Bill· HRH.R. 5191 (96th)referred
United States · United States Congress · 6 September 1979
Health Care for All Americans Act - Establishes a comprehensive "national health insurance system" (defined as the programs established by this Act and Medicare for the financing of health-care services). States the findings and purposes of this Act. Enumerates the rights of eligible individuals, providers, and insurers and health maintenance organizations (HMOs). Requires that such individuals and entities have their views considered with respect to actions under this Act affecting them. Gives such an individual the right to: (1) choose any participating provider with respect to a covered service; (2) the prompt and accurate making of decisions under this Act; (3) be heard on any grievance related to benefits under this Act; and (4) confidential treatment and use of information collected under this Act. Gives such a provider the right to: (1) decide whether or not to participate in the system; (2) the prompt and accurate payment for services; and (3) choose the mode and place of practice (with respect to a physician provider). Gives such an insurer and HMO the right to: (1) decide whether or not to participate in the system; and (2) carry on a supplemental health insurance business. Defines terms used in this Act. Title I: Eligibility, Entitlement, and Enrollment - Extends eligibility for the benefits of this Act to: (1) U.S. citizens; (2) aliens lawfully admitted or permanently residing in the U.S. under color of law, including refugees; (3) aliens admitted to the U.S. as employees of a foreign government or international organization which has entered into an agreement with the U.S.; and (4) aliens admitted as temporary visitors from a foreign government which has entered into such an agreement. Directs the National Health Board (established by this Act), after consultation with the Secretary of State, to recommend to the President that executive agreements be entered into: (1) with foreign governments and international organizations to make their employees and officers eligible for health benefits in return for a payment of the national community-rated premium plus an amount equal to what would otherwise be payable as the Medicare hospital insurance payroll tax, if such employees were so taxed; and (2) with foreign governments upon a determination that it is in the national interest to make nationals or citizens of such nations who visit the U.S. eligible for benefits in return for comparable treatment of U.S. citizens abroad. Entitles each eligible individual to: (1) enroll in a qualified plan offered by an insurer or HMO and to change enrollment during certain periods; (2) have payment made on such individual's behalf and not be charged any fee for basic covered services; and (3) be issued a health insurance enrollment card. Stipulates that such a card shall not identify the category or basis for the individual's enrollment. Requires enrollment information to be available and provided: (1) by employers to employees; (2) by or through the Board to Medicare-eligible individuals; (3) by the Secretaries of Defense, Transportation, Commerce, and HEW to active- duty uniformed service personnel under their jurisdiction; (4) by the Social Security Commissioner to Supplemental Security Income (SSI)- eligible individuals; (5) by managers of Federal and State institutions to residents; (6) by State welfare agencies to Aid to Families with Dependent Children (AFDC)-eligible persons; and (7) by or through State health boards to other individuals. Directs the Board to notify State health boards of the identity of eligible individuals who, in certain Federal information returns, have failed to indicate enrollment under a qualified plan. Requires providers to transmit to their respective health boards requests for payment for eligible persons who did not indicate enrollment at the time of receiving services. Directs State health boards to make special efforts to locate such persons and provide for their enrollment. Defines "first general open enrollment period", "general open enrollment period", and "special enrollment period" for purposes of the program. Stipulates that all members of a family (other than those who are Medicare or SSI-eligible or residents of a Federal or State institution) be enrolled at any time in only one qualified plan. Requires employers to offer qualified employees during specified enrollment periods the choice of enrollment under: (1) at least one plan offered by an insurer belonging to (A) the Blue Cross-Blue Shield consortium or (B) the commercial insurance consortium; and (2) at least one plan offered by an HMO belonging to (A) the individual group practice HMO consortium or (B) the prepaid group practice HMO consortium (if such a plan is available in the area in which the employees obtain health care services). Allows the employer to also offer enrollment in plans offered by a self-insurer. Requires an offer of enrollment to be made first to a collective bargaining representative or other employee representative designated under law. Requires each employee to elect a plan in accordance with procedures established by the Board. Directs the employer to enroll such employee in a plan in accordance with procedures in the absence of such an election. Requires any employer offering in conjunction with a qualified plan a plan with benefits supplemental to basic services to provide employees with written information regarding additional employee costs for such supplemental plan. Limits a family which is offered a choice of plans to enroll under only one qualified plan. Subjects an employer who knowingly fails to comply with these requirements to a civil penalty which may be assessed by the Board and collected by civil suit in a district court. Requires active-duty members of the uniformed services to enroll in a plan from among such health plans offered by or through the Department of Defense as the Secretary of Defense, after consultation with the Secretaries of HEW, Transportation, Commerce, and the Board, finds are consistent with the statutory requirements regarding uniformed services medical care and with policy requiring provision of basic and other covered health services to such members and their families. Requires Medicare-eligible individuals to enroll with the Board or a participating HMO in accordance with the Medicare program. Allows SSI-eligible individuals, residents of Federal or State institutions not otherwise enrolled, AFDC-eligible individuals, or other individuals not otherwise enrolled to enroll