I 
108TH CONGRESS 
1ST SESSION H. R. 1200
To provide for health care for every American and to control the cost and 
enhance the quality of the health care system. 
IN THE HOUSE OF REPRESENTATIVES 
MARCH 11, 2003
Mr. MCDERMOTT (for himself, Mr. RANGEL, Mr. STARK, Mr. SERRANO, Ms. 
BALDWIN, Mr. WEINER, Mr. KUCINICH, Mr. CONYERS, Ms. LEE, Mr. 
FARR, Mr. DELAHUNT, Ms. WOOLSEY, Mr. HINCHEY, Mr. NADLER, Mr. 
SANDERS, Mrs. CHRISTENSEN, Mr. WAXMAN, and Ms. ROYBAL-ALLARD) 
introduced the following bill; which was referred to the Committee on En-
ergy and Commerce, and in addition to the Committees on Ways and 
Means, Government Reform, and Armed Services, for a period to be sub-
sequently determined by the Speaker, in each case for consideration of 
such provisions as fall within the jurisdiction of the committee concerned 
A BILL 
To provide for health care for every American and to control 
the cost and enhance the quality of the health care system.
Be it enacted by the Senate and House of Representa-
tives of the United States of America in Congress assembled, 
SECTION 1. SHORT TITLE; TABLE OF CONTENTS. 
(a) SHORT TITLE.—This Act may be cited as the 
‘‘American Health Security Act of 2003’’. 
(b) TABLE OF CONTENTS.—The table of contents of 
this Act is as follows:
Sec. 1. Short title; table of contents. 
TITLE 
I—ESTABLISHMENT 
OF 
A 
STATE-BASED 
AMERICAN 
HEALTH SECURITY PROGRAM; UNIVERSAL ENTITLEMENT; EN-
ROLLMENT 
Sec. 101. Establishment of a State-based American Health Security Program. 
Sec. 102. Universal entitlement. 
Sec. 103. Enrollment. 
Sec. 104. Portability of benefits. 
Sec. 105. Effective date of benefits. 
Sec. 106. Relationship to existing Federal health programs. 
TITLE II—COMPREHENSIVE BENEFITS, INCLUDING PREVENTIVE 
BENEFITS AND BENEFITS FOR LONG-TERM CARE 
Sec. 201. Comprehensive benefits. 
Sec. 202. Definitions relating to services. 
Sec. 203. Special rules for home and community-based long-term care services. 
Sec. 204. Exclusions and limitations. 
Sec. 205. Certification; quality review; plans of care. 
TITLE III—PROVIDER PARTICIPATION 
Sec. 301. Provider participation and standards. 
Sec. 302. Qualifications for providers. 
Sec. 303. Qualifications for comprehensive health service organizations. 
Sec. 304. Limitation on certain physician referrals. 
TITLE IV—ADMINISTRATION 
Subtitle A—General Administrative Provisions 
Sec. 401. American Health Security Standards Board. 
Sec. 402. American Health Security Advisory Council. 
Sec. 403. Consultation with private entities. 
Sec. 404. State health security programs. 
Sec. 405. Complementary conduct of related health programs. 
Subtitle B—Control Over Fraud and Abuse 
Sec. 411. Application of Federal sanctions to all fraud and abuse under Amer-
ican Health Security Program. 
Sec. 412. Requirements for operation of State health care fraud and abuse con-
trol units. 
TITLE V—QUALITY ASSESSMENT 
Sec. 501. American Health Security Quality Council. 
Sec. 502. Development of certain methodologies, guidelines, and standards. 
Sec. 503. State quality review programs. 
Sec. 504. Elimination of utilization review programs; transition. 
TITLE VI—HEALTH SECURITY BUDGET; PAYMENTS; COST 
CONTAINMENT MEASURES 
Subtitle A—Budgeting and Payments to States 
Sec. 601. National health security budget.
Sec. 602. Computation of individual and State capitation amounts. 
Sec. 603. State health security budgets. 
Sec. 604. Federal payments to States. 
Sec. 605. Account for health professional education expenditures. 
Subtitle B—Payments by States to Providers 
Sec. 611. Payments to hospitals and other facility-based services for operating 
expenses on the basis of approved global budgets. 
Sec. 612. Payments to health care practitioners based on prospective fee sched-
ule. 
Sec. 613. Payments to comprehensive health service organizations. 
Sec. 614. Payments for community-based primary health services. 
Sec. 615. Payments for prescription drugs. 
Sec. 616. Payments for approved devices and equipment. 
Sec. 617. Payments for other items and services. 
Sec. 618. Payment incentives for medically underserved areas. 
Sec. 619. Authority for alternative payment methodologies. 
