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Originally Processed With FOIA(s):
FOIA Number:
1999-0118-F
1999-0118-F
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This is not a textual record. This is used as an
administrative marker by the George Bush Presidential
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George H.W. Bush Presidential Records
Collection/Office of Origin: Cabinet Affairs, White House Office of
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Porter, Richard, Files
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07136-004
Folder Title:
Health Care Reform Studies II [2]
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10
14
7
1
A REPORT TO THE GOVERNOR AND LEGISLATURE
PREPARED PURSUANT TO CHAPTER 829, STATUTES OF 1989
(AB 350)
JOHN K. GEOGHEGAN
SECRETARY
BUSINESS, TRANSPORTATION AND HOUSING AGENCY
CLIFFORD L. ALLENBY
SECRETARY
HEALTH AND WELFARE AGENCY
MARCH 1, 1990
To the Governor and Members of the California Legislature:
On October 10, 1989, in accordance with the provisions of AB 350,
Governor Deukmejian assigned the secretaries of Business, Transportation
and Housing and Health and Welfare the responsibility of preparing a
report on health insurance coverage.
We were directed to examine the insurance rating system and general
health care delivery, including the potential for achieving savings in
medical care costs. This report provides information on those topics.-
We hoped at the outset that the process of developing the report could
lead to agreements among all groups-employers, health care providers,
insurance carriers and labor.
The process produced an examination of the problem unequalled in
intensity and thoroughness by anything going on in any state in the
country. But it did not produce a consensus.
Nevertheless, it did bring a focus, new information, and some compromises
which leave all parties in a better position to pursue this challenge in
the future.
If we have set out ideas that will be a part of future discussion and
increased understanding, then the work of everyone involved will have
been worthwhile.
We want to thank those who assisted us as formal members of the advisory
task force we first called together in November and also the many other
individuals from associations, academia, and the Legislature who
participated diligently in our working group efforts. We would like to
especially commend the members of respective agency staffs who devoted
many hours to this project: John Ramey, Sandra Shewry, Mark Helmar and
Richard Krolack of Health and Welfare, John Sullivan and Anne Eowan of
Business, Transportation and Housing.
JOHN K. GEOGHEGAN
Secretary
Business, Transportation
CLIFFORD Health Secretary Cliffond and L. falls Welfare ALLENBY Agency
and Housing Agency
TABLE OF CONTENTS
I
Preface
3
II
Guiding Principles
5
III
Coverage of Working Californians and
Their Families
7
A.
Voluntary Incentive System
7
B.
Mandatory Coverage
7
1.
Cost Sharing Partnership.
9
2.
Basic Benefits
10
3.
Affordability
11
4.
Increased Reimbursement For CAL-CARE Providers
13
5.
CAL-CARE Program Benefit Conformity
14
6.
Cost Containment
15
A.
Fail Safe Affordability
15
Option A: Open CAL-CARE
15
Option B: Eliminate Mandate
15
Option C: Establish Cost Limits for Employers. 16
Option D: Fair Share Fee
16
B.
Underwriting Changes
16
C.
Universal Pre-existing Condition Language
18
D.
Employee Cost Sharing
18
E.
Reforms in Tort Law.
18
F.
Health Coverage Data Base Development
19
G.
Hospital Employment of Physicians
19
H.
CMAC Negotiated Hospital Per Diem Rates
20
I.
Drug Utilization Review
20
J.
Reduce Double Coverage
20
7.
Federal Cooperation
21
8.
Funding
22
Charts
1.
Federal Poverty Level
23
2.
Resource Allocation
24
3.
Benefit Schedule
25
PREFACE:
Assembly Bill No 350 (Chapter 929, Statutes of 1989) required the
Governor to designate a state agency to report to the Legislature and the
Governor, by March 1, 1990, on factors relevant to a solution of problems
posed by a large and growing percentage of the state's population that is
unsponsored for payment of health related costs. Specifically, the
report is to include information on the following items:
1.
The number of people in California who lack health insurance
coverage;
2.
The impact of the lack of health insurance on California employers
and those businesses providing health insurance;
3.
The impact of Proposition 99 funds on the problem of uncompensated
care in California;
4.
Fiscal incentives, other than those contained in existing
statutes, which might further encourage business to provide health
insurance coverage to their workers;
5.
Recommendations on how the current system of underwriting the cost
of health insurance might be improved;
6.
The possibility of cost savings by consolidating workers'
compensation health benefits under employer sponsored health care
coverage; and
7.
Recommendations on the fiscal responsibility of those employers
who do not provide basic health care coverage for their employees
in order to insure that the cost of uncompensated care to both the
public and private sectors is shared as equally as possible.
In addition, the Governor in designating the Secretaries of the Business,
Transportation and Housing Agency and the Health and Welfare Agency to
make the report, asked also for information on ways to reduce medical
care costs. This report addresses all of these items except for numbers
3 and 6. Proposition 99 funds were not examined because they cannot be
counted on as a long term source of support. The issue of consolidating
workers' compensation health coverage is not discussed because it was
generally agreed that it was better to allow a reasonable time for recent
changes to that program to have an impact before proposing further
modifications.
The Secretaries of the Business, Transportation and Housing Agency and
the Health and Welfare Agency requested the assistance of an advisory
task force preparing the report called for in AB 350. The task force
included representatives from health care providers, employers,
3
employees, and consumers. After an initial organization meeting in
November, 1989 the task force sought to have information developed via
working groups focused on cost containment, employer participation, and
an affordable benefit package. These groups held a number of open
meetings through December. Each meeting was well attended and resulted
in multiple opportunities for interested parties to express their
concerns, identify additional issues, and propose solutions.
At the conclusion of these focused meetings, the working groups combined
for six open meetings to hear about seven alternative proposals offered
by various groups as solutions to California's growing health insurance
problems. The seven proposals were a modified AB 350 (Brown), a Medi-Cal
Buy-In plan, Health Access' Universal Coverage plan, a California Medical
Association Employer Mandate proposal, AB 328 (Margolin), Oregon's recent
health reforms, and a plan proposed in New York called UNY-CARE.
Following these meetings, staff developed a set of guiding principles and
a draft proposal which was used to prepare this document. The AB 350
Task Force members met in mid-February to provide feedback to the Agency
Secretaries on the draft. In addition, feedback was obtained from
extensive written comment and a three-hour public meeting.
According to 1986 data, 22% of Californians are not insured privately or
sponsored by government for health expense. There is good evidence to
conclude that the number of these persons is growing at an accelerating
rate. This phenomenon causes a significant burden on all sectors of our
health care system and society. Existing studies have suggested that the
lack of health insurance coverage results in reduced access to medical
care and an overall worsening of health status, particularly among those
with chronic illnesses and those without access to adequate preventive
care. Lack of health insurance also creates additional financial burdens
on government, health care providers, and employers who do provide
coverage for their employees. As those without coverage rely more and
more heavily on the publicly supported county based "safety net,"
government costs for providing these services continues to escalate.
Private providers are similarly impacted as the demands of uncompensated
or "charity" care continue to grow. The resultant cost shifts drive up
the insurance costs of those who do provide insurance coverage for their
employees. This increase in overall costs will in turn likely result in
even greater numbers of unsponsored persons creating a spiral of
increasing costs and further reductions in coverage. Responsible public
policy seeks to alleviate this problem before it escalates to a level
that will cause serious disruption to our general welfare and to existing
successful health care relationships. The following principles were used
to identify options to address the problem.
4
GUIDING PRINCIPLES
BUILD ON EXISTING INSURANCE AND SERVICE DELIVERY SYSTEMS
The strengths of the existing pluralistic network of service
delivery systems are the preferred basis for expanding health care
coverage. Although these systems do not currently provide the
optimal level of coverage and cost containment, they do provide
coverage and care to millions of Californians. The State has seen
a dramatic growth in enrollments in managed care systems. The
California Department of Corporations reports that more than nine
million Californians are enrolled in managed care systems. These
systems insure access while placing restraints on unnecessary
services and costs. Any new approach should provide incentives
for the health care system to provide expanded, affordable
coverage through the expansion of managed care systems. It should
also provide for a series of evolutionary steps to modify the
current system of private insurance and provider rate setting if
assumptions regarding access and price stability do not
materialize in a reasonable time frame.
Existing state policy rationally seeks to maximize federal
participation in health care funding. A proposal should continue
that policy for the coverage of all possible eligible persons
while standardizing a basic benefit package to all Californians.
MINIMUM BENEFIT PACKAGE
Affordability is the primary obstacle to access to adequate health
insurance coverage. A proposal should identify an affordable,
medically viable and actuarialy sound package of minimum benefits
or a minimum package defined by a cost limit.
FAIR TO BUSINESS
Any proposal should seek to be fair to businesses. Business has a
primary fiscal and managerial role in health coverage for most of
the population. Affordability is a primary factor in
availability. Achieving affordability would be a positive factor
in our business climate.
AVOID NONPRODUCTIVE EMPLOYMENT INCENTIVES
A proposal should be designed to enable employers to make
employment and personnel decisions based on productivity rather
than on avoiding health coverage costs. Any proposal should not
encourage employers to cap their number of employees or hours
worked by an employee per month. Retaining current flexibility
benefits employers and employees alike.
5
COVER EMPLOYEES AND DEPENDENTS
A workable solution to this complex issue should provide for
coverage of dependents as well as employees. Expansion of
coverage to dependents is both cost effective and socially
responsible. It is cost effective due to economies of scale
associated with large risk pools and reduced per capita costs for
dependent coverage. Social responsibility is cost effective in
the short term and long term because dependent coverage funds
health services for an additional quarter of the uninsured
population, a significant portion which includes non-working
spouses and children.
O
AFFORDABILITY
Future year costs must directly be addressed. Any proposal
without a viable cost containment strategy as an integral part of
the package will fail. Future unwarranted cost increases should
be guarded against in the strongest possible terms. Managed care
should be encouraged to accentuate positive cost containment
incentives.
Consideration should be given to low income employees' ability to
share the burden of health coverage. Consideration must also be
given to the resources available to businesses, particularly small
businesses, for their share of the burden.
PRUDENT REALLOCATION OF EXISTING RESOURCES
Major components of a proposal must be appropriately supported to
make it viable. To this end, a proposal should prudently
allocate resources within the health care insurance and delivery
systems.
The combination of cost containment measures, system reforms, and
resource allocation should provide both structural and fiscal
integrity to a proposal.
MAINTAIN SAFETY NET
A proposal should recognize the importance of maintaining and
stabilizing the existing publicly supported "safety net" health
care system. This system is crucial in providing needed health
care services to any remaining population of uninsured persons.
6
AFFORDABLE BASIC HEALTH CARE FOR CALIFORNIA
III. Coverage of Working Californians and Their Families
Voluntary Incentive System for Employers Not Now Offering Health
Coverage to Employees and Their Families
This report examines options which are designed to preserve the
existing employer-based system of health care coverage of working
Californians. In that system, employer participation is
voluntary. A plan to bring more employees into employer provided
health care under a voluntary system would rely on devising
incentives which somehow outrace the disincentives now encountered
by the minority of businesses not offering health care. This is a
challenging task, given the cost increases being inflicted on
firms already providing health coverage.
It is possible that inducements alone -- such as a tax credit
would influence some groups on the margin, but the core problem of
uncovered Californians would remain. The only way a voluntary
approach can work is through inducements coupled with simultaneous
implementation of systemic cost containment reforms.
A voluntary, incentive option could be pursued in conjunction with
most of the employer/employee subsidies, cost containment, and the
"fail safe affordability" options described in the following
sections. It would not require an ERISA exemption because there
would be no mandatory schedule of benefits. This report envisions
"buying" cost containment reforms from providers and insurance
carriers in exchange for better Medi-Cal funding and more "paying
customers" from the ranks of the uncovered employed. In an
incentive approach, the number of new participating employers and
employees (and likewise the new health dollars) would be
uncertain, making bargaining for cost containment less assured of
success.
Mandatory Coverage by Employers of All Working Californians and
Their Families
Mandatory coverage of all working Californians guarantees reaching
the majority of the uncovered. Under a mandatory option, covering
all workers prevents the kind of unproductive employment decisions
that can occur if a mandate exempts employers with fewer than five
employees, for example, or employees working fewer than a set
number of hours per week. A mandate, by making more predictable
the level of new resources devoted to health care, makes systemic
cost containment reform more achievable. It allows for a
fundamental change in health insurance underwriting that
guarantees availability of insurance. Importantly, most insurance
7
carriers assert that these underwriting changes are not achievable
without mandatory coverage. Under the mandate model used to help
develop this report, employers could choose to offer a minimum
level of health care coverage to all employees and their
dependents. Employees receiving health care coverage via the
Medicare Program (i.e., over 64 years of age) would be excluded
from the mandate requirements. All employees would be required to
accept and participate in purchasing the minimum level of health
care coverage. Employers choosing not to offer coverage would be
liable for "first dollar" health care costs of their uninsured
employees, plus a penalty charge collected by the State. In
either situation, the obligation would begin following the
employee's third month of work.
8
1.
Cost Sharing Partnership Among Employers, Employees and Government
Cost of coverage, under the model tested for this report, would be
shared by employers, employees and government:
a.
Employer contribution: at least 75% of the cost of premiums
for individual coverage or 50% of the premium cost for family
coverage. If the minimum level of coverage is defined by a
list of required benefits, the dollar value of the mandate on
employer participation applies to the lowest cost plan made
available to employees which meets the basic benefit plan
requirements. Employers would pay a pro-rata share of
premium cost for part-time workers, i.e., persons working
fewer than 35 hours per week.
b.
Employee contribution: up to 25% of the cost of premiums for
individual coverage or up to 50% of the premium cost for
family coverage, under whatever plan agreed upon by employer
and employee. Part-time employees would pay a pro-rata share
of premium costs.
C. Medi-Cal buy-in: low wage employees, low income self-
employed, and low profit employers would be able to buy into
a minimum, state program such as the existing Medi-Cal
program.
d. The state would assist business in providing the required
health coverage through the provision of a tax credit and a
direct subsidy of premium costs.
e.
The state would subsidize the premium cost for those least
able to afford coverage -- full-time employees, part-time
employees, and self employed low income persons. These
subsidies could be provided on the basis of a sliding scale
with graduated subsidies for persons based on a percent of
the Federal Poverty Level (FPL). See Chart 1 for current
FPLs.
9
2.
Basic Benefits to Cover Essential Health Care Needs
Obtaining an appropriate balance in the design of a benefit
package is crucial to overall viability and affordability of
legislated health care coverage. The schedule of benefits should
be restricted to those services that are medically necessary.
During the Task Force deliberations a work group attempted to list
essential basic services. A detailed description of such a
benefit package is included in this report in the appendix. The
benefit package presented in the appendix is, with the exception of
the inclusion of advance practice nurses, the one presented by the
California Medical Association. Depending on affordability and
efficacy, modifications to the benefit package may be desirable.
10
3.
Affordability For Those Least Able to Pay For Coverage
To assure the affordability of health care coverage to employees
and employers, the state would subsidize the purchase of coverage
for those facing financial hardship. Those individuals and
businesses least able to afford coverage will be offered the
option of purchasing it through the CAL-CARE Program. CAL-CARE
benefits for persons choosing this buy-in option will be
restricted to the mandated minimum benefit package and will be
available at a significant cost saving over the rates charged by
commercial carriers.
Estimated monthly premium costs for the CAL-CARE plan are:
Single adult
$ 84.80
Two person family
$168.11
Family groups of three or more
$278.11
These premiums cover the basic scope of benefits (with the rate
increases for CAL-CARE services) and program administrative costs,
including a sales commission component. Program administrative
costs account for approximately six percent of total premium
costs.
a. Affordability for California Businesses
To help insure that the benefits mandated under this proposal
are affordable to employers, the CAL-CARE program will be
available to business depending on its number of employees
and financial circumstances. Businesses which meet the size
and fiscal criteria will have the option to purchase health
care coverage via the CAL-CARE program, and will also be
eligible for partial subsidization of their premium costs.
Charitable organizations will be given the option of
purchasing coverage through the CAL-CARE Program. This
option will at least be restricted to federally designated
501 (c)3 organizations. No governmental entity will be
eligible for this option.
b.
Affordability for Full-Time Employees, Part-Time Employees,
and Self-Employed Persons of Low-Income.
Those individuals least able to afford coverage will be
offered the option of purchasing coverage through the CAL-
CARE Program. The benefits will be restricted to a mandated
minimum benefit package and will be available at a
significant cost saving over the rates charged by commercial
carriers. In addition, the state would subsidize purchase of
coverage for those facing financial hardship.
This subsidy could be provided on a sliding scale based on
the FPL. This subsidy schedule would be available to low
11
wage employees and low income self-employed individuals. In
each case this subsidy would be based on CAL-CARE rates.
All part-time workers will be offered the option of coverage
through CAL-CARE. The purpose of offering all part-time
workers the CAL-CARE option is to reduce the administrative
obligations and associated costs to individual employers.
Employers with part-time employees would be spared the need
to deal with substantial additional record keeping
requirements or the need to coordinate coverage in the case
of employees with more than one employer. This option would
not preclude any employer from providing coverage if they
chose to do so.
Employee and employer responsibility for the cost of premiums
for part-time workers and their dependents would be charged
on a pro-rata basis. If a worker works one half time, the
employer would contribute one half of 75% (50% with family
coverage) of the cost of the lowest cost insurance plan
available to the employee through the employer. The employee
would contribute one half of 25% (50%) of the lowest cost
plan available to him/her. The balance of the premium would
be contributed through other jobs, through agreement between
employee/employer, or through additional state subsidies for
low income part-time employees. Premium contributions for
persons working more than one part-time job would be
aggregated with proportional shares contributed by each
employer.
In addition, the state will actively pursue additional
federal financial participation for those family units
eligible. This action should result in the availability of
additional resources to subsidize full-time employees, part-
time employees and self-employed persons of low wage.
12
4.
Increased Reimbursement for CAL-CARE Providers
The CAL-CARE Program will increase its provider rates in targeted
areas to assure adequate access to services is available
throughout the state. $640 million in provider rate increases
will be targeted to improve enrollee access and to realign rates
toward a resource based relative value scale.
One option for distribution of the funds which achieves these
goals is:
Service Category
Full Year Cost
% Adjustment
Physicians (Specific
$253,631,500
35%
specialties to receive higher
or lower percents)
Other Medical
$ 37,902,175
25%
Emergency Medical Transportation
$ 1,834,500
30%
Other Services
$ 19,916,090
10%
Home Health Agencies
$ 4,125,000
30%
Dental Services
$ 20,837,600
40%
Prepaid Health Plans
$ 24,732,000
15%
CHDP
$ 19,156,000
40%
County Organized Health Systems
$ 8,382,000
15%
Hospital Inpatient/Outpatient
$200,000,000
fixed
fixed dollar amount to be distributed via CMAC negotiations
Managed care incentives
$ 49,753,135
fixed
13
5.
CAL-CARE Program Benefit Conformity
The benefits provided to CAL-CARE enrollees meeting federal and
state Medicaid eligibility requirements will be revised to be
consistent with the benefits in this report, with the following
supplemental services being provided to publicly sponsored
patients: long-term care, unlimited hospitalization, and durable
medical equipment. In addition, mental health services provided
through the Short-Doyle Medi-Cal Program will continue; mental
health fee-for-service CAL-CARE services will be restricted to
those offered via a basic benefit package.
Making these changes to the existing Medi-Cal schedule of benefits
will result in revenue available for the purpose of this program
of $80 million.
14
6.
Cost Containment Measures to Assure the Continued Affordability of
Health Care Coverage
A.
Fail safe affordability
Long-term and ongoing affordability of mandated coverage
costs to employees, employers and the state tax payer is
essential to the viability of this proposal. The proposal
makes a substantial amount of new dollars available to the
health care industry without imposing onerous regulatory
mechanisms. There are regulatory schemes such as payroll
taxes, or "pay or play" mechanisms that attempt to contain
costs by increasing government's role in the financing and
delivery of health care. If a comprehensive legislative
solution to the coverage of the uninsured is not enacted, it
is likely that such an approach will appear on the ballot in
the early 1990s. Absent adoption of significant regulatory
involvement on the part of state or federal government,
assurances must be made that the mandate does not result in
an unrestrained demand on resources. Therefore, a strong
incentive is needed to engender serious cost containment
efforts on the part of providers, insurers and business.
Beginning in the third year of program implementation, a
three-year rolling average of California's medical inflation
rate (M-CPI) will be compared to the overall California
Consumer Price Index (CPI). If the M-CPI exceeds the CPI one
of the following options should be adopted. Alternatively,
instead of using the M-CPI/CPI "trigger" an appointed
commission (e.g., CMAC) or elected official (e.g., Insurance
Commissioner) could make an annual determination on whether
the mandate continues to be affordable. A finding of
"unaffordability" would "trigger" one of the following
options.
Option A: Open CAL-CARE
The CAL-CARE Program will become available to any person or
entity wishing to purchase it. The existing Medi-Cal Program
has demonstrated the State's ability to contain program costs
and overall expenditures via rate setting mechanisms,
negotiated hospital rates, prior authorization and aggressive
utilization review, low administrative costs and automated
provider billing. CAL-CARE will continue to make use of
these features.
Option B: Eliminate Mandate
The mandate on employers would be repealed. This option
presupposes that a more stringent government-dominated system
would be implemented as an alternative to the mandate.
15
Option C: Establish Cost Limits For Employers
The employer mandate would be defined as a specific dollar
amount adjusted periodically. Employers would share this
cost. The benefit package would include whatever benefits
were chosen by employers and employees within the dollars
available to purchase coverage.
Option D: Fair Share Fee
A fee on the gross receipts of all benefactors of an
excessive medical inflation rate would be levied. The size
of the fee would be varied in relation to the excess of
medical inflation. Proceeds from the fee could be
redistributed to payers of health care costs or to the
subsidy system operated by the state for deserving businesses
and employees.
B. Underwriting changes to provide available and affordable
premiums:
A principal problem with an employer/employee mandate for
health insurance has been the disparity in cost in the health
insurance market. Under current rating and market conditions
two businesses of similar size in the same industry could
have differing costs under the mandate by a factor of 10 or
more depending on the health history of their employees and
dependents, and all with no guarantee of issuance or
renewability. Something clearly must change in the small
group insurance market before a mandate for health coverage
would be practical. The health insurance industry in
California has come forward with a proposal which makes
consideration of a mandate possible.
As with all proposals of substance, the California health
industry's proposal is not without controversy. Detractors
have forwarded a counterproposal that combines a Medicaid
buy-in concept with changes in the underwriting system not
too dissimilar from what is contained in this report. A
fundamental point of the detractors' proposal is that there
should not be a mandate. There are two problems with the
detractors' proposal. First, it assumes that businesses
individually will respond to the need for health insurance
for their employees. While it is true that most employers do
cover their employees, it ignores the recent trend for more
employees to be without coverage. This is largely a function
of affordability. The detractors assume that individual
employers will act counter to their economic interest. We
believe that it will take a collective effort represented by
the mandate to bring about the change necessary for an
alteration in the economy of health care coverage. Secondly,
the detractors' proposal advocates the expansion of Medicaid
16
as a purely government sponsored program for low-income
individuals. That does nothing to address the currently
existing problems in the Medicaid program, nor does it offer
an option for businesses which cannot afford to purchase
health insurance.
The California health insurance industry is making a genuine
effort to be part of the solution to the problem of the
uninsured. Policymakers look forward to the day when other
parties which are benefactors of a solution will be equally
as inclined to contribute to the solution. Consistent with
the proposal made by California's health insurance industry,
the report recommends:
-
Each carrier participating in the small group (25 or
fewer) market would be required to accept applications
for enrollment on a guaranteed issue/guaranteed
renewable basis, from any small group within the
carrier's service area seeking coverage unless the
carrier has a lack of delivery system capacity. Such
carriers would also have to cease enrolling new large
groups.
Different classes of carriers would have different
requirements:
-
"A" Carriers participate in the small group market
subject either to Federal HMO Act rating
restrictions, or state restrictions on rate
categories and a 30 percent rate band between
lowest and highest small group rates, with
adjustments. "A" carriers are not subject to
reinsurance assessments and may not cede expenses
to the reinsurer.
-
"B" Carriers participate in the small group market;
have broad flexibility in establishing rating
categories; may cede a large portion of the cost of
high risk small groups to the reinsurer which they
collectively finance through assessments; and may
not charge small group rates which exceed their
lowest small group rates by more than 40 percent,
with adjustments.
-
Carriers not writing small group coverage would be
required to pay reinsurance assessments where the
capacity of "B" carriers to pay those assessments
is exceeded or where a "B" carrier demonstrates
that an assessment will adversely impact its large
group rates.
17
C.
Universal pre-existing condition language
All insurance carriers doing business in the state will be
prohibited from imposing pre-existing condition exclusions of
longer than six months. Persons changing plans after six
months will be considered to have met the pre-existing
condition waiting period.
D.
Employee cost sharing via premium contributions, copayments,
and deductibles
-
Employees will be required to pay up to 25% of the cost
of premiums for individual coverage or up to 50% of the
premium cost for family coverage.
-
Copayments will be required for the basic plan as
follows:
-
$5 per primary care office visit; no copayment for
referral visits, preventive care, or maternity
care.
-
$2 per outpatient prescription for generic drugs.
-
$5 per outpatient prescription for brand name
drugs.
-
$50 for inpatient admission; no copayment for
maternity care, readmission for the same condition
within 90 days or for hospital outpatient (except
emergency) services.
-
$25 per emergency room visit; no copayment if
admitted to hospital (hospital copayment will
apply).
Deductibles will be permitted. Unaffordable deductibles
should be avoided.
E.
Reforms in tort law
The direct costs of malpractice are estimated at two percent
of total health care expenditures. This figure does not
include the costs of "defensive medicine" (i.e., ordering of
excessive or unnecessary tests). Efforts to reduce this cost
inflator include:
-
Require that plaintiff and defense counsel exercise
reasonable inquiry into the facts and the law before
taking legal action, including filing complaints.
Judges would have discretion to fine lawyers for lack of
reasonable inquiry.
-
Provide immunity to physicians who provide emergency
services to individuals with whom the physician has no
18
patient relationship and has no reasonable expectation
of compensation.
-
Clarify in statute that nothing prohibits any
carrier/insurer doing business in the state from
requiring mediation or arbitration prior to litigation
for covered services. This will be required in CAL-
CARE.
-
Assure that responsible third parties or their casualty
carriers reimburse health insurers for all injury-
related medical expenses. Participating California
health insurers will be assisted by the notice and lien
provisions similar to those now in effect for Medi-Cal.
F.
Develop data base to support management and evaluation of
health coverage
A provider specific data collection system (similar to the
hospital discharge data currently collected by OSHPD) will be
developed to assist payers in managing their health care
resources. Information could be collected from insurance
carriers or individual physicians.
G. Hospital employment of physicians
California is the only major state which prohibits hospitals
from employing physicians and charging patients for their
services. The Business and Professions Code should be
amended to permit any licensed health care corporation to
practice medicine. This change would allow:
Hospitals and skilled nursing facilities to employ
physician directors of patient care services to manage
the independent medical staff members of those services;
Full-time employed physicians having offices in or
adjacent to the hospital, being singularly loyal to that
hospital, to have their malpractice insurance premiums
paid at a much lower cost as part of the hospital's
liability coverage;
Corporate competition among hospitals to become more
intense in bidding for "Preferred Provider" designation
from insurance carriers and large business enterprises
endeavoring to maintain low premium costs.
An increasing number of private hospitals to participate
in staff model HMOs.
19
H. Allow PHPs serving CAL-CARE enrollees to use CMAC negotiated
hospital per diem rates
Those prepaid health plans which serve CAL-CARE enrollees
would be allowed to purchase hospital coverage using CMAC
negotiated rates for CAL-CARE enrollees, thereby benefitting
from the state's purchasing power. This change will help to
assure the financial viability of prepaid health plans and
encourage the expansion of managed health care arrangements
for CAL-CARE enrollees.
I.
Drug utilization review
The inappropriate use of prescription drugs is a significant
factor contributing to the cost of increasing health care
expenditures. In addition, the medical community has
expressed concerns regarding the adverse health impacts of
drug interactions and negative side effects. Outpatient
drugs are a part of the proposed minimum benefit plan.
Therefore, it may be appropriate to insist on drug
utilization review as a part of any health plan.
J. Reduce double coverage
The dollar value of the more costly coverage will be
considered to be employee income for those persons who
maintain double coverage, i.e., when both spouses receive
family coverage through their employers.
The above cost containment provisions should be pursued as a
matter of public policy, whether the resulting system includes an
employer mandate or not. Business has repeatedly cited the
spiraling cost of health insurance as the reason for not providing
coverage to their employees. These reforms are critical, not only
as an incentive for covering the four million unsponsored
employees and their dependents, but to prevent a further erosion
in the already inadequate coverage now in place.
20
7.
Federal Cooperation
Implementation of this plan requires a federal exemption be
granted to Employee Retirement Income Security Act (ERISA). The
exemption will be limited to the benefit plan included in this
proposal. Any changes to the mandated benefits will require
further Congressional and Presidential action.
Any program which avoids the issue of an ERISA waiver is not
viable. At present, the primary vehicle for avoiding an ERISA
waiver is a "play or pay" system where employers "voluntarily"
choose to directly provide coverage to employees and dependents
(play) or pay an additional "tax," with the public sector picking
up costs for providing coverage to unsponsored employees and
dependents.
It is difficult to consider such a system "voluntary" when the
option to not "playing" is to face a tax which is not levied on
employers who do provide coverage. Determining the correct rate
for the "pay" option is difficult because by definition one could
assume that over time, only those employers whose actual costs are
less than the pay option would opt to play. This would create an
environment where the publicly funded portion of the program would
constantly be underfunded, resulting in the need for constant
funding adjustments.
Additionally, changes to California's Medicaid state plan and
implementing state statutes will be needed to conform the current
Medi-Cal scope of benefits to the mandated benefit package and to
require mandatory mediation for all persons enrolled in the CAL-
CARE Program.
21
8.
Funding
It is assumed that currently existing obligations will be
redirected to fund any program changes which will be required.
The sources are as follows:
The existing tax credit authorized under SB 1207 (Chapter
797, Statutes of 1989) scheduled to become operative on
January 1, 1992. Current estimates are that this statute
will result in a tax expenditure of $1.1 billion.
Additional funds will become available through redirection of
the existing county provided "safety net." As individuals
who currently receive health services through the county
provided "safety net" are converted to health insurance, some
proportion of the resources will become available for this
proposal. The maximum available would be half of the state
funds now expended for local medically indigent programs.
This amount is approximately $700 million.
Additional federal funds will be available as a result of the
Medi-Cal rate adjustments and through any federal
participation for those family units which are covered
through insurance and who are determined to be eligible for
CAL-CARE. The total is at least $320 million.
$80 million will become available as the existing Medi-Cal
benefit schedule is adjusted to reflect the mandated schedule
of benefits contained in this proposal.
This information is summarized in Chart 2, attached.
22
CHART 1: FEDERAL POVERTY LEVEL INDEX
1989
Size of Family
100% FPL
200% FPL
300% FPL
(adults & Children)
1 person
$ 5,980
$ 11,960
$17,940
2 people
8,020
16,040
24,060
3 people
10,060
20,120
30,180
4 people
12,100
24,200
36,300
5 people
14,140
28,280
42,420
6 people
16,180
32,360
48,540
7 people
18,220
36,440
54,660
8 people
20,260
40,520
60,780
for each add'l person, :
2,040
4,080
6,120
23
Chart 2: Resource Allocation
Available Funds ($ in millions)
$1,100
Tax expenditure value of existing SB 1207 tax credit
0 - - 700
Redirection of existing local medically indigent program
funds
80
Savings from M/C benefit conformity
320
New federal funds for M/C rate increase
$1,500 - 2,200
Proposed Expenditures ($ in millions)
$860 - 1,560 Employer and employee subsidies and revised SB 1207 tax
credit
640
M/C Rate Increase
$1,500 - 2,200
24
Basic Benefits to Cover Essential Health Care Needs
The mandated basic benefit package could include:
a.
Hospital inpatient care for a period of at least 30 days of
hospitalization in a hospital licensed pursuant to
subdivision (a) of Section 1250 of the Health and Safety Code
in each calendar year, including all of the following:
1.
Semi-private room and board, including meals; private
room and special diets when prescribed as medically
necessary; and general nursing services.
2.
Hospital services, including use of operating room and
related facilities, intensive care unit and services,
labor and delivery room; anesthesia; radiology,
laboratory and other diagnostic services.
3.
Drugs and medications administered while an inpatient.
4. Dressings; casts; equipment; oxygen services; and
radiation therapy.
5.
Inhalation therapy following prior authorization.
b.
Medical and surgical services, which shall be provided on an
out-patient basis when medically appropriate, including all
of the following:
1.
Surgical services performed by a physician and surgeon
licensed pursuant to Chapter 5 of Division 2 of the
Business and Professions Code or the Osteopathic
Initiative Act, or by a podiatrist within his or her
scope of practice.
2.
Radiology, nuclear medicine, ultrasound, laboratory and
other diagnostic services.
3.
Dressings, casts and use of castroom; anesthesia and
oxygen services when medically necessary.
4.
Blood derivatives and their administration, and whole
blood when a volunteer blood program is not available to
the enrollee.
5.
Home, office, and hospital visits by a physician and
surgeon licensed pursuant to Chapter 5 of Division 2 of
the Business and Professions Code or the Osteopathic
Initiative Act, or by a podiatrist within his or her
scope of practice.
25
6.
Radiation therapy; chemotherapy of proven benefit.
7.
Preventive services for health maintenance of minors,
including well-child examinations, health evaluations,
physical examinations for early detection and diagnosis
of disease or other conditions, and immunizations and
vaccinations in accordance with the Guidelines for
Health Supervision of Children and Youth as adopted by
the American Academy of Pediatrics in September 1987.
8. Medical and surgical consultation by a physician and
surgeon licensed pursuant to Chapter 5 of Division 2 of
the Business and Professions Code or the Osteopathic
Initiative Act, or by a podiatrist within his or her
scope of practice.
9.
Sterilization.
10. Nothing in this section shall preclude the use of
advance practice nurses in providing covered services.
C.
Comprehensive maternity and perinatal care, including the
services of a physician and surgeon licensed pursuant to
Chapter 5 of Division 2 of the Business and Professions Code
or the Osteopathic Initiative Act all necessary hospital
services. Nothing in this section shall preclude the use of
advance practice nurses in providing covered services.
d. Emergency care, including emergency ambulance transportation.
e. One hundred days of skilled nursing, and home health care
benefits limited to skilled home nursing services provided on
a part-time, intermittent basis as prescribed by the
patient's physician.
f.
Hospice services.
g.
Plastic and reconstructive services limited to the following:
1.
To correct a physical functional disorder resulting form
a congenital disease or anomaly;
2.
To correct a physical functional disorder following an
injury or incidental to surgery covered by the basic
health care coverage;
3.
For reconstructive surgery and associated procedures
following a mastectomy which resulted from disease,
illness or injury. Internal breast prostheses required
incidental to the surgery will be provided.
26
h.
Preventive care including periodic routine physical exams and
proven preventive procedures and screenings for well-children
in accordance with the Guidelines for Health Supervision of
Children and Youth as adopted by the American Academy of
Pediatrics in September 1987, when prescribed by a physician
and surgeon licensed pursuant to Chapter 5 of Division 2 of
the Business and Professions Code or the Osteopathic
Initiative Act.
i.
Mental health benefits, including all of the following:
1. Inpatient care or acute residential care for a period of
at least 10 days in each calendar year.
2. At least 15 outpatient visits in each calendar year.
j. Prescription drugs, limited to drugs approved by the federal
Food and Drug Administration for approved indications,
generic equivalents listed as substitutable in the federal
Food and Drug Administration publication, "Approved Drug
Products With Therapeutic Equivalence Evaluation."
Plans may impose cost containment measures such as use of
generics or a formulary on this service.
k. At least 10 outpatient visits in each calendar year for
speech, occupational and/or physical therapy.
1. Preventive child dental services.
SERVICES NOT REQUIRED AS PART OF MANDATE: The following services will
not be required as part of mandated basic benefits. Coverage of such
services will remain subject to labor negotiations, individual choice, or
the out-of-pocket responsibility of individuals.
a. Services which are not medically necessary for the diagnosis,
treatment or prevention of injury or illness, or to improve
the functioning of a malformed body member, even though such
services are not specifically listed as exclusions;
b. Any services which are received prior to the enrollee's
effective date of coverage;
C. Custodial, domiciliary care, or rest cures for which
facilities of an acute care general hospital are not
medically required. Custodial care is care that does not
require the regular services of trained medical or allied
health professionals and that is designed primarily to assist
in activities of daily living. Custodial care includes, but
is not limited to, help in walking, getting in and out of
27
bed, bathing, dressing, preparation and feeding of special
diets, and supervision of medications which are ordinarily
self-administered;
d. Personal or comfort items, or a private room in a hospital
unless medically necessary;
e.
Emergency facility services for non-emergency conditions;
f. Medical, surgical (including implants and transplants), or
other health care procedures, services, drugs or devices
which are either: 1) not recognized in accord with generally
accepted medical standards as being safe and effective for
use in the treatment in question, or 2) outmoded, not
efficacious or not sufficiently cost effective to be covered
by the basic benefit package.
g. Transportation except as specified in subdivision (d) of
listed benefits.
h. Implants, except pacemakers, intraocular lenses, and
artificial hips.
i. Any transplants and directly associated services for the
patient and donor, including, but not limited to, organ, bone
marrow, skin and cornea;
J. Prescription and non-prescription drugs, except those
provided as an in-patient hospital benefit and as specified
in subdivision (j) of listed benefits. Any exclusion of
drugs and medicines also excludes their administration;
k. Sex change operations; investigation of or treatment for
infertility; reversal of sterilization; conception by
artificial means; and contraceptive supplies and devices;
1.
Eyeglasses, contact lenses (except the first intraocular lens
following cataract surgery); routine eye examinations,
including eye refractions, except provided as part of a
routine examination under "preventive care;" hearing aids;
orthopedic shoes; orthodontic appliances; and routine foot
care;
m. Speech, occupational and physical therapy except as specified
in subdivision (k) of listed benefits;
n. Durable medical equipment including, but not limited to,
hospital beds, wheelchairs, walk-aids, or other medical
equipment and supplies not specifically listed in the
schedule of benefits, except while in the hospital;
28
O. Dental services and services for temporomandibular joint
problems, except as specified in subdivision (1) of listed
benefits and for repair necessitated by accidental injury to
sound natural teeth or jaw, provided such repair commences
within 90 days of the accidental injury or as soon thereafter
as is medically feasible and provided the enrollee is
eligible for covered services at the time that services are
provided.
p. Mental health services except as specified in subdivision (i)
of listed benefits.
q. Treatment of chemical dependency, except for acute in-patient
detoxification.
r. Obesity treatment; weight loss programs.
S. Cosmetic surgery, including treatment for complications of
cosmetic surgery, except as specifically provided in
subdivision (g) of listed benefits.
t. Medical services received from or paid for by the Veterans'
Administration; benefits to the extent that benefits are
payable under the terms of any automobile medical, automobile
no-fault or liability, under-insured or uninsured motorist or
similar contract of insurance; benefits paid under the
Workers' Compensation Act or any employers' liability law or
federal law for the injury or illness.
u. Conditions resulting from acts of war (declared or not);
V. Any service or supply not specifically listed as a covered
service.
This benefit package is not to be construed to prohibit a
carrier's ability to impose cost control mechanisms such as prior
authorization.
29
feb
RECOMMENDATIONS TO THE CONGRESS
BY
THE PEPPER COMMISSION
U.S. BIPARTISAN COMMISSION ON COMPREHENSIVE
HEALTH CARE
"Access to Health Care and Long-Term Care for All Americans"
March 2, 1990
Summary: Recommendations on Access to Health Care
THE PEPPER COMMISSION PROPOSAL ASSURES UNIVERSAL HEALTH CARE COVERAGE
FOR ALL AMERICANS THROUGH A JOB-BASED/PUBLIC SYSTEM.
1.
Businesses with 100 or fewer employees are encouraged to provide
health insurance for their employees and non-working dependents.
*
To make insurance more available and affordable:
-- The private insurance market is reformed.
--
A minimum package is available.
--
Tax credits/subsidies for certain small employers are
available.
--
Self-employed and unincorporated businesses can deduct
100% of their premiums.
*
If employers purchase coverage and achieve a specified
coverage target, there is no requirement to provide private
insurance or participate in the federal public health
insurance plan ("public plan").
2.
All businesses with more than 100 employees must provide private
health insurance (for a specified benefit package) or contribute
to the public plan for all employees and non-working dependents.
3.
The public plan will cover employees and dependents that
contribute and non-working individuals who buy in or are
subsidized.
*
The plan replaces Medicaid for the specified services and
pays providers according to Medicare rules.
*
The fully phased-in plan is financed and administered
primarily by the federal government, although states can opt
to administer it.
4.
The minimum benefit package includes primary and preventive
care, physician and hospital care and other services. Services
are subject to cost-sharing, with subsidies for low-income people
and limits on out-of-pocket spending.
5.
System reforms include measures to contain costs, assure quality
and initiate innovative delivery systems for the underserved.
6.
For both administrative and fiscal reasons, the plan will be
phased in, beginning with making coverage available for children
through the public plan.
