I
103D CONGRESS
1ST SESSION
H. R. 3600
To ensure individual and family security through health care coverage for
all Americans in a manner that contains the rate of growth in health
care costs and promotes responsible health insurance practices, to pro-
mote choice in health care, and to ensure and protect the health care
of all Americans.
IN THE HOUSE OF REPRESENTATIVES
NOVEMBER 20, 1993
Mr. GEPHARDT (for himself, Mr. BONIOR, Mr. HOYER, Mr. FAZIO, Mrs. KEN-
NELLY, Mr. LEWIS of Georgia, Mr. RICHARDSON, Mr. DINGELL, Mr.
ROSTENKOWSKI, Mr. FORD of Michigan, Mr. WAXMAN, Mrs. COLLINS of
Illinois, Mr. STARK, Mr. WILLIAMS, Mr. CLAY, Mr. BROOKS, Mr. MOAK-
LEY, Mr. ABERCROMBIE, Mr. ACKERMAN, Mr. ANDREWS of Maine, Mr.
BARRETT of Wisconsin, Mr. BERMAN, Mr. BILBRAY, Mr. BLACKWELL,
Mr. BORSKI, Mr. BROWN of California, Ms. BROWN of Florida, Mr.
CARDIN, Mr. CLYBURN, Mr. COYNE, Mr. DE LUGO, Ms. DELAURO, Mr.
DEUTSCH, Mr. DICKS, Mr. DIXON, Mr. DURBIN, Mr. EDWARDS of Cali-
fornia, Mr. ENGEL, Ms. ENGLISH
of Arizona, Ms. ESHOO, Mr.
FALEOMAVAEGA, Mr. FILNER, Mr. FLAKE, Mr. FOGLIETTA, Mr. FRANK
of Massachusetts, Mr. GEJDENSON, Mr. GIBBONS, Mr. HASTINGS, Mr.
HILLIARD, Mr. HINCHEY, Ms. EDDIE BERNICE JOHNSON of Texas, Mr.
JOHNSTON of Florida, Mr. KANJORSKI, Mr. KREIDLER, Mr. LAFALCE,
Mr. LANTOS, Mr. LEVIN, Ms. LONG, Mr. MARTINEZ, Mr. MATSUI, Ms.
MCKINNEY, Mrs. MEEK, Mr. MINGE, Mrs. MINK, Mr. MURPHY, Mr.
MURTHA, Ms. NORTON, Mr. OBERSTAR, Mr. OBEY, Mr. OWENS, Mr.
PASTOR, Mr. PAYNE of New Jersey, Mr. RAHALL, Mr. RANGEL, Mr.
REYNOLDS, Mr. ROMERO-BARCELO´, Mr. RUSH, Mr. SABO, Mr. SAWYER,
Mr. SCOTT, Mr. SERRANO, Ms. SHEPHERD, Mr. SKAGGS, Ms. SLAUGH-
TER, Mr. SMITH of Iowa, Mr. STOKES, Mr. STRICKLAND, Mr. STUDDS,
Mr. SWIFT, Mr. SYNAR, Mr. THORNTON, Mrs. THURMAN, Mr. TRAFI-
CANT, Mr. UNDERWOOD, Mrs. UNSOELD, Mr. VENTO, Mr. WATT, Mr.
WHEAT, Mr. WISE, and Mr. YATES) introduced the following bill; which
was referred jointly to the Committee on Energy and Commerce, to the
Committee on Ways and Means, and to the Committee on Education and
Labor for consideration of such provisions in titles I, III, VI, VIII, X,
and XI as fall within its jurisdiction pursuant to clause 1(g) of rule X;
and concurrently, for a period ending not later than two weeks after all
three committees of joint referral report to the House (or a later time
if the Speaker so designates), to the Committee on Armed Services for
consideration of subtitle A of title VIII and such provisions of title I as
fall within its jurisdiction pursuant to clause 1(c) of rule X, to the Com-
mittee on Veterans’ Affairs for consideration of subtitle B of title VIII
and such provisions of title I as fall within its jurisdiction pursuant to
clause 1(u) of rule X, to the Committee on Post Office and Civil Service
for consideration of subtitle C of title VIII and such provisions of title
I as fall within its jurisdiction pursuant to clause 1(o) of rule X, to the
Committee on Natural Resources for consideration of subtitle D of title
VIII and such provisions of title I as fall within its jurisdiction pursuant
to clause 1(n) of rule X, to the Committee on the Judiciary for consider-
ation of subtitles C through F of title V and such other provisions as
fall within its jurisdiction pursuant to clause 1(l) of rule X, to the Com-
mittee on Rules for consideration of sections 1432(d), 6006(f), and
9102(e)(5), and to the Committee on Government Operations for consid-
eration of subtitle B of title V and section 5401
FEBRUARY 4, 1994
Additional sponsors: Mr. CARR of Michigan and Mr. SWETT
A BILL
To ensure individual and family security through health care
coverage for all Americans in a manner that contains
the rate of growth in health care costs and promotes
responsible health insurance practices, to promote choice
in health care, and to ensure and protect the health
care of all Americans.
Be it enacted by the Senate and House of Representa-
tives of the United States of America in Congress assembled,
Table
SECTION 1. SHORT TITLE; TABLE OF TITLES AND SUB-
TITLES.
(a) SHORT TITLE.—This Act may be cited as the
‘‘Health Security Act’’.
(b) TABLE OF TITLES AND SUBTITLES IN ACT.—The
following are the titles and subtitles contained in this Act:
Page
TITLE I—HEALTH CARE SECURITY
Subtitle A—Universal Coverage and Individual Responsibility ...............
Subtitle B—Benefits .................................................................................
Subtitle C—State Responsibilities ............................................................
Subtitle D—Health Alliances ...................................................................
118
Subtitle E—Health Plans .........................................................................
224
Subtitle F—Federal Responsibilities ........................................................
256
Subtitle G—Employer Responsiblities ......................................................
303
Subtitle J—General Definitions; Miscellaneous Provisions ......................
323
TITLE II—NEW BENEFITS
Subtitle A—Medicare Outpatient Prescription Drug Benefit ..................
343
Subtitle B—Long-Term Care ...................................................................
389
TITLE III—PUBLIC HEALTH INITIATIVES
Subtitle A—Workforce Priorities Under Federal Payments ....................
504
Subtitle B—Academic Health Centers .....................................................
548
Subtitle C—Health Research Initiatives ..................................................
560
Subtitle D—Core Functions of Public Health Programs; National Ini-
tiatives Regarding Preventive Health ...........................
564
Subtitle E—Health Services for Medically Underserved Populations ......
578
Subtitle F—Mental Health; Substance Abuse .........................................
615
Subtitle G—Comprehensive School Health Education; School-Related
Health Services .............................................................
627
Subtitle H—Public Health Service Initiative ...........................................
667
Subtitle I—Coordination With COBRA Continuation Coverage ..............
668
TITLE IV—MEDICARE AND MEDICAID
Subtitle A—Medicare and the Alliance System ........................................
674
Subtitle B—Savings in Medicare Program ..............................................
752
Subtitle C—Medicaid ................................................................................
807
Subtitle D—Increase in SSI Personal Needs Allowance ..........................
832
TITLE V—QUALITY AND CONSUMER PROTECTION
Subtitle A—Quality Management and Improvement ...............................
835
Subtitle B—Information Systems, Privacy, and Administrative Sim-
plification ......................................................................
859
Subtitle C—Remedies and Enforcement ..................................................
887
Table
Subtitle D—Medical Malpractice ..............................................................
933
Subtitle E—Fraud and Abuse ..................................................................
948
Subtitle F—McCarran-Ferguson Reform .................................................
979
TITLE VI—PREMIUM CAPS; PREMIUM-BASED FINANCING;
AND PLAN PAYMENTS
Subtitle A—Premium Caps ......................................................................
984
Subtitle B—Premium-Related Financing .................................................
1025
Subtitle C—Payments to Regional Alliance Health Plans .......................
1086
TITLE VII—REVENUE PROVISIONS
Subtitle A—Financing Provisions ............................................................
1094
Subtitle B—Tax Treatment of Employer-Provided Health Care .............
1133
Subtitle C—Employment Status Provisions .............................................
1143
Subtitle D—Tax Treatment of Funding of Retiree Health Benefits .......
1153
Subtitle E—Coordination With COBRA Continuing Care Provisions .....
1157
Subtitle F—Tax Treatment of Organizations Providing Health Care
Services and Related Organizations ..............................
1159
Subtitle G—Tax Treatment of Long-term Care Insurance and Services
1171
Subtitle H—Tax Incentives for Health Services Providers ......................
1192
Subtitle I—Miscellaneous Provisions ........................................................
1199
TITLE VIII—HEALTH AND HEALTH-RELATED PROGRAMS
OF THE FEDERAL GOVERNMENT
Subtitle A—Military Health Care Reform ...............................................
1207
Subtitle B—Department of Veterans Affairs ...........................................
1218
Subtitle C—Federal Employees Health Benefits Program ......................
1233
Subtitle D—Indian Health Service ...........................................................
1249
Subtitle E—Amendments to the Employee Retirement Income Security
Act of 1974 ...................................................................
1262
Subtitle F—Special Fund for WIC Program ...........................................
1274
TITLE IX—AGGREGATE GOVERNMENT PAYMENTS TO
REGIONAL ALLIANCES
Subtitle A—Aggregate State Payments ...................................................
1277
Subtitle B—Aggregate Federal Alliance Payments .................................
1296
Subtitle C—Borrowing Authority to Cover Cash-Flow Shortfalls ...........
1308
TITLE X—COORDINATION OF MEDICAL PORTION OF
WORKERS COMPENSATION AND AUTOMOBILE INSURANCE
Subtitle A—Workers Compensation Insurance ........................................
