year equal to the difference between the 
total number of days of intensive residen-
tial services which the individual may re-
ceive during the year under part A (as de-
termined under subparagraph (B)) and the 
number of days of such services which the 
individual has received during the year; or 
(iii) in the case of any other such 
services, for up to 90 days during any cal-
endar year, except that such services may 
be furnished to the individual for the num-
ber of additional days during the year de-
scribed in clause (ii). 
(2) INTENSIVE
RESIDENTIAL
SERVICES
DE-
FINED.— 
(A) IN
GENERAL.—Subject to subpara-
graphs (B) and (C), the term ‘‘intensive resi-
dential services’’ means inpatient services pro-
vided in any of the following facilities: 
(i) Residential detoxification centers. 
(ii) Crisis residential programs or 
mental illness residential treatment pro-
grams. 
(iii) Therapeutic family or group 
treatment homes. 
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(iv) Residential centers for substance 
abuse treatment. 
(B) REQUIREMENTS FOR FACILITIES.—No 
service may be treated as an intensive residen-
tial service under subparagraph (A) unless the 
facility at which the service is provided— 
(i) is legally authorized to provide 
such service under the law of the State (or 
under a State regulatory mechanism pro-
vided by State law) in which the facility is 
located or is certified to provide such serv-
ice by an appropriate accreditation entity 
approved by the State in consultation with 
the Secretary; and 
(ii) meets such other requirements as 
the Secretary may impose to assure the 
quality of the intensive residential services 
provided. 
(C) SERVICES
FURNISHED
TO
AT-RISK 
CHILDREN.—In the case of services furnished 
to an individual described in section 204(b)(1), 
no service may be treated as an intensive resi-
dential service under this subsection unless the 
service is furnished in conformity with the plan 
of an organized system of care for mental 
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health and substance abuse services in accord-
ance with section 204(b)(2). 
(D) MANAGEMENT STANDARDS.—No serv-
ice may be treated as an intensive residential 
service under subparagraph (A) unless the serv-
ice is furnished in accordance with standards 
established by the Secretary for the manage-
ment of such services. 
(3) INTENSIVE
COMMUNITY-BASED
SERVICES 
DEFINED.— 
(A) IN
GENERAL.—The term ‘‘intensive 
community-based services’’ means the items 
and services described in subparagraph (B) pre-
scribed by a physician (or, in the case of serv-
ices furnished to an individual described in sec-
tion 204(b)(1), by an organized system of care 
for mental health and substance abuse services 
in accordance with such section) and provided 
under a program described in subparagraph 
(D) under the supervision of a physician (or, to 
the extent permitted under the law of the State 
in which the services are furnished, a non-phy-
sician mental health professional) pursuant to 
an individualized, written plan of treatment es-
tablished and periodically reviewed by a physi-
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cian (in consultation with appropriate staff par-
ticipating in such program) which sets forth the 
physician’s diagnosis, the type, amount, fre-
quency, and duration of the items and services 
provided under the plan, and the goals for 
treatment under the plan, but does not include 
any item or service that is not furnished in ac-
cordance with standards established by the Sec-
retary for the management of such services. 
(B) ITEMS AND SERVICES DESCRIBED.— 
The items and services described in this sub-
paragraph are— 
(i) partial hospitalization services con-
sisting of the items and services described 
in subparagraph (C); 
(ii) psychiatric rehabilitation services; 
(iii) day treatment services for indi-
viduals under 19 years of age; 
(iv) in-home services; 
(v) case management services, includ-
ing collateral services designated as such 
case management services by the Sec-
retary; 
(vi) ambulatory detoxification services; 
and 
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(vii) such other items and services as 
the Secretary may provide (but in no event 
to include meals and transportation), 
that are reasonable and necessary for the diag-
nosis or active treatment of the individual’s 
condition, reasonably expected to improve or 
maintain the individual’s condition and func-
tional level and to prevent relapse or hos-
pitalization, and furnished pursuant to such 
guidelines relating to frequency and duration of 
services as the Secretary shall by regulation es-
tablish (taking into account accepted norms of 
medical practice and the reasonable expectation 
of patient improvement). 