Subtitle C—Mandatory Assignment and Administrative Provisions 
Sec. 631. Mandatory assignment. 
Sec. 632. Procedures for reimbursement; appeals. 
TITLE VII—PROMOTION OF PRIMARY HEALTH CARE; DEVELOP-
MENT OF HEALTH SERVICE CAPACITY; PROGRAMS TO ASSIST 
THE MEDICALLY UNDERSERVED 
Subtitle A—Promotion and Expansion of Primary Care Professional Training 
Sec. 701. Role of Board; establishment of primary care professional output 
goals. 
Sec. 702. Establishment of Advisory Committee on Health Professional Edu-
cation. 
Sec. 703. Grants for health professions education, nurse education, and the Na-
tional Health Service Corps. 
Subtitle B—Direct Health Care Delivery 
Sec. 711. Setaside for public health. 
Sec. 712. Setaside for primary health care delivery. 
Sec. 713. Primary care service expansion grants. 
Subtitle C—Primary Care and Outcomes Research 
Sec. 721. Set-aside for outcomes research. 
Sec. 722. Office of Primary Care and Prevention Research. 
Subtitle D—School-Related Health Services 
Sec. 731. Authorizations of appropriations. 
Sec. 732. Eligibility for development and operation grants. 
Sec. 733. Preferences. 
Sec. 734. Grants for development of projects. 
Sec. 735. Grants for operation of projects. 
Sec. 736. Federal administrative costs. 
Sec. 737. Definitions.
TITLE VIII—FINANCING PROVISIONS; AMERICAN HEALTH 
SECURITY TRUST FUND 
Sec. 800. Amendment of 1986 code; section 15 not to apply. 
Subtitle A—American Health Security Trust Fund 
Sec. 801. American Health Security Trust Fund. 
Subtitle B—Taxes Based on Income and Wages 
Sec. 811. Payroll tax on employers. 
Sec. 812. Health care income tax. 
Subtitle C—Increase in Excise Taxes on Tobacco Products 
Sec. 821. Increase in excise taxes on tobacco products. 
TITLE IX—CONFORMING AMENDMENTS TO THE EMPLOYEE 
RETIREMENT INCOME SECURITY ACT OF 1974
Sec. 901. ERISA inapplicable to health coverage arrangements under State 
health security programs. 
Sec. 902. Exemption of State health security programs from ERISA preemp-
tion. 
Sec. 903. Prohibition of employee benefits duplicative of benefits under State 
health security programs; coordination in case of workers’ com-
pensation. 
Sec. 904. Repeal of continuation coverage requirements under ERISA and cer-
tain other requirements relating to group health plans. 
Sec. 905. Effective date of title. 
TITLE X—ADDITIONAL CONFORMING AMENDMENTS 
Sec. 1001. Repeal of certain provisions in Internal Revenue Code of 1986. 
Sec. 1002. Repeal of certain provisions in the Employee Retirement Income Se-
curity Act of 1974. 
Sec. 1003. Repeal of certain provisions in the Public Health Service Act and 
related provisions. 
Sec. 1004. Effective date of title.
(2) CONSIDERATION.—In providing for eligi-
bility under paragraph (1), the Board shall consider 
reciprocity in health care services offered to United 
States citizens who are nonimmigrants in other for-
eign states, and such other factors as the Board de-
termines to be appropriate. 
(c) TREATMENT OF OTHER INDIVIDUALS.—
(1) BY BOARD.—The Board also may make eli-
gible for benefits for health care services under the 
appropriate State health security program under this 
Act other individuals not described in subsection (a) 
or (b), and regulate the nature of the eligibility of 
such individuals, in order—
(A) to preserve the public health of com-
munities; 
(B) to compensate States for the addi-
tional health care financing burdens created by 
such individuals; and 
(C) to prevent adverse financial and med-
ical consequences of uncompensated care, 
while inhibiting travel and immigration to the 
United States for the sole purpose of obtaining 
health care services.
(2) BY STATES.—Any State health security pro-
gram may make individuals described in paragraph 
(1) eligible for benefits at the expense of the State. 
(d) LAWFUL RESIDENT ALIEN DEFINED.—For pur-
poses of this section, the term ‘‘lawful resident alien’’ 
means an alien lawfully admitted for permanent residence 
and any other alien lawfully residing permanently in the 
United States under color of law, including an alien with 
lawful temporary resident status under section 210, 210A, 
or 234A of the Immigration and Nationality Act (8 U.S.C. 
1160, 1161, or 1255a). 
SEC. 103. ENROLLMENT. 
