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.
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 404(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
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, dis-
ability, handicapping condition, or (subject to
the professional qualifications of the provider)
illness. Nothing in this subparagraph shall be
construed as requiring the provision of a type
or class of services which services are outside
the scope of the provider’s normal practice.
(B) No charge will be made for any cov-
ered services other than for payment authorized
by this Act.
(C) The provider agrees to furnish such in-
formation as may be reasonably required by the
Board or a State health security program, in
accordance with uniform reporting standards
established under section 401(g)(1), for—
(i) quality review by designated enti-
ties;
(ii) the making of payments under
this Act (including the examination of
records as may be necessary for the
verification of information on which pay-
ments are based);
(iii) statistical or other studies re-
quired for the implementation of this Act;
and
(iv) such other purposes as the Board
or State may specify.
(D) The provider agrees not to bill the pro-
gram for any services for which benefits are not
available because of section 204(d).
(E) In the case of a provider that is not
an individual, the provider agrees not to employ
or use for the provision of health services any
individual or other provider who or which has
had a participation agreement under this sub-
section terminated for cause.
(F) In the case of a provider paid under a
fee-for-service basis under section 612, the pro-
vider agrees to submit bills and any required
supporting documentation relating to the provi-
sion of covered services within 30 days (or such
shorter period as a State health security pro-
gram may require) after the date of providing
such services.
(2) TERMINATION OF PARTICIPATION AGREE-
MENTS.—
(A) IN
GENERAL.—Participation agree-
ments may be terminated, with appropriate
notice—
(i) by the Board or a State health se-
curity program for failure to meet the
requirements of this title, or
(ii) by a provider.
(B) TERMINATION
PROCESS.—Providers
shall be provided notice and a reasonable oppor-
tunity to correct deficiencies before the Board
or a State health security program terminates
an agreement unless a more immediate termi-
nation is required for public safety or similar
reasons.
SEC. 302. QUALIFICATIONS FOR PROVIDERS.
(a) IN GENERAL.—A health care provider is consid-
ered to be qualified to provide covered services if the pro-
vider is licensed or certified and meets—
(1) all the requirements of State law to provide
such services,
(2) applicable requirements of Federal law to
provide such services, and
(3) any applicable standards established under
subsection (b).
(b) MINIMUM PROVIDER STANDARDS.—
(1) IN GENERAL.—The Board shall establish,
evaluate, and update national minimum standards to
assure the quality of services provided under this
Act and to monitor efforts by State health security
programs to assure the quality of such services. A
State health security program may also establish ad-
ditional minimum standards which providers must
meet.
(2) NATIONAL MINIMUM STANDARDS.—The na-
tional minimum standards under paragraph (1) shall
be established for institutional providers of services,
individual health care practitioners, and comprehen-
sive health service organizations. Except as the
Board may specify in order to carry out this title,
a hospital, nursing facility, or other institutional
provider of services shall meet standards for such a
facility under the medicare program under title
XVIII of the Social Security Act. Such standards
also may include, where appropriate, elements relat-
ing to—
(A) adequacy and quality of facilities;
(B) training and competence of personnel
(including continuing education requirements);
(C) comprehensiveness of service;
(D) continuity of service;
(E) patient satisfaction (including waiting
time and access to services); and
(F) performance standards (including or-
ganization, facilities, structure of services, effi-
ciency of operation, and outcome in palliation,
improvement of health, stabilization, cure, or
rehabilitation).
(3) TRANSITION
IN
APPLICATION.—If the
Board provides for additional requirements for pro-
viders under this subsection, any such additional re-
quirement shall be implemented in a manner that
provides for a reasonable period during which a pre-
viously qualified provider is permitted to meet such
an additional requirement.
(4) EXCHANGE OF INFORMATION.—The Board
shall provide for an exchange, at least annually,
among State health security programs of informa-
tion with respect to quality assurance and cost
containment.