Hillarie Clinton Kaiser Permanente Universal Health Plan

Health Security Act HEALTH SECURITY ACT 103d CONGRESS 1st Session

H. R. / S._ IN THE HOUSE OF REPRESENTATIVES / IN THE SENATE OF THE UNITED STATES
Mr. XXXXXXXXXXXXXXXXXX _(for himself, [insert cosponsor list attached])_ introduced
the following bill; which was [read twice and] referred to the Committee on _XXXXXXXXXXXXXXX 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 Representatives of the United States of America in Congress assembled, Health Security
Act Table

SECTION 1. SHORT TITLE; TABLE OF TITLES AND SUBTITLES.

(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:

TITLE I_HEALTH CARE SECURITY
Subtitle A_Universal Coverage and Individual Responsibility
Subtitle B_Benefits
Subtitle C_State Responsibilities
Subtitle D_Health Alliances
Subtitle E_Health Plans
Subtitle F_Federal Responsibilities
Subtitle G_Employer Responsiblities [
Subtitle H_Reserved] [
Subtitle I_Reserved]
Subtitle J_General Definitions; Miscellaneous Provisions

TITLE II_NEW BENEFITS
Subtitle A_Medicare Outpatient Prescription Drug Benefit
Subtitle B_Long -Term Care

TITLE III_PUBLIC HEALTH INITIATIVES
Subtitle A_Workforce Priorities Under Federal Payments
Subtitle B_Academic Health Centers
Subtitle C_Health Research Initiatives
Subtitle D_Core Functions of Public Health Programs; National Initiatives Regarding Preventive Health
Subtitle E_Health Services for Medically Underserved Populations
Subtitle F_Mental Health; Substance Abuse
Subtitle G_Comprehensive School Health Education; School -Related Health Services
Subtitle H_Public Health Service Initiatives Fund
Subtitle I_Coordination With COBRA Continuation Coverage

TITLE IV_MEDICARE AND MEDICAID
Subtitle A_Medicare and the Alliance System
Subtitle B_Savings in Medicare Program
Subtitle C_Medicaid
Subtitle D_Increase in SSI Personal Needs Allowance

TITLE V_QUALITY AND CONSUMER PROTECTION

Subtitle A_Quality Management and Improvement
Subtitle B_Information Systems, Privacy, and Administrative Simplification
Subtitle C_Remedies and Enforcement
Subtitle D_Medical Malpractice
Subtitle E_Fraud and Abuse
Subtitle F_McCarran -Ferguson Reform

TITLE VI_PREMIUM CAPS; PREMIUM -BASED FINANCING; AND PLAN PAYMENTS
Subtitle A_Premium Caps
Subtitle B_Premium -Related Financings
Subtitle C_Payments to Regional Alliance Health Plans

TITLE VII_REVENUE PROVISIONS
Subtitle A_Financing Provisions
Subtitle B_Tax Treatment of Employer -Provided Health Care
Subtitle C_Employment Status Provisions
Subtitle D_Tax Treatment of Funding of Retiree Health Benefits
Subtitle E_Coordination With COBRA Continuing Care Provisions
Subtitle F_Tax Treatment of Organizations Providing Health Care
Services and Related Organizations
Subtitle G_Tax Treatment of Long -term Care Insurance and Services
Subtitle H_Tax Incentives for Health Services Providers
Subtitle I_Miscellaneous Provisions

TITLE VIII_HEALTH AND HEALTH -RELATED PROGRAMS OF THE FEDERAL
GOVERNMENT
Subtitle A_Military Health Care Reform
Subtitle B_Department of Veterans Affairs
Subtitle C_Federal Employees Health Benefits Program
Subtitle D_Indian Health Service
Subtitle E_Amendments to the Employee Retirement Income Security Act of 1974
Subtitle F_Special Fund for WIC Program

TITLE IX_AGGREGATE GOVERNMENT PAYMENTS TO REGIONAL ALLIANCES
Subtitle A_Aggregate State Payments
Subtitle B_Aggregate Federal Alliance Payments
Subtitle C_Borrowing Authority to Cover Cash -Flow Shortfalls

TITLE X_COORDINATION OF MEDICAL PORTION OF WORKERS COMPENSATION AND AUTOMOBILE INSURANCE
Subtitle A_Workers Compensation Insurance
Subtitle B_Automobile Insurance
Subtitle C_Commission on Integration of Health Benefits
Subtitle D_Federal Employees' Compensation Act
Subtitle E_Davis -Bacon Act and Service Contract Act
Subtitle F_Effective Dates

TITLE XI_TRANSITIONAL INSURANCE REFORM TITLE XII_TEMPORARY ASSESSMENT ON EMPLOYERS WITH RETIREE HEALTH BENEFIT COSTS
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 competitiveness of the Nation, and strains Federal, State, and local budgets;
(C) an excessive burden of forms, paperwork, and bureaucratic procedures confuses consumers and overwhelms health care providers;

(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 industries and individuals in the United States.

(2) Under any reform of the health care system_

(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, including 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 providers, 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 improvements;

(G) competition in the health care industry should ensure that health plans and health care providers are efficient and charge reasonable prices;

(H) a partnership between the Federal Government and each State should allow the State and its local communities to design an effective, high -quality system of care that serves the residents of the State;

(I) all individuals should have a responsibility 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 protected from unauthorized disclosure and use.

Purposes
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 consumers and health care professionals.
(3) To control the cost of health care for employers, 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 responsibility for their health care coverage. Health Security Act

Title I TITLE I_HEALTH CARE SECURITY
table of contents of title
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 2TREATMENT 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 escription 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 health and substance abuse services.
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. Health Security Act HEALTH SECURITY ACT 103d CONGRESS 1st Session http://www.aapsonline.org/clinton/AAPS/WELCOME.PDF
http://www.aapsonline.org/clinton/AAPS/WELCOME.PDF
H. R. / S._ IN THE HOUSE OF REPRESENTATIVES / IN THE SENATE OF THE
UNITED STATES Mr. XXXXXXXXXXXXXXXXXX
_(for himself, [insert cosponsor list attached])_ introduced
the following bill; which was [read twice and] referred to the
Committee on _XXXXXXXXXXXXXXX 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 Representatives of the
United States of America in Congress assembled, Health Security
Act Table
SECTION 1. SHORT TITLE; TABLE OF TITLES AND SUBTITLES.

(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:
TITLE I_HEALTH CARE SECURITY
Subtitle A_Universal Coverage and Individual Responsibility
Subtitle B_Benefits
Subtitle C_State Responsibilities
Subtitle D_Health Alliances
Subtitle E_Health Plans
Subtitle F_Federal Responsibilities
Subtitle G_Employer Responsiblities [
Subtitle H_Reserved] [
Subtitle I_Reserved]
Subtitle J_General Definitions; Miscellaneous Provisions
TITLE II_NEW BENEFITS
Subtitle A_Medicare Outpatient Prescription Drug Benefit
Subtitle B_Long -Term Care
TITLE III_PUBLIC HEALTH INITIATIVES
Subtitle A_Workforce Priorities Under Federal Payments
Subtitle B_Academic Health Centers
Subtitle C_Health Research Initiatives
Subtitle D_Core Functions of Public Health Programs; National
Initiatives Regarding Preventive Health
Subtitle E_Health Services for Medically Underserved Populations
Subtitle F_Mental Health; Substance Abuse
Subtitle G_Comprehensive School Health Education; School -Related
Health Services
Subtitle H_Public Health Service Initiatives Fund
Subtitle I_Coordination With COBRA Continuation Coverage
TITLE IV_MEDICARE AND MEDICAID
Subtitle A_Medicare and the Alliance System
Subtitle B_Savings in Medicare Program
Subtitle C_Medicaid
Subtitle D_Increase in SSI Personal Needs Allowance
TITLE V_QUALITY AND CONSUMER PROTECTION

Subtitle A_Quality Management and Improvement
Subtitle B_Information Systems, Privacy, and Administrative
Simplification
Subtitle C_Remedies and Enforcement
Subtitle D_Medical Malpractice
Subtitle E_Fraud and Abuse
Subtitle F_McCarran -Ferguson Reform
TITLE VI_PREMIUM CAPS; PREMIUM -BASED FINANCING; AND PLAN PAYMENTS
Subtitle A_Premium Caps
Subtitle B_Premium -Related Financings
Subtitle C_Payments to Regional Alliance Health Plans
TITLE VII_REVENUE PROVISIONS
Subtitle A_Financing Provisions
Subtitle B_Tax Treatment of Employer -Provided Health Care
Subtitle C_Employment Status Provisions
Subtitle D_Tax Treatment of Funding of Retiree Health Benefits
Subtitle E_Coordination With COBRA Continuing Care Provisions
Subtitle F_Tax Treatment of Organizations Providing Health Care
Services and Related Organizations
Subtitle G_Tax Treatment of Long -term Care Insurance and Services
Subtitle H_Tax Incentives for Health Services Providers
Subtitle I_Miscellaneous Provisions