(C) ITEMS
AND
SERVICES
INCLUDED
AS 
PARTIAL
HOSPITALIZATION
SERVICES.—For 
purposes of subparagraph (B)(i), partial hos-
pitalization services consist of the following: 
(i) Individual and group therapy with 
physicians or psychologists (or other men-
tal health professionals to the extent au-
thorized under State law). 
(ii) Occupational therapy requiring 
the skills of a qualified occupational thera-
pist. 
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(iii) Services of social workers, trained 
psychiatric nurses, behavioral aides, and 
other staff trained to work with psychiatric 
patients (to the extent authorized under 
State law). 
(iv) Drugs and biologicals furnished 
for therapeutic purposes (which cannot, as 
determined in accordance with regulations, 
be self-administered). 
(v) Individualized activity therapies 
that are not primarily recreational or di-
versionary. 
(vi) Family counseling (the primary 
purpose of which is treatment of the indi-
vidual’s condition). 
(vii) Patient training and education 
(to the extent that training and edu-
cational activities are closely and clearly 
related to the individual’s care and treat-
ment). 
(viii) Diagnostic services. 
(D) PROGRAMS
DESCRIBED.—A program 
described in this subparagraph is a program 
(whether facility-based or freestanding) which is 
furnished by an entity— 
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(i) legally authorized to furnish such a 
program under State law (or the State reg-
ulatory mechanism provided by State law) 
or certified to furnish such a program by 
an appropriate accreditation entity ap-
proved by the State in consultation with 
the Secretary; and 
(ii) meeting such other requirements 
as the Secretary may impose to assure the 
quality of the intensive community-based 
services provided. 
(g) CARE COORDINATION SERVICES.— 
(1) IN GENERAL.—In this title, the term ‘‘care 
coordination services’’ means services provided by 
care coordinators (as defined in paragraph (2)) to 
individuals described in paragraph (3) for the co-
ordination and monitoring of home and community- 
based long term care services to ensure appropriate, 
cost-effective utilization of such services in a com-
prehensive and continuous manner, and includes— 
(A) transition management between inpa-
tient facilities and community-based services, 
including assisting patients in identifying and 
gaining access to appropriate ancillary services; 
and 
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(B) evaluating and recommending appro-
priate treatment services, in cooperation with 
patients and other providers and in conjunction 
with any quality review program or plan of care 
under section 205. 
(2) CARE COORDINATOR.— 
(A) IN GENERAL.—In this title, the term 
‘‘care coordinator’’ means an individual or non-
profit or public agency or organization which 
the State health security program determines— 
(i) is capable of performing directly, 
efficiently, and effectively the duties of a 
care coordinator described in paragraph 
(1); and 
(ii) demonstrates capability in estab-
lishing and periodically reviewing and re-
vising plans of care, and in arranging for 
and monitoring the provision and quality 
of services under any plan. 
(B) INDEPENDENCE.—State health secu-
rity programs shall establish safeguards to as-
sure that care coordinators have no financial in-
terest in treatment decisions or placements. 
Care coordination may not be provided through 
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any structure or mechanism through which 
quality review is performed. 
(3) ELIGIBLE INDIVIDUALS.—An individual de-
scribed in this paragraph is an individual described 
in section 203 (relating to individuals qualifying for 
long term and chronic care services). 
(h) DENTAL SERVICES.— 
(1) IN GENERAL.—In this title, subject to sub-
section (b), the term ‘‘dental services’’ means the 
following: 
(A) Emergency dental treatment, including 
extractions, for bleeding, pain, acute infections, 
and injuries to the maxillofacial region. 
