>ty ) rights "u su* security is a ,unit$ ,/ates p]son or if su* transaction is facilitat$ by a ,unit$ ,/ates p]son1 includ+ a trad+ facility locat$ 9 ! ,unit$ ,/ates or a brok]4 7d7 ,security & o!r def9itions ,= purposes ( ?is section-- 7#a7 ,9 g5]al ,! t]m security means-- 7,a7 any %>e ( /ock 9 a corporation1 7,b7 any p>tn]%ip or b5eficial own]%ip int]e/ 9 a widely held or publicly trad$ p>tn]%ip or tru/1 7,c7 any note1 bond1 deb5ture1 or o!r evid5ce ( indebt$ness issu$ by a nongov]nm5tal entity ! b5eficial own]%ip ( :i* is trad$ on an e/abli%$ m>ket1 or 7,d7 any evid5ce ( an int]e/ 91 or a d]ivative f9ancial in/rum5t 9-- 7i7 any security describ$ 9 subp>agraph 7,a71 7,b71 or 7,c71 7ii7 any specifi$ index1 or 7iii7 any o!r note1 bond1 or deb5ture issu$ by a nongov]nm5tal entity4 7#b7 ,d]ivative f9ancial in/rum5t ,! t]m d]ivative f9ancial in/rum5t means any option1 =w>d contract1 %ort position1 notional pr9cipal contract1 cr$it default swap1 or any simil> f9ancial in/rum5t4 7#c7 ,specifi$ index ,! t]m specifi$ index means any #a or m ( any comb9ation (-- 7,a7 a fix$ rate1 price1 or am\nt1 or 7,b7 a v>iable rate1 price1 or am\nt1 :i* is bas$ on any curr5t objectively det]m9able in=mation :i* is n )9 ! control ( any ( ! p>ties to ! contract or in/rum5t & is n unique to any ( ! p>ties' circum/ances4 7e7 ,exceptions to imposition ( tax 7#a7 ,exception = initial issues ,no tax %all be impos$ "u subsection 7a7 on any cov]$ transaction ) respect to ! initial issuance ( any security describ$ 9 subp>agraph 7,a71 7,b71 or 7,c7 ( subsection 7d77#a74 7#b7 ,exception = retirem5t acc\nts1 etc ,no tax %all be impos$ "u subsection 7a7 on any cov]$ transaction ) respect to any security :i* is held 9 any plan1 acc\nt1 or arrangem5t describ$ 9 section #bbj1 #bbc1 #dja7;a71 #djc7;a71 #djc7;b71 #djh1 #djh;,a1 #ebi1 or #ecj 7includ+ assets held 9 a segregat$ asset acc\nt describ$ 9 section #hag z "p ( any su* plan1 acc\nt1 or arrangem5t74 7#c7 ,exception = c]ta9 mutual fund transactions ,no tax %all be impos$ "u subsection 7a7 on any cov]$ transaction-- 7,a7 ) respect to ! pur*ase ( any int]e/ 9 a regulat$ inve/m5t company 7z def9$ 9 section #hea7 :i* issues only /ock :i* is r$eemable on ! dem& ( ! /ock hold]1 7,b7 by a regulat$ inve/m5t company 7z s def9$7 :i* is #ajj p]c5t own$ by #a or m plans1 acc\nts1 or arrangem5ts describ$ 9 p>agraph 7#b71 & 7,c7 to ! ext5t su* tax is prop]ly allocable to any class ( %>es ( a regulat$ inve/m5t company 7z s def9$7 :i* is #ajj p]c5t own$ by #a or m plans1 acc\nts1 or arrangem5ts describ$ 9 p>agraph 7#b74 7f7 ,by :om paid 7#a7 ,9 g5]al ,! tax impos$ by ?is section %all be paid by-- 7,a7 9 ! case ( a transaction :i* occurs on a trad+ facility locat$ 9 ! ,unit$ ,/ates1 su* trad+ facility1 7,b7 9 ! case ( a transaction n describ$ 9 subp>agraph 7,a7 :i* is execut$ by a brok]1 su* brok]1 7,c7 9 ! case ( a transaction n describ$ 9 subp>agraph 7,a7 or 7,b71 ) respect to a security