TITLE VIII_HEALTH AND HEALTH -RELATED PROGRAMS OF THE FEDERAL
GOVERNMENT
Subtitle A_Military Health Care Reform
Subtitle B_Department of Veterans Affairs
Subtitle C_Federal Employees Health Benefits Program
Subtitle D_Indian Health Service
Subtitle E_Amendments to the Employee Retirement Income Security
Act of 1974
Subtitle F_Special Fund for WIC Program
TITLE IX_AGGREGATE GOVERNMENT PAYMENTS TO REGIONAL ALLIANCES
Subtitle A_Aggregate State Payments
Subtitle B_Aggregate Federal Alliance Payments
Subtitle C_Borrowing Authority to Cover Cash -Flow Shortfalls
TITLE X_COORDINATION OF MEDICAL PORTION OF WORKERS COMPENSATION AND
AUTOMOBILE INSURANCE
Subtitle A_Workers Compensation Insurance
Subtitle B_Automobile Insurance
Subtitle C_Commission on Integration of Health Benefits
Subtitle D_Federal Employees' Compensation Act
Subtitle E_Davis -Bacon Act and Service Contract Act
Subtitle F_Effective Dates
TITLE XI_TRANSITIONAL INSURANCE REFORM TITLE XII_TEMPORARY
ASSESSMENT ON EMPLOYERS WITH RETIREE HEALTH BENEFIT COSTS 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 competitiveness of the Nation, and
strains Federal, State, and local budgets; (C) an excessive burden
of forms, paperwork, and bureaucratic procedures confuses consumers
and overwhelms health care providers; (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 industries and individuals in the United
States. (2) Under any reform of the health care system_ (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, including 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 providers, 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 improvements;

(G) competition in the health care industry should ensure that
health plans and health care providers are efficient and charge
reasonable prices; (H) a partnership between the Federal Government
and each State should allow the State and its local communities to
design an effective, high -quality system of care that serves the
residents of the State; (I) all individuals should have a
responsibility 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 protected from
unauthorized disclosure and use. Purposes 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 consumers and health care professionals. (3) To control
the cost of health care for employers, 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
responsibility for their health care coverage. Health Security Act
Title I TITLE I_HEALTH CARE SECURITY table of contents of title
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 2TREATMENT 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 escription 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 health and substance abuse services.
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. urable
medical equipment and prosthetic and orthotic devices.
Sec._1125._Vision care. Sec._1126. ental 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. efinition 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. Sec._1204._Financial solvency; fiscal oversight; guaranty
fund. Sec._1205._Restrictions on funding of additional benefits.
Part 2_Requirements for State Single -payer Systems
Sec._1221._Single -payer system described. Sec._1222._General
requirements for single -payer systems. Sec._1223._Special rules for
States operating Statewide single -payer system. Sec._ 1224._Special
rules for alliance -specific single -payer systems.

Subtitle D_Health Alliances Sec._1300._Health alliance defined.
Part 1_Establishment of Regional and Corporate Alliances Subpart
A_Regional Alliances Sec._1301._Regional alliance defined.
Sec._1302._Board of directors. Sec._1303._Provider advisory boards
for regional alliances. Subpart B_Corporate Alliances
Sec._1311._Corporate alliance defined; individuals eligible for
coverage through corporate alliances; additional definitions.
Sec._1312._Timing of elections. Sec._1313._Termination of alliance
election. Part 2_General Responsibilities and Authorities of
Regional Alliances Sec._1321._Contracts with health plans.
Sec._1322._Offering choice of health plans for enrollment;
establishment of fee -for-service schedule. Sec._1323._Enrollment
rules and procedures. Sec._1324._Issuance of health security cards.
Sec._1325._Consumer information and marketing.
Sec._1326._Ombudsman. Sec._1327. ata collection; quality.
Sec._1328._Additional duties. Sec._1329._Additional authorities for
regional alliances to address needs in areas with inadequate health
services; prohibition of insurance role. Sec._1330._Prohibition
against self -dealing and conflicts of interest. Part 3_Authorities
and Responsibilities Relating to Financing and Income
Determinations SUBPART A_COLLECTION OF FUNDS Sec._1341._Information
and negotiation and acceptance of bids. Sec._1342._Amount of
premiums charged. Sec._1343. etermination of family obligation for
family share and alliance credit amount. Sec._1344._Notice of
family payments due. Sec._1345._Collection of premium payments.
Sec._1346._Coordination among regional alliances. SUBPART
B_PAYMENTS Sec._1351._Payment to regional alliance health plans.
Sec._1352._Alliance administrative allowance percentage.
Sec._1353._Payments for graduate medical education and academic
health centers. SUBPART C_FINANCIAL MANAGEMENT
Sec._1361._Management of finances and records. SUBPART D_REDUCTIONS
IN COST SHARING; INCOME DETERMINATIONS Sec._1371._Reduction in cost
sharing for low -income families. Sec._1372._Application process for
cost sharing reductions. Sec._1373._Application for premium
reductions and reduction in liability to alliance.
Sec._1374._General provisions relating to application process.
Sec._1375._End -of-year reconciliation for premium discount and
repayment reduction with actual income. Part 4_Responsibilities and
Authorities of Corporate Alliances Sec._1381._Contracts with health
plans. Sec._1382._Offering choice of health plans for enrollment.
Sec._1383._Enrollment; issuance of health security card.
Sec._1384._Community -rated premiums within premium areas.
Sec._1385._Assistance for low -wage families. Sec._1386._Consumer
information and marketing; consumer assistance; data collection and
quality; additional duties. Sec._1387._Plan and information
requirements. Sec._1388._Management of funds; relations with
employees. Sec._1389._Cost control. Sec._1390._Payments by
corporate alliance employers to corporate alliances.
Sec._1391._Coordination of payments. Sec._1392._Applicability of
ERISA enforcement mechanisms for enforcement of certain

requirements. Sec._1393._Applicability of certain ERISA protections
to covered individuals. Sec._1394. isclosure and reserve
requirements. Sec._1395._Trusteeship by the Secretary of insolvent
corporate alliance health plans. Sec._1396._Guaranteed benefits
under trusteeship of the secretary. Sec._1397._Imposition and
collection of periodic assessments on self -insured corporate
alliance plans.

Subtitle E_Health Plans Sec._1400._Health plan defined. Part
1_Requirements Relating to Comprehensive Benefit Package
Sec._1401._Application of requirements. Sec._1402._Requirements
relating to enrollment and coverage. Sec._1403._Community rating.
Sec._1404._Marketing of health plans; information.
Sec._1405._Grievance procedure. Sec._1406._Health plan arrangements
with providers. Sec._1407._Preemption of certain State laws
relating to health plans. Sec._1408._Financial solvency.
Sec._1409._Requirement for offering cost sharing policy.
Sec._1410._Quality assurance. Sec._1411._Provider verification.
Sec._1412._Consumer disclosures of utilization management
protocols. Sec._1413._Confidentiality, data management, and
reporting. Sec._1414._Participation in reinsurance system. Part
2_Requirements Relating to Supplemental Insurance
Sec._1421._Imposition of requirements on supplemental insurance.
Sec._1422._Standards for supplemental health benefit policies.
Sec._1423._Standards for cost sharing policies. Part 3_Requirements
Relating to Essential Community Providers Sec._1431._Health plan
requirement. Sec._1432._Sunset of requirement. Part 4_Requirements
Relating to Workers' Compensation and Automobile Medical Liability
Coverage Sec._1441._Reference to requirements relating to workers
compensation services. Sec._1442._Reference to requirements
relating to automobile medical liability services.

Subtitle F_Federal Responsibilities Part 1_National Health Board
SUBPART A_ESTABLISHMENT OF NATIONAL HEALTH BOARD
Sec._1501._Creation of National Health Board; membership.
Sec._1502._Qualifications of board members. Sec._1503._General
duties and responsibilities. Sec._1504._Annual report.
Sec._1505._Powers. Sec._1506._Funding. SUBPART B_RESPONSIBILITIES
RELATING TO REVIEW AND APPROVAL OF STATE SYSTEMS Sec._1511._Federal
review and action on State systems. Sec._1512._Failure of
participating States to meet conditions for compliance.
Sec._1513._Reduction in payments for health programs by secretary
of health and human services. Sec._1514._Review of Federal
determinations. Sec._1515._Federal support for State
implementation. SUBPART C_RESPONSIBILITIES IN ABSENCE OF STATE
SYSTEMS Sec._1521._Application of subpart. Sec._1522._Federal
assumption of responsibilities in non -participating States.
Sec._1523._Imposition of surcharge on premiums under
federally -operated system. Sec._1524._Return to State operation.
SUBPART D_ESTABLISHMENT OF CLASS FACTORS FOR CHARGING PREMIUMS

Sec._1531._Premium class factors. SUBPART E_RISK ADJUSTMENT AND
REINSURANCE METHODOLOGY FOR PAYMENT OF PLANS Sec._1541. evelopment
of a risk adjustment and reinsurance methodology.
Sec._1542._Incentives to enroll disadvantaged groups.
Sec._1543._Advisory committee. Sec._1544._Research and
demonstrations. Sec._1545._Technical assistance to States and
alliances. SUBPART F_RESPONSIBILITIES FOR FINANCIAL REQUIREMENTS
Sec._1551._Capital standards for regional alliance health plan.
Sec._1552._Standard for guaranty funds. 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. Sec._1572._Establishment of
breakthrough drug committee. SUBPART B_CERTIFICATION OF ESSENTIAL
COMMUNITY PROVIDERS Sec._1581._Certification. Sec._1582._Categories
of providers automatically certified. Sec._1583._Standards for
additional providers. Sec._1584._Certification process; review;
termination of certifications. Sec._1585._Notification of health
alliances and participating States. Part 3_Specific
Responsibilities of Secretary of Labor. Sec._1591._Responsibilities
of Secretary of Labor.

