I
104TH CONGRESS
1ST SESSION
H. R. 381
To improve health status in medically disadvantaged communities through
comprehensive community-based managed care programs.
IN THE HOUSE OF REPRESENTATIVES
JANUARY 4, 1995
Mr. TOWNS introduced the following bill; which was referred to the Committee
on Commerce
A BILL
To improve health status in medically disadvantaged commu-
nities through comprehensive community-based managed
care programs.
Be it enacted by the Senate and House of Representa-
tives 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
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than the national average, and in which a majority of the
following conditions occur at rates greater than the na-
tional 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 child-
hood 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 pro-
vides 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.
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(c) SECRETARY.—The term ‘‘Secretary’’ means the
Secretary of Health and Human Services.
SEC. 3. MEDICAID STATE PLAN REQUIREMENTS FOR COM-
PREHENSIVE 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 dis-
trict plan.’’
SEC. 4. HEALTH ALLIANCE OBLIGATIONS WITH RESPECT
TO COMPREHENSIVE HEALTH ACCESS DIS-
TRICTS.
Each Health Alliance or other health insurance pur-
chasing cooperative created as a result of the enactment
of comprehensive health care reform legislation that re-
ceives premiums on behalf of persons formerly insured
under title XIX of the Social Security Act and whose
boundaries encompass a comprehensive health access dis-
trict shall insure that at least one comprehensive commu-
nity-based health access plan is available to persons living
in such district.
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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 ac-
cess plan must—
(1) be a public or private organization, orga-
nized 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 quali-
fied 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 en-
sure that funds for the payment of providers
are available only for such payments and can-
not be otherwise used by the plan;
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(B) reinsurance purchased by the plan of
an amount which is reasonably adequate to in-
sure against unexpected costs;
(C) a demonstration of financial viability,
as evidenced by the plan’s obtaining a signifi-
cant amount of reinsurance, line of credit, or
performance bond; or
(D) such other mechanisms and require-
ments as the State finds appropriate.
(b) SERVICE REQUIREMENTS.
(1) BASIC
BENEFITS.—A health access plan
shall provide, either directly or through arrange-
ments 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 fur-
nished by licensed practitioners within the scope
of their practice as defined by State law.
(E) Dental services.
(F) Vision services.
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(G) Preventive health care services (includ-
ing children’s eye and ear examinations to de-
termine the need for vision and hearing correc-
tion, 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 para-
graph (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 ill-
ness, substance abuse and addiction, childhood
developmental 
disorders 
(particularly 
those
caused by children’s exposure to violence), asth-
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ma, teen pregnancy, unhealthy behaviors (such
as smoking and high-fat diets), and lead poison-
ing); and
(B) design and implement programs of
prevention, early intervention, or treatment in-
tended 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 eco-
nomic services (such as child day care, nutritional
services, vocational training, and adult literacy pro-
grams).
(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 ac-
count and is representative of the cultural iden-
tity and diversity of the community being
served.
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(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 Serv-
ice Act) and hospitals operated by units of local gov-
ernment, in developing its service network.
(3) DEVELOPMENT
OF
NEW
HEALTH
RE-
SOURCES.—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 nec-
essary (where a significant proportion of the popu-
lation in the community health access district is non-
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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 ac-
cess 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 pa-
tients 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, termi-
nated 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.