during specified periods in any qualified health plan available to such individuals. Provides for the mandatory enrollment of such individuals who fail to enroll in a plan, in accordance with regulations of the Board and rules and procedures of the State health boards. Title II: Benefits and Providers - Includes as basic covered services: (1) inpatient and outpatient hospital services (and inpatient mental health services up to (A) 150 consecutive days for Medicare-eligible individuals, or (B) 45 consecutive days for other eligible individuals, during certain periods of treatment as determined under Medicare); (2) physicians' services, including hospital-based physicians (and services for the treatment of mental illness and outpatient mental health services to the extent that expenses for such services do not exceed the fee-equivalent of 20 psychiatric visits per year, as determined under Medicare); (3) post-hospital extended care services up to 100 days during any spell of illness; (4) the following preventive health services: (A) basic immunizations; (B) pre-and post-natal maternal care; (C) well-child care (including periodic physical examinations, hearing and vision screening, and developmental screening and examinations) for persons up to the age of 18 years; and (D) such other services as the Board may add on a year-by-year basis after consultation with appropriate experts and a determination by the Board that such services will be cost-effective (but limits the expenditure for such additional preventive services to $500,000,000 for the first effective year (defined as the third year after the year of enactment) and for subsequent years an increase tied to the average annual rate of increase in the gross national product. Includes as additional basic services: (1) outpatient physical therapy services, outpatient speech pathology services; (2) health clinic services, including rural health clinic services; (3) home dialysis supplies; (4) tests and other diagnostic tests; (5) X-ray therapy; (6) durable medical equipment used in the patient's home; (7) ambulance service, to the extent provided by regulations; (8) prosthetic devices (other than dental), including lenses after cataract surgery and replacements; (9) leg, arm, back, and neck braces, and artificial legs, arms, and eyes, including replacements; (10) insulin and outpatient prescription drugs for treatment of chronic conditions (but for Medicare-eligible individuals only to the extent provided under such program); (11) one audiological examination per individual per year and the provision of one hearing aid per individual for any three-year period; and (12) mental health day care services to the extent of two days for each day of inpatient mental health services permitted by this program. Excludes as basic services: (1) items and services for which payment may not be made under Medicare; and (2) for other than Medicare-eligible individuals payment for (A) orthopedic shoes or other supportive devices for the feet, (B) certain physician services described under Medicare, and (C) certain inpatient hospital services described under Medicare. Authorizes the Board, after consultation with the Commission on Health-Care Benefits and the Commission on Quality of Health Care (established by this Act), to exclude payment for an item or service under a plan under this program and Medicare on the basis of cost-effectiveness, notwithstanding any other provision. Makes specified provisions of title XI (General Provisions and Professional Standards Review) and title XVIII (Medicare) of the Social Security Act applicable to basic services provided under qualified plans to the same extent as they apply under Medicare. Authorizes the Board, after consultation with the Commissions on Health-Care Benefits and Quality of Health Care, to establish a list of high-risk, high-cost, elective, or overutilized items or services for which payment may be made only if one or more of the following conditions are met: (1) the provider is board-certified in the relevant specialty; (2) the diagnosis and recommended service are supported by a second opinion or specific objective findings; (3) the provider-institution is adequately equipped and staffed; (4) the specialist or institution is providing care upon referral by a primary-care physician; or (5) the provider has demonstrated through statistical services that it provides high-quality services and properly uses appropriate methods and technologies. Title III: Financing and Planning - Part A, Budget and Planning Process - Specifies the annual timetable for the budget process for the national health insurance system as follows: (1) by January 15th proposed annual State budgets are to be prepared by the State Health Boards, in accordance with regulations and after consultation with specified interests, and submitted to the Board; (2) the Board shall transmit for inclusion without change in the Budget presented by the President an estimate of the anticipated Federal expenditures related to the appropriate Annual Budgets; (3) by March 1st a comprehensive Annual Budget is to be prepared and adopted by the Board and transmitted to the President, Congress, the States, and the public; (4) the Congressional Budget Office shall submit to the appropriate congressional committees as soon as practicable after receipt of the Annual Budget an analysis of its impact on the Federal Budget; (5) by July 1st the annual State budgets are to be adopted by the State Health Boards, taking into consideration the State Health Care Improvement Plan mandated by this Act, and transmitted to the Board; and (6) on the following January 1st the budget year begins. Specifies the contents of the Annual Budget and annual State Budgets, including enumerated items in the following categories: (1) anticipated expenditures; (2) anticipated revenues; (3) separate schedules, including Medicare and other public programs; (4) premium rates, including the national community-rated and group-rated premium amounts and national premium rate; and (5) five-year projections. Places the following limitations on expenditures under this program: (1) total anticipated expenditures for a year may not exceed the amount of the estimated expenditures by more than the average annual rate of increase in the gross national product for the three-year period ending with the year before the year in which the Annual Budget is adopted; (2) the amounts budgeted for covered health-care services for the U.S. and for any State are the maximum amounts that may be expended for such services (except for costs