Subtitle G_Employer Responsiblities Sec._1601._Payment requirement.
Sec._1602._Requirement for information reporting.
Sec._1603._Requirements relating to new employees.
Sec._1604._Auditing of records. Sec._1605._Prohibition of certain
employer discrimination. Sec._1606._Obligation relating to retiree
health benefits. Sec._1607._Prohibition on self -funding of cost
sharing benefits by regional alliance employers.
[Subtitle H_Reserved] [
Subtitle I_Reserved]
Subtitle J_General Definitions; Miscellaneous Provisions Part
1_General Definitions Sec._1901. efinitions relating to employment

and income. Sec._1902._Other general definitions. Part
2_Miscellaneous Provisions Sec._1911._Use of interim, final
regulations.
Title I,
Subtitle A 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 t his 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 individual 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)).
(d) Treatment of Medicare -Eligible Individuals._Subject to
section 1012(a), a medicare -eligible individual is entitled to
health benefits under the medicare program instead of the
entitlement under subsection (a).
(e) Treatment of Prisoners._A prisoner (as defined in section
1902(26)) is entitled to health care services 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 individual)_
(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:

(1) An individual from purchasing any health care ser vices.
(2) An individual from purchasing supplemental insurance
(offered consistent with this Act) to cover health care services
not included within the comprehensive benefit package.
(3) An individual who is not an eligible individual from
purchasing health insurance (other than through a regional
alliance).
(4) Employers from providing coverage for benefits in addition
to the comprehensive benefit package (subject to part 2 of subtitle
E). SEC. 1004. APPLICABLE HEALTH PLAN PROVIDING COVERAGE.
(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 alliance 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.
(b) Choice of Plans f or Certain Groups._
(1) Military personnel and families._For military personnel
and families who elect a Uniformed 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 section 1801 of title 38, United
States Code, as inserted by section 8101(a) of this Act, that plan
shall be the applicable health plan.
(3) Indians._For those individuals who are eligible to enroll,
and who elect to enroll, in a health program of the Indian Health
Service under section 8302(b), that program shall be the applicable
health plan. SEC. 1005. TREATMENT OF OTHER NONIMMIGRANTS.
(a) Undocumented Aliens Ineligible for Benefits._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 Fore ign Government Officials._Subject
to conditions established by the National Health Board in
consultation with the Secretary of 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 enrollment in the regional alliance health plan for the
alliance area in which the nonimmigrant resides.
(c) Reciprocal Treatment of Other Nonimmigrants._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 described 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 alliance eligible
individuals residing in a State, the entitlement 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 alliances._
(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 an
employee benefit plan (described in subparagraph (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 alliance eligible individual.
(B) Qualifying employer defined._In subparagraph (A), the term
``qualifying employer'' 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
arrangement described in section 1311(b)(1)(C), and

(ii) provides such notice to the regional alliance involved as
the Board specifies.
(C) Benefits plan described._A plan described in this
subparagraph is an employee benefit plan that_
(i) provides (through insurance or otherwise) the
comprehensive benefit package, and
(ii) provides an employer contribution of at least 80 percent
of the premium (or premium equivalent) for coverage
(b) Corporate Alliance Eligible Individuals._
(1) In general._In the case of corporate alliance 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 eligible individual until the individual becomes
a corporate alliance eligible individual, unless paragraph (2)(A)
applies to the individual.
(c) General Effective Date Defined._In this Act, the term
``general effective date'' means January 1, 1998. 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 indiv idual 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 applicable, the
children of the individual's spouse) if they are eligible
individuals.
(c) Classes of Family Enrollment; Terminology._
(1) In general._In this Act, each of the following is a
separate class of family enrollment under this Act:
(A) Coverage only of an ind ividual (referred to in this Act as
the ``individual'' class of enrollment).
(B) Coverage of a married couple without children (referred to
in this Act as the ``couple -only'' class of enrollment).
(C) Coverage of an unmarried individual and one or more
children (referred to in this Act as the ``single parent'' class of
enrollment).
(D) Coverage of a married couple and one or more children
(referred to in this Act as the ``dual parent'' class of
enrollment).
(2) References to family and couple classe s of enrollment._In
this Act:

(A) Family._The term ``family'', with respect to a class of
enrollment, refers to enrollment in a class of enrollment described
in subparagraph (B), (C), or (D) of paragraph (1).
(B) Couple._The term ``couple'', with respect to a class of
enrollment, refers to enrollment in a class of enrollment described
in subparagraph (B) or (D) of paragraph (1).
(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 individual and the
individual's spouse.
(e) Child Defined._
(1) In general._In this Act, except as otherwise provided, the
term ``child'' means an eligible individual 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 in dividual.
(2) Application of State law._Subject to paragraph (3),
determinations of whether a person is the child of another person
shall be made in accordance with applicable State law.
(3) National rules._The National Health Board may establish
such national rules respecting individuals who will be treated as
children as the Board determines to be necessary. Such rules shall
be consistent with the following principles:
(A) Step and foster child._A child includes a step child or
foster child who is an eligible individual living with an adult in
a regular parent -child relationship.
(B) Disabled child._A child includes an unmarried dependent
eligible individual regardless 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 emancipated minor or married individual shall not
be treated as a child.
(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,
(2) the treatment of individuals who are under 19 years of age
and who are not a dependent of an eligible individual, and

(3) changes in family composition occurring during a year, as
the Board finds appropriate. SEC. 1012. TREATMENT OF CERTAIN
FAMILIES.
(a) Treatment of Medicare -Eligible Individuals Who are
Qualified Employees or Spouses of Qualified Employees._
(1) In general._Except as specifically provided, in the case
of an individual who is an individual described in paragraph (2)
with respect to 2 consecutive months in a year (and it is
anticipated would be in the following month), the individual shall
not be treated as a medicare -eligible individual under this Act
during the following month and the remainder of the year.
(2) Individual described._An individual described in this
paragraph with respect to a month is a medicare -eligible individual
(determined without regard to paragraph (1)) who is a qualifying
employee or the spouse or family member of a qualifying employee in
the month.
(3) Exception._Paragraph (1) shall not apply, in the case of
an individual, if the individual described in paragraph (2)
terminates qualifying employment in the month preceding the first
month in which paragraph (1) applies. The previous sentence shall
apply until with respect to qualifying employment occurring before
such first 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 as a separate family, and
(2) all the individuals not described in any such group shall
be treated collectively as a separate family.
(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 section 1902(13)) .
(3) SSI recipients 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 veteran who makes an election to enroll with a
health plan of the Department of Veterans Affairs under chapter 18
of title 38, United States Code.
(B) Family exception._Subparagraph (A) shall not apply with
respect to coverage under a health plan referred to in such
subparagraph if, for the area in which the electing veteran
resides, such health plan offers coverage to family members of an

electing veteran and the veteran elects family enrollment under
such plan (instead of individual enrollment).

(2) Active duty military personnel._
(A) In general._Subject to subparagraph (B), the term ``active
duty military personnel'' means an individual on active duty in the
Uniformed Services of the United States.
(B) Exception._If an individual described in subparagraph (A)
elects family coverage under section 1073a(d)(1) of title 10,
United States Code, then paragraph (5) of subsection (c) shall not
apply with respect to such coverage.
(3) Electing indians._
(A) In general._Subject to subparagraph (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 individuals eligible to elect._No
such election shall be made with respect to an individual in a
family (as defined without regard to this section) 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 one health plan or program referred
to in this subsection 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 individual 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 another 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 subparagraph (A). _(3) Payment
rules._
(A) Continued treatment as family._Except as provided in
subparagraph (B), nothing in this subsection shall be construed as
affecting the payment liabilities between families and health
alliances or between health alliances and health plans.
(B) Transfer payment._In the case of an election under
paragraph (1), the health plan described in paragraph (2)(A) shall
make payment to the health plan referred to in paragraph (1) in
accordance with rules specified by the Board.
(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 defined in section 6121(c)(1)),

(2) is not a child , and
(3) who is a qualifying employee both of a regional 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).
(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 regional alliance
employer and whose spouse is an qualifying employee of a corporate
alliance employer, or
(B) who is a qualifying employee of a corporate alliance
employer and whose spouse is an qualifying employee of a regional
alliance employer, the individual and the individual's spouse may
elect the applicable health plan to be either a regional alliance
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 corporate alliance
employers._In the case of a married individual_
(A) who is a qualifying employee of a corporate alliance
employer, and
(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
individual 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 consistent with section 1222(3).
(b) Individual Responsibilities._In the case of an individual
who resides in a single -payer State, the responsibilities 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 package shall
consist of the following items and services (as described in part

2), subject to the cost sharing requirements 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 health 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).
(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 diagnostic services
(described in section 1121).
(12) Outpatient prescription drugs and biologicals (described
in section 1122).
(13) Outpatient rehabilitation services (described 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 section 1127).
(18) Investigational treatments (described in section 1128).
(b) No Other Limitations or Cost Sharing._The items and
services in the comprehensive benefit package 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.
(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 ESCRIPTION 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 hospi tal 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 detoxification 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 gi ven 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 provided 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 primarily engaged in
providing services to inpatients that are equivalent to the
services provided by a hospital defined in section 1861(e);
(B) in the case of an item or service provided to an
individual whose applicable health plan is specified pursuant to
section 1004(b)(2), a facility operated by the Department of
Veterans Affairs that is primarily engaged in providing services to
inpatients that are equivalent to the services provided by a
hospital defined in section 1861(e); and
(C) in the case of an item or service provided 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 section 1861(e).
(2) Inpatient hospital services._The term ``inpatient hospital
services'' means items and services described in paragraphs (1)
through (3) of section 1861(b) of the Social Security Act when
provided 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) furnished 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 service that is described in
section 1114 but is not provided 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 provides health professional services.
(2) Health Professional Services._The term ``health
professional services'' means professional services that_
(A) are lawfully provided by a physician; or
(B) would be described in subp aragraph (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 hospital 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 described 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 immunization, test, or clinician
visit specified in one of subsections (b) through (h) that is
provided consistent 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 subsections (b) through (h), but only when provided
consistent with any requirements for such immunizations, 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 specified in this
subsection are age -appropriate immunizations 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 subsection 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 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 specified in this
subsection are age -appropriate immunizations 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 subsection are 1
urinalysis.
(3) Clinician visits._The clinician visits specified in this
subsection are 3 clinician visits.
(d) Individuals Age 6 to 19._For an individual at least 6
years of age, but less than 20 years of age:
(1) Immunizations._The immunizations specified in this
subsection are age -appropriate immunizations for the following
illnesses:
(A) Tetanus.
(B) Diphtheria.
(2) Tests._The tests specified in this subsection 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 negative smears have been
obtained; and
(ii) annually for fema les who are at risk for fertility
related infectious illnesses.
(B) Annual screening for chlamydia and gonorrhea for females
who have reached childbearing age and are at risk for fertility
related infectious illnesses.
(3) Clinician visits._The clinician visits specified in this
subsection are 5 clinician visits.
(e) Individuals Age 20 to 39._For an individual at least 20
years of age, but less than 40 years of age:

