I 
113TH 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 14, 2013 
Mr. MCDERMOTT introduced the following bill; which was referred to the 
Committee on Energy and Commerce, and in addition to the Committees 
on Ways and Means, Oversight and Government Reform, Armed Services, 
and Education and the Workforce, for a period to be subsequently deter-
mined 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. 
This Act may be cited as the ‘‘American Health Secu-
rity Act of 2013’’. 
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SEC. 2. SENSE OF THE HOUSE OF REPRESENTATIVES CON-
CERNING THE STATUS OF HEALTH CARE. 
It is the sense of the House of Representatives that 
the 113th Congress should recognize and proclaim that 
health care is a human right. 
SEC. 3. TABLE OF CONTENTS. 
The table of contents of this Act is as follows: 
Sec. 1. Short title. 
Sec. 2. Sense of the House of Representatives concerning the status of health 
care. 
Sec. 3. 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. 
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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 
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Sec. 711. Set-aside for public health. 
Sec. 712. Set-aside 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. 
Sec. 813. Surcharge on high income individuals. 
Subtitle C—Other Financing Provisions 
Sec. 821. Tax on Securities Transactions. 
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. 
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Sec. 1003. Repeal of certain provisions in the Public Health Service Act and 
related provisions. 
Sec. 1004. Effective date of title. 
TITLE I—ESTABLISHMENT OF A 
STATE-BASED 
AMERICAN 
HEALTH 
SECURITY 
PRO-
GRAM; UNIVERSAL ENTITLE-
MENT; ENROLLMENT 
SEC. 101. ESTABLISHMENT OF A STATE-BASED AMERICAN 
HEALTH SECURITY PROGRAM. 
(a) IN GENERAL.—There is hereby established in the 
United States a State-Based American Health Security 
Program to be administered by the individual States in 
accordance with Federal standards specified in, or estab-
lished under, this Act. 
(b) STATE HEALTH SECURITY PROGRAMS.—In order 
for a State to be eligible to receive payment under section 
604, a State shall establish a State health security pro-
gram in accordance with this Act. 
(c) STATE DEFINED.— 
(1) IN GENERAL.—In this Act, subject to para-
graph (2), the term ‘‘State’’ means each of the 50 
States and the District of Columbia. 
(2) ELECTION.—If the Governor of Puerto 
Rico, the Virgin Islands, Guam, American Samoa, or 
the Northern Mariana Islands certifies to the Presi-
dent that the legislature of the Commonwealth or 
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territory has enacted legislation desiring that the 
Commonwealth or territory be included as a State 
under the provisions of this Act, such Common-
wealth or territory shall be included as a ‘‘State’’ 
under this Act beginning January 1 of the first year 
beginning 90 days after the President receives the 
notification. 
SEC. 102. UNIVERSAL ENTITLEMENT. 
(a) IN GENERAL.—Every individual who is a resident 
of the United States and is a citizen or national of the 
United States or lawful resident alien (as defined in sub-
section (d)) is entitled to benefits for health care services 
under this Act under the appropriate State health security 
program. In this section, the term ‘‘appropriate State 
health security program’’ means, with respect to an indi-
vidual, the State health security program for the State in 
which the individual maintains a primary residence. 
(b) TREATMENT OF CERTAIN NONIMMIGRANTS.— 
(1) IN GENERAL.—The American Health Secu-
rity Standards Board (in this Act referred to as the 
‘‘Board’’) may make eligible for benefits for health 
care services under the appropriate State health se-
curity program under this Act such classes of aliens 
admitted to the United States as nonimmigrants as 
the Board may provide. 
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(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. 
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(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, 
2015, of all individuals who are eligible to be en-
rolled as of such date; and 
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(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 (to be 
referred to as a ‘‘smart card’’) that shall be used for pur-
poses of identification and processing of claims for bene-
fits under the program. The State health security program 
may provide for issuance of such cards by employers for 
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purposes of carrying out enrollment pursuant to sub-
section (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 
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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, 2015. 
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)— 
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(A) no benefits shall be available under 
title XVIII of the Social Security Act for any 
item or service furnished after December 31, 
2014; 
(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, 2015, 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 
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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, 2014. 
(c) TRICARE.—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, 
2014. 
(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. 
(e) TREATMENT OF PREMIUM CREDITS, COST-SHAR-
ING REDUCTIONS, AND SMALL EMPLOYER CREDITS.— 
(1) IN GENERAL.—For each calendar year, the 
Secretary of the Treasury shall transfer to the 
American Health Security Trust Fund an amount 
equal to the sum of— 
(A) the premium assistance credit amount 
which would have been allowable to taxpayers 
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residing in such State in such calendar year 
under section 36B of the Internal Revenue 
Code of 1986 (relating to refundable credit for 
coverage under a qualified health plan), as 
added by section 1401 of the Patient Protection 
and Affordable Care Act, if such section were in 
effect for such year, 
(B) the amount of cost-sharing reductions 
which would have been required with respect to 
eligible insured residing in such State in such 
calendar year under section 1402 of the Patient 
Protection and Affordable Care Act if such sec-
tion were in effect for such year, plus 
(C) the amount of tax credits which would 
have been allowable to eligible small employers 
doing business in such State in such calendar 
year under section 45R of the Internal Revenue 
Code of 1986 if such section were in effect for 
such calendar year. 