7.
At full implementation, all Americans will be required to have
health insurance through their employer or the public plan.
1
Phase-In Schedule and Cost of the Commission Health Care Proposal
(Dollars are in Billions, 1990)
Year 1
O
Initiate Insurance Reforms.
O
Allow all uninsured pregnant woman and children through age 6, to
enroll in the public plan (fully subsidized to 185 percent of
poverty).
O
Raise Medicaid reimbursement rates for obstetrical and pediatric
care.
Total Net New Federal Cost:
$3.4
% of Americans Without Health Insurance:
14%
Year 2
O
Firms with fewer than 25 employees and average payrolls below
$18,000 become eligible to receive a 40% tax credit/subsidy for
the cost of health insurance that is provided. Employees of
these firms with family income of less than 200 percent of
poverty receive a subsidy.
O
Public plan is available to uninsured children up to age 18.
O
Improve physician reimbursement.
Total Net New Federal Costs:
$13.5-16.8
Additional Cost from Year 1:
$10.1-13.4
% of Americans Without Health Insurance:
8%-11%*
Year 3
O
Firms with 100 or more employees are required to provide health
insurance or contribute a portion of payroll to cover employees
and dependents in the public plan.
Total Net New Federal Costs:
$17-20.3
Additional Cost from Year 2:
$3.5
% of Americans Without Health Insurance:
6%-8%*
Year 4
O
If 80% of uninsured employees of firms with 25-100 employees (as
of year 1) are not insured through their employers, along with
their dependents, all employers of this size are required to
provide coverage or contribute toward the cost of their coverage
in the public plan.
O
Raise Medicaid hospital reimbursement rates.
Total Net New Federal Costs:
$19.8 - 23.1
Additional Cost from Year 3:
$2.8
% of Americans Without Health Insurance:
5%-7%*
2
Year 5
O
If 80% of uninsured employees of firms with fewer than 25
employees (as of year 1) are not insured through their
employers, all employers of this size are required to provide
coverage or contribute toward the cost of their coverage in the
public plan.
O
Allow all uninsured adults into the public plan.
O
Retain subsidy to small firms with low wage employees.
Total Net New Federal Costs:
$31.8
Additional Cost from Year 4:
$11.8
% of Americans Without Health Insurance:
0%**
Year 6
O
Retain subsidy to small firms with low wage employees and their
employees.
Total Net New Federal Costs:
$31.8
Additional Cost from Year 5:
$0
Year 7
O
Eliminate explicit subsidy to small firms with low wage workers
and their employees.
Total Net New Federal Costs:
$23.4
Additional Cost from Year 6:
($8.4)
* Depends on how many smaller firms voluntarily choose to purchase
health insurance.
** If 80 percent of uninsured workers and their dependents in firms of
fewer than 25 are now insured the Secretary of Health and Human
Services must submit to Congress a plan to insure any remaining
uninsured. If employers with fewer than 25 do not meet this target,
then the imposition of a requirement to cover all workers and their
dependents or contribute to a public plan will ensure that all
Americans now have health insurance.
3
Summary: Recommendations on Long-Term Care
THE PEPPER COMMISSION PROPOSAL PROVIDES HOME AND COMMUNITY-BASED LONG-
TERM CARE SERVICES AND PROTECTION AGAINST IMPOVERISHMENT FOR PEOPLE IN
NURSING HOMES.
1.
The plan has three components.
*
Severely disabled persons of all ages are eligible for
social insurance for home and community-based care.
*
The plan establishes a Nursing Home Program (NHP) for
nursing home care to provide an ample floor of financial
protection, ensuring that no one faces impoverishment.
*
In addition, all nursing home users are entitled to social
insurance for the first three months of nursing home care.
This "front-end" insurance allows people who have short
stays to return home with resources intact.
2.
Financing and administration
*
The federal government finances the home and community-based
care program and the three-month "front-end" nursing home
care.
The federal and state governments share financial
responsibility for the NHP.
All three components of the plan are administered by the
states according to federal guidelines.
States are responsible for cost containment, quality
assurance and consumer protection within federal standards.
3.
Private sector role
*
Private long-term care insurance fills gaps not covered by
this plan, subject to government standards and oversight.
*
The federal government encourages the development of
private long-term care insurance through clarification of
the tax code.
4.
The benefits will be phased in over time.
5
Phase-In Schedule and Cost of Commission Long-Term Care Proposal
(Dollars are in Billions, 1990)
Phase I
O
Home Care to 200 hours per year
Home Care
$10.8
Nursing Home Care
$ 0.0
Total Costs Phase I
$10.8
Phase II
O
Implement 3 Month Front-end Nursing Home
O
Implement Nursing Home Program
Home Care
$10.8
Nursing Home Care
$12.8
Net Increase From Phase I
$12.8
Total Costs Phase II
$23.6
Phase III
O
Increase Home Care to 400 hours per year
O
Begin to Improve Nursing Home Reimbursement Rates
Home Care
$18.6
Nursing Home Care
$15.6
Net Increase From Phase II
$10.6
Total Costs Phase III
$34.2
Phase IV (Year 4)
O
Fully Implement the Home Care Program
O
Further Improve Nursing Home Reimbursement Rates
Home Care
$24.0
Nursing Home Care
$18.8
Net Increase from Phase III
$8.6
Total Costs Phase IV
$42.8
6
Net New Federal Costs of the Commission Proposal
(Billions of Dollars, 1990)
SOURCE OF EXPENDITURE
Access to Health Care
Public health insurance of
non-workers
$12.4
Federal Contribution to the
public plan
6.3
Tax Expenditure
6.7
Augmented Medicaid Physician
and Hospital Payments
4.0
Less savings from Medicare, CHAMPUS, Medicaid
(6.0)
Sub-Total (Access to Health Care)
$23.4*
Access to Long-Term Care
Home Health Care for the Severely
Disabled Elderly (includes cost-sharing)
15.0
Home Health Care for the Severely
Disabled Non-Elderly (includes cost-sharing)
9.0
Nursing Home Care for the Severely Disabled Elderly
16.8
Nursing Home Care for the Severely Disabled
Non-Elderly
2.0
Sub-Total (Access to Long-Term Care)
$42.8
Total Net New Federal Expenditures
$66.2**
*Phase-in plan includes the cost of temporary tax
credits/subsidies for certain small businesses. Those costs are
not reflected in these totals, which represent the cost at full
implementation.
**Program costs are larger than the net new federal expenditures.
On health care, states maintain Medicaid spending on services
absorbed by the new public plan. On long-term care, states share
in the cost of the Nursing Home Program with initial amounts
equivalent to state Medicaid spending on long-term care services
covered by the overall plan.
7
8
PEPPER COMMISSION RECOMMENDATIONS ON ACCESS TO HEALTH CARE
Structure of Job-Based/Federal Public Health Insurance Plan
1.
Employer Responsibilities (in businesses with more than 100
employees and smaller businesses only if a specified coverage
target is not met) :
*
All businesses are required to provide private health
insurance for at least the specified benefit package to all
employees (and non-working dependents) or contribute to the
public plan on their behalf.
If employers choose to provide private insurance, they must
pay at least 80% of the premium for full-time workers and
their non-working dependents and a share of the premium for
part-time workers and their non-working dependents.
Alternatively, employers may contribute to the public plan
for coverage for their employees and non-working dependents.
The contribution will be equal to a percentage of payroll.
The percentage will be set at a level that encourages
employers who now purchase private insurance to retain that
coverage and establish a fair balance of additional coverage
responsibilities between the private and public sectors.
Employers may choose to purchase private insurance for their
full-time workers and contribute to the public plan for
part-time workers.
2.
Individual responsibilities
*
All workers receive the specified benefit package through
their own employer, although they may receive extra benefits
from their spouse's employer. Rules, consistent with tax
policy, determine the plan to which children are assigned.
Individuals pay up to 20% of the premium for private
insurance.
To participate in the public plan, individuals who are
working pay a percentage of wages as their share of the
premium. Self-employed and non-working individuals pay the
cost of the plan, subject to their ability to pay. People
with incomes below 100% of poverty pay nothing and no one
with an income below 200% of poverty would pay more than
three per cent of income for the premium for adults or one
percent of income for the premium for children and pregnant
women.
*
For low income people, whether covered by the public plan or
private insurance, premiums and cost-sharing are subsidized
by the federal government. Individuals or families whose
income is under 100% of the federal poverty level pay no
premiums, deductibles or coinsurance. Individuals or
families whose income is up to 200% of poverty at a minimum
will pay premiums, deductibles and coinsurance on a sliding
scale.
9
*
At full implementation, individuals must obtain health
insurance through their employer or the public plan.
3.
Public Plan
*
At full implementation, the public plan is financed and
administered primarily by the federal government. As under
Medicare, insurers may administer claims and may, under
contract, offer managed care options. States also may
administer claims.
*
The public plan pays providers for the specified services
with rates set according to the rules of the Medicare
program.
*
The public plan subsumes Medicaid for the specified
benefits. Medicaid remains intact for all services not
covered by the package.
*
Participation in the public plan is financed through:
-- employer contributions
-- individual contributions
-- federal revenues
-- state contributions equal to Medicaid expenditures for
covered services, adjusted for general inflation
4.
State Role
*
State governments no longer have responsibility for
providing the specified benefit package for their low income
residents. The new public plan replaces Medicaid for those
services. Medicaid is retained for services not included in
the package.
*
States contribute to the public program as specified above.
A state, at its option and subject to federal rules, can
administer the public plan. All aspects of the
administration must be conducted through a new agency which
is unconnected to the welfare or Medicaid departments.
*
States retain the responsibility for regulating financial
stability of insurers.
5.
Specified Benefit Package
*
Basic services including hospital and surgical services,
physician services, diagnostic tests and limited mental
health services (45 inpatient days and 25 outpatient
visits).
*
Preventive services including prenatal care, well-child
care, mammograms, pap smears, colorectal and prostate cancer
screening procedures and other preventive services that
evidence shows are effective relative to cost.
10
*
Early, periodic, screening, diagnosis and treatment services
(EPSDT) are included for children in the public program.
Privately insured families can buy this coverage for their
children from the public plan at cost (or at a subsidized
rate for families under 200% of poverty).
Deductibles are $250 for an individual and $500 for a
family. Coinsurance is 20% for all services except prenatal
care, well-child care, mammograms and pap smears, which have
no coinsurance, and limited mental health services which
have 50% coinsurance. The maximum a person or family must
spend out of pocket is $3,000 in a year.
One year after the effective date of this plan, the Office
of Technology Assessment shall report to the Secretary on an
assessment of the cost-effectiveness of prescription drugs
for the purpose of inclusion in the benefit package as a
preventive service.
Assistance for Small Business
1.
Insurance reforms and a minimum benefit package will make
obtaining private insurance for small groups more predictable and
affordable. (See below.)
2.
To stimulate voluntary coverage, employers with fewer than 25
workers and average payroll below $18,000 will be eligible for
tax credits/subsidies for 40% of the cost of health insurance for
workers and their dependents. After the tax credit/subsidy for
employers of ten employees or less ends, businesses of ten
employees or less, previously eligible for the credit, who are at
extreme financial risk would be allowed to purchase coverage from
the public plan at a percentage of payroll. This specific
percentage of payroll would be consistently set at a relatively
low rate to ensure affordability.
3.
No employer with fewer than 100 workers would be required to
purchase coverage or contribute to the cost of coverage if
coverage targets were met voluntarily. (See phase-in schedule
for details.)
Insurance Market Reform
1.
For all employment-based health insurance:
*
No pre-existing conditions exclusions.
*
No denial of coverage for any individual in the group.
2.
For those who wish to sell a health insurance product to
employers in the small group market new rules would apply:
*
Guaranteed acceptance of all groups wishing to purchase
insurance.
Insurers would set rates on the same terms to all groups in
specified areas.
11
*
Rates may not be increased selectively for any group
enrolled in a plan.
Enrollment would be for a specified minimum period.
States would be restricted from regulating the content of
health insurance benefits, but benefits would be
standardized, to the extent possible, across carriers. At
least one basic benefit package would have to be offered by
each insurer in the small group market.
Managed care plans would be required to be offered to small
groups if such plans are available to larger employers in
the area.
A self-financed voluntary reinsurance mechanism through
which insurers could reinsure high-risk persons or groups
would be established.
Quality Assurance
1. The federal government should develop and implement a
comprehensive national system of quality assurance which
includes:
*
The development of national practice guidelines and
standards of care, already begun by the newly created Agency
for Health Care Policy and Research. Physicians and
physician organizations should be widely utilized in
establishing and reviewing practice guidelines and standards
of care.
The development and implementation of a uniform data system
that covers all health care encounters, regardless of
payment source or setting. These data would provide a common
foundation for all payers' quality assessment activities and
for examining the effectiveness of medical care and
identifying health policy and research concerns.
The development and testing of new, more effective methods
of quality assurance and assessment.
The development and oversight of local review organizations
that have skills in data integration and analysis, quality
assessment and quality assurance.
2.
The appropriate committees of jurisdiction in Congress should
hold hearings on the malpractice issue. The Prospective Payment
Assessment Commission and the Physician Payment Review Commission
will be directed to review costs under the new program. The cost
containment commission described below will convene experts,
providers, lawyers and consumers to study and conduct
demonstration projects related to medical malpractice reform in
order to make recommendations to Congress on actions to be taken
on the federal level.
12
Cost Containment Initiatives
1.
Insuring all Americans through a job-based/public program and
reforming the private insurance market will distribute the costs
of insurance more fairly by:
*
Reducing the cost-shift that now occurs from the uninsured
to the insured population.
Reducing the cost-shift that now occurs from employers who
do not provide insurance to employers who cover their
workers and dependents.
Assuring small business access to a minimum benefit package
at predictable rates, regardless of employees' health
status.
2.
Adoption of a quality assurance strategy (described above) and
reform of the medical malpractice system will assure greater
value for the dollar in the delivery of medical services.
3.
Measures to promote efficiency in provider payment would include:
*
Cost-sharing in the minimum benefit package
that makes consumers sensitive to price.
*
Insurance reform that leads insurers to compete around
efficient service delivery, rather than competing for "good"
risks.
Extending "managed care" to small employers and including
"managed care" as a means to provide the minimum benefit
package in private insurance and the public plan.
Extending Medicare payment rules to the public program,
which, in turn, serves as a model for private insurance.
Recommending that the appropriate committees of jurisdiction
in Congress hold hearings on the costs associated with
medical malpractice liability, that the Prospective Payment
Assessment Commission and the Physician Payment Review
Commission review costs under the program proposed by the
Commission and that a National Cost Containment Commission,
made up 'of experts, public and private payers, providers
and consumers, be created to assess cost experience and
initiatives to contain costs in the public and private
sectors and to make periodic recommendations to the Congress
on federal initiatives.
Delivery Issues
1.
Expanding health care insurance coverage should reinforce --not
replace -- support for primary care delivery systems targeted at
the poor and underserved. Organized primary care providers
(e.g., local health departments and community health centers)
should be recognized and reimbursed by private and public payors
on the same basis as all other providers.
13
2.
The federal government should:
*
Promote an adequate supply and appropriate mix of personnel
and facilities for underserved areas and populations through
mechanisms including:
-- Provider payment methods in public programs that
promote the availability of primary care practitioners
and facilities and assure access to other needed
services;
-- Special initiatives (such as the National Health
Service Corps and other financial incentives) to
attract a range of providers (physicians and other
practitioners) to underserved areas, and to assist such
providers through mechanisms such as professional
backup systems and support networks for rural providers
(e.g., telecommunications with other professionals and
facilities, mobile medical services).
*
Support local efforts to develop outreach and facilitating
services, for example, health education, transportation,
home visiting, and translation services -- preferably linked
to health care delivery programs -- to facilitate access to
services and to encourage patients to seek and continue
participation in health care.
*
Support local efforts to reduce organizational and
bureaucratic barriers to access through efforts such as the
coordination and/or co-location of medical, welfare and
social services (e.g., medical referrals, nutrition
counseling and eligibility determinations for welfare and
housing programs).
Undertake and support research and evaluation efforts to
determine the effectiveness of primary care models and
services aimed at addressing the needs of underserved
communities.
*
Support programs of health promotion, disease prevention,
risk reduction and health education toward the reduction of
excess morbidity and mortality and toward the increase of
healthy lifestyles. Federal support for such programs
should total at least $1 billion annually beyond current
federal efforts.
*
Support an effective continuum of care, including short-term
hospital-based and/or longer-term community based alcoholism
and other drug treatment services.
Phase-In Schedule
Phase I (Year 1)
*
Institute insurance reform.
14
*
Allow all uninsured pregnant women, and children ages 0-6,
to enroll in public plan, if they are from non-working
families or in families of workers whose employers do not
provide coverage. Costs would be subsidized, according to
ability to pay, at least for those with family incomes below
200% of poverty.
*
Begin to improve reimbursement to providers for persons now
served by Medicaid.
Phase II (Year 2)
*
Firms with 0-25 workers and average payrolls below $18,000
become eligible to receive a 40% tax credit/subsidy for cost
of coverage if they provide it. The subsidy would be
available for five years.
*
The public plan is made available to uninsured children up
to age 18 (those from non-working families or families where
workers' employers do not offer coverage). Subsidies would
be available based on ability to pay, at least for those
with family incomes below 200% of poverty.
Phase III (Year 3)
*
Firms with 100 or more workers are required to provide
private insurance coverage or contribute a portion of
payroll toward the cost of covering employees and dependents
in the public plan.
Phase IV (Year 4)
*
If 80% of uninsured employees of firms with 25-100 workers
(as of Year 1) are not insured through their employers,
along with their dependents, all employers of this size are
required to provide private insurance coverage or contribute
toward the cost of their coverage in the public plan.
*
If coverage target is met, the Secretary of Health and Human
Services is required to recommend to Congress ways to cover
those still left out.
Phase V (Year 5)
*
If 80% of uninsured employees of firms with 0-25 workers (as
of Year 1) are not insured through their employers, all
employers of this size are required to provide coverage or
contribute toward the cost of their coverage in the public
plan.
*
If coverage target is met, the Secretary of Health and Human
Services is required to recommend to Congress ways to
increase coverage options for employees (and their non-
working dependents) who are not covered by their employers.
*
All non-working adults are covered through the public plan.
15
Phase VI (Year 6)
*
Congress considers the Secretary's recommendations.
*
All individuals are required to have insurance coverage
through their employers or through the public plan.
Revenues for Health Care
A.
Although some of the revenues necessary to support the above
recommendations could come from savings achieved elsewhere in the
federal budget, the Commission is committed to raising whatever
additional revenues are necessary.
B.
In considering what revenue options to adopt, the Commission
recommends that the choice be guided by the following three
criteria:
1.
The final tax package ought to be progressive, requiring a
higher contribution from those most able to bear increased
tax burdens. That is, families with higher incomes would be
asked to contribute a greater share of their incomes than
required of lower income families.
2.
Since persons of all ages would benefit, persons of all ages
should contribute to financing the recommendations.
3.
Revenues chosen should grow fast enough to keep up with
benefit growth so that new sources of revenue will not need
to be enacted over time. Rates of growth would need to be
in excess of 8% to 9% per year.
C.
Various combinations of revenue sources may be used that together
meet these criteria even if individual tax sources may fall short
in one category.
16
PEPPER COMMISSION RECOMMENDATIONS ON LONG-TERM CARE
Structure of the Plan
1.
Social Insurance for Home and Community-based Care
*
Severely disabled individuals of all ages are eligible for
this program. This includes individuals who need hands-on
or supervisory assistance with three out of five ADL's
(Activities of Daily Living) (eating, transferring,
toileting, dressing, bathing), or who are severely
cognitively impaired.
*
Eligibility is determined by a state/local government or
federally-funded non-profit assessment agency using
standardized assessment criteria. This agency conducts
annual audits of case managers (described below) and
monitors the quality of care.
*
Case managers determine the number of hours of care and mix
of services the beneficiary receives.
-- The case manager develops an individual care plan
tailored to needs of the beneficiary. The availability
of informal supports is included in the decision to
allocate resources.
-- The case manager operates within a budget set by the
federal government, and conducts periodic reassessments
of the beneficiary with special consideration to be
given to cost containment. The case manager budget,
in conjunction with other available services, will be
sufficient to provide all services, needed by the
patient.
*
The benefits include:
-- Home health care
-- Physical, occupational, speech and other appropriate
therapy services.
--
Personal care services (feeding, transferring, personal
hygiene)
--
Homemaker chore services (meal preparation, laundry,
housework)
--
Grocery shopping and transportation
--
Medication management
--
Adult day health and social day care
Respite care for caregivers
--
Cost-effective training of family members for delivery
of home-based family care, and support counseling of
family caregivers.
17
2.
Nursing Home Program (NHP)
*
Individuals of all ages who are determined eligible for
nursing home care by a federally certified assessment agency
are covered by this program for the entire length of their
stay.
*
The plan treats income and assets as follows:
--
The plan protects $30,000 in non-housing assets for
single individuals and $60,000 for couples.
--
The plan provides a housing allowance equal to 30% of
monthly income for the first year of a nursing home
stay for single persons and, for married persons, as
long as the spouse is alive, but at least a year.
--
The plan provides a $100/month personal needs
allowance.
-- The plan provides income protection for the spouse
living in the community up to 200% of the poverty level
for a couple.
-- Any remaining income goes toward the cost of the
nursing home care.
3.
Three-Month Front-end Coverage: Protection to Return Home
*
All nursing home users are covered for the first three
months of care with full protection for their income and
assets, except for a modest copayment.
*
Benefits include:
--
Skilled nursing care
-- Custodial care
Individual Role
1.
Home and Community-based Care
*
Individuals pay 20% of the costs of care up to a maximum of
the national average cost of home and community-based care.
*
The federal government subsidizes the coinsurance at least
for persons with incomes below 200% of the federal poverty
level.
2.
Nursing Home Program
*
Individuals contribute their income toward the cost of care
minus the housing and personal needs allowances.
*
Individuals contribute non-housing assets above $30,000 for
single persons and $60,000 for married persons.
18
3.
Three-month "Front-end" Nursing Home Care
*
Individuals pay 20% of the costs of care up to a maximum of
the national average cost of nursing home care.
The federal government subsidizes the coinsurance at least
for persons with incomes below 200% of the federal poverty
level.
Financing
1.
The federal government is responsible for the home and
community-based care program and the three-month "front-end"
nursing home care program.
2.
The federal and state governments share the financial
responsibility for the NHP.
Administration
1.
The federal government contracts with states to administer all
three components of the plan.
2.
The federal government sets standards and guidelines for
administration. These include the following:
*
Standardized assessment criteria for determining
eligibility for home and community-based care and nursing
home care.
Certification of assessment agencies.
Guidelines for certifying case managers.
Determination of case manager budgets.
Determination of provider payment rates for home and
community-based care and nursing home care.
3.
State administrative functions include the following:
*
Building on the current infrastructure for management and
delivery of services, where long-term care programs already
exist.
*
Designing and implementing the system for managing and
delivering services, in states without existing programs.
*
Certifying providers.
*
Establishing the review and appeals process.
Private Sector Role
1.
Private long-term care insurance fills gaps not covered by this
plan.
19
2.
The federal government encourages the deveropment private
long-term care insurance through clarification of the tax code.
This includes:
*
Treating, for tax purposes, the premiums paid and the
benefits received as health insurance.
*
Enabling qualified long-term care policies to be sold in
employers' cafeteria plans.
3.
The federal and state governments share responsibility for
standards and oversight of the private long-term care market.
*
The federal government establishes minimum standards which
private long-term care policies must meet to be eligible for
the tax clarification. It establishes methods of
disseminating to consumers non-biased, professional
information regarding private long-term care policies.
*
States regulate private long-term care insurance, using
federal or stricter standards. The federal government will
encourage states to strengthen civil penalties for
misrepresenting policy standards, knowingly selling
duplicative insurance or marketing unapproved policies by
direct mail. In addition, states should train benefits
specialists regarding private long-term care insurance and
the availability of state information on that insurance.
Phase-In Schedule
Phase I
*
A maximum of 200 hours of home care per year is made
available to all severely disabled persons.
Phase II
*
The three-month "front-end" nursing home care benefit is
made available to all eligible nursing home users.
*
The nursing home program is implemented providing income and
asset protection for all eligible nursing home users.
Phase III
*
The maximum hours of home care available per year is
increased to 400.
*
Begin to improve nursing home reimbursement rates.
Phase IV
*
The home care program is fully implemented.
*
Further improve nursing home reimbursement rates.
20
Research Agenda for Long-Term Care
1.
The federal government should move aggressively to contain costs
and mitigate human suffering by funding a research and
development program aimed at preventing, delaying and dealing
with long-term illnesses and disabilities. This effort should
include research on outcome measures and national practice
guidelines in long-term care. That effort should move toward a
funding level of $1 billion annually and should do the following:
*
Explore how to reduce the risk for certain physical and
mental disorders (e.g, Alzheimer's disease, osteoporosis,
breast cancer, urinary incontinence) that are associated
with increased need for long-term care
Examine how to enhance the quality of long-term care
including the integration of services and case management.
Improve functional assessment tools to best target services
to populations in need of care
Examine the special long-term care problems of
subpopulations such as disadvantaged racial and ethnic
minorities and the rural elderly and nonelderly disabled.
Evaluate the implementation of the home and community-based
care program.
Revenues for Long-Term Care
A. Although some of the revenues necessary to support the above
recommendations could come from savings achieved elsewhere in the
federal budget, the Commission is committed to raising whatever
additional revenues are necessary.
B. In considering what revenue options to adopt, the Commission
recommends that the choice be guided by the following three
criteria:
1.
The final tax package ought to be progressive, requiring a
higher contribution from those most able to bear increased
tax burdens. That is, families with higher incomes would be
asked to contribute a greater share of their incomes than
required of lower income families.
2.
Since persons of all ages would benefit, persons of all ages
should contribute to financing the recommendations.
3. Revenues chosen should grow fast enough to keep up with
benefit growth so that new sources of revenue will not need
to be enacted over time. Rates of growth would need to be
in excess of 8% to 9% per year.
C.
Various combinations of revenue sources may be used that together
meet these criteria even if individual tax sources may fall short
in one category.
21
Health
Access
America
The AMA proposal to improve access to affordable, quality health care
Summary of Purpose
Americans desire access to a health care system that delivers quality services to every American at
affordable prices. And, we want a system that is easy to understand and use.
The American health care system is now under review by a number of groups. These re-
views are being undertaken because many Americans lack health insurance coverage. The increasing
cost of health insurance for many Americans who have coverage, particularly the increasing costs
within the Medicare program and employment-related coverage is of increasing concern.
The physicians of America, who are represented by the American Medical Association, be-
lieve that improvements need to be made promptly to our health care system, especially addressing
the access and cost problems.
Thus, the AMA has developed a proposal to ensure access to the benefits of the American
health care system for every citizen. The diversity of those without insurance necessitates a broad-
based approach, utilizing both the public and private sectors, to fashion solutions. Many difficult
decisions regarding the allocation of society's resources will need to be made to accomplish the goal
of extending access to everyone.
It is a challenge. A challenge to decide whether such expanded access is something soci-
ety is willing to pay for, to transfer revenues from other programs for, and to provide sufficient sup-
port within the legislative process to bring about concrete results.
The AMA believes that a national dialogue must take place to address these challenges
and critical issues. The problems facing the American health care system cannot be solved by any
one organization. A collaborative process should be pursued, working with government and others.
The AMA is committed to the process of debate and negotiation. In the months ahead, we
will meet with other health care providers and representatives of government, labor, business, the in-
surance industry and other interested groups to develop refinements and modifications to our
proposal as needed.
America's physicians, committed to delivering quality care, want to work with all deci-
sion-makers toward positive solutions. We recognize that, primarily due to cost constraints, priorities
will need to be established to accomplish different elements of our proposed plan. Our proposal
lays out an outline for action - and the time for action is now.
In developing the specific provisions of this proposal, the AMA has considered what it be-
lieves are a number of fundamental principles that should underscore the national discussion on im-
proving our health care system. These fundamental principles are:
M
AMERICAN
ASSOCIATION
MEDICAL
American Medical Association 535 North Dearborn Street Chicago, Illinois 60610
Health
Access
America
Improvements to the American health care system should preserve the strengths of our current
system.
Affordable coverage for appropriate health care should be available to all Americans, regardless of
income.
Particular efforts are needed to assure continued access by the elderly to affordable health care
services.
Health care services should be delivered with high quality at appropriate costs.
Patients should be free to determine from whom and the manner in which health care benefits
are delivered.
All physicians should be committed to the highest ethical standards in the delivery of care to
patients.
The specific provisions of the AMA proposal build on the above principles. The specific
provisions are designed to accomplish the goal of expanding access to affordable, quality health care
for all Americans.
Health
Access
America
The AMA proposal to improve access to affordable, quality health care
Backgrounder
After several decades of scientific and technological advance, the United States has become the
premier nation in providing high quality, comprehensive medical care and education. No health care
system in the world can match the high caliber of medicine practiced throughout this country,
nor the widespread availability of medical procedures and technology now considered common in
the U.S.
However, the outstanding level of care found in our system has not provided solutions to
serious problems that leave millions of Americans without health insurance coverage. Despite na-
tional spending of over $500 billion and 11 percent of the U.S. gross national product on health
care each year, 33 million Americans do not have access to affordable medical insurance for them-
selves and their families. Public opinion polls find Americans are discontented with this inequity
despite the very high level of satisfaction with the quality of medical care practiced in the United
States.
Americans desire access to high quality health care services at affordable prices and a
health care system that is easy to understand and use. Public opinion polls show that Americans fa-
vor a system of employer-provided health care insurance that would slow rising costs, improve ac-
cess for the poor and elderly, and remove the bureaucratic paperwork that serves only to complicate
and stretch the resources of the system.
Who are the uninsured? Approximately 213 million or 87 percent of Americans today en-
joy access to fine health care services through private or public insurance. Unfortunately, that leaves
about 13 percent or 33 million without adequate access to care because they can not afford pri-
vate insurance and public assistance is unavailable. About 70 percent of the uninsured, around 24
million, are working Americans and their families. About three million persons, some of whom
are employed, are considered "medically uninsurable" by private companies due to health condi-
tions. The Medicaid system, designed to aid those below poverty levels, assists only about 40 per-
cent of our poor, many of whom are children.
While many in our society lack sufficient access to the system, an overwhelming percent-
age of Americans who do have proper access are satisfied with the level of care they receive. It is a
system that allows many persons to remain uninsured, and rising costs trouble many Americans.
American physicians, who are represented through the American Medical Association,
share the view that improvements need to be made promptly to our health care system, especially
M
AMERICAN
ASSOCIATION
MEDICAL
American Medical Association 535 North Dearborn Street Chicago, Illinois 60610
Health
Access
America
addressing the access and cost problems. In basic terms, certain principles should underscore the
national discussion on improving our health care system:
Strength. Improvements to the American health care system should preserve the
strengths of our present system.
Access. Affordable coverage for appropriate health care should be available to all Americans, re-
gardless of income.
Freedom. The right to determine the manner in which health care benefits are delivered.
Affordability. Health care services delivered at appropriate cost and without excessive li-
ability costs and paperwork interference.
Security. Continued access to health care for the elderly.
Quality. Access to care through physicians who are committed to the highest ethical
standards.
After an extensive review of the strengths and weaknesses of the American system, the AMA has devel-
oped a 16-point proposal to expand access to health care coverage to all Americans, while controlling
inappropriate cost increases, and reducing paperwork and bureaucracy. Many of the elements con-
tained in the AMA plan have already taken legislative form, such as the Medicare Reform package in-
troduced by Rep. Charles Rose (D-N.C.). Other elements are part of a legislative approach calling for
additional action to bring about needed reforms.
Primary to the AMA proposal is the belief that improving our system of health care must be based
upon the strengths and successes of our present system. These strengths include:
The vast majority of Americans are satisfied with their physicians and the health care services they
receive.
Most patients have the ability to freely choose their physician, hospital and system of care.
Technology is widely available and science remains free to conduct research in the best interests of
the patient.
The medical education system continues to produce highly trained, competent physicians.
Medical professionals remain free to act as patient advocates rather than agents of the government
or other interests.
These strengths are the foundation on which the American Medical Association has based its proposal
for reform. The individual's freedom of choice, combined with a free and independent medical pro-
fession, remain as the cornerstones of our system - a system that does not allow government to dic-
tate choices to patients.
Clearly, our health care system needs substantive revision to provide access to every American, but it
would be counterproductive to "fix" aspects of the system that work well. And so, the AMA has select-
ed to begin a process that will ask for the participation of all interested parties - government, the in-
surance industry, other health care providers, and the public - contribute to the dialogue on im-
proving the U.S. health care system.
The sixteen-point proposal
The AMA proposal is a blueprint for extending access, controlling inappropriate health care cost in-
creases, and sustaining the Medicare program to assure proper health care for all. It is summarized
as follows:
1. Effect major Medicaid reform to provide uniform adequate benefits to all persons below the
poverty level.
2. Require employer provision of health insurance for all full-time employees and their families,
creating tax incentives and state risk pools to enable new and small businesses to afford such
coverage.
3. Create risk pools in all states to make coverage available for the medically uninsurable and oth-
ers for whom individual health insurance policies are too expensive and group coverage is
unavailable.
4. Enact Medicare reform to avoid future bankruptcy of the program by creating an actuarially
sound, prefunded program to assure the aging population of continued access to quality health
care. The program would include catastrophic benefits and be funded through individual and
employer tax contributions during working years. There would be no program tax on senior
citizens.
5. Expand long-term care financing through expansion of private sector coverage encouraged by
tax incentives, with protection for personal assets, and Medicaid coverage for those below the
poverty level.
6. Enact professional liability reform essential to reducing inordinate costs attributable to liability
insurance and defensive medicine, thus reducing health care costs.
7. Develop professional practice parameters under the direction of physician organizations to help
assure only appropriate, high quality medical services are provided, lowering costs and main-
taining quality of care.
8. Alter the tax treatment of employee health care benefits to reward people for making economi-
cal health care insurance choices.
9. Develop proposals which encourage cost-conscious decisions by patients.
10. Seek innovation in insurance underwriting, including new approaches to creating larger rather
than smaller risk spreading groups and reinsurance.
11. Urge expanded federal support for medical education, research and the National Institutes of
Health, to continue progress toward medical breakthroughs which historically have resulted in
many lifesaving and cost-effective discoveries.
12. Encourage health promotion by both physicians and patients to promote healthier lifestyles and
disease prevention.
13. Amend ERISA or the federal tax code SO that the same standards and requirements apply to
self-insured (ERISA) plans as to state-regulated health insurance policies, providing fair
Health
Access
America
competition.
14. Repeal or override state-mandated benefit laws to help reduce the cost of health insurance,
while assuring through legislation that adequate benefits are provided in all insurance, includ-
ing self-insurance programs.
15. Seek reductions in administrative costs of health care delivery and diminish the excessive and
complicated paperwork faced by patients and physicians alike.
16. Encourage physicians to practice in accordance with the highest ethical standards and to pro-
vide voluntary care for persons who are without insurance and who cannot afford health
services.
Strengthening the American health care system through the elements contained in this proposal will
present an enormous challenge to all concerned. For its part, the AMA intends to move forward vigor-
ously on legislative and other fronts, as well as encouraging every interested party to join in the dia-
logue toward this goal. Our common objective will continue to be providing high quality care at rea-
sonable cost, and access for every American.
2/90
Health
Access
America
The AMA proposal to
improve access to affordable,
quality health care
MERICAN MEDICAL
American Medical Association
Health Access America
An AMA proposal to improve access to affordable, quality health care
Americans desire access to high quality health care services at affordable prices and a health
care system that is easy to understand and use. Improvements to our current system are
needed to meet these desires of the American people.
The American health care system is currently under review by two blue-ribbon commissions,
several national medical associations, various health policy professionals, as well as by the
Administration and by the Congress of the United States. Primarily, this review has been
prompted because a large number of Americans lack health insurance coverage. The increasing
cost of health insurance for many Americans with coverage, particularly employment-related
coverage, also is of major concern, as are increasing costs within the Medicare program.
The physicians of America who are represented through the American Medical Association
share the view that improvements need to be made promptly to our health care system,
especially by addressing cost issues and the lack of insurance coverage.
Thus, the AMA has developed a proposal to ensure access by every citizen to the benefits of
the American health care system. The diversity of those without insurance necessitates a broad-
based approach, utilizing both the public and private sectors, to fashion solutions. Many
difficult decisions regarding the allocation of society's resources will need to be made to
accomplish the goal of extending access to health care to all Americans. This beneficial goal
cannot be achieved without substantial cost.
Thus, in many ways, this proposal presents a challenge to society. A basic challenge for society
is whether it is willing to pay for access to coverage by all citizens.
Societal priorities will have to be considered. Revenues may have to be transferred from current
programs, or new sources of revenue found. Public support for legislation necessary to bring
about concrete results will have to be stimulated, and Congress and the Administration will
have to take the lead to bring the legislative goals to fruition. Are the goals of this proposal -
the continuation and improvement of our health care system - worthy of the costs involved?
The AMA believes the answer is an unequivocal yes.
The AMA believes that a national dialogue must take place to address these challenges and
critical issues. The problems facing the American health care system cannot be solved by any
one organization. A collaborative process should be pursued, working with government
and others.
The AMA is committed to the process of debate and negotiation. We are discussing this proposal
with other health care organizations and representatives of labor, business, the insurance
industry and other interested groups, as well as the government, and we will be developing
refinements and modifications as needed. America's physicians, committed to delivering
quality care, want to work with government and other decision makers toward positive
solutions. We recognize that modifications to our proposal will be necessary and that, primarily
due to cost constraints, priorities and phase-in strategies will need to be established in the
accomplishment of different elements of the proposal. But the proposal lays out an outline
for action - and the time for action is now.
1
In developing the specific provisions of this proposal, the AMA has taken into considera-
tion what it believes are a number of fundamental principles that should underscore the
national discussion on improving the health care system in this country. These fundamental
principles are:
Improvements to the American health care system should preserve the strengths
of our current system.
Affordable coverage for appropriate health care should be available to all
Americans, regardless of income.
Particular efforts are needed to assure continued access by the elderly to
affordable health care services.
Health care services should be delivered with high quality at appropriate costs.
Patients should be free to determine from whom and the manner in which health
care benefits are delivered.
All physicians should be committed to the highest ethical standards in the
delivery of care to patients.
Each of the above principles is restated below, followed by the relevant specific points of the
AMA's 16-point proposal which build upon that principle and which are designed to accom-
plish the goal of expanding access to affordable quality health care to all Americans. The
specific 16 points are then summarized at the end of this proposal. Some elements referred to
are already in legislative form - such as the Medicare Reform elements, introduced in the
Congress as H.R. 2600 by Rep. Charles Rose (Dem. - N.C.). Other elements will form part of a
legislative approach calling for development of legislative proposals or support for proposals
already developed by others. Some elements of this proposal require further developmental
work, which will be proceeding rapidly.
2
The AMA's Proposal
Improvements to the American health care system should preserve
the strengths of our current system.
Our health care system needs improvement, but such improvement needs to be accomplished
in a manner that does not jeopardize the access to quality care enjoyed by the vast majority
of Americans.
Widespread health care insurance exists - but many are left uninsured
Approximately 213 million or 87 percent of all Americans today have private or public health
insurance coverage providing them access to the highest quality of health care services of
any country in the world. Employment-related insurance provides coverage for 60 percent
of all Americans, with an additional 27 percent of Americans being covered by government
programs or individual policies. Unfortunately, the fact remains that for 13 percent, or about
33 million Americans, access is limited or even unavailable because of a lack of public or
private health insurance coverage [based on most recent preliminary estimates from the
Bureau of the Census].
Most individuals who lack insurance coverage also lack regular contact with a physician.
Without insurance, they often delay medical care until they are very sick and have no alter-
native but to seek treatment in clinics or emergency rooms. This, of course, is not the most
desirable way to deliver care. It increases use of the most expensive care, further driving up
health care costs. Delaying care can also result in additional discomfort, increased health risks
and greater financial impact for the individuals involved.
Broad public satisfaction with health care
National polls demonstrate that the overwhelming majority of Americans are satisfied with
their physicians and the health care services they receive. Yet a significant number are not
happy with the cost of health care services, nor are they satisfied with a system that allows
so many to go without health insurance. It is clear that the system requires improvement.
However, efforts to improve the system should not place at risk the access to quality care
currently enjoyed by the vast majority of Americans.
Additional strengths
There are a number of other strengths of our current system, including:
The ability of most patients to choose the physician, hospital, and system of health care
delivery they want.
The widespread availability of new technologies to Americans.
The freedom to conduct medical and scientific research in the best interests of patients and
to individualize the treatment of patients according to the best interests of each patient.
A superior medical education system, which seeks to attract the best and brightest and
which provides a rigorous and comprehensive learning process to assure the public of well-
trained physicians.
An independent medical profession where physicians are able to act as patient advocates
rather than as agents of the government, which is concerned mainly about the budget.
3
The individual patient's freedom of choice to pursue services which meet his or her health
care needs, combined with a free and independent medical profession, are firmly based on the
American recognition of the importance of the individual and are cornerstones for our strong
American health care system. For the most part, unless the patient selects a delivery system
with limited choice, our system does not restrict where or from whom the patient can seek
medical services. Unlike other types of health care systems, our system does not place arbitrary
limitations or overall spending caps on medical services. All of this is not to say there is no
proper role for the government.