1314
Subtitle B—Automobile Insurance ...........................................................
1326
Subtitle C—Commission on Integration of Health Benefits ....................
1331
Subtitle D—Federal Employees’ Compensation Act ................................
1333
Subtitle E—Davis-Bacon Act and Service Contract Act .........................
1333
Subtitle F—Effective Dates .....................................................................
1334
TITLE XI—TRANSITIONAL INSURANCE REFORM
Findings
SEC. 2. FINDINGS.
The Congress finds as follows:
(1) Under the current health care system in the
United States—
(A) individuals risk losing their health care
coverage when they move, when they lose or
change jobs, when they become seriously ill, or
when the coverage becomes unaffordable;
(B) continued escalation of health care
costs threatens the economy of the United
States, undermines the international competi-
tiveness of the Nation, and strains Federal,
State, and local budgets;
(C) an excessive burden of forms, paper-
work, and bureaucratic procedures confuses
consumers and overwhelms health care pro-
viders;
(D) fraud and abuse sap the strength of
the health care system; and
(E) health care is a critical part of the
economy of the United States and interstate
commerce, consumes a significant percentage of
public and private spending, and affects all in-
dustries and individuals in the United States.
(2) Under any reform of the health care
system—
Findings
(A) health insurance and high quality
health care should be secure, uninterrupted,
and affordable for all individuals in the United
States;
(B) comprehensive health care benefits
that meet the full range of health needs, includ-
ing primary, preventive, and specialized care,
should be available to all individuals in the
United States;
(C) the current high quality of health care
in the United States should be maintained;
(D) individuals in the United States should
be afforded a meaningful opportunity to choose
among a range of health plans, health care pro-
viders, and treatments;
(E) regulatory and administrative burdens
should be reduced;
(F) the rapidly escalating costs of health
care should be contained without sacrificing
high quality or impeding technological improve-
ments;
(G) competition in the health care industry
should ensure that health plans and health care
providers are efficient and charge reasonable
prices;
Purposes
(H) a partnership between the Federal
Government and each State should allow the
State and its local communities to design an ef-
fective, high-quality system of care that serves
the residents of the State;
(I) all individuals should have a responsi-
bility to pay their fair share of the costs of
health care coverage;
(J) a health care system should build on
the strength of the employment-based coverage
arrangements that now exist in the United
States;
(K) the penalties for fraud and abuse
should be swift and severe; and
(L) an individual’s medical information
should remain confidential and should be pro-
tected from unauthorized disclosure and use.
SEC. 3. PURPOSES.
The purposes of this Act are as follows:
(1) To guarantee comprehensive and secure
health care coverage.
(2) To simplify the health care system for con-
sumers and health care professionals.
Purposes
(3) To control the cost of health care for em-
ployers, employees, and others who pay for health
care coverage.
(4) To promote individual choice among health
plans and health care providers.
(5) To ensure high quality health care.
(6) To encourage all individuals to take respon-
sibility for their health care coverage.
TITLE I—HEALTH CARE
SECURITY
TABLE OF CONTENTS OF TITLE
Page
Subtitle A—Universal Coverage and Individual Responsibility
PART 1—UNIVERSAL COVERAGE
Sec. 1001. Entitlement to health benefits ...............................................
Sec. 1002. Individual responsibilities ......................................................
Sec. 1003. Protection of consumer choice ...............................................
Sec. 1004. Applicable health plan providing coverage ............................
Sec. 1005. Treatment of other nonimmigrants .......................................
Sec. 1006. Effective date of entitlement .................................................
PART 2—TREATMENT OF FAMILIES AND SPECIAL RULES
Sec. 1011. General rule of enrollment of family in same health plan ....
Sec. 1012. Treatment of certain families ................................................
Sec. 1013. Multiple employment situations ............................................
Sec. 1014. Treatment of residents of States with statewide single-payer
systems ..........................................................................
Subtitle B—Benefits
PART 1—COMPREHENSIVE BENEFIT PACKAGE
Sec. 1101. Provision of comprehensive benefits by plans .......................
PART 2—DESCRIPTION OF ITEMS AND SERVICES COVERED
Sec. 1111. Hospital services ....................................................................
Sec. 1112. Services of health professionals .............................................
Sec. 1113. Emergency and ambulatory medical and surgical services ...
Sec. 1114. Clinical preventive services ....................................................
Sec. 1115. Mental illness and substance abuse services .........................
Purposes
Sec. 1116. Family planning services and services for pregnant women
Sec. 1117. Hospice care ..........................................................................
Sec. 1118. Home health care ..................................................................
Sec. 1119. Extended care services ..........................................................
Sec. 1120. Ambulance services ................................................................
Sec. 1121. Outpatient laboratory, radiology, and diagnostic services ....
Sec. 1122. Outpatient prescription drugs and biologicals .......................
Sec. 1123. Outpatient rehabilitation services ..........................................
Sec. 1124. Durable medical equipment and prosthetic and orthotic de-
vices ...............................................................................
Sec. 1125. Vision care .............................................................................
Sec. 1126. Dental care ............................................................................
Sec. 1127. Health education classes .......................................................
Sec. 1128. Investigational treatments .....................................................
PART 3—COST SHARING
Sec. 1131. Cost sharing ..........................................................................
Sec. 1132. Lower cost sharing ................................................................
Sec. 1133. Higher cost sharing ...............................................................
Sec. 1134. Combination cost sharing ......................................................
Sec. 1135. Table of copayments and coinsurance ...................................
Sec. 1136. Indexing dollar amounts relating to cost sharing .................
PART 4—EXCLUSIONS
Sec. 1141. Exclusions ..............................................................................
PART 5—ROLE OF THE NATIONAL HEALTH BOARD
Sec. 1151. Definition of benefits .............................................................
Sec. 1152. Acceleration of expanded benefits .........................................
Sec. 1153. Authority with respect to clinical preventive services ...........
Sec. 1154. Establishment of standards regarding medical necessity ......
PART 6—ADDITIONAL PROVISIONS RELATING TO HEALTH CARE PROVIDERS
Sec. 1161. Override of restrictive State practice laws ............................
Sec. 1162. Provision of items or services contrary to religious belief or
moral conviction ............................................................
Subtitle C—State Responsibilities
Sec. 1200. Participating State ................................................................
PART 1—GENERAL STATE RESPONSIBILITIES
Sec. 1201. General State responsibilities ................................................
Sec. 1202. State responsibilities with respect to alliances ......................
Sec. 1203. State responsibilities relating to health plans .......................
101
Sec. 1204. Financial solvency; fiscal oversight; guaranty fund ..............
106
Sec. 1205. Restrictions on funding of additional benefits ......................
108
PART 2—REQUIREMENTS FOR STATE SINGLE-PAYER SYSTEMS
Sec. 1221. Single-payer system described ...............................................
109
Sec. 1222. General requirements for single-payer systems .....................
109
Purposes
Sec. 1223. Special rules for States operating statewide single-payer
system ...........................................................................
114
Sec. 1224. Special rules for alliance-specific single-payer systems .........
117
Subtitle D—Health Alliances
Sec. 1300. Health alliance defined ..........................................................
118
PART 1—ESTABLISHMENT OF REGIONAL AND CORPORATE ALLIANCES
SUBPART A—REGIONAL ALLIANCES
Sec. 1301. Regional alliance defined .......................................................
118
Sec. 1302. Board of directors .................................................................
119
Sec. 1303. Provider advisory boards for regional alliances ....................
120
SUBPART B—CORPORATE ALLIANCES
Sec. 1311. Corporate alliance defined; individuals eligible for coverage
through corporate alliances; additional definitions .......
121
Sec. 1312. Timing of elections ................................................................
127
Sec. 1313. Termination of alliance election ............................................
129
PART 2—GENERAL RESPONSIBILITIES AND AUTHORITIES OF REGIONAL
ALLIANCES
Sec. 1321. Contracts with health plans ..................................................
131
Sec. 1322. Offering choice of health plans for enrollment; establish-
ment of fee-for-service schedule ....................................
132
Sec. 1323. Enrollment rules and procedures ..........................................
138
Sec. 1324. Issuance of health security cards ..........................................
148
Sec. 1325. Consumer information and marketing ..................................
148
Sec. 1326. Ombudsman ...........................................................................
150
Sec. 1327. Data collection; quality ..........................................................
150
Sec. 1328. Additional duties ...................................................................
150
Sec. 1329. Additional authorities for regional alliances to address
needs in areas with inadequate health services; prohi-
bition of insurance role .................................................
151
Sec. 1330. Prohibition against self-dealing and conflicts of interest ......
152
PART 3—AUTHORITIES AND RESPONSIBILITIES OF REGIONAL ALLIANCES
RELATING TO FINANCING AND INCOME DETERMINATIONS
SUBPART A—COLLECTION OF FUNDS
Sec. 1341. Information and negotiation and acceptance of bids ............
153
Sec. 1342. Calculation and publication of general family share and
general employer premium amounts .............................
156
Sec. 1343. Determination of family share for families ...........................
158
Sec. 1344. Notice of family payments due ..............................................
163
Sec. 1345. Collections ..............................................................................
168
Sec. 1346. Coordination among regional alliances ..................................
171
SUBPART B—PAYMENTS
Sec. 1351. Payment to regional alliance health plans ............................
174
Sec. 1352. Alliance administrative allowance percentage .......................
178
Sec. 1353. Payments to the Federal Government for academic health
centers and graduate medical education .......................
179
Purposes
SUBPART C—FINANCIAL MANAGEMENT
Sec. 1361. Management of finances and records ....................................
180
SUBPART D—REDUCTIONS IN COST SHARING; INCOME DETERMINATIONS
Sec. 1371. Reduction in cost sharing for low-income families ................
183
Sec. 1372. Application process for cost sharing reductions ....................