associated with uniformed service members); (3) a State Health Board may not provide for total expenditures for items covered in the budget in excess of those contained in the Annual Budget with respect to the State; (4) the total anticipated expenditures for the U.S. and for any State for the provision of basic services within a category of services or of providers are the maximum amounts that may be expended for such purposes (within percentage variations that the Board may permit); and (5) the percentage increase in the anticipated expenditures per capita for covered health-care services over the actual expenditures for such services for the previous year are limited according to specified formulas. Directs the Board, in consultation with the President's Commission on the Health of Americans, to prepare and annually revise, before the adoption of each Annual Budget, a National Health Care Improvement Plan which describes: (1) needs over a five-year period relating to the accessibility, quality, and cost of health care; (2) the effect of the provisions of this program on meeting such needs; and (3) recommendations. Directs the Governor of each State to prepare and annually revise a State Health Care Improvement Plan in accordance with Board standards and guidelines which describes: (1) needs over a five-year period relating to the accessibility, quality, and cost of health care; and (2) specific actions for meeting such needs. Requires such State Plan to include to the extent appropriate the objectives of: (1) the State health plan in effect under title XV of the Public Health Service Act (National Health Planning and Development); (2) the State medical assistance plan in effect under Medicaid; and (3) any plan submitted by the State to receive assistance under the Public Health Service Act and the Community Mental Health Centers Act. Title III - Part B, Payments to Providers - Provides for payment to providers as follows: (1) insurers and HMOs shall make payments to providers furnishing services to (A) their respective enrollees and (B) individuals not enrolled at the time of services but who are subsequently enrolled; (2) the Board shall make payments to providers furnishing services to a Medicare-eligible individual who is not enrolled in a plan offered by a HMO: and (3) the Secretary of Defense shall pay for services furnished to a member of the uniformed services on active duty. Requires each insurer or HMO to provide for payments of such allocated portion of the approved prospective budget (required under this Act) of the provider as reflects, in accordance with Board regulations, the proportion of the costs in the budget used to provide such services to such enrollees. Prohibits payment for expenditures by an institutional provider for covered services it furnishes to the extent such expenditures are not included in such approved prospective budget. Requires Board regulations to provide for methods of cost apportionment among insurers and HMOs in accordance with specified criteria. Allows such methods to include apportionment based on: (1) the number of treatments of particular conditions or diagnoses; (2) the relative value of the health-care services furnished (with respect to indices of relative values to be established by the Board); or (3) the number of admissions, patient days, diagnoses, or other easily determinable factor that may fairly allocate costs. Allows a State health board, when regulations provide for more than one apportionment method, to select and require the use of one such method. Requires each institutional provider in a State with an approved prospective budget to transmit annually to the State Health Board an experience report which shows the differences between the actual expenditures and services provided by the provider and those allowed for in its approved prospective budget. Directs the State Health Board to provide for: (1) the retention by the provider of one-half of savings produced by actions which lowered expenditures below those predicted; and (2) adjustments, to the extent appropriate, in the amounts of payments made by insurers and HMOs or in the prospective budget for the following year to correct unintended differences in the amount or source of payments to a provider. Provides for payment to a provider, other than an institutional provider (defined as including hospitals, skilled nursing facilities, home health agencies, community health centers and clinics, and, to the extent provided by the National Health Board, HMOs), for covered services (other than drugs, hearing aids, durable medical equipment, or laboratory services) in accordance with the lowest of: (1) the fee charged by the provider; (2) the fee agreed upon between the provider and the insurer or HMO; or (3) the applicable maximum fee schedule for the service (established by this Act). Allows the National Health Board, upon the recommendation of a State Health Board, to increase the payment to a physician provider on an individual basis to recognize performance of unusual merit by such physician. Allows such a provider to elect to be paid on a salary or fee-for-time basis if the total amount payable in a year is not greater than the total amount payable for the equivalent amount of services as computed by the applicable maximum fee schedule. Provides for payment to a provider for: (1) durable medical equipment and laboratory services in accordance with the lowest of: (A) the charge for such service; (B) the charge agreed upon between the provider and the insurer or HMO; or (C) the maximum reasonable cost for such service; and (2) drugs and hearing aids in accordance with the lowest of: (A) the provider's fee charged for dispensing the drug or hearing aid; (B) the charge agreed upon between the provider and the insurer or HMO; or (C) the highest fee permitted under the applicable fee schedule. Provides for payment to a provider for other covered services in accordance with the lowest of: (1) the charge for the service; (2) the charge agreed upon between the provider and the insurer or HMO; or (3) the maximum reasonable cost of the service, as established by the State Health Boards in accordance with national guidelines and standards. Allows the National Health Board to permit experimental or demonstration methods of reimbursement which will further the purposes of this Act. Provides for periodic review of reimbursement methods. Sets forth procedures with respect to the budget limitations, including the following: (1) monitoring by the State Health Boards, the consortia (all the clearinghouses certified under this