I

103D CONGRESS

2D SESSION H. R. 4294

To improve health status in medically disadvantaged communities through

comprehensive community-based managed care programs.

IN THE HOUSE OF REPRESENTATIVES

APRIL 21, 1994

Mr. TOWNS introduced the following bill; which was referred to the Committee

on Energy and Commerce

A BILL

To improve health status in medically disadvantaged communities through comprehensive community-based managed

care programs.

1 Be it enacted by the Senate and House of Representa2 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 Access District Act’’.

6 SEC. 2. DEFINITIONS.

7 (a) COMPREHENSIVE HEALTH ACCESS DISTRICT.—

8 The term ‘‘comprehensive health access district’’ means

9 a community in which unemployment and the percentage

10 of resident with incomes below the poverty line are greater
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1 than the national average, and in which a majority of the

2 following conditions occur at rates greater than the na3 tional average:

4 (1) Infant mortality and low birth-weight

5 babies.

6 (2) Proportion of children below the age of 5

7 who have not received age-appropriate routine child8 hood immunizations.

9 (3) Hospitalization for preventable illnesses and

10 conditions that may be managed successfully on an

11 outpatient basis, such as otitis media, diabetes, and

12 hypertension.

13 (4) Emergency room visits for nonemergency

14 conditions.

15 (5) Accidental injury.

16 (6) Incidence of tuberculosis, acquired immune

17 deficiency syndrome, Black Lung disease, or cancer.

18 (7) Incidence of violent crimes.

19 (b) COMPREHENSIVE COMMUNITY-BASED HEALTH

20 ACCESS PLAN.—The term ‘‘comprehensive community21 based health access plan’’ (hereafter in this Act referred

22 to as a ‘‘health access plan’’) means an entity that pro23 vides health care services on a prepaid, capitated basis or

24 any other risk basis and that the Secretary has certified

25 meets the requirements contained in section 5 of this Act.
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1 (c) SECRETARY.—The term ‘‘Secretary’’ means the

2 Secretary of Health and Human Services.

3 SEC. 3. MEDICAID STATE PLAN REQUIREMENTS FOR COM4 PREHENSIVE HEALTH ACCESS DISTRICTS.

5 Section 1902(a) of the Social Security Act (42 U.S.C.

6 1396a(a)) is amended by adding after paragraph (62) the

7 following new paragraph:

8 ‘‘(63) provide that each comprehensive health

9 access district located within the State is served by

10 a comprehensive community-based health access dis11 trict plan.’’

12 SEC. 4. HEALTH ALLIANCE OBLIGATIONS WITH RESPECT

13 TO COMPREHENSIVE HEALTH ACCESS DIS14 TRICTS.

15 Each Health Alliance or other health insurance pur16 chasing cooperative created as a result of the enactment

17 of comprehensive health care reform legislation that re18 ceives premiums on behalf of persons formerly insured

19 under title XIX of the Social Security Act and whose

20 boundaries encompass a comprehensive health access dis21 trict shall insure that at least one comprehensive commu22 nity-based health access plan is available to persons living

23 in such district.
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1 SEC. 5. COMPREHENSIVE COMMUNITY-BASED HEALTH AC2 CESS PLANS.

3 To be certified as a comprehensive community-based

4 health access plan, an entity must meet all of the following

5 requirements:

6 (a) ORGANIZATIONAL REQUIREMENTS.—A health ac7 cess plan must—

8 (1) be a public or private organization, orga9 nized under the laws of any State;

10 (2) locate its primary place of business in the

11 comprehensive health access district it serves;

12 (3) give preference in hiring to otherwise quali13 fied individuals who live within the comprehensive

14 health access district; and

15 (4) have made adequate provision against the

16 risk of insolvency, which provision is satisfactory to

17 the State and which assures that individuals enrolled

18 in the plan are in no case liable for debts of the plan

19 in case of the plan’s insolvency. Provisions against

20 the risk of insolvency may include—

21 (A) escrow or similar arrangements to en22 sure that funds for the payment of providers

23 are available only for such payments and can24 not be otherwise used by the plan;
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1 (B) reinsurance purchased by the plan of

2 an amount which is reasonably adequate to in3 sure against unexpected costs;

4 (C) a demonstration of financial viability,

5 as evidenced by the plan’s obtaining a signifi6 cant amount of reinsurance, line of credit, or

7 performance bond; or

8 (D) such other mechanisms and require9 ments as the State finds appropriate.

10 (b) SERVICE REQUIREMENTS.