186
Sec. 1373. Application for premium discounts and reduction in liabil-
ities to alliances .............................................................
191
Sec. 1374. General provisions relating to application process ................
193
Sec. 1375. End-of-year reconciliation for premium discount and repay-
ment reduction with actual income ...............................
196
PART 4—RESPONSIBILITIES AND AUTHORITIES OF CORPORATE ALLIANCES
Sec. 1381. Contracts with health plans ..................................................
199
Sec. 1382. Offering choice of health plans for enrollment ......................
200
Sec. 1383. Enrollment; issuance of health security card ........................
201
Sec. 1384. Community-rated premiums within premium areas ..............
203
Sec. 1385. Assistance for low-wage families ...........................................
205
Sec. 1386. Consumer information and marketing; data collection and
quality; additional duties ...............................................
206
Sec. 1387. Plan and information requirements ......................................
206
Sec. 1388. Management of funds; relations with employees ...................
207
Sec. 1389. Cost control ...........................................................................
207
Sec. 1390. Payments by corporate alliance employers to corporate alli-
ances ..............................................................................
208
Sec. 1391. Coordination of payments .....................................................
208
Sec. 1392. Applicability of ERISA enforcement mechanisms for en-
forcement of certain requirements ................................
209
Sec. 1393. Applicability of certain ERISA protections to enrolled indi-
viduals ...........................................................................
209
Sec. 1394. Disclosure and reserve requirements .....................................
210
Sec. 1395. Trusteeship by the Secretary of insolvent corporate alliance
health plans ...................................................................
211
Sec. 1396. Guaranteed benefits under trusteeship of the Secretary ......
216
Sec. 1397. Imposition and collection of periodic assessments on self-in-
sured corporate alliance plans .......................................
220
Sec. 1398. Payments to Federal government by multiemployer cor-
porate alliances for academic health centers and grad-
uate medical education ..................................................
224
Subtitle E—Health Plans
Sec. 1400. Health plan defined ...............................................................
224
PART 1—REQUIREMENTS RELATING TO COMPREHENSIVE BENEFIT PACKAGE
Sec. 1401. Application of requirements ..................................................
226
Sec. 1402. Requirements relating to enrollment and coverage ...............
226
Sec. 1403. Community rating .................................................................
231
Sec. 1404. Marketing of health plans; information ................................
231
Sec. 1405. Grievance procedure ..............................................................
233
Sec. 1406. Health plan arrangements with providers .............................
234
Sec. 1407. Preemption of certain State laws relating to health plans ...
237
Sec. 1408. Financial solvency .................................................................
239
Purposes
Sec. 1409. Requirement for offering cost sharing policy ........................
239
Sec. 1410. Quality assurance ..................................................................
239
Sec. 1411. Provider verification ..............................................................
239
Sec. 1412. Consumer disclosures of utilization management protocols ..
240
Sec. 1413. Confidentiality, data management, and reporting ................
240
Sec. 1414. Participation in reinsurance system ......................................
241
PART 2—REQUIREMENTS RELATING TO SUPPLEMENTAL INSURANCE
Sec. 1421. Imposition of requirements on supplemental insurance ........
241
Sec. 1422. Standards for supplemental health benefit policies ...............
243
Sec. 1423. Standards for cost sharing policies .......................................
246
PART 3—REQUIREMENTS RELATING TO ESSENTIAL COMMUNITY PROVIDERS
Sec. 1431. Health plan requirement .......................................................
249
Sec. 1432. Sunset of requirement ...........................................................
252
PART 4—REQUIREMENTS RELATING TO WORKERS’ COMPENSATION AND
AUTOMOBILE MEDICAL LIABILITY COVERAGE
Sec. 1441. Reference to requirements relating to workers compensation
services ..........................................................................
256
Sec. 1442. Reference to requirements relating to automobile medical li-
ability services ...............................................................
256
Subtitle F—Federal Responsibilities
PART 1—NATIONAL HEALTH BOARD
SUBPART A—ESTABLISHMENT OF NATIONAL HEALTH BOARD
Sec. 1501. Creation of National Health Board; membership .................
256
Sec. 1502. Qualifications of board members ...........................................
258
Sec. 1503. General duties and responsibilities ........................................
259
Sec. 1504. Annual report ........................................................................
262
Sec. 1505. Powers ...................................................................................
263
Sec. 1506. Funding .................................................................................
264
SUBPART B—RESPONSIBILITIES RELATING TO REVIEW AND APPROVAL OF
STATE SYSTEMS
Sec. 1511. Federal review and action on State systems .........................
264
Sec. 1512. Failure of participating States to meet conditions for com-
pliance ...........................................................................
270
Sec. 1513. Reduction in payments for health programs by Secretary of
Health and Human Services .........................................
272
Sec. 1514. Review of Federal determinations .........................................
273
Sec. 1515. Federal support for State implementation ............................
273
SUBPART C—RESPONSIBILITIES IN ABSENCE OF STATE SYSTEMS
Sec. 1521. Application of subpart ...........................................................
275
Sec. 1522. Federal assumption of responsibilities in non-participating
States ............................................................................
275
Sec. 1523. Imposition of surcharge on premiums under federally-oper-
ated system ...................................................................
277
Sec. 1524. Return to State operation .....................................................
278
Purposes
SUBPART D—ESTABLISHMENT OF CLASS FACTORS FOR CHARGING PREMIUMS
Sec. 1531. Premium class factors ...........................................................
278
SUBPART E—RISK ADJUSTMENT AND REINSURANCE METHODOLOGY FOR
PAYMENT OF PLANS
Sec. 1541. Development of a risk adjustment and reinsurance method-
ology ..............................................................................
279
Sec. 1542. Incentives to enroll disadvantaged groups ............................
285
Sec. 1543. Advisory committee ...............................................................
285
Sec. 1544. Research and demonstrations ................................................
286
Sec. 1545. Technical assistance to States and alliances .........................
286
SUBPART F—RESPONSIBILITIES FOR FINANCIAL REQUIREMENTS
Sec. 1551. Capital standards for regional alliance health plan ..............
286
Sec. 1552. Standard for guaranty funds ................................................
287
PART 2—RESPONSIBILITIES OF DEPARTMENT OF HEALTH AND HUMAN
SERVICES
SUBPART A—GENERAL RESPONSIBILITIES
Sec. 1571. General responsibilities of Secretary of Health and Human
Services .........................................................................
289
Sec. 1572. Advisory council on breakthrough drugs ...............................
290
SUBPART B—CERTIFICATION OF ESSENTIAL COMMUNITY PROVIDERS
Sec. 1581. Certification ...........................................................................
293
Sec. 1582. Categories of providers automatically certified .....................
293
Sec. 1583. Standards for additional providers ........................................
296
Sec. 1584. Certification process; review; termination of certifications ...
297
Sec. 1585. Notification of health alliances and participating States ......
299
PART 3—SPECIFIC RESPONSIBILITIES OF SECRETARY OF LABOR
Sec. 1591. Responsibilities of Secretary of Labor ..................................
300
Subtitle G—Employer Responsibilities
Sec. 1601. Payment requirement ............................................................
303
Sec. 1602. Requirement for information reporting .................................
303
Sec. 1603. Requirements relating to new employees ..............................
314
Sec. 1604. Auditing of records ................................................................
315
Sec. 1605. Prohibition of certain employer discrimination .....................
316
Sec. 1606. Prohibition on self-funding of cost sharing benefits by re-
gional alliance employers ...............................................
316
Sec. 1607. Equal voluntary contribution requirement ............................
317
Sec. 1608. Employer retiree obligation ...................................................
321
Sec. 1609. Enforcement ..........................................................................
323
Subtitle J—General Definitions; Miscellaneous Provisions
PART 1—GENERAL DEFINITIONS
Sec. 1901. Definitions relating to employment and income ....................
323
Sec. 1902. Other general definitions .......................................................
331
Subtitle B—Miscellaneous Provisions
Title I, Subtitle A
Sec. 1911. Use of interim, final regulations ...........................................
341
Sec. 1912. Social Security Act references ...............................................
341
TITLE I—HEALTH CARE
SECURITY
Subtitle A—Universal Coverage
and Individual Responsibility
PART 1—UNIVERSAL COVERAGE
SEC. 1001. ENTITLEMENT TO HEALTH BENEFITS.
(a) IN GENERAL.—In accordance with this part, each
eligible individual is entitled to the comprehensive benefit
package under subtitle B through the applicable health
plan in which the individual is enrolled consistent with this
title.
(b) HEALTH SECURITY CARD.—Each eligible indi-
vidual is entitled to a health security card to be issued
by the alliance or other entity that offers the applicable
health plan in which the individual is enrolled.
(c) ELIGIBLE INDIVIDUAL DEFINED.—In this Act,
the term ‘‘eligible individual’’ means an individual who is
residing in the United States and who is—
(1) a citizen or national of the United States;
(2) an alien permanently residing in the United
States under color of law (as defined in section
1902(1)); or
(3) a long-term nonimmigrant (as defined in
section 1902(19)).
Title I, Subtitle A
(d) TREATMENT OF MEDICARE-ELIGIBLE INDIVID-
UALS.—Subject to section 1012(a), a medicare-eligible in-
dividual is entitled to health benefits under the medicare
program instead of the entitlement under subsection (a).
(e) TREATMENT OF PRISONERS.—A prisoner (as de-
fined in section 1902(26)) is entitled to health care serv-
ices provided by the authority responsible for the prisoner
instead of the entitlement under subsection (a).
SEC. 1002. INDIVIDUAL RESPONSIBILITIES.
(a) IN GENERAL.—In accordance with this Act, each
eligible individual (other than a medicare-eligible indi-
vidual)—
(1) must enroll in an applicable health plan for
the individual, and
(2) must pay any premium required, consistent
with this Act, with respect to such enrollment.
