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[Congressional Bills 103th Congress]
[From the U.S. Government Publishing Office]
[H.R. 4294 Introduced in House (IH)]

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.

    Be it enacted by the Senate and House of Representatives of the 
United States of America in Congress assembled,

SECTION 1. SHORT TITLE.

    This Act may be cited as the ``Comprehensive Health Access District 
Act''.

SEC. 2. DEFINITIONS.

    (a) Comprehensive Health Access District.--The term ``comprehensive 
health access district'' means a community in which unemployment and 
the percentage of resident with incomes below the poverty line are 
greater than the national average, and in which a majority of the 
following conditions occur at rates greater than the national average:
            (1) Infant mortality and low birth-weight babies.
            (2) Proportion of children below the age of 5 who have not 
        received age-appropriate routine childhood immunizations.
            (3) Hospitalization for preventable illnesses and 
        conditions that may be managed successfully on an outpatient 
        basis, such as otitis media, diabetes, and hypertension.
            (4) Emergency room visits for nonemergency conditions.
            (5) Accidental injury.
            (6) Incidence of tuberculosis, acquired immune deficiency 
        syndrome, Black Lung disease, or cancer.
            (7) Incidence of violent crimes.
    (b) Comprehensive Community-Based Health Access Plan.--The term 
``comprehensive community-based health access plan'' (hereafter in this 
Act referred to as a ``health access plan'') means an entity that 
provides health care services on a prepaid, capitated basis or any 
other risk basis and that the Secretary has certified meets the 
requirements contained in section 5 of this Act.
    (c) Secretary.--The term ``Secretary'' means the Secretary of 
Health and Human Services.

SEC. 3. MEDICAID STATE PLAN REQUIREMENTS FOR COMPREHENSIVE HEALTH 
              ACCESS DISTRICTS.

    Section 1902(a) of the Social Security Act (42 U.S.C. 1396a(a)) is 
amended by adding after paragraph (62) the following new paragraph:
            ``(63) provide that each comprehensive health access 
        district located within the State is served by a comprehensive 
        community-based health access district plan.''

SEC. 4. HEALTH ALLIANCE OBLIGATIONS WITH RESPECT TO COMPREHENSIVE 
              HEALTH ACCESS DISTRICTS.

    Each Health Alliance or other health insurance purchasing 
cooperative created as a result of the enactment of comprehensive 
health care reform legislation that receives premiums on behalf of 
persons formerly insured under title XIX of the Social Security Act and 
whose boundaries encompass a comprehensive health access district shall 
insure that at least one comprehensive community-based health access 
plan is available to persons living in such district.

SEC. 5. COMPREHENSIVE COMMUNITY-BASED HEALTH ACCESS PLANS.

