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 
process of developing or operating a system 
with appropriate public agencies in the area to 
coordinate the delivery of such services to indi-
viduals in the area). 
(B) The system provides for the participa-
tion and coordination of multiple agencies and 
providers that serve the needs of children in the 
area, including agencies and providers involved 
with child welfare, education, juvenile justice, 
criminal justice, health care, mental health, and 
substance abuse prevention and treatment. 
(C) The system provides for the involve-
ment of the families of children to whom mental 
health services and substance abuse treatment
services are provided in the planning of treat-
ment and the delivery of services. 
(D) The system provides for the develop-
ment and implementation of individualized 
treatment plans by multidisciplinary and multi-
agency teams, which are recognized and fol-
lowed by the applicable agencies and providers 
in the area. 
(E) The system ensures the delivery and 
coordination of the range of mental health serv-
ices and substance abuse treatment services re-
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 
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: 
(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 
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 requirement that each 
State health security program establish a quality review 
program that meets the requirements for such a program 
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 
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 
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); 
(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.— 
(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.