(b) LIMITATION ON DISENROLLMENT.—No eligible
individual shall be disenrolled from an applicable health
plan until the individual—
(1) is enrolled under another applicable health
plan, or
(2) becomes a medicare-eligible individual.
SEC. 1003. PROTECTION OF CONSUMER CHOICE.
Nothing in this Act shall be construed as prohibiting
the following:
Title I, Subtitle A
(1) An individual from purchasing any health
care services.
(2) An individual from purchasing supplemental
insurance (offered consistent with this Act) to cover
health care services not included within the com-
prehensive benefit package.
(3) An individual who is not an eligible indi-
vidual from purchasing health insurance (other than
through a regional alliance).
(4) Employers from providing coverage for ben-
efits in addition to the comprehensive benefit pack-
age (subject to part 2 of subtitle E).
SEC. 1004. APPLICABLE HEALTH PLAN PROVIDING COV-
ERAGE.
(a) 
SPECIFICATION
OF
APPLICABLE
HEALTH
PLAN.—Except as otherwise provided:
(1) GENERAL
RULE: 
REGIONAL
ALLIANCE
HEALTH PLANS.—The applicable health plan for a
family is a regional alliance health plan for the alli-
ance area in which the family resides.
(2) CORPORATE ALLIANCE HEALTH PLANS.—In
the case of a family member that is eligible to enroll
in a corporate alliance health plan under section
1311(c), the applicable health plan for the family is
such a corporate alliance health plan.
Title I, Subtitle A
(b) CHOICE OF PLANS FOR CERTAIN GROUPS.—
(1) MILITARY PERSONNEL AND FAMILIES.—For
military personnel and families who elect a Uni-
formed Services Health Plan of the Department of
Defense under section 1073a(d) of title 10, United
States Code, as inserted by section 8001(a) of this
Act, that plan shall be the applicable health plan.
(2) VETERANS.—For veterans and families who
elect to enroll in a veterans health plan under sec-
tion 1801 of title 38, United States Code, as in-
serted by section 8101(a) of this Act, that plan shall
be the applicable health plan.
(3) INDIANS.—For those individuals who are el-
igible to enroll, and who elect to enroll, in a health
program of the Indian Health Service under section
8302(b) or 8306(b), that program shall be the appli-
cable health plan.
SEC. 1005. TREATMENT OF OTHER NONIMMIGRANTS.
(a) UNDOCUMENTED ALIENS INELIGIBLE FOR BEN-
EFITS.—An undocumented alien is not eligible to obtain
the comprehensive benefit package through enrollment in
a health plan pursuant to this Act.
(b) DIPLOMATS AND OTHER FOREIGN GOVERNMENT
OFFICIALS.—Subject to conditions established by the Na-
tional Health Board in consultation with the Secretary of
Title I, Subtitle A
State, a nonimmigrant under subparagraph (A) or (G) of
section 101(a)(15) of the Immigration and Nationality Act
may obtain the comprehensive benefit package through en-
rollment in the regional alliance health plan for the alli-
ance area in which the nonimmigrant resides.
(c) RECIPROCAL
TREATMENT
OF
OTHER
NON-
IMMIGRANTS.—With respect to those classes of individuals
who are lawful nonimmigrants but who are not long-term
nonimmigrants (as defined in section 1902(19)) or de-
scribed in subsection (b), such individuals may obtain such
benefits through enrollment with regional alliance health
plans only in accordance with such reciprocal agreements
between the United States and foreign states as may be
entered into.
SEC. 1006. EFFECTIVE DATE OF ENTITLEMENT.
(a) REGIONAL ALLIANCE ELIGIBLE INDIVIDUALS.—
(1) IN GENERAL.—In the case of regional alli-
ance eligible individuals residing in a State, the enti-
tlement under this part (and requirements under
section 1002) shall not take effect until the State
becomes a participating State (as defined in section
1200).
(2) TRANSITIONAL RULE FOR CORPORATE ALLI-
ANCES.—
Title I, Subtitle A
(A) IN GENERAL.—In the case of a State
that becomes a participating State before the
general effective date (as defined in subsection
(c)) and for periods before such date, under
rules established by the Board, an individual
who is covered under a plan (described in sub-
paragraph (C)) based on the individual (or the
individual’s spouse) being a qualifying employee
of a qualifying employer, the individual shall
not be treated under this Act as a regional alli-
ance eligible individual.
(B) QUALIFYING EMPLOYER DEFINED.—In
subparagraph (A), the term ‘‘qualifying em-
ployer’’ means an employer that—
(i) 
is 
described 
in 
section
1311(b)(1)(A), or is participating in a
multiemployer plan described in section
1311(b)(1)(B) or plan described in section
1311(b)(1)(C), and
(ii) provides such notice to the re-
gional alliance involved as the Board speci-
fies.
(C) BENEFITS PLAN DESCRIBED.—A plan
described in this subparagraph is an employee
benefit plan that—
Title I, Subtitle A
(i) provides (through insurance or
otherwise) the comprehensive benefit pack-
age, and
(ii) provides an employer contribution
of at least 80 percent of the premium (or
premium equivalent) for coverage.
(b) CORPORATE
ALLIANCE
ELIGIBLE
INDIVID-
UALS.—
(1) IN GENERAL.—In the case of corporate alli-
ance eligible individuals, the entitlement under this
part shall not take effect until the general effective
date.
(2) TRANSITION.—For purposes of this Act and
before the general effective date, in the case of an
eligible individual who resides in a participating
State, the individual is deemed a regional alliance el-
igible individual until the individual becomes a cor-
porate alliance eligible individual, unless subsection
(a)(2)(A) applies to the individual.
(c) GENERAL EFFECTIVE DATE DEFINED.—In this
Act, the term ‘‘general effective date’’ means January 1,
1998.
Title I, Subtitle A
PART 2—TREATMENT OF
FAMILIES AND SPECIAL RULES
SEC. 1011. GENERAL RULE OF ENROLLMENT OF FAMILY IN
SAME HEALTH PLAN.
(a) IN GENERAL.—Except as provided in this part
or otherwise, all members of the same family (as defined
in subsection (b)) shall be enrolled in the same applicable
health plan.
(b) FAMILY DEFINED.—In this Act, unless otherwise
provided, the term ‘‘family’’—
(1) means, with respect to an eligible individual
who is not a child (as defined in subsection (c)), the
individual; and
(2) includes the following persons (if any):
(A) The individual’s spouse if the spouse is
an eligible individual.
(B) The individual’s children (and, if appli-
cable, the children of the individual’s spouse) if
they are eligible individuals.
(c) CLASSES
OF FAMILY ENROLLMENT; TERMI-
NOLOGY.—
(1) IN GENERAL.—In this Act, each of the fol-
lowing is a separate class of family enrollment:
Title I, Subtitle A
(A) Coverage only of an individual (re-
ferred to in this Act as the ‘‘individual’’ enroll-
ment or class of enrollment).
(B) Coverage of a married couple without
children (referred to in this Act as the ‘‘couple-
only’’ enrollment or class of enrollment).
(C) Coverage of an unmarried individual
and one or more children (referred to in this
Act as the ‘‘single parent’’ enrollment or class
of enrollment).
(D) Coverage of a married couple and one
or more children (referred to in this Act as the
‘‘dual parent’’ enrollment or class of enroll-
ment).
(2) REFERENCES
TO
FAMILY
AND
COUPLE
CLASSES OF ENROLLMENT.—In this Act:
(A) FAMILY.—The terms ‘‘family enroll-
ment’’ and ‘‘family class of enrollment’’, refer
to enrollment in a class of enrollment described
in subparagraph (B), (C), or (D) of paragraph
(1).
(B) COUPLE.—The term ‘‘couple class of
enrollment’’ refers to enrollment in a class of
enrollment described in subparagraph (B) or
(D) of paragraph (1).
Title I, Subtitle A
(d) SPOUSE; MARRIED; COUPLE.—
(1) IN
GENERAL.—In this Act, the terms
‘‘spouse’’ and ‘‘married’’ mean, with respect to a
person, another individual who is the spouse of the
person or married to the person, as determined
under applicable State law.
(2) COUPLE.—The term ‘‘couple’’ means an in-
dividual and the individual’s spouse.
(e) CHILD DEFINED.—
(1) IN GENERAL.—In this Act, except as other-
wise provided, the term ‘‘child’’ means an eligible in-
dividual who (consistent with paragraph (3))—
(A) is under 18 years of age (or under 24
years of age in the case of a full-time student),
and
(B) is a dependent of an eligible individual.
(2) APPLICATION OF STATE LAW.—Subject to
paragraph (3), determinations of whether a person
is the child of another person shall be made in ac-
cordance with applicable State law.
(3) NATIONAL
RULES.—The National Health
Board may establish such national rules respecting
individuals who will be treated as children under this
Act as the Board determines to be necessary. Such
Title I, Subtitle A
rules shall be consistent with the following prin-
ciples:
(A) STEP AND FOSTER CHILD.—A child in-
cludes a step child or foster child who is an eli-
gible individual living with an adult in a regular
parent-child relationship.
(B) DISABLED
CHILD.—A child includes
an unmarried dependent eligible individual re-
gardless of age who is incapable of self-support
because of mental or physical disability which
existed before age 21.
(C) CERTAIN 3-GENERATION FAMILIES.—A
child includes the grandchild of an individual, if
the parent of the grandchild is a child and the
parent and grandchild are living with the
grandparent.
(D) TREATMENT
OF
EMANCIPATED
MI-
NORS AND MARRIED INDIVIDUALS.—An emanci-
pated minor or married individual shall not be
treated as a child.
(E) CHILDREN PLACED FOR ADOPTION.—
A child includes a child who is placed for adop-
tion with an eligible individual.
