Health Care Reform bill

TABLE OF CONTENTS:

Title I: Establishment of a State-Based American Health

Security Program; Universal Entitlement; Enrollment

Title II: Comprehensive Benefits, Including Preventive

Benefits and Benefits for Long Term Care

Title III: Provider Participation

Title IV: Administration

Subtitle A: General Administrative Provisions

Subtitle B: Control Over Fraud and Abuse

Title V: Quality Assessment

Title VI: Health Security Budget; Payments; Cost Containment

Measures

Subtitle A: Budgeting and Payments to States

Subtitle B: Payments by States to Providers

Subtitle C: Mandatory Assignment and Administrative

Provisions

Title VII: Promotion of Primary Health Care; Development of

Health Service Capacity; Programs to Assist the Medically

Underserved

Subtitle A: Promotion and Expansion of Primary Care

Professional Training

Subtitle B: Direct Health Care Delivery

Subtitle C: Primary Care and Outcomes Research

Title VIII: Financing Provisions; American Health Security

Trust Fund

Subtitle A: American Health Security Trust Fund

Subtitle B: Increases in Corporate and Individual Income

Tax Rates; Health Security Premium; and Surtax on

Individuals with Income Over $1,000,000

Subtitle C: Employment Tax Changes

Subtitle D: Other Revenue Increases Primarily Affecting

Individuals

Subtitle E: Other Revenue Increases Primarily Affecting

Businesses

Subtitle F: Estimated Tax Provisions

Subtitle G: Alternative Taxable Years

Subtitle H: Deduction for Charitable Contribution of

Appreciated Property Limited to Adjusted Basis

Subtitle I: Minimum 5 Percent Rate of Tax on Interest Paid

to Foreign Persons

American Health Security Act of 1993 - Title I: Establishment of a State-Based American Health Security Program; Universal Entitlement; Enrollment - Establishes in the United States an American Health Security Program (AHSP) to be administered by the States (including the District of Columbia and, if they so choose, U.S. territories) in accordance with Federal standards established under this Act. Requires a State to establish a State health security program in accordance with this Act to receive Federal health care funding.

(Sec. 102) Entitles every individual who is a resident of the United States and is a U.S. citizen or national or a lawful resident alien to benefits for health care services under this Act under the appropriate State program. Sets forth provisions regarding the treatment of nonimmigrants and other individuals.

(Sec. 103) Requires each State program to: (1) provide a mechanism for the enrollment of individuals entitled or eligible for benefits (which includes a process for the automatic enrollment of individuals at the time of birth, immigration, or other acquisition of lawful resident status in the United States and provides for the enrollment of all individuals who are eligible to be enrolled as of January 1, 1995); and (2) issue a health security card, to enrolled individuals.

(Sec. 104) Makes benefits portable when enrollees move or travel between States. Prohibits imposition of a minimum residence or waiting period in excess of three months for program benefit eligibility. Allows reciprocal arrangements between programs in adjacent States for coverage for enrollees residing in the border region.

(Sec. 105) Makes benefits available under this Act for items and services furnished on or after January 1, 1995.

(Sec. 106) Supersedes Medicare, Medicaid, the Federal Employee Health Benefits Program, and CHAMPUS, which must pay for completion of services they covered before January 1, 1995. Specifies that nothing in this Act affects the eligibility of veterans for Veterans Administration health benefits and services, or of Indians for benefits and services of the Indian Health Service.

Title II: Comprehensive Benefits, Including Preventive Benefits and Benefits for Long Term Care - Entitles all eligible individuals to have payment made (if medically necessary and appropriate for the maintenance of health or for the diagnosis, treatment, or rehabilitation of a health condition) for inpatient and outpatient hospital services, professional services of State-authorized practitioners, community-based primary health services, preventive services, long-term and chronic care services, prescription drugs, biologicals, insulin, and medical foods, mental health services, substance abuse treatment services, diagnostic tests, and other specified items and services, including outpatient therapy, durable medical equipment, home dialysis, ambulance, prosthetic devices, and other items and services specified by the American Health Security Standards Board (Board) (established by title IV of this Act).

Specifies that: (1) no deductibles, coinsurance, or copayments may be charged for benefits; (2) no provider may charge a patient for covered services; (3) no private insurance may duplicate program benefits; and (4) States and employers may provide additional benefits at their own expense.