(1) Immunizations._The immunizations specified in this
subsection are booster immunizations against tetanus and diphtheria
every 10 years.
(2) Tests._The tests specified in this subsection 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 fertility 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.
(f) 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 specified in this
subsection are booster immunizations against tetanus and diphtheria
every 10 years.
(2) Tests._The tests specified in this subsection 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 fertility 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.
(g) 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 specified in this
subsection are booster immunizations against tetanus and diphtheria
every 10 years.
(2) Tests._The tests specified in this subsection are as
follows:
(A) Papanicolaou smears and pelvic exams for females every 2
years.
(B) Mammograms for females every 2 years.
(C) Cholesterol every 5 years.
(3) Clinician v isits._The clinician visits specified in this
subsection are 1 clinician visit every 2 years.
(h) Individuals Age 65 or Older._For an individual at least 65
years of age who is enrolled under a health plan:

(1) Immunizations._The immunizations specified 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 s pecified in this subsection 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.
(3) Clinician visits._The clinician visits specified in this
subsection are 1 clinician visit every year.
(i) Clinician Visit._For purposes of this section, the term
``clinician visit'' includes the following health professional
services (as defined in section 1112(c)):
(1) A co mplete medical history.
(2) An appropriate physical examination.
(3) Risk assessment.
(4) Targeted health advice and counseling, including nutrition
counseling.
(5) The administration of age -appropriate immunizations and
tests specified in subsections (b) through (h).
(j) Immunizations and Tests Not Administered During Clinician
Visit._Notwithstanding subsection (i)(5), the clinical preventive
services described in this section include an immunization or test
described in this section that is administered to an individual
consistent with any periodicity schedule for the immunization or
test during 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 during a clinician
visit. SEC. 1115. MENTAL HEALTH AND SUBSTANCE ABUSE SERVICES.
(a) Coverage._The mental health and substance abuse services
that are described in this section are the following items and
services for eligible individuals, as defined in section 1001(c),
who satisfy the eligibility requirements in subsection (b):
(1) Inpatient and residential mental health and substance
abuse treatment.
(2) Intensive nonresidential mental health and substance abuse
treatment.
(3) Outpatient mental health and substance abuse treatment,
including case management, screening and assessment, crisis
services, and collateral services.
(b) Eligibility._The eligibility requirements referred to in
subsection (a) are as follows:
(1) Inpatient, re sidential, nonresidential, and outpatient
treatment._An eligible individual is eligible to receive coverage
for inpatient and residential mental health and substance abuse

treatment, intensive nonresidential mental health and substance
abuse treatment, or outpatient mental health and substance abuse
treatment (except case management and collateral services) if the
individual_

(A) has, or has had during the 1 -year period preceding the
date of such treatment, a diagnosable mental or substance abuse
disorder; and
(B) is experiencing, or is at significant risk of
experiencing, functional impairment in family, work, school, or
community activities. For purposes of this paragraph, an individual
who has a diagnosable mental or substance abuse disorder, is
receiving treatment for such disorder, but does not satisfy the
functional impairment 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 el igible individual is eligible to
receive coverage for case management if_
(A) the health plan in which the individual is enrolled has
elected to offer case management and determines that the individual
should receive such services; and
(B) the individual is eligible to receive coverage for, and is
receiving, outpatient mental health and substance abuse treatment.
(3) Screening and assessment and crisis services._All eligible
individuals enrolled under a health plan are eligible to receive
coverage for outpatient mental health and substance abuse treatment
consisting of screening and assessment and crisis services.
(4) Collateral services._An eligible individual is eligible to
receive coverage for outpatient mental health and substance abuse
treatment consisting of collateral services if the individual is a
family member (as defined in section 1011(b)) of an individual who
is receiving inpatient and residential mental health and substance
abuse treatment, intensive nonresidential mental health and
substance abuse treatment, or outpatient mental health and
substance abuse treatment.
(c) Inpatient and Residential Trea tment._
(1) Definition._For purposes of this subtitle, the term
``inpatient and residential mental health 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
provided with respect to a diagnosable mental or substance abuse
disorder to_
(A) an inpatient of a hospital, psychiatric hospital,
residential treatment center, residential detoxification center,
crisis residential program, or mental health residential treatment
program; or
(B) a resident of a therapeutic family or group treatment home
or community residential treatment and recovery center for
substance abuse. The National Health Board shall specify those
health professional services described in section 1112 that shall

be treated as inpatient and residential mental health and substance
abuse treatment when provided to such an inpatient or resident.

(2) Limitations._Coverage for inpatient and residential mental
health and substance abuse treatment is subject to the following
limitations:
(A) Least restrictive setting._Such treatment is covered only
when_
(i) provided to an individual in the least restrictive
inpatient or residential setting that is effective and appropriate
for the individual; and
(ii) less restrictive intensive nonresidential or outpatient
treatment would be ineffective or inappropriate.
(B) Licensed facility._Such treatment is only covered when
provided by a facility described in paragraph (1) that is legally
authorized to provide the treatment in the State in which the
facility is located.
(C) Day limits._Subject to subparagraph (D), such treatment is
covered for each period beginning on the date an episode of
inpatient or residential treatment begins and ending on the date
the episode ends, except that, prior to January 1, 2001, such
treatment is not covered after such an episode exceeds 30 days
unless the individual receiving treatment poses a threat to their
own life or the life of another individual. Whether such a threat
exists shall be determined by a health professional designated by
the health plan in which the individual receiving treatment is
enrolled. For purposes of this subtitle, an episode of inpatient
and residential mental health and substance abuse treatment shall
be considered to begin on the date an individual is admitted to a
facility for such treatment and to end on the date the individual
is discharged from the facility.
(D) Annual limit._Prior to January 1, 2001, such treatment in
all settings is subject to an aggregate annual limit of 60 days.
(E) Inpatient hospital treatment for substance
abuse._Substance abuse treatment, when provided to an inpatient of
a hospital or psychiatric hospital, is covered under this section
only for medical detoxification associated with withdrawal from
alcohol or drugs.
(d) Intensive Nonresidential Treatment._
(1) Definition._For purposes of this subtitle, the term
``intensive nonresidential mental health and substance abuse
treatment'' means diagnostic or therapeutic items or services
provided with respect to a diagnosable mental or substance abuse
disorder to an individual_
(A) participating in a partial hospitalization program, a day
treatment program, a psychiatric rehabilitation program, or an
ambulatory detoxification program; or
(B) receiving home -based mental health services or behavioral
aide mental health services. The National Health Board shall
specify those health professional services described in section
1112 that shall be treated as intensive nonresidential mental

health and substance abuse treatment when provided to such an
individual.

(2) Limitations._Coverage for intensive nonresidential mental
health and substance abuse treatment is subject to the following
limitations:
(A) Discretion of plan._A health plan may cover intensive
nonresidential mental health and substance abuse treatment at its
discretion.
(B) Treatment purposes._Such treatment is covered only when
provided_
(i) to avert the need for, or as an alternative to, treatment
in residential or inpatient settings;
(ii) to facilitate the earlier discharge of an individual
receiving inpatient or residential care;
(iii) to restore the functioning of an individual with a
diagnosable mental health or substance abuse disorder; or
(iv) to assist the individual to develop the skills and gain
access to the support services the individual needs to achieve the
maximum level of functioning of the individual within the
community.
(C) Annual limit._
(i) In general._Prior to January 1, 2 001, such treatment in
all settings is subject to an aggregate annual limit of 120 days.
(ii) Relationship to other annual limits._For each 2 days of
intensive nonresidential mental health and substance abuse
treatment provided to an individual, the number of treatment days
available to the individual before the annual aggregate limit on
inpatient and residential mental health and substance abuse
treatment described in subsection (c)(2)(D) is exceeded shall be
reduced by 1 day. The preceding sentence shall not apply after an
individual has received 60 days of intensive nonresidential mental
health and substance abuse treatment in a year.
(iii) Additional days._A maximum of 60 additional days of
intensive nonresidential mental health and substance abuse
treatment may be provided to an individual if a health professional
designated by the health plan in which the individual receiving
treatment is enrolled determines that such additional treatment is
medically necessary or appropriate.
(D) Out-of-pocket maximum._Prior to January 1, 2001, expenses
for intensive nonresidential mental health and substance abuse
treatment that an individual incurs prior to satisfying a
deductible applicable to such treatment, and copayments and
coinsurance paid by or on behalf of the individual for such
treatment, that substitute for inpatient and residential mental
health and substance abuse treatment (up to 60 days) may be applied
toward the annual out -of-pocket limit on cost sharing under any
cost sharing schedule described in part 3 of this subtitle.
(e) Outpatient Treatment._
(1) Definition._For purposes of this subtitle, the term
``outpatient mental health and substance abuse treatment'' means

the following services provided with respect to a diagnosable
mental or substance abuse disorder in an outpatient setting:

(A) Screening and assessment.
(B) Diagnosis.
(C) Medical management.
(D) Substance abuse counseling and relapse prevention.
(E) Crisis services.
(F) Somatic treatment services.
(G) Psychotherapy.
(H) Case management.
(I) Collateral services.
(2) Limitations._Coverage for outpatient mental health and
substance abuse treatment is subject to the following limitations:
(A) Health professional services._Such treatment is covered
only when it constitutes health professional services (as defined
in section 1112(c)(2)).
(B) Substance abuse counseling._Substance abuse counseling and
relapse prevention is covered only when provided by a substance
abuse treatment provider who_
(i) is legally author ized to provide such services in the
State in which the services are provided; and
(ii) provides no items or services other than substance abuse
counseling and relapse prevention, medical management, or
laboratory and diagnostic tests for individuals with substance
abuse disorders.
(C) Annual limits._
(i) Pychotherapy and col lateral services._Prior to January 1,
2001, psychotherapy and collateral services are subject to annual
limits of 30 visits for each type of service. Additional visits may
be covered, at the discretion of the health plan in which the
individual receiving treatment is enrolled, to prevent
hospitalization or to facilitate earlier hospital release, for
which the annual aggregate limit on inpatient and residential
mental health and substance abuse treatment described in subsection
(c)(2)(D) shall be reduced by 1 day for each 4 visits.
(ii) Substance abuse._At the discretion of the health plan in
which an individual receiving outpatient substance abuse treatment
is enrolled, the annual aggregate limit on inpatient and
residential mental health and substance abuse treatment described
in subsection (c)(2)(D) may be reduced by 1 day for each 4
outpatient visits. Within 12 months after inpatient and residential
treatment or intensive nonresidential treatment, 30 visits in group
therapy shall be covered for substance abuse counseling and relapse
prevention. For individuals who were not initially treated in an
inpatient, residential, or intensive nonresidential setting,
additional visits shall be covered for which the annual aggregate
limit on inpatient and residential mental health and substance
abuse treatment described in subsection (c)(2)(D) shall be reduced
by 1 day for each 4 visits.

(D) Out-of-pocket maximum._Prior to January 1, 2001, expenses
for outpatient mental health and substance abuse treatment that an
individual incurs prior to satisfying a deductible applicable to
such treatment, and copayments 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.
(E) Detoxification._Outpatient detoxification shall be
provided only in the context of a treatment program. If the first
detoxification treatment is unsuccessful, subsequent treatments are
covered if a health professional designated by the health plan in
which the individual receiving treatment is enrolled determines
that there is a substantial chance of success.
(f) Other Definitions._For purposes of this subtitle:
(1) Case management._The term ``case management'' means
services that assist individuals in gaining access to needed
medical, social, educational, and other services.
(2) Diagnosable mental or substance abuse disorder._The term
``diagnosable mental or substance abuse disorder'' means a disorder
that is listed in any authoritative text specifying diagnostic
criteria for mental or substance abuse disorders that is identified
by the National Health Board.
(3) Psychiatric hospital._The term ``psychiatric 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 provided 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 providing services
to inpatients that are equivalent to the services provided by a
psychiatric hospital;
(B) in the case of an item or service provided to an
individual whose applicable health plan is specified pursuant to
section 1004(b)(2), a facility operated by the Department of
Veterans Affairs that is engaged in providing services to
inpatients that are equivalent to the services provided by a
psychiatric hospital; and
(C) in the case of an item or service provided 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 inpatients that
are equivalent to the services provided by a psychiatric hospital.
SEC. 1116. FAMILY PLANNING SERVICES AND SERVICES FOR PREGNANT
WOMEN.
The services described in this section are the following items
and services:

(1) Voluntary family planning services.
(2) Contraceptiv e devices that_
(A) may only be dispensed upon prescription; and

(B) are subject to approval by the Secretary 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 paragraphs (2), (3), and (4)(A)
of such section (with the exception 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. 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 described in section
1861(ll) of the Social Security Act (as added by section 2006).
(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 inpatient 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 continued 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 described in this
section are the items and services described in section 1861(h) of
the Social Security Act when provided to an inpatient of a skilled
nursing facility or a rehabilitation facility.
(b) Limitations._Coverage for extended care services is
subject to the following limitations:
(1) Hospital alternative._Such services are covered only as an
alternative to inpatient treatment 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 ``rehabilitation
facility'' means an institution (or a distinct 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 nur sing facility._The term ``skilled nursing
facility'' means an institution (or a distinct part of an
institution) which is primarily engaged in providing to residents_
(A) skilled nursing care and related services for residents
who require medical or nursing care; or

(B) rehabilitation services to residents for rehabilitation
from illness or injury. SEC. 1120. AMBULANCE SERVICES.
(a) Coverage._The ambulance services described in this section
are the following items and services:
(1) Ground transporta tion by ambulance.
(2) Air transportation by an aircraft equipped for
transporting an injured or sick individual.
(3) Water transportation by a vessel equipped for transporting
an injured or sick individual.
(b) Limitations._Coverage for ambulance services is subject to
the following limitations:
(1) Medical indication._Ambulance services are covered only in
cases in which the use of an ambulance is indicated by the medical
condition of the individual concerned.
(2) Air transport._Air transportati on is covered only in cases
in which there is no other method of transportation or where the
use of another method of transportation is contra -indicated by the
medical condition of the individual concerned.
(3) Water transport._Water transportation is covered only in
cases in which there is no other method of transportation or where
the use of another method of transportation is contra -indicated by
the medical condition of the individual concerned. SEC. 1121.
OUTPATIENT LABORATORY, RADIOLOGY, AND DIAGNOSTIC SERVICES.
The items and services described in this section are
laboratory, radiology, and diagnostic services provided upon
prescription to individuals who are not inpatients of a hospital,
hospice, skilled nursing facility, or rehabilitation facility. SEC.
1122. OUTPATIENT PRESCRIPTION DRUGS AND BIOLOGICALS.

(a) Coverage._The items described in this section are the
following:
(1) Covered outpatient drugs described in section 1861(t) of
the Social Security Act (as amended by section 2001(b))_
(A) except that, for purposes of this section, a medically
accepted indication with respect to the use of a covered outpatient
drug includes any use which has been approved by the Food and Drug
Administration for the drug, and includes another use of the drug
if_
(i) the drug has been approved by the Food and Drug
Administration; and
(ii) such use is supported by one or more citations which are
included (or approved for inclusion) in one or more of the
following compendia: the American Hospital Formulary Service -Drug
Information, the American Medical Association Drug Evaluations, the
United States Pharmacopoeia -Drug Information, and other
authoritative compendia as identified by the National Health Board,
unless the Board has determined that the use is not medically
appropriate or the use is identified as not indicated in one or
more such compendia; or
(iii) such use is medically accepted based on supportive
clinical evidence in peer reviewed medical literature appearing in

publications which have been identified for purposes of this clause
by the Board; and

(B) notwithstanding any exclusion from coverage that may be
made with respect to such a drug under title XVIII of such Act
pursuant to section 1862(a)(18) of such Act.
(2) Blood clotting factors when provided on an outpatient
basis.
(b) Revision of Compendia List._The National Health Board may
revise the list of compendia in subsection (a)(1)(A)(ii) designated
as appropriate for identifying medically accepted indications for
drugs.
(c) Blood c lotting factors._For purposes of this subtitle, the
term ``blood clotting factors'' has the meaning given such term in
section 1861(s)(2)(I) of the Social Security Act. SEC. 1123.
OUTPATIENT REHABILITATION SERVICES.
(a) Coverage._The outpatient rehabilitation services described
in this section are_
(1) outpatient occupational therapy;
(2) outpatient physical therapy; and
(3) outpatient speech pathology services for the purpose of
attaining or restoring speech.
(b) Limitations._Coverage for outpati ent rehabilitation
services is subject to the following limitations:
(1) Restoration of capacity or minimization of
limitations._Such services include only items or services used to
restore functional capacity or minimize limitations on physical and
cognitive functions as a result of an illness or injury.
(2) Reevaluation._At the end of each 60 -day period of
outpatient rehabilitation services, the need for continued services
shall be reevaluated by the person who is primarily responsible for
providing the services. Additional periods of services are covered
only if such person determines that functioning is improving. SEC.
1124. DURABLE MEDICAL EQUIPMENT AND PROSTHETIC AND ORTHOTIC
DEVICES.
(a) Coverage._The items and services described in this section
are_
(1) durable medical equipment, including accessories and
supplies necessary for repair and maintenance of such equipment;
(2) prosthetic devices (other than dental) which replace all
or part of the function of an internal body organ (including
colostomy bags and supplies directly related to colostomy care),
including replacement of such devices;
(3) accessories and supplies which are used directly with a
prosthetic device to achieve the therapeutic benefits of the
prosthesis or to assure the proper functioning of the device;
(4) leg, arm, back, and neck braces;
(5) artificial legs, arms, and eyes, including replacements if
required because of a change in the patient's physical condition;
and