    To be certified as a comprehensive community-based health access 
plan, an entity must meet all of the following requirements:
    (a) Organizational Requirements.--A health access plan must--
            (1) be a public or private organization, organized under 
        the laws of any State;
            (2) locate its primary place of business in the 
        comprehensive health access district it serves;
            (3) give preference in hiring to otherwise qualified 
        individuals who live within the comprehensive health access 
        district; and
            (4) have made adequate provision against the risk of 
        insolvency, which provision is satisfactory to the State and 
        which assures that individuals enrolled in the plan are in no 
        case liable for debts of the plan in case of the plan's 
        insolvency. Provisions against the risk of insolvency may 
        include--
                    (A) escrow or similar arrangements to ensure that 
                funds for the payment of providers are available only 
                for such payments and cannot be otherwise used by the 
                plan;
                    (B) reinsurance purchased by the plan of an amount 
                which is reasonably adequate to insure against 
                unexpected costs;
                    (C) a demonstration of financial viability, as 
                evidenced by the plan's obtaining a significant amount 
                of reinsurance, line of credit, or performance bond; or
                    (D) such other mechanisms and requirements as the 
                State finds appropriate.
    (b) Service Requirements.
            (1) Basic benefits.--A health access plan shall provide, 
        either directly or through arrangements with providers, the 
        following basic benefits:
                    (A) Hospital services, including inpatient, 
                outpatient and 24-hour emergency services.
                    (B) Emergency and ambulatory medical and surgical 
                services.
                    (C) Physicians' services.
                    (D) Medical care other than physicians' services 
                recognized under State law and furnished by licensed 
                practitioners within the scope of their practice as 
                defined by State law.
                    (E) Dental services.
                    (F) Vision services.
                    (G) Preventive health care services (including 
                children's eye and ear examinations to determine the 
                need for vision and hearing correction, well child 
                services, immunizations against vaccine-preventable 
                diseases, and screening for elevated blood lead 
                levels).
                    (H) Outpatient laboratory, radiology, and 
                diagnostic services.
                    (I) Ambulance services.
                    (J) Mental health and substance abuse services.
                    (K) Family planning services and services for 
                pregnant women.
                    (L) Outpatient prescription drugs and biologicals.
            (2) Community-based health services.--In addition to 
        providing the services described in paragraph (b)(1), a health 
        access plan shall--
                    (A) identify the most frequent causes of morbidity 
                and mortality in the comprehensive health access 
                district (such as acquired immune deficiency syndrome, 
                tuberculosis, mental illness, substance abuse and 
                addiction, childhood developmental disorders 
                (particularly those caused by children's exposure to 
                violence), asthma, teen pregnancy, unhealthy behaviors 
                (such as smoking and high-fat diets), and lead 
                poisoning); and
                    (B) design and implement programs of prevention, 
                early intervention, or treatment intended to ameliorate 
                or eliminate the factors identified in subparagraph 
                (b)(2)(A).
            (3) Coordination of services.--In addition to providing the 
        services described in paragraphs (b)(1) and (b)(2), a health 
        access plan must promote its enrollees' access to social, 
        educational or economic services (such as child day care, 
        nutritional services, vocational training, and adult literacy 
        programs).
    (c) Service Network Requirements.--
            (1) Basic service network.--A health access plan shall 
        enter into arrangements with a sufficient number and variety of 
        providers to guarantee that--
                    (A) the plan's enrollees have access to the 
                services described in subsection 4(b); and
                    (B) the provider network takes into account and is 
                representative of the cultural identity and diversity 
                of the community being served.
            (2) Traditional community providers.--A health access plan 
        shall, to the extent feasible, draw upon health care providers 
        currently serving the community, including community health 
        centers (as defined in section 330(a) of the Public Health 
        Service Act) and hospitals operated by units of local 
        government, in developing its service network.
            (3) Development of new health resources.--A health access 
        plan shall develop new health resources in the community (such 
        as school-based clinics, mobile screening programs, and clinics 
        based in public housing) to meet needs that are not met by 
        existing community resources.
    (d) Access Standards.--A health access plan shall insure that each 
individual enrolled in it--
            (1) is linked with the primary care physician within the 
        health access plan's provider network of the individual's 
        choice and has access to that doctor on a 24-hour a day, 7-day 
        a week basis;
            (2) has round-the-clock telephone access to a central 
        program office for information purposes as well as to voice 
        grievances; and
            (3) has access to interpreter services as necessary (where 
        a significant proportion of the population in the community 
        health access district is non-English speaking, the health 
        access plan shall insure that a corresponding proportion of its 
        health care providers have a multilingual capability).
    (e) Quality Assurance Standards.--A health access plan shall 
establish and maintain a quality assurance program that includes at 
least the following activities:
            (1) Treatment standards.--A health access plan shall 
        establish--
                    (A) minimum standards for treating patients that 
                participating providers must satisfy;
                    (B) a program of ongoing medical record reviews and 
                other provider audits to insure compliance with the 
                plan's treatment standards; and
                    (C) a system of sanctions to insure that providers 
                who do not comply with the plan's treatment standards 
                will be penalized and, if found to be repeatedly out of 
                compliance, terminated from participation in the health 
                access plan service network.
            (2) Data collection.--A health access plan shall monitor 
        morbidity and mortality within the comprehensive health access 
        district and identify the leading causes of death and disease.
            (3) Member surveys.--A health access plan shall survey its 
        enrollees on a regular basis to determine their satisfaction 
        with the quality of services received.
            (4) Independent quality audits.--A health access plan shall 
        be evaluated on a regular basis by an independent health care 
        accrediting organization.
    (f) Effective Grievance Procedures.--A health access plan must 
provide for effective procedures for hearing and resolving grievances 
between the plan and individuals enrolled in the plan.
    (g) Confidentiality of Enrollee Records.--
            (1) A health access plan shall ensure that information 
        concerning its enrollees is protected from unauthorized 
        disclosure by the plan, its employees or its providers.
            (2) To promote the coordination of benefits to health plan 
        enrollees, a health access plan may disclose information about 
        its enrollees to the extent necessary to facilitate the 
        enrollee's receipt of services and assistance from other 
        entities.