describ$ 9 section 7d77#a77;,d71 ! p>ty id5tifi$ by ! ,secret>y1 or 7,d7 9 any o!r case1 ! pur*as] ) respect to ! transaction4 7#b7 ,)hold+ if pur*as] is n a ,unit$ ,/ates p]son ,see section #addg = )hold+ by sell] if pur*as] is a =eign p]son4 7g7 ,adm9i/ration ,! ,secret>y %all c>ry out ?is section 9 consultation ) ! ,securities & ,ex*ange ,commission & ! ,commodity ,futures ,trad+ ,commission4 7h7 ,guidance2 regulations ,! ,secret>y %all-- 7#a7 provide guidance reg>d+ su* in=mation report+ conc]n+ cov]$ transactions z ! ,secret>y deems appropriate1 & 7#b7 prescribe su* regulations z are necess>y or appropriate to prev5t avoidance ( ! purposes ( ?is section1 includ+ ! use ( non-,unit$ ,/ates p]sons 9 su* transactions or ! improp] allocation ( taxes to classes ( %>es describ$ 9 subsection 7e77#c77;,c74 4 7b7 ,cr$it = fir/ #ajj1jjj ( /ock transactions p] ye> ,subp>t ,c ( "p ,,iv ( sub*apt] ,a ( *apt] #a is am5d$ by ins]t+ aft] section #cf;,b ! foll[+ new section3 #cf;,c4 ,cr$it = securities transaction taxes 7a7 ,all[ance ( cr$it ,9 ! case ( any pur*as] ) respect to a cov]$ transaction1 !re %all be all[$ z a cr$it aga9/ ! tax impos$ by ?is subtitle = ! taxable ye> an am\nt equal to ! less] (-- 7#a7 ! aggregate am\nt ( tax impos$ "u section #ddge on cov]$ transactions dur+ ! taxable ye> ) respect to :i* ! taxpay] is ! pur*as]1 or 7#b7 #bej 7#ejj 9 ! case ( a jo9t return74 7b7 ,aggregation rule ,= purposes ( ?is section1 all p]sons treat$ z a s+le employ] "u subsection 7a7 or 7b7 ( section #eb1 or subsection 7m7 or 7o7 ( section #dad1 %all be treat$ z "o taxpay]4 7c7 ,def9itions ,= purposes ( ?is section1 any t]m us$ 9 ?is section :i* is also us$ 9 section #ddge %all h ! same mean+ z :5 us$ 9 section #ddge4 4 7c7 ,)hold+ ,sub*apt] ,a ( *apt] #c is am5d$ by add+ at ! end ! foll[+ new section3 #addg4 ,)hold+ on securities transactions 7a7 ,9 g5]al ,9 ! case ( any outb\nd securities transaction1 ! transf]or %all d$uct & )hold a tax equal to ! tax impos$ "u section #ddge ) respect to su* transaction4 7b7 ,outb\nd securities transaction ,= purposes ( ?is section1 ! t]m outb\nd securities transaction means any cov]$ transaction to :i* section #ddge7;a7 applies if-- 7#a7 su* transaction does n occur on a trad+ facility locat$ 9 ! ,unit$ ,/ates1 & 7#b7 ! pur*as] ) respect to su* transaction is n a ,unit$ ,/ates p]son4 4 7d7 ,con=m+ am5dm5ts 7#a7 ,section #fbaa7;b77#d77;,a71 z am5d$ by ! ,pati5t ,protection & ,af=dable ,c>e ,act1 is am5d$ by ins]t+ #cf;,c1 aft] #cf;,b14 7#b7 ,section #acbd7;b77#b7 ( title #ca1 ,unit$ ,/ates ,code1 is am5d$ by ins]t+ #cf;,c1 aft] #cf;,b14 7#c7 ,! table ( sub*apt]s = *apt] #cf is am5d$ by ins]t+ aft] ! item relat+ to sub*apt] ,b ! foll[+ new item3 ,sub*apt] ,c4 ,tax on securities transactions4 4 7#d7 ,! table ( sections = sub*apt] ,a ( *apt] #c is am5d$ by add+ at ! end ! foll[+ new item3 ,sec4 #addg4 ,)hold+ on securities transactions4 4 7#e7 ,! table ( sections = subp>t ,c ( "p ,,iv ( sub*apt] ,a ( *apt] #a is am5d$ by ins]t+ aft] ! item relat+ to section #cf;,b ! foll[+ new item3 ,sec4 #cf;,c4 ,cr$it = securities transaction taxes4 4 7e7 ,effective date ,! am5dm5ts made by ?is section %all apply to transactions occurr+ m ?an #ahj days aft] ! date ( ! enactm5t ( ?is ,act4 ,,ix ,con=m+ ,am5dm5ts to ! ,employee ,retirem5t ,income ,security ,act ( #aigd #ija4 ,,erisa inapplicable to heal? cov]age arrangem5ts "u ,/ate heal? security programs ,section #d ( ! ,employee ,retirem5t ,income ,security ,act ( #aigd 7#bi ,u4,s4,c4 #ajjc7 is am5d$-- 7#a7 9 subsection 7a71 by /rik+ 7b7 or 7c7 & ins]t+ 7b71 7c71 or 7d72 & 7#b7 by add+ at ! end ! foll[+ new subsection3 7d7 ,! provisions ( ?is title %all n apply to any arrangem5t =m+ a "p ( a ,/ate heal? security program e/abli%$ pursuant to section #aja7;b7 ( ! ,am]ican ,heal? ,security ,act ( #bjac4 4 #ijb4 ,exemption ( ,/ate heal? security programs f ,,erisa preemption ,section #ead7;b7 ( ! ,employee ,retirem5t ,income ,security ,act ( #aigd 7#bi ,u4,s4,c4 #aadd7;b77 7z am5d$ by sections #ijd7;b77#c77;,b7 & #ajjb7;b7 ( ?is ,act7 is am5d$ by add+ at ! end ! foll[+ new p>agraph3 7#aj7 ,subsection 7a7 ( ?is section %all n apply to ,/ate heal? security programs e/abli%$ pursuant to section #aja7;b7 ( ! ,am]ican ,heal? ,security ,act ( #bjac4 4 #ijc4 ,prohibition ( employee b5efits duplicative ( b5efits "u ,/ate heal? security programs2 coord9ation 9 case ( work]s' comp5sation 7a7 ,9 g5]al ,"p #e ( subtitle ,b ( title ,i ( ! ,employee ,retirem5t ,income ,security ,act ( #aigd is am5d$ by add+ at ! end ! foll[+ new section3 #ebb4 ,prohibition ( employee b5efits duplicative ( ,/ate heal? security program b5efits2 coord9ation 9 case ( work]s' comp5sation 7a7 ,subject to subsection 7b71 no employee b5efit plan may provide b5efits :i* duplicate paym5t = any items or s]vices = :i* paym5t may be made "u a ,/ate heal? security program e/abli%$ pursuant to section #aja7;b7 ( ! ,am]ican ,heal? ,security ,act ( #bjac4 7b7 7#a7 ,ea* work]s comp5sation c>ri] t is liable = paym5t = work]s comp5sation s]vices furni%$ 9 a ,/ate %all reimburse ! ,/ate heal? security plan = ! ,/ate 9 :i* ! s]vices are furni%$ = ! co/ ( su* s]vices4 7#b7 ,9 ?is subsection3 7,a7 ,! t]m work]s comp5sation c>ri] means an insurance company t und]writes work]s comp5sation m$ical b5efits ) respect to #a or m employ]s & includes an employ] or fund t is f9ancially at risk = ! provision ( work]s comp5sation m$ical b5efits4 7,b7 ,! t]m work]s comp5sation m$ical b5efits means1 ) respect to an enrollee :o is an employee subject to ! work]s comp5sation laws ( a ,/ate1 ! compreh5sive m$ical b5efits = "w-relat$ injuries & illnesses provid$ = "u su* laws ) respect to su* an employee4 7,c7 ,! t]m work]s comp5sation s]vices means items & s]vices includ$ 9 work]s comp5sation m$ical b5efits & includes items & s]vices 7includ+ rehabilitation s]vices & long-t]m c>e s]vices7 