(Sec. 203) Covers home and community-based long-term care services for qualifying individuals unable to perform at least two of five listed activities of daily living without assistance. Limits the cost of such services to 65 percent (or an alternative percentage determined by the Board) of the cost of nursing home care for an individual in the same area in which the services were provided.

(Sec. 204) Makes mental health, substance abuse, nursing facility, and home health services subject to utilization review. Directs the Board to make national determinations on coverage of experimental services, with professional and public input. Specifies that where the Board has recognized practice guidelines, coverage is limited to services provided according to the guidelines or any exceptions process established by the Board. Allows the Board to limit quantities of eyeglasses, contact lenses, hearing aids, and durable medical equipment that will be covered. Excludes from coverage cosmetic procedures, personal comfort items, and services furnished in non-participating facilities.

Specifies that: (1) nursing facility and home health services (other than post-hospital services) furnished to an individual who is not qualifying are not covered services unless the services are determined to meet specified standards and, with respect to nursing facility services, to be provided in the least restrictive and most appropriate setting; and (2) benefits are not available under this Act with respect to services involving unapproved capital expenditures.

Title III: Provider Participation - Requires providers, to receive payment, to agree: (1) not to discriminate based on race, national origin, income, religion, age, sex or sexual orientation, disability, handicapping condition, or (subject to the professional qualifications of the provider) illness; (2) not to charge patients for covered services; (3) to furnish necessary information to the Board or program; (4) not to expend any amounts on, or bill the program for any services for which benefits are not available because of, unapproved capital expenditures; (5) not to employ other providers whose participation has been terminated for cause; and (6) to submit bills within a specified time frame.

(Sec. 302) Considers a health care provider to be qualified if it is licensed or certified and meets State law requirements, applicable Federal requirements, and additional standards that the Board may specify. Requires: (1) the Board to establish, evaluate, and update national minimum standards to assure the quality of services provided and to monitor efforts by programs to assure such quality; (2) a reasonable transition period for any new standards; and (3) the Board to provide for an exchange of information among programs with respect to quality assurance and cost containment.

(Sec. 303) Defines a "comprehensive health service organization" (CHSO) as a public or private organization which, in return for a fee for service, furnishes or arranges a full range of health services and out-of-area coverage in the case of urgently needed services to an identified population in a specified service area which enrolls voluntarily in the organization. Sets forth various CHSO requirements regarding enrollment, withdrawal for cause, marketing of services, accessibility of services, continuity of care, consumer and provider representation on the board of directors, a patient grievance program, health education, medical standards committees, use of allied health professionals, premiums, utilization and bonus information, provision of services to enrollees at institutions operating under global budgets, limitation on capital expenditures, and provision of emergency services to nonenrollees.

(Sec. 304) Extends current Medicare prohibitions on physician self-referrals for clinical laboratory services to other services and applies such prohibitions to AHSP.

Title IV: Administration - Subtitle A: General Administrative Provisions - Establishes the American Health Security Standards Board to develop policies and procedures for enrollment, benefits, provider participation, national and State funding levels, determination of medical necessity and appropriateness (including the coverage of new technologies and the application of medical practice guidelines), quality assurance, assisting programs with planning for capital expenditures and service delivery, and other functions and to establish uniform reporting standards for health services and programs. Authorizes the Board to make statistical and other studies, test alternative payment methods, and develop and test information and budget systems. Provides for the appointment of an Executive Director of the Board and an Inspector General.

(Sec. 402) Directs the Board to provide for an American Health Security Advisory Council to advise the Board on matters of general policy, in the formulation of regulations, and in the performance of the Board's duties and to study the operation of, and utilization of health services under, this Act.

(Sec. 403) Directs the Board to appoint advisory committees on benefits, cost containment, primary care and the medically underserved, mental health and substance abuse treatment, prescription drugs, and rehabilitation and chronic care management. Authorizes the Board to appoint other temporary advisory committees.

(Sec. 404) Establishes an American Health Security Quality Council which shall be responsible for quality review activities (under title V). Directs the Quality Council to report to the Board annually.