Act with respect to the financing of covered services), insurers, and HMOs of payment made to providers; (2) reporting by insurers and each consortium of excessive payments; (3) investigation and corrective actions by the State Health Boards; (4) shifting of funds among categories of services or providers and use of contingency funds for excess expenditures due to unforeseen circumstances; (5) modification of reimbursement methods; (6) additional certifications by State Health Boards of the need for particular services; and (7) requiring insurers and HMOs to make payments for services during certain periods. Allows philanthropic contributions and supplemental payments by State and local governments to finance services additional to those reimbursed under this Act. Stipulates that capital expenditures assisted by such assistance shall not be recognized by a State Health Board in its review of prospective budgets and maximum fee schedules. Requires each institutional provider to submit to the State Health Board its proposed prospective budget for the subsequent year which covers all medical services (not merely covered services) and includes the following: (1) anticipated costs, broken down by schedules for specified costs; (2) the proportion of such costs associated with covered services; and (3) anticipated revenues, broken down by source with respect to each class of items of anticipated costs. Authorizes the National Health Board to require accompanying documentation relating to specified factors for purposes of review. Specifies the manner in which certain costs shall be treated in such prospective budgets, including the following provisions: (1) the costs of all physicians' services under contract with the provider shall be included and the amount budgeted for such services shall be reasonable in relation to the cost of obtaining such services on a salaried or other basis, whichever is less; (2) the total cost of wages and fringe-benefits for nonsupervisory employees shall be included and shall reflect any existing collective-bargaining agreement; (3) the costs of furnishing basic services to ineligible individuals shall be included if no other reimbursement is obtainable by the provider; (4) depreciation costs shall not be included, except for certain capital costs, debt repayments, and costs associated with the closing of a facility; and (5) a reasonable rate of return on equity capital with respect to certain proprietary institutions shall be included. Directs the National Health Board, after appropriate consultation, to establish guidelines respecting review and approval by State Health Boards of proposed prospective budgets of institutional providers. Requires such guidelines to include: (1) standards to determine which budgets and budgetary elements may be approved without individual scrutiny; and (2) the detailed review of a random sample. Specifies standards which may be included with respect to providers of inpatient services. Requires the guidelines to provide for the collection and reporting of data in such uniform manner as the Board may set. Establishes procedures for the review and approval of prospective budgets by the State Health Boards, including the following provisions: (1) each review shall be made public and shall (A) assess whether changes in services or capital expenditures conform to the current plan of the health systems agency in the area (mandated under title XV of the Public Health Service Act) and the most recent State Health Care Improvement Plan; (B) review the quality, accessibility, and effectiveness of provider services, taking into consideration any relevant findings of professional standards review organizations (PSROs) and of any national provider accreditation organization for that category of provider; (2) a provider shall be given the opportunity to comment on any pending disapproval; (3) the State Health Board shall consider any timely recommendations submitted by consumer groups, the provider, and employee organizations, including negotiated recommendations; (4) a State Health Board may delegate its review functions to an independent entity; and (5) such budgets may not provide for any capital acquisition or expenditure unless the provider has participated in a planning process in accordance with regulations. Requires a State Health Board to approve a budget without modification, taking into account the following factors: (1) total limits on anticipated expenditures; (2) the health systems agency plan; (3) demographic factors; (4) the impact of inflation on budget costs; (5) the effects of any approved capital expenditure or reduction, service modification plans, or future wage increases; and (6) certain other efficiency and cost-effectiveness objectives. Requires resubmission of a budget to the State Health Board if a modification is required for excess expenditures. Disallows payments to an institutional provider for covered services not included in its approved prospective budget. Requires each State Health Board to develop maximum fee schedules for covered services (other than durable medical equipment and laboratory services) after opportunity for negotiations with participating providers. Directs the National Health Board to develop guidelines for such schedules which: (1) establish the relative value of particular services, taking into account specified factors; (2) provide for geographical variations in fees, taking into consideration certain criteria; (3) set the maximum fee for a service which can be provided by two or more categories of health personnel at the lowest of the maximum fees authorized for such categories; and (4) include a formula for allowing annual changes in such schedules. Requires payment for the provision of: (1) durable medical equipment and laboratory services to be the lower of (A) the charge, or (B) the reasonable cost of the equipment or service; and (2) drugs and hearing aids to be the lower of (A) the charge, or (B) the reasonable cost of the drug or aid, plus a reasonable professional fee. Directs the National Health Board to establish guidelines for the reasonable cost of durable medical equipment, laboratory services, drugs, and hearing aids which shall be the lowest cost at which any such item of comparable quality is (or could be made) generally available in an accessible area. Provides for the computation of the professional fee with respect to drugs and hearing aids. Outlines procedures for the use of negotiations to determine the amounts of payments to providers. Directs the National Health Board to establish criteria for the