(2) DETERMINATION.—The amounts deter-
mined under paragraph (1) shall be estimated by the 
Secretary of the Treasury in consultation with the 
Secretary of Health and Human Services. 
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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)). 
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(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 an intellectual disability. 
(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. 
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(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) 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. 
(c) 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. 
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(d) 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. 
(e) 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. 
(f) TAFT-HARTLEY AND MEW BENEFIT PLANS.— 
Notwithstanding any other provision of law, a health plan 
may be provided for under a collective bargaining agree-
ment or a MEWA if such plan is limited to coverage that 
is supplemental to the coverage provided for under the 
State-based American Health Security Program and avail-
able only to employees or their dependents or to retirees 
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; 
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(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 
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(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) Immunizations recommended by the 
Advisory Committee on Immunization Practices 
of the Centers for Disease Control and Preven-
tion. 
(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, including evidence-informed preventive care 
and screenings included in the comprehensive 
guidelines of the Health Resources and Services 
Administration. 
(D) Periodic screening mammography, Pap 
smears, and colorectal examinations and exami-
nations for prostate cancer. 
(E) Physical examinations. 
(F) Family planning services. 
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(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. 
(I) Evidence-based items or services that 
have in effect a rating of ‘‘A’’ or ‘‘B’’ in the 
current recommendations of the United States 
Preventive Services Task Force. 
(J) With respect to women, such additional 
preventive care and screenings not described in 
subparagraph (I) that are included in the com-
prehensive guidelines of the Health Resources 
and Services Administration. 
(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 
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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. 
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(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 
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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 
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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-
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tablished by the Secretary for the management 
of such services, and, in the case of services fur-
nished to an individual described in section 
204(b)(1) who is not an inpatient of a hospital, 
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). 
(D) INTENSIVE COMMUNITY-BASED SERV-
ICES.—Intensive community-based services (as 
described in paragraph (3))— 
(i) for an unlimited number of days 
during any calendar year, in the case of 
services described in section 1861(ff)(2)(E) 
of the Social Security Act (42 U.S.C. 
1395x(ff)(2)(E)) that are furnished to an 
individual who is a seriously mentally ill 
adult, a seriously emotionally disturbed 
child, or an adult or child with serious sub-
stance abuse disorder (as determined in ac-
cordance with criteria established by the 
Secretary); 
(ii) in the case of services described in 
section 1861(ff)(2)(C) of the Social Secu-
rity Act (42 U.S.C. 1395x(ff)(2)(C)), for 
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up to 180 days during any calendar year, 
except that such services may be furnished 
to the individual for a number of addi-
tional days during the year equal to the 
difference between the total number of 
days of intensive residential services which 
the individual may receive during the year 
under part A (as determined under sub-
paragraph (B)) and the number of days of 
such services which the individual has re-
ceived 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. 
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(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 ensure the 
quality of the intensive residential services 
provided. 
(C) SERVICES
FURNISHED
TO
AT-RISK 
CHILDREN.—In the case of services furnished 
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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 
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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; 
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(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: 
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(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 
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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 ensure 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, 
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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 
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and monitoring the provision and quality 
of services under any plan. 
(B) INDEPENDENCE.—State health secu-
rity programs shall establish safeguards to en-
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. 
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(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. 
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(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 
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years of age or older for protection of the 
2d permanent molars. 
(B) TREATMENT OF DENTAL DISEASE.— 
Prior to January 1, 2020, 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. 
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(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. 
(i) NURSING FACILITY; NURSING FACILITY SERV-
ICES.—Except as may be provided by the Board, the 
terms ‘‘nursing facility’’ and ‘‘nursing facility services’’ 
have the meanings given such terms in sections 1919(a) 
and 1905(f), respectively, of the Social Security Act. 
(j) SERVICES IN INTERMEDIATE CARE FACILITIES 
FOR
INDIVIDUALS
WITH
AN
INTELLECTUAL
DIS-
ABILITY.—Except as may be provided by the Board— 
(1) the term ‘‘intermediate care facility for indi-
viduals with an intellectual disability’’ has the mean-
ing given the term ‘‘intermediate care facility for in-
dividuals with mental retardation’’ in section 
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1905(d) of the Social Security Act (as in effect be-
fore the enactment of this Act); and 
(2) the term ‘‘services in intermediate care fa-
cilities for individuals with an intellectual disability’’ 
means services described in section 1905(a)(15) of 
such Act (as so in effect) in an intermediate care fa-
cility for individuals with an intellectual disability to 
an individual determined to require such services in 
accordance with standards specified by the Board 
and comparable to the standards described in section 
1902(a)(31)(A) of such Act (as so in effect). 
(k) OTHER TERMS.—Except as may be provided by 
the Board, the definitions contained in section 1861 of the 
Social Security Act shall apply. 
SEC. 203. SPECIAL RULES FOR HOME AND COMMUNITY- 
BASED LONG-TERM CARE SERVICES. 