(a) IN GENERAL.—Each State health security pro-
gram shall provide a mechanism for the enrollment of indi-
viduals entitled or eligible for benefits under this Act. The 
mechanism shall—
(1) include a process for the automatic enroll-
ment of individuals at the time of birth in the 
United States and at the time of immigration into 
the United States or other acquisition of lawful resi-
dent status in the United States; 
(2) provide for the enrollment, as of January 1, 
2003, of all individuals who are eligible to be en-
rolled as of such date; and
(3) include a process for the enrollment of indi-
viduals made eligible for health care services under 
subsections (b) and (c) of section 102. 
(b) AVAILABILITY OF APPLICATIONS.—Each State 
health security program shall make applications for enroll-
ment under the program available—
(1) at employment and payroll offices of em-
ployers located in the State; 
(2) at local offices of the Social Security Ad-
ministration; 
(3) at social services locations; 
(4) at out-reach sites (such as provider and 
practitioner locations); and
(5) at other locations (including post offices 
and schools) accessible to a broad cross-section of in-
dividuals eligible to enroll. 
(c) ISSUANCE OF HEALTH SECURITY CARDS.—In 
conjunction with an individual’s enrollment for benefits 
under this Act, the State health security program shall 
provide for the issuance of a health security card that shall 
be used for purposes of identification and processing of 
claims for benefits under the program. The State health 
security program may provide for issuance of such cards 
by employers for purposes of carrying out enrollment pur-
suant to subsection (a)(2).
SEC. 104. PORTABILITY OF BENEFITS. 
(a) IN GENERAL.—To ensure continuous access to 
benefits for health care services covered under this Act, 
each State health security program—
(1) shall not impose any minimum period of 
residence in the State, or waiting period, in excess 
of 3 months before residents of the State are enti-
tled to, or eligible for, such benefits under the pro-
gram; 
(2) shall provide continuation of payment for 
covered health care services to individuals who have 
terminated their residence in the State and estab-
lished their residence in another State, for the dura-
tion of any waiting period imposed in the State of 
new residency for establishing entitlement to, or eli-
gibility for, such services; and 
(3) shall provide for the payment for health 
care services covered under this Act provided to indi-
viduals while temporarily absent from the State 
based on the following principles: 
(A) Payment for such health care services 
is at the rate that is approved by the State 
health security program in the State in which 
the services are provided, unless the States con-
cerned agree to apportion the cost between 
them in a different manner.
(B) Payment for such health care services 
provided outside the United States is made on 
the basis of the amount that would have been 
paid by the State health security program for 
similar services rendered in the State, with due 
regard, in the case of hospital services, to the 
size of the hospital, standards of service, and 
other relevant factors. 
(b) 
CROSS-BORDER
ARRANGEMENTS.—A 
State 
health security program for a State may negotiate with 
such a program in an adjacent State a reciprocal arrange-
ment for the coverage under such other program of health 
care services to enrollees residing in the border region. 
SEC. 105. EFFECTIVE DATE OF BENEFITS. 
Benefits shall first be available under this Act for 
items and services furnished on or after January 1, 2005. 
SEC. 106. RELATIONSHIP TO EXISTING FEDERAL HEALTH 
PROGRAMS. 
(a) MEDICARE, MEDICAID AND STATE CHILDREN’S 
HEALTH INSURANCE PROGRAM (SCHIP).—
(1) IN GENERAL.—Notwithstanding any other 
provision of law, subject to paragraph (2)—
(A) no benefits shall be available under 
title XVIII of the Social Security Act for any
item or service furnished after December 31, 
2004; 
(B) no individual is entitled to medical as-
sistance under a State plan approved under 
title XIX of such Act for any item or service 
furnished after such date; 
(C) no individual is entitled to medical as-
sistance under an SCHIP plan under title XXI 
of such Act for any item or service furnished 
after such date; and 
(D) no payment shall be made to a State 
under section 1903(a) or 2105(a) of such Act 
with respect to medical assistance or child 
health assistance for any item or service fur-
nished after such date. 
(2) TRANSITION.—In the case of inpatient hos-
pital services and extended care services during a 
continuous period of stay which began before Janu-
ary 1, 2005, and which had not ended as of such 
date, for which benefits are provided under title 
XVIII, under a State plan under title XIX, or a 
State child health plan under title XXI, of the Social 
Security Act, the Secretary of Health and Human 
Services and each State plan, respectively, shall pro-
vide for continuation of benefits under such title or 
plan until the end of the period of stay. 
(b) FEDERAL EMPLOYEES HEALTH BENEFITS PRO-
GRAM.—No benefits shall be made available under chapter 
89 of title 5, United States Code, for any part of a cov-
erage period occurring after December 31, 2004. 
(c) CHAMPUS.—No benefits shall be made available 
under sections 1079 and 1086 of title 10, United States 
Code, for items or services furnished after December 31, 
2004. 