Government's role should be: (1) to encourage the private sector to provide health care
coverage for the most people possible; (2) to assist the private sector to deliver the highest
quality of care for the most reasonable cost; and (3) to provide financial assistance for those
Americans who otherwise lack health care coverage. Clearly, to address the access problems
existing today, government programs of assistance must be expanded and properly targeted.
However, it would be just as clearly counterproductive if government were to extend its efforts
to "fix" aspects of the system which are not broken and, in fact, are operating well.
Despite some major problems, our health care system is strong. Never before has the lifesaving
medical care and technology found in our system been able to do so much for so many to
improve and save lives. Despite this overall success, however, the American Medical Association
is deeply committed, along with many other groups in this country, to finding solutions to the
problems that do exist. We must find ways to extend needed health insurance coverage to those
who lack it. We must also develop better methods to control inappropriate rising costs.
Affordable coverage for appropriate health care costs should be
available to all Americans, regardless of income.
All Americans should be assured of affordable coverage of their appropriate health care costs,
regardless of their income, through private insurance and through partially or fully government-
financed programs for those of low income.
In order to extend coverage to those who are currently uninsured, it is helpful to understand
in brief who the uninsured are. It is working Americans and their families who lack health
insurance coverage that make up the large majority of the uninsured. About 24 million of the
33 million uninsured persons are workers and their families. For the most part, the remaining
uninsured are unemployed persons and their families who are below the federally established
poverty level but are not covered by Medicaid. Medicaid actually only covers about 40 percent of
those in poverty. An additional category of the uninsured includes persons at various income
levels, some of whom are employed and some of whom are not, who are considered by insur-
ance companies as "medically uninsurable" because of health conditions. Recent estimates
indicate there are about three million persons in this category.
To accomplish the extension of access to insurance coverage to those without it, several specific
actions are needed:
Point 1
Effect major Medicaid reform to provide uniform adequate benefits to all persons below the
poverty level. The AMA Medicaid Reform proposal would set new national requirements to
assure that in all states persons below poverty income levels are eligible for and receive a
4
uniform set of adequate benefits, so that no poor person is left without access to needed health
care. The AMA believes strongly that federal and state governments must assure access to and
funding for medical care for persons with incomes below the poverty level.
The federal poverty level should be adjusted by a state cost-of-living modifier to assure that
Medicaid eligibility truly reflects the economic realities in the various states. Income status
should be the only eligibility criterion; other existing categorical requirements should be
repealed. At the same time, using one national formula by which eligibility will be determined
in the various states will eliminate state discretion in setting the economic level of eligibility.
This will avoid perpetuating the widespread inequities existing across state boundaries in the
Medicaid program today.
Medicaid benefits need to assure provision of all medically necessary physician and hospital
services - and should not differ across state lines. Because of the impoverished status of
Medicaid beneficiaries, added coverage for prescription drugs, rehabilitative services, and
emergency services must be provided. Because unrealistically low reimbursement levels
reduce access, Medicaid reimbursement levels should be increased to the Medicare level.
Recognizing the substantial costs of Medicaid expansion, some phased-in approach probably
will be necessary. One initial approach would include: expanding Medicaid coverage for women
and children by requiring a phased-in coverage for pregnant women and children; phasing
in a requirement that Medicaid eligibility shall equal 100 percent of the poverty level (state
adjusted); and creating a basic national level of Medicaid benefits that must be covered,
including necessary inpatient and outpatient hospital and emergency services; rural health
clinic and other laboratory and x-ray services; home health services; early and periodic
screening, diagnosis, and treatment for individuals under 21; family planning; physician
services; prescription drugs; and rehabilitative services.
This AMA uniform benefit package consists of the presently required services plus prescription
drugs, rehabilitative services, and emergency services. States, solely at their own expense,
could cover additional benefits beyond the basic national level.
There is widespread support for needed Medicaid reforms, including that evidenced by the
report of the Health Policy Agenda for the American People (HPA), a broad-based group of
organizations representing consumers, business, labor, government, health care professionals,
hospitals and insurance companies.
Point 2
Require employer provision of health insurance for all full-time employees and their families,
with tax help to employers. About 24 million of the 33 million uninsured are employed
individuals and their families. Tax incentives must be provided and risk pools created so that
new and small businesses can afford the cost of such coverage. At first only larger businesses
should be subject to this requirement.
To make the transition manageable for all businesses, the program should be phased in over
several years. Additional elements in a legislative program to bring about required employer
coverage include:
5
a. Preempt state-mandated benefit laws for employer health benefit plans to assist small
businesses to afford a basic program. Such plans would be required to meet minimum
standards of coverage, including basic hospital, physician, diagnostic, prenatal and well-
baby care, with reasonable annual limits on employees' incurred expenses for premiums,
co-insurance and deductibles.
b. Amend the Internal Revenue Code or ERISA to allow states to require self-insured
employers to participate in private, not-for-profit uninsured and uninsurable risk pools
established pursuant to state law.
C. Establish a Federal incentive program for states to enact legislation to set up private, not-
for-profit health benefit pools (including uninsurable, uninsured and small business).
d. Require such pools to offer to small businesses (less than 25 employees) access to basic
benefits policy at group rates.
e. Make permanent the temporary 25 percent income-tax deduction for premiums for health
benefits plans for the self-employed. Expand deduction to 100 percent of premium pay-
ment for self-employed and others who must pay 100 percent of a health benefit premium.
f. Expand COBRA continuation coverage to require employers to pay the same share of an
employee health benefit premium that was paid by the employer, prior to termination, for
up to four months after the qualifying event.
g. Require employers to offer an enrollment period for employees who lose coverage because
a spouse or other family member lost coverage due to change of employment.
h. Eliminate provisions excluding pre-existing conditions from employee health benefit plans.
Because of the particular importance of the relationship of a basic benefits package to the
affordability of required insurance, the AMA is making additional efforts to construct a package
that is affordable. It is the essential basic benefits in any health insurance program which
impact most on saving lives and improving the quality of life.
Point 3
Create state-level risk pools in all states to make available coverage for the medically uninsur-
able, for whom access to coverage is not available, and for others for whom individual health
insurance policies are too expensive and group coverage is not available.
A state risk pool is a legislatively created insurance program that can be funded in a variety of
ways including state tax revenues or insurance company contributions. Risk pools help assure
that no American would be unable to obtain affordable health insurance because of a health
condition. Small employers should have access to such risk pools so that they could acquire
coverage for their employees at affordable rates if it was unavailable for a better price in the
private market. Rates should be set at standard group rates. Premium assistance from the state
would be provided for those persons not covered through employment and who were between
100 percent and 150 percent of the poverty level. (Only about 15 states currently have risk
pools designed to make coverage available to the medically uninsurable.)
Elements of a phased-in legislative approach which can accomplish extension of access to the
medically uninsurable and for those otherwise unable to obtain coverage include:
a. Requiring, as a condition of federal tax deduction, that all payors for employee health
benefits (payment of premium, or direct payment for services by self-insured plan) must
participate in a private not-for-profit risk pool established pursuant to state law. The pool
would provide subsidized coverage for those who have been denied coverage or have lost
coverage because of a medical condition and underwriting rules.
b. Allowing a 100 percent tax deduction of premium payment for individuals who purchase
insurance coverage through the pool.
Particular efforts are needed to assure continued access by the
elderly to affordable health care services.
To assure continued access by the elderly to affordable health care services, two major actions
are needed:
Point 4
Enact Medicare reform to avoid the future financial bankruptcy of the program by creating an
actuarially sound prefunded program to assure senior citizens continued access to quality
health care. Today four workers' tax contributions support a single Medicare beneficiary. As our
population ages, there will be only two workers paying taxes to support each beneficiary by the
middle of the next century. A shrinking worker base means substantially higher premiums in
the years to come. Without further support, the system will collapse. This reform measure
would include a new approach to catastrophic benefits. The program would be funded through
individual and employer tax contributions during working years. There would be no program
tax on senior citizens and all persons reaching eligibility age would be entitled to a voucher
for purchase in the private sector of a comprehensive health insurance policy meeting federal
standards. Senior citizens would retain freedom to choose their system of delivery of care
(e.g., fee-for-service, HMO, PPO). The creation of an enhanced trust fund beyond immediate
payout needs (prefunding) would create investment income and thus end up costing taxpayers
much less than continuation of the current system.
The reform elements noted above are in legislative form, introduced in the Congress as H.R.
2600 by Rep. Charles Rose (Dem.-N.C.).
Point 5
Expand long-term care financing through expansion of private sector coverage encouraged by
tax incentives and an asset protection program, and provide Medicaid coverage for those below
poverty. The "asset protection" approach in essence means that individuals who purchase
long-term care insurance would be able to protect designated assets up to the dollar value of
the insurance benefits from being included in any eligibility determination for Medicaid
coverage for long-term care. This kind of program has been introduced in the Congress by Rep.
Barbara Kennelly (Dem.-Conn.), as H.R. 4631. Sliding scale subsidies should be provided for
the purchase of long-term care insurance for individuals with incomes between 100 percent
and 200 percent of poverty level. Employer-provided long-term care insurance should be
treated in the same tax fashion as health insurance coverage. A tax deduction or credit should
be created to encourage family care giving.
7
A phased-in legislative approach to accomplish the above elements would call for:
a. Amending the Internal Revenue Code to allow businesses and individuals to treat payment
for long-term care insurance policies in the same manner as health benefit plans are
now treated.
b. Allowing individuals to deduct for income tax purposes 100 percent of the cost of long-
term care insurance premiums without meeting the 7 percent floor for health costs or
the 2 percent for miscellaneous deductions.
C. Amending the tax code to allow for penalty-free and tax-free withdrawals from individual
retirement accounts (IRAs) for purchase of long-term care insurance policies.
d. Amending Medicaid to allow for an asset protection program so that resource eligibility
requirements are adjusted to allow an individual to retain assets up to the amount that
private sector insurance pays on his or her behalf for long-term care.
Health care services should be delivered with high quality at
appropriate costs.
Inappropriate costs include costs for defensive medicine, excessive administrative costs which
include unnecessarily complicated hurdles for patients to receive care and benefits and inter-
fere with the doctor-patient relationship, and costs brought about by delivery of services which
are outside of professionally developed practice parameters and which are not justified after
appropriate peer review.
To address the above issues, certain specific actions are needed:
Point 6
Reduce health care costs through professional liability reform to reduce the inappropriate
cost of such insurance and defensive medicine. Defensive medicine, the ordering of tests and
procedures which might not otherwise be ordered but for liability concerns, drives up the cost
of medical services. It has been estimated that liability insurance premiums and defensive
medicine add about 15 percent to the average physician's bill. In addition, the AMA has
developed legislative reforms and has also developed a pilot program for administrative
adjudication of liability claims which is designed to lower the costs of liability insurance while
preserving the rights of injured patients. Elements of a legislative approach include:
a. Support federal funding to states to demonstrate alternative dispute resolution systems for
medical professional liability cases.
b. Adopt federal legislation that would establish the following selected tort reforms:
— limitations of $250,000 or lower on recovery of noneconomic damages
— the mandatory offset of collateral sources (e.g., health insurance and disability benefits)
of plaintiff compensation
— decreasing sliding scale regulation for attorney contingency fees
— periodic payment for future awards of damages
- limiting the period for tolling statutes of limitations for minors
- requiring a certificate of merit as a prelude to filing medical liability cases
— adoption of basic medical expert witness criteria
Such legislation should override conflicting state laws.
8
Point 7
Develop professional practice parameters to help assure that only high quality appropriate
medical services are provided, thus impacting favorably on the quality and cost of medical
care. Such parameters are professionally developed strategies for patient care developed to
assist physicians in clinical decision making.
Practice parameters include guidelines, standards and other patient care strategies. Guidelines
are recommendations for patient care, which may identify a particular care strategy or a range
of care strategies. Standards are generally accepted principles for patient care. Practice param-
eters may outline a range of appropriate tests and procedures for management of a given
clinical condition or may identify a range of clinical conditions for which a given procedure or
treatment may be appropriate. It remains the physician's responsibility to choose what is most
appropriate for the individual patient.
The primary benefit of parameters is appropriate patient care. Secondary advantages include
improved use of resources, reduced liability, and better review criteria. The AMA, in conjunction
with national specialty societies, is currently working diligently to facilitate the development
of practice parameters, as part of its long-standing efforts to foster high quality care and
appropriate utilization.
To accomplish the above goals, legislative support is needed on a continuing basis for adequate
appropriations for health care assessment research and professionally developed practice
parameters. One significant step in this direction has been taken in legislation enacted in
1989 (P.L. 101-239). Efforts will also seek adoption by HHS, quality assurance programs and
utilization review organizations of parameters developed by professional organizations.
Point 8
Alter the tax treatment of employee health care benefits to reward people for making econom-
ical health care insurance choices. This reduces the tendency to overinsure which occurs when
an excessive number of ordinary, routine and highly predictable health services are covered by
insurance. The AMA supports two tax reforms to reduce incentives to overinsure. The first
would place a limit on the amount of the employer-provided health insurance that is tax-
exempt to the employee. The second would provide tax-exempt rebates to employees who
select health insurance plans with premiums less than their employer's contribution to more
expensive plans. Such plans would still be required to contain coverage for basic benefits.
Point 9
Encourage cost-conscious decisions by patients, for example, through insurance companies,
employers and government programs providing patients more information, prior to service, of
the amount insurance or the program will cover.
The enactment in Congress of the resource-based relative value system (RBRVS) for physician
payment under Medicare, which was largely supported by AMA, ultimately should help to
provide patients with information ahead of time as to what Medicare will pay for a service. This
system will also create a more rational basis of physician payment under the Medicare program.
Point 10
Seek innovation in insurance underwriting, including new approaches to creating larger risk
spreading groups and reinsurance.
Point 11
Urge expanded federal support for medical education, research and the National Institutes
of Health (NIH), to help bring about continuing medical breakthroughs which historically have
resulted in many lifesaving discoveries. The American people have benefited greatly from
scientific discoveries and technological developments derived from our nation's past support
for medical research. Cost-saving as well as lifesaving medical advances made in our country
have improved both the quality and duration of life for countless persons both in our own
nation and around the globe. We must continue to strongly support such medical research to
remain on the leading edge of advancing the state of medical knowledge.
Point 12
Encourage health promotion and disease prevention. Both physicians and patients need to
be encouraged to become more active participants in health promotion and disease prevention,
including healthier lifestyles. Such activities favorably affect not only the extent and quality of
life but also significantly reduce the cost of care. For example, one recent estimate indicates
that 35 percent of all hospitalized patients are there due to an alcohol or drug abuse problem.
Health-related problems due to other life-style choices, such as smoking, have been widely
documented in recent years. Recent estimates by the Centers for Disease Control's Office of
Smoking and Health indicate that 390,000 Americans die each year from tobacco-related
illness and that the direct health care dollar costs related to such illness is about $22 billion
per year. The AMA has been very active and continues to promote programs to eliminate
smoking, discourage alcohol and drug abuse, reduce cholesterol, encourage better adolescent
health, and other similar programs which are all aimed at improving health and reducing
costs of health care.
Point 13
Amend ERISA or the federal tax code so that the same standards and requirements apply to
self-insured (ERISA) plans that apply to state-regulated health insurance policies. Currently,
employers who self-insure the health care of their employees are exempt from most state
requirements that apply to commercial and Blue Cross/Blue Shield insurance policies. This
"unequal playing field" removes the self-insured plans from equitable participation in state
risk pools, leaving many people without access to affordable health insurance, including small
employers. The amendment called for regarding ERISA would not mean that self-insured plans
would be subject to state-mandated benefits, since another provision of this proposal calls for
a repeal or override of such mandates.
Patients should be free to determine from whom and the manner
in which health care benefits are delivered.
Patients should remain free to choose their physician and health care delivery system
(e.g., indemnity, HMO, PPO). The individual patient's freedom of choice to pursue his or her
health care needs combined with a free and independent medical profession are based on the
American recognition of the importance of the individual and are the cornerstones for our
strong American health care system.
10
Several particular actions are needed in pursuit of these goals:
Point 14
Repeal or override state-mandated benefit laws, to help reduce the cost of health insurance,
while assuring through legislation that adequate benefits are provided in all insurance, includ-
ing self-insurance programs. Individuals should be free to choose, at their own cost, additional
coverages if desired but such coverages should not be mandated as part of all policies.
Currently, health insurance policies must comply with a myriad of mandated benefit laws in
the various states - over 700 such mandates nationwide according to the Health Insurance
Association of America (HIAA). The HIAA estimates that, but for such mandates, 16 percent of
the small firms that do not offer health insurance would do SO and that 51 percent of the firms
that converted to self-insurance between 1981 and 1984 would not have done so.
Point 15
Seek reductions in the administrative costs of health care delivery and the excessive and
complicated paperwork nightmare faced by patients and their families who seek to obtain
benefits. There has developed in the last several years a burgeoning multiplicity of unrestrained
insurance conditions and paperwork requirements. The frustration of physicians in dealing
with the differing managed care requirements of multiple insurance companies, self-insureds,
and government programs results in increased costs and interference with the physician-
patient relationship.
All physicians should be committed to the highest ethical standards
in the delivery of care to patients.
Point 16
Encourage physicians to practice in accordance with the highest ethical standards and
to provide voluntary care. In times of strain upon the health care delivery system, where
physicians are called upon to deal with multiple competing pressures - particularly from
insurance carriers and the government — it is well to note that the AMA will continue its
efforts to encourage all physicians to:
Treat their patients as individuals.
Use their best professional judgment in every case.
Inform their patients of the benefits, risks and estimated costs of treatment.
Treat their patients with courtesy, dignity, respect, compassion and timely attention to their
medical needs.
The AMA will also continue its long-standing efforts to encourage physicians to provide health
care services without charge or at reduced rates for persons who are without insurance and
cannot afford health services. Numerous medical society sponsored efforts to provide free or
reduced-fee care to the needy are in place in many but not all areas of the nation. However,
these efforts are not enough to provide such care to all of those in need. Recent AMA surveys
indicate physicians provide an average of 150 hours of care annually free of charge - coming
close to $11 billion of uncharged care. Such efforts will clearly need to continue for the
foreseeable future.
11
Summary of AMA Proposal
The elements of the AMA proposed plan may be summarized in the following 16 points:
1. Increase access by enacting major Medicaid Reform.
2. Increase access by requiring employer provision of health insurance.
3. Increase access by creating state-level risk pools in all states.
4. Maintain access and reduce costs for the elderly by enacting Medicare Reform.
5. Increase access and reduce costs for the elderly by enacting necessary legislation to
finance expanded long-term care coverage.
6. Reduce health care costs through professional liability reform.
7. Maintain quality and reduce costs through development of professional practice
parameters.
8. Reduce health care costs through altering the tax treatment of employee health
care benefits.
9. Reduce costs by encouraging cost-conscious decisions by patients.
10. Reduce costs by seeking innovation in insurance underwriting.
11. Maintain quality through expanded federal support for medical education, research and
the National Institutes of Health (NIH).
12. Maintain quality and reduce costs through increased health promotion and disease
prevention.
13. Reduce costs and increase access by amending ERISA or the federal tax code to equalize
treatment of self-insured and insurance plans.
14. Reduce costs and increase access by repealing or overriding state-mandated benefit laws.
15. Reduce costs by reducing administrative costs and paperwork.
16. Maintain quality and access through encouraging physicians to practice in accordance
with the highest ethical standards and to provide voluntary care.
Conclusion
Accomplishing the goal of strengthening the American health care system through the elements
contained in this AMA proposal will present an enormous challenge to all concerned. For its
part, the AMA intends to move forward vigorously on legislative and other fronts. The AMA
welcomes and encourages the support of others to help bring about an improved American
health care system.
February 1990
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ASSOCIATION AMERICAN MEDICAL
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American Medical Association
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II
101ST CONGRESS
2D SESSION
S.2246
To amend title ХѴШ of the Social Security Act to provide improved medicare
home health benefits, and for other purposes.
IN THE SENATE OF THE UNITED STATES
MARCH 7 (legislative day, JANUARY 23), 1990
Mr. BRADLEY (for himself, Mr. MATSUNAGA, Mr. DURENBERGER, and Mr. Moy-
NIHAN) introduced the following bill; which was read twice and referred to
the Committee on Finance
A
BILL
To amend title ХѴШ of the Social Security Act to provide
improved medicare home health benefits, and for other pur-
poses.
1
Be it enacted by the Senate and House of Representa-
2 tives of the United States of America in Congress assembled,
3 SECTION 1. SHORT TITLE.
4
This Act may be cited as the "Medicare Home Benefits
5 Improvement Act of 1990".
6 SEC. 2. IN-HOME RESPITE CARE FOR CERTAIN CHRONICALLY
7
DEPENDENT INDIVIDUALS.
8
(a) IN GENERAL.-Section 1832(a) of the Social Securi-
9 ty Act (42 U.S.C. 1395k(a)), as restored by section 201(a)(1)
2
1 of the Medicare Catastrophic Coverage Repeal Act of 1989,
2 is amended-
3
(1) in paragraph (2)(A)-
4
(A) by inserting "(i)" after "(A)", and
5
(B) by inserting before the semicolon at the
6
end the following: ", and (ii) in-home respite care
7
for up to 80 hours in any period described in sec-
8
tion 1861(jj)(4), but not to exceed 80 hours in any
9
calendar year"; and
10
(2) by adding at the end the following new sen-
11
tence: "In the case of in-home respite care (described
12
in paragraph (2)(A)(ii)) provided on any day, such care
13
provided for 3 hours or less on the day shall be count-
14
ed (for purposes of the limitation in such paragraph) as
15
3 hours of such care.".
16
(b) IN-HOME RESPITE CARE FOR CHRONICALLY DE-
17 PENDENT INDIVIDUAL DEFINED.-Section 1861 of such Act
18 (42 U.S.C. 1395x), as restored by section 201(a)(1) of the
19 Medicare Catastrophic Coverage Repeal Act of 1989 and as
20 amended by the Omnibus Budget Reconciliation Act of 1989,
21 is amended by inserting after subsection (ii) the following new
22 subsection:
23
"(jj)(1) The term 'in-home respite care' means the
24
following items and services furnished, under the
25
supervision of a registered professional nurse, to a
S
2246 IS
3
1
chronically dependent individual (as defined in para-
2
graph (2)) during the period described in paragraph (4)
3
by a home health agency or by others under arrange-
4
ments with them made by such agency in a place of
5
residence used as such individual's home:
6
"(A) Services of a homemaker/home health
7
aide (who has successfully completed a training
8
program approved by the Secretary).
9
"(B) Personal care services.
10
"(C) Nursing care provided by a licensed
11
professional nurse.
12
"(2) The term 'chronically dependent individual'
13
means an individual who-
14
"(A) is dependent on a daily basis on a pri-
15
mary caregiver who is living with the individual
16
and is assisting the individual without monetary
17
compensation in the performance of at least 2 of
18
the activities of daily living (described in para-
19
graph (3)), and
20
"(B) without such assistance could not per-
21
form such activities of daily living.
22
"(3) The 'activities of daily living', referred to in
23
paragraph (2), are as follows:
24
"(i) Eating.
25
"(ii) Bathing.
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4
1
"(iii) Dressing.
2
"(iv) Toileting.
3
"(v) Transferring in and out of a bed or
4
in and out of a chair.
5
"(4)(A) The period described in this paragraph
6
begins on the date that the Secretary determines that a
7
chronically dependent individual has incurred out-of-
8
pocket part B cost sharing (as defined in paragraph
9
(5)(A)) in an amount equal to the part B limit (as de-
10
termined under paragraph (5)(B)) for the calendar year
11
in which such date occurs.
12
"(B) In the case of an individual who qualifies
13
under subparagraph (A), if the hour limitation for the
14
calendar year applies, the period described in subpara-
15
graph (A) shall begin on the first day of the succeeding
16
calendar year.
17
"(5) For purposes of this subsection-
18
"(A) The term 'out-of-pocket part B cost
19
sharing' means, with respect to an individual cov-
20
ered under part B, the amount of expenses that
21
the individual incurs that is attributable to-
22
"(i) the deductions established under
23
section 1833(b), and
24
"(ii) the difference between the payment
25
amount provided under part B and the pay-
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5
1
ment amount that would be provided under
2
part B if '100 percent' and 'O percent' were
3
substituted for '80 percent' and '20 percent',
4
respectively, each place either appears in
5
sections 1833(a), 1833(i)(2), 1834(c)(1)(C),
6
1835(b)(2), 1866(a)(2)(A), 1881(b)(2), and
7
1881(b)(3).
8
"(B)(i) The part B limit for 1991 is $1,780.
9
The part B limit for any succeeding year shall be
10
such an amount (rounded to the nearest multiple
11
of $1) as the Secretary estimates, for that suc-
12
ceeding year, will reflect a level of out-of-pocket
13
part B expenses that only 5.5 percent of the aver-
14
age number of individuals enrolled under part B
15
(other than individuals enrolled with an eligible
16
organization under section 1876 or an organiza-
17
tion described in section 1833(a)(1)(A)) will equal
18
or exceed in that succeeding year.
19
"(ii) Not later than September 1 of each year
20
(beginning with 1991), the Secretary shall pro-
21
mulgate the part B limit under this subparagraph
22
for the succeeding year.".
23
(c) PAYMENT.-Section 1833(a) of such Act (42 U.S.C.
24 13951(a)), as restored by the Medicare Catastrophic Coverage
25 Repeal Act of 1989, is amended-
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6
1
(1) in paragraph (2), by inserting "(A)(ii)," after
2
"subparagraphs" the first place it appears,
3
(2) in paragraph (3), by striking "(D)" and insert-
4
ing "(A)(ii), (D),", and
5
(3) by adding at the end the following:
6 "Payment for in-home respite care for chronically dependent
7 individuals shall be paid on the basis of an hour of such care
8 provided. In applying paragraph (2) in the case of an organi-
9 zation receiving payment under subparagraph (A) of para-
10 graph (1) or under a reasonable cost reimbursement contract
11 under section 1876 and providing coverage of in-home res-
12 pite care, the Secretary shall provide for an appropriate ad-
13 justment in the amount of payments otherwise made to re-
14 flect the aggregate increase in payments that would other-
15 wise be made with respect to enrollees in the organization if
16 payments were made other than under such clause or such a
17 contract if payments were to be made on an individual-by-
18 individual basis.
19
(d) CERTIFICATION.-Section 1835(a)(2) of such Act
20 (42 U.S.C. 1395n(a)(2)), as restored by the Medicare Cata-
21 strophic Coverage Repeal Act of 1989, is amended-
22
(1) in subparagraph (E), by striking "and" at the
23
end;
24
(2) in subparagraph (F), by striking the period at
25
the end and inserting "; and"; and
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7
1
(3) by inserting after subparagraph (F) the follow-
2
ing new subparagraph:
3
"(G) in the case of in-home respite care pro-
4
vided during a period described in section
5
1861(jj)(4), the individual was a chronically de-
6
pendent individual during the 3-month period im-
7
mediately preceding the beginning of the period
8
described in such section.".
9
(e) STANDARDS FOR UTILIZATION.-
10
(1) Section 1862(a) of such Act (42 U.S.C.
11
1395y(a)), as restored by section 201(a)(1) of the Medi-
12
care Catastrophic Coverage Repeal Act of 1989, is
13
amended-
14
(A) in paragraph (1)-
15
(i) in subparagraph (D), by striking
16
"and" at the end,
17
(ii) in subparagraph (E), by striking the
18
semicolon at the end and inserting ", and",
19
and
20
(iii) by adding at the end the following
21
new subparagraph:
22
"(F) in the case of in-home respite care,
23
which is not reasonable and necessary to assure
24
the health and condition of the individual is main-
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8
1
tained in the individual's noninstitutional resi-
2
dence;"; and
3
(B) in paragraph (6), by inserting "and
4
except, in the case of in-home respite care, as is
5
otherwise permitted under paragraph (1)(F)" after
6
"paragraph (1)(C)".
7
(2) The Secretary of Health and Human Services
8
shall take appropriate efforts to assure the quality, and
9
provide for appropriate utilization of, in-home respite
10
care under the amendments made by this section.
11
(f) EFFECTIVE DATE.-The amendments made by this
12 section shall apply to items and services furnished on or after
13 January 1, 1991.
14 SEC. 3. EXTENDING HOME HEALTH SERVICES.
15
(a) IN GENERAL.-Section 1861(m) of the Social Secu-
16 rity Act (42 U.S.C. 1395x(m)), as restored by section
17 201(a)(1) of the Medicare Catastrophic Coverage Repeal Act
18 of 1989, is amended by adding at the end the following new
19 sentence:
20 "For purposes of paragraphs (1) and (4) and sections
21 1814(a)(2)(C) and 1835(a)(2)(A), nursing care and home
22 health aide services shall be considered to be provided or
23 needed on an 'intermittent' basis if they are provided or
24 needed less than 7 days each week and, in the case they are
S
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9
1 provided or needed for 7 days each week, if they are provided
2 or needed for a period of up to 38 consecutive days.".
3
(b) PAYMENT UNDER PART B.-Section 1833(d) of the
4 Social Security Act (42 U.S.C. 13951(d)), as restored by sec-
5 tion 201(a)(1) of the Medicare Catastrophic Coverage Repeal
6 Act of 1989, is amended-
7
(1) by striking "(d) No payment" and inserting
8
"(d)(1) Except as provided in paragraph (2), no pay-
9
ment"; and
10
(2) by adding at the end the following new para-
11
graph:
12
"(2) In the case of home health services furnished
13
to an individual enrolled under this part for which pay-
14
ment is made only as a result of the application of the
15
last sentence of section 1861(m), payment shall be
16
made under this part.".
17
(c) EFFECTIVE DATE.-The amendments made by this
18 section shall apply to services furnished in cases of initial
19 periods of home health services beginning on or after
20 January 1, 1991.
21 SEC. 4. EXPANSION OF HOSPICE BENEFIT.
22
(a) IN GENERAL.-Section 1812 of the Social Security
23 Act (42 U.S.C. 1395d), as restored by section 101(a)(1) of
24 the Medicare Catastrophic Coverage Repeal Act of 1989 and
S 2246 IS-2
10
1 as amended by the Omnibus Budget Reconciliation Act of
2 1989, is amended-
3
(1) in subsection (a)(4), by striking "90 days
4
each" and all that follows through "with respect to"
5
and inserting the following: "90 days each, a subse-
6
quent period of 30 days, and a subsequent extension
7
period with respect to"; and
8
(2) in subsection (d)-
9
(A) in paragraph (1), by striking "90 days
10
each" and all that follows through "lifetime" and
11
inserting the following: "90 days each, a subse-
12
quent period of 30 days, and a subsequent exten-
13
sion period during the individual's lifetime", and
14
(B) in paragraph (2)(B), by striking "a 90- or
15
30-day period," and inserting "a 90- or 30-day
16
period or a subsequent extension period,".
17
(b) CONFORMING AMENDMENT.-Section 1814(a)(7)(A)
18 of such Act (42 U.S.C. 1395f(a)(7)(A)), as restored by section
19 101(a)(1) of the Medicare Catastrophic Coverage Repeal Act
20 of 1989, is amended-
21
(1) in clause (i), by striking "and" at the end;
22
(2) in clause (ii), by striking the semicolon at the
23
end and inserting ", and"; and
24
(3) by adding at the end the following new clause:
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11
1
"(iii) in a subsequent extension period, the
2
medical director or physician described in clause
3
(i)(II) recertifies at the beginning of the period
4
that the individual is terminally ill;".
5
(c) EFFECTIVE DATE.-The amendments made by this
6 section shall apply with respect to care and services furnished
7 on or after January 1, 1991.
8 SEC. 5. COVERAGE OF HOME INTRAVENOUS DRUG THERAPY
9
SERVICES.
10
(a) IN GENERAL.-Section 1832(a)(2)(A) (42 U.S.C.
11 1395k(a)(2)(A)) as amended by section 2(a)(1) of this Act, is
12 further amended-
13
(1) by striking ", and (ii)" and inserting ", (ii)";
14
and
15
(2) by striking "calendar year" and inserting ",
16
calendar year, and (iii) home intravenous drug therapy
17
services".
18
(b) HOME INTRAVENOUS DRUG THERAPY SERVICES
19 DEFINED.-Section 1861 (42 U.S.C. 1395x) as amended by
20 section (2)(b) of this Act, is further amended by adding at the
21 end the following new subsection:
22
"(kk)(1) The term 'home intravenous drug therapy serv-
23 ices' means the items and services described in paragraph
24 (2) furnished to an individual who is under the care of a
25 physician-
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12
1
"(A) in a place of residence used as such individ-
2
ual's home;
3
"(B) by a qualified home intravenous drug therapy
4
provider (as defined in paragraph (4)) or by others
5
under arrangements with them made by such provider;
6
and
7
"(C) under a plan established and periodically re-
8
viewed by a physician.
9
"(2) The items and services described in this paragraph
10 are such nursing, pharmacy, and related services (including
11 medical supplies, intravenous fluids, delivery, and equipment)
12 as are necessary to conduct safely and effectively an intrave-
13 nously administered drug regimen through use of a covered
14 home intravenous drug.
15
"(3)(A) The term 'covered home intravenous drug'
16 means a drug dispensed to an individual that-
17
"(i) is an antibiotic drug and the Secretary has
18
not determined, for the specific drug or for the indica-
19
tion to which it is applied, that the drug cannot be ad-
20
ministered safely and effectively in a home setting, or,
21
"(ii) is not an antibiotic drug and the Secretary
22
has determined, for the specific drug and indication for
23
which the drug is being applied, that the drug can gen-
24
erally be administered safely and effectively in a home
25
setting.
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13
1
"(B) Not later than January 1, 1991 (and periodically
2 thereafter), the Secretary shall publish a list of the drugs that
3 are covered home intravenous drugs with respect to which
4 home intravenous drug therapy may be provided under this
5 title.
6
"(4) The term 'qualified home intravenous drug therapy
7 provider' means any entity that the Secretary determines
8 meets the following requirements:
9
"(i) The entity is capable of providing or arrang-
10
ing for the items and services described in paragraph
11
(2) and covered home intravenous drugs.
12
"(ii) The entity maintains clinical records on all
13
patients.
14
"(iii) The entity adheres to written protocols and
15
policies with respect to the provision of items and
16
services.
17
"(iv) The entity makes services available (as
18
needed) 7 days a week on a 24-hour basis.
19
"(v) The entity coordinates all services with the
20
patient's physician.
21
"(vi) The entity conducts a quality assessment and
22
assurance program, including drug regimen review and
23
coordination of patient care.
24
"(vii) The entity assures that only trained person-
25
nel provide covered home intravenous drugs (and any
S
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14
1
other service for which training is required to safely
2
provide the service).
3
"(viii) The entity assumes responsibility for the
4
quality of services provided by others under arrange-
5
ments with the agency or entity.
6
"(ix) In the case of an entity in any State in
7
which State or applicable law provides for the licensing
8
of entities of this nature, (I) is licensed pursuant to
9
such law, or (II) is approved, by the agency of such
10
State or locality responsible for licensing entities of this
11
nature, as meeting the standards established for such
12
licensing.
13
"(x) The entity meets such other requirements as
14
the Secretary may determine are necessary to assure
15
the safe and effective provision of home intravenous
16
drug therapy services and the efficient administration
17
of the home intravenous drug therapy benefit.".
18
(c) PAYMENT.-
19
(1) IN GENERAL.-Part B of such Act, as
20
restored by section 201(a)(1) of the Medicare Cata-
21
strophic Coverage Repeal Act of 1989, is amended-
22
(A) in subsection (a)(2)(B) of section 1833
23
(42 U.S.C. 13951), by striking "or (E)" and
24
inserting "(E), or (F)";
S 2246 IS
15
1
(B) in subsection (a)(2)(D) of such section, by
2
striking "and" at the end;
3
(C) in subsection (a)(2)(E) of such section, by
4
striking the semicolon and inserting "; and";
5
(D) by inserting after subsection (a)(2)(E) of
6
such section the following new subparagraph:
7
"(F) with respect to home intravenous drug
8
therapy services, the amounts described in section
9
1834(d)(1);"
10
(E) in subsection (b) of such section, by strik-
11
ing "services, (3)" and inserting "services and
12
home intravenous drug therapy services, (3)"; and
13
(F) by adding at the end of section 1834, the
14
following new subsection:
15
"(c) HOME INTRAVENOUS DRUG THERAPY SERV-
16 ICES.-
17
"(1) IN GENERAL.-With respect to home intra-
18
venous drug therapy services, subject to paragraph (3),
19
payment under this part shall be made in an amount
20
equal to the lesser of the actual charges for such serv-
21
ices or the fee schedule established under paragraph
22
(2).
23
"(2) ESTABLISHMENT OF FEE SCHEDULE.-The
24
Secretary shall establish by regulation before the
25
beginning of calendar year 1991 and each succeeding
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16
1
calendar year a fee schedule for home intravenous drug
2
therapy services for which payment is made under this
3
part. A fee schedule established under this subsection
4
shall be on a per diem basis.
5
"(3) LIMITATION ON ACCEPTANCE OF, AND PAY-
6
MENTS FOR, CERTAIN REFERRALS.-
7
"(A) IN GENERAL.-Except as provided in
8
subparagraph (B), a home intravenous drug ther-
9
apy provider may not provide home intravenous
10
drug therapy services under this part to an indi-
11
vidual if the individual's referring physician (as
12
defined in subparagraph (D)), or an immediate
13
family member of the physician-
14
"(i) has an ownership interest in the
15
provider, or
16
"(ii) receives compensation from the
17
provider.
18
"(B) EXCEPTIONS.-
19
"(i) Subparagraph (A)(i) shall not
20
apply-
21
"(I) if the ownership interest is the
22
ownership of stock which is traded over
23
a publicly-regulated exchange and was
24
purchased on terms generally available
25
to the public, or
S
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17
1
"(II) if the provider is a sole home
2
intravenous drug therapy provider (as
3
defined by the Secretary) in a rural
4
area.
5
"(ii) Subparagraph (A)(ii) shall not apply
6
if the compensation is reasonably related to
7
items or services actually provided by the
8
physician and does not vary in proportion to
9
the number of referrals made by the referring
10
physician, but such exception shall not apply
11
to compensation provided for direct patient
12
care services.
13
"(iii) Subparagraph (A) shall not be con-
14
strued to apply to a referring physician
15
whose only ownership or financial relation-
16
ship with the provider is as an uncompensat-
17
ed officer or director of the provider.
18
"(iv) Subparagraph (A) also shall not
19
apply in such cases, established by the Sec-
20
retary in regulations, in which the nature of
21
the ownership or compensation does not pose
22
a substantial risk of program abuse.
23
"(C) SANCTIONS.-
24
"(i) DENIAL OF PAYMENT.-No pay-
25
ment may be made under this part for home
S
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18
1
intravenous drug therapy services which are
2
provided in violation of subparagraph (A).
3
"(ii) CIVIL MONEY PENALTY FOR IM-
4
PROPER CLAIMS.-Any person (including a
5
home intravenous drug therapy provider or
6
physician) that presents or causes to be pre-
7
sented a claim for an item or service that
8
such person knows or should know is for an
9
item or service for which payment may not
10
be made under subparagraph (A) shall be
11
subject to a civil money penalty of not more
12
than $15,000 for each such item or service.
13
The provisions of section 1128A (other than
14
the first sentence of subsection (a) and other
15
than subsection (b)) shall apply to a civil
16
money penalty under the previous sentence
17
in the same manner as such provisions apply
18
to a penalty or proceeding under section
19
1128A(a).
20
"(D) REFERRING PHYSICIAN DEFINED.-In
21
this paragraph, the term 'referring physician'
22
means, with respect to providing home intrave-
23
nous drug therapy services to an individual, a
24
physician who-
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19
1
"(i) prescribed the covered home intra-
2
venous drug for which the services are to be
3
provided, or
4
"(ii) established the plan of care for
5
such services.".
6
(2) PROPAC STUDY.-The Prospective Payment
7
Assessment Commission shall conduct a study, and
8
make recommendations to Congress and the Secretary
9
of Health and Human Services by not later than
10
March 1, 1992, concerning appropriate adjustment to
11
the payment amounts provided under section 1886(d)
12
of the Social Security Act for inpatient hospital serv-
13
ices to account for reduced costs to hospitals resulting
14
from the amendments made by this section.
15
(3) INSPECTOR GENERAL REPORT ON POTEN-
16
TIALLY ABUSIVE OWNERSHIP OR COMPENSATION AR-
17
RANGEMENTS.-The Inspector General of the Depart-
18
ment of Health and Human Services shall study and
19
report to Congress, by not later than May 1, 1991,
20
concerning-
21
(A) physician ownership of, or compensation
22
from, an entity providing items or services to
23
which the physician makes referrals and for
24
which payment may be made under the medicare
25
program;
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20
1
(B) the range of such arrangements and the
2
means by which they are marketed to physicians;
3
(C) the potential of such ownership or com-
4
pensation to influence the decision of a physician
5
regarding referrals and to lead to inappropriate
6
utilization of such items and services; and
7
(D) the practical difficulties involved in
8
enforcement actions against such ownership and
9
compensation arrangements that violate current
10
anti-kickback provisions.