(B) Prevention and diagnosis of dental dis-
ease, including examinations of the hard and 
soft tissues of the oral cavity and related struc-
tures, radiographs, dental sealants, fluorides, 
and dental prophylaxis. 
(C) Treatment of dental disease, including 
non-cast fillings, periodontal maintenance serv-
ices, and endodontic services. 
(D) Space maintenance procedures to pre-
vent orthodontic complications. 
(E) Orthodontic treatment to prevent se-
vere malocclusions. 
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(F) Full dentures. 
(G) Medically necessary oral health care. 
(H) Any items and services for special 
needs patients that are not described in sub-
paragraphs (A) through (G) and that— 
(i) are required to provide such pa-
tients the items and services described in 
subparagraphs (A) through (G); 
(ii) are required to establish oral func-
tion (including general anesthesia for indi-
viduals with physical or emotional limita-
tions that prevent the provision of dental 
care without such anesthesia); 
(iii) consist of orthodontic care for se-
vere dentofacial abnormalities; or 
(iv) consist of prosthetic dental de-
vices for genetic or birth defects or fitting 
for such devices. 
(I) Any dental care for individuals with a 
seizure disorder that is not described in sub-
paragraphs (A) through (H) and that is re-
quired because of an illness, injury, disorder, or 
other health condition that results from such 
seizure disorder. 
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(2) LIMITATIONS.—Dental services are subject 
to the following limitations: 
(A) PREVENTION AND DIAGNOSIS.— 
(i) 
EXAMINATIONS
AND
PROPHY-
LAXIS.—The examinations and prophylaxis 
described in paragraph (1)(B) are covered 
only consistent with a periodicity schedule 
established by the Board, which schedule 
may provide for special treatment of indi-
viduals less than 18 years of age and of 
special needs patients. 
(ii) DENTAL SEALANTS.—The dental 
sealants described in such paragraph are 
not covered for individuals 18 years of age 
or older. Such sealants are covered for in-
dividuals less than 10 years of age for pro-
tection of the 1st permanent molars. Such 
sealants are covered for individuals 10 
years of age or older for protection of the 
2d permanent molars. 
(B) TREATMENT OF DENTAL DISEASE.— 
Prior to January 1, 2014, the items and serv-
ices described in paragraph (1)(C) are covered 
only for individuals less than 18 years of age 
and special needs patients. On or after such 
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date, such items and services are covered for all 
individuals enrolled for benefits under this Act, 
except that endodontic services are not covered 
for individuals 18 years of age or older. 
(C) SPACE MAINTENANCE.—The items and 
services described in paragraph (1)(D) are cov-
ered only for individuals at least 3 years of age, 
but less than 13 years of age and— 
(i) are limited to posterior teeth; 
(ii) involve maintenance of a space or 
spaces for permanent posterior teeth that 
would otherwise be prevented from normal 
eruption if the space were not maintained; 
and 
(iii) do not include a space maintainer 
that is placed within 6 months of the ex-
pected eruption of the permanent posterior 
tooth concerned. 
(D) ORTHODONTIC TREATMENT.—Prior to 
January 1, 2014, the items and services de-
scribed in paragraph (1)(E) are covered only 
for individuals at least 6 years of age, but less 
than 12 years of age, who have severe 
dentofacial abnormalities. On or after such 
date, such items and services are covered only 
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for individuals at least 6 years of age, but less 
than 12 years of age. 
(E) DENTURES.—Prior to January 1, 
2014, the dentures described in paragraph 
(1)(F) are not covered, except for special needs 
patients. On or after such date, dentures are 
covered for an individual consistent with a peri-
odicity schedule established by the Board, ex-
cept that the limitation of periodicity provided 
in such schedule shall not apply to a special 
needs patient. 