(d) TREATMENT OF BENEFITS FOR VETERANS AND 
NATIVE AMERICANS.—Nothing in this Act shall affect the 
eligibility of veterans for the medical benefits and services
provided under title 38, United States Code, or of Indians 
for the medical benefits and services provided by or 
through the Indian Health Service. 
TITLE II—COMPREHENSIVE BEN-
EFITS, INCLUDING PREVEN-
TIVE BENEFITS AND BENE-
FITS FOR LONG-TERM CARE 
SEC. 201. COMPREHENSIVE BENEFITS. 
(a) IN GENERAL.—Subject to the succeeding provi-
sions of this title, individuals enrolled for benefits under 
this Act are entitled to have payment made under a State 
health security program for the following items and serv-
ices if medically necessary or appropriate for the mainte-
nance of health or for the diagnosis, treatment, or rehabili-
tation of a health condition: 
(1) HOSPITAL SERVICES.—Inpatient and out-
patient hospital care, including 24-hour-a-day emer-
gency services. 
(2) 
PROFESSIONAL
SERVICES.—Professional 
services of health care practitioners authorized to 
provide health care services under State law, includ-
ing patient education and training in self-manage-
ment techniques. 
(3) 
COMMUNITY-BASED
PRIMARY
HEALTH 
SERVICES.—Community-based primary health serv-
ices (as defined in section 202(a)). 
(4) PREVENTIVE
SERVICES.—Preventive serv-
ices (as defined in section 202(b)). 
(5) LONG-TERM, ACUTE, AND CHRONIC CARE 
SERVICES.—
(A) Nursing facility services. 
(B) Home health services. 
(C) Home and community-based long-term 
care services (as defined in section 202(c)) for 
individuals described in section 203(a). 
(D) Hospice care.
(E) Services in intermediate care facilities 
for individuals with mental retardation. 
(6) PRESCRIPTION DRUGS, BIOLOGICALS, INSU-
LIN, MEDICAL FOODS.—
(A) Outpatient prescription drugs and bio-
logics, as specified by the Board consistent with 
section 615. 
(B) Insulin. 
(C) Medical foods (as defined in section 
202(e)). 
(7) DENTAL SERVICES.—Dental services (as de-
fined in section 202(h)). 
(8) MENTAL HEALTH AND SUBSTANCE ABUSE 
TREATMENT
SERVICES.—Mental health and sub-
stance abuse treatment services (as defined in sec-
tion 202(f)). 
(9) DIAGNOSTIC TESTS.—Diagnostic tests. 
(10) OTHER ITEMS AND SERVICES.—
(A) OUTPATIENT
THERAPY.—Outpatient 
physical therapy services, outpatient speech pa-
thology services, and outpatient occupational 
therapy services in all settings. 
(B) DURABLE MEDICAL EQUIPMENT.—Du-
rable medical equipment.
(C) HOME DIALYSIS.—Home dialysis sup-
plies and equipment. 
(D) AMBULANCE.—Emergency ambulance 
service. 
(E) PROSTHETIC DEVICES.—Prosthetic de-
vices, including replacements of such devices. 
(F) ADDITIONAL ITEMS AND SERVICES.—
Such other medical or health care items or serv-
ices as the Board may specify. 
(b) COST-SHARING.—
(1) IN GENERAL.—Except as provided in this 
subsection, there are no deductibles, coinsurance, or 
copayments applicable to acute care and preventive 
benefits provided under this title. 
(2) COST-SHARING
FOR
LONG-TERM
CARE 
SERVICES.—
(A) IN GENERAL.—
(i) payments for home and commu-
nity-based long-term care services are sub-
ject to coinsurance of 20 percent; and 
(ii) payments for nursing facility serv-
ices are subject to coinsurance of 35 per-
cent.
(B) EXCEPTION.—With respect to the co-
insurance 
established 
under 
subparagraph 
(A)—
(i) such coinsurance shall not apply to 
an individual with income (as defined by 
the Secretary) of not more than 100 per-
cent of the income official poverty line ap-
plicable to a family of the size involved; 
and 
(ii) in the case of an individual with 
such income that exceeds 100 percent, but 
is less than 200 percent, of such applicable 
poverty line, the coinsurance shall be re-
duced in the same proportion as the pro-
portion of such income is less than 200 
percent of such applicable poverty line. 
(c) PROHIBITION OF BALANCE BILLING.—As pro-
vided in section 531, no person may impose a charge for 
covered services for which benefits are provided under this 
Act. 
(d) NO DUPLICATE HEALTH INSURANCE.—Each 
State health security program shall prohibit the sale of 
health insurance in the State if payment under the insur-
ance duplicates payment for any items or services for 
which payment may be made under such a program.