(a) QUALIFYING INDIVIDUALS.—For purposes of sec-
tion 201(a)(5)(C), individuals described in this subsection 
are the following individuals: 
(1) ADULTS.—Individuals 18 years of age or 
older determined (in a manner specified by the 
Board)— 
(A) to be unable to perform, without the 
assistance of an individual, at least 2 of the fol-
lowing 5 activities of daily living (or who has a 
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similar level of disability due to cognitive im-
pairment)— 
(i) bathing; 
(ii) eating; 
(iii) dressing; 
(iv) toileting; and 
(v) transferring in and out of a bed or 
in and out of a chair; 
(B) due to cognitive or mental impair-
ments, to require supervision because the indi-
vidual behaves in a manner that poses health or 
safety hazards to himself or herself or others; 
or 
(C) due to cognitive or mental impair-
ments, to require queuing to perform activities 
of daily living. 
(2) CHILDREN.—Individuals under 18 years of 
age determined (in a manner specified by the Board) 
to meet such alternative standard of disability for 
children as the Board develops. Such alternative 
standard shall be comparable to the standard for 
adults and appropriate for children. 
(b) LIMIT ON SERVICES.— 
(1) IN GENERAL.—The aggregate expenditures 
by a State health security program with respect to 
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home and community-based long-term care services 
in a period (specified by the Board) may not exceed 
65 percent (or such alternative ratio as the Board 
establishes under paragraph (2)) of the average of 
the amount of payment that would have been made 
under the program during the period if all the home- 
based long-term care beneficiaries had been resi-
dents of nursing facilities in the same area in which 
the services were provided. 
(2) ALTERNATIVE RATIO.—The Board may es-
tablish for purposes of paragraph (1) an alternative 
ratio (of payments for home and community-based 
long-term care services to payments for nursing fa-
cility services) as the Board determines to be more 
consistent with the goal of providing cost-effective 
long-term care in the most appropriate and least re-
strictive setting. 
SEC. 204. EXCLUSIONS AND LIMITATIONS. 
(a) IN GENERAL.—Subject to section 201(e), benefits 
for service are not available under this Act unless the serv-
ices meet the standards specified in section 201(a). 
(b) SPECIAL DELIVERY REQUIREMENTS FOR MEN-
TAL HEALTH AND SUBSTANCE ABUSE TREATMENT SERV-
ICES PROVIDED TO AT-RISK CHILDREN.— 
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(1) REQUIRING
SERVICES
TO
BE
PROVIDED 
THROUGH ORGANIZED SYSTEMS OF CARE.—A State 
health security program shall ensure that mental 
health services and substance abuse treatment serv-
ices are furnished through an organized system of 
care, as described in paragraph (2), if— 
(A) the services are provided to an indi-
vidual less than 22 years of age; 
(B) the individual has a serious emotional 
disturbance or a substance abuse disorder; and 
(C) the individual is, or is at imminent risk 
of being, subject to the authority of, or in need 
of the services of, at least 1 public agency that 
serves the needs of children, including an agen-
cy involved with child welfare, special education, 
juvenile justice, or criminal justice. 
(2) REQUIREMENTS FOR SYSTEM OF CARE.—In 
this subsection, an ‘‘organized system of care’’ is a 
community-based service delivery network, which 
may consist of public and private providers, that 
meets the following requirements: 
(A) The system has established linkages 
with existing mental health services and sub-
stance abuse treatment service delivery pro-
grams in the plan service area (or is in the 
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quired by individuals under 22 years of age who 
have a serious emotional disturbance or a sub-
stance abuse disorder. 
(F) The system provides for the manage-
ment of the individualized treatment plans de-
scribed in subparagraph (D) and for a flexible 
response to changes in treatment needs over 
time. 
(c) TREATMENT OF EXPERIMENTAL SERVICES.—In 
applying subsection (a), the Board shall make 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 input 
from representatives of health care professionals and pa-
tients and public comment. 
(d) APPLICATION
OF PRACTICE GUIDELINES.—In 
the case of services for which the American Health Secu-
rity Quality Council (established under section 501) has 
recognized a national practice guideline, the services are 
considered to meet the standards specified in section 
201(a) if they have been provided in accordance with such 
guideline or in accordance with such guidelines as are pro-
vided by the State health security program consistent with 
title V. For purposes of this subsection, a service shall 
be considered to have been provided in accordance with 
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a practice guideline if the health care provider providing 
the service exercised appropriate professional discretion to 
deviate from the guideline in a manner authorized or an-
ticipated by the guideline. 
(e) SPECIFIC LIMITATIONS.— 
(1) LIMITATIONS
ON
EYEGLASSES, CONTACT 
LENSES, HEARING
AIDS, AND
DURABLE
MEDICAL 
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: 
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(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 
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 
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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 the requirement that 
each State health security program establish a quality re-
view program that meets the requirements for such a pro-
gram 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 
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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 
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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); 
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(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.— 
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(A) IN
GENERAL.—Participation agree-
ments may be terminated, with appropriate no-
tice— 
(i) by the Board or a State health se-
curity program for failure to meet the re-
quirements 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.— 
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(1) IN GENERAL.—The Board shall establish, 
evaluate, and update national minimum standards to 
ensure the quality of services provided under this 
Act and to monitor efforts by State health security 
programs to ensure the quality of such services. A 
State health security program may also establish ad-
ditional minimum standards which providers shall 
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 (42 U.S.C. 1395 et 
seq.). Such standards also may include, where ap-
propriate, elements relating 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; 
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(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 con-
tainment. 
