American Health Security Act of 1995

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: National 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

Subtitle D: School-Related Health Services

Title VIII: Financing Provisions; American Health Security

Trust Fund

Subtitle A: American Health Security Trust Fund

Subtitle B: Taxes Based on Income and Wages

Subtitle C: Increase in Excise Taxes on Tobacco

Products

Title IX: Conforming Amendments to the Employee Retirement

Income Security Act of 1974

American Health Security Act of 1995 - 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 (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, 1996.

(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, 1996. 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, acute, and chronic care services, prescription drugs, biologicals, insulin, and medical foods, dental services, mental health services and 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 acute care benefits, except for specified cost-sharing for long-term care services; (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 persons 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) Sets forth special delivery requirements for mental health and substance abuse treatment services provided to at-risk children. 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 established exception process. 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.

(Sec. 205) Specifies that: (1) States may require providers to certify that covered services were provided according to program requirements; (2) quality review programs must meet Federal standards; and (3) States may require plans of care for coverage of certain services.

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 employ other providers whose participation has been terminated for cause; and (5) 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 capitated payment amount, 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, accessibility of services, continuity of care, consumer and provider representation on the board of directors, a patient grievance program, medical standards committees, premiums, utilization and bonus information, provision of services to enrollees at institutions operating under global budgets, marketing of services, and provision of emergency services to nonenrollees.

(Sec. 304) Extends current Medicare prohibitions on physician self-referrals 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, 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 and the Secretary to consult with private entities.

(Sec. 404) 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 single-agency administration, a State health security budget, provider payment and quality review methodologies consistent with Federal standards, freedom to choose providers, 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 State Health Security Advisory Council 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. 405) 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 to 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 - Establishes the American Health Security Quality Council in order to: (1) review and evaluate each practice guideline developed under specified provisions of the Public Health Service Act; (2) review and evaluate each standard of quality, performance measure, and medical review criterion developed under specified provisions of the Public Health Service Act; (3) develop criteria for entities conducting quality reviews; (4) report to the Board annually; and (5) perform the functions of the Council described in sections 502 and 505.

(Sec. 502) Directs the Council to: (1) adopt methods for profiling the patterns of practice of health care professionals and for identifying outliers; (2) develop guidelines for certain medical procedures to be performed only at tertiary centers; (3) develop standards for education and sanctions with respect to outliers; and (4) disseminate such methods, guidelines, and standards to the States.

(Sec. 503) 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. Requires the quality review entity to meet the criteria for competence for such entities developed by the Council.

(Sec. 504) Expresses the intent to replace random utilization controls with a systematic review of patterns of practice that compromise the quality of care by January 1, 1998. Supersedes all existing Federal utilization review programs, including random case-by-case reviews and programs requiring pre-certification of medical procedures on a case-by-case basis, with exceptions. Specifies that nothing in this section shall preclude case management of catastrophic, mental health, or substance abuse cases where necessary to achieve appropriate, cost-effective, and beneficial comprehensive medical care.

(Sec. 505) Requires: (1) each State program to develop and use a uniform electronic data base in order to perform systematic quality review and support comparative outcomes research and analysis; (2) the Council to establish a set of clinical data derived from patient medical records to be transmitted to State electronic data bases to be used by State health security programs; (3) the Board to designate standards for software in order to assure compatibility; and (4) the Council to establish standards, as specified, for the use and disclosure by a State health security program of such data.

Title VI: Health Security Budget; Payments; Cost Containment Measures - Subtitle A: Budgeting and Payments to States - Directs the Board to establish a national 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 quality assessment, professional education, 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 quality assessment, professional training, 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. Permits programs to provide for a process for the approval of capital expenditures based on information derived from regional planning agencies.

(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 establish a separate budget account for health professional education expenditures and to distribute funds consistent with the achievement of specified national and program goals, including the receipt by the Board of reports to monitor compliance, and taking into account the potentially higher costs of placing health professional students in clinical education programs in health professional shortage areas.