(e) STATE PROGRAM MAY PROVIDE ADDITIONAL 
BENEFITS.—Nothing in this Act shall be construed as 
limiting the benefits that may be made available under a 
State health security program to residents of the State 
at the expense of the State. 
(f) EMPLOYERS MAY PROVIDE ADDITIONAL BENE-
FITS.—Nothing in this Act shall be construed as limiting 
the additional benefits that an employer may provide to 
employees or their dependents, or to former employees or 
their dependents. 
SEC. 202. DEFINITIONS RELATING TO SERVICES. 
(a) COMMUNITY-BASED PRIMARY HEALTH SERV-
ICES.—In this title, the term ‘‘community-based primary 
health services’’ means ambulatory health services fur-
nished—
(1) by a rural health clinic; 
(2) by a federally qualified health center (as de-
fined in section 1905(l)(2)(B) of the Social Security 
Act), and which, for purposes of this Act, include 
services furnished by State and local health agencies; 
(3) in a school-based setting; 
(4) by public educational agencies and other 
providers of services to children entitled to assist-
ance under the Individuals with Disabilities Edu-
cation Act for services furnished pursuant to a writ-
ten Individualized Family Services Plan or Indi-
vidual Education Plan under such Act; and 
(5) public and private nonprofit entities receiv-
ing Federal assistance under the Public Health 
Service Act. 
(b) PREVENTIVE SERVICES.—
(1) IN GENERAL.—In this title, the term ‘‘pre-
ventive services’’ means items and services—
(A) which—
(i) are specified in paragraph (2); or 
(ii) the Board determines to be effec-
tive in the maintenance and promotion of 
health or minimizing the effect of illness, 
disease, or medical condition; and 
(B) which are provided consistent with the 
periodicity schedule established under para-
graph (3). 
(2) SPECIFIED
PREVENTIVE
SERVICES.—The 
services specified in this paragraph are as follows: 
(A) Basic immunizations. 
(B) Prenatal and well-baby care (for in-
fants under 1 year of age). 
(C) Well-child care (including periodic 
physical examinations, hearing and vision 
screening, and developmental screening and ex-
aminations) for individuals under 18 years of 
age. 
(D) Periodic screening mammography, Pap 
smears, and colorectal examinations and exami-
nations for prostate cancer. 
(E) Physical examinations. 
(F) Family planning services. 
(G) Routine eye examinations, eyeglasses, 
and contact lenses. 
(H) Hearing aids, but only upon a deter-
mination of a certified audiologist or physician 
that a hearing problem exists and is caused by 
a condition that can be corrected by use of a 
hearing aid. 
(3) SCHEDULE.—The Board shall establish, in 
consultation with experts in preventive medicine and 
public health and taking into consideration those 
preventive services recommended by the Preventive 
Services Task Force and published as the Guide to 
Clinical Preventive Services, a periodicity schedule 
for the coverage of preventive services under para-
graph (1). Such schedule shall take into consider-
ation the cost-effectiveness of appropriate preventive 
care and shall be revised not less frequently than
once every 5 years, in consultation with experts in 
preventive medicine and public health. 
(c) HOME
AND
COMMUNITY-BASED
LONG-TERM 
CARE SERVICES.—In this title, the term ‘‘home and com-
munity-based long-term care services’’ means the following 
services provided to an individual to enable the individual 
to remain in such individual’s place of residence within 
the community: 
(1) Home health aide services. 
(2) Adult day health care, social day care or 
psychiatric day care. 
(3) Medical social work services.
(4) Care coordination services, as defined in 
subsection (g)(1). 
(5) Respite care, including training for informal 
caregivers. 
(6) Personal assistance services, and home-
maker services (including meals) incidental to the 
provision of personal assistance services. 
(d) HOME HEALTH SERVICES.—
(1) IN
GENERAL.—The term ‘‘home health 
services’’ means items and services described in sec-
tion 1861(m) of the Social Security Act and includes 
home infusion services.
(2) HOME
INFUSION
SERVICES.—The term 
‘‘home infusion services’’ includes the nursing, phar-
macy, and related services that are necessary to con-
duct the home infusion of a drug regimen safely and 
effectively under a plan established and periodically 
reviewed by a physician and that are provided in 
compliance with quality assurance requirements es-
tablished by the Secretary. 
(e) MEDICAL FOODS.—In this title, the term ‘‘med-
ical foods’’ means foods which are formulated to be con-
sumed or administered enterally under the supervision of 
a physician and which are intended for the specific dietary 
management of a disease or condition for which distinctive 
nutritional requirements, based on recognized scientific 
principles, are established by medical evaluation. 