Title I, Subtitle A
(f) ADDITIONAL RULES.—The Board shall provide
for such additional exceptions and special rules, including
rules relating to—
(1) families in which members are not residing
in the same area or in which children are not resid-
ing with their parents,
(2) the treatment of eligible individuals who are
under 19 years of age and who are not a dependent
of an eligible individual,
(3) changes in family composition occurring
during a year, and
(4) treatment of children of parents who are
separated or divorced,
as the Board finds appropriate.
SEC. 1012. TREATMENT OF CERTAIN FAMILIES.
(a) TREATMENT OF MEDICARE-ELIGIBLE INDIVID-
UALS WHO ARE QUALIFYING EMPLOYEES OR SPOUSES OF
QUALIFYING EMPLOYEES.—
(1) IN GENERAL.—Except as specifically pro-
vided, in the case of an individual who is an indi-
vidual described in paragraph (2) with respect to 2
consecutive months in a year (and it is anticipated
would be in the following month and in such fol-
lowing month would be a medicare-eligible individual
but for this paragraph), the individual shall not be
Title I, Subtitle A
treated as a medicare-eligible individual under this
Act during such following month and the remainder
of the year.
(2) INDIVIDUAL DESCRIBED.—An individual de-
scribed in this paragraph with respect to a month is
an individual who is a qualifying employee or the
spouse or family member of a qualifying employee in
the month.
(b) SEPARATE TREATMENT FOR CERTAIN GROUPS
OF INDIVIDUALS.—In the case of a family that includes
one or more individuals in a group described in subsection
(c)—
(1) all the individuals in each such group within
the family shall be treated collectively as a separate
family, and
(2) all the individuals not described in any such
group shall be treated collectively as a separate fam-
ily.
(c) GROUPS OF INDIVIDUALS DESCRIBED.—Each of
the following is a group of individuals described in this
subsection:
(1) AFDC recipients (as defined in section
1902(3)).
(2) Disabled SSI recipients (as defined in sec-
tion 1902(13)) .
Title I, Subtitle A
(3) SSI recipients (as defined in section
1902(33)) who are not disabled SSI recipients.
(4) Electing veterans (as defined in subsection
(d)(1)).
(5) Active duty military personnel (as defined
in subsection (d)(2)).
(6) Electing Indians (as defined in subsection
(d)(3)).
(7) Prisoners (as defined in section 1902(26)).
(d) SPECIAL RULES.—In this Act:
(1) ELECTING VETERANS.—
(A) DEFINED.—Subject to subparagraph
(B), the term ‘‘electing veteran’’ means a vet-
eran who makes an election to enroll with a
health plan of the Department of Veterans Af-
fairs under chapter 18 of title 38, United
States Code, as added by section 8101(a)(1).
(B) FAMILY
EXCEPTION.—Subparagraph
(A) shall not apply with respect to coverage
under a health plan referred to in such sub-
paragraph if, for the area in which the electing
veteran resides, such health plan offers cov-
erage to family members of an electing veteran
and the veteran elects family enrollment under
such plan (instead of individual enrollment).
Title I, Subtitle A
(2) ACTIVE DUTY MILITARY PERSONNEL.—
(A) IN
GENERAL.—Subject to subpara-
graph (B), the term ‘‘active duty military per-
sonnel’’ means an individual on active duty in
the Uniformed Services of the United States.
(B) EXCEPTION.—If an individual de-
scribed in subparagraph (A) elects family cov-
erage under section 1073a(e)(2)(A) of title 10,
United States Code (as added by section
8001(a)), then paragraph (5) of subsection (c)
shall not apply with respect to such coverage.
(3) ELECTING INDIANS.—
(A) IN
GENERAL.—Subject to subpara-
graph (B), the term ‘‘electing Indian’’ means
an eligible individual who makes an election
under section 8302(b) of this Act.
(B) FAMILY ELECTION FOR ALL INDIVID-
UALS ELIGIBLE TO ELECT.—No such election
shall be made with respect to an individual in
a family (as defined without regard to this sec-
tion) unless such election is made for all eligible
individuals (described in section 8302(a)) who
are family members of the family.
(4) MULTIPLE
CHOICE.—Eligible individuals
who are permitted to elect coverage under more than
Title I, Subtitle A
one health plan or program referred to in this sub-
section may elect which of such plans or programs
will be the applicable health plan under this Act.
(e) QUALIFYING STUDENTS.—
(1) IN GENERAL.—In the case of a qualifying
student (described in paragraph (2)), the student
may elect to enroll in a regional alliance health plan
offered by the regional alliance for the area in which
the school is located.
(2) QUALIFYING STUDENT.—In paragraph (1),
the term ‘‘qualifying student’’ means an individual
who—
(A) but for this subsection would receive
coverage under a health plan as a child of an-
other person, and
(B) is a full-time student at a school in an
alliance area that is different from the alliance
area (or, in the case of a corporate alliance,
such coverage area as the Board may specify)
providing the coverage described in subpara-
graph (A).
(3) PAYMENT RULES.—
(A) CONTINUED
TREATMENT
AS
FAM-
ILY.—Except as provided in subparagraph (B),
nothing in this subsection shall be construed as
Title I, Subtitle A
affecting the payment liabilities between fami-
lies and health alliances or between health alli-
ances and health plans.
(B) TRANSFER PAYMENT.—In the case of
an election under paragraph (1), for transfer
payments see section 1346(e).
(f) SPOUSES
LIVING
IN
DIFFERENT
ALLIANCE
AREAS.—The Board shall provide for such special rules
in applying this Act in the case of a couple in which the
spouses reside in different alliance areas as the Board
finds appropriate.
SEC. 1013. MULTIPLE EMPLOYMENT SITUATIONS.
(a) MULTIPLE EMPLOYMENT OF AN INDIVIDUAL.—
In the case of an individual who—
(1)(A) is not married or (B) is married and
whose spouse is not a qualifying employee (as de-
fined in section 1901(b)(1)),
(2) is not a child, and
(3) who is a qualifying employee both of a re-
gional alliance employer and of a corporate alliance
employer (or of 2 corporate alliance employers),
the individual may elect the applicable health plan to be
either a regional alliance health plan (for the alliance area
in which the individual resides) or a corporate alliance
health plan (for an employer employing the individual).
Title I, Subtitle A
(b) MULTIPLE EMPLOYMENT WITHIN A FAMILY.—
(1) MARRIED
COUPLE
WITH
EMPLOYMENT
WITH A REGIONAL ALLIANCE EMPLOYER AND WITH
A CORPORATE ALLIANCE EMPLOYER.—In the case of
a married individual—
(A) who is a qualifying employee of a re-
gional alliance employer and whose spouse is a
qualifying employee of a corporate alliance em-
ployer, or
(B) who is a qualifying employee of a cor-
porate alliance employer and whose spouse is a
qualifying employee of a regional alliance em-
ployer,
the individual and the individual’s spouse may elect
the applicable health plan to be either a regional alli-
ance health plan (for the alliance area in which the
couple resides) or a corporate alliance health plan
(for an employer employing the individual or the
spouse).
(2) MARRIED COUPLE WITH DIFFERENT COR-
PORATE ALLIANCE EMPLOYERS.—In the case of a
married individual—
(A) who is a qualifying employee of a cor-
porate alliance employer, and
Title I, Subtitle A
(B) whose spouse is a qualifying employee
of a different corporate alliance employer,
the individual and the individual’s spouse may elect
the applicable health plan to be a corporate alliance
health plan for an employer employing either the in-
dividual or the spouse.
SEC. 1014. TREATMENT OF RESIDENTS OF STATES WITH
STATEWIDE SINGLE-PAYER SYSTEMS.
(a) UNIVERSAL COVERAGE.—Notwithstanding the
previous provisions of this title, except as provided in part
2 of subtitle C, in the case of an individual who resides
in a State that has a Statewide single-payer system under
section 1223, universal coverage shall be provided con-
sistent with section 1222(3).
(b) INDIVIDUAL RESPONSIBILITIES.—In the case of
an individual who resides in a single-payer State, the re-
sponsibilities of such individual under such system shall
supersede the obligations of the individual under section
1002.
Title I, Subtitle B
Subtitle B—Benefits
PART 1—COMPREHENSIVE
BENEFIT PACKAGE
SEC. 1101. PROVISION OF COMPREHENSIVE BENEFITS BY
PLANS.
(a) IN GENERAL.—The comprehensive benefit pack-
age shall consist of the following items and services (as
described in part 2), subject to the cost sharing require-
ments described in part 3, the exclusions described in part
4, and the duties and authority of the National Health
Board described in part 5:
(1) Hospital services (described in section
1111).
(2) Services of health professionals (described
in section 1112).
(3) Emergency and ambulatory medical and
surgical services (described in section 1113).
(4) Clinical preventive services (described in
section 1114).
(5) Mental illness and substance abuse services
(described in section 1115).
(6) Family planning services and services for
pregnant women (described in section 1116).
(7) Hospice care (described in section 1117).
Title I, Subtitle B
(8) Home health care (described in section
1118).
(9) Extended care services (described in section
1119).
(10) Ambulance services (described in section
1120).
(11) Outpatient laboratory, radiology, and diag-
nostic services (described in section 1121).
(12) 
Outpatient 
prescription 
drugs 
and
biologicals (described in section 1122).
(13) Outpatient rehabilitation services (de-
scribed in section 1123).
(14) Durable medical equipment and prosthetic
and orthotic devices (described in section 1124).
(15) Vision care (described in section 1125).
(16) Dental care (described in section 1126).
(17) Health education classes (described in sec-
tion 1127).
(18) Investigational treatments (described in
section 1128).
(b) NO OTHER LIMITATIONS OR COST SHARING.—
The items and services in the comprehensive benefit pack-
age shall not be subject to any duration or scope limitation
or any deductible, copayment, or coinsurance amount that
is not required or authorized under this Act.