SEC. 303. QUALIFICATIONS FOR COMPREHENSIVE HEALTH 
SERVICE ORGANIZATIONS. 
(a) IN GENERAL.—For purposes of this Act, a com-
prehensive health service organization (in this section re-
ferred to as a ‘‘CHSO’’) is a public or private organization 
which, in return for a capitated payment amount, under-
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takes to furnish, arrange for the provision of, or provide 
payment with respect to— 
(1) a full range of health services (as identified 
by the Board), including at least hospital services 
and physicians services; and 
(2) out-of-area coverage in the case of urgently 
needed services; 
to an identified population which is living in or near a 
specified service area and which enrolls voluntarily in the 
organization. 
(b) ENROLLMENT.— 
(1) IN GENERAL.—All eligible persons living in 
or near the specified service area of a CHSO are eli-
gible to enroll in the organization; except that the 
number of enrollees may be limited to avoid over-
taxing the resources of the organization. 
(2) MINIMUM ENROLLMENT PERIOD.—Subject 
to paragraph (3), the minimum period of enrollment 
with a CHSO shall be 1 year, unless the enrolled in-
dividual becomes ineligible to enroll with the organi-
zation. 
(3) WITHDRAWAL
FOR
CAUSE.—Each CHSO 
shall permit an enrolled individual to disenroll from 
the organization for cause at any time. 
(c) REQUIREMENTS FOR CHSOS.— 
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(1) ACCESSIBLE
SERVICES.—Each CHSO, to 
the maximum extent feasible, shall make all health 
services readily and promptly accessible to enrollees 
who live in the specified service area. 
(2) CONTINUITY OF CARE.—Each CHSO shall 
furnish services in such manner as to provide con-
tinuity of care and (when services are furnished by 
different providers) shall provide ready referral of 
patients to such services and at such times as may 
be medically appropriate. 
(3) BOARD OF DIRECTORS.—In the case of a 
CHSO that is a private organization— 
(A) 
CONSUMER
REPRESENTATION.—At 
least one-third of the members of the CHSO’s 
board of directors shall be consumer members 
with no direct or indirect, personal or family fi-
nancial relationship to the organization. 
(B) PROVIDER
REPRESENTATION.—The 
CHSO’s board of directors shall include at least 
one member who represents health care pro-
viders. 
(4) PATIENT
GRIEVANCE
PROGRAM.—Each 
CHSO shall have in effect a patient grievance pro-
gram and shall conduct regularly surveys of the sat-
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isfaction of members with services provided by or 
through the organization. 
(5) MEDICAL STANDARDS.—Each CHSO shall 
provide that a committee or committees of health 
care practitioners associated with the organization 
will promulgate medical standards, oversee the pro-
fessional aspects of the delivery of care, perform the 
functions of a pharmacy and drug therapeutics com-
mittee, and monitor and review the quality of all 
health services (including drugs, education, and pre-
ventive services). 
(6) QUALITY AND OTHER REPORTING REQUIRE-
MENTS.— 
(A) IN GENERAL.—The Board shall deter-
mine appropriate measures to assess the quality 
of care furnished by the CHSO, such as meas-
ures of— 
(i) clinical processes and outcomes; 
(ii) patient and, where practicable, 
caregiver experience of care; and 
(iii) utilization (such as rates of hos-
pital admissions for ambulatory care sen-
sitive conditions). 
(B) OTHER DUTIES.—The CHSO shall— 
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(i) define processes to promote evi-
dence-based medicine and patient engage-
ment, report on quality and cost measures, 
and coordinate care, such as through the 
use of telehealth, remote patient moni-
toring, and other such enabling tech-
nologies; and 
(ii) demonstrate to the Board that the 
CHSO meets patient-centeredness criteria 
specified by the Board, such as the use of 
patient and caregiver assessments or the 
use of individualized care plans. 
(C) 
REPORTING
REQUIREMENTS.—A 
CHSO shall submit data in a form and manner 
specified by the Board on measures the Board 
determines necessary in order to evaluate the 
quality of care furnished by the CHSO. Such 
data may include care transitions across health 
care settings, including hospital discharge plan-
ning and post-hospital discharge follow-up by 
CHSO professionals, as the Board determines 
appropriate. 
(D) 
QUALITY
PERFORMANCE
STAND-
ARDS.—The Board shall establish quality per-
formance standards to assess the quality of care 
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furnished by CHSOs and shall seek to improve 
the quality of care furnished by CHSOs over 
time by specifying higher standards, new meas-
ures, or both for purposes of assessing such 
quality of care. 
(7) PREMIUMS.—Premiums or other charges by 
a CHSO for any services not paid for under this Act 
shall be reasonable. 
(8) UTILIZATION AND BONUS INFORMATION.— 
Each CHSO shall— 
(A) comply with the requirements of sec-
tion 1876(i)(8) of the Social Security Act (re-
lating to prohibiting physician incentive plans 
that provide specific inducements to reduce or 
limit medically necessary services); and 
(B) make available to its membership utili-
zation information and data regarding financial 
performance, including bonus or incentive pay-
ment arrangements to practitioners. 
