I
105TH CONGRESS
1ST SESSION
H. R. 356
To improve health status in medically disadvantaged communities through
comprehensive community-based managed care programs.
IN THE HOUSE OF REPRESENTATIVES
JANUARY 7, 1997
Mr. TOWNS introduced the following bill; which was referred to the Committee
on Commerce
A BILL
To improve health status in medically disadvantaged commu-
nities through comprehensive community-based managed
care programs.
Be it enacted by the Senate and House of Representa-
tives of the United States of America in Congress assembled,
SECTION 1. SHORT TITLE.
This Act may be cited as the ‘‘Comprehensive Health
Access District Act’’.
SEC. 2. DEFINITIONS.
(a) COMPREHENSIVE HEALTH ACCESS DISTRICT.—
The term ‘‘comprehensive health access district’’ means
a community in which unemployment and the percentage
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of residents with incomes below the poverty line are great-
er than the national average, and in which a majority of
the following conditions occur at rates greater 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.—The term ‘‘comprehensive community-
based health access plan’’ (hereafter in this Act referred
to as a ‘‘health access plan’’) means an entity that pro-
vides health care services on a prepaid, capitated basis or
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any other risk basis and that the Secretary has certified
meets the requirements contained in section 5 of this Act.
(c) SECRETARY.—The term ‘‘Secretary’’ means the
Secretary of Health and Human Services.
SEC. 3. MEDICAID STATE PLAN REQUIREMENTS FOR COM-
PREHENSIVE HEALTH ACCESS DISTRICTS.
Section 1902(a) of the Social Security Act (42 U.S.C.
1396a(a)) is amended by adding after paragraph (62) the
following new paragraph:
‘‘(63) provide that each comprehensive health
access district located within the State is served by
a comprehensive community-based health access dis-
trict plan.’’
SEC. 4. HEALTH ALLIANCE OBLIGATIONS WITH RESPECT
TO COMPREHENSIVE HEALTH ACCESS DIS-
TRICTS.
Each Health Alliance or other health insurance pur-
chasing cooperative created as a result of the enactment
of comprehensive health care reform legislation that re-
ceives premiums on behalf of persons formerly insured
under title XIX of the Social Security Act and whose
boundaries encompass a comprehensive health access dis-
trict shall insure that a least one comprehensive commu-
nity-based health access plan is available to persons living
in such district.
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SEC 5. COMPREHENSIVE COMMUNITY-BASED HEALTH AC-
CESS PLANS.
To be certified as a comprehensive community-based
health access plan, an entity must meet all of the following
requirements:
(a) 
ORGANIZATIONAL
REQUIREMENTS.—A
health access plan must—
(1) be a public or private organization, or-
ganized under the laws of any State;
(2) locate its primary place of business in
the comprehensive health access district it
serves;
(3) give preference in hiring to otherwise
qualified individuals who live within the com-
prehensive health access district; and
(4) 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. Provisions against the risk of insolvency
may include—
(A) escrow or similar arrangements to
ensure that funds for the payment of pro-
viders are available only for such payments
and cannot be otherwise used by the plan;
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(B) reinsurance purchased by the plan
of an amount which is reasonably adequate
to insure against unexpected costs;
(C) a demonstration of financial via-
bility, as evidenced by the plan’s obtaining
a significant amount of reinsurance, line of
credit, or performance bond; or
(D) such other mechanisms and re-
quirements as the State finds appropriate.
(b) SERVICE REQUIREMENTS.—
(1) BASIC
BENEFITS.—A health access
plan shall provide, either directly or through ar-
rangements with providers, the following basic
benefits:
(A) Hospital services, including inpa-
tient, outpatient and 24-hour emergency
services.
(B) Emergency and ambulatory medi-
cal and surgical services.
(C) Physicians’ services.
(D) Medical care other than physi-
cians’ services recognized under State law
and furnished by licensed practitioners
within the scope of their practice as de-
fined by State law.
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(E) Dental services.
(F) Vision services.