Title I, Subtitle B
(c) HEALTH PLAN.—Unless otherwise provided in
this subtitle, for purposes of this subtitle, the term ‘‘health
plan’’ has the meaning given such term in section 1400.
PART 2—DESCRIPTION OF ITEMS
AND SERVICES COVERED
SEC. 1111. HOSPITAL SERVICES.
(a) COVERAGE.—The hospital services described in
this section are the following items and services:
(1) Inpatient hospital services.
(2) Outpatient hospital services.
(3) 24-hour a day hospital emergency services.
(b) LIMITATION.—The hospital services described in
this section do not include hospital services provided for
the treatment of a mental or substance abuse disorder
(which are subject to section 1115), except for medical de-
toxification as required for the management of medical
conditions associated with withdrawal from alcohol or
drugs (which is not covered under such section).
(c) DEFINITIONS.—For purposes of this subtitle:
(1) HOSPITAL.—The term ‘‘hospital’’ has the
meaning given such term in section 1861(e) of the
Social Security Act, except that such term shall
include—
(A) in the case of an item or service pro-
vided to an individual whose applicable health
Title I, Subtitle B
plan is specified pursuant to section 1004(b)(1),
a facility of the uniformed services under title
10, United States Code, that is primarily en-
gaged in providing services to inpatients that
are equivalent to the services provided by a hos-
pital defined in such section 1861(e);
(B) in the case of an item or service pro-
vided to an individual whose applicable health
plan is specified pursuant to section 1004(b)(2),
a facility operated by the Department of Vet-
erans Affairs that is primarily engaged in pro-
viding services to inpatients that are equivalent
to the services provided by a hospital defined in
such section 1861(e); and
(C) in the case of an item or service pro-
vided to an individual whose applicable health
plan is specified pursuant to section 1004(b)(3),
a facility operated by the Indian Health Service
that is primarily engaged in providing services
to inpatients that are equivalent to the services
provided by a hospital defined in such section
1861(e).
(2) INPATIENT HOSPITAL SERVICES.—The term
‘‘inpatient hospital services’’ means items and serv-
ices described in paragraphs (1) through (3) of sec-
Title I, Subtitle B
tion 1861(b) of the Social Security Act when pro-
vided to an inpatient of a hospital. The National
Health Board shall specify those health professional
services described in section 1112 that shall be
treated as inpatient hospital services when provided
to an inpatient of a hospital.
SEC. 1112. SERVICES OF HEALTH PROFESSIONALS.
(a) COVERAGE.—The items and services described in
this section are—
(1) inpatient and outpatient health professional
services, including consultations, that are provided
in—
(A) a home, office, or other ambulatory
care setting; or
(B) an institutional setting; and
(2) services and supplies (including drugs and
biologicals which cannot be self-administered) fur-
nished as an incident to such health professional
services, of kinds which are commonly furnished in
the office of a health professional and are commonly
either rendered without charge or included in the bill
of such professional.
(b) LIMITATION.—The items and services described
in this section do not include items or services that are
described in any other section of this part. An item or
Title I, Subtitle B
service that is described in section 1114 but is not pro-
vided consistent with a periodicity schedule for such item
or service specified in such section or under section 1153
may be covered under this section if the item or service
otherwise meets the requirements of this section.
(c) DEFINITIONS.—Unless otherwise provided in this
Act, for purposes of this Act:
(1) 
HEALTH
PROFESSIONAL.—The 
term
‘‘health professional’’ means an individual who pro-
vides health professional services.
(2) HEALTH
PROFESSIONAL
SERVICES.—The
term ‘‘health professional services’’ means profes-
sional services that—
(A) are lawfully provided by a physician; or
(B) would be described in subparagraph
(A) if provided by a physician, but are provided
by another person who is legally authorized to
provide such services in the State in which the
services are provided.
SEC. 1113. EMERGENCY AND AMBULATORY MEDICAL AND
SURGICAL SERVICES.
The emergency and ambulatory medical and surgical
services described in this section are the following items
and services provided by a health facility that is not a hos-
Title I, Subtitle B
pital and that is legally authorized to provide the services
in the State in which they are provided:
(1) 24-hour a day emergency services.
(2) Ambulatory medical and surgical services.
SEC. 1114. CLINICAL PREVENTIVE SERVICES.
(a) COVERAGE.—The clinical preventive services de-
scribed in this section are—
(1) an item or service for high risk populations
(as defined by the National Health Board) that is
specified and defined by the Board under section
1153, but only when the item or service is provided
consistent with any periodicity schedule for the item
or service promulgated by the Board;
(2) except as modified by the National Health
Board under section 1153, an age-appropriate im-
munization, test, or clinician visit specified in one of
subsections (b) through (h) that is provided con-
sistent with any periodicity schedule for the item or
service specified in the applicable subsection or by
the National Health Board under section 1153; and
(3) an immunization, test, or clinician visit that
is provided to an individual during an age range
other than the age range for such immunization,
test, or clinician visit that is specified in one of sub-
sections (b) through (h), but only when provided
Title I, Subtitle B
consistent with any requirements for such immuniza-
tions, tests, and clinician visits established by the
National Health Board under section 1153.
(b) INDIVIDUALS
UNDER
3.—For an individual
under 3 years of age:
(1) IMMUNIZATIONS.—The immunizations spec-
ified in this subsection are age-appropriate immuni-
zations for the following illnesses:
(A) Diphtheria.
(B) Tetanus.
(C) Pertussis.
(D) Polio.
(E) Haemophilus influenzae type B.
(F) Measles.
(G) Mumps.
(H) Rubella.
(I) Hepatitis B.
(2) TESTS.—The tests specified in this sub-
section are as follows:
(A) 1 hematocrit.
(B) 2 blood tests to screen for blood lead
levels for individuals who are at risk for lead
exposure.
(3) CLINICIAN
VISITS.—The clinician visits
specified in this subsection are 1 clinician visit for
Title I, Subtitle B
an individual who is newborn and 7 other clinician
visits.
(c) INDIVIDUALS AGE 3 TO 5.—For an individual at
least 3 years of age, but less than 6 years of age:
(1) IMMUNIZATIONS.—The immunizations spec-
ified in this subsection are age-appropriate immuni-
zations for the following illnesses:
(A) Diphtheria.
(B) Tetanus.
(C) Pertussis.
(D) Polio.
(E) Measles.
(F) Mumps.
(G) Rubella.
(2) TESTS.—The tests specified in this sub-
section are 1 urinalysis.
(3) CLINICIAN
VISITS.—The clinician visits
specified in this subsection are 3 clinician visits.
(d) INDIVIDUALS AGE 6 TO 12.—For an individual
at least 6 years of age, but less than 13 years of age,
the clinician visits specified in this subsection are 3 clini-
cian visits.
(e) INDIVIDUALS AGE 13 TO 19.—For an individual
at least 13 years of age, but less than 20 years of age:
Title I, Subtitle B
(1) IMMUNIZATIONS.—The immunizations spec-
ified in this subsection are age-appropriate immuni-
zations for the following illnesses:
(A) Tetanus.
(B) Diphtheria.
(2) TESTS.—The tests specified in this sub-
section are as follows:
(A) Papanicolaou smears and pelvic exams,
for females who have reached childbearing age
and are at risk for cervical cancer, every 3
years, but—
(i) annually until 3 consecutive nega-
tive smears have been obtained, if medi-
cally necessary; and
(ii) annually for females who are at
risk for fertility related infectious illnesses.
(B) Annual screening for chlamydia and
gonorrhea for females who have reached child-
bearing age and are at risk for fertility related
infectious illnesses.
(3) CLINICIAN
VISITS.—The clinician visits
specified in this subsection are 3 clinician visits.
(f) INDIVIDUALS AGE 20 TO 39.—For an individual
at least 20 years of age, but less than 40 years of age:
Title I, Subtitle B
(1) IMMUNIZATIONS.—The immunizations spec-
ified in this subsection are booster immunizations
against tetanus and diphtheria every 10 years.
(2) TESTS.—The tests specified in this sub-
section are as follows:
(A) Papanicolaou smears and pelvic exams
for females every 3 years, but—
(i) annually if an abnormal smear has
been obtained, until 3 consecutive negative
smears have been obtained; and
(ii) annually for females who are at
risk for fertility related infectious illnesses.
(B) Annual screening for chlamydia and
gonorrhea for females who are at risk for fer-
tility related infectious illnesses.
(C) Cholesterol every 5 years.
(3) CLINICIAN
VISITS.—The clinician visits
specified in this subsection are 1 clinician visit every
3 years.
(g) INDIVIDUALS AGE 40 TO 49.—For an individual
at least 40 years of age, but less than 50 years of age:
(1) IMMUNIZATIONS.—The immunizations spec-
ified in this subsection are booster immunizations
against tetanus and diphtheria every 10 years.
Title I, Subtitle B
(2) TESTS.—The tests specified in this sub-
section are as follows:
(A) Papanicolaou smears and pelvic exams
for females every 2 years, but—
(i) annually if an abnormal smear has
been obtained, until 3 consecutive negative
smears have been obtained; and
(ii) annually for females who are at
risk for fertility related infectious illnesses.
(B) Annual screening for chlamydia and
gonorrhea for females who are at risk for fer-
tility related infectious illnesses.
(C) Cholesterol every 5 years.
(3) CLINICIAN
VISITS.—The clinician visits
specified in this subsection are 1 clinician visit every
2 years.
(h) INDIVIDUALS AGE 50 TO 65.—For an individual
at least 50 years of age, but less than 65 years of age:
(1) IMMUNIZATIONS.—The immunizations spec-
ified in this subsection are booster immunizations
against tetanus and diphtheria every 10 years.
(2) TESTS.—The tests specified in this sub-
section are as follows:
(A) Papanicolaou smears and pelvic exams
for females every 2 years.