(6) fitting and training for use of the items des cribed in
paragraphs (1) through (5).
(b) Limitation._An item or service described in this section
is covered only if it improves functional ability or prevents
further deterioration in function.
(c) Durable Medical Equipment._For purposes of this subtitle,
the term ``durable medical equipment'' has the meaning given such
term in section 1861(n) of the Social Security Act. SEC. 1125.
VISION CARE.
(a) Coverage._The vision care described in this section is
diagnosis and treatment for defects in vision.
(b) Limitation._Eyeglasses and contact lenses are covered only
for individuals less than 18 years of age. SEC. 1126. DENTAL CARE.
(a) Coverage._The dental care described in this section is the
following:
(1) Emergency dental treatment, including simple extractions,
for acute infections, bleeding, and injuries to natural teeth and
oral structures for conditions requiring immediate attention to
prevent risks to life or significant medical complications, as
specified by the National Health Board.
(2) Prevention and diagnosis of dental disease, including oral
dental examinations, radiographs, dental sealants, fluoride
application, and dental prophylaxis.
(3) Treatment of dental disease, including routine fillings,
prosthetics for genetic defects, periodontal maintenance, and
endodontic services.
(4) Space maintenance procedures to prevent orthodontic
complications.
(5) Interceptive orthodontic treatment to prevent severe
malocclusion.
(b) Limitations._Coverage for dental care is subject to the
following limitations:
(1) Prevention and diagnosis._Prior to January 1, 2001, the
items and services described in subsection (a)(2) are covered only
for individuals less than 18 years of age. On or after such date,
such items and services are covered for all eligible individuals
enrolled under a health plan, except that dental sealants are not
covered for individuals 18 years of age or older.
(2) Treatment of dental disease._Prior to January 1, 2001, the
items and services described in subsection (a)(3) are covered only
for individuals less than 18 years of age. On or after such date,
such items and services are covered for all eligible individuals
enrolled under a health plan, except that endodontic services are
not covered for individuals 18 years of age or older.
(3) Space maintenance._The items and services described in
subsection (a)(4) are covered only for individuals at least 3 years
of age, but less than 13 years of age and_
(A) are limited to posterior teeth;

(B) involve maintenance of a spac e or spaces for permanent
posterior teeth that would otherwise be prevented from normal
eruption if the space were not maintained; and
(C) do not include a space maintainer that is placed within 6
months of the expected eruption of the permanent posterior tooth
concerned.
(4) Interceptive orthodontic treatment._Prior to January 1,
2001, the items and services described in subsection (a)(5) are not
covered. On or after such date, such items and services are covered
only for individuals at least 6 years of age, but less than 12
years of age. SEC. 1127. HEALTH EDUCATION CLASSES.
(a) Coverage._Subject to subsection (b), the items and
services described in this section are health education and
training classes to encourage the reduction of behavioral risk
factors and to promote healthy activities. Such education and
training classes may include smoking cessation, nutrition
counseling, stress management, support groups, and physical
training classes.

(b) Discretion of Plan._A health plan may offer education and
training classes at its discretion.
(c) Construction._This section shall not be construed to
include or limit education or training that is provided in the
course of the delivery of health professional services (as defined
in section 1112(c)). SEC. 1128. INVESTIGATIONAL TREATMENTS.
(a) Coverage._Subject to subsection (b), the items and
services described in this subsection are qualifying
investigational treatments that are administered for a
life-threatening disease, disorder, or other health condition (as
defined by the National Health Board).
(b) Discretion of Plan._A health plan may cover an
investigational treatment described in subsection (a) at its
discretion.
(c) Routine Care During Investigational Treatments._The
comprehensive benefit package includes an item or service described
in any other section of this part, subject to the limitations and
cost sharing requirements applicable to the item or service, when
the item or service is provided to an individual in the course of
an investigational treatment, if_
(1) the treatment is a qualifying investigational treatment;
and
(2) the item or service would have been provided to the
individual even if the individual were not receiving the
investigational treatment.
(d) Definitions._For purposes of this subtitle:
(1) Qualifying investigational treatment._The term
``qualifying investigational treatment'' means a treatment_
(A) the effectiveness of which has not been determined; and
(B) that is under clinical investigation as part of an
approved research trial.

(2) Approved research trial._The term ``approved research
trial'' means_
(A) a research trial approved by the Secretary of Health and
Human Services, the Director of the National Institutes of Health,
the Commissioner of the Food and Drug Administration, the Secretary
of Veterans Affairs, the Secretary of Defense, or a qualified
nongovernmental research entity as defined in guidelines of the
National Institutes of Health; or
(B) a peer -reviewed and approved research program, as defined
by the Secretary of Health and Human Services, conducted for the
primary purpose of determining whether or not a treatment is safe,
efficacious, or having any other characteristic of a treatment
which must be demonstrated in order for the treatment to be
medically necessary or appropriate. PART 3_COST SHARING SEC. 1131.
COST SHARING.
(a) In General._Each health plan shall offer to individuals
enrolled under the plan one of the following cost sharing
schedules, which schedule shall be offered to all such enrollees:
(1) lower cost sharing (described in section 1132);
(2) higher cost sharing (described in section 1133); or
(3) combination cost sharing (described in section 1134).
(b) Cost Sharing for Low -Income Families._For provisions
relating to reducing cost sharing for certain low -income families,
see section 1371.
(c) Deductibles, Cost Sharing, and Out -of-Pocket Limits on
Cost Sharing._
(1) Application on an annual basis._The deducti bles and
out-of-pocket limits on cost sharing for a year under the schedules
referred to in subsection (a) shall be applied based upon expenses
incurred for items and services furnished in the year.
(2) Individual and family general deductibles._
(A) Individual._Subject to subparagraph (B), with respect to
an individual enrolled under a health plan (regardless of the class
of enrollment), any individual general deductible in the cost
sharing schedule offered by the plan represents the amount of
countable expenses (as defined in subparagraph (C)) that the
individual may be required to incur in a year before the plan
incurs liability for expenses for such items and services furnished
to the individual.
(B) Family._In the case of an individual enrolled under a
health plan under a family class of enrollment (as defined in
section 1011(c)(2)(A)), the individual general deductible under
subparagraph (A) shall not apply to countable expenses incurred by
any member of the individual's family in a year at such time as the
family has incurred, in the aggregate, countable expenses in the
amount of the family general deductible for the year.
(C) Countable expense._In this paragraph, the term ``countable
expense'' means, with respect to an individual for a year, an
expense for an item or service covered by the comprehensive benefit
package that is subject to the general deductible and for which,

but for such deductible and other cost sharing under this subtitle,
a health plan is liable for payment. The amount of countable
expenses for an individual for a year under this paragraph shall
not exceed the individual general deductible for the year.

(3) Coinsurance and copayments._After a general or separate
deductible that applies to an item or service covered by the
comprehensive benefit package has been satisfied for a year,
subject to paragraph (4), coinsurance and copayments are amounts
that an individual may be required to pay with respect to the item
or service.
(4) Individual and family limits on cost sharing._
(A) Individual._Subject to subparagraph (B), with respect to
an individual enrolled under a health plan (regardless of the class
of enrollment), the individual out -of-pocket limit on cost sharing
in the cost sharing schedule offered by the plan represents the
amount of expenses that the individual may be required to incur
under the plan in a year because of a general deductible, separate
deductibles, copayments, and coinsurance before the plan may no
longer impose any cost sharing with respect to items or services
covered by the comprehensive benefit package that are provided to
the individual, except as provided in subsections (d)(2)(D) and
(e)(2)(D) of section 1115.
(B) Family._In the case of an individual enrolled under a
health plan under a family class of enrollment (as defined in
section 1011(c)(2)(A)), the family out -of-pocket limit on cost
sharing in the cost sharing schedule offered by the plan represents
the amount of expenses that members of the individual's family, in
the aggregate, may be required to incur under the plan in a year
because of a general deductible, separate deductibles, copayments,
and coinsurance before the plan may no longer impose any cost
sharing with respect to items or services covered by the
comprehensive benefit package that are provided to any member of
the individual's family, except as provided in subsections
(d)(2)(D) and (e)(2)(D) of section 1115. SEC. 1132. LOWER COST
SHARING.
(a) In General._The lower cost sharing schedule referred to in
section 1131 that is offered by a health plan_
(1) may not include a deductible;
(2) shall have_
(A) an annual individual out -of-pocket limit on cost sharing
of $1500; and
(B) an annual family out -of-pocket limit on cost sharing of
$3000;
(3) except as provided in paragraph (4)_
(A) shall prohibit payment of any coinsurance; and
(B) subject to section 1152, shall require payment of the
copayment for an item or service (if any) that is specified for the
item or service in the table under section 1135; and
(4) shall r equire payment of coinsurance for an out -of-network
item or service (as defined in section 1402(f)) in an amount that

is a percentage (determined under subsection (b)) of the applicable
payment rate for the item or service established under section
1322(c), but only if the item or service is subject to coinsurance
under the higher cost sharing schedule described in section 1133.