selection of the negotiating groups for each of the following groups of providers: (1) hospitals; (2) skilled nursing facilities; (3) home health care agencies; (4) other institutional providers, including community health centers, migrant health centers, and health clinics; (5) physicians; (6) other non-institutional providers, such as pharmacists, physical and occupational therapists; and (7) hospital employees. Sets forth requirements for representation within such groups. Requires that the selection guidelines by the National Health Board shall provide for: (1) differences in the sizes of the various negotiating groups; (2) proportional representation for each type of health-care provider; (3) three-year terms for each representative; and (4) nomination and election methods. Provides that such negotiations shall concern: (1) limitations with respect to payments made to institutional providers on the basis of approved prospective budgets; (2) maximum-fee schedules; (3) reasonable cost levels with respect to durable medical equipment, laboratory services, drugs, and hearing aids; and (4) other cost control methods. Allows a State Health Board to incorporate within its annual State budget the provision of any agreement reached as the result of such negotiations which would keep expenditures within the budgetary limits. Title III- Part C, Determining Amounts of Premiums and Incentive Payments and Benefits - Directs the National Health Board to establish, in conjunction with the adoption of the Annual Budget and after negotiations with consortia, participating insurers, and HMOs: (1) a national community-rated premium; and (2) a national premium rate. Requires the national community-rated premium to be set so that, if such amount were paid by the members of each family enrolled through an employer plan, the total premiums paid would equal the anticipated expenditures under the Annual Budget, including payments to providers for basic services and administrative costs, but excluding administrative costs for the National and State Health Boards, PSROs, contingency funding, and the costs of covered services to persons who are Medicare-, SSI-, AFDC-eligible residents of Federal or State institutions, or members of the uniformed services on active duty. Requires that the national premium rate be set so that the sum of all wage-related and non-wage related premiums, the government payment for unpaid private premiums, and the voluntary premiums under international agreements equals the anticipated expenditures for covered services to Medicare- eligible, SSI-eligible, and AFC-eligible individuals, and residents of Federal and State institutions. Directs the Board to establish a group-related premium for SSI-eligible individuals and for residents of Federal and State institutions who are enrolled in a qualified plan. Requires that: (1) such premium be set so that the total amounts paid on behalf of such individuals equals the expenditures for furnishing care to such persons; and (2) such premium be adjusted annually to reflect the actual cost experience with respect to such expenditures. Provides that the national community-rated premium and the national premium rate are to apply as the State community-rated premium and the premium rate for each State, unless a State is able to provide for reduced premiums by negotiating a lower level of approved expenditures than would otherwise be provided for in the national budget. Requires each State to establish a group-rated premium for AFDC-eligible individuals and residents of State institutions. Requires that such premium: (1) be set so that the total amounts paid on behalf of such individuals equals the expenditures for furnishing care to such persons; and (2) be adjusted annually to reflect the actual cost experience with respect to such expenditures. Permits a participating insurer or HMO to offer eligible individuals (other than Medicare eligibles) an incentive to enroll in a qualified plan by providing additional services or by paying dividends or cash rebates on premiums. Permits an HMO to offer such incentives to Medicare-eligible persons. Sets forth requirements with respect to such dividend and cash rebates, including that: (1) in the case of employed enrollees, they be divided between the employees and employer in accordance with Board procedures; and (2) they not be treated as taxable income to individuals or income under federally-assisted welfare programs, nor reduce any credit relating to a limit on the amount of private premium payments. Sets a limit on the amount of premiums paid with respect to members of a family unit as employees and by members of the family unit. Provides for a refund to families of amounts in excess of such limit. Title III-Part D, Payment and Collection of Premiums - Requires each employer to pay to the applicable consortium on behalf of each employee for each payroll period an amount equal to the product of the wages paid during such period and the applicable State premium rate. Permits an employer (subject to any collective-bargaining agreement) to require employees to pay up to 35 percent of such amount. Requires an employer to pay any voluntary contributions such employee may wish to have made on his behalf. Permits an employer to obtain certification from the Board as an impacted employer and so qualify for: (1) a payment from the Board if such employer is a State employer or nonprofit employer; or (2) a tax credit with respect to other employers. Specifies the formula for determining such payment or credit. Defines terms for the purposes of this section. Requires all persons (with specified exceptions) to pay to the applicable consortium an amount equal to the product of one-half the State premium rate and the amount of non-wage-related income of such persons' family units. Requires such persons to file quarterly information returns in accordance with Board regulations. Authorizes the Board to impose a collection surcharge for untimely payments. Prescribes the payment procedure for premiums under executive agreements. Requires: (1) the Board to make monthly premium payments to consortia on behalf of SSI-eligible individuals and residents of Federal institutions; and (2) each State to make monthly premium payments to consortia on behalf of AFDC-eligible individuals and residents of State institutions. Sets forth rules regarding Government compensation to consortia for certain uncollected premiums and an assessment against State or local governments which fail to make a required employer payment. Title III-Part E Distribution of Premiums - Requires