American Health Security Act of 1997

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

Title X: Additional Conforming Amendments

American Health Security Act of 1997 - Title I: Establishment of a State-Based American Health Security Program; Universal Entitlement; Enrollment - Establishes the American Health Security Program (AHSP), to be administered by the States. Requires a State to establish a State health security program (program) to receive Federal health care funding.

(Sec. 102) Entitles every individual who is a U.S. resident and is a U.S. citizen or national or a lawful resident alien to benefits.

(Sec. 103) Requires each State program to provide an enrollment mechanism and issue a health security card to each enrollee.

(Sec. 104) Makes benefits portable. Prohibits a minimum residence or waiting period in excess of a specified period. Allows reciprocal arrangements for coverage of border region enrollees.

(Sec. 106) Supersedes titles XVIII (Medicare) and XIX (Medicaid) of the Social Security Act, the Federal Employee Health Benefits Program, and the Civilian Health and Medical Program of the Uniformed Services (CHAMPUS).

Title II: Comprehensive Benefits, Including Preventive Benefits and Benefits for Long Term Care - Entitles all eligible individuals to payment items and services specified by the American Health Security Standards Board (Board) (established by title IV of this Act).

Prohibits: (1) deductibles, coinsurance, or copayments for acute care and preventive benefits, subject to exception; (2) providers from charging a patient for covered services; and (3) duplicative private insurance.

(Sec. 203) Covers a percentage of home and community-based long-term care services.

(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.

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 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 excluded providers; and (5) to submit bills within a specified time.

(Sec. 302) Considers a health care provider to be qualified if the provider is licensed or certified and meets State law requirements, Federal requirements, and additional standards specified by the Board. Requires: (1) establishment of national minimum quality assurance standards and related monitoring; and (2) an exchange of information among programs regarding quality assurance and cost containment.

(Sec. 303) Defines a "comprehensive health service organization" (CHSO) as a public or private organization that, in return for a capitated payment, furnishes or arranges for a full range of health services and out-of-area coverage for urgently needed services. Regulates CHSOs.

(Sec. 304) Extends current Medicare prohibitions on physician self-referrals and applies the 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. Mandates uniform reporting standards.

(Sec. 402) Mandates an American Health Security Advisory Council.

(Sec. 404) Requires: (1) each State to submit a plan for a program for providing health care services to residents; (2) the Board to provide States incentives to develop regional planning mechanisms; (3) State programs to meet Federal standards; and (4) each State to appoint a State Health Security Advisory Council.

Allows: (1) programs not meeting Federal requirements to be placed in receivership; and (2) States to use fiscal agents to process claims.

Subtitle B: Control Over Fraud and Abuse - Authorizes provider exclusion, civil monetary penalties, and criminal prosecution for fraud or abuse, based on current Medicaid standards.

(Sec. 412) Requires each program to establish and maintain a health care fraud and abuse unit.

Title V: Quality Assessment - Establishes the American Health Security Quality Council.

(Sec. 502) Mandates: (1) methods for profiling practice patterns and for identifying those with quality deficiencies; (2) guidelines for procedures performed only at tertiary centers; and (3) standards for education and sanctions regarding those with quality deficiencies.

(Sec. 503) Requires each participating State to establish an entity to conduct quality reviews.

(Sec. 504) Expresses the intent to replace random utilization controls with a systematic review of patterns of practice. Supersedes all existing Federal utilization review programs.

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 specifying the total expenditures to be made by the Federal Government and the States for covered health care services.

(Sec. 602) Provides for the allocation of funds in the budget by the Board to the States.

(Sec. 604) Provides for programs to receive Federal funds equal to a weighted average of a specified percentage of their population-based share of the budget.

(Sec. 605) Requires each program to establish a separate budget account for health professional education expenditures.

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; and (2) facility budgets be adjusted to reflect payments made by CHSOs. Allows programs to permit institutions and facilities to raise funds from private sources for specified purposes.

(Sec. 612) Requires: (1) State programs to pay individual practitioners on a fee-for-service basis; and (2) the Board to establish models for such payment and for global fee payment methodologies. 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.

(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: (1) the Board to establish a list of approved durable medical equipment and therapeutic devices and equipment; and (2) 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 adopted by the Board.

(Sec. 618) Directs the Board to establish model payment methodologies and other incentives that promote the provision of services in medically underserved areas.

(Sec. 619) Authorizes programs to use alternative payment methodologies, provided certain requirements are met.

Subtitle C: Mandatory Assignment and Administrative Provisions - Requires that participating providers accept program payment as full payment. Permits provider exclusion and civil penalties for violations.

(Sec. 632) Requires a provider payment appeals process.

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 - Sets forth Board responsibilities regarding the education of health professionals.

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 by a specified date.

(Sec. 702) Mandates an Advisory Committee on Health Professional Education.

(Sec. 703) Requires transfer of specified revenues from the American Health Security Trust Fund (Fund) for certain existing programs supporting health professional education and nursing education and for the National Health Service Corps.

Subtitle B: Direct Health Care Delivery - Mandates transfer of specified Fund revenues to the Public Health Service for 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 the prevention and treatment of substance abuse, grants for HIV health care services, public health formula grants, and primary care service expansion grants.

(Sec. 713) Mandates grants to primary care centers to plan, develop, and deliver primary care to medically underserved populations.

Subtitle C: Primary Care and Outcomes Research - Mandates transfer of specified 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 in the National Institutes of Health an Office of Primary Care and Prevention Research and a national data system and clearinghouse on primary care and prevention research. Authorizes appropriations.

Subtitle D: School-Related Health Services - Authorizes appropriations for this subtitle. Mandates grants to State health agencies or to local community partnerships to develop and operate school health service sites.

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 (Fund). Appropriates to the Fund the increase in tax liabilities attributable to the application of amendments made by this title and receipts from: Medicare, Medicaid, Federal employees' health benefits program, CHAMPUS, 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 the 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 - Imposes a health care excise tax on every employer and on the self-employed, railroad employers, and railroad employee representatives.

Imposes an individual health care income tax. 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 the Employee Retirement Income Security Act of 1974 (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 ERISA continuation coverage requirements.

Title X: Additional Conforming Amendments - Repeals specified provisions of the Health Insurance Portability and Accountability Act, ERISA, and the Public Health Service Act.