I
106TH CONGRESS
1ST SESSION
H. R. 304
To improve health status in medically disadvantaged communities through
comprehensive community-based managed care programs.
IN THE HOUSE OF REPRESENTATIVES
JANUARY 6, 1999
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.—
In this Act, the term ‘‘comprehensive health access dis-
trict’’ means a community in which unemployment and the
percentage of residents with incomes below the poverty
line are greater than the national average, and in which
a majority of the following conditions occur at rates great-
er than the national average:
(1) Infant mortality and low birth-weight ba-
bies.
(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.—In this Act, the terms ‘‘comprehensive
community-based health access plan’’ and ‘‘health access
plan’’ mean an entity that provides health care services
on a prepaid, capitated basis or any other risk basis and
that the Secretary has certified meets all the requirements
contained in section 5.
(c) SECRETARY.—In this Act, 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—
(1) by striking the period at the end of para-
graph (65) and inserting ‘‘; and’’, and
(2) by inserting after paragraph (65) the fol-
lowing new paragraph:
‘‘(66) provide that each comprehensive health
access district located within the State is served by
a comprehensive community-based health access dis-
trict plan (as such terms are defined in section 2 of
the Comprehensive Health Access District Act).’’.
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 a least one comprehensive commu-
nity-based health access plan is available to persons living
in such district.
SEC 5. COMPREHENSIVE COMMUNITY-BASED HEALTH AC-
CESS PLANS.
(a) ORGANIZATIONAL REQUIREMENTS.—
(1) IN GENERAL.—A health access plan must—
(A) be a public or private organization, or-
ganized under the laws of any State;
(B) locate its primary place of business in
the comprehensive health access district it
serves;
(C) give preference in hiring to otherwise
qualified individuals who live within the com-
prehensive health access district; and
(D) have made adequate provision against
the risk of insolvency, which provision is satis-
factory to the State and which assures that in-
dividuals enrolled in a plan are in no case liable
for debt of the plan in case of the plan’s insol-
vency.
(2) METHODS OF PROVIDING AGAINST RISK OF
INSOLVENCY.—The provisions against the risk of in-
solvency under paragraph (1)(D) 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;
(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.
(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 (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-
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 (A).
(3) COORDINATION OF SERVICES.—In ad-
dition to providing the services described in
paragraphs (1) and (2), a health access plan
must promote its enrollees’ access to social,
educational or economic services (such as child
day care, nutritional services, vocational train-
ing, and adult literacy programs).
(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 (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.
(2) TRADITIONAL COMMUNITY PROVIDERS.—A
health access plan shall, to the extent feasible, draw
upon health care providers currently serving the
community, including health centers (as defined in
section 330(a) of the Public Health Service Act) and
hospitals operated by units of local government, 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
schoolbased 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-
English speaking, the health access plan shall insure
that a corresponding proportion of its health care
providers have 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.
(3) MEMBER SURVEYS.—A health access plan
shall survey its enrollees on a regular basis to deter-
mine their satisfaction with the quality of services
received.
(4) INDEPENDENT QUALITY AUDITS.—A health
access plan shall be evaluated on a regular basis by
an independent health care accrediting organization.
(f) EFFECTIVE GRIEVANCE PROCEDURES.—A health
access plan must provide for effective procedures for hear-
ing and resolving grievances between the plan and individ-
uals enrolled in the plan.
(g) CONFIDENTIALITY OF ENROLLEE RECORDS.—
(1) A health access plan shall ensure that infor-
mation concerning its enrollees is protected from un-
authorized disclosure by the plan, its employees or
its providers.
(2) To promote the coordination of benefits to
health plan enrollees, a health access plan may dis-
close information about its enrollees to the extent
necessary to facilitate the enrollee’s receipt of serv-
ices and assistance from other entities.
SEC. 6. DESIGNATION OF COMPREHENSIVE HEALTH AC-
CESS DISTRICTS AND CERTIFICATION OF
COMPREHENSIVE 
COMMUNITY-BASED
HEALTH ACCESS PLANS.
The Secretary shall designate a community that
meets the criteria set forth in section 2(a) as a comprehen-
sive health access district and shall certify an entity that
meets the requirements set forth in section 5 as a com-
prehensive community-based health access plan. Each
such certification and designation shall be reviewed every
five years. The Secretary may delegate all or part of the
certification function for health access plans to the State
in which the health access plan operates.
SEC. 7. NATIONAL HEALTH OUTCOMES RESEARCH AND
EVALUATION.
(a) PROVISION OF INFORMATION.—In order to evalu-
ate the performance of health access plans in improving
the health status of persons living in comprehensive health
access districts, each health access plan shall provide the
Secretary, at a time and in a manner specified by the Sec-
retary, at least the following information:
(1) Information on the characteristics of enroll-
ees that may affect their need for or use of health
services.
(2) Information on the types of treatments and
services and outcomes of treatments with respect to
the clinical health, functional status and well-being
of enrollees.
(3) Information on enrollee satisfaction.
(4) Information on health care expenditures,
volume and prices of procedures, and use of special-
ized services.
(b) ANALYSIS
OF INFORMATION.—The Secretary
shall analyze the information reported by health access
plans in order to report to Congress, the plans and the
public, not less often than annually, on the following:
(1) The health status of persons living in com-
prehensive health access district (particularly those
indicators listed in section 2(a)).
(2) The level and rate of expenditures by health
access plans on medical services and other programs
to improve health status.
(3) The effectiveness of health access plans in
improving health outcomes (particularly outcomes
related to health indicators listed in section 2(a)).
(c) RESEARCH.—
(1) The Secretary shall examine the relation-
ship between socioeconomic factors and health status
and, based on his findings, suggest interventions ap-
propriate to comprehensive health access districts.