11
Such report shall include such recommendations as
12
may be appropriate to strengthen current law provi-
13
sions to prevent program abuse.
14
(d) CERTIFICATION.-
15
(1) IN GENERAL.-Section 1835(a)(2) of such Act
16
(42 U.S.C. 1395n(a)(2)) as amended by section 2(d) of
17
this Act, is further amended-
18
(A) by striking "and" at the end of subpara-
19
graph (F);
20
(B) by striking the period at the end of sub-
21
paragraph (G) and inserting "; and"; and
22
(C) by inserting after subparagraph (G) the
23
following new subparagraph:
24
"(H) in the case of home intravenous drug
25
therapy services, (i) such services are or were re-
S
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21
1
quired because the individual needed such services
2
or the administration of a covered home intrave-
3
nous drug, (ii) a plan for furnishing such services
4
has been established and is reviewed periodically
5
by a physician, (iii) such services are or were fur-
6
nished while the individual is or was under the
7
care of a physician, (iv) such services are adminis-
8
tered in a place of residence used as such individ-
9
ual's home, and (v) with respect to such services
10
initiated before January 1, 1993, such services
11
have been reviewed and approved by a utilization
12
and peer review organization under section
13
1154(a)(16) before the date such services were
14
initiated (or, in the case of services first initiated
15
on an outpatient basis, within 1 working day
16
(except in exceptional circumstances) of the date
17
of initiation of the services)."
18
(2) PRIOR APPROVAL REQUIRED.-Section
19
1154(a) of such Act (42 U.S.C. 1320c-3(a)), as re-
20
stored by section 201(a)(1) of the Medicare Catastroph-
21
ic Coverage Repeal Act of 1989, is amended by adding
22
at the end the following new paragraph:
23
"(16) The organization shall perform the review
24
described in paragraph (1) with respect to home intra-
25
venous drug therapy services (as defined in section
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2246 IS
22
1
1861(kk)(1)) initiated before January 1, 1993, within 1
2
working day of the date of the organization's receipt of
3
a request for such review. The Secretary shall estab-
4
lish criteria to be used by such an organization in con-
5
ducting reviews with respect to the appropriateness of
6
home intravenous drug therapy services under this
7
paragraph.".
8
(e) CERTIFICATION OF HOME INTRAVENOUS DRUG
9 THERAPY PROVIDERS; INTERMEDIATE SANCTIONS FOR
10 NONCOMPLIANCE.-
11
(1) TREATMENT AS PROVIDER OF SERVICES.-
12
Section 1861(u) of such Act (42 U.S.C. 1395x(u)), as
13
restored by section 201(a)(1) of the Medicare Cata-
14
strophic Coverage Repeal Act of 1989, is amended by
15
inserting "home intravenous drug therapy provider,"
16
after "hospice program,".
17
(2) CONSULTATION WITH STATE AGENCIES AND
18
OTHER ORGANIZATIONS.-Section 1863 of such Act
19
(42 U.S.C. 1395z), as restored by section 201(a)(1) of
20
the Medicare Catastrophic Coverage Repeal Act of
21
1989, is amended by striking "and (dd)(2)" and insert-
22
ing "(dd)(2), and (kk)(4)".
23
(3) USE OF STATE AGENCIES IN DETERMINING
24
COMPLIANCE.-Section 1864(a) of such Act (42
25
U.S.C. 1395aa(a)), as restored by section 201(a)(1) of
S
2246 IS
23
1
the Medicare Catastrophic Coverage Repeal Act of
2
1989, is amended-
3
(A) in the first sentence, by inserting "or a
4
home intravenous drug therapy provider," after
5
"hospice program", and
6
(B) in the second sentence, by striking "or
7
hospice program" and inserting "hospice program,
8
or home intravenous drug therapy provider".
9
(4) APPLICATION OF INTERMEDIATE SANC-
10
TIONS.-Section 1846 of such Act (42 U.S.C. 1395w-
11
2), as restored by section 201(a)(1) of the Medicare
12
Catastrophic Coverage Repeal Act of 1989, is
13
amended-
14
(A) in the heading, by adding "AND FOR
15
QUALIFIED HOME INTRAVENOUS DRUG THERAPY
16
PROVIDERS" at the end;
17
(B) in subsection (a), by inserting "or that a
18
qualified home intravenous drug therapy provider
19
that is certified for participation under this title no
20
longer substantially meets the requirements of
21
section 1861(kk)(4)" after "under this part"; and
22
(C) in subsection (b)(2)(A)(iv) by inserting "or
23
home intravenous drug therapy services" after
24
"clinical diagnostic laboratory tests".
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24
1
(f) USE OF REGIONAL INTERMEDIARIES IN ADMINIS-
2 TRATION OF BENEFIT.-Section 1816 of such Act (42
3 U.S.C. 1395h), as restored by section 201(a)(1) of the Medi-
4 care Catastrophic Coverage Repeal Act of 1989, is amended
5 by adding at the end thereof the following new subsection:
6
"(k) With respect to carrying out functions relating to
7 payment for home intravenous drug therapy services and
8 covered home intravenous drugs, the Secretary may enter
9 into contracts with agencies or organizations under this sec-
10 tion to perform such functions on a regional basis."
11
(g) EFFECTIVE DATE.-The amendments made by this
12 section shall apply to items and services furnished on or after
13 January 1, 1991.
14 SEC. 6. FINANCING THROUGH INCREASE IN MEDICARE PART B
15
PREMIUM.
16
(a) INCREASE IN PREMIUM.-Section 1839 of the
17 Social Security Act (42 U.S.C. 1395r), as restored by section
18 202(a) of the Medicare Catastrophic Coverage Repeal Act of
19 1989, is amended by adding at the end the following new
20 subsection:
21
"(g)(1) Except as provided in subsection (f), the monthly
22 premium for each individual enrolled under this part other-
23 wise determined, without regard to this subsection, shall be
24 increased (for months occurring in 1991 through 1995) by
25 the following additional premium or (for months after Decem-
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25
1 ber 1995) by such an additional premium determined in ac-
2 cordance with paragraph (2):
3
"(A) For months in 1991, $.55.
4
"(B) For months in 1992, $.95.
5
"(C) For months in 1993, $1.08.
6
"(D) For months in 1994, $1.29.
7
"(E) For months in 1995, $1.57.
8
"(2)(A) The Secretary shall, during September of 1995
9 and of each year thereafter, determine and promulgate the
10 additional premium under this subsection for months in the
11 succeeding year. Such premium amount shall be equal to the
12 amount the Secretary estimates to be necessary SO that the
13 aggregate amount of premiums collected under this subsec-
14 tion for months in the year will equal the total of the benefits
15 and administrative costs which the Secretary estimates will
16 be payable in such year from the Federal Hospital Insurance
17 Trust Fund and the Federal Supplementary Medical Insur-
18 ance Trust Fund that are attributable to the amendments
19 made by the Medicare Home Benefits Improvement Act of
20 1990. In calculating such additional premium, the Secretary
21 shall include an appropriate amount for a contingency
22 margin, and shall adjust such premium to take into account
23 the amounts by which the additional premiums established
24 under this subsection with respect to months in any year are
25 greater or less than the amounts required to pay for benefits
S 2246 IS
26
1 paid and such administrative costs incurred in such year that
2 are attributable to the Medicare Home Benefits Improvement
3 Act of 1990.
4
"(B) If any premium increase for a month under this
5 paragraph is not a multiple of 10 cents, the Secretary shall
6 round the increase to the nearest multiple of 10 cents.".
7
(b) CONFORMING AMENDMENTS.-
8
(1) Section 1839 of such Act (42 U.S.C. 1395r),
9
as restored by section 202(a) of the Medicare Cata-
10
strophic Coverage Repeal Act of 1989, is amended-
11
(A) in the second sentence of subsections
12
(a)(1) and (a)(4), by inserting "(other than costs
13
relating to the amendments made by the Medicare
14
Home Benefits Improvement Act of 1990)"
15
before the period;
16
(B) in subsection (a)(2), by striking "and (e)"
17
and inserting ", (e), and (g)";
18
(C) in subsection (a)(3), by striking "subsec-
19
tion (e)" and inserting "subsections (e) and (g)";
20
(D) in subsection (b), by striking "determined
21
under subsection (a) or (e)" and inserting "other-
22
wise determined under this section (without
23
regard to subsections (f) and (g))"; and
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27
1
(E) in subsection (e)(1), by inserting "except
2
as provided in subsection (g)," after "subsection
3
(a)".
4
(2) Section 1844(a) of such Act (42 U.S.C.
5
1395w(a)), as restored by section 202(a) of the Medi-
6
care Catastrophic Coverage Repeal Act of 1989, is
7
amended by adding at the end the following:
8 "In computing the amount of aggregate premiums and pre-
9 miums per enrollee under paragraph (1), there shall not be
10 taken into account premiums attributable to section
11 1839(g).".
12
(c) EFFECTIVE DATE.-The amendments made by this
13 section shall apply to monthly premiums for months begin-
14 ning with January 1991.
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1 and reimbursing long-term home care services for seriously
2 mentally ill individuals and family caregivers.
3
"(b) DEFINITION.-As used in section, the term 'seri-
4 ously mentally ill individual' means an individual who a li-
5 censed mental health professional in the individual's State of
6 residence certifies-
7
"(1) has schizophrenia, bipolar or unipolar disor-
8
der or other significant mental illness that restrict the
9
ability of the individual to function in activities of daily
10
living, employment, and social interaction;
11
"(2) has been previously institutionalized or is at
12
risk of being institutionalized in the absence of the
13
services provided under this section; and
14
"(3) is not institutionalized at the time of the cer-
15
tification.
16
"(c) REQUIREMENTS.-Demonstration projects con-
17 ducted under this section shall-
18
"(1) each be conducted over a period of 3 years;
19
"(2) be conducted in sites that are chosen to be
20
geographically diverse and include at least one rural
21
site;
22
"(3) be sensitive to the needs of racial and ethnic
23
minorities;
24
"(4) include outreach and case management ac-
25
tivities;
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1
"(5) be responsive to family needs and concerns
2
and appropriately involve and consult with family
3
members regarding the provision of services under this
4
section;
5
"(6) specify, at the time of application, specific
6
outcome expectations to be met by the project and
7
identify appropriate mechanisms for measuring such
8
outcomes; and
9
"(7) include testing the use of different agencies
10
as Case Management Agencies and providing for the
11
selection of such agencies in consultation with the
12
Comptroller General.
13
"(d) OTHER SERVICES.-Demonstration projects con-
14 ducted under this section may-
15
"(1) provide services or reimbursement for nursing
16
care, homemaker or homehealth aide services, psycho-
17
social services, medical services, including the provi-
18
sion, monitoring, and testing of necessary medications,
19
client and family education, training, and counseling,
20
respite care, crisis intervention, information and refer-
21
ral services, and rehabilitation; and
22
"(2) provide services to seriously mentally ill indi-
23
viduals or provide services to home caregivers (includ-
24
ing family members) when such services augment and
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1
support home caregivers in the care of seriously men-
2
tally ill individuals.
3
"(e) EVALUATION.-The Secretary shall provide for the
4 evaluation of the projects on a concurrent basis and shall
5 prepare and submit to the appropriate Committees of Con-
6 gress, not later than 18 months after the initiation of the
7 projects and on the completion of the projects, a report on the
8 findings of the evaluation. Such evaluation shall measure the
9 cost and effectiveness of funded projects against the outcome
10 expectations identified in the initial applications and include
11 relevant data on client and family satisfaction and perceived
12 benefits, together with such additional information as the
13 Secretary may consider appropriate.
14
"(f) AUTHORIZATION OF APPROPRIATIONS.-There
15 are authorized to be appropriated from the Federal Hospital
16 Insurance Trust Fund for each of the fiscal years 1991,
17 1992, and 1993, not to exceed $10,000,000 to carry out
18 demonstration projects under this section and not to exceed
19 $1,000,000 to carry out the evaluation of such projects under
20 subsection (e).
21 "SEC. 2152. DEMONSTRATION PROJECTS FOR WORKING AGE
22
INDIVIDUALS WITH SEVERE FUNCTIONAL LIMI-
23
TATIONS.
24
"(a) IN GENERAL.-The Secretary shall conduct at
25 least 5 and not more than 10 demonstration projects to deter-
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1 mine the feasibility of providing long-term home care benefits
2 under title ХѴШ of this Act for working-age individuals
3 with severe functional limitations (as defined in subsection
4 (b)).
5
"(b) DEFINITION.-As used in this section, the term
6 'working-age individual with severe functional limitations'
7 means an individual who is over 18 years of age, but under
8 65 years of age, who is not entitled to benefits under title
9 ХѴШ but who is a chronically ill individual, within the
10 meaning of section 1861(jj)(1)(A)(i).
11
"(c) REQUIREMENTS.-Demonstration projects under
12 this section-
13
"(1) shall include, in the items and services cov-
14
ered under long-term home care, personal care serv-
15
ices, short term respite, and emergency assistance and
16
shall permit coverage of items and services provided
17
either by home health agencies or by other qualified
18
persons;
19
"(2) may provide for limited cost-sharing for long-
20
term home care;
21
"(3) shall provide that payment rates for long-
22
term home care provided by persons other than home
23
health agencies shall be comparable to the payment
24
rates for such care provided by home health agencies;
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1
"(4) shall provide that each plan of care for an in-
2
dividual shall take into account the capability of the in-
3
dividual to direct the long-term home care of the indi-
4
vidual and to train persons in providing that care;
5
"(5) shall test the effectiveness of consumer-di-
6
rected living centers that are primarily engaged in as-
7
sisting working age individuals with severe functional
8
limitations in maximizing their independence;
9
"(6) shall, to the maximum extent practicable,
10
cover working age individuals with severe functional
11
limitations who-
12
"(A) are at imminent risk of institutionaliza-
13
tion within 30 days if such individual is not pro-
14
vided long-term home care;
15
"(B) are institutionalized but who, if provid-
16
ed long-term home care, could be discharged from
17
the institution; or
18
"(C) need long-term home care to secure or
19
continue employment, to increase independence,
20
to enable present caregivers to secure or continue
21
employment, or to stabilize families;
22
"(7) shall include projects under which personal
23
care services are made available away from the pri-
24
mary residence of the individual, as well as at that res-
25
idence; and
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1
"(8) shall include projects under which family
2
members may be employed as caregivers if the family
3
members would be employed if not providing such care
4
or if the individual requires more than 20 hours a week
5
of long-term home care.
6
"(d) CONSULTATION, EVALUATION, REPORT.-
7
"(1) CONSULTATION.-In designing and evaluat-
8
ing the projects conducted under this section, the Sec-
9
retary shall consult with experts in the field of disabil-
10
ity policy and independent living and with groups rep-
11
resenting working age individuals with severe function-
12
al limitations.
13
"(2) EVALUATION.-The Secretary shall provide
14
for the evaluation of the projects conducted under this
15
section on a concurrent basis. Such evaluation shall in-
16
clude an evaluation of the size of the demand, cost, rel-
17
ative effectiveness, and impact on quality of life, of
18
providing long-term home care to working age individ-
19
uals with severe functional limitations.
20
"(3) REPORT.-Not later than 18 months after
21
the date on which the projects conducted under this
22
section are completed, the Secretary shall prepare and
23
submit, to the appropriate Committees of Congress, a
24
report concerning the findings of the evaluation under
25
paragraph (2). The Secretary shall include in such
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1
report recommendations for appropriate legislative
2
changes.
3
"(e) FUNDING.-The Secretary shall make available
4 from the Federal Hospital Insurance Trust Fund-
5
"(1) for each of fiscal years 1991, 1992, and
6
1993 not to exceed $10,000,000 to carry out demon-
7
stration projects under this section; and
8
"(2) for the 3-fiscal-year period beginning with
9
fiscal year 1991 not to exceed $1,000,000 to carry out
10
the evaluation of such projects under this section.
11 "SEC. 2153. GENERAL AUTHORITY.
12
"(a) PAYMENTS.-Payments under demonstration
13 projects under this part may be made in advance or by way of
14 reimbursement, as may be determined by the Secretary, and
15 shall be made in such installments and on such conditions as
16 the Secretary finds necessary to carry out the purpose of this
17 section.
18
"(b) MEDICARE WAIVERS.-The Secretary may waive
19 such requirements of title ХѴШ as may be required to carry
20 out demonstration projects under this section."
21 SEC. 1003. EFFECTIVE DATE.
22
(a) IN GENERAL.-Except as otherwise provided in this
23 section, this division and the amendments made by this divi-
24 sion, shall become effective on the date of enactment of this
25 Act.
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1
(b) COVERAGE OF HOME AND COMMUNITY-BASED
2 CARE SERVICES.-Part B of title XXI of the Social Security
3 Act (as added by section 1002 of this Act) shall require pay-
4 ment for services provided in accordance with such part after
5 1 year after the date of enactment of this Act.
6
(c) COVERAGE FOR NURSING HOME CARE.-Part C of
7 such title shall apply to nursing home care provided in ac-
8 cordance with such part on or after January 1 of the third
9 year that begins after the date of enactment of this Act.
10
(d) FEDERAL LONG-TERM CARE INSURANCE PRO-
11 GRAM.-Part D of such title shall require the establishment
12 of a Federal long-term care insurance program in accordance
13 with such part on and after January of the second year that
14 begins after the date of enactment of this Act. Payment for
15 nursing care under such part shall begin on January 1 of the
16 third year that begins after the date of enactment of this Act.
17
(e) TRAINING AND RESEARCH.-Part E of such title
18 shall require training and research programs in accordance
19 with such part on and after January 1, 1991.
20 Division C-Grants to States for Es-
21
tablishment and Implementation of
22
State Health Objectives Plans
23 SEC. 2001. SHORT TITLE.
24
This division may be cited as the "Health Objectives
25 2000 Act".
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1 SEC. 2002. REFERENCES.
2
Whenever in this division an amendment or repeal is
3 expressed in terms of an amendment to, or repeal of, a sec-
4 tion or other provision, the reference shall be considered to
5 be made to a section or other provision of the Public Health
6 Service Act (42 U.S.C. 201 et seq.).
7 SEC. 2003. PURPOSE.
8
It is the purpose of this division to implement the Year
9 2000 National Health Objectives through the provision of as-
10 sistance to Designated Official State Public Health Agencies
11
to-
12
(1) provide sufficient capacity and resources to
13
States and localities to assist such States and localities
14
in achieving the Year 2000 National Health Objec-
15
tives, including-
16
(A) reducing tobacco, alcohol, and other drug
17
use and abuse;
18
(B) improving nutrition;
19
(C) increasing physical activity and fitness;
20
(D) improving mental health and preventing
21
mental illness;
22
(E) reducing environmental health hazards,
23
improving occupational safety and health, and
24
preventing and controlling unintentional injuries;
25
(F) reducing violent and abusive behavior;
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1
(G) preventing and controlling HIV infection
2
and AIDS and sexually transmitted diseases;
3
(H) immunizing against and controlling infec-
4
tious diseases;
5
(I) improving maternal and infant health;
6
(J) improving oral health;
7
(K) reducing adolescent pregnancy and im-
8
proving reproductive health;
9
(L) preventing, detecting, and controlling
10
high blood cholesterol and high blood pressure;
11
(M) preventing, detecting, and controlling
12
cancer and other chronic diseases and disorders;
13
(N) maintaining the health and quality of life
14
of older individuals;
15
(O) improving health education and access to
16
preventive health services; and
17
(P) improving surveillance and data systems;
18
(2) create and develop a partnership of Federal,
19
State, and local health agencies, voluntary health orga-
20
nizations, and other health groups to develop initiatives
21
for preventing disease and illness;
22
(3) enable States and localities to address national
23
health policy issues; and
24
(4) assess the health status of the population of
25
the United States.
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1 SEC. 2004. AMENDMENT TO PUBLIC HEALTH SERVICE ACT.
2
Title XIX of the Public Health Service Act (42 U.S.C.
3 300w et seq.) is amended by adding at the end thereof the
4 following new part:
5 "PART D-NATIONAL HEALTH OBJECTIVES GRANTS To
6
STATES
7 "SEC. 1941. DEFINITIONS AND ADMINISTRATION.
8
"(a) DEFINITIONS.-As used in this part:
9
"(1) ADVISORY COMMITTEE.-The term 'Adviso-
10
ry Committee' means the National Health Objectives
11
Advisory Committee established under section 1948(a).
12
"(2) CORE PRIORITIES.-The term 'Core Prior-
13
ities' means the National Health Priorities that are
14
designated by the Secretary as 'Core National Health
15
Priorities' and that must be included in the State
16
health objectives provided in the State health objec-
17
tives plan of each State.
18
"(3) NATIONAL HEALTH PRIORITIES.-The term
19
'National Health Priorities' means the priorities estab-
20
lished under section 1948(b).
21
"(4) STATE AGENCY.-The term 'State agency'
22
means the department, agency, commission, or other
23
entity designated and vested with authority under
24
State law over matters concerning public health.
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1
"(5) STATE PLAN.-The term 'State plan' means
2
the health objectives plan of a State submitted under
3
section 1946.
4
"(6) STATE REPORT.-The term 'State report'
5
means the annual report of a State required under sec-
6
tion 1947.
7
"(b) ADMINISTRATION.-The Secretary shall carry out
8 this part through the Centers for Disease Control.
9 "SEC. 1942. AUTHORIZATION OF APPROPRIATIONS.
10
"For the purpose of making allotments to States to
11 carry out this part, there are authorized to be appropriated-
12
"(1) $600,000,000 for fiscal year 1991;
13
"(2) $700,000,000 for fiscal year 1992;
14
"(3) $800,000,000 for fiscal year 1993;
15
"(4) $900,000,000 for fiscal year 1994; and
16
"(5) $1,000,000,000 for fiscal year 1995.
17 "SEC. 1943. ALLOTMENTS.
18
"(a) AMOUNT.-
19
"(1) IN GENERAL.-The Secretary shall use not
20
to exceed 90 percent of the amounts appropriated
21
under section 1942 for each fiscal year to make allot-
22
ments in accordance with paragraphs (2) and (3).
23
"(2) POPULATION.-From amounts available for
24
allotments under paragraph (1), the Secretary shall
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1
allot in each fiscal year to each State an amount that
2
equals-
3
"(A) $25,000, if the population of the State
4
does not exceed 50,000;
5
"(B) $75,000, if the population of the State
6
exceeds 50,000 but does not exceed 450,000;
7
"(C) $1,000,000, if the population of the
8
State exceeds 450,000 but does not exceed
9
1,000,000;
10
"(D) $1,500,000, if the population of the
11
State exceeds 1,000,000 but does not exceed
12
3,000,000;
13
"(E) $2,000,000, if the population of the
14
State exceeds 3,000,000 but does not exceed
15
6,000,000;
16
"(F) $2,500,000, if the population of the
17
State exceeds 6,000,000 but does not exceed
18
10,000,000;
19
"(G) $3,000,000, if the population of the
20
State exceeds 10,000,000 but does not exceed
21
15,000,000; and
22
"(H) $4,000,000, if the population of the
23
State exceeds 15,000,000.
24
"(3) RELATIVE POPULATION.-To the extent
25
that all amounts available for allotment under para-
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1
graph (1) for each fiscal year are not otherwise allotted
2
to States under paragraph (2), such excess shall be al-
3
lotted to each State in an amount that bears the same
4
ratio to such excess amount for such fiscal year as the
5
total population of the States bears to the population of
6
all States.
7
"(4) ADJUSTMENT.-If for any fiscal year the
8
amount appropriated under section 1942 is less than
9
the total of all amounts listed under paragraph (2), the
10
amount allotted to each State shall be an amount that
11
bears the same ratio to the total of all amounts avail-
12
able for allotment under such section as the amount of
13
the allotment that the State is entitled to under para-
14
graph (2) bears to the total of all such amounts under
15
such paragraph.
16
"(b) UNALLOTTED AMOUNTS.-To the extent that all
17 the amounts appropriated under section 1942 for a fiscal year
18 and available for allotment in such fiscal year are not other-
19 wise allotted to States because one or more State has notified
20 the Secretary that such State does not intend to use the full
21 amount of their allotment, such excess shall be allotted
22 among each of the remaining States in proportion to the
23 amount otherwise allotted to such States for such fiscal year
24 under subsection (a)(3).
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1
"(c) ADMINISTRATION AND TRAINING.-The Secretary
2 shall use not to exceed 10 percent of the amounts appropri-
3 ated under section 1942 for each fiscal year as provided for in
4 section 1948(f).
5 "SEC. 1944. PAYMENTS UNDER ALLOTMENTS TO STATES.
6
"(a) IN GENERAL.-
7
"(1) PLAN REQUIREMENT.-For each fiscal year,
8
the Secretary shall make payments from amounts ap-
9
propriated for that fiscal year, as provided for in sec-
10
tion 6503(a) of title 31, United States Code, to each
11
State, if such State has submitted an approved State
12
plan, from its allotment under section 1943.
13
"(2) CARRYOVER FUNDS.-Any amount paid to a
14
State for a fiscal year and remaining unobligated at the
15
end of such year shall remain available for the next
16
fiscal year to such State for the purposes for which it
17
was made.
18
"(b) REDUCTION IN AMOUNT.-
19
"(1) IN GENERAL.-The Secretary, at the request
20
of a State, may reduce the amount of payments that a
21
State is entitled to under subsection (a) in an amount
22
equal to-
23
"(A) the fair market value of any supplies or
24
equipment furnished the State; and
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1
"(B) the total amount of any pay, allow-
2
ances, and travel expenses of any officer or em-
3
ployee of the Federal government when detailed
4
to the State and the amount of any other costs
5
incurred in connection with the detail of such offi-
6
cer or employee;
7
when the furnishing of such supplies or equipment or
8
the detail of such officers or employees is for the con-
9
venience and at the request of the State and for the
10
purpose of conducting activities described in section
11
1945.
12
"(2) USE OF REDUCTION.-The amount by which
13
any payment is reduced under paragraph (1) shall be
14
available for payment by the Secretary of the costs in-
15
curred in furnishing the supplies or equipment or in de-
16
tailing the personnel, on which the reduction of the
17
payment is based, and the amount shall be considered
18
to be part of the payment and to have been paid to the
19
State.
20 "SEC. 1945. USE OF ALLOTMENTS.
21
"(a) STATE PLAN.-Except as provided in subsections
22 (b) and (c), a State shall utilize amounts paid to it under
23 section 1944, from the allotment of such State under section
24 1943(a), to develop and implement a State plan, in accord-
25 ance with section 1946, for-
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1
"(1) each of the fiscal years 1991 and 1992,
2
that-
3
"(A) develops and collects data to assess the
4
public health needs and status of the individuals
5
that reside in the State;
6
"(B) requires and provides assistance for
7
planning necessary to assist projects and programs
8
described in the State plan; and
9
"(C) provides for the availability of assist-
10
ance to projects and programs described in the
11
State plan; and
12
"(2) fiscal year 1993, and for each fiscal year
13
thereafter during which the State receives payments
14
under section 1944, that in addition to the activities
15
described in paragraph (1), provides for the funding of
16
projects and programs authorized under sections 1904
17
and 1910.
18
"(b) LIMITATIONS.-A State shall not use amounts
19 paid to it under section 1944, to-
20
"(1) provide inpatient services;
21
"(2) make cash payments to intended recipients of
22
health services;
23
"(3) purchase or improve land, purchase, con-
24
struct, or permanently improve (other than minor re-
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1
modeling) any building or other facility, or purchase
2
major medical equipment; or
3
"(4) satisfy any requirement for the expenditure of
4
non-Federal funds as a condition for the receipt of Fed-
5
eral funds.
6
"(c) ADMINISTRATION.-Not more than 10 percent of
7 the total amount paid to a State under section 1944 from the
8 State allotment under section 1943(a) for any fiscal year shall
9 be used for administering the funds made available under sec-
10 tion 1944. The State shall pay from non-Federal sources any
11 additional costs of administering such funds. For purposes of
12 this subsection, the term 'administration' shall not be con-
13 strued to include collection or assessment of data.
14 "SEC. 1946. STATE HEALTH OBJECTIVES PLAN AND DESCRIP-
15
TION OF ACTIVITIES.
16
"(a) IN GENERAL.-To receive a payment under sec-
17 tion 1944 from the State allotment for a fiscal year under
18 section 1943(a), a State shall prepare and submit, to the Sec-
19 retary, a State health objectives plan at such time, in such
20 manner, and containing such information as the Secretary
21 shall require. Such State plan shall meet the requirements of
22 subsection (b) and shall contain assurances satisfactory to the
23 Secretary that the State will meet the requirements of sub-
24 section (c).
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1
"(b) REQUIREMENTS.-A State plan submitted under
2 subsection (a) shall-
3
"(1) contain a specific set of not less than five
4
State health objectives that shall be chosen from the
5
National Health Priorities described by the Secretary
6
under section 1948, and that shall include all Core Pri-
7
orities identified under such section;
8
"(2) contain an annual budget that describes the
9
manner in which the payments made under section
10
1944 are to be used by the State, and such budget
11
shall-
12
"(A) specify the portion of such funds that
13
are to be used at each level of the State or local
14
government, and the portion of such funds that
15
are to be allocated for grants to local agencies of
16
public health, community-based health organiza-
17
tions, voluntary nonprofit health organizations,
18
and other entities selected by the State help meet
19
State objectives under paragraph (6); and
20
"(B) commit the State to use not less than
21
80 percent of such payments to meet State objec-
22
tives that, as determined by the State agency
23
after an analysis of the National Health Priorities,
24
and based on the available State data described in
25
paragraph (3), are critical to improving the health
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1
status of the individuals who reside within the
2
State;
3
"(3) in terms of each State objective-
4
"(A) provide assurances satisfactory to the
5
Secretary that there is a minimum set of data
6
available to satisfactorily measure the health
7
status of individuals who reside within the State;
8
"(B) utilize the date described in subpara-
9
graph (A) to identify the improvement that the
10
State expects to make in the health status of indi-
11
viduals who reside within the State during the
12
term of the State plan;
13
"(C) specify the particular strategies, projects
14
and programs intended to be used by the State to
15
improve the health status of individuals who
16
reside within the State;
17
"(D) specify the methods intended to be used
18
by the State to evaluate the progress made by the
19
State in improving the health status of individuals
20
who reside within the State; and
21
"(E) provide services targeted at improving
22
the health status of individuals who reside within
23
the State at the level of State or local govern-
24
ment that the State determines is most likely to
25
be effective in achieving the State objectives;
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1
"(4) provide for the establishment of procedures
2
through which the State shall monitor the progress of
3
local health agencies, community-based organizations,
4
and health organizations in implementing the
5
State objectives;
6
"(5) identify public health personnel requirements
7
that the State determines are reasonably ne sary and
8
appropriate to permit the State to achieve e State
9
objectives;
10
"(6) identify the mechanism by which the State
11
shall select, and allocate assistance provided under this
12
part to local units of government, local agencies of
13
public health, community-based health organizations,
14
voluntary nonprofit health organizations, and other en-
15
tities within the State to help meet the State objec-
16
tives; and
17
(7) contain a description (that may be revised
18
throughout the year as may be necessary to reflect
19
substantial changes in the projects and programs as-
20
sisted by the State) of the intended use of the pay-
21
ments the State will receive under section 1944 for the
22
fiscal year for which the State plan is submitted, in-
23
cluding information concerning the projects and pro-
24
grams to be supported and services to be provided,
25
which shall be made available to the public within the
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1
State in a manner that will facilitate comment from
2
any individual during the period of the development of
3
the description and after the transmittal of such.
4
"(c) ASSURANCES.-As part of the State plan required
5 under subsection (a), a State shall provide assurances satis-
6 factory to the Secretary that such State-
7
"(1) shall use the amounts allotted to it under
8
section 1943 in accordance with the requirements of
9
the State plan and of this part;
10
"(2) shall establish reasonable criteria for the
11
evaluation of the effective performance of entities that
12
receive assistance from the allotment to the State
13
under this part;
14
"(3) shall identify those populations, areas, and lo-
15
calities in the State that demonstrate a need for the
16
services for which funds may be provided by the State
17
under this part; and
18
"(4) shall use amounts made available under sec-
19
tion 1944 for any period to supplement and increase
20
the level of State, local, and other Federal assistance
21
that would, in the absence of amounts available under
22
section 1944, be made available for the programs and
23
activities for which funds are provided for under this
24
part, and shall not use funds made available under this
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1
part to supplant such State, local, and other Federal
2
funds.
3 "SEC. 1947. STATE HEALTH OBJECTIVES REPORT.
4
"(a) IN GENERAL.-Not later than 120 days after the
5 end of each fiscal year for which assistance is provided under
6 this part, each State, in cooperation with participating local
7 units of government, shall prepare and submit, to the Secre-
8 tary, an annual State health objectives report concerning the
9 activities of the State under this part, that meets the require-
10 ments of this section.
11
"(b) REQUIREMENTS.-A State report submitted under
12 subsection (a) shall be in such form and contain such informa-
13 tion as the Secretary determines, after consultation with the
14 heads of the State agencies and the Comptroller General, to
15 be necessary-
16
"(1) to determine whether funds were expended
17
by the State in accordance with this part and consist-
18
ent with the needs within the State as proscribed in
19
the State plan;
20
"(2) to secure a description of the projects and
21
programs within the State operated or assisted with
22
amounts provided under allotments made under this
23
part; and
24
"(3) to secure a record of-
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1
"(A) the purposes for which amounts
2
provided under this part were expended;
3
"(B) the recipients of such funds; and
4
"(C) the progress made toward achieving the
5
purposes for which such funds were provided.
6
"(c) UNIFORM DATA ITEM.-A State report submitted
7 under subsection (a) shall include information concerning at
8 least one uniform data item on each National Health Priority
9 addressed in the State plan, to be determined in consultation
10 with the Secretary.
11
"(d) ADDITIONAL CONTENTS.-The Secretary may re-
12 quire States to include additional information in the State
13 report submitted under this section if such requirements are
14 not unduly burdensome.
15
"(e) AVAILABILITY.-The State shall ensure that the
16 State report is available for public inspection within the
17 State, and the Secretary shall provide copies, on request, to
18 any interested individual.
19 "SEC. 1948. RESPONSIBILITIES OF THE SECRETARY.
20
"(a) ADVISORY CoMMiTTee.-
21
"(1) ESTABLISHMENT.-The Secretary shall es-
22
tablish an advisory committee, to be known as the 'Na-
23
tional Health Objectives Advisory Committee', to
24
advise the Secretary concerning National Health
25
Priorities.
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1
"(2) COMPOSITION.-The Advisory Committee
2
shall be composed of 9 members, of which-
3
"(A) one member shall be the Assistant Sec-
4
retary for Health, who shall serve as chairperson;
5
"(B) two members shall be appointed by the
6
Secretary from the general public;
7
"(C) one member shall be appointed by the
8
Administrator of the Environmental Protection
9
Agency;
10
"(D) two members shall be appointed by
11
the Association of State and Territorial
12
Health Officials;
13
"(E) one member shall be appointed by the
14
National Association of County Health Officials;
15
"(F) one member shall be appointed by the
16
United States Conference of Local Health Offi-
17
cials; and
18
"(G) one member shall be appointed by the
19
Association of Schools of Public Health.
20
"(3) MEETINGS AND DUTY.-The Advisory Com-
21
mittee shall meet not less than once each year for the
22
purpose of providing advice to the Secretary concern-
23
ing the selection, revision, implementation, and evalua-
24
tion of the National Health Priorities.
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1
"(b) NATIONAL HEALTH PRIORITIES.-The Secretary,
2 in consultation with the heads of other Federal agencies and
3 the Advisory Committee, and taking into account the 'Year
4 2000 Health Objectives' developed by the United States
5 Public Health Service, shall establish-
6
"(1) National Health Priorities that shall form the
7
basis for all activities that receive assistance under this
8
part;
9
"(2) from the priorities established under para-
10
graph (1), a set of Core Priorities that shall be included
11
in each State plan; and
12
"(3) in cooperation with other appropriate nation-
13
al organizations, an estimate of the personnel and
14
training that will be needed throughout the United
15
States to accomplish the priorities established under
16
paragraph (1).
17
"(c) REVIEW OF STATE PLANS.-The Secretary shall
18 review each proposed State plan, and each proposed amend-
19 ment thereto, submitted by a State under section 1946, and
20 approve each such plan or amendment, or each portion of
21 such plan or amendment, that the Secretary determines com-
22 plies with the requirements of this part.
23
"(d) STATE REPORT.-The Secretary shall receive and
24 review each State report submitted by a State under section
25 1947, and shall compile, evaluate, and prepare and submit, to
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1 the appropriate Committees of Congress, and the President,
2 an annual National Health Objectives Report concerning the
3 data and information contained in such State.
4
"(e) OTHER ASSISTANCE.-The Secretary shall pro-
5 vide consultation, guidance, and technical assistance to State
6 and local units of government, and to other entities partici-
7 pating in the programs created under this part, to-
8
"(1) assist in the development of data sets as re-
9
quired under section 1946, and uniform data items re-
10
quired under section 1947; and
11
"(2) assist States with State plans, or amend-
12
ments to such plans, that the Secretary determines
13
does not comply with the requirements of this part, in
14
revising such plans or amendments to comply with the
15
requirements of this part.
16
"(f) RESEARCH AND TRAINING.-From amounts made
17 available under section 1943(c), the Secretary shall-
18
"(1) utilize not more than 5 percent, or
19
$5,000,000 whichever is less, to administer the assist-
20
ance made available to States under such section;
21
"(2) utilize 50 percent of all such remaining
22
amounts to provide assistance for the professional
23
training of public health personnel, including-
24
"(A) the identification of new knowledge
25
bases and skills for State and local public health
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1
personnel that are reasonably necessary and ap-
2
propriate to permit the States to achieve the Na-
3
tional Health Priorities; and
4
"(B) encouraging the training and education
5
of appropriate numbers of such personnel in such
6
knowledge bases and skills by establishing opera-
7
tive agreements with schools of public health and
8
other institutions that train and educate such per-
9
sonnel; and
10
"(3) utilize all such remaining amounts to provide
11
assistance for research, pilot and demonstration
12
projects and programs that the Secretary determines to
13
show the potential impact of regional or national sig-
14
nificance with respect to the National Health Prior-
15
ities.".
16 SEC. 2005. REPEAL.
17
Effective October 1, 1992, sections 1901, 1902, 1903,
18 1905, 1906, 1907, 1908, 1909, and 1910A of the Public
19 Health Service Act (42 U.S.C. 300w, 300w-1, 300w-2,
20 300w-4, 300w-5, 300w-6, 300w-7, 300w-8, 300w-9) are
21 repealed.
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1
"(ii) to require both a medical device to
2
compensate for the loss of a vital body func-
3
tion that is necessary to avert death or major
4
loss of bodily functional capacity and sub-
5
stantial and ongoing nursing care to avert
6
death or further disability;
7
"(3) the individual (or legal guardian) has filed an
8
application for such benefits, and is in need of, benefits
9
covered under this title;
10
"(4) receiving nursing home services in a nursing
11
facility would be in the best interest of the individual;
12
and
13
"(5) the Secretary determines that the individual
14
meets the eligibility requirements imposed under this
15
subsection.
16
"(b) CURRENT INDIVIDUALS.-An individual who is in
17 a hospital or nursing home on the date of the enrollment of
18 the individual in the program established by this part shall be
19 ineligible for coverage under this section until the individual's
20 first spell of illness beginning after such date.
21 "SEC. 2123. LIMITATIONS ON PAYMENT.
22
"(a) IN GENERAL.-Monthly reimbursement for nursing
23 home services covered under this part shall be an amount the
24 Secretary determines to be reasonable and appropriate,
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1 taking into account the average cost of providing appropriate
2 care.
3
"(b) PROSPECTIVE PAYMENT.-To the extent feasible,
4 the Secretary shall establish a prospective payment mecha-
5 nism for payment for nursing home services covered under
6 this part that takes into account the expected resource utili-
7 zation of individual patients based on the degree of impair-
8 ment of the patients and other factors affecting service re-
9 quirements.
10 "SEC. 2124. REIMBURSEMENT.
11
"Certified nursing homes shall accept payment for serv-
12 ices rendered under this part as payment in full and shall not
13 be allowed to pass on additional charges to beneficiaries for
14 covered services.
15 "SEC. 2125. RELATIONSHIP TO OTHER ENTITLEMENT PRO-
16
GRAMS.
17
"Notwithstanding" any other provision of law, in the
18 case of any service covered under this part that is also cov-
19 ered under any other Federally administered entitlement pro-
20 gram, the Secretary shall act as a secondary payer under this
21 part.
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1
"PART D-INSURANCE COVERAGE FOR NURSING
2
HOME CARE THAT EXCEEDS 6 MONTHS
3 "SEC. 2131. ESTABLISHMENT OF FEDERAL LONG-TERM CARE
4
INSURANCE PROGRAM.
5
"The Secretary shall establish an optional insurance
6 program for individuals 45 years of age and older (and, under
7 section 2137, for individuals of any age) to cover nursing
8 home stays that exceed 6 months.
9 "SEC. 2132. ELIGIBILITY.
10
"(a) DETERMINATION.
11
"(1) IN GENERAL.-A Screening Agency shall
12
determine whether an individual is eligible to receive
13
benefits covered under this part.
14
"(2) SCREENING TOOL.-The agency shall use
15
the same screening the first 6 months of nursing home
16
care under part C in order to determine the continued
17
need of an individual for nursing home care and there-
18
fore eligibility for benefits under this part.