Title I, Subtitle B
(B) Mammograms for females every 2
years.
(C) Cholesterol every 5 years.
(3) CLINICIAN
VISITS.—The clinician visits
specified in this subsection are 1 clinician visit every
2 years.
(i) INDIVIDUALS AGE 65 OR OLDER.—For an indi-
vidual at least 65 years of age who is enrolled under a
health plan:
(1) IMMUNIZATIONS.—The immunizations spec-
ified in this subsection are as follows:
(A) Booster immunizations against tetanus
and diphtheria every 10 years.
(B) Age-appropriate immunizations for the
following illnesses:
(i) Influenza.
(ii) Pneumococcal invasive disease.
(2) TESTS.—The tests specified in this sub-
section are as follows:
(A) Papanicolaou smears and pelvic exams
for females who are at risk for cervical cancer
every 2 years.
(B) Mammograms for females every 2
years.
(C) Cholesterol every 5 years.
Title I, Subtitle B
(3) CLINICIAN
VISITS.—The clinician visits
specified in this subsection are 1 clinician visit every
year.
(j) CLINICIAN VISIT.—For purposes of this section,
the term ‘‘clinician visit’’ includes the following health pro-
fessional services (as defined in section 1112(c)):
(1) A complete medical history.
(2) An appropriate physical examination.
(3) Risk assessment.
(4) Targeted health advice and counseling, in-
cluding nutrition counseling.
(5) The administration of age-appropriate im-
munizations and tests specified in subsections (b)
through (h).
(k) IMMUNIZATIONS AND TESTS NOT ADMINISTERED
DURING CLINICIAN VISIT.—Notwithstanding subsection
(i)(5), the clinical preventive services described in this sec-
tion include an immunization or test described in this sec-
tion that is administered to an individual consistent with
any periodicity schedule for the immunization or test dur-
ing the age range specified for the immunization or test,
and any administration fee for such immunization or test,
even if the immunization or test is not administered dur-
ing a clinician visit.
Title I, Subtitle B
SEC. 1115. MENTAL ILLNESS AND SUBSTANCE ABUSE SERV-
ICES.
(a) COVERAGE.—The mental illness and substance
abuse services that are described in this section are the
following items and services for eligible individuals, as de-
fined in section 1001(c), who satisfy the eligibility require-
ments in subsection (b):
(1) Inpatient and residential mental illness and
substance abuse treatment (described in subsection
(c)).
(2) Intensive nonresidential mental illness and
substance abuse treatment (described in subsection
(d)).
(3) Outpatient mental illness and substance
abuse treatment (described in subsection (e)), in-
cluding case management, screening and assessment,
crisis services, and collateral services.
(b) ELIGIBILITY.—The eligibility requirements re-
ferred to in subsection (a) are as follows:
(1) INPATIENT, RESIDENTIAL, NONRESIDEN-
TIAL, AND
OUTPATIENT
TREATMENT.—An eligible
individual is eligible to receive coverage for inpatient
and residential mental illness and substance abuse
treatment, intensive nonresidential mental illness
and substance abuse treatment, or outpatient mental
illness and substance abuse treatment (except case
Title I, Subtitle B
management 
and 
collateral 
services) 
if 
the
individual—
(A) has, or has had during the 1-year pe-
riod preceding the date of such treatment, a
diagnosable mental disorder or a diagnosable
substance abuse disorder; and
(B) is experiencing, or is at significant risk
of experiencing, functional impairment in fam-
ily, work, school, or community activities.
For purposes of this paragraph, an individual who
has a diagnosable mental disorder or a diagnosable
substance abuse disorder, is receiving treatment for
such disorder, but does not satisfy the functional im-
pairment criterion in subparagraph (B) shall be
treated as satisfying such criterion if the individual
would satisfy such criterion without such treatment.
(2) CASE MANAGEMENT.—An eligible individual
is eligible to receive coverage for case management
if—
(A) a health professional designated by the
health plan in which the individual is enrolled
determines that the individual should receive
such services; and
(B) the individual is eligible to receive cov-
erage for, and is receiving, outpatient mental
Title I, Subtitle B
illness and substance abuse treatment with re-
spect to a diagnosable mental disorder or a
diagnosable substance abuse disorder.
(3) SCREENING AND ASSESSMENT AND CRISIS
SERVICES.—All eligible individuals enrolled under a
health plan are eligible to receive coverage for out-
patient mental illness and substance abuse treat-
ment consisting of screening and assessment and
crisis services.
(4) COLLATERAL SERVICES.—An eligible indi-
vidual is eligible to receive coverage for outpatient
mental illness and substance abuse treatment con-
sisting of collateral services if the individual is a
family member (described in section 1011(b)) of an
individual who is receiving inpatient and residential
mental illness and substance abuse treatment, inten-
sive nonresidential mental illness and substance
abuse treatment, or outpatient mental illness and
substance abuse treatment.
(c) INPATIENT AND RESIDENTIAL TREATMENT.—
(1) DEFINITION.—For purposes of this subtitle,
the term ‘‘inpatient and residential mental illness
and substance abuse treatment’’ means the items
and services described in paragraphs (1) through (3)
of section 1861(b) of the Social Security Act when
Title I, Subtitle B
or a psychiatric hospital, as determined by a
health professional designated by the health
plan in which the individual receiving such
treatment is enrolled.
(B) 
RESIDENTIAL
SUBSTANCE
ABUSE
TREATMENT.—Such treatment, when provided
with respect to a diagnosable substance abuse
disorder in a setting that is not a hospital or
a psychiatric hospital, is covered only if a
health professional designated by the health
plan in which the individual receiving such
treatment is enrolled determines (based on cri-
teria that the plan may choose to employ) that
the individual should receive such treatment.
(C) LEAST RESTRICTIVE SETTING.—Such
treatment is covered only when—
(i) provided to an individual in the
least restrictive inpatient or residential set-
ting that is effective and appropriate for
the individual; and
(ii) less restrictive intensive nonresi-
dential or outpatient treatment would be
ineffective or inappropriate.
(D) ANNUAL LIMIT.—Prior to January 1,
2001, such treatment is subject to an aggregate
Title I, Subtitle B
annual limit of 30 days. A maximum of 30 ad-
ditional days of such treatment shall be covered
for an individual if a health professional des-
ignated by the health plan in which the indi-
vidual is enrolled determines in advance that—
(i) the individual poses a threat to his
or her own life or the life of another indi-
vidual; or
(ii) the medical condition of the indi-
vidual requires inpatient treatment in a
hospital or a psychiatric hospital in order
to initiate, change, or adjust pharma-
cological or somatic therapy.
(E) INPATIENT
HOSPITAL
TREATMENT
FOR
SUBSTANCE
ABUSE.—Such 
treatment,
when provided in a hospital or a psychiatric
hospital with respect to a diagnosable substance
abuse disorder, is covered under this section
only for detoxification requiring the manage-
ment of psychiatric conditions associated with
withdrawal from alcohol or drugs. The items
and services described in this section do not in-
clude medical detoxification as required for the
management of medical conditions associated
Title I, Subtitle B
with withdrawal from alcohol or drugs (which is
covered under section 1111).
(d) INTENSIVE NONRESIDENTIAL TREATMENT.—
(1) DEFINITION.—For purposes of this subtitle,
the term ‘‘intensive nonresidential mental illness and
substance abuse treatment’’ means diagnostic or
therapeutic items or services provided with respect
to a diagnosable mental disorder or a diagnosable
substance abuse disorder to an individual—
(A) participating in a partial hospitaliza-
tion program, a day treatment program, a psy-
chiatric rehabilitation program, or an ambula-
tory detoxification program; or
(B) receiving home-based mental illness
services or behavioral aide mental illness serv-
ices.
The National Health Board shall specify those
health professional services described in section 1112
that shall be treated as intensive nonresidential men-
tal illness and substance abuse treatment when pro-
vided to such an individual.
(2) LIMITATIONS.—Coverage for intensive non-
residential mental illness and substance abuse treat-
ment is subject to the following limitations:
Title I, Subtitle B
(A) DISCRETION OF PLAN.—An individual
shall receive coverage for such treatment if a
health professional designated by the health
plan in which the individual is enrolled deter-
mines (based on criteria that the plan may
choose to employ) that the individual should re-
ceive such treatment.
(B) TREATMENT PURPOSES.—Such treat-
ment is covered only when provided—
(i) to avert the need for, or as an al-
ternative to, treatment in residential or in-
patient settings;
(ii) to facilitate the earlier discharge
of an individual receiving inpatient or resi-
dential care;
(iii) to restore the functioning of an
individual with a diagnosable mental dis-
order or a diagnosable substance abuse
disorder; or
(iv) to assist such an individual to de-
velop the skills and gain access to the sup-
port services the individual needs to
achieve the maximum level of functioning
of the individual within the community.
(C) ANNUAL LIMIT.—
Title I, Subtitle B
(i) IN GENERAL.—Prior to January 1,
2001, the number of covered days of inpa-
tient and residential mental illness and
substance abuse treatment that are avail-
able to an individual under the 30-day
limit described in the first sentence of sub-
section (c)(2)(D) shall be reduced by 1 day
for each 2 covered days of intensive non-
residential mental illness and substance
abuse treatment that are provided to the
individual, until such number is reduced to
zero.
(ii) ADDITIONAL
DAYS.—After the
number of covered days referred to in
clause (i) has been reduced to zero with re-
spect to an individual, the individual shall
receive coverage for a maximum of 60 days
of intensive nonresidential mental illness
and substance abuse treatment if a health
professional designated by the health plan
in which the individual is enrolled deter-
mines that the individual should receive
such treatment.
(D) DETOXIFICATION.—Intensive nonresi-
dential mental illness and substance abuse
Title I, Subtitle B
treatment consisting of detoxification is covered
only if it is provided in the context of a treat-
ment program.