(9) PROVISION OF SERVICES TO ENROLLEES AT 
INSTITUTIONS
OPERATING
UNDER
GLOBAL
BUDG-
ETS.—The organization shall arrange to reimburse 
for hospital services and other facility-based services 
(as identified by the Board) for services provided to 
members of the organization in accordance with the 
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global operating budget of the hospital or facility ap-
proved under section 611. 
(10) BROAD MARKETING.—Each CHSO shall 
provide for the marketing of its services (including 
dissemination of marketing materials) to potential 
enrollees in a manner that is designed to enroll indi-
viduals representative of the different population 
groups and geographic areas included within its 
service area and meets such requirements as the 
Board or a State health security program may speci-
fy. 
(11) 
ADDITIONAL
REQUIREMENTS.—Each 
CHSO shall meet— 
(A) such requirements relating to min-
imum enrollment; 
(B) such requirements relating to financial 
solvency; 
(C) such requirements relating to quality 
and availability of care; and 
(D) such other requirements, 
as the Board or a State health security program 
may specify. 
(d) PROVISION OF EMERGENCY SERVICES TO NON-
ENROLLEES.—A CHSO may furnish emergency services 
to persons who are not enrolled in the organization. Pay-
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ment for such services, if they are covered services to eligi-
ble persons, shall be made to the organization unless the 
organization requests that it be made to the individual 
provider who furnished the services. 
SEC. 304. LIMITATION ON CERTAIN PHYSICIAN REFERRALS. 
(a) APPLICATION TO AMERICAN HEALTH SECURITY 
PROGRAM.—Section 1877 of the Social Security Act, as 
amended by subsections (b) and (c), shall apply under this 
Act in the same manner as it applies under title XVIII 
of the Social Security Act; except that in applying such 
section under this Act any references in such section to 
the Secretary or title XVIII of the Social Security Act are 
deemed references to the Board and the American Health 
Security Program under this Act, respectively. 
(b) EXPANSION OF PROHIBITION TO CERTAIN ADDI-
TIONAL DESIGNATED SERVICES.—Section 1877(h)(6) of 
the Social Security Act (42 U.S.C. 1395nn(h)(6)) is 
amended by adding at the end the following: 
‘‘(M) Ambulance services. 
‘‘(N) Home infusion therapy services.’’. 
(c) CONFORMING AMENDMENTS.—Section 1877 of 
such Act is further amended— 
(1) in subsection (a)(1)(A), by striking ‘‘for 
which payment otherwise may be made under this 
title’’ and inserting ‘‘for which a charge is imposed’’; 
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(2) in subsection (a)(1)(B), by striking ‘‘under 
this title’’; 
(3) by amending paragraph (1) of subsection 
(g) to read as follows: 
‘‘(1) DENIAL OF PAYMENT.—No payment may 
be made under a State health security program for 
a designated health service for which a claim is pre-
sented in violation of subsection (a)(1)(B). No indi-
vidual, third-party payor, or other entity is liable for 
payment for designated health services for which a 
claim is presented in violation of such subsection.’’; 
and 
(4) in subsection (g)(3), by striking ‘‘for which 
payment may not be made under paragraph (1)’’ 
and inserting ‘‘for which such a claim may not be 
presented under subsection (a)(1)’’. 
TITLE IV—ADMINISTRATION 
Subtitle A—General Administrative 
Provisions 
SEC. 
401. 
AMERICAN 
HEALTH 
SECURITY 
STANDARDS 
BOARD. 
(a) ESTABLISHMENT.—There is hereby established 
an American Health Security Standards Board. 
(b) APPOINTMENT AND TERMS OF MEMBERS.— 
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(1) IN
GENERAL.—The Board shall be com-
posed of— 
(A) the Secretary of Health and Human 
Services; and 
(B) 6 other individuals (described in para-
graph (2)) appointed by the President with the 
advice and consent of the Senate. 
The President shall first nominate individuals under 
subparagraph (B) on a timely basis so as to provide 
for the operation of the Board by not later than 
January 1, 2014. 
(2) SELECTION
OF
APPOINTED
MEMBERS.— 
With respect to the individuals appointed under 
paragraph (1)(B): 
(A) The members shall be chosen on the 
basis of backgrounds in health policy, health ec-
onomics, the healing professions, and the ad-
ministration of health care institutions. 
(B) The members shall provide a balanced 
point of view with respect to the various health 
care interests and at least 2 of them shall rep-
resent the interests of individual consumers. 
(C) At least 1 member shall have a nurs-
ing background. 
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(D) Not more than 3 members shall be 
from the same political party. 
(E) To the greatest extent feasible, the 
members shall represent the various geographic 
regions of the United States and shall reflect 
the racial, ethnic, and gender composition of 
the population of the United States. 
(3) TERMS OF APPOINTED MEMBERS.—Individ-
uals appointed under paragraph (1)(B) shall serve 
for a term of 6 years, except that the terms of 5 of 
the individuals initially appointed shall be, as des-
ignated by the President at the time of their ap-
pointment, for 1, 2, 3, 4, and 5 years. During a 
term of membership on the Board, no member shall 
engage in any other business, vocation or employ-
ment. 