(b) Out-of-Network Coinsurance Percentage._
(1) In general._The National Health Board shall determine a
percentage referred to in subsection (a)(4). The percentage_
(A) may not be less than 20 percent; and
(B) shall be the same with respect to all out -of-network items
and services that are subject to coinsurance, except as provided in
paragraph (2).
(2) Exception._The National Health Board may provide for a
percentage that is greater than a percentage determined under
paragraph (1) in the case of an out -of-network item or service for
which the coinsurance is greater than 20 percent of the applicable
payment rate under the higher cost sharing schedule described in
section 1133. SEC. 1133. HIGHER COST SHARING.
The higher cost sharing schedule referred to in section 1131
that is offered by a health plan_

(1) shall have an annual individual general deductible of $200
and an annual family general deductible of $400 that apply with
respect to expenses incurred for all items and services in the
comprehensive benefit package except_
(A) an item or service with respect to which a separate
individual deductible applies under paragraph (2), (3), or (4); or
(B) an item or service described in paragraph (5), (6), or (7)
with respect to which a deductible does not apply;
(2) shall require an individual to incur expenses during each
episode of inpatient and residential mental health and substance
abuse treatment (described in section 1115) equal to the cost of
one day of such treatment before the plan provides benefits for
such treatment to the individual;
(3) shall require an individual to incur expenses in a year
for outpatient prescription drugs and biologicals (described in
section 1122) equal to $250 before the plan provides benefits for
such items to the individual;
(4) shall require an individual to incur expenses in a year
for dental care described in section 1126, except the items and
services for prevention and diagnosis of dental disease described
in section 1126(a)(2), equal to $50 before the plan provides
benefits for such care to the individual;
(5) may not require any deductible for clinical preventive
services (described in section 1114);
(6) may not require any deductible for clinician visits and
associated services related to prenatal care or 1 post -partum visit
under section 1116;
(7) may not require any deductible for the items and services
for prevention and diagnosis of dental disease described in section
1126(a)(2);
(8) shall have_

(A) an annual individual out -of-pocket limit on cost sharing
of $1500; and
(B) an annual family out -of-pocket limit on cost sharing of
$3000;
(9) shall prohibit payment of any copayment; and
(10) subject to section 1152, shall require payment of the
coinsurance for an item or service (if any) that is specified for
the item or service in the table under section 1135. SEC. 1134.
COMBINATION COST SHARING.
(a) In General._The combination cost sharing schedule referred
to in section 1131 that is offered by a health plan_
(1) shall have_
(A) an annual individual out -of-pocket limit on cost sharing
of $1500; and
(B) an annual family out -of-pocket limit on cost sharing of
$3000; and
(2) otherwise shall require different cost sharing for
in-network items and services than for out -of-network items and
services.
(b) In-Network Items and Services._With respect to an
in-network item or service (as defined in section 1402(f)(1)), the
combination cost sharing schedule that is offered by a health plan_
(1) may not apply a deductible;
(2) shall prohibit payment of any coinsuran ce; and
(3) shall require payment of a copayment in accordance with
the lower cost sharing schedule described in section 1132.
(c) Out-of-Network Items and Services._With respect to an
out-of-network item or service (as defined in section 1402(f)(2)),
the combination cost sharing schedule that is offered by a health
plan_
(1) shall require an individual and a family to incur expenses
before the plan provides benefits for the item or service in
accordance with the deductibles under the higher cost sharing
schedule described in section 1133;
(2) shall prohibit payment of any copayment; and
(3) shall require payment of coinsurance in accordance with
such schedule. SEC. 1135. TABLE OF COPAYMENTS AND COINSURANCE.
(a) In General._The following table specifies, for different
items and services, the copayments and coinsurance referred to in
sections 1132 and 1133: Copayments and Coinsurance for Items and
Services Benefit Section Lower Cost Sharing Schedule Higher Cost
Sharing Schedule Inpatient hospital services No copayment 20
percent of applicable payment rate Outpatient hospital services
$10 per visit 20 percent of applicable payment rate Hospital
emergency room services $25 per visit (unless patient has an
emergency medical condition as defined in section 1867(e)(1) of the
Social Security Act) 20 percent of applicable payment rate
Services of health professionals $10 per visit 20 percent of
applicable payment rate Emergency services other than hospital
emergency room services $25 per visit (unless patient has an

emergency medical condition as defined in section 1867(e)(1) of the
Social Security Act) 20 percent of applicable payment rate
Ambulatory medical and surgical services $10 per visit 20 percent
of applicable payment rate Clinical preventive services No
copayment No coinsurance Inpatient and residential mental health
and substance abuse treatment No copayment 20 percent of applicable
payment rate Intensive nonresidential mental health and substance
abuse treatment No copayment 20 percent of applicable payment rate

Outpatient mental health and substance abuse treatment (except
psychotherapy, collateral services, and case management) $10 per
visit 20 percent of applicable payment rate Outpatient
psychotherapy and collateral services $25 per visit until January
1, 2001, and $10 per visit thereafter 50 percent of applicable
payment rate until January 1, 2001, and 20 percent thereafter Case
management No copayment No coinsurance Family planning and
services for pregnant women (except clinician visits and associated
services related to prenatal care and 1 post -partum visit) $10 per
visit 20 percent of applicable payment rate Clinician visits and
associated services related to prenatal care and 1 post -partum
visit No copayment No coinsurance Hospice care No copayment 20
percent of applicable payment rate Home health care No copayment
20 percent of applicable payment rate Extended care services No
copayment 20 percent of applicable payment rate Ambulance services
No copayment 20 percent of applicable payment rate Outpatient
laboratory, radiology, and diagnostic services No copayment 20
percent of applicable payment rate Outpatient prescription drugs
and biologicals $5 per prescription 20 percent of applicable
payment rate Outpatient rehabilitation services $10 per visit 20
percent of applicable payment rate Durable medical equipment and
prosthetic and orthotic devices No copayment 20 percent of
applicable payment rate Vision care $10 per visit (No additional
charge for 1 set of necessary eyeglasses for an individual less
than 18 years of age) 20 percent of applicable payment rate Dental
care (except space maintenance procedures and interceptive
orthodontic treatment) $10 per visit 20 percent of applicable
payment rate Space maintenance procedures and interceptive
orthodontic treatment $20 per visit 40 percent of applicable
payment rate Health education classes All cost sharing rules
determined by plans cost sharing rules determined by plans
Investigational treatment for life -threatening condition All cost
sharing rules determined by plans cost sharing rules determined by
plans

(b) Applicable Payment Rate._For purposes of this section, the
term ``applicable payment rate'', when used with respect to an item
or service, means the applicable payment rate for the item or
service established under section 1322(c). SEC. 1136. INDEXING
DOLLAR AMOUNTS RELATING TO COST SHARING.
(a) In General._Any deductible, copayment, out -of-pocket limit
on cost sharing, or other amount expressed in dollars in this
subtitle for items or services provided in a year after 1994 shall

be such amount increased by the percentage specified in subsection

(b) for the year.
(b) Percentage._The percentage specified in this subsection
for a year is equal to the product of the factors described in
subsection (d) for the year and for each previous year after 1994.
(c) Rounding._Any increase (or decrease) under subsection (a)
shall be rounded, in the case of an amount specified in this
subtitle of_
(1) $200 or les s, to the nearest multiple of $1,
(2) more than $200, but less $500, to the nearest multiple of
$5, or
(3) $500 or more, to the nearest multiple of $10.
(d) Factor._
(1) In general._The factor described in this subsection for a
year is 1 plus the general health care inflation factor (as
specified in section 6001(a)(3) and determined under paragraph (2))
for the year.
(2) Determination._In computing such factor for a year, the
percentage increase in the CPI for a year (referred to in section
6001(b)) shall be determined based upon the percentage increase in
the average of the CPI for the 12 -month period ending with August
31 of the previous year over such average for the preceding
12-month period. PART 4_EXCLUSIONS SEC. 1141. EXCLUSIONS.
(a) Medical Necessity._The comprehensive benefit package does
not include_
(1) an item or service (other than services referred to in
paragraph (2)) that is not medically necessary or appropriate; or
(2) an item or service that the National Health Board may
determine is not medically necessary or appropriate in a regulation
promulgated under section 1154.
(b) Additional Exclusions._The comprehensive benefit package
does not include the following items and services:
(1) Custodial care, except in the case of hospice care under
section 1117.
(2) Surgery and other procedures performed solely for cosmetic
purposes and hospital or other services incident thereto, unless_
(A) required to correct a congenital anomaly; or
(B) required to restore or correct a part of the body that has
been altered as a result of_
(i) accidental injury;
(ii) disease; or
(iii) surgery that is otherwise covered under this subtitle.
(3) Hearing aids.
(4) Eyeglasses and contact lenses for individuals at least 18
years of age.
(5) In vitro fertilization services.
(6) Sex change surgery and related services.
(7) Private duty nursing.
(8) Personal comfort items, except in the case of hospice care
under section 1117.

(9) Any dental procedures involving orthodontic care, inlays,
gold or platinum fillings, bridges, crowns, pin/post retention,
dental implants, surgical periodontal procedures, or the
preparation of the mouth for the fitting or continued use of
dentures, except as specifically described in section 1126. PART
5_ROLE OF THE NATIONAL HEALTH BOARD SEC. 1151. DEFINITION OF
BENEFITS.
(a) In General._The National Health Board may promulgate such
regulations or establish such guidelines as may be necessary to
assure uniformity in the application of the comprehensive benefit
package across all health plans.
(b) Flexibility in Delivery._The regulations or guidelines
under subsection (a) shall permit a health plan to deliver covered
items and services to individuals enrolled under the plan using the
providers and methods that the plan determines to be appropriate.
SEC. 1152. ACCELERATION OF EXPANDED BENEFITS.
(a) In General._Subject to subsection (b), at any time prior
to January 1, 2001, the National Health Board, in its discretion,
may by regulation expand the comprehensive benefit package by_
(1) adding any item or service that is added to the package as
of January 1, 2001; and
(2) requiring that a cost sharing schedule described in part 3
of this subtitle reflect (wholly or in part) any of the cost
sharing requirements that apply to the schedule as of January 1,
2001. No such expansion shall be effective except as of January 1
of a year.
(b) Condition._The Board may not expand the benefit package
under subsection (a) which is to become effective with respect to a
year, by adding any item or service or altering any cost sharing
schedule, unless the Board estimates that the additional increase
in per capita health care expenditures resulting from the addition
or alteration, for each regional alliance for the year, will not
cause any regional alliance to exceed its per capita target (as
determined under section 6003(a)). SEC. 1153. AUTHORITY WITH
RESPECT TO CLINICAL PREVENTIVE SERVICES.
(a) In General._With respect to clini cal preventive services
described in section 1114, the National Health Board_
(1) shall specify and define specific items and services as
clinical preventive services for high risk populations and shall
establish and update a periodicity schedule for such items and
services;
(2) shall update the periodicity schedules for the
age-appropriate immunizations, tests, and clinician visits
specified in subsections (b) through (h) of such section;
(3) shall establish rules with respect to coverage for an
immunization, test, or clinician visit that is not provided to an
individual during the age range for such immunization, test, or
clinician visit that is specified in one of subsections (b) through
(h) of such section; and

(4) may otherwise modify the items and services described in
such section, taking into account age and other risk factors, but
may not modify the cost sharing for any such item or service.
(b) Consultation._In performing the functions described in
subsection (a), the National Health Board shall consult with
experts in clinical preventive services. SEC. 1154. ESTABLISHMENT
OF STANDARDS REGARDING MEDICAL NECESSITY.
The National Health Board may promulgate such regulations as
may be necessary to carry out section 1141(a)(2) (relating to the
exclusion of certain services that are not medically necessary or
appropriate). PART 6_ADDITIONAL PROVISIONS RELATING TO HEALTH CARE
PROVIDERS SEC. 1161. OVERRIDE OF RESTRICTIVE STATE PRACTICE LAWS.