(f) MENTAL
HEALTH
AND
SUBSTANCE
ABUSE 
TREATMENT SERVICES.—
(1) SERVICES
DESCRIBED.—In this title, the 
term ‘‘mental health and substance abuse treatment 
services’’ means the following services related to the 
prevention, diagnosis, treatment, and rehabilitation 
of mental illness and promotion of mental health: 
(A) INPATIENT HOSPITAL SERVICES.—In-
patient hospital services furnished primarily for 
the diagnosis or treatment of mental illness or
substance abuse for up to 60 days during a 
year, reduced by a number of days determined 
by the Secretary so that the actuarial value of 
providing such number of days of services 
under this paragraph to the individual is equal 
to the actuarial value of the days of inpatient 
residential services furnished to the individual 
under subparagraph (B) during the year after 
such services have been furnished to the indi-
vidual for 120 days during the year (rounded to 
the nearest day), but only if (with respect to 
services furnished to an individual described in 
section 204(b)(1)) such services are furnished 
in conformity with the plan of an organized sys-
tem of care for mental health and substance 
abuse services in accordance with section 
204(b)(2). 
(B) INTENSIVE RESIDENTIAL SERVICES.—
Intensive residential services (as defined in 
paragraph (2)) furnished to an individual for 
up to 120 days during any calendar year, ex-
cept that—
(i) such services may be furnished to 
the individual for additional days during 
the year if necessary for the individual to
complete a course of treatment to the ex-
tent that the number of days of inpatient 
hospital services described in subparagraph 
(A) that may be furnished to the individual 
during the year (as reduced under such 
subparagraph) is not less than 15; and 
(ii) reduced by a number of days de-
termined by the Secretary so that the actu-
arial value of providing such number of 
days of services under this paragraph to 
the individual is equal to the actuarial 
value of the days of intensive community-
based services furnished to the individual 
under subparagraph (D) during the year 
after such services have been furnished to 
the individual for 90 days (or, in the case 
of services described in subparagraph 
(D)(ii), for 180 days) during the year 
(rounded to the nearest day). 
(C) OUTPATIENT
SERVICES.—Outpatient 
treatment services of mental illness or sub-
stance abuse (other than intensive community-
based services under subparagraph (D)) for an 
unlimited number of days during any calendar 
year furnished in accordance with standards es-
year equal to the difference between the 
total number of days of intensive residen-
tial services which the individual may re-
ceive during the year under part A (as de-
termined under subparagraph (B)) and the 
number of days of such services which the 
individual has received during the year; or 
(iii) in the case of any other such 
services, for up to 90 days during any cal-
endar year, except that such services may 
be furnished to the individual for the num-
ber of additional days during the year de-
scribed in clause (ii). 
(2) INTENSIVE
RESIDENTIAL
SERVICES
DE-
FINED.—
(A) IN
GENERAL.—Subject to subpara-
graphs (B) and (C), the term ‘‘intensive resi-
dential services’’ means inpatient services pro-
vided in any of the following facilities: 
(i) Residential detoxification centers. 
(ii) Crisis residential programs or 
mental illness residential treatment pro-
grams. 
(iii) Therapeutic family or group 
treatment homes.
(iv) Residential centers for substance 
abuse treatment. 
(B) REQUIREMENTS FOR FACILITIES.—No 
service may be treated as an intensive residen-
tial service under subparagraph (A) unless the 
facility at which the service is provided—
(i) is legally authorized to provide 
such service under the law of the State (or 
under a State regulatory mechanism pro-
vided by State law) in which the facility is 
located or is certified to provide such serv-
ice by an appropriate accreditation entity
approved by the State in consultation with 
the Secretary; and 
(ii) meets such other requirements as 
the Secretary may impose to assure the 
quality of the intensive residential services 
provided. 
(C) SERVICES
FURNISHED
TO
AT-RISK 
CHILDREN.—In the case of services furnished 
to an individual described in section 204(b)(1), 
no service may be treated as an intensive resi-
dential service under this subsection unless the 
service is furnished in conformity with the plan 
of an organized system of care for mental
health and substance abuse services in accord-
ance with section 204(b)(2). 
(D) MANAGEMENT STANDARDS.—No serv-
ice may be treated as an intensive residential 
service under subparagraph (A) unless the serv-
ice is furnished in accordance with standards 
established by the Secretary for the manage-
ment of such services. 
