113 
sistent with the State health security budget for 
such expenditures. 
(3) PROVISION OF REQUIRED INFORMATION; DI-
AGNOSIS-RELATED GROUP.—No budget for an insti-
tution or facility for a year may be approved unless 
the institution or facility has submitted on a timely 
basis to the State health security program such in-
formation as the program or the Board shall specify, 
including in the case of hospitals information on dis-
charges classified by diagnosis-related group. 
(c) ADJUSTMENTS IN APPROVED BUDGETS.— 
(1) ADJUSTMENTS TO GLOBAL BUDGETS THAT 
CONTRACT WITH COMPREHENSIVE HEALTH SERVICE 
ORGANIZATIONS.—Each State health security pro-
gram shall develop an administrative mechanism for 
reducing operating funds to institutions or facilities 
in proportion to payments made to such institutions 
or facilities for services contracted for by a com-
prehensive health service organization. 
(2) AMENDMENTS.—In accordance with stand-
ards established by the Board, an operating and 
capital budget approved under this section for a year 
may be amended before, during, or after the year if 
there is a substantial change in any of the factors 
relevant to budget approval.
114 
(d) DONATIONS PERMISSIBLE.—The States health 
security programs may permit institutions and facilities 
to raise funds from private sources to pay for newly con-
structed facilities, major renovations, and equipment. The 
expenditure of such funds, whether for operating or cap-
ital expenditures, does not obligate the State health secu-
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
115 
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 
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
116 
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-
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
117 
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 
number of medically underserved individuals, of pop-
ulations served by the organization. 
(3) ADJUSTMENT
FOR
SERVICES
NOT
PRO-
VIDED.—The State health security program shall ad-
just such average amounts to take into account the 
cost of covered health care services that are not pro-
vided by the comprehensive health service organiza-
tion under section 303(a). 
SEC. 614. PAYMENTS FOR COMMUNITY-BASED PRIMARY 
HEALTH SERVICES. 
(a) IN GENERAL.—In the case of community-based 
primary health services, subject to subsection (b), pay-
ments under a State health security program shall— 
(1) be based on a global budget described in 
section 611; 
(2) be based on the basic primary care capita-
tion amount described in subsection (c) for each in-
dividual enrolled with the provider of such services; 
or
118 
(3) be made on a fee-for-service basis under 
section 612. 
(b) PAYMENT ADJUSTMENT.—Payments under sub-
section (a) may include, consistent with the budgets devel-
oped under this title— 
(1) an additional amount, as set by the State 
health security program, to cover the costs incurred 
by a provider which serves persons not covered by 
this Act whose health care is essential to overall 
community health and the control of communicable 
disease, and for whom the cost of such care is other-
wise uncompensated; 
(2) an additional amount, as set by the State 
health security program, to cover the reasonable 
costs incurred by a provider that furnishes case 
management 
services 
(as 
defined 
in 
section 
1915(g)(2) of the Social Security Act), transpor-
tation services, and translation services; and 
(3) an additional amount, as set by the State 
health security program, to cover the costs incurred 
by a provider in conducting health professional edu-
cation programs in connection with the provision of 
such services. 
(c) BASIC PRIMARY CARE CAPITATION AMOUNT.—
119 
(1) IN GENERAL.—The basic primary care capi-
tation amount described in this subsection for an en-
rollee with a provider of community-based primary 
health services 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 
such an enrollee, based on actuarial characteristics 
(as defined 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 
number of medically underserved individuals, of pop-
ulations served by the provider. 
(3) ADJUSTMENT
FOR
SERVICES
NOT
PRO-
VIDED.—The State health security program shall ad-
just such average amounts to take into account the 
cost of community-based primary health services 
that are not provided by the provider. 
(d) COMMUNITY-BASED PRIMARY HEALTH SERVICES 
DEFINED.—In this section, the term ‘‘community-based 
primary health services’’ has the meaning given such term 
in section 202(a).