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in the budgets established under this title, and other
relevant factors.
SEC. 616. PAYMENTS FOR APPROVED DEVICES AND EQUIP-
MENT.
(a) ESTABLISHMENT OF LIST.—The Board shall es-
tablish a list of approved durable medical equipment and
therapeutic devices and equipment (including eyeglasses,
hearing aids, and prosthetic appliances), that the Board
determines are necessary for the maintenance or restora-
tion of health or of employability or self-management and
eligible for coverage under this Act.
(b) CONSIDERATIONS AND CONDITIONS.—In estab-
lishing the list under subsection (a), the Board shall take
into consideration the efficacy, safety, and cost of each
item contained on such list, and shall attach to any item
such conditions as the Board determines appropriate with
respect to the circumstances under which, or the frequency
with which, the item may be prescribed.
(c) PRICES.—For each such listed item covered under
this Act, the Board shall from time to time determine a
product price or prices which shall constitute the maxi-
mum to be recognized under this Act as the cost of the
item to a provider thereof. The Board may conduct nego-
tiations, on behalf of State health security programs, with
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equipment and device manufacturers and distributors in
determining the applicable product price or prices.
(d) EXCLUSIONS.—The Board may exclude from cov-
erage under this Act ineffective, unsafe, or overpriced
products where better alternatives are determined to be
available.
SEC. 617. PAYMENTS FOR OTHER ITEMS AND SERVICES.
In the case of payment for other covered health serv-
ices, the amount of payment under a State health security
program shall be established by the program—
(1) in accordance with payment methodologies
which are specified by the Board, after consultation
with the American Health Security Advisory Coun-
cil, or methodologies established by the State under
section 620, and
(2) consistent with the State health security
budget.
SEC. 618. PAYMENT INCENTIVES FOR MEDICALLY UNDER-
SERVED AREAS.
(a) MODEL PAYMENT METHODOLOGIES.—In addi-
tion to the payment amounts otherwise provided in this
title, the Board shall establish model payment methodolo-
gies and other incentives that promote the provision of
covered health care services in medically underserved
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areas, particularly in rural and inner-city underserved
areas.
(b) CONSTRUCTION.—Nothing in this title shall be
construed as limiting the authority of State health security
programs to increase payment amounts or otherwise pro-
vide additional incentives, consistent with the State health
security budget, to encourage the provision of medically
necessary and appropriate services in underserved areas.
SEC. 619. AUTHORITY FOR ALTERNATIVE PAYMENT METH-
ODOLOGIES.
A State health security program, as part of its plan
under section 404(a), may use a payment methodology
other than a methodology required under this subtitle so
long as—
(1) such payment methodology does not affect
the entitlement of individuals to coverage, the
weighting of fee schedules to encourage an increase
in the number of primary care providers, the ability
of individuals to choose among qualified providers,
the benefits covered under the program, or the com-
pliance of the program with the State health security
budget under subtitle A, and
(2) the program submits periodic reports to the
Board showing the operation and effectiveness of the
alternative methodology, in order for the Board to
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evaluate the appropriateness of applying the alter-
native methodology to other States.
Subtitle C—Mandatory Assignment
and Administrative Provisions
SEC. 631. MANDATORY ASSIGNMENT.
(a) NO BALANCE BILLING.—Payments for benefits
under this Act shall constitute payment in full for such
benefits and the entity furnishing an item or service for
which payment is made under this Act shall accept such
payment as payment in full for the item or service and
may not accept any payment or impose any charge for
any such item or service other than accepting payment
from the State health security program in accordance with
this Act.
(b) ENFORCEMENT.—If an entity knowingly and will-
fully bills for an item or service or accepts payment in
violation of subsection (a), the Board may apply sanctions
against the entity in the same manner as sanctions could
have been imposed under section 1842(j)(2) of the Social
Security Act for a violation of section 1842(j)(1) of such
Act. Such sanctions are in addition to any sanctions that
a State may impose under its State health security
program.
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SEC. 632. PROCEDURES FOR REIMBURSEMENT; APPEALS.
(a) PROCEDURES FOR REIMBURSEMENT.—In accord-
ance with standards issued by the Board, a State health
security program shall establish a timely and administra-
tively simple procedure to assure payment within 60 days
of the date of submission of clean claims by providers
under this Act.
(b) APPEALS PROCESS.—Each State health security
program shall establish an appeals process to handle all
grievances pertaining to payment to providers under this
title.
TITLE VII—PROMOTION OF PRI-
MARY HEALTH CARE; DEVEL-
OPMENT OF HEALTH SERV-
ICE CAPACITY; PROGRAMS TO
ASSIST THE MEDICALLY UN-
DERSERVED
Subtitle A—Promotion and Expan-
sion of Primary Care Profes-
sional Training
SEC. 701. ROLE OF BOARD; ESTABLISHMENT OF PRIMARY
CARE PROFESSIONAL OUTPUT GOALS.
(a) IN GENERAL.—The Board is responsible for—
(1) coordinating health professional education
policies and goals, in consultation with the Secretary
of Health and Human Services (in this title referred