Subtitle B: Payments by States to Providers - Directs that: (1) payment for operating expenses for institutional and facility- based care under State programs be made directly to each institution or facility under an annual prospective global budget approved under the program; (2) such budgets take into account discharges by diagnosis-related group, prior expenditures, the extent to which debt service for capital expenditures has been included in the proposed operating budget, the extent to which capital expenditures are financed directly or indirectly through reductions in direct care to patients, 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; and (3) facility budgets be adjusted to reflect payments made by CHSOs. Allows programs to permit institutions and facilities to raise funds from private sources to pay for newly constructed facilities, major renovations, and equipment.

(Sec. 612) Requires: (1) State programs to pay individual practitioners on a fee-for-service basis, as negotiated between States and practitioner representatives; (2) the Board to establish models for such payment and for global fee payment methodologies to encourage payment for combinations of services; and (3) practitioners to bill State programs within 30 days of providing services. Permits States to require electronic billing.

(Sec. 613) Authorizes programs to pay CHSOs based on annual budgets or risk-adjusted capitation payments, reduced by the costs of covered services not provided by the CHSO.

(Sec. 614) Directs that programs pay for community-based primary health services based on global budgets, basic primary care capitation amounts for enrollees, or fee-for-service, taking into account costs of serving non-covered patients, providing case management, transportation, and translation, and providing health professional education programs.

(Sec. 615) Requires: (1) the Board to establish a list of approved prescription drugs and to determine maximum prices; and (2) each program to pay for such drugs based on such maximum prices and to pay separate dispensing fees to pharmacies.

(Sec. 616) Directs the Board to establish a list of approved durable medical equipment and therapeutic devices and equipment and programs to pay for such items based on maximum prices determined by the Board.

(Sec. 617) 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. 618) 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 payments amounts within their budgets to encourage provision of appropriate services in underserved areas.

(Sec. 619) Authorizes programs to utilize alternative payment methodologies, provided that such methodologies do not affect the entitlement of individuals to coverage, the weighting 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 applying such methodologies to other States.

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) overseeing program health professional education expenditures; (3) 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 (4) 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, 2001.

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 Service 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, prevention and treatment of tuberculosis, prevention and treatment of sexually transmitted diseases, preventive health block grants, grants to States for community mental health services and prevention and treatment of substance abuse, grants for HIV health care services, and public health formula grants; and (2) primary care service expansion grants.

(Sec. 713) Directs the Board to make primary service expansion grants to 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. Specifies that grant funds may be used to plan, develop, and deliver primary care in such 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. Requires the Director of NIH to establish a national data system and clearinghouse on primary care and prevention research. Authorizes appropriations.

Subtitle D: School-Related Health Services - Authorizes appropriations through FY 2002 for this subtitle.

(Sec. 734) Directs the Secretary to make grants to State health agencies or to local community partnerships to develop and operate school health service sites. Requires preference in making grants to be given to those communities showing the most substantial level of need.

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 employees' health benefits program, and the CHAMPUS program, Maternal and Child Health program (under title V of the Social Security Act), vocational rehabilitation programs, drug abuse and mental health services programs under the Public Health Service Act, programs providing general hospital or medical assistance, and certain other Federal programs. Transfers to such trust fund amounts in the Federal Hospital Insurance Trust Fund and the Federal Supplementary Medical Insurance Trust Fund.

Subtitle B: Taxes Based on Income and Wages - Creates a health care excise tax on every employer with respect to each employee equal to 8.7 percent of wages paid. Imposes the tax on the self-employed, railroad employers, and railroad employee representatives.

Imposes an individual health care income tax equal to 2.2 percent of taxable income. Prohibits credits against the tax and any effect on the minimum tax in relation to the individual health care income tax.

Subtitle C: Increase in Excise Taxes on Tobacco Products - Increases the excise taxes on tobacco products.

Title IX: Conforming Amendments to the Employee Retirement Income Security Act of 1974 - Makes ERISA inapplicable to health coverage arrangements under State health security programs. Exempts State health security programs from ERISA preemption. Prohibits employee benefits duplicating State health security program benefits and requires that a liable workers' compensation carrier reimburse the State health security plan. Repeals continuation coverage requirements under ERISA.