(Sec. 405) Requires: (1) each State to submit to the Board a plan for a program for providing health care services to residents of the State (but allows neighboring States to join in regional plans); (2) the Board to provide incentives for States to develop regional planning mechanisms to promote the rational distribution of, adequate access to, and efficient use of, tertiary care facilities, equipment, and services; (3) State programs to meet Federal standards, including establishment of a State Health Security Advisory Council (SHSAC), single-agency administration, a State health security budget and establishment of an approval process for capital expenditures, provider payment and quality review methodologies consistent with Federal standards, freedom to choose providers, a procedure for carrying out long-term regional management and planning functions, including establishment of District Health Advisory Councils (DHACs), a consumer ombudsman, an annual report, and a fraud and abuse prevention and control unit; and (4) the Governor of each State to provide for appointment of a SHSAC to advise and make recommendations to the Governor and State regarding program implementation.

Allows: (1) programs not meeting Federal requirements, after notice, to be placed in receivership under the Board's jurisdiction; and (2) States to use fiscal agents, after competitive bidding, to process claims.

(Sec. 406) Directs each program to establish DHACs covering distinct geographic areas for purposes of: (1) advising and making recommendations to the State with respect to implementation of the program in that geographic area; (2) receiving and investigating complaints by eligible persons and service providers concerning program administration and taking corrective action; and (3) carrying out district management and planning functions with the program. Sets forth provisions regarding: (1) DHAC assistance and technical support to community organizations and agencies submitting applications for funding under appropriate State and Federal public health programs; and (2) waiver of the requirement that a State establish DHACs under specified circumstances.

(Sec. 407) Requires the Secretary of Health and Human Services (Secretary) to direct all activities of the Department of Health and Human Services toward contributions to health of the people in a manner complementary to this Act.

Subtitle B: Control Over Fraud and Abuse - Authorizes the Board to exclude providers from participation, impose civil monetary penalties, and seek criminal prosecution for fraud or abuse, based on current Medicaid standards. Requires providers to disclose relevant information about their ownership interest in health facilities and services, based on current Medicaid standards.

(Sec. 412) Requires the Board: (1) through the Inspector General, to establish a national health care fraud and abuse data base, including the identity of any provider who has been convicted, had a license revoked, has been excluded or suspended from participation, or has been subjected to a civil penalty with respect to a State program, Medicare, Medicaid, or any other federally funded health program; and (2) to establish rules to protect the confidentiality of information in the data base. Requires States to provide relevant information for this purpose and periodically inquire of the data base to determine provider qualifications to participate in programs. Sets penalties for submitting false information.

(Sec. 413) Requires each program to establish and maintain a health care fraud and abuse unit.

(Sec. 414) Directs the Board to provide for the assignment of a unique identifier to each participating provider and to each individual eligible for services, which shall be used for claims and payment.

Title V: Quality Assessment - Directs the Quality Council to: (1) collect data from outcomes research and develop practice guidelines on the basis of such data and existing clinical knowledge; (2) adopt methodologies for profiling the patterns of practice of health care professionals and for identifying outliers (i.e., health care providers whose patterns of practice suggest quality deficiencies); (3) develop standards for the development of centers of excellence for designated procedures and for education of and sanctions for outliers; and (4) disseminate all quality guidelines and standards to the States for implementation.

(Sec. 502) Requires each participating State to establish an entity to conduct quality reviews of persons providing covered services under its program which meet Federal standards for the adoption of practice guidelines, identification of outliers, development of remedial programs and monitoring for outliers, and the application of sanctions. Allows the State to adopt alternative methodologies to those adopted by the Quality Council, provided that the State can demonstrate that the efficacy of such review and education programs meets Federal standards. Mandates that the quality review entity be administratively independent of the individual or board that administers the program and not provide any financial incentive to reviewers to favor one pattern of practice over another.

(Sec. 503) Permits a State program to: (1) require, as a condition of payment for institutional health care and other specified services, periodic professional certification; (2) establish a utilization review program and deny coverage and payment for services to the extent the services are determined under such a program not to meet specified coverage standards under certain circumstances; and (3) require, consistent with standards established by the Board, that payment for services exceeding specified levels or duration be provided only as consistent with a plan of care or treatment formulated by providers of the services or other qualified professionals (and such a plan may include utilization review at specified intervals as a further condition of payment for services). Directs the Board to provide for the establishment of Federal standards for utilization review programs conducted by State programs, designed to assure cost-effective and medically appropriate use of services consistent with such standards.