(3) DEFINITIONS.—For purposes of this title: 
(A) MEDICALLY NECESSARY ORAL HEALTH 
CARE.—The term ‘‘medically necessary oral 
health care’’ means oral health care that is re-
quired as a direct result of, or would have a di-
rect impact on, an underlying medical condi-
tion. Such term includes oral health care di-
rected toward control or elimination of pain, in-
fection, or reestablishment of oral function. 
(B) SPECIAL NEEDS PATIENT.—The term 
‘‘special needs patient’’ includes an individual 
with a genetic or birth defect, a developmental 
disability, or an acquired medical disability. 
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(i) NURSING FACILITY; NURSING FACILITY SERV-
ICES.—Except as may be provided by the Board, the 
terms ‘‘nursing facility’’ and ‘‘nursing facility services’’ 
have the meanings given such terms in sections 1919(a) 
and 1905(f), respectively, of the Social Security Act. 
(j) SERVICES IN INTERMEDIATE CARE FACILITIES 
FOR INDIVIDUALS WITH MENTAL RETARDATION.—Ex-
cept as may be provided by the Board— 
(1) the term ‘‘intermediate care facility for indi-
viduals with mental retardation’’ has the meaning 
specified in section 1905(d) of the Social Security 
Act (as in effect before the enactment of this Act); 
and 
(2) the term ‘‘services in intermediate care fa-
cilities for individuals with mental retardation’’ 
means services described in section 1905(a)(15) of 
such Act (as so in effect) in an intermediate care fa-
cility for individuals with mental retardation to an 
individual determined to require such services in ac-
cordance with standards specified by the Board and 
comparable to the standards described in section 
1902(a)(31)(A) of such Act (as so in effect). 
(k) OTHER TERMS.—Except as may be provided by 
the Board, the definitions contained in section 1861 of the 
Social Security Act shall apply. 
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SEC. 203. SPECIAL RULES FOR HOME AND COMMUNITY- 
BASED LONG-TERM CARE SERVICES. 
(a) QUALIFYING INDIVIDUALS.—For purposes of sec-
tion 201(a)(5)(C), individuals described in this subsection 
are the following individuals: 
(1) ADULTS.—Individuals 18 years of age or 
older determined (in a manner specified by the 
Board)— 
(A) to be unable to perform, without the 
assistance of an individual, at least 2 of the fol-
lowing 5 activities of daily living (or who has a 
similar level of disability due to cognitive im-
pairment)— 
(i) bathing; 
(ii) eating; 
(iii) dressing; 
(iv) toileting; and 
(v) transferring in and out of a bed or 
in and out of a chair; 
(B) due to cognitive or mental impair-
ments, to require supervision because the indi-
vidual behaves in a manner that poses health or 
safety hazards to himself or herself or others; 
or 
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(C) due to cognitive or mental impair-
ments, to require queuing to perform activities 
of daily living. 
(2) CHILDREN.—Individuals under 18 years of 
age determined (in a manner specified by the Board) 
to meet such alternative standard of disability for 
children as the Board develops. Such alternative 
standard shall be comparable to the standard for 
adults and appropriate for children. 
(b) LIMIT ON SERVICES.— 
(1) IN GENERAL.—The aggregate expenditures 
by a State health security program with respect to 
home and community-based long-term care services 
in a period (specified by the Board) may not exceed 
65 percent (or such alternative ratio as the Board 
establishes under paragraph (2)) of the average of 
the amount of payment that would have been made 
under the program during the period if all the home- 
based long-term care beneficiaries had been resi-
dents of nursing facilities in the same area in which 
the services were provided. 
(2) ALTERNATIVE RATIO.—The Board may es-
tablish for purposes of paragraph (1) an alternative 
ratio (of payments for home and community-based 
long term care services to payments for nursing fa-
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cility services) as the Board determines to be more 
consistent with the goal of providing cost-effective 
long-term care in the most appropriate and least re-
strictive setting. 
SEC. 204. EXCLUSIONS AND LIMITATIONS. 
