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SEC. 204. EXCLUSIONS AND LIMITATIONS.
(a) IN GENERAL.—Subject to section 201(e), benefits
for service are not available under this Act unless the
services meet the standards specified in section 201(a).
(b) MENTAL HEALTH SERVICES AND SUBSTANCE
ABUSE TREATMENT SERVICES.—
(1) IN GENERAL.—Mental health services and
substance abuse treatment services furnished for an
individual in excess of a threshold specified in para-
graph (2) are not covered services unless the services
are determined under a utilization review program to
meet the standards specified in section 201(a) and,
with respect to inpatient or residential treatment
services, to be provided in the least restrictive and
most appropriate setting.
(2) UTILIZATION REVIEW THRESHOLD.—
(A) IN
GENERAL.—Subject to subpara-
graphs (B) and (C), the thresholds specified in
this paragraph are—
(i) 20 outpatient visits in a year, and
(ii) 15 days of inpatient services in a
year.
(B) ALTERNATIVE
NATIONAL
THRESH-
OLDS.—The Board may specify alternative
thresholds to those specified in subparagraph
(A).
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(C) ADDITIONAL STATE THRESHOLDS.—A
State health security program may specify
thresholds in addition to those established
under 
the 
previous 
subparagraphs, 
which
thresholds may be higher or lower than the
number of outpatient visits or days of inpatient
services otherwise specified.
(c) TREATMENT OF EXPERIMENTAL SERVICES.—In
applying subsection (a), the Board shall make, after con-
sultation with a technical advisory committee, national
coverage determinations with respect to those services that
are experimental in nature. Such determinations shall be
made consistent with a process that provides for profes-
sional input and public comment.
(d) APPLICATION OF NATIONAL PRACTICE GUIDE-
LINES.—In the case of services for which the Board has
recognized national practice guidelines, the services are
considered to meet the standards specified in section
201(a) only if they have been provided in accordance with
such guidelines or in accordance with such guidelines as
are provided by the State health security program consist-
ent with title V.
(e) SPECIFIC LIMITATIONS.—
(1) LIMITATIONS
ON
EYEGLASSES, CONTACT
LENSES, HEARING
AIDS, AND
DURABLE
MEDICAL
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EQUIPMENT.—Subject to section 201(e), the Board
may impose such limits relating to the costs and fre-
quency of replacement of eyeglasses, contact lenses,
hearing aids, and durable medical equipment to
which individuals enrolled for benefits under this Act
are entitled to have payment made under a State
health security program as the Board deems appro-
priate.
(2) OVERLAP WITH PREVENTIVE SERVICES.—
The coverage of services described in section 201(a)
(other than paragraph (3)) which also are preventive
services are required to be covered only to the extent
that they are required to be covered as preventive
services.
(3) MISCELLANEOUS EXCLUSIONS FROM COV-
ERED SERVICES.—Covered services under this Act
do not include the following:
(A) Surgery and other procedures (such as
orthodontia) performed solely for cosmetic pur-
poses (as defined in regulations) and hospital or
other services incident thereto, unless—
(i) required to correct a congenital
anomaly;
(ii) required to restore or correct a
part of the body which has been altered as
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a result of accidental injury, disease, or
surgery; or
(iii) otherwise determined to be medi-
cally necessary and appropriate under sec-
tion 201(a).
(B) Personal comfort items or private
rooms in inpatient facilities, unless determined
to be medically necessary and appropriate
under section 201(a).
(C) The services of a professional practi-
tioner if they are furnished in a hospital or
other facility which is not a participating pro-
vider.
(f) NURSING
FACILITY
SERVICES
AND
HOME
HEALTH SERVICES.—Nursing facility services and home
health services (other than post-hospital services, as de-
fined by the Board) furnished to an individual who is not
described in section 203(a) are not covered services unless
the services are determined to meet the standards speci-
fied in section 201(a) and, with respect to nursing facility
services, to be provided in the least restrictive and most
appropriate setting.
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SEC. 205. CERTIFICATION; QUALITY REVIEW; PLANS OF
CARE.
(a) CERTIFICATIONS.—State health security pro-
grams may require, as a condition of payment for institu-
tional health care services and other services of the type
described in such sections 1814(a) and 1835(a) of the So-
cial Security Act, periodic professional certifications of the
kind described in such sections.
(b) QUALITY REVIEW.—For requirement that each
State health security program establish a quality review
program that meets the requirements for such a program
under title V, see section 405(b)(1)(H).
(c) PLAN OF CARE REQUIREMENTS.—A State health
security program may require, consistent with standards
established by the Board, that payment for services ex-
ceeding specified levels or duration be provided only as
consistent with a plan of care or treatment formulated by
one or more providers of the services or other qualified
professionals. Such a plan may include, consistent with
subsection (b), case management at specified intervals as
a further condition of payment for services.
TITLE III—PROVIDER
PARTICIPATION
SEC. 301. PROVIDER PARTICIPATION AND STANDARDS.
(a) IN GENERAL.—An individual or other entity fur-
nishing any covered service under a State health security
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program under this Act is not a qualified provider unless
the individual or entity—
(1) is a qualified provider of the services under
section 302;
(2) has filed with the State health security pro-
gram a participation agreement described in sub-
section (b); and
(3) meets such other qualifications and condi-
tions as are established by the Board or the State
health security program under this Act.
(b) REQUIREMENTS
IN
PARTICIPATION
AGREE-
MENT.—
(1) IN
GENERAL.—A participation agreement
described in this subsection between a State health
security program and a provider shall provide at
least for the following:
(A) Services to eligible persons will be fur-
nished by the provider without discrimination
on the ground of race, national origin, income,
religion, age, sex or sexual orientation, disabil-
ity, handicapping condition, or (subject to the
professional qualifications of the provider) ill-
ness. Nothing in this subparagraph shall be
construed as requiring the provision of a type