(Sec. 504) Requires: (1) each State program to develop and use a uniform electronic data base which uses software designated by the Board and which assures confidentiality for all patient records to enable systematic quality review and outcomes analysis; and (2) the Board to designate such software and establish standards designed to protect the privacy of patients. Limits access by government agencies to patient records.

Title VI: Health Security Budget; Payments; Cost Containment Measures - Subtitle A: Budgeting and Payments to States - Directs the Board to establish an American health security budget which specifies the total expenditures to be made by the Federal Government and the States for covered health care services and allocates those expenditures among the States. Prohibits such budget from exceeding the budget for the preceding year increased by the percentage increase in gross domestic product. Divides the budget into capital expenditures, administrative, and operating components.

(Sec. 602) Provides for the allocation of funds in the budget by the Board to the States, based on the national average per capita costs of covered services adjusted for differences among the States in costs and the health status of populations. Permits the use of statistical models to estimate State capitation amounts. Sets forth State adjustment factors to reflect differences in relative needs for funds and directs that such factors be applied in a budget-neutral manner resulting in no change in total Federal expenditures from the national per capita average.

(Sec. 603) Requires each program to submit to the Board a proposed and final annual budget broken into capital expenditure, administrative, and operating components, with the operating component broken into facility-based services, individual practitioner payments, payments to CHSOs, and payments for other items and services. Sets forth provisions regarding proposed and final budget deadlines, adjustments in allocations, and expenditure limits.

(Sec. 604) Provides for programs to receive Federal funds equal to a weighted average of 86 percent of their population-based share of the budget, which the Board may adjust between 81 and 91 percent based on State economic conditions.

(Sec. 605) Requires each program to provide for a process for the approval of capital expenditures to: (1) meet the need for covered health care services consistent with State budgets and the development of medical technology; (2) establish an efficient balance between the need for services and the delivery of services; and (3) expand the delivery of services in medically underserved areas. Prohibits approval of expenditures by programs to the extent that they are attributable to a capital expenditure which was subject to, but not approved under, such process. Directs the Board to specify standards for the capital approval process which meet specified requirements.

Subtitle B: Payments by States to Providers - Directs that: (1) payment for operating expenses for hospital and nursing facility services under State programs be made directly to each hospital or nursing facility under an annual prospective global budget approved under the program; (2) such budgets take into account discharges by diagnosis-related group, prior expenditures, change in the consumer price index and other price indices, compensation, occupancy levels, past financial and clinical performance, training, technological changes, and incentives to maintain costs without reducing care; (3) capital expenditures be subject to prior approval; (4) a budget of a hospital or nursing facility be subject to prior review by the SHSAC and appropriate DHAC; (5) facility budgets be adjusted to reflect payments made by CHSOs; and (6) the Board promulgate regulations permitting hospitals and nursing facilities to raise funds from private sources to pay for newly constructed facilities, major renovations, and equipment.

(Sec. 612) Directs that payments under a program for home health services, hospice care, home and community-based long-term care services, and certain facility-based outpatient services be based on a global budget, a capitation amount, a specified fee schedule, or an alternative prospective payment method approved by the program.

(Sec. 613) Entitles every independent health care practitioner to be paid a fee for each billable covered service. Directs the Board to establish models and encourage programs to implement alternative payment methodologies that incorporate global fees for related services or for a basic group of services furnished to an individual over a period of time. Permits a program to deny payment for any service for which it did not receive a bill and supporting documentation from such a practitioner within 30 days. Requires denial of payment for any service attributable to a capital expenditure subject to approval which has not been approved. Prohibits a practitioner from imposing a charge for a service for which such payment is denied.

Directs the program to establish, on a prospective basis, a payment schedule for any payment method for a class of services of practitioners, after negotiations with organizations representing the practitioners involved. Sets forth guidelines regarding such schedules based on a national relative value scale.

(Sec. 614) Authorizes programs to pay CHSOs based on annual budgets or risk-adjusted capitation payments, plus an amount equal to the amount of capital expenditures approved, reduced by the costs of covered services not provided by the CHSO. Requires that, in the case of a for-profit CHSO, the total amount of capitation payments in a period be reduced by operating profit for the period less a reasonable rate of return on equity capital and that such profit be additionally limited to such amounts as the Board determines are attributable to operating efficiencies and not to any reduction of care provided.