(a) IN GENERAL.—Subject to section 201(e), benefits 
for service are not available under this Act unless the serv-
ices meet the standards specified in section 201(a). 
(b) SPECIAL DELIVERY REQUIREMENTS FOR MEN-
TAL HEALTH AND SUBSTANCE ABUSE TREATMENT SERV-
ICES PROVIDED TO AT-RISK CHILDREN.— 
(1) REQUIRING
SERVICES
TO
BE
PROVIDED 
THROUGH ORGANIZED SYSTEMS OF CARE.—A State 
health security program shall ensure that mental 
health services and substance abuse treatment serv-
ices are furnished through an organized system of 
care, as described in paragraph (2), if— 
(A) the services are provided to an indi-
vidual less than 22 years of age; 
(B) the individual has a serious emotional 
disturbance or a substance abuse disorder; and 
(C) the individual is, or is at imminent risk 
of being, subject to the authority of, or in need 
of the services of, at least 1 public agency that 
serves the needs of children, including an agen-
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cy involved with child welfare, special education, 
juvenile justice, or criminal justice. 
(2) REQUIREMENTS FOR SYSTEM OF CARE.—In 
this subsection, an ‘‘organized system of care’’ is a 
community-based service delivery network, which 
may consist of public and private providers, that 
meets the following requirements: 
(A) The system has established linkages 
with existing mental health services and sub-
stance abuse treatment service delivery pro-
grams in the plan service area (or is in the 
process of developing or operating a system 
with appropriate public agencies in the area to 
coordinate the delivery of such services to indi-
viduals in the area). 
(B) The system provides for the participa-
tion and coordination of multiple agencies and 
providers that serve the needs of children in the 
area, including agencies and providers involved 
with child welfare, education, juvenile justice, 
criminal justice, health care, mental health, and 
substance abuse prevention and treatment. 
(C) The system provides for the involve-
ment of the families of children to whom mental 
health services and substance abuse treatment 
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services are provided in the planning of treat-
ment and the delivery of services. 
(D) The system provides for the develop-
ment and implementation of individualized 
treatment plans by multidisciplinary and multi-
agency teams, which are recognized and fol-
lowed by the applicable agencies and providers 
in the area. 
(E) The system ensures the delivery and 
coordination of the range of mental health serv-
ices and substance abuse treatment services re-
quired by individuals under 22 years of age who 
have a serious emotional disturbance or a sub-
stance abuse disorder. 
(F) The system provides for the manage-
ment of the individualized treatment plans de-
scribed in subparagraph (D) and for a flexible 
response to changes in treatment needs over 
time. 
(c) TREATMENT OF EXPERIMENTAL SERVICES.—In 
applying subsection (a), the Board shall make national 
coverage determinations with respect to those services that 
are experimental in nature. Such determinations shall be 
made consistent with a process that provides for input 
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from representatives of health care professionals and pa-
tients and public comment. 
(d) APPLICATION
OF PRACTICE GUIDELINES.—In 
the case of services for which the American Health Secu-
rity Quality Council (established under section 501) has 
recognized a national practice guideline, the services are 
considered to meet the standards specified in section 
201(a) if they have been provided in accordance with such 
guideline or in accordance with such guidelines as are pro-
vided by the State health security program consistent with 
title V. For purposes of this subsection, a service shall 
be considered to have been provided in accordance with 
a practice guideline if the health care provider providing 
the service exercised appropriate professional discretion to 
deviate from the guideline in a manner authorized or an-
ticipated by the guideline. 
(e) SPECIFIC LIMITATIONS.— 
(1) LIMITATIONS
ON
EYEGLASSES, CONTACT 
LENSES, HEARING
AIDS, AND
DURABLE
MEDICAL 
EQUIPMENT.—Subject to section 201(e), the Board 
may impose such limits relating to the costs and fre-
quency of replacement of eyeglasses, contact lenses, 
hearing aids, and durable medical equipment to 
which individuals enrolled for benefits under this Act 
are entitled to have payment made under a State 
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health security program as the Board deems appro-
priate. 