(3) INTENSIVE
COMMUNITY-BASED
SERVICES 
DEFINED.—
(A) IN
GENERAL.—The term ‘‘intensive 
community-based services’’ means the items 
and services described in subparagraph (B) pre-
scribed by a physician (or, in the case of serv-
ices furnished to an individual described in sec-
tion 204(b)(1), by an organized system of care 
for mental health and substance abuse services 
in accordance with such section) and provided 
under a program described in subparagraph 
(D) under the supervision of a physician (or, to 
the extent permitted under the law of the State 
in which the services are furnished, a non-phy-
sician mental health professional) pursuant to 
an individualized, written plan of treatment es-
tablished and periodically reviewed by a physi-
cian (in consultation with appropriate staff par-
ticipating in such program) which sets forth the 
physician’s diagnosis, the type, amount, fre-
quency, and duration of the items and services 
provided under the plan, and the goals for 
treatment under the plan, but does not include 
any item or service that is not furnished in ac-
cordance with standards established by the Sec-
retary for the management of such services. 
(B) ITEMS AND SERVICES DESCRIBED.—
The items and services described in this sub-
paragraph are—
(i) partial hospitalization services con-
sisting of the items and services described 
in subparagraph (C); 
(ii) psychiatric rehabilitation services; 
(iii) day treatment services for indi-
viduals under 19 years of age; 
(iv) in-home services; 
(v) case management services, includ-
ing collateral services designated as such 
case management services by the Sec-
retary; 
(vi) ambulatory detoxification services; 
and
(vii) such other items and services as 
the Secretary may provide (but in no event 
to include meals and transportation), 
that are reasonable and necessary for the diag-
nosis or active treatment of the individual’s 
condition, reasonably expected to improve or 
maintain the individual’s condition and func-
tional level and to prevent relapse or hos-
pitalization, and furnished pursuant to such 
guidelines relating to frequency and duration of 
services as the Secretary shall by regulation es-
tablish (taking into account accepted norms of 
medical practice and the reasonable expectation 
of patient improvement). 
(C) ITEMS
AND
SERVICES
INCLUDED
AS 
PARTIAL
HOSPITALIZATION
SERVICES.—For 
purposes of subparagraph (B)(i), partial hos-
pitalization services consist of the following: 
(i) Individual and group therapy with 
physicians or psychologists (or other men-
tal health professionals to the extent au-
thorized under State law). 
(ii) Occupational therapy requiring 
the skills of a qualified occupational thera-
pist.
(iii) Services of social workers, trained 
psychiatric nurses, behavioral aides, and 
other staff trained to work with psychiatric 
patients (to the extent authorized under 
State law). 
(iv) Drugs and biologicals furnished 
for therapeutic purposes (which cannot, as 
determined in accordance with regulations, 
be self-administered). 
(v) Individualized activity therapies 
that are not primarily recreational or di-
versionary. 
(vi) Family counseling (the primary 
purpose of which is treatment of the indi-
vidual’s condition). 
(vii) Patient training and education 
(to the extent that training and edu-
cational activities are closely and clearly 
related to the individual’s care and treat-
ment). 
(viii) Diagnostic services. 
(D) PROGRAMS
DESCRIBED.—A program 
described in this subparagraph is a program 
(whether facility-based or freestanding) which is 
furnished by an entity—
(i) legally authorized to furnish such a 
program under State law (or the State reg-
ulatory mechanism provided by State law) 
or certified to furnish such a program by 
an appropriate accreditation entity ap-
proved by the State in consultation with 
the Secretary; and 
(ii) meeting such other requirements 
as the Secretary may impose to assure the 
quality of the intensive community-based 
services provided. 
(g) CARE COORDINATION SERVICES.—
(1) IN GENERAL.—In this title, the term ‘‘care 
coordination services’’ means services provided by 
care coordinators (as defined in paragraph (2)) to 
individuals described in paragraph (3) for the co-
ordination and monitoring of home and community-
based long term care services to ensure appropriate, 
cost-effective utilization of such services in a com-
prehensive and continuous manner, and includes—
(A) transition management between inpa-
tient facilities and community-based services, 
including assisting patients in identifying and 
gaining access to appropriate ancillary services; 
and
(B) evaluating and recommending appro-
priate treatment services, in cooperation with 
patients and other providers and in conjunction 
with any quality review program or plan of care 
under section 205. 
(2) CARE COORDINATOR.—
(A) IN GENERAL.—In this title, the term 
‘‘care coordinator’’ means an individual or non-
profit or public agency or organization which 
the State health security program determines—
(i) is capable of performing directly, 
efficiently, and effectively the duties of a
care coordinator described in paragraph 
(1); and 
(ii) demonstrates capability in estab-
lishing and periodically reviewing and re-
vising plans of care, and in arranging for 
and monitoring the provision and quality 
of services under any plan. 
(B) INDEPENDENCE.—State health secu-
rity programs shall establish safeguards to as-
sure that care coordinators have no financial in-
terest in treatment decisions or placements. 
Care coordination may not be provided through
any structure or mechanism through which 
quality review is performed. 