11 (1) BASIC BENEFITS.—A health access plan

12 shall provide, either directly or through arrange13 ments with providers, the following basic benefits:

14 (A) Hospital services, including inpatient,

15 outpatient and 24-hour emergency services.

16 (B) Emergency and ambulatory medical

17 and surgical services.

18 (C) Physicians’ services.

19 (D) Medical care other than physicians’

20 services recognized under State law and fur21 nished by licensed practitioners within the scope

22 of their practice as defined by State law.

23 (E) Dental services.

24 (F) Vision services.
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1 (G) Preventive health care services (includ2 ing children’s eye and ear examinations to de3 termine the need for vision and hearing correc4 tion, well child services, immunizations against

5 vaccine-preventable diseases, and screening for

6 elevated blood lead levels).

7 (H) Outpatient laboratory, radiology, and

8 diagnostic services.

9 (I) Ambulance services.

10 (J) Mental health and substance abuse

11 services.

12 (K) Family planning services and services

13 for pregnant women.

14 (L) Outpatient prescription drugs and

15 biologicals.

16 (2) COMMUNITY-BASED HEALTH SERVICES.—In

17 addition to providing the services described in para18 graph (b)(1), a health access plan shall—

19 (A) identify the most frequent causes of

20 morbidity and mortality in the comprehensive

21 health access district (such as acquired immune

22 deficiency syndrome, tuberculosis, mental ill23 ness, substance abuse and addiction, childhood

24 developmental disorders (particularly those

25 caused by children’s exposure to violence), asth-
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1 ma, teen pregnancy, unhealthy behaviors (such

2 as smoking and high-fat diets), and lead poison3 ing); and

4 (B) design and implement programs of

5 prevention, early intervention, or treatment in6 tended to ameliorate or eliminate the factors

7 identified in subparagraph (b)(2)(A).

8 (3) COORDINATION OF SERVICES.—In addition

9 to providing the services described in paragraphs

10 (b)(1) and (b)(2), a health access plan must promote

11 its enrollees’ access to social, educational or eco12 nomic services (such as child day care, nutritional

13 services, vocational training, and adult literacy pro14 grams).

15 (c) SERVICE NETWORK REQUIREMENTS.—

16 (1) BASIC SERVICE NETWORK.—A health access

17 plan shall enter into arrangements with a sufficient

18 number and variety of providers to guarantee that—

19 (A) the plan’s enrollees have access to the

20 services described in subsection 4(b); and

21 (B) the provider network takes into ac22 count and is representative of the cultural iden23 tity and diversity of the community being

24 served.
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1 (2) TRADITIONAL COMMUNITY PROVIDERS.—A

2 health access plan shall, to the extent feasible, draw

3 upon health care providers currently serving the

4 community, including community health centers (as

5 defined in section 330(a) of the Public Health Serv6 ice Act) and hospitals operated by units of local gov7 ernment, in developing its service network.

8 (3) DEVELOPMENT OF NEW HEALTH RE9 SOURCES.—A health access plan shall develop new

10 health resources in the community (such as school11 based clinics, mobile screening programs, and clinics

12 based in public housing) to meet needs that are not

13 met by existing community resources.

14 (d) ACCESS STANDARDS.—A health access plan shall

15 insure that each individual enrolled in it—

16 (1) is linked with the primary care physician

17 within the health access plan’s provider network of

18 the individual’s choice and has access to that doctor

19 on a 24-hour a day, 7-day a week basis;

20 (2) has round-the-clock telephone access to a

21 central program office for information purposes as

22 well as to voice grievances; and

23 (3) has access to interpreter services as nec24 essary (where a significant proportion of the popu25 lation in the community health access district is non-
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1 English speaking, the health access plan shall insure

2 that a corresponding proportion of its health care

3 providers have a multilingual capability).

4 (e) QUALITY ASSURANCE STANDARDS.—A health ac5 cess plan shall establish and maintain a quality assurance

6 program that includes at least the following activities:

7 (1) TREATMENT STANDARDS.—A health access

8 plan shall establish—

9 (A) minimum standards for treating pa10 tients that participating providers must satisfy;

11 (B) a program of ongoing medical record

12 reviews and other provider audits to insure

13 compliance with the plan’s treatment standards;

14 and

15 (C) a system of sanctions to insure that

16 providers who do not comply with the plan’s

17 treatment standards will be penalized and, if

18 found to be repeatedly out of compliance, termi19 nated from participation in the health access

20 plan service network.