(G) Preventive health care services
(including children’s eye and ear examina-
tions to determine the need for vision and
hearing correction, well child services, im-
munizations 
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
SERV-
ICES.—In addition to providing the services de-
scribed in paragraph (b)(1), a health access
plan shall—
(A) identify the most frequent causes
of morbidity and mortality in the com-
prehensive health access district (such as
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acquired immune deficiency syndrome, tu-
berculosis, mental illness, substance abuse
and addiction, childhood developmental dis-
orders (particularly those caused by chil-
dren’s exposure to violence), asthma, teen
pregnancy, unhealthy behaviors (such as
smoking and high-fat diets), and lead poi-
soning); and
(B) design and implement programs
of prevention, early intervention, or treat-
ment intended to ameliorate or eliminate
the factors identified in subparagraph
(b)(2)(A).
(3) COORDINATION OF SERVICES.—In ad-
dition to providing the services described in
paragraphs (b)(1) and (b)(2), a health access
plan must promote its enrollees’ access to so-
cial, educational or economic services (such as
child day care, nutritional services, vocational
training, 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—
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(A) the plan’s enrollees have access to
the services described in subsection 4(b);
and
(B) the provider network takes into
account and is representative of the cul-
tural identity and diversity of the commu-
nity being served.
(2) TRADITIONAL
COMMUNITY
PROVID-
ERS.—A health access plan shall, to the extent
feasible, draw upon health care providers cur-
rently serving the community, including com-
munity 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—
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(1) is linked with the primary care physi-
cian within the health access plan’s provider
network of the individual’s choice and has ac-
cess 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 pur-
poses as well as to voice grievances; and
(3) has access to interpreter services as
necessary (where a significant proportion of the
population in the community health access dis-
trict is non-English speaking, the health access
plan shall insure that a corresponding propor-
tion of its health care providers have multi-
lingual capability).
(e) 
QUALITY
ASSURANCE
STANDARDS.—A
health access 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
patients that participating providers must
satisfy;
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(B) a program of ongoing medical
record reviews and other provider audits to
insure compliance with the plan’s treat-
ment standards; and
(C) a system of sanctions to insure
that providers who do not comply with the
plan’s treatment standards will be penal-
ized and, if found to be repeatedly out of
compliance, terminated 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 determine their satisfaction with the quality
of services received.
(4) INDEPENDENT
QUALITY
AUDITS.—A
health access plan shall be evaluated on a regu-
lar basis by an independent health care accred-
iting organization.
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(f) EFFECTIVE
GRIEVANCE
PROCEDURES.—A
health access plan must provide for effective proce-
dures for hearing and resolving grievances between
the plan and individuals enrolled in the plan.
(g) 
CONFIDENTIALITY
OF
ENROLLEE
RECORDS.—
(1) A health access plan shall ensure that
information concerning its enrollees is protected
from unauthorized 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 disclose information about its enrollees to
the extent necessary to facilitate the enrollee’s
receipt of services and assistance from other en-
tities.
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) of this Act a
comprehensive health access district and shall certify an
entity that meets the criteria set forth in section 5 of this
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Act as a comprehensive health access plan. Each such cer-
tification and designation shall be reviewed every five
years. The Secretary may delegate all or part of the cer-
tification function 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.
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(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, no less 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) of this Act).
(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) of
this Act).
(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.
(2) The Secretary may contract with non-gov-
ernmental entities to perform this research. Persons
undertaking this work shall have access to the infor-
mation provided by the health access plans to the
Secretary.
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SEC. 8. CHANGES TO THE MEDICAID STATUTE TO FACILI-
TATE STATE CONTRACTS WITH COMPREHEN-
SIVE COMMUNITY-BASED HEALTH ACCESS
PLANS.
(a) Section 1903(m)(2) of the Social Security Act (42
U.S.C. 1396b(m)(2)) is amended by adding after subpara-
graph (H) the following new subparagraph:
‘‘(I) Clause (ii) of subparagraph (A) does not
apply to any entity certified as a comprehensive
health access plan pursuant to section 6 of the Com-
prehensive Health Access District Act.’’
(b) This amendment shall apply to payments for med-
ical assistance for calendar quarters beginning on or after
July 1, 1996.
SEC. 9. REGULATIONS AND EFFECTIVE DATE.
(a) The Secretary shall promulgate regulations nec-
essary to implement this Act.
(b) This Act shall take effect on July 1, 1998, with-
out regard to whether or not final regulations to carry out
this Act have been promulgated by such date.
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