commonly us$ = treatm5t ( "w-relat$ injuries & illnesses4 4 7b7 ,con=m+ am5dm5t ,section #d7;b7 ( su* ,act 7#bi ,u4,s4,c4 #ajjc7;b77 is am5d$ by add+ at ! end ! foll[+3 ,p>agraph 7#c7 %all apply subject to section #ebb7;b7 7relat+ to reimbursem5t ( ,/ate heal? security plans by work]s comp5sation c>ri]s744 7c7 ,cl]ical am5dm5t ,! table ( cont5ts 9 section #a ( su* ,act is am5d$ by ins]t+ aft] ! item relat+ to section #eba ! foll[+ new items3 ,sec4 #ebb4 ,prohibition ( employee b5efits duplicative ( ,/ate heal? security program b5efits2 coord9ation 9 case ( work]s' comp5sation4 4 #ijd4 ,repeal ( cont9uation cov]age requirem5ts "u ,,erisa & c]ta9 o!r requirem5ts relat+ to gr\p heal? plans 7a7 ,9 g5]al ,"p #f ( subtitle ,b ( title ,i ( ! ,employee ,retirem5t ,income ,security ,act ( #aigd 7#bi ,u4,s4,c4 #aafa et seq47 is repeal$4 7b7 ,con=m+ am5dm5ts 7#a7 ,section #ejb7;a7 ( su* ,act 7#bi ,u4,s4,c4 #aacb7;a77 is am5d$-- 7,a7 by /rik+ p>agraph 7#g72 & 7,b7 by r$esignat+ p>agraphs 7#h71 7#i71 & 7#aj7 z p>agraphs 7#g71 7#h71 & 7#i71 respectively4 7#b7 ,section #ejb7;c77#a7 ( su* ,act 7#bi ,u4,s4,c4 #aacb7;c77#a77 is am5d$ by /rik+ p>agraph 7#a7 or 7#d7 ( section #fjf14 7#c7 ,section #ead7;b7 ( su* ,act 7#bi ,u4,s4,c4 #aadd7;b77 is am5d$-- 7,a7 9 p>agraph 7#g71 by /rik+ section #bjf7;d77#c77;,b77i771 & all t foll[s & ins]t+ section #bjf7;d77#c77;,b77i7742 & 7,b7 by /rik+ p>agraph 7#h74 7#d7 ,! table ( cont5ts 9 section #a ( ! ,employee ,retirem5t ,income ,security ,act ( #aigd is am5d$ by /rik+ ! items relat+ to "p #f ( subtitle ,b ( title ,i ( su* ,act4 #ije4 ,effective date ( title ,! am5dm5ts made by ?is title %all take effect ,janu>y #a1 #bjae4 ,x ,additional ,con=m+ ,am5dm5ts #ajja4 ,repeal ( c]ta9 provisions 9 ,int]nal ,rev5ue ,code ( #aihf ,! provisions ( titles ,,iii & ,,iv ( ! ,heal? ,insurance ,portability & ,acc\ntability ,act ( #aiif1 o!r ?an subtitles ,d & ,h ( title ,,iii & section #cdb1 are repeal$ & ! provisions ( law t 7 am5d$ or repeal$ by su* provisions are h]eby re/or$ z if su* provisions _h n be5 enact$4 #ajjb4 ,repeal ( c]ta9 provisions 9 ! ,employee ,retirem5t ,income ,security ,act ( #aigd 7a7 ,9 g5]al ,"p #g ( subtitle ,b ( title ,i ( ! ,employee ,retirem5t ,income ,security ,act ( #aigd is repeal$ & ! items relat+ to su* "p 9 ! table ( cont5ts 9 section #a ( su* ,act are repeal$4 7b7 ,con=m+ am5dm5t ,section #ead7;b7 ( su* ,act 7#bi ,u4,s4,c4 #aadd7;b77 is am5d$ by /rik+ p>agraph 7#i74 #ajjc4 ,repeal ( c]ta9 provisions 9 ! ,public ,heal? ,s]vice ,act & relat$ provisions 7a7 ,9 g5]al ,titles ,,xxii & ,,xxvii ( ! ,public ,heal? ,s]vice ,act are repeal$4 7b7 ,additional am5dm5ts 7#a7 ,section #acja7;b7 ( su* ,act 7#db ,u4,s4,c4 #cjj;e7b77 is am5d$ by /rik+ p>agraph 7#f74 7#b7 ,sections #ajd & #aia ( ! ,heal? ,insurance ,portability & ,acc\ntability ,act ( #aiif are repeal$4 #ajjd4 ,effective date ( title ,! am5dm5ts made by ?is title %all take effect ,janu>y #a1 #bjag4