(Sec. 615) Directs that programs pay for community-based primary health services based on global budgets, basic primary care capitation amounts for enrollees, a fee schedule (under section 613), or an alternative prospective payment method approved by the program.

(Sec. 616) Requires: (1) the Board to establish classifications of prescription drugs based on the recommendations of the Advisory Committee on Prescription Drugs and to negotiate maximum prices with manufacturers; and (2) each program to pay for such drugs based on such maximum prices and to pay separate dispensing fees to pharmacies.

(Sec. 617) Directs: (1) the Board to establish a list of approved durable medical equipment and therapeutic devices and equipment; and (2) State programs to pay for such items based on maximum prices determined by the Board.

(Sec. 618) Requires State programs to pay for other items and services based on methodologies to be adopted by the Board, consistent with the State health security budget.

(Sec. 619) Directs the Prospective Payment Assessment Commission to advise the Board concerning the approval of prospective global budgets for hospitals and nursing facilities. Renames and continues the Physician Payment Review Commission as the Practitioner Payment Review Commission. Requires the Director of the Office of Technology Assessment to provide for the appointment of a: (1) General Health Care Payment Review Commission; and (2) Long-Term Care Payment Review Commission.

(Sec. 620) Directs the Board to establish model payment methodologies and other incentives to promote the provision of services in medically underserved areas. Permits programs to adjust payment amounts within their budgets to encourage provision of appropriate services in underserved areas.

(Sec. 621) Authorizes programs to utilize alternative payment methodologies, provided that such methodologies do not affect the entitlement of individuals to coverage, the weighing of fee schedules to encourage an increase in the number of primary care providers, the ability of individuals to choose among qualified providers, the benefits covered under the Program, or compliance with the State health security budget. Requires States to report on the operation and effectiveness of alternative methodologies to enable the Board to evaluate the appropriateness of the alternative methodology.

Subtitle C: Mandatory Assignment and Administrative Provisions - Specifies that participating providers: (1) must accept payment from a program as full payment for covered services; and (2) may not impose additional charges on patients. Permits the Board to exclude from participation and subject to civil penalties violators of such provision.

(Sec. 632) Requires programs to establish: (1) procedures for reimbursing providers within 60 days of bill submission; and (2) an appeals process to handle grievances pertaining to provider payments.

Title VII: Promotion of Primary Health Care; Development of Health Service Capacity; Programs to Assist the Medically Underserved - Subtitle A: Promotion and Expansion of Primary Care Professional Training - Makes the Board responsible for: (1) coordinating health professional education policies and goals to achieve national goals; (2) developing and maintaining a system to monitor the number and specialties of individuals through their health professional education, any postgraduate training, and professional practice; and (3) developing, coordinating, and promoting other policies that expand the number of primary care practitioners.

Sets as national goals that: (1) at least 50 percent of graduate medical residencies be in primary care within five years of this Act's enactment; and (2) there be a certain number, specified by the Board, of midlevel primary care practitioners employed in the health care system as of January 1, 2000.

Directs the Board to: (1) establish a method of applying such goals to program goals for each medical residency program or consortium of programs and reducing payments for residency programs failing to meet their goals; (2) advise the Public Health Service on allocations of funding under specified programs to increase the supply of midlevel primary care practitioners; and (3) commission a study of the potential benefits and disadvantages of expanding the scope of practice authorized under State laws for any class of midlevel primary care practitioners.

(Sec. 702) Requires the Board to establish an Advisory Committee on Health Professional Education to advise the Board concerning graduate medical education policies under this title.

(Sec. 703) Directs the Board to transfer specified revenues from the American Health Security Trust Fund (Trust Fund) for specified existing programs supporting health professional education and nursing education and for the National Health Services Corps.

Subtitle B: Direct Health Care Delivery - Requires the Board to transfer specified Trust Fund revenues to the Public Health Service for: (1) maternal and child health block grants, preventive health block grants, grants to States for community mental health services and prevention and treatment of substance abuse, and grants for HIV health care services; and (2) grants to nonprofit community health centers and similar facilities.

(Sec. 713) Directs the Board to make grants to plan, develop, and operate primary care centers (i.e., nonprofit community health centers, migrant health centers, and other federally qualified health centers) to serve medically underserved populations in urban and rural areas.