SEC. 6. DESIGNATION OF COMPREHENSIVE HEALTH ACCESS DISTRICTS AND 
              CERTIFICATION OF COMPREHENSIVE COMMUNITY-BASED HEALTH 
              ACCESS PLANS.

    The Secretary shall designate a community that meets the criteria 
set forth in section 2(a) of this Act a comprehensive health access 
district and shall certify an entity that meets the criteria set forth 
in section 5 of this Act as a comprehensive health access plan. Each 
such certification and designation shall be reviewed every five years. 
The Secretary may delegate all or part of the certification function to 
the State in which the health access plan operates.

SEC. 7. NATIONAL HEALTH OUTCOMES RESEARCH AND EVALUATION.

    (a) Provision of Information.--In order to evaluate the performance 
of health access plans in improving the health status of persons living 
in comprehensive health access districts, each health access plan shall 
provide the Secretary, at a time and in a manner specified by the 
Secretary, at least the following information:
            (1) Information on the characteristics of enrollees that 
        may affect their need for or use of health services.
            (2) Information on the types of treatments and services and 
        outcomes of treatments with respect to the clinical health, 
        functional status and well-being of enrollees.
            (3) Information on enrollee satisfaction.
            (4) Information on health care expenditures, volume and 
        prices of procedures, and use of specialized services.
    (b) Analysis of Information.--The Secretary shall analyze the 
information reported by health access plans in order to report to 
Congress, the plans and the public, no less than annually, on the 
following:
            (1) The health status of persons living in comprehensive 
        health access districts (particularly those indicators listed 
        in section 2(a) of this Act).
            (2) The level and rate of expenditures by health access 
        plans on medical services and other programs to improve health 
        status.
            (3) The effectiveness of health access plans in improving 
        health outcomes (particularly outcomes related to health 
        indicators listed in section 2(a) of this Act).
    (c) Research.--
            (1) The Secretary shall examine the relationship between 
        socioeconomic factors and health status and, based on his 
        findings, suggest interventions appropriate to comprehensive 
        health access districts.
            (2) The Secretary may contract with nongovernmental 
        entities to perform this research. Persons undertaking this 
        work shall have access to the information provided by the 
        health access plans to the Secretary.

SEC. 8. CHANGES TO THE MEDICAID STATUTE TO FACILITATE STATE CONTRACTS 
              WITH COMPREHENSIVE COMMUNITY-BASED HEALTH ACCESS PLANS.

    (a) Section 1903(m)(2) of the Social Security Act (42 U.S.C. 
1396b(m)(2)) is amended by adding after subparagraph (H) the following 
new subparagraph:
            ``(I) Clause (ii) of subparagraph (A) does not apply to any 
        entity certified as a comprehensive health access plan pursuant 
        to section 6 of the Comprehensive Health Access District Act.''
    (b) This amendment shall apply to payments for medical assistance 
for calendar quarters beginning on or after July 1, 1995.

SEC. 9. REGULATIONS AND EFFECTIVE DATE.

    (a) The Secretary shall promulgate regulations necessary to 
implement this Act.
    (b) This Act shall take effect on July 1, 1995, without regard to 
whether or not final regulations to carry out this Act have been 
promulgated by such date.

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