19
"(3) PERIODIC EVALUATION.-The Case Man-
20
agement Agency shall continue to make such an eval-
21
uation periodically, pursuant to regulations of the Sec-
22
retary, as long as an individual remains in a nursing
23
home.
24
"(b) ELECTION OF COVERAGE.-
25
"(1) IN GENERAL.-Subject to the other provi-
26
sions of this subsection and section 2137, an individual
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1
shall have the option to purchase coverage under this
2
part at 45 years of age or at 65 years of age.
3
"(2) INITIAL YEAR.-During the 1-year period
4
beginning on the effective date of this part, an individ-
5
ual who is 45 years of age or over shall be eligible to
6
purchase insurance under this part, except that such an
7
individual shall not be eligible to purchase insurance
8
while confined to a hospital or nursing home or within
9
6 months after a period of confinement in a nursing
10
home or 90 days after a period of confinement in a
11
hospital.
12
"(3) EXTENSION BEYOND INITIAL YEAR.-If an
13
individual is confined to a nursing home or hospital
14
during a period that extends beyond the first year after
15
the effective date of this part, an individual shall be eli-
16
gible to enroll in the program established by this part
17
during the 60-day period beginning after the individ-
18
ual's first spell of illness.
19
"(4) SUBSEQUENT YEARS.-During years subse-
20
quent to the period referred to in paragraph (2), an in-
21
dividual shall be eligible to purchase insurance under
22
this part within 6 months of the 45th or 65th birthday
23
of the individual.
24
"(5) ACTIVATION OF BENEFITS.-To receive cov-
25
erage under the insurance program established by this
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1
part, an individual shall have purchased such coverage
2
at least 1 month prior to admission to a nursing facili-
3
ty, unless the reason for the need of services is because
4
of an accident or stroke subsequent to the date that
5
such individual signed up for coverage under this part.
6 "SEC. 2133. PREMIUM RATES.
7
"(a) IN GENERAL.-Except as provided under section
8 2137(b), the Secretary shall determine one premium rate for
9 individuals electing to purchase coverage under this part at
10 age 45 (or between ages 45 and 64 during the initial enroll-
11 ment period) and a separate rate for those who elect such
12 coverage at age 65 (or at age 65 and over during the initial
13 enrollment period).
14
"(b) REVISION.-The Secretary shall revise the premi-
15 ums annually.
16
"(c) RATES.-In developing premium rates under the
17 program established by this part, the Secretary shall establish
18 rates that are expected to cover 45 percent of the estimated
19 costs of nursing home stays that exceed 6 months for those
20 individuals enrolled in the program.
21
"(d) COST SHARING FOR Low-INCOME INDIVID-
22 UALS.-
23
"(1) IN GENERAL.-Subject to paragraph (2), the
24
Secretary shall pay-
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1
"(A) an amount equal to 100 percent of the
2
amount of the premium charged an eligible indi-
3
vidual under this section if the income of the indi-
4
vidual does not exceed 100 percent of the poverty
5
line for a single individual (as defined in section
6
673(2) of the Community Services Block Grant
7
Act (42 U.S.C. 9902(2)));
8
"(B) an amount equal to 75 percent of the
9
amount of the premium charged an eligible indi-
10
vidual under this section if the income of the indi-
11
vidual is between 100 percent and 150 percent of
12
the poverty line for a single individual (as defined
13
in section 673(2) of the Community Services
14
Block Grant Act (42 U.S.C. 9902(2))); and
15
"(C) an amount equal to 50 percent of the
16
amount of the premium charged an eligible indi-
17
vidual under this section if the income of the indi-
18
vidual is between 150 percent and 200 percent of
19
the poverty line for a single individual (as defined
20
in section 673(2) of the Community Services
21
Block Grant Act (42 U.S.C. 9902(2))).
22
"(2) MINIMUM PAYMENT.-Notwithstanding
23
paragraph (1), an eligible individual who elects to pur-
24
chase insurance under this part shall pay not less than
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1
$5 per month as part of the premium for such
2
insurance.
3 "SEC. 2134. BENEFITS.
4
"(a) TYPES.-An eligible individual who elects to pur-
5 chase insurance under this part shall be eligible to receive
6 from a nursing facility for an unlimited period of time (contin-
7 gent on the continued need of the individual for services)-
8
"(1) nursing care, provided by or under the super-
9
vision of a registered professional nurse;
10
"(2) physical, occupational, or speech therapy fur-
11
nished by the facility or by others under arrangements
12
with the facility;
13
"(3) medical social services;
14
"(4) drugs, biologicals, supplies, appliances, and
15
equipment for use in the facility, that are ordinarily
16
furnished by the facility for the care and treatment of
17
inpatients;
18
"(5) medical services of interns and residents-in-
19
training under an approved teaching program of a hos-
20
pital with which the facility has in effect a transfer
21
agreement and other diagnostic or therapeutic services
22
provided by a hospital with which the facility has in
23
effect a transfer agreement; and
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1
"(6) such other health services necessary to the
2
health of patients as are generally provided by nursing
3
facilities.
4
"(b) DURATION.-The duration of benefits covered
5 under this part shall be unlimited as long as the Case Man-
6 agement Agency determines, through its periodic review of a
7 patient, that the patient continues to require nursing home
8 services.
9 "SEC. 2135. QUALIFIED SERVICE PROVIDERS.
10
"(a) IN GENERAL.-Covered nursing home services
11 under this part shall be provided by qualified service
12 providers.
13
"(b) TYPES.-A provider shall be considered a qualified
14 service provider under this part if the provider is a nursing
15 facility that is certified by the State and meets the require-
16 ments of this part and any other standards established by the
17 Secretary by regulation for the safe and efficient provision of
18 services covered under this part.
19 "SEC. 2136. REIMBURSEMENT.
20
"(a) AMOUNT.-Monthly reimbursement for nursing
21 home services under this part shall be 65 percent of the
22 amount the Secretary determines to be reasonable and appro-
23 priate to cover the cost of care provided under this part,
24 taking into account the average cost of providing appropriate
25 care in the most efficient manner.
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1
"(b) PROSPECTIVE PAYMENT.-To the extent feasible,
2 the Secretary shall establish a prospective payment mecha-
3 nism for payment for nursing home services under this part
4 that takes into account the expected resource utilization of
5 individual patients based on their degree of disability and
6 other factors determining service requirements.
7
"(c) ROOM AND BOARD.-
8
"(1) IN GENERAL.-Notwithstanding section
9
2132(b)(2), payment for room and board under this part
10
shall be made by an individual participating in the pro-
11
gram established by this part for those days spent in a
12
nursing facility beyond 6 months.
13
"(2) MANNER OF PAYMENT.-Subject to para-
14
graph (4), such payments for room and board shall be
15
made by an individual directly to the nursing facility
16
and shall be reduced by the amount of payments made
17
by the Secretary under paragraph (4).
18
"(3) RATES.-Charges for room and board shall
19
be 35 percent of the average per diem rate paid by the
20
Secretary to nursing facilities receiving reimbursement
21
under this part.
22
"(4) PAYMENT BY SECRETARY FOR CERTAIN
23
LOW-INCOME INDIVIDUALS.-The Secretary shall pay
24
directly to the nursing facility-
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1
"(A) an amount equal to 100 percent of the
2
amount of the room and board charges imposed
3
under this subsection for an eligible individual
4
under this section if the income of the individual
5
does not exceed 100 percent of the poverty line
6
for a single individual (as defined in section 673(2)
7
of the Community Services Block Grant Act (42
8
U.S.C. 9902(2)));
9
"(B) an amount equal to 75 percent of the
10
amount of such room and board charges for an el-
11
igible individual whose income is between 100
12
percent and 150 percent of the poverty line for a
13
single individual (as defined in section 673(2) of
14
the Community Services Block Grant Act (42
15
U.S.C. 9902(2))); and
16
"(C) an amount equal to 50 percent of the
17
amount of such room and board charges for an el-
18
igible individual whose income is between 150
19
percent and 200 percent of the poverty line for a
20
single individual (as defined in section 673(2) of
21
the Community Services Block Grant Act (42
22
U.S.C. 9902(2))).
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1 "SEC. 2137. EXTENSION OF ELIGIBILITY TO INDIVIDUALS OF
2
ANY AGE.
3
"(a) IN GENERAL.-Notwithstanding the previous pro-
4 visions of this part, the Secretary shall provide, in accordance
5 with this section, the option for individuals to purchase cover-
6 age under this part without regard to age.
7
"(b) SEPARATE PREMIUM RATES.-In the case of indi-
8 viduals who purchase coverage under this section, the Secre-
9 tary shall apply premium rates (which may vary for classes of
10 such individuals) that provide for average, per individual sub-
11 sidies that approximate the average, per individual subsidies
12 that are provided under this part for individuals not enrolled
13 under this section.
14
"(c) EFFECTIVE DATE OF OPTION.-This section shall
15 only apply to benefits for periods beginning on or after Janu-
16 ary 1 of the fifth year beginning after the date of the enact-
17 ment of this section.
18
"PART E-TRAINING AND RESEARCH
19 "SEC. 2141. GRANTS FOR TRAINING FOR HOME AND COMMUNI-
20
TY-BASED CARE FOR THE ELDERLY.
21
"(a) IN GENERAL.-The Secretary shall make grants to
22 schools of nursing, social work, allied health, and public
23 health of accredited universities to develop and conduct pro-
24 grams to train individuals in the provision, supervision, plan-
25 ning, and analysis of home and community-based care and
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1 nursing home care for the elderly, disabled, and chronically ill
2 children and in the administration of such programs.
3
"(b) USE OF FUNDS.-Funding made available under
4 this section may be used for curriculum development, faculty
5 support, and traineeships and fellowships.
6
"(c) GRANT PREFERENCES.-In awarding grants under
7 this section, the Secretary shall give a preference to pro-
8 grams that-
9
"(1) provide for the development or conduct of
10
programs for continuing education and certification of
11
professionals currently working in the field of geriatric
12
health in the provision of services to the chronically
13
impaired and working in the field of pediatric care spe-
14
cialization in the provision of care services to chron-
15
ically ill, disabled, and medical technology dependent
16
children;
17
"(2) have established or will establish affiliations
18
with nursing homes, agencies providing home and com-
19
munity-based care, senior citizen centers, adult day
20
care centers, and other institutions and agencies pro-
21
viding health and social services to the impaired elder-
22
ly, for the purpose of providing in-service training to
23
individuals being trained at the grant-receiving institu-
24
tion and technical assistance to the institution provid-
25
ing services; and
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1
"(3) have established or will establish affiliations
2
with programs of geriatric training based in accredited
3
medical schools or schools of nursing, or both.
4
"(d) AUTHORIZATION OF APPROPRIATIONS.-There
5 are authorized to be appropriated to carry out this section
6 $15,000,000 for fiscal year 1991, $20,000,000 for fiscal year
7 1992, and $25,000,000 for fiscal year 1993.
8 "SEC. 2142. GRANTS FOR HOME HEALTH AIDES.
9
"(a) IN GENERAL.-The Secretary shall make grants to
10 State approved programs (that meet requirements established
11 by the Secretary relating to minimum course hours, curricu-
12 lum content, competency evaluation, and qualifications of in-
13 structors) to develop and conduct programs to train individ-
14 uals in the provision of home health aide services. Such train-
15 ing programs shall be designed and conducted according to
16 guidelines and requirements established by the Secretary by
17 regulation.
18
"(b) GRANT PREFERENCES.-Preference shall be given
19 to programs that have established or will have established
20 affiliations with nursing homes, agencies providing home and
21 community-based care, senior citizen centers, adult day
22 health care centers, and other institutions providing health
23 and social services to the impaired elderly, for the purpose of
24 providing in-service training to individuals being trained at
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1 the grant-receiving program and technical assistance to the
2 institution providing services.
3
"(c) AUTHORIZATION OF APPROPRIATIONS.-There
4 are authorized to be appropriated to carry out this section
5 $10,000,000 for each of the fiscal years 1991 and 1992 and
6 $25,000,000 for fiscal year 1993.
7 "SEC. 2143. GRANTS FOR MODEL CONSUMER TRAINING PRO-
8
GRAMS.
9
"(a) IN GENERAL.-The Secretary shall make grants
10 available to accredited university schools of nursing to devel-
11 op model consumer training programs. Such programs shall
12 provide information and training about the delivery of home
13 care services for caregivers as well as general information
14 about the home and community-based care service system for
15 consumers or potential consumers of home care or home
16 health services, or both, pursuant to regulations established
17 by the Secretary.
18
"(b) AUTHORIZATION OF APPROPRIATIONS.-There
19 are authorized to be appropriated to carry out this section
20 $5,000,000 for fiscal year 1991, $10,000,000 for fiscal year
21 1992, and $15,000,000 for fiscal year 1993.
22 "SEC. 2144. CENTERS FOR LONG-TERM CARE PLANNING AND
23
TECHNICAL ASSISTANCE.
24
"(a) IN GENERAL.-The Secretary shall through grants
25 or contracts, or both, assist public or private nonprofit enti-
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1 ties in meeting the costs of planning and developing new cen-
2 ters, and operating existing and new centers, for multidisci-
3 plinary health planning development and assistance under
4 this section for the purpose of-
5
"(1) assisting the Secretary in carrying out this
6
part;
7
"(2) providing such technical and consulting as-
8
sistance as States may require;
9
"(3) conducting research, studies, and analysis of
10
planning and resource development for the provision of
11
long-term care services; and
12
"(4) developing long-term care planning approach-
13
es, methodologies, policies, and standards.
14
"(b) NUMBER OF CENTERS.-The Secretary shall pro-
15 vide assistance under this section SO that at least 6 such cen-
16 ters shall be in operation by January 1, 1991.
17
"(c) CASE-MANAGEMENT AGENCIES.-Agencies as-
18 sisted under this section-
19
"(1) may enter into arrangements with Case Man-
20
agement Agencies for the provision of such services as
21
may be appropriate and necessary in assisting the
22
agencies in performing their functions under this part;
23
and
24
"(2) shall develop and use methods (satisfactory to
25
the Secretary) to disseminate to such agencies long-
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1
term care planning approaches, methodologies, policies,
2
and standards.
3
"(d) STAFF.-
4
"(1) DIRECTOR.-Each center shall have a full-
5
time director who possesses a demonstrated capacity
6
for substantial accomplishment and leadership in the
7
field of planning and resource development in the area
8
of long-term care.
9
"(2) ADDITIONAL STAFF.-Each center shall
10
employ such other additional staff as may be appropri-
11
ate. The staff of the center shall meet such additional
12
requirements as the Secretary may by regulation pre-
13
scribe.
14
"(e) AUTHORIZATION OF APPROPRIATIONS.-There
15 are authorized to be appropriated to carry out this section
16 $10,000,000 for fiscal year 1992 and $15,000,000 for each
17 of the fiscal years 1993 and 1994.
18
"PART F-DEMONSTRATION PROJECTS
19 "SEC. 2151. DEMONSTRATION PROJECTS FOR SERIOUSLY MEN-
20
TALLY ILL INDIVIDUALS.
21
"(a) IN GENERAL.-The Secretary shall conduct at
22 least 5 (but not more than 10) demonstration projects to de-
23 termine the relative effectiveness, cost, and impact on quality
24 of long-term home care of using different models of providing
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1
scribed in section 2112(a)(2)(B)(ii), who resides in a
2
State shall be an amount that the Secretary estimates
3
is equal to 100 percent of the amount that would be
4
payable, under the plan of the State approved under
5
title XIX during the month if such individual were pro-
6
vided appropriate care in an appropriate institutional
7
setting, if no limit on amount, duration, or scope of
8
covered institutional services applied other than medi-
9
cal necessity.
10 "SEC. 2116. HOME AND COMMUNITY-BASED CARE ADVISORY
11
COUNCIL.
12
"(a) ESTABLISHMENT.-No later than 60 days after
13 the date of enactment of this title, there shall be established
14 an independent body to be known as the 'Home and Commu-
15 nity-Based Care Advisory Council' (hereinafter referred to in
16 this section as the 'Council').
17
"(b) MEMBERSHIP.-
18
"(1) IN GENERAL.-The Council shall be com-
19
posed of 13 individuals appointed by the Secretary.
20
"(2) EXPERTISE.-To the maximum extent prac-
21
ticable, the Council shall include individuals with ex-
22
pertise in pediatrics, geriatrics, gerontology, disability,
23
case management of home and community-based serv-
24
ices and home and community-based care reimburse-
25
ment, home and community-based care consumers and
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1
their representatives, home and community-based care
2
providers and their representatives, professionals with
3
expertise in long-term care including nurses, social
4
workers, discharge planners, third party payors, long-
5
term care ombudsmen, and State and local health and
6
social service agency representatives.
7
"(3) TERM.-An appointment to the Council shall
8
be for a term of not to exceed 4 years.
9
"(c) PURPOSE.-The purpose of the Council shall be-
10
"(1) to assist the Secretary in assuring the prompt
11
and efficient implementation of this part;
12
"(2) to regularly review the implementation of
13
this part; and
14
"(3) to recommend to the Secretary and Congress
15
any necessary modifications of this part.
16
"(d) CONSULTATION.-The Secretary shall regularly
17 and closely consult with the Council in the implementation
18 and administration of this part.
19
"(e) MEETINGS.-To carry out this section, the Secre-
20 tary shall meet with the Council at least once every month
21 during the 24-month period beginning 60 days after the date
22 of enactment of this title and at least quarterly after such
23 period.
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1 "SEC. 2117. QUALITY ASSURANCE BOARDS AND COMMUNITY
2
ADVISORY BOARDS.
3
"(a) QUALITY ASSURANCE BOARD.-A State shall es-
4 tablish and appoint members to a quality assurance board
5 that will monitor the quality of care provided under this part
6 in a given area of the State, pursuant to procedures estab-
7 lished by the Secretary by regulation.
8
"(b) COMMUNITY ADVISORY BOARD.-A State shall
9 establish and appoint members to a community advisory
10 board for each Case Management Agency pursuant to regula-
11 tions by the Secretary. The advisory board shall be composed
12 of consumers of services and their families, representatives of
13 agencies and organizations, professionals providing services
14 to the elderly, and public members. Public members and con-
15 sumers and their families shall form a majority of the mem-
16 bers of the advisory board.
17 "SEC. 2118. HOME AND COMMUNITY-BASED CARE QUALITY
18
ASSURANCE.
19
"(a) HOME AND COMMUNITY-BASED CARE SERVICES
20 CONSUMERS' BILL OF RIGHTS.-The Secretary shall pro-
21 mulgate regulations that shall establish a bill of rights for
22 consumers of home and community-based services (hereafter
23 referred to in this section as the 'consumer'), that shall recog-
24 nize the following as the rights of consumers that may be
25 asserted by the consumer or the representative or guardian of
26 the consumer:
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1
"(1) TREATMENT OF INDIVIDUAL.-To be treat-
2
ed with courtesy, respect, and full recognition of one's
3
dignity, individuality, and right to control one's own
4
household and lifestyle.
5
"(2) FULL INFORMATION.-T be fully informed
6
by the individual's case management team of his or her
7
condition.
8
"(3) REFUSAL OF TREATMENT.-To refuse all or
9
part of any treatment, care, or service, and to be in-
10
formed of the likely consequences of such refusal.
11
"(4) NONDISCRIMINATION.-To receive treat-
12
ment, care, and services in compliance with all State
13
and local laws and regulations without discrimination
14
in the provision or quality of services based on race,
15
religion, gender, age, or creed (except as provided
16
under the Age Discrimination Act of 1975 (42 U.S.C.
17
6101 et seq.)), or because of a change in the source of
18
payment.
19
"(5) FREEDOM FROM ABUSE.-To be free from
20
mental and physical abuse, neglect, and exploitation,
21
and to be free from chemical and physical restraints.
22
"(6) RESPECT AND PRIVACY.-To receive respect
23
and privacy in the home care consumer's treatment,
24
care, and services in caring for personal needs, in com-
25
munications, and in all daily activities.
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1
"(7) CONFIDENTIALITY.-To be assured of the
2
confidential treatment of personal and financial records
3
and to approve or refuse the release of such records to
4
any individuals outside the agency except as otherwise
5
required by law or third-party payment contract.
6
"(8) EXERCISE OF RIGHTS.-To be free to fully
7
exercise the consumer's civil rights and to be assisted
8
in doing SO when assistance is needed.
9
"(9) TRANSITION OF SERVICES.-To receive as-
10
sistance to assure a smooth transition in services con-
11
sistent with the welfare of the home care consumer.
12
"(b) HOME AND COMMUNITY-BASED PROVIDER QUAL-
13 ITY ASSURANCE REQUIREMENTS.-
14
"(1) IN GENERAL.-In addition to such other re-
15
quirements as may apply, the Secretary shall promul-
16
gate regulations that require that in order to receive
17
funding under this title for the provision of home or
18
community-based services (hereinafter referred to in
19
this section as 'services'), all qualified providers shall,
20
not later than 6 months after the date of the publica-
21
tion of such regulations-
22
"(A) comply with the consumers' bill of
23
rights promulgated under subsection (a);
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1
"(B)(i) implement procedures for promptly re-
2
viewing and resolving the grievances of consum-
3
ers; and
4
"(ii) provide an oral notification and a writ-
5
ten copy of such procedures to each consumer (or
6
the representative or guardian of the consumer)
7
who receives services provided by a qualified
8
provider;
9
"(C) ensure that each provider employed by
10
or under contract with a home care or home
11
health agency receives training-
12
"(i) sufficient to meet a level of profi-
13
ciency established by the Secretary in regu-
14
lations (in consultation with representatives
15
of the elderly, disabled, and children, home
16
health and home care agencies, and experts
17
in the fields of geriatric nursing, pediatric
18
nursing, geriatric social work, pediatric social
19
work, mental health, rehabilitation, and other
20
appropriate health care professionals) that
21
are appropriate in content and amount as are
22
consistent with the requirements of section
23
4021(b) of the Omnibus Budget Reconcilia-
24
tion Act of 1987;
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1
"(ii) that develops separate levels of
2
proficiency in and is reflective of the range of
3
skills required of providers that provide dif-
4
ferent levels of services; and
5
"(iii) the extent of which shall be made
6
available on request to each consumer with
7
respect to the amount of training or level of
8
certification achieved by each provider;
9
"(D) supervise all care providers employed
10
by or under contract with a qualified provider in
11
accordance with regulations promulgated by the
12
Secretary (including regular random on-site super-
13
visory visits by registered nurses or other appro-
14
priate health care professionals); and
15
"(E) perform annual evaluations of the qual-
16
ity of services provided by providers employed by
17
or under contract with a qualified provider that
18
shall document consumer involvement through a
19
process that shall include client interviews.
20
"(2) DURABLE MEDICAL EQUIPMENT SERV-
21
ICES.-In addition to such other requirements as may
22
apply, to receive funding for the provision of durable
23
medical equipment services under this title, a qualified
24
provider shall in each case of a consumer to which
25
such services are provided-
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1
"(A) issue written instructions for the oper-
2
ation of such equipment;
3
"(B) provide sufficient training to the con-
4
sumer, the family of the consumer, and the staff
5
to permit the appropriate and safe operation of all
6
such equipment; and
7
"(C) formulate an emergency plan that is ap-
8
propriate for the services provided to the home
9
care consumer.
10
"(c) CASE MANAGEMENT AGENCY QUALITY ASSUR-
11 ANCE REQUIREMENTS.-In addition to such other require-
12 ments as may apply, the Secretary shall promulgate regula-
13 tions requiring that an agency, to receive funding for the pro-
14 vision of case management services under this title, shall, not
15 later than 6 months after the date of the publication of such
16 regulations—
17
"(1)(A) comply with the consumers' bill of rights
18
promulgated under subsection (a); and
19
"(B) provide an oral notification and a written
20
copy of such bill of rights to each consumer (or the
21
representative or guardian of the consumer) who re-
22
ceives services under this title;
23
"(2)(A) implement procedures for the prompt
24
review and resolution of the grievances of consumers;
25
and
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1
"(B) provide an oral notification and a written
2
copy of such procedures to each consumer (or the rep-
3
resentative or guardian of such consumer) who receives
4
services from the agency;
5
"(3) provide to each consumer (or the representa-
6
tive or guardian of the consumer) a written statement
7
of the services to be provided to the consumer and the
8
schedule for the provision of such services, as agreed
9
on by the consumer;
10
"(4) provide to each consumer a clear written
11
statement as to how the consumer (or the representa-
12
tive or guardian of the consumer), may appeal the ben-
13
efit and level decisions made by the agency;
14
"(5) maintain procedures that assure prompt
15
access by eligible consumers to services;
16
"(6) ensure that the personnel that provide case
17
management services to each consumer have received
18
adequate training as prescribed in regulations promul-
19
gated by the Secretary, in consultation with the appro-
20
priate Home Care Quality Assurance Board; and
21
"(7) establish and implement case management
22
procedures that shall include-
23
"(A) a plan of care that establishes reasona-
24
ble and measurable client objectives and the serv-
25
ices to be provided to meet such objectives;
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1
"(B) a plan of care that employs outcome
2
measures of care insofar as they are appropriate
3
and available for each consumer served;
4
"(C) methods for a review that shall be con-
5
ducted at least once during every 3-month period
6
of-
7
"(i) the needs of the consumer; and
8
"(ii) the plan of care for the consumer;
9
"(D) methods for follow-up and on-going
10
monitoring of patient and services delivery; and
11
"(E) a statement of the criteria and proce-
12
dures to be applied for the discharge or transfer of
13
the consumer to another agency, program, or
14
service.
15
"(d) STANDARD AND EXTENDED SURVEY.-Sections
16 1891 (c) and (d) shall apply to home health agencies certified
17 to receive payments for services provided under this title.
18
"(e) SURVEY.-The Secretary shall develop and imple-
19 ment a standard and extended survey of home care agencies
20 certified to receive payments for services provided under this
21 title.
22 "SEC. 2119. CERTIFICATION.
23
"(a) REQUIREMENT.-
24
"(1) IN GENERAL.-A State shall-
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1
"(A) survey home care agencies, home
2
health agencies, and adult day health care centers
3
to determine their eligibility to participate in the
4
program established under this part; and
5
"(B) certify such an agency or center as eli-
6
gible to participate in such program if the agency
7
meets the requirements of this part and regula-
8
tions prescribed by the Secretary.
9
"(2) FREQUENCY.-A State shall conduct the
10
survey and certification required under paragraph (1)
11
not less than once during each fiscal year.
12
"(b) INDIVIDUAL PROVIDERS.-
13
"(1) IN GENERAL.-To be eligible to be reim-
14
bursed for services covered under this part, a qualified
15
service provider referred to in section 2114 shall be li-
16
censed or, if applicable, certified by the State in which
17
the provider practices pursuant to the requirements of
18
this part and regulations prescribed by the Secretary.
19
"(2) HOMEMAKERS AND HOME HEALTH
20
AIDES.-To be reimbursed for services covered under
21
this part, a homemaker or home health aide must be a
22
trained employee of a certified home care or home
23
health agency working under professional supervision.
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1
"(3) WAIVER.-The Secretary may waive the
2
certification requirement for providers that do not pro-
3
vide direct patient care.
4 "SEC. 2120. REIMBURSEMENT.
5
"(a) ACCEPTANCE OF REFERRALS AND REIMBURSE-
6 MENT.-
7
"(1) IN GENERAL.-Except as provided in para-
8
graph (2), a home health or home care agency or other
9
provider certified by a State to provide services reim-
10
bursable under this part shall provide services to all in-
11
dividuals referred to the provider by a Case Manage-
12
ment Agency or by an organization under contract
13
with the agency to provide case management services
14
and accept as payment in full the reimbursement
15
amounts provided under this part.
16
"(2) EXCEPTION.-The service requirement im-
17
posed under paragraph (1) shall not apply if the re-
18
quirement would be in conflict with the operating poli-
19
cies under which the provider was certified (such as
20
the maximum number of individuals an agency may
21
care for at any time).
22
"(b) ADDITIONAL SERVICES.-Nothing contained in
23 this part shall be construed to preclude any individual who is
24 eligible to receive services under this part from purchasing
25 home and community-based services that are more generous
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1 than services provided for in the care plan of the individual.
2 If an individual purchases more generous services, a provider
3 may not charge such individual higher rates for such services
4 than the amount the provider is reimbursed under this part.
5
"(c) RELATIONSHIP TO OTHER ENTITLEMENT PRO-
6 GRAMS.-Notwithstanding any other provision of law, in the
7 case of any service covered under this part that is also cov-
8 ered under another Federally administered entitlement pro-
9 gram, the Secretary shall act as a secondary payer under this
10 part.
11
"(d) REIMBURSEMENT.-Reimbursement for services
12 provided under this part shall be subject to the requirements
13 of this part and regulations prescribed by the Secretary.
14
"PART C-COVERAGE OF FIRST 6 MONTHS OF
15
NURSING HOME CARE
16 "SEC. 2121. BENEFITS.
17
"(a) IN GENERAL.-Subject to subsections (c) and (d),
18 an individual who meets the eligibility criteria prescribed in
19 section 2122 shall be eligible under the program established
20 by this part for coverage for services described in subsection
21 (b) provided to the individual by a nursing facility that are
22 required by the individual, while the individual is an inpatient
23 of the facility, for a period of time not to exceed 6 months for
24 a spell of illness.
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1
"(b) TYPES.-Coverage may be provided under this
2 part for-
3
"(1) nursing care provided by or under the super-
4
vision of a registered professional nurse;
5
"(2) bed and board in connection with the furnish-
6
ing of nursing care;
7
"(3) physical, occupational, or speech therapy fur-
8
nished by a facility or by others under arrangements
9
with a facility;
10
"(4) medical social services;
11
"(5) drug, biological, supply, appliance, and equip-
12
ment for use in the facility, that is ordinarily furnished
13
by the facility for the care and treatment of an
14
inpatient;
15
"(6) medical service of an intern or resident-in-
16
training under an approved teaching program of a hos-
17
pital with which a facility has in effect a transfer
18
agreement or other diagnostic or therapeutic service
19
provided by a hospital with which a facility has in
20
effect a transfer agreement; and
21
"(7) such other health services necessary to the
22
health of a patient as are generally provided by a nurs-
23
ing home facility.
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1
"(c) BENEFITS AFTER COVERED STAYS.-An individ-
2 ual shall be eligible for additional nursing home coverage
3 under this part subsequent to a covered stay if-
4
"(1) the individual has not been an inpatient in a
5
hospital or nursing facility for at least 6 consecutive
6
months after any covered stay; and
7
"(2)(A) the individual has a diagnosis that is dif-
8
ferent from that provided for the preceding nursing
9
home stay; or
10
"(B) there has been a substantial worsening of the
11
condition of the individual since the latest discharge of
12
the individual.
13 "SEC. 2122. ELIGIBILITY.
14
"(a) IN GENERAL.-An individual shall be eligible for
15 benefits under this part if-
16
"(1)(A) for benefits provided before January 1 of
17
the fourth year that begins after the date of the enact-
18
ment of this title, the individual is-
19
"(i) 65 years of age or older; or
20
"(ii) eligible for benefits under part A of title
21
ХѴШ as the result of disability; and
22
"(B) has been determined by a Screening Agency
23
through a screening process (conducted in accordance
24
with section 2102) to be-
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1
"(i) completely dependent with respect to at
2
least one age-appropriate activity of daily living
3
or unable to perform two or more age-appropriate
4
activities of daily living without human assistance
5
or supervision; or
6
"(ii) SO cognitively impaired (due to adult
7
onset, acquired chronic organic disease of the
8
brain occurring in clear consciousness, and includ-
9
ing those individuals who would meet such crite-
10
ria except for the presence of a transient delirium
11
in such individuals) as to require constant supervi-
12
sion from another individual because such im-
13
paired individual engages in inappropriate behav-
14
ior patterns that pose a substantial health and
15
safety hazard to such impaired individual or to
16
others;
17
"(2) the individual is-
18
"(A) under 19 years of age; and
19
"(B) has been determined by a Screening
20
Agency through a screening process (conducted in
21
accordance with section 2102)-
22
"(i) to be unable to perform one or more
23
age-appropriate activities of daily living
24
without human assistance or supervision; or
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1
tered professional social worker to direct its
.
2
social services program.
3
"(15) RESPITE CARE.-The term 'respite care'
4
means a temporary break provided to an individual
5
who supplies regular care to a dependent relative or
6
friend. For purposes of this title, the break may not
7
exceed 30 days or 720 hours, in a calendar year. The
8
term includes institutional or noninstitutional patient
9
supervisory services to temporarily relieve the care-
10
giver of an eligible individual as determined by a Care
11
Management Agency and included in the care plan of
12
the individual.
13
"(17) SPELL OF ILLNESS.-The term 'spell of ill-
14
ness' means a period of consecutive days beginning
15
with the first day on which an individual is furnished a
16
covered service and ending with the close of the first 6
17
consecutive months thereafter during which the indi-
18
vidual is not an inpatient of a hospital or a nursing
19
facility.
20 "SEC. 2102. LONG-TERM CARE AGENCIES.
21
"(a) LONG-TERM CARE SCREENING AGENCY.-
22
"(1) ESTABLISHMENT.-The Secretary shall con-
23
tract with entities to act as Long-Term Care Screening
24
Agencies (hereinafter referred to in this title as the
25
'Screening Agency') for each designated area of a
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1
State. It shall be the responsibility of such agency to
2
assess the eligibility of individuals residing in the geo-
3
graphic jurisdiction of the agency, for services provided
4
under this title according to the requirements of this
5
title and regulations prescribed by the Secretary.
6
"(2) ELIGIBILITY.-The Screening Agency shall
7
determine the eligibility of an individual based on the
8
results of a preliminary telephone or written question-
9
naire (completed by the applicant, by the caregiver of
10
the applicant, or by the legal guardian or representa-
11
tive of the applicant) that shall be validated through
12
the use of a screening tool administered in person by a
13
physician, nurse practitioner, or registered professional
14
nurse, to each applicant determined eligible through
15
initial telephone or written questionnaire interviews not
16
later than 15 days from the date on which such indi-
17
vidual initially applied for services under this part.
18
"(3)
QUESTIONNAIRES
AND
SCREENING
19
TOOLS.-
20
"(A) IN GENERAL.-The Secretary shall es-
21
tablish a telephone or written questionnaire and a
22
screening tool to be used by the Screening
23
Agency to determine the eligibility of an individ-
24
ual for services under this title consistent with re-
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1
quirements of this title and standards established
2
by the Secretary by regulation.
3
"(B) QUESTIONNAIRES.-The questionnaire
4
shall include questions about the functional im-
5
pairment, mental status, and living arrangement
6
of an individual and other criteria that the Secre-
7
tary shall prescribe by regulation.
8
"(C) SCREENING TOOLS.-The screening
9
tool should measure functional impairment caused
10
by physical or cognitive conditions as well as in-
11
formation concerning cognition disability, behav-
12
ioral problems (such as wandering or abusive and
13
aggressive behavior), the living arrangement of an
14
individual, availability of caregivers, and any
15
other criteria that the Secretary shall prescribe by
16
regulation. The screening tool shall be adminis-
17
tered in person.
18
"(4) NOTIFICATION.-Not later than 15 days
19
after the date on which an individual initially applied
20
for services under this part (by phone or written ques-
21
tionnaire), the Screening Agency shall notify such indi-
22
vidual that such individual is not eligible for benefits,
23
or that such individuals must schedule an in-person
24
screening to determine final eligibility for benefits
25
under this title. The Screening Agency shall notify
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1
such individual of its final decision not later than 2
2
working days after the in-person screening.
3
"(5) IN-PERSON SCREENING.-An individual (or
4
the legal guardian or representative of such individual)
5
whose application for long-term care benefits under
6
this title is denied on the basis of information provided
7
through a telephone or written questionnaire, shall be
8
notified of such individual's right to an in-person
9
screening by a nurse or appropriate health care profes-
10
sionals.
11
"(6) APPEALS.-The Secretary shall establish a
12
mechanism for hearings and appeals in cases in which
13
individuals contest the eligibility findings of the Screen-
14
ing Agency.
15
(7) FUNDING LEVEL.-The Screening Agency
16
shall be responsible for determining the estimated fund-
17
ing level that shall be allotted for individuals eligible
18
for home and community-based care, pursuant to
19
standards established under section 2115(e) and regula-
20
tions of the Secretary.
21
"(b) LONG-TERM CARE CASE MANAGEMENT
22
AGENCY.-
23
"(1) ESTABLISHMENT.-The Secretary shall con-
24
tract with a State or, in any case in which a State de-
25
clines to contract with the Secretary, a private non-
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1
profit organization, to establish and administer a Long-
2
Term Care Case Management Agency (hereinafter re-
3
ferred to in this title as 'Case Management Agency')
4
for each designated area of a State. Such agency shall
5
demonstrate expertise in the delivery of health and
6
social services to the chronically ill and disabled pursu-
7
ant to requirements established in this title and such
8
standards as the Secretary may establish by regulation
9
(including standards for training and qualification of
10
personnel, financial responsibility, and governance).
11
"(2) DUTIES.-A Case Management Agency shall
12
provide case management services for eligible individ-
13
uals directly or through contracts with home care or
14
home health agencies that meet the requirements of
15
this title and standards prescribed by the Secretary by
16
regulation for providing case management services.
17
"(3) CARE PLAN.-The Case Management
18
Agency shall develop a care plan for each individual
19
determined to be eligible by a Screening Agency. In
20
developing a care plan for an individual, the Case
21
Management Agency shall design a plan that meets the
22
service needs of the individual, consistent with the re-
23
sources available to the agency.
24
"(4) FUNDING.-
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1
"(A) IN GENERAL.-The actual level of
2
funding allotted to an eligible individual by the
3
Case Management Agency to cover services in-
4
cluded in the individual's care plan may fall above
5
or below the estimated annualized level allotted to
6
the individual by the Screening Agency based on
7
the detailed assessment and plan of care provided
8
by the Case Management Agency.
9
"(B) LIMITATION.-The Case Management
10
Agency shall allocate the resources available from
11
the Screening Agency (as described in section
12
2115(a)) to ensure that the total expenditures for
13
home and community-based care for individuals
14
eligible for services covered under this title resid-
15
ing within the geographic jurisdiction of the
16
agency do not exceed the total amount available
17
monthly to the Case Management Agency, pursu-
18
ant to this section, for home and community-based
19
services. The Case Management Agency shall es-
20
tablish specific financial controls (including author-
21
izing the amount, scope, and duration of services
22
to be provided to an individual) to carry out this
23
subparagraph.
24
"(c) REGISTRY.-A Case Management Agency shall
25 maintain a registry of qualified providers of home and com-
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1 munity-based and nursing home care in the State and shall
2 assist individuals in choosing qualified providers to carry out
3 the care plan. An individual eligible for services under this
4 title shall be free to choose from the registry the home care
5 agency, home health agency, or other qualified provider of
6 services to carry out the care plan of such individual. The
7 Case Management Agency shall assist the individual in locat-
8 ing alternative providers if the individual becomes dissatisfied
9 with the provider initially chosen.
10
"(d) MONITORING.- State shall, along with the Sec-
11 retary, monitor the performance of all designated Case Man-
12 agement Agencies and assure the fiscal stability of such
13 agencies. A State shall act as the financial guarantor of each
14 agency.
15 "SEC. 2103. CONTRIBUTION OF STATE FUNDS.
16
"(a) ESTIMATE.-The Secretary shall estimate the
17 amount that a State would have spent during each calendar
18 year for individuals eligible for long-term care services under
19 each Federal-State entitlement program in the absence of the
20 program established by this title. Such estimate shall be up-
21 dated annually based on the projected increases in the cost of
22 carrying out this title.
23
"(b) CONTRIBUTION.-For residents of a State to be
24 eligible to participate in the program established by this title
25 during a calendar year, the State shall contribute the amount
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1 estimated under subsection (a) to the Secretary to share in
2 the costs of providing services to such State residents under
3 the program established by this title for such calendar year.
4 "PART B-COVERAGE OF HOME AND COMMUNITY-
5
BASED CARE SERVICES
6 "SEC. 2111. BENEFITS.
7
"An individual who meets the eligibility criteria pre-
8 scribed in section 2112 shall be eligible under the program
9 established by this part for coverage for home and communi-
10 ty-based care services that are-
11
"(1) determined to be necessary by a Case Man-
12
agement Agency;
13
"(2) described in the care plan of the individual;
14
"(3) services for which the individual is eligible;
15
and
16
"(4) consistent with the need for care of the indi-
17
vidual, regulations issued by the Secretary, and stand-
18
ards established under this part.
19 "SEC. 2112. ELIGIBILITY.