(c) VACANCIES.— 
(1) IN GENERAL.—The President shall fill any 
vacancy in the membership of the Board in the same 
manner as the original appointment. The vacancy 
shall not affect the power of the remaining members 
to execute the duties of the Board. 
(2) VACANCY
APPOINTMENTS.—Any member 
appointed to fill a vacancy shall serve for the re-
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mainder of the term for which the predecessor of the 
member was appointed. 
(3) REAPPOINTMENT.—The President may re-
appoint an appointed member of the Board for a 
second term in the same manner as the original ap-
pointment. A member who has served for 2 consecu-
tive 6-year terms shall not be eligible for reappoint-
ment until 2 years after the member has ceased to 
serve. 
(4) REMOVAL FOR CAUSE.—Upon confirmation, 
members of the Board may not be removed except 
by the President for cause. 
(d) CHAIR.—The President shall designate 1 of the 
members of the Board, other than the Secretary, to serve 
at the will of the President as Chair of the Board. 
(e) COMPENSATION.—Members of the Board (other 
than the Secretary) shall be entitled to compensation at 
a level equivalent to level II of the Executive Schedule, 
in accordance with section 5313 of title 5, United States 
Code. 
(f) GENERAL DUTIES OF THE BOARD.— 
(1) IN
GENERAL.—The Board shall develop 
policies, procedures, guidelines, and requirements to 
carry out this Act, including those related to— 
(A) eligibility; 
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(B) enrollment; 
(C) benefits; 
(D) provider participation standards and 
qualifications, as defined in title III; 
(E) national and State funding levels; 
(F) methods for determining amounts of 
payments to providers of covered services, con-
sistent with subtitle B of title VI; 
(G) the determination of medical necessity 
and appropriateness with respect to coverage of 
certain services; 
(H) assisting State health security pro-
grams with planning for capital expenditures 
and service delivery; 
(I) planning for health professional edu-
cation funding (as specified in title VI); 
(J) allocating funds provided under title 
VII; and 
(K) encouraging States to develop regional 
planning mechanisms (described in section 
404(a)(3)). 
(2) REGULATIONS.—Regulations authorized by 
this Act shall be issued by the Board in accordance 
with the provisions of section 553 of title 5, United 
States Code. 
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(g) UNIFORM REPORTING STANDARDS; ANNUAL RE-
PORT; STUDIES.— 
(1) UNIFORM REPORTING STANDARDS.— 
(A) IN GENERAL.—The Board shall estab-
lish uniform reporting requirements and stand-
ards to ensure an adequate national data base 
regarding health services practitioners, services 
and finances of State health security programs, 
approved plans, providers, and the costs of fa-
cilities and practitioners providing services. 
Such standards shall include, to the maximum 
extent feasible, health outcome measures. 
(B) REPORTS.—The Board shall analyze 
regularly information reported to it, and to 
State health security programs pursuant to 
such requirements and standards. 
(2) ANNUAL REPORT.—Beginning January 1, 
of the second year beginning after the date of the 
enactment of this Act, the Board shall annually re-
port to Congress on the following: 
(A) The status of implementation of the 
Act. 
(B) Enrollment under this Act. 
(C) Benefits under this Act. 
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(D) Expenditures and financing under this 
Act. 
(E) 
Cost-containment 
measures 
and 
achievements under this Act. 
(F) Quality assurance. 
(G) Health care utilization patterns, in-
cluding any changes attributable to the pro-
gram. 
(H) Long-range plans and goals for the de-
livery of health services. 
(I) Differences in the health status of the 
populations of the different States, including in-
come and racial characteristics. 
(J) Necessary changes in the education of 
health personnel. 
(K) Plans for improving service to medi-
cally underserved populations. 
(L) Transition problems as a result of im-
plementation of this Act. 
(M) Opportunities for improvements under 
this Act. 
(3) STATISTICAL ANALYSES AND OTHER STUD-
IES.—The Board may, either directly or by con-
tract— 
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(A) make statistical and other studies, on 
a nationwide, regional, State, or local basis, of 
any aspect of the operation of this Act, includ-
ing studies of the effect of the Act upon the 
health of the people of the United States and 
the effect of comprehensive health services upon 
the health of persons receiving such services; 
(B) develop and test methods of providing 
through payment for services or otherwise, ad-
ditional incentives for adherence by providers to 
standards of adequacy, access, and quality; 
methods of consumer and peer review and peer 
control of the utilization of drugs, of laboratory 
services, and of other services; and methods of 
consumer and peer review of the quality of serv-
ices; 
(C) develop and test, for use by the Board, 
records and information retrieval systems and 
budget systems for health services administra-
tion, and develop and test model systems for 
use by providers of services; 
(D) develop and test, for use by providers 
of services, records and information retrieval 
systems useful in the furnishing of preventive 
or diagnostic services; 
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(E) develop, in collaboration with the phar-
maceutical profession, and test, improved ad-
ministrative practices or improved methods for 
the reimbursement of independent pharmacies 
for the cost of furnishing drugs as a covered 
service; and 
(F) make such other studies as it may con-
sider necessary or promising for the evaluation, 
or for the improvement, of the operation of this 
Act. 
(4) REPORT
ON
USE
OF
EXISTING
FEDERAL 
HEALTH CARE FACILITIES.—Not later than 1 year 
after the date of the enactment of this Act, the 
Board shall recommend to Congress one or more 
proposals for the treatment of health care facilities 
of the Federal Government. 