21 (2) DATA COLLECTION.—A health access plan

22 shall monitor morbidity and mortality within the

23 comprehensive health access district and identify the

24 leading causes of death and disease.
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1 (3) MEMBER SURVEYS.—A health access plan

2 shall survey its enrollees on a regular basis to deter3 mine their satisfaction with the quality of services

4 received.

5 (4) INDEPENDENT QUALITY AUDITS.—A health

6 access plan shall be evaluated on a regular basis by

7 an independent health care accrediting organization.

8 (f) EFFECTIVE GRIEVANCE PROCEDURES.—A health

9 access plan must provide for effective procedures for hear10 ing and resolving grievances between the plan and individ11 uals enrolled in the plan.

12 (g) CONFIDENTIALITY OF ENROLLEE RECORDS.—

13 (1) A health access plan shall ensure that infor14 mation concerning its enrollees is protected from un15 authorized disclosure by the plan, its employees or

16 its providers.

17 (2) To promote the coordination of benefits to

18 health plan enrollees, a health access plan may dis19 close information about its enrollees to the extent

20 necessary to facilitate the enrollee’s receipt of serv21 ices and assistance from other entities.
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1 SEC. 6. DESIGNATION OF COMPREHENSIVE HEALTH AC2 CESS DISTRICTS AND CERTIFICATION OF

3 COMPREHENSIVE COMMUNITY-BASED

4 HEALTH ACCESS PLANS.

5 The Secretary shall designate a community that

6 meets the criteria set forth in section 2(a) of this Act a

7 comprehensive health access district and shall certify an

8 entity that meets the criteria set forth in section 5 of this

9 Act as a comprehensive health access plan. Each such cer10 tification and designation shall be reviewed every five

11 years. The Secretary may delegate all or part of the cer12 tification function to the State in which the health access

13 plan operates.

14 SEC. 7. NATIONAL HEALTH OUTCOMES RESEARCH AND

15 EVALUATION.

16 (a) PROVISION OF INFORMATION.—In order to evalu17 ate the performance of health access plans in improving

18 the health status of persons living in comprehensive health

19 access districts, each health access plan shall provide the

20 Secretary, at a time and in a manner specified by the Sec21 retary, at least the following information:

22 (1) Information on the characteristics of enroll23 ees that may affect their need for or use of health

24 services.

25 (2) Information on the types of treatments and

26 services and outcomes of treatments with respect to
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1 the clinical health, functional status and well-being

2 of enrollees.

3 (3) Information on enrollee satisfaction.

4 (4) Information on health care expenditures,

5 volume and prices of procedures, and use of special6 ized services.

7 (b) ANALYSIS OF INFORMATION.—The Secretary

8 shall analyze the information reported by health access

9 plans in order to report to Congress, the plans and the

10 public, no less than annually, on the following:

11 (1) The health status of persons living in com12 prehensive health access districts (particularly those

13 indicators listed in section 2(a) of this Act).

14 (2) The level and rate of expenditures by health

15 access plans on medical services and other programs

16 to improve health status.

17 (3) The effectiveness of health access plans in

18 improving health outcomes (particularly outcomes

19 related to health indicators listed in section 2(a) of

20 this Act).

21 (c) RESEARCH.—

22 (1) The Secretary shall examine the relation23 ship between socioeconomic factors and health status

24 and, based on his findings, suggest interventions ap25 propriate to comprehensive health access districts.
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1 (2) The Secretary may contract with non2 governmental entities to perform this research. Per3 sons undertaking this work shall have access to the

4 information provided by the health access plans to

5 the Secretary.

6 SEC. 8. CHANGES TO THE MEDICAID STATUTE TO FACILI7 TATE STATE CONTRACTS WITH COMPREHEN8 SIVE COMMUNITY-BASED HEALTH ACCESS

9 PLANS.

10 (a) Section 1903(m)(2) of the Social Security Act (42

11 U.S.C. 1396b(m)(2)) is amended by adding after subpara12 graph (H) the following new subparagraph:

13 ‘‘(I) Clause (ii) of subparagraph (A) does not

14 apply to any entity certified as a comprehensive

15 health access plan pursuant to section 6 of the Com16 prehensive Health Access District Act.’’

17 (b) This amendment shall apply to payments for med18 ical assistance for calendar quarters beginning on or after

19 July 1, 1995.

20 SEC. 9. REGULATIONS AND EFFECTIVE DATE.

21 (a) The Secretary shall promulgate regulations nec22 essary to implement this Act.

23 (b) This Act shall take effect on July 1, 1995, with24 out regard to whether or not final regulations to carry out

25 this Act have been promulgated by such date.
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