20
"(a) IN GENERAL.-An individual shall be eligible for
21 benefits under this part only if the individual-
22
"(1)(A) with respect to benefits before January 1
23
of the fourth year that begins after the date of the en-
24
actment of this title, is-
25
"(i) 65 years of age or older; or
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1
"(ii) eligible for benefits under part A of title
2
ХѴШ as the result of a disability; and
3
"(B) has been determined by a Screening Agency
4
through a screening process (conducted in accordance
5
with section 2102) to be-
6
"(i) completely dependent (does not partici-
7
pate) in at least one age-appropriate activity of
8
daily living or unable to perform two or more
9
age-appropriate activities of daily living without
10
human assistance or supervision; or
11
"(ii) SO cognitively impaired (due to adult
12
onset, acquired chronic organic disease of the
13
brain occurring in clear consciousness, and includ-
14
ing those individuals who would meet such crite-
15
ria except for the presence of a transient delirium
16
in such individuals) as to require constant supervi-
17
sion from another individual because such im-
18
paired individual engages in inappropriate behav-
19
ioral patterns that pose a substantial health and
20
safety hazard to such impaired individual or to
21
others; or
22
"(2)(A) is under 19 years of age; and
23
"(B) has been determined by a Screening Agency
24
through a screening process (conducted in accordance
25
with section 2102)-
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1
"(i) to be unable to perform one or more
2
age-appropriate activities of daily living without
3
human assistance or supervision; or
4
"(ii) to require both a medical device to com-
5
pensate for the loss of a vital body function that is
6
necessary to avert death or major loss of bodily
7
functional capacity and substantial and ongoing
8
nursing care to avert death or further disability;
9
or
10
"(3)(A) would be eligible for benefits under title
11
ХѴШ on the basis of a disability except for the re-
12
quired 24-month waiting period;
13
"(B) has been determined by a Screening Agency
14
through a screening process (conducted in accordance
15
with section 2102) to be completely dependent (does
16
not participate) in at least one age-appropriate activity
17
of daily living or unable to perform two or more age-
18
appropriate activities of daily living without human as-
19
sistance or supervision; and
20
"(C) has a medical prognosis that such individ-
21
ual's life expectancy is 12 months or less.
22
"(b) APPLICATION.-An individual shall be eligible for
23 benefits under this part only if-
24
"(1) the individual has filed an application for, and
25
is in need of, benefits covered under this part;
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1
"(2) the legal guardian of the individual has filed
2
an application on behalf of an individual who is in need
3
of benefits covered under this part; or
4
"(3) the representative of an individual who is
5
cognitively impaired, who has no legal guardian, and
6
who is in need of benefits covered under this part, files
7
an application on behalf of the individual.
8 "SEC. 2113. RESPITE CARE.
9
"(a) ELIGIBILITY.-An individual shall be eligible for
10 respite care benefits under this part if-
11
"(1)(A) the individual meets the requirements es-
12
tablished in section 2112;
13
"(B) the individual is dependent on a daily basis
14
on a primary caregiver and is assisting the individual
15
without monetary compensation in the performance of
16
at least two age-appropriate activities of daily living;
17
and
18
"(C) without such assistance the individual could
19
not perform such activities of daily living; or
20
"(2) the individual has dementia or other cognitive
21
impairments, as determined by a Screening Agency.
22
"(b) DETERMINATION OF NEED.-The determination
23 of the need of an individual for respite care shall be made by
24 the Case Management Agency. An analysis of such need
25 shall be included in the care plan of the individual.
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1
"(c) SERVICES.-Respite care services under this sec-
2 tion may include home and community-based services or
3 nursing home services described in section 2121(b).
4
"(d) PERIOD OF COVERAGE.-Coverage for such serv-
5 ices shall be for short periods of time of not to exceed 30 days
6 or 720 hours during a given calendar year.
7
"(e) REIMBURSEMENT RATES.-Reimbursement rates
8 for respite care services covered under this section shall be
9 the same as rates established elsewhere in this part for home
10 and community-based services and nursing home services.
11 "SEC. 2114. QUALIFIED SERVICE PROVIDERS.
12
"(a) IN GENERAL.-Services provided to eligible indi-
13 viduals pursuant to a plan of care under this part shall be
14 provided by qualified service providers.
15
"(b) TYPES.-A qualified service provider shall
16 include-
17
"(1) a home care agency certified by the State;
18
"(2) a home health agency certified by the
19
Secretary;
20
"(3) an adult day health care center certified by
21
the State; and
22
"(4) other certified or licensed provider of specific
23
services including a registered professional nurse, quali-
24
fied social worker, physician, nurse practitioner, physi-
25
cal, occupational or speech therapist, certified dietitian,
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1
and other providers as the Secretary shall designate by
2
regulation that meet standards established by the
3
Secretary.
4
"(c) APPROVAL REQUIRED FOR REIMBURSEMENT.-
5 No individual or agency shall be eligible for reimbursement
6 for services provided to an individual under this part unless
7 the Case Management Agency approves the provision of
8 services to such individual or agency.
9 "SEC. 2115. PAYMENT FOR SERVICES.
10
"(a) CASE MANAGEMENT AGENCIES.-The Secretary
11 shall pay an amount monthly to each Case Management
12 Agency that equals the sum of the amounts allotted by the
13 Screening Agency for eligible individuals in the geographic
14 jurisdiction of such Case Management Agency who have
15 been determined by such Screening Agency to be eligible to
16 receive services covered under this part.
17
"(b) SERVICE PROVIDERS.-
18
"(1) DIRECT PAYMENTS.-The Case Manage-
19
ment Agency shall make direct payments to certified
20
home care and home health agencies, and other quali-
21
fied providers of home and community-based services
22
reimbursable under this part, in accordance with such
23
methods as the State may establish pursuant to regula-
24
tions promulgated by the Secretary.
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1
"(2) FULL PAYMENT FOR SERVICES.-All provid-
2
ers of home and community-based care services under
3
the program established under this part shall accept
4
payment rates established by the Case Management
5
Agency as payment in full for services and shall not
6
pass on additional charges to beneficiaries for services
7
rendered under a plan of care.
8
"(c) PROVIDERS OF CASE MANAGEMENT SERVICES.-
9 If a Case Management Agency contracts with a home health
10 or home care agency to provide case management services,
11 the Case Management Agency shall make direct payments to
12 such organization in accordance with such methods as the
13 State may establish pursuant to regulations promulgated by
14 the Secretary.
15
"(d) LIMIT ON PAYMENT FOR HOME HEALTH AND
16 COMMUNITY-BASED SERVICES.-
17
"(1) INITIAL PERIOD.-During the 3-year period
18
beginning on the date of enactment of this title, the
19
maximum amount of payments that may be made to a
20
Case Management Agency for home and community-
21
based services provided to an individual who resides in
22
the geographic jurisdiction of the agency and who is el-
23
igible for services under this part shall be, on an an-
24
nualized basis, not more than 65 percent of the aver-
25
age amount payable, including the cost of ancillary
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1
services, for the same number of care days in a skilled
2
nursing facility under title XVIII in the area in which
3
the home and community-based care is provided.
4
"(2) SUBSEQUENT YEARS.-In years subsequent
5
to the period referred to in paragraph (1), the maxi-
6
mum amount referred to in such paragraph shall be es-
7
tablished by the Secretary according to such prospec-
8
tive payment methods as the Secretary may establish
9
by regulation to assure that no payment is made for
10
home and community-based services that will exceed
11
the cost of an alternative placement in a nursing facili-
12
ty, less a reasonable estimate of the cost of room and
13
board in such facilities or in the community.
14
"(e) AMOUNT OF COVERAGE.-
15
"(1) IN GENERAL.-Subject to subsection (d) and
16
other provisions of this subsection, the amount of cov-
17
erage allotted to an eligible individual shall be the
18
amount necessary to carry out the service needs of the
19
individual.
20
"(2) MAXIMUM AVERAGE AMOUNT.-In the case
21
of an individual in a given geographic area, the aver-
22
age amount payable for such individual shall not
23
exceed an amount determined by multiplying-
24
"(A) the maximum amount prescribed in sub-
25
section (d); by
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1
"(B) a measure of the severity of the need
2
for services of the individual.
3
"(3) SEVERITY OF NEED FOR SERVICES.-For
4
purposes of paragraph (2), the severity of the need for
5
services of an individual shall be estimated by such sta-
6
tistical models and techniques, that shall include a
7
measure of the severity of dependency in activities of
8
daily living, cognitive impairment, living arrangement,
9
age, and such other factors as the Secretary shall
10
specify by regulation, except that all individuals deter-
11
mined to be eligible for services under this part shall
12
be presumed to face a monthly need for services of at
13
least 5 percent of the maximum allotment. In deter-
14
mining eligibility, the Secretary shall not use any
15
measures of the income and assets of the individual.
16
Expenditures authorized by this paragraph shall be
17
made only for the services specified in this part in ac-
18
cordance with a written care plan prepared through
19
case management services provided by the Case Man-
20
agement Agency or a home care or home health
21
agency under contract with the agency to provide case
22
management services.
23
"(4)
CHRONICALLY-ILL
INDIVIDUAL.-The
24
amount of coverage allotted in a month to an eligible
25
individual who is a chronically-ill individual, as de-
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1 (relating to military medical programs and CHAMPUS) and
2 title 38 (relating to Veterans' health care) of the United
3 States Code.
4 SEC. 505. RELATION TO ERISA.
5
The provisions of the Employee Retirement Income Se-
6 curity Act are superseded to the extent inconsistent with the
7 requirements of this division.
8
Division B-Life Care Long-Term
9
Care Protection Act
10 SEC. 1001. SHORT TITLE; TABLE OF CONTENTS.
11
(a) SHORT TITLE.-This division may be cited as the
12 "Lifecare Long-Term Care Protection Act".
13
(b) TABLE OF CONTENTS.-The table of contents of
14 this division is as follows:
Sec. 1001. Short title; table of contents.
Sec. 1002. Lifecare long-term care protection program.
"TITLE XXI-LIFECARE LONG-TERM CARE PROTECTION PROGRAM
"Part A-General Provisions
"Sec. 2101. Definitions.
"Sec. 2102. Long-term care agencies.
"Sec. 2103. Contribution of State funds.
"Part B-Coverage of Home and Community-Based Care Services
"Sec. 2111. Benefits.
"Sec. 2112. Eligibility.
"Sec. 2113. Respite care.
"Sec. 2114. Qualified service providers.
"Sec. 2115. Payment for services.
"Sec. 2116. Home and Community-Based Advisory Council.
"Sec. 2117. Quality assurance boards and community advisory boards.
"Sec. 2118. Home and community-based care quality assurance.
"Sec. 2119. Certification.
"Sec. 2120. Reimbursement.
"Part C-Coverage of First 6 Months of Nursing Home Care
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50
"Sec. 2121. Benefits.
"Sec. 2122. Eligibility.
"Sec. 2123. Limitations on payment.
"Sec. 2124. Reimbursement.
"Sec. 2125. Relationship to other entitlement programs.
"Part D-Insurance Coverage for Nursing Home Care That Exceeds 6 Months
"Sec. 2131. Establishment of Federal Long-Term Care Insurance Program.
"Sec. 2132. Eligibility.
"Sec. 2133. Premium rates.
"Sec. 2134. Benefits.
"Sec. 2135. Qualified service providers.
"Sec. 2136. Reimbursement.
"Sec. 2137. Extension of eligibility to individuals of any age.
"Part E-Training and Research
"Sec. 2141. Grants for training for home and community-based care for the elder-
ly.
"Sec. 2142. Grants for home health aides.
"Sec. 2143. Grants for model consumer training programs.
"Sec. 2144. Centers for long-term care planning and technical assistance.
"Part F-Demonstration Projects
"Sec. 2151. Demonstration projects for seriously mentally ill individuals.
"Sec. 2152. Demonstration projects for working age individuals with severe func-
tional limitations.
"Sec. 2153. General authority.".
Sec. 1003. Effective date.
1 SEC. 1002. LIFECARE LONG-TERM CARE PROTECTION PRO-
2
GRAM.
3
The Social Security Act is amended by adding at the
4 end the following new title:
5 "TITLE XXI-LIFECARE LONG-
6
TERM CARE PROTECTION PRO-
7
GRAM
8
"PART A-GENERAL PROVISIONS
9 "SEC. 2101. DEFINITIONS.
10
"As used in this title:
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1
"(1) ACTIVITY OF DAILY LIVING.-The term 'ac-
2
tivity of daily living' includes:
3
"(A) BATHING.-Getting water and cleans-
4
ing the whole body, including turning on the
5
water for a bath, shower, or sponge bath, getting
6
to, in, and out of a tub or shower, and washing
7
and drying oneself;
8
"(B) DRESSING.-Getting clothes from clos-
9
ets and drawers and then getting dressed, includ-
10
ing putting on braces or other devices and fasten-
11
ing buttons, zippers, snaps, or other closures, se-
12
lecting appropriate attire, and dressing in the
13
proper order;
14
"(C) TOILETING.-Going to a bathroom for
15
bowel and bladder function, transferring on and
16
off the toilet, cleaning after elimination, and ar-
17
ranging clothes;
18
"(D) TRANSFERrING.-Moving in and out of
19
bed and in and out of a chair or wheelchair; or
20
"(E) EATING.-Transferring food from a
21
plate or its equivalent into the body, including
22
cutting food SO as to make possible safe ingestion.
23
"(2) ADULT DAY HEALTH CARE.-The term
24
'adult day health care' means a community-based
25
group program designed to-
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1
"(A) meet the need for adult day health care
2
for functionally impaired individuals in a struc-
3
tured, comprehensive program; and
4
"(B) provide a variety of health and social
5
services furnished by an adult day health care
6
center in an ambulatory group care setting during
7
any part of a day, but on a less than 24-hour
8
basis, to an individual described in section 2112.
9
"(3) ADULT DAY HEALTH CARE CENTER.-
10
"(A) IN GENERAL.-The term 'adult day
11
health care center' means a public agency or pri-
12
vate organization (or a subdivision thereof), with
13
an identifiable administrative unit headed by a Di-
14
rector, that meets such standards for personnel,
15
program, physical characteristics of the facility,
16
recordkeeping, and such other aspects of the func-
17
tion of such center as the Secretary considers nec-
18
essary or desirable for the health, safety, and ef-
19
fective treatment of patients and establishes by
20
regulation.
21
"(B) PROFESSIONAL ORGANIZATION STAND-
22
ARDS.-In promulgating such regulations, the
23
Secretary shall carefully consider certification
24
standards established by the National Council on
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1
Aging and its professional membership unit, the
2
National Institute for Adult Day Care.
3
"(C) PERSONNEL.-Such standards shall in-
4
clude the participation in the provision of the
5
services of the center of a multidisciplinary group
6
of personnel that includes at least—
7
"(i) one physician or nurse practitioner,
8
which could be the individual's own physi-
9
cian or nurse practitioner;
10
"(ii) one registered professional nurse;
11
"(iii) one social worker;
12
"(iv) individuals with skills representing
13
physical, recreational, or occupational ther-
14
apy or speech-language pathology; and
15
"(v) a dietitian.
16
"Such personnel may be employed directly by the
17
center or on a consultant basis, as specified by the
18
Secretary by regulation.
19
"(D) STATE CERTIFICATION.-To be con-
20
sidered an adult health care center under this
21
title, a center shall be certified by a State, pursu-
22
ant to regulations issued by the Secretary.
23
"(4) CARE PLAN.-
24
"(A) IN GENERAL.-The term 'care plan'
25
means a plan that has been developed by a Case
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1
Management Agency, or a home care or home
2
health agency working under contract with the
3
Case Management Agency to provide case man-
4
agement services. Such a care plan shall be based
5
on the results of a comprehensive needs assess-
6
ment of an eligible individual conducted by a case
7
management team in cooperation with the individ-
8
ual, the family of the individual, or other informal
9
caregivers, and in consultation with such other
10
health professionals as the case management team
11
considers appropriate for the needs of the individ-
12
ual. A care plan developed by a home care or
13
home health agency is subject to review and ap-
14
proval by the Case Management Agency. Any
15
entity performing case management services for
16
individuals determined eligible for services under
17
this title shall not be allowed to self-refer for
18
services included in the care plan of such
19
individual.
20
"(B) CONTENTS.-The plan shall-
21
"(i) include a definition of specific out-
22
come goals on which improvement, reduced
23
rate of decline, maintenance, or improved
24
quality of life for the individual is expected;
25
and
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1
"(ii) identify the specific mix of services
2
necessary to meet the outcome goals allotted
3
to the patient and reimbursable under this
4
title as determined by the procedure de-
5
scribed in section 2102.
6
"(5) CASE MANAGEMENT SERVICES.-
7
"(A) IN GENERAL.-The term 'case manage-
8
ment services' means services performed by a
9
case management team that include-
10
"(i) conducting a comprehensive needs
11
assessment in cooperation with an individual
12
and the family of an individual and in consul-
13
tation with such other health professionals
14
(including a physical therapist, occupational
15
therapist, nurse practitioner, certified dieti-
16
tian, or physician) as the case management
17
team considers appropriate for the needs of
18
the individual to assess the physical, social,
19
cognitive, and environmental status of
20
the individual;
21
"(ii) developing, implementing, and
22
modifying (when necessary) the care plan of
23
an individual;
24
"(iii) coordinating the services provided
25
under the care plan;
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1
"(iv) monitoring the care plan to ensure
2
the quality, quantity, timeliness, and effec-
3
tiveness of the services;
4
"(v) monitoring the progress of an indi-
5
vidual toward achievement of the goals spec-
6
ified in the care plan; and
7
"(vi) reviewing and revising, as neces-
8
sary, the care plan at least once every three
9
months or earlier in the event that the condi-
10
tion of the individual changes.
11
"(B) REQUIREMENT.-Individuals providing
12
case management services to children and the dis-
13
abled under this title shall demonstrate their expe-
14
rience with the special needs of these populations.
15
"(6) CASE MANAGEMENT TEAM.-The term
16
'case management team' means a registered profession-
17
al nurse and a qualified social worker (who is licensed
18
or certified, if applicable, in the State in which the in-
19
dividual is providing services), working in consultation
20
with other health professionals as needed, who are em-
21
ployed by a Case Management Agency or by a certi-
22
fied home health agency, home care agency, or other
23
private nonprofit organization under contract with the
24
agency to provide case management services pursuant
25
to the requirements of this title and standards pre-
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1
scribed by the Secretary by regulation. Such nurse and
2
social worker shall meet standards of education, train-
3
ing, and experience established by the Secretary by
4
regulation to qualify to provide case management serv-
5
ices under this title. The case management team for
6
any person determined eligible for services under this
7
title, as defined under section 2112(a)(2)(B)(ii), shall
8
also include a physician.
9
"(7) COMPREHENSIVE NEEDS ASSESSMENT.-
10
The term 'comprehensive needs assessment' means a
11
comprehensive interdisciplinary assessment of the
12
status and needs of an individual that is conducted by a
13
case management team. The assessment shall address
14
functional status (including activities of daily living), in-
15
strumental activities of daily living (such as housekeep-
16
ing, shopping, transportation, meal preparation, and
17
taking medication), medically defined conditions, drug
18
regimen, nutrition status, mental status, living arrange-
19
ment, and availability of caregiver support.
20
"(8) HEAVY CHORE SERVICES.-The term 'heavy
21
chore services' means heavy cleaning and minor home
22
repair. Chore services may not be used to perform ac-
23
tivities that are the responsibility of a housing author-
24
ity or landlord, or both. Heavy chore services shall be
25
provided by personnel not requiring special training but
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1
who work under supervision of the case management
2
agency or other qualified provider. Heavy chore serv-
3
ices include those services determined by a case man-
4
ager to be necessary to protect the health and safety of
5
an individual such as washing floors and walls, wood-
6
cutting, changing storm windows, replacing window
7
panes, door and window locks, installing minor home
8
adaptations, snow shoveling, weatherization, and such
9
other needed heavy chore services as are specified by a
10
case manager.
11
"(9) HOME AND COMMUNITY-BASED CARE SERV-
12
ICES.-The term 'home and community-based care
13
services' means items and services provided to an indi-
14
vidual-
15
"(A) under a written plan of care for furnish-
16
ing such items and services to the individual;
17
"(B) except as provided clauses (iv), (v), and
18
(xii) of subparagraph (C), on a visiting basis in a
19
place of residence of the individual and in other
20
facilities (but not including a nursing facility); and
21
"(C) that include-
22
"(i) homemaker services;
23
"(ii) home health aide services;
24
"(iii) heavy chore services;
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1
"(iv) adult day health care provided at
2
an adult day health care center;
3
"(v) respite care;
4
"(vi) home mobility aids and minor ad-
5
aptations to the home of the individual that
6
promote independence (such as installation of
7
an emergency alarm system, railings, ramps,
8
and special toilets) that are approved by the
9
case manager and included in the care plan
10
of the individual;
11
"(vii) nursing care provided by or under
12
the supervision of a registered professional
13
nurse;
14
"(viii) medical social work services;
15
"(ix) physical, occupational, or speech
16
therapy or rehabilitative services to preserve
17
and restore functional capability or to pre-
18
vent functional deterioration;
19
"(x) transportation to and from health
20
or social services;
21
"(xi) nutrition and dietary counseling
22
provided by or under the supervision of a
23
qualified dietitian; and
24
"(xii) any of the items and services re-
25
ferred to in clauses (i) through (xi)-
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1
"(I) that are provided on an outpa-
2
tient basis, under arrangements made
3
by the case manager, at a hospital or
4
nursing facility, or at a rehabilitation
5
center that meets such standards as
6
may be prescribed in regulation; and
7
"(II) the furnishing of which
8
cannot readily be made available to the
9
individual in such place of residence, or
10
can be provided more economically or
11
effectively in such hospital, facility, or
12
center.
13
"(10) HOME CARE AGENCY.-The term 'home
14
care agency' means an agency in any State that has
15
been certified by the State to provide home care serv-
16
ices pursuant to regulations of the Secretary. Such
17
services include homemaker services, heavy chore serv-
18
ices, and respite services.
19
"(11) HOME HEALTH AGENCY.-The term 'home
20
health agency' means an agency in any State that has
21
been certified by the Secretary to provide home health
22
services. Such services shall include home health aide
23
services, homemaker services, nursing services, respite
24
services, medical social work services, and occupa-
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1
tional, physical, speech therapy, and nutrition and die-
2
tary counseling.
3
"(12) HOME HEALTH AIDE SERVICES.-
4
"(A) IN GENERAL.-The term 'home health
5
aide services' means the services provided by a
6
home health aide who meets such educational,
7
training, and any other requirements as the Secre-
8
tary shall establish by regulation and who is em-
9
ployed by a home health or home care agency or
10
whose services are provided under a contract
11
with, or subcontract on behalf of, a Case Manage-
12
ment Agency.
13
"(B) SERVICES.-Such services shall in-
14
clude—
15
"(i) providing personal care in following
16
the instructions of the case management
17
team of an individual under the supervision
18
of a registered professional nurse or, if ap-
19
propriate, a physical, speech, or occupational
20
therapist;
21
"(ii) assisting the individual with activi-
22
ties of daily living;
23
"(iii) assisting the individual with the
24
taking of medications ordered by a physician,
25
that are ordinarily self-administered;
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1
"(iv) assisting and reinforcing the indi-
2
vidual with necessary self-help skills; and
3
"(v) reporting to the registered profes-
4
sional nurse supervisor any change in the
5
condition or family situation of the individual.
6
"(13) HOMEMAKER SERVICES.-
7
"(A) IN GENERAL.-The term 'homemaker
8
services' means services provided by a homemak-
9
er who meets such educational, training, and any
10
other requirements as the Secretary shall establish
11
by regulation and who is employed by a home
12
health or home care agency or who are working
13
under contract with, or subcontract on behalf of, a
14
Case Management Agency.
15
"(B) SERVICES.-Homemaker services may
16
include-
17
"(i) organizing the homemaking activity
18
of the household with the active participation
19
of an individual, if possible, and other re-
20
sponsible family members;
21
"(ii) coordinating efforts of other family
22
members in planning and carrying out the
23
duties necessary for the normal functioning
24
of the household;
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1
"(iii) performing routine housekeeping
2
tasks, planning and preparing meals, doing
3
the marketing and simple errands, and taking
4
care of light laundry;
5
"(iv) assisting the individual with per-
6
sonal care services including performing ac-
7
tivities of daily living; and
8
"(v) performing such incidental house-
9
hold services as are essential to the care of
10
an individual at home, such as reporting to a
11
registered professional nurse supervisor
12
changes in the condition or family situation
13
of the individual and following a written case
14
plan established by a case management
15
team.
16
"(14) NURSING FACILITY.-
17
"(A) IN GENERAL.-The term 'nursing facil-
18
ity' means an institution that meets such require-
19
ments as the Secretary shall prescribe by regula-
20
tion to ensure the safe and efficient provision of
21
nursing home services under this title.
22
"(B) REQUIREMENTS.-
23
"(i)
REGISTERED
PROFESSIONAL
24
NURSE.-All nursing facilities shall maintain
25
at least one registered professional nurse on
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1
duty at all times. The Secretary may provide
2
limited waivers of such requirement if-
3
"(I) the facility demonstrates to
4
the satisfaction of the Secretary that it
5
has been unable, despite diligent efforts
6
(including offering wages at the commu-
7
nity prevailing rate) to recruit and
8
retain appropriate personnel;
9
"(II) the Secretary determines that
10
a waiver of the requirement will not en-
11
danger the health, safety, or well being
12
of residents of the facility;
13
"(III) the facility meets any other
14
requirements that the Secretary may es-
15
tablish for the approval of such a
16
waiver; and
17
"(IV) such waiver is not for a
18
period in excess of 6 months, but such
19
may be renewed on a limited basis for
20
additional periods not to exceed 6
21
months.
22
"(ii) REGISTERED PROFESSIONAL
23
SOCIAL WORKER.-All nursing facilities
24
shall maintain at least one full-time regis-
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1 and hourly payments, SO long as the amount of payments
2 under such methodology do not exceed, in the aggregate, the
3 amount of payments that would otherwise be made under the
4 methodology described in subsection (a).
5 SEC. 315. APPLICATION TO MEDICARE PROGRAM.
6
Payment methodologies established under this subtitle
7 in a State shall also be applied to payments under medicare
8 for services furnished in the State.
9
Subtitle C-Sources of Revenues
10 SEC. 331. STATE SOURCES OF REVENUES.
11
(a) IN GENERAL.-Each State shall be responsible for
12 establishing a financing program for the implementation of
13 the State CHC program in the State. Such financing pro-
14 gram may include State funding from general revenues, ear-
15 marked taxes, sales taxes, subject to section 332, employer
16 and employee health insurance premiums and cost-sharing,
17 and such other measures consistent with this division as the
18 State may provide.
19
(b) START-UP FUNDS.-In order to assist each State in
20 the development and implementation of the State CHC pro-
21 gram, each State is entitled to receive $10,000,000.
22
(c) ON-GOING ENTITLEMENT.-Each State with a
23 State CHC program approved by the National CHC Board is
24 entitled to funding from the Board in the amounts provided
25 under section 303.
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1 SEC. 332. COST-SHARING.
2
(a) IN GENERAL.-Except as provided in this section, a
3 State CHC program may permit qualified health plans to
4 charge premiums and cost-sharing for services under this di-
5 vision.
6
(b) LIMITATION ON COST-SHARING.-
7
(1) INCOME UNDER POVERTY LINE.-No premi-
8
ums or other cost-sharing may be imposed with respect
9
to any individual in a family the income of which (as
10
determined in accordance with standards specified by
11
the National CHC Board) in the previous year is less
12
than 200 percent of the income official poverty line (as
13
defined in paragraph (5)).
14
(2) OTHER SERVICES.-No deductibles or other
15
cost-sharing may be imposed with respect to-
16
(A) items and services provided to a preg-
17
nant woman,
18
(B) well-baby care, for an individual in a
19
family the income of which (as so determined) in
20
the previous year is less than 150 percent of the
21
income official poverty line.
22
(3) GENERAL LIMIT ON COST-SHARING.-Subject
23
to paragraph (6), premiums in a calendar year and
24
cost-sharing with respect to expenses incurred in a cal-
25
endar year for required items and services other than
26
long-term care may not exceed-
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1
(A) a deductible of more than $200 for a
2
family consisting of 1 individual or $500 for
3
family consisting of more than 1 individual,
4
(B) a coinsurance rate of 20 percent, and
5
(C) total premiums and cost-sharing for a
6
family consisting of 1 individual of $1,000 or
7
$2,500 for a family consisting of more than 1 in-
8
dividual.
9
(4) PAYMENT AMOUNT IS PAYMENT IN FULL.-
10
No individual shall be liable for payment of any
11
amounts for basic covered health care services fur-
12
nished under this division except as permitted in this
13
section.
14
(5) INCOME OFFICIAL POVERTY LINE DE-
15
FINED.-In this section, the term "income official pov-
16
erty line" means the income official poverty line, as
17
defined by the Office of Management and Budget, and
18
revised annually in accordance with section 673(2) of
19
the Omnibus Budget Reconciliation Act of 1981, appli-
20
cable to a family of the size involved.
21
(6) INDEXING.-The dollar amounts specified in
22
paragraph (3) shall be increased, for years after 1994,
23
by the same percentage as the percentage increase in
24
the consumer price index for all urban consumers (U.S.
25
city average) between January 1993 and January of
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1
the previous year. If such dollar amounts are not a
2
multiple of $10, they shall be rounded to the nearest
3
multiple of $10.
4
(c)
COMMUNITY-RATED PREMIUMS.-Premiums
5 charged by a qualified health plan under this division shall be
6 community-rated and shall not reflect the health status of
7 individuals or insured groups.
8 SEC. 333. TRUST FUND AND ALLOCATIONS.
9
(a) USE OF TRUST FUND.-
10
(1) IN GENERAL.-There is hereby created on the
11
books of the Treasury of the United States a trust fund
12
to be known as the "Federal Long-Term Care Trust
13
Fund" (in this section referred to as the "Trust
14
Fund"). The Trust Fund shall consist of such gifts and
15
bequests as may be made (as is hereby authorized to be
16
received) and such amounts as may be deposited in, or
17
appropriated to, such fund as provided in this division.
18
(2) APPROPRIATION.-There are hereby appro-
19
priated to the Trust Fund amounts equivalent to 100
20
percent of the additional revenues received as a result
21
of the provisions of section 333(a) of this Act. The
22
amounts appropriated by the preceding sentence shall
23
be transferred from time to time (not less frequently
24
than monthly) from the general fund in the Treasury to
25
the Trust Fund, such amounts to be determined on the
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1
basis of estimates by the Secretary of the Treasury of
2
the revenues, specified in the preceding sentence, paid
3
to or deposited into the Treasury; and proper adjust-
4
ments shall be made in amounts subsequently trans-
5
ferred to the extent prior estimates were in excess of
6
or were less than the revenues specified in the preced-
7
ing sentence.
8
(3) INCORPORATION OF TRUST FUND PROVI-
9
SIONS.-The provisions of subsections (b) through (i) of
10
section 1841 of the Social Security Act shall apply to
11
the Trust Fund in the same manner as they apply to
12
the Federal Supplemental Medical Insurance Trust
13
Fund, except that any reference to the Secretary of
14
Health and Human Services or the Administrator of
15
the Health Care Financing Administration shall be
16
deemed a reference to National CHC Board.
17
(b) ALLOCATION TO STATES.-
18
(1) IN GENERAL.-Payments in each calendar
19
year to each State from the Trust Fund for long-term
20
care benefits in the State shall be in an amount equal
21
to the Federal matching percentage for the State of
22
the product of-
23
(A) the number of residents of the State in
24
the calendar year who are within each age group
25
(specified under paragraph (3)), and
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1
(B) the Federal per capita allocation for indi-
2
viduals within the age group.
3
For purposes of this paragraph, the term "Federal
4
matching percentage" for a State means 100 percent
5
minus the ratio of the per capita income of the State to
6
the per capita income of the 50 States (and the Dis-
7
trict of Columbia).
8
(2) DETERMINATION OF FEDERAL PER CAPITA
9
ALLOCATION.-
10
(A) INITIALLY.-The Secretary shall estab-
11
lish initial Federal per capita allocations for indi-
12
viduals within each of the age groups. Such allo-
13
cations shall be established in a manner SO that-
14
(i) the ratios of the allocations among
15
the different age groups reflects the ratios of
16
the average per capita costs incurred in pro-
17
viding long-term care to the population of in-
18
dividuals within the respective age groups
19
nationwide, and
20
(ii) the average level of the allocation
21
reflects the level of expenditures for such
22
services under current law.
23
(B) LIMITATION ON INCREASE IN FEDERAL
24
PER CAPITA ALLOCATION.-After 1994, the
25
amount of each of the Federal per capita alloca-
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1
tion for a calendar year shall be such Federal per
2
capita allocation for the previous calendar year in-
3
creased by an index (specified by the Secretary)
4
that reflects the year-to-year rate of increase in
5
average, nationwide costs of a representative mar-
6
ketbasket of the items and services composing
7
long-term care.
8
(3) AGE GROUPS.-For purposes of this subsec-
9
tion, each of the following shall be considered a sepa-
10
rate age group of individuals:
11
(A) Individuals over 64, and under 75, years
12
of age.
13
(B) Individuals over 74, and under 85, years
14
of age.
15
(C) Individuals over 84 years of age.
16
TITLE IV-ADMINISTRATION
17 SEC. 401. NATIONAL COMPREHENSIVE HEALTH CARE BOARD.
18
(a) IN GENERAL.-There is hereby established as an
19 independent agency a National CHC Board (in this section
20 referred to as the "National Board").
21
(b) APPOINTMENT AND TERMS OF MEMBERS.-The
22 National Board shall consist of 7 individuals approved by the
23 President, with the advice and consent of the Senate. Such
24 individuals shall serve for a term of 5 years, except that the
25 terms of individuals initially appointed shall be (as specified
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1 by the President) for such fewer number of years as will pro-
2 vide for the expiration of terms on a staggered basis.
3
(c) DUTIES.-The National Board is responsible for the
4 overall administration of this division, as well as the develop-
5 ment of specific guidelines to permit States to carry out this
6 division.
7
(d) REPORT.-The National Board shall report to Con-
8 gress on the status of expenditures under this division, long-
9 range plans and goals for the organization and delivery of
10 personal health services, differences in the health status of
11 the populations of the different States, as well as opportuni-
12 ties for improvements in the program provided under this di-
13 vision.
14
(e) NATIONAL ADVISORY BOARD.-
15
(1) The National Board shall provide for appoint-
16
ment of a National Advisory Board to advise the Na-
17
tional Board on its activities.
18
(2) Such Advisory Board shall consist of 15 mem-
19
bers who are representatives of employers, unions,
20
health care providers, health care insurers, consumer
21
organizations, State CHC Boards, and public health
22
professionals, as well as the general public. Such mem-
23
bers shall serve for terms of 3 years, except that, in
24
the initial appointment, 5 members shall be each ap-
25
pointed for terms of 1-year, 2-years, and 3-years.
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1
(3) Such Advisory Board shall sponsor site visits
2
and studies that are concerned with issues of access to
3
health care services, utilization of health care services,
4
and consumer participation and satisfaction in the pro-
5
vision of health care services.
6 SEC. 402. STATE COMPREHENSIVE HEALTH CARE PROGRAMS.
7
(a) IN GENERAL.-Each State shall submit to the Na-
8 tional CHC Board a plan for its State CHC program in the
9 State.
10
(b) REVIEW AND APPROVAL OF PLANS.-The National
11 CHC Board shall review plans submitted under subsection (a)
12 and determine whether such plans meet the requirements for
13 approval. The Board shall not approve such a plan unless it
14 finds that the plan provides, consistent with the provisions of
15 this division, for-
16
(1) adequate financing of health services under the
17
plan,
18
(2) freedom of choice of eligible individuals in the
19
selection among qualified health plans,
20
(3) effective cost containment measures and pay-
21
ment methodologies consistent with title III,
22
(4) adequate administration, including the designa-
23
tion of a single State agency responsible for adminis-
24
tration of the program and the establishment of a
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1
public advisory board (with board representation of in-
2
terested parties),
3
(5) appropriate safeguards and grievance proce-
4
dures,
5
(6) responsive quality control mechanisms (includ-
6
ing the establishment of a State Commission on Qual-
7
ity),
8
(7) organization of a State commission to develop
9
programs and schedules to reduce excess hospital beds,
10
and
11
(8) an organized grievance procedure available to
12
consumers through which complaints about the organi-
13
zation and administration of personal medical care
14
services may be filed and hearings held (at the discre-
15
tion of the State CHC Board). Programs under para-
16
graph (7) shall provide for appropriate plans to refi-
17
nance outstanding hospital debt (for hospitals in which
18
beds will be reduced) and to retrain (where necessary)
19
staff displaced by a reduction in excess hospital beds.
20
(c) OPERATIONAL STATUS.-A State CHC program in
21 a State shall not be considered operational unless it is ap-
22 proved under subsection (b) and it has enrolled at least 90
23 percent of the eligible individuals in the State under the
24 program.
25
(d) FAILURE OF APPROVAL.-
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1
(1) If the National CHC Board finds that a State
2
plan submitted under subsection (a) does not meet the
3
requirements for approval under subsection (b) or that
4
a State plan, previously approved, no longer meets
5
such requirements the Board shall provide notice to the
6
State CHC Board of such failure and that unless cor-
7
rective action is taken within a period of 90 days the
8
sanctions described in paragraph (2) may be applied,
9
effective 90 days after the end of such 90-day period.
10
(2) The sanctions described in this paragraph
11
are-
12
(A) that expenses of employers in the State
13
for health-related items may not be deducted from
14
income under section 212 of the Internal Revenue
15
Code of 1986, and
16
(B) amounts otherwise payable under this di-
17
vision to the State shall be reduced by 10 per-
18
cent.
19 SEC. 403. COMMISSIONS ON QUALITY.
20
(a) NATIONAL COMMISSION ON QUALITY.-
21
(1) IN GENERAL.-The National CHC Board
22
shall provide for appointment of a National Commis-
23
sion on Quality to establish, evaluate, and update na-
24
tional minimum standards to assure the quality of serv-
25
ices provided under this division and to monitor efforts
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1
by State CHC Boards to assure the quality of such
2
services. Members of the Board shall be appointed to
3
serve for fixed (and staggered) terms and in a manner
4
as to provide for representation of the viewpoints of
5
relevant health professions, health institutions and pro-
6
grams, the general public (including representation of
7
various population groups in the public).
8
(2) NATIONAL MINIMUM STANDARDS.-The na-
9
tional minimum standards under paragraph (1) shall be
10
established for institutional providers of services, physi-
11
cians and other individual health care personnel, and
12
organized delivery programs. Such standards shall in-
13
clude elements relating to-
14
(A) adequacy and quality of facilities,
15
(B) competence of personnel,
16
(C) comprehensiveness of service,
17
(D) continuity of service,
18
(E) patient satisfaction (including waiting
19
time and access to services), and
20
(F) performance standards (including organi-
21
zation, facilities, and structure of services, and
22
outcome in palliation, improvement of health, sta-
23
bilization, cure, or rehabilitation).
24
(3) ANNUAL REPORT.-The National Commission
25
on Quality shall prepare an annual report on quality
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1
assurance under this division. Such report shall include
2
an assessment of the impact of this division on health
3
care quality, access, and beneficiary cost.
4
(4) EXCHANGE OF INFORMATION.-The National
5
Commission on Quality shall provide for an exchange,
6
at least annually, among State Commissions on Quality
7
of information respecting quality assurance and cost
8
containment.
9
(b) STATE COMMISSION ON QUALITY.-
10
(1) IN GENERAL.-Each State CHC Board shall
11
provide for an appointment of a State Commission on
12
Quality to implement national minimum standards in
13
each State. Members of such a Board shall be appoint-
14
ed to serve for fixed (and staggered) terms and in a
15
manner as to provide for representation of the view-
16
points of relevant health professions, health institutions
17
and programs, the general public (including representa-
18
tion of various population groups in the public).
19
(2) MODIFICATION OF STANDARDS.-Each State
20
Commission on Quality may, with the consent of the
21
National Commission on Quality, provide for the appli-
22
cation of modified national minimum standards due to
23
special conditions or opportunities in the State.
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1 SEC. 404. NATIONAL ADVISORY COMMISSION ON TECHNOL-
2
OGY ASSESSMENT AND CLINICAL EFFECTIVE-
3
NESS.
4
(a) ESTABLISHMENT.-The National CHC Board shall
5 establish a National Advisory Commission on Technology
6 Assessment and Clinical Effectiveness (in this section re-
7 ferred to as the "Commission").
8
(b) DUTIES.-The Commission shall, in close consulta-
9 tion with the Secretary of Health and Human Services, make
10 recommendations related to-
11
(1) technological development and clinical treat-
12
ment effectiveness;
13
(2) outcomes of drugs, devices, and clinical proce-
14
dures; and
15
(3) possible inclusion of new drugs and technologi-
16
cal procedures as covered health services and discon-
17
tinuance of payment for inefficient procedures.
18 SEC. 405. NATIONAL RESOURCES EQUALIZATION FUND.
19
(a) ESTABLISHMENT.-There is hereby established a
20 National Resources Equalization Fund, to be administered by
21 the National CHC Board.
22
(b) PURPOSE.-The Fund shall be used by the Board to
23 augment the capability of medically under-developed areas to
24 provide services under this division and to strengthen their
25 abilities to provide local services.
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1
(c) FUNDING.-There are authorized to be appropriated
2 for the Fund for fiscal year 1994, $1,000,000,000, and, for
3 each fiscal year thereafter, amounts equal to 1 percent of the
4 expenditures to be made under this division in that fiscal
5 year.
6
(d) GRANTS.-The Board shall provide, upon applica-
7 tion, for making amounts available in the fund to States and
8 localities.
