114 
rity program to provide for continued support for such ex-
penditures unless included in an approved global budget. 
SEC. 612. PAYMENTS TO HEALTH CARE PRACTITIONERS 
BASED ON PROSPECTIVE FEE SCHEDULE. 
(a) FEE FOR SERVICE.— 
(1) IN
GENERAL.—Every independent health 
care practitioner is entitled to be paid, for the provi-
sion of covered health services under the State 
health security program, a fee for each billable cov-
ered service. 
(2) GLOBAL FEE PAYMENT METHODOLOGIES.— 
The Board shall establish models and encourage 
State health security programs to implement alter-
native payment methodologies that incorporate glob-
al fees for related services (such as all outpatient 
procedures for treatment of a condition) or for a 
basic group of services (such as primary care serv-
ices) furnished to an individual over a period of 
time, in order to encourage continuity and efficiency 
in the provision of services. Such methodologies shall 
be designed to ensure a high quality of care. 
(3) BILLING
DEADLINES; ELECTRONIC
BILL-
ING.—A State health security program may deny 
payment for any service of an independent health 
care practitioner for which it did not receive a bill 
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115 
and appropriate supporting documentation (which 
had been previously specified) within 30 days after 
the date the service was provided. Such a program 
may require that bills for services for which payment 
may be made under this section, or for any class of 
such services, be submitted electronically. 
(b) PAYMENT RATES BASED ON NEGOTIATED PRO-
SPECTIVE FEE SCHEDULES.—With respect to any pay-
ment method for a class of services of practitioners, the 
State health security program shall establish, on a pro-
spective basis, a payment schedule. The State health secu-
rity program may establish such a schedule after negotia-
tions with organizations representing the practitioners in-
volved. Such fee schedules shall be designed to provide in-
centives for practitioners to choose primary care medicine, 
including general internal medicine and pediatrics, over 
medical specialization. Nothing in this section shall be con-
strued as preventing a State from adjusting the payment 
schedule amounts on a quarterly or other periodic basis 
depending on whether expenditures under the schedule will 
exceed the budgeted amount with respect to such expendi-
tures. 
(c) BILLABLE COVERED SERVICE DEFINED.—In this 
section, the term ‘‘billable covered service’’ means a service 
covered under section 201 for which a practitioner is enti-
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116 
tled to compensation by payment of a fee determined 
under this section. 
SEC. 613. PAYMENTS TO COMPREHENSIVE HEALTH SERV-
ICE ORGANIZATIONS. 
(a) IN GENERAL.—Payment under a State health se-
curity program to a comprehensive health service organi-
zation to its enrollees shall be determined by the State— 
(1) based on a global budget described in sec-
tion 611; or 
(2) based on the basic capitation amount de-
scribed in subsection (b) for each of its enrollees. 
(b) BASIC CAPITATION AMOUNT.— 
(1) IN GENERAL.—The basic capitation amount 
described in this subsection for an enrollee shall be 
determined by the State health security program on 
the basis of the average amount of expenditures that 
is estimated would be made under the State health 
security program for covered health care services for 
an enrollee, based on actuarial characteristics (as de-
fined by the State health security program). 
(2) 
ADJUSTMENT
FOR
SPECIAL
HEALTH 
NEEDS.—The State health security program shall 
adjust such average amounts to take into account 
the special health needs, including a disproportionate 
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