(2) OVERLAP WITH PREVENTIVE SERVICES.— 
The coverage of services described in section 201(a) 
(other than paragraph (3)) which also are preventive 
services are required to be covered only to the extent 
that they are required to be covered as preventive 
services. 
(3) MISCELLANEOUS EXCLUSIONS FROM COV-
ERED SERVICES.—Covered services under this Act 
do not include the following: 
(A) Surgery and other procedures (such as 
orthodontia) performed solely for cosmetic pur-
poses (as defined in regulations) and hospital or 
other services incident thereto, unless— 
(i) required to correct a congenital 
anomaly; 
(ii) required to restore or correct a 
part of the body which has been altered as 
a result of accidental injury, disease, or 
surgery; or 
(iii) otherwise determined to be medi-
cally necessary and appropriate under sec-
tion 201(a). 
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(B) Personal comfort items or private 
rooms in inpatient facilities, unless determined 
to be medically necessary and appropriate 
under section 201(a). 
(C) The services of a professional practi-
tioner if they are furnished in a hospital or 
other facility which is not a participating pro-
vider. 
(f) NURSING
FACILITY
SERVICES
AND
HOME 
HEALTH SERVICES.—Nursing facility services and home 
health services (other than post-hospital services, as de-
fined by the Board) furnished to an individual who is not 
described in section 203(a) are not covered services unless 
the services are determined to meet the standards speci-
fied in section 201(a) and, with respect to nursing facility 
services, to be provided in the least restrictive and most 
appropriate setting. 
SEC. 205. CERTIFICATION; QUALITY REVIEW; PLANS OF 
CARE. 
(a) CERTIFICATIONS.—State health security pro-
grams may require, as a condition of payment for institu-
tional health care services and other services of the type 
described in such sections 1814(a) and 1835(a) of the So-
cial Security Act, periodic professional certifications of the 
kind described in such sections. 
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(b) QUALITY REVIEW.—For requirement that each 
State health security program establish a quality review 
program that meets the requirements for such a program 
under title V, see section 404(b)(1)(H). 
(c) PLAN OF CARE REQUIREMENTS.—A State health 
security program may require, consistent with standards 
established by the Board, that payment for services ex-
ceeding specified levels or duration be provided only as 
consistent with a plan of care or treatment formulated by 
one or more providers of the services or other qualified 
professionals. Such a plan may include, consistent with 
subsection (b), case management at specified intervals as 
a further condition of payment for services. 
TITLE III—PROVIDER 
PARTICIPATION 
SEC. 301. PROVIDER PARTICIPATION AND STANDARDS. 
(a) IN GENERAL.—An individual or other entity fur-
nishing any covered service under a State health security 
program under this Act is not a qualified provider unless 
the individual or entity— 
(1) is a qualified provider of the services under 
section 302; 
(2) has filed with the State health security pro-
gram a participation agreement described in sub-
section (b); and 
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(3) meets such other qualifications and condi-
tions as are established by the Board or the State 
health security program under this Act. 
(b) REQUIREMENTS
IN
PARTICIPATION
AGREE-
MENT.— 
(1) IN
GENERAL.—A participation agreement 
described in this subsection between a State health 
security program and a provider shall provide at 
least for the following: 
(A) Services to eligible persons will be fur-
nished by the provider without discrimination 
on the ground of race, national origin, income, 
religion, age, sex or sexual orientation, dis-
ability, handicapping condition, or (subject to 
the professional qualifications of the provider) 
illness. Nothing in this subparagraph shall be 
construed as requiring the provision of a type 
or class of services which services are outside 
the scope of the provider’s normal practice. 
(B) No charge will be made for any cov-
ered services other than for payment authorized 
by this Act. 