Subtitle C: Primary Care and Outcomes Research - Requires the Board to transfer specified Trust Fund revenues to the Agency for Health Care Policy and Research for health outcomes research.

(Sec. 722) Amends the Public Health Service Act to establish within the Office of the Director of the National Institutes of Health (NIH) an Office of Primary Care and Prevention Research to be headed by a Director who shall identify and coordinate research activities relating to primary care and prevention, including care provided by multidisciplinary teams. Authorizes appropriations. Requires the Director to establish: (1) a Coordinating Committee on Research on Primary Care and Prevention Research; and (2) an Advisory Committee on Research on Primary Care and Prevention Research.

Requires the Director of NIH to establish a national data system and clearinghouse on primary care and prevention research.

Title VIII: Financing Provisions; American Health Security Trust Fund - Subtitle A: American Health Security Trust Fund - Amends the Internal Revenue Code to create the American Health Security Trust Fund. Appropriates to the trust fund the increase in tax liabilities attributable to the application of amendments made by this title and receipts from the following programs: Medicare, Medicaid, Federal employee health benefit program, and the CHAMPUS program. Transfers to such trust fund amounts in the Federal Hospital Insurance Trust Fund and the Federal Supplementary Medical Insurance Trust Fund.

Subtitle B: Increases in Corporate and Individual Income Tax Rates; Health Security Premium, Surtax on Individuals With Incomes Over $1,000,000 - Increases individual and corporate income tax rates, including the imposition of a health premium on such increased rates.

Imposes a surtax on individuals with incomes over $1 million.

Subtitle C: Employment Tax Changes - Increases the tax on employers for hospital insurance. Modifies self-employment and railroad retirement tax provisions.

Makes State and local employees subject to the hospital insurance tax.

Subtitle D: Other Revenue Increases Primarily Affecting Individuals - Makes permanent the overall limitation on itemized deductions for high-income taxpayers.

Makes permanent the phaseout of the deduction for personal exemptions for such taxpayers.

Removes residence sale, purchase, or lease expenses and meals while traveling from the deduction for moving expenses. Increases the overall dollar limitation for moving expenses in connection with the commencement of work.

Makes the highest estate and gift tax rates permanent.

Denies any deduction for club membership fees as an entertainment expense.

Includes increased social security benefits in gross income.

Provides for the collection of a monthly long-term health care premium for the elderly (other than the low-income elderly) for deposit into the American Health Security Trust Fund.

Subtitle E: Other Revenue Increases Primarily Affecting Businesses - Applies mark-to-market accounting method rules for certain securities held by dealers in securities (with specified exceptions for certain types of securities such as those held for investment or as a hedge).

Increases the applicable recovery period for depreciation of nonresidential real property under the accelerated cost recovery system.

Includes imported property income of a controlled foreign corporation or related person as foreign base company income.

Requires the separate application of the limitation on the foreign tax credit on imported property income. Applies the look-thru rules in the case of controlled foreign corporations to such income.

Repeals: (1) the deduction for intangible drilling and development costs in the case of oil and gas wells and geothermal wells; (2) the percentage depletion for oil and gas wells; and (3) the application of like-kind exchange rules to real property.

Disallows the capitalization of a percentage of advertising expenses. Allows the amortization of such disallowed amount.

Subtitle F: Estimated Tax Provisions - Increases individual and corporate estimated tax payments. Repeals special rules which denied the use of a previous year's liability safe harbor for certain individuals with significant increases in tax liability from one year to the next. Modifies corporate annualized income installment provisions.

Subtitle G: Alternative Taxable Years - Provides that the taxable year for an S corporation or partnership must be the same as an entity's reporting period if an entity has annual reports or statements which ascertain income profit or loss and are provided to shareholders or used for credit purposes.

Revises computation of the amount of the required payment that must be made by a partnership or S corporation that elects a taxable year other than the required taxable year.

Subtitle H: Deduction for Charitable Contribution of Appreciated Property Limited to Adjusted Basis - Limits the deduction for charitable contribution of appreciated property to the amount which would have been gained had the property been sold by the taxpayer at its fair market value.

Subtitle I: Minimum 5 Percent Rate of Tax on Interest Paid to Foreign Persons - Sets a minimum rate of tax on interest paid to foreign persons notwithstanding any treaty obligations.