(h) EXECUTIVE DIRECTOR.— 
(1) APPOINTMENT.—There is hereby estab-
lished the position of Executive Director of the 
Board. The Director shall be appointed by the 
Board and shall serve as secretary to the Board and 
perform such duties in the administration of this 
title as the Board may assign. 
(2) DELEGATION.—The Board is authorized to 
delegate to the Director or to any other officer or 
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employee of the Board or, with the approval of the 
Secretary of Health and Human Services (and sub-
ject to reimbursement of identifiable costs), to any 
other officer or employee of the Department of 
Health and Human Services, any of its functions or 
duties under this Act other than— 
(A) the issuance of regulations; or 
(B) the determination of the availability of 
funds and their allocation to implement this 
Act. 
(3) COMPENSATION.—The Executive Director 
of the Board shall be entitled to compensation at a 
level equivalent to level III of the Executive Sched-
ule, in accordance with section 5314 of title 5, 
United States Code. 
(i) INSPECTOR GENERAL.—The Inspector General 
Act of 1978 (5 U.S.C. App.) is amended— 
(1) in section 12(1), by inserting after ‘‘Cor-
poration;’’ the first place it appears the following: 
‘‘the Chair of the American Health Security Stand-
ards Board;’’; 
(2) in section 12(2), by inserting after ‘‘Resolu-
tion Trust Corporation,’’ the following: ‘‘the Amer-
ican Health Security Standards Board,’’; and 
(3) by inserting before section 9 the following: 
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‘‘SPECIAL PROVISIONS CONCERNING AMERICAN HEALTH 
SECURITY STANDARDS BOARD 
‘‘SEC. 8M. The Inspector General of the American 
Health Security Standards Board, in addition to the other 
authorities vested by this Act, shall have the same author-
ity, with respect to the Board and the American Health 
Security Program under this Act, as the Inspector General 
for the Department of Health and Human Services has 
with respect to the Secretary of Health and Human Serv-
ices and the medicare and medicaid programs, respec-
tively.’’. 
(j) STAFF.—The Board shall employ such staff as the 
Board may deem necessary. 
(k) ACCESS
TO INFORMATION.—The Secretary of 
Health and Human Services shall make available to the 
Board all information available from sources within the 
Department or from other sources, pertaining to the du-
ties of the Board. 
SEC. 402. AMERICAN HEALTH SECURITY ADVISORY COUN-
CIL. 
(a) IN GENERAL.—The Board shall provide for an 
American Health Security Advisory Council (in this sec-
tion referred to as the ‘‘Council’’) to advise the Board on 
its activities. 
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(b) MEMBERSHIP.—The Council shall be composed 
of— 
(1) the Chair of the Board, who shall serve as 
Chair of the Council; and 
(2) 20 members, not otherwise in the employ of 
the United States, appointed by the Board without 
regard to the provisions of title 5, United States 
Code, governing appointments in the competitive 
service. 
The appointed members shall include, in accordance with 
subsection (e), individuals who are representative of State 
health security programs, public health professionals, pro-
viders of health services, and of individuals (who shall con-
stitute a majority of the Council) who are representative 
of consumers of such services, including a balanced rep-
resentation of employers, unions, consumer organizations, 
and population groups with special health care needs. To 
the greatest extent feasible, the membership of the Council 
shall represent the various geographic regions of the 
United States and shall reflect the racial, ethnic, and gen-
der composition of the population of the United States. 
(c) TERMS OF MEMBERS.—Each appointed member 
shall hold office for a term of 4 years, except that— 
(1) any member appointed to fill a vacancy oc-
curring during the term for which the member’s 
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predecessor was appointed shall be appointed for the 
remainder of that term; and 
(2) the terms of the members first taking office 
shall expire, as designated by the Board at the time 
of appointment, at the end of the first year with re-
spect to 5 members, at the end of the second year 
with respect to 5 members, at the end of the third 
year with respect to 5 members, and at the end of 
the fourth year with respect to 5 members after the 
date of enactment of this Act. 
(d) VACANCIES.— 
(1) IN GENERAL.—The Board shall fill any va-
cancy in the membership of the Council in the same 
manner as the original appointment. The vacancy 
shall not affect the power of the remaining members 
to execute the duties of the Council. 
(2) VACANCY
APPOINTMENTS.—Any member 
appointed to fill a vacancy shall serve for the re-
mainder of the term for which the predecessor of the 
member was appointed. 
(3) REAPPOINTMENT.—The Board may re-
appoint an appointed member of the Council for a 
second term in the same manner as the original ap-
pointment. 
(e) QUALIFICATIONS.— 
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(1) PUBLIC
HEALTH
REPRESENTATIVES.— 
Members of the Council who are representative of 
State health security programs and public health 
professionals shall be individuals who have extensive 
experience in the financing and delivery of care 
under public health programs. 
(2) PROVIDERS.—Members of the Council who 
are representative of providers of health care shall 
be individuals who are outstanding in fields related 
to medical, hospital, or other health activities, or 
who are representative of organizations or associa-
tions of professional health practitioners. 