(3) ELIGIBLE INDIVIDUALS.—An individual de-
scribed in this paragraph is an individual described 
in section 203 (relating to individuals qualifying for 
long term and chronic care services). 
(h) DENTAL SERVICES.—
(1) IN GENERAL.—In this title, subject to sub-
section (b), the term ‘‘dental services’’ means the 
following: 
(A) Emergency dental treatment, including 
extractions, for bleeding, pain, acute infections, 
and injuries to the maxillofacial region. 
(B) Prevention and diagnosis of dental dis-
ease, including examinations of the hard and 
soft tissues of the oral cavity and related struc-
tures, radiographs, dental sealants, fluorides, 
and dental prophylaxis. 
(C) Treatment of dental disease, including 
non-cast fillings, periodontal maintenance serv-
ices, and endodontic services. 
(D) Space maintenance procedures to pre-
vent orthodontic complications. 
(E) Orthodontic treatment to prevent se-
vere malocclusions.
(F) Full dentures. 
(G) Medically necessary oral health care. 
(H) Any items and services for special 
needs patients that are not described in sub-
paragraphs (A) through (G) and that—
(i) are required to provide such pa-
tients the items and services described in 
subparagraphs (A) through (G); 
(ii) are required to establish oral func-
tion (including general anesthesia for indi-
viduals with physical or emotional limita-
tions that prevent the provision of dental 
care without such anesthesia); 
(iii) consist of orthodontic care for se-
vere dentofacial abnormalities; or 
(iv) consist of prosthetic dental de-
vices for genetic or birth defects or fitting 
for such devices. 
(I) Any dental care for individuals with a 
seizure disorder that is not described in sub-
paragraphs (A) through (H) and that is re-
quired because of an illness, injury, disorder, or 
other health condition that results from such 
seizure disorder.
(2) LIMITATIONS.—Dental services are subject 
to the following limitations: 
(A) PREVENTION AND DIAGNOSIS.—
(i) 
EXAMINATIONS
AND
PROPHY-
LAXIS.—The examinations and prophylaxis 
described in paragraph (1)(B) are covered 
only consistent with a periodicity schedule 
established by the Board, which schedule 
may provide for special treatment of indi-
viduals less than 18 years of age and of 
special needs patients. 
(ii) DENTAL SEALANTS.—The dental 
sealants described in such paragraph are 
not covered for individuals 18 years of age 
or older. Such sealants are covered for in-
dividuals less than 10 years of age for pro-
tection of the 1st permanent molars. Such 
sealants are covered for individuals 10 
years of age or older for protection of the 
2d permanent molars. 
(B) TREATMENT OF DENTAL DISEASE.—
Prior to January 1, 2010, the items and serv-
ices described in paragraph (1)(C) are covered 
only for individuals less than 18 years of age 
and special needs patients. On or after such
date, such items and services are covered for all 
individuals enrolled for benefits under this Act, 
except that endodontic services are not covered 
for individuals 18 years of age or older. 
(C) SPACE MAINTENANCE.—The items and 
services described in paragraph (1)(D) are cov-
ered only for individuals at least 3 years of age, 
but less than 13 years of age and—
(i) are limited to posterior teeth; 
(ii) involve maintenance of a space or 
spaces for permanent posterior teeth that 
would otherwise be prevented from normal 
eruption if the space were not maintained; 
and 
(iii) do not include a space maintainer 
that is placed within 6 months of the ex-
pected eruption of the permanent posterior 
tooth concerned. 
(D) ORTHODONTIC TREATMENT.—Prior to 
January 1, 2010, the items and services de-
scribed in paragraph (1)(E) are covered only 
for individuals at least 6 years of age, but less 
than 12 years of age, who have severe 
dentofacial abnormalities. On or after such 
date, such items and services are covered only
for individuals at least 6 years of age, but less 
than 12 years of age. 
(E) DENTURES.—Prior to January 1, 
2010, the dentures described in paragraph 
(1)(F) are not covered, except for special needs 
patients. On or after such date, dentures are 
covered for an individual consistent with a peri-
odicity schedule established by the Board, ex-
cept that the limitation of periodicity provided 
in such schedule shall not apply to a special 
needs patient. 
(3) DEFINITIONS.—For purposes of this title: 
(A) MEDICALLY NECESSARY ORAL HEALTH 
CARE.—The term ‘‘medically necessary oral 
health care’’ means oral health care that is re-
quired as a direct result of, or would have a di-
rect impact on, an underlying medical condi-
tion. Such term includes oral health care di-
rected toward control or elimination of pain, in-
fection, or reestablishment of oral function. 
(B) SPECIAL NEEDS PATIENT.—The term 
‘‘special needs patient’’ includes an individual 
with a genetic or birth defect, a developmental 
disability, or an acquired medical disability.