(C) The provider agrees to furnish such in-
formation as may be reasonably required by the 
Board or a State health security program, in 
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accordance with uniform reporting standards 
established under section 401(g)(1), for— 
(i) quality review by designated enti-
ties; 
(ii) the making of payments under 
this Act (including the examination of 
records as may be necessary for the 
verification of information on which pay-
ments are based); 
(iii) statistical or other studies re-
quired for the implementation of this Act; 
and 
(iv) such other purposes as the Board 
or State may specify. 
(D) The provider agrees not to bill the pro-
gram for any services for which benefits are not 
available because of section 204(d). 
(E) In the case of a provider that is not 
an individual, the provider agrees not to employ 
or use for the provision of health services any 
individual or other provider who or which has 
had a participation agreement under this sub-
section terminated for cause. 
(F) In the case of a provider paid under a 
fee-for-service basis under section 612, the pro-
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vider agrees to submit bills and any required 
supporting documentation relating to the provi-
sion of covered services within 30 days (or such 
shorter period as a State health security pro-
gram may require) after the date of providing 
such services. 
(2) TERMINATION OF PARTICIPATION AGREE-
MENTS.— 
(A) IN
GENERAL.—Participation agree-
ments may be terminated, with appropriate no-
tice— 
(i) by the Board or a State health se-
curity program for failure to meet the re-
quirements of this title; or 
(ii) by a provider. 
(B) TERMINATION
PROCESS.—Providers 
shall be provided notice and a reasonable oppor-
tunity to correct deficiencies before the Board 
or a State health security program terminates 
an agreement unless a more immediate termi-
nation is required for public safety or similar 
reasons. 
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SEC. 302. QUALIFICATIONS FOR PROVIDERS. 
(a) IN GENERAL.—A health care provider is consid-
ered to be qualified to provide covered services if the pro-
vider is licensed or certified and meets— 
(1) all the requirements of State law to provide 
such services; 
(2) applicable requirements of Federal law to 
provide such services; and 
(3) any applicable standards established under 
subsection (b). 
(b) MINIMUM PROVIDER STANDARDS.— 
(1) IN GENERAL.—The Board shall establish, 
evaluate, and update national minimum standards to 
assure the quality of services provided under this 
Act and to monitor efforts by State health security 
programs to assure the quality of such services. A 
State health security program may also establish ad-
ditional minimum standards which providers must 
meet. 
(2) NATIONAL MINIMUM STANDARDS.—The na-
tional minimum standards under paragraph (1) shall 
be established for institutional providers of services, 
individual health care practitioners, and comprehen-
sive health service organizations. Except as the 
Board may specify in order to carry out this title, 
a hospital, nursing facility, or other institutional 
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provider of services shall meet standards for such a 
facility under the medicare program under title 
XVIII of the Social Security Act. Such standards 
also may include, where appropriate, elements relat-
ing to— 
(A) adequacy and quality of facilities; 
(B) training and competence of personnel 
(including continuing education requirements); 
(C) comprehensiveness of service; 
(D) continuity of service; 
(E) patient satisfaction (including waiting 
time and access to services); and 
(F) performance standards (including or-
ganization, facilities, structure of services, effi-
ciency of operation, and outcome in palliation, 
improvement of health, stabilization, cure, or 
rehabilitation). 
(3) TRANSITION
IN
APPLICATION.—If the 
Board provides for additional requirements for pro-
viders under this subsection, any such additional re-
quirement shall be implemented in a manner that 
provides for a reasonable period during which a pre-
viously qualified provider is permitted to meet such 
an additional requirement. 
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(4) EXCHANGE OF INFORMATION.—The Board 
shall provide for an exchange, at least annually, 
among State health security programs of informa-
tion with respect to quality assurance and cost con-
tainment. 
SEC. 303. QUALIFICATIONS FOR COMPREHENSIVE HEALTH 
SERVICE ORGANIZATIONS. 