the consortia to: (1) compute for each capitation individual an amount equal to the average anticipated expenditure in the State budget for the individual, including certain administrative costs and funds for the contingency fund, but excluding the administrative costs of the State health board; and (2) report such amounts to the Board for review. Requires each consortium to adjust capitation amounts to reflect for a specific capitation individual: (1) the relative actual costs of providing covered services in the area of such person's residency; and (2) the actuarial risk associated with the individual's characteristics. Requires that such risk adjustment be made to eliminate financial incentives for insurers or HMOs to practice risk selection or experience rating. Requires that the total of capitation amounts and adjusted capitation amounts for enrollees in a State be equal to the total expenditures in the State budget for the provision and administration of covered services, excluding State health board administrative expenses. Requires each consortium to apportion to its members an adjusted capitation amount for each capitation individual and a group-rated premium for each group-rated individual. Requires these amounts to be paid to members in installments consistent with Board guidelines. Directs the Board to provide supplementary payments from the Health Resources Distribution Fund to participating HMOs in operation for less than five years. Requires consortia to provide, in accordance with Board guidelines, for redistribution of collected premiums to assure that each consortium is provided an adjusted capitation amount for each capitation individual, and a group-rated premium for each group-rated individual. Directs each consortium to maintain a contingency fund for expenditures for unforeseen circumstances beyond the control of insurers or HMOs. Authorizes the Board, in any year when premiums collected are less than amounts provided in the annual budget, to guarantee the principle and interest of loans issued by the consortia to assure adequate revenues. Sets forth requirements with respect to such loans. Directs the Board, in any year when premiums collected are greater than provided for in the annual budget, to provide for the consortia to distribute such excess funds, including appropriate adjustments in subsequent national and State budgets. Title IV: Administration-Part A, National Health Board and State Health Boards Establishes an independent, five-member National Health Board, to be appointed by the President, to (among other specific functions): (1) establish commissions, bureaus, divisions, offices, and other entities required by this Act or deemed appropriate; (2) perform the functions of a participating insurer, HMO, or consortium with respect to any area or group of insurers for which there is no certified insurer or consortium; (3) perform the functions of a State health board with respect to any State in which such a board has not been established; (4) establish administrative procedures with respect to consumer and provider appeals from State health board decisions; (5) be responsible for the general implementation of this Act; and (6) study and evaluate on a continuing basis the operation of this Act. Transfers to the Board all functions of the Secretary of HEW relating to specified provisions of: (1) the Social Security Act (including Maternal and Child Health Services, Professional Standards Review Organizations, Medicaid, and Medicare); (2) the Public Health Service Act (but excluding, among other provisions, certain provisions of title III (Administration), title IV (National Research Institutes), title V (Miscellaneous), title X (Population Research), and title XIV (Safety of Public Water Systems); (3) the Community Mental Health Centers Act; (4) the Comprehensive Alcohol Abuse and Alcoholism Prevention, Treatment, and Rehabilitation Act of 1970; (5) the Drug Abuse Office and Treatment Act of 1972; and (6) the provision of health care services to Indians (PL 94-437). Requires the Board to have: (1) an Ombudsman, to investigate complaints about program operation; (2) an advocate, to assist consumers in determining and protecting their rights to services; and (3) an inspector general, to direct the auditing and investigative activities of the Board. Directs the Board to establish the following Commissions: (1) Commission on Benefits, to review and make recommendations with respect to the provision of basic covered services under qualified plans and determine their cost and effectiveness in improving public health; (2) Commission on Quality, to review and make recommendations with respect to the quality of health services provided under this Act; (3) Commission on Access, to review and make recommendations with respect to the utilization of covered services by the different categories of eligible individuals; and (4) Commission on Health Care Organization, to review and make recommendations with respect to the cost and effectiveness of methods for the delivery of services. Requires at least one-half of the members of each Commission to be consumers or representatives of consumers and to include appropriate representation of health care providers and other participants. Establishes: (1) a nine-member Commission on the Health of Americans, to be appointed by the President, to conduct an ongoing review of the health status of the U.S. population and to review a broad range of proposals for improving such health status, including research, environmental programs, highway safety, public health programs, and personal health services programs; and (2) under the direction of the National Health Board, a National Institutes of Health Care Research which shall be composed of (A) an Institute of Health Statistics, (B) an Institute of Health Services Research, and (C) an Institute of Health Technology Evaluation. Transfers to such Institutes certain functions of the Secretary under the Public Health Service Act. Requires each State to charter as a public corporation a State health insurance corporation in accordance with Board guidelines. Directs each State health board (that is, the board of directors of the State corporation) to establish an ombudsman, an advocate, and such advisory commissions as are appropriate to carry out its functions. Delineates the duties of such boards. Title IV - Part B, Participating Insurers, Health Maintenance Organizations, and Consortia - Directs the Board to certify an insurer or HMO when certain conditions are met, including a participation agreement between the Board