(E) OUT-OF-POCKET MAXIMUM.—Prior to
January 1, 2001, expenses for intensive non-
residential mental illness and substance abuse
treatment that an individual incurs prior to sat-
isfying a deductible applicable to such treat-
ment, and copayments and coinsurance paid by
or on behalf of the individual for such treat-
ment, may not be applied toward any annual
out-of-pocket limit on cost sharing under any
cost sharing schedule described in part 3 of this
subtitle if such treatment is provided—
(i) with respect to a diagnosable sub-
stance abuse disorder; or
(ii) pursuant to subparagraph (C)(ii).
(e) OUTPATIENT TREATMENT.—
(1) DEFINITION.—For purposes of this subtitle,
the term ‘‘outpatient mental illness and substance
abuse treatment’’ means the following services pro-
vided with respect to a diagnosable mental disorder
or a diagnosable substance abuse disorder in an out-
patient setting:
(A) Screening and assessment.
Title I, Subtitle B
(B) Diagnosis.
(C) Medical management.
(D) Substance abuse counseling and re-
lapse prevention.
(E) Crisis services.
(F) Somatic treatment services.
(G) Psychotherapy.
(H) Case management.
(I) Collateral services.
(2) LIMITATIONS.—Coverage for outpatient
mental illness and substance abuse treatment is sub-
ject to the following limitations:
(A) HEALTH PROFESSIONAL SERVICES.—
Such treatment is covered only when it con-
stitutes health professional services (as defined
in section 1112(c)(2)).
(B) DISCRETION OF PLAN.—An individual
shall receive coverage for outpatient mental ill-
ness and substance abuse treatment consisting
of substance abuse counseling and relapse pre-
vention if a health professional designated by
the health plan in which the individual is en-
rolled determines (based on criteria that the
plan may choose to employ) that the individual
should receive such treatment. This subpara-
Title I, Subtitle B
graph does not apply to group therapy covered
pursuant to subparagraph (C)(ii)(II).
(C) ANNUAL LIMITS.—
(i) PSYCHOTHERAPY
AND
COLLAT-
ERAL
SERVICES.—Prior to January 1,
2001, psychotherapy and collateral services
are subject to an aggregate annual limit of
30 visits per individual. Additional visits
may be covered, at the discretion of the
health plan in which the individual receiv-
ing treatment is enrolled, to prevent hos-
pitalization or to facilitate earlier hospital
release, for which the number of covered
days of inpatient and residential mental ill-
ness and substance abuse treatment that
are available to an individual under the 30-
day limit described in the first sentence of
subsection (c)(2)(D) shall be reduced by 1
day for each 4 visits. After such number
has been reduced to zero, no additional vis-
its under the preceding sentence may be
covered.
(ii) SUBSTANCE ABUSE COUNSELING
AND RELAPSE PREVENTION.—
Title I, Subtitle B
(I) IN GENERAL.—Except as pro-
vided in subclause (II), the number of
covered days of inpatient and residen-
tial mental illness and substance
abuse treatment that are available to
an individual under the 30-day limit
described in the first sentence of sub-
section (c)(2)(D) shall be reduced by
1 day for each 4 visits for substance
abuse counseling and relapse preven-
tion that are covered for the indi-
vidual under subparagraph (B). After
such number has been reduced to
zero, no visits for substance abuse
counseling and relapse prevention may
be covered, except as provided in sub-
clause (II).
(II) GROUP THERAPY.—Prior to
January 1, 2001, substance abuse
counseling and relapse prevention con-
sisting of group therapy is subject to
a separate aggregate annual limit of
30 visits, if such therapy occurs with-
in 12 months after the individual has
received, with respect to a diagnosable
Title I, Subtitle B
substance abuse disorder, inpatient
and residential mental illness and sub-
stance abuse treatment or intensive
nonresidential mental illness and sub-
stance abuse treatment. The provi-
sions of clause (i) and subclause (I)
do not apply to therapy that is de-
scribed in the preceding sentence.
(D) DETOXIFICATION.—Outpatient mental
illness and substance abuse treatment con-
sisting of detoxification is covered only if it is
provided in the context of a treatment program.
(E) OUT-OF-POCKET MAXIMUM.—Prior to
January 1, 2001, expenses for outpatient men-
tal illness and substance abuse treatment that
an individual incurs prior to satisfying a de-
ductible applicable to such treatment, and co-
payments and coinsurance paid by or on behalf
of the individual for such treatment, may not be
applied toward any annual out-of-pocket limit
on cost sharing under any cost sharing schedule
described in part 3 of this subtitle.
(f) OTHER DEFINITIONS.—For purposes of this sub-
title:
Title I, Subtitle B
(1) CASE MANAGEMENT.—The term ‘‘case man-
agement’’ means services that assist individuals in
gaining access to needed medical, social, educational,
and other services.
(2) DIAGNOSABLE
MENTAL
DISORDER
AND
DIAGNOSABLE SUBSTANCE ABUSE DISORDER.—The
terms 
‘‘diagnosable 
mental 
disorder’’ 
and
‘‘diagnosable substance abuse disorder’’ mean a dis-
order that—
(A) is listed in the Diagnostic and Statis-
tical Manual of Mental Disorders, Third Edi-
tion, Revised or a revised version of such man-
ual (except V Codes for Conditions Not Attrib-
utable to a Mental Disorder That Are a Focus
of Attention or Treatment);
(B) is the equivalent of a disorder de-
scribed in subparagraph (A), but is listed in the
International Classification of Diseases, 9th Re-
vision, Clinical Modification, Third Edition or a
revised version of such text; or
(C) is listed in any authoritative text speci-
fying diagnostic criteria for mental disorders or
substance abuse disorders that is identified by
the National Health Board.
Title I, Subtitle B
(3) PSYCHIATRIC HOSPITAL.—The term ‘‘psy-
chiatric hospital’’ has the meaning given such term
in section 1861(f) of the Social Security Act, except
that such term shall include—
(A) in the case of an item or service pro-
vided to an individual whose applicable health
plan is specified pursuant to section 1004(b)(1),
a facility of the uniformed services under title
10, United States Code, that is engaged in pro-
viding services to inpatients that are equivalent
to the services provided by a psychiatric hos-
pital;
(B) in the case of an item or service pro-
vided to an individual whose applicable health
plan is specified pursuant to section 1004(b)(2),
a facility operated by the Department of Vet-
erans Affairs that is engaged in providing serv-
ices to inpatients that are equivalent to the
services provided by a psychiatric hospital; and
(C) in the case of an item or service pro-
vided to an individual whose applicable health
plan is specified pursuant to section 1004(b)(3),
a facility operated by the Indian Health Service
that is engaged in providing services to inpa-
Title I, Subtitle B
tients that are equivalent to the services pro-
vided by a psychiatric hospital.
SEC. 1116. FAMILY PLANNING SERVICES AND SERVICES
FOR PREGNANT WOMEN.
The services described in this section are the fol-
lowing items and services:
(1) Voluntary family planning services.
(2) Contraceptive devices that—
(A) may only be dispensed upon prescrip-
tion; and
(B) are subject to approval by the Sec-
retary of Health and Human Services under the
Federal Food, Drug, and Cosmetic Act.
(3) Services for pregnant women.
SEC. 1117. HOSPICE CARE.
The hospice care described in this section is the items
and services described in paragraph (1) of section
1861(dd) of the Social Security Act, as defined in para-
graphs (2), (3), and (4)(A) of such section (with the ex-
ception of paragraph (2)(A)(iii)), except that all references
to the Secretary of Health and Human Services in such
paragraphs shall be treated as references to the National
Health Board.
Title I, Subtitle B
SEC. 1118. HOME HEALTH CARE.
(a) COVERAGE.—The home health care described in
this section is—
(1) the items and services described in section
1861(m) of the Social Security Act; and
(2) home infusion drug therapy services de-
scribed in section 1861(ll) of the Social Security Act
(as inserted by section 2005).
(b) LIMITATIONS.—Coverage for home health care is
subject to the following limitations:
(1) INPATIENT
TREATMENT
ALTERNATIVE.—
Such care is covered only as an alternative to inpa-
tient treatment in a hospital, skilled nursing facility,
or rehabilitation facility after an illness or injury.
(2) REEVALUATION.—At the end of each 60-
day period of home health care, the need for contin-
ued care shall be reevaluated by the person who is
primarily responsible for providing the home health
care. Additional periods of care are covered only if
such person determines that the requirement in
paragraph (1) is satisfied.
SEC. 1119. EXTENDED CARE SERVICES.
(a) COVERAGE.—The extended care services de-
scribed in this section are the items and services described
in section 1861(h) of the Social Security Act when pro-
Title I, Subtitle B
vided to an inpatient of a skilled nursing facility or a reha-
bilitation facility.
(b) LIMITATIONS.—Coverage for extended care serv-
ices is subject to the following limitations:
(1) HOSPITAL
ALTERNATIVE.—Such services
are covered only as an alternative to inpatient treat-
ment in a hospital after an illness or injury.
(2) ANNUAL LIMIT.—Such services are subject
to an aggregate annual limit of 100 days.
(c) DEFINITIONS.—For purposes of this subtitle:
(1) REHABILITATION FACILITY.—The term ‘‘re-
habilitation facility’’ means an institution (or a dis-
tinct part of an institution) which is established and
operated for the purpose of providing diagnostic,
therapeutic, and rehabilitation services to individuals
for rehabilitation from illness or injury.
(2) SKILLED
NURSING
FACILITY.—The term
‘‘skilled nursing facility’’ means an institution (or a
distinct part of an institution) which is primarily en-
gaged in providing to residents—
(A) skilled nursing care and related serv-
ices for residents who require medical or nurs-
ing care; or
(B) rehabilitation services to residents for
rehabilitation from illness or injury.