(a) IN GENERAL.—For purposes of this Act, a com-
prehensive health service organization (in this section re-
ferred to as a ‘‘CHSO’’) is a public or private organization 
which, in return for a capitated payment amount, under-
takes to furnish, arrange for the provision of, or provide 
payment with respect to— 
(1) a full range of health services (as identified 
by the Board), including at least hospital services 
and physicians services; and 
(2) out-of-area coverage in the case of urgently 
needed services; 
to an identified population which is living in or near a 
specified service area and which enrolls voluntarily in the 
organization. 
(b) ENROLLMENT.— 
(1) IN GENERAL.—All eligible persons living in 
or near the specified service area of a CHSO are eli-
gible to enroll in the organization; except that the 
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number of enrollees may be limited to avoid over-
taxing the resources of the organization. 
(2) MINIMUM ENROLLMENT PERIOD.—Subject 
to paragraph (3), the minimum period of enrollment 
with a CHSO shall be twelve months, unless the en-
rolled individual becomes ineligible to enroll with the 
organization. 
(3) WITHDRAWAL
FOR
CAUSE.—Each CHSO 
shall permit an enrolled individual to disenroll from 
the organization for cause at any time. 
(c) REQUIREMENTS FOR CHSOS.— 
(1) ACCESSIBLE
SERVICES.—Each CHSO, to 
the maximum extent feasible, shall make all services 
readily and promptly accessible to enrollees who live 
in the specified service area. 
(2) CONTINUITY OF CARE.—Each CHSO shall 
furnish services in such manner as to provide con-
tinuity of care and (when services are furnished by 
different providers) shall provide ready referral of 
patients to such services and at such times as may 
be medically appropriate. 
(3) BOARD OF DIRECTORS.—In the case of a 
CHSO that is a private organization— 
(A) 
CONSUMER
REPRESENTATION.—At 
least one-third of the members of the CHSO’s 
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board of directors must be consumer members 
with no direct or indirect, personal or family fi-
nancial relationship to the organization. 
(B) PROVIDER
REPRESENTATION.—The 
CHSO’s board of directors must include at 
least one member who represents health care 
providers. 
(4) PATIENT
GRIEVANCE
PROGRAM.—Each 
CHSO must have in effect a patient grievance pro-
gram and must conduct regularly surveys of the sat-
isfaction of members with services provided by or 
through the organization. 
(5) MEDICAL STANDARDS.—Each CHSO must 
provide that a committee or committees of health 
care practitioners associated with the organization 
will promulgate medical standards, oversee the pro-
fessional aspects of the delivery of care, perform the 
functions of a pharmacy and drug therapeutics com-
mittee, and monitor and review the quality of all 
health services (including drugs, education, and pre-
ventive services). 
(6) PREMIUMS.—Premiums or other charges by 
a CHSO for any services not paid for under this Act 
must be reasonable. 
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(7) UTILIZATION AND BONUS INFORMATION.— 
Each CHSO must— 
(A) comply with the requirements of sec-
tion 1876(i)(8) of the Social Security Act (re-
lating to prohibiting physician incentive plans 
that provide specific inducements to reduce or 
limit medically necessary services); and 
(B) make available to its membership utili-
zation information and data regarding financial 
performance, including bonus or incentive pay-
ment arrangements to practitioners. 
(8) PROVISION OF SERVICES TO ENROLLEES AT 
INSTITUTIONS
OPERATING
UNDER
GLOBAL
BUDG-
ETS.—The organization shall arrange to reimburse 
for hospital services and other facility-based services 
(as identified by the Board) for services provided to 
members of the organization in accordance with the 
global operating budget of the hospital or facility ap-
proved under section 611. 
(9) BROAD
MARKETING.—Each CHSO must 
provide for the marketing of its services (including 
dissemination of marketing materials) to potential 
enrollees in a manner that is designed to enroll indi-
viduals representative of the different population 
groups and geographic areas included within its 
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