and the insurer or HMO containing specified provisions. Requires the insurer or HMO to: (1) become a member of the appropriate consortium; (2) offer enrollment in at least one qualified health plan which provides basic services without a charge other than the premium; (3) accept during open enrollment all eligible persons in the order they apply without restriction, up to its capacity (but permits the Board to provide for enrollment limits to reflect needs for cost-effective services and for special characteristics of self-insurers); (4) issue an enrollment card for each enrolled person; (5) pay participating providers in amounts no greater than permitted under this Act; (6) report to the State health board and its consortium on payments made and expenses incurred; (7) maintain and afford access to records by the consortium, State health boards, and the Board and provide confidential treatment of individually-identifiable records; (8) offer any rebates or other benefits to all enrollees on the same basis; (9) establish hearing procedures for an enrollee or provider who is dissatisfied with respect to certain services or payments; and (10) comply with other reasonable regulations respecting marketing and customer service practices which the Board establishes. Directs the Board to agree that, in return for agreed-upon services and understandings, the insurer or HMO is to be paid by its consortium for each enrollee in a qualified plan. Requires the Board to certify in each State one consortium for each of the following types of insurers or HMOS: (1) a Blue Cross-Blue Shield consortium, representing nonprofit State-chartered medical/hospital service corporations; (2) a commercial insurance carrier consortium, representing profit-making commercial insurers not directly furnishing health care services; (3) a prepaid group practice HMO consortium; (4) an individual practice association HMO consortium; and (5) a self-insurer consortium. Permits an insurer or HMO to serve as a member of a different consortium with the approval of the Board and the consortium. Sets forth requirements with respect to these consortia including: (1) a participation agreement between the Board and the consortium containing specified provisions; (2) that the consortium provide for premium collection and reallocation and pay members for each enrollee; (3)that a contingency fund be maintained; (4) that certain information be reported regularly to the Board; (5) that the consortium negotiate with provider groups in establishing prospective budgets and maximum fee schedules in areas where its members offer plans; (6) that certain review procedures be established for dissatisfied enrollees and providers; and (7) that other regulations be followed. Establishes as a defense in any civil or criminal antitrust action brought with respect to actions by a participating insurer or HMO or consortium that such actions were taken in the course of performing duties required under agreements entered into under this Act. Directs the Board, after consultation with the Attorney General and the Federal Trade Commission, to prescribe standards and procedures for the conduct of insurers, HMOs, and consortia which is consistent with the promotion of competition. Directs the Board to investigate complaints by a participating insurer or HMO that another participating organization has engaged in anticompetitive activity. Title V: Health Care Improvement Program - Directs the National Health Board to establish a program to improve the distribution of health care resources in the United States in order to promote the improvement in the quality, accessibility, and efficiency of services provided under this Act. Establishes in the Treasury the Health Resources Distribution Fund. Directs the Board to make grants to the State health boards from the Fund for projects to achieve the purposes of the program, including: (1) the conversion or closure of health care facilities; (2) the provision of health care services in health manpower shortage areas; (3) renovations of institutional health care facilities; (4) HMO and other delivery systems; (5) educational programs for health professionals to meet projected needs; and (6) continuing professional education programs. Requires that the Board allocate an amount to each State health board based on the State's needs as reflected in the National Health Care Improvement Plan. Requires that each State health board provide for a program for the education of consumers concerning health and their rights and privileges under this Act. Directs the Board to: (1) study the impact of this Act on, and means of improving, the Medicaid programs, and report appropriate recommendations to Congress within five years of enactment; (2) provide for the development and demonstration of methods to improve (A) the coordination of services by different providers, (B) the provision of services, and (C) peer review and control of utilization and quality in the provision of drugs, laboratory services, and other services under this Act and Medicare; (3) provide for demonstration projects to evaluate the feasibility of providing hospice services as part of basic covered health- care services; (4) provide for an analysis of provider malpractice and the provision of malpractice insurance, and report recommendations to Congress within two years of enactment. Directs the Board to provide for the conduct of a demonstration project in the organization, delivery, and financing of personal care services to groups likely to require such services. Requires that the Board make grants for establishing and maintaining programs to provide personal care services for a substantial population of persons residing in their homes who would otherwise be required to reside in an institution providing personal care services. Sets forth requirements with respect to such program. Directs the Board to transmit to Congress a comprehensive report with appropriate recommendations within five years of enactment. Title VI- Effective Dates, Transition Provisions, Amendments - Part A, Effective Dates and Transition Provisions - Sets forth effective dates for provisions of this Act. Provides for a special national premium rate for the period between October 1 and December 31 of the year before the first effective year. Directs the Board to establish for localities within each State maximum fee schedules applicable to services reimbursed under Medicare Part B for the period between July 1 and January 1 of the first effective year. Requires the Board to establish regulations, guidelines, standards, and