No State may, through licensure or otherwise, restrict the
practice of any class of health professionals beyond what is
justified by the skills and training of such professionals. SEC.
1162. PROVISION OF ITEMS OR SERVICES CONTRARY TO RELIGIOUS BELIEF
OR MORAL CONVICTION.

A health professional or a health facility may not be required
to provide an item or service in the comprehensive benefit package
if the professional or facility objects to doing so on the basis of
a religious belief or moral conviction.

Title I, Subtitle C Subtitle C_State Responsibilities SEC. 1200.
PARTICIPATING STATE.

(a) In General._For purposes of the approval of a State health
care system by the Board under section 1511, a State is a
``participating State'' if the State meets the applicable
requirements of this subtitle.
(b) Submission of System Document._
(1) In general._In order to be approved as a participating
State under section 1511, a State shall submit to the National
Health Board a document (in a form and manner specified by the
Board) that describes the State health care system that the State
is establishing (or has established).
(2) Deadline._If a State is not a participating State with a
State health care system in operation by January 1, 1998, the
provisions of subpart B of part 2 of subtitle F (relating to
Federal operation of a State health care system) shall take effect.
(3) Submission of information subsequent to approval._A State
approved as a participating State under section 1511 shall submit
to the Board an annual update to the State health care system not
later than February 15 of each year following the first year for
which the State is a participating State that contains_
(A) such information as the Board may require to determine
that the system shall meet the applicable requirements of subtitle
C for the succeeding year; and
(B) such information as the Board may require to determine
that the State operated the system during the previous year in
accordance with the Board's approval of the system for such

previous year. PART 1_GENERAL STATE RESPONSIBILITIES SEC. 1201.
GENERAL STATE RESPONSIBILITIES.

The responsibilities for a participating State are as follows:

(1) Regional alliances._Establishing one or more regional
alliances (in accordance with section 1202).
(2) Health plans._Certifying health plans (in accordance with
section 1203).
(3) Financial solvency of plans._Assuring the financial
solvency of health plans (in accordance with section 1204).
(4) Administration. esignating an agency or official charged
with coordinating the State responsibilities under Federal law.
(5) Workers compensation and automobile insurance._Conforming
State laws to meet the requirements of title X (relating to medical
benefits under workers compensation and automobile insurance).
(6) Other responsibilities._Carrying out other
responsibilities of participating States specified under this Act.
SEC. 1202. STATE RESPONSIBILITIES WITH RESPECT TO ALLIANCES.
(a) Establishment of Alliances._
(1) In general._A participating State shall_
(A) establish and maintain one or more regional alliances in
accordance with this section and subtitle D, and ensure that such
alliances meet the requirements of this Act; and
(B) designate alliance areas in accordance with subsection
(b).
(2) Deadline._A State may not be a participating State for a
year unless the State has established such alliances by March 1 of
the previous year.
(b) Alliance Areas._
(1) In general._In accordance with this subsection, each State
shall designate a geographic area assigned to each regional
alliance. Each such area is referred to in this Act as an
``alliance area''.
(2) Population required._
(A) In general._Each alliance area shall encompass a
population large enough to ensure that the alliance has adequate
market share to negotiate effectively with health plans providing
the comprehensive benefit package to eligible individuals who
reside in the area.
(B) Treatment of consolidated metropolitan statistical
areas._An alliance area that includes a Consolidated Metropolitan
Statistical Area within a State is presumed to meet the
requirements of subparagraph (A).
(3) Single alliance in each area._No geographic area may be
assigned to more than one regional alliance.
(4) Boundaries._In establishing boundaries for alliance areas,
the State may not discriminate on the basis of or otherwise take
into account race, ethnicity, language, religion, national origin,
socio-economic status, disability, or perceived health status.

(5) Treatment of metropolitan areas._The e ntire portion of a
metropolitan statistical area located in a State shall be included
in the same alliance area.
(6) No portions of State permitted to be outside alliance
area._Each portion of the State shall be assigned to a regional
alliance under this subsection.
(c) State Coordination of Regional Alliances._One or more
States may allow or require two or more regional alliances to
coordinate their operations, whether such alliances are in the same
or different States. Such coordination may include adoption of
joint operating rules, contracting with health plans, enforcement
activities, and establishment of fee schedules for health
providers.
(d) Assistance in Collection of Amounts Owed to
Alliances._Each State shall assure that the amounts owed to
regional alliances in the State are collected and paid to such
alliances.
(e) Assistance in Eligibility Verifications._
(1) In general._Each State shall assure that the
determinations of eligibility for cost sharing assistance (and
premium discounts and cost sharing reductions for families) are
made by regional alliances in the State on the basis of the best
information available to the alliances and the State.
(2) Provision of information._Each State shall use the
information available to the State under section 6103(l)(7)(D)(x)
of the Internal Revenue Code of 1986 to assist regional alliances
in verifying such eligibility status.
(f) Special Requirements for Alliances With Single -Payer
System._If the State operates an alliance -specific single -payer
system (as described in part 2), the State shall assure that the
regional alliance in which the system is operated meets the
requirements for such an alliance described in section 1224(b).
(g) Payment of Shortfalls for Certain Administrative
Errors._Each participating State is financially responsible, under
section 9201(c)(2), for administrative errors described in section
9201(e)(2). SEC. 1203. STATE RESPONSIBILITIES RELATING TO HEALTH
PLANS.
(a) Criteria for Certification._
(1) In general._For pu rposes of this section, a participating
State shall establish and publish the criteria that are used in the
certification of health plans under this section.
(2) Requirements._Such criteria shall be established with
respect to_
(A) the quality of the plan,
(B) the financial stability of the plan,
(C) the plan's capacity to deliver the comprehensive benefit
package in the designated service area,
(D) other applicable requirements for health plans under parts
1, 3, and 4 of subtitle E, and

(E) other requirements imposed by the State consistent with
this part.
(b) Certification of Health Plans._A participating State shall
certify each plan as a regional alliance health plan that it
determines meet the criteria for certification established and
published under subsection (a).
(c) Monitoring._A participating State shall monitor the
performance of each State -certified regional alliance health plan
to ensure that it continues to meet the criteria for certification.
(d) Limitations on Authority._A participating State may not_
(1) discriminate against a plan based on the domicile of the
entity offering of the plan; and
(2) regulate premium rates charged by health plans, except as
may be required under title VI (relating to the enforcement of cost
containment rules for plans in the State) or as may be necessary to
ensure that plans meet financial solvency requirements under
section 1408.
(e) Assuring Adequate Access to a Choice of Health Plans._
(1) General access._
(A) In general._Each part icipating State shall ensure that_
(i) each regional alliance eligible family has adequate access
to enroll in a choice of regional alliance health plans providing
services in the area in which the individual resides, including (to
the maximum extent practicable) adequate access to a plan whose
premium is at or below the weighted average premium for plans in
the regional alliance, and
(ii) each such family that is eligible for a premium discount
under section 6104(b) is provided a discount in accordance with
such section (including an increase in such discount described in
section 6104(b)(2)).
(B) Authority._In order to carry out its responsibility under
subparagraph (A), a participating State may require, as a condition
of entering into a contract with a regional alliance under section
1321, that one or more certified regional alliance health plans
cover all (or selected portions) of the alliance area.
(2) Access to plans using centers of excellence._Each
participating State may require, as a condition of entering into a
contract with a regional alliance under section 1321, that one or
more certified health plans provide access (through reimbursement,
contracts, or otherwise) of enrolled individuals to services of
centers of excellence (as designated by the State in accordance
with rules promulgated by the Secretary).
(3) Use of incentives to enroll and serve disadvantaged
groups._A State may provide_
(A) for an adjustment to the risk -adjustment methodology under
section 1542(c) and other financial incentives to regional alliance
health plans to ensure that such plans enroll individuals who are
members of disadvantaged groups, and

(B) for appropriate extra services, such as outreach to
encourage enrollment and transportation and interpreting services
to ensure access to care, for certain population groups that face
barriers to access because of geographic location, income levels,
or racial or cultural differences.
(f) Coordination of Workers' Compensation Services and
Automobile Insurance._Each participating State shall comply with
the responsibilities regarding workers' compensation and automobile
insurance specified in title X.
(g) Implementation of Mandatory Reinsurance System._If the
risk adjustment and reinsurance methodology developed under section