9
TITLE V-EFFECTIVE DATES; TRANSITION;
10
RELATION TO OTHER PROGRAMS
11 SEC. 501. EFFECTIVE DATES.
12
(a) IN GENERAL.-The comprehensive health care pro-
13 gram established under this division shall first apply to health
14 care services furnished during the 3rd calendar year begin-
15 ning after the date of the enactment of this Act.
16
(b) EXCEPTION.-However, such program shall not
17 apply with respect to any calendar year unless, before the
18 beginning of the year, the Secretary of Health and Human
19 Services has determined that at least 1/2 of the number of
20 States have enacted legislation necessary to implement this
21 division in such States.
22 SEC. 502. TRANSITION.
23
(a) AUTHORIZATION OF APPROPRIATIONS.-There are
24 authorized to be appropriated for each of 3 fiscal years begin-
25 ning after the date of the enactment of this Act such sums as
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1 may be necessary to provide for financial assistance to States
2 in the planning and development of State CHC programs.
3
(b) FEHBP.-Notwithstanding any other provision of
4 law, no health benefits plan may be offered under chapter 89
5 of title 5, United States Code, after the effective date of this
6 division unless the plan is a qualified health plan under this
7 division.
8 SEC. 503. TREATMENT OF MEDICARE AND MEDICAID PRO-
9
GRAMS.
10
(a) MEDICARE PROGRAM.-
11
(1) Except as specifically provided in this division,
12
nothing in this division shall be construed as changing
13
medicare.
14
(2) To the extent that individuals who are entitled
15
to benefits under medicare are enrolled under a State
16
CHC program under this division, the medicare pro-
17
gram shall be primary payor with respect to any dupli-
18
cative benefits.
19
(b) MEDICAID PROGRAMS.-Except as specifically pro-
20 vided in this division, the medicaid program shall not apply in
21 any State with a State CHC program approved and in oper-
22 ation under this division.
23 SEC. 504. TREATMENT OF CERTAIN PROGRAMS.
24
Nothing in this division shall be construed as making
25 any changes in the programs of health care under title 10
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1 SEC. 202. EXCLUSIONS.
2
(a) GENERAL EXCLUSIONS.-Basic covered health
3 services do not include items and services for which payment
4 may not be made under medicare, including the following
5 items and services:
6
(1)(A) Except for items and services described in
7
the succeeding subparagraphs, items and services not
8
reasonable and necessary for the diagnosis or treatment
9
of illness, injury, or condition, or to improve the func-
10
tioning of a malformed body member.
11
(B) In the case of preventive health services (in-
12
cluding immunizations), services which are not reason-
13
able and necessary for the prevention of illness.
14
(C) In the case of hospice care, care which is not
15
reasonable and necessary for the palliation or manage-
16
ment of terminal illness.
17
18
(D) In the case of persona care services, services
19
which are not reasonable and necessary to assure the
20
health and condition of the individual is maintained in
the individual's noninstitutinal residence.
21
22
(2)(A) Subject to sparagraph (B), items and
23
services not provided withthe United States.
24
(B) Subparagraph (A)rll not apply to_
25
(i) emergency in hql Or physicians'
26
physician available is Canada closer exico individual's if the hospital services or
residence
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1
than a hospital or physician in the United States,
2
or
3
(ii) items and services required by a citizen of
4
the United States while traveling en route be-
5
tween a residence in the United States and
6
Alaska.
7
(3) Services which constitute personal comfort
8
items.
9
(4) Items and services, other than preventive
10
health services, for routine physical checkups, eye-
11
glasses, and hearing aids.
12
(5) Cosmetic surgery, except for prompt repair of
13
accidental injury or for improvement of the functioning
14
of malformed body member.
(6) Services rendered by immediate relatives of
15
the individual or members of the individual's house-
16
17
hold.
(7) Services, other than preventive health serv-
18
ices, in connection with the care, treatment, filling, re-
19
moval, or replacerent of teeth or structures directly
20
supporting teeth, eept for inpatient hospital services medical
21
in connection witheatment of an underlying
22
23
condition. (8)(A) Subject subparagraph (B), treatment of
24
flat feet conditiod the prescription of supportive
25
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1
devices thereof, the treatment of subluxations of the
2
foot, or routine foot care (including the cutting or re-
3
moval of corns or calluses, the trimming of nails, and
4
other routine hygienic care).
5
(B) Subparagraphs (A) shall not apply to services
6
or treatment required to prevent serious handicapping
7
for patients with a diagnosed case of diabetes mellitus.
8
(b) EXCLUSIONS OF NON-MEDICARE INDIVIDUALS.-
9 Basic covered health services do not include, for individuals
10 who are not entitled to benefits under medicare, the following
11 items and services:
12
(1) Orthopedic shoes or other supportive devices
13
for the feet.
14
(2) Professional services of chiropractors.
15
(3) Inpatient hospital services furnished outside
16
the United States and described in section 1814(f) of
17
the Social Security Act.
18
(c) ADDITIONAL EXCLUSIONS.-The National CHC
19 Board, after consultation with the National Advisory Board
20 and the Commission on Quality, may stipulate, upon the
21 basis of the cost and effectiveness of providing particular
22 health care items or services, that payment may not be made
23 by a qualified health plan, underthis division, or under medi-
24 care, for such an item or service.
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1 SEC. 203. PROVIDER STANDARDS.
2
(a) IN GENERAL.-Except as otherwise provided in this
3 division, the provisions of title ХѴШ of the Social Security
4 Act with respect to-
5
(1) definitions of terms and descriptions of health
6
care providers (under section 1861 of such Act), and
7
(2) conditions of participation for health care pro-
8
viders (under section 1866 of such Act) and the use of
9
State or other agencies in determining compliance with
10
standards (under sections 1863 and 1864 of such Act),
11 shall apply to basic covered health care services provided
12 under qualified health plans to the same extent as they apply
13 to items and services for which payment may be made under
14 title ХѴШ of such Act.
15
(b) ADDITIONAL CONDITIONS FOR PROVISIONS OF
16 CERTAIN SERVICES.-
17
(1) UNDER THIS DIVISION.-In the case of high-
18
risk, high-cost, elective, or over-utilized items or serv-
19
ices, specified by the National CHC Board, for which
20
payment may otherwise be made under this division or
21
medicare, the Board may restrict coverage of such
items or services to a provider-
22
(A) that is certified by an appropriate spe-
23
cialty board the relevant medical specialty, or
24
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1
(B) that is adequately equipped and staffed
2
(in accordance with regulations of the Board) to
3
furnish the items or services.
4
(2) UNDER MEDICARE.-Notwithstanding any
5
provision of title ХѴШ of the Social Security Act to
6
the contrary, payment may only be made under such
7
title for an item or service for which a restriction is in
8
effect under paragraph (1) if it is provided by a provid-
9
er who meets the requirements of such paragraph.
10
(c) ORGANIZED APPROACHES TO DELIVERY OF SERV-
11 ICES.-The National CHC Board shall sponsor efforts to en-
12 courage State CHC Board and providers of services to devel-
13 op and expand organized approaches to the delivery of health
14 services, including health maintenance organizations, hospi-
15 tal-based and community-oriented team health services, and
16 neighborhood-hospital-home health care plans.
17 SEC. 204. STATE APPROVAL OF QUALIFIED HEALTH PLANS.
18
(a) IN GENERAL.-Each State CHC program shall pro-
19 vide for the review and approval or disapproval of health
20 plans as qualified health plans in the State for purposes of
21 this division.
22
(b) REQUIREMENTS.-A State may not approve a
23 health plan as a qualified health plan under its State CHC
24 program unless the State finds that the plan-
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1
(1) provides for benefits at least equal to the mini-
2
mum benefits specified in section 202,
3
(2) provides for enrollment of individuals in a
4
manner consistent with this division,
5
(3) provides for establishment of budgets and pay-
6
ments for services in a manner consistent with this di-
7
vision,
8
(4) establishes a responsive grievance procedure
9
for the receipt and resolution of grievances concerning
10
the enrollment of individuals and delivery of services
11
under this division,
12
(5) provides for benefits in an acceptable quality
13
(as determined by the State),
14
(6) does not discriminate in its enrollment and
15
provision of benefits on the basis of race, religion, sex,
16
marital status, health status, or other impermissible
17
basis (as specified by the National CHC Board),
18
(7) provides for economic operation and adminis-
19
tration,
20
(8) provides for minimum retention charges,
21
(9) provides for simplified procedural require-
22
ments, and
23
(10) meets such other requirements as the Nation-
24
al CHC Board may specify to insure against fraud and
abuse under this division.
25
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1
(c) LIMITATIONS ON NON-HMO QUALIFIED HEALTH
2 PLANS.-
3
(1) IN GENERAL.-A State may limit the number
4
of qualified health plans which may be offered in a
5
State.
6
(2) EXCEPTION FOR HEALTH MAINTENANCE
7
PLANS.-Paragraph (1) shall not apply to qualified
8
health plans that are qualified health maintenance or-
9
ganizations (as defined in section 1310(d) of the Public
10
Health Service Act) or meet the requirements of sub-
11
paragraphs (A) through (C) of section 1876(b)(2) of the
12
Social Security Act.
13
(d) WITHDRAWAL OF APPROVAL.-If a State deter-
14 mines that a health plan, that has been previously approved
15 as a qualified health plan, no longer meets the requirements
16 of a qualified health plan, the State shall withdraw approval
17 of the plan and shall provide a procedure whereby individuals
18 enrolled in the plan may be enrolled in other qualified health
19 plans.
20
TITLE III-FINANCING
21
Subtitle A-Budget Process
22 SEC. 301. NATIONAL HEALTH ESTIMATES.
23
(a) IN GENERAL.-The National CHC Board shall es-
24 tablish every 2 years a biennial estimate of expenditures and
25 revenues under this division which estimates-
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1
(1) the expenditures to be made in the period cov-
2
ered under the estimate by States and the Federal
3
Government for required benefits under this division
4
(including administrative costs),
5
(2) the revenues required to meet such expendi-
6
tures, and
7
(3) an average per capita level of Federal contri-
8
bution for each State.
9 Such estimate shall not include expenditures or revenues at-
10 tributable to the operation of medicare.
11
(b) INITIAL NATIONAL ESTIMATE.-
12
(1) EXPENDITURES.-The level of expenditures
13
in the first year of the program under this division
14
shall be based on the average of State and Federal ex-
15
penditures for required health care benefits for a base
16
period (identified by the National CHC Board) in-
17
creased to the first year by the percentage increase in
18
the medical care component of the consumer price
19
index for all urban consumers between the base period
20
and the first year. Such estimate shall treat as expend-
21
itures for the base period those expenditures that
22
would have resulted from the delivery of free or dis-
23
counted care for required services.
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1
(c) LIMITATIONS ON Non-HMO QUALIFIED HEALTH
2 PLANS.-
3
(1) IN GENERAL.-A State may limit the number
4
of qualified health plans which may be offered in a
5
State.
6
(2) EXCEPTION FOR HEALTH MAINTENANCE
7
PLANS.-Paragraph (1) shall not apply to qualified
8
health plans that are qualified health maintenance or-
9
ganizations (as defined in section 1310(d) of the Public
10
Health Service Act) or meet the requirements of sub-
11
paragraphs (A) through (C) of section 1876(b)(2) of the
12
Social Security Act.
13
(d) WITHDRAWAL OF APPROVAL.-If a State deter-
14 mines that a health plan, that has been previously approved
15 as a qualified health plan, no longer meets the requirements
16 of a qualified health plan, the State shall withdraw approval
17 of the plan and shall provide a procedure whereby individuals
18 enrolled in the plan may be enrolled in other qualified health
19 plans.
20
TITLE III-FINANCING
21
Subtitle A-Budget Process
22 SEC. 301. NATIONAL HEALTH ESTIMATES.
23
(a) IN GENERAL.-The National CHC Board shall es-
24 tablish every 2 years a biennial estimate of expenditures and
25 revenues under this division which estimates-
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1
(1) the expenditures to be made in the period cov-
2
ered under the estimate by States and the Federal
3
Government for required benefits under this division
4
(including administrative costs),
5
(2) the revenues required to meet such expendi-
6
tures, and
7
(3) an average per capita level of Federal contri-
8
bution for each State.
9 Such estimate shall not include expenditures or revenues at-
10 tributable to the operation of medicare.
11
(b) INITIAL NATIONAL ESTIMATE.-
12
(1) EXPENDITURES.-The level of expenditures
13
in the first year of the program under this division
14
shall be based on the average of State and Federal ex-
15
penditures for required health care benefits for a base
16
period (identified by the National CHC Board) in-
17
creased to the first year by the percentage increase in
18
the medical care component of the consumer price
19
index for all urban consumers between the base period
20
and the first year. Such estimate shall treat as expend-
21
itures for the base period those expenditures that
22
would have resulted from the delivery of free or dis-
23
counted care for required services.
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1
(2) FEDERAL CONTRIBUTIONS.-The average per
2
capita annual level of Federal contribution for each
3
State in the first year shall be equal to the sum of-
4
(A) the amount of the annual expenditures of
5
the Federal Government made during the base
6
period (identified under paragraph (2)) on required
7
services (other than under medicare) for residents
8
of the State, computed on an average per capita
9
basis, increased by the percentage increase in the
10
medical care component of the consumer price
11
index for all urban consumers between the base
12
period and the first year, and
13
(B) 1/3 of the amount of additional expendi-
14
tures (as estimated by the National CHC Board)
15
required to be made in the State on an annual
16
basis for required services in the first year for
17
which expenditures were not being made during
18
the base period, computed on an average per
19
capita basis.
20
(c) SUBSEQUENT NATIONAL HEALTH ESTIMATES.-
21
(1) EXPENDITURES.-The level of expenditures
22
provided under subsequent national health estimates
23
shall be based on the level of expenditures in the previ-
24
ous national health estimate increased or decreased by
25
the percentage increase or decrease, respectively,
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1
during the previous 2 years in the gross national prod-
2
uct of the United States.
3
(2) FEDERAL CONTRIBUTION.-The average per
4
capita annual levels of Federal contribution for each
5
State in each subsequent national health estimate shall
6
be based on the average annual per capita levels of
7
Federal contribution for the State in the previous esti-
8
mate period increased or decreased by the percentage
9
increase or decrease, respectively, during the previous
10
2 years in the gross national product of the United
11
States. The National CHC Board may adjust such av-
12
erage annual per capita levels of Federal contribution
13
(A) in order to take into account the changes in re-
14
quired services and changes in the relative per capita
15
expenditures required for services due to change in de-
16
mography of the population and (B) among the States
17
in order to make equitable adjustments based on
18
changes in the required services and changes in the
19
relative per capita expenditures for required services
20
among the States and in order to take into account
21
each State's past performance in containing costs of
22
such services in the State.
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1 SEC. 302. STATE HEALTH BUDGETS.
2
(a) IN GENERAL.-Each State CHC Board shall estab-
3 lish every 2 years a biennial State health budget which pro-
4 vides for-
5
(1) the expenditures to be made under the State
6
CHC program in the period covered under the budget
7
under this division (including administrative costs), and
8
(2) the revenues to meet such expenditures. Such
9
budget shall not include expenditures or revenues at-
10
tributable to the operation of medicare.
11
(b) COORDINATION.-Each State health budget shall be
12 coordinated, in a manner specified by the National CHC
13 Board, with the national health estimate established under
14 section 301(a).
15
(c) MAINTENANCE OF EFFORT.-
16
(1) FIRST YEAR.-Each State health budget for
17
the first year shall provide for a contribution by the
18
State of amounts not less than the amounts provided
19
by the State in the base year (identified by the Nation-
20
al CHC Board) increased by the percentage increase in
21
the medical care component of the consumer price
22
index for all urban consumers between the base period
23
and first year.
24
(2) SUBSEQUENT BUDGET PERIODS.-Each State
25
health budget for a subsequent budget period shall pro-
26
vide for a contribution by the State of amounts not less
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1
than the amounts provided by the State in the previous
2
budget period increased or decreased by the percentage
3
increase or decrease, respectively, during the previous
4
2 years in the gross national product of the United
5
States.
6
(d) ANNUAL PUBLICATION.-The State shall provide
7 for the publication annually of the most recent State health
8 budget established under this section.
9 SEC. 303. PAYMENTS TO STATES.
10
(a) IN GENERAL.-Each State with an approved State
11 CHC program is entitled to receive, from amounts in the
12 Treasury not otherwise appropriated, an amount equal to the
13 product of (1) the average number of residents of the State,
14 and (2) the average annual per capita Federal contribution
15 level (computed under section 301), adjusted to take into ac-
16 count differences in the health care consumption pattern of
17 the State, from the national average, resulting from the age
18 and sex composition of the population of the State, compared
19 to the national average for all States. The National CHC
20 Board shall provide for periodic adjustments in payments
21 under this section to take into account the differences be-
22 tween the actual average number of residents of each State
23 (and their age and sex composition) compared to such number
24 (and composition) used under the previous sentence.
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1
(b) USE OF COMPREHENSIVE HEALTH CARE
2 FUNDS.-
3
(1) IN GENERAL.-All revenues (including deduct-
4
ible and coinsurance payments) provided to finance the
5
program under this division shall be deposited, with re-
6
spect to each State, into a Comprehensive Health Care
7
Fund for the State. Payments to qualified health plans
8
shall be made from such Funds.
9
(2) NATIONAL AMOUNTS.-Paragraph (1) shall
10
not apply to such revenues as are required to provide
11
for the National CHC Board and national administra-
12
tive expenses.
13 SEC. 304. ESTABLISHMENT OF EXCHANGE PROGRAM.
14
The National CHC Board shall establish a program
15 under which, if a State furnishes covered health services to
16 residents of another State, the first State would receive credit
17 for payments for the services against the amounts to which
18 the other State is otherwise entitled to receive.
19
Subtitle B-Payments to Qualified
20
Health Plans and to Providers
21 SEC. 311. PAYMENTS TO QUALIFIED HEALTH PLANS.
22
(a) COMPUTATION OF ADJUSTED AVERAGE PER
23 CAPITA Cost.-Based on a methodology established by the
24 National CHC Board, each State CHC program shall com-
25 pute an adjusted average per capita cost for required services
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1 under the program in the State for different classes of individ-
2 uals. Such adjusted average per capita cost shall reflect the
3 average per capita level of expenditures that the State esti-
4 mates (based on actual experience or actuarial equivalent,
5 with appropriate adjustments to assure actuarial equivalence)
6 is required to provide for expenditures in the State for serv-
7 ices (and related administrative costs) under the State CHC
8 program. Such adjusted average per capita cost shall be com-
9 puted for individuals based on age and sex and such other
10 factors as will assure actuarial equivalence and otherwise
11 provide for equitable distribution of funds to qualified health
12 plans.
13
(b) PAYMENT TO PLANS.-Each State CHC program
14 shall provide for payment to qualified health plans, for indi-
15 viduals enrolled under this division, on a monthly basis in an
16 amount equal to the adjusted average per capita cost comput-
17 ed under subsection (a) with respect to such individuals. The
18 program may provide for retroactive adjustment in such pay-
19 ments to take into account any difference between the actual
20 number (or composition) of individuals enrolled under the
21 plan and the number of such individuals estimated to be SO
22 enrolled in determining the amount of the advance payment.
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1 SEC. 312. PAYMENTS TO PROVIDERS UNDER QUALIFIED
2
HEALTH PLANS.
3
(a) IN GENERAL.-Each State CHC program shall pro-
4 vide for the payment of providers by qualified health plans in
5 a manner consistent with this subtitle.
6
(b) MANDATORY ASSIGNMENT.-Each provider of serv-
7 ices or other practitioner that receives funding under this di-
8 vision agrees to accept the payment amount recognized under
9 the State CHC program for services covered under the pro-
10 gram as payment in full for such services and may not impose
11 any charges for such services other than those permitted with
12 respect to such services under section 332.
13
(c) CONTINUUM OF CARE.-The National CHC Board,
14 in order to avoid fragmented care, shall develop financial in-
15 centives, in the payment methods provided under this sub-
16 title, to promote a continuum of care.
17
(d) DIRECT PAYMENT FOR CERTAIN HEALTH PRO-
18 FESSIONALS.-A State CHC program shall require qualified
19 health plans (other than health maintenance plans) to provide
20 for direct payment to nurse practitioners, nurse midwives,
21 physicians' assistants, and similar health professionals who
22 are authorized to provide health services under State law
23 while not under the direct supervision of a physician.
24 SEC. 313. PAYMENTS TO INSTITUTIONAL PROVIDERS.
25
(a) IN GENERAL.-Payment for institutional care, in-
26 cluding hospital services and nursing facility services, shall be
HR 4253 IH
32
1 made in each State on the basis of a biennial prospective
2 budgeting system, established by the State consistent with its
3 State health budget established under section 302 after nego-
4 tiations with institutional providers.
5
(b) WAIVERS.-The National CHC Board may waive
6 the requirement of subsection (a) in the case of a State, but
7 only if the State demonstrates that the payment methodology
8 used will not result in expenditures exceeding those provided
9 under its State health budget.
10 SEC. 314. PAYMENTS FOR PHYSICIANS' SERVICES.
11
(a) IN GENERAL.-Except as otherwise provided in this
12 section, payment for physicians' services shall be based on
13 payment schedules established by each State CHC Board.
14 Such schedules-
15
(1) shall be established after negotiations with or-
16
ganizations representing physicians,
17
(2) shall be based on a national relative value
18
scale, developed by the National CHC Board taking
19
into account the relative value scale developed under
20
section 1848 of the Social Security Act, and
21
(3) shall be in amounts consistent with the State
22
health budget adopted under section 302.
23
(b) ALTERNATIVE PAYMENT MECHANISMS.-Payment
24 for physicians' services may be based on alternative payment
25 methodologies, including capitation methods, annual salary
HR 4253 IH
I
101ST CONGRESS
2D SESSION
H. R. 4253
To provide for an equitable and universal national health plan administered by the
States, and for other purposes.
IN THE HOUSE OF REPRESENTATIVES
MARCH 13, 1990
Ms. OAKAR (for herself, Mr. STOKES, Mr. RAHALL, Mr. FAUNTROY, and Mr.
HAYES of Illinois) introduced the following bill; which was referred jointly to
the Committees on Ways and Means and Energy and Commerce
A
BILL
To provide for an equitable and universal national health plan
administered by the States, and for other purposes.
1
Be it enacted by the Senate and House of Representa-
2 tives of the United States of America in Congress assembled,
3 SECTION 1. SHORT TITLE.
4
This Act may be cited as the "Comprehensive Health
5 Care for All Americans Act" and also may be cited as the
6 "Claude Pepper Comprehensive Health Care Act".
7 SEC. 2. HONORING CLAUDE PEPPER.
8
The comprehensive health care program provided under
9 this Act is enacted in honor of Senator Claude Pepper and
2
1 his 50 years of public service efforts to provide comprehen-
2 sive health care and long-term care for Americans of all ages.
3 SEC. 3. DIVISION OF ACT.
4
This Act is divided into 5 divisions as follows:
5
DIVISION A-Comprehensive Health Care Act
6
DIVISION B-Life Care Long-Term Care Protec-
7
tion
8
DIVISION C-Grants to States for Establishment
9
and Implementation of State Health Objectives Plans
10
DIVISION D-Independence for Older Americans
11
DIVISION E-Authorization of Additional Funds
12
for Research for AIDS, Hypertension, Sickle Cell
13
Anemia, Infant Mortality, and Breast Cancer
14
Division A-Comprehensive Health
15
Care Act
16 SEC. 100. SHORT TITLE; TABLE OF CONTENTS.
17
(a) SHORT TITLE.-This division may be cited as the
18 "Comprehensive Health Care Act".
19
(b) TABLE OF CONTENTS.-The table of contents of
20 this division is as follows:
Sec. 1. Short title; table of contents.
Sec. 2. General definitions.
TITLE I-UNIVERSAL ELIGIBILITY AND ENROLLMENT
Sec. 101. Universal eligibility.
Sec. 102. Enrollment.
Sec. 103. Choice of qualified health plan.
Sec. 104. Issuance of Comprehensive Health Care card.
TITLE II-BENEFITS AND PROVIDERS
Sec. 201. Basic covered health services.
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Sec. 202. Exclusions.
Sec. 203. Provider standards.
Sec. 204. State approval of qualified health plans.
TITLE III-FINANCING
SUBTITLE A-BUDGET PROCESS
Sec. 301. National health budget.
Sec. 302. State health budgets.
Sec. 303. Payments to States.
Sec. 304. Establishment of exchange program.
SUBTITLE B-PAYMENTS TO QUALIFIED HEALTH PLANS AND TO
PROVIDERS
Sec. 311. Payments to qualified health plans.
Sec. 312. Payments to providers.
Sec. 313. Payments to institutional providers.
Sec. 314. Payments for physicians' services.
Sec. 315. Application to medicare program.
SUBTITLE C-SOURCES OF REVENUES
Sec. 331. State sources of revenues.
Sec. 332. Cost-sharing.
Sec. 333. Trust fund and allocations.
TITLE IV-ADMINISTRATION
Sec. 401. National Comprehensive Health Care Board.
Sec. 402. State comprehensive health care programs.
Sec. 403. Commissions on Quality.
Sec. 404. National Advisory Commission on Technology Assessment and Clinical
Effectiveness.
Sec. 405. National Resources Equalization Fund.
TITLE V-EFFECTIVE DATES; TRANSITION; RELATION TO OTHER
PROGRAMS
Sec. 501. Effective dates.
Sec. 502. Transition.
Sec. 503. Treatment of medicare and medicaid programs.
Sec. 504. Treatment of certain programs.
Sec. 505. Treatment of ERISA.
1 SEC. 2. GENERAL DEFINITIONS.
2
In this division:
3
(1) The term "basic covered health services"
4
means those basic covered health services specified in
5
section 201.
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1
(2) The term "medicare" means the program of
2
health insurance established under title ХѴШ of the
3
Social Security Act.
4
(3) The term "medicaid" means the program of
5
medical assistance of States approved under title XIX
6
of the Social Security Act.
7
(4) The term "National CHC Board" means the
8
National Comprehensive Health Care Board.
9
(5) The term "qualified health plan" means a
10
health plan (whether offered by an insurer, health
11
maintenance organization, or other entity) approved by
12
a State under section 204.
13
(6) The term "State CHC Board" means a State
14
Comprehensive Health Care Board.
15
(7) The term "State CHC program" means a
16
State comprehensive health care program approved
17
under section 402.
18
(8) The term "State" includes the District of Co-
19
lumbia, Puerto Rico, the United States Virgin Islands,
20
Guam, American Samoa, and the Northern Mariana
21
Islands.
22
(9) Except as otherwise provided, the definitions
23
contained in section 1861 of the Social Security Act
24
shall apply in this division.
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1 TITLE I-UNIVERSAL ELIGIBILITY
2
AND ENROLLMENT
3 SEC. 101. UNIVERSAL ELIGIBILITY.
4
(a) IN GENERAL.-Each individual who is a resident of
5 the United States and is a citizen or national of the United
6 States or lawful resident alien (as defined in subsection (c)) is
7 eligible to enroll with a qualified health plan for coverage for
8 health benefit under this division under the State CHC pro-
9 gram in the State in which the individual maintains a primary
10 residence.
11
(b) TREATMENT OF CERTAIN NONIMMIGRANTS.-
12
(1) IN GENERAL.-The National CHC Board may
13
make eligible to enroll for coverage for health benefits
14
under paragraph (1), the Board shall consider reciproc-
15
ity in health care benefits offered to United States
16
provide.
17
(2) CONSIDERATION.-In providing for eligibility
18
under paragraph (1), the Board shall consider recipro--
19
city in health care benefits offered to United States
20
citizens who are nonimmigrants to other foreign states,
21
and such other factors as the Board deems appropriate.
22
(3) FINANCIAL ASSISTANCE.-Notwithstanding
23
any other provision of this division, in the case of
24
aliens made eligible under this subsection, the National
25
Board shall provide such financial assistance to States
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1
as to assure that States are not required to contribute
2
to the costs of health care benefits provided to such
3
aliens.
4
(c) LAWFUL RESIDENT ALIEN DEFINED.-In this sec-
5 tion, the term "lawful resident alien" means an alien law--
6 fully admitted for permanent residence and any other alien
7 lawfully residing permanently in the United States under
8 color of law, including an alien with lawful temporary resi-
9 dent status under section 210, 210A, or 245A of the Immi-
10 gration and Nationality Act.
11 SEC. 102. ENROLLMENT IN QUALIFIED HEALTH PLANS.
12
(a) ENROLLMENT PROCESS.-
13
(1) IN GENERAL.-Each State CHC program
14
shall specify an understandable and readily available
15
process for the enrollment of eligible individuals resid-
16
ing in the State in qualified health plans. Such enroll-
17
ments may occur at places of employment, offices of
18
the State CHC program, and other locations.
19
(2) DEFAULT ENROLLMENT.-In the case of an
20
eligible individual who otherwise is not enrolled in a
21
qualified health plan under any State CHC program,
22
the State shall provide a process for enrollment of the
23
individual at the time and place at which the individual
24
first is provided (after the effective date of benefits
25
under this division) basic covered health services.
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1
(3) ISSUANCE OF CHC CARD.-Upon enrollment
2
in a qualified health plan, each eligible individual shall
3
be issued a Comprehensive Health Care card, which
4
indicates the qualified health plan in which the individ-
5
ual is enrolled.
6
(b) TREATMENT OF MARRIED INDIVIDUALS.-A State
7 may not require married individuals to enroll in the same
8 qualified health plan.
9
(c) TREATMENT OF MINOR DEPENDENTS.-In the case
10 of an unmarried individual under 18 years of age, enrollment
11 in a qualified health plan shall be effected, in a manner speci-
12 fied under each State CHC program in accordance with
13 guidelines of the National CHC Board, by a parent or guardi-
14 an of the child. Except in such cases as the Board may pro-
15 vide, such enrollment shall be in the qualified health plan in
16 which the enrolling parent or guardian is enrolled.
17
(d) TREATMENT OF MEDICARE-ELIGIBLE INDIVID-
18 UALS.-Individuals entitled to benefits under medicare shall
19 be enrolled in a qualified health plan in the same manner as
20 other eligible individuals, but such enrollment shall only
21 apply to benefits under such a plan that are not otherwise
22 provided under medicare.
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1
TITLE II-BENEFITS AND
2
PROVIDERS
3 SEC. 201. BASIC COVERED HEALTH SERVICES.
4
(a) IN GENERAL.-Subject to section 202, the basic
5 covered health services provided under this division by each
6 qualified health plan are as follows:
7
(1) HOSPITAL CARE.-Subject to subsection (b)(2)
8
(relating to special limitation on mental health care),
9
inpatient and outpatient hospital care.
10
(2) PHYSICIANS SERVICES AND OTHER PROFES-
11
SIONAL MEDICAL SERVICES.-Subject to subsection
12
(b)(2) (relating to special limitation on mental health
13
care), physicians' services and professional services of
14
nurse practitioners, nurse midwives, social workers,
15
physicians' assistants, and similar health professionals
16
who are authorized to provide health services under
17
State law while not under the direct supervision of a
18
physician.
19
(3) TESTS.-Diagnostic and screening tests.
20
(4) PRE-NATAL AND WELL-BABY CARE.-Pre-
21
natal and well-baby care (for infants under 1 year of
22
age).
23
(5) MENTAL HEALTH SERVICES.-Subject to sub-
24
section (b)(2), diagnosis, evaluation, treatment, and
25
crisis intervention for a mental illness.
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1
(6) DRUG AND ALCOHOL ABUSE TREATMENT
2
PROGRAMS.-Subject to subsection (b)(3), inpatient and
3
outpatient drug and alcohol abuse treatment services
4
provided under a treatment program approved by the
5
State and through provider organizations that meet
6
State qualification standards, including-
7
(A) for acute care-
8
(i) intervention,
9
(ii) assessment, diagnosis, and referral
10
(by State-certified alcohol and drug profes-
11
sionals),
12
(iii) medical detoxification according to
13
individual need,
14
(iv) minimum 14-day primary treatment
15
program and post-detoxification,
16
(v) aftercare treatment,
17
(vi) outpatient treatment, and
18
(vii) day treatment; and
19
(B) for long-term care-
20
(i) long-term halfway house care,
21
(ii) three-quarter way house care,
22
(iii) primary youth treatment,
23
(iv) detoxification and long-term treat-
24
ment for pregnant, addicted women to reha-
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1
bilitate mother and prevent addicted infant
2
births,
3
(v) relapse prevention programs in non-
4
traditional settings, and
5
(vi) outpatient counseling and group
6
therapy.
7
(7) HOSPICE CARE.-Hospice care for individuals
8
certified to be terminally ill, including case-manage-
9
ment services, provided by a hospice program approved
10
under medicare or approved by the State.
11
(8) POST-HOSPITAL SKILLED NURSING FACILITY
12
SERVICES.-Subject to the limitations on nursing facili-
13
ty services and personal care services in subparagraph
14
(B) and (C) of paragraph (9), post-hospital skilled nurs-
15
ing services and home health services.
16
(9) LONG-TERM CARE.-
17
(A) IN GENERAL.-Subject to the succeeding
18
provisions of this paragraph, nursing facility serv-
19
ices and personal care services for individuals de-
20
termined (in a manner specified under the State
21
CHC program, in accordance with guidelines of
22
the National CHC Board) to be impaired in 2 or
23
more activities of daily living (as defined by the
24
National CHC Board) or to have a severe cogni-
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1
tive impairment creating a comparable need for
2
such services.
3
(B) BENEFICIARY LIMITATION.-
4
(i) INITIAL PHASE.-During an initial
5
phase (of at least 2 years, but not more than
6
5 years, duration, beginning on the effective
7
date of benefits under this division) to be
8
specified by the National CHC Board, bene-
9
fits under this paragraph are limited to indi-
10
viduals entitled to benefits under part A of
11
title ХѴШ of the Social Security Act,
12
except that, in determining entitlement to
13
such benefits, any references to required pe-
14
riods of disability in section 226(b) of such
15
Act shall be reduced by 18 months.
16
(ii) TRANSITION TO ENTIRE POPULA-
17
TION.-
18
(I) INFANTS.-After the initial
19
phase, the benefits under this paragraph
20
shall be made available to eligible indi-
21
viduals under 1 year or age.
22
(II) OTHERS.-In a manner and
23
time specified by the National CHC
24
Board, the benefits under this para-
25
graph shall also be made available to all
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1
eligible individuals without regard to
2
medicare entitlement or age.
3
(C) LIMITATION ON AMOUNT.-
4
(i) INITIAL PHASE.-During the initial
5
phase referred to in subparagraph (B)(i), ben-
6
efits under this paragraph with respect to
7
any individual are limited to 90 days in any
8
calendar year. Days of receipt of such bene-
9
fits under paragraph (8) shall not be counted
10
against the limitation specified in this clause.
11
(ii) TRANSITION TO ELIMINATE LIMI-
12
TATION ON AMOUNT.-In a manner and
13
time specified by the National CHC Board,
14
the benefits under this paragraph shall be in-
15
creased to cover all days in a year.
16
(D) INCLUSION OF CASE MANAGEMENT.-
17
Benefits under subparagraph (A) include benefits
18
for case management services, including assess-
19
ment of care needs, prior authorization and ar-
20
rangement for services, and continuing review of
21
care needs.
22
(10) PREVENTIVE HEALTH SERVICES.-As de-
23
fined by the National CHC Board:
24
(A) Basic immunizations.
25
(B) Pre-natal and post-natal care.
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1
(C) Well-child care (including periodic physi-
2
cal examinations, hearing and vision screening
3
and developmental screening and examinations)
4
for individuals under 23 years of age.
5
(D) Annual screening mammography and
6
periodic colorectal examinations and examinations
7
for prostat cancer.
8
(E) Annual pap smears.
9
(F) Such other health services as are de-
10
signed to prevent, or to minimize the effect of, ill-
11
ness, disease, or medical condition as specified by
12
the National CHC Board.
13
(11) OTHER MEDICAL AND HEALTH SERVICES.-
14
Other medical and health services specified by the Na-
15
tional CHC Board, including the following:
16
(A) Services and supplies incidental to the
17
provision of physicians' services.
18
(B) Hospital services incidental to physicians'
19
services rendered to outpatients.
20
(C) Appropriate medical services relating to
21
treatment of infection with the etiologic agent for
22
acquired immune deficiency syndrome (AIDS) or
23
treatment for (or prevention of) opportunistic dis-
24
eases relating to AIDS.
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1
(D) Diagnostic services furnished to outpa-
2
tients of hospitals.
3
(E) Outpatient physical therapy services, out-
4
patient speech pathology services, and outpatient
5
occupational therapy services.
6
(F) Health clinic services, including rural
7
health clinic services.
8
(G) Home dialysis supplies and equipment.
9
(H) Diagnostic x-ray tests, diagnostic labora-
10
tory tests, and other diagnostic tests.
11
(I) X-ray (and related) therapy.
12
(J) Durable medical equipment used in the
13
patient's home.
14
(K) Ambulance service, to the extent provid-
15
ed in regulation.
16
(L) Prosthetic devices (other than dental)
17
which replace all or part of an internal body
18
organ (including lens after cataract surgery), in-
19
cluding replacements of such devices.
20
(M) Leg, arm, back, and neck braces, and ar-
21
tificial legs, arms, and eyes, including necessary
22
replacements.
23
(N) Opthalmological examinations.
24
(O) Upon a determination of a certified au-
25
diologist or physician that a hearing problem
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1
exists and is caused by a condition which can be
2
corrected by use of a hearing aid-
3
(i) audiometric examination,
4
(ii) hearing aid evaluation test, and
5
(iii) a hearing aid specified by prescrip-
6
tion as a result of the hearing aid evaluation
7
test (including binaural hearing aids in ex-
8
ceptional cases prescribed by a physician).
9
(P) Health care and health promotion serv-
10
ices designed to prevent or minimize the effect of
11
illness, disease, or medical condition, as the Na-
12
tional CHC Board may, in its discretion, specify.
13
(b) LIMITATIONS ON AMOUNT, DURATION, AND
14 SCOPE.-
15
(1) No LIMITS IN GENERAL.-Except as provided
16
in this subsection, a qualified health plan may not limit
17
the amount, duration, or scope of services for benefits
18
required under subsection (a) beyond those specified in
19
the State plan.
20
(2) LIMITATION ON MENTAL HEALTH SERV-
21
ICES.-A qualified health plan is not required under
22
subsection (a) to provide-
23
(A) inpatient mental health services for an
24
individual unless the individual requires continuing
25
professional care and the individual's mental con-
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1
dition is determined to be amenable to modifica-
2
tion through treatment in an inpatient setting; or
3
(B)(i) more than 45 days of inpatient mental
4
health services with respect to any individual for
5
a calendar year, or (ii) more than 20 outpatient
6
mental health visits with respect to any individual
7
for a calendar year.
8
(3) STATE LIMITATIONS ON SUBSTANCE ABUSE
9
TREATMENT PROGRAMS.-A State CHC program may
10
limit the amount, duration, or scope of substance treat-
11
ment services required to be provided by a qualified
12
health plan under subsection (a)(6).
13
(c) ADDITIONAL BENEFITS.-Nothing in this section
14 shall be construed as limiting the health care benefits that a
15 State or qualified health plan may provide.
16
(d) No DUPLICATE PRIVATE INSURANCE.-No private
17 insurance may be sold which provides for benefits that
18 duplicates basic covered health services described in subsec-
19 tion (a).
20
(e) STATE-FINANCING OF SUPPLEMENTAL BENE-
21 FITS.-There is no Federal financing available under this
22 Act for benefits other than basic covered health services de-
23 scribed in subsection (a).
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1
Division D-Independence for Older
2
Americans
3 SEC. 3001. SHORT TITLE.
4
This division may be cited as the "Independence for
5 Older Americans Act".
6 SEC. 3002. FINDINGS.
7
The Congress finds that-
8
(1) by the year 2020 the number of Americans
9
aged 65 and over will increase to over 50,000,000; by
10
the year 2040 will more than double from present
11
levels to 67,000,000 and those 85 and older will more
12
than quadruple to 13,000,000;
13
(2) more than 1 of every 5 persons 65 years of
14
age or older will be hospitalized during the next year;
15
(3) one of every 4 Americans over age 65 has
16
some degree of activity limitation in performing daily
17
tasks such as walking, buying groceries, and doing
18
housework; and many more older Americans face nu-
19
merous psychological, social, economic and environ-
20
mental obstacles to living independently;
21
(4) death rates among older people from acute
22
conditions have decreased dramatically from the year
23
1900, while chronic conditions which inhibit independ-
24
ence are now the prevalent health problem for older
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142
1
Americans and will increase greatly during the next
2
century;
3
(5) the diseases and conditions of aging that result
4
in dependency are widespread, including 4,000,000
5
victims of Alzheimer's disease, 50,000,000 older
6
Americans suffering from arthritis and related disor-
7
ders, and 5,000,000 victims of incontinence;
8
(6) older people require a large proportion of the
9
Nation's health care resources and face a higher aver-
10
age out-of-pocket medical cost burden than younger
11
people; approximately one-third of the Nation's health
12
care costs, an estimated $180,000,000,000 in 1989,
13
will be spent on people over age 65; the average per
14
capita out-of-pocket cost of persons 65 years of age or
15
older is expected to equal 18.5 percent of income by
16
1991;
17
(7) Americans of all ages desire an independent,
18
healthy existence for older individuals;
19
(8) advances in biomedical, psychological, and
20
social research offer promise of major breakthroughs in
21
diseases and conditions that rob the elderly of their in-
22
dependence;
23
(9) independence for older Americans is an
24
achievable goal for our Nation's research and health
25
care systems.