procedures providing for the orderly administration of the Act, and to report to Congress within 18 months of enactment its progress in establishing implementation procedures. Directs the General Accounting Office to report to Congress within 18 months of enactment on the Board's progress. Provides that this Act does not alter or affect any contractual or other nonstatutory obligation of an employer to pay for or provide health services to present or former employees if the effect shifts the obligation in any part to such persons. Sets forth provisions relating to transfer of functions. Title VI: - Part B, Medicare-Related Amendments - Amends title XVIII of the Social Security Act (Medicare) to conform such Act with the Health Care for All Americans Act. Eliminates the prohibition against Federal supervision or control over the practice of medicine and the compensation of employees and officers of health care providers. Includes the following changes among those relating to eligibility: (1) broadens Medicare entitlement to include citizens of the U.S., persons legally admitted for permanent residence, and certain other persons aged 65 and over; (2) deletes the 24-month waiting period for eligibility for the disabled; and (3) entitles individuals to enroll in a participating HMO. Changes Medicare Part B from a voluntary insurance program to an entitlement program financed by premium payments and Federal funds. Includes the following among the changes relating to the scope of benefits: (1) deletes the limitation on inpatient hospital days; (2) adds mental health day care services; (3) replaces the existing limitation on inpatient psychiatric hospital services with a 150 consecutive day limit for Medicare purposes and a 45-consecutive-day limit for purposes of the Health Care for All Americans Act. Limits payment for outpatient psychiatric services and services related to the diagnosis or treatment of mental illness to an annual amount equal to 20 times the fee set forth in the maximum fee schedule for a psychiatrist's visit. Limits to $100 payment for certain outpatient therapy services in the therapist's office or beneficiary's home. Conforms coverage for end-stage renal disease with the provisions of the Health Care for All Americans Act. Includes the following among the changes relating to exclusions from coverage: (1) extends the applicability of exclusions to the Health Care for All Americans Act; (2) stipulates that preventive services are not excluded; (3) excludes hearing aids and related examinations only if they exceed one every three years, and one per individual; (4) eliminates the exclusion relating to orthopedic shoes; (5) permits the waiver, under certain conditions of the foot care exclusions for persons with diabetes mellitus; and (6) adds a new exclusion for insulin or outpatient prescription drugs for chronic conditions exceeding maximum amounts established by the Board. Makes technical and conforming amendments to Medicare Parts A and B relating to: (1) requirements for certification and requests for payment; (2) agreements with participating providers; (3) the use of State agencies to determine compliance with conditions of participation; (4) PSROs; and (5) payments to HMOs. Requires providers prescribing outpatient prescription drugs to use only generic or other names and specify such amounts as the Board may provide to insure quality and efficiency. Makes certain revisions with respect to payments to institutional and other providers and the administration of benefits. Repeals the deductible and coinsurance provision of the Medicare Part A program and the existing definition of "reasonable cost". Expands the definition of employment subject to the Medicare hospital insurance tax to include employment with Federal, State, and local governments, service performed for charitable organizations, service performed by certain employee representatives, certain students, and other organizations. Repeals provisions relating to the establishment of the Health Insurance Benefits Advisory Council. Applies certain procedural provisions of title II of the Social Security Act (Old-Age, Survivors and Disability Insurance) to Medicare and to the Health Care for All Americans Act. Amends title XIX of the Social Security Act (Medicaid) to establish a new arrangement for the determination of the Federal Medicaid payment, by which payment is to be equal to "excess State payments" according to a specified formula. Increases the Federal share of certain State Medicaid expenditures, including: (1) the training and compensation of skilled professional personnel (from 75 to 90 percent); (2) operation of management information systems (from 75 to 90 percent); and (3) general administration (from 50 to 90 percent). Establishes certain additional State Medicaid plan requirements including that States: (1) continue to provide services (other than those covered under the Health Care for All Americans Act) in the amount, duration, and scope as were covered by the States in the quarter before the first effective year of the program; (2) pay premiums on behalf of AFDC-eligible recipients; and (3) reimburse providers in a manner consistent with methods established by the Board. Requires any State not having a Medicaid program to enter into an agreement with the Board by which the State agrees to pay premiums on behalf of AFDC-eligible recipients and receives financial assistance from the Board. Amends title XI of the Social Security Act (General Provisions and PSROs) to: (1) extend the provisions for uniform reporting and disclosure of ownership and related information to the Health Care for All Americans Act; and (2) repeal the provisions relating to limitations on capital expenditures and programs for determining the qualifications of certain health care personnel. Amends the Internal Revenue Code to eliminate the present deduction for health insurance payments. Permits a deduction for amounts of medical expense not compensated for by insurance, in excess of three percent of adjusted gross income. Adds a new excess health insurance credit for impacted employers. Establishes special rules for computing such credit with respect to controlled groups of corporations and employees of partnerships and proprietorships which are under common control. Amends title XIII of the Public Health Service Act (Health Maintenance Organizations) to make conforming and certain other revisions with respect to the organization and operation of HMOs.
![Official portrait of Rep. Flood, Daniel J. [D-PA-11]](https://www.congress.gov/img/member/f000209_200.jpg)