(3) CONSUMERS.—Members who are represent-
ative of consumers of such care shall be individuals, 
not engaged in and having no financial interest in 
the furnishing of health services, who are familiar 
with the needs of various segments of the population 
for personal health services and are experienced in 
dealing with problems associated with the consump-
tion of such services. 
(f) DUTIES.— 
(1) IN GENERAL.—It shall be the duty of the 
Council— 
(A) to advise the Board on matters of gen-
eral policy in the administration of this Act, in 
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the formulation of regulations, and in the per-
formance of the Board’s duties under section 
401; and 
(B) to study the operation of this Act and 
the utilization of health services under it, with 
a view to recommending any changes in the ad-
ministration of the Act or in its provisions 
which may appear desirable. 
(2) REPORT.—The Council shall make an an-
nual report to the Board on the performance of its 
functions, including any recommendations it may 
have with respect thereto, and the Board shall 
promptly transmit the report to the Congress, to-
gether with a report by the Board on any rec-
ommendations of the Council that have not been fol-
lowed. 
(g) STAFF.—The Council, its members, and any com-
mittees of the Council shall be provided with such secre-
tarial, clerical, or other assistance as may be authorized 
by the Board for carrying out their respective functions. 
(h) MEETINGS.—The Council shall meet as fre-
quently as the Board deems necessary, but not less than 
4 times each year. Upon request by 7 or more members 
it shall be the duty of the Chair to call a meeting of the 
Council. 
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(i) COMPENSATION.—Members of the Council shall 
be reimbursed by the Board for travel and per diem in 
lieu of subsistence expenses during the performance of du-
ties of the Board in accordance with subchapter I of chap-
ter 57 of title 5, United States Code. 
(j) FACA NOT APPLICABLE.—The provisions of the 
Federal Advisory Committee Act shall not apply to the 
Council. 
SEC. 403. CONSULTATION WITH PRIVATE ENTITIES. 
The Secretary and the Board shall consult with pri-
vate entities, such as professional societies, national asso-
ciations, nationally recognized associations of experts, 
medical schools and academic health centers, consumer 
groups, and labor and business organizations in the for-
mulation of guidelines, regulations, policy initiatives, and 
information gathering to ensure the broadest and most in-
formed input in the administration of this Act. Nothing 
in this Act shall prevent the Secretary from adopting 
guidelines developed by such a private entity if, in the Sec-
retary’s and Board’s judgment, such guidelines are gen-
erally accepted as reasonable and prudent and consistent 
with this Act. 
SEC. 404. STATE HEALTH SECURITY PROGRAMS. 
(a) SUBMISSION OF PLANS.— 
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(1) IN GENERAL.—Each State shall submit to 
the Board a plan for a State health security pro-
gram for providing for health care services to the 
residents of the State in accordance with this Act. 
(2) REGIONAL PROGRAMS.—A State may join 
with 1 or more neighboring States to submit to the 
Board a plan for a regional health security program 
instead of separate State health security programs. 
(3) REGIONAL
PLANNING
MECHANISMS.—The 
Board shall provide incentives for States to develop 
regional planning mechanisms to promote the ration-
al distribution of, adequate access to, and efficient 
use of, tertiary care facilities, equipment, and serv-
ices. 
(4) STATES THAT FAIL TO SUBMIT A PLAN.— 
In the case of a State that fails to submit a plan as 
required under this subsection, the American Health 
Security Standards Board Authority shall develop a 
plan for a State health security program in such 
State. 
(b) REVIEW AND APPROVAL OF PLANS.— 
(1) IN
GENERAL.—The Board shall review 
plans submitted under subsection (a) and determine 
whether such plans meet the requirements for ap-
proval. The Board shall not approve such a plan un-
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less it finds that the plan (or State law) provides, 
consistent with the provisions of this Act, for the fol-
lowing: 
(A) Payment for required health services 
for eligible individuals in the State in accord-
ance with this Act. 
(B) Adequate administration, including the 
designation of a single State agency responsible 
for the administration (or supervision of the ad-
ministration) of the program. 
(C) The establishment of a State health se-
curity budget. 
(D) Establishment of payment methodolo-
gies (consistent with subtitle B of title VII). 
(E) Assurances that individuals have the 
freedom to choose practitioners and other 
health care providers for services covered under 
this Act. 
(F) A procedure for carrying out long-term 
regional management and planning functions 
with respect to the delivery and distribution of 
health care services that— 
(i) ensures participation of consumers 
of health services and providers of health 
services; and 
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(ii) gives priority to the most acute 
shortages and maldistributions of health 
personnel and facilities and the most seri-
ous deficiencies in the delivery of covered 
services and to the means for the speedy 
alleviation of these shortcomings. 
(G) The licensure and regulation of all 
health providers and facilities to ensure compli-
ance with Federal and State laws and to pro-
mote quality of care. 
(H) Establishment of a quality review sys-
tem in accordance with section 503. 
(I) Establishment of an independent om-
budsman for consumers to register complaints 
about the organization and administration of 
the State health security program and to help 
resolve complaints and disputes between con-
sumers and providers. 
(J) Publication of an annual report on the 
operation of the State health security program, 
which report shall include information on cost, 
progress towards achieving full enrollment, pub-
lic access to health services, quality review, 
health outcomes, health professional training, 
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