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1 TITLE I-TASK FORCE ON INDE-
2
PENDENCE FOR OLDER AMERI-
3
CANS
4 SEC. 3101. ESTABLISHMENT.
5
(a) COMPOSITION.-There is established in the Depart-
6 ment of Health and Human Services (hereinafter referred to
7 as the "Department") the Task Force on Independence for
8 Older Americans (hereinafter referred to as the "Task
9 Force"). The Task Force shall be composed of-
10
(1) the Assistant Secretary for Health;
11
(2) the Surgeon General of the United States;
12
(3) the Assistant Secretary for Planning and Eval-
13
uation;
14
(4) the Director of the National Institute on
15
Aging, as well as the Directors of other components of
16
the National Institutes of Health as may be appointed
17
by the Secretary of Health and Human Services (here-
18
inafter referred to as the "Secretary");
19
(5) the Commissioner of the Administration on
20
Aging;
21
(6) the Commissioner of the Food and Drug Ad-
22
ministration;
23
(7) the Chief Medical Director of the Department
24
of Veterans Affairs;
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1
(8) such additional members as the Secretary con-
2
siders appropriate.
3
(b) CHAIRMAN.-The Secretary shall select a Chairman
4 for the Task Force from among its members.
5
(c) QUORUM.-A majority of the members of the Task
6 Force shall constitute a quorum, but a lesser number may
7 hold hearings.
8
(d) MEETINGS.-The Task Force shall meet periodical-
9 ly at the call of the Chairman, but not less than twice each
10 year.
11
(e) APPOINTMENT OF EXECUTIVE SECRETARY; AD-
12 MINISTRATIVE STAFF AND SUPPORT.-The Secretary shall
13 appoint an Executive Secretary for the Task Force and shall
14 provide the Task Force with such administrative staff and
15 support as may be necessary to enable the Task Force to
16 carry out its functions.
17 SEC. 3102. DUTIES.
18
The Task Force shall-
19
(1) coordinate research conducted by or through
20
the Department and other Federal agencies on condi-
21
tions and diseases leading to dependence among the el-
22
derly;
23
(2) establish a mechanism for the sharing of infor-
24
mation among all officers and employees of the agen-
25
cies participating on the Task Force;
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1
(3) identify the most promising areas of research
2
concerning diseases, behavioral and social conditions
3
leading to dependence among the elderly;
4
(4) establish mechanisms to use the results of re-
5
search concerning the conditions and diseases leading
6
to dependence among the elderly in the development of
7
policies, programs, and means to improve the quality of
8
life for older Americans; and
9
(5) review and evaluate public and private spend-
10
ing on such research.
11 SEC. 3103. REPORTS TO CONGRESS.
12
Within 1 year after the effective date and annually
13 thereafter, the Task Force shall transmit to the Congress,
14 and make available to the public, a report on-
15
(1) progress made by research sponsored by the
16
Federal Government on the conditions and diseases
17
leading to dependence among the elderly;
18
(2) new directions in research on such conditions
19
and diseases which the Task Force considers potential-
20
ly important; and
21
(3) recommendations for resource allocations.
22 SEC. 3104. AUTHORIZATION OF APPROPRIATIONS.
23
To carry out this title, there are authorized to be appro-
24 priated $100,000 for each of the fiscal years 1991 through
25 1993.
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1
TITLE II-GERIATRIC RESEARCH
2
AND TRAINING CENTERS
3 SEC. 3201. ESTABLISHMENT.
4
Section 445A of the Public Health Service Act is
5 amended to read as follows:
6 "SEC. 445A. COMPREHENSIVE INDEPENDENCE RESEARCH,
7
TRAINING, AND DEMONSTRATION CENTERS.
8
"(a) The Director of the National Institute on Aging
9 shall enter into cooperative agreements with, and make
10 grants to, public and private nonprofit entities for the devel-
11 opment of comprehensive centers of excellence for geriatric
12 research and training of researchers and for the demonstra-
13 tion and dissemination of the applications of such research.
14
"(b) Each center developed or expanded under this sec-
15 tion shall-
16
"(1) utilize the facilities of a single institution, or
17
be formed from a consortium of cooperating institu-
18
tions, meeting such research and training qualifications
19
as may be prescribed by the Director;
20
"(2) be a comprehensive center including re-
21
search, training, demonstration and dissemination ac-
22
tivities related to enhancing the independence of older
23
Americans;
24
"(3) be affiliated with one or more nursing homes;
25
and
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1
"(4) conduct-
2
"(A) research into the aging processes and
3
into the diagnosis, treatment, and rehabilitation of
4
diseases, disorders, and complications related to
5
aging, particularly those which reduce the ability
6
of the elderly to live independently;
7
"(B) programs to develop individuals capable
8
of conducting research concerning aging and con-
9
cerning such diseases, disorders, and complica-
10
tions;
11
"(C) development and demonstration of ap-
12
plications of research findings to increase the in-
13
dependence of older Americans;
14
"(D) development and demonstration of
15
training programs for older Americans and their
16
families to prolong independence;
17
"(E) training of health care professionals in
18
acute and chronic care methods which promote in-
19
dependence; and
20
"(F) research and demonstration of public
21
education and prevention programs to improve the
22
health and independence of older Americans.
23
"(c) To carry out this section, there are authorized to be
24 appropriated $32,500,000 in fiscal year 1991, $40,000,000
25 in fiscal year 1992, and $50,000,000 in fiscal year 1993.".
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1 TITLE II-AVAILABILITY OF IN-
2
FORMATION TO HEALTH PRO-
3
FESSIONALS, OLDER AMERI-
4
CANS, AND THE GENERAL
5
PUBLIC
6 SEC. 3301. NATIONAL INDEPENDENCE FOR OLDER AMERI-
7
CANS INFORMATION PROGRAM.
8
The Secretary, acting through the Director of the Na-
9 tional Institute on Aging, shall prepare a comprehensive plan
10 for a National Independence for Older Americans Informa-
11 tion Program. The plan shall contain provisions to implement
12 the provisions of this title.
13 SEC. 3302. INFORMATION CLEARINGHOUSE.
14
(a) The Secretary, acting through the Director of the
15 National Institute on Aging, shall establish a clearinghouse
16 to make available information on the latest developments to
17 improve the health and independence of older Americans
18 available to Federal agencies, States, health care profession-
19 als, and the general public. A computer-based data system
20 shall be established to aid in the accomplishment of these
21 responsibilities.
22
(b) The clearinghouse shall support programs to develop
23 model curricula for the training of health professionals and
24 other methods to speed the transfer of medical research de-
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1 velopments designed to improve the health and independence
2 of older Americans to health care providers.
3
(c) The Secretary shall establish a toll-free telephone
4 communications system to provide health care professionals
5 and the general public with information and advice designed
6 to increase and maintain the independence of older
7 Americans.
8
(d) The Secretary may enter into contracts or coopera-
9 tive agreements with, and make grants to, public and private
10 nonprofit entities to carry out this section.
11 SEC. 3304. PUBLIC INFORMATION CAMPAIGNS.
12
(a) The Secretary, acting through the Director of the
13 National Institute on Aging, shall make grants to nonprofit
14 and to public entities concerned with the health and inde-
15 pendence of older Americans, and may enter into contracts
16 with public and private entities, for the development and de-
17 livery of public service announcements and paid advertising
18 messages about the importance of health and nutrition, and
19 screening techniques, such as pap smears and mammograms,
20 in avoiding and preventing illnesses and conditions which in-
21 hibit the independence of older Americans. Such information
22 shall also inform the general public on the availability of
23 treatments for conditions such as immobility, incontinence,
24 and memory loss which reduce the need for the dependent
25 care of older Americans.
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1
(b) The Secretary shall determine the form and manner
2 of such agreements necessary to carry out this section.
3 SEC. 3305. AUTHORIZATION OF APPROPRIATIONS
4
To carry out this title, there are authorized to be appro-
5 priated $20,000,000 in fiscal year 1991 and such sums as
6 necessary in fiscal year 1992 and 1993.
7 TITLE IV-PREVENTION OF AND
8
RECOVERY FROM CHRONIC
9
ILLNESS
10 SEC. 3401. COMPREHENSIVE GERIATRIC ASSESSMENT.
11
(a) The National Institute on Aging, in cooperation with
12 the Health Care Financing Administration, shall support re-
13 search to determine (1) the most effective techniques of geri-
14 atric assessment; (2) the most effective method of targeting
15 comprehensive geriatric assessment to appropriate popula-
16 tions of older persons to determine their health care needs;
17 and (3) the most effective means of providing for such needs
18 to maximize health and independence.
19
(b) The report shall include an evaluation of the feasibil-
20 ity and cost of a geriatric assessment to be done at admission
21 or enrollment in all institutional or community-based health
22 services for older persons. Such an assessment shall include,
23 but not be limited to, evaluating factors such as physical and
24 mental health, nutrition, prescription medications and the av-
25 erage amount of physical activity performed by said persons.
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1
(c) The National Institute on Aging and the Health
2 Care Financing Administration shall report to Congress on
3 the results of this research and recommended guidelines on or
4 before March 1, 1994.
5 SEC. 3402. FRAILTY AND IMMOBILITY PREVENTION AND RE-
6
HABILITATION.
7
(a) The Secretary, acting through the Director of the
8 National Institute on Aging, shall develop (1) model tech-
9 niques to aid in the prevention and rehabilitation of older
10 persons from frailty and other mobility problems; and (2)
11 model curricula for the health professions for training in the
12 use of such techniques.
13
(b) The National Institute on Aging may establish up to
14 5 demonstration programs at Comprehensive Independence
15 Research Training and Demonstration Centers to prevent the
16 loss of mobility and to help frail older persons regain inde-
17 pendence, using existing and experimental techniques. Physi-
18 ological, behavioral, and environmental factors shall be con-
19 sidered in this investigation.
20
(c) The Secretary, acting through the Director of the
21 National Institute on Aging, shall conduct research to the
22 extent which falls are associated with loss of confidence to
23 function independently and increase the need for long-term
24 care.
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152
1 SEC. 3403. RECOVERY FROM CHRONIC ILLNESS.
2
(a) The Secretary, acting through the Director of the
3 National Institute on Aging, shall develop (1) model tech-
4 niques to aid in the recovery and rehabilitation of older per-
5 sons from chronic and debilitating illness, especially those re-
6 siding in nursing homes; and (2) model curricula for the
7 health professions for training in the use of such techniques.
8
(b) The Secretary shall report to Congress on or before
9 March 1, 1992, on the results of model development for frail-
10 ty and rehabilitation, including the design of programs for the
11 recovery of nursing home patients.
12 SEC. 3404. AUTHORIZATION OF APPROPRIATIONS.
13
To carry out this title, there are authorized to be appro-
14 priated $3,000,000 in fiscal year 1991, and $5,000,000 for
15 each fiscal year 1992 through 1995.
16 TITLE V-RESEARCH ON HEALTH,
17
RETIREMENT, AND INDEPEND-
18
ENCE
19 SEC. 3501. HEALTH CARE DATA.
20
(a) The Secretary, acting through the Director of the
21 National Institute on Aging, shall commence a 10-year
22 health and retirement history survey. Said survey shall in-
23 clude information on health functioning and expenditures;
24 longevity; labor force and retirement; women in the labor
25 force; housing and living arrangements; and financial status
26 of older Americans.
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1
(b) The Secretary, acting through the Director of the
2 National Institute on Aging, shall establish an advisory panel
3 on data collection to review existing government surveys and
4 census data to coordinate information on the health and re-
5 tirement status of older Americans. Said panel shall include,
6 but not be limited to, representatives from the Bureau of the
7 Census; the Department of Labor; the Federal Reserve
8 Board; the National Center for Health Statistics; the Social
9 Security Administration; and the Health Care Financing Ad-
10 ministration.
11 SEC. 3502. HEALTH PROMOTION AND DISEASE PREVENTION
12
DATA.
13
(a) The National Center for Health Statistics shall in-
14 clude persons age 75 and over in the National Health and
15 Nutrition Examination Survey.
16
(b) The Director of the National Center for Health Sta-
17 tistics shall develop questions related to health promotion and
18 disease prevention appropriate for older persons to be includ-
19 ed in the National Health Interview Survey and the National
20 Health and Nutrition Examination Survey.
21
(c) The Director of the National Center for Health Sta-
22 tistics shall develop questions related to the health promotion
23 and disease prevention practices of health care providers with
24 special relevance to older persons to be included in the Na-
25 tional Ambulatory Medical Care Survey.
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1
SEC. 3503. INVESTIGATOR-INITIATED RESEARCH GRANTS.
2
(a) The National Institute on Aging shall request pro-
3 posals from individual and team investigators on behavioral,
4 social, and environmental mechanisms for promoting the
5 health and independence of older Americans.
6
(b) Such investigation shall include, but not be limited
7 to, social support of older persons, environmental factors, and
8 psychological implications of aging.
9 SEC. 3504. AUTHORIZATION OF APPROPRIATIONS.
10
To carry out this title, there are authorized to be appro-
11 priated $5,000,000 in fiscal year 1991, $7,200,000 in fiscal
12 year 1992, $7,500,000 in fiscal year 1993, and such sums as
13 necessary in subsequent fiscal years.
14
TITLE VI-AUTHORIZATION OF
15
APPROPRIATIONS FOR NIH
16 SEC. 3601. AUTHORIZATION.
17
The National Institutes of Health are authorized to be
18 appropriated $1,000,000,000 in fiscal year 1991, to be added
19 to the National Institute on Aging and other institutes in
20 proportion to their current spending levels on aging research.
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155
1 Division E-Authorization of Addi-
2
tional Funds for Research for
3
AIDS, Hypertension, Sickle Cell
4
Anemia, Infant Mortality, and
5
Breast Cancer
6 SEC. 4001. ADDITIONAL AUTHORIZATION OF APPROPRIA-
7
TIONS.
8
In addition to the sums authorized to be appropriated
9 for under titles III, IV, and XXIII of the Public Health
10 Service Act for each of fiscal years 1991 through 1995, there
11 are authorized to be appropriated-
12
(1) such amounts as may be necessary to provide
13
for $1,200,000,000 for research relating to acquired
14
immune deficiency syndrome (AIDS),
15
(2) such amounts as may be necessary to provide
16
for $200,000,000 for research relating to hypertension,
17
(3) such amounts as may be necessary to provide
18
for $75,000,000 for research relating to sickle cell
19
anemia,
20
(4) such amounts as may be necessary to provide
21
for $300,000,000 for research relating to infant mor-
22
tality, and
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156
1
(5) to the National Cancer Institute $25,000,000
2
for research into prevention and cure of breast cancer
3
(other than research which involves treatment or clini-
4
cal trials).
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I
101ST CONGRESS
2D SESSION
H. R. 4280
To amend the Social Security Act to provide for a program of health insurance
for children under 23 years of age and for mothers to be financed through a
general payroll tax.
IN THE HOUSE OF REPRESENTATIVES
MARCH 15, 1990
Mr. STARK introduced the following bill; which was referred to the Committee on
Ways and Means
A
BILL
To amend the Social Security Act to provide for a program of
health insurance for children under 23 years of age and for
mothers to be financed through a general payroll tax.
1
Be it enacted by the Senate and House of Representa-
2 tives of the United States of America in Congress assembled,
3 SECTION 1. SHORT TITLE.
4
This Act may be cited as the "Health Insurance for
5 Children and Mothers Act of 1990".
6 SEC. 2. HEALTH INSURANCE FOR CHILDREN AND MOTHERS.
7
(a) IN GENERAL.-The Social Security Act is amended
8 by adding at the end the following new title:
2
3
1
"TITLE XXI-HEALTH INSURANCE FOR
1
"(A) is a pregnant woman (as defined in
2
CHILDREN AND MOTHERS
2
paragraph (2)),
3 "SEC. 2100. ESTABLISHMENT OF PROGRAM OF HEALTH INSUR-
3
"(B) is a resident of the United States, and
4
ANCE FOR CHILDREN AND MOTHERS.
4
"(C) is a citizen or national of the United
5
"There is hereby established a program of health insur-
5
States or a permanent resident alien (as defined in
6 ance for children under 23 years of age and mothers, to be
6
subsection (d)),
7 financed by payroll taxes.
7
is entitled to benefits under this title as a pregnant
8
"PART A-ELIGIBILITY
8
woman.
9 "SEC. 2101. GENERAL ELIGIBILITY.
9
"(2) PREGNANT WOMAN DEFINED.-In this title,
10
"(a) CHILDREN.-
10
the term 'pregnant woman' means a woman during the
11
"(1) IN GENERAL.-Every individual who-
11
period-
12
"(A) is a child (as defined in paragraph (2)),
12
"(A) beginning on the date she receives the
13
"(B) is a resident of the United States, and
13
examination or test which forms the basis for the
14
"(C) is a citizen or national of the United
14
certification of pregnancy under section
15
States or a permanent resident alien (as defined in
15
2102(b)(1), and
16
subsection (d)),
16
"(B) ending on the last day of the month in
17
is, upon registration under section 2102, entitled to
17
which the 60-day period (beginning on the date of
18
benefits under this title as a child.
18
termination of the pregnancy) ends.
19
"(2) CHILD DEFINED.-In this title, the term
19
"(c) PREGNANT CHILDREN.-In the case of an individ-
20
'child' means an individual from birth until the end of
20 ual who is entitled under this section to benefits under this
21
the month in which the individual attains 23 years of
21 title as a child and as a pregnant woman, the individual is
22
age.
22 entitled to benefits as both.
23
"(b) MOTHERS.-
23
"(d) PERMANENT RESIDENT ALIEN DEFINED.-In this
24
"(1) IN GENERAL.-Every woman who-
24 section, the term 'permanent resident alien' means an alien
25 lawfully admitted for permanent residence or or otherwise
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4
5
1 permanently residing in the United States under color of law,
1
"(A) may be made by a physician (or such
2 and includes an alien granted asylum under section 208 of
2
other qualified health professionals as the Secre-
3 the Immigration and Nationality Act or lawfully admitted as
3
tary may designate) on the basis of such tests or
4 a temporary resident under section 210, 210A, or 245A of
4
procedures as the Secretary may specify,
5 such Act.)
5
"(B) shall be stated on such form as the Sec-
6 "SEC. 2102. REGISTRATION; CERTIFICATION OF PREGNANCY.
6
retary shall specify, and
7
"(a) REGISTRATION OF CHILDREN.-
7
"(C) shall be filed with the Secretary in a
8
"(1) IN GENERAL.-The Secretary shall establish
8
manner specified by the Secretary.
9
a process for the registration of children at the time of
9
"(2) REGISTRATION.-The Secretary shall estab-
10
birth in the United States or at the time of immigration
10
lish a process for the registration of pregnant women in
11
into the United States or other acquisition of lawful
11
connection with the filing of a certification of pregnan-
12
permanent resident status in the United States.
12
cy under paragraph (1)(C).
13
"(2) TRANSITIONAL REGISTRATION.-The Secre-
13 "SEC. 2103. COVERAGE PERIOD.
14
tary also shall establish a process for the registration of
14
"(a) IN GENERAL.-No payments may be made under
15
children born before the effective date of benefits under
15 this part with respect to the expenses of an individual unless
16
this title.
16 such expenses were incurred by such individual during a
17
"(3) EFFECT OF FAILURE TO REGISTER.-The
17 period which, with respect to the individual, is a coverage
18
failure of a child to be registered under this subsection
18 period under this section.
19
shall not be considered to deny the child's entitlement
19
"(b) CHILDREN.-With respect to an individual entitled
20
to benefits under this title, but merely to delay pay-
20 to benefits under this title as a child, the coverage period
21
ment with respect to such benefits under this title.
21 shall begin on the first date (on or after the effective date of
22
"(b) CERTIFICATION OF PREGNANCY AND REGISTRA-
22 benefits under this title) on which the individual meets the
23 TION OF PREGNANT WOMEN.-
23 requirements for such entitlement under section 2101(a) and
24
"(1) CERTIFICATION OF PREGNANCY.-A certifi-
24 shall end on the day before the first month in which the indi-
25
cation of pregnancy for purposes of this title-
25 vidual no longer meets such requirements.
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6
7
1
"(c) PREGNANT WOMEN.-With respect to an individ-
1
copayments, subject to the periodicity schedule estab-
2 ual entitled to benefits under this title as a pregnant woman,
2
lished with respect to the services under paragraph (2):
3 the coverage period shall begin on the first date (on or after
3
"(A) Newborn and well-baby care, including
4 the effective date of benefits under this title) on which the
4
normal newborn care and pediatrician services for
5 individual meets the requirements for such entitlement under
5
high-risk deliveries.
6 section 2101(b) and shall end on the day before the first
6
"(B) Well-child care, including routine office
7 month in which the individual no longer meets such require-
7
visits, routine immunizations (including the vac-
8 ments.
8
cine itself), routine laboratory tests, and preven-
9
"PART B-BENEFITS
9
tive dental care.
10 "SEC. 2111. SCOPE OF BENEFITS FOR CHILDREN.
10
"(2) PERIODICITY SCHEDULE.-The Secretary, in
11
"(a) IN GENERAL.-Except as provided in the succeed-
11
consultation with the American Academy of Pediatrics,
12 ing provisions of this section, the benefits provided to an indi-
12
shall establish a schedule of periodicity which reflects
13 vidual by the program established by this part shall consist of
13
the general, appropriate frequency with which services
14 the same benefits that are available under title ХѴШ to indi-
14
listed in paragraph (1) should be provided to healthy
15 viduals entitled to benefits under part A of that title and en-
15
children.
16 rolled under part B of that title.
16 "SEC. 2112. SCOPE OF BENEFITS FOR PREGNANT WOMEN.
17
"(b) WELL CHILD SERVICES.-
17
"(a) IN GENERAL.-In the case of an individual entitled
18
"(1) IN GENERAL.-In addition to the benefits de-
18 to benefits under this title as a pregnant woman, the benefits
19
scribed in subsection (a), in the case of an individual
19 under this title shall consist of entitlement to have payment
20
entitled to benefits under this title as a child, the bene-
20 made for the following, without the application of deducti-
21
fits under this title shall include entitlement to have
21 bles, coinsurance, or copayments, subject to the periodicity
22
payment made (in the same manner as for physicians'
22 schedule established with respect to the services under sub-
23
services under part B of title XVIII) for the following,
23 section (b) and prior authorization of certain services under
24
without the application of deductibles, coinsurance, or
24 subsection (c):
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8
9
1
"(1) Prenatal care, including care for all complica-
1
"(B) related to a highly prevalent complica-
2
tions of pregnancy.
2
tion of pregnancy,
3
"(2) Inpatient labor and delivery services.
3
or in the case of emergency services.
4
"(3) Postnatal care.
4 "SEC. 2123. EXCLUSIONS.
5
"(4) Postnatal family planning services.
5
"(a) IN GENERAL.-Except as provided in subsections
6
"(b) PERIODICITY SCHEDULE.-The Secretary, in con-
6 (b) and (c), section 1862 shall apply to expenses incurred for
7 sultation with the American College of Obstetrics and Gyne-
7 items and services provided under this title the same manner
8 cology, shall establish a schedule of periodicity which reflects
8 as such section applies to items and services provided under
9 the general, appropriate frequency with which services listed
9 title ХѴШ.
10 in subsection (a) should be provided to pregnant women with-
10
"(b) BENEFITS EXCEPTION.-
11 out complications of pregnancy.
11
"(1) CHILDRENS' SERVICES.-In applying section
12
"(c) PRIOR AUTHORIZATION REQUIRED FOR CERTAIN
12
1862(a) with respect to services described in section
13 SERVICES.-
13
2121(b)(1) (relating to well-child services), payment
14
"(1) IN GENERAL.-Except in the case of items
14
shall not be denied under paragraph (1), (7), or (12) of
15
and services specified under paragraph (2), benefits are
15
such section 1862(a) if the services are provided in ac-
16
not available with respect to an item or service under
16
cordance with the periodicity schedule described in sec-
17
subsection (a) unless the provision of the item or serv-
17
tion 2121(b)(2).
18
ice has been approved by a utilization and quality con-
18
"(2) SERVICES FOR PREGNANT WOMEN.-In ap-
19
trol peer review organization before the provision of
19
plying section 1862(a) with respect to services de-
20
the item or service.
20
scribed in section 2122(a) (other than paragraph (2)
21
"(2) EXCEPTION FOR ROUTINE OR COMMON
21
thereof), payment shall not be denied under paragraph
22
ITEMS AND SERVICES.-Paragraph (1) shall not apply
22
(1) or (7) of such section 1862(a) if the services are
23
to items and services which the Secretary has specified
23
provided in accordance with the periodicity schedule
24
on a list as being either-
24
described in section 2122(b).
25
"(A) related to normal pregnancy, or
25
"(c) COORDINATION OF PAYMENTS.-
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10
11
1
"(1) PRIMARY TO GROUP HEALTH PLANS.-Sec-
1
"(2) items and services for which an individual is
2
tion 1862(b)(1) (relating to requirements of group
2
entitled under this title as a pregnant woman.
3
health plans) shall not apply under this title.
3
"(c) ADJUSTMENT OF PAYMENTS.-
4
"(2) SECONDARY TO MEDICARE.-Payment shall
4
"(1) ESTABLISHMENT OF NEW DRGS AND
5
not be made under this title with respect to benefits to
5
WEIGHTS.-In making payment under this title with
6
the extent that payment for such benefits may be made
6
respect to inpatient hospital services, the Secretary
7
under title ХѴШ.
7
shall make such adjustments in the diagnosis-related
8
"PART C-PAYMENT FOR BENEFITS AND FINANCING
8
groups and weighting factors with respect to dis-
9 "SEC. 2131. PAYMENTS FOR BENEFITS.
9
charges within such groups, otherwise established
10
"(a) IN GENERAL.-Except as otherwise provided in
10
under section 1886(d)(4) as may be necessary-
11 this section-
11
"(A) to reflect the types of discharges occur-
12
"(1) payment of benefits under this title with re-
12
ring under this title which are not occurring under
13
spect to benefits shall be made in the same amounts
13
title ХѴШ, and
14
and on the same basis as payment may be made with
14
"(B) to provide for a weighting factor, for
15
respect to such benefits under title ХѴШ, and
15
cesearian section deliveries, which is 95 percent
16
"(2) the provisions of sections 1814, 1833, 1842,
16
of the weighting factor that otherwise would be
17
1848, and 1886 shall apply to payment of benefits
17
established.
18
under this title in the same manner as they apply to
18
"(2) PAYMENT FOR OBSTETRICAL SERVICES.-
19
benefits under title ХѴШ.
19
"(A) GLOBAL FEE.-In making payment
20
"(b) No COST-SHARING FOR CERTAIN SERVICES.-No
20
under this title with respect to the group of ob-
21 deductibles, coinsurance, copayments, or other cost-sharing
21
stetrical services typical of treatment throughout a
22 shall be imposed with respect to-
22
course of pregnancy, the Secretary shall establish,
23
"(1) well-child care services described in section
23
as a schedule under section 1848, a global fee
24
2111(b)(1), and
24
with respect to such group of services.
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12
13
1
"(B) BONUS FOR EARLY PRESENTATION.-
1 Trust Fund' (in this section referred to as the "Trust Fund').
2
The fee schedule amount with respect to obstetri-
2 The Trust Fund shall consist of such gifts and bequests as
3
cal services under this title shall be increased by
3 may be made as provided in section 201(i)(1) and amounts
4
5 percent in the case of services furnished to
4 appropriated under paragraph (2).
5
women who have presented for prenatal care
5
"(2) There are hereby appropriated to the Trust Fund
6
during the first trimester.
6 amounts equivalent to 100 percent of-
7
"(C) DISINCENTIVE FOR CESEARIAN SEC-
7
"(A) the taxes imposed by sections 3101(c) or
8
TIONS.-The fee schedule amount otherwise es-
8
3111(c) of the Internal Revenue Code of 1986,
9
tablished with respect to a cesearian section shall
9
"(B) the taxes imposed by section 1401(c) of such
10
be 95 percent of the fee schedule amount other-
10
Code, and
11
wise established.
11
"(C) the taxes imposed by sections 3201(c),
12
"(c) CONDITIONS OF AND LIMITATIONS ON PAY-
12
3211(a)(3), and 3221(e) of such Code.
13 MENTS.-The provisions of sections 1814 and 1835 shall
13 The amounts appropriated by the preceding sentence shall be
14 apply to payment for services under this title in the same
14 transferred from time to time from the general fund in the
15 manner as they apply to payment for services under parts A
15 Treasury to the Trust Fund, such amounts to be determined
16 and B, respectively, of title ХѴШ.
16 on the basis of estimates by the Secretary of the Treasury of
17
"(d) USE OF TRUST FUND.-In carrying out this sec-
17 the taxes, paid to or deposited into the Treasury; and proper
18 tion, any reference in title ХѴШ to a trust fund shall be
18 adjustments shall be made in amounts subsequently trans-
19 treated as a reference to the Children and Mothers Health
19 ferred to the extent prior estimates were in excess of or were
20 Insurance Trust Fund established under section 2132.
20 less than the taxes specified in such sentence.
21 "SEC. 2132. CHILDREN AND MOTHERS HEALTH INSURANCE
21
"(b) INCORPORATION OF PROVISIONS.-
22
TRUST FUND.
22
"(1) IN GENERAL.-Subject to paragraph (2), the
23
"(a) ESTABLISHMENT.-(1) There is hereby created on
23
provisions of subsections (b) through (j) of section 1817
24 the books of the Treasury of the United States a trust fund to
24
shall apply to the Trust Fund in the same manner as
25 be known as the 'Children and Mothers Health Insurance
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14
15
1
they apply to the Federal Hospital Insurance Trust
1 for purposes of this title in the same manner as they apply for
2
Fund.
2 purposes of title ХѴШ.
3
"(2) EXCEPTIONS.-In applying paragraph (1)-
3
"(c) CERTIFICATION, PROVIDER QUALIFICATION,
4
"(A) the Board of Trustees and Managing
4 Етс.-Тhе provisions of sections 1863 through 1875, sec-
5
Trustee of the Trust Fund shall be composed of
5 tions 1878 through 1880, section 1883, section 1885, and
6
the members of the Board of Trustees and the
6 sections 1887 through 1892 shall apply to this title in the
7
Managing Trustee, respectively, of the Federal
7 same manner as they apply to title ХѴШ.
8
Hospital Insurance Trust Fund; and
8
"(d) HEALTH MAINTENANCE ORGANIZATIONS AND
9
"(B) any reference in section 1817 to the
9 COMPETITIVE MEDICAL PLANS.-
10
Federal Hospital Insurance Trust Fund, to title
10
"(1) IN GENERAL.-Except as provided in this
11
ХѴШ (or part A thereof), or to section 3102(b)
11
subsection, section 1876 shall apply to individuals enti-
12
of the Internal Revenue Code of 1986 is deemed
12
tled to benefits under this title in the same manner as
13
a reference to the Trust Fund under this section,
13
such section applies to individuals entitled to benefits
14
this title, and to section 3102(c) of such Code, re-
14
under part A, and enrolled under part B, of title
15
spectively.
15
ХѴШ.
16
"PART D-GENERAL PROVISIONS
16
"(2) LIMITATION TO REASONABLE COST REIM-
17 "SEC. 2151. INCORPORATION OF CERTAIN MEDICARE PROVI-
17
BURSEMENT CONTRACTS FOR PREGNANT WOMEN.-
18
SIONS.
18
"(A) IN GENERAL.-The provisions of sec-
19
"(a) USE OF CARRIERS AND INTERMEDIARIES.-The
19
tion 1876 relating only to risk-sharing contracts
20 Secretary shall provide for the administration of this title
20
(and not to reasonable cost reimbursement con-
21 through the use of fiscal intermediaries and carriers in the
21
tracts) shall not apply to individuals entitled to
22 same manner as title ХѴШ is carried out through the use of
22
benefits under this title only as pregnant women.
23 such fiscal intermediaries and carriers.
23
"(B) REPORT.-Not later than January 1,
24
"(b) DEFINITIONS.-Except as otherwise provided in
24
1992, the Secretary shall submit to the Con-
25 this title, the definitions contained in section 1861 shall apply
25
gress a report concerning recommendations on
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16
17
1
how the provisions of section 1876 relating to
1
(1) Section 201(g)(1)(A) of the Social Security Act
2
risk-sharing contracts may be adapted to apply to
2
(42 U.S.C. 401(g)(1)(A)) is amended by striking "and
3
benefits provided under this title to pregnant
3
the Federal Supplementary Medical Insurance Trust
4
women.
4
Fund" and inserting ", Federal Supplementary Medical
5
"(3) APPLICATION.-In applying section 1876
5
Insurance Trust Fund, and the Children and Mothers
6
under this section-
6
Health Insurance Trust Fund".
7
"(A) the provisions of such section relating
7
(2) Section 201(i)(1) of such Act (42 U.S.C.
8
only to individuals enrolled under part B of title
8
401(i)(1)) is amended by striking "and the Federal
9
ХѴШ shall not apply;
9
Supplementary Medical Insurance Trust Fund" and in-
10
"(B) any reference to a Trust Fund estab-
10
serting ", Federal Supplementary Medical Insurance
11
lished under title ХѴШ and to benefits under
11
Trust Fund, and the Children and Mothers Health In-
12
such title is deemed a reference to the Children
12
surance Trust Fund".
13
and Mothers Health Insurance Trust Fund and to
13
(c) EFFECTIVE DATE.-The amendments made by this
14
benefits under this title;
14 section shall take effect on the date of the enactment of this
15
"(C) the adjusted average per capita cost and
15 Act, except that no benefits shall be available under title
16
the adjusted community rate shall be determined
16 XXI of the Social Security Act for items or services fur-
17
on the basis of benefits under this title; and
17 nished before January 1, 1992.
18
"(D) subsection (f) shall not apply.
18 SEC. 3. INCREASE IN EMPLOYMENT TAXES TO FUND HEALTH
19 "SEC. 2152. INCORPORATION OF PEER REVIEW PROVISIONS
19
INSURANCE FOR CHILDREN AND PREGNANT
20
AND FRAUD AND ABUSE PROVISIONS.
20
WOMEN.
21
"The provisions of sections 1121 through 1126, sections
21
(a) GENERAL RULE.-
22 1128 through 1128B, section 1134, section 1138, and part B
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(1) EMPLOYEE TAX.-Section 3101 of the Inter-
23 of title XI shall apply to this title in the same manner as they
23
nal Revenue Code of 1986 (relating to rate of tax on
24 apply to title XVIII.".
24
employees) is amended by redesignating subsections (c)
25
(b) CONFORMING AMENDMENTS.-
25
and (d) as subsections (d) and (e), respectively, and by
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inserting after subsection (b) the following new subsec-
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inserting after subsection (c) the following new subsec-
2
tion:
2
tion:
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"(c) ADDITIONAL TAX To FUND HEALTH INSURANCE
3
"(c) ADDITIONAL TAX To FUND HEALTH INSURANCE
4 FOR CHILDREN AND PREGNANT WOMEN.-In addition to
4 FOR CHILDREN AND PREGNANT WOMEN.-In addition to
5 the taxes imposed by the preceding subsections, there is
5 the taxes imposed by the preceding subsections, there is
6 hereby imposed on the income of every individual a tax equal
6 hereby imposed for each taxable year, on the self-employ-
7 to 1.45 percent of the wages (as defined in section 3121(a))
7 ment income of every individual, a tax equal to 2.9 percent of
8 received by the individual with respect to employment (as
8 the self-employment income for such taxable year."
9 defined in section 3121(b)."
9
(4) RAILROAD RETIREMENT TAXES.-
10
(2) EMPLOYER TAX.-Section 3111 of such Code
10
(A) Section 3201 of such Code is amended
11
is amended by redesignating subsection (c) as subsec-
11
by redesignating subsection (c) as subsection (d)
12
tion (d) and by inserting after subsection (b) the follow-
12
and by inserting after subsection (b) the following
13
ing new subsection.
13
new subsection:
14
"(c) ADDITIONAL TAX To FUND HEALTH INSURANCE
14
"(c) ADDITIONAL TAX TO FUND HEALTH INSURANCE
15 FOR CHILDREN AND PREGNANT WOMEN.-In addition to
15 FOR CHILDREN AND PREGNANT WOMEN.-In addition to
16 the taxes imposed by the preceding subsections, there is
16 other taxes, there is hereby imposed on the income of each
17 hereby imposed on every employer an excise tax, with re-
17 employee a tax equal to 1.45 percent of the compensation
18 spect to having individuals in his employ, equal to 1.45 per-
18 received during any calendar year by such employee for serv-
19 cent of the wages (as defined in section 3121(a)) paid by the
19 ices rendered by such employee."
20 employer with respect to employment (as defined in section
20
(B) Subsection (a) of section 3211 of such
21 3121(b))."
21
Code is amended by redesignating paragraph (3)
22
(3) SELF-EMPLOYMENT TAX.-Section 1401 of
22
as paragraph (4) and by inserting after paragraph
23
such Code is amended by redesignating subsections (c)
23
(2) the following new paragraph:
24
and (d) as subsections (d) and (e), respectively, and by
24
"(3) ADDITIONAL TAX TO FUND HEALTH INSUR-
25
ANCE FOR CHILDREN AND PREGNANT WOMEN.-In
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addition to other taxes, there is hereby imposed on the
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graphs (B)(i), (C), and (D) of paragraph (2) shall not
2
income of each employee representative a tax equal to
2
apply for purposes of such taxes."
3
2.9 percent of the compensation received during any
3
(2) Subsection (a) of section 201 of the Social Se-
4
calendar year by such employee representative for
4
curity Act is amended-
5
services rendered by such employee representative."
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(A) by striking "sections 3101(b) and
6
(C) Section 3221 of such Code is amended
6
3111(b)" each place it appears in paragraph (3)
7
by redesignating subsection (e) as subsection (f)
7
and inserting "sections 3101(b) and (c) and
8
and by inserting after subsection (d) the following
8
3111(b) and (c),", and
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new subsection:
9
(B) by striking "section 1401(b)" each place
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"(e) ADDITIONAL TAX TO FUND HEALTH INSURANCE
10
it appears in paragraph (4) and inserting "subsec-
11 FOR CHILDREN AND PREGNANT WOMEN.-In addition to
11
tions (b) and (c) of section 1401".
12 other taxes, there is hereby imposed on every employer an
12
(3) Section 218 of the Social Security Act is
13 excise tax, with respect to having individuals in his employ,
13
amended by adding at the end thereof the following
14 equal to 1.45 percent of the compensation paid during any
14
new subsection:
15 calendar year by such employer for services rendered to such
15
"Certain Taxes Not Covered
16 employer."
16
"(g) For purposes of this section, section 3101 of the
17
(b) CONFORMING AMENDMENTS.-
17 Internal Revenue Code of 1986 shall be applied as if it did
18
(1) Subsection (u) of section 3121 of such Code is
18 not contain subsection (c) thereof and section 2111 of such
19
amended by adding at the end thereof the following
19 Code shall be applied as if it did not contain subsection (c)
20
new paragraph:
20 thereof."
21
"(4) APPLICATION OF TAX FOR HEALTH INSUR-
21
(4)(A) Subsection (d) of section 3201 of such Code
22
ANCE FOR CHILDREN AND PREGNANT WOMEN.-The
22
(as redesignated by this section) is amended by striking
23
provisions of paragraphs (1) and (2) of this subsection
23
"subsections (a) and (b)" and inserting "subsections (a),
24
shall also apply for purposes of the taxes imposed by
24
(b), and (c)".
25
sections 3101(c) and 3111(c); except that subpara-
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(B) Paragraph (4) of section 3211(a) of such Code
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(1) The amendments made by this section (other
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(as redesignated by this section) is amended by striking
2
than by subsection (a)(3)) shall apply to remuneration
3
"paragraphs (1) and (2)" and inserting "paragraphs (1),
3
paid after December 31, 1991.
4
(2), and (3)".
4
(2) The amendment made by subsection (a)(3)
5
(C) Subsection (f) of section 3221 of such Code
5
shall apply to taxable years beginning after Decem-
6
(as redesignated by this section) is amended by striking
6
ber 31, 1991.
7
"subsections (a) and (b)" and inserting "subsections (a),
8
(b), and (e)".
9
(D) Clause (i) of section 3231(e)(2)(B) of such
10
Code is amended by striking "TIER 1 TAXES" in the
11
heading and inserting "TIER 1 TAXES AND TAXES TO
12
FUND HEALTH INSURANCE FOR CHILDREN AND PREG-
13
NANT WOMEN".
14
(E) Subparagraph (A) of section 3231(e)(4) of such
15
Code is amended by striking "sections 3201(a),
16
3211(a)(1), and 3221(a)" and inserting "sections
17
3201(a) and (c), 3211(a)(1) and (a)(3), and 3221(a) and
18
(e)".
19
(F) Subsection (a) of section 15 of the Railroad
20
Retirement Act of 1974 is amended by adding at the
21
end thereof the following new sentence: "For purposes
22
of this section, the Railroad Retirement Tax Act shall
23
be applied as if it did not contain sections 3201(c),
24
3211(a)(3), and 3221